Psychosis, Mood, and Personality: A Clinical Perspective John R. Chamberlain, M.D. Assistant Director, Psychiatry and the Law Program Assistant Clinical Professor University of California San Francisco Department of Psychiatry

Psychiatric Diagnosis Psychiatric disorders are syndromes The underlying pathology (or pathologies) of these disorders are not understood The disorders are defined by the presence of a specified number of symptoms The combination of symptoms necessary to make a diagnosis are defined by a consensus of experts

Psychiatric Diagnosis Most disorders are further defined by a minimum duration of the symptoms To be considered a disorder the symptoms must result in distress or impairment The symptoms must not be the result of substance use (except for the substance use disorders) or a general medical condition

Psychiatric Diagnosis Many psychiatric diagnoses and symptoms are described with terms also used by non-psychiatrists This can result in confusion because the psychiatric meaning is often different or more specific than the lay meaning Examples: Depression ≠ Sadness or the blues Anxiety ≠ Worry or nervousness Insane ≠ Mental Illness

Diagnostic Areas  Mood Disorders  Anxiety Disorders  Psychotic Disorders  Cognitive Disorders  Substance Use Disorders  Somatoform Disorders  Personality Disorders  Impulse Control Disorders  Paraphilias

Diagnostic Areas  Mood Disorders  Major Depression  Bipolar Disorder  Dysthymia  Cyclothymia  Anxiety Disorders  Panic Disorder  Obsessive Compulsive Disorder  Posttraumatic Stress Disorder  Generalized Anxiety Disorder  Social Anxiety Disorder  Phobias

Diagnostic Areas  Psychotic Disorders  Schizophrenia  Schizoaffective Disorder  Delusional Disorder  Substance Use Disorders  Substance Intoxication  Substance Withdrawal  Substance Abuse  Substance Dependence  Impulse Control Disorders  Pathological Gambling  Pyromania

Diagnostic Areas  Personality Disorders AAAA  Schizoid  Schizotypal  Paranoid BBBB  Borderline  Antisocial  Histrionic  Narcissistic CCCC  Avoidant  Dependent  Obsessive Compulsive

Diagnostic Areas  Cognitive Disorders  Dementia  Delirium  Paraphilias  Voyeurism  Froutterism  Exhibitionism  Pedophilia  Sadism  Masochism

Diagnostic Areas  Somatoform Disorders  Hypochondriasis  Somatization Disorder  Pain Disorder  Conversion Disorder  Body Dysmorphic Disorder  Undifferentiated Somatoform Disorder

Assessment Clinical interview  History  Psychiatric  Medical  Social  Family  Substance use  Mental status examination  Cognitive screen

Assessment Medical evaluation Radiologic examination Laboratory evaluation EEG or other special testing Review of collateral information Psychological testing

Syndromes  Mania  Three or more symptoms, present for one week or more  Elevated, Expansive, or Irritable Mood  Grandiosity  Distractibility  Racing thoughts  Pressured speech  Decreased need for sleep  Increased goal directed activity  Increased participation in pleasurable activities

Syndromes  Major Depression  Five or more symptoms for two weeks or more  Depressed Mood  Anhedonia (loss of enjoyment in usual activities)  Suicidal thoughts (not just thoughts of death)  Decreased energy  Altered sleep (increased or decreased)  Altered appetite (increased or decreased)  Decreased concentration  Psychomotor agitation or retardation  Decreased self-esteem, excessive guilt

Syndromes  Posttraumatic Stress Disorder  Experience of a severe stressor—typically a threat to one’s life (or bodily integrity) or the life (or bodily integrity) of someone nearby  Recurrent re-experience of the trauma  Persistent increased arousal  Altered emotional status

Syndromes  Schizophrenia  Symptoms are present for six months or more  Hallucinations  Delusions  Disorganized speech  Disorganized or catatonic behavior  Negative symptoms

Syndromes  Schizoaffective Disorder  Symptoms of schizophrenia  Presence of mood symptoms for essentially the entire time of the disorder  Must have at least one period of two weeks with only psychotic symptoms  No periods of mood symptoms without psychosis

Syndromes  Delusional Disorder  Encapsulated, non-bizarre delusions  The delusions are possible although the evidence is against them  Multiple sub-types  Persecutory  Grandiose  Erotomanic

Syndromes Substance Use Disorders  Abuse  Maladaptive pattern of use of a substance  Recurrent use resulting in failure to fulfill major obligations at work, school, home  Recurrent use in situations in which it is physically hazardous  Recurrent legal problems  Continued use despite social or interpersonal problems caused or exacerbated by the effects of the substance

Syndromes Substance Use Disorders  Dependence  Maladaptive pattern of use of a substance  Tolerance  Withdrawal  Use in larger amounts or for longer than intended  Persistent desire or unsuccessful efforts to decrease use  Important activities are given up or reduced  Persistent use despite knowledge of physical or psychiatric problems related to use  Great deal of time is spent in activities necessary to obtain, use, or recover from the effects of the substance

Syndromes Personality Disorders This term refers to a group of disorders characterized by longstanding maladaptive patterns of perceiving, experiencing, and interacting with the environment, other people, and one’s own emotions The disorders are placed into three clusters—A, B, and C Some of these disorders appear to be related to other psychiatric conditions (e.g. mood, anxiety, and psychotic disorders) For example, avoidant personality disorder has many features in common with social anxiety disorder

Syndromes Personality Disorders Some of the personality disorders are found at a greater than expected frequency in families with other psychiatric conditions As a result it is thought these disorders reside on a continuum with one another For example, schizotypal personality disorder is found more often in families of individuals with schizophrenia than in the general population

Syndromes Personality Disorders In other cases the similarity between personality disorders and other psychiatric disorders is in name only In these cases the similar names imply an association that is not seen in the clinical presentation or in the epidemiology This can lead to confusion for clinicians, students, and patients For example, obsessive-compulsive personality disorder and obsessive-compulsive disorder have little in common other than their names

Treatment Just as the underlying pathology of psychiatric disorders is not understood, the mechanisms by which treatment for these conditions work are unclear The biopsychosocial model is currently popular and stresses the importance of viewing and treating psychiatric disorders as being comprised of biological, social, and psychological factors Treatments can be divided into psychotherapy (i.e. talk therapy and somatic therapy (i.e. medications, electroconvulsive therapy)

Treatment Medications  Antidepressants  Anxiolytics  Mood stabilizers  Antipsychotics

Treatment CBT (cognitive behavioral psychotherapy) focuses on identifying and changing negative styles of thinking and behaving Can be conducted in either individual or group settings Focused on the present Is brief—utilizing twelve to sixteen sessions on a once a week basis Requires the patient to practice skills between sessions

Treatment IPT (interpersonal psychotherapy) focuses on identifying and working through disturbed personal relationships that may contribute to the symptoms of depression Focused on the present Is brief—utilizing twelve to sixteen sessions on a once a week basis Requires the patient to practice skills between sessions