Introduction and general aspects
Psychiatry is the branch of medicine that is concerned with the study and treatment of disorders of mental function. A substantial proportion of patients seen by a doctor suffer from psychiatric illness rather than organic disease. Some of these psychiatric problems occur as a consequence of individual social circumstances that may be difficult to alter. Physical and psychiatric disorders often coincide because:
• Patients with psychiatric problems can present with physical manifestations (e.g. abdominal pain in the irritable bowel syndrome).
• Chronic or severe physical ill-health can result in a psychiatric disorder (e.g. depression in the setting of chronic pain).
• Psychiatric symptoms can be part of a physical disease complex (e.g. depression in hypothyroidism).
• Patients with established psychiatric disorders can also develop physical disease.
For these reasons, the psychological aspects of disease cannot be the exclusive preserve of psychiatrists but must be the concern of all doctors.
In primary care in the UK approximately 15% of attenders suffer from psychiatric ill-health. Most of the illnesses are minor mood disorders, taking the form of various combinations of depression and anxiety, and about twothirds are short-lived in nature and clear within 6 months. However, about 5% of primary care consultations involve patients suffering from major depression requiring energetic treatment. The major psychosesschizophrenia and manic-depressive illness are much less common in this setting. The general hospital physician and surgeon will tend to see psychiatric disorders that are associated with physical disease or caused by certain physical treatments as well as disorders related to alcohol and other forms of drug use and abuse.
About 25% of all those referred to psychiatric departments are aged 65 years and over; this includes patients with disorders such as depression and confusional states, which may be reversible, and dementias, which usually are not. It has been estimated that in England about half a million people over 65 years suffer from moderate or severe dementia, and about one-quarter of these are aged 85 years or more.
During the nineteenth century the rise of psychiatry resulted in a remarkable growth in mental asylums. Today these mental hospitals are being closed and patients are being discharged to community-based facilities, e.g. hostels, supervised accommodation and rehabilitation facilities. This community care has led to the integration of psychiatry into the community, but there is some anxiety that chronic psychiatric patients end up sleeping rough or occupying low-grade accommodation.
Thus the closure of mental hospitals must be accompanied by the simultaneous development of community facilities linked to a hospital inpatient service
The psychiatric interview
The interview is of prime importance in making a psychiatric diagnosis:
• It is a technique for obtaining information.
• It serves as a standard situation in which to assess the patient’s emotions and attitudes.
• The first interview serves to establish an understanding with the patient that will be the basis of any subsequent therapeutic relationship
The psychiatric history
The history records data from several sources. These include the patient’s complaints, recent and remote past history and their present life situation up to the time of referral or admission.
The history consists of:
REASON FOR REFERRAL-a brief statement of why and how the patient came to the attention of the doctor
COMPLAINTs-as reported by the patient
PRESENT ILLNEss-a detailed account of the illness from the earliest time at which a change was noted
until the patient came to the attention of the doctor and the degree to which the illness is recognized by the patient (insight)
FAMILY HISTORy-this should focus on the family atmosphere in the patient’s childhood, early stresses (including death or separation) and the occurrence of mental illness in family members
PERSONAL HISTORY-a short biography that covers childhood and school, jobs held and lost, marriage and divorce, children, and the present housing, social and financial situation
PERSONALITY -this consists of a person’s attitudes and beliefs, moral values and standards, leisure activities and interests and usual reaction to stress and setback
MEDICAL HISTORy-this includes health during childhood, menstrual history, previous mental health and the use and abuse of alcohol, tobacco and drugs Supplementary information should be obtained from a close relative or friend who can provide corroboration and additional details.
SYMPTOMS AND SIGNS OF A PSYCHIATRIC DISORDER
Appearance and general behaviour
Facial appearance, posture and movement provide information about a patient’s mood. Patients with retarded depression sit with shoulders hunched, immobile, and with the gaze directed at the floor. Agitated depressives are often tremulous and restless, adjusting their clothing and pacing up and down, while manic patients are often overactive and disinhibited.
Certain uncommon disorders of behaviour are encountered, mainly in schizophrenia. These include the following:
STEREOTYPY is repetition of movements that do not appear to have a purpose; the movement may be
repeated in a regular sequence (e.g. rocking backward sand forwards).
MANNERISMS are repeated movements that appear to have some functional significance (e.g. saluting).
NEGATIVISM is when patients do the opposite of what is asked and actively resist efforts to persuade them to comply.
ECHOPRAXI A is when patients automatically imitate the interviewer’s movements despite being asked not to do this.
Disorders of thinking are usually recognized from the patient’s speech.
