Saturday, August 1, 2015
Mental Illness
Psychiatry Clinical Examination Format with Examples
Psychiatric Clinical Examination
Basic Information
Name, Age, Sex, Occupation, Address
Identification Marks � Medico legal purpose
Informant � to be reliable (who is staying with patient during the illness)
Chief Complaints (as patient and relative say)
General
- Sleep Disturbances, Appetite, Appearance, Sex, Personal Relationship, Day to Day Activity, Behaviour.
Schizophrenia
- Talking to Self, Laughing to Self, Hearing Voices, Suspicious about Others, Not doing any job, Lack of Personal Care, Violent behavior, Suicidal Attempt, Somebody trying to kill him, Somebody watching him.
Depression
Reduced Activity, Not talking with Others, Crying Spells, Death Wish, Guilty Feeling, Worried about Future Life.
Mania
- Excessive Talk, increased Activity, Frequently Changing the Dress, Dressed Neatly, Talk about Superior power, Talk of Wealthiness, Talking that she is the God.
Delusional disorders
- Suspicious about Wife or Husband
- Crawling sensation over the head or body
Psychotic Symptoms
- Hearing Voices, Suspicious about Others
Neurotic Symptoms
- Headache, vomiting, palpitation, Chest pain, Fear of Death, Fear of having some Illness, Fear to go to Crowded Place, Fear to Stay Alone, Fear to stay in Height Place, Repeated checking, Repeated washing, Repeated thought, multiple pain site.
Hysterical Symptoms
- Sudden fainting attack, H/O jerky movements for long time., Mute
History of Present Illness
- Onset - Sudden, gradual
- Precipitating Factors
- Course � Episodic, Progressive
H/O Previous Illness
- Past Psychiatric Consultation
- Past Medical History
Family History
- Pedigree Chart
-
- Male Female
� Mental Illness
Died
- Family Background
- Parents and Siblings
- Family History of Mental Illness
Personal Life History
A. Early Childhood
1. Developmental Mile Stones
2. Intrafamilial Relationship
B. Middle Childhood
1. Friends
2. School
C. Adolescence
1. Puberty
2. Psychosexual History
3. Dating & Peer Relationship
4. School Performance
5. Drug & Alcohol abuse
D. Early Adulthood
1. Marital and Other Adult Relationship
2. Work History
3. Recreational & Vocational pursuits
4. military History
5. Prison History
E. Middle and Old Adulthood
1. Changing Family constellation
2. Retirement
3. Loses
4. Aging
- Birth, Childhood, Education Occupation, Marriage, Sexual Practice, Mental History (Female), Habits liked Alcohol, Drugs & Smoking, Religious Practices, Hobbies, Interests, Daily Activity)
Pre morbid Personality
- Reserved (Introvert)
- Social (Extrovert)
- Suspicious (Paranoid)
- Perfectionist (Obsessive)
- Hysterical
- Antisocial
- Aggressive
- Frequent Mood Change (Cyclothymics)
Mental Status Examination
General Appearance & Behaviour
- dressing, Care of Hair, Care of Nail
- Personal Hygiene
- Psycho Motor Activity
- Touch of Surrounding or Not
- Rapport
Speech
- Tone & Quantum of Speech
- Relevant / Irrelevant
- Coherent /incoherent
- Neologism
Mood & Emotional State
- Affect � Reacting or Not
- Subjective Mood
- Objective Mood
- Depressed, Irritate, Elated, Agitated, labile Mood
Thought Form & Context
Thought form
- Circumstantialities
- Derailment
- Flight of Ideas
- Neologism
- Thought Block
Thought Context
- Delusions
- Ideas of Reference
- Obsessions
- Preoccupation with Suicidal Ideas
Perception
- Illusion
- Hallucinations
Higher Functions
1. Alertness
2. Orientation
a. Person
b. Time
c. Place
3. Attention and Concentration
4. Memory
a. Immediate
b. Recent
c. Remote
5. Abstract Thinking
6. Judgment
Insight
- Whether the person knows that he is mentally ill or not and to what extent.
Mood Disorders (Affective Disorder)
Mood � Internal Emotional State of an Individual
Mood Disorder � Excessive swing of Mood
Normal � Mild Elation to Mild Depression depending on many factors.
--------------------
Classification
--------------------
1. Manic Depressive Psychosis - Bipolar Affective Disorders
2. Endogenus Depression - Major Depression
3. Neurotic Depression - Dysthymic Disorder Depression
It is the common cold of Psychiatric Illness, Commonly people says � Sad � Depressed � Down, Mood out, Dull, Lost of Interest & isolated.
========================================
Depression
========================================
� reaction to an event such as death of a loved one or Change in financial situation or it may come without any obvious external cause
--------------------
Epidemiology
--------------------
-Wide Spread Problem
-Young and Old
-Rich and Poor
-Men & Women
India � 1-6 % population
5 � 20 % Psychiatric Out Patient
Age 30 � 50 Yrs.
> 60 Yrs. 13 � 22 % Depression
Female > Male
--------------------
Major Depression
--------------------
Presence of
a. Depressed Mood
b. Loss of Interest and Pleasure
c. 4 or more of following symptoms
Feelings of worthlessness or guilt
Impaired Concentration
Loss of Energy and Fatigue
Thoughts Suicide
Loss or increase of Appetite & Weight
Insomnia or Excessive sleep
Retardation or Agitation
- Symptoms for atleast 2 weeks, Major Depression
- Major Depression may present with or without psychotic symptoms.
