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 A Short Textbook of PSYCHIATRY Every effort has been made to ensure that drug dosage schedules in this book are accurate and conform to the standards accepted at the time of publication. However, as recommendations for treatment vary in the light of continuing research and clinical experience, t...

 A Short Textbook of PSYCHIATRY Every effort has been made to ensure that drug dosage schedules in this book are accurate and conform to the standards accepted at the time of publication. However, as recommendations for treatment vary in the light of continuing research and clinical experience, the reader is advised to verify drug dosage schedules contained in the product information sheets included in the package of each drug as well as Summary of Product Characteristics (SPC), before any drug is administered. It is the responsibility of the treating physician, relying on experience and knowledge about the patient, to determine the dose(s) and the best treatment for the patient. Neither the publisher nor the author assumes responsibility for any possible untoward consequences.  A Short Textbook of PSYCHIATRY Seventh Edition Niraj Ahuja MBBS MD MRCPsych Consultant Psychiatrist Newcastle Upon Tyne, UK Formerly Associate Professor (Psychiatry) GB Pant Hospital and Associated Maulana Azad Medical College (MAMC) and Lok Nayak Hospital, New Delhi, India Formerly also at Department of Psychiatry Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry Lady Hardinge Medical College (LHMC) and Smt. SK Hospital, New Delhi All India Institute of Medical Sciences (AIIMS), New Delhi, India Contributing Editor Savita Ahuja MBBS DGO DFSRH DRCOG ® JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi St Louis (USA) Panama City (Panama) London (UK) Ahmedabad Bengaluru Chennai Hyderabad Kochi Kolkata Lucknow Mumbai Nagpur Published by Jitendar P Vij Jaypee Brothers Medical Publishers (P) Ltd Corporate Office 4838/24 Ansari Road, Daryaganj, New Delhi - 110002, India, Phone: +91-11-43574357, Fax: +91-11-43574314 Registered Office B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi - 110 002, India Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021 +91-11-23245672, Rel: +91-11-32558559, Fax: +91-11-23276490, +91-11-23245683 e-mail: [email protected], Website: www.jaypeebrothers.com Offices in India Ahmedabad, Phone: Rel: +91-79-32988717, e-mail: [email protected] Bengaluru, Phone: Rel: +91-80-32714073, e-mail: [email protected] Chennai, Phone: Rel: +91-44-32972089, e-mail: [email protected] Hyderabad, Phone: Rel:+91-40-32940929, e-mail: [email protected] Kochi, Phone: +91-484-2395740, e-mail: [email protected] Kolkata, Phone: +91-33-22276415, e-mail: [email protected] Lucknow, Phone: +91-522-3040554, e-mail: [email protected] Mumbai, Phone: Rel: +91-22-32926896, e-mail: [email protected] Nagpur, Phone: Rel: +91-712-3245220, e-mail: [email protected] Overseas Offices North America Office, USA, Ph: 001-636-6279734, e-mail: [email protected], [email protected] Central America Office, Panama City, Panama, Ph: 001-507-317-0160, e-mail: [email protected], Website: www.jphmedical.com Europe Office, UK, Ph: +44 (0) 2031708910, e-mail: [email protected] A Short Textbook of Psychiatry © 2011, Niraj Ahuja All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher. This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error (s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only. First Edition: 1990 Second Edition: 1992 Third Edition: 1995 Fourth Edition: 1999 Fifth Edition: 2002 Sixth Edition: 2006 Reprint: 2009 Seventh Edition: 2011 ISBN: 978-93-80704-66-1 Typeset at JPBMP typesetting unit Printed at  For Manisha and Neha  Preface to the Seventh Edition It is rather humbling to consider that it has been two decades that the Short Textbook of Psychiatry has enjoyed a wide distribution among the undergraduate medical students, interns, junior residents, postgraduate psychiatry students, nursing students, psychology and psychiatric social work students, occupational therapy and physi- otherapy students, general medical practitioners, other physicians and health professionals in India and some other countries. I am really indebted to the many astute readers who have provided a very constructive and useful feedback, along with encouraging comments regarding the existing format and the contents of the book. The seventh edition of the Short Textbook of Psychiatry has been once again extensively revised and updated. Significant changes have been made in almost all the chapters, especially in chapters on diagnosis and classification, psychoactive substance use disorders, psychopharmacology, schizophrenia, mood disorders and other biological methods of treatment. Coloured-shaded boxes have been added at various places in the text to highlight the important points in tables and figures. The chapter on psychiatric history and examination contains a summary of laboratory tests in psychiatry, in additions to other significant changes. The appendices have been revised and contain a glossary of common psychiatric terms. The Short Textbook of Psychiatry sincerely hopes to retain its original aim of providing a brief yet compre- hensive account of the psychiatric disorders and their allied aspects in a ‘user-friendly’ and ‘easy-to-follow’ manner. I am grateful to Shri Jitendar P Vij, Chairman and Managing Director, Jaypee Brothers Medical Publishers (P) Ltd for his exquisite control over the production and distribution of the Short Textbook of Psychiatry over the last 20 years. I hope you enjoy reading the book and I warmly welcome critical comments and constructive suggestions. Please send your comments by email to [email protected]. July 2010 Niraj Ahuja  Preface to the First Edition Psychiatry, as a branch of Medicine, has been cold-shouldered by physicians for a long time. There are vari- ous reasons for such an attitude. But, the most important exposition is an unfamiliarity with the psychiatric disorders and their treatment. This is easy to understand in the light of the fact that an easily comprehensible, non-intimidating and concise text on psychiatry was not earlier available. Recently too, the various postgraduate entrance examinations have laid an increasing emphasis on psychiatry and its related branches. Keeping this in mind, the Medical Examination Review—Psychiatry (Multiple Choice Questions with Explanatory Answers) was written, the new edition of which appears this year. Its tremendous success during the last four years and encouraging suggestions from the readers have been a source of stimulation for drafting this text. The Short Textbook of Psychiatry aims to provide a brief yet comprehensive account of psychiatric disor- ders and their allied aspects. While striving to make the book simple and easy-to-follow, an attempt has been made to keep the book aligned to the most recent developments in classification, terminology and treatment methods. The Short Textbook of Psychiatry is addressed to medical students, interested physicians and other health professionals. A postgraduate student in psychiatry will find the text elementary and basic, although a first year postgraduate will find it useful for a broad introduction to the subject. I will like to put on record my deep appreciation for Shri Jitendar P Vij, Managing Director; Mr. Pawaninder Vij, Production Manager and their efficient staff at the Jaypee Brothers Medical Publishers (P) Ltd, New Delhi for bringing out this volume in a short time. I welcome critical comments and constructive suggestions from the readers. January 1990 Niraj Ahuja  Contents 1. Diagnosis and Classification in Psychiatry......................................................................................1 2. Psychiatric History and Examination...............................................................................................5 3. Organic (Including Symptomatic) Mental Disorders................................................................... 19 4. Psychoactive Substance Use Disorders........................................................................................ 33 5. Schizophrenia................................................................................................................................. 54 6. Mood Disorders.............................................................................................................................. 69 7. Other Psychotic Disorders............................................................................................................. 83 8. Neurotic, Stress-related and Somatoform Disorders................................................................... 89 9. Disorders of Adult Personality and Behaviour........................................................................... 113 10. Sexual Disorders........................................................................................................................... 121 11. Sleep Disorders............................................................................................................................. 133 12. Behavioural Syndromes Associated with Psychological Disturbances and Physiological Factors............................................................................................................ 142 13. Mental Retardation...................................................................................................................... 153 14. Child Psychiatry............................................................................................................................ 162 15. Psychopharmacology................................................................................................................... 