Psychiatric Disorders

Introduction
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
APPEARANCE

What does the patient look. like, smell like and sound like? Give a written description.

Self Neglect: cleanliness, shaven, make up, state of hair and clothes

Bizarre Appearance: secret documents openly displayed, special clothes or ornaments with symbolic significance, etc.

BEHAVIOUR

Involuntary movements: tics

Mannerisms

Stereotypes

Purposeful behaviour: pacing, fiddling

RAPPORT

Includes Demeanour: threatening, seductive, friendly

AFFECT

Mood: inner emotional experience: can be inferred, but is best described

Affect: outer expression of mood

Level: elevated, lowered, euthymic

Range: restricted, increased, normal

Congruity: does the affect match what is being discussed?

SPEECH

Slow Speech: Long pauses before answering, long pauses between words

Pressure of Speech: An increase in the amount of spontaneous speech as compared with what is considered ordinary or socially customary. The patient talks rapidly and is difficult to interrupt. Some sentences may be left uncompleted because of eagerness to get on to a new idea. Simple questions that could be answered at great length, so that the answer takes minutes rather than seconds and indeed may not stop at all if the speaker is not interrupted. Even when interrupted, the speaker often continues to talk. Speech tends to be loud and emphatic. Sometimes speakers with severe pressure will talk without any social stimulation and talk even though no one is listening. When patients are receiving phenothiazines or lithium carbonate, their speech is slowed down by medication, and then it can be judged only on the basis of amount, volume and social appropriateness. This disorder may be accompanied by derailment, tangentiality, or incoherence, but it is distinct from them.

Non Social Speech: Talks, mutters, whispers to self, out of context of conversation with examiner.

Muteness: Almost mute, (fewer than 20 words in all) Totally mute

Poverty of Speech (Poverty of Thought, Laconic Speech): Restriction in the amount of spontaneous speech, so that replies to questions tend to be brief, concrete, and unelaborated. Unprompted additional information is rarely provided. Replies may be monosyllabic, and some questions may be left unanswered altogether.

When confronted with this speech pattern, the interviewer may find himself frequently prompting the patient to encourage elaboration of replies. To elicit this finding, the examiner must allow the patient adequate time to answer and to elaborate his answer.

Example  Interviewer "Do you think there is a lot of corruption in government?" Patient "Yeah seem to be" Interviewer "Do you think Haldeman and Ehrlichman and Mitchell have been fairly treated?" Patient "I don't know". Interviewer "Were you working at all before you came to the hospital?" Patient "No". Interviewer "What kind of jobs have you had in the past?" Patient "Oh some janitor jobs painting" Interviewer "What kind of work do you do?" Patient "I don't, don't like any kind of work.

That's silly". Interviewer "How far did you go in school?" Patient "I'm still in 11th grade". Interviewer "How old are you?" Patient "Eighteen”.

Neologisms: New word formation. A neologism is defined here as a completely new word or phrase whose derivation cannot be understood. Sometimes the term "neologism" has also been used to mean a word that has been incorrectly built up but with origins that are understandable as due to a misuse of the accepted methods of word formation. For purposes of clarity, these should be referred to as word approximations (discussed in the following section). Neologisms are quite uncommon.

Examples  "I got so angry I picked up a dish and threw it at the geshinker". "So I sort of bawked the whole thing up".

Word Approximations (Paraphasia, Metonyms): Old words that are used in a new and unconventional way, or new words that are developed by conventional rules of work formation. Often the meaning will be evident even though the usage seems peculiar or bizarre (i.e.: gloves referred to as "handshoes", a ballpoint pen referred to as "paper skate" etc). 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 (i.e.: a watch may be called a "time vessel" the stomach a "food vessel" a television set a "news vessel" etc). "One is called 'per God' and the other is called 'per the Devil"' miracle willed through God's 'turn horn' .... "Well, there is. a frequenting of clairvoyance ..." "Per God". "Per the Devil" and "turn horn" are neologisms; "frequenting of clairvoyance" is an example of ordinary words used idiosyncratically. Write down examples.

Disorder of Content of Speech: 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; i.e., rate incoherence in preference to flight of ideas, and flight of ideas in preference to poverty of speech.

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 Content of Speech (Poverty of Thought, Empty Speech, Alogia, Verbigeration, Negative Formal thought Disorder): Although replies are long enough so that speech is adequate in amount, it conveys little information. Language tends to be vague, often over abstract or over concrete, repetitive and stereotyped. The interviewer may recognise this finding_ by observing that the patient has spoken at some length but has not given adequate information to answer the question. Alternatively, the patient may provide enough information to answer the question, but require many words to do so, so that a lengthy reply can be summarised in a sentence or two.

Sometimes the interviewer may characterise the speech as "empty philosophising".

Exclusions  This finding differs from circumstantially in that the circumstantial patient tends to provide a wealth of detail.

Example  Interviewer "Tell me what you are like, what kind of person you are". Patient "Ah one hell of an odd thing to say perhaps in these particular circumstances, I happen to be quite pleased with who I am or how I am and many of the problems that I have and have been working on I have are difficult for me to handle or to work on because I am not aware of them as problems which upset me personally. I have to get my feelers way out to see how it is and where that what I may be or seem to be is distressing, too painful or uncomfortable to people who make a difference to me emotionally and personally or possibly on an economic or professional level. And I am I think becoming more aware that perhaps on an analogy the matter of some who understand or enjoy loud rages of anger, the same thing can be true for other people, and I have to kind of try to learn to see when that's true and what I can do about it".

Misleading Answers: Patient's answers are misleading because answers Yes or No to everything, or frequent self contradictions, or appears to be deliberately misleading. Do not include incoherence, flight of ideas or poverty of speech here.

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, the interviewer's clothing or appearance, etc.

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: Speech that has an excessively stilted or formal quality. It may seem rather quaint or outdated, or may appear pompous, distant, or overpolite. The stilted quality is usually achieved through use of particular word choices (multisyllabic when monosyllabic alternatives are available and equally appropriate), extremely polite phraseology. ("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, Phonemic: Recognisable 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 recognised his error and may attempt to correct it.

Example  "I slipped on the lice and broke my arm while running to catch the bus"

Paraphasia, Semantic: Substitution of an inappropriate word during his effort to say something specific. The speaker may or may not recognise his error and attempt to correct it. It typically occurs in both Broca's and Wernicke's aphasia. It 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 her;

does she want treatment;

how rational is her understanding of the problem and its treatment

COGNITIVE EXAMINATION

ORIENTATION

SPECIFIC TESTS

PHYSICAL EXAMINATION Special attention to:

the signs and causes of delirium

stigmata of drug use (acute: intoxication, and chronic, eg needle track marks, stigmata of alcohol and tobacco use) and abuse

stigmata of self harm, eg scars

general body habitus: obesity, degree of fitness

Neurological examination

Delirium, Dementia, and other Cognitive Disorders
Although most psychiatric disorders are presumed to have an underlying alteration in function, this group are separated off by having a suspected cause in another area of medical specialty. For example, delirium, is commonly caused by alterations in brain oxygenation and would be better assessed by a physician to determine possible treatable causes. The organic disorders may have an underlying basis that is treatable or untreatable and treatment may or may not improve symptoms. This group 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