BASICS OF PSYCHIATRY, schizophrenia

BASICS OF PSYCHIATRY

• Two Greek words:
• "psyche": mind.
• "iatry": healing or cure.

• Branch of medicine.

• Deals with problems of the mind and its treatment.

• Coined by German physician Johann Christian Reil.

Approach to a Patient

• History is taken from the patient and informant.

Examination

• General physical examination.

• Systemic examination.

• Mental status examination (MSE).

Investigation

• Limited role.

• Rules out other abnormalities.

History

Informant

• History is taken directly from the informant.

Reliability of informant

• Consistent
• Information given is the same in each interview.

• Chronological
• Information is given in chronological order.

• Coherent
• All pieces of information are logically connected.

• Closeness with the patient
• Length of stay with the patient.

• Concern for the patient
• Esp in MLC
• Genuine concern for the patient.
• e.g., Vested interest in a divorce case.

• Intellectual/Observation

Mental Status Examination (MSE)

• Examination of a psychiatric patient.

Which mental functions are examined in the Mental State Examination 100-7?

General Appearance and Behavior

Dressing

• With respect to weather conditions.

• e.g., Patient with layers of warm clothes on a hot day.

• Inappropriate dressing.

• May suggest Schizophrenia.

Grooming

• Self-care.

• e.g., Patient with
• uncombed hair,
• foul-smelling,
• poor grooming.

• May suggest Schizophrenia.

• Also suggest severity of depression

Speech

Rate of speech

• Number of words a person speaks in a minute.

• Mania:
• High rate of speech.

• Depression:
• Low rate of speech.

Coherence

• Whether speech is understandable.

• Incoherent speech:
• illnesses like schizophrenia.

Mood and Affect

• Denotes feelings and emotions of a person.

Feature	Mood	Affect
Definition	Persistent → most of time pervasive → most of place	Expression of emotion observed by the therapist.
Expression	The patient will tell.	Expressed on the face through body language.
Phenomenon	An internal phenomenon.	An external phenomenon.
Duration	Long-term history	Cross-sectional history

Abnormalities of Affect

• Flat affect (Blunt affect)
• Emotion does not change even with stimuli.
• e.g., When talking about a sad or good event.
• Seen in conditions like schizophrenia.

• Labile affect
• Rapid and abrupt changes in emotion without stimuli.
• e.g., Patient starts laughing/crying without any reason.
• Seen in mania and organic mental disorders.

Important Information

Anhedonia

• Decreased interest in pleasurable activity.

• Seen in depression and schizophrenia.

DISORDERS OF THOUGHT

• Stream () Movie (Content) in TV/PC (TV is my Possession)
• Stream
• Stream when circumstances allow (circumstantiality)
• with remote
• Remote has cover (preservation)
• Apply pressure (pressure of speech) on remote
• eat it like clang clang clang ()
• someone block (thought block) it
• keep in proximity (prolixity) to TV
• Radiation fly (flight of ideas) from remote to tv
• Movie (Content)
• Works on a belief (or delusion)
• TV/PC - Possession
• we can insert into it, withdraw from it and broadcast from it

• Filling a Form
• Railway (derailment) nnu Salad (Word salad) um Tangum (Tangentiality) kazhichapo Loose (Loosening) motion ayi

1. Flow/Stream

a. Speed/Tempo of thought

• Mnemonic:
• ↑ Speed → remember a flight (flight of ideas) → speed when flying in proximity (prolixity) to another
• ↓ speed → circle (circumstantial) and retard (retardation) speed → to stop

Increased

• Flight of ideas
• Thoughts follow each other rapidly.
• The goal is not reached.
• Connections between thoughts exist.
• By chance factor.
• Clang associations or rhyming words.
• Ex:
• Birds are fun, Im slim, im the king, from boston ring
• my friend is mukesh → mukesh loves cricket → cricket is a game → games are good
• Seen in Mania > schizophrenia and organic mental disorders.

