PSYCHIATRY –
Introduction
Dr. Hakan Atalay
Yeditepe University Hospital
History
• The first specific description of a mental illness
appeared in approximately 3000 bc in a depiction of
senile deterioration ascribed to Prince Ptah-hotep.
• The syndromes of melancholia and hysteria
appeared in the Sumerian and Egyptian literature as
far back as 2600 bc.
• In the Ebers papyrus (approximately 1500 bc),
senile deterioration and alcoholism were described.
• In India, in approximately 1400 bc, a classification
of psychiatric disorders was included in the medical
classification system of Ayur-Veda.
History
• Hippocrates (approximately 460 to 370 BC) is usually
regarded as the one who introduced the concept of
psychiatric illness into medicine.
• His writings described
• - acute mental disturbances with fever (perhaps
delirium),
• - acute mental disturbances without fever (probably
analogous to functional psychoses but called mania),
• - chronic disturbance without fever (called melancholia),
• - hysteria (broader than its later use), and
• - Scythian disease (similar to transvestism).
History
• Philippe Pinel (1745 to 1826), a French physician,
simplified the complex diagnostic systems that
preceded him by recognizing four fundamental
clinical types:
• mania (conditions with acute excitement or fury),
• melancholia (depressive disorders and delusions
with limited topics),
• dementia (lack of cohesion in ideas), and
• idiotism (idiocy and organic dementia).
History
Karl Ludwig Kahlbaum (1828 to 1899), a German
descriptive psychiatrist who foreshadowed Emil
Kraepelin, introduced the concepts of (1) the
temporary symptom complex, as opposed to the
underlying disease, (2) the distinction between
organic and non-organic mental disorder, and
(3) the consideration of the patient's age at the
time of onset and the characteristic
development of the disorder as bases for
classification.
History
Kraepelin (1856 to 1926) synthesized three
approaches: the clinical-descriptive, the
somatic, and the consideration of the
course of the disorder. He viewed mental
illnesses as organic disease entities that
could be classified on the basis of
knowledge about their causes, courses,
and outcomes.
History
He brought the manic and depressive
disturbances together into one illness,
manic-depressive psychosis, and
distinguished it, on the basis of its periods
of remission, from the chronic
deteriorating illness called dementia
praecox, which Eugen Bleuler later
renamed schizophrenia.
History
• Sigmund Freud (1856 to 1939), after studying
hysteria, the prototypical neurosis, went on to
divide the neuroses into the actual neuroses,
the result of dammed-up sexual excitation, and
the psychoneuroses, the result of unconscious
conflict and compromise symptom formation.
• Freud recognized only the following subtypes of
neurosis: anxiety neurosis, anxiety hysteria
(phobia), obsessive-compulsive neurosis,
and hysteria.
History
• DSM-III was published in 1980.
• Seven years later, DSM-III-R was
published.
• Less than 1 year after the publication of
DSM-III-R, plans were announced for the
publication of DSM-IV.
• Delayed by 2 years, DSM-IV was
ultimately published in 1994.
DSM-III
• DSM-III was the first official diagnostic system to specify
inclusion and exclusion diagnostic criteria.
• Diagnostic reliability is better, and this is of benefit to
researchers attempting to replicate another researcher's
findings and to clinicians who can communicate more
effectively with one another.
• DSM-III was the first official psychiatric classification to
introduce a multiaxial evaluation system in which
different domains of information are described on five
different axes.
Multiaxial system
• Axis I consists of all clinical disorders, except for personality
disorders and mental retardation, both of which are reported
on Axis II.
• Prominent maladaptive personality traits that do not meet
criteria for a specific disorder and defense mechanisms are
also noted on Axis II.
• Axis III is for general medical conditions that might be
relevant to understanding or managing the patient's
psychiatric disorder.
• Axis IV is for noting psychosocial and environmental
problems that are relevant to the diagnosis, treatment, and
prognosis of Axis I and Axis II disorders.
• Axis V is the global assessment of functioning (GAF) scale, a
100-point rating based on symptom severity, social
functioning, and occupational functioning.
