Psychiatric Disorders

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3]; Associate Editor(s)-in-Chief: Tamar Sifri [4]

Overview

Psychiatric disorders, (also known as mental disorders or mental illnesses) are syndromes characterized "characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. [These] disorders are usually associated with significant distress in social, occupational, or other important activities." Psychiatric disorders typically do not apply in situations where an individual is acting in response to a common stressor or loss nor to socially deviant behavior. During mental health status examinations, several appearance, behavioral, mood, and speech patterns serve as indicators of psychiatric disorders, and can help determine whether a patient is suffering from a psychiatric disorder. Treatments for psychiatric disorders can be biological (medical), psychological, and/or social.

Types of psychiatric disorders

Cognitive disorders

Cognitive disorders are psychiatric disorders that are characterized by the loss of cognitive function and typically primarily affect learning, memory, perception, and problem solving.

Dementia

A typically permanent cognitive disorder that particularly affects the memory and leads to decreased overall level of functioning. Major types of Dementia

• Alzheimer's Disease
• Vascular Dementia
• Lewy Body Dementia

Psychotic Disorders

Psychotic disorders are severe psychiatric disorders that are characterized by a loss of touch with reality and result in abnormal thinking and perceptions. The most common symptoms of psychotic disorders are delusions and hallucinations, while broad clusters of symptoms categorized as positive or negative, with positive symptoms including delusions, hallucinations or disorganized thoughts, and negative symptoms including social withdrawal and loss of enjoyment, motivation or drive. Psychotic disorders include Schizophrenia and Schizoaffective disorder.

Mood disorders

Mood disorders are psychiatric disorders characterized by typically severe mood changes (elevation or lowering of mood) as in the case of depression or bipolar disorder. These mood changes may occur continuously, intermittently or cyclically.

Anxiety disorders

Anxiety disorders are psychiatric disorders characterized by persistent and often debilitating worry or fear. The anxiety experienced may worsen over time and impede an individual's ability to function. Common symptoms of anxiety disorders include anxiety or excessive worrying, phobias, and panic attacks.

Substance abuse disorders

Substance abuse disorders are psychiatric disorders caused by substance use, abuse, intoxication or withdrawal. Substances involved may be legal such as tobacco, caffeine and alcohol, or illegal substances such as cannabis or cocaine.

Personality disorders

Personality disorders are psychiatric disorders defined by specified kinds of maladaptive behavior patterns that can harm long-term personal relationships or inhibit an individual's functioning in society. DSM IV groups personality disorders into three clusters: Cluster A, B, and C. It is not unusual for a patient to fulfill criteria for more than one personality disorder; the diagnoses are by no means mutually exclusive.

Mental health status examination

Common signs of psychiatric disorders that should be observed include:
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.

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?

Speech

• Observe irregular speech patterns (e.g. slow speaking pace, long pauses before answering or between words)
• Identify increased 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.
• Note any poverty of speech (laconic speech):
  • Restricted amount of spontaneous speech, with brief, concrete, and unelaborated answers to questions.
  • Rare provision of unprompted information.
  • Monosyllabic replies or ignored questions.
• Note instances of:
  • Neologism use (creation of a completely new word or phrase whose derivation cannot be understood).
    • Example: "I got so angry I picked up a dish and threw it at the geshinker."
  • 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").
  • 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".
  • 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.
  • 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.
  • Intense distraction: 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."
    • Inappropriate word substitution: Semantic substitutions that distort or obscure meaning. 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.

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.

Treatment of psychiatric disorders

Treatments of psychiatric disorders can be biological, psychological, and/or social.

Biological treatments

Biological treatments commonly include medications and electroconvulsive therapy (ECT). Many psychiatrists consider that physical aspects of lifestyle such as activity level and diet influence psychiatric disorder's symptomatology.

Psychological treatments

Psychiatric treatments, typically in the form of psychological therapy, range from hypnosis, to psychoanalytically-informed psychotherapy and psychoanalysis, to cognitive and behavioral (CBT) strategies. Psychoanalytic and CBT techniques are often used long-term to treat patients with personality disorders though they can also be used to treat of a wide variety of other conditions.