• Prolixity
• Thoughts are fast but slower than flight of ideas.
• Also known as ordered flight of ideas.
• Goal is reached.
• Seen in conditions like Hypomania.

Decreased

• Retardation
• Decrease in the speed of thought.
• Seen in Depression

• Circumstantiality
• Thinking proceeds slowly.
• Gives unnecessary and trivial details.
• The goal is ultimately reached.
• Seen in conditions like Mania.

• Mnemonic: Mania → Booking Ticket for America d/t mania →
• Thinking Circumstances in America (like things happening there) → slow down process of booking → Circumstantiality → Mania
• then 2 cases
1. Book ticket to america due to mania → Prolixity → Hypomania
2. Book ticket to so many countries except america → Mania

b. Continuity

• Perseveration
• Thought persists beyond the point of relevance.
• Seen in
• organic mental disorders (Pathognomic) >
• Mnemonic: Preserve (Preservation) organic () vegetables
• schizophrenia.

• Thought block
• Sudden arrest of thought
• A blank is left
• Person begins with an entirely new thought.
• Seen in schizophrenia.

2. Content

Delusion

• A false, fixed, and unshakeable idea or belief.

• Held with extraordinary conviction.
• e.g., 20-year-old male claims neighbors want to kill him, cannot be convinced otherwise.

• Unexplained by the person's cultural, social, and educational background.
• e.g., Superstitions are not delusions
• Refusing to cross a road after a black cat is a cultural belief, not a delusion.

Types of Delusion

• Delusion of Persecution
• Most common delusion.
• Patient believes someone is planning to harm or kill them.

• Folie a deux:
• Shared delusion
• Separate both person, treat primary person

• Delusion of Reference
• Patient believes someone is talking about or spying on them.

• Delusion of Grandiosity
• Patient believes
• they are God,
• have supernatural powers,
• know famous people,
• have vast knowledge, or
• are very wealthy.
• Seen in Schizophrenia > Mania.

• Delusion of Nihilism
• Delusion of Negation.
• Patient denies the existence of
• their body,
• loved ones,
• the world.
• Seen in schizophrenia and depression.

• Cotard syndrome:
• A patient with depression + nihilism.
• Severe psychotic depression
• Mood congruent

• Declerambault's Syndrome/Erotomania/Delusion of Love
• Patient believes someone (usually of higher stature) is in love with them.
• Mnemonic: Declare the love

• Othello's Syndrome/Delusion of infidelity/Morbid jealousy
• Patient believes their partner is having an affair.
• Linked to prolonged alcohol use.

Delusional Misidentification Syndrome

• Problem in identifying other people.

Capgras Syndrome

• CAPGRAS:
• Close person replaced by a stranger.

• Patient believes a closely related person has been replaced by an exact double.

• Physical appearance acknowledged as the same.

• Argument with the close person.

• CAP → we dont like → we go away

• Fregoli → Free things we like → we go towards

Fregoli Syndrome

• Patient believes a familiar person is posing as a stranger
• can take multiple appearances

• Physical appearance change is acknowledged.
• I know you dont look like my wife, but you are my wife

• Argument with a stranger.

3. Form

• Form means organization or plan formation

• Thoughts have a start, middle, and end.

• Abnormality is known as formal thought disorder.
• e.g., in schizophrenia.

• Normal thought
• Everything is logically connected.
• e.g., Planning a date:
• book a cab → reach cafe → order coffee → drink, pay → come back.

• Fill a form of multiple pages
• Schizophrenia → fill but idfferent order
• Normal → fill pages 1 → 2 → 3 order

Abnormal Form / Formal thought examples

• Mnemonic:
• Railway (derailment) nnu Salad (Word salad) um Tangum (Tangentiality) kazhichapo Loose (Loosening) motion ayi

Loosening of association

• Break in logical connection between thoughts.
• Speed is normal
• (vs. flight of ideas: increased speed, has connections).

• Sentences do not make sense.
• e.g., Order coffee → come home → reach cafe → black shirt → drinking → book cab.

