Download Evidence-based approaches to psychiatry In this hierarchy

To treat the disease of mental
The history of psychiatry
Philippe Pinel
The founder of psychiatry
as a medical discipline
Liberated the insane from
their chains
The history of psychiatry
Esquirol
The prototype of the
psychiatric specialist
Originated the descriptive
clinical approach
The history of psychiatry
Kraepelin
The founder of contemporary
scientific psychiatry，
psychopharmacolgy and
psychiratric genetics.
His nosological system
established around 1900 has
remained valid until today.
The history of psychiatry
 Sigmund Freud
 The founder the psychoanalysis
 His work influenced the clinical
approaches, the humanities and
social sciences.
 He is considered one of the most
prominent thinkers of the first
half of the 20th century.
The history of psychiatry
 Chlorpromazine
 Initiated a virtual revolution in psychiatry and
psychopharmacology.
 The focus of psychiatry began to turn toward brain
biological theories.
Chapter 1
Symptoms and signs of
psychiatric disorder
Chapter 1
Descriptive psychopathology （症状学）
The objective description of symptoms or
abnormal states of mind and limited to
the description of conscious experiences
and observable behavior.
Chapter 1
The use of empathic understanding to
explore and clarify the patient's
subjective experiences
“feel oneself into the other”
Chapter 1
Disorders of Mood
Disorders of Perception
Disorders of Thinking
Disorders of Memory
Disorders of Consciousness
Disorders of Concentration
 Insight
Disorders of Mood
Mood is usually characterized as a prevailing and
prolonged emotional state that determines a
person’s overall perception, feeling, thinking and
behaviour for a considerable period of time.
Affect is short-lived and changeable, emerges in
immediate reaction to a particular aspect or object.
Disorders of Mood
Depression（抑郁） is abnormal when it
is out of proportion to the misfortune, or
is unduly prolonged.
Lowering self-esteem
Pessimistic or negative thinking
Reduction or loss of the experience of
pleasure.
Disorders of Mood
Disorders of Mood
Clinical association
Depressive disorder
Schizophrenia
Anxiety
OCD
Organic disorder
Disorders of Mood
Elation（情绪高涨） is an extreme
degree of happy mood often coupled with
other changes, including increased
feelings of self-confidence, well-being,
increased activities.
Elation occurs most often in mania and
hypomania.
Disorders of Mood
Anxiety（焦虑） is abnormal when its
severity is out of proportion to the threat
of danger or when it outlasts the threat.
The essential anxious feeling including
dread, restlessness, narrowing attention,
worrying thoughts, increased alertness
and irritability.
Disorders of Mood
Somatic symptoms means muscle tension,
pain and respiration increase.
Autonomic symptoms are increasing of
heart rate, sweating, dry mouth, and may
be an urge to urinate or defecate.
Disorders of Perception
Perception（知觉） is the process of
becoming aware of what is presented
through the sense organs.
Perception cannot be terminated by an
effort of will.
Specific kinds of perceptual disorders are
symptoms of severe psychiatric disorders.
Disorders of Perception
Illusions（错觉） is based on a percept
of a real object or event, which is
misinterpreted .
Illusions occur when level of
consciousness is reduced, as in delirium.
Disorders of Perception
Hallucination（幻觉） is a percept
experienced in absence of an external
stimulus to the corresponding sense
organ.
Hallucination differs from an illusion in
not being based on a percept of a real
object or event.
Disorders of Perception
Categories of hallucinations
According to complexity:
elementary
complex
According to sensory modality: auditory
visual
olfactory and gustatory
tactile
According to special features:
second person
third person
Gedankenlautwerden
echo de la pensee
Disorders of Perception
Elementary hallucination refers to simple
experiences such as whistles, twitters and
flash of light.
Complex hallucination refers to
complicated experiences such as hearing
voices and music, or seeing faces and
scenes.
Disorders of Perception
 The most common hallucination is auditory
hallucinations（幻听）, usually in the form of voices.