Disorders of the stream of thought
There are abnormalities in the amount and speed of the thoughts experienced. At one extreme, there is pressure of thought, in which ideas arise in remarkable abundance and variety and pass rapidly through the mind. Poverty of thought is the opposite experience, when there appears to be a lack or absence of any thoughts whatsoever and patients report their minds to be blank or starved of ideas. Pressure of thought characteristically occurs in mania, and poverty of thought in depression; either may be experienced in schizophrenia. The stream of thought can also be suddenly interrupted. Minor degrees of this phenomenon are not uncommon, especially in normal people who are tired or tense.
Severe thought blocking, in which there is a particularly abrupt and complete interruption of the stream of thought, strongly suggests schizophrenia. Patients often describe the experience as a sudden and complete emptying of their minds and may interpret the experience in an unusual way (e.g. as having had their thoughts removed by some alien person, presence or machine).
Disorders of the form of thought
These include flight of ideas, perseveration, and loosening of associations.
FLIGHT OF IDEAS. The patient’s thoughts and speech move quickly from one topic to another, such that one train of thought is not completed before another appears. It is often accompanied by clang associations (the tendency to use two or more words with a similar sound), punning (the use of one word with two or more different meanings), rhyming, and responding to distracting cues in the immediate surroundings. Flight of ideas is characteristic of mania.
PERSEVERATION. This is the persistent and inappropriate repetition of the same thoughts or actions. It is often associated with dementia but can occur in otherconditions.
LOOSENING OF ASSOCIATIONS. This is manifested by a loss of the normal structure of thinking. The most striking impression is an extreme lack of clarity. There are several forms. Knight’s move or derailment denotes transition from one topic to another, either between sentences or within a sentence, with no logical relationship between the two topics and no evidence of flight of ideas as described above. When this abnormality is extreme and disrupts not merely the connections between sentences but also the finer grammatical structure of speech, it is termed word salad or verbigeration. One effect of loosened associations is sometimes termed talking past the point; the patient always seems to get near to talking about the matter in hand but never quite gets there.
In psychiatric disorders, mood may be altered in three ways:
1 Its nature may be changed.
2 It may fluctuate more than usual.
3 It may be inconsistent either with the patient’s
thoughts and actions or with occurrences in the patient’s immediate environment.
Changes in the nature of mood
Changes in the nature of mood may be towards depression, anxiety or elation .
DEPRESSION may mean the symptom of feeling sad, melancholic or low in spirits, or it may mean the syndrome of depression as characterized by low mood, lack of enjoyment, reduced energy and changes in appetite, sleep and libido.
ANXIETY is a common symptom of worry or apprehension that is often accompanied by physical symptoms such as palpitations, trembling, butterflies in the stomach and hyperventilation.
ANXIETY AND DEPRESSION can occur separately or together and may be associated with an obvious cause or may appear to arise without reason.
ELATION refers to a subjective feeling of high spirits, vitality and even ecstasy, which mayor may not be accompanied by exuberant behaviour, increased energy and overactivity.
PHOBIA is an intense fear of a specific object, activity or situation coupled with a wish to avoid it. The fear is irrational in that it is out of all proportion to the real danger. The patient recognizes that it is an exaggerated fear but finds it difficult to control. Objects that provoke such fear include insects, spiders and other animals (e.g. dogs, cats and horses) or natural phenomena such as lightning or the dark. Situations that provoke phobic reactions include open spaces (agoraphobia), closed spaces such as lifts and underground trains (claustrophobia), high places, and crowds.
Changes in the fluctuation of mood
These may result in a total loss of emotion or an inability to experience pleasure. The former is termed apathy.
When the normal variation of mood is reduced rather than lost, the mood is described as blunted. Emotions that are changeable in a rapid, abrupt and excessive way are termed labile emotions
Inconsistent or inappropriate mood
This occurs when the normal emotional expression of the person fails to match his thoughts and actions. For example, a patient may laugh when describing the death of a close and loved relative. Such incongruity needs to be distinguished from laughter that indicates that someone is ill at ease when talking about a distressing subject. Changes of mood are found in a variety of psychiatric disorders, including depression, mania, anxiety, organic psychoses and schizophrenia.
Thought content refers to the worries and preoccupations manifested by the patient and elicited on interview. Abnormal beliefs and experiences are, of course, part of the thought content, but are regarded as sufficiently important to be discussed separately (see below).
An obsession, is a recurrent, persistent thought, impulse or image that enters the mind despite the individual’s effort to resist it. The individual recognizes that the obsession is self-generated and is not implanted by anyone nor arises from elsewhere.
A compulsion is a repetitive and seemingly purposeful action performed in a stereotyped way, referred to as a compulsive ritual. Compulsions are accompanied by a subjective sense that they must be carried out and by an urge to resist. Common obsessions concern dirt, contamination, orderliness and dread of illness, while corresponding compulsions would be repeated hand-washings and checkings.