Psychopathology /Mental

health disorders

Micro syllabus
Unit1
1. Definitions and types
(perspectives)of psychopathology
2. Def. of signs, symptoms, syndrome,
illness, disorder, disease
3. 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. ),

5. Differentiate between Dilirum and

Demnetia and Amnesia
6. Dementia vs. normal aging
7. Changes in DSM 5 in the
classification of dementia and
amnestic disorders

Epilepsy
1. Definition
2. Why mental health professions have
to deal epileptic patients
3. Types ( partial and generalized and
their subtype just a short
description)
4. Pre, post, and inter-ictal symptoms
5. Hysterical 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)

Cognitive disorders
Cognition includes- memory, language,
orientation, conducting of interpersonal
relationship, performance of
actions( praxis), and problem solving
Cognitive disorders reflect disruption in
one or more of these domains, and are
also frequently complicated by
behavioral symptoms

 In DSM three group of disordersdementia, delirium, and amnestic

disorders- are characterized by primary
symptoms common to all the disorders
which is an impairment of cognitions
Other disorders can exhibit some
cognitive impairment as a symptom,
cognitive symptom is cardinal symptom in
delirium, dementia and amnestic
disorders

 In past these disorders were classified

under the heading organic brain
disorders or organic mental disorders
Organic (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 contents
1. What is dementia? ( clinical features)
2. Causes of dementia?
3. Course and prognosis
4. Differential diagnosis ( differentiate between) Dementia vs. delirium
5. Dementia: reversal vs. irreversible
6. Types of dementia ( focus on Vascular vs. Alzheimers type in
regard to clinical features)
7. Normal ageing vs. dementia
8. Dementia vs. MR
9. Sun-downing
10.Pseudo-dementia
11.Risk of dementia
12.Briefly - management and treatment

Delirium
1. Clinical features
2. Types and Diagnostic Criteria
3. Tests
4. Causes (aetiology)
5. Differential Diagnosis ( mostly w/ Dementia)
6. Course and prognosis
7. Epidemiology ( Include India data )
8. Treatment and management (focus in psychosocial interventions)
9. Why it is called syndromanal disorder?
10.
Delirium is characterized by global impairment in consciousness?
Explain.

Features 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 typecause by vessel hemorrhage, 3) Other
medical conditions (eg. HIV infection, head
trauma)
4) substance induced- multiple etiologies
5) NOS-if cause if unknown

- It 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:
1. General medical condition
2. 2. substance induces ( eg. Cocaine)
3. Multiple causes
4. 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 attend
Delirium 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 functions
Abnormalities 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:
1. Caused by medical condition ( e.g.,
hypoxia)
2. Caused by toxin or medication
( diazepam, marijuana)
3. NOS

 Amnestic 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 memories
Patients with amnestic disorders do not have good
insight into their neuropsychiatirc conditions
The 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 something
Confusion: inability to think clearly/
it occurs characteristically in states
of impaired consciousness but it can
occur consciousness is normal
Consciousness: awareness of the self
and the environment

Cognitive disorder NOS

Allows the diagnosis of cognitive
disorders that does not fit in above
categories

Amnestic disorders
Syllabus for amnestic disorders
(pp no. 344-350, Synopsis (10th Ed.)

- Amnestic 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 disorders
Amnesia 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

Systemic medical conditions

Thiamine deficiency (Korsakoffs syndrome) Hypoglycemia
Primary brain conditions
Seizures
Head 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 amnesia
Electroconvulsive therapy
Multiple sclerosis
Substance related causes
Alcohol use disorders
Neurotoxins
Benzodiazepines (and other sedative-hypnotics)
Many over-the-counter preparations

Diagnostic 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)

- Time in which the patient is amnestic can

begin at the point of trauma, or include the
period before the trauma
- Short term and recent memory are usually
impaired
- They cannot remember what they had in
lunch and breakfast (recent), name of the
hospital or their doctors
- In 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)