 Voices talking to each other about the patient, and
voices commenting about the patient‘s ongoing acting
or thinking, are considered to be typical to
schizophrenia (third-person hallucination，第三人称
幻听）.
 Voices calling the patient's name or talking without
comments to the patient are considered to be nonspecific(second-person hallucination）.
 Voices which anticipate, speak (Gedankenlautwerden，
思维化声) or repeat(echo de la pensee，思维回响) the
patient’s thoughts also suggest schizophrenia.
Disorders of Perception
Visual hallucinations（幻视） often raise
the suspicion of an organic disorder, they
also occur in schizophrenia and severe
affective disorders.
The content of visual hallucinations is of
little significance in diagnosis.
Disorders of Perception
Tactile hallucinations（幻触） may be
experienced as sensations of being
touched, pricked or strangled, which
suggest schizophrenia and drug abuse.
Disorders of Perception
Hallucinations of smell and taste are
often unpleasant, which is also called
olfactory and gustatory hallucination.
They are infrequent and may occur in
schizophrenia, severe depression, and
epilepsy.
Disorders of Perception
Reflex hallucination（反射性幻觉） is a
rare phenomenon in which a stimulus in
one sensory modality results in a
hallucination in another.
Disorders of Perception
One said he see a snake in the corner, but
in fact it was a length of rope.
Illusions
Disorders of Perception
One said he hear some people talking
with each other about his private affairs
just outside of the room, but others in the
same room hear nothing.
Auditory hallucination (third-person)
Disorders of Perception
A female patient complain that as soon as
she saw her neighbor , she would hear
voices commenting her dress.
Reflex hallucination
Disorders of thoughts
Disorders of thoughts are the most
diagnostically significant symptoms in
psychiatry.
It contain two aspects: disorder of
thoughts content and disorder of the
thinking process.
Disorders of thoughts
 The most important symptom in disorders of
thoughts content is delusion（妄想）.
 A delusion is a belief that is firmly held on
inadequate grounds, it could not be affected by
rational argument or evidence to the contrary,
and is not a conventional belief that the person
might be expected to hold given his educational,
cultural and religious background.
 In short, a delusion is a false unshakable belief
which is out of the patient's background.
Disorders of thoughts
According to onset:
Primary
Secondary
According to delusional experiences:
delusional mood
delusional perception
delusional memory
According to the theme:
persecutory
delusion of reference
grandiose
guilty delusions
hypochondriacal
nihilistic
jealousy
sexual
delusion of control
thoughts insertion
thoughts withdrawal
thoughts broadcasting
Disorders of thoughts
 A primary delusion（原发性妄想） is one that appears
suddenly and with full conviction but without any
mental events leading up to it.
 Primary delusions are given considerable weight in the
diagnosis of schizophrenia.
 Primary delusion experiences often start with an idea,
but sometimes the first experience could also be
delusional mood, delusional perception, or delusional
memory.
Disorders of thoughts
Delusional mood（妄想心境） is
preceding mood that often a feeling of
foreboding that some as yet unidentified
bad event is about to take place, then the
delusion follows, and the delusion
appears to explain this feeling of mood.
Disorders of thoughts
Delusional perception（妄想知觉） is the
attaching of a new significance to a
familiar percept without any rational
reason
The perception may be normal, however
the delusional interpretation is morbid.
Disorders of thoughts
Delusional memory（妄想记忆） is a
delusional interpretation attached to past
event.
 The past event actually exists, but the
significance attached to it is delusional
Disorders of thoughts
Second delusions（继发性妄想） are
delusions apparently derived from
preceding morbid experience.
Secondary delusions may accumulate
until there is a complicated and stable
delusional system, which also called
systematic delusion.
Disorders of thoughts
 The most common theme of delusion is
persecutory（被害妄想）.
 The patient with this symptom believe that
some persons or organizations are trying to
inflict harm on the patient, damage his
reputation, or make him insane.
 Persecutory is common in schizophrenia,
organic disorders and severe affective disorders.
