Basics of psychiatry notes

BASICS OF PSYCHIATRY
TONY SCARIA 2010
KMC

Term psychiatry Johaann Christian reil
Dementia precox Benedict morel
4 A’S of schizophrenia Bleuler
ECT Cerletti & Bini
Cognitive therapy Aaron beck
Defense mechansism Anna freud
TONY SCARIA 2010 KMC

• There are three basics in psychiatry –
• cognition (is also a higher mental function) means thought;
• conation means action &
• affect meaning mood.

2 major classificatory systems in psychiatry
• ICD -10
• Chapter V (F)
• DSM-5
• By American psychiatric association

PSYCHOANALYTIC THEORY OF SIGMUND FREUD

PSYCHOANALYTIC THEORY
HELPS TO EXPLAIN
CONVERSION DISORDER

NEUROTIC PSYCHIATRIC
JUDGEMENT + -
INSIGHT + -
PERSONALITY + -
REALIY CONTACT + -

MSE
• GENERAL APPEARANCE & BEHAVIOUR
• General appearance
• Attitude towards examiner
• Comprehension
• Gait and posture
• Motor activity
• Social manner
• rapport

• SPEECH
• Rate & quantity
• Volume & tone
• Flow & rhythm
• MOOD & AFFECT
• THOUGHT
• Stream & form
• content
• PERCEPTION
• COGNITION
• Consciousness
• Orientation
• Attention
• Concentration
• Memory
• Intelligence
• Abstract thinking
• JUDGEMENT
• INSIGHT

General appearance & behaviour
• Rapport (doctor – patient relationship)
• Absent in psychosis
• Built
• Schizophrenia  thin athletic
• Bipolar fat

EYE TO EYE CONTACT
• DOWNCAST EUES IN DEPRESSION
• POOR EYE CONTACT IN AUTISM

Mood and affect describe emotions
• Affect  cross sectional emotional state
• Mood is sustained or longitudinal emotional state

EUTHYMIA
• NORMAL
MOOD
DYSTHYMIA
• DEPRESSED
MOOD FOR 2
YEARS
CYCLOTHYMIA
• FLUCTUATION
IN MOOD

ALEXITHYMIA
• INABILITY TO EXPRESS ONES
EMOTIONS

Neuroanatomic substrate of emotions
• Generated in Limbic system
• Hippocampus ,amygdala,hypothalamus,cingulate gyrus,thalamic and corticalb
areas
• Regulation is done by frontal lobe

Mood
• Quality
• Fluctuations
• Appropriateness and congruency

Quality of mood
• Predominant affective (mood)
• Euphoric mood (elevation of mood)
• Excessive happiness with out any reason
• In hypomania / mania
• Depressed mood
• Excessive sadness
• In depression

Fluctations
• Refers to change in mood / affect
• Labile mood /emotional lability
• Excessive variations in mood with out any apparent reason
• Mania
• Affective flattening
• Absence of changes in mood irrespective of the situation
• Does not experience any emotions hence affect remains the same

Appropriateness & congruency
• Appropriateness
• In relation to social situation
• Eg : sadness in funeral appropriate mood
• Congruency
• Emotional state of patient in sync with his thought or
speech
• Eg : appearing sad while describing dead person

Other disturbances in emotion
• Alexithymia
• Lack of words to describe emotions
• Inability to describe and recognize emotions
• Anhedonia
• Loss of capcity to experience pleasure
• Unable to enjoy / loss of interest and withdrawal
• a/w depression
• Abreaction
• Emotional release or discharge after recalling a painful experience

Perception
• Receiving information using one of the sensory modalities
• Disturbances in perception
• Hallucination
• Illusion

Illusion
• Altered perception of real object
• Misinterpretation of stimulus (sensory input)
• Sensory input in ext environment
• Perception is in internal mind (inner subjective space)
• Mistaking a rope as a snake
• Seen in delirium