172 16. Other Biological Methods of Treatment..................................................................................... 199 17. Psychoanalysis.............................................................................................................................. 205 18. Psychological Treatments............................................................................................................ 213 19. Emergency Psychiatry.................................................................................................................. 221 20. Legal and Ethical Issues in Psychiatry......................................................................................... 229 21. Community Psychiatry................................................................................................................. 235 Appendices.......................................................................................................................................... 241 Appendix I: Nobel Prizes in Psychiatry and Allied Disciplines.............................................................................. 241 Appendix II: Some Important Contributors in Psychiatry..................................................................................... 242 Appendix III: Glossary of Some Important Terms in Psychiatry........................................................................... 246 Suggested Further Reading................................................................................................................ 249 Index.......................................................................................................................................................................................... 253  1 Diagnosis and Classification in Psychiatry Classification is a process by which phenomena are DEFINITION OF A PSYCHIATRIC organized into categories so as to bring together those DISORDER phenomena that most resemble each other and to sepa- rate those that differ. Any classification of psychiatric The simplest way to conceptualize a psychiatric disorders, like that of medical illnesses, should ideally disorder is a disturbance of Cognition (i.e. Thought), be based on aetiology. For a large majority of psychiat- Conation (i.e. Action), or Affect (i.e. Feeling), or any ric disorders, no distinct aetiology is known at present, disequilibrium between the three domains. However, although there are many attractive probabilities for this simple definition is not very useful in routine several of them. Therefore, one of the most rational clinical practice. ways to classify psychiatric disorders at present is Another way to define a psychiatric disorder or probably syndromal. A syndrome is defined as a group mental disorder is as a clinically significant psycho- of symptoms and signs that often occur together, and logical or behavioural syndrome that causes significant delineate a recognisable clinical condition. (subjective) distress, (objective) disability, or loss of The syndromal approach of classifying psychiat- freedom; and which is not merely a socially deviant ric disorders, on the basis of their clinical signs and behaviour or an expected response to a stressful life symptoms, is very similar to the historical approach event (e.g. loss of a loved one). Conflicts between of classification of medical illnesses, when aetiology the society and the individual are not considered of a majority of medical illnesses was still obscure. psychiatric disorders. A psychiatric disorder should There are three major purposes of classification be a manifestation of behavioural, psychological, and/ of psychiatric disorders: or biological dysfunction in that person (Definition 1. To enable communication regarding the diagnosis modified after DSM-IV-TR, APA). of disorders, Although slightly lengthy, this definition defines 2. To facilitate comprehension of the underlying a psychiatric disorder more accurately. causes of these disorders, and 3. To aid prediction of the prognosis of psychiatric NORMAL MENTAL HEALTH disorders. This syndromal approach of classification, in the According to the World Health Organization (WHO), absence of clearly known aetiologies, fulfils these Health is a state of complete physical, mental and purposes reasonably well. social well-being, and not merely absence of disease Before proceeding to look at current classifications or infirmity. of psychiatric disorders, it is important to define what Normal mental health, much like normal health, is is meant by the term, psychiatric disorder. a rather difficult concept to define. There are several  2 A Short Textbook of Psychiatry models available for understanding what may consti- Table 1.1: Some Models of Normality in Mental Health tute ‘normality’ (see Table 1.1). 1. Medical Model (Normality as Health): Normal men- Although, normality is not an easy concept to tal health is conceptualized as the absence of any define, some of the following traits are more com- psychiatric disorder (‘disease’) or psychopathology. monly found in ‘normal’ individuals. 2. Statistical Model (Normality as an Average): Statisti- 1. Reality orientation. cally normal mental health falls within two standard 2. Self-awareness and self-knowledge. deviations (SDs) of the normal distribution curve for 3. Self-esteem and self-acceptance. the population. 4. Ability to exercise voluntary control over their 3. Utopian Model (Normality as Utopia): In this model, behaviour. the focus in defining normality is on ‘optimal func- 5. Ability to form affectionate relationships. tioning’. 6. Pursuance of productive and goal-directive activi- 4. Subjective Model: According to this model, normality ties. is viewed as an absence of distress, disability, or any help-seeking behaviour resulting thereof. This defini- tion is similar in many ways to the medical model. CLASSIFICATION IN PSYCHIATRY 5. Social Model: A normal person, according to this definition, is expected to behave in a socially Like any growing branch of Medicine, Psychiatry has ‘acceptable’ behaviour. seen rapid changes in classification to keep up with a 6. Process Model (Normality as a Process): This model conglomeration of growing research data dealing with views normality as a dynamic and changing process, epidemiology, symptomatology, prognostic factors, rather than as a static concept. This model can be treatment methods and new theories for the causation combined with any other model mentioned here. of psychiatric disorders. 7. Continuum Model (Normality as a Conti nuum): Although first attempts to classify psychiatric Normality and mental disorder are considered by disorders can be traced back to Ayurveda, Plato (4th this model as falling at the two ends of a continuum, century BC) and Asclepiades (1st century BC), clas- rather than being disparate entities. According to sification in Psychiatry has certainly evolved ever this model, it is the severity (scores above the ‘cut- since. off’) that determines whether a particular person’s At present, there are two major classifications in experience constitutes a symptom of a disorder or Psychiatry, namely ICD-10 (1992) and DSM-IV-TR falls on the healthy side of the continuum. (2000). ICD-10 (International Classification of Diseases, classification of mental disorders. DSM-IV-TR is a 10th Revision, 1992) is World Health Organisation’s text revision of the DSM-IV which was originally classification for all diseases and related health prob- published in 1994. lems (and not only psychiatric disorders). The next editions of ICD (ICD-11) and DSM Chapter ‘F’ classifies psychiatric disorders as Men- (DSM-V) are likely to be available in the years tal and Behavioural Disorders (MBDs) and codes them 2012-14. on an alphanumeric system from F00 to F99. ICD-10 For the purpose of this book, it is intended to is now available in several versions, the most impor- follow the ICD-10 classification. ICD-10 is easy to tant of which are listed in Table 1.2. There are several follow, has been tested extensively all over the world versions of ICD-10; some are listed in Table 1.3. (51 countries; 195 clinical centres), and has been found DSM-IV-TR (Diagnostic and Statistical Manual to be generally applicable across the globe. At some of Mental Disorders, IV Edition, Text Revision, 2000) places in the book, DSM-IV-TR diagnostic criteria are is the American Psychiatric Association (APA)’s also discussed, wherever appropriate.  Diagnosis and Classification in Psychiatry 3 Table 1.2: Mental and Behavioural Disorders in ICD-10 1. F00-F09 Organic, Including Symptomatic, Mental such as eating disorders, non-organic sleep disor- Disorders, such as delirium, dementia, organic am- ders, sexual dysfunctions (not caused by organic nestic syndrome, and other organic mental disorders. disorder or disease), mental and behavioural dis- 2. F10-F19 Mental and Behavioural Disorders due to orders associated with puerperium, and abuse of Psychoactive Substance Use, such as acute intoxica- non-dependence-producing substances. tion, harmful use, dependence syndrome, withdrawal 7. F60-F69 Disorders of Adult Personality and Behav- state, amnestic syndrome, and psychotic disorders iour, such as specific personality disorders, enduring due to psychoactive substance use. personality changes, habit and impulse disorders, 3. F20-F29 Schizophrenia, Schizotypal and Delusional gender-identity disorders, disorders of sexual pre- Disorders, such as schizophrenia, schizotypal dis- ference, and psychological and behavioural disorders order, persistent delusional disorders, acute and associated with sexual development and orientation. transient psychotic disorders, induced delusional 8. F70-F79 Mental Retardation, including mild, moder- disorder, and schizo-affective disorders. ate, severe, and profound mental retardation. 