Psychopathology_introduction _signs and Symptoms

Psychopathology II (MPS 333)

Psychopathology /Mental health disordersMicro syllabusUnit1Definitions and types (perspectives)of psychopathologyDef. of signs, symptoms, syndrome, illness, disorder, disease Classification- Reliability, validity, two major systems (DSM vs. ICD), merits and demerits of classification , differences in DSM and ICD

4. Signs/symptoms-definition with examples (Hallucination, Delusion, Obsession, Illusion, Disruptions of thinking) 5. Cognitive disorders ( Delirium, Dementia, and Amnestic disorders)- Features, name of subtypes based on causes for all three types), some conditions causing amnestic disorders ( e.g., ECT, HIV, etc. ), Global transiant amnesia 5. Differentiate between Dilirum and Demnetia and Amnesia6. Dementia vs. normal aging7. Changes in DSM 5 in the classification of dementia and amnestic disorders EpilepsyDefinitionWhy mental health professions have to deal epileptic patientsTypes ( partial and generalized and their subtype just a short description)Pre, post, and inter-ictal symptomsHysterical vs. epileptic fit

DSM multi axis Axis I - All categories of clinical syndromes (a configuration of symptoms), except personality disorders and mental retardation Axis II - Personality disorders (long-standing patterns of maladaptive behavior) and mental retardation (deficient cognitive functioning) Axis III - General medical conditions Axis IV- Psychosocial stressors (recent stressors, social resources, sociocultural background) and environmental problems Axis V - Global level of current functioning (overall clinical rating of degree of impairment) 6Cognitive disordersCognition includes- memory, language, orientation, conducting of interpersonal relationship, performance of actions( praxis), and problem solvingCognitive disorders reflect disruption in one or more of these domains, and are also frequently complicated by behavioral symptoms In DSM three group of disorders- dementia, delirium, and amnestic disorders- are characterized by primary symptoms common to all the disorders which is an impairment of cognitionsOther disorders can exhibit some cognitive impairment as a symptom, cognitive symptom is cardinal symptom in delirium, dementia and amnestic disordersIn past these disorders were classified under the heading organic brain disorders or organic mental disordersOrganic (identifiable pathological conditions such as brain tumor) vs. functional ( e.g., depression)This dichotomy is no longer accepted Every mental disorders has an organic components

Dementia Micro contentsWhat is dementia? ( clinical features)Causes of dementia?Course and prognosisDifferential diagnosis ( differentiate between) Dementia vs. deliriumDementia: reversal vs. irreversible Types of dementia ( focus on Vascular vs. Alzheimers type in regard to clinical features) Normal ageing vs. dementiaDementia vs. MR Sun-downing Pseudo-dementiaRisk of dementia Briefly - management and treatment

11DeliriumClinical features Types and Diagnostic Criteria Tests Causes (aetiology) Differential Diagnosis ( mostly w/ Dementia) Course and prognosisEpidemiology ( Include India data )Treatment and management (focus in psychosocial interventions)Why it is called syndromanal disorder? Delirium is characterized by global impairment in consciousness? Explain.

12Features of Dementia Marked by severe impairment in memory, judgment and cognition. There are six categories : 1) dementia of Alzheimers type which usually occurs in persons older than 65 years of age, 2) vascular type-cause by vessel hemorrhage, 3) Other medical conditions (eg. HIV infection, head trauma) 4) substance induced- multiple etiologies5) NOS-if cause if unknownIt is characterized by progressive impairment of cognitive functions occurring in clear consciousness Consist of variety of symptoms that suggest chronic and widespread dysfunction Global impairment in intellect is essential; feature( manifested as difficult with memory, attention, thinking and comprehension)

Delirium: marked by short term confusion and changes in cognition; There are four subcategories based on causes:General medical condition2. substance induces ( eg. Cocaine) Multiple causes 4) Delirium NOS ( Not otherwise specified)

It is defined by the acute onset of fluctuating impairment and a disturbance of consciousness with reduced ability to attendDelirium is a syndrome not a disease- it has many causes, all of which result in a similar pattern of signs and symptoms relating the patients level of consciousness and cognitive impairment In DSM it is characterized as a disturbance of consciousness and change in cognition that develops over short time

Delirium is called syndromonal disorder Hallmark is impairment of consciousness usually occurring in association with global impairment of cognitive functionsAbnormalities of mood, perception, and behavior are common psychiatric symptoms; tremors, incordination, and urinary incontinence are common neurological symptoms Rapid improvement when causative factors are identified and treated

Amnestic disorders: marked by memory impairment and forgetfulness . Three subcategories are: Caused by medical condition ( e.g., hypoxia) Caused by toxin or medication ( diazepam, marijuana) NOSAmnestic disorders are a broad categories that include a variety of diseases and conditions that are present with an amnestic syndrome The syndrome is defined as promarily by impairment in the ability to create new memoriesPatients with amnestic disorders do not have good insight into their neuropsychiatirc conditionsThe central feature is the development of a memory disorder characterized by impairment to learn new information ( anterograde amnesia) and the inability to recall previously remembered knowledge (retrograde) Must result in significant problems for a patient in their social and occupational functioning) Confusion- is the state of being bewildered or unclear in ones mind about somethingConfusion: inability to think clearly/ it occurs characteristically in states of impaired consciousness but it can occur consciousness is normalConsciousness: awareness of the self and the environment

Cognitive disorder NOSAllows the diagnosis of cognitive disorders that does not fit in above categories Amnestic disordersSyllabus for amnestic disorders(pp no. 344-350, Synopsis (10th Ed.)

