BCS 246: Lecture 2

HO for Biology of Mental Disorders (BCS 246)
Lecture 2 (9/10)

Issues from/after last class:

A. Regarding class/materials for class:

Trimble is required text, not DSM IV (though again recommend to all)
Calendars (everyone has one now?) if not come to my office after class and get one
Handout from lecture 1 (same as above)
Prerequisites: if have biology/chemistry background of some type this will do (not necessarily neuroscience background, though may be easier)
Strongly encourage taking some notes since some of my lecture material will be tested on that is not part of readings
Hang on to handouts for quiz/test review

B. Unfinished business from class 1:

Critical issue in definition of disorder: functional impairment, outside the "norm" of functioning in a given situation (adjustment)
Second video (patient with schizophrenia) is a patient that is actually in remission (if kept going would have seen ongoing delusions [children in purse, stuffed animals; where she goes the neighbors go, even Rochester NY]

Handout for today:

Mental status exam of severely ill patient (like 2nd vignette from first lecture; Brief history (from Trimble, Kaplan & Sadock [K&S] material); case vignettes, brief mental status discussion of new patients and particularly phenomena particularly relevant to neurobiology (DSM IV terms).

Mental Status of patient with schizophrenia (name really isn't Ms. Patient)

Appearance and behavior: Ms. Patient is a pleasant, casually dressed and somewhat disheveled, cooperative single white female appearing somewhat older than her stated age. She exhibits normal psychomotor activity, no sign of extrapyramidal side effects (from medication), tardive dyskinesia (long term motor side effect of some medications), and interacts appropriately in most group situations. However, her verbal production when in unstructured settings remains extremely disorganized, with her verbalizing predominantly delusional material. She appears disheveled and often talks to herself. She is often observed laughing inappropriately and giving knowing looks at people when she is not engaged in conversation with them.
Speech pattern and thought content: Patient's speech, when asked direct questions, can be logical and goal directed (particularly in group setting). After a brief period of time, however (less than one minute), she exhibits marked derailment, illogicality, and frank tangentiality. She has excessive delusional speech in particularly in the PM.
Mood: Patient is usually euthymic (normal mood, as opposed to dysthymic [sad], or euphoric [abnormally "high"], with episodes of irritability and verbal outbursts not particularly focused on any individual, this having improved somewhat with Clozaril and Klonopin treatment.
Affect: Affect is labile, with episodes of agitation, quickly changing to giggling and agreeableness, though the agitated states are currently infrequent and not focused on individuals but toward what seems to be internal stimuli.
Psychotic symptomatology: Although she denies auditory hallucinations, she appears to be attending to internal stimuli on a regular basis. However, this could be the result of her own intrusive thoughts rather than hallucinations. Patient continues to have fixed delusions including her belief that she has many children (hundreds to thousands), abnormalities of her body (internal organ damage), and believing she is doctor as well as a policewoman. She often expresses the belief that other patients are jealous of her due to her being a policewoman.
General cognitive performance: Due to her current actively psychotic state and distractibility, it is difficult to formally assess cognitive abilities. Past testing has placed Ms. Patient in the low normal range of intelligence (verbal/performance IQ on WAIS: 85/80 during relative remission of symptoms and considered valid). There is no evidence of severe memory impairment indicating "course" organic brain dysfunction.
Risk for aggression or suicidal behavior: Ms. Patient has a history of outwardly aggressive behavior (assaultiveness) but has not exhibited this recently (since institution of clozaril treatment). She currently has no homicidal or suicidal ideation and does not seem to be a risk to herself or others. She uses honor card privileges appropriately and I feel this is an important component of her treatment (gain greater autonomy and practice appropriate behavior off the unit).
BPRS (Brief Psychiatric Rating Scales (actually over 20 actual scales, these pertinent to this patient)

#6 (Hostility) - 3                     #11 (Unusual Thought Content) - 6
#15 (Conceptual Disorganization) - 6
all scores unchanged from last ratings

Historical perspective:

First attempt at a history of psychiatry was in 1830 (Friedreich)
Prior to this translations from Greek/Roman were what were being used in psychiatry (not history)
Earliest recorded ideas regarding psychiatry
Egypt and Near East
Mental illness caused by magical influences of malevolent deities
Therapists were priests
Used religious or magical rites including incantations, medications, other physical therapies
Hebrews
God as source of health and disease
Disease was punishment by God for sin
Priests called upon to cure through their special relationship with God
Religious and magical views have prevailed in many societies (even today)
Greek and Roman psychiatry overall
Psychiatry as part of other disciplines, usually cults of healing based on myth or religion
Various cults had different view:
Mental illness as mostly psychological
Mental illness as mostly somatic (biological)
Mental illness as a mixture of psychological and somatic
Very similar to today ("enduring viewpoints" psychological/biological/combination!!!)
Greek psychiatry:
Ionians, 6th century BC
First to depart from theological concepts and viewed world in naturalistic and materialistic terms
World and life forms composed of four elements: Air, Water, Earth, Fire
Characteristics of these elements were: Dry, Wet, Cold, Hot
Mental function based on "atoms" in motion and on the humors and body substances
Mental illness -> changes in size and motions of atoms, or amount of humors and vital substances, or when toxic substances appeared in the body
Hereclitus (535-470 BC[65 y/o?]) also believed that mental health depended on equilibrium between opposite psychological tendencies that existed in the soul (another interesting and "enduring viewpoint" particularly in Eastern societies)
Hippocrates (born 450-355 BC [95 y/o?]) K&S says not really his writings but many others, possibly the first example of authorship patterns with senior author always going first?
A "physician" who borrowed heavily from Ionians, in terms of somatic compounds and naturalistic vs. theological approach to mental illness
Emphasized the need for close examination, detailed description, and focused on prognosis
Emphasized brain as center of affect and mental disorder
Four essential humors: Blood, Phlegm, Yellow Bile, Black Bile secreted by different organs (which?), and possessed different qualities varying with seasons (not enduring but major interest in this today!!)
Need for correct mixture of "humors" (actually a continuum theory)
Disorders or maladies having longitudinal course (though didn't describe distinct entities)
Treatment based on restoring balance of humors

Case vignettes:

1) Hypomanic episode (make sure have DSM IV criteria for this from own text or library)

2) Dysthymic disorder (make sure have DSM IV criteria for this from own text or library)

* Note relation to historical ideas of Hippocrates

Sanguine personality traits: optimistic, cheerful, lively, confident, optimistic, "positive affectivity"

Phlegmatic personality traits: stoic, unflappable, nonchalant, indifferent, calm, unemotional

Choleric personality traits: bad-tempered, irritable, quick-tempered (labile), cantankerous

Melancholic personality traits: joyless, cheerless, gloomy, unhappy, pensive, thoughtful, sad, depressing