Psychosis, Mood, and Psychosis, Mood, and Personality: A Clinical Personality: A Clinical

PerspectivePerspectiveJohn R. Chamberlain, M.D.John R. Chamberlain, M.D.

Assistant Director,Assistant Director,Psychiatry and the Law ProgramPsychiatry and the Law Program

Assistant Clinical ProfessorAssistant Clinical ProfessorUniversity of California San University of California San

FranciscoFranciscoDepartment of PsychiatryDepartment of Psychiatry

Psychiatric DiagnosisPsychiatric DiagnosisPsychiatric disorders are syndromesPsychiatric disorders are syndromes

The underlying pathology (or pathologies) of The underlying pathology (or pathologies) of these disorders are not understoodthese disorders are not understood

The disorders are defined by the presence of The disorders are defined by the presence of a specified number of symptomsa specified number of symptoms

The combination of symptoms necessary to The combination of symptoms necessary to make a diagnosis are defined by a make a diagnosis are defined by a consensus of expertsconsensus of experts

Psychiatric DiagnosisPsychiatric DiagnosisMost disorders are further defined by a Most disorders are further defined by a

minimum duration of the symptomsminimum duration of the symptoms

To be considered a disorder the To be considered a disorder the symptoms must result in distress or symptoms must result in distress or impairmentimpairment

The symptoms must not be the result of The symptoms must not be the result of substance use (except for the substance use (except for the substance use disorders) or a general substance use disorders) or a general medical conditionmedical condition

Psychiatric DiagnosisPsychiatric DiagnosisMany psychiatric diagnoses and symptoms are Many psychiatric diagnoses and symptoms are

described with terms also used by non-described with terms also used by non-psychiatristspsychiatrists

This can result in confusion because the psychiatric This can result in confusion because the psychiatric meaning is often different or more specific than meaning is often different or more specific than the lay meaningthe lay meaning

Examples:Examples:Depression ≠ Sadness or the bluesDepression ≠ Sadness or the blues

Anxiety ≠ Worry or nervousnessAnxiety ≠ Worry or nervousness

Insane ≠ Mental IllnessInsane ≠ Mental Illness

Diagnostic AreasDiagnostic Areas

Mood DisordersMood Disorders

Anxiety DisordersAnxiety Disorders

Psychotic DisordersPsychotic Disorders

Cognitive DisordersCognitive Disorders

Substance Use DisordersSubstance Use Disorders

Somatoform DisordersSomatoform Disorders

Personality DisordersPersonality Disorders

Impulse Control DisordersImpulse Control Disorders

ParaphiliasParaphilias

Diagnostic AreasDiagnostic Areas

Mood DisordersMood Disorders Major DepressionMajor Depression Bipolar DisorderBipolar Disorder DysthymiaDysthymia CyclothymiaCyclothymia

Anxiety DisordersAnxiety Disorders Panic DisorderPanic Disorder Obsessive Compulsive DisorderObsessive Compulsive Disorder Posttraumatic Stress DisorderPosttraumatic Stress Disorder Generalized Anxiety DisorderGeneralized Anxiety Disorder Social Anxiety DisorderSocial Anxiety Disorder PhobiasPhobias

Diagnostic AreasDiagnostic Areas Psychotic DisordersPsychotic Disorders

SchizophreniaSchizophrenia Schizoaffective DisorderSchizoaffective Disorder Delusional DisorderDelusional Disorder

Substance Use DisordersSubstance Use Disorders Substance IntoxicationSubstance Intoxication Substance WithdrawalSubstance Withdrawal Substance AbuseSubstance Abuse Substance DependenceSubstance Dependence

Impulse Control DisordersImpulse Control Disorders Pathological GamblingPathological Gambling PyromaniaPyromania

Diagnostic AreasDiagnostic Areas

Personality DisordersPersonality Disorders AA

SchizoidSchizoid SchizotypalSchizotypal ParanoidParanoid

BB BorderlineBorderline AntisocialAntisocial HistrionicHistrionic NarcissisticNarcissistic

CC AvoidantAvoidant DependentDependent Obsessive CompulsiveObsessive Compulsive

Diagnostic AreasDiagnostic Areas

Cognitive DisordersCognitive Disorders DementiaDementia DeliriumDelirium

ParaphiliasParaphilias VoyeurismVoyeurism FroutterismFroutterism ExhibitionismExhibitionism PedophiliaPedophilia SadismSadism MasochismMasochism

