Classification and Assessment in Psychiatry Flashcards
Defining psychiatric disorders
Realism
Kendler proposed 3 approaches to question the underlying nature of psychiatric disorders: realism, constructivism and pragmatism.
Realism = the assertion that mental illness exists.
Biological psychiatry suggests disorders will eventually be identified by genetics/biomarkers/cerebral pathways.
Disturbance = distracability
Defining psychiatric disorders
Constructivism
Kendler proposed 3 approaches to question the underlying nature of psychiatry disorders: realism, constructivism and pragmatism.
Constructivism = psychiatric disorders have no biological reality and are the construction of social convention by humans.
Anti-psychiatry view
Defining Psychiatric Disorders
Pragmatism
Kendler proposed 3 approaches to question the underlying nature of psychiatry disorders: realism, constructivism and pragmatism.
Pragmatism = also referred to as utility. Psychiatric classification is based on what is useful and works, rather than what is real.
Criticism - danger that will detract from scientific basis and psychiatric diagnosis not belonging to a legitimate biomedical discipline.
Prominent psychiatrist involved in the classification of psychosis
Emil Kraeplin (1918)
He delineated schizophrenia from bipolar affective disorder on the basis of clinical symptoms, course and family history.
Symptom-based theoretical models to psychiatric diagnosis:
Monothetic approach
The monothetic approach identifies that certain symptoms are essential to diagnosis. Symptoms are narrow and very specific.
Symptom-based theoretical models to psychiatric diagnosis:
Polythetic approach
The polythetic approach identifies a broad range of symptoms, none of which takes precedence over the others.
This approach is used in current classification.
Co-morbidity
Two or more discrete, unrelated entities are present in the same person
E.g. obsessional personality disorder and schizophrenia
Consanguinity
The overlap between symptoms from two or more conditions that occur together with such frequency that they should be regarded as a single entity.
E.g. schizophrenia and anxiety symptoms, rather than 1. Schizophrenia 2. Generalised anxiety disorder (as 2 separate entities)
Co-occurrence
The term is used when the nature of the relationship between disorders is uncertain due to insufficient research evidence
E.g. as in mixed anxiety and depressive disorder (MADD)
Defintion:
Personality
The totality of a person’s emotional and behavioural traits that characteristise their day to day living.
Defintion:
Personality
The totality of a person’s emotional and behavioural traits that characteristise their day to day living.
Definition:
Personality disorder
A deeply ingrained, maladaptive pattern of behaviour which is normally recognisable by adolescence and continues throughout adult life.
History of psychiatry:
Hippocrates and personality disorder
Hippocrates believed the balance of 4 humours represented the different elements of personality:
- Yellow bile - Liver - bad-tempered
- Black bile - Spleen - melancholic
- Blood - optimistic/confident
- Phlegm - placid/apathetic
History of psychiatry:
Prominent psychiatrist who contributed to our modern understanding of personality
Schneider.
His work Psychopathic Personalities for Modern Classificatory systems was published in 1923 and translated to English in 1950.
Sensory distortion
Hyper/hypo -aethesia
Hyper = increased intensity of sensation
- result of intense emotions or reduced physiological threshold
Hypo = decreased intensity of sensation
- can occur in delirium, threshold for sensations is raised
Definition:
Dysmegaloplasia
A change in the perceived shape of an object.
Micro-/macro-psia = objects are smaller/larger than in reality.
Causes: retinal disease, disorders of accommodation/convergence
Atropine, hyoscine poisoning
Commonly = pareital/temporal lobe lesion (can occur during aura of seizure)
Rare = schizophrenia
Sensory distortion
Changes in the perception of a real stimulus in the intensity and quality or in the spatial form of a perception.
Sensory deception
An occurrence of a new perception, which may or may not be in response to an eternal stimulus.
- Illusion
(Misinterpretation of stimuli arising from an external object)
- Hallucination
(Perception without adequate external stimulus)
Completion illusion
These depend on inattention, such as misreading words in newspapers or missing typos, as we read the word as complete.
Affect illusion
Arise in the context of a particular mood state.
E.g. a delerious person in a perplexed/bewildered state may perceived innocent gestures as threatening
Pareidolia
Vivid illusions which cannot be explained by mindset or affect. They are the result of excessive fantasy thinking and a vivid visual imagery.
