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