Diagnostic AreasDiagnostic Areas

Somatoform DisordersSomatoform Disorders HypochondriasisHypochondriasis Somatization DisorderSomatization Disorder Pain DisorderPain Disorder Conversion DisorderConversion Disorder Body Dysmorphic DisorderBody Dysmorphic Disorder Undifferentiated Somatoform DisorderUndifferentiated Somatoform Disorder

AssessmentAssessmentClinical interview History

PsychiatricMedicalSocialFamilySubstance use

Mental status examination

Cognitive screen

AssessmentAssessment

Medical evaluation

Radiologic examination

Laboratory evaluation

EEG or other special testing

Review of collateral information

Psychological testing

SyndromesSyndromes

Mania Mania Three or more symptoms, present for one Three or more symptoms, present for one

week or moreweek or more Elevated, Expansive, or Irritable MoodElevated, Expansive, or Irritable Mood GrandiosityGrandiosity DistractibilityDistractibility Racing thoughtsRacing thoughts Pressured speechPressured speech Decreased need for sleepDecreased need for sleep Increased goal directed activityIncreased goal directed activity Increased participation in pleasurable activitiesIncreased participation in pleasurable activities

SyndromesSyndromes Major Depression Major Depression Five or more symptoms for two weeks or Five or more symptoms for two weeks or

moremore Depressed MoodDepressed Mood Anhedonia (loss of enjoyment in usual activities)Anhedonia (loss of enjoyment in usual activities) Suicidal thoughts (not just thoughts of death)Suicidal thoughts (not just thoughts of death) Decreased energyDecreased energy Altered sleep (increased or decreased)Altered sleep (increased or decreased) Altered appetite (increased or decreased)Altered appetite (increased or decreased) Decreased concentrationDecreased concentration Psychomotor agitation or retardationPsychomotor agitation or retardation Decreased self-esteem, excessive guiltDecreased self-esteem, excessive guilt

SyndromesSyndromes Posttraumatic Stress DisorderPosttraumatic Stress Disorder

Experience of a severe stressor—typically Experience of a severe stressor—typically a threat to one’s life (or bodily integrity) a threat to one’s life (or bodily integrity) or the life (or bodily integrity) of someone or the life (or bodily integrity) of someone nearbynearby

Recurrent re-experience of the traumaRecurrent re-experience of the trauma

Persistent increased arousalPersistent increased arousal

Altered emotional statusAltered emotional status

SyndromesSyndromes

SchizophreniaSchizophrenia Symptoms are present for six months Symptoms are present for six months

or moreor more HallucinationsHallucinations DelusionsDelusions Disorganized speechDisorganized speech Disorganized or catatonic behaviorDisorganized or catatonic behavior Negative symptomsNegative symptoms

SyndromesSyndromes

Schizoaffective DisorderSchizoaffective Disorder Symptoms of schizophreniaSymptoms of schizophrenia

Presence of mood symptoms for Presence of mood symptoms for essentially the entire time of the disorderessentially the entire time of the disorder

Must have at least one period of two Must have at least one period of two weeks with only psychotic symptomsweeks with only psychotic symptoms

No periods of mood symptoms without No periods of mood symptoms without psychosispsychosis

SyndromesSyndromes

Delusional DisorderDelusional Disorder Encapsulated, non-bizarre delusionsEncapsulated, non-bizarre delusions

The delusions are possible although the The delusions are possible although the evidence is against themevidence is against them

Multiple sub-typesMultiple sub-types

PersecutoryPersecutory

GrandioseGrandiose

Erotomanic Erotomanic

SyndromesSyndromes

Substance Use DisordersSubstance Use Disorders AbuseAbuse

Maladaptive pattern of use of a substanceMaladaptive pattern of use of a substance Recurrent use resulting in failure to fulfill major Recurrent use resulting in failure to fulfill major

obligations at work, school, homeobligations at work, school, home Recurrent use in situations in which it is Recurrent use in situations in which it is

physically hazardousphysically hazardous Recurrent legal problemsRecurrent legal problems Continued use despite social or interpersonal Continued use despite social or interpersonal

problems caused or exacerbated by the effects problems caused or exacerbated by the effects of the substanceof the substance

SyndromesSyndromes

Substance Use DisordersSubstance Use Disorders DependenceDependence

Maladaptive pattern of use of a substance Maladaptive pattern of use of a substance ToleranceTolerance WithdrawalWithdrawal Use in larger amounts or for longer than intendedUse in larger amounts or for longer than intended Persistent desire or unsuccessful efforts to decrease Persistent desire or unsuccessful efforts to decrease

useuse Important activities are given up or reducedImportant activities are given up or reduced Persistent use despite knowledge of physical or Persistent use despite knowledge of physical or

psychiatric problems related to usepsychiatric problems related to use Great deal of time is spent in activities necessary to Great deal of time is spent in activities necessary to

obtain, use, or recover from the effects of the obtain, use, or recover from the effects of the substancesubstance

