Introduction to Psychiatry

Dr Vivek Kumar
Associate Professor
 Index
Definition. Forensic Psychiatry.
Epidemiology. Ethics in Psychiatry.
Etiology. Major Establishments.
Classification in Indian Psychiatric
Psychiatry. Society.
Assessment of a National Mental Health
Psychiatric Patient. Programme.
Lab tests in Psychiatry.
 Psychiatry? And Psychiatrist?
Psychiatry is the branch of medicine focused on the
diagnosis, treatment and prevention of mental,
emotional and behavioral disorders.

A psychiatrist is a medical doctor who specializes in

mental health, including substance use disorders.
Psychiatrists are qualified to assess both the mental and
physical aspects of psychological problems.
Who are Clinical Psychologist?
PhD or M.Phill in clinical psychology.

Clinical psychology is different from psychiatry.

Although practitioners in both fields are experts
in mental health, clinical psychologists treat mental
disorders primarily through psychotherapy (Non
Psychopharmacological Management).

Central to its practice are psychological

assessment, clinical formulation, and psychotherapy.
Psychiatrists Contributions
Sigmund Freud- Topographical Theory, Oedipus complex. Father
of psychoanalysis- a therapeutic technique. Books - The Interpretation of
Dreams, Beyond the Pleasure Principle, Civilization and Its Discontents and
The Ego and the Id.
Aaron Beck - American psychiatrist; contributed to cognitive therapy. Books -
Cognitive Therapy of Depression, The Evolution of Psychotherapy.
Carl Jung - Swiss psychiatrist who founded analytical psychology. The
Structure and Dynamics of the Psyche, The Psychology of Religion and
Psychological Types
Alfred Adler - Alfred Adler is best known for his theory of individual
psychology.
Eugen Bleuler - Work on Schizophrenia. 
Nathan S. Kline - Field of Psychopharmacology.
Harry Stack Sullivan - Best known for his work on interpersonal relations.
Emil Kraepelin – Developed first system of psychiatric nosology.
Clinical Psychologists Contribution.
William Wundt - The Father of Experimental Psychology,”
William James (1842) - published “The Principles of
Psychology” 
Ivan Petrovich Pavlov - Classic Conditioning.
B.F. Skinner – Operant Conditioning.
Jean Piaget - Child development and cognitive psychology.
Erik Homburger Erikson - theory of Psychosocial Stages of
Human Development.
Albert Bandura  - Social Learning Theory.
Anna Freud (1895) - “Beating Fantasies and Daydreams,” “The
Ego and The Mechanisms of Defense.”
 Epidemiology (Global)
Share of global
Number of people with Share of males:females
Disorder population with
the disorder (2017) with disorder (2017)
disorder (2017)

Any mental health disorder 10.7% 792 million 9.3% males; 11.9% females

Depression 3.4% [2-6%] 264 million 2.7% males; 4.1% females

Anxiety disorders 3.8% [2.5-7%] 284 million 2.8% males; 4.7% females

Bipolar disorder 0.6% [0.3-1.2%] 46 million 0.55% males;0.65% females

Eating disorders
(clinical anorexia & bulimia) 0.2% [0.1-1%] 16 million 0.13% males;0.29% females

Schizophrenia 0.3% [0.2-0.4%] 20 million 0.26% males;0.25% females

Any mental or substance use 13% [11-18%] 970 million 12.6% males; 13.3% females
disorder

Alcohol use disorder 1.4% [0.5-5%] 107 million 2% males; 0.8% females

Drug use disorder (excluding 0.9% [0.4-3.5%] 71 million 1.3% males; 0.6% females
alcohol)
 Epidemiology (Indian)
Both sexes Males Females
All mental disorders 14·3% (12·9–15·7) 14·2% (12·8–15·6) 14·4% (13·1–15·8)
Intellectual disability 4·5% (3·0–6·0) 4·7% (3·1–6·3) 4·3% (2·9–5·7)
Depressive disorders 3·3% (3·1–3·6) 2·7% (2·5–3·0) 3·9% (3·6–4·3)
Anxiety disorders 3·3% (3·0–3·5) 2·7% (2·4–2·9) 3·9% (3·6–4·3)
Conduct disorder 0·8% (0·6–1·0) 1·0% (0·8–1·3) 0·6% (0·4–0·7)
Bipolar disorder 0·6% (0·5–0·7) 0·6% (0·5–0·7) 0·6% (0·5–0·7)
ADHD 0·4% (0·3–0·5) 0·6% (0·5–0·7) 0·2% (0·2–0·3)
Autism spectrum 0·4% (0·3–0·4) 0·5% (0·5–0·6) 0·2% (0·2–0·2)
disorders
Schizophrenia 0·3% (0·2–0·3) 0·3% (0·2–0·3