Groups of Conditions in DSM-IV-TR
•
Disorders usually first diagnosed in infancy, childhood, or adolescence
•
Delirium, dementia, amnestic, and other cognitive disorders
•
Mental disorders due to a general medical condition
•
Substance-related disorders
•
Schizophrenia and other psychotic disorders
•
Mood disorders
•
Anxiety disorders
•
Somatoform disorders
•
Factitious disorders
•
Dissociative disorders
•
Sexual and gender identity disorders
•
Eating disorders
•
Sleep disorders
•
Impulse-control disorders not elsewhere classified
•
Adjustment disorders
•
Personality disorders
•
Other conditions that may be a focus of clinical attention
www.dsm5.org
The human brain contains approximately 100 000
000 000 nerve cells or neurons, with each
having appr. 10 000 synapses.
(1) the cell body or soma, which contains the nucleus
and can be considered the metabolic center of the
neuron;
(2) the dendrites, processes that arise from the cell body,
branch extensively, and serve as the major recipient
zones of input from other neurons;
(3) the axon, a single process that arises from a
specialized portion of the cell body (the axon hillock)
and conveys information to other neurons; and
(4) the axon terminals, fine branches near the end of the
axon that form contacts (synapses) generally with the
dendrites or the cell bodies of other neurons, release
neurotransmitters, and thereby provide a mechanism
for interneuronal communication.
Projection neurons have long axons and convey
information from the periphery to the brain
(sensory neurons), from one brain region to
another, or from the brain to effector organs
(motor neurons). In contrast, local circuit
neurons or interneurons have short axons and
process information within distinct regions of the
brain.
Neurons can also be classified according to the
neurotransmitters they contain (e.g., the
dopamine neurons of the substantia nigra).
Brain also contains several types of glial cells,
which are at least ten times more numerous
than the neurons.
Oligodendrocytes and Schwann cells, are relatively small
cells that wrap their membranous processes around axons
in a tight spiral. (The resulting myelin sheath facilitates the
conduction of action potentials along the axon.)
Astrocytes, the most numerous class of glial cells, appear to
serve a number of functions, including participation in the
formation of the blood-brain barrier, removal of certain
neurotransmitters from the synaptic cleft, buffering of the
extracellular potassium (K+) concentration, and, possibly a
nutritive function as well.
The third class of glial cells, the microglia, are actually
derived from macrophages and function as scavengers,
eliminating the debris resulting from neuronal death and
injury.
THE INTERNAL AND EXTERNAL WORLDS
Brain is connected to two “worlds”: the world
within us, the internal milieu of the body;
and the world outside us, the external
environment.
In a profound sense, the principal task of the
brain is to mediate this divide -to mediate
between the body (the vegetative functions)
and the ever-changing world around us.
EXTERNAL WORLD
The brain is connected
to the outside world in
two main ways. The
first is through the
sensory apparatus;
the second is through
the motor apparatus.
This is how we receive
information from the
world and how we act
on the world.
Perceiving and representing the external world
Sensation is generated by
specialized sensory
receptors (in the eye, ear,
etc.) that transform
selected physical features
of the environment into
nerve impulses and send
the resultant information to
the brain: vision, hearing,
somatic sensation,..
Taste and smell are
“chemical” in nature.
Projection and Association Cortex
In the projection cortex the nervous tracts
derived from the various sensorimotor
organs literally project the receptor and
effector surfaces of those organs onto the
cortex, forming tiny functional maps of the
body all over the brain.
The pattern of neural activity representing the
information in the primary cortex still retains
its original topographic organization with the
receptive field of the sense organ.
Posterior and anterior half of the
brain
The posterior half of the hemispheres of the
brain is traditionally defined in
neuropsychology as a functional unit for
reception, analysis, and storage of
information.
Anterior half is defined as the functional unit
for programming, regulation, and
verification of action.
FUNCTIONAL BRAIN
SYSTEMS
Thalamocortical Systems
Basal Ganglia System
Limbic System
Talamocortical System
The thalamus and its
interactions with the
cerebral cortex have
primary importance in
the sensory, motor, and
associative functions of
the brain. Moreover, the
thalamus and its
interactions with the
cerebellar cortex are now
known to be involved in
cognition.
Basal Ganglia
The basal ganglia, once
thought of only as
part of the motor
system, is now
known to be a
complex system
within itself, and
plays a key role in the
cognitive functions of
the brain.
Limbic System
In contrast to the
thalamus and basal
ganglia, the limbic
system has long been
associated with
psychiatric symptoms
because of its clear
involvement in the
experience and
expression of emotions.
