Review of Psychiatry PDF

Review of Psychiatry Praveen Tripathi MBBS, MD Consultant, Psychiatry Kailash Hospital and Research Institute Noida, Uttar Pradesh, India Foreword Kailash Kedia MBBS, MD The Health Sciences Publisher New Delhi | London | Pa...

Review of Psychiatry Praveen Tripathi MBBS, MD Consultant, Psychiatry Kailash Hospital and Research Institute Noida, Uttar Pradesh, India Foreword Kailash Kedia MBBS, MD The Health Sciences Publisher New Delhi | London | Panama | Philadelphia  Contents 1. Basics 1 2. Schizophrenia Spectrum and Other Psychotic Disorders 10 3. Mood Disorders 27 4. Neurotic, Stress Related and Somatoform Disorders 43 5. Substance Related and Addictive Disorders 63 6. Organic Orga nic Mental Disorders 78 7. Personality Disorders 89 8. Eating Disorders 95 9. Sleep Disorders 98 10. Sexual Disorders 103 11. Child Psychiatry 107 12. Psychoanalysis 115 13. Miscellaneous 122 Chapter 1 Basics Psychiatry is the branch of medicine which deals with b. Depressed mood: Excessive sadness of mood, morbid psychological processes. o establish diagnosis which is usually seen in depression. of a psychiatric disorder both history and clinical exami- Fluctuations Fluctuations:: It refers to the changes in mood/affect. nation are required. Te clinical examination in psychia- Te common disturbances of fluctuations are as try, wherein the clinician records the psychiatric signs follows: and symptoms, is known as Mental Status Examination a. Labile mood: Excessive variations in mood with- (MSE)Q. out any apparent reason. It is also known as emotional labilityQ. For example, a man starts Mental Status Examination crying and then starts laughing without any apparent reason. It is usually seen in mania. In mental status examination, following areas of mental b. Affective flattening flattening : Absence of changes in mood functioning are assessed: irrespective irrespective of the situation. In this condition, A. General appearance and behavior : Te appearance of patient doesn’t experience any emotions hence the patient is described along with any gross abnor- his affect remains the same. For example, a malities (such as abnormalities of dressing etc). schizophrenic patient would not look happy B. Speech Speech:: Various aspects of speech such as rate, tone, during festivals and did not appear sad when volume, spontaneity of speech are described. C. Mood and affect: Te terms “affect” and “mood” are his mother died. His mood remained the same both used to describe the emotions or emotional irrespective of the situation. state. “Affect”Q is the cross sectional emotional state Appropriat eness and congruency: Appropriateness Appropriateness whereas “mood” is the sustained or longitudinal of affect is described in relation to the social situa- emotional state. For example, if an individual who tion. For example, in a funeral, the expected emo- was extremely sad for last one month, gets extremely tional state is sadness. Hence, being sad in a funeral and unusually happy for a moment; it can be said is an appropriate affect. If a man starts laughing that his affect is happy (euphoric), whereas his mood and looks extremely happy in a funeral, it would is depressed. Te term affect and mood are at times be diagnosed as inappropriate affect. Congruency used interchangeably. Affect and mood are further of mood is described in relation to the thought con- described under the following three subheads: tent of the person. Congruency describes whether Quality: It refers to the predominant affective (or the emotional state of person is in sync with his mood) state. Tere can be various disturbances in thought/speech or not. For example, if a man is the quality of mood, common ones include: thinking about or talking about the events which a. Euphoric mood (elevation of mood): mood): Euphoria led to his mother’s death, he is expected to be sad. refers to a state of excessive happiness, without Hence, appearing sad while talking about mother’s any reason. It is usually seen in mania or hypo- death is a congruent affect. If a person, looks very mania. happy and smiles while describing his mothers 2 Review of Psychiatry death, it would be considered as incongruent voices are coming from the wall or from outside mood. It must be stressed that while “appropri- (PseudohallucinationsQ are experi- the house. (Pseudohallucinations ateness” of affect is described after comparing the enced in the inner subjective space, or originat- current affect with the expected affect in the given ing from within the mind. For example, a patient social situation, the congruence is described after with auditory pseudohallucinat pseudohallucinations ions will report comparing the current affect with the expected that the voices are originating within his mind affect in the context of the patients thoughts. and not from outside). Few other important disturbances of emotions emotions d. Hallucinations are not under the willful con- include: trolQ of the patient. It means that the patient can a. Alexithymia Alexithymia:: It refers to the inability to understand neither start the hallucinations nor can he stop emotions of others and inability to express emo- them. tions of self. Although alexithymia is closely related Hallucinations can occur in any modality. Te to affective flattening, alexithymia Q is “lack of most common hallucinations in psychiatric disorders words to describe emotions” rather than absence are auditory hallucinationsQ. Te most common of emotions. hallucinations in organic psychiatric disorders b. Anhedoni Anhedonia a: It refers to the loss of capacity to expe- (such as delirium) are vis visual ual hall hallucin ucinationsQ. In ations rience pleasure. Te patient is unable to enjoy any- patients with temporal lobe epilepsyQ all kinds of thing in the life. hallucinations halluc inations can be present including olfactory olfactory and tactile hallucinations. actile hallucinations are also a Neuroanatomical substra Neuroanatomical te of emotions: Limbic systemQ substrate (which includes hippocampus, amygdala, hypothalamus, typical feature of cocaine intoxication. cingulate gyrus and related thalamic and cortical areas) hallucinations : Few specific hallucinations: a. Hypnagogic hallucinationsQ: Tese hallucina- is the neural substrate for the emotional experiences. Te tions occur while falling asleep or while going regulation of emotions is a function of frontal lobeQ. to sleep. Since hypnagogic has the word “go” in D. Perception Perception:: Perception is the receiving of information it, hence its easy to remember that they occur using one of the sensory modalities (i.e. auditory, vis- while “going” to sleep. Hypnagogic hallucina- ual, tactile, olfactory