- Delusions, Hallucination & Bizaree Behaviour
--------------------
Dysthymic Disorder
--------------------
Depressed Mood � 2 Years
Other Symptoms
Or Sleep
Or Appetite, Energy
Self Esteem
Poor Concentration & Hopelessness
--------------------
Masked Depression
--------------------
--------------------
Seasonal Depression � Winter
--------------------
--------------------
Aetiology for Depression
--------------------
Biological Factors
Genetic Factors
- Higher among the relatives of Individual
Biochemical
- Reduced Norepinephrine, Serotonin & Dopamine
- Transposition of Sodium and Potassium
Psychological Factors
- Low Self-Esteem
- Guilt
- Lack of Support System
- Lack of Clear Goals
- Feelings of Failure
- Inability to fulfill expectations
- Separation or Object Loss
Cognitive
- Narrow negative attitude about self, environment & future, bad or inadequate judgement
Behavioural
- Hopelessness, Loss of positive reinforcement
Socio Cultural Factors
- Social Situations
- Minority Group
- Women in a male-dominant Occupation
- Role Loss (Empty nest syndrome)
Adverse Events
- Injustice
- Poverty
- Unemployment
Alcohol & Depression
- Alcohol, Drug Abuse
--------------------
Complications
--------------------
Recover spontaneously after sometime some patient may so far
His work & day to day activity suffer
Loss in productivity & financial status
Alcoholism or Drug Abuse
Suicide
--------------------
Management
--------------------
Hospitalisation Indiacation: Severe Depression, Suicidal Tendencies
Drug Therapy: Anti-Depressant
Electro-Convulsive Therapy
Psychotherapy - Problem Oriented, Positive Reinforcement, Family Therapy, Group Therapy & Cognitive Therapy
Nursing Care in Depression
Promote food intake & Sleep & Monitoring Food Intake & Drugs
Take safety measures � In suicidal tendency
Diminish feeling of loneliness
Interaction focus on present & not the past � Reassurance
Provide non-intellectual activities (Cleaning & Exercise)
Strict record of Sleeping � Discourse sleep during daytime
Health Education
Family Education
========================================
Bipolar Disorders
========================================
- Mood swings from profound depression to extreme euphoria (Mania) with intervening period of normalcy.
Mixed
Manic
Depressed
========================================
MANIA
========================================
It is mood disorder
Patient excessively Happy & Energetic
Usually occur as a part of Bipolar
Very rarely mania alone occur (recurrently)
Primary Mania Affective or Mood Disorder
Secondary Mania Due to Organic Disorder
--------------------
Aetiology
--------------------
Biological Factors
- Genetic Factors: Among the relative of Bipolar Disorders
- Biochemical: Excessive Serotonin & Norepinephrine
Psychological Factors
- Faulty dynamics in the family system and disturbed ego development gives way to a strong id.
--------------------
Clinical Features
--------------------
Persistently Elevated, Expansive or Irritable Mood
Inflated Self Esteem or Grandiosity
Hyperactivity or Psychomotor Agitation
Sleep Disturbance
Pressure of Speech, More Talkative
Flight of Ideas
Distracted � Poor attention Span
Pleasurable Activity � Spending, - Sexual Activity
Dress in Bright Colour, Excessive Make Up & Jewellery
Impaired Occupational Functioning
Psychotic Symptoms
Delusions, Hallucinations
--------------------
Hypomonia
--------------------
Euphoric, Elated, Dressing Colourfully, Cracking Jokes, Excessive Talk, Overactivity
Manic Excitement
Irritable, Excited, Violent
--------------------
Management
--------------------
Hospitalisation - Excited
Drug Treatment
- Anti-Psychotics
- Anti-Manic
- ECT
Nursing Care Manic Patient
Special attention to patient diet
Drugs for restlessness & overactivity
Emotional Needs
_________________
�2005 DR.M.RAJARAM
Mental Disorders - An Introduction
What is Mental Illness ?
It is the Disorder of Mind:
Triad of Mind Cognition (or) Behaviour,Emotion, Conation or thought
The Character of Medical Illness :
1. Person�s behaviour is causing distress & suffering to the Individual or Others.
2. Abnormal changes in one�s thinking, feeling, memory, perceptions and judgment � Change in talk & behaviour.
3. Abnormal behaviour cum disturbance in person�s day to day activity, job and Interpersonal relationship.
�A person who is sad, bad or odd can be considered as mad, if these qualities cause problems to him & to others.�
Signs & symptoms of Mental Illness
Sudden onset
Onset
Gradual progressive
Mild
Cl. future
Very severe
I. General Behaviour
1. Sleep disturbance � Insomnia
2. Loss of appetite refusal of food
a. intrest depression
b. appetite
c. time Mania
d. Refuse to eat � paranoid
3. Personal appearance
- Neglected, poor self care - schizophrenia
- Neatly & colourful - mania
- Appear seductive � Hysteria
4. Sex :
- feel & lost their libido
5. Personel Relationship
- Hostile, Angry
- Withdrawn & aloof
- Excited & unnecessary interferes
6. Interest in work hobbies & surrounding
- May decline
7. Behaviour
- Peculiarly, Irritate others, dangerous to himself, overactive, restless,
8. Disturbance in thinking
- evident from his talk.
- Excessive talk, Irrelevant talk, meaningless, Incoherent talk, thought block, thought Insertion, thought withdrawal, thought broadcasting.
- Disorder of content of thought (Delusions)
Delusion � false fixed Belief
Character
1. Person convinced about a particular belief.
2. Cannot be corrected by reason or logic.
3. Not shared by members & same community
Primary � arises from own
Delusion
Secondary � part of Psychiatric symptoms
Types
- Paranoid Delusion
- Delusion of grandiose
- Delusion of Jealousy or infidelity
- Delusion of Control (Passivity phenomenon)
- Hypochondriacal Delusion
- Nihilistic Delusion
II. Ideas of Reference
- People around talk about him and make fun of him.
III. Disturbance of Perception
1. Illusion
� Misinterpretation (False perception of a real sensory stimulus.
2. Hallucination
- False perception which occurs without an external stimulus
- Auditory, Visual, Olfactory, Gustatory and Tactile
- Normal � Hyponogagic & hypnopompic
IV Disturbance of memory
- Due to Lack of Interest, Agitation or Poor Registration.
Amnesia : lack of memory for certain period of person walking life. HI, post ECI, Epilepsy.
Dysamnesia or Paramnesia
- damage to hippocampus & mammillary bodies
- Confabulation � Alcoholic, Encephalitis.