E.g. vivid pictures in fire, without conscious effort from the patient
Trailing phenomena
Moving objects are seen as a series of discrete, discontinuous images.
Associated with hallucinogenic drugs
Causes of hallucinations
- Intense emotion
- Psychiatric disorders
- Disorders of sensory organs
- Disorders of the CNS (Lesion of diencephalon/
cortex) - Sensory deprivation
- Suggestion
Elementary auditory hallucinations
These are unformed and may be experienced as simple noises, bells, undifferentiated voices or whispers.
Gedankenlautwerden
Auditory hallucination in which one hears one’s own thoughts spoken out loud.
- First rank symptom (Schneider)
Écho de la pensée (thought echo)
Phenomenon of hearing thoughts spoken aloud after they occur.
SCAN classes this as a disorder of thought, rather than a hallucinatory experience.
It is though Gedankenlautwerden and écho de la pensée may be prerequisites to thought broadcast.
Lilliputian hallucinations
Visual hallucinations in which microsopia effects hallucinations and people often see tiny people of objects. Accompanied with pleasure/amusements.
Can be seen in delirium tremens
Defintion:
Olfactory hallucinations
Hallucinations of odour (phantosmia) which can occur in:
- schizophrenia
- organic states (e.g. temporal lobe epilepsy)
- uncommonly in depressive psychosis
Definition:
Gustatory hallucinations
Hallucinations of taste (phantaguesia)
Can occur in schizophrenia/organic states
Frequently occur with hallucinations in other modalities
Definition:
Tactile hallucinations
Hallucinations of touch.
Formication = sensation of small animals crawling over the body (acute organic states).
Cocaine bug = formication + delusions of persecution
In the absence of organic brain disease, the most likely diagnosis is schizophrenia.
Classification of tactile hallucinations
Superficial (affect the skin)
-thermic, haptic (hand brushing against the skin), hygric (fluid running from head to stomach) and paresethetic
Kinaesthetic/vestibular: (occur in organic status such as DT, acute alcohol intoxication, benzodiazepine withdrawal)
- affect muscles/joints. Limbs being ‘twisted’ or ‘pulled’. Can occur in schizophrenia.
- Sensation of flying/sinking
Visceral
- deep twisting/tearing pains.
Definition:
Hallucinatory syndromes (hallucinosis)
Disorders in which there are persistent hallucinations in any sensory modality in the absence of other psychotic features.
Alcoholic hallucinosis:
Usually auditory and occur during periods of relative abstinence. Clear consciousness, rarely persist >1 week. Long-standing alcohol misuse
Organic hallucinosis:
20-30% of patients with dementia (especially Alzheimer’s). Commonly auditory or visual.
Definition:
Functional hallucinations
An auditory stimulus causes a hallucination, however both stimulus and hallucination are experienced. (A real sensation is required for the hallucination)
E.g. a patient heard the voice of God when her clock ticked, later she heard voices from the running tap
Definiton:
Hypnagogic/hypnopompic hallucinations
Hypnagogic = hallucinations whilst falling asleep
3x more common than
hypnopompic; 37% adults
Visual/auditory hallucinations
Hypnompompic = hallucinations whilst waking
They can occur in narcolepsy
Not indicative of psychopathology, despite being true hallucinations
Defence mechanisms were organised into how many levels by Valliant’s classification?
Four Levels:
- Psychotic defences
- Immature defences
- Neurotic defences
- Mature defences
What are psychotic defences according to Valliant’s classification (Level 1)
Pathological defence mechanisms which distort experiences in which they eliminate the need to deal with reality.
- Distortion
- Denial
- Delusional projection
- Splitting*
Found frequently in borderline personality
disorder; people are divided into polar
opposites e.g. perfect or flawed
*Comes up in exams, but not part of Valliant classification
What are immature defences according to Valliant’s classification (Level 2)
Immature Defences:
1.Schizoid fantasy
2. Projection
3. Acting out
4. Hypochondriasis
5. Passive aggression
6. Idealisation*
7. Projective Identification - an aspect of self is
projected on to someone else. The projector
tries to coerce the recipient with what has
been projected to feel as sense of union.*
*Comes up in exams, not part of Valliant’s classification
What are neurotic defences according to Valliant’s classification (Level 3)
Neurotic defences:
Tend to have short term advantages but lead to problems longer term.