and gustatory). wo most impor- tions are seen in narcolepsy. tant disturbances of perception are: b. Hypnopompic hallucinationsQ: Tese halluci- IllusionsQ: Illusion is false perception of a real nations occur while getting up from the sleep. object. For example, a man mistakes a rope for c. Reflex hallucinations (SynesthesiaQ)):: In reflex snake in night. hallucinations, stimulus in one sensory moda- Hallucinations Hallucinations:: Hallucination is a false perception lity produces hallucinations in another sensory sensory in the absence of any object or stimulus. For exam- modality. For example, a patient reports that ple, a patient of delirium reported seeing snakes on whenever he sees a white bulb (stimulus in the ground of his room, when in reality there was visual modality), he starts hearing voices of god nothing there. Hallucinations have the following (hallucination in auditory modality). Reflex hal- properties and all these properties must be present lucinations are a feature of cannabis and LSDQ to diagnose a perception as hallucination. (and other hallucinogens) intoxication intoxication.. a. Hallucinations occur in the absence absence of any sen- d. Functiona hallucination:: Here, stimulus in one Functionall hallucination sory or perceptual stimulus. sensory modality, modality, produces hallucinations in the b. Hallucinations are as vivid (clear or detailed) same sensory modality. For example, a patient as true perceptions. It means that the person reported that whenever he heard the sound of who experiences e xperiences hallu hallucinations cinations is able to give a a ticking clock (stimulus in auditory modality), detailed description of what he is experiencing. he would also start hearing voices of god (hal- c. Hallucinations are experienced in outer objec- lucinations in auditory modality). modality). tive spaceQ. It means that patients experiences E. Tought (Cognition): (Cognition): Te terms “thought” and that the source of hallucinations hallucinations is in the outer “cognition” Q are at times used interchangeably, how- world. For example, a patient who is having ever in a stricter sense cognition is the mental process auditory hallucinations will report that the of acquiring knowledge which includes thoughts but  Basics 3 also experiences and sensations. Te thought distur- d. CircumstantialityQ: It is a pattern of speech bances are primary in many psychiatric disorders like which progresses with inclusion of lots of schizophrenia. Tought and its disturbances can be unnecessary details and goes round and round described under the following subheads. before reaching the final goal. For example, a Stream (Flow of thought): thought): It refers to the speed with medical student was asked about his preferred which thoughts follow each other. other. Te disturbances branch in postgraduation and he replied by say- of stream includes: ing “Sir, in the first year i was very interested in a. Flight of ideasQ: Here, the thoughts follow each physiology, however in the second year i started other very rapidly, and connection between dif- liking pathology. In the third year, i started liking ferent thoughts appears to be due to chance fac- ophthalmology however in the final year i rea- tors or rhyming. It is usually seen in mania. For lized that i have a lot of liking for orthopedics example, a manic patient when asked about his too and i liked putting casts and working with hometown said “I live in Delhi…my cat has a big POP. I also think that after MBBS one should belly…..i like l ike to eat Jelly…..lilly Jelly…..lilly lilly li lly lilly”. Some get married as soon as possible and that noone authors describe “flight of ideas” as an abnor- should have more than two kids…Well..you see mality of form of thought. i like pediatrics as a subject and want to do my b. Inhibition of thinking : Here thoughts come in postgraduation postgrad uation in the pediatr p ediatrics” ics”. In this exam- mind very slowly and thought progresses with ple the thought process progressed with inclu- a slow rate. sion of lots of irrelevant details however in the Form of thought: Te form refers to the “organi- end, the goal was reached as student said that zation” of thought or the “association” between he wants to become a pediatrician. the consecutive thoughts. Normally, the thoughts e. angentiality Q: In tangentiality, the answer are well organized and there is a connection is related to the question in some distant way between various components of a single thought and the goal of thought is never reached. For and between the consecutive thoughts. In formal example, a patient was asked about his favorite thought disorders, there are disturbance in the bollywood actor and he replied “Well, you see organization, associations and connections of the the hindi movies are mostly hero centric and thoughts. Te important formal thought disorders usually deal with the relationship issues whereas include: the hollywood movies have lots of action and a. Derailment : In derailment, the association bet- science fiction. I think the Hindi Film Industry ween two successive thoughts is disturbed. For is growing rapidly and its a good medium for example, a patient said Jawahar Lal Nehru was entertainment entert ainment ofo f masses”. In this example, ex ample, the the first prime minister of India and he was a congress leader. Sachin endulkar scored 100 patients answer was distantly related to ques- international internat ional hundreds” hund reds”. In this example, exampl e, there tion, however the exact answer was never given. is no link between the first thought about Nehru Neologism:: A neologismQ is coining of a new f. Neologism and second thought about endulkar. word, whose derivation cannot be understood. associationQ: Here, the connection b. Loosening of association For example, a patient would use the word is lost between components of a single thought. “tintintapa” for a pen. Neologism is highly sug- For example, a patient says “I thought that it will gestive of schizophrenia. rain today, Modi is the current prime minister g. Word approximations (metonyms): (metonyms): Here, old of India”. In this example examp le the phrase phras e before the th e words are used ini n a new or unconventional way. comma is totally disconnected from the phrase Te meaning will be easily evident, though the after the comma and hence this represents loos- word in itself might appear strange. For exam- ening of association. ple, a patient would us the world “time vessel” c. Incoherence : It is the total lack of organization so for watch, and use the word “handshoes” for that the thought is incomprehensible and does gloves. not make any sense. For example, a