- filling up � memory gap.
Organic memory impairment
-Dementia
V Consciousness
- Awarness of surroundings
confusion
Disorientation
VI. Disturbance of Affect or Mood
- Mood � Internal Emotional state of an Individual
- Affect � External expression of Emotional Context
- Elation, Depression, Anxiety, Inappropriate affect, Apathy, Incongruous affect.
VII. Distrubances Motor Activities.
Catalepsy � Immobile position that is constantly maintained.
Waxy Flexibility � person can be moulded into a position which is then maintained.
Negativism � Motiveless resistance
Stupor � Lack of reaction & unawareness of surroundings.
Echoprasia � Pathological imitate of movements of one person by another.
Posturing � Voluntary assumption of bizarre & maintaining it for long periods of time.
Abnormality
- Away from Normal
- Statistically infrequent
- It is not according to the Society�s Standard or expectation.
- Maladaptive
- produce personal distress
- legally � not to judge � right or wrong.
Biological Factors
Psychological Factors
Social Factors
1. Biological Factors
- Genetic (Hereditary)
� Twin studios
- Biochemical
� Neuro-transmitters � Dopamive, Serotomia, Acelzlchibica, Noepinepha, Epi*** -etc
- Brain Damage
- Infection, Injury, Intoxication, Tumours
2. Psychological Factors � Personality & Temperament
- Early upbringing
- Conflicts
3. Social Factors
- Loss
- Psychosocial Stress
- Adversity
- Poverty
- Migration
- Unemployment
- Urbanisation
General Classification of Mental Disorders
Normal Classification
According to ICD or DSM
1. Organic Mental Disorder
- Delirium
- Dementia
2. Functional (non-organic) Mental Disorders
a. Psychotic Disorders
- Schizophrenia
- Mood Disorder
- Delusional Disorder
b. Neurotic Disorders
- Anxiety Disorder
- Phobic Disorder
- Obsessive Compulsive Disorder
- Hysteria
- Hypochondriasis
3. Personality Disorders
4. Psychosexual Disorders
5. Stress related Disorders
- Acute Stress Reaction
- Post Traumatic Stress Disorder
- Adjustment Disorder
6. Mental Disorders due to Psychoactive Substance Abuse
- Alcohol Dependence
- Other drugs Dependence
7. Psychosomatic Disorders
8. Child Psychiatric Disorders
- Autism
- Developmental disorders
- Mental Retardation
- Attention Defecit Disorders
- Emotional Disorders
- Habit Disorders
9. Other Disorders
- Eating Disorder
- Sleep Disorder
- Disorders of Memory
- Epilepsy & Psychiatric
- Psychiatric Disturbances in Women
- Psychiatric Disturbances in Adolescence
- Psychiatric Disturbances in Old Age
Schizophrenia - Overview of this common psychiatric disorder
It is most common Psychotic Disorder
- 50% of patients in all Mental Hospital Admission.
It is Greek Word
- Schizo � Split
- Phrenic � Mind
- Split Mind
Definition
- It is a functional Psychosis
- Disturbances in Thinking, Emotion, Volition & Perception.
- Clear Consciousness
Epidemiology
- Prevalent in all cultures and all part of the world
- 3 to 4 / 1000 in any community
- 1 % of general population in lifetime
- 2/3 of cases 15 � 30 yrs
- Lower Social Classes
Etiology
Biological
Psychological
Social
Biological
- Genetic Factors
Monozygotic twin of Schizophrenic - 47
Child of Two Schizophrenic Parents - 40
Dizygotic twin of a Schizophrenic Parents - 12
- Bio Chemical Factors
Dopamine Hypothesis (Dopamine)
Transmethylation Hypothesis (Abnormal Transmethylation of Catecholamines)
Indolamine Hypothesis (Defect in metabolism of Indolamine � Serotonin)
Psychological
- Withdrawn and Social Contact
- Ego Boundary Disturbances
Social & Environmental
- Family with lot of conflict
- Communication of parents with Children
- Low Social Class
Positive Symptoms
Clinical Features
Negative Symptoms
Positive Symptoms
- Delusions
- Hallucinations
- Aggression
- Agitation
- Suspiciousness
- Hostility
- Excitement
- Grandiosity
- Conceptual Disorganization
Negative Symptoms
- Apathy
- Withdrawal
- Avolition
- Blunted Affect
- Stereotyped Thinking
- Artificial Gestures
- Lack of Spontaneity
Thought Disturbance
Condensation � Ideas are mixed, not necessarily logical
Displacement � Associated Idea, not correct one
Symbolisation � Abstract thoughts are replaced by concrete ones.
Over Inclusive Thinking � Irrelevant thoughts are incorporated into the speech.
- Neolologism
Incoherence and Mutism
- Thought Block
- Delusion � Disturbance content of thought
- Delusions of Persecutions
- Delusions of Grandeur
Austism
- Slow Progressive withdrawal from reality
Volitional Disturbance
- Deterioration in will power, drive and ambition
- Apathy � Self Neglect
Affect Disturbances
- Flattening or Blunt affect
Perceptional Disturbances
- Hallucinations
Behavioral Changes
Withdrawal Changes
↓
Withdrawal from reality into fantasy
↓
Increase Apathy
↓
Stupor or Catatonic Stupor
Reverse � Catatonic Excitement
- Echolalia, Echopraxia, Negativism
- Poor Personal Hygiene
- Lack of Insight
Types of Schizophrenia
1. Paranoid
2. Hebephrenic
3. Catatonic
4. Residual
5. Undifferentiated
6. Simple
Paranoid Schizophrenia
- Persecutory or Grandiose Delusions together with associated jealous
- Hallucinations
- Unfocussed Anxiety, Anger, Argumentativeness and Violence
- Doubts about Gender Identity
Hebephrenic Schizophrenia
- Incoherence and Flat, Incongruous or Silly Effect
- 15 � 25 Years
- Extreme Social Impairment, Poor Pre morbid Personality, Early Insidious Onset and a Chronic Course without Significant remissions.
