To treat the disease of mental. The history of psychiatry Philippe Pinel The founder of psychiatry as a medical discipline Liberated the insane

To treat the disease of mental

The history of psychiatryThe history of psychiatry

Philippe PinelThe founder of psychiatry

as a medical disciplineLiberated the insane from

their chains


Esquirol The prototype of the

psychiatric specialistOriginated the descriptive

clinical approach


Kraepelin The founder of contemporary

scientific psychiatry ， psychopharmacolgy and psychiratric genetics.

His nosological system established around 1900 has remained valid until today.


Sigmund Freud The founder the psychoanalysis His work influenced the clinical

approaches, the humanities and social sciences.

He is considered one of the most prominent thinkers of the first half of the 20th century.


Chlorpromazine Initiated a virtual revolution in psychiatry and

psychopharmacology. The focus of psychiatry began to turn toward brain

biological theories.

Chapter 1Chapter 1

Symptoms and signs of psychiatric disorder

Chapter 1Chapter 1

Descriptive psychopathology （症状学）The objective description of symptoms or

abnormal states of mind and limited to the description of conscious experiences and observable behavior.

Chapter 1Chapter 1

The use of empathic understanding to explore and clarify the patient's subjective experiences

“feel oneself into the other”

Chapter 1Chapter 1

Disorders of MoodDisorders of PerceptionDisorders of ThinkingDisorders of MemoryDisorders of ConsciousnessDisorders of Concentration Insight

Disorders of MoodDisorders of Mood

Mood is usually characterized as a prevailing and prolonged emotional state that determines a person’s overall perception, feeling, thinking and behaviour for a considerable period of time.

Affect is short-lived and changeable, emerges in immediate reaction to a particular aspect or object.


Depression （抑郁） is abnormal when it is out of proportion to the misfortune, or is unduly prolonged.

Lowering self-esteemPessimistic or negative thinkingReduction or loss of the experience of

pleasure.



Clinical associationDepressive disorderSchizophreniaAnxiety OCDOrganic disorder


Elation （情绪高涨） is an extreme degree of happy mood often coupled with other changes, including increased feelings of self-confidence, well-being, increased activities.

Elation occurs most often in mania and hypomania.


Anxiety （焦虑） is abnormal when its severity is out of proportion to the threat of danger or when it outlasts the threat.

The essential anxious feeling including dread, restlessness, narrowing attention, worrying thoughts, increased alertness and irritability.


Somatic symptoms means muscle tension, pain and respiration increase.

Autonomic symptoms are increasing of heart rate, sweating, dry mouth, and may be an urge to urinate or defecate.

Disorders of Perception Disorders of Perception

Perception （知觉） is the process of becoming aware of what is presented through the sense organs.

Perception cannot be terminated by an effort of will.

Specific kinds of perceptual disorders are symptoms of severe psychiatric disorders.


Illusions （错觉） is based on a percept of a real object or event, which is misinterpreted .

Illusions occur when level of consciousness is reduced, as in delirium.


Hallucination （幻觉） is a percept experienced in absence of an external stimulus to the corresponding sense organ.

Hallucination differs from an illusion in not being based on a percept of a real object or event.


Categories of hallucinationsAccording to complexity: elementary complexAccording to sensory modality: auditory visual olfactory and gustatory tactileAccording to special features: second person third person Gedankenlautwerden echo de la pensee


Elementary hallucination refers to simple experiences such as whistles, twitters and flash of light.

Complex hallucination refers to complicated experiences such as hearing voices and music, or seeing faces and scenes.


The most common hallucination is auditory hallucinations （幻听） , usually in the form of voices.

Voices talking to each other about the patient, and voices commenting about the patient‘s ongoing acting or thinking, are considered to be typical to schizophrenia (third-person hallucination ，第三人称幻听） .

Voices calling the patient's name or talking without comments to the patient are considered to be non-specific(second-person hallucination ） .

Voices which anticipate, speak (Gedankenlautwerden ，思维化声 ) or repeat(echo de la pensee ，思维回响 ) the patient’s thoughts also suggest schizophrenia.


Visual hallucinations （幻视） often raise the suspicion of an organic disorder, they also occur in schizophrenia and severe affective disorders.

The content of visual hallucinations is of little significance in diagnosis.


