Terminology In Psychiatry

Dr.Md. Gias Uddin Sagor MBBS;M PHIL (Psychiatry)Associate Professor & Head

Dept . of PsychiatryCMOSHMC.

Aims• Descriptive, not aetiology-based• Definition of psychosis• Definitions of psychotic symptoms

– hallucinations vs delusions– useful terminology for your psychiatry placement

• Awareness of range of psychotic illnesses.• Awareness of DSM-5. • Approach to a patient suffering from

psychiatric illness.

WHY do I need to know about Psychotic Illnesses?

• GP – Is the Front line service.– Early detection improves prognosis!– Worried relatives asking you about patient.– Increased burden on health services; worse

physical health.

Cont………..

• Surgeons / Obs & Gynae – delusional pts insisting on unnecessary operations.

• A&E – pts present with bizarre complaints & behavior; overdose.

• Pediatrics – child protection issues; early onset psychosis.

Cont…………………

• Psychiatry – our area of expertise!

– Mental health and act,– Forensic, – Suicide prevention.

What do I Really Have to Know?

Think ORGANIC!– Oxygenation, Glucose, Electrolyte disturbance,

endocrine– Toxicity – iatrogenic, self-inflicted, accidental– Drugs & alcohol– Cerebral pathology.

Mental state abnormalities in psychotic illness

Perception Thought Behaviour

Hallucinations Illusions

Auditory

Tactile

Olfactory & Gustatory

Visual

Form Content

Delusions

Overvalued IdeasCircumstantiality

Fusion

Knight´s Move Thinking

Derailment

Word Salad

Thought Block

Pseudohallucinations

Catatonia

Thought

Content

DelusionsOvervalued Ideas

of Reference

Control,Passivity

of Paranoia:Reference

Persecution Grandeur

Body imageHypochondriasis

LitigationReligiouspolitical

Mental disorder A mental disorder is a

syndrome that characterized by clinically significant disturbance in an individuals cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological , biological, or developmental processes under lying mental functioning .

CONT.

• Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.

Insight

• Subjective awareness of morbid change in one self.

• Correct attitude to this changes. • Patient should realize that these

changes signifies a mental disorder and he needs treatment .

Type of mental disorder

• 1. Psychotic disorder • 2. Neurotic disorder• 3. Organic disorder

Psychotic disorder

• 1. Lack of insight • 2. Inability to distinguish between

subjective experience and external reality

• 3. Failure to maintain ordinary life demands

Hallmarks of psychotic disorders

A. Impaired reality testing

• Hallucinations • Delusions

B.Disorganized behavior

Example

• Schizophrenia• Schz like disorder• Delusional disorder• Mood disorder with

psychotic features.

Neurotic disorder

• Insight intact • Patient keep in touch of

reality• Patient maintain ordinary life

demand

Example

• Anxiety disorders • Depression• Somatoform disorders • Functional sexual

disorder

Organic disorder

Psychiatric disorders that arise from demonstrable abnormalities of brain structure and function.

Example

• Dementia• Delirium• Stroke with behavioral

problem• Amnestic disorders • Head injury• Epilepsy

Sensation

The process through which the senses

pick up visual, auditory, and other sensory stimuli and transmit them to the brain; sensory information that has registered in the brain but has not been interpreted.

Perception

• It is the process of becoming aware of what is presented through our sense organ.

• The process by which sensory information is actively organized and interpreted by the brain

• Perception can be attended or ignored, but it can not be terminated by an effort of will.

22 Organizational Behavior / Perception

•

Receiving Stimuli(External & Internal)

Selecting StimuliExternal factors : Nature,

Location,Size,contrast,Movement,repetition,similarityInternal factors : Learning,

needs,age,Interest,

Organizing Figure Background ,Perceptual Grouping( similarity, proximity,closure, continuity)

ResponseCovert: Attitudes ,

Motivation,Feeling

Overt: Behavior

Perceptual Process

Interpreting Attribution ,Stereotyping,Halo Effect, Projection

24 Organizational Behavior / Perception

25 Organizational Behavior / Perception

26 Organizational Behavior / Perception

Image

• It is the awareness of percept that has been generated within the mind.

• Imagery can be called up and terminated by an effort of will.

Illusions

• Illusions are misinterpretations of external stimuli.

