Introduction to Psychiatry

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Introduction to Psychiatry

• Psychiatry is a medical specialty that studies, prevents, and treats mental disorders in humans.
• The term "psychiatry" comes from the Greek "psyche" (soul or mind) and "iatros" (healer or doctor), coined by Johann Christian Reil in 1808.

History of Psychiatry

Ancient Times

• Mental disorders were considered supernatural in origin from the 5th century BC to ancient Greece and Rome.
• Hippocrates (4th century BC) theorized that physiological abnormalities may be the root of mental disorders.
• Early manuals on mental disorders were written by the Greeks.

Middle Ages

• The first psychiatric hospitals were built in the medieval Islamic world from the 8th century (Baghdad, Fes, and Cairo).
• Medieval Muslim physicians relied on clinical observations and made significant advances in psychiatry.
• They provided psychotherapy, moral treatment, baths, drug medication, music therapy, and occupational therapy for mentally ill patients.

11th Century

• Avicenna (Persian physician) recognized "physiological psychology" in the treatment of illnesses involving emotions.
• Avicenna also developed a system for associating changes in pulse rate with inner feelings, a precursor to the word association test.

13th Century

• Psychiatric hospitals were built in medieval Europe but were only used as custodial institutions, providing no treatment.

19th Century

• Universities played a part in the administration of asylums in Germany, leading to a competitive environment for psychiatrists.
• The Brattleboro Retreat (1834) in the US was the country's first financially stable private asylum, marking the beginning of private psychiatric hospitals.

Development of Biological Treatment in the 20th Century

• ECT, brain surgery, neuroleptics, and benzodiazepines were developed.

Why Study Psychiatry?

• Psychiatric disorders are prevalent and often go untreated.
• Depression is diagnosed in only 50% of those with depression who present to GPs.
• Half the patients who commit suicide sought treatment in a primary care setting within 1 month of dying.

Barriers to Diagnosis and Treatment in Primary Care Settings

• Patient factors: somatic complaints, denial, stigma, and shame.
• Physician factors: lack of time, fear of embarrassment, uncertainty, and lack of knowledge.

Classification Systems

• Categorical, dimensional, and multiaxial types.
• ICD-10 (World Health Organization) and DSM-5 (American Psychiatric Association) are the two main classification systems in international use.

ICD-10

• International Classification of Disease, 10th edition.
• Covers the whole of medicine, with a specific chapter for mental and behavioral disorders.

DSM-5

• Diagnostic and Statistical Manual of Mental Disorders, 5th edition.
• Comprises the official classification system of the American Psychiatric Association.

Psychiatric Interview

• The single most important skill required in psychiatry.
• Serves various functions, including collecting clinical information, eliciting emotions, and establishing a doctor-patient relationship.

Components of Psychiatric Assessment

• Identifying data, chief complaint, history of present illness, past psychiatric history, past medical history, medications, allergies, family history, social history, medical review of systems, and mental status exam.

Mental Status Examination

• Describes the sum total of the examiner's observations and impressions of the psychiatric patient at the time of interview.
• Includes general appearance and behavior, speech, mood and affect, thought process and content, perception, and cognitive functions.### Presentation Status
• Informal presentation

History of Presenting Complaint

• Nature of problem
• Chronology of each symptom
• Onset and duration
• Severity of symptoms and degree of functional impairment
• Precipitating factors
• Perpetuating factors
• Protective factors
• Factors worsening or improving

Past Psychiatric History

• Similar or other symptoms in the past
• Psychiatric diagnosis
• Psychiatric admission
• Any treatments (drugs, psychotherapy, psychosocial interventions, from primary care, counselling)
• ECT (Electroconvulsive therapy)
• Outcomes of treatment, any recovery, remission
• Suicide, DSH (Deliberate self-harm) attempts

Past Medical History

• Full medical history
• Endocrine, CNS, systemic illness
• Chronic medical conditions: diabetes, ischemic heart disease, epilepsy, asthma (use of steroids), stroke
• Chronology of illnesses, hospitalizations
• Recovery

Medications History

• Current medications
• All drugs taken for psychiatric or medical illness: dose, duration, and outcome
• Drugs that may precipitate psychiatric disorders
• Side effects of psychiatric medication
• Allergies
• May need to check with the GP

