Psychiatry

Psychiatry is the branch of medicine focused on the diagnosis, treatment and prevention of
mental, emotional and behavioral disorders.

Terms : all following naming are used interchangeably:

- Psychiatric disorder
- Psychological disorder
- Mental disorder

Factors of illness

• Biological (drug and genetic): these contribute to disturbance of normal brain

physiology .

• Psychological: function of the mind at any point of time and how these function
developed from childhood .

• Social: current social situation .

Biopsychosocial approach .

 In psychiatry , in contrast to medicine , no clear cause is identified to cause

disturbance normal physiology and explain the symptoms .

 Mind function :
1- perception of information
2- thinking : meaning of information.
3- memory :relate information to preexisting once.
4- comprehension
5- learning .
And all these are accompanied by emotional aspect : fear , happy . and reflected as
behavior.
Disturbance of these function by above factors lead to clinical manifestation of
psychiatric disorder.
Terms further

• Psychiatrist: qualified doctor of medical school of psychiatric specialty ,

can do both medical tx after dx and psychotherapy .

• Psychologist: not doctor but of psychological graduation . Can do

psychotherapy and psychological test like psychometry.

• Social worker : graduate from psychology , can do psychotherapy with

medication prescription .

• Prevalence
Depend on study destination : for discrete symptoms may reach to 70-90% but in Iraq
prevalence of psychiatric disorder ( sign and symptoms ) 20% , while DM is 6-10%.
Depression is 10-20% while anxiety is 5-10%.. but comorbities is rule rather than
exception .

• Services
- asylum ( for chronic psychiatric disorders in attachment with psychiatric
consultation).
- outpatient and primary health care (by family medicine doctor , easier to them to
avoid stigma ).

- referral system- hospital ( secondary health care center) to short admission less
than 6wks or treat them as outpatient ). can be reffered to tertiary services like
community base rehabilitation services , psychiatric sevices , geriatric serves , child
services .

* so every doctor whatever speciality , should be aware about psychiatric disorders and
treat them as possible unless complicated cases require psychiatrist consultation .
 New services are result from old services problems :

1- stigma

2- high economic budget .

3- worsening of condition and decrease of productivity .

*pt treated according to types and severity of condition in primary , econdary or

tertiary services.

History
• History of psychiatry is history of humanity

• Ancient Greece , Egypt , Mesopotamia , Rome ,India

supernature , exorcism (is the religious or spiritual practice of evicting demons or

other spiritual entities from a person, or an area, that is believed to be possessed).

Hippocrates four humors

- blood: sanginous morel likely aggressive.

- black bile: melancholic
- yellow bile: irritable and euphoric.
- phlegm "saliva" : more likely introverted .

dissection

• Middle ages Europe ------------ dark ages , exorcism

• Middle ages East ------------- Averroes , Rhazis , Avicenna

Bimaristans first mental units in history

• Dark ages East ------------- exorcism

• Enlightenment Europe ----------------- modern psychiatry

Psychology
- Diagnosis of psychopathological conditions depends on the presence of syndrome
not called disease because we know little about morbid psychopathology.
- The syndrome define as group of signs and symptoms and to be pathological it
depend on the following criteria

1- Statistical
a. What is common -> normal
b. Uncommon -> abnormal
But this theory is NOT true because not every common is NORMAL !! for example if
there is person never visit a dentist this would not make ABNORMAL in comparison
with people who visit dentist.

2- Cultural
Mean any phenomena that deviate from the standard culture is ABNORMAL, this
theory is also FALSE because in the Islamic society there is many things are
abnormal in comparison to the western society.

3- Morbid pathology
Mean morbid change in physiology, histology, anatomy, etc.

Clinically, How we determine signs and symptoms of any syndrome are

pathological? It depends on the presence of the following criteria
- How much the phenomena
o Severe, frequent and persist ?
o Affect daily activity ?
o Interfering with function ?
o Without enough cause ?
Type of psychopathology
1- Descriptive describe the phenomena regardless the cause, it depends on the
form and content for example; “someone talk rapidly (FORM), he is talking about
courageness (CONTENT)“

2- Etiological it describe the pathogenesis “ how the symptoms develop? ”

depending on Biopsychosocial approach and psychological development theories
- Behavioral
- Humanistic
- Psychodynamic
- Cognitive

Disorder of mental functions

- Disorder of appearance and behavior
- Disorder of speech
- Disorder of thinking
- Disorder of perception
- Disorder of emotion
- Disorder of cognitive function
- Disorder of self-experience