Cont…………

• Usually non-pathological– Bush looks like a killer in the dark– “cocktail party” illusion: hearing your

name across a noisy room– A stray hair may feel like a spider on the

neck• BUT illusions occur in psychosis

– e.g. girl complains her face is melting when she looks in mirror.

Hallucinations

• It is a percept experienced in the absence of an external stimulus to the corresponding sense organ.

Type of hallucinations

According to complexity

• A. Elementary Bangs, whistles,

flashes of light• B. Complex Hearing voices, music,

seeing faces and scenes

According to sensory modality(Pathological)

• Auditory• Visual• Olfactory• Gustatory• Somatic / Hygric

(visceral) / Sexual Tactile Deep

According to special features

• Auditory Second person Third person Gedankenlautwerden Echo de la pensee• Visual• Extracampine• Autoscopic• Reflex• Hypnagogic and

Hypnopompic.

Auditory

Auditory hallucinations are perceptions of sounds absent of any external stimulus while in a conscious state.

Classifications of Auditory hallucinations A. Second personvoice speaking to theperson addressing him as YOU

B.Third personVoice talking about the person as HE or SHE

C.Thought EchoHearing ones own thought spoken aloud.

D.GedankenlautwerdenVoices seem to speak the patients thought

Visual

A visual hallucination is "the perception of an external visual stimulus where none exists.

Somatic Hallucinations

 

A. His body is being mutilated, i.e. twisted, torn, or disemboweled..B.Invasion by animals in the person's internal organs such as snakes in the stomach or frogs in the rectum.

Sensory impression (sight, touch, sound, smell, or taste) that has no basis in external stimulation.

C.Sensation of insects crawling underneath the skin

Deep somatic Hallucinations

Feeling of viscera being pulled upon or distended

Sexual stimulation Electric shocks.

Olfactory

Smelling odors that are not really present.

Gustatory

Perception of taste without a stimulus.

Extracampine

Visual hallucinations located out side the field of vision, usually behind the head

Autoscopic

Seeing ones own body projected into external space, usually in front of one self, for short period

Reflex Hallucination

A stimulus in one sensory modality results in a hallucination in another.

Music can provoke visual hallucination

Non-pathological:

– Hypnagogic (going off to sleep)

– Hypnopompic (waking up)

Audible Thoughts• The patient may hear people

– repeating his thoughts out loud just after he has thought them,

– answering his thoughts, – saying aloud what he is about to think so

that his thoughts repeat the voices. – He often becomes very upset ill the gross

intrusion into his privacy and concerned that he cannot maintain or control of any part of himself, not even his thoughts.

Voices arguing

• A 24 year old male patient reported hearing voices coming from the nurse's office. The voice, deep in pitch and roughly spoken, repeatedly said, – ‘He is a bloody paradox', and another,

higher in pitch, said, he should be locked up'.

– A female voice occasionally interrupted, saying `He is not - he is a lovely man'.

Voices giving a Running Commentary

just before, during or after the patient's activities.

• A housewife heard a voice coming from the house across the road....

• The voice went on incessantly in a flat monotone describing everything she was doing, with an admixture of critical comments.

Characteristics of hallucinations that indicate of psychosis

• Higher frequency of hallucinatory experiences• Localization of voices outside the head• Greater linguistic complexity• Greater emotional response• The extent to which patients believe that other

people share this experience.• They are constant.• They are independent of will.

A person experiencing this hallucination might have the following

symptoms.

• Appear preoccupied and unaware of his or her surroundings

• Talk to himself or herself• Have difficulty understanding or following

conversations, and misinterpret the words and actions of others

• May isolate himself or herself or use radio or other sounds to tune out the voices.

Clinical association of hallucination

• Schizophrenia • Severe mood disorder• Dissociative disorder• Organic disorder

Causes of Hallucinations• Being drunk or high, or coming down from such drugs as marijuana,

LSD, cocaine/crack, PCP, amphetamines, heroin, ketamine, and alcohol• Severe dehydration• Delirium or dementia• Epilepsy that involves a part of the brain called the temporal lobe (odor

hallucinations are most common)• Fever, especially in children and the elderly• Narcolepsy and sleep disturbances• Psychiatric illness, such as schizophrenia, bipolar disorder, psychotic

depression• Sensory problems, such as blindness or deafness (Seen in Charles

Bonnet syndrome andd Anton's syndrome)• Severe illness, including liver failure, kidney failure, AIDS, Parkinson's

Disease and brain cancer.