Family History

• Family tree to include patient's siblings and parents (e.g., adoptees, biological, separation, divorce, steps)
• Pt's nature of relationship with the family and among family
• Nature of death if anyone not alive
• Known or suspected Hx of mental illness
• Suicides, suicidal behaviors, or Hx of DSH in relatives
• Hx of substance misuse

Personal History

• Mother's pregnancy
• Neuro-developmental milestones: birth, walking, talking, sitting, and socializing age
• Childhood separation or emotional problems
• Home and school environment (Bullying, school refusal, shyness, conduct disorders)
• Schooling and academic achievements
• Relationships with friends and family

Social History

• Profession and employment record, current employment
• Financial situation in general
• Current and past debt problems, spending, etc.
• Marital status: single, married, divorced, widowed
• Children: ages if dependent, parental responsibility
• Housing situation, past and present-living alone
• Stressors
• Social supports
• Typical day

Forensic History

• Past and present charges, penalties, arrests, and convictions (Violence/Anger, sexual offences, etc.)
• Pending court cases
• Unrecorded offences
• Relationship to symptoms and substance misuse

Pre-morbid Personality

• Life-long persistent characteristics prior to illness
• Moral and religious beliefs
• Leisure activities and hobbies
• How would others (e.g., relatives/friends) describe them

Multiaxial System

• Axis I: Clinical Disorders and Other Conditions That May Be a Focus of Clinical Attention
• Axis II: Personality Disorders and Mental Retardation
• Axis III: General Medical Conditions
• Axis IV: Psychosocial and Environmental Problems
• Axis V: Global Assessment of Functioning

Phenomenology

• Study of events, either psychological or physical
• In psychiatry, it involves the observation and categorization of abnormal psychic events
• The internal experiences of the patient and their consequent behavior

Perception

• Awareness of objects and interpretation of sensory information
• Disorders of perception:
  • Illusions
  • Hallucinations
  • Depersonalization
  • Derealization

Thought Disorders

• Formal thought disorders (FTD)
• Serious problems with thinking, feeling, and behavior
• Components of thought:
  • Flow/stream
  • Form of thought
  • Content
  • Possession
• Disorders of flow:
  • Pressure of thought
  • Poverty of thoughts
  • Thought blocking
  • Loosening of association (derailment)
  • Flight of ideas
  • Perseveration
  • Word salad
  • Circumstantialities
  • Tangentiality
  • Echolalia
  • Neologism

Schizophrenia

• Definition, diagnosis, epidemiology, and pathophysiology
• Terminology:
  • Psychosis
  • Delusion
  • Perceptual disturbances
• Delusions:
  • Fixed, false beliefs that remain despite evidence to the contrary
  • Categorized as:
    • Bizarre
    • Non-bizarre
  • Referential delusion
  • Persecutory or paranoid delusion
  • Delusion of control
  • Delusions of grandeur
  • Delusions of guilt
  • Somatic delusion
  • Erotomanic delusion
  • Religious delusion

Classification of Delusions

• According to special feature:
  • Systematized
  • Non-systematized
  • Shared
• According to theme:
  • Persecutory (paranoid)
  • Delusion of reference
  • Grandiose (expansive)
  • Religious
  • De Clerambault's syndrome
  • Delusion of jealousy
  • Delusion of guilt and worthlessness
  • Nihilistic delusion
  • Hypochondriacal delusions### Symptoms of Schizophrenia
• Hallucinations: the 5 A's (Anhedonia, Affect, Attention, Avolition, Alogia)
• Delusions
• Bizarre behavior
• Disorganized speech
• Catatonia

Phases of Schizophrenia

• Prodrome
• Active psychotic
• Residual

Diagnosis of Schizophrenia (DSM-5)

• Two or more symptoms must be present for at least 1 month:
  • Delusions
  • Hallucinations
  • Disorganized speech
  • Grossly disorganized or catatonic behavior
  • Negative symptoms
• Significant social, occupational, or functional deterioration
• Duration of illness for at least 6 months
• Exclude other causes of psychosis

Epidemiology of Schizophrenia

• Approximately 1% of the population
• More likely to be victims of violent crime (14x)

Types of Schizophrenia

• Paranoid type: highest functioning type, older age of onset
• Disorganized type: poor functioning type, early onset
• Catatonic type: rare
• Undifferentiated type: characteristic of more than one subtype or none of the subtypes
• Residual type: prominent negative symptoms