Subtypes
- Cerebrovascular diseases ( affecting the hyppocampus)
- Multiple sclerosis
- Korsakoffs syndrome (amnsetic syndrome caused by thiamine
deficiency, most commonly associated w/ poor nutritional habits
A 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 entity
The 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

Transient global amnesia

- Transient global amnesia is characterized
by the abrupt loss of the ability to recall
recent events or to remember new
information
- The 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 hours
- Patients with transient global amnesia
almost universally experience complete
improvement

Differential diagnosis
1. Dementia and delirium
2. Normal aging (not significant
impairment (minor) vs.
significant)
3. Dissociative disorders (lost their
orentation to self and more
selective memory deficits than
patients w/ amnestic syndrome)
4. Factitious disorder ( inconsistent
results in memory tests)

Course and prognosis

- Course depends on etiology and
treatment (particularly acute
treatment)
- Generally it has static course
- Little improvement over the time but
also no progression on the disorder
- Exception 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 psychotherapy

- Primary treatment treat underline cause
- Supportive prompts ( like dates, names) make
reduce patients anxiety
- After 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
brain
- Understanding the course of recovery in such
patients helps clinicians to be sensitive to the
injury inherent in damage to the central nervous
system

Epilepsy
Syllabus
1. What is epilepsy
2. Signs and symptoms
3. Seizures
4. Types
5. Clinical features
6. Hysterical fit vs. epileptic fit

- The 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
drugs
- 30-50 % of all persons w/ epilepsy have psychiatric
difficulties sometime during the course of illness
- The most common behavioral symptom of epilepsy is
a change in personality
- Psychosis 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 itself
- Nonictal periods are categorized as preictal,
postictal, and interictal
- The 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 incontinence
- Diagnosis 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
years
- Brief disruptions of consciousness but no true
loss of consciousness and no convulsions
- EEG gives characteristic patterns 3 /sec spike

Partial seizures
- They 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 seizure
- Other 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 persons
- About 30 % of patients with complex partial seizures have
major mental illness such as depression

symptoms

Tonic seizures
During 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 seizures
During 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) seizures

A 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 a
tonic-clonic seizure(formerly known
as agrand mal seizure).

 Hysterical fit and epileptic fit (self

study)

What is psychopathology?
The study of abnormal sate of mind
It embraces three distinct
approaches:
a) Descriptive ( also call
phenomenology) , b) Psychodynamic
psychology, c) experimental
psychopathology

Terms used to describe symptoms

1. The form and content of
symptoms
2. Primary 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)

The significance of individual

symptoms
- Psychiatric disorders are diagnosed when
a defined of symptoms ( a syndrome) is
present
- Almost 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)

Importance of patients experience

- symptoms and signs are only part of
subject matter of psychopathology
- It 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

Cultural Variations in
psychopathology

Descriptions of symptoms and signs

Pseudo-hallucination??

Disorders of mood
Two terms used to refer an
emotional state- mood and
affect
Mood 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

 Changes in the nature of the mood:

can be towards anxiety, depression,
elation, or irritability and anger
Variations in mood: normal mood
varies in relation to persons situationsin 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 flatteningreduced variations ( extreme flattening
sometimes called apathy)

 Incongruous mood ( what about embarrassed

laughter???- this person is in awkward situation (ill at
ease)
Anxiety
Normal response to danger
Becomes abnormal when it is out of proportion to the
threat of danger or when it outlasts the danger
Coupled 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 irritability
Somatic: Muscle tensions, perspiration, muscle tension
tremor etc.
Autonomic components: activation of ANS

 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

Depression
It is a normal response to loss or
misfortunes
It becomes abnormal when it is out of
proportion to the misfortune ( or
loss), or unduly prolonged
Coupled 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)

Elation
An 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 anger
State of increased readiness for
anger ( they mostly occur in
many kinds of disorders so that
it has less value in diagnosis)

Disorders of perception
Perception (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

Sensory distortions
1. Change in intensity ( Hyperanethesiaincreased 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 usual
2. Changes 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)

Illusions
Misperception of external stimuli
They occur when general level sensory stimulation is
reduced and when attention is not focused on
relevant sensory modality
It 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 emotions
But 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 phobia
Q2. What are the three main ways
that mood can be disordered?
Q3. Differentiate perception and
imagery?