Catatonic Schizophrenia
- Psychomotor Disturbance
- Catatonic Stupor or Rigidity
- Catatonic Excitement
- Catatonic Posturing
- Negativism
Residual Schizophrenia
- Atleast one episode of Schizophrenia in the past but without Prominent Psychotic Symptoms at present.
- Emotional Blunting, Social Withdrawal, Eccentric Behaviour, Illogical Thinking & Loosening Associations.
Undifferentiated Schizophrenia
- Prominent Psychotic Symptoms that cannot be classified in any Category
Simple Schizophrenia
- Insidious Onset, Progressive Development of Odd Behaviour, Wandering Tendency, Self-Absorbed, Idle and Aimless Activity
Course of Illness
Sub chronic
- Less than 2 years at least 6 Months
- From the beginning patient show signs of Illness more or less continuously
Chronic
- Duration > 2 Years
Good Prognosis
- Later Onset, Precipitating Factors, Acute Onset, Pre morbid personality, Affective (Depression) Symptoms, Paranoid Catatonic, Married, Family History of Mood Disorders, Good Support Care, Positive Symptoms
Management
1. Somatic (Physical Therapies)
a. Antipsychotic Medications
b. ECT
2. Psychological Treatment
a. Hospitalisation
b. Psychotherapy
c. Rehabilitation � Social, Vocational
d. Aftercare � Day Treatment, Halfway Homes
It is most common Psychotic Disorder
- 50% of patients in all Mental Hospital Admission.
It is Greek Word
- Schizo � Split
- Phrenic � Mind
- Split Mind
Definition
- It is a functional Psychosis
- Disturbances in Thinking, Emotion, Volition & Perception.
- Clear Consciousness
Epidemiology
- Prevalent in all cultures and all part of the world
- 3 to 4 / 1000 in any community
- 1 % of general population in lifetime
- 2/3 of cases 15 � 30 yrs
- Lower Social Classes
Etiology
Biological
Psychological
Social
Biological
- Genetic Factors
Monozygotic twin of Schizophrenic - 47
Child of Two Schizophrenic Parents - 40
Dizygotic twin of a Schizophrenic Parents - 12
- Bio Chemical Factors
Dopamine Hypothesis (Dopamine)
Transmethylation Hypothesis (Abnormal Transmethylation of Catecholamines)
Indolamine Hypothesis (Defect in metabolism of Indolamine � Serotonin)
Psychological
- Withdrawn and Social Contact
- Ego Boundary Disturbances
Social & Environmental
- Family with lot of conflict
- Communication of parents with Children
- Low Social Class
Positive Symptoms
Clinical Features
Negative Symptoms
Positive Symptoms
- Delusions
- Hallucinations
- Aggression
- Agitation
- Suspiciousness
- Hostility
- Excitement
- Grandiosity
- Conceptual Disorganization
Negative Symptoms
- Apathy
- Withdrawal
- Avolition
- Blunted Affect
- Stereotyped Thinking
- Artificial Gestures
- Lack of Spontaneity
Thought Disturbance
Condensation � Ideas are mixed, not necessarily logical
Displacement � Associated Idea, not correct one
Symbolisation � Abstract thoughts are replaced by concrete ones.
Over Inclusive Thinking � Irrelevant thoughts are incorporated into the speech.
- Neolologism
Incoherence and Mutism
- Thought Block
- Delusion � Disturbance content of thought
- Delusions of Persecutions
- Delusions of Grandeur
Austism
- Slow Progressive withdrawal from reality
Volitional Disturbance
- Deterioration in will power, drive and ambition
- Apathy � Self Neglect
Affect Disturbances
- Flattening or Blunt affect
Perceptional Disturbances
- Hallucinations
Behavioral Changes
Withdrawal Changes
↓
Withdrawal from reality into fantasy
↓
Increase Apathy
↓
Stupor or Catatonic Stupor
Reverse � Catatonic Excitement
- Echolalia, Echopraxia, Negativism
- Poor Personal Hygiene
- Lack of Insight
Types of Schizophrenia
1. Paranoid
2. Hebephrenic
3. Catatonic
4. Residual
5. Undifferentiated
6. Simple
Paranoid Schizophrenia
- Persecutory or Grandiose Delusions together with associated jealous
- Hallucinations
- Unfocussed Anxiety, Anger, Argumentativeness and Violence
- Doubts about Gender Identity
Hebephrenic Schizophrenia
- Incoherence and Flat, Incongruous or Silly Effect
- 15 � 25 Years
- Extreme Social Impairment, Poor Pre morbid Personality, Early Insidious Onset and a Chronic Course without Significant remissions.
Catatonic Schizophrenia
- Psychomotor Disturbance
- Catatonic Stupor or Rigidity
- Catatonic Excitement
- Catatonic Posturing
- Negativism
Residual Schizophrenia
- Atleast one episode of Schizophrenia in the past but without Prominent Psychotic Symptoms at present.
- Emotional Blunting, Social Withdrawal, Eccentric Behaviour, Illogical Thinking & Loosening Associations.
Undifferentiated Schizophrenia
- Prominent Psychotic Symptoms that cannot be classified in any Category
Simple Schizophrenia
- Insidious Onset, Progressive Development of Odd Behaviour, Wandering Tendency, Self-Absorbed, Idle and Aimless Activity
Course of Illness
Sub chronic
- Less than 2 years at least 6 Months
- From the beginning patient show signs of Illness more or less continuously
Chronic
- Duration > 2 Years
Good Prognosis
- Later Onset, Precipitating Factors, Acute Onset, Pre morbid personality, Affective (Depression) Symptoms, Paranoid Catatonic, Married, Family History of Mood Disorders, Good Support Care, Positive Symptoms
Management
1. Somatic (Physical Therapies)
a. Antipsychotic Medications
b. ECT
2. Psychological Treatment
a. Hospitalisation
b. Psychotherapy
c. Rehabilitation � Social, Vocational
d. Aftercare � Day Treatment, Halfway Homes
e. Education about the Illness for Patients and families
By DR.M.RAJARAM
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< ------------------------------------------------------------------------------------------------------------------->
Psychiatric Clinical Examination
Basic Information
Name, Age, Sex, Occupation, Address
Identification Marks � Medico legal purpose
Informant � to be reliable (who is staying with patient during the illness)
Chief Complaints (as patient and relative say)
General
- Sleep Disturbances, Appetite, Appearance, Sex, Personal Relationship, Day to Day Activity, Behaviour.