Dopamine Hypothesis of Psychosis

• The exact cause of schizophrenia is unknown, but it appears to be partly related to increased dopamine activity in certain neuronal tracts
• Evidence supporting: cocaine and amphetamines increase dopamine activity and can lead to schizophrenic-like symptoms
• Evidence against: dopamine-inhibiting drugs modify dopamine within minutes, associated with improvement taking several days

Other Neurotransmitter Abnormalities

• Elevated serotonin
• Elevated norepinephrine
• Decrease in gamma-aminobutyric acid (GABA)

Genetics

• Schizophrenia has a large genetic component
• If one identical twin has schizophrenia, the risk of the other identical twin having schizophrenia is 50%
• A biological child of a schizophrenic person has a higher chance of developing schizophrenia, even if adopted

Prognosis

• Better prognosis: later onset, good social support, positive symptoms, mood symptoms, female sex
• Worse prognosis: early onset, poor social support, negative symptoms, family history +ve, male sex, many relapses

Schizophreniform Disorder

• Diagnosis: same criteria as Schizophrenia
• Symptoms last between 1 and 6 months
• Prognosis: 1/3 recover, 2/3 develop Schizoaffective/Schizophrenia
• Treatment: hospitalization, antipsychotics, supportive psychotherapy

Brief Psychotic Disorder

• Diagnosis: same criteria as Schizophrenia
• Symptoms last from 1 day to 1 month
• Prognosis: 50-80% recovery
• Treatment: hospitalization (brief), psychotherapy, antipsychotics +/- benzodiazepines

Schizoaffective Disorder

• Clinical Diagnosis: challenging
• Criteria: Schizophrenia + mood disorder
• Prognosis: better than schizophrenia, worse than mood disorder
• Treatment: hospitalization, psychotherapy, medical (antipsychotics, mood stabilizers, antidepressants, ECT)

Comparing Time Courses and Prognoses of Psychotic Disorders

• Time Course:
  • < 1 month: brief psychotic disorder
  • 1-6 months: schizophreniform disorder
  • 6 months: schizophrenia
• Prognosis from best to worst: mood disorder, brief psychotic disorder, schizoaffective disorder, schizophreniform disorder, schizophrenia

Shared Psychotic Disorder

• Diagnosis: patient shares delusional symptoms of a person they are in a close relationship with
• Prognosis: 20-40% recover upon removal from inducing person
• Treatment: separate patient from inducing person, psychotherapy, antipsychotics if symptoms persist

Antipsychotic Drugs

• Typical neuroleptics: dopamine antagonists, better at treating positive symptoms
• Atypical neuroleptics: antagonize serotonin and dopamine receptors, better at treating negative symptoms
• Side effects: extrapyramidal symptoms, anticholinergic symptoms, tardive dyskinesia, neuroleptic malignant syndrome

Mood Disorders

• Definition: abnormal range of moods and loss of control over them
• Distress: caused by the severity of their moods and the resulting impairment in social and occupational functioning
• Investigate medical or substance-induced causes of mood episodes before making a primary psychiatric diagnosis

Mood Episodes

• Manic Episode: abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy
• Hypomanic Episode: abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy
• Depressive Episode: characterized by symptoms of major depressive disorder

Bipolar Disorder

• Definition: a serious mental illness in which common emotions become intensely and often unpredictably magnified
• In DSM-5, Bipolar and related disorders are separated from the depressive disorders and placed between the chapters on schizophrenia spectrum and other psychotic disorders and depressive disorders
• Specifiers: anxious distress, mixed features, rapid cycling, melancholic features, atypical features, psychotic features, catatonia, peripartum onset, seasonal pattern

Diagnosis and DSM-5 Criteria

• At least one lifetime manic episode is required for the diagnosis of bipolar I disorder
• Hypomanic episodes are common in bipolar I disorder but are not required for the diagnosis
• Depressive episodes are common in bipolar I disorder but are not required for the diagnosis
• The occurrence of the manic and depressive episode(s) is not better explained by another psychotic disorder

This quiz covers the basics of psychiatry, its definition, and its role in studying and treating mental disorders. It also touches on the assessment process, including mental status examinations and psychological tests.