Disorder of appearance and behavior

1- General appearance
o Poor self care( self neglection) -> depression and schizophrenia
o Very-good self care -> mania (colourful clothes) (attention seeking in adolescent)
o Dressed well for gender and weather -> trans-sexuality (male wear female clothes
and female wear male clothes).cultural reflexion , religion reflexion.
o Clean or not -> bad in depression and schizophrenia
2- Gait
o Slow in schizophrenia
o Rapid in anxiety and mania
3- Attitude
Frank, guarded, conscious, suspicious toward doctor or indifferent?
4- Posture
- Anxiety -> face to the roof with widely opened eyes, his hands on the doctors deck,
legs directed backward “ready to RUN”
- Depression -> looking downward, hands in his lap, legs directed forward
5- Facial expression
o Sad -> depression
o Worried -> anxiety
o Happy -> manic
o Apathy -> schizophrenia, severe depression.
6- Eye to eye contact
o lost -> depression, social phobia .
o grazing -> suspicious
7- Activity
o Depression -> agitated, retarded, calm
o Restlessness -> anxiety -> irritability -> agitation ( restless. And irri. In anxiety
disorder while all range in bipolar disorder and schizophrenia)
8- Abnormal movement

Tics involuntary rapid sudden irregular movement with no goals (nonpurposeful)

and could be vocal (‫)یتنحنح‬
Mannerism voluntary, repetitive goal directed behavior try for attention
seeker .
Chorea sudden rapid involuntary semi-purposeful movement
Athetoid sudden slow involuntary semi-purposeful movement
Ecopraxia repeating the examiner movement locations ( in autism and catatonic
schizophrenia) .

Waxy flexibility in very cooperative patients, in which we can put patient in any
posture we want & keep it with no rejection and it associated with woody
muscle tone . (catatonic schizophrenia) .
 Speech disorder
1- Rate
Slow in depression or Rapid in mania

2-relevance : Irrelevant ‘’lack of logical association between speech BUT back to

the start point‘’ In wernicka aphasia or in schizophrenia .

3- Incoherent ‘’formal though disorder in which speech is illogical, patient deviate

from the reality and NOT back to the start point‘’ and it is of two types.

a- Dereatment: gradually deviate

b- Knight’s Moves: sever sudden lack of association between the idea (jumping)
Both types are formal though disorder seen in schizophrenia which
appeared as incoherent speech (not logical)

Circumstantiality ‘’the patient talk more and in details about specific things
then he answer about your question‘’ seen in obsessive compulsive disorder.

Neologism ‘’patient invented his own unique words according to his own
experience‘’ seen in schizophrenia

Preservation of speech patient says the same answer/reason after each

Question. May occur in motor activity . in organic ds like delerum , dementia .. occur
in catatonia .

o Where are you from? Baghdad

o What is your name? Baghdad etc.

Echolalia patient repeats what you say just like Parrot Talkative. In autism and
catatonia .

Sterotype of speech … repeat specific sentences in autism .

Tone of speech -> monotonus seen in depression and Parkinson

 Disorders of thinking
1- Form
- Retardation or slow speech …. In depression
- Poverty ( give little ideas).. in schizophrenia and severe depression.
- Fast ( talk rapidly with fast thinking and many ideas and ideas are logic and
understandable , but disconnection could occur by chance or due to
similarity of letters "punning " or due to clang ‫)سجع‬.. mania
- Circumstantiality ‘’the patient talk more and in details about specific things then
he answer about your question‘’ seen in obsessive compulsive disorder. Return back
to point .
- schizophrenic formal disorders ( derailment, stream of thinking goes away from
point )
- Knight’s Moves: sever sudden lack of association between the idea (jumping).

2- Content of speech
Pre-occupation what occupies patient mind at any point of time
- Anxiety pt , mind occupied with fear.
- Depressed pt , occupied with sadness.

Obsession repetitive intrusive horrifying idea, in which patient know well they are
NOT logical but he/she can’t remove them from their consciousness awareness
content:
1- Religious ( ‫)رغبة بالكفر اثناء الصالة‬
2- Aggression (when you see a knife you will imagine how you will kill somebody by
using this knife)
3- Sexual
4- Cleanness (‫)اكثر من مره تنظیف‬