Schizophrenia
- Talking to Self, Laughing to Self, Hearing Voices, Suspicious about Others, Not doing any job, Lack of Personal Care, Violent behavior, Suicidal Attempt, Somebody trying to kill him, Somebody watching him.
Depression
Reduced Activity, Not talking with Others, Crying Spells, Death Wish, Guilty Feeling, Worried about Future Life.
Mania
- Excessive Talk, increased Activity, Frequently Changing the Dress, Dressed Neatly, Talk about Superior power, Talk of Wealthiness, Talking that she is the God.
Delusional disorders
- Suspicious about Wife or Husband
- Crawling sensation over the head or body
Psychotic Symptoms
- Hearing Voices, Suspicious about Others
Neurotic Symptoms
- Headache, vomiting, palpitation, Chest pain, Fear of Death, Fear of having some Illness, Fear to go to Crowded Place, Fear to Stay Alone, Fear to stay in Height Place, Repeated checking, Repeated washing, Repeated thought, multiple pain site.
Hysterical Symptoms
- Sudden fainting attack, H/O jerky movements for long time., Mute
History of Present Illness
- Onset - Sudden, gradual
- Precipitating Factors
- Course � Episodic, Progressive
H/O Previous Illness
- Past Psychiatric Consultation
- Past Medical History
Family History
- Pedigree Chart
-
- Male Female
� Mental Illness
Died
- Family Background
- Parents and Siblings
- Family History of Mental Illness
Personal Life History
A. Early Childhood
1. Developmental Mile Stones
2. Intrafamilial Relationship
B. Middle Childhood
1. Friends
2. School
C. Adolescence
1. Puberty
2. Psychosexual History
3. Dating & Peer Relationship
4. School Performance
5. Drug & Alcohol abuse
D. Early Adulthood
1. Marital and Other Adult Relationship
2. Work History
3. Recreational & Vocational pursuits
4. military History
5. Prison History
E. Middle and Old Adulthood
1. Changing Family constellation
2. Retirement
3. Loses
4. Aging
- Birth, Childhood, Education Occupation, Marriage, Sexual Practice, Mental History (Female), Habits liked Alcohol, Drugs & Smoking, Religious Practices, Hobbies, Interests, Daily Activity)
Pre morbid Personality
- Reserved (Introvert)
- Social (Extrovert)
- Suspicious (Paranoid)
- Perfectionist (Obsessive)
- Hysterical
- Antisocial
- Aggressive
- Frequent Mood Change (Cyclothymics)
Mental Status Examination
General Appearance & Behaviour
- dressing, Care of Hair, Care of Nail
- Personal Hygiene
- Psycho Motor Activity
- Touch of Surrounding or Not
- Rapport
Speech
- Tone & Quantum of Speech
- Relevant / Irrelevant
- Coherent /incoherent
- Neologism
Mood & Emotional State
- Affect � Reacting or Not
- Subjective Mood
- Objective Mood
- Depressed, Irritate, Elated, Agitated, labile Mood
Thought Form & Context
Thought form
- Circumstantialities
- Derailment
- Flight of Ideas
- Neologism
- Thought Block
Thought Context
- Delusions
- Ideas of Reference
- Obsessions
- Preoccupation with Suicidal Ideas
Perception
- Illusion
- Hallucinations
Higher Functions
1. Alertness
2. Orientation
a. Person
b. Time
c. Place
3. Attention and Concentration
4. Memory
a. Immediate
b. Recent
c. Remote
5. Abstract Thinking
6. Judgment
Insight
- Whether the person knows that he is mentally ill or not and to what extent.
Mood Disorders (Affective Disorder)
Mood � Internal Emotional State of an Individual
Mood Disorder � Excessive swing of Mood
Normal � Mild Elation to Mild Depression depending on many factors.
--------------------
Classification
--------------------
1. Manic Depressive Psychosis - Bipolar Affective Disorders
2. Endogenus Depression - Major Depression
3. Neurotic Depression - Dysthymic Disorder Depression
It is the common cold of Psychiatric Illness, Commonly people says � Sad � Depressed � Down, Mood out, Dull, Lost of Interest & isolated.
========================================
Depression
========================================
� reaction to an event such as death of a loved one or Change in financial situation or it may come without any obvious external cause
--------------------
Epidemiology
--------------------
-Wide Spread Problem
-Young and Old
-Rich and Poor
-Men & Women
India � 1-6 % population
5 � 20 % Psychiatric Out Patient
Age 30 � 50 Yrs.
> 60 Yrs. 13 � 22 % Depression
Female > Male
--------------------
Major Depression
--------------------
Presence of
a. Depressed Mood
b. Loss of Interest and Pleasure
c. 4 or more of following symptoms
Feelings of worthlessness or guilt
Impaired Concentration
Loss of Energy and Fatigue
Thoughts Suicide
Loss or increase of Appetite & Weight
Insomnia or Excessive sleep
Retardation or Agitation
- Symptoms for atleast 2 weeks, Major Depression
- Major Depression may present with or without psychotic symptoms.
