PSY 2016-1 - Abnormal Psychology and Psychiatry 2017 - 2018
Professor Bruce G Charlton
Professor Bruce G Charlton
Feb 19 2018
- Introduction to Psychiatric disorders
- Features of psychosis
- Sedatives/ hypnotics
- Neuroleptics/ Antipsychotics
- Mania & Bipolar Disorder
- Mood stabilizers
- Depression (Melancholia)
- Electroconvulsive Therapy
- Tricyclic Antidepressants
- Anxiety states and personality traits
- Panic, Phobias, PTSD, OCD
What I try to do in lectures – an event, close attention, minimum distraction – but breaks so this can be maintained.Please do ask questions, and have class discussions – but note questions down, and wait until I ask for questions – after I have finished explanations.Lecture notes - not handoutsAdvise not to use laptops in class unless you have a specific reason for doing so – e.g. handwriting (sit in the back row)Assigned reading as we go – online referencesAttendance - Very Important - No ReCap – can record personally if your wish.If miss, your responsibility to find out from other students what was taught, or e-mail me with xplanation.But probably best not to do this course if you cannot or do not intend to attend the great majority of sessions.Punctuality - Start at 5 past the hour. Each session split with breaksCore texts:
- Psychiatric Drugs Explained – David Healy
- Plus specific reference online – given for each lectureWhat is psychiatry?Medicine - psychological causes, signs, symptoms, treatmentsConc on ill health - qv psychologyMainly therapeutic and human orientatedWho are psychiatrists?Who are clinical psychologists?How do people get to see psych/psychols?What kind of people become psychiatric patients?What do psych/psychols actually do?New areas of psychiatryLifestyle management eg sexual function, effectiveness at work, sleep problems etc.Cognitive enhancement - ‘smart drugs’.New problems in Psychiatry
- Invention of new diagnoses to sell drugs/ create work
- Widening of diagnostic categories to sell drugs/ create work
- Widening drug indications from where they are overall effective to where they overall do more harm than good – e.g. SSRI antidepressants.
- Widening drug use to new groups – eg antidepressants and antipsychotics in children and young teenagers
- Increase in psych problems caused by psych drugs – side effects, dependence (‘Iatrogenic’ problems)
NATURE OF PSYCHIATRIC ILLNESS
What is it? No clear answer - a collection of problems united by history
- Historical - public health function wrt behavior– ‘safety’, asylum -
- ‘Suffering’ psychological symptoms – majority are milder/ functional (but mania, dementia)
- Pathological brain process - but not always diagnosable - usually presumed rather than proven. Definite brain diseases ‘organic’ often treated by physicians - neurologists or geriatricians
- Of exclusions - no physical disease can be found eg. hysteria
- Psychopathology - disturbance in basic psychological function - concentrations or memory - hallucinations or thought disorder.
- Social deviance and control - crime, psychopaths, USSR schiz.
- Evolutionary perspective – fitness-reducing problems of social functioning
PSYCHOSIS – In hospital unable to function or suicide risk; qualitative abnormality; lack insight - signs (‘inside’ the disorder) – schizophrenia, mania, psychotic/ endogenous depression…
NEUROSIS – Outside hospital, GP, at work; quantitative exaggeration of normal symptoms – anxiety, obsessive ruminations, misery/ depression, hypochondria, fatigue…
NOTE: Psychological treatments (NOT in this course)
Drugs – six main types
- Hypnotics/ Sedatives
- Neuroleptics/ Antipsychotics
- Mood stabilizers - lithium
ECT – electroconvulsive therapy
PSY 2016-2 Abno Psych and Psychiatry – 2017-2018
Bruce G Charlton
Psychotic features: Hallucinations, Delusions and Thought Disorder
Reference: Mellar CS, First rank symptoms of schiz. BJ Psych 1970; 117: 15-23
Search youTube ‘schizophrenia’ ‘gerald’ https://www.youtube.com/watch?v=gGnl8dqEoPQ
Sensory perception when there is no real object to perceive - a false perception (NOT a distortion of a real perception or a misinterpretation).
Halluc appears to the patient as a normal sensory experience, indistinguishable from real.