• Seen in schizophrenia.

Derailment/Knight's Move Thinking

• Jump to a different topic without logical connection.

• No pause (unlike thought block).

• Train has no stop → no pause between districts

• In Block → we pause between districts

Tangentiality

• Reply to a question is oblique or tangential.

• Patient moves away from the topic and never answers.

• The goal is not reached.

• Beat around the bush, don't give a direct answer

Neologism

• A completely new word or phrase is used.

• Derivation cannot be understood.
• e.g., A patient calls their watch a "pratnityat".

• Seen in disorders like schizophrenia.

Incoherence/Word Salad

• Thoughts are incomprehensible.

• e.g., "I will go umbrella black fly water".

• Seen in disorders like schizophrenia.

Ganser Syndrome:

• Seen in prisoners, under extreme stress

• Unconscious dissociative phenomenon

• Mnemonic: Gangster (Ganser) are Very Burden (Vorbeireden)

• Can be seen in other populations also.

Talking past the point/Vorbeireden

• Reply shows the question was understood.

• Classic feature of Ganser syndrome.

• Not due to malingering

• Pseudo stupidity

• Patient deliberately talks about an associated topic.
• e.g.,
• Q: "What color is grass?" A: "It is red."
• Q: 2+ 2 = 5

4. Possession

• Loss of control or sense of possession of thinking.

• Mnemonic: Rosie was my obsession (), alien (Thought alienation) came and possessed () her

Two important abnormalities:

Obsession (R.O.S.I.E)

• R - Recurrent thoughts/Images/Impulses.

• O - Own thoughts.

• S - Senseless.

• I - Irresistible.
• e.g.,
• Recurring thoughts of dirty hands;
• patient knows they are his own and senseless
• but cannot stop them.

• Seen in obsessive-compulsive disorders.

Thoughts under outside influence/
Passivity phenomenon/
Thought alienation

• I was Passive () → Alien () came and possessed () me

• Thought Insertion:
• Patient feels outside thoughts are inserted into their mind.

• Thought Withdrawal:
• Patient feels someone is taking thoughts from their mind.

• Thought Broadcast:
• Patient feels their thoughts are broadcasted to everyone.

• Seen in schizophrenia
• (First-rank symptoms).

PERCEPTION

Abnormalities of Perception

Illusion

• Stimulus +

• False perception of a real object.

• e.g., Seeing a snake under the bed, which turns out to be a rope when lights are on.

Hallucination

• False perception without a real object.

• Stimulus -

• Psychotic symptom.

Characteristics of Normal Perception/Object

• It is clear

• Occurs in outer objective space.

• Independent of one's will.

Characteristics of Hallucination

• To the patient, it is very clear as vivid as real

• Occurs in the Outer Objective Space
• (OO)

• Independent of the Person's Will.

• Characteristics are similar to real objects.
• e.g., Seeing Mahatma Gandhi as clearly as a real person.

Pseudo-hallucination

• Clear and involuntary, like hallucinations.

• Occur in the inner subjective space
• (IS)

Types of Hallucination

• 5 types.

Auditory Hallucination

• Most common type.

• Patient is able to hear something.

Visual hallucinations

• e.g., Flashing lights, an animal, a human face, or an entire human.

• Most common in organic mental disorders.

• Seen in Schizophrenia.

• Organic farm is my vision

Olfactory hallucinations

• Patient perceives an unpleasant odor.

Gustatory hallucinations

• Patient tastes something sweet, sour, or bitter.

• Seen in disorders like schizophrenia.

• Olfactory and gustatory are seen in temporal lobe disorders (e.g., epilepsy).

Tactile hallucinations

• cocaine bugs or magnum bugs.
• Also Ergot and Arsenic
• All 3 A/w black disoloration

• Superficial or over the skin:
• hot, cold, tingling.

• Also known as formication.

• Patients experience insects crawling under skin.

• Cocaine users complain of this feeling.

• Clinically, many scratch marks are seen.