patient says h. Perseveration Perseveration:: It is repetition of the same res- “India me churchgate pulses p ulses cricket cricke t computer” computer ”. ponse, beyond the point of relevance. For 4 Review of Psychiatry example, a patient was asked the following may claim that they have committed unpardon- questions. Q: What is your name. Ans. Mahesh able sins. It is usually seen in severe depression. kumar….Q: Where do you live. Ans: Mahesh Bizarre Vs Nonbizarre Delusions Kumar…..Q: How many children do you have… delusions:: Te term bizarre is used for Bizarre delusions A: Mahesh Kumar. Kumar. delusions which are scientifically impossible It must be noted that the perseveration is in and culturally implausible (ununderstandable). response to a question and is not spontaneous. For example, if a patient says that aliens have Content of thought: It refers to what person is actu- stolen his heart, it would be an example of ally thinking about. Delusion is a disorder of con- bizarre delusion. tent of thought. It is defined as a false, unshakeable Nonbizarre Nonbiza delusions:: Tese are delusions which rre delusions belief that cannot be explained on the basis of per- are false but are possible, i.e. they can happen. sons social and cultural background. Te following For example, if a patient develops a delusion are the types of delusion: that his family members wants to take away his a. Delusion of persecution persecution:: It is the most common property, it would be an example of nonbizarre type of delusion.Te patient believes that some- delusion, since it is not impossible for a family one wants to harm him. For example, a patient member to take away property of another family claimed that Indian police along with CBI is member. hatching a conspiracy to kill him. Possession of thought: Normally one experiences that b. Delusion of reference: Te patient believes that their thoughts belong to themselves and no one else can influence their thinking process, also there is a events happening around him are somehow sense of control over one’s thought. In disturbances related to him. For example, a patient claimed of possession of thought either the patients experi- that the tube light of his apartment was flicker- ences that others are tampering with their thoughts ing as there was a camera fitted inside through or that they have lost control over their thoughts. Te which his movements are being recorded. disorders of possession include the following: c. Delusion of grandeur or grandiosity: Te patient a. ObsessionsQ: Here, a thought comes repeatedly believes that he has some exceptional identity or into the mind of patient against his will. Te power. For example, a patient claimed that he is patient recognizes the thought as his own, how- the reincarnation of Lord Hanuman and that he ever is distressed by the repetitive and intrusive can carry the mountains on his shoulders. nature of the thought. Te patient feels that he d. Delusion of love (erotomaniaQ, fan fantasy tasy lover syn- has lost control over his thoughts. drome):: Patient may have false belief that some- drome) b. Tought alienation: alienation: Here, the patient feels that one is in love with them. It is also known as de their thoughts are under control of an outside Clerambault syndrome. syndrome. For example, a rickshaw ri ckshaw agency or that others are interfering with their puller claimed that Katrina Kaif is in love with thought process. Tought alienation pheno- him though he admitted that he has never met menon is of following types: her. – Tought insertion: insertion: Patient feels that some e. Nihilistic delusion (delusion of negation, Cotard’s Nihilistic external agency is inserting foreign thoughts syndromeQ)):: Here, the patient may deny exis- into their mind. tence of their body, their mind, or the world in – Tought withdrawal: Patient experiences general. Tey may claim that everybody is dead, that his thoughts are being withdrawn from the world has stopped, etc. Te basic theme of their mind by an external agency. delusion is the “end of existence” exist ence”. – Tought broadcast: Patient experiences that f. Delusion of infidelity (delusion of jealousy): jealousy): Te thoughts are escaping from their minds and patient has a false belief that his partner/spouse other people are able to access them. is having an affair. It is also known as morbid F. Higher mental functions: functions : In this component of MSE, jealousy or Othello syndromeQ. various higher mental functions like attention, con- g. Delusion of guilt: Here, the patient may develop centration, memory, judgement, abstract thinking and a delusion that they are bad or evil person and insight are assessed.  Basics 5 CLASSIFICATION are known to affect brain parenchyma) For example, delirium, dementia. At present, there are two major classificatory systems in B. Functional (Nonorganic) mental disorders: disorders : Tese dis- psychiatry. orders do not have any demonstrable disturbance 1. ICD-10 (International classification of diseases, 10th of brain parenchyma. For example, schizophrenia, edition):: It is published by WHO and provides classi- edition) mania, etc. fication for all medical disorders (including psychia- Tis classification is at best arbitrary, since with the tric disorders). Te psychiatric disorders have been advent of science its possible to demonstrate brain classified in the chapter-V (F)Q of ICD-10. parenchyma disturbances even in so called “func- 2. DSM-5 (Diagnostic and statistical manual of mental tional” mental disorders. disorders):: It is published by American Psychiatric disorders) Psychoses vs neuroses: Te functional disorders can be Association. Te fifth edition of DSM was published further classified into psychotic disorders (psychoses) in 2013. and neurotic disorders (neuroses). Psychiatric disorders have been classified in multiple A. Psychoses Psychoses:: Psychotic disorders are characterized by ways. Te most important classifications includes organic lack of awareness of illness (also known as lack of vs functional psychiatric disorders and psychosis vs neu- insight)Q and impaired reality testing (i.e. the patients rosis. loses contact with reality and start living in a fantasy Organic vs Functional (Nonorganic) mental disorders : world created by their ill minds). For example, schizo- Tis was the first major classification of psychiatric/men- phrenia, bipolar disorder. Delusions and hallucina- tal disorders. tions are the prototype psychotic symptoms. A. Organic mental disorders: disorders: Tese disorders are caused B. Neuroses Neuroses:: Neurotic disorders are characterized by aware- by demonstrable demonstrable disturbances of brain (primary ness of the