22Amnestic disorders are broad category of disorders that comprise variety of diseases and conditions presenting w/ amnsetic syndrome

Amnestic syndrome is characterized primarily by the impairment in the ability to create new memory There are three types of amnestic disorders diagnosis based on etiology; 1) Amnestic disorder caused by general medical condition, 2) substance-induced persisting amnestic disorder, and 3) amnestic disorder NOS

Epidemiology No adequate studies have reported on the incidence or prevalence of amnestic disordersAmnesia is most commonly found in alcohol use disorders and in head injury. In general practice and hospital settings, the frequency of amnesia related to chronic alcohol abuse has decreased, and the frequency of amnesia related to head trauma has increased

24Systemic medical conditionsThiamine deciency (Korsakoffs syndrome) HypoglycemiaPrimary brain conditions SeizuresHead trauma (closed and penetrating) Cerebral tumors (especially thalamic and temporal lobe) Cerebrovascular diseases (especially thalamic and temporal lobe) Surgical procedures on the brain Encephalitis due to herpes simplex Hypoxia (including non fatal hanging attempts and carbon monoxide poisoning) Transient global amnesiaElectroconvulsive therapy Multiple sclerosis Substance related causes Alcohol use disorders Neurotoxins Benzodiazepines (and other sedative-hypnotics)Many over-the-counter preparations25Diagnostic criteria(refer the DSM)

Clinical features

Amnestic disorders are characterized as having , specific impairment of episodic memory, manifesting as inability to learn new information (anterograde amnesia) and to recall past events (retrograde amnesia), in the absence of evidence for generalized intellectual dysfunction, accompanied by significant impairment in social or occupational functioning and evidence of general medical condition etiologically related to the memory impairment (DSM IV)27Time in which the patient is amnestic can begin at the point of trauma, or include the period before the traumaShort term and recent memory are usually impairedThey cannot remember what they had in lunch and breakfast (recent), name of the hospital or their doctorsIn some case it is profound that they cannot orient them to city and time Onset can be sudden ( as in trauma, cerebrovascular events, and neurotoxic chemical assaults ), or gradual ( as in nutritional deficiency and brain tumors)

28SubtypesCerebrovascular diseases ( affecting the hyppocampus) Multiple sclerosis Korsakoffs syndrome (amnsetic syndrome caused by thiamine deficiency, most commonly associated w/ poor nutritional habitsA syndrome of severe memory impairment accompanied by confabulation and irritability was first described by the Russian neuropsychiatrist, Korakov (1889)

The word Korsakov syndrome has been used to denote both a clinical picture and a pathological entityThe alternative Wernicke-Korsakov was proposed by Victor (1971) because the chronic amnestic syndrome often follows an acute neurological syndrome ( described by Wernicke 1981)

Alcoholic black outs Electroconvulsive therapy Head injury ( both closed and penetrating) Global transient amnesia

29Transient global amnesiaTransient global amnesia is characterized by the abrupt loss of the ability to recall recent events or to remember new informationThe syndrome is often characterized by mild confusion and a lack of insight into the problem, aclearsensorium, and, occasionally, the inability to perform some well learned complex tasks Episodes last from 6 to 24 hoursPatients with transient global amnesia almost universally experience complete improvementDifferential diagnosisDementia and delirium Normal aging (not significant impairment (minor) vs. significant)Dissociative disorders (lost their orentation to self and more selective memory deficits than patients w/ amnestic syndrome)Factitious disorder ( inconsistent results in memory tests)

31Course and prognosisCourse depends on etiology and treatment (particularly acute treatment) Generally it has static courseLittle improvement over the time but also no progression on the disorderException are acute amnesia (e.g., global transient amnesia (resolves in hoirs or days), amnesia due to head injury (improves steadily in months subsequent to trauma)

Treatment and psychotherapyPrimary treatment treat underline causeSupportive prompts ( like dates, names) make reduce patients anxietyAfter recovery, psychotherapy of some type (cognitive, psychodynamic, or supportive) may help incorporate patients amnestic experience into life Psychodynamic interventions may be of considerable value for patients who have amnestic disorders that result from insults to the brainUnderstanding the course of recovery in such patients helps clinicians to be sensitive to the injury inherent in damage to the central nervous system EpilepsySyllabus What is epilepsySigns and symptomsSeizures TypesClinical featuresHysterical fit vs. epileptic fit

34The most common chronic neurological disease in general population and affects For psychologist/psychiatrist the major concern about epilepsy are the psychological ramifications of a diagnosis for a patient and the psychological and cognitive effects of commonly used anticonvulsant drugs30-50 % of all persons w/ epilepsy have psychiatric difficulties sometime during the course of illnessThe most common behavioral symptom of epilepsy is a change in personalityPsychosis and violence occurs much less commonly that was previously believed

Definitions: A seizure is a transient paroxysmal (sudden recurrence of intensification in symptoms like seizure or spasm-in this case seizure) pathophysiological disturbance of cerebral function caused by a spontaneous, excessive discharge of neurons The ictus, or ictal event is the seizure itselfNonictal periods are categorized as preictal, postictal, and interictalThe symptoms of ictal period is determined by the site of the origin in the brain

Interictal symptoms are influenced by the ictal event and other neuropsychiatric and psychosocial factors, such as comorbid psychiatric or neurological illness, presence of the psychological stressors, premorbid personality traits etc.,

Classification

Generalized tonic-clonic seizure (grand mal)Exhibit classic symptoms of loss of conciousness, generalized tonic-clonic movements of the limbs ( convulsion), tougue biting, and incontinenceDiagnosis of ictal event is relatively straightforward, but postictal events (characterized by slow gradual recovery of conciousness and cognition), occasionally presents a diagnostic dilemma