Hallucination
• False perception with out stimulus
• Clear/ 3 dimensional/ vivid
• Absence of corresponding external stimuli
• Occurs in outer objective space
• Pseudohallucination  originating from with in mind
• Insight is absent
• Not under willful control of patient (no voluntary control)

True hallucination Pseudohallucination
Outside Inside
Clear hazy
No control Can be controlled
Illness May not Illness

Types
• Visual  organic psychiatric ds (delirium)
• In organic disorders
• Auditory  most common hallucination in psychiatric disorders
• Tactile hallucination  cocaine poisoning
• Olfactory  temporal lobe epilepsy

• Imagery incomplete not clear subjective and can be controlled
• Lesions of temporal lobe can cause all type of hallucination and
formed visual hallucination

Auditory hallucination
• Most common hallucination
• Voices talking to the patient or ordering him (second person)
hallucinations and voices talking to one another referring the patient
(third person) hallucination  commonly in schizophrenia
• Echo de la pensee
• Repeat his thoughts immediately he has thought of them
• Gedankenlautwerden
• Voice seem to anticipate what the patient thinks afew moments later or speak his own
thoughts as she speaks them

Visual hallucination
• unFormed
• Flashes
• In disorders of visual cortex or visual pathway
• formed
• Objects people
• Organic mental disorders
• Temporal lobe lesions
• Prominent visual hallucination in the absence of auditory
• organic brain ds
• Extracampine
• Hallucination beyond possible sensory field
• Seeing somebody standing behind you

Autoscopic hallucination
/phantom mirror image
• Seeing ones own body projected in
to space
• May convince the person that he
has a double (doppelganger)
• Visual hallucination
• In patients with temporal lobe
epilepsy

• When person does not see his
own mirror image

Olfactory hallucination
• Unpleasasnt smell or tastes
• Depressive disorders
• Schizophrenia
• Irritation of olfactory bulb
• Temporal lobe epilepsy

Tactile hallucination
• Insects crawling in the body or under the skin
• In cocaine poisoning
• Amphetamine abuse
• Delirium tremens
• Opiod withdrawal

Few specific hallucinations
• Hypnagogic
• In narcolepsy
• While Going to sleep
• Hypnompic hallucination
• While getting up from sleep

Reflex hallucination / synaesthesia
• Cannabis & LSD poisoning
Stimulus in one sensory
modality (white bulb)
Hallucination in another sensory
modality (hearing voices of god)

Functional hallucination
Stimulus in one sensory
modality (white bulb)
Hallucination in same sensory
modality (seeing god)

Phantom limb hallucination
• Experiences sensation in the absence of any stimulus

Constituents of normal thought
• Constancy
• Stick to the topic
• Continuity
• Connected properly with proper meaning
• Organisation
• Organised properly
Clarity is not
constituent of normal
thinking

Disorders of thought in
• Stream
• Possession
• Content
• Form

Disorders of stream of thought
Tempo
• Flight of ideas
• Rapid speech move from idea to
idea abruptly
• Pressurised speech
• Inhibition
• Thought comes very slowly and
thought progresses with a slow
rate
Continuity
• Thought block
• Sudden arrest of train of thought

Clang association
• Disorder of stream of thought
• Refers to sequence of thoughts stimulated by sound of preceding
words rather than by their meaning
• Based on rhyming
• In mania

Loose association
• Involves shifting of ideas from one subject to
another in an oblique or unrelated manner
• In schizophrenia

Flight of ideas
• Flight of ideas is a disorder
of thinking in which the
patient expresses
thoughts very rapidly, with
constant shifting from one
idea to another, though
the ideas are often
connected.

Prolixity
• Lively embellishment of speech
• Adding emotions (spicey) to speech
• In hypomania

• Flight of idea – is a disorder in which two successive thoughts are
connected by superficial association.
• Prolixity – is ordered flight of ideas (Milder variey of flight of ideas) ,
found in hypomaniA.