Hallucinations
A percept experienced in the absence of external
stimulus to the relevant sense organs
Perception 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 be
Its 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)

Pseudohullucination
Experience similar to hallucination but do not
meet all the requirements of the definition
It has two meanings:
a) 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
b) Experience appears to originate in the
external space (world) but it seems unrealthis is also called perceived hallucination

Types of hallucination
According to complexity
1. Elementary (experience such as
bangs, whistles, flashes of light etc.)
2. Complex (hearing voices or music,
seeing scene, faces etc.)
According to sensory modality
3. Auditory
4. Visual
5. Olfactory and gustatory (taste and
smell)
6. Somatic (tactile and deep)

According to special features

Auditory
1. second person
2. third person
3. 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

Visual
1. Extracampine: hallucination
located outside the visual field
(usually behind the head)
lilliputian: visual hallucination of
dwarf figures( smaller than the
corresponding real percept)

Autoscopic 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

Abnormalities in the meaning

attached to percept
Delusional 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)

Diagnostic 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/
schizophrenia
However content of second-person auditory
hallucinations ( addressing to the patient- e.g. ,you are
going to meet an accident) may have diagnostic
implications
Voices 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

 visual hallucination always suggest

organic disorder
Hallucinations 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 bulbs
Tactile 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)

Disorders of thinking
What is thinking?
There are three legitimate uses of the word think. These are:
1. Undirected fantasy thinking, also called autistic thinking
or dereistic thinking ( it is quite normal but some quit,
shy people may compensate for the disappointmentsschizoid individual became schizophrenic when his autistic
thinking became uncontrollable)
2. Imaginative thinking which does not go beyond the
rational and the possible
3. Rational thinking or conceptual thinking which attempts to
solve the problem

Types of disorders of thinking

1. Based on particular kind of
abnormal thoughts
a. Delusions
b. Obsessions
2. Disorders of stream of thoughts
(speed and pressure)
3. Disorders of the form of
thoughts
4. Abnormal beliefs about the
possession of thoughts

Disorders of the stream of

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

3. Thought 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

Disorders 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:
1. 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)

2. 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:
a. Clang associations: a second word
similar to first one)
b. Puns : a second meaning of the first word
c. Rhymes
Foi is characteristic of mania

3. 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

There are three types of loosening of

associations:
1. 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 foi
2. Talking past the point (vorbeireden):
seems always about to get near to the matter
in hand but skirts round it and never reaches it
3. Verbigeration: 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

Other related disorder of

thinking:
a. Overinclusion: widening of
boundaries of concepts , such
that things are grouped together
that are not normally regarded
as closely connected
b. Neologisms: words or phrases
invented by patients, often to
describe morbid experience
( most often in chronic
schizophrenia)

Delusions
Definition
A 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

Characteristic of delusions
1. Firmly held despite evidence to the
contrary
. The hallmark of delusion is that it
is held with conviction and
cannot be altered with the
evidence to the contrary
. Strongly 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)

Partial 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)

2. 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

Q. Delusions are false beliefs? Can

this be included as criterion while
defining them?
Q2. What is double orientation?

Types of delusion
According to fixity
1.Complete ( full delusion)
2. Partial delusion ( some doubts at the
start or during the recovery)
According to onset
1. Primary (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)
2. Secondary (derived from previous
morbid experience)

Other delusional experiences

1. 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)

2. 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)

3. 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

According to theme
1. Persecutory (paranoid): diagnostic significance depressive
patients may think justified vs. schizophrenic patients resents
and thinks it is unwarranted
2. Delusions of reference: objects, events, or people,
unconnected w/ the patient have personal significance to
him ( an article in newspaper is directed specially to him)
3. Grandiose (expansive): exaggerated self importance
( occur in mania and schizophrenia)
4. 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 patient
5. Nihilistic
6. Hypochondriacal: Concerned with illness
7. Religious
8. Jealous
9. Sexual or amorous: ( loved by a man who is usually inaccessible
to her)
10.Delusion of control

