Psychiatric Disorders

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Psychiatry is one of the major specialties of medicine, and is concerned with the diagnosis and treatment of the psychiatric disorders. This volume on psychiatry is currently in the initial stages of development. Further development will be a project of the Educational Taskforce of the World Psychiatric Association. For further information, please contact Dan Stein (dan.stein@curie.uct.ac.za).

Overview

Psychiatric disorders, (also known as mental disorders or mental illnesses) are syndromes characterized "characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. [These] disorders are usually associated with significant distress in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not [psychiatric] disorders unless the deviance or conflict results from a dysfunction in the individual, as described above." During mental health status examinations, several appearance, behavioral, mood, and speech patterns serve as indicators of psychiatric disorders, and can help determine whether a patient is suffering from a psychiatric disorder.

Mental health status examination

Observe:
Appearance

• Give a written description of the patient's physical state, noting bizarre physical traits or possessions such as special clothes or ornaments with symbolic significance.
• Note possible self-neglect (e.g. lack of cleanliness).

Behavior

• Involuntary movements or tics.
• Distinctive mannerisms.
• Purposeful behavior such as pacing or fiddling.
• Threatening, seductive, or friendly demeanor.
• Congruity between the affect (outer expression of mood) and the topics of discussion.

Mood

• Ask about patient's mood and overall emotional state.
• Infer or observe mood, whether elevated, lowered, euthymic, etc.
• Note the range of the patient's moods from restricted to increased.

Speech

• Observe irregular speech patterns (e.g. slow speaking pace, long pauses before answering or between words)
• Note any increases in amounts of spontaneous speech relative to social norms. This may manifest as:
  • Rapid speech.
  • Lack of sentence completion due to eagerness to move on to a new idea.
  • Simple questions answered at great length, unnecessarily.
  • Refusal to be interrupted
  • Loud and emphatic speech.
  • Speaking regardless of lack of social stimulus or listener. Patient may talk, mutter, or whisper to self out of the context of the conversation with the examiner.
  • Muteness.
• Poverty of speech (laconic speech) may also be observed:
  • Restricted amount of spontaneous speech, with brief, concrete, and unelaborated answers to questions.
  • Rare provision of unprompted information.
  • Monosyllabic replies or ignored questions.
• Use of neologisms (creation of a completely new word or phrase whose derivation cannot be understood). Note examples of neologisms.
  • Example: "I got so angry I picked up a dish and threw it at the geshinker."
• Note instances of:
  • Word approximations (giving existing words a new and unconventional meaning or creating new words using conventional rules of word formation). Often the meaning of a word will be evident even though the usage seems peculiar or bizarre (e.g.: gloves referred to as "handshoes"). Sometimes the word approximations may be based on the use of stock words, so that the patient uses one or several words repeatedly in ways that give them a new meaning (e.g.: a watch may be called a "time vessel," the stomach a "food vessel," a television set a "news vessel"). Note examples of word approximations.
• Disordered speech content: Three types of disordered content are specified: incoherence, flight of ideas and poverty. There are overlapping concepts and in each case, the effect is to make it very difficult to grasp what the patient means. However, the symptoms are defined in terms of specific components so that it should, in most cases, be possible to say whether one, two or all three symptoms are present. If in doubt, rate hierarchically with most severe observations at the top.
• Incoherence of speech: see Incoherence in section on Thought Form
• Clanging: A pattern of speech in which sounds rather than meaningful relationships appear to govern work choice, so that the intelligibility of the speech is impaired and redundant words are introduced. In addition to rhyming relationships, this pattern of speech may also include punning associations, so that a word similar in sound brings in a new thought.
  • Example: "I'm not trying to make noise. I'm trying to make sense. If you can make sense out of nonsense, well, have fun. I'm trying to make sense out of sense. I'm not making sense (cents) anymore. I have to make dollars".
• Poverty of speech content (Alogia, Verbigeration, Negative Formal Thought Disorder): Although replies are average in length, they convey little information. Vague and repetitive language that is either overly abstract or concrete. The interviewer may characterize the speech as "empty philosophizing".
• Misleading answers: Patient's answers are misleading (e.g. answers yes or no to everything or frequent contradicts self) whether consciously or inadvertently.
• Distractible speech: During the course of a discussion or interview, the patient repeatedly stops talking in the middle of a sentence or idea and changes the subject in response to a nearby stimulus, such as an object on a desk or the interviewer's clothing or appearance.
  • Example: "Then I left San Francisco and moved to– Where did you get that tie? It looks like it's left over from the '50s. I like the warm weather in San Diego. Is that a conch shell on your desk? Have you ever gone scuba diving?"
• Stilted speech: Excessively stilted or formal speech. It may seem outdated, pompous, distant, or over-polite. The stilted quality is usually achieved through use of particular word choices (multisyllabic words when monosyllabic alternatives are available and appropriate), extremely polite phrases. ("Excuse me, madam, may I request a conference in your office at your convenience?"), or stiff and formal syntax ("Whereas the attorney comported himself indecorously, the physician behaved as is customary for a born gentleman.").
• Paraphasia:
  • Recognizable mispronunciation of a word because sounds or syllables have slipped out of sequence. Severe forms occur in aphasia, milder forms may occur as "slips of the tongue" in everyday speech. The speaker often recognizes their error and may attempt to correct it.
    • Example: "I slipped on the lice and broke my arm while running to catch the bus."
  • Substitution of an inappropriate word during an effort to say something specific. The speaker may or may not recognize this error and attempt to correct it. It typically occurs in both Broca's and Wernicke's aphasia. This type of paraphrasia may be difficult to distinguish from incoherence, since incoherence may also be due to semantic substitutions that distort or obscure meaning.