Disorders of thoughts
 Delusions of reference（关系妄想） are
concerned with the idea that objects, events or
people have a personal significance for the
patient, but in fact these events or people have
nothing to do with the patient.
 Delusions of reference also occur in
schizophrenia, organic disorders and severe
affective disorders.
Disorders of thoughts
Grandiose delusions（夸大妄想） are
beliefs of exaggerated self-importance.
Such ideas occur particularly in mania as
well as schizophrenia.
Disorders of thoughts
Guilty delusions（罪恶妄想） are beliefs
of sinfulness because of a minor illegal
behavior
It often occurs in severe depression
Disorders of thoughts
 The nihilistic delusions（虚无妄想） are beliefs that
something has ceased to exist.
 The patient with hypochondriacal（疑病妄想）
delusions believe that he is suffering from a severe
disease, despite all medical evidence to the contrary.
 Delusions of jealousy（嫉妒妄想） are beliefs that
his/her partner is unfaithful.
 A patient with sexual delusion（钟情妄想） believes
that she is loved by a man who is usually inaccessible to
her.
Disorders of thoughts
 A patient with a delusion of control （影响妄想）
believes that his actions, movements or
thoughts are controlled by an outside agency
and not willed by himself.
 These are also called passivity phenomena.
 This symptom strongly suggests schizophrenia.
Disorders of thoughts
Patients with delusions concerning the
possession of thoughts lose the normal
convictions that thoughts are private and
cannot be shared unwillingly, including
thoughts insertion, thoughts withdrawal
and thoughts broadcasting.
They are strongly associated with
schizophrenia.
Disorders of thoughts
 Thoughts insertion（思维插入） is the
delusion that certain thoughts are not the
patient’s own but implanted by an outside
agency.
 Thought withdrawal（思维被窃） is the
delusion that thoughts have been taken out of
the mind.
 Thought broadcasting（思维播散） is the
delusion that unspoken thoughts are known to
other people through radio, high-tech
equipment, or in some other way.
Disorders of thoughts
A patient felt guilty and apologized to
everyone in the office for her late for
work.
Guilty delusion
Disorders of thoughts
A patient refused to drink any water at
home because he believes his parents will
poison him by water.
Persecutory delusion
Disorders of thoughts
A patient believed that an article in
magazine suggests that he has been under
surveillance .
Delusions of reference
Disorders of thoughts
A patient believes many people around
hear her thoughts through a special
electronic instrument.
Thought broadcasting
Disorders of thoughts
A patient believes that his thoughts are
influenced by an outside agency.
Delusions of control
Disorders of thoughts
A patient believes that some thoughts are
implanted in his mind by an outside
agency.
thought insertion
Disorders of thoughts
 Obsessions（强迫观念） are recurrent
persistent thoughts, impulses, or images that
enter the mind despite efforts to exclude them.
Obsessions are regarded as untrue, useless, or
senseless.
 The characteristic feature of obsessions is the
subjective sense of a struggle, the patient resist
the obsession, which nevertheless intrudes into
awareness.
Disorders of thoughts
Forms of obsessions
Obsessional thoughts（强迫思维）
Obsessional ruminations （强迫穷思竭虑）
Obsesional doubts （强迫怀疑）
Obsessional impulses （强迫意向）
Disorders of thoughts
Content of obsessions
Thoughts about dirt and contamination
Aggressive thoughts
Thoughts about orderlines
Thoughts about illness
Thoughts about sex
Disorders of thoughts
Compulsions（强迫行为） are repetitive
purposeful behaviors, performed in a
stereotyped way(which is also called
compulsive ritual，强迫仪式), in
response to an obsession. Compulsions
are recognized as senseless but the
compulsive behavior must be carried out.
Disorders of thoughts
Although the compulsive behavior
transiently reduces the anxiety associated
with the obsession, in fact the
compulsions help maintain the obsession.
Disorders of thoughts
Forms of compulsions
Checking rituals （强迫检查）
Cleaning rituals （强迫清洗）
Counting rituals （强迫计数）
Dressing rituals （强迫着装）
Disorders of thoughts
Overvalued idea（超价观念） is an
acceptable comprehensible idea pursued
by the patient beyond the bounds of
reason.
