Liaison psychiatry and mood disorders

Therapy (CBT).

o This involves: identifying negative automatic thoughts (keeping a diary to

monitor them), testing and correcting automatic thoughts (reallife

experiments), cognitive rehearsals, anticipating critical difficulties that maybe

encountered and using rehearsals to counter them. Problem solving is taught.

Behavioural techniques such as activity scheduling are done to help the client

gain mastery/pleasure from succeeding at graded tasks.

o There is evidence to show that it is as effective as antidepressants in the

treatment of mild to moderate depression and there is some evidence to

support its use even in more severe disorders.

o The effects of CBT are longer lasting than antidepressant treatment.

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I. Schizophrenia
II. Disorders related to schizophrenia
III. Mood disorders
A. Brief History1
19th Century ­ All serious mental disorders seen as expressions of a single entity
(Einheitpsychose, Griesinger) i.e. a unitary psychosis
Morel (1852) ­ proposed mental illnesses could be separated and classified, based on
cause. Described démence précoce: starting in adolescence, withdrawal, odd
mannerisms, self neglect and intellectual decline
Kahlbaum (1863) ­ described catatonia with characteristic motor features (also
described hebephrenia and dementia paranoides)
Hecker (1871) ­ wrote an account of hebephrenia (very similar to our current
Emil Kraeplin (1855 1926) ­ Argued against unitary psychosis. Proposed division
into dementia praecox (`dementia' emphasises the importance he gave to cognitive
impairments and persisting disability) and manic depressive psychosis (episodic with
normal functioning in between).
Dementia praecox further divided into 3 subtypes: catatonic, hebephrenic and
paranoid. Then later added 4th subtype: simple
Defined paraphrenia separately (started middle life, free from changes in emotion and
volition seen in dementia praecox)
Eugen Bleuler (1857 1959) ­ proposed the name schizophrenia to denote `splitting' of
psychic functions. More optimistic about outcome. Made distinction between
fundamental symptoms:
o The 4 `A's:
Disturbances of Associations (thought disorder)
Affective flattening
Autism (social withdrawal)
Ambivalence (apathy)
And accessory symptoms:
o He believed these to be derived from loosening of associations
Abnormal behaviour
Kurt Schneider (1887 1967) ­ identified symptoms characteristic of the disorder,
rarely found in other disorders. Not supposed to have central psychopathological
role and not necessary nor sufficient for the diagnosis. Nor do they have prognostic
significance. (See box 1).
Box 1.
Schneider's symptoms of the first rank:
3 forms of auditory hallucination
Audible thoughts (thought echo)
Voices commenting on actions (running commentary)

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Voices discussing the patient (3rd person hallucinations)
Alien thoughts
Thought insertion
Thought withdrawal
Thought broadcasting
Passivity phenomena
Made will (impulses)
Made acts
Made affect (feelings, emotions)
Somatic passivity (bodily sensation or function imposed by external
Delusional perception
Kasanin (1933) described schizoaffective disorder
Leonard (1957) ­ Separated schizophrenia from cycloid psychoses (non affective
psychoses with good outcome)
Further sub divided schizophrenia into systemic (catatonia, hebephrenia, paraphrenia)
and non systemic (affect laden paraphrenia, schizophasia and periodic catatonia)
Langfeldt (1961) ­ Differentiated schizophreniform states from true schizophrenia,…read more

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Characterised by:
Difficulty in focusing attention or thinking clearly
Minor perceptual disturbances
Anxiety, depression
Perplexity, suspiciousness
`Negative' symptoms ­ reduced drive, amotivation, anergia, social withdrawal,
decline in functioning
Sleep disturbance
Reduced sense of control
Delusional mood/atmosphere
Individual delusions and hallucinations
The Acute Syndrome
Characterised by:
Delusions, variable in type and content.…read more

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The Chronic Syndrome
Characterised by:
Reduced intensity of delusions and hallucinations
Underactivity, social withdrawal, lack of drive and volition
Inappropriate dress
Neglect of appearance and self care
Deterioration of social behaviour
Thought disorder
Blunted affect
Cognitive impairment
Movement disorder
Clinical Syndromes in Schizophrenia
Factor analysis of the symptoms assessed using the PANSS (Positive and Negative
Syndrome Scale) revealed 5 main groups of symptoms:
1. Core negative symptoms
2. Core positive symptoms
3. Excitement
4. Depressive symptoms
5.…read more

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Three clinical syndromes
Liddle (1987), using factor analysis, described 3 overlapping clinical syndromes which he
linked with patterns of neuropsychological deficit and to regional cerebral blood flow (see
Table 2). The most reproducible finding relates to psychomotor poverty.…read more

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Cognitive deficits can be discerned from early childhood.
Impairments become more marked at time of illness and can partially resolve after
resolution of the acute episode 11
Can develop into Alzheimer's type picture in late life in minority of cases
Within the first few years of the illness, patients show an intellectual decline of
around 10 IQ points together with poor performance on tests assessing attention,
memory and executive function. 25% will show low premorbid intellect and no
further IQ decline.…read more

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Social Factors
Social Class
Schizophrenia is overrepresented in lower social classes but is this cause (i.e. social
causation) or an effect of the illness itself (so called `downward drift'). Goldberg and
Morrison (1963) found that people with schizophrenia were of lower social class than their
fathers and they had usually changed status after their illness began (supporting the
`downward drift' theory).…read more

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Table 3: Risk of schizophrenia in first degree relatives
Patients Increased risk in first degree relatives of patients
Schizophrenia Schizophrenia, schizo affective & Schizotypal personality
Schizophrenia & Mood disorders.
N.B: The risk of bipolar illness is not increased in the first degree relatives of patients with
Twin Studies
A recent meta analysis (Sullivan, 2003) of twin studies showed that schizophrenia
has a heritability of 81%.…read more

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It is also associated with high rates of psychosis (schizophrenia like
and affective) of about 30%. This is one of the loci associated with schizophrenia and
is associated with the COMT gene (see below).
With regards to `Anticipation' phenomenon (age at onset decreases and severity
increases across generations), there have been many who found evidence for the
same, however it has not been established conclusively.…read more

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Brown et al (2004) recently showed that
serological evidence of influenza infection during early pregnancy was associated with a 7
fold increased risk of schizophrenia in the offspring but note that confidence intervals were
wide and included unity (ie. the results may be somewhat unreliable).
Other Prenatal Factors:
There have been links with 2nd trimester exposure to a wide variety of respiratory
infections including pneumonia, tuberculosis and bronchitis Links have also been
made with poliovirus, rubella and maternal antibodies to HSV (type 2).…read more


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