- Delusions, Hallucination & Bizaree Behaviour
--------------------
Dysthymic Disorder
--------------------
Depressed Mood � 2 Years
Other Symptoms
Or Sleep
Or Appetite, Energy
Self Esteem
Poor Concentration & Hopelessness
--------------------
Masked Depression
--------------------
--------------------
Seasonal Depression � Winter
--------------------
--------------------
Aetiology for Depression
--------------------
Biological Factors
Genetic Factors
- Higher among the relatives of Individual
Biochemical
- Reduced Norepinephrine, Serotonin & Dopamine
- Transposition of Sodium and Potassium
Psychological Factors
- Low Self-Esteem
- Guilt
- Lack of Support System
- Lack of Clear Goals
- Feelings of Failure
- Inability to fulfill expectations
- Separation or Object Loss
Cognitive
- Narrow negative attitude about self, environment & future, bad or inadequate judgement
Behavioural
- Hopelessness, Loss of positive reinforcement
Socio Cultural Factors
- Social Situations
- Minority Group
- Women in a male-dominant Occupation
- Role Loss (Empty nest syndrome)
Adverse Events
- Injustice
- Poverty
- Unemployment
Alcohol & Depression
- Alcohol, Drug Abuse
--------------------
Complications
--------------------
Recover spontaneously after sometime some patient may so far
His work & day to day activity suffer
Loss in productivity & financial status
Alcoholism or Drug Abuse
Suicide
--------------------
Management
--------------------
Hospitalisation Indiacation: Severe Depression, Suicidal Tendencies
Drug Therapy: Anti-Depressant
Electro-Convulsive Therapy
Psychotherapy - Problem Oriented, Positive Reinforcement, Family Therapy, Group Therapy & Cognitive Therapy
Nursing Care in Depression
Promote food intake & Sleep & Monitoring Food Intake & Drugs
Take safety measures � In suicidal tendency
Diminish feeling of loneliness
Interaction focus on present & not the past � Reassurance
Provide non-intellectual activities (Cleaning & Exercise)
Strict record of Sleeping � Discourse sleep during daytime
Health Education
Family Education
========================================
Bipolar Disorders
========================================
- Mood swings from profound depression to extreme euphoria (Mania) with intervening period of normalcy.
Mixed
Manic
Depressed
========================================
MANIA
========================================
It is mood disorder
Patient excessively Happy & Energetic
Usually occur as a part of Bipolar
Very rarely mania alone occur (recurrently)
Primary Mania Affective or Mood Disorder
Secondary Mania Due to Organic Disorder
--------------------
Aetiology
--------------------
Biological Factors
- Genetic Factors: Among the relative of Bipolar Disorders
- Biochemical: Excessive Serotonin & Norepinephrine
Psychological Factors
- Faulty dynamics in the family system and disturbed ego development gives way to a strong id.
--------------------
Clinical Features
--------------------
Persistently Elevated, Expansive or Irritable Mood
Inflated Self Esteem or Grandiosity
Hyperactivity or Psychomotor Agitation
Sleep Disturbance
Pressure of Speech, More Talkative
Flight of Ideas
Distracted � Poor attention Span
Pleasurable Activity � Spending, - Sexual Activity
Dress in Bright Colour, Excessive Make Up & Jewellery
Impaired Occupational Functioning
Psychotic Symptoms
Delusions, Hallucinations
--------------------
Hypomonia
--------------------
Euphoric, Elated, Dressing Colourfully, Cracking Jokes, Excessive Talk, Overactivity
Manic Excitement
Irritable, Excited, Violent
--------------------
Management
--------------------
Hospitalisation - Excited
Drug Treatment
- Anti-Psychotics
- Anti-Manic
- ECT
Nursing Care Manic Patient
Special attention to patient diet
Drugs for restlessness & overactivity
Emotional Needs
_________________
�2005 DR.M.RAJARAM
Mental Disorders - An Introduction
What is Mental Illness ?
It is the Disorder of Mind:
Triad of Mind Cognition (or) Behaviour,Emotion, Conation or thought
The Character of Medical Illness :
1. Person�s behaviour is causing distress & suffering to the Individual or Others.
2. Abnormal changes in one�s thinking, feeling, memory, perceptions and judgment � Change in talk & behaviour.
3. Abnormal behaviour cum disturbance in person�s day to day activity, job and Interpersonal relationship.
�A person who is sad, bad or odd can be considered as mad, if these qualities cause problems to him & to others.�
Signs & symptoms of Mental Illness
Sudden onset
Onset
Gradual progressive
Mild
Cl. future
Very severe
I. General Behaviour
1. Sleep disturbance � Insomnia
2. Loss of appetite refusal of food
a. intrest depression
b. appetite
c. time Mania
d. Refuse to eat � paranoid
3. Personal appearance
- Neglected, poor self care - schizophrenia
- Neatly & colourful - mania
- Appear seductive � Hysteria
4. Sex :
- feel & lost their libido
5. Personel Relationship
- Hostile, Angry
- Withdrawn & aloof
- Excited & unnecessary interferes
6. Interest in work hobbies & surrounding
- May decline
7. Behaviour
- Peculiarly, Irritate others, dangerous to himself, overactive, restless,
8. Disturbance in thinking
- evident from his talk.
- Excessive talk, Irrelevant talk, meaningless, Incoherent talk, thought block, thought Insertion, thought withdrawal, thought broadcasting.
- Disorder of content of thought (Delusions)
Delusion � false fixed Belief
Character
1. Person convinced about a particular belief.
2. Cannot be corrected by reason or logic.
3. Not shared by members & same community
Primary � arises from own
Delusion
Secondary � part of Psychiatric symptoms
Types
- Paranoid Delusion
- Delusion of grandiose
- Delusion of Jealousy or infidelity
- Delusion of Control (Passivity phenomenon)
- Hypochondriacal Delusion
- Nihilistic Delusion
II. Ideas of Reference
- People around talk about him and make fun of him.
III. Disturbance of Perception
1. Illusion
� Misinterpretation (False perception of a real sensory stimulus.
2. Hallucination
- False perception which occurs without an external stimulus
- Auditory, Visual, Olfactory, Gustatory and Tactile
- Normal � Hyponogagic & hypnopompic
IV Disturbance of memory
- Due to Lack of Interest, Agitation or Poor Registration.
Amnesia : lack of memory for certain period of person walking life. HI, post ECI, Epilepsy.
Dysamnesia or Paramnesia
- damage to hippocampus & mammillary bodies
- Confabulation � Alcoholic, Encephalitis.
- filling up � memory gap.