Delusion concerning
possession of thoughts
11. Thought insertion
12. Thought withdrawal
13. Thought broadcasting

According to other features

Shared 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

Obsessional and compulsive

symptoms
Obsessions
Def.: They are recurrent persistent thoughts, impulses or images
that enter the mind despite efforts to exclude them
- One 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 happen
- Obsessions 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
delusions
Various forms of obsessions
1. Obsessional thoughts: repeated and intrusive words or
phrases which are upsetting to the patient ( e.g.,
repeated obscenities coming into the awareness of
religious person)
2. Obsessional ruminations: repeated worrying themes
of a more complex kind ( about ending of the world)
3. Obsessional doubts: repeated themes expressing
uncertainty about the previous actions (whether or not
person turned locked the door)
4. 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 on
5. Obsessional 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

The content of obsessions

Although the content (themes) are various but
most can be grouped into 6 categories
1. Dirt and contamination (idea of harming
others through the spread of diseases)
2. Aggression (striking another person or
shouting angry or obscene)
3. Orderliness (about the ways objects are to be
arranged)
4. Illness (fearful kind, e.g., fear of cancer
venereal diseases)
5. Sex (concern practices that individual find
shameful)
6. 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 resist
- Like obsessions, compulsions are recognized as senseless
- It 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:
1. Checking rituals
2. Cleaning rituals
3. Counting rituals
4. Dressing 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
emotions
Derealization: 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 working
- Occur 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 disorders

Motor symptoms and signs

- Tics: irregular repeated movements involving a group of
muscles, for examples sideways movements of the head or
the raising of one shoulder
- Mannerisms: 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 so
- Ambitendence: 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 movement
- Waxy 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 memory
- Amnesia: failure of memory ( term dysmnesia is
occasionally used)
- Paramnesia: distortion of memory
Different related terms
Immediate 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 later
Recent memory: concerns events in last few days
Remote (long term) memory: concerns events over longer
periods of time
Recall/Recognition

Disorders of recognition
Jamais vu: failure to recognize
events that have been
encountered before
Dj vu: conviction that an event
repeats one that has been
experienced in the past when in
fact it is novel
Confabulation: reporting as
memories of events that has
been experienced at one time, ,
of events that took place at
another time, or never involved

Q. Psychogenic amnesia ( due to

repression)??

Disorders of consciousness
Consciousness: awareness of the self
and the environment
- Level of consciousness between
extremes of alertness and coma
- Quality 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
maintained
Confusion: inability to think clearly/ it
occurs characteristically in states of
impaired consciousness but it can
occur consciousness is normal

Syllabus for signs and symptoms

Please read all the ppts and
additionally PP 273-283 (10th ed.
Sadock & Sadock)
Syllabus for Classification/DSM/ICD
1. Multi-axial systems
2. ICD-10 vs. DSM IV-TR
3. GAF ( assigning GAF)
4. Provisional Diagnosis
5. Differential diagnosis

Overview
Delirium, Dementia, Amnestic, and Other Cognitive
Disorders
1. Delirium: 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 MMSE

Mental disorders due to General

medical conditions
-We will study epilpsy

Personality Disorders
[Syllabus ( PPTs and Synopsis pp. 791821)

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 significance
- What 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
personality
- In 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 personality
- Because 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

Recap ( norms of
abnormality)
1. Statistical norms
2. Cultural norms ( geographical
norms)
3. Individual norm
4. Ideal 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:
a. Personas enduring patterns must be pervasive
(consistent across situations) and inflexible as well as
stable and of long duration
b. It 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 PD
1. Diagnostic 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)
2. 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 PDs
The DSM-IV TR personality disorders are
grouped in in three clusters ( not in ICD10)
1. Cluster A: disorders often seems odd or
eccentric, w/ unusual behaviors ( like
distrust, suspiciousness, social
detachment)- Paranoid, Schizoid,
schizotypal
2. Cluster B- dramatic, emotional, and
erratic- histrionic, narcissistic, antisocial,
and BPD
3. Cluster C- anxiety, fearfulness (avoidant,
dependant, OCPD)