Social treatments

Social treatments of psychiatric disorders are based on the notion that housing, family, social support structures, and financial difficulty all play a role in the genesis of psychiatric disorders and affect prognosis. Social treatments aim to improve these circumstances to decrease negative stimulus or situations for the patient.

For more psychiatric treatments, refer to Treatments.

History of psychiatric disorders

The history of mental disorders have long been a process of trial and error guided by public attitudes and medical theory with each society developing its own responses. By tracking these developments, a deeper understanding of human interaction and acceptance of this disability can be gathered.

Ancient Egypt

With the first "great civillization," that of the Ancient Egyptians, came the first signs of change in the treatment of the mentally ill. Egypt, like the early stone-age societies (and indeed most societies for the next 3-and-a-half millennia), regarded mental illness as magical or religious in nature. Egyptian psychiatric theory was deeply rooted in the Egyptian conception of the self – the khat (the body), the ka (one’s guardian spirit, who guides the individual to the afterlife), and the ba (symbolized by a bird carrying the key to eternity, which leaves the body after death and resides in heaven), all playing their part in the cyclical nature of life and death. The societal obsession with death and life after death meant that the health of the mind or soul played an essential part in one’s overall health. In Ancient Egypt the first known psychiatric text (written around 20th century BC which explains the causes of "hysteria"), the first known mental hospital (a temple complex near modern Saqqara which is thought to be meant for the treatment of the mentally ill), and the first known mental physician are found in history. The Egyptian focus on the well-being of the soul is embodied in the Temple of Imhotep at Memphis in the 29th century BC, a popular center for the treatment of mental illness. Methods used to attempt to cure the mentally ill included using opium to induce visions, performing rituals or delivering prayers to specific gods, and "sleep therapy," a method of interpreting dreams to discover the source of the illness. Egyptian society, with its fixation on the health of the soul, is the first major example of mental healthcare as a major priority for a society in history.

Ancient Judaism

The concept of a single God as articulated in Judaism paved the way for a shift in views on mental health. While still almost completely religious in nature, the adoption of monotheism allowed for the idea that mental illness was not a problem like any other, caused by one of the gods, but rather caused by problems in the relationship between the individual and God, in some sense (to put it in modern terms) self-conflict or repressed guilt. Although the origin of the Israelite tribes have been dated to the late 2nd millennium BC, the májor period of growth for Judaism occurred in the 6th century BC, when the Kingdom of Judah was conquered by Babylon and exiled to the Babylonian kingdom. On the waters of the Euphrates, the rabbis of the remaining tribes formulated for the first time a cohesive Jewish identity and doctrine, revitalizing monotheism in the face of ideological opposition. To the Hebrews, mental health (spiritual health), was the key to righteousness and to God. By formulating this new concept of a monotheistic, and in many ways, personal deity, the ancient Hebrews moved the idea of mental health away from mysticism and into organized religion.

Medieval Islam

Muslim psychology

More than a thousand years later, Islam was beginning to spread across the Arabian Peninsula and across Asia and into Africa and parts of southern Europe. Like Judaism, Islam stressed the need for individual understanding of their mental situation. Unlike most ancient and medieval societies which believed mental illness to be caused by either demonic possession or as punishment from a God, Islamic neuroethics held a more sympathetic attitude towards the mentally ill, as exemplified in Sura 4:5 of the Qur'an:

"Do not give your property which God assigned you to manage to the insane: but feed and cloth the insane with this property and tell splendid words to him."

This Quranic verse summarized Islam's attitudes towards the mentally ill, who were considered unfit to manage property but must be treated humanely and be kept under care by a guardian, according to Islamic law. This positive neuroethical understanding of mental health consequently led to the establishment of the first psychiatric hospitals in the medieval Islamic world, and an early scientific understanding of neuroscience and psychology by medieval Muslim physicians and psychologists, who discovered that mental disorders are caused by dysfunctions in the brain.