These types of though NOT applicable into act “just though”. If it applicable into
act “very rare” we call it “compulsion”
. ‫ مثال ایدك وصخة لكن هو مؤمن انها نظیفه‬.. ‫هنا الشخص تاتي فكرة لكن غیر مؤمن بها‬
Delusion
Define as fix, false, blizzard beliefs beyond social, cultural, and educational
background. They are NOT liable for discussion or even reversed. the difference
between Over-valued idea and delusion this ideas less sever intensity like in
delusion can be discuses and reversed by conversation (the person accepts the
possibility that the belief may not be true). Delusion is a sign of psychotic
disorder and can occur in

o Schizophrenia
o Depression
o Mania with psychotic disorder
3
- . ‫ او انه الوحید الذي یفهم باالمور السیاسیة‬.‫ شخص مؤمن ایمان كامل انه یعالج السرطان‬-
over-value idea ‫ مقبول من حیث المنطق المجتمعي بالتالي ممكن یكون‬.. ‫ عمتي عاملتلي سحر‬-
- Primary Delusion: occur during psychiatric function processing and is base
for secondary delusion.
Delusion of the mood: patient feel something wrong in the Environment but
he/she not sure about it.
‫اكو شي متغیر واني متاكد منه لكن انتو متعرفون‬
Sudden delusion
Delusion of idea: sudden onset of idea in response to Perception or conclusion but
there are no relation between Them.
Delusion of memory: sudden onset of delusion based on previous Memory but
there is no relation between them

For examples:
o I saw the sun rising, then I realize I am the prophet (delusion of idea by conclusion)
o I saw the prime ministers when I was child then I realize I am from the British royal
family (delusion of memory)

- Secondary delusion gradually develop as consequence of primary delusion with

clear contents
1. Paranoid ) ‫)جنون العظمة‬have two main stone
a. Grandiosity where the patient feel he is great person ‫االمام یحجي ویایه‬
b. Persecutory )‫ (االضطهاد‬where the patient feel there is organization like CIA or
persons want to hurt him or listen to his idea and thought As the person has
grandiosity he will develop persecutory as a result of grandees thinking but NOT vise
verse
‫انسان بسیط یجي یكول الشرطة كاعد تراقبني ویسد البردات ویخاف من التلیفونات‬
2. Jealousy more common in male he feel his wife is disloyal him and in other
relationship with other man (othelo) .
‫االحساس بان الحبیبة خائنة‬

3. Love more common in female she feel that she loved by a person from
higher class .
‫الوهم باالن الوزیر یحبه ویمشي بامرهه‬

4. Somatic patient feel that he has disease but no exist actually (as the delusion fix
false idea when the doctor inform him that he is normal and all the investigations
are normal he say “this is wrong and these are not my investigation I am sure I have
that disease”
‫دكتور باع الورم بایدي هاي سرطان‬

5. Poverty patient feel that he is poor in contrast to the reality (seen in depression)
‫الوهم بانه خسر كل الثروة‬

6. Nihilism patient feels that he is no longer existed “ I am died person “ may be

seen in depression
‫ دكتور هسه ما عندي دماغ‬.. ‫دكتور اني میت وكاعد تتحلل العظام‬

7. delusion of reference patient interpret normal things in delusion way “ he see

two person talk between them he is sure that they talk about him “
‫المذیع باالخبار كاعد یحجي علیه‬

Disorder of perception
Illusion Misinterpretation of stimulus it may be physiological as in darkness or
psychological may occur in complex seizure.

Example :
- Pt has illusion so when doctor comes , the think they are angles come to
take his soul out.
- In dark , see trees are dangerous things
Hallucination Perception without stimulus and should be
1. arising from the sense organ (outer space) not from the mind (inner space)
2. equal in quality to real perception
3. should be clear
4. should be vivid

uditory
visual hallucination is usually associated with organic brain damage ( visual
cortex and temporal lobe lesion ) while auditory hallucination associated with
psychotic disorder like in schizophrenia , can occur in depression with
psychotic feature ( delusion and hallucination )

Auditory hallucination
o simple : simple sound ( noise like)
o complex
o music.
o voice from a second person ( one person talk to pt).
o voice from third person (two voice talking about the patient).
o thought echo: the patient hears his though as it form inside his brain.
o commentary : voice or voices tell the patient to do something.

Visual and auditory hallucination and all psychritic featurs could occur in
normal people but no goes with path-physiological criteria especially in
exhaustion .
Olfactory mostly in aura of epilepsy , tactile mostly in cocaine intoxication
like bugs on skin (cocaine bugs), proprioceptive hallucination like change in
environment(proprioceptive hallucination which mainly occur in joint or
neurological disese) .G
pseudo-hallucination criteria
1. arise from the mind (inner space)
2. less vivid
3. patient have some degree of control over it
4. less distressing (in true hallucination it is like a real person talk with you so you
can ignore him while in pseudo-hallucination it is not like that)
hallucination may be normal as in sleeping (when you hear voice try to
awake you) (hypnopapic) or as you start to wake up (hypnocampic)
visual

Done By: Yassir Abbas Abd Al-Star