The content of the overvalued idea is
usually understandable and acceptable
considering the person’s background.
And overvalued ideas are not so firmly
Disorders of thoughts
Disorders of thinking processes including
the disorders of the stream of thoughtand
the form of thought.
Disorders of thoughts
In disorders of the stream of thought
（思维进展障碍）, the amount and the
speed of thinking are changed.
Disorders of thoughts
 In pressure of thought（思维迫促）, which occurs in
mania, ideas arise in unusual variety and abundance ,
thought pass through the mind rapidly.
 In poverty of thought （思维贫乏）, which occurs in
depression, the patient has few thoughts and these lack
variety and richness , thoughts seem to move slowly
through the mind.
 In thought block （思维中断）, the stream of thoughts
is interrupted suddenly, and the patient feels that his
mind has gone blank. It suggests schizophrenia
Disorders of thoughts
Disorders of the form of thinking （思维
形式障碍） can be categorized into
perseveration, flight of ideas, loosening of
associations and so on.
Disorders of thoughts
Perseveration（重复思维） is the
persistent and inappropriate repetition of
the same thoughts.
 Perseveration occurs in dementia and
frontal lobe injury.
Disorders of thoughts
In flight of ideas（思维奔逸）, thoughts
and speech move quickly from one topic
to another so that one piece of thought is
not carried out to completion before
another thought starts.
Flight of ideas is characteristic of mania.
Disorders of thoughts
Loosening of associations（思维散漫）
denotes a loss of the normal structure of
thinking.
They occur most often in schizophrenia.
There are three characteristic kinds of
loosening associations:
Talking past the point
Derailment or knight’s move thinking
Verbigeration
Disorders of thoughts
A patient said he feel his thinking is very
slowly and can’t understand the
interviewer’s questions quickly.
poverty of thought
Disorders of thoughts
A patient feels his mind sometimes
suddenly become blank because another
person remove his thoughts.
thought block
Disorders of thoughts
The interviewer ask the patient ‘how old
are you’ the patient answer ’59’ the
second question is ‘ what is your name ’
the patient still say ‘59’, the third answer
is still”59”
Perseveration
Disorders of thoughts
The question is “why do you believe that
you will be killed”. The patient answered
“My friend has an electric-radio receiver,
but he never tell me where it is. In fact, I
have been to nuclear power plant, and
there is nothing dangerous.”
Derailment
Disorders of memory
Immediate memory（瞬时记忆）
concerns the retention of information
over a short period measured in minutes.
Recent memory（近记忆） concerns
events that in the last few days.
Long term memory（远记忆） concerns
events over longer periods of time.
Disorders of memory
Some organic conditions can lead to a
partial effect known as amnestic
disorder（遗忘综合症）, in which the
patient is unable to remember events
occurring a few minutes before, but can
recall remote events. In dementia, it
usually progresses with time and becomes
severe, but rarely total.
Disorders of memory
 In case of unconsciousness, memory is impaired
for the interval between the ending of complete
unconsciousness and restoration of full
consciousness, this is called anterograde
amnesia（顺行性遗忘）.
 Some causes of unconsciousness lead also to
inability to recall events before the onset of
unconsciousness, that is retrograde amnesia
（逆行性遗忘）.
Disorders of memory
Psychogenic amnesia（心因性遗忘） is
thought to result from an active process
of repression which prevents the recall of
memories that would evoke unpleasant
emotions.
Disorders of memory
 Disorders of recognition occur occasionally in
neurological and psychiatric disorders:
 Jamais vu （识旧如新）is the failure to recognize
events that have been encountered before.
 Déjà vu（识新如旧） is the conviction that an event
repeats one that has been experienced before while in
fact it is novel.
 Confabulation（虚构） is the reporting as memories of
events at one time, of events that took place at another
time, or never involve the person. It is characteristic of
amnestic syndrome.
Disorders of memory
A female said she has forget who she is
and her whole life experience.