- Displacement
- Reaction formation
- Repression
- Intellectulisation
- Dissociation
- Isolation*
- Regression*
- Rationalisation*
- Controlling*
- Externalisation*
- Undoing*
*Come up in exams, not part of Valliant classification
What are mature defences according to Valliant’s classification (Level 4)
Mature defences
Considered the most advanced form of defence mechanism
- Altruism
- Anticipation
- Sublimation
- Suppression
- Humor
- Identification
- Introjection
Sublimation
Mature defence mechanism
Deals with stress by channelling potentially disruptive feelings or impulses into socially acceptable behaviour
Displacement
Neurotic defence mechanism
The process in which interest or emotion is shifted from one object to a less threatening one, so the latter replaces the former.
E.g. Someone have difficulties with their boss at work my distance anger onto their family by being irritable
Projection
Immature defence
Falsely attributing your own unacceptable feelings, impulses or thoughts to another person
Projective Identification
Immatue defence:
an aspect of self is projected on to someone else. The projector tries to coerce the recipient with what has been projected to feel as sense of union.* There is a sense of feeling controlled or manipulated by the recipient.
Intellectualisation
Neurotic defence mechanism
Focusing on details to avoid painful thoughts or emotions
Rationalisation
Mature defence mechanism
The creation of false, but credible justifications. Patient feels emotions (in intellectualisation these are avoided) and seeks alternative reasons to avoid the reality of the situation.
Reaction formation
Neurotic defence mechanism
Substituting behaviour, thoughts or feelings which are the exact opposite of your own unacceptable thoughts or feelings.
Reaction formation
Neurotic defence mechanism
Substituting behaviour, thoughts or feelings which are the exact opposite of your own unacceptable thoughts or feelings.
Reaction formation
Neurotic defence mechanism
Substituting behaviour, thoughts or feelings which are the exact opposite of your own unacceptable thoughts or feelings.
Reaction formation
Neurotic defence mechanism
Substituting behaviour, thoughts or feelings which are the exact opposite of your own unacceptable thoughts or feelings.
Idealisation
Immature defence mechanism
Seeing someone or an object as omnipotent e.g. you will save me
Repression
Neurotic defence mechanism
Removing disturbing thoughts/emotions/experiences from conclusion awareness.
Suppression
Mature defence mechanism
Consciously avoiding thinking about something
Mental State Definitions
Feeling
An active experience of somatic sensation (such as touch or heat) or a passive subjectovr experience of an emotion.
Used to describe a reaction to an experience.
Mental State Definitions
Affect
A patient’s present emotional responsiveness
- Within normal range
- Constricted (restricted in range and intensity)
- Blunted
- Flat (no expression)
Mental State Definitions
Mood
A prevailing state or disposition
Reflex hallucination
These occur in one sensory modality in response to a stimulus in another sensory modality.
(In functional hallucinations the real stimulus and hallucination occur in the same modality)
Depersonalisation
A subjective state as if one is unreal, generally felt to be strange and unpleasant.
Features include:
- Emotional numbness
- Changes in sensory experience
- Distorted sense of time
- Heightened self-observation
Big 5 personality traits
Openness to experience Conscientious Extraversion Agreeableness Neurotocism
DSM V personality clusters: A,B,C
Mad (A), Bad (B), Sad (C)
(= ICD 10 equivalent)
A -
Schizotypal (listed alongside schizophrenia)
Schizoid (schizoid)
Paranoid (paranoid)
B - Narcissistic (other) Borderline (emotionally unstable) Antisocial (Dissocial) Histrionic (Histrionic)
C-
Obsessive compulsive (Anankastic)
Avoidant (Anxious-avoidant)
Dependent (Dependent)
Who developed the term catatonia?
Kahlbaum
Catatonia = disturbance of motor functions amid disturbance of mood and thought
What are the ten first rank symptoms of schizophrenia?