Special Hallucinations

Reflex hallucinations (Morbid Synaesthesia)

• A real stimulus in one sensory modality
• produces a hallucination in a different modality.

• e.g., Patient hears a ringtone (auditory perception) and
• sees a man walking into the room (visual hallucination).

• Seen in
• psychotic disorders
• hallucinogens like LSD

• Mnemonic: Morbid Synasthesia → Pacha light ⇒ Death

Delusion vs Hallucination

SCHIZOPHRENIA AND
OTHER PSYCHOTIC DISORDERS

Schizophrenia

• The prototypical psychotic disorder.

• Prognosis order: CPU Hard Disk
• Catatonia > Paranoid > Undifferentiated > Hebephrenic > Simple

History

Bleuler’s ‘Four A’s’

1. Association Disturbances:
1. e.g., Loosening of Association.

2. Affective Flattening.

3. Autism:
• Fantasy Thinking (patient engrossed in their own world).

4. Ambivalence:
• Inability to take decisions.

• Mnemonic:
• Schizophrenia → Remember Blue (Bleuler) Film Anyan
• Ambi () de Austism () Affected () his Association ()

Kurt Schneider:

• Schneider's First Rank Symptoms (SFRS)
1. Audible Thoughts / Thought Echo (First person auditory hallucination).
2. Voices discussing the patient (Third person auditory hallucination).
3. Voices commenting on one's action / Running commentary.
4. Thought Insertion.
5. Thought Withdrawal (part of Thought Alienation).
6. Thought Broadcast.
7. Made Impulses.
1. Made IFA
2. Patient experiences urges that are not their own,
3. but someone else is making them have them
8. Made Feelings
1. The patient experiences feelings, e.g., crying,
2. which they state are not theirs,
3. but someone is making them experience it
9. Made Acts.
1. The patient says an action was not done by them,
2. but someone made them do it
10. Somatic Passivity:
• Bodily sensation imposed by an external agency.
• e.g., Patient claims abdominal pain is from radio waves sent by aliens.
11. Delusional Perception:
• Delusional meaning given to a normal perception.
• e.g., Patient saw his wife in a red saree and claims she wants to kill him
  (Red = Danger).

Epidemiology

• Gender: Prevalence is nearly equal in males and females.

• Peak age of onset:
• Males
• 10-25 yrs
• Female
• 25-35 yrs,
• >40 yrs.

• Late-onset schizophrenia:
• After 45 years of age
• Good prognosis.

Etiology

• 1. Genetic Factors
• Concordance rate is higher in monozygotic twins.
• Higher risk in family members of patients with schizophrenia, bipolar disorder.
• Chromosome 22q11.2 Deletion syndrome/ Di-George Syndrome /
  Velocardiofacial syndrome (VCFS)
• 30% of these cases may develop schizophrenia.

• 2. Neurotransmitters
• Dopamine hypothesis:
• Increased
• Serotonin (5HT):
• Increased
• GABA, Glutamate, Norepinephrine, Acetylcholine:
• Decreased

• 3. Risk factors
• Cannabis use:
• Use in adolescence may increase the risk of schizophrenia.

Symptoms

• 1. Positive symptoms/ Psychotic symptoms
• Caused by ↑↑ Dopamine in the Mesolimbic pathway
• Delusions: M/C is Delusion of Persecution
• Hallucinations: M/C is Auditory Hallucination
• Positive symptoms respond well to antipsychotics;

• 2. Negative symptoms
• Caused by ↑↑ Dopamine in the Mesocortical pathway

Symptom	Description
Anhedonia	Decrease in interest (M/c negative symptom)
Avolition	Decrease in will or drive
Affective blunting	Decrease in expression of emotion
Associality	Decrease in social interaction
Alogia	Decrease in verbal output

• negative symptoms does not respond well

• 3. Disorganized symptoms

Symptom	Description
Disorganized speech/thought	Formal thought disorder
Disorganized behavior	Bizarre behavior
Disorganized affect	Inappropriate emotional expression (e.g., laughing at a funeral)

• 4. Catatonic symptoms/Motor Symptoms
• Patient has Catatonia if 3 or more symptoms are present.

