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Introduction to Psychiatry III

Luz S. Katigbak, MD
De La Salle University
College of Medicine
May 17, 2010
• Classification of Psychiatric Disorders
• Diagnostic Tree
• Multiaxial Diagnosis
• Psychiatric Signs and Symptoms
Classification in Psychiatry
• To distinguish one psychiatric diagnosis
from another
• To provide a common language among
health care professionals
• To explore the still unknown causes of
many mental disorders
Two Most Important
Systems of Classifications
• Diagnostic and Statistical Manual of
Mental Disorders (DSM) – by American
Psychiatric Association + mental health

• International Classification of Diseases

(ICD) – World Health Organization
Groups of Conditions in
• Disorders usually firs diagnosed in infancy,
childhood, or adolescence
• Delirium, dementia, amnestic, and other
cognitive disorders
• Mental disorders due to a general medical
• Substance-related disorders
• Schizophrenia and other psychotic disorders
• Mood disorders
• Anxiety disorders
• Somatoform disorders
• Factitious disorders
Groups of Conditions in
• Dissociative disorders
• Sexual and other gender identity disorders
• Eating disorders
• Sleep disorders
• Impulse-control disorders not elsewhere
• Adjustment disorders
• Personality disorders
• Other conditions that may be a focus of clinical
Diagnostic Tree
Psychiatric Diagnostic Tree

Neuro-Psychiatric Disorders
Primary Secondary
(Psychiatric/Functional) (Neurological/Organic)

Psychotic Non-Psychotic Psychotic Non-Psychotic

Thought D/O Neurotic Delirium Amnestic
Mood D/O Personality D/O Dementia Sleep
Substance Tic
PDD Psychosomatic
• No known structural damage or clear cut etiologic factors to
account for the disorder
1. Psychotic
– Impaired reality testing
– Impaired mental functioning
– Gross/severe impairment in social/occupational functioning
– Sever ego regression (i.e. poor hygiene)
a. Thought Disorders
1. Schizophrenia – > 6 months
2. Schizophreniform – < 6 months
3. Brief Psychotic Disorder – < 4 weeks
4. Delusional Disorder – non-bizarre
b. Mood/Affective Disorders
1. Major Depressive Disorder
2. Bipolar I
3. Bipolar II
2. Non-Psychotic 1. Oppositional Defiant
2. Conduct
– Intact reality testing
3. Abuse and Neglect
– With/without impairment 4. Reactive Attachment
in social/occupational 5. Selective Mutism
functioning 6. Gender Identity
– Distressing signs and 7. Factitious
symptoms recognized as 8. Dissociative
alien; unacceptable to 9. Feeding
self (i.e. ego-dystonic) 10. Eating
– Behavior does not 11. Elimination
actively violate gross 12. Sexual
social norms even if 13. Somatoform
disabling 14. Stereotypic Movement
15. Mood: Dysthymia,
16. Anxiety
17. Adjustment
2. Non-Psychotic
– Personality Disorders
• Inflexible and maladaptive traits  significant functional
impairment and subject distress
• Signs and symptoms are acceptable to self (i.e. ego-syntonic)
a. Odd, eccentric - Paranoid, Schizoid, Schizotypal
b. Dramatic – Antisocial, Borderline, Histrionic, Narcissistic
c. Anxious - Avoidant, Dependent, Obsessive-Compulsive,
Passive-Aggressive, Depressive, Sado-masochistic
1. Non-Psychotic
a. Psychosomatic – psychological factors leading to
medical illness; e.g. acne, asthma, allergies,
b. Amnestic D/O
c. Sleep D/O
d. Tic D/O
e. Developmental Disorders – MR, ADHD, Learning
D/O, Motor Skills D/O, Communication D/O
1. Psychotic
– Caused by a specific agent
– Structural + functional change in the brain
– Leads to cognitive impairment, particularly in
orientation, judgment and intellectual function
a. Global - delirium, pervasive developmental d/o
(PDD), mental retardation (MR), dementia
b. Specific - impairments associated with physical
condition – e.g. psychoactive substance abuse
Neurotic D/O Psychotic Personality
D/o D/O
Ego Functions Mild-mod impairment Severe impairment Mild-mod impairment
(+) reality testing (+) reality testing
(-) reality testing

Developmental Stage Later developmental Regression to very Later developmental

stages and danger early era of stages and danger
situations annihilation, situations
fragmentation ad

