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PSYCHIATRY
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Lecture notes of 263 pages for the course MBBS at ALL INDIA INSTITUTE OF MEDICAL SCIENCE (PSYCHIATRY)
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PSYCHIATRYBACHELOR OF SCIENCE IN NURSING (BSN)
B.SC NURSING
, Contents
1. Diagnosis and Classification in Psychiatry ......................................................................................1
2. Psychiatric History and Examination ...............................................................................................5
3. Organic (Including Symptomatic) Mental Disorders ................................................................... 19
4. Psychoactive Substance Use Disorders ........................................................................................ 33
5. Schizophrenia ................................................................................................................................. 54
6. Mood Disorders .............................................................................................................................. 69
7. Other Psychotic Disorders ............................................................................................................. 83
8. Neurotic, Stress-related and Somatoform Disorders ................................................................... 89
9. Disorders of Adult Personality and Behaviour ........................................................................... 113
10. Sexual Disorders ........................................................................................................................... 121
11. Sleep Disorders ............................................................................................................................. 133
12. Behavioural Syndromes Associated with Psychological Disturbances
and Physiological Factors ............................................................................................................ 142
13. Mental Retardation ...................................................................................................................... 153
14. Child Psychiatry ............................................................................................................................ 162
15. Psychopharmacology ................................................................................................................... 172
16. Other Biological Methods of Treatment ..................................................................................... 199
17. Psychoanalysis .............................................................................................................................. 205
18. Psychological Treatments ............................................................................................................ 213
19. Emergency Psychiatry .................................................................................................................. 221
20. Legal and Ethical Issues in Psychiatry ......................................................................................... 229
21. Community Psychiatry ................................................................................................................. 235
Appendices .......................................................................................................................................... 241
Appendix I: Nobel Prizes in Psychiatry and Allied Disciplines .............................................................................. 241
Appendix II: Some Important Contributors in Psychiatry..................................................................................... 242
Appendix III: Glossary of Some Important Terms in Psychiatry........................................................................... 246
Suggested Further Reading ................................................................................................................ 249
Index .......................................................................................................................................................................................... 253
, 1 Diagnosis and Classification
in Psychiatry
Classification is a process by which phenomena are DEFINITION OF A PSYCHIATRIC
organized into categories so as to bring together those DISORDER
phenomena that most resemble each other and to sepa-
rate those that differ. Any classification of psychiatric The simplest way to conceptualize a psychiatric
disorders, like that of medical illnesses, should ideally disorder is a disturbance of Cognition (i.e. Thought),
be based on aetiology. For a large majority of psychiat- Conation (i.e. Action), or Affect (i.e. Feeling), or any
ric disorders, no distinct aetiology is known at present, disequilibrium between the three domains. However,
although there are many attractive probabilities for this simple definition is not very useful in routine
several of them. Therefore, one of the most rational clinical practice.
ways to classify psychiatric disorders at present is Another way to define a psychiatric disorder or
probably syndromal. A syndrome is defined as a group mental disorder is as a clinically significant psycho-
of symptoms and signs that often occur together, and logical or behavioural syndrome that causes significant
delineate a recognisable clinical condition. (subjective) distress, (objective) disability, or loss of
The syndromal approach of classifying psychiat- freedom; and which is not merely a socially deviant
ric disorders, on the basis of their clinical signs and behaviour or an expected response to a stressful life
symptoms, is very similar to the historical approach event (e.g. loss of a loved one). Conflicts between
of classification of medical illnesses, when aetiology the society and the individual are not considered
of a majority of medical illnesses was still obscure. psychiatric disorders. A psychiatric disorder should
There are three major purposes of classification be a manifestation of behavioural, psychological, and/
of psychiatric disorders: or biological dysfunction in that person (Definition
1. To enable communication regarding the diagnosis modified after DSM-IV-TR, APA).
of disorders, Although slightly lengthy, this definition defines
2. To facilitate comprehension of the underlying a psychiatric disorder more accurately.
causes of these disorders, and
3. To aid prediction of the prognosis of psychiatric NORMAL MENTAL HEALTH
disorders.