Symptom	Description
Stupor	• Conscious but mute and immobile • Unresponsive to environment
Excitement	• Extreme, non-goal-directed hyperactivity
Mutism	• No or minimal verbal response
Catalepsy	• Holding odd posture for long (passive)
Posturing	• Holding odd posture for long (active)
Waxy Flexibility	• Person can be molded like a wax candle; • initial resistance then smooth bending
Negativism	• Opposes or gives no response to instructions • (negative attitude towards examiner)
Automatic Obedience	• Excessive cooperation • (doing whatever is asked even if harmful)
Mannerism	• Repetitive, odd, purposeful movements
Stereotypy	• Repetitive, odd, non-purposeful movements
Echolalia	• Repeating words of another person
Echopraxia	• Repeating actions of another person
Grimacing	• Maintaining odd facial expressions
Ambitendency	• Inability to decide on a motor movement

• Treatment:
• DOC: Lorazepam
• Resistant catatonia/stupor: Indirect ECT (Methohexital)
• +/- antidepressant.

• Note

Other terms	Features
Akinetic mutism	• Mute • Immobile • Responsive to environment
Twilight state	• Disturbed consciousness • Hallucinations present • Automatic Unconscious awareness actions
Oneiroid state	• Dream-like state • Severe confusion • Disoriented to time and place • Hallucinatory absorption • Detachment from real world
Oneiroid schizophrenia	• Extreme involvement in hallucinations • Exclusion of real-world interaction

Diagnosis

• According to DSM-5,
• 5 symptoms of schizophrenia: in order
• Deluded () person → in a Hall () → speaking () some rubbish → cat () walks in → he treats cat negatively kick ()
1. Delusions.
2. Hallucinations.
3. Disorganized speech.
4. Catatonic or Grossly disorganized behavior.
5. Negative symptoms.
• DSM-5 Criteria:
• ≥2 symptoms for ≥ 1 month.
• At least 1 symptom must be from the first 3
• Delusions,
• Hallucinations,
• Disorganized speech
• Total duration of disturbance:
• 6 months.

• ICD-11 Criteria:
• Duration of schizophrenia should be 1 month.

Subtypes of Schizophrenia

• Present in ICD-10, DSM-IV, based on symptoms.

• Removed from DSM-5, ICD-11.

ICD-11 (DSM-5) classification based on course:

• Schizophrenia, First episode.

• Schizophrenia, Multiple episodes
• Remission (duration at least 1 year).

• Schizophrenia, Continuous course.

• In ICD-11 and DSM-5,
• catatonia is a separate diagnostic category.

• First-line treatment of catatonic symptoms:
• Lorazepam (IM/IV/Oral)
• ECT

Suicide

Prognostic Factors

Acute Psychotic Disorder

• Symptoms similar to schizophrenia but do not meet duration criteria.

• Abrupt onset.

• Often resolve completely.

• May be preceded by a stressor (e.g., life event, fever).

Differential Diagnosis with fever:

1. Acute psychosis.

2. Delirium.
• Delirium has impaired consciousness;
• acute psychosis does not.

• Trans wore brief

Treatment:

• Antipsychotics.

Schizoaffective Disorder

• Symptoms of both schizophrenia and mood disorder for the majority of the illness.
• Almost 1 : 1 ratio
• e.g., 8 months of hallucinations/delusions with 7 months of depressive symptoms.

2 Subtypes:

• Bipolar Type:
• Manic Symptoms.
• Antipsychotics + Mood Stabilizer.

• Depressive Type:
• Depressive Symptoms.
• Antipsychotics + Antidepressant.

Delusional Disorder

• Patient has only delusions.

• 1 or more persistent delusions.

• Functioning is not markedly impaired.

• NO Hallucinations

Treatment:

• Antipsychotics.