Onset Acute Acute Chronic

Attitude of patient Ego-alien, Variable Ego-syntonic

towards illness Ego-dystonic

Attitude Moderate concern Great concern; fear Annoyance; anger

Genetic and other Undetermined; Present in some Undetermined;

biological factors Possibly present in categories Possibly present in
some categories some categories
Multiaxial Assessment
Multiaxial Assessment
• Facilitates comprehensive and systematic
– Mental disorders
– General medical conditions
– Psychosocial and environmental problems
– Level of functioning
Multiaxial Assessment
• Provides a convenient format for
organizing and communicating clinical
• Capturing the complexity of clinical
• Describes the heterogeneity of individuals
• Promotes the biopsychosocial model in
clinical, educational, and research settings
Multiaxial Assessment
Axis I: Clinical Disorders
Other Conditions That may Be a Focus
of Clinical Attention
Axis II: Personality Disorders
Mental Retardation
Axis III: General Medical Conditions
Axis IV: Psychosocial and Environmental Problems
Axis V: Global Assessment of Functioning
Axis I
• Clinical Disorders
• Other Conditions That may Be a Focus
of Clinical Attention
• Except Personality Disorders and Mental
Axis II
• Personality Disorders
• Mental Retardation
• Prominent maladaptive personality
features and defense mechanisms
Axis III
• General Medical Conditions (GMC)
• Relevant to the understanding or management of mental
• Encourage thoroughness in evaluation
• Enhance communication among health care providers
Axis III
• Directly etiological? – physiological
– Axis I – Mental Disorder due to a GMC, e.g. Mood Disorder Due to
Hypothyroidism, With Depressive Features
– Axis III – Hypothyroidism

• Insufficiently clear?
– Axis I – Major Depressive Disorder
– Axis III – Hypertension

• Importance to the overall understanding or treatment of the

individual with the mental disorder
– Axis I – Psychological reaction to an Axis III GMC MC Adjustment
Disorder with depressed mood as a reaction to Breast Ca
– Axis I – Major Depressive Disorder; Axis III - Arrhythmia
Axis IV
• Psychosocial and Environmental Problems
• Development and exacerbation of mental disorder
• Assess stress as to
– Impact in patient’s life
– Change in patient’s life
– Degree of control the patient has over the stressor
– Degree of change desired by the patient
– Number of stressors
• Problems with primary support group
• Problems related to the social environment
• Educational problems
• Occupational problems
• Housing problems
• Economic problems
• Problems with access to health care services
• Problems related to interaction with the legal system/crime
• Other psychosocial and environmental problems
Axis V
• Global Assessment of Functioning
• Useful in planning treatment and measuring its impact,
and in prognosis
• Psychological, social, and occupational functioning
• Do not include impairment in functioning due to physical
or environmental limitations
• 100 points scale, 10-point range
• Two components: severity and functioning
• Patients who had a high level of functioning before an
episode of illness generally have a better prognosis than
those who had a low level of functioning
Psychiatric Signs and Symptoms
Nonspecific Psychiatric
Signs and Symptoms
• Sleep – insomnia, hypersomnia
• Appetite – anorexia, hyperphagia
• Anhedonia
• Obsession
• Compulsion
Mental Status Examination
• Appearance
• Overt Behavior
• Attitude
• Speech
• Mood
• Affect
• Thinking
– Form
– Content
• Perceptions
Mental Status Examination
• Sensorium
– Alertness
– Orientation
– Concentration
– Memory (immediate, recent, long term)
– Calculations
– Fund of knowledge
– Abstract reasoning
• Insight
• Judgment
Overt Behavior
agitation, bradykinesia, catatonic
excitement, catatonic posturing, catatonic
rigidity, catatonic stupor, cerea
flexibitas/waxy flexibility, hyperactive,
negativism, overactive,
circumstantiality, clang association,
tangentiality, confabulation, coprolalia,
derailment, echolalia, flight of ideas,
loosening of association, neologism,
verbigeration, phobia, posturing, poverty of
speech content, pressured speech, word
• anxious mood, depression, dysphoria,
elation, elevated mood, euphoria,
euthymia, excited, expansive mood,
irritable mood, la belle indifference, labile
• broad-ranged, full, constricted, restricted,
blunted, flat
• appropriate, inappropriate
Form of Thinking
• derailment, echolalia, illogical thinking, loosening of association,
neologism, perseveration, verbigeration, poverty of speech content,
pressured speech, blocking
Content of Thinking
• Concrete thinking, delusion of infidelity, persecution, poverty,
reference, thought broadcasting, self accusation, erotomania, guilt,
ideas of reference, illogical thinking, idea of reference, nihilism,
paranoid delusion, perseveration, verbigeration, phobia, posturing,
• Concrete thinking, confabulation, constricted affect, conversion
phenomena, coprophagia, coprolalia, delirium, delirium treemns,
delusion, infidelity, persecution, poverty, referenec, thought
broadcasting, slef accusatoion, dementia, denial, depression,
derailment, derealization, dsplacement, dysphoria, echolalia,
elation, elevaed mood, emotional insight, erotomania, euphoria,
euthymia, excited, expansive mood, externalization, flat affect, flight
of ideas, formication, fugue, guilt, halluciantion, hyperactive,
hypersomnia, hypnagogic, hypnopompic, ideas of reference,
illogical thinking, idea of refernec, illogoial thinking, illusion,
inappropriate affect, impaired, intelelctual insight, irritable mood, la
belle indiffernce, labile mood, lilliputian hallucination, loosening of
association, negativismneologism, nihilism, overactve, paranoid
delusion, perseveration, verrbigeration, phobia, posturing, poverty of
speech content, pressured speech, primary porcess thinking,
projection, psudodemntai, psudologica fantastica, psychotic,
rationalization, reaction formation
Thank you.