illness (insight is present) and reality contact brain disturbances or systemic disturbances which is also intact. For example, anxiety disorders, depression. QUESTIONS AND ANSWERS QUESTIONS D. Inability to recognize recognize and describe feelings E. Inappropriate mood 1. Which of the following are sections of Mental State Examination? (DNB NEE 2014-15) 4. A person who who laughs at one minute minute and cries the A. Mood and affect B. Spe Speech echandlan langua guage ge next minute without any clear stimulus is said to C. Cognition D. All of the above have: (AIIMS Nov 2005) A. Incongruent affect Affect and Mood B. Euphoria C. Labile affect 2. A 25-year-old woman complaints of intense D. Split personality depressed mood for last 6 months. She also reports 5. Emotion is controlle controlledd by: (PGI 1997) inability to enjoy previously pleasurable activities. A. Limbic system B. Frontal lobe Tis symptom is known as: (AIIMS Nov 2005) C. emporal lobe D. Occipital lobe A. Anhedonia B. Avolition C. Apathy D. Amotivation Perception 3. A Alexithym lexithymiaia is: (Kerala 2000, DNB 2004) 6. Phantom limb is an example of disorder of: A. A feeling of intense rapture (DNB NEE 2104-15) B. Pathological sadness A. Tought B. Perception C. Affective flattening C. Cognition D. None of the above 6 Review of Psychiatry 7. A patient wanting to scratch for itching in his A. At the beginning of the sleep amputated limb is an example of: B. At the end of sleep, while getting up (DNB NEE 2014-15) C. After head trauma A. Illusion D. After convulsions B. Pseudohallucination 15. Hallucinations Hallucinations which occur at the “start” of sleep C. Phantom limb hallucination hallucination are known as: (JIPMER 2002, DNB 2005) D. Autoscopic hallucination A. Hypnagogic hallucinations hallucinations 8. A patient sees a rope and gets afraid that it is a B. Hypnopompic hallucinations snake. Tis sign is known as: C. Jactatio capitis nocturna (DNB NEE 2014-15, PGI 2002) D. Extracampine hallucinations A. Illusion B. Hallucination C. Delusion D. Depersonalization 16. Hallucinatio ns are seen in all except: Hallucinations E. Derealization (MP 1999, DNB 2001) A. Schizophrenia 9. A 8-year-old child after a tonsillectomy sees a bear B. Seizures due to intracerebral intracerebral space occupying occupying in her room. She screams in fright. A nurse who lesions rushes on switching the light, finds a rug wrapped C. Lysergic acid diethyl amide intoxication (LSD on an armchair. What child experiences is best intoxication) described as? (DNB 2006, Kerala 1997) D. Anxiety A. Illusion B. Hallucination C. Delusion D. Depersonalization 17. Olfactory hallucinations are seen in: (PGI May 2011) 10. Which statement is not true about hallucinations? A. Schizophrenia (AIIMS 2009) B. Alzheimer’s disease A. It is as vivid as a real perception perception C. Mesial temporal sclerosis B. It occurs in inner subjective subjective space D. Body dysmorphic dysmorphic disorder C. It is independent of will of observer E. emporal lobe epilep epilepsy sy D. It occurs in the absence of any perceptual stimulus 18. Visual hallucinations are seen in: (PGI Jun 2009) A. Hebephrenic schizophrenia schizophrenia 11. All of the following are features of hallucinations, B. Residual schizophrenia except: (AI 2003) C. Simple schizophrenia A. It is independent of will of observer D. Delirium B. Sensory organs are not involved E. emporal lobe epilep epilepsy sy C. It is as vivid as a real perception perception D. It occurs in the absence of any perceptual 19. Reflex hallucinations is a morbid variety of: stimulus (AIIMS May 2009, 2011) A. Kinesthesia B. Paresthesia 12. Formed visual hallucinations are seen in lesions C. Hyperesthesia D. Synesthesia of: (PGI 2006, 2000) A. Frontal lobe B. emporal lobe Thought C. Occipital lobe D. Parietal lobe 20. Te term “cognition “cognition”” is used to imply about: 13. Te following is suggestive of an organic cause of (AI 1997, Jharkhand 2003, DNB 1998) behavioral symptoms: (AI 2002) A. Affect B. Perception A. Formal thought thought disorder C. Tought D. Speech B. Auditory hallucinations 21. rue about thought is all except: (PGI Feb 2007) C. Delusion of guilt A. Perseveration is out of context repetition repetition D. Prominent visual hallucinations B. Circumstant Circumstantiality iality is over inclusion of irrelevant irrelevant 14. When is hypnopompic phenomenon experienced? details while eventually getting back to the or igi- (Bihar 2006, DNB 2002) nal point  Basics 7 C. Verbigeration Verbigeration is senseless senseless repetition 29. A false belief which is unexplained by reality and D. Vorb Vorbeireden eireden is skirting around the end point but is shared by a number of people is: never reaching it (AIIMS 2003, 2004 Jipmer 1998) E. Loosening of association association is logically connected connected A. Illusion B. Delusion thoughts with loss of goal. C. Obsession D. Superstition 22. Perseveration is: (AI 2005) 30. Te primary delusions are disorder of: (AI 1999) A. Persistent and inappropriate repetition of the A. Flow of thought same thoughts B. Form of thought B. Feeling of distress in a patient with schizophrenia C. Content of thought thought C. Characteristic of schizophrenia schizophrenia D. Possession of thought D. Characteristic of obsessive obsessive compulsive disorder 31. Delusions are not likely to be seen in: (AI 2012) 23. In schizophrenia, characteris characteristic tic feature is: A. Dementia B. Depression (PGI 1997) C. Schizop Schizophrenia hrenia D. Conversion disorder A. Formal thought thought disorder 32. Delusions can be seen in all of the following except: B. Delusion (SGPGI 2002, DNB 2001) C. Hallucination A. OCD B. Depression D. Apathy C. Mania D. Schizophrenia 24. Loosening of association is an example of: 33. Delusion of persecution can be seen in: (AI 2006) (PGI Jun 2009) A. Formal thought thought disorder A. Schizophrenia B. Schneider’s first rank symptoms B. Delusional disorder C. Perseveration C. Manic episode D. Concrete thinking D. Melancholic depression 25. Not a disorder of form of thought is: 34. Delusion of grandiosity can be seen in: (AIIMS May 2012) PGI Nov 2010, May 2011) A. angentiality A. Hypomania B. Derailment B. Paranoid schizophrenia C. Tought block C. Schizoaffective disorder D. Loosening of association D. Kleptomania/Pyromania 26. Which of the following is/are thought disorder? E. Cyclothymia (DNB NEE 2014-15) 35. Nihilistic Nihilistic ideas are seen in: (PGI Dec 2008) A. Circumstan Circumstantiality tiality B. angentiality A. Simple schizophrenia C. Prolixity D. All of the above B. Paranoid schizophrenia 27. Schizophrenia Schizophrenia and depression both have the fol- C. Cotard’s syndrome lowing features except: (PGI 2002) D. Depression A. Formal thought thought disorder E. Body dysmorphic disorder B. Social withdrawal 36. A 25-year 25-year-old -old university student had a fight with C. Poor personal care the neighbouring boy. On the next day while out, D. Decreased interest interest in sex he started feeling that two men in police uniform E. Suicidal tendency were observing his movements. When he reached reached 28. Delusion is a disorder of: home in the evening he was frightened and told (DNB NEE 2014-15, AIIMS Nov 2006, AI 2007) his family members that police was after him and A. Perception B. Tought would arrest him. Despite reassurances by family C. Insight D. Affect members, he remained afraid that he is about to 8 Review of Psychiatry be arrested. Te history is suggestive of which 6. B. Perception. In phantom limb, the patient feels psychiatric sign/symptom: (AIIMS Nov 2003) sensations in the amputated limb. Hence, its a A. Delusion of persecution disorder of perception. B. Delusion of reference 7. C. Phantom limb hallucination. Since, patient expe- C. Somatic passivity riences sensation in the absence of any stimulus, D. Tought insertion it is a hallucination. In autoscopic hallucination, 37. A man had a fight with his neighbor. Te next day patient sees himself in the mirror and feels that he started feeling that police is following him and “he” is the “image” i.e. what he is seeing is not his brain is being controlled by radio waves by only an image image but him. his neighbor. Te history is suggestive of which 8. A. Illusion. psychiatric psychiatric sign/symptom: (AIIMS 1999) 9. A. Illusion. A. Tought insertion Illusion is false perception of a real object. B. Somatic passivity 10. B. It occurs in inner subjective space. Hallucinations C. Delusion of persecution occur in outer and objective space; pseudohal- D. Obsession lucinations occur in inner and subjective space. 11. None > B. 38. Healthy thinking includes all of the following All the statements are correct. However However,, if one has except: (AIIMS 2011) to chose, the best answer would be B (sensory A. Continuity B. Constancy organs are not involved) as rest three options C. Organization D. Clarity form the criterion of hallucinations. 12. B. emporal lobe. Te lesions of temporal lobe can Insight cause all types of hallucinations and formed 39. Te awareness regarding the disease in mental visual halluc hallucinations inations (elab (elaborate orate visual halluc hallucina- ina- status examination is known as: tions) should raise a strong doubt of an organic (AIIMS Nov 2012, May 2013) cause, specifically a temporal lobe pathology. A. Insight B. Orientation 13. D. Prominent visual hallucinations hallucinations.. Te presence C. Judgment D. Rapport of prominent visual hallucinations is a strong pointer towards an organic cause (i.e. a distur- 40. Impaired insight is found in: (PGI 1997) bance of brain parenchyma such as tumors). A. Acute psychosis psychosis B. Schizophrenia 14. B. At the end of sleep. While getting up. C. Anxiety disorder 15. A. Hypnagogic hallucinations. Tese occur while D. Obsessive compulsive compulsive disorder disorder “going” to sleep. Jactatio capitis nocturna, or rhythmic movement disorder is a neurological 41. If a person is asked, “what will he do if he he sees a disorder characterized by involuntary move- house on fire”? Ten what is being tested in that ments, usually of head and neck, before and person? (DNB NEE 2014-15) during the sleep. A. Social Judgment Judgment B. est Judgment Judgment 16. D. Anxiety. C. Response Judgment D. None 17. A, B, C, E. Olfactoryy hallucinations can be seen in temporal Olfactor ANSWERS lobe epi-lepsy, medial temporal sclerosis (which 1. D. All of the above is a common cause of epilepsy). Tough rare, 2. A. Anhedonia. Anhedonia is seen in both depres- olfactory hallucinations can also be present in sion as well as schizophrenia. schizophrenia and Alzheimer’s disease. 3. D. Inability to recognize and describe feelings. 18. A, D, E. 4. C. Labile affect. Visual hallucination hallucinationss are the most common type 5. B. Frontal lobe. Te neuroanatomical substrate for of hallucinations in delirium. emporal lobe generation gene ration of emotions is limbic system however epilepsy can present with all types of hallucina- the regulation/control of emotions is a function tions including visual hallucinations. In hebe- of frontal lobe. phrenic schizophrenia, the primary symptom is  Basics 9 disorganized behavior and formal though dis- 31. D. Conversion disorder. Conversion disorder is a orders however hallucinations can also be seen. neurotic disorder (described in later chapters). 19. D. Synesthesia. Delusion is not a feature of conversion disorder. disorder. 20. C. Tought. 32. None > A. 21. E. Loosening of association is logically connected Delusion can be seen in schizophrenia, mania, thoughts with loss of goal. In loosening of asso- depression as well as OCD. However the best ciation, the connec-tions between the thought is answer here would be OCD, as delusions are lost. Te rest of the statements are true. Verbige- rarely seen in OCD. ration is a senseless repetition of one or several 33. A, B, C, D. sentences or phrases. For example, a patient Delusions can be seen in all these disorders. Mel- continued to repeat the following sentences for ancholic depression is usually seen in elderlies. hours “Life is great. Te lord is great. Summer 34. B, C. will come soon” ItsIts an example of verbigeration. Delusion of grandiosity can be seen in paranoid Vorbeireden Vorb eireden or vorbeigehen is seen in Ganser’s schizophrenia schizo phrenia and schizoaffective disorders. syndrome (described in later chapters) and is Delusion of grandiosity can be seen in mania but another name for approximate answers in which not in hypomania. 35. B, C, D. patient reaches close to the right answer, but Nihilistic delusions can be seen in paranoid never gives the right answer. answer. schizophrenia, Cotard’s Cotard’s syndrome and depres- 22. A. Persistent and inappropriat inappropriatee repetition of the sion. same thoughts. 36. A. Delusion of persecution. 23. A. Formal thought disorders are characteristic 37. C. Delusion of persecution. Here, in the question the abnormalities in schizophrenia. In schizophre- history for delusion of persecution (i.e police is nia, the abnormalities of affect, perception, motor following) is clear. Te second half where patient system as well as thought are present, however feels that his mind is being controlled by radio the characteristic abnormality in schizophrenia waves is suggestive suggestive of possible possible though alienation is that of thought, and more specifically the form phenomenon but we have not been provided of thought (known as formal thought disorder). with any further details. 