Occur in: Schizophrenia, Mania, Psychotic depression, Brain disease, dysfunction, some drugs.
Also (normal) Hypnagogic (going to sleep) and hypnopompic (waking-up) hallucinations. Some studies have shown high prevalence of hallucinations – around 10% population?
Any sensory modality - hearing, vision, touch, taste, smell.
- Bodily sensations (being touched, fluid inside – maybe a fluid level, formication)
- Delusions of smell or taste - eg smell/ taste poison or taste a poison, or depressive (rotting, disgusting smell etc). eg. led to suicide, or avoidance.
- Visual hallucinations - usually assoc with brain disease
- Delirium – from general disease (eg infection with temperature) – e.g. dust falling through air. Delirium tremens –snakes and elephants.
- Hallucinogenic drugs – lights, colours, shapes, or complex scenes.
- Auditory hallucinations – hearing voices when nobody is there. A classic sign of madness. With mania and psychotic depression hallucinations are Mood Congruent
Delusion = A false belief – that is an idea (not a perception)
- False, unshakeable and dominating belief – feels true and usually evokes emotional response and action
- Out of keeping with personal and cultural background
- No insight – only ‘diagnosed’ by other peopleEg. A primary delusion Not caused by hallucination: Light turned green and I knew I was the son of God.Many delusions are secondary to hallucinations – i.e. false beliefs to ‘explain’ hallucinations – hallucinated sensation in skin explained in terms of insects crawling under the skin.A persecutory delusion: Middle-aged unmarried woman believed that men unlock doors of her home, anaesthetize, sexually interfere with her. Meanwhile police using rays to keep her under surveillance.Delusions in mania and psychotic depression are mood congruent – eg depressed patient guilty of a serious crime, a manic patient is a god.Thought Disorder (TD)Subjectively – thought disorder refers to the subject’s report of their thinking processes which they perceive as abnormal – this relies on introspection and the subject’s ability to describe this.Thought disorder is also associated with observed behavioural abnormalities – mainly of speech, sometimes of movements, facial expressions presumably indicate thought processes.TD is similar to what happens in dreams – cannot follow a line of reasoning, bizarre things seem plausible, strange twists and turns of dreaming.
- Psychotic Depression – Retardation. Part of ‘psychomotor retardation’.
- Accelerated thinking/ Flight of ideas – mania. Pressure of speech. Makes sense, but thought is experienced as rapid, ideas follow in quick succession and direction of thought determined by chance associations, distractions and ‘clang’ associations.“they thought I was in the pantry at home – peekaboo – there’s a magic box – poor darling Catherine - you know, Catherine the great – the fire grate – I’m always up the chimney – I want to scream with joy – halleluiah!”
- Schizophrenia: Thought-blocking –. Thought and speech suddenly stop in the middle of a theme or mid-sentence – and a new and unconnected subject takes over. May be described as thought-withdrawal (a delusional explanation – a Schneiderian first rank symptom). Or thoughts can be derailedConcrete thinking – schizophrenia.Acts out literal meaning of words - Shoes off – why?‘I like to keep my feet on the ground’,Walking sideways – due to drug ‘side’-effectsPSY 2016-3 – Abno. Psychol. and Psychiatry – 2017-18Bruce CharltonCatatoniaM. Fink, MA Taylor. Catatonia: Subtype or Syndrome in DSM? Am J Psychiatry 2006; 163: 1875-1876YouTube – search and watch Symptoms of Schizophrenia (1940) Lasts 13.08 minutes. Note – the masks are to preserve anonymity.CatatoniaUsed to be wrongly regarded as a subtype of schizophrenia.Not a disorder/ disease, but a group of abnormal movements (motor features) that can be regarded as a type of psychopathology (like hallucinations or delusions).Usually found with other psychotic disorders – but catatonia needs to be regarded separately because:1. Requires specific treatment.2. Is made worse by some common treatments for psychoses especially antipsychotics, and3. With the proper treatment is usually completely and rapidly curable.Catatonia can occur in several psychiatric disorders esp affective disorders – mania, melancholia/ psychotic depression, schizophrenia. Also, after brain infections such as syphilis or encephalitis lethargica.Catatonia can also be a drug side effect e.g.:Dopamine-blocking drugs – e.g. antipsychotics.SSRIs – indirectly dopamine-blockingWithdrawal of L-dopaCatatonic features:Patient may go through phases displaying various of these signs
- Immobility, Rigidity-statue, Waxy flexibility
- Mutism, verbally unresponsive – may still move etc – Stupor – generally unresponsive, may not visibly respond to pain, but may later remember.