Psychogenic amnesia
Disorders of memory
A head injured patient complained that
he can’t remember the events before he
injured.
Retrograde amnesia
Disorders of memory
A patient stayed at hospital yesterday,
but today he insists he had been to his
daughter’s home last night.
Confabulation
Disorders of consciousness
Consciousness(意识) is awareness of the
self and the environment.
Disorders of consciousness
Coma（昏迷） is the most extreme form
of impaired consciousness.
 Coma can be graded by the extent of the
remaining reflex response and by the
type of electroencephalogram activity.
Disorders of consciousness
 Clouding of consciousness（意识混浊） refer
to a state which ranges from barely perceptible
impairment to definite drowsiness in which the
person reacts incompletely to stimuli. Attention,
concentration, and memory are impaired to
varying degrees and orientation is disturbed.
Thinking seems muddled, and events may be
interpreted inaccurately.
 It is a defining feature of delirium.
Disorders of consciousness
 Stupor（木僵）, in the sense used in
psychiatry, refers to a condition in which the
patient is immobile, mute, and unresponsive
but appears to be fully conscious in that the
eyes are usually open and follow external
objects. Reflexes are also normal and resting
posture is maintained.
 It may occur in catatonia.
Disorders of consciousness
Confusion（意识模糊） means an
inability to think clearly. It occurs
characteristically in states of impaired
consciousness but it can occur when
consciousness is normal.
 In delirium, confusion occurs together
with partial impairment of consciousness.
Disorders of attention and
concentration （注意障碍）
Attention is the ability to focus on the
matter in hand.
Concentration is the ability to maintain
that focus.
Disorders of attention and
concentration
 Attention and concentration may be impaired
in a wide variety of psychiatric disorders
including depression, mania, anxiety,
schizophrenia and delirium.
 Therefore , the finding of abnormalities of
attention and concentration does not assist in
diagnosis.
 But these abnormalities are important in
management because they can interfere with a
patient’s ability to work, study or drive.
Insight
 In psychopathology, the term insight
（自知力） refers to awareness of
morbid change in oneself and a correct
attitude to this change including a
realization that it signifies a mental
disorder.
Insight
 Insight is not simply present or absent. It has
several facets, each being a matter of degree
and could be assessed by following questions:
Is the patient aware of phenomena that others have
observed?
If so, does he recognize the phenomena as
abnormal?
If so, does he consider that they are caused by
mental illness?
If so, does he think that he needs treatment?
Insight
 The value of determining the degree of
insight is that it helps to predict whether
a patient is likely to comply with
treatment.
Chapter 2
Classification and diagnosis
Classification and diagnosis
 What is mental illness or mental disorder?
 In ICD10 the definition of mental disorder is: a
clinically recognizable set of symptoms or
behavior associated in most cases with distress
and with interference with personal functions.
Social deviance or conflict alone, without
personal dysfunction, should not be included in
mental disorder as defined here”.
Classification and diagnosis
 ICD10 is the International Classification of
Diseases produced by the World Health
Organization as an aid to the collection of
international statistics about disease. The
system is revised every few years and the
present edition is the tenth.
 Of twenty-one chapters, chapter 5 is devoted to
psychiatry. It is the current main psychiatric
classification.
Classification and diagnosis
In 1952 the American Psychiatric
Association(APA) published the first
edition of the Diagnostic and Statistical
Manual.
The present edition is DSM 4 textual
revision which published in 2000.
Classification and diagnosis
DSM has a multi-axial classification with
five axes in particular.
Axis 1 clinical syndromes and conditions.
Axis 2 personality disorder.
Axis 3 physical disorder and conditions.
Axis 4 severity of psychosocial stressors.
Axis 5 highest level of adaptive function.