Running commentary Voices heard arguing Thought echo Thought insertion Thought withdrawal Thought broadcast Delusional perception Made affect Made volition (impulse or behaviour controlled by an outside force)
Synaesthesia
The stimulation of one sensory pathway leads to experience in a second sensory pathway
E.g. hearing a smell
Intellectual disability
IQ 35-49
Moderate intellectual disability
Intellectual disability
IQ 20-34
Severe intellectual disability
Intellectual disability
IQ 70-90
Borderline intellectual disability
Intellectual disability
IQ <20
Profound intellectual disability
Intellectual disability
IQ 50-69
Mild intellectual disability
Disorder of thought content
Primary delusion (apophany)
A delusion which arises spontaneously, from normal psychological processes and not a result of psychopathology
Delusional perception
Delusional memory
Delusional mood
Autochthonous delusion
Disorder of thought content
Secondary delusion
A delusion which develops as a consequence of a morbid experience
E.g. a delusion secondary to auditory hallucinations
Hyperschemazia
Perceived magnification of body parts
Ansosognosia
Denial of illness
Hemiasomatognosia
Belief that half of the body is missing
Migraine, aura with epilepsy
Disorders of stream of thought
Disorders of tempo
Flight of ideas
Prolixity
Inhibition or slowing of thinking
Circumstantiality
Disorders of stream of thought
Disorder of continuity of thinking
Preservation
Thought blocking
Disorders of stream of thought
Disorder of continuity of thinking
Perseveration
Thought blocking
Flight of ideas
(Typical of mania, can occur in hypomania, occasionally in schizophrenia and organic states - especially lesions of hypothalamus)
Disorder of thought tempo.
Thoughts follow each other rapidly, with no general direction of thinking and connections seem to be due to chance (although easily understood).
- verbal association (e.g. alliteration, assonance)
- clang association
- clichés
- proverbs
Prolixity
Disorder of thought tempo
Lesser tempo than flight of ideas - seen in hypomania.
Patient is able to return to task in hand.
Clang and verbal associations are less marked.
Inhibition/slowing of thinking
Can be seen in depression, manic stupor, dementia
Train of thought is slowed and number of ideas or metal images is decreased.
Circumstantiality
Disorder of thought tempo
Thinking proceeds slowly (with many unnecessary or trivial detailwls), however final point is eventually reached.
Perseveration
Disorder of continuity or thinking
May be verbal or ideational.
Mental operations persist beyond the point of relevance and prevent progress of thinking.
Common in general and localised organic disorders of the brain.
What is the difference between perserveration and verbal stereotypy?
In verbal stereotypy, the same word/phrase is used regardless of the situation.
In perserveration, the word/phrase/idea persists beyond the point at which is relevant.
What is the difference between preserveration and verbal stereotypy?
In verbal stereotypy, the same word/phrase is used regardless of the situation.
In preserveration, the word/phrase/idea persists beyond the point at which is relevant.
Thought blocking
Disorder of continuity of thinking
Sudden arrest of the train of thought, leaving a ‘blank’. An entirely new thought may then begin.
Possession of thought
-Obsessions and compulsions
(Obsession [rumination] is a thought that
persists and dominates beyond the point of
relevance or usefulness.
Compulsion = obsessional motor act)
-Thought alienation
Experience that one’s thoughts are under control
of an outside agency or others are involved in
their thinking)
Thought alienation
- Thought insertion
- Thought deprivation (thoughts suddenly
disappear or removed by a foreign influence) - Thought broadcast - several definitionsWhen the person is thinking, others are thinking
in unison with them.
Thoughts escaping from the mind and others
can access
Hearing ones thoughts spoken aloud, therefore
others can hear
Content of delusions
Delusions of persecution
Delusions of reference Delusions of guilt Delusions of harm to self/loved ones Delusions around theft Delusoons of being poisoned/infected Delusions of passivity e.g. witchcraft, demonic possession, hypnotism etc.
Content of delusions
Delusions of infidelity
Can occur in organic and functional disorders
- especially associated with alcohol dependency
- can be seen in affective psychosis, can represent a morbid exaggeration of a preformed jealous attitude
Content of delusions
Other
Delusions of love /erotomania Grandiose delusions Delusions of ill health Delusions of guilt Nihilistic delusions (negation of existence of body/mind/loved ones/world around them) Delusions of poverty
Capgras syndrome
Delusional misidentification
Patient believes someone close, normally a family member, has been replaced by a double.
Fregoli syndrome
Delusional misidentification syndrome
It is believed that various people that the patients meet are the same person, in disguise .