- Catalepsy = posturing – upper and lower body at right angles/ arms above head/ psychological pillow
- Mannerisms – saluting, caricatured normal movements - hands and fingers oddly.
- Interaction with people: Copying/ Echoing movements and speech. Or Negativism – physical resistance, psychological negativism.
- Meaningless, unprovoked excitement, violence, talking/ singing/ undressingAbout 10 percent of emergency psychiatric admissions have catatonia – usually mild - about 0.1 percent (one in a thousand) prevalence in population.Untreated catatonia could be rapidly fatal, usually lasts months- year-plus, sometimes catatonia was permanent.Should treat as early as possible.Cause: ? How psychiatric phenomena/ brain altering drugs may cause movement disorder.Similar to Tonic Immobility – imminent predationResponse to extreme, inescapable, unlocalisable anxiety.Treatment of catatonia
- High dose benzodiazepines eg lorazepam
- Most powerful treatment ECT – electroconvulsive therapy / electroshockNote – it is important to diagnose C. because it may happen in schizophrenia or mania, but is made worse by neuroleptics/ antipsychotics. May provoke the neuroleptic malignant syndromeAntipsychotics are given to many patients with ‘psychotic’ symptoms such as hallucinations and delusions, but usually worsen catatonia and may cause it – this can be fatal - Neuroleptic Malignant SyndromeSerotonin-enhancing drugs e.g. SSRIs. Serotonin syndrome.PSY 2016 – 4 Abnormal Psychol and Psychiatry 2017-18Bruce G CharltonSchizophreniaMA Taylor et al. The failure of the schizophrenia concept… Acta Psychiatrica Scandinavica 2012; 122: 173-83]SchizophreniaThe classic form of ‘madness’.Usually stated to be about 1% of population everywhere – but nature, prevalence and prognosis does vary by time and place.May have originated in 1700s, became common through the 1800s equal incidence in men and women; seems to be getting rarer over recent years and becoming mainly a Male disorder.Schizophrenia is not one ‘disease’ with one cause – it is a collection of several diseases with – probably – several causes - that produce broadly characteristic symptoms, and have different outcomes.Clinical features – characteristic symptomsUsually post-puberty, insidious onset late teens early twenties, both sexes.Poor prognosis/ outcome, the patient never returning fully to normal – if persists more than six months.(But brief psychotic episodes may be the clinically identical to schizophrenia in terms of psychotic features – yet improve in days and the patient returns to normal and many never have another episode.)In general un-understandability – perplexed mood, not serve any purpose. No insight into condition.HebephreniaCore schizophrenia is Hebephrenia/ Disorganized subtype – original and most characteristic schizophrenia syndrome.Dominated by thought-disorder – Disorganized speech, subjective experiences of abnormal thought processes.Fatuous affect/ emotions, silly facial expressions, progresses to apathy and indifferenceAlso hallucinations – typically hearing voices, and delusions – often of paranoid ‘self-reference’.‘Pane of glass’ – lack of empathic contact‘Paranoid Schizophrenia’ is much comment diagnosis dominated by hallucinations and delusions. May be almost the same as manic-depressive disorder ‘Bipolar Type 1’? “Negative symptoms” – these are usually a side effect of antipsychotics =
- Affective flattening/ blunted emotions;
- Avolia reduced drive/ motivation;
- Alogia = ‘poverty’ of thought, and little speech;
- Anhedonia – inability to feel pleasure
Distinctive ‘Schneiderian’ First Rank symptoms – Hallucinations and Delusions
Specific types of auditory hallucinations – spoken thoughts, arguing, running commentary
A period of perplexity, paranoid suspiciousness about ‘something going-on’ - The primary delusion is regarded as the explanation.