-Absence seizure ( petit mal): this is a subtype of generalized seizure The epileptic nature of seizure go unrecognized because the characteristic motor or sensory manifestations of epilepsy may be absent or so slight that may not get attention ( or suspicion) Petit mal usually begins in childhood between 5-7 yearsBrief disruptions of consciousness but no true loss of consciousness and no convulsionsEEG gives characteristic patterns 3 /sec spike

Partial seizuresThey are classified as simple ( without alteration of consciousness), or complex (with alteration of consciousness)Somewhat more than half of all patients w/ partial seizure have complex partial seizureOther terms used for complex partial seizure are temporal lobe epilepsy, psychomotor seizure, and limbic epilepsy Complex partial seizure ( the most common form of epilepsy in adults), affects 3 in 1000 personsAbout 30 % of patients with complex partial seizures have major mental illness such as depression

symptoms

Tonic seizuresDuring a tonic seizure, the persons muscles initially stiffen and they lose consciousness. The persons eyes roll back into their head as the muscles (including those in the chest, arms and legs) contract and the back arches. As the chest muscles tighten, it becomes harder for the person to breathe the lips and face may take on a bluish hue, and the person may begin to make gargling noises.

Clonic seizuresDuring aclonic seizure, the individuals muscles begin to spasm and jerk. The elbows, legs and head will flex, and then relax rapidly at first, but the frequency of the spasms will gradually subside until they cease altogether. As the jerking stops, it is common for the person to let out a deep sigh, after which normal breathing resumes.

Tonic-clonic (grand mal) seizuresA tonic seizure is typically accompanied by a clonic seizure it is rare to experience one without the other. When both are experienced at the same time, this is known as atonic-clonic seizure(formerly known as agrand mal seizure).

Hysterical fit and epileptic fit (self study)What is psychopathology?The study of abnormal sate of mindIt embraces three distinct approaches:a) Descriptive ( also call phenomenology) , b) Psychodynamic psychology, c) experimental psychopathology 50Terms used to describe symptomsThe form and content of symptomsPrimary and secondary symptoms- they are used in two different meaning ; first is temporal and second is causal ( arising directly to pathological condition and arising as a reaction to a primary symptom) 51The significance of individual symptoms Psychiatric disorders are diagnosed when a defined of symptoms ( a syndrome) is presentAlmost any single symptom can be experiences by a healthy person ( even hallucination)- ( exception isolated delusion is generally considered to be evidence of psychiatric disorders if it is definite and persistent)

52Importance of patients experiencesymptoms and signs are only part of subject matter of psychopathologyIt is concerned also with patients experience of illness, and the way in which psychiatric disorder changes his view o f himself, his hopes for future, and his view of the world

53Cultural Variations in psychopathology Descriptions of symptoms and signs Pseudo-hallucination?? Disorders of moodTwo terms used to refer an emotional state- mood and affectMood is now in more general use as it has been adopted in major classifications In psychiatric disorders mood may be abnormal in three ways;1. altered in nature, 2. more or less than normal fluctuations, and 3. may be inconsistent with patients clients thoughts and actions or circumstances56 Changes in the nature of the mood: can be towards anxiety, depression, elation, or irritability and angerVariations in mood: normal mood varies in relation to persons situations- in abnormal states mood may continue to vary but the variations may be greater or less (Liability- increased variations, extremes variations are sometimes called emotional incontinence, blunting or flattening- reduced variations ( extreme flattening sometimes called apathy)

57 Incongruous mood ( what about embarrassed laughter???- this person is in awkward situation (ill at ease)

AnxietyNormal response to dangerBecomes abnormal when it is out of proportion to the threat of danger or when it outlasts the dangerCoupled w/ somatic and autonomic components, and psychological Psychological components: essential feelings of dread and apprehension accompanied by restlessness and narrowing of attention to focus on the source of danger, worrying thoughts, increased alertness and irritabilitySomatic: Muscle tensions, perspiration, muscle tension tremor etc. Autonomic components: activation of ANS

58 Phobia: habitual avoidance of a situation (object) to an extent that exceeds the extent of danger ( persistent irrational fear of, and wish to avoid a specific object of situation)Anticipatory anxiety: anxiety when thinking about a phobic object/situation

59Depression It is a normal response to loss or misfortunesIt becomes abnormal when it is out of proportion to the misfortune ( or loss), or unduly prolongedCoupled with other changes like lowering of self esteem, self-criticism and pessimistic world view ( characteristic features- turned corners of mouth, furrowed eyebrow, hunched and dejected posture)

60ElationAn extreme degree of mood coupled w/ increased feeling of self-confidence and well-being, increased arousal and increased activity ( occurs in mania and hypomania)Irritability and angerState of increased readiness for anger ( they mostly occur in many kinds of disorders so that it has less value in diagnosis)

61Disorders of perceptionPerception (process of becoming aware of what is presented through the sense organs) vs. Imagery (awareness of percept that has not arisen from the sense organs but has been generated within the mind

62Sensory distortionsChange in intensity ( Hyperanethesia- increased intensity of sensations, and hypoanesthesia, e.g., anxious people may perceive sensations as more intense than usual, in mania perceptions seem more intense and vivid than usualChanges in quality (visual distortions brought about by toxic substances which color all perceptions- coloring of yellow, green and red have been called xanthopsia, chloropsia, and erthropsia, schizophrenic patients experience sensations as unpleasent ( food tastes bitter, flower smells like burning flesh)

63IllusionsMisperception of external stimuliThey occur when general level sensory stimulation is reduced and when attention is not focused on relevant sensory modalityIt occurs when the level of consciousness is reduced in delirium ( in both healthy and abnormal state illusions are likely when person is anxious) Stimuli from a perceive object are combined with a mental images to produce a false perceptions ( unfortunately the word illusion is also used for perceptions which dont agree with the physical stimuli, such as Muller-Lyer illusion)Generally it is understood that it is as the result of set, lack of perceptual clarity, and intense emotionsBut the fact is the intense emotions produce a set, and may decrease perceptual clearness (acuity) Illusions are not in themselves morbid as they can occur in anybody when they can be corrected ( interpreting shadow as ghost)In delirium the perceptual threshold is raised, and patient is usually anxious and bewildered, so illusions are quite common ( patient may interpret innocents gestures of doctor as threat)

Recap:Q1. what are the essential characteristic/features of phobiaQ2. What are the three main ways that mood can be disordered?Q3. Differentiate perception and imagery?

