Classification and Management of Psychiatric Disorders

CLASSIFICATION AND MANAGEMENT OF PSYCHIATRIC DISORDERS

UNIT OBJECTIVE

• Apply knowledge and skills of managing psychiatric disorder.

SPECIFIC OBJECTIVES

• At the end of this unit, you should be able to:
    - Describe the management of a patient with neurotic disorders.
    - Demonstrate the skills of managing a patient with psychosis.
    - Apply knowledge and skill of managing a patient with personality disorder.

NEUROSIS

Definition

• Neurosis is a class of functional mental disorders characterized by:
    - Distress without delusions or hallucinations.
• Also referred to as psychoneurosis or neurotic disorder.

Examples of Neuroses

1. Anxiety Neurosis
2. Obsessive Compulsive Neurosis
3. Hysterical Neurosis

ANXIETY

Definition

• Anxiety is described as:
    - A state of apprehension, uncertainty, or tension resulting from the anticipation of an imagined or unreal threat.

Causes of Neurotic Disorders (e.g., Anxiety)

• Possible causes include:
    1. Emotional conflict.
    2. Maladjustment to life situations.
    3. Genetic and constitutional factors.

Continuum of Anxiety

• Anxiety ranges from:
    - Mild → Moderate → Severe → Panic state.
• Panic state is the most extreme form, where:
    - The individual is completely frozen.
    - Self-awareness is absent.
    - Functioning requires assistance and may include hallucinations.

GENERAL FEATURES OF ANXIETY

• Physical symptoms can include:
    - Shortness of breath.
    - Choking sensation.
    - Palpitations and accelerated heart rate.
    - Chest discomfort or pain.
    - Sweating.
    - Dizziness, feeling faint.
    - Nausea or abdominal distress.
    - Depersonalization or derealization.
    - Numbness or tingling sensation.
    - Flushes or chills.
    - Trembling or shaking.
    - Fear of dying.
    - Fear of losing control.

Case Study

• Patient presents with dental problem and anxiety.

MANAGEMENT OF ANXIETY

1. Benzodiazepines:
      - Effective for controlling panic attacks when administered in high doses (e.g., Diazepam).
2. Antidepressants:
      - Such as Imipramine, also effective in controlling panic attacks.
3. Controlled Breathing:
      - Useful for patients who hyperventilate; practice of controlled breathing under supervision.
4. Diet:
      - Suggest a caffeine-free diet to avoid exacerbation of symptoms.

OBSESSIVE COMPULSIVE NEUROSIS

Definition

• Obsessive Compulsive Disorder (OCD) characterized by:
    - Obsessional thinking, compulsive behavior, and varying degrees of anxiety, depression, and depersonalization.

Etiology

• Contributing factors to OCD include:
    1. Genetic factors.
    2. Evidence of brain disorder.
    3. Abnormal serotonergic function.
    4. Excessive demands during early intensive toilet training.

Main Clinical Features

1. Obsessional Rituals:
      - Patients perform tasks in a particular order or number of times (e.g., putting on socks starting with the left foot).
2. Obsessional Doubts:
      - Patients may second-guess themselves (e.g., revisiting to check a closed door).
3. Obsessional Rumination:
      - Internal debates on simple everyday actions reviewed endlessly.
4. Obsessional Phobias:
      - Fear of harming oneself or others (e.g., fear of knives).

Diagnosis

• Diagnosis of OCD necessitates:
    - Recognition that the feeling, thought, or action is irrational and experienced with subjective compulsion.
    - Attempts to resist lead to increased tension or anxiety.

Differentials and Management

• Differential diagnoses can include:
    - Generalized Anxiety Disorder (GAD), panic disorder, phobic disorder, depressive disorders, schizophrenia, organic cerebral disorders.
• Management Strategies:
    - Counseling, pharmacotherapy with anxiolytic drugs and tricyclic antidepressants, behavior therapy (exposure to cues) and psychotherapy.

CONVERSION AND DISSOCIATIVE DISORDERS

Definition

• Previously known as hysteria; these disorders involve physical symptoms without associated physical pathology and are of psychological origin.
    - Hypothesized that symptoms help patients avoid unbearable anxiety resulting in primary gain.

Epidemiology

• More common in females than males; tend to start before age 35.

Types of Dissociative Disorders

1. Dissociative Amnesia:
      - Inability to recall significant periods of life; may deny knowledge of personal identity.
2. Dissociative Fugue:
      - Patients wander away from usual surroundings, may deny knowledge of their whereabouts.
3. Dissociative Stupor:
      - Characterized by motionlessness, mutism, and awareness of surroundings.
4. Ganser Syndrome:
      - Patient provides approximate answers to questions (e.g., answering 2+2=5).