Tactile hallucinations （幻触） may be experienced as sensations of being touched, pricked or strangled, which suggest schizophrenia and drug abuse.


Hallucinations of smell and taste are often unpleasant, which is also called olfactory and gustatory hallucination.

They are infrequent and may occur in schizophrenia, severe depression, and epilepsy.


Reflex hallucination （反射性幻觉） is a rare phenomenon in which a stimulus in one sensory modality results in a hallucination in another.


One said he see a snake in the corner, but in fact it was a length of rope.

Illusions


One said he hear some people talking with each other about his private affairs just outside of the room, but others in the same room hear nothing.

Auditory hallucination (third-person)


A female patient complain that as soon as she saw her neighbor , she would hear voices commenting her dress.

Reflex hallucination

Disorders of thoughts Disorders of thoughts

Disorders of thoughts are the most diagnostically significant symptoms in psychiatry.

It contain two aspects: disorder of thoughts content and disorder of the thinking process.


The most important symptom in disorders of thoughts content is delusion （妄想） .

A delusion is a belief that is firmly held on inadequate grounds, it could not be affected by rational argument or evidence to the contrary, and is not a conventional belief that the person might be expected to hold given his educational, cultural and religious background.

In short, a delusion is a false unshakable belief which is out of the patient's background.

Disorders of thoughts Disorders of thoughts According to onset:

Primary

Secondary

According to delusional experiences:

delusional mood

delusional perception

delusional memory

According to the theme:

persecutory

delusion of reference

grandiose

guilty delusions

hypochondriacal

nihilistic

jealousy

sexual

delusion of control

thoughts insertion

thoughts withdrawal

thoughts broadcasting


A primary delusion （原发性妄想） is one that appears suddenly and with full conviction but without any mental events leading up to it.

Primary delusions are given considerable weight in the diagnosis of schizophrenia.

Primary delusion experiences often start with an idea, but sometimes the first experience could also be delusional mood, delusional perception, or delusional memory.


Delusional mood （妄想心境） is preceding mood that often a feeling of foreboding that some as yet unidentified bad event is about to take place, then the delusion follows, and the delusion appears to explain this feeling of mood.


Delusional perception （妄想知觉） is the attaching of a new significance to a familiar percept without any rational reason

The perception may be normal, however the delusional interpretation is morbid.


Delusional memory （妄想记忆） is a delusional interpretation attached to past event.

The past event actually exists, but the significance attached to it is delusional


Second delusions （继发性妄想） are delusions apparently derived from preceding morbid experience.

Secondary delusions may accumulate until there is a complicated and stable delusional system, which also called systematic delusion.


The most common theme of delusion is persecutory （被害妄想） .

The patient with this symptom believe that some persons or organizations are trying to inflict harm on the patient, damage his reputation, or make him insane.

Persecutory is common in schizophrenia, organic disorders and severe affective disorders.


Delusions of reference （关系妄想） are concerned with the idea that objects, events or people have a personal significance for the patient, but in fact these events or people have nothing to do with the patient.

Delusions of reference also occur in schizophrenia, organic disorders and severe affective disorders.


Grandiose delusions （夸大妄想） are beliefs of exaggerated self-importance.

Such ideas occur particularly in mania as well as schizophrenia.


Guilty delusions （罪恶妄想） are beliefs of sinfulness because of a minor illegal behavior

It often occurs in severe depression


The nihilistic delusions （虚无妄想） are beliefs that something has ceased to exist.

The patient with hypochondriacal （疑病妄想） delusions believe that he is suffering from a severe disease, despite all medical evidence to the contrary.

Delusions of jealousy （嫉妒妄想） are beliefs that his/her partner is unfaithful.

A patient with sexual delusion （钟情妄想） believes that she is loved by a man who is usually inaccessible to her.


A patient with a delusion of control （影响妄想） believes that his actions, movements or thoughts are controlled by an outside agency and not willed by himself.

These are also called passivity phenomena. This symptom strongly suggests schizophrenia.


Patients with delusions concerning the possession of thoughts lose the normal convictions that thoughts are private and cannot be shared unwillingly, including thoughts insertion, thoughts withdrawal and thoughts broadcasting.

They are strongly associated with schizophrenia.


Thoughts insertion （思维插入） is the delusion that certain thoughts are not the patient’s own but implanted by an outside agency.