Organic memory impairment
-Dementia
V Consciousness
- Awarness of surroundings
confusion
Disorientation
VI. Disturbance of Affect or Mood
- Mood � Internal Emotional state of an Individual
- Affect � External expression of Emotional Context
- Elation, Depression, Anxiety, Inappropriate affect, Apathy, Incongruous affect.
VII. Distrubances Motor Activities.
Catalepsy � Immobile position that is constantly maintained.
Waxy Flexibility � person can be moulded into a position which is then maintained.
Negativism � Motiveless resistance
Stupor � Lack of reaction & unawareness of surroundings.
Echoprasia � Pathological imitate of movements of one person by another.
Posturing � Voluntary assumption of bizarre & maintaining it for long periods of time.
Abnormality
- Away from Normal
- Statistically infrequent
- It is not according to the Society�s Standard or expectation.
- Maladaptive
- produce personal distress
- legally � not to judge � right or wrong.
Biological Factors
Psychological Factors
Social Factors
1. Biological Factors
- Genetic (Hereditary)
� Twin studios
- Biochemical
� Neuro-transmitters � Dopamive, Serotomia, Acelzlchibica, Noepinepha, Epi*** -etc
- Brain Damage
- Infection, Injury, Intoxication, Tumours
2. Psychological Factors � Personality & Temperament
- Early upbringing
- Conflicts
3. Social Factors
- Loss
- Psychosocial Stress
- Adversity
- Poverty
- Migration
- Unemployment
- Urbanisation
General Classification of Mental Disorders
Normal Classification
According to ICD or DSM
1. Organic Mental Disorder
- Delirium
- Dementia
2. Functional (non-organic) Mental Disorders
a. Psychotic Disorders
- Schizophrenia
- Mood Disorder
- Delusional Disorder
b. Neurotic Disorders
- Anxiety Disorder
- Phobic Disorder
- Obsessive Compulsive Disorder
- Hysteria
- Hypochondriasis
3. Personality Disorders
4. Psychosexual Disorders
5. Stress related Disorders
- Acute Stress Reaction
- Post Traumatic Stress Disorder
- Adjustment Disorder
6. Mental Disorders due to Psychoactive Substance Abuse
- Alcohol Dependence
- Other drugs Dependence
7. Psychosomatic Disorders
8. Child Psychiatric Disorders
- Autism
- Developmental disorders
- Mental Retardation
- Attention Defecit Disorders
- Emotional Disorders
- Habit Disorders
9. Other Disorders
- Eating Disorder
- Sleep Disorder
- Disorders of Memory
- Epilepsy & Psychiatric
- Psychiatric Disturbances in Women
- Psychiatric Disturbances in Adolescence
- Psychiatric Disturbances in Old Age
Schizophrenia - Overview of this common psychiatric disorder
It is most common Psychotic Disorder
- 50% of patients in all Mental Hospital Admission.
It is Greek Word
- Schizo � Split
- Phrenic � Mind
- Split Mind
Definition
- It is a functional Psychosis
- Disturbances in Thinking, Emotion, Volition & Perception.
- Clear Consciousness
Epidemiology
- Prevalent in all cultures and all part of the world
- 3 to 4 / 1000 in any community
- 1 % of general population in lifetime
- 2/3 of cases 15 � 30 yrs
- Lower Social Classes
Etiology
Biological
Psychological
Social
Biological
- Genetic Factors
Monozygotic twin of Schizophrenic - 47
Child of Two Schizophrenic Parents - 40
Dizygotic twin of a Schizophrenic Parents - 12
- Bio Chemical Factors
Dopamine Hypothesis (Dopamine)
Transmethylation Hypothesis (Abnormal Transmethylation of Catecholamines)
Indolamine Hypothesis (Defect in metabolism of Indolamine � Serotonin)
Psychological
- Withdrawn and Social Contact
- Ego Boundary Disturbances
Social & Environmental
- Family with lot of conflict
- Communication of parents with Children
- Low Social Class
Positive Symptoms
Clinical Features
Negative Symptoms
Positive Symptoms
- Delusions
- Hallucinations
- Aggression
- Agitation
- Suspiciousness
- Hostility
- Excitement
- Grandiosity
- Conceptual Disorganization
Negative Symptoms
- Apathy
- Withdrawal
- Avolition
- Blunted Affect
- Stereotyped Thinking
- Artificial Gestures
- Lack of Spontaneity
Thought Disturbance
Condensation � Ideas are mixed, not necessarily logical
Displacement � Associated Idea, not correct one
Symbolisation � Abstract thoughts are replaced by concrete ones.
Over Inclusive Thinking � Irrelevant thoughts are incorporated into the speech.
- Neolologism
Incoherence and Mutism
- Thought Block
- Delusion � Disturbance content of thought
- Delusions of Persecutions
- Delusions of Grandeur
Austism
- Slow Progressive withdrawal from reality
Volitional Disturbance
- Deterioration in will power, drive and ambition
- Apathy � Self Neglect
Affect Disturbances
- Flattening or Blunt affect
Perceptional Disturbances
- Hallucinations
Behavioral Changes
Withdrawal Changes
↓
Withdrawal from reality into fantasy
↓
Increase Apathy
↓
Stupor or Catatonic Stupor
Reverse � Catatonic Excitement
- Echolalia, Echopraxia, Negativism
- Poor Personal Hygiene
- Lack of Insight
Types of Schizophrenia
1. Paranoid
2. Hebephrenic
3. Catatonic
4. Residual
5. Undifferentiated
6. Simple
Paranoid Schizophrenia
- Persecutory or Grandiose Delusions together with associated jealous
- Hallucinations
- Unfocussed Anxiety, Anger, Argumentativeness and Violence
- Doubts about Gender Identity
Hebephrenic Schizophrenia
- Incoherence and Flat, Incongruous or Silly Effect
- 15 � 25 Years
- Extreme Social Impairment, Poor Pre morbid Personality, Early Insidious Onset and a Chronic Course without Significant remissions.