4. F31-F39 Mood (Affective) Disorders, such as manic 9. F80-F89 Disorders of Psychological Development, episode, depressive episode, bipolar affective disor- such as specific developmental disorders of speech der, recurrent depressive disorder, and persistent and language, specific developmental disorders of mood disorder. scholastic skills, specific developmental disorders 5. F40-F48 Neurotic, Stress-related and Somatoform of motor function, mixed specific developmental Disorders (There is no category with code number disorders, and pervasive developmental disorders. F49), such as anxiety disorders, phobic anxiety 10. F90-F98 Behavioural and Emotional Disorders with disorders, obsessive-compulsive disorder, dissocia- Onset Usually Occurring in Childhood and Ado- tive (conversion) disorders, somatoform disorders, lescence, such as hyperkinetic disorders, conduct reaction to stress, and adjustment disorders, and disorders, mixed disorders of conduct and emotions, other neurotic disorders. tic disorders, and other disorders. 6. F50-F59 Behavioural Syndromes Associated with 11. F99 Unspecified Mental Disorder Physiological Disturbances and Physical Factors, The presence of a diagnostic hierarchy implied Table 1.3: Some Versions of ICD-10 that the conditions higher up in the hierarchy needed A. Clinical Descriptions and Diagnostic Guidelines to be considered first, before making a diagnosis of (CDDG) those lower down in the hierarchy. For example, it was B. Diagnostic Criteria for Research (DCR) felt that a current diagnosis of organic mental disorder C. Multi-axial Classification Version such as delirium would exclude a diagnosis of anxi- D. Primary Care Version ety disorder in presence of agitation; and alcohol and drug induced disorders would take precedence over a Earlier classifications in psychiatry were based on diagnosis of primary mood disorder. hierarchies of diagnoses with presence of a diagnosis The current classifications however encourage higher in the hierarchy usually ruling out a diagnosis recording of multiple diagnoses in a given patient (as lower in the hierarchy. This was felt to be in keeping co-morbidity) regardless of any hierarchy. Although with the teaching of Medicine at large at the time, a diagnostic hierarchy makes much clinical sense, where there was emphasis on making a single diag- consideration and recording of co-morbidity can be nosis of one disease rather than explaining different helpful in identifying more of patient’s needs; for symptoms by different disease entities. example, a diagnosis of co-morbid anxiety disorder  4 A Short Textbook of Psychiatry in a patient with bipolar disorder helps identify and Table 1.4: The Five Axes of DSM-IV-TR treat the anxiety component adequately. AXIS I: Clinical Psychiatric Diagnosis AXIS II: Personality Disorders and Mental Retardation MULTI-AXIAL CLASSIFICATION AXIS III: General Medical Conditions AXIS IV: Psychosocial and Environmental Problems The process of making a correct diagnosis is a very AXIS V: Global Assessment of Functioning: Current useful clinical exercise as evidence-based manage- and in past one year ment can be dependent on making a correct diagnosis. (Rated on a scale) However, sometimes making a clinical diagnosis can lead to labelling of patient and can be stigmatizing. This can also degrade the patient to “just another case” In this system, an individual patient is diagnosed on and does not direct attention to the whole individual. five separate axes, ensuring a more through evaluation In the last few decades, there has been an upsurge of needs (see Table 1.4). of interest in multi-axial systems for achieving a This method helps in making a more holistic, more comprehensive description of an individual’s biopsychosocial assessment of an individual patient. clinical problems and needs. The pattern adopted by Recently, ICD-10 has also brought out its own multi- DSM-IV-TR is a very good example of this attempt. axial classification version (see Table 1.3).  2 Psychiatric History and Examination Familiarity with the technique of psychiatric assess- Table 2.1: Psychiatric vs Medical Interview ment is important not only for a psychiatrist but A psychiatric interview can be different from a medical also for a medical practitioner or any mental health interview in several ways, some of which can include: professional, since more than one-third of medical 1. Presence of disturbances in thinking, behaviour and patients can present with psychiatric symptoms. emotions can interfere with meaningful communi- cation INTERVIEW TECHNIQUE 2. Collateral information from significant others can be really important In no other branch of Medicine is the history taking 3. Important to obtain detailed information of personal interview as important as in Psychiatry. All physicians history and pre-morbid personality need to communicate with their patients and a skilful 4. Need for more astute observation of patient’s behav- interview can clearly help in obtaining better informa- iour tion, making a more accurate diagnosis, establishing 5. Difficulty in establishing rapport may be encountered a better rapport with patients, and working towards more often better adherence with management plan. 6. Patients may lack insight into their illness and may A psychiatric interview is usually different from have poor judgement the routine medical interview in several ways (Table 7. Usually more important to elicit information regard- 2.1). A few important points regarding the interview ing stressors and social situation technique are mentioned below. These serve as pointers towards a technique which clearly has to During the interview session(s), the patient should be mastered over a period of time with repeated be put at ease and an empathic relationship should be examinations. established. A consistent scheme should be used each time for In psychiatric assessment, history taking interview recording the interview, although the interview need and mental status examination need not always be not (and should not) follow a fixed and rigid method. conducted separately (though they must be recorded The interview technique should have flexibility, individually). During assessment, the interviewer varying according to appropriate clinical circum- should observe any abnormalities in verbal and non- stances. verbal communication and make note of them. Whenever possible, the patient should be seen first. It is helpful to record patient’s responses verba- When the account of historical information given by tim rather than only naming the signs (for example, the patient and the informant(s) is different, it is useful rather than just writing delusion of persecution, it is to record them separately. better to record in addition: “my neighbour is trying to  6 A Short Textbook of Psychiatry poison me”). It is best done in the patient’s own spoken The informants’ identification data should be language, whenever possible. recorded along with their relationship to the patient, It is useful to ask open-ended and non-directive whether they stay with the patient or not, and the questions (for example, “how are you feeling today”?) duration of stay together. rather than asking direct, leading questions (for exam- Finally, a comment should be made regarding the ple, “are you feeling sad at present”?). reliability of the information provided. The reliability Arguably the most important interviewing skills of the information provided by the informants should are listening, and demonstrating that you are interested be assessed on the following parameters: in listening and attending to the patient. It is important 1. Relationship with patient, to remember that listening is an active, and not a 2. Intellectual and observational ability, passive, process. 3. Familiarity with the patient and length of stay with Confidentiality must always be observed. How- the patient, and ever, in cases of suicidal/homicidal risk and child 4. Degree of concern regarding the patient. abuse, an exception may have to be made (see Chapter The source of referral (such as a letter from 20 for details). Patients suffering from psychiatric patient’s general practitioner or a letter of referral from disorders are usually no more violent than the general the referring physician/surgeon in case of a liaison population. However, it is important to ensure safety psychiatry referral) often provides valuable informa- if any risks are apparent. tion regarding the patient’s condition. A comprehensive psychiatric interview often requires more than one session. The psychiatric assess- PRESENTING (CHIEF) COMPLAINTS ment can be discussed under the following headings. The presenting complaints and/or reasons for con- IDENTIFICATION DATA sultation should be recorded. Both the patient’s and the informant’s version should be recorded, if relevant. If It is best to start the interview by obtaining some the patient has no complaints (due to absent insight) identification data which may include Name (includ- this fact should also be noted. ing aliases and pet names), Age, Sex, Marital status, It is important to use patient’s own words and to Education, Occupation, Income, Residential and note the duration of each presenting complaint. Some Office Address(es), Religion, and Socioeconomic of the additional points which should be noted include: background, as appropriate according to the setting. It 1. Onset of present illness/symptom. is useful to record the source of referral of the patient. 2. Duration of present illness/symptom. In medicolegal cases, in addition, two identification 3. Course of symptoms/illness. marks should also be recorded. 