Thought withdrawal （思维被窃） is the delusion that thoughts have been taken out of the mind.

Thought broadcasting （思维播散） is the delusion that unspoken thoughts are known to other people through radio, high-tech equipment, or in some other way.


A patient felt guilty and apologized to everyone in the office for her late for work.

Guilty delusion


A patient refused to drink any water at home because he believes his parents will poison him by water.

Persecutory delusion


A patient believed that an article in magazine suggests that he has been under surveillance .

Delusions of reference


A patient believes many people around hear her thoughts through a special electronic instrument.

Thought broadcasting


A patient believes that his thoughts are influenced by an outside agency.

Delusions of control

Disorders of thoughtsDisorders of thoughts

A patient believes that some thoughts are implanted in his mind by an outside agency.

thought insertion


Obsessions （强迫观念） are recurrent persistent thoughts, impulses, or images that enter the mind despite efforts to exclude them. Obsessions are regarded as untrue, useless, or senseless.

The characteristic feature of obsessions is the subjective sense of a struggle, the patient resist the obsession, which nevertheless intrudes into awareness.


Forms of obsessionsObsessional thoughts （强迫思维）Obsessional ruminations （强迫穷思竭

虑）Obsesional doubts （强迫怀疑）Obsessional impulses （强迫意向）


Content of obsessionsThoughts about dirt and contamination Aggressive thoughts Thoughts about orderlines Thoughts about illnessThoughts about sex


Compulsions （强迫行为） are repetitive purposeful behaviors, performed in a stereotyped way(which is also called compulsive ritual ，强迫仪式 ), in response to an obsession. Compulsions are recognized as senseless but the compulsive behavior must be carried out.


Although the compulsive behavior transiently reduces the anxiety associated with the obsession, in fact the compulsions help maintain the obsession.


Forms of compulsions Checking rituals （强迫检查）Cleaning rituals （强迫清洗）Counting rituals （强迫计数）Dressing rituals （强迫着装）


Overvalued idea （超价观念） is an acceptable comprehensible idea pursued by the patient beyond the bounds of reason.

The content of the overvalued idea is usually understandable and acceptable considering the person’s background. And overvalued ideas are not so firmly


Disorders of thinking processes including the disorders of the stream of thoughtand the form of thought.


In disorders of the stream of thought （思维进展障碍） , the amount and the speed of thinking are changed.


In pressure of thought （思维迫促） , which occurs in mania, ideas arise in unusual variety and abundance , thought pass through the mind rapidly.

In poverty of thought （思维贫乏） , which occurs in depression, the patient has few thoughts and these lack variety and richness , thoughts seem to move slowly through the mind.

In thought block （思维中断） , the stream of thoughts is interrupted suddenly, and the patient feels that his mind has gone blank. It suggests schizophrenia


Disorders of the form of thinking （思维形式障碍） can be categorized into perseveration, flight of ideas, loosening of associations and so on.


Perseveration （重复思维） is the persistent and inappropriate repetition of the same thoughts.

Perseveration occurs in dementia and frontal lobe injury.


In flight of ideas （思维奔逸） , thoughts and speech move quickly from one topic to another so that one piece of thought is not carried out to completion before another thought starts.

Flight of ideas is characteristic of mania.

Disorders of thoughtsDisorders of thoughtsLoosening of associations （思维散漫）

denotes a loss of the normal structure of thinking.

They occur most often in schizophrenia.There are three characteristic kinds of

loosening associations: Talking past the point Derailment or knight’s move thinking Verbigeration


A patient said he feel his thinking is very slowly and can’t understand the interviewer’s questions quickly.

poverty of thought


A patient feels his mind sometimes suddenly become blank because another person remove his thoughts.

thought block


The interviewer ask the patient ‘how old are you’ the patient answer ’59’ the second question is ‘ what is your name ’ the patient still say ‘59’, the third answer is still”59”

Perseveration


The question is “why do you believe that you will be killed”. The patient answered “My friend has an electric-radio receiver, but he never tell me where it is. In fact, I have been to nuclear power plant, and there is nothing dangerous.”

Derailment

Disorders of memory Disorders of memory

Immediate memory （瞬时记忆） concerns the retention of information over a short period measured in minutes.

Recent memory （近记忆） concerns events that in the last few days.