24. A. Formal thought disorder disorder.. 38. D. Clarity. Cla rity. Healthy thinking has three characte- 25. C. Tought block. ristics (1) Continuity (2) Organization and (3) 26. D. All of the above. Prolixity is a milder form of “flight Constancy. of ideas”. As mentioned mentione d in the text, flight flig ht of ideas 39. A. Insight can be considered as both a disorder of stream 40. A, B. of thought and form of thought. Only first two options are psychotic illnesses in 27. A. Formal thought disorder is seen only in schizo- which insight is impaired. impaired. phrenia and not in depression. Rest all options 41. B. est Judgment. In mental status examination, the can be present in either of the illnesses. judgment of the the patient patient is is also also described. described. Patient 28. B. Tought. Delusion is a disorder of content of is given hypothetical scenarios such as “you see thought. that a house is on fire” or “you find a letter lying 29. D. Superstition. Tere are many beliefs which are on the road” r oad” and isi s asked “what will you do”. Tis false and are shared by whole communities is called “test judgment” as patient’s judgment is e.g. black magic, witches etc. Tese beliefs are being tested in a hypothetical scenario. Tere are considered as superstitions. In comparison, other forms of judgment like “social judgment” delusions are not shared by members of the which describ describeses wheth whether er a person is able to inter inter-- same sociocultural background. For example, if a act socially in an appropriate manner. manner. Finally, in villager starts claiming that he is lord lord hanuman, “personal judgment” j udgment”, patient is i s asked about his hi s no one in his village will share his belief. future plans and it is assessed whether he has a 30. C. Content of thought. logical plan for his future or not. Chapter Schizophrenia Spectrum and 2 Other Psychotic Disorders Schizophrenia is the prototype of psychotic disorders. It is C. Affect disturbances: disturbances: Disturbances of emotions such as one of the most common serious mental disorders. inappropriate affect. D. Association disturbances: disturbances : Disturbances of association HISTORY of thoughts such as formal thought disorders. Emil Kraepelin Kurt Schneider Kraepelin classified psychiatric illnesses into two clini- Schneider described a group of symptoms, popularly types: Dementia PraecoxQ and Manic Depressive cal types: known as Schneiderian First Rank Symptoms (SFRS) Q IllnessQ. Te basis of this classification is the course of which were frequently seen in patients of schizophrenia illness and the cognitive decline. and were characteristic of the illness. It must be however Dementia Praecox is characterized by a chronic and remembered that these symptoms can also be present in deteriorati ng course along with gradual decline of cog- deteriorating other illnesses and hence are not specific or pathogno- nitive functions (i.e. gradual decline of memory, atten- monic of schizophrenia. Tere are 11 Schneiderian First tion and goal directed behavior). Te term “dementia” Rank Symptoms. was used to indicate gradual decline in cognitive func- A. Tree thought phenomenon: phenomenon: Tese three together are tions and the term “praecox’ was added since the onset known as thought alienation phenomenon in which of illness was in young age (praecox means early onset). patient feels as if some one is tampering with his mind In contrast Manic Depressive illness is characterized and thoughts. Te thought alienation includes the fol- by distinctQ episodes of illness alternating with period lowing: of normal functioning. Also, there is no cognitive Tought insertion (patient reports that someone is decline.. decline putting thoughts in his mind) Tought withdrawal (patient experiences that Eugen Bleuler thoughts are being taken out of his mind) Tought broadcast (patient experiences that Bleuler coined the term “Schizophrenia”Q, which thoughts are leaving his mind and that others are replaced dementia praecox in scientific literature. Bleuler able to access his thoughts, e.g. patient would say proposed four symptoms which he called as fundamental that “everybody understands my thoughts, though schizophrenia. Tese symp- (or primary) symptoms of schizophrenia. I never neve r say anything a nything””. toms are also known as 4 A ’s of BleulerQ. Tey include: A’s B. Tree made phenomenon: phenomenon: Here the patient experi- A. Autistic thinking and behavior (Autism) (Autism):: Excessive ences that his emotions, actions and drives are being fantasy thinking which is irrational and withdrawn influenced by others. It includes the following: behavior. Made volition volition:: Te patient experiences that his B. Ambiva lence: Marked inability to take a decision. Ambivalence actions are being controlled by an external agency  Schizophrenia Spectrum and Other Psychotic Disorders 11 and not by himself. For example, a patient would said “I will have dinner di nner at a restaurant rest aurant tonight” tonig ht”. repeatedly put his hand in the fan, and on asking Te German word “Gedankenlautwerden “Gedankenlautwerden”” or the the reason reported, “I don’t want to do it myself french word “echo“echo de pensees” pensees” is occasionally but I am being controlled by aliens who can mani- used to describe these audible thoughts. pulate my actions, I am a robot for them and they D. Somatic passivity: In somatic passivity, patient expe- have my remote control”. riences tactile or visceral hallucinations which he Made affect : Te patient experiences that someone believes are being imposed by some external agent. is changing his affect (emotions). For example, a For example, a patient reported that he feels intense patient reported “at times I start laughing loudly burning sensation inside his right knee and claimed and at times I cry. Te neighbours control my emo- that it is because of UV rays sent by FBI agents from tions, they can change it whenever they want to. I New York York””. feell helpless” fee help less”. E. Delusional perception: perception: In Delusional perception, a Made impulses: impulses: Te patient experiences that some- delusion is attached to a normal perception. For exam- one is putting certain “drives” in his mind. For ple, a patient of schizophrenia schizophrenia looked at the ceiling fan example, a patient suddenly threw his coffee mug and immediately understood that the “all the people onto a nurse. On asking about it he reported “a sud- in the city cit y consider conside r him a homosexual” homose xual”. In this exam- den impulse came over me, this impulse