Thought blocking
• In thought blocking, the patient suddenly
stops talking, usually in the middle of a
sentence, and cannot complete his or her
thoughts. Affect is said to be incongruent
when what is observed by the examiner
(affect) does not match the subjective
statement of how the patient feels (mood).
• Schizophrenia
• Severe anxiety disorder

Disorders of thought content
• Delusions
• obsessions
• An obsession is the ego-dystonic
persistence of a thought or feeling that
cannot be eliminated from
consciousness voluntarily
• ideas of reference
• belief that an object, event, or person in
one’s environment (commonly the
television or radio) has particular
personal significance

• Delusion
• False fixed belief
• Idea
• False fluctuating belief

Delusions disorder of content of thought
Firm unshakable belief that is not accepted by other members of
patients culture & society
• Somatic type
• Jealous type
• Grandiose type
• Persecutory type
• Erotomanic type
• Late paraphrenia
• Shared psychotic disorder
• Acute paranoid disorder

Superstition
• Superstition
• A false belief unexplained by reality shared by a number of people.
• Delusion
• false belief unexplained by reality not shared by a number of people.

Delusion of persecution  a beautiful mind
• Most common
• Patient believes someone wants to harm him

Delusion of reference
• Patient believes that events happening around him are some how
related to him

Delusion of infidelity / Othello syndrome
/morbid jealousy
• False belief that his partener or spouse is having an affair
• Othello syndrome

Delusion of misidentification
• Capgras syndrome
• Delusion of double
• Fregoli syndrome
• Complete stranger is a familiar person

Capgras syndrome in schizophrenia
• A familiar person has been replaced by impostor
• Delusion of double

• Fregoli syndrome
• in which a person holds a
delusional belief that different
people are in fact a single person
who changes appearance or is in
disguise

Delusion of grandeur
• The patient believes that he has some exceptional identity or power
• In mania

Nilhilistic delusion
• Cotards syndrome
• Accompnied by ideas concerning bodily fns
• Putrefaction of eyes / intestine
• Depression
• Deny existence of body mind or world in general

Delusion of guilt
• Committed unpardonable sins
• In severe depression

Delusion of love / fantasy lover syndrome
• False belief that some one is in love with them
• De clerambaults syndrome
• A woman usually beleves that a man
frequently older & of higher status is

• Somatic type:
• This disorder is characterized by a single hypochondriacal delusional system
distinct from the personality. Delusions may be sometimes associated with
tactile or olfactory hallucinations or illusional misinterpretation.
• (Subtypes includes: Delusional infestation, Delusional halitosis, Delusional
dysmorphophobia)

Hypochondriacal delusion
• Wrongly believes that he has severe medical illness

Delusion of infestation
• One is infested with small but visible organism
• As a monosymptomatic delusiona disorder  EKBOM SYNDOME
• a/c confusional state
• Secondary to fomication

Delusion of control
• His actions impulses or thoughts are controlled by external agency &
accordingly called as made action made impulse made affect
• PASSIVITY PHENOMENON

Scientifically impossible and culturally implausible False but possible

Mood congruent delusions
• Mood and delusions are
congruent
• Mood disorders
Mood incongruent delusions
• Mood and delusions are
incongruent

delusions
Primary
• Morbid psychological process
which arise as a result of morbid
psychological process
Secondary
• d/t some other
psychopathological
phenomenon

Depersonalization
Sense of unrealityor strangeness to
self manifested by feeling detached
from & being an outside observer of
ones mental process or body

Depersonalisation

Derealisation
• Feeling detached from ones environment

Disorders of possession of thought
• Insertion
• Thought alienation
• Withdrawal
• Thought possession disorder is seen in
schizophrenia OCD

Thought alienation
• Disorders of content of thought /possession of thought

Thought insertion
• patient feels that some external agency is inserting foreign thoughts
in to their mind

Thought withdrawal
• Thoughts are being withdrawn from their mind by an external agency