4. Predisposing factors. 5. Precipitating factors (include life stressors). INFORMANTS 6. Perpetuating and/or relieving factors. Since sometimes the history provided by the patient HISTORY OF PRESENT ILLNESS may be incomplete, due to factors such as absent in- sight or uncooperativeness, it is important to take the When the patient was last well or asymptomatic should history from patient’s relatives or friends who act as be clearly noted. This provides useful information informants and sources of collateral information. It is about the onset as well as duration of illness. Establish- important to take the patient’s consent before taking ing the time of onset is really important as it provides this collateral history unless the patient does not have clarity about the duration of illness and symptoms. capacity to consent. The symptoms of the illness, from the earliest time  Psychiatric History and Examination 7 at which a change was noticed (the onset) until the mellitus, hypertension, coronary artery disease, acute present time, should be narrated chronologically, in intermittent porphyria, syphilis and HIV positivity (or a coherent manner. AIDS) should be explored. The presenting (chief) complaints should be expanded. In particular, any disturbances in physio- TREATMENT HISTORY logical functions such as sleep, appetite and sexual functioning should be enquired. One should always Any treatment received in present and/or previous enquire about the presence of suicidal ideation, ideas episode(s) should be asked along with history of of self-harm and ideas of harm to others (see Chapter treatment adherence, response to treatment received, 19 for details), with details about any possible intent any adverse effects experienced or any drug allergies and/or plans. which should be prominently noted in medical records. It is also essential to consider and record any im- portant negative history (such as history of alcohol/ FAMILY HISTORY drug use in new onset psychosis). A life chart (Fig. 2.1) provides a valuable display The family history usually includes the ‘family of of the course of illness, episodic sequence, polarity origin’ (i.e. the patient’s parents, siblings, grandpar- (if any), severity, frequency, relationship to stressors, ents, uncles, etc.). The ‘family of procreation’ (i.e. and response to treatment, if any. the patient’s spouse, children and grandchildren) is conventionally recorded under the heading of personal PAST PSYCHIATRIC AND MEDICAL history. HISTORY Family history is usually recorded under the fol- lowing headings: Any history of any past psychiatric illness should be 1. Family structure: Drawing of a ‘family tree’ (pedi- obtained. Any past history of having received any gree chart) can help in recording all the relevant psychotropic medication, alcohol and drug abuse or information in very little space which is easily dependence, and psychiatric hospitalisation should readable. An example of a typical family tree is be enquired. given in Figure 2.2. It should be noted whether A past history of any serious medical or neuro- the family is a nuclear, extended nuclear or joint logical illness, surgical procedure, accident or hospi- family. Any consanguineous relationships should talisation should be obtained. The nature of treatment be noted. The age and cause of death (if any) of received, and allergies, if any, should be ascertained. family members should be asked. A past history of relevant aetiological causes such 2. Family history of similar or other psychiatric ill- as head injury, convulsions, unconsciousness, diabetes nesses, major medical illnesses, alcohol or drug dependence and suicide (and suicidal attempts) should be recorded. 3. Current social situation: Home circumstances, per capita income, socioeconomic status, leader of the family (nominal as well as functional) and current attitudes of family members towards the patient’s illness should be noted. The communication patterns in the family, range of affectivity, cultural and religious values, and social Fig. 2.1: An Example of Life Chart support system, should be enquired about, where relevant.  8 A Short Textbook of Psychiatry Fig. 2.2: A Typical Family Tree and Common Pedigree Symbols  Psychiatric History and Examination 9 PERSONAL AND SOCIAL HISTORY Any school phobia, non-attendance, truancy, any learning difficulties and reasons for termination of In a younger patient, it is often possible to give studies (if occurs prematurely) should be noted. more attention to details regarding earlier personal history. In older patients, it is sometimes harder to get a Play History detailed account of the early childhood history. Parents The questions to be asked include, what games were and older siblings, if alive, can often provide much played at what stage, with whom and where. Rela- additional information regarding the past personal tionships with peers, particularly the opposite sex, history. Not all questions need to be asked from all should be recorded. The evaluation of play history patients and personal history (much like rest of the his- is obviously more important in the younger patients. tory taking) should be individualised for each patient. Personal history can be recorded under the follow- Puberty ing headings: The age at menarche, and reaction to menarche (in females), the age at appearance of secondary sexual Perinatal History characteristics (in both females and males), nocturnal Difficulties in pregnancy (particularly in the first emissions (in males), masturbation and any anxiety three months of gestation) such as any febrile illness, related to changes in puberty should be asked. medications, drugs and/or alcohol use; abdominal trauma, any physical or psychiatric illness should be Menstrual and Obstetric History asked. Other relevant questions may include whether The regularity and duration of menses, the length the patient was a wanted or unwanted child, date of of each cycle, any abnormalities, the last menstrual birth, whether delivery was normal, any instrumenta- period, the number of children born, and termination tion needed, where born (hospital or home), any peri- of pregnancy (if any) should be asked for. natal complications (cyanosis, convulsions, jaundice), APGAR score (if available), birth cry (immediate or Occupational History delayed), any birth defects, and any prematurity. The age at starting work; jobs held in chronological order; reasons for changes; job satisfactions; ambitions; Childhood History relationships with authorities, peers and subordinates; Whether the patient was brought up by mother or present income; and whether the job is appropriate someone else, breastfeeding, weaning and any history to the educational and family background, should suggestive of maternal deprivation should be asked. be asked. The age of passing each important developmental milestone should be noted. The age and ease of toilet Sexual and Marital History training should be asked. Sexual information, how acquired and of what kind; The occurrence of neurotic traits should be noted. masturbation (fantasy and activity); sex play, if any; These include stuttering, stammering, tics, enuresis, adolescent sexual activity; premarital and extramarital encopresis, night terrors, thumb sucking, nail biting, sexual relationships, if any; sexual practices (normal head banging, body rocking, morbid fears or phobias, and abnormal); and any gender identity disorder, are somnambulism, temper tantrums, and food fads. the areas to be enquired about. The duration of marriage(s) and/or relationship(s); Educational History time known the partner before marriage; marriage The age of beginning and finishing formal education, arranged by parents with or without consent, or academic achievements and relationships with peers by self-choice with or without parental consent; and teachers, should be asked. number of marriages, divorces or separations; role in  10 A Short Textbook of Psychiatry marriage; interpersonal and sexual relations; contra- One of the most reliable methods of assessment ceptive measures used; sexual satisfaction; mode and of premorbid personality is interviewing an informant frequency of sexual intercourse; and psychosexual familiar with the patient prior to the onset of illness. dysfunction (if any) should be asked. Conventionally, the details of the ‘family of pro- ALCOHOL AND SUBSTANCE HISTORY creation’ are recorded here. Although alcohol and drug history is often elicited as a Premorbid Personality (PMP) part of personal history, it is often customary to record It is important to elicit details regarding the personality it separately. Alcohol and drugs can often contribute of the individual (temperament, if the age is less than to causation of several psychiatric symptoms and are 16 years). Instead of using labels such as schizoid or often present co-morbidly alongside many psychiatric histrionic, it is more useful to describe the personality diagnoses. in some detail. The following subheadings are often used for the PHYSICAL EXAMINATION description of premorbid personality. 1. Interpersonal relationship: Interpersonal rela- A detailed general physical examination (GPE) and tionships with family members, friends, and systemic examination is a must in every patient. work colleagues; introverted/extroverted; ease Physical disease, which is aetiologically important (for of making and maintaining social relationships. causing psychiatric symptomatology), or accidentally 2. Use of leisure time: Hobbies; interests; intel- co-existent, or secondarily caused by the psychiatric lectual activities; critical faculty; energetic/ condition or treatment, is often present and can be sedentary. detected by a good physical examination. 