Delusional misidentifcation syndromes
Capgras syndrome
Fregoli syndrome
Intermetamorphisis
(Delusion people have swapped identities whilst
maintaining the same appearance)
Subjective doubles
(Delusional belief the patient has a doppelganger)
Reduplicative paramnesia
(Belief identical places and events exist)
Cotard syndrome
A delusion in which a person believes they are dead.
Accompanied with delusions they are rotting, malodorous or body parts do not exist.
Couvade Syndrome
Abnormality in experience of self in which a spouse also complains of obstetric symptoms during pregnancy and birth.
De Clerambault’s syndrome (Erotomania)
The patient (often a single person) believes that an exalted person is in love with her.
The supposed lover is often inaccessible.
Othello syndrome
Delusional belief, or overvalued idea, that one’s spouse is being unfaithful.
Munchausen’s syndrome
Factitious disorder
Repeated presentations at hospital for an apparent acute illness with plausible symptoms/history, which are false. Unlike malingering, there does not appear to be secondary gain.
Disorder of form of thinking
Formal thought disorder
Disorders of conceptual or abstract thinking
-Commonly seen in schizophrenia, organic brain disease
Asyndesis
Lack of connection between successive thoughts
Derailment
Thought slides on to a subsidiary thought
Substitution
A major thought is substituted by a subsidiary thought
Omission
Senseless omission of a though, or part of it
Argyll Robertson pupil
Tertiary syphilis; also reported in diabetes
Reacts poorly to light, normally to accommodation and convergence
Thomas Szaz
American-Hungarian Psychiatrist who was a social critic of the moral and social role of psychiatry.
He wrote ‘The Myth of Mental Illness’
Intermetamorphasis
People have swapped identities while maintaining the same appearance..
Psychological and physical transformation
Subjective Doubles
Delusional belief that someone has a double or doppelganger
Catatonia
Kahlbaum
Disturbed motor function and disturbance in mood and thought.
Stupor Posturing Cerea flexibilitus Gegenhalten Automatic obedience Mitmachen Mitgehen Ambitendency Psychological pillow Forced grasping Verbigeration Logoorrhoea Echolalia Echopraxia Mannerism Stereotypies
Stupor
Immobility and mutism
Posturing
Maintaining the same posture for long periods of time
Cerea flexibilitas
Waxy flexibility
Patient can be positioned in an uncomfortable posture which is maintained for a long time
Gegenhalten
Negativism
Resistance to examiner attempting to move body parts
Automatic obedience
Exaggerated co-operation
Echopraxia
Imitating examiner’s movement
Mitgehen
Extreme form of mitmachen,slightest pressure causes limb movement
Mitmachen
Body can be put into any posture even if given instructions to resist. Body part immediately returns to position when removed
Mannerism
Repetitive goals directed behaviour e.g. saluting
Stereotypies
Non-goal directed repetitive movement e.g. rocking
Atypical depression (DSM-IV)
Subtype of major depressive disorder; responds best to MAOI.
- Mood reactivity i.e. mood brightens in
response to events - At least 2 of:Significant weight gain or appetite increase
Hypersomnia
Leaden paralysis
Long-standing interpersonal rejection
sensitivity causing social or occupational
impairment
ADHD
Impulsivity, hyperactivity and inattention
Consciousness
State of awareness of self and the environment
Active attention
A person focuses their attention on an internal or external event with conscious effort
Inactive attention
A person passively is drawn to an internal or external event without effort on their part
Disorder of consciousness
Disorder of - perception
Dream-like change of consciousness
- often seen in delirium
Disorientated from time and place, not person. Outstanding feature is presence of visual hallucinations; often small animals. Associated with fear/terror.
Lilliputian hallucinations (small people/animals) accompanied by pleasure.
Continuous voices or organised auditory hallucinations are rare.
Tactile hallucinations can occur.
Lowering of consciousness
‘Psychologically benumbed’; no hallucinations, illusions, delusions or restlessness.
Apathetic and slowed down. Cannot express clearly and may preservate.
Restricted consciousness
Awareness narrowed to a few ideas and attitudes which dominate the patient’s mind. Disorientation from time and place.
Ganser Syndrome
A dissociative state; unconscious production of symptoms to avoid court appearance.
Give approximate answers, clouding of consciousness.
Could be organic or psychotic state.