This syndromal approach of classification, in the According to the World Health Organization (WHO),
absence of clearly known aetiologies, fulfils these Health is a state of complete physical, mental and
purposes reasonably well. social well-being, and not merely absence of disease
Before proceeding to look at current classifications or infirmity.
of psychiatric disorders, it is important to define what Normal mental health, much like normal health, is
is meant by the term, psychiatric disorder. a rather difficult concept to define. There are several
, 2 A Short Textbook of Psychiatry
models available for understanding what may consti- Table 1.1: Some Models of Normality in Mental Health
tute ‘normality’ (see Table 1.1). 1. Medical Model (Normality as Health): Normal men-
Although, normality is not an easy concept to tal health is conceptualized as the absence of any
define, some of the following traits are more com- psychiatric disorder (‘disease’) or psychopathology.
monly found in ‘normal’ individuals. 2. Statistical Model (Normality as an Average): Statisti-
1. Reality orientation. cally normal mental health falls within two standard
2. Self-awareness and self-knowledge. deviations (SDs) of the normal distribution curve for
3. Self-esteem and self-acceptance. the population.
4. Ability to exercise voluntary control over their 3. Utopian Model (Normality as Utopia): In this model,
behaviour. the focus in defining normality is on ‘optimal func-
5. Ability to form affectionate relationships. tioning’.
6. Pursuance of productive and goal-directive activi- 4. Subjective Model: According to this model, normality
ties. is viewed as an absence of distress, disability, or any
help-seeking behaviour resulting thereof. This defini-
tion is similar in many ways to the medical model.
CLASSIFICATION IN PSYCHIATRY
5. Social Model: A normal person, according to
this definition, is expected to behave in a socially
Like any growing branch of Medicine, Psychiatry has
‘acceptable’ behaviour.
seen rapid changes in classification to keep up with a 6. Process Model (Normality as a Process): This model
conglomeration of growing research data dealing with views normality as a dynamic and changing process,
epidemiology, symptomatology, prognostic factors, rather than as a static concept. This model can be
treatment methods and new theories for the causation combined with any other model mentioned here.
of psychiatric disorders. 7. Continuum Model (Normality as a Conti nuum):
Although first attempts to classify psychiatric Normality and mental disorder are considered by
disorders can be traced back to Ayurveda, Plato (4th this model as falling at the two ends of a continuum,
century BC) and Asclepiades (1st century BC), clas- rather than being disparate entities. According to
sification in Psychiatry has certainly evolved ever this model, it is the severity (scores above the ‘cut-
since. off’) that determines whether a particular person’s
At present, there are two major classifications in experience constitutes a symptom of a disorder or
Psychiatry, namely ICD-10 (1992) and DSM-IV-TR falls on the healthy side of the continuum.
(2000).
ICD-10 (International Classification of Diseases, classification of mental disorders. DSM-IV-TR is a
10th Revision, 1992) is World Health Organisation’s text revision of the DSM-IV which was originally
classification for all diseases and related health prob- published in 1994.
lems (and not only psychiatric disorders). The next editions of ICD (ICD-11) and DSM
Chapter ‘F’ classifies psychiatric disorders as Men- (DSM-V) are likely to be available in the years
tal and Behavioural Disorders (MBDs) and codes them 2012-14.
on an alphanumeric system from F00 to F99. ICD-10 For the purpose of this book, it is intended to
is now available in several versions, the most impor- follow the ICD-10 classification. ICD-10 is easy to
tant of which are listed in Table 1.2. There are several follow, has been tested extensively all over the world
versions of ICD-10; some are listed in Table 1.3. (51 countries; 195 clinical centres), and has been found
DSM-IV-TR (Diagnostic and Statistical Manual to be generally applicable across the globe. At some
of Mental Disorders, IV Edition, Text Revision, 2000) places in the book, DSM-IV-TR diagnostic criteria are
is the American Psychiatric Association (APA)’s also discussed, wherever appropriate.
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