Psychiatric Terminology: Mood and Affect

• A state of unease or dissatisfaction.

General Terminology

• Affect Physical expression of mood.
  • Can be blunted, restricted, reactive, expansive, dysphoric, or labile.
  • Labile is most commonly associated with bipolar
• Mood: Internalized feeling that can be observed.
  • Can be euthymic, euphoric, irritable, depressed, or labile.
  • Expansive and Elevated are types of overly happy.
  • Elevated is peculiar to a specific person
• Delusions: False, fixed, idiosyncratic beliefs that persist despite evidence to the contrary and not typical of a patient’s culture/religion.
  • Specific types include control, bizarre, nihilistic, erotomanic, grandiose, religiose, jealous, persecutory, somatic, referential, mixed and unspecified
  • Referential is when unrelated events have reference to the individual
• Illusions: Misperceptions of actual stimuli, like things looking smaller (micropsia) or bigger (macropsia).
• Hallucinations: Perceptions in the absence of external stimuli with types including auditory, tactile, visual, olfactory, and gustatory.
• Disorganized Thinking
• Disorganized Motor Behavior: Psychomotor agitation/retardation, abnormal movements, odd repetitive movements, mannerisms, tremors and catatonia.
• Negative Symptoms/Psychomotor Poverty (The 5 A's): Cannot be treated
  • Avolition: Lack of motivation, withdrawal from daily activity
  • Anhedonia: Withdrawal from leisure/sexual activities and inability to find activities pleasurable
  • Alogia: Short, monosyllable answers to questions
  • Asociality: Limited social interactions
  • Affect Blunting: Diminished facial and vocal expressions.
• Positive Symptoms: Hallucinations or delusions.
• Thought-Form Disturbances: Thought-form is how thoughts are formulated, organized and expressed.
  • Flight of Ideas: Rapidly move from one idea to another
  • Tangential: Goes off on tangents if asked a question, does not directly answer it
  • Derailing: Starts answering logically, then goes off-course
  • Neologisms: Invention of new words or phrases
  • Perseveration: Repetition of out of context words
  • Circumstantiality: Unnecessary detail, but returns to original subject
  • **Thought Blocking:" Sudden stop in flow of speech
  • Echolalia: Repeating words of someone else.
• Thought-Content Disturbances: Describes what the patient is thinking, magical thinking, delusions, poverty of thought, overvalued ideas, fantasy, phobias, ideas of reference
• Confabulation: Disturbance in memory where the patient fills in gaps with fabricated ideas or events.
• Delirium: Alterations in levels of consciousness, medical condition usually present
• Psychosis: Syndrome of severe psychiatric symptoms that leads to disorganized thoughts & impaired function.
  • Cause is increased Dopamine
  • Abnormalities in one or more of the following domains, i.e., delusions, hallucinations, disorganized thinking, disorganized motor behavior, negative symptoms.
• Motor Disturbances:
  • Psychomotor Agitation: Too much movement
  • Psychomotor Retardation: Too little movement
  • Abnormal Movements: Tremors, Tics, Mannerisms, Odd repetitive behaviours
  • Catatonia: Catatonia may involve catatonia, mutism staying still, fast or strange movements, lack of speech and other unusual behaviors.
• Insight: Perception of one's own state and nature of illness.

Schizophrenia Spectrum & Other Psychotic Disorders:

• A diagnosis of schizophrenia requires 2 of 5 or more symptoms present for more than one month where one symptom must be delusions, hallucinations or disorganized speech Symptoms must be present for the majority period of at least six months
  • Criteria A: Requires two or more of following 5 symptoms:
    • Delusions
    • Hallucinations
    • Disorganized Speech
    • Disorganized Motor behavior
    • Negative Symptoms
  • Criteria B: After excluding schizoaffective / mood disorders, another medical condition & substances.
• Schizophrenia includes both positive (hallucinations, delusions, disorganized speech) and negative (emotional blunting and social withdrawal) symptoms.
  • Presentations include impaired congition & incoherent speech
  • Risk factors include genetics, perinatal hypoxia, stress, infection, malnutrition & maternal diabetes
  • Onset earlier for males at 10-25 & later for females at 25-35
  • Increased mortality rate & suicide risk
• Schizophreniform Disorder: Psychotic symptoms lasting more than 1 month but less than 6 months.
  • If symptoms persist this becomes schizoprenia despite treatment
• Schizoaffective Disorder: Requires 2 weeks of psychosis apart from mood symptoms as main deficit, but prominent mood component is also present.
• Schizotypal Personality Disorder: Pattern of social & interpersonal limitations with discomfort in social settings & difficulty maintaining close relationships, and also perceptual & cognitive distortions + eccentric behav
• Delusional Disorder: One or more delusions lasting a month or longer.
  • Function isn’t markedly impaired & behaviour isn’t bizarre, hallucinations not present.
• Brief Psychotic Disorder: Psychotic symptoms last for a day or longer but resolve in less than a month.
• Delirium: Acute alterations in levels of consciousness, usually secondary to something else.
• Substance-Induced Psychosis: May be the primary cause or comorbid.
  • Symptoms start after substance use.
  • Daily cannabis use before age 15 has 2x risk of schizophrenia
• Psychosis due to Another Medical Condition: No changes in consciousness levels.
  • Common causes are cerebral infections (HIV, Neurosyphilis), Brain Trauma & Epilepsy
• Amafufunyane: Culture-bound syndrome common in Nguni, Sesotho & Tsonga.
  • Sudden onset of abdominal pain, incoherence & violent behaviour, Restlessness, mutism & amnesia after the event.
• Ukuthwasa: Culture-bound syndrome due to calling to be a healer.
  • Communications from ancestors, visions, signs, dreams.
  • Symptoms may appear psychotic but there is a clouding of consciousness.