Long term memory （远记忆） concerns events over longer periods of time.


Some organic conditions can lead to a partial effect known as amnestic disorder （遗忘综合症） , in which the patient is unable to remember events occurring a few minutes before, but can recall remote events. In dementia, it usually progresses with time and becomes severe, but rarely total.


In case of unconsciousness, memory is impaired for the interval between the ending of complete unconsciousness and restoration of full consciousness, this is called anterograde amnesia （顺行性遗忘） .

Some causes of unconsciousness lead also to inability to recall events before the onset of unconsciousness, that is retrograde amnesia（逆行性遗忘） .


Psychogenic amnesia （心因性遗忘） is thought to result from an active process of repression which prevents the recall of memories that would evoke unpleasant emotions.


Disorders of recognition occur occasionally in neurological and psychiatric disorders:

Jamais vu （识旧如新） is the failure to recognize events that have been encountered before.

Déjà vu （识新如旧） is the conviction that an event repeats one that has been experienced before while in fact it is novel.

Confabulation （虚构） is the reporting as memories of events at one time, of events that took place at another time, or never involve the person. It is characteristic of amnestic syndrome.


A female said she has forget who she is and her whole life experience.

Psychogenic amnesia


A head injured patient complained that he can’t remember the events before he injured.

Retrograde amnesia

Disorders of memoryDisorders of memory

A patient stayed at hospital yesterday, but today he insists he had been to his daughter’s home last night.

Confabulation

Disorders of consciousness Disorders of consciousness

Consciousness( 意识 ) is awareness of the self and the environment.


Coma （昏迷） is the most extreme form of impaired consciousness.

Coma can be graded by the extent of the remaining reflex response and by the type of electroencephalogram activity.


Clouding of consciousness （意识混浊） refer to a state which ranges from barely perceptible impairment to definite drowsiness in which the person reacts incompletely to stimuli. Attention, concentration, and memory are impaired to varying degrees and orientation is disturbed. Thinking seems muddled, and events may be interpreted inaccurately.

It is a defining feature of delirium.


Stupor （木僵） , in the sense used in psychiatry, refers to a condition in which the patient is immobile, mute, and unresponsive but appears to be fully conscious in that the eyes are usually open and follow external objects. Reflexes are also normal and resting posture is maintained.

It may occur in catatonia.


Confusion （意识模糊） means an inability to think clearly. It occurs characteristically in states of impaired consciousness but it can occur when consciousness is normal.

In delirium, confusion occurs together with partial impairment of consciousness.

Disorders of attention and Disorders of attention and concentration concentration （注意障碍）（注意障碍）

Attention is the ability to focus on the matter in hand.

Concentration is the ability to maintain that focus.

Disorders of attention and Disorders of attention and concentrationconcentration

Attention and concentration may be impaired in a wide variety of psychiatric disorders including depression, mania, anxiety, schizophrenia and delirium.

Therefore , the finding of abnormalities of attention and concentration does not assist in diagnosis.

But these abnormalities are important in management because they can interfere with a patient’s ability to work, study or drive.

Insight Insight

In psychopathology, the term insight（自知力） refers to awareness of morbid change in oneself and a correct attitude to this change including a realization that it signifies a mental disorder.

Insight Insight

Insight is not simply present or absent. It has several facets, each being a matter of degree and could be assessed by following questions:

Is the patient aware of phenomena that others have observed?

If so, does he recognize the phenomena as abnormal?

If so, does he consider that they are caused by mental illness?

If so, does he think that he needs treatment?

Insight Insight

The value of determining the degree of insight is that it helps to predict whether a patient is likely to comply with treatment.

Chapter 2Chapter 2

Classification and diagnosis

Classification and diagnosisClassification and diagnosis

What is mental illness or mental disorder?

In ICD10 the definition of mental disorder is: a clinically recognizable set of symptoms or behavior associated in most cases with distress and with interference with personal functions. Social deviance or conflict alone, without personal dysfunction, should not be included in mental disorder as defined here”.


ICD10 is the International Classification of Diseases produced by the World Health Organization as an aid to the collection of international statistics about disease. The system is revised every few years and the present edition is the tenth.

Of twenty-one chapters, chapter 5 is devoted to psychiatry. It is the current main psychiatric classification.