3. Predominant mood: Optimistic/pessimistic; stable/prone to anxiety; cheerful/despondent; MENTAL STATUS EXAMINATION (MSE)* reaction to stressful life events. 4. Attitude to self and others: Self-confidence Mental status examination is a standardised format in level; self-criticism; self-consciousness; self- which the clinician records the psychiatric signs and centred/thoughtful of others; self-appraisal of symptoms present at the time of the interview. abilities, achievements and failures. MSE should describe all areas of mental function- 5. Attitude to work and responsibility: Decision ing (Table 2.2). Some areas, however, may deserve making; acceptance of responsibility; flexibility; more emphasis according to the clinical impressions perseverance; foresight. that may arise from the history; for example, mood 6. Religious beliefs and moral attitudes: Religious and affect in depression, and cognitive functions in beliefs; tolerance of others’ standards and delirium and dementia. beliefs; conscience; altruism. 7. Fantasy life: Sexual and nonsexual fantasies; General Appearance and Behaviour daydreaming-frequency and content; recurrent A rich deal of information can be elicited from ex- or favourite daydreams; dreams. amination of the general appearance and behaviour. 8. Habits: Food fads; alcohol; tobacco; drugs; While examining, it is important to remember patient’s sleep. sociocultural background and personality. * The definitions of some MSE terms are described in Appendix III.  Psychiatric History and Examination 11 Table 2.2: Mental Status Examination Attitude towards examiner 1. General Appearance and Behaviour Cooperation/guardedness/evasiveness/hostility/com- i. General Appearance bativeness/haughtiness, ii. Attitude towards Examiner Attentiveness, iii. Comprehension Appears interested/disinterested/apathetic, iv. Gait and Posture Any ingratiating behaviour, v. Motor Activity Perplexity vi. Social Manner vii. Rapport Comprehension 2. Speech Intact/impaired (partially/fully) i. Rate and Quantity ii. Volume and Tone Gait and posture iii. Flow and Rhythm 3. Mood and Affect Normal or abnormal (way of sitting, standing, walk- 4. Thought ing, lying) i. Stream and Form Motor activity ii. Content 5. Perception Increased/decreased, 6. Cognition (Higher Mental Functions) Excitement/stupor, i. Consciousness Abnormal involuntary movements (AIMs) such as ii. Orientation tics, tremors, akathisia, iii. Attention Restlessness/ill at ease, iv. Concentration Catatonic signs (mannerisms, stereotypies, posturing, v. Memory waxy flexibility, negativism, ambitendency, automatic vi. Intelligence obedience, stupor, echopraxia, psychological pillow, vii. Abstract thinking forced grasping) (see Chapter 5 for details), 7. Insight Conversion and dissociative signs (pseudoseizures, 8. Judgement possession states), Social withdrawal, Autism, Understandably, general appearance and behav- Compulsive acts, rituals or habits (for example, nail iour needs to be given more emphasis in the examina- biting), tion of an uncooperative patient. Reaction time General appearance Social manner and non-verbal The important points to be noted are: behaviour Physique and body habitus (build) and physical ap- Increased, decreased, or inappropriate behaviour pearance (approximate height, weight, and appear- Eye contact (gaze aversion, staring vacantly, staring ance), at the examiner, hesitant eye contact, or normal eye Looks comfortable/uncomfortable, contact). Physical health, Grooming, Hygiene, Self-care, Rapport Dressing (adequate, appropriate, any peculiarities), Whether a working and empathic relationship Facies (non-verbal expression of mood), can be established with the patient, should be men- Effeminate/masculine tioned.  12 A Short Textbook of Psychiatry Hallucinatory Behaviour over time), depth or intensity of affect (normal, in- creased or blunted) and appropriateness of affect (in Smiling or crying without reason, Muttering or talking relation to thought and surrounding environment). to self (non-social speech). Mood is described as general warmth, euphoria, Odd gesturing in response to auditory or visual elation, exaltation and/or ecstasy (seen in severe hallucinations. mania) in mania; anxious and restless in anxiety and depression; sad, irritable, angry and/or despai- Speech red in depression; and shallow, blunted, indifferent, Speech can be examined under the following headings: restricted, inappropriate and/or labile in schizophrenia. Anhedonia may occur in both schizophrenia and Rate and quantity of speech depression. Whether speech is present or absent (mutism), If present, whether it is spontaneous, whether produc- Thought tivity is increased or decreased, Normal thinking is a goal directed flow of ideas, Rate is rapid or slow (its appropriateness), Pressure symbols and associations initiated by a problem or a of speech or poverty of speech. task, characterised by rational connections between successive ideas or thoughts, and leading towards Volume and tone of speech a reality oriented conclusion. Therefore, thought Increased/decreased (its appropriateness), process that is not goal-directed, or not logical, or does Low/high/normal pitch not lead to a realistic solution to the problem at hand, is not considered normal. Flow and rhythm of speech Traditionally, in the clinical examination, thought Smooth/hesitant, Blocking (sudden), is assessed (by the content of speech) under the four Dysprosody, Stuttering/Stammering/Cluttering, Any headings of stream, form, content and possession of accent, thought. However, since there is widespread disagree- Circumstantiality, Tangentiality, ment regarding this subdivision, ‘thought’ is discussed Verbigeration, Stereotypies (verbal), here under the following two headings of ‘stream and Flight of ideas, Clang associations. form’, and ‘content’. Mood and Affect Stream and form of thought Mood is the pervasive feeling tone which is sustained For obvious reasons, the ‘stream of thought’ overlaps (lasts for some length of time) and colours the total with examination of ‘speech’. Spontaneity, produc- experience of the person. Affect, on the other hand, is tivity, flight of ideas, prolixity, poverty of content of the outward objective expression of the immediate, speech, and thought block should be mentioned here. cross-sectional experience of emotion at a given time. The ‘continuity’ of thought is assessed; Whether The assessment of mood includes testing the qual- the thought processes are relevant to the questions ity of mood, which is assessed subjectively (‘how asked; Any loosening of associations, tangentiality, do you feel’) and objectively (by examination). The circumstantiality, illogical thinking, perseveration, or other components are stability of mood (over a period verbigeration is noted. of time), reactivity of mood (variation in mood with stimuli), and persistence of mood (length of time the Content of thought mood lasts). Any preoccupations; The affect is similarly described under quality of Obsessions (recurrent, irrational, intrusive, ego- affect, range of affect (of emotional changes displayed dystonic, ego-alien ideas);  Psychiatric History and Examination 13 Contents of phobias (irrational fears); (i.e. whether the voices were addressing the patient Delusions (false, unshakable beliefs) or Over-valued or were discussing him in third person); also enquire ideas; about command (imperative) hallucinations (which Explore for delusions/ideas of persecution, reference, give commands to the person). grandeur, love, jealousy (infidelity), guilt, nihilism, Enquire whether the hallucinations occurred dur- poverty, somatic (hypochondriacal) symptoms, hope- ing wakefulness, or were they hypnagogic (occurring lessness, helplessness, worthlessness, and suicidal while going to sleep) and/or hypnopompic (occurring ideation. while getting up from sleep) hallucinations. Delusions of control, thought insertion, thought with- drawal, and thought broadcasting are Schneiderian Illusions and misinterpretations first rank symptoms (SFRS). The presence of neolo- Whether visual, auditory, or in other sensory fields; gisms should be recorded here. whether occur in clear consciousness or not; whether any steps taken to check the reality of distorted per- Perception ceptions. Perception is the process of being aware of a sensory experience and being able to recognize it by compar- Depersonalisation/derealisation ing it with previous experiences. Depersonalisation and derealisation are abnormalities Perception is assessed under the following headings: in the perception of a person’s reality and are often described as ‘as-if’ phenomena. Hallucinations The presence of hallucinations should be noted. Somatic passivity phenomenon A hallucination is a perception experienced in the Somatic passivity is the presence of strange sensa- absence of an external stimulus. The hallucinations tions described by the patient as being imposed on can be in the auditory, visual, olfactory, gustatory or the body by ‘some external agency’, with the patient tactile domains. being a passive recipient. It is one of the Schneider’s Auditory hallucinations are commonest types of first rank symptoms. hallucinations in non-organic psychiatric disorders. It is really important to clarify whether they are Others elementary (only sounds are heard) or complex (voices Autoscopy, abnormal vestibular sensations, sense of heard). presence should be noted here. The hallucination is experienced much like a true perception and it seems to come from an external Cognition (Neuropsychiatric) Assessment objective space (for example, from outside the ears in Assessment of the cognitive or higher mental func- the