Catatonic Schizophrenia
- Psychomotor Disturbance
- Catatonic Stupor or Rigidity
- Catatonic Excitement
- Catatonic Posturing
- Negativism
Residual Schizophrenia
- Atleast one episode of Schizophrenia in the past but without Prominent Psychotic Symptoms at present.
- Emotional Blunting, Social Withdrawal, Eccentric Behaviour, Illogical Thinking & Loosening Associations.
Undifferentiated Schizophrenia
- Prominent Psychotic Symptoms that cannot be classified in any Category
Simple Schizophrenia
- Insidious Onset, Progressive Development of Odd Behaviour, Wandering Tendency, Self-Absorbed, Idle and Aimless Activity
Course of Illness
Sub chronic
- Less than 2 years at least 6 Months
- From the beginning patient show signs of Illness more or less continuously
Chronic
- Duration > 2 Years
Good Prognosis
- Later Onset, Precipitating Factors, Acute Onset, Pre morbid personality, Affective (Depression) Symptoms, Paranoid Catatonic, Married, Family History of Mood Disorders, Good Support Care, Positive Symptoms
Management
1. Somatic (Physical Therapies)
a. Antipsychotic Medications
b. ECT
2. Psychological Treatment
a. Hospitalisation
b. Psychotherapy
c. Rehabilitation � Social, Vocational
d. Aftercare � Day Treatment, Halfway Homes
It is most common Psychotic Disorder
- 50% of patients in all Mental Hospital Admission.
It is Greek Word
- Schizo � Split
- Phrenic � Mind
- Split Mind
Definition
- It is a functional Psychosis
- Disturbances in Thinking, Emotion, Volition & Perception.
- Clear Consciousness
Epidemiology
- Prevalent in all cultures and all part of the world
- 3 to 4 / 1000 in any community
- 1 % of general population in lifetime
- 2/3 of cases 15 � 30 yrs
- Lower Social Classes
Etiology
Biological
Psychological
Social
Biological
- Genetic Factors
Monozygotic twin of Schizophrenic - 47
Child of Two Schizophrenic Parents - 40
Dizygotic twin of a Schizophrenic Parents - 12
- Bio Chemical Factors
Dopamine Hypothesis (Dopamine)
Transmethylation Hypothesis (Abnormal Transmethylation of Catecholamines)
Indolamine Hypothesis (Defect in metabolism of Indolamine � Serotonin)
Psychological
- Withdrawn and Social Contact
- Ego Boundary Disturbances
Social & Environmental
- Family with lot of conflict
- Communication of parents with Children
- Low Social Class
Positive Symptoms
Clinical Features
Negative Symptoms
Positive Symptoms
- Delusions
- Hallucinations
- Aggression
- Agitation
- Suspiciousness
- Hostility
- Excitement
- Grandiosity
- Conceptual Disorganization
Negative Symptoms
- Apathy
- Withdrawal
- Avolition
- Blunted Affect
- Stereotyped Thinking
- Artificial Gestures
- Lack of Spontaneity
Thought Disturbance
Condensation � Ideas are mixed, not necessarily logical
Displacement � Associated Idea, not correct one
Symbolisation � Abstract thoughts are replaced by concrete ones.
Over Inclusive Thinking � Irrelevant thoughts are incorporated into the speech.
- Neolologism
Incoherence and Mutism
- Thought Block
- Delusion � Disturbance content of thought
- Delusions of Persecutions
- Delusions of Grandeur
Austism
- Slow Progressive withdrawal from reality
Volitional Disturbance
- Deterioration in will power, drive and ambition
- Apathy � Self Neglect
Affect Disturbances
- Flattening or Blunt affect
Perceptional Disturbances
- Hallucinations
Behavioral Changes
Withdrawal Changes
↓
Withdrawal from reality into fantasy
↓
Increase Apathy
↓
Stupor or Catatonic Stupor
Reverse � Catatonic Excitement
- Echolalia, Echopraxia, Negativism
- Poor Personal Hygiene
- Lack of Insight
Types of Schizophrenia
1. Paranoid
2. Hebephrenic
3. Catatonic
4. Residual
5. Undifferentiated
6. Simple
Paranoid Schizophrenia
- Persecutory or Grandiose Delusions together with associated jealous
- Hallucinations
- Unfocussed Anxiety, Anger, Argumentativeness and Violence
- Doubts about Gender Identity
Hebephrenic Schizophrenia
- Incoherence and Flat, Incongruous or Silly Effect
- 15 � 25 Years
- Extreme Social Impairment, Poor Pre morbid Personality, Early Insidious Onset and a Chronic Course without Significant remissions.
Catatonic Schizophrenia
- Psychomotor Disturbance
- Catatonic Stupor or Rigidity
- Catatonic Excitement
- Catatonic Posturing
- Negativism
Residual Schizophrenia
- Atleast one episode of Schizophrenia in the past but without Prominent Psychotic Symptoms at present.
- Emotional Blunting, Social Withdrawal, Eccentric Behaviour, Illogical Thinking & Loosening Associations.
Undifferentiated Schizophrenia
- Prominent Psychotic Symptoms that cannot be classified in any Category
Simple Schizophrenia
- Insidious Onset, Progressive Development of Odd Behaviour, Wandering Tendency, Self-Absorbed, Idle and Aimless Activity
Course of Illness
Sub chronic
- Less than 2 years at least 6 Months
- From the beginning patient show signs of Illness more or less continuously
Chronic
- Duration > 2 Years
Good Prognosis
- Later Onset, Precipitating Factors, Acute Onset, Pre morbid personality, Affective (Depression) Symptoms, Paranoid Catatonic, Married, Family History of Mood Disorders, Good Support Care, Positive Symptoms
Management
1. Somatic (Physical Therapies)
a. Antipsychotic Medications
b. ECT
2. Psychological Treatment
a. Hospitalisation
b. Psychotherapy
c. Rehabilitation � Social, Vocational
d. Aftercare � Day Treatment, Halfway Homes
e. Education about the Illness for Patients and families
By DR.M.RAJARAM
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