was sent ple there was a normal perception in the first step (i.e. by CBI officers who wanted me to throw the mug. the patient saw a ceiling fan) and in the second step a I tried resisting the impulse, but could not control delusion was attached to this normal perception (i.e. it”. the delusion that everybody in city considers patient C. Tree auditory hallucinations: a homosexual). Delusional perception is a type of Voices arguing or discussi ng: Te patient reports discussing “primary delusion” delusion”Q. Primary delusions are those hearing of two or more voices which argue or delusions which arise directly as a result of morbid discuss about the patient. Te patient is usually psychological processes whereas secondary delusions referred to in third person (hence also called third develop secondarily to some other psychopathologi- psychopathologi- person auditory hallucinations Q). For example, cal phenomenon. For example, a patient who had the first voice would say “he is a strange man, he continuous auditory hallucinations of a voice which doesn’t have any a ny good qualities” quali ties”. Te second voice voi ce said “you will be killed” k illed”, started believi be lieving ng that “some- would respond “yes, also look how fat he has body wants want s to harm me”.me”. Now, this “delusion of perse- per se- become”. In this example the patient pat ient is hearing hear ing two cution” which developed is a secondary delusion as it voices and the voices are using the word “he” to developed secondarily to the auditory hallucinations. refer to the patient, hence patient is being referred to in third person. Voices commenting on patient’s action action:: Here, the EPIDEMIOLOGY patient hears voices which give a running com- Te lifetime prevalence of schizophrenia is 1% whereas mentary on the patient’s activities. For example, the point prevalence is 0.5–1% 0.5–1%.. Te incidence rate is a patient who was working in the kitchen heard thousand. 0.15–0.25 per thousand. the following voice “she has peeled the potato and A. Prevalence in specific population: population: Schizophrenia has now she is about to switch on the gas. Now, she heritability. Te prevalence in general popula- high heritability Q has started tot o wash the potatoes” pot atoes”. Te voice usually usua lly tion is 1% however in relatives of patients, the rate refers to the patient in third person, hence this can is higher. higher. Te following table mentions the rates for again be an example of third person auditory hal- specific population groups. lucinations. Te usual age of onset of schizophrenia is adoles- Audible thoughts thoughts:: Here the patients hears a voice, cenceQ and young adulthood. adulthood. When the onset occurs which would say aloud whatever patient would after age of 45 years, years, the disorder is called as late-onset think. For example, a patient had a thought that “I schizophrenia. Q will have dinner at a restaur restaurant ant tonight”. Immediately Immediately It is equally prevalent in men and women, however he heard a voice of a middle aged women who the onset is earlier in men. 12 Review of Psychiatry Table 1: Prevalence of Schizophrenia in specific populations. C. Neuropathologic Neuropathological factors:: Te neuropathology of al factors General: 1% schizophrenia is still not clear. Abnormalities have been found in various structures, such as: Non twin sibling of a schizophrenia schizophrenia patient: 8% Cerebral ventricles ventricles:: Reduction in cortical gray matter Dizygotic twin of a schizophrenic schizophrenic patient: 12% volume and enlargement of lateral and third ven- Monozygotic twin of a schizophrenic schizophrenic patient: 47% tricles has been consistently observed. Child with one parent with with schizophrenia: 12% Limbic system: system: Abnormalities in limbic system Child with both parents parents with schizophrenia: 40% components such as hippocampus (smaller in size and functionally abnormal), amygdala (smaller size) and parahippocampal gyrus (smaller size) Schizophrenia is more prevalent in lower socioeconomic have been observed. status. It was earlier believed that different body types Prefrontal cortex: Anatomical abnormalities have were related to different personalities and also had dif- been found. ferent vulnerability to some disorders. Tree types of body Talamus Talamus:: Neuronal loss especially in medial dor- types were described: asthenic (thin and weak), weak), athletic sal nucleus of thalamus. (muscular) and pyknic (short and fat). fat). Te asthenicQ Basal ganglia and cerebellum cerebellum:: Abnormalities have and to a lesser extent athletic persons were believed to be been reported without any conclusive proof. predisposed for development of schizophrenia whereas the pyknic were believed to be predisposed to manic SYMPTOMS depressive illness (bipolar (bipolar disorder). disorder). Te symptoms of schizophrenia can be divided into vari- ous symptom complexes, described as follows: ETIOLOGY AND PATHOGENESIS A. Positive symptoms H In DSM-4, the presence of A. Genetic factors: factors : (or psychotic symp- bizarre delusions was considered Schizophrenia has a genetic contribution as toms):: he two toms) enough to satisfy the Criterion A for reflected by higher monozygotic concordance rate positive symptoms schizophrenia, however in DSM-5, the than dizygotic concordance rate. Several genes include delusions concept of bizarre delusions has been removed and it no longer carries any appear to make a contribution to schizophrenia and hallucinations hallucinations.. special diagnostic signicance. signicance. and nine linkage sites have been identified: 1q, 5q, Tey respond well 6p, 6q, 8p, 10p, 13q, 15q and 22q. to medications and the presence of positive symp- Several candidate genes contributing to schizo- toms is a good prognostic factor Q in schizophrenia. phrenia have been identified, and they include Delusions Delusions:: Te most common delusion in schizo- a-7 nicotinic receptor, DISC 1 (Disrupted in schizo- phrenia is delusion of persecution. A category of phrenia), COM (catechol-o-methyl transferase), delusion that holds special significance in schizo- phrenia is the so called “bizarre delusions”. delusions”. NRG 1 (Neuregulin 1), GRM-3 (Glutamate recep- Bizarre delusions are those that are considered tor metabotropic), RGS-4 (Regulator of G protein physically impossible and culturally implausible signalling) and DAOA (or G-72) (D-Amino acid (or ununderstandable). For example, “a patient oxidase activator). claimed that he has been sent by aliens from mars B. Biochemical factors: and his purpose is to evaporate all the water from Dopamine hypothesis hypothesis:: Tis hypothesis proposes earth and make it i t dry”. Tis patient is i s having a that excess of dopaminergic activity Q is responsi- bizarre delusion as his belief is both impossible ble for schizophrenia. and ununderstandable. Serotonin Serotonin:: Currently, along with dopamine, an Hallucinations Hallucinations:: Te most common hallucinations excess of serotonin is also considered to be respon- in schizophrenia are auditory hallucinationsQ. sible for symptoms of schizophrenia. Visual hallucinations are the second most com- Other neurotransmitters neurotransmitters like GABA, glutamate, glutamate, mon, however the presence of visual hallucination norepinephrine, acetylcholine, nicotine have also should always raise the suspicion of an organic been implicated in pathogenesis of schizophrenia. mental disorder.  