case of an auditory hallucination). If the hallucina- tions is an important part of the MSE. A significant tion does not either appear to be a true perception or disturbance of cognitive functions commonly points comes from a subjective internal space (for example, to the presence of an organic psychiatric disorder. It inside the person’s own head in the case of auditory is usual to use Folstein’s mini mental state examina- hallucination), then it is called as a pseudohallucina- tion (MMSE) for a systematic clinical examination of tion. higher mental functions. It should be further enquired what was heard, how many voices were heard, in which part of the day, Consciousness male or female voices, how interpreted and whether The intensity of stimulation needed to arouse the these are second person or third person hallucinations patient should be indicated to demonstrate the level of  14 A Short Textbook of Psychiatry alertness, for example, by calling patient’s name in a (also used for testing attention; are described under normal voice, calling in a loud voice, light touch on the attention). arm, vigorous shaking of the arm, or painful stimulus. b. Recent Memory Grade the level of consciousness: conscious/ con- Ask how did the patient come to the room/hospital; fusion/somnolence/clouding/delirium/stupor/coma. what he ate for dinner the day before or for breakfast Any disturbance in the level of consciousness should the same morning. Give an address to be memorised ideally be rated on Glasgow Coma Scale, where a and ask it to be recalled 15 minutes later or at the end numeric value is given to the best response in each of the interview. of the three categories (eye opening, verbal, motor). c. Remote Memory Ask for the date and place of marriage, name and birth- Orientation days of children, any other relevant questions from Whether the patient is well oriented to time (test by the person’s past. Note any amnesia (anterograde/ asking the time, date, day, month, year, season, and retrograde), or confabulation, if present. the time spent in hospital), place (test by asking the present location, building, city, and country) and Intelligence person (test by asking his own name, and whether Intelligence is the ability to think logically, act ration- he can identify people around him and their role in ally, and deal effectively with environment. that setting). Disorientation in time usually precedes Ask questions about general information, keeping disorientation in place and person. in mind the patient’s educational and social back- ground, his experiences and interests, for example, Attention ask about the current and the past prime ministers and Is the attention easily aroused and sustained; Ask the presidents of India, the capital of India, and the name patient to repeat digits forwards and backwards (digit of the various states. span test; digit forward and backward test), one at a Test for reading and writing; Use simple tests of time (for example, patient may be able to repeat 5 calculation. digits forward and 3 digits backwards). Start with two digit numbers increasing gradually up to eight digit Abstract thinking numbers or till failure occurs on three consecutive Abstract thinking is characterised by the ability to: occasions. a. assume a mental set voluntarily, b. shift voluntarily from one aspect of a situation to Concentration another, Can the patient concentrate; Is he easily distractible; c. keep in mind simultaneously the various aspects Ask to subtract serial sevens from hundred (100-7 of a situation, test), or serial threes from fifty (50-3 test), or to count d. grasp the essentials of a ‘whole’ (for example, backwards from 20, or enumerate the names of the situation or concept), and months (or days of the week) in the reverse order. e. to break a ‘whole’ into its parts. Note down the answers and the time taken to Abstract thinking testing assesses patient’s concept perform the tests. formation. The methods used are: a. Proverb Testing: The meaning of simple proverbs Memory (usually three) should be asked. a. Immediate Retention and Recall (IR and R) b. Similarities (and also the differences) between Use the digit span test to assess the immediate familiar objects should be asked, such as: table/ memory; digit forwards and digit backwards subtests chair; banana/orange; dog/lion; eye/ear.  Psychiatric History and Examination 15 Table 2.3: Clinical Rating of Insight The answers may be overly concrete or abstract. The appropriateness of answers is judged. Concretisa- Insight is rated on a 6-point scale from one to six. tion of responses or inappropriate answers may occur 1. Complete denial of illness. in schizophrenia. 2. Slight awareness of being sick and needing help, but denying it at the same time. Insight 3. Awareness of being sick, but it is attributed to exter- Insight is the degree of awareness and understanding nal or physical factors. that the patient has regarding his illness. 4. Awareness of being sick, due to something unknown in self. Ask the patient’s attitude towards his present state; 5. Intellectual Insight: Awareness of being ill and that whether there is an illness or not; if yes, which kind of the symptoms/failures in social adjustment are due illness (physical, psychiatric or both); is any treatment to own particular irrational feelings/thoughts; yet needed; is there hope for recovery; what is the cause of does not apply this knowledge to the current/future illness. Depending on the patient’s responses, insight experiences. can be graded on a six-point scale (Table 2.3). 6. True Emotional Insight: It is different from intellec- Judgement tual insight in that the awareness leads to significant basic changes in the future behaviour. Judgement is the ability to assess a situation correctly and act appropriately within that situation. Both social and test judgement are assessed. Table 2.4: Some Investigations in Psychiatry i. Social judgement is observed during the hospital stay and during the interview session. It includes I. Biological Investigations an evaluation of ‘personal judgement’. Medical Screen ii. Test judgement is assessed by asking the patient Some of the following tests may be useful in screen- what he would do in certain test situations, such ing for the medical disorders causing the psychiatric as ‘a house on fire’, or ‘a man lying on the road’, symptoms. Some examples of indications are stated in front of the tests (these examples are not intended to be or ‘a sealed, stamped, addressed envelope lying comprehensive). on a street’. Haemoglobin: Routine screen. Judgement is rated as Good/Intact/Normal or Poor/ Total and differential leucocyte counts: Routine screen, Impaired/Abnormal. Treatment with antipsychotics (e.g. clozapine), lithium, carbamazepine. INVESTIGATIONS Mean Corpuscular Volume (MCV): Alcohol dependence (increased). After a detailed history and examination, investi- Urinalysis: Routine screen; Drug screening. gations (laboratory tests, diagnostic standardised Peripheral smear: Anaemia. interviews, family interviews, and/or psychological Renal function tests: Treatment with lithium. tests) are carried out based on the diagnostic and Liver function tests: Treatment with carbamazepine, aetiological possibilities. Some of these investigations valproate, benzodiazepines. Alcohol dependence. are described briefly in Table 2.4. Serum electrolytes: Dehydration, SIADH, Treatment with carbamazepine, antipsychotics, lithium. FORMULATION Blood glucose: Routine screen (age>35 years), treatment with antipsychotics After a comprehensive psychiatric assessment, a diagnostic formulation summarises the detailed posi- Contd...  16 A Short Textbook of Psychiatry Contd... Thyroid function tests: Refractory depression, rapid Brain Imaging Tests (Cranial) cycling mood disorder. Treatment with lithium, car- Computed Tomography (CT) Scan: Dementia, delirium, bamazepine. seizures, first episode psychosis. Electrocardiogram (ECG): Age>35 years, Treatment with Magnetic Resonance Imaging (MRI) Scan: Dementia. lithium, antidepressants, ECT, antipsychotics. Higher resolution than CT scan. HIV testing: Intravenous drug users, suggestive sexual Positron Emission Tomography (PET) Scan: Research tool history, AIDS dementia. for study of brain function and physiology. VDRL: Suggestive sexual history. Single Photon Emission Computed Tomography (SPECT) Chest X-ray: Age>35 years, Treatment with ECT. Scan: Research tool. Skull X-ray: History of head Injury. Magnetic Resonance (MR) Angiography: Research tool Serum CK: Neuroleptic malignant syndrome (markedly Magnetic Resonance Spectroscopy (MRS): Research tool increased levels). Neuroendocrine Tests Toxicology Screen Dexamethasone Suppression Test (DST): Research tool Useful when substance use is suspected; for example, in depression (response to antidepressants or ECT). If alcohol, cocaine, opiates, cannabis, phencyclidine, plasma cortisol is >5 mg/100 ml following administra- benzodiazepines, barbiturates; remember that certain tion of dexamethasone (1 mg, given at 11 PM the night medications can cause false positive results (for example, before and plasma cortisol taken at 4 PM and 11 PM quetiapine for methadone). the next day), it indicates non-suppression. Drug Levels TRH Stimulation Test: Lithium-induced hypothyroidism, Drug levels are indicated to test for therapeutic blood refractory depression. If the serum TSH is >35 mIU/ml levels, for toxic blood levels, and for testing drug (following 500 mg of TRH given IV), the test is positive. compliance. Examples are lithium (0.6-1.0 meq/L), Serum Prolactin Levels: Seizures vs. pseudoseizures, carbamazepine (4-12 mg/ml), valproate (50-100 mg/ galactorrhoea with antipsychotics. ml), haloperidol (8-18 ng/ml), tricyclic antidepressants Serum 17-hydroxycorticosteroid: Organic mood (depres- (nortriptyline 50-150 ng/ml; imipramine 200-250 ng/ sion) disorder. ml), benzodiazepines, barbiturates and clozapine (350- Serum Melatonin Levels: Seasonal mood disorders. 