In 1952 the American Psychiatric Association(APA) published the first edition of the Diagnostic and Statistical Manual.

The present edition is DSM 4 textual revision which published in 2000.


DSM has a multi-axial classification with five axes in particular.

Axis 1 clinical syndromes and conditions. Axis 2 personality disorder. Axis 3 physical disorder and conditions. Axis 4 severity of psychosocial stressors. Axis 5 highest level of adaptive function.


DSM-5 was released in 2013.

http://www.dsm5.org

Chapter 3 Chapter 3

Assessment

AssessmentAssessment

Psychiatric history Name, age, and address of the patient Name(s) of informant(s) and their relationship to the

patient History of present condition Family history Personal history Past illness Personality

AssessmentAssessment

Mental state examination Appearance and behaviour Speech Mood Thoughts Perceptions Cognitive function Insight

Chapter 6 Chapter 6

Evidence-based approaches to psychiatry

Evidence-based approaches to psychiatryEvidence-based approaches to psychiatry

What is evidence-based medicine ？Evidence-based medicine （循证医学）

is a systematic way of obtaining clinically important information about aetiology, diagnosis, prognosis, and treatment.


The evidence-based approach is a process in which the following steps are applied:

Formulation of an answerable clinical question; Identification of best evidence; Critical appraisal of the evidence for validity and

utility; Implementation of the findings; Evaluation of performance.


Archibald Cochrane, an epidemiologist ，is the most important scientist in evidence-based approaches.

He emphasized the need to use evidence from randomized controlled trials because randomized controlled trials is more reliable than any other kind.


Combination of computerized searching all of the relevant randomized trials and the statistical techniques of meta-analysis is called “systematic reviews”


The Cochrane Collaboration is now the largest organization in the world engaged in the production and maintenance of systematic reviews.

http://www. cochrane.org


Hierarchy of evidence

Ⅰ Evidence from a systematic review of randomized controlled trials or evidence from at least one randomized controlled trial.

Ⅱ Evidence from at least one controlled trial without randomization or quasi-experimental study. ( quasi-experimental designs are used when randomization is impossible)

Ⅲ Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case control studies.

Ⅳ Evidence from expert committee reports or opinions and clinical experience of respected authorities.


In this hierarchy, evidence from randomized trials is regarded as more valid than evidence from non-randomized trials.

Chapter 16 Chapter 16

Psychiatry and medicine

Psychiatry and medicinePsychiatry and medicine

The presentation of psychiatric disorders is common in all settings and differs from one medical setting to another.


General practice

Emergency Medical/surgical outpatients

Medical/surgical inpatients

Depression/anxiety ++ ++ +++ +++Delirium - + - +++Alcohol abuse ++ +++ ++ +++Psychosis + + - -Somatoform disorders

+++ + +++ ++

The relative prevalence of common psychiatric disorders in medical settings

- rare; + uncommon; ++ common; +++ very common


Some patients seen in general practice and hospital outpatient clinics have somatic symptoms which cannot be explained by medical disease and many of these have a psychiatric disorder such as depression , anxiety and somatoform disorder.

Depression is associated with somatic symptoms, such as fatigue, weigh loss, and pain, which may lead to referral to medical specialty.

Anxiety is associated with symptoms of autonomic arousal and panic attack, such as palpitations, chest pain, dizziness and breathless symptoms.


The psychiatric services for general hospitals are often named consultation-liaison psychiatry（会诊 - 联络精神病学） .

In consultation work, the psychiatrist is available to give opinions on patients referred by physicians and surgeons.

In liaison work, the psychiatrist is a member of a medical or surgical team, and offers advice about any patient to whose care the psychiatrist feels able to contribute.

Review of this class Review of this class

Chapter 1Definition of the descriptive

psychopathologyThe concepts and the clinical meanings

of mental symptoms. The distinctions between the confusing

symptoms are also critical important.


Chapter 2The definition of mental disorder in

ICD10 The conception of ICD and DSM.


Chapter 6The concept of evidence-based medicine The fundamental principles of EBM.


Chapter 16The presentation of psychiatric disorder

in medical settingsThe conception of consultation - liaison

psychiatry.

Documents

To treat the disease of mental. The history of psychiatry Philippe Pinel The founder of psychiatry as a medical discipline Liberated the insane