Substance-Related Disorders

• Cluster of cognitive, behavioral, physiological symptoms from continued use which cause substance-related problems.
• Requires two or more of following symptoms in a 12-month period:
  • Impaired control:
    • Substance is taken in large amounts or durations longer than intended
    • Persistent desire or unsuccessful attempts to cut down substance use
    • Great deal of time spent obtaining, using or recovering from substance
    • Craving, strong desire or urge to use
  • Social Impairment:
    • Failure to fulfil major obligations
    • Continued use despite persistent problems caused or exacerbated by substance
    • Give up or reduce important activities
  • Risky Use
    • Recurrent use in hazardous situations
    • Continued use despite knowledge of problem
  • Pharmacological Criteria
    • Tolerance (need increased amount for effect previously attained by less)
    • Withdrawal symptoms characteristic of that substance
• Symptoms graded as mild, moderate or severe
• Can cause intoxication (after ingestion), withdrawal (after cessation) or mental disorders

Intoxication vs Withdrawal

• With recent ingestion vs cessation of substance after heavy use:
  • Alcohol: Resulting in Impaired sexual / aggressive behaviour, labile mood & Impaired judgement, slurred speech, incoordination & unsteady gait, nystagmus, impaired memory & attention, stupor and or coma
    • Whereas cessation causes ANS Hyperactivity, insomnia, hand tremor, N+V, Transient hallucinations and anxiety.
  • Cannabis: Resulting in Euphoria, Anxiety, Impaired judgement, increased appetite, conjunctival inflammation, dry mouth & tachycardia
    • Chronic use causes amotivational syndrome: Social withdrawal and Lack of hygiene and care for self
  • Opioids: Resulting in intense feeling of pleasure, dulling of pain & mental functions, impaired memory attention and judgement, slurring of speech, inattention to environment & respiratory and Cardiac Depression
  • Stimulants Resulting in Euphoria, increased energy & hyperactivity, increased self-confidence & gradiosity anxiety / aggression & hallucinations

Depression & Related Disorders

• Consistent low/depressed mood & loss of interest in pleasurable activities.
• Described as sad, empty & irritable moods with accompanying feelings of worthlessness, guilt and anhedonia
  • Includes impairments in neurocognitive function primarily with concentration & memory
  • Also include impairments in neurovegetative function primarily with sleep, appetite, libido & other functioning
  • Must always exclude hypomania and Mainia
• Major Depressive Disorder (MDD): Requires 5/9 symptoms for min 2 weeks
  • Depressed Mood
  • Interest ↓ (Anhedonia)
  • Guilt and feelings of worthlessness & hopelessness
  • Suicidality
  • Sleep disturbances (Too much or Insomnia)
  • Psychomotor retardation or agitation
  • Appetite or Weight changes
  • Concentration ↓
  • Energy ↓
• An impairment in functioning with mania & another medical condition excluded.
• Grief: Intense sadness about a loss.
• Adjustment Disorder: Emotional or behavioural symptoms that occur within 3 months of an identifiable stressor.
  • Symptoms do not persist for more than 6 months if stressor is removed.
• Persistent Depressive Disorder: mild depressive symptoms lasting 2+ years
• Premenstrual Dysphoric Disorder: The patient must experience a premenstrual pattern of symptoms in at least half of menstrual cycles.
• Substance/Medication-Induced Anxiety Disorder: Panic attacks or anxiety is predominant in the clinical picture with evidence that symptoms developed during/soon after substance intoxication or withdrawal or after exposure to a medication
• Other specified anxiety disorder can be anxiety that clinically causes distress/ impairmnet, but does not meet the criteria.
• **Depression with Atypical Features:**Characterized by mood reactivity (transient feeling of improvement in reposnse to positive event Hypersomnia & hyperphagia

Bipolar & Related Disorders:

• Mania: A distinct period of abnormally and persistently elevated mood. Requires: Elevated goals, distractibility, gradiosity, flight of ideas and decreased sleep.