Schizophrenia Spectrum and Other Psychotic Disorders 13 Te positive symptoms of schizophrenia are due Stupor: Extreme hypoactivity or immobility Q and to dopamine excess in mesolimbic tract (neural minimal responsiveness to stimuli. pathway from ventral segmental area to nucleus Excitement: Extreme hyperactivity which is usually accumbens)Q. non goal directed (i.e. the patient is very active but B. Negative symptoms symptoms:: Negative symptoms represent doesn’t do any meaningful work). “loss of normal functions” in patients with schizo- Posturing/catalepsy: Spontaneous maintenance of phrenia. Tese symptoms respond poorly to medica- posture for long periods of time. tions and their presence is a bad prognostic factorQ Waxy flexibility: When examiner makes a passive in schizophrenia. Following are the negative symp- movement on patient, there is a feeling of plastic toms: resistance which resembles bending of a soft wax Avoliti on:: Loss of will or drive to indulge in goal Avolition candle. directed activities (such as grooming and hygiene, Automati Automaticc obedience: Excessive cooperation with education and occupational activities). examiner’s commands despite unpleasant conse- Apathy: Loss of concern for an idea or task or quences. For example, a patient kept on protruding results. For example, a student who had deve- his tongue in response to examiner’s commands, loped schizophrenia failed in exams. However he despite the fact that his tongue would be pricked appeared unconcerned with his results. by a pin everytime he protruded it. Anhedoni Anhedonia a: Loss of ability to derive pleasure from Echolalia Echolalia:: Mimicking of examiner’s speech. speech. activities or relationships. Echopraxia Echopraxia:: Mimicking of examiner’s movements. movements. Asociality: Indifference to social relationships and Negativism Negativism:: Patient refuses to accept examiner’s decrease in the drive to socialize. instructions or any attempts to move him. Affective flattening blunting): Inability of patient flattening (or blunting): GrimacingQ: Maintenance of odd facial expres- to under- stand emotions of others and inability to sions.. sions express own emotions. Stereotypy: Spontaneous repetition of odd odd,, pur- Alogia Alogia:: Decrease in verbal communication. movements. For example, making strange poseless movements. Te negative symptoms are due to decreased movements of fingers repeatedlyQ. dopamine activity in mesocortical pathway (neu- Gegenhalten: Resistance to passive movement, ral pathway from ventral segmental area to prefron- which is directly proportional to the strength of tal cortex). C. Disorganiz force applied. Disorganization symptoms:: Tis symptom complex ation symptoms includes the following symptoms: Mannerisms Mannerisms:: Spontaneous repetition of odd odd,, pur- Formal thought disorder: Tese are the distur- movements. For example, repeatedly poseful movements. bances in the form of thought characterized by loss saluting the passerby. of organization of thought. Perseveration Perseveration:: It is an induced movement which is Disorganized behavior : It is the odd and inap- senselessly repeated. For example, A patient takes propriate behavior which may break the social his tongue out and in, when asked however then norms. For example, a hospitalized schizophrenic keeps on repeating the out and in movement , even patient would masturbate in front of the nursing when whe n he is no long longer er ask asked. ed. It mus mustt be note notedd tha thatt staff, another patient of schizophrenia would wear perseveration occurs in response to an instruction, sweaters and coats in hot summer season. wherea whe reass ste stereot reotypy ypy and man manneris nerisms ms are spon spontane tane-- Inappropriate affect: Affect which is not in sync ous. Perseveration is also a sign of brain damage with the social situation. (organic brain disorders) disorders )Q. D. Motor symptoms (cataton (catatonic symptoms): Te term “cat- ic symptoms): “cat- Ambiten dency: Inability to decide the desired motor Ambitendency atonia”” was given by Karl Kahlbaum who described atonia Q movement. For example, when offered a hand for these motor symptoms for the first time. Tese symp- handshake, patient may repeatedly bring his hand toms are sometimes described along with disorgani- forward and backward as he is not able to decide zation symptoms. For more clarity, they have been whether he wants to shake the hand or not. It is described separately here. Tese include: ambivalence in motor movements Q. 14 Review of Psychiatry DIAGNOSIS E. Residual schizophrenia: schizophrenia: Residual schizophrenia is characterized by progression from an early stage (with According to DSM-5, two or more of the following symp- prominent delusions and hallucinations) to a later toms should be present for a duration of 1 month period stage where the delusions and hallucinations have and at least one of these must be either (1), (2) or (3) become minimal and mostly negative symptoms are 1. Delusions present. 2. Hallucinations F. Simple schizophre- H DSM-5 Upda te: The DSM-4 3. Disorganized Disorganized speech (or formal thought disorder) nia:: nia Tere are described des cribed multiple subtypes of schizo- 4. Disorganized Disorganized or catatonic behavior prominent negative phrenia (like paranoid, catatonic, dis- 5. Negative Negative symptoms. symptoms. organized, catatonic, undifferentiated, symptoms without residual). The DSM-5 has eliminated Te total duration of illness should be at at least any history of posi- all of them and does not describe any 6 months, and the 6 months period must include at least tive symptoms like subtypes. one month of above mentioned symptoms. delusion and hallucinations. It has the worst prog- Te ICD-10 also nosis.. nosis H uses similar criterion DSM-5 Update: In DSM-4, only one G. Post schizophrenic depression: depression: A depressive episode for diagnosis of schizo-