Delusion A delusion is a belief that is firmly held

on inadequate grounds, is not affected by rational arguments or evidence to the contrary, and is not a conventional belief that the person might be expected to hold given her educational cultural and religious background.

Criteria for delusion• False and unshakeable belief despite

evidence to the contrary.• These beliefs are not shared by others

in the same culture.• It should be held on inadequate

grounds.• Delusion should have marked effect on

the persons feeling and actions

For example,

A person can believe that he is the President of the United States.

This is a delusion clearly, but to the person having the delusion it is reality.

Type of delusions

Delusions of grandeur –

Beliefs of exaggerated self importance. Patient think that he is famous, publicly important ,having unusual power and abilities or is a God.

Delusional Jealousy -

• Believing a spouse or partner is unfaithful when it is not true.

• Persecutory or paranoid delusions – Believing one is being followed, spied

upon, secretly listened to, Trying to inflict harm, damage his reputation, make him insane etc.

Delusions of reference

• Thinking that random events(objects ,events, or people, unconnected with the pt ) contain a special meaning for you alone.

Erotomanic type (Sexual Delusion)

• Delusion that another person, often a prominent figure, is in love with the individual.

• The individual may breach the law as he/she tries to obsessively make contact with the desired person.

Somatic type:

• Delusions that the person has some physical defect or general medical condition.

• The core belief of this type of disorder is delusions around bodily functions and sensations.

Hypochondrical Delusion

• Patients believes, wrongly and in the face of all medical evidence to the contrary, that he is suffering from a disease.

Mixed type

• Patients exhibit more than one of the delusions simultaneously[4] , and no one delusional theme predominates.[1]

Cotard syndrome (Nihilistic)

• In which patients believe that they have lost all their possessions, status, and strength as well as their entire being, including their organs.

Delusion of control

• This is a false belief that another person, group of people, or external force controls one's general thoughts, feelings, impulses, or behavior.

Delusion of guilt or sin (or delusion of self-accusation)

• This is an ungrounded feeling of remorse or guilt of delusional intensity.

Delusion of mind being read:Thought Broad Cast

• The false belief that other people can know one's thoughts.

Thought Withdrawal

• Thoughts have been taken out of the mind.

Delusion of thought insertion:

• The belief that another thinks implanted in his mind.

Primary Delusion

• It appears suddenly and with full conviction but with out any mental events leading up to it.

Delusional Mood

• When a patient experiences a delusion, he responds emotionally.

Delusional Perception

First abnormal experience attaching a new significance to a familiar percept without any reason to do so.

Delusional Memory

• Delusional interpretation is attached to first event.

• Other • Bizarre" delusions – Things that are impossible in real

world. such as believing one is a werewolf,

that one's spouse is an octopus, or that giant worms make subway tunnels.

Non bizarre delusions• Involving situations that occur in our

real life, such as being followed, poisoned, infected, loved at a distance. Or deceived by spouse or lover, or having a disease

• It must have at least one month duration

Classifications of delusions

According to fixity• Complete• Partial

According to onset• Primary• Secondary

Delusional experiences

• Delusional mood • Delusional perception• Delusional memory

Contd………..

According to theme• Persecutory• Delusion of references• Grand use delusion • Delusional guilt• Nihilistic delusion• Hypochondrical delusion • Jealous delusion• Sexual or amorous delusion• Delusion of control • Delusion concerning about possession of thought• Thought insertion • Thought withdrawn, Thought broad casting• Shared delusion

Overvalued ideas

An over valued idea is an isolated, but acceptable comprehensible idea pursued by the patient beyond the bounds of reason.

Example Anorexia nervosa Body image disorder

Depersonalization

• It means change of self awareness such as

• The persons feels unreal• Detached from his own experience• Unable to feel emotion .

Derealization Similar change in relation to

environment such as

• Objects appear unreal• People appear as life less creature • Feeling two dimensional cardboard

figure

EmotionEmotion is state of psychological arousalwhich occurs in response to some externalor internal stimuli. It has two part Affect: Short lived emotional response to an

idea or event . Mood: Sustained and pervasive emotional

response which colors whole psychic life.

