Download Psychiatric Issues and the Criminal Justice System

Psychosis, Mood, and Personality:
A Clinical Perspective
John R. Chamberlain, M.D.
Assistant Director,
Psychiatry and the Law Program
Assistant Clinical Professor
University of California San Francisco
Department of Psychiatry
Psychiatric Diagnosis
Psychiatric disorders are syndromes
The underlying pathology (or pathologies) of these
disorders are not understood
The disorders are defined by the presence of a
specified number of symptoms
The combination of symptoms necessary to make
a diagnosis are defined by a consensus of
experts
Psychiatric Diagnosis
Most disorders are further defined by a
minimum duration of the symptoms
To be considered a disorder the symptoms
must result in distress or impairment
The symptoms must not be the result of
substance use (except for the substance
use disorders) or a general medical
condition
Psychiatric Diagnosis
Many psychiatric diagnoses and symptoms are described
with terms also used by non-psychiatrists
This can result in confusion because the psychiatric
meaning is often different or more specific than the lay
meaning
Examples:
Depression ≠ Sadness or the blues
Anxiety ≠ Worry or nervousness
Insane ≠ Mental Illness
Diagnostic Areas

Mood Disorders

Anxiety Disorders

Psychotic Disorders

Cognitive Disorders

Substance Use Disorders

Somatoform Disorders

Personality Disorders

Impulse Control Disorders

Paraphilias
Diagnostic Areas

Mood Disorders





Major Depression
Bipolar Disorder
Dysthymia
Cyclothymia
Anxiety Disorders
Panic Disorder
Obsessive Compulsive Disorder
Posttraumatic Stress Disorder
 Generalized Anxiety Disorder
 Social Anxiety Disorder
 Phobias



Diagnostic Areas

Psychotic Disorders




Substance Use Disorders





Schizophrenia
Schizoaffective Disorder
Delusional Disorder
Substance
Substance
Substance
Substance
Intoxication
Withdrawal
Abuse
Dependence
Impulse Control Disorders


Pathological Gambling
Pyromania
Diagnostic Areas

Personality Disorders

A
Schizoid
 Schizotypal
 Paranoid


B
Borderline
 Antisocial
 Histrionic
 Narcissistic


C
Avoidant
 Dependent
 Obsessive Compulsive

Diagnostic Areas

Cognitive Disorders



Dementia
Delirium
Paraphilias
Voyeurism
 Froutterism
 Exhibitionism
 Pedophilia
 Sadism
 Masochism

Diagnostic Areas
 Somatoform
Disorders
 Hypochondriasis
 Somatization
 Pain
Disorder
Disorder
 Conversion Disorder
 Body Dysmorphic Disorder
 Undifferentiated Somatoform Disorder
Assessment
Clinical interview
History
Psychiatric
Medical
Social
Family
Substance use
Mental status examination
Cognitive screen
Assessment
Medical evaluation
Radiologic examination
Laboratory evaluation
EEG or other special testing
Review of collateral information
Psychological testing
Syndromes
Mania
 Three or more symptoms, present for one week or
more

Elevated, Expansive, or Irritable Mood
 Grandiosity
 Distractibility
 Racing thoughts
 Pressured speech
 Decreased need for sleep
 Increased goal directed activity
 Increased participation in pleasurable activities

Syndromes
Major Depression
 Five or more symptoms for two weeks or more

Depressed Mood
 Anhedonia (loss of enjoyment in usual activities)
 Suicidal thoughts (not just thoughts of death)
 Decreased energy
 Altered sleep (increased or decreased)
 Altered appetite (increased or decreased)
 Decreased concentration
 Psychomotor agitation or retardation
 Decreased self-esteem, excessive guilt

Syndromes
 Posttraumatic
Stress Disorder
 Experience
of a severe stressor—typically a
threat to one’s life (or bodily integrity) or the
life (or bodily integrity) of someone nearby
 Recurrent
re-experience of the trauma
 Persistent
increased arousal
 Altered
emotional status
Syndromes
 Schizophrenia
 Symptoms
more
are present for six months or
 Hallucinations
 Delusions
 Disorganized
speech
 Disorganized or catatonic behavior
 Negative symptoms
Syndromes
 Schizoaffective
 Symptoms
Disorder
of schizophrenia
 Presence
of mood symptoms for essentially the
entire time of the disorder
 Must
have at least one period of two weeks
with only psychotic symptoms
 No
periods of mood symptoms without
psychosis
Syndromes

Delusional Disorder

Encapsulated, non-bizarre delusions

The delusions are possible although the evidence is
against them

Multiple sub-types

Persecutory

Grandiose

Erotomanic
Syndromes
Substance Use Disorders
 Abuse





Maladaptive pattern of use of a substance
Recurrent use resulting in failure to fulfill major
obligations at work, school, home
Recurrent use in situations in which it is physically
hazardous
Recurrent legal problems
Continued use despite social or interpersonal problems
caused or exacerbated by the effects of the substance
Syndromes
Substance Use Disorders
 Dependence
Maladaptive pattern of use of a substance
 Tolerance
 Withdrawal
 Use in larger amounts or for longer than intended
 Persistent desire or unsuccessful efforts to decrease use
 Important activities are given up or reduced
 Persistent use despite knowledge of physical or
psychiatric problems related to use
 Great deal of time is spent in activities necessary to
obtain, use, or recover from the effects of the substance

Syndromes
Personality Disorders
This term refers to a group of disorders characterized by
longstanding maladaptive patterns of perceiving,
experiencing, and interacting with the environment, other
people, and one’s own emotions
The disorders are placed into three clusters—A, B, and C
Some of these disorders appear to be related to other
psychiatric conditions (e.g. mood, anxiety, and psychotic
disorders)
For example, avoidant personality disorder has many
features in common with social anxiety disorder
Syndromes
Personality Disorders
Some of the personality disorders are found at a
greater than expected frequency in families with
other psychiatric conditions
As a result it is thought these disorders reside on a
continuum with one another
For example, schizotypal personality disorder is
found more often in families of individuals with
schizophrenia than in the general population
Syndromes
Personality Disorders
In other cases the similarity between personality disorders
and other psychiatric disorders is in name only
In these cases the similar names imply an association that is
not seen in the clinical presentation or in the epidemiology
This can lead to confusion for clinicians, students, and
patients
For example, obsessive-compulsive personality disorder and
obsessive-compulsive disorder have little in common other
than their names
Treatment
Just as the underlying pathology of psychiatric
disorders is not understood, the mechanisms by
which treatment for these conditions work are
unclear
The biopsychosocial model is currently popular and
stresses the importance of viewing and treating
psychiatric disorders as being comprised of
biological, social, and psychological factors
Treatments can be divided into psychotherapy (i.e.
talk therapy and somatic therapy (i.e. medications,
electroconvulsive therapy)
Treatment
Medications

Antidepressants

Anxiolytics

Mood stabilizers

Antipsychotics
Treatment
CBT (cognitive behavioral psychotherapy) focuses on
identifying and changing negative styles of thinking
and behaving
Can be conducted in either individual or group settings
Focused on the present
Is brief—utilizing twelve to sixteen sessions on a once a
week basis
Requires the patient to practice skills between sessions
Treatment
IPT (interpersonal psychotherapy) focuses on identifying
and working through disturbed personal relationships
that may contribute to the symptoms of depression
Focused on the present
Is brief—utilizing twelve to sixteen sessions on a once a
week basis
Requires the patient to practice skills between sessions