66Hallucinations A percept experienced in the absence of external stimulus to the relevant sense organsPerception without an object (Esquirols)A false perception, which is not a sensory distortions or misinterpretation, but which occurs as the same time as real perceptions (Jaspers) Illusion-originating in the outside world or within the persons body) It cannot be terminated at will but illusions can beIts occurrence generally indicate psychiatric disorders but it occurs occasionally in healthy people as well ( generally during falling asleep (hypnagogic hullucination) or on waking (hypnopomic hullucination)

PseudohullucinationExperience similar to hallucination but do not meet all the requirements of the definitionIt has two meanings: it is a sensory experience that differs from hallucination in not seeming to the patient to represent external reality. Instead percepts seem to locate within the mind rather than in external space resembling imagery ( but unlike imagery they cannot be dismissed at will)- this is also called imagined psuedohullucination Experience appears to originate in the external space (world) but it seems unreal- this is also called perceived hallucination

68Types of hallucinationAccording to complexityElementary (experience such as bangs, whistles, flashes of light etc.)Complex (hearing voices or music, seeing scene, faces etc.)According to sensory modalityAuditoryVisualOlfactory and gustatory (taste and smell) Somatic (tactile and deep)

69According to special featuresAuditory1. second person2. third person3. Gendankenlautwerden ( voice seem to speak patients thought as he is thinking them)4. echo de la pensee (or repeat them immediately after he has thought them0

70Visual1. Extracampine: hallucination located outside the visual field (usually behind the head)lilliputian: visual hallucination of dwarf figures( smaller than the corresponding real percept) 71Autoscopic hallucination (seeing ones own body projected into external space usually in front of oneself ( reported occasionally by mentally healthy people with sensory deprivation ( when it is called out-of-body experience), or after a near fatal accident or heart attack ( called a near-death experience) Reflex hallucination (rare condition in which a stimulus in one sensory modality results in a hallucination in another (music may provoke musical hallucinations, it occurs usually after taking drugs like LSD or rarely in schizophrenia) Hypnagogic and hypnopomic hallucinations

72Abnormalities in the meaning attached to perceptDelusional perception: in some disorders abnormal meaning or significance is attached to a normal percept. This is called delusional perception ( this is disorder of thinking not disorder of perception (covered in disorder of thinking in subsequent slides)

73Diagnostic associations(very important)Following kind of hallucinations have implications for diagnosis Auditory hallucination: mostly voices heard speaking clearly to or about to patient have diagnostic implication ( e.g., third-person hallucination (she washing her face. He is wasting time.) are strongly associated w/ schizophreniaHowever content of second-person auditory hallucinations ( addressing to the patient- e.g. ,you are going to meet an accident) may have diagnostic implicationsVoices w/ derogatory content (e.g., you are failure , you are wicked) suggest sever depression especially when patient accept them as justified, but in schizophrenia patients more often resent such outcomes (versus justified in depressive). Voices which anticipate, echo, or repeat the patients thoughts also suggest schizophrenia

74 visual hallucination always suggest organic disorderHallucinations of taste and smell are infrequent, they occur in schizophrenia, severe depressive disorders, and temporal lobe epilepsy, and in tumors affecting the olfactory pathways or bulbsTactile and somatic hallucinations: not of much diagnostic implication; however hallucinatory sensations of sexual intercourse suggest schizophrenia specially if interpreted in unusual way (e.g., as resulting from intercourse with prosecutors) 75Disorders of thinkingWhat is thinking? There are three legitimate uses of the word think. These are:Undirected fantasy thinking, also called autistic thinking or dereistic thinking ( it is quite normal but some quit, shy people may compensate for the disappointments- schizoid individual became schizophrenic when his autistic thinking became uncontrollable) Imaginative thinking which does not go beyond the rational and the possibleRational thinking or conceptual thinking which attempts to solve the problem

76Types of disorders of thinking Based on particular kind of abnormal thoughtsa. Delusions b. Obsessions2. Disorders of stream of thoughts (speed and pressure)3. Disorders of the form of thoughts4. Abnormal beliefs about the possession of thoughts

77Disorders of the stream of thought ( the amount and the speed of thinking are changed)Pressure of thought: ideas arise in unusual variety and abundance and pass through the mind rapidly ( in mania)Poverty of thought: patient has few thoughts, and these lack variety and richness and seem to move slowly through mind ( in depressive disorders)

78Thought block: sometimes the stream of thought is interrupted suddenly

-The patient feels that his mind has gone blank, and observer notices sudden interruption in patients speech/ in anxious and tires people minor thought blocking is normal experience

- in thought blocking the interruptions are sudden, striking , and repeated experienced by patient as an abrupt and complete emptying of his/her mind 79Disorders of the form of the thought ( also known as formal thought disorder) is usually recognized from speech and writing but sometimes evident from the patient's behaviors ( e.g., unable to file paper under appropriate category heading)

Formal thought disorders can be divided into:perseveration: persistent and inappropriate repetition of same thought ( can be examined by persons words or actions- in response to series of simple questions person may give correct answer to the first but continue to give the same answer inappropriately to subsequent questions)