  • A. Requires a distinct period of abnormally and persistently elevated, expansive, or irritable mood, with abnormally/persistently increased goal-directed energy.

• Hypomania: More functional form of Mania. Not severe enough to cause impairment socio-occupationally - no psychosis

• Bipolar 1: Includes At least one manic episode and sometimes major depressive episodes

• Bipolar 2: Hypomanic episodes with major depressive episodes

• Cyclothymia Hypomanic and depressive symptoms (not major) for at least 2 years

• Mixed Episode: Both manic and major depressive episodes occur almost daily during one-week period

• **Substance-Induced:**Symptoms can beattributed to effects of specific substances.

• Other Specified: Symptoms do not meet full criteria for other bipolar and related disorders, but cause distress/impairment

• Unspecified: Symptoms displayed, but not enough information for a diagnosis

Anxiety Disorders

• Separation Anxiety Disorder: Developmentally inappropriate and excessive fear/anxiety, At Least 3/9: Recurrent excessive distress when anticipating or experiencing separation, Persistent and excessive worry about losing major figures, reluctance to sleep away from major figures
• Selective Mutism: Failure to speak in specific social situations lasting at least a month
• Specific Phobia: Specific objects/situations provoke immediate anxiety, and are actively avoided
• Social anxiety disorder/ Social phobia: Fears of criticism from others

DSM Diagnostic Criteria For Panic Disorder

• Includes palpitation, tachycardia sweating, trembling, shortness of breath, chest pain and nausea .

Generalised Anxiety Disorder

• Persistent restlessness, fatigue and muscle tention 3/6 symptoms needed during 6+month period.

Additional:

• Subtance/Medication/Other Specified, Unspecified anxiety diagnoses can be made depending on symptom specifics.

Obsessive-Compulsive & Related Disorders:

Recurrent/intrusive thoughts and feelings/sensation. (is ego dystonic)

• Compulsions* Standardized/Recurrent. (attempt to reduce anxiety. . )ex: counting
• *OCD requires exclusion of psychosis OCPD Obsessions concern about details/ perfectionism
• Excoriation* Characterised by repetitive behaviour of picking skin which results in damage
• Hoarding* Persistent difficulty discarding or parting with possessions.
• Trichotillomanja* Urges to pull out hair.
• Body Dysmorphia* Repetitive behaviours of mental acts in response to perceived defects/flaws in physical appearance.
• PTSD diagnostic criteria requires exclusion related to substance/ general medical issues.

Personality Disorders

Cluster A : Odd & eccentric “mad”

• Paranoid PD is a pervasive distrustful pattern where others motives are malevolent requires 4/7 symptoms which include: suspecting infidelity in spouse; unforgiving; bears grudges; suspicious; always percieveing attacks/quickly reacting;
• Perceives attacks and reacts quickly
• Schizoid PD requires 4/7 symptom pattern: Detachment with flattened affects, indifference to criticism, sexual experiences of little interest, chooses tasks to do alone; neither desires/enjoys in close relationships
• Schizotypal PD: Requires 5/10 symptoms pattern ; Magical thinking with odd beliefs/unusual perception, eccentric behaviour

Cluster B : Dramatic, emotional, erratic “bad”

• Antisocial PD disregard for violating others, Requires: Irresponsible decision, conformity to laws, remorse lacking and poor temper and emotional controls.
• Borderline PD: Requires pervasive pattern of instability of relationships , unstable relationships. +Impulsivity. and 5/9 or more symptoms: Avoidment+mood instabilities + identity disturbances/ emptiness/ and dissasoscaitve/ paranoid symptoms
• Histrionic PD: Requires excessive emotionality and attention seeking.
• Symptoms: PRAISE ME: Provocative/ sexually behaviour and emotions rapidly shifting

Clusterc

• Anxious, fearful
• Avoidant PD : Requires pattern of social inhibitions and feelings of inadequacy/ - hypersensitivity to negative evaluaHon :CRINGES Certainty of being liked before willing to be involved with ohers/preoccupation with rejection and shows resnt in íntimate relacionen
• Dependant PD: Require of other person . needs reassurance for decision
  • Fears of separation: requires responsibihes aken by Ohers
• OCD patterns preoccupation with order and perfectionism. Does need for control and inflexible. Shows devotion for tasks than social activities