Classification and diagnosis
DSM-5 was released in 2013.
http://www.dsm5.org
Chapter 3
Assessment
Assessment
Psychiatric history
 Name, age, and address of the patient
 Name(s) of informant(s) and their relationship to the
patient
 History of present condition
 Family history
 Personal history
 Past illness
 Personality
Assessment
Mental state examination







Appearance and behaviour
Speech
Mood
Thoughts
Perceptions
Cognitive function
Insight
Chapter 6
Evidence-based
approaches to psychiatry
Evidence-based approaches to psychiatry
What is evidence-based medicine ？
Evidence-based medicine（循证医学） is
a systematic way of obtaining clinically
important information about aetiology,
diagnosis, prognosis, and treatment.
Evidence-based approaches to psychiatry
 The evidence-based approach is a process in
which the following steps are applied:
 Formulation of an answerable clinical question;
 Identification of best evidence;
 Critical appraisal of the evidence for validity and
utility;
 Implementation of the findings;
 Evaluation of performance.
Evidence-based approaches to psychiatry
Archibald Cochrane, an epidemiologist，
is the most important scientist in
evidence-based approaches.
He emphasized the need to use evidence
from randomized controlled trials
because randomized controlled trials is
more reliable than any other kind.
Evidence-based approaches to psychiatry
Combination of computerized searching
all of the relevant randomized trials and
the statistical techniques of meta-analysis
is called “systematic reviews”
Evidence-based approaches to psychiatry
The Cochrane Collaboration is now the
largest organization in the world engaged
in the production and maintenance of
systematic reviews.
http://www. cochrane.org
Evidence-based approaches to psychiatry
 Hierarchy of evidence
 Ⅰ Evidence from a systematic review of randomized
controlled trials or evidence from at least one randomized
controlled trial.
 Ⅱ Evidence from at least one controlled trial without
randomization or quasi-experimental study. ( quasiexperimental designs are used when randomization is
impossible)
 Ⅲ Evidence from non-experimental descriptive studies,
such as comparative studies, correlation studies, and case
control studies.
 Ⅳ Evidence from expert committee reports or opinions
and clinical experience of respected authorities.
Evidence-based approaches to psychiatry
In this hierarchy, evidence from
randomized trials is regarded as more
valid than evidence from nonrandomized trials.
Chapter 16
Psychiatry and medicine
Psychiatry and medicine
The presentation of psychiatric disorders
is common in all settings and differs from
one medical setting to another.
Psychiatry and medicine
The relative prevalence of common psychiatric disorders in medical settings
Depression/anxiety
Delirium
Alcohol abuse
Psychosis
Somatoform
disorders
General
practice
Emergency
Medical/surgic
al outpatients
Medical/surgic
al inpatients
++
++
+
+++
++
+
+++
+
+
+++
++
+++
+++
+++
+++
++
- rare; + uncommon; ++ common; +++ very common
Psychiatry and medicine
 Some patients seen in general practice and hospital
outpatient clinics have somatic symptoms which cannot
be explained by medical disease and many of these have
a psychiatric disorder such as depression , anxiety and
somatoform disorder.
 Depression is associated with somatic symptoms, such
as fatigue, weigh loss, and pain, which may lead to
referral to medical specialty.
 Anxiety is associated with symptoms of autonomic
arousal and panic attack, such as palpitations, chest
pain, dizziness and breathless symptoms.
Psychiatry and medicine
 The psychiatric services for general hospitals
are often named consultation-liaison psychiatry
（会诊-联络精神病学）.
 In consultation work, the psychiatrist is
available to give opinions on patients referred
by physicians and surgeons.
 In liaison work, the psychiatrist is a member of
a medical or surgical team, and offers advice
about any patient to whose care the psychiatrist
feels able to contribute.
Review of this class
Chapter 1
Definition of the descriptive
psychopathology
The concepts and the clinical meanings
of mental symptoms.
The distinctions between the confusing
symptoms are also critical important.
Review of this class
Chapter 2
The definition of mental disorder in
ICD10
The conception of ICD and DSM.
Review of this class
Chapter 6
The concept of evidence-based medicine
The fundamental principles of EBM.
Review of this class
Chapter 16
The presentation of psychiatric disorder
in medical settings
The conception of consultation - liaison
psychiatry.