Important medieval Muslim psychologists included Muhammad who discussed mental health and mental illness; al-Kindi (Alkindus) who was a pioneer of psychotherapy and music therapy; Ali ibn Sahl Rabban al-Tabari who was a pioneer of clinical psychiatry and clinical psychology, Ahmed ibn Sahl al-Balkhi who was a pioneer of medical psychology, cognitive psychology, cognitive therapy, psychophysiology and psychosomatic medicine; al-Farabi (Alpharabius) who was a pioneer of social psychology; Ali ibn Abbas al-Majusi (Haly Abbas) who was a pioneer of neuroanatomy and neurophysiology; Abu al-Qasim al-Zahrawi (Abulcasis) who was a pioneer in neurosurgery; Ibn al-Haytham (Alhazen) who was a founder of experimental psychology and psychophysics; Abū Rayhān al-Bīrūnī who was a pioneer in experimental psychology for accurately describing reaction time; Avicenna (Ibn Sina) who was a pioneer of physiological psychology and neuropsychiatry; Ibn Zuhr (Avenzoar) who was pioneer of neurology and neuropharmacology; and Averroes who accurately described Parkinson's disease.

Psychiatric hospitals

As a result of the new positive Islamic understanding of mental illness, the first psychiatric hospitals and insane asylums were built in the Islamic world as early as the 8th century. The first psychiatric hospitals were built by Arab Muslims in Baghdad in 705, Fes in the early 8th century, and Cairo in 800. Other famous psychiatric hospitals were built in Damascus and Aleppo in 1270.

The Arabic physician Rhazes wrote the landmark texts El-Mansuri and Al-Hawi in the 10th century, which presented definitions, symptoms, and treatments for many illnesses, including mental illnesses, and also ran the psychiatric ward of a Baghdad hospital. Such institutions could not exist in Europe at the time because of fear of demonic possessions. In the centuries to come, Islam would eventually serve as a critical way station of knowledge for Renaissance Europe, through the Latin translations of many scientific Islamic texts.

Medieval Europe

Middle Ages

Mental illness in the Middle Ages was very often diagnosed as witchcraft. Those found acting irrationally or suffering hallucinations were thought to be possessed and were subsequently tortured and usually killed. The definitive guide to diagnosis at the time was the Malleus Maleficarum. Recent psychologists have read case studies of proposed witchcraft and have suggested explanations like ergot poisoning.

Asylums

Occurring with the Renaissance, the legislation of witchcraft diminished and was replaced with insane asylums. Treatment in asylums was very poor, often secondary to prisons. The most well known of these asylums was Bedlam where at one time spectators could pay a penny to watch the inmates as a form of entertainment.

Moral reform in Europe

Nearing the turn of the nineteenth century, psychologists and activists began the reform to treat the mentally ill humanely. Notable people include Phillipe Pinel, Johann Guggenbuhl, William Tuke, and Dorothea Dix. Providing a supportive environment for the mentally ill saw great success and these individuals are credited with the development of clinical psychology.

Modern medicine

By the turn of the twentieth century, psychologists were in seeking medical treatments for most mental illness. Early forms included bloodletting, and spinning; later forms included electro convulsive therapy, and lobotomies. Walter Freeman wrote in the 1940’s, that lobotomies would: “Make good American citizens of society’s misfits, schizophrenics, homosexuals, and radicals”. Psychoactive drugs began being administered in the middle decades of the twentieth century. Chlorpromazine was widely used in Europe and the United States to treat schizophrenia. Lithium began being used in the 1960s to treat manic depression. The use of medical drugs has greatly decreased the need for asylums.

See also

• Asylums, Bedlam and mental hospitals
• Sigmund Freud and psychoanalysis
• Neurology
• Development of psychiatric medications
• Care in the community
• Eugenics and the targeting of the mentally ill for extermination
• Psychiatric survivors movement
• DSM-IV Codes
• Structured Clinical Interview for DSM-IV (SCID)

External links

• The Merck Manual Section 15 Psychiatric Disorders[5]
• ICD-10 "Blue Book"
• Internet Mental Health
• Ohio University - The History of Mental Illness

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).

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