Conversion Disorder

• Symptoms mimic physical illness, classified as:
    - With Motor Symptoms or Deficits:
      - Includes psychogenic paralysis, gait disorder, tremors, dysphonia, mutism.
    - With Sensory Symptoms or Deficits:
      - Includes anesthesia, parathesia, hyperaesthesia, pain, deafness, blindness.
    - With Seizures and Convulsions:
      - Differentiation from epilepsy can be made as follows:
        1. Patient remains conscious, may be inaccessible.
        2. The movement pattern is not regular.
        3. Absence of incontinence, cyanosis, injury from biting the tongue.

Epidemic Hysteria

• Occasionally, conversion disorders spread within a group, often in closed groups (e.g., girls' schools).
• Symptoms can include fainting, dizziness.

Management of Epidemic Hysteria

• Counseling, closing the institution, appropriate investigations to rule out physical causes, treat any anxiety.

REACTIVE DEPRESSION

Definition

• Depression is a mood disorder with lowered mood and vitality causing distress.
• Reactive depression is also called exogenous depression due to external causes.

Etiology

• Caused by traumatic events such as:
    - Bereavement, failing an important exam, loss of property, chronic illness.

Clinical Features

• Symptoms include:
    - Loss of appetite, insomnia, mutism, loss of libido, neglect of hygiene, avoidance of social contacts, extreme sadness, crying spells, psychomotor retardation, suicidal thoughts, poor concentration.

Management

• Psychotherapy is the preferred treatment. Monitor closely for suicidal ideation.

PSYCHOSIS

Definition

• Psychosis involves significant impairment of mental functioning.
• Characterized by:
    - Severe affective disturbances, profound introspection, withdrawal from reality, inability to evaluate external reality, formation of delusions or hallucinations, and personality disintegration.

Affective Disorders

MANIA

• Defined as:
    - An affective disorder with elevated mood and increased psychomotor activity. Hypomania is a mild form.

Etiology

• The cause of mania is largely unknown.

Clinical Features of Mania

• Includes:
    - Grandiosity, pressurized speech, flight of ideas, increased activity, and impulsivity with possibly harmful consequences (e.g., spending sprees, substance use).

Management of Mania

1. Antipsychotics:
      - E.g., Haloperidol.
2. Electroconvulsive Therapy (ECT):
      - Can be beneficial.
3. Ensure proper hydration and nutrition:
      - Monitor for risks of dehydration and starvation.

PSYCHOTIC DEPRESSION

Definition

• Also known as endogenous depression; requires specialized care due to psychotic features.

Clinical Features

• Common symptoms:
    - Psychomotor retardation, lack of response to humor, significant weight loss, insomnia, feelings of worthlessness, suicidal ideation.

Management

• Antidepressants (e.g., Imipramine, Amitriptyline) and ECT alongside psychotherapy and behavioral therapy.

SCHIZOPHRENIA

Definition

• Psychiatric syndrome characterized by disintegration of personality and impaired functioning across various domains, leading to distorted thinking, emotional disturbance, and motor behavior.

Subtypes of Schizophrenia

1. Simple Schizophrenia:
      - Onset in adolescence marked by apathy, social withdrawal, poor performance; few clear schizophrenic symptoms.
2. Hebephrenic Schizophrenia:
      - Onset in late adolescence with silliness, unusual affect, and thought disorder; often includes delusions and hallucinations.
3. Catatonic Schizophrenia:
      - Late onset with severe motor symptoms fluctuating between stupor and excitement.
4. Paranoid Schizophrenia:
      - Onset in middle adulthood with paranoid delusions and auditory hallucinations; personality remains better integrated.
5. Residual Schizophrenia:
      - Long-term state post-psychotic episodes; symptoms include social withdrawal and flattened affect.

Diagnosis of Schizophrenia

• Based on Schneider’s first rank symptoms including:
    1. Thought withdrawal.
    2. Thought insertion.
    3. Thought broadcasting.
    4. Echoing thoughts.
    5. Hallucinations discussing the individual in third person.
    6. Feelings of passivity or external control of thoughts and behavior.

Management of Schizophrenia

• Hospitalization is required for the first episodes and acute relapses.
• Use of neuroleptics is common; options can be:
    - Chlorpromazine, Thioridazine, Trifluoperazine, Fluphenazine, Haloperidol, etc.
• Monitor dosage during treatment: baseline and maximum dosages vary per drug.

Additional Management Approaches

• ECT indicated for severe depressive symptoms and unresponsive cases.
• Psychotherapy: suitable for motivated patients, including:
    - Psychoanalytic therapy, group therapy (less effective in acute stages), supportive therapy for resettling patients, behavioral treatment, and cognitive therapy focusing on correcting misperceptions and misbehaviors.

Dosages of Antipsychotic Drugs

(Table documenting the relative dose and maximum dose for various antipsychotic medications follows.)