How disturbances occurs in emotion

It may be abnormal in three ways

• 1. Nature may be altered• 2.Fluctuate more or less than usual• 3.It may be inconsistent with the

patient’s thought or actions or with his current circumstances.

Abnormal state of emotionVariation may be greater or less than

normal such as :Liability of mood – increased variation.Emotional incontinence – extreme

variationBlunting- reduced variation Flattening- more than blunting Apathy- severe flattening Incongruity- not suited to the present

context

Irritability

It is a state of Increased readiness foranger or minimum provocation butmaximum response. It may occur in Anxiety disorders Depression Mania Dementia Drug intoxications

Attention

Ability to focus on the matter in hand

Concentration

Ability to maintain that focus

Consciousness

• Awareness of the self and the environment .

• Level of consciousness vary between the extreme of alertness and coma.

Clouding of consciousness

Attention ,concentration and memory are impaired to varying degrees orientation is disturbed.

• Thinking seems muddled and look in drowsy.

• Events interpreted inaccurately.

Definitive features of delirium

Coma

• No external evidence of mental activity and little motor activity other than breathing.

• Does not respond even to strong stimuli.

Confusion

Inability to think clearly or impairment of consciousness as well as muddled thinking.

Motor symptoms and sign in psychiatry

• Tics• Mannerisms• Stereotypes• Catatonia• Catalepsy• Posturing• Grimacing• Schauzkrampf• Negativism• Echopraxia• Mitgehen• Ambitentendence

Tics

• Irregular repeated movements involving group of muscles.

Mannerism

• Repeated movements that appear to have some functional significance.

Stereotypes

• Repeated movements that are regular(un like tics) and without obvious significance(unlike mannerism).

Catatonia

• State of increased muscle tone affecting extension and flexion abolished by voluntary movements.

Catalepsy

• Describe the tonus in catatonia.

• It is detected when a patients limb can be placed in a position in which they then remain for long periods whilst at the same time muscle tone is uniformly

increased.

Cataplexy

• Sudden and transient episode of muscle weakness accompanied by full conscious awareness, typically triggered by emotions such as laughing, crying, terror, etc

Narcolepsy

• Irresistible attack of sleep

Posturing • Adoption of unusual bodily

postures continuously for a long time.

• Posture may appear to have a symbolic meaning (Standing with both arms. Outstretched -crucified)

• or may have no apparent significance. standing in one leg

Grimacing

• Same meaning as in everyday speech.

Schautzkramp

• Pouting of the lips to bring them closer to the nose.

Negativism

• Do the opposite what is asked and actively resist efforts to persuade them to comply.

Echopraxia

• Imitation of the interviewers movement automatically even when asked not to do.

Mitgehen

• Excessive compliance.• Patients limb can be

moved into any position with the slightest pressure.

Ambitendence

• Simultaneous contradictory movement.

Stupor • Patient is immobile• Mute• Unresponsive• But appears to fully conscious in that

eyes are usually open and follow external objects.

• If the eyes are closed , the patient resists attempts to open them

Psychomotor retardation with clear consciousness

Tips for GP trainees working in psychiatry

• Treat the patients with dignity at all times. You will never regret it.• Try not to be afraid of psychiatry or psychiatric patients, you cannot

catch madness.• The psychiatric multidisciplinary team is less hierarchical than a

standard medical team – respect this. Recognising the skills and knowledge of the multidisciplinary team will enhance your ability to care for your patients.

• Most psychiatric units are very different from hospital wards. Remember that many psychiatric nurses are not trained or experienced in spotting medical problems and you should not expect them to… that's your job.

• Know how neuroleptic malignant syndrome presents and how to manage it.• Attend a breakaway training course that shows you physical techniques to remove

yourself from violent encounters. Hopefully you will never have to use the skills, but you'll never regret having them, even when you have finished psychiatry and doing other jobs.

• Direct confrontation and shouting at agitated patients rarely calms the situation or leads to a favourable result. Always try to de-escalate tense situations. Offer oral medication before resorting to the intramuscular route.

• Always write up rapid tranquilisation on the ‘as required’ section of the patient's drug chart on all admissions. Write oral and intramuscular routes separately and remember that some drugs (for example, haloperidol) have different 24-hour maximum doses for oral and intramuscular routes.