500 μg/L). Biochemical Tests Electrophysiological Tests 5-HIAA: Research tool (depression, suicidal and/or EEG (Electroencephalogram): Seizures, dementia, pseu- aggressive behaviour). doseizures vs. seizures, episodic abnormal behaviour. MHPG: Research tool (depression). BEAM (Brain electrical activity mapping): Provides Platelet MAO: Research tool (depression). topographic imaging of EEG data. Catecholamine levels: Organic anxiety disorder (e.g. Video-Telemetry EEG: Pseudoseizures vs. seizures. pheochromocytoma). Evoked potentials (e.g. p300): Research tool. Genetic Tests Polysomnography/Sleep studies: Sleep disorders, sei- Cytogenetic work-up is useful in some cases of mental zures (occurring in sleep). The various components in retardation. sleep studies include EEG, ECG, EOG, EMG, airflow Sexual Disorder Investigations measurement, penile tumescence, oxygen saturation, Papaverine test: Male erectile disorder (intracavernosal body temperature, GSR (Galvanic skin response), and injection of papaverine is sometimes used to differentiate body movement. organic from non-organic male erectile disorder). Holter ECG: Panic disorder. Nocturnal penile tumescence: Male erectile disorder. Contd...  Psychiatric History and Examination 17 Contd... Serum testosterone: Sexual desire disorders, Male erectile used projective tests of personality are Rorschach inkblot disorder. test, TAT (Thematic apperception test), DAPT (Draw-a- Penile Doppler: Male erectile disorder. person test), and sentence completion test (SCT). Miscellaneous Tests Neuropsychological Tests Lactate provocation test: Panic disorders (In about 70% Some of the commonly used neuropsychological tests are of patients with panic disorders, sodium lactate infusion Wisconsin card sorting test, Wechsler memory scale, PGI can provoke a panic attack). memory scale, BG test (Bender Gestalt test), BVRT (Benton Drug assisted interview (Amytal interview): Useful in visual retention test), Luria-Nabraska neuropsychological catatonia, unexplained mutism, and dissociative stupor. test battery, Halstead-Reitan neuropsychological test bat- Discussed in Chapter 18. tery, and PGI battery of brain dysfunction. CSF examination: Meningitis. Rating Scales II. Psychological Investigations Several rating scales are used in psychiatry to quantify the Objective Tests psychopathology observed. Some of the commonly used These are pen-and-paper objective tests, which are scales are BPRS (Brief psychiatric rating scale), SANS employed to test the various aspects of personality and (Scale for assessment of negative symptoms), SAPS (Scale intelligence in a person. for assessment of positive symptoms), HARS (Hamilton’s Objective personality tests: Some examples of objective anxiety rating scale), HDRS (Hamilton’s depression rating personality tests are MMPI (Minnesota multiple personal- scale), and Y-BOCS (Yale-Brown obsessive-compulsive ity inventory) and 16-PF (16 personality factors). scale). Intelligence tests: Some commonly used tests of intel- Diagnostic Standardized Interviews ligence are WAIS (Wechsler adult intelligence scale), The use of these instruments makes the diagnostic Stanford-Binet test and Bhatia’s battery of intelligence assessment more standardized. These include PSE tests. (Present state examination), SCAN (Schedules for clinical Projective Tests assessment in neuropsychiatry), SCID (Structured clinical In projective tests, ambiguous stimuli are used which are interview for DSM-IV), and IPDE (International personal- not clear to the person immediately. Some commonly ity disorder examination). Table 2.5: Diagnostic Formulation tive (and important negative) information regarding the patient under the focus of care, before listing Biological Psychological Social differential diagnosis, prognostic factors, and a man- Predisposing agement plan. Precipitating The diagnostic formulation focuses on aetiological factors based on the biopsychosocial model (Table 2.5; Perpetuating Fig. 2.3). Similarly, it is useful to devise the manage- Protective ment plan based on the biopsychosocial model (Table 2.6). It is possible to use specific formulations based on Table 2.6: Management Plan treatment options; for example, a cognitive formula- tion for CBT and a psychodynamic formulation for Biological Psychological Social psychodynamic psychotherapy. Short-term Thus, psychiatric assessment is an initial step Medium-term towards diagnosis and management of psychiatric Long-term disorders. 18 A Short Textbook of Psychiatry SPECIAL INTERVIEWS There are different formats available for detailed eval- uation of special populations such as uncooperative patients, hostile and aggressive patients (Chapter 19), suicidal patients (Chapter 19), and children. These Fig. 2.3: Aetiological Factors Drawn on a Timeline formats should be used whenever appropriate.  Organic (Including 3 Symptomatic) Mental Disorders It is assumed that all psychological and behavioural evaluating a patient with any psychological or behav- processes, whether normal or abnormal, are a result of ioural clinical syndrome. The presence of following normal or deranged brain function. A rational corol- features requires a high index of suspicion for an lary would be that all psychiatric disorders are due to organic mental disorder (or what is loosely called as abnormal brain functioning and are therefore organic. organicity): However, this would be a gross oversimplification. 1. First episode. According to our present knowledge, there are 2. Sudden onset. broadly three types of psychiatric disorders: 3. Older age of onset. 1. Those due to a known organic cause. 4. History of drug and/or alcohol use disorder. 2. Those in whose causation an organic factor has 5. Concurrent medical or neurological illness. not yet been found or proven. 6. Neurological symptoms or signs, such as seizures, 3. Those primarily due to psychosocial factors. impairment of consciousness, head injury, sensory Only disorders with a known organic cause are or motor disturbance. called organic mental disorders. Thus, organic mental 7. Presence of confusion, disorientation, memory disorders are behavioural or psychological disorders impairment or soft neurological signs. associated with transient or permanent brain dysfunc- 8. Prominent visual or other non-auditory (e.g. olfac- tion and include only those mental and behavioural tory, gustatory or tactile) hallucinations. disorders that are due to demonstrable cerebral disease These disorders can be broadly subcategorised or disorder, either primary (primary brain pathology) into the following categories: or secondary (brain dysfunction due to systemic dis- 1. Delirium, eases). The use of term organic here does not imply 2. Dementia, that other psychiatric disorders are ‘non-organic’ in the 3. Organic amnestic syndrome, and sense of having no biological basis. It simply means 4. Other organic mental disorders. that the organic mental disorders have a demonstrable and independently diagnosable cerebral disease or DELIRIUM disorder, unlike other psychiatric disorders that do not at present. Delirium is the commonest organic mental disorder Since organic brain illness can mimic any psychi- seen in clinical practice. Five to fifteen percent of atric disorder, especially in the initial stages, organic all patients in medical and surgical inpatient units mental disorder should be the first consideration in are estimated to develop delirium at some time in  20 A Short Textbook of Psychiatry their lives. This percentage is higher in postoperative Lability of affect is usually present. Motor and patients. verbal perse veration, dysno mia, agraphia and Delirium is the most appropriate substitute for a impaired comprehension can also be seen. variety of names used in the past such as acute con- fusional states, acute brain syndrome, acute organic Diagnosis reaction, toxic psychosis, and metabolic (and other The diagnosis of delirium is frequently missed, as acute) encephalopathies. the possibility can be overlooked in medical/surgical settings. It is important to recognize delirium at the Clinical Features earliest possible as delirium often has an underlying Delirium is characterised by the following features: aetiology which may be correctable. Any delay in 1. A relatively acute onset, diagnosis, and thus starting treatment, may lead to 2. Clouding of consciousness, characterised by permanent deficits which can be irreversible. a decreased awareness of surroundings and a The diagnosis of delirium is mainly clinical. No decreased ability to respond to environmental ancillary laboratory test is diagnostic, although tests stimuli, and may help in finding the aetiology. 