SyndromesSyndromesPersonality DisordersPersonality Disorders

This term refers to a group of disorders characterized This term refers to a group of disorders characterized by longstanding maladaptive patterns of perceiving, by longstanding maladaptive patterns of perceiving, experiencing, and interacting with the environment, experiencing, and interacting with the environment, other people, and one’s own emotionsother people, and one’s own emotions

The disorders are placed into three clusters—A, B, and The disorders are placed into three clusters—A, B, and CC

Some of these disorders appear to be related to other Some of these disorders appear to be related to other psychiatric conditions (e.g. mood, anxiety, and psychiatric conditions (e.g. mood, anxiety, and psychotic disorders)psychotic disorders)

For example, avoidant personality disorder has many For example, avoidant personality disorder has many features in common with social anxiety disorderfeatures in common with social anxiety disorder

SyndromesSyndromesPersonality DisordersPersonality Disorders

Some of the personality disorders are found Some of the personality disorders are found at a greater than expected frequency in at a greater than expected frequency in families with other psychiatric conditionsfamilies with other psychiatric conditions

As a result it is thought these disorders reside As a result it is thought these disorders reside on a continuum with one anotheron a continuum with one another

For example, schizotypal personality disorder For example, schizotypal personality disorder is found more often in families of individuals is found more often in families of individuals with schizophrenia than in the general with schizophrenia than in the general populationpopulation

SyndromesSyndromesPersonality DisordersPersonality Disorders

In other cases the similarity between personality In other cases the similarity between personality disorders and other psychiatric disorders is in name disorders and other psychiatric disorders is in name onlyonly

In these cases the similar names imply an association In these cases the similar names imply an association that is not seen in the clinical presentation or in the that is not seen in the clinical presentation or in the epidemiologyepidemiology

This can lead to confusion for clinicians, students, and This can lead to confusion for clinicians, students, and patientspatients

For example, obsessive-compulsive personality For example, obsessive-compulsive personality disorder and obsessive-compulsive disorder have disorder and obsessive-compulsive disorder have little in common other than their nameslittle in common other than their names

TreatmentTreatmentJust as the underlying pathology of psychiatric Just as the underlying pathology of psychiatric

disorders is not understood, the mechanisms disorders is not understood, the mechanisms by which treatment for these conditions work by which treatment for these conditions work are unclearare unclear

The biopsychosocial model is currently popular The biopsychosocial model is currently popular and stresses the importance of viewing and and stresses the importance of viewing and treating psychiatric disorders as being treating psychiatric disorders as being comprised of biological, social, and comprised of biological, social, and psychological factorspsychological factors

Treatments can be divided into psychotherapy Treatments can be divided into psychotherapy (i.e. talk therapy and somatic therapy (i.e. (i.e. talk therapy and somatic therapy (i.e. medications, electroconvulsive therapy)medications, electroconvulsive therapy)

TreatmentTreatment

MedicationsMedications

AntidepressantsAntidepressants

AnxiolyticsAnxiolytics

Mood stabilizersMood stabilizers

AntipsychoticsAntipsychotics

TreatmentTreatment

CBT (cognitive behavioral psychotherapy) focuses on CBT (cognitive behavioral psychotherapy) focuses on identifying and changing negative styles of thinking identifying and changing negative styles of thinking and behavingand behaving

Can be conducted in either individual or group settingsCan be conducted in either individual or group settings

Focused on the present Focused on the present

Is brief—utilizing twelve to sixteen sessions on a once a Is brief—utilizing twelve to sixteen sessions on a once a week basisweek basis

Requires the patient to practice skills between sessionsRequires the patient to practice skills between sessions

TreatmentTreatment

IPT (interpersonal psychotherapy) focuses on identifying IPT (interpersonal psychotherapy) focuses on identifying and working through disturbed personal relationships and working through disturbed personal relationships that may contribute to the symptoms of depressionthat may contribute to the symptoms of depression

Focused on the present Focused on the present

Is brief—utilizing twelve to sixteen sessions on a once a Is brief—utilizing twelve to sixteen sessions on a once a week basisweek basis

Requires the patient to practice skills between sessionsRequires the patient to practice skills between sessions