Thought broadcasting
• Patient experiences that thoughts are escaping from their minds and
other people are able to access them

Obsessions disorder of thought possession
• Thought comes repeatedly in to the mind of patient against his will

Obsession
•Repetitive
•Own thoughts
•Intrusive
•Anxiety provoking
Compulsion
•Repetitive
•Mental/physical act
•Disabling
•Anxiety relieving
Most common obsession is
fear of contamination
Most common compulsion is
washing followed by checking

Ego syntonic thoughts
• Ego in liason
• Patient himself knows his
thoughts are correct
• Homosexuality
Ego dystonic thought
• Ego not in liason
• Patient himself knows his
toughts are Irrational thoughts
• OCD

Disorders of form of thought
• Derailement
• Circumstantiality
• Tangentility
• Loosening of associations
• Incoherence
• Neologism
• Word approximation
• preservation
Although certain forms of formal thought disorder are more
frequently associated with specific psychiatric disorders (for
example, tangentiality, flight of ideas, and clang association in
mania, and illogical thinking and loose association in
schizophrenia), no form of thought dis order appears to be
disorder specific.

looseness of associations,
• flow of thought is disconnected—ideas shift from one subject to another in
a completely unrelated way
• Unrelated and unconnected ideas shift from one subject to another
• In flight of ideas there are rapid, continuous verbalizations or plays on words that
produce constant shifting from one idea to another. Ideas tend to be connected.
• 4 types
• Derailement / knights move
• Word salad
• Verbigeration
• Vorbeireden

• Derailement / knights move
• Refers to transition from one topic to another either b/w sentences or in mid
sentences with no logica; relation ship b/w sentences
• Word salad /incoherence  common in schizophrenia
• Extreme from of derailement
• Where grammatical structure is also affected
• Verbigeration
• Senseless repetition of words or phrases over and over again
• Vorbeireden
• Subject seems always about to get near to matter but never reaches it

Circumstantiality😵
• Pattern of speech which progresses
with inclusion of lots of unnecessary
details and goes round & round before
reaching final goal
• Boring details

• Circumstantiality
• pt will reply to question but include unnecessary details before coming to
final answer
• loss of a goal-directed thought process: the patient brings in many irrelevant
details and comments, but eventually will get back to the point.

Tangentiality
Answer is related to the qstn in a distant
way and goal of thought is never reached

Vorbeireden
• Failure to reach central idea of discussion
• Skirts around it & infact never reaches it
• Approximate answers
• In ganser syndrome
• Schizoprenia
• Ganser syndrome
• Syndrome of approximate answers

Word approximations (metonyms)
• Old words are used in a new or unconventiontal way
• Meaning is easily evident
• Though the word appears strange

neologism
• A neologism is a fabricated word made up by the patient, which is
usually a combination of existing words.
• Most common characteristic of schizophrenia

Perseveration
• Perseveration, often associated with cognitive disorders,
• patient displays an inability to change the topic or gives the same
response to different questions.
• Perseveration is repetition beyond point of relevance in response to
stimulus pt will give same answers to different questions asked like
what is your father name RAM, what is your mother name RAM,
where do you live RAM.
• refers to a response that persists even after a new stimulus has been
introduced––for example, a patient asked to repeat the phrase “no
ifs, and, or buts” responds by saying, “no ifs, ifs, ifs, ifs.”

Magical thinking
• Magical thinking is a form of
thinking similar to that of
preoperational-phase children
(Jean Piaget) in which thoughts
and ideas are believed to have
special powers (eg, to cause or
stop outside events).