3. Disorientation (most commonly in time, then in According to ICD-10, for a definite diagnosis place and usually later in person), associated with of delirium, symptoms (mild or severe) should be a decreased attention span and distractibility. present in each one of the five areas described. These Marked perceptual disturbances such as illu- include impairment of consciousness and attention (on sions, misinterpretations, and hallucinations also a continuum from clouding to coma; reduced ability occur. These are most commonly visual though to direct, focus, sustain, and shift attention), global other perceptual domains can also be involved. disturbance of cognition, psychomotor disturbances, There is often a disturbance of sleep-wake cycle; disturbance of sleep-wake cycle, and emotional dis- most commonly, insomnia at night with daytime turbances. drowsiness. Diurnal variation is marked, usually with The onset is usually rapid, the course diurnally worsening of symptoms in the evening and night fluctuating, and the total duration of the condition (called sun downing). There is also an impairment much less than 6 months. The above clinical picture of registration and retention of new memories. is so characteristic that a fairly confident diagnosis of Psychomotor disturbance, usually in form of delirium can be made even if the underlying cause is agitation and occasionally retardation, is present. not clearly established. Generalised autonomic dysfunc tion, speech and A history of underlying physical or brain disease, thought disturbances (such as slurring of speech, and/or evidence of cerebral dysfunction (e.g. an abnor- incoherence, dysarthria, and fleeting delusions) are mal EEG, usually but not always, showing slowing often present. of the background activity) may help in reaching the The motor symptoms in delirium can include: diagnosis. 1. Asterixis (flapping tremor), 2. Multifocal myoclonus, Predisposing Factors 3. Carphologia or floccillation (picking movements Presence of certain predisposing factors lowers the at cover-sheets and clothes), threshold for the development of delirium (Table 3.1). 4. Occupational delirium (elaborate pantomimes as if continuing their usual occupation in the hospital Aetiology bed), and The list of possible causes of delirium is virtually 5. Tone and reflex abnormalities. endless. Any factor which disturbs the metabolism of  Organic (Including Symptomatic) Mental Disorders 21 brain sufficiently can cause delirium. The aetiology of One of the important causes of delirium, namely delirium demonstrates a threshold phenomenon, with post-cardiac surgery delirium, is discussed in Chapter a combination of factors adding up to cross a threshold 12. The most common causes are listed in Table 3.2. for causing delirium, which appears to be different for each individual. Management 1. In cases where a cause is not obvious (or other contributory causes are suspected), a battery of Table 3.1: Predisposing Factors in Delirium investigations should be done which can include 1. Pre-existing brain damage or dementia complete blood count, urinalysis, blood glucose, 2. Extremes of age (very old or very young) blood urea, serum electrolytes, liver and renal 3. Previous history of delirium function tests, thyroid function tests, serum B12 and 4. Alcohol or drug dependence folate levels, X-ray chest, ECG, CSF examination, 5. Generalised or focal cerebral lesion urine for porphyrins, drug screens, VDRL, HIV 6. Chronic medical illness testing, arterial pO2 and pCO2, EEG, and brain 7. Surgical procedure and postoperative period imaging (such as cranial CT scan or MRI scan). 8. Severe psychological symptoms (such as fear) 2. Identification of the cause and its immediate 9. Treatment with psychotropic medicines correction, e.g. 50 mg of 50% dextrose IV for 10. Present or past history of head injury 11. Individual susceptibility to delirium hypoglycaemia, O2 for hypoxia, 100 mg of B1 IV Table 3.2: Delirium: Some Important Causes Metabolic Causes iv. Anticonvulsants, L-dopa, Opiates i. Hypoxia, Carbon dioxide narcosis v. Salicylates, Steroids, Penicillin, Insulin ii. Hypoglycaemia vi. Methyl alcohol, heavy metals, biocides. iii. Hepatic encephalopathy, Uremic encephalopa- Nutritional Deficiencies thy i. Thiamine, Niacin, Pyridoxine, Folic acid, B12 iv. Cardiac failure, Cardiac arrhythmias, Cardiac ii. Proteins arrest Systemic Infections v. Water and electrolyte imbalance (Water, Na+, i. Acute and Chronic, e.g. Septicaemia, Pneumo- K+, Mg++, Ca++) nia, Endocarditis vi. Metabolic acidosis or alkalosis Intracranial Causes vii. Fever, Anaemia, Hypovolemic shock i. Epilepsy (including post-ictal states) viii. Carcinoid syndrome, Porphyria ii. Head injury, Subarachnoid haemorrhage, Sub- Endocrine Causes dural haematoma i. Hypo- and Hyperpituitarism iii. Intracranial infections, e.g. Meningitis, En- ii. Hypo- and Hyperthyroidism cephalitis, Cerebral malaria iii. Hypo- and Hyperparathyroidism iv. Migraine iv. Hypo- and Hyperadrenalism v. Stroke (acute phase), Hypertensive encephalo- Drugs (Both ingestion and withdrawal can cause pathy delirium) and Poisons vi. Focal lesions, e.g. right parietal lesions (such i. Digitalis, Quinidine, Antihypertensives as abscess, neoplasm) ii. Alcohol, Sedatives, Hypnotics (especially bar- Miscellaneous biturates) i. Postoperative states (including ICU delirium) iii. Tricyclic antidepressants, Antipsychotics, An- ii. Sleep deprivation ticholinergics, Disulfiram iii. Heat, Electricity, Radiation  22 A Short Textbook of Psychiatry for thiamine deficiency, and IV fluids for fluid and Impairment of all these functions occurs globally, electrolyte imbalance. causing interference with day-to-day activities and 3. Symptomatic measures: As many patients are interpersonal relationships. There is impairment of agitated, emergency psychiatric treatment may judgement and impulse control, and also impairment be needed. Small doses of benzodiazepines(lora- of abstract thinking. There is however usually no im- zepam or diazepam) or antipsychotics (haloperi- pairment of consciousness (unlike in delirium; Table dol or risperidone) may be given either orally or 3.3). The course of dementia is usually progressive parenterally. Maintenance treatment can continue though some forms of dementia can be reversible. till recovery occurs, usually within a week’s time. Additional features may also be present. These There is an increased risk of stroke in elderly include: patients with dementia with prescription of 1. Emotional lability (marked variation in emotional atypical antipsychotics such as olanzapine and expression). risperidone. 2. Catastrophic reaction (when confronted with an 4. Supportive medical and nursing care. assignment which is beyond the residual intellec- tual capacity, patient may go into a sudden rage). DEMENTIA 3. Thought abnormalities, e.g. perseveration, delu- Dementia is a chronic organic mental disorder, char- sions. acterised by the following main clinical features: 4. Urinary and faecal incontinence may develop in 1. Impairment of intellectual functions, later stages. 2. Impairment of memory (predominantly of recent 5. Disorientation in time; disorientation in place and memory, especially in early stages), person may also develop in later stages. 3. Deterioration of personality with lack of personal 6. Neurological signs may or may not be present, care. depending on the underlying cause. Table 3.3: A Comparison of Delirium and Dementia Features Delirium Dementia 1. Onset Usually acute Usually insidious 2. Course Usually recover in 1 week; Usually protracted, although may be reversible may take up to 1 month in some cases 3. Clinical features a. Consciousness Clouded Usually normal b. Orientation Grossly disturbed Usually normal; disturbed only in late stages c. Memory Immediate retention and Immediate retention and recall normal recall disturbed Recent memory disturbed Recent memory disturbed Remote memory disturbed only in late stages d. Comprehension Impaired Impaired only in late stages e. Sleep-wake cycle Grossly disturbed Usually normal f. Attention and concentration Grossly disturbed Usually normal g. Diurnal variation Marked; sundowning may Usually absent be present h. Perception Visual illusions and Hallucinations may occur hallucinations very common i. Other features Asterixis; multifocal myoclonus Catastrophic reaction; perseveration  Organic (Including Symptomatic) Mental Disorders 23 Diagnosis 3. Depressive pseudodementia: Depression in the elderly patients may mimic dementia clinically. It Like delirium, the diagnosis of dementia is clinical is called as depressive pseudodementia (Table 3.4). though ancillary laboratory investigations may help Identification of depression is very important as it in elucidating the underlying aetiology. is far more easily treatable than dementia. According to ICD-10, the following features are The depressed patients often complain of memory required for diagnosis: evidence of decline in both impairment, difficulty in sustaining attention and memory and thinking, sufficient enough to impair concentration, and reduced intellectual capacity. In personal activities of daily living, memory impairment contrast, patients with dementia do not often complain (typically affecting registration, storage, and retrieval of these disturbances. In fact, when confronted with of new information though previously learned material evidence of memory impairment, they often con- may also be lost particularly in later stages, impaired fabulate. As depression may often be superimposed thinking, presence of clear consciousness (conscious- on dementia, it is at times necessary to undertake a ness can be impaired if delirium is also present), and therapeutic trial with antidepressants, if the clinical a duration of at least 6 months. picture is unclear. The following conditions must be kept in mind in It is useful to differentiate dementia into cortical the differential diagnosis of dementia. and subcortical subtypes (Table 3.5). 1. Normal aging process: Although impairment of memory and intellect are commoner in elderly, Aetiology their mere presence does not justify a diagnosis A large number of conditions can cause dementia of dementia. Dementia is diagnosed only when (Table 3.6). However, a majority of cases are due to there is demonstrable evidence of memory and a few common causes such as Alzheimer’s disease other intellectual impairment which is of sufficient and multi-infarct dementia. Some clinically important severity to interfere with social and/or occupati