General diagnostic criteria is

included in the syllabus

Etiology Included
- Genetic factor
- Biological factor
- Psychoanalytic factors

 Personality Disorders
Described on Axis II; chronic patterns of maladaptive, pervasive,
stable, and distressing behavior and inner experience. They are
clustered into three main categories.
Types
Cluster 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

Diagnostic criteria for BPD is

included in syllabus

Schizophrenia and schizophrenia like

disorders

Schizophrenia
Syllabus
Refer Sadock & Sadock and document
uploaded in moodle. Exclude the
phicaltherapy component.
Concentrate in
*( emphasize on historical
development/types/ subtypes/ clinical
features/ differential diagnosis/ etiology)

- Of all the psychiatric syndrome,

schizophrenia is much the most
difficult to define and describe
- The 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

Predominant clinical features of

acute schizophrenia:
delusions/hallucinations/ and
interfernce with thinking
Chronic schizophrenia: apathy/lack of
desire/slowness/and social
withdrawal

The most frequent symptoms of acute

schizophrenia
Symptom
Frequency
Lack of insight 97
Auditory hallucination 74
Ideas of reference 70
Suspiciousness 66
Voices speaking to the patient 65
Delusional mood 64
Delusions of persecution 64
Thought alienation 2
Thoughts spoken aloud 50

Behavioral characteristic of chronic schizophrenia

Characteristic
frequency
- Social withdrawal 74
- Underactivity56
- Lack of conversation 54
- Few leisure interest 50
- Slowness 48
- Overacivity 41
- Odd idea 34
- Depression34
- Odd behavior 34
- Neglect of appearance 30
- Odd postures and movements 25
- Threats or violence 25
- Poor meal time behavior13
- Socially embarrassing behavior8
- Sexually unusual behavior 8
- Suicidal attempts 4
- Incontinence

Clinical 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 affect
auditory hallucination/
Delusions
generalized deficits in cognitive functions (learning, memory,
perception, motor skills)
impaired insight/

Chronic 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 deteriorate
Speech is often abnormal
Hallucinations are common
Delusions are systematized and also held with little
emotions

Historical 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 schizophrenia
- In 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

- Morel 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-neglect
- Not 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 symptoms
- It lead him to argue against a division into dementia
praecox and manic-depressive psychosis
- This grouping put hebephernia and catatonia as subclasses
of dementia praecox

- Kraepelins description of dementia

praecox appeared for the first time in 1893,
in the fourth edition of his textbook
- He 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)

- Kraepelin 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 preacox
- Eugen 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

- Since Bleuer was preoccupied more with

psychopathological mechanism than with
symptoms themselves, his approach to
diagnosis was less precise than that of
Kraepelin
- Kurt 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

- Schneider (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

Schneiders symptoms of first rank

Hearing thoughts spoken aloud
Third-person hallucination
Hallucination in the form of a
commentary
Somatic hallucination
Thought withdrawal or insertion
Thought broadcasting
Delusional perception
Feelings or actions experienced as
made or influenced by external
agents

- In Denmark and Norway, cases of

psychosis after stressful events have
received much attention
- The 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

Delusional disorders and other

psychotic disorders
( syllabus: follow class PPTs of groups
and synopsis)

Addiction
- Definition and usage of word drug
- Forms of in taking drugs
- Blood-brain barrier
- Psychoactive substances
- Characteristic of addiction
a) Tolerance, b) withdrawal, c) drug
seeking behaviors

Other related terminologies:

- Dependance/abuse/misuse/
Intoxication
- Codependance
- Enabling
- Denial
- Cross tolerance
- Neuroadptation

Models of addiction
-

Alcoholism ( abuse and dependency):

refer Synopsis

Psychopathy and ASPD