Emotions
The internal milieu refers to the world of respiration,
digestion, blood pressure, temperature control,
sexual reproduction, and the like. These organs
are responsible for the body's survival.
Operation of the viscera is of critical importance for
understanding the “inner world” in the
psychological sense (i.e., the world of subjective
experience).
The operation of these systems forms the basis of
our basic motivations or “drives”, and
modifications in our drives are experienced as
emotions.
Emotion
Emotion is akin to a
sensory modality -an
internally directed
sensory modality that
provides information
about the current
state of bodily self, as
opposed to the state
of the object world.
Emotions and Visceral Systems
Basic emotions
The seeking system (appetitive, dopamin)
* The lust subsystem (endorphin)
The rage system (serotonin)
The fear system (NE)
The Panic system (opioids)
Play and other social emotions
Cortical tone and arousal
Modifications in these internally directed brain
systems also affect our level of
consciousness in general. For this reason,
the visceral component of the brain is
traditionally defined as a functional unit for
modulating cortical tone and arousal.
Episodic memory also is inextricable from
emotion and consciousness.
Hypothalamus
Information travels up through the spinal cord
from the interior of the body, reaches, in the
first instance, the hypothalamus -which is
the controlling mechanism of the autonomic
nervous system. The hypothalamus is
intimately connected with the group of
structures known as the limbic system.
The functions of the internal milieu are
“projected” onto the hypothalamus.
Hypothalamus
The hypothalamus relays this information to a
range of other structures throughout the limbic
system and the rest of the brain. In this way,
the prevailing state of the body is linked with
concurrent objects in the external world, and
these links are committed to memory.
Then limbic system as a whole may be
regarded as the “association” area for visceral
information.
Feeling
The perception of
visceral information is
registered
consciously as
feelings of emotion
and (via association)
as reminiscences, in
the form of: “I saw
that, and it made me
feel like this”.
Executive control: PFC,
superstructure over the brain.
An extremely important aspect of prefrontal
lobe maturation involves the gradual
development of inhibitory control over the
stereotyped motor patterns released by the
visceral systems of the brain.
The developing prefrontal lobes also gain
inhibitory control over emotionality and
consciousness in general, thus providing the
basis of directed thinking and attention, and
so forth.
Neurotransmitters
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There are four broad classes of
neurotransmitter and neuromodulator
substances in the brain: monoamines,
amino acids, peptide neurotransmitters,
and the much more recently discovered
neurotrophins (also known as neurotrophic
factors).
Two additional neurotransmitters that do
not fit into these four major classes are the
gas nitric oxide and the purine-related
neurotransmitters adenosine and
adenosine triphosphate (ATP).
MONOAMINE
NEUROTRANSMITTERS
Serotonin
Dopamine
Norepinephrine ve epinephrine
Histamine
Acetylcholine
Monoamine
Neurotransmitters
The monoamine neurotransmitters, although
present in only a small percentage of neurons
localized in small nuclei of the brain, have
enormous impact on total brain functioning
because the diffuse projections of axons from
these monoaminergic neurons can affect virtually
every brain region.
Amino Acide NTs
In contrast to the monoamine
neurotransmitters, the amino acid
neurotransmitters are widely distributed in
the brain, and it is possible to conceptualize
the brain as reflecting the balance between
the excitatory amino acid glutamate, and
the inhibitory amino acid g-aminobutyric
acid (GABA).
AMINOACID
NEUROTRANSMITTERS
Glutamate
Aspartate
GABA
Glycine
Taurine
Neurotrophic factors
The prototypical trophic factor is nerve
growth factor (NGF): brain-derived
neurotrophic factor (BDNF),
neurotrophin-3 (NT-3) and NT-4/5
The biological effects of neurotrophins
are mediated via binding to specific
transmembrane receptors that trigger
changes in intracellular second
messengers.
Neurotrophic factors
The prototypical trophic factor is nerve growth
factor (NGF): brain-derived neurotrophic factor
(BDNF), neurotrophin-3 (NT-3) and NT-4/5
The biological effects of neurotrophins are
mediated via binding to specific transmembrane
receptors that trigger changes in intracellular
second messengers.