Echolalia
• echolalia.
• repetition of the examiner’s words or phrases by the patient
• Like parrot

Insight
• Awareness regarding ds in MSE
• Impaired in ac psychosis & schizophrenia

Formal thought disorder
• Schicophrenia mainly
• Schizoaffective disorder

Déjà vu Familiarity feelings to an event which has never
happened
Deja pence The feeling of recognising a new thought as having
already previously occupied
JAMAIS VU UNFAMILIARITY FEELINGS TO AN EVENT WHICH HAS
BEEN EXPERIENCED IN PAST
echo de la pense Thought echo
First person auditory hallucination
Hearing ones own thought louder (heard aloud)
DEJA ENTENDU FEELING OF AUDITORY RECOGNITION TO AN EVENT
WHHICH HAS NEVER HAPPENED

INSIGHT
• EPIPHANY
• MULTIDIMENSIONAL MODEL OF INSIGHY
• RECOGNITION OF ILLNESS
• ACCEPTING NEED OF Rx
• UNDERSTANDING ABNORMALITY

Mini mental status examination

MMSE
• Quantify impairement of cognitive functions
• Orientation
• Attention
• Calculation
• Recall
• Language
• Ability to follow simple commands
• Maximum = 30
• <23 mild
• <20  definitive organic

• Mmse donot help in localisation
• Help in localisation
• Bender gestalt test
• Luria Nebraska battery

HIGHER MENTAL FUNCTIONS

CONSCIOUSNESS
• AWARENESS OF SELF & SURROUNDINGS

QUANTITATIVE CHANGES IN
CONSCIOUSNESS
• CLOUDING OF CONSCIOUSNESS
• DROWSINESS
• SOPOR
• COMA
QUANTITATIVE CHANGES IN
CONSCIOUSNESS
• CONFUSION
• DELIRIUM
• SOMNOLENCE
• ONEIROID STATE
• TWILIGHT STAGE
• STUPOR
• FUGUE STATE

• ONEROID STATE  DREAM LIKE STATE IN AN AWAKE PATIENT

TWILIGHT STAGE
• TRANSIENT STATE OF ALTERED SENSORIUM
• PATIENT IS NOT AWARE OF ACTIVITIES CARRIED OUT IN THIS PERIOD

STUPOR
• PATIENT IS AWAKE BUT UNRESPONSIVE TO HIS ENVIRONMENT
• PATIENT IS MUTE & IMMOBILE
• PATIENT APPEARS AWAKE

Cognitive distortions

• Amnesia  inability to recall past things
• Paramnesia distorted or falsified recall of events in relation to
details or their temporal relationship
• Hypermnesia  extreme degree of retension

Amnesia
Retrograde
• Amnesia for events before in a
point of time
Anterograde
• Amnesia for event after a point
in time

Paramnesia
Confabulation Unintentional filling of gaps with material that are
untrue & fanciful
False memory syndrome Memory of trauma or event that actually did not
occur
Déjà vu
Jamais vu
Deja pense
Deja endendu

Abstract thinking
• Ability to understand essence of ehole / hidden meaning
• Assessed by interpretation of common proverbs
• Loss of abstract thinking is referred to as concrete thinking
• Can occur in organic disorders /mental retardation/schizophrenia

Concrete thinking

Disorders of motor activity
Mannerism Odd repetitive goal directed movements
stereotype • Odd repetitive non goal directed movements
• With out any stimulus
Perseveration • Persistent repetition of movement or speech
beyond fulfilment of purpose
• In
Echopraxia Senslessly repeats movements of others around
Tic Sudden involuntary rapid recurrent rhythmic
movement

Catatonia
• Disorders of movement & posture a/w psychiatric disorders
• In bipolar disorderes & schizophrenia
• Organic  encephalitis midline lesions
• Waxy flexibility
• Patient can be moulded like wax in to a position that is then maintained
• Catatonic mutism
• Automatic obedience ‘
• Catatonic excitement
• Excited uncontrolled motor activity

Decreased psychomotor activity In depression & in parkinsonism
Increased Manina ADHD
Repetitive stereotyped Autism

Echopraxia
• Sensless
repetition of
movement of
others around
him

Serial substractin test
• To assess concentration & recent memory

Rosarch inkblot test to assess personality

Basics of psychiatry notes

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