Insight

• Does the patient know there is a problem; how does she assess her impairment, disability, and handicap due to the problem?
• How important is it to them?
• Do they want treatment?
• How rational is their understanding of the problem and its treatment?

Physical examination

Pay special attention to:

• Signs and causes of delirium
• Stigmata of drug use and abuse (acute: intoxication vs chronic: needle track marks, stigmata of alcohol and tobacco use)
• Stigmata of self-harm such as scars
• General body habitus: obesity, degree of fitness

Types of psychiatric disorders

Cognitive disorders

Cognitive disorders are psychiatric disorders that are characterized by the loss of cognitive function and typically primarily affect learning, memory, perception, and problem solving.

Dementia

A typically permanent cognitive disorder that particularly affects the memory and leads to decreased overall level of functioning. Major types of Dementia

• Alzheimer's Disease
• Vascular Dementia
• Lewy Body Dementia

Psychotic Disorders

Psychotic disorders are severe psychiatric disorders that are characterized by a loss of touch with reality and result in abnormal thinking and perceptions. The most common symptoms of psychotic disorders are delusions and hallucinations, while broad clusters of symptoms categorized as positive or negative, with positive symptoms including delusions, hallucinations or disorganized thoughts, and negative symptoms including social withdrawal and loss of enjoyment, motivation or drive. Psychotic disorders include Schizophrenia and Schizoaffective disorder.

Mood disorders

Mood disorders are psychiatric disorders characterized by typically severe

mood changes (elevation or lowering of mood) as in the case of depression or bipolar disorder. These mood changes may occur continuously, intermittently or cyclically.

Anxiety disorders

Anxiety disorders are psychiatric disorders characterized by persistent and often debilitating worry or fear. The anxiety experienced may worsen over time and impede an individual's ability to function. Common symptoms of anxiety disorders include anxiety or excessive worrying, phobias, and panic attacks.

Substance abuse disorders

Substance abuse disorders are psychiatric disorders caused by substance use, abuse, intoxication or withdrawal. Substances involved may be legal such as tobacco, caffeine and alcohol, or illegal substances such as cannabis or cocaine.

Personality disorders

Personality disorders are psychiatric disorders defined by specified kinds of maladaptive behavior patterns that can harm long-term personal relationships or inhibit an individual's functioning in society. DSM IV groups personality disorders into three clusters: Cluster A, B, and C. It is not unusual for a patient to fulfill criteria for more than one personality disorder; the diagnoses are by no means mutually exclusive.

Psychiatric Treatments

Treatments of psychiatric disorders can be biological, psychological, and/or social.

Biological treatments

Biological treatments commonly include medications and electroconvulsive therapy (ECT). Many psychiatrists consider that physical aspects of lifestyle such as activity level and diet influence psychiatric disorder's symptomatology.

Psychological

Psychiatric treatments, typically in the form of psychological therapy, range from hypnosis, to psychoanalytically-informed psychotherapy and psychoanalysis, to cognitive and behavioral (CBT) strategies. Psychoanalytic and CBT techniques are often used long-term to treat patients with personality disorders though they can also be used to treat of a wide variety of other conditions.

Social

Social treatments of psychiatric disorders are based on the notion that housing, family, social support structures, and financial difficulty all play a role in the genesis of psychiatric disorders and affect prognosis. Social treatments aim to improve these circumstances to decrease negative stimulus or situations for the patient.

For more psychiatric treatments, refer to Treatments.

External links

• The Merck Manual Section 15 Psychiatric Disorders[4]
• ICD-10 "Blue Book"
• Internet Mental Health

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