Secondary delusions to explain thought disorder
Broadcasting of thought & insertion of thought – delusions which explain the experience of thought disorder. Controlled thoughts and movements - delusions which explain the experience of thought disorder
Duration of at least 6 months before diagnosis – to diff from mania in type I bipolar disorder and Brief Psychotic Disorder – episode less than a month with complete recovery.
When schiz. Is chronic, usually progressive with relapses and remissions. The longer it goes on, the worse the prognosis. The more gradual the onset, the worse the prognosis.
Evidence that the prognosis has become worse over recent decades especially in developed countries – linked to the increased usage of, and dependence on, and damage from antipsychotic drugs.
Antipsychotic/ Neuroleptic drugs – tranquillize/ demotivated (?self treat by heavy smoking)
Minor tranquillizers/ sedation e.g. benzodiazepines
Unknown – many theories - probably many causes for many different but overlapping disorders
Probably some cases caused by new genetic mutations – but low fertility means these are usually not passed-on.
If core schizophrenia was a disorder of the industrial revolution era, but is now disappearing, the cause may be linked to some aspect of this era - ? infection, toxin.
PSY 2016-5 Abnormal Psychology and Psychiatry 2017-18
Bruce G Charlton
Tranquillisation, Sedatives and Hypnotics
Ref Laura Allison and Joanna Moncrieff. ‘Rapid tranquillisation’… History of Psychiatry. 2014; 25: 57-69
Tranquilliser - a drug which calms, reduces anxiety and agitation.
Sedative – tends to induce sleep, but not always.
Hypnotic – drug given specifically to cause sleep.
Sedatives and Hypnotics are often the same drug in different doses – low dose sedation/ tranquillisation and higher doses cause sleep.
But some particular drugs are only marketed or prescribed specifically to induce sleep (e.g. zopliclone or zolpidem) – and some drugs tranquillise without sedation (flupenthixol, haloperidol).
These drugs are usually given over the short term – especially in the day time – i.e. days or weeks
Behavioural control in Psychiatry
Probably the original function of psychiatry – to prevent suicide, or protect the public.
- Physical restraints
All kinds of restraints were used in the past – straps, ropes, chains, cages, restraining chairs, strait jacket, padded cell.
2. Sedative/ hypnotic (sleep-inducing) drugs which made patient drowsy/ sleepy less motivated to be violent. Sleep may also be curative in psychosis.
Paraldehyde from 1880s
Barbiturates from around 1900
Antihistamines eg promethazine from 1940s
Benzodiazepines eg diazepam/ Valium from 1960s
Sedation still remains a very important mode of controlling behaviour – most acutely agitated patients continue to receive e.g. benzodiazepines (e.g. lorazepam) or sedative antihistamines (e.g. promethazine).
- The neuroleptic/ antipsychotic effect - causing demotivation, indifference to environment, and blunting of emotions e.g. chlorpromazine (1950). Will discuss in the lecture on these drugs.
Sleep is, obviously, biologically necessary. Insufficient sleep must have deleterious effects. Sleep is disrupted in many psychiatric disorders, especially those with psychotic symptoms. Patients with mania may stop sleeping for several days, getting worse and worse.
Early drugs late 19th century included bromide and barbiturates, meprobamate/ Miltown 1955.
Benzodiazepines – e.g. Diazepam/ Valium. Variably effective. Safe in overdose. Suppress deep NREM sleep (stages III and IV).
So – with benzos you may fall asleep earlier and sleep longer – but less deeply, less satisfying sleep. Effects wear off with repeated us (tolerance). Produce rebound insomnia if stopped suddenly.
Nowadays ‘Z-drugs’ such as zopiclone, or zolpidem instead of BZs – work on BZ receptors, but less effective, more prone to dependence.
Antihistamines – promethazine (Phenergan), diphenhydramine (Nytol), or trimeprazine (Vallergan) available without prescription. Problem with hang-over.
Melatonin – A natural hormone, elevated at night. Doesn’t work for everyone, but may be able to produce more normal sleep architecture (i.e. with both deep sleep and REM sleep)
Sleep is very important. Drugs may help in the short term, or even be necessary when people are over-active, but so far all hypnotic drugs have significant problems.