802. Flight of idea (foI): thought and speech move quickly from one topic to another so that one train of thought is not carried to completion before another takes place- The normal logical sequence of ideas is generally preserved, although ideas may be linked by distracting cues in the surroundings and the distractions arising from words that have been spoken/ these verbal distractions are of three kinds:Clang associations: a second word similar to first one)Puns : a second meaning of the first word Rhymes Foi is characteristic of mania813. Loosening of associations: loss of normal structure of the thinking- to observer patients discourse seems muddled and illogical and it does not become clearer when the patient is questioned further

( general lack of clarity of anxious or less intelligent people is different than lack of clarity observed in loosening of association in a sense anxious people express clarity when they are put at ease or when interviewer reframes questions in more simpler ways give more time to respond)

- but in loosening of association more the interviewer tries to ask question less he/she understand it

82There are three types of loosening of associations:Derailment (Knights move): transition from one topic to another, either between sentences or in mid-sentence, w/o logical relationship between the topics and no evidence of the associations described above under foiTalking past the point (vorbeireden): seems always about to get near to the matter in hand but skirts round it and never reaches itVerbigeration: speech is reduced to the senseless repetition of sounds, words or phrases ( can occur w/ sever aphasia and occasionally in schizophrenia)- when the abnormality is extreme the disorder is called word salad

83Other related disorder of thinking: Overinclusion: widening of boundaries of concepts , such that things are grouped together that are not normally regarded as closely connectedNeologisms: words or phrases invented by patients, often to describe morbid experience ( most often in chronic schizophrenia)

84DelusionsDefinitionA belief that is firmly held on inadequate grounds, and which is not affected by rational argument or evidence to the contrary and which is not conventional belief that the person might be expected to hold given his/her cultural and educational background 85Characteristic of delusionsFirmly held despite evidence to the contraryThe hallmark of delusion is that it is held with conviction and cannot be altered with the evidence to the contraryStrongly held non-delusional ideas are called over-valued ideas- the beliefs of a convinced spiritualist are not undermined by the counter arguments of non-believer ( e.g., Ganesh idol drinking milk)86Partial delusions- usually held strongly from the start, sometimes at first held with a degree of doubts ( also experienced by patients who had full delusion and then started doubting during recovery)

872. Delusions are held on inadequate grounds: some delusions appear suddenly with out any previous thinking about the subject (primary), and some appear to be attempts to explain another abnormal experience ( delusions that the hallucination voices are those of people who are spying- this delusion failed to meet this criterion but meet the first criterion so it still qualifies as delusion)

3. Delusions are not belief shared by other from the same culture

88Q. Delusions are false beliefs? Can this be included as criterion while defining them?Q2. What is double orientation?89Types of delusionAccording to fixity1.Complete ( full delusion)2. Partial delusion ( some doubts at the start or during the recovery) According to onsetPrimary (appears suddenly and with and with full conviction but w/o any mental events leading up to it; they are given considerable weightage during diagnosis of schizophrenia) Secondary (derived from previous morbid experience)

90Other delusional experiences1. Delusional mood ( usually patient first experiences the delusion and responds emotionally, but occasionally change of mood precedes the delusions and when the delusion follows it explains the mood- this change of mood is called delusional mood ( it is mood from which delusion arises)912. Delusional perception: (sometimes the first abnormal experience is the attaching of a new significance to a familiar percept without any reason to do so (position of letter left on patients desk may be interpreted as a sign to die)

-Abnormality is in attaching the meaning to the percept ( in the later stages of perception) 923. Delusional memory: a new significance is attached to past event ( a patient who believes that there is a plot to kill him, may remember that he vomited after a meal, eaten long before his present delusional system began, and conclude that he was poisoned on that occasion)

Q. Illusion of doubles (Lillusion de sosies)??Q. Fergoli delusion 93According to themePersecutory (paranoid): diagnostic significance depressive patients may think justified vs. schizophrenic patients resents and thinks it is unwarrantedDelusions of reference: objects, events, or people, unconnected w/ the patient have personal significance to him ( an article in newspaper is directed specially to him)Grandiose (expansive): exaggerated self importance ( occur in mania and schizophrenia) Delusion of guilt and worthlessness: most often occur in depressive disorders ( sometimes also called depressive delusions) typical themes are minor infringement of law in past will be discovered and bring shame upon the patientNihilisticHypochondriacal: Concerned with illnessReligiousJealousSexual or amorous: ( loved by a man who is usually inaccessible to her)Delusion of control

94 Delusion concerning possession of thoughts11. Thought insertion12. Thought withdrawal13. Thought broadcasting

95According to other featuresShared delusions- Usually other people recognize delusions as false argue w/ the patient in an attempt to correct them. Occasionally a person who lives w/ deluded patient comes to share his delusional beliefs. This condition is called folie a deux

96Obsessional and compulsive symptoms ObsessionsDef.: They are recurrent persistent thoughts, impulses or images that enter the mind despite efforts to exclude themOne characteristic feature-there is subjective sense of struggle (patient resists the obsession)Another characteristic feature-a conviction that to think something is to make it more likely to happenObsessions are recognized as his/her own and not implanted from elsewhere ( in contrast to Delusion of thought insertion)Obsessions are regarded as untrue or senseless ( important distinction from obsession) They are usually about the matter which person finds unpleasant or distressing