Intraneuronal Signaling
Pathways
Cyclic AMP System
Cyclic GMP
Phosphoinositide (PI)
Direct Coupling Between G Proteins and Ion
Channels
Tyrosine Phosphorylation
Signal Transduction
The process of chemical neurotransmission
refers strictly to the release of a
neurotransmitter by a presynaptic neuron,
the travel of that neurotransmitter across
some space (e.g., the synaptic cleft), and
the binding of that neurotransmitter to its
specific receptor on a postsynaptic neuron
(or an autoreceptor on a presynaptic
neuron).
Psychopharmacology
Neuroelectrophysiology
Molecular neurobiology
Genetic
Cognitive neuroscience
Neuroimaging
Psychoneuroendocrinology
TOPOGRAPHICAL MODEL OF
THE MIND
CONSCIOUS
UNCONSCIOUS
PRECONSCIOUS
PSYCHOSEXUAL
DEVELOPMENT
Oral stage
Anal stage
Urethral stage
Phallic stage
Latency stage
Genital stage
STRUCTURE OF PSYCHIC
APPARATUS
ID
EGO
SUPEREGO
EGO PSYCHOLOGY
EGO VS ID
DEFENSE MECHANİSMS
EGO AS AN ADAPTATION ORGAN
CONFLICT-FREE EGO SPHERES
ERIKSON
Basic trust & Mistrust
Autonomy & Shame and doubt
Initiative & Guilt
Industry & Inferiority
Identity & Role confusion
Intimacy & Isolation
Generativity & Stagnation
Integrity & Despair
OBJECT RELATIONS THEORY
Attachment theory
Self and Other
Integration of the Self
Mirror neurons
Theory of Mind
Cognitive (and) Behavior
Therapy
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Klasik koşullama (Pavlov)
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Operan (Edimsel) Koşullama
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Öğrenme Kuramı
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Cognitive (Affective) Neuroscience
Behavior therapy
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Systematic desensitization
Graded exposure
Flooding
Participant modeling
Assertiveness and social skills training
Aversion therapy
Eye movement desensitization
Positive reinforcement
Cognitive therapy
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Beck: CT is “based on underlying
theoretical rationale that an individual's
affect and behavior are largely
determined by the way in which he
structures the world.”
Cognitive therapy
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Eliciting automatic thoughts
Testing automatic thoughts
Identifying maladaptive assumptions
Testing the validity of maladaptive
assumptions
Behavioral techniques
Imagery
CBT
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I am fearful
I am moderately fearful,
quite generous, and
fairly intelligent.
I always have been My fears vary from time
to time and from
and always will be
situation to situation.
a coward
I have a defect in
I avoid situations too
my character
much, and I have
many fears.
CBT
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Overgeneralizing
If it's true in one case, it
applies to any case.
Excessive
responsibility
Catastrophizing
I am responsible for all
bad things, etc.
Dichotomous
thinking
Always think of the
worst.
Everything is either one
extreme or another.
DBT
Dialectical behavior therapy (DBT) is a
therapeutic methodology developed by Marsha M.
Linehan, a psychology researcher at the
University of Washington, to treat persons with
borderline personality disorder (BPD).
DBT combines standard cognitive-behavioral
techniques for emotion regulation and realitytesting with concepts of mindful awareness,
distress tolerance, and acceptance largely
derived from Buddhist meditative practice.
DBT
Linehan united commitment to the core conditions
of acceptance and change through the Hegelian
principle of dialectical progress, in which thesis +
antithesis → synthesis, and proceeded to
assemble a modular array of skills for emotional
self-regulation, drawn from Western (e.g.,
cognitive behavioral therapy and an interpersonal
variant, “assertiveness training”) and Eastern
(e.g., Buddhist mindfulness meditation)
psychological traditions.
All DBT involves two components:
* An individual component in which the therapist and
patient discuss issues that come up during the week,
recorded on diary cards, and follow a treatment target
hierarchy. Self-injurious and suicidal behaviors take first
priority, followed by therapy interfering behaviors. Then
there are quality of life issues and finally working towards
improving one's life generally. During the individual
therapy, the therapist and patient work towards
improving skill use. Often, a skills group is discussed and
obstacles to acting skillfully are addressed.
All DBT involves two components:
* The group, which ordinarily meets once
weekly for two to two-and-a-half hours,
learns to use specific skills that are broken
down into four modules:
- core mindfulness skills,
- interpersonal effectiveness skills,
- emotion regulation skills, and
- distress tolerance skills.