• Check if a patient has been prescribed antipsychotics before.

• Become fluent in the performance and recording of the mental state examination, you'll be doing a lot of it! Take a crib sheet with the headings on for the first few oncalls and clinics till it becomes second nature (as it will).

• Take drug charts and all admission forms to A&E when oncall in case you need to admit a patient. That way you can take care of all the paperwork at once.

• Make sure you know which consultant is oncall and their contact details. Find this out at the start

of the shift rather than out-of-hours when you need to speak to them urgently.

• Initially you should be discussing all patients you see with a psychiatry consultant.

• Always do a risk assessment. Always ask about suicidal ideation, thoughts of self-harm and thoughts of harm towards others. Other domains of risk include vulnerability from others, self-neglect and psychosis. Remember that not all risks are predictable.

• If you ever think you need to call the consultant, do. But before you do, formulate the patient using the biopsychosocial precipitating/ predisposing/maintaining matrix. Be clear what the main areas of

risk are, and how likely you think they are to happen.

• Learn the process, and become familiar with the paperwork of detaining patients under section 5:2 of the Mental Health Act. When you need to do this you don't want to be learning on the job and paperwork errors cause great headaches for the entire trust.

• Try to de-escalate situations before resorting to the Mental Health Act. If patients feel they have been listened to they can often be persuaded to stay informally.

• Think about any child protection issues.

• Get in the habit of taking a personal alarm with you. Know how to use it. Know how to provide assistance to others who need it.

• Do not get involved in restraint unless you have proper training. Without it, restraint is very dangerous for the patient (and for you).

• People with personality disorders can be difficult to manage. They can bring up polarised feelings within you, and between your team (technically known as splitting). Try and get some exposure to the STEPPS programme for

borderline personality disorder.

• Learn some cognitive behavioural therapy (CBT). If you can't attend a course get some teaching from your team psychologist. GPs pay good money to go on courses to get this experience! Make sure this training finds its way onto your CV.

• Listen to the nurses! They spend much much longer with the patients than you do and have a wealth of knowledge and experience that they are usually happy to share.

• Try to do some home visits with the community psychiatric nurses if appropriate.

• Let it be known that you are interested in seeing some mental health assessments performed by the consultants. This will give you insight into the process which will be useful when you are a GP.

• Learn how to manage the core psychiatric diagnoses such as depression, schizophrenia, and bipolar disorder.

• Get a good chart to guide you when changing patients medications.• Try to become familiar with the side-effect profile of common or significant

psychotropic medications such as lithium, clozapine, the antipsychotics, and antidepressants.

• Learn to spot extrapyramidal side effects. Always write up procycladine ‘as required’

for patients who are on antipsychotics.

• The Maudsley Guidelines are a fantastic resource.1

• Don't let your physical medicine slip – some psychiatrists have been out of the general hospital for long enough to feel deskilled in managing physical (that is, non-mental health) problems. Your team will often be looking for your leadership in this area.

• Remember to consider organic causes of psychiatric presentations.• Mental health stigma and prejudice is real and widespread. Make sure you are not

part of the problem.• Treating people with alcohol issues is difficult. Accept that until they become

motivated, you won't cure them.

• Make sure you laugh. Psychiatry is emotionally demanding and without this release you will really struggle.

• Attend the Balint group, engage with the Balint group, write about the Balint group in your eportfolio (educational supervisors love it!).

• Always do a physical exam and blood tests when admitting a patient unless they really are too agitated. Try not to leave it to someone else to do the next day. It would be awful to miss a medical problem that could result in significant harm to the patient.

• Regardless of your placement try to sit in on or get experience of Child and Adolescent Mental Health Services, Working Age Mental Health Services and Older People's Mental Health Services, liaison psychiatry, eating disorder services, and any other specialist clinics that you think will be useful or interesting.

• Remember that disinhibited older patients with dementia can be the population most prone to assaulting staff.

• When starting patients on SSRIs warn them that anxiety can get worse in the initial period. Also warn them that positive effects generally take at least 2 weeks and often a month to kick in.

• 1mg lorazepam = 5–10mg diazepam.2

• Always warn patients benzodiazepines are addictive (and antidepressents aren't).• Make your consultant's secretary your best friend. Make tea, offer biscuits, make them want to work for you.

Thank you