The presence of resistance is important because in lack of conviction about the truth of the idea, it distinguishes from delusionsVarious forms of obsessionsObsessional thoughts: repeated and intrusive words or phrases which are upsetting to the patient ( e.g., repeated obscenities coming into the awareness of religious person) Obsessional ruminations: repeated worrying themes of a more complex kind ( about ending of the world) Obsessional doubts: repeated themes expressing uncertainty about the previous actions (whether or not person turned locked the door)Obsessional impulses: repeated urges to carry out action ( usually actions that are aggressive), ( e.g., urge to pick up knife and to stab another person)-whatever the urge person has no wish to carry, resist it strongly and does not act onObsessional phobia: denotes an obsessional symptom associated w/ avoidence as well as anxiety ( person with obsessional impulse to injure another person w/ knife would avoid knives)-sometimes obsessional fear of illness are called illness phobias

The content of obsessionsAlthough the content (themes) are various but most can be grouped into 6 categoriesDirt and contamination (idea of harming others through the spread of diseases)Aggression (striking another person or shouting angry or obscene)Orderliness (about the ways objects are to be arranged)Illness (fearful kind, e.g., fear of cancer venereal diseases) Sex (concern practices that individual find shameful)Religion ( take the form of doubts about fundamentals of belief)

Compulsions: are repetitive and seemingly purposeful behaviors, performed in a stereotyped way (an alternative name of compulsive rituals) Accompanied by a subjective sense that the behavior must be carried out and by an urge to resistLike obsessions, compulsions are recognized as senselessIt can be understandably associated w/ obsessions (compulsion to wash hands is usually associated w/ obsessional thoughts that hands are contaminated)Sometimes obsessional ideas concern the consequence of failing out to carry compulsions in correct way (e.g., another person will suffer accidents)Four common compulsive acts:Checking ritualsCleaning ritualsCounting ritualsDressing rituals ( lays out or puts on in special order)

Obsessional slowness

Depersonalization and derealization Depersonalization: change of self-awareness such that person feels unreal, detached from his own experience and unable to feel the emotionsDerealization: change in relation to the environmnet, such that objects appear unreal and people appear lifeless, two dimensional cardboard figures- Despite the inability to feel emotion, both of these experiences are described as unpleasant

Because patients find it difficult to describe these experiences and they resort to metaphor leading to confusion with delusions (e.g., patient may say as if part of my brain has stopped working it could be explored and ruled out from delusional belief that brain is no longer workingOccur in GAD and phobic anxiety disorders, depressive disorders, schizophrenia, and temporal lobe epilepsy, as well as in depersonalization disorder (a very rare disorder) They dont help in diagnosis as they occur in many disordersMotor symptoms and signsTics: irregular repeated movements involving a group of muscles, for examples sideways movements of the head or the raising of one shoulderMannerisms: repeated movements that appear to have some functional significance ( e.g., saluting)Stereotypies: repeated movements that are regular ( contrast to tics) and with out obvious significance ( contrast to mannerism) ( e.g. , rocking to and fro)Posturing: adoption of unusual bodily postures for a long time ( it may or may not have symbolic meaning, e.g, both arms outstretched as if being crucified) Grimacing: same meaning as in everyday usage ( The term Schauzkrampf is used to denote pouting of the lips to bring them closer to the nose)

Negativism: patients are said to have negativism if they do the opposite of what they are asked to do and actively resist efforts to persuade them to comply Echopraxia: imitation of interview movement automatically even when asked not to do soAmbitendence: patients are said to show ambitendence when they alternate between opposite movements ( e.g., putting out the arms to shake hands, and then withdrawing it, extending it again, and so on repeatedly) Catatonia: is the state of increased muscle tone affecting extension and flexion and abolished by voluntary movementWaxy flexibility: term to describe tonus in catatonia (it is detected when patients limbs can be placed in a position in which they then remain for long whilst at the same time muscle tone is uniformly increased

Q. psychological pillow??

Disorders of memoryAmnesia: failure of memory ( term dysmnesia is occasionally used)Paramnesia: distortion of memoryDifferent related termsImmediate memory: concerns retention of information over short period measured in minutes (tested by remember a name and address, which they did not know before the test) and to recall it about 5 minutes laterRecent memory: concerns events in last few daysRemote (long term) memory: concerns events over longer periods of timeRecall/Recognition

Disorders of recognitionJamais vu: failure to recognize events that have been encountered beforeDj vu: conviction that an event repeats one that has been experienced in the past when in fact it is novelConfabulation: reporting as memories of events that has been experienced at one time, , of events that took place at another time, or never involved the person

Q. Psychogenic amnesia ( due to repression)??

Disorders of consciousnessConsciousness: awareness of the self and the environmentLevel of consciousness between extremes of alertness and comaQuality of consciousness varies from ( e.g., sleep differ from unconsciousness, and so as stupor) Coma: most extreme form of impaired consciousness; no external evidence of mental activity, and little motor activity other than breathing/ does not respond to even strong stimuli/ graded by the extent of the remaining reflex responses and EEG activity

Clouding of consciousness: state which ranges barely perceptible impairment to definite drowsiness in which the person reacts incompletely (attention, concentration and memory are impaired to varying degrees and orientation is disturbed). Thinking seems muddled and events may be interpreted inaccurately

Stupor: refers to a condition in which the patient is immobile, mute, and unresponsive but appears to be fully conscious in that the eye are usually open and follow external objects/ if eyes are closed patients resists to open them/ reflexes are normal and resting posture is maintainedConfusion: inability to think clearly/ it occurs characteristically in states of impaired consciousness but it can occur consciousness is normal Syllabus for signs and symptomsPlease read all the ppts and additionally PP 273-283 (10th ed. Sadock & Sadock)

Syllabus for Classification/DSM/ICDMulti-axial systemsICD-10 vs. DSM IV-TRGAF ( assigning GAF)Provisional DiagnosisDifferential diagnosis

111Overview

Delirium, Dementia, Amnestic, and Other Cognitive DisordersDelirium: disturbance in conscious experience, with attentional/perceptual and memory deficits caused by a medical or physiological condition (e.g., due to substance intoxication or withdrawal)2. Dementia: Alzheimer type: memory impairment, cognitive impairment (e.g., planning and object recognition, or agnosia; motor dysfunction, or apraxia; language disturbance, or aphasia) not due to other factors that can cause these deficits.Vascular dementia: progressive dementia like Alzheimers disease, but unlike Alzheimers, symptoms begin abruptly, often due to stroke. Cognitive dysfunction may be more localized rather than pervasive.3. Amnestic disorders: disorders of an organic natures involving loss of memory; may be transient or chronic and caused by drug use or medication

MSE and MMSEMental disorders due to General medical conditions-We will study epilpsy

Personality Disorders [Syllabus ( PPTs and Synopsis pp. 791-821)

What is personality?that which distinguishes one individual from another, the emphasis being on patterns of behaviors and relations with others, rather than the physical aspects which is of lesser significanceWhat are personality traits? surface characteristic (generalized predisposition to certain consistencies of behavior) Personality can be described as either traits or by underlying tendencies ( may be in terms of drives, needs, constructs, unconscious mechanism)

Despite all the work carried out on other approaches, traits remain the most current and comprehensive way of describing personalityIn any one person , traits of personality do not cover the whole field of behavior ( e.g, a person may be friendly , honest, and tidy, careful, etc. in some situations and not in other)Traits tend to be associated into groups, giving rise to types of personalityBecause of limited field of particular traits in any one person, it is therefore possible for individuals of the same type to behave differently in similar situations

Traits can very in intensity and when sufficiently strong can be regarded as abnormal in statistical sense ( extreme traits are less common than the average) However at sufficient level ( statistically abnormal level) , they can then interfere with individuals relations with other people . When they pass beyond the bounds of what is socially tolerable, they will be regarded abnormal in the sense of being morbid ( cultural norms)

Recap ( norms of abnormality)Statistical normsCultural norms ( geographical norms)Individual normIdeal norms

Clinical features of PD There are certain individuals who do not display the obvious symptoms ( q. sign vs. symptoms?) of Axis-I disorder, however there are certain inflexible and maladaptive traits that they are unable to perform some expected roles by their society- this state or case is referred as that this person is having personality disorder Recap ( Multi-axial system and differences between axis-1 disorder and axis ii disorders) According to DSM-IV-TR, the criteria for diagnosing PD are:Personas enduring patterns must be pervasive (consistent across situations) and inflexible as well as stable and of long durationIt must also cause either clinically significant distress or impairment in functioning and be manifested in at least two of the following areas:Cognition, affectivity, interpersonal functioning or impulse control ( impulsivity)

Difficulty in diagnosing PDDiagnostic criteria of PDS are not as sharply defined as for most disorders in axis 1 ( e.g, in dependent PD goes to excessive lengths to obtain nurturance and support from others)Diagnostic criteria are not mutually exclusive ( people often show characteristic of more than one disorder)( these problem increase the unreliability of diagnosis) ( pls refer pp 374-75)

Categories of PDsThe DSM-IV TR personality disorders are grouped in in three clusters ( not in ICD-10)Cluster A: disorders often seems odd or eccentric, w/ unusual behaviors ( like distrust, suspiciousness, social detachment)- Paranoid, Schizoid, schizotypalCluster B- dramatic, emotional, and erratic- histrionic, narcissistic, antisocial, and BPDCluster C- anxiety, fearfulness (avoidant, dependant, OCPD)

General diagnostic criteria is included in the syllabus Etiology Included Genetic factorBiological factorPsychoanalytic factors

Personality DisordersDescribed on Axis II; chronic patterns of maladaptive, pervasive, stable, and distressing behavior and inner experience. They are clustered into three main categories. TypesCluster A: Odd/Eccentric Symptoms 1. Paranoid Suspicious, sees hidden meanings in innocent remarks, fears betrayal 2. Schizoid No close friends, aloof and detached 3. Schizotypal Social/interpersonal deficits with five (or more) of the following: suspicious thinking, strange beliefs, strange speech, eccentric behavior, unusual perceptions, ideas of reference, marked social anxiety

Cluster B: Dramatic/Erratic Symptoms 1. Antisocial Irresponsible, deceitful; poor regard for rights of others; lack of empathy and remorse; violates social norms; exploitative 2. Histrionic Seeks center of attention, often using physical appearance; often sexually provocative/seductive; emotionally shallow; quickly assumes more intimacy than exists early in relationships; impressionistic thinking 3. Narcissistic Inflated sense of self, arrogant, deficient in empathy, sees self as special, sense of entitlement 4. Borderline Strong and chronic feelings of emptiness, mood instability, disturbance in identity, fears abandonment; unstable, impulsive interpersonal relationships, suicidal gestures, self-mutilation

Cluster C: Anxious/Fearful Symptoms 1. Avoidant Inhibited with others; limits social contact; fears criticism and rejection 2. Dependent Wants others to make decisions; fears taking care of self; passive

3. Obsessive-compulsive Rigid, preoccupied with details, perfectionistic; has difficulty delegating responsibility; hoards money, objects

132Diagnostic criteria for BPD is included in syllabus

134

Schizophrenia and schizophrenia like disorders Schizophrenia SyllabusRefer Sadock & Sadock and document uploaded in moodle. Exclude the phicaltherapy component. Concentrate in*( emphasize on historical development/types/ subtypes/ clinical features/ differential diagnosis/ etiology) 139Of all the psychiatric syndrome, schizophrenia is much the most difficult to define and describeThe main reason is that over the past 100 years divergent concepts of schizophrenia has been held in different countries and by different psychiatrists

It is useful to start with simple comparison between two basic concepts: acute vs. chronic

140Predominant clinical features of acute schizophrenia: delusions/hallucinations/ and interfernce with thinkingChronic schizophrenia: apathy/lack of desire/slowness/and social withdrawal

141The most frequent symptoms of acute schizophreniaSymptom FrequencyLack of insight97Auditory hallucination74Ideas of reference70Suspiciousness66Voices speaking to the patient65Delusional mood64Delusions of persecution 64Thought alienation2Thoughts spoken aloud50

142Behavioral characteristic of chronic schizophreniaCharacteristic frequencySocial withdrawal 74Underactivity56Lack of conversation54Few leisure interest 50Slowness48Overacivity41Odd idea34Depression34Odd behavior34Neglect of appearance30Odd postures and movements25Threats or violence25Poor meal time behavior13Socially embarrassing behavior8Sexually unusual behavior8Suicidal attempts4Incontinence

143Clinical features(Describe both acute and chronic syndrome)The acute syndrome: prosecutor idea hallucination social withdrawal impaired performance at work disorder of stream of thoughts (pressure of thoughts, poverty of thoughts, thoughts blocking) disorders of form of thoughts(also called formal thought disorder, foi-loosening of association)abnormalities of mood (blunting or flattening of affect) incongruity of affectauditory hallucination/Delusionsgeneralized deficits in cognitive functions (learning, memory, perception, motor skills)impaired insight/

144Chronic syndrome: diminished volition (lack of drive and initiative)Catatonic ( stupor and excitement are most striking catatonic symptoms)Disorder of muscle tome (waxy flexibility, catalepsy)Various forms of movement occurs:stereotypy (repeated movement that does not appear to be goal directed), Mannerism ( goal directed movement), ambitendence (a form of ambivalence in which person begins to make a movement but, before completing it, starts the opposite movement)Social behavior may deteriorateSpeech is often abnormalHallucinations are commonDelusions are systematized and also held with little emotions

145Historical development

The development of idea (construct) about schizophrenia (historical development)Some of the diagnostic problem encountered today can be understood better with some knowledge of the historical developments of ideas of schizophreniaIn 19th century , one view was that all serious mental disorders were expressions of single entity which Griesinger called Einheitpsychose (unitary psychosis)The alternative view, by Morel in France, wsa that could be separated and classified

146Morel searched for specific entities and argued for classification based on cause, symptoms, and outcome (Morel 1860)In 1852 he gave the name de`mece pre`coce to a disorder which he described starting in adolescence and leading first to withdrawal, odd mannerism, and self-neglectNot long after, Kahlbaum (1863) described the syndrome of catatonia And Hecker(1871) wrote an account of a condition he called hebephrenia Emil Kraepelin (1855-1926) derived his idea from the study of course of the disorder as well as the symptomsIt lead him to argue against a division into dementia praecox and manic-depressive psychosisThis grouping put hebephernia and catatonia as subclasses of dementia praecox

147Kraepelins description of dementia praecox appeared for the first time in 1893, in the fourth edition of his textbookHe describes it as a series of states, the common characteristic of which is a peculier destruction of the internal connections of the psychic personality. The effects of this injury predominate in the emotional and volitional spheres of mental like ( Kraepelin, 1919)He originally divided dementia preacox into three types: catatonic, hebephrenic, and paranoid)

148Kraepelin seperated the condition he named paraphrenia from dementia praecox on the ground that it started in middle life and seemed to be free from the changes in emotion and volition found in dementia preacoxEugen Bleuler (1857-1959): Expanded and worked on Kraepelins idea od demetia preacox, but he was more concerned with the mechanism of symptom formation ( applying some Freudian views) unlike emphasis on prognosis by Kraepelin Bleuler proposed the name schizophrenia to denote splitting of psychic functions which he thought to be of central importance

149Since Bleuer was preoccupied more with psychopathological mechanism than with symptoms themselves, his approach to diagnosis was less precise than that of KraepelinKurt Schneider (1887-1967): tried to make the diagnosis more reliable by identifying a group of symptoms characteristic of schizophrenia, but rarely found in other disorders Unlike Bleulers fundamental symptoms, Schneiders symptoms were not supposed to have any central psychological role

150Schneider (1959) identified some symptoms (abnormal modes of experience) of schizophrenia as first rank of importance because they had special value in helping to determine the diagnosis of schizophrenia ( not because they were thought to be basic disturbances) He further said that symptoms of first rank importance do not always have to be present for a diagnosis to be made 151Schneiders symptoms of first rank Hearing thoughts spoken aloudThird-person hallucinationHallucination in the form of a commentarySomatic hallucinationThought withdrawal or insertionThought broadcastingDelusional perceptionFeelings or actions experienced as made or influenced by external agents

152In Denmark and Norway, cases of psychosis after stressful events have received much attentionThe term reactive psychosis or psychogenic psychosis are commonly applied to conditions which appear to be precipitated by stress, are to some extent understandable in their symptoms, and have a good prognosis ( in current schemes such disorders would be classified as brief psychotic disorder or schizophreniform disorder 153Delusional disorders and other psychotic disorders( syllabus: follow class PPTs of groups and synopsis)

154AddictionDefinition and usage of word drugForms of in taking drugsBlood-brain barrierPsychoactive substancesCharacteristic of addiction a) Tolerance, b) withdrawal, c) drug seeking behaviors

Other related terminologies:Dependance/abuse/misuse/ IntoxicationCodependanceEnablingDenialCross toleranceNeuroadptation

Models of addiction-

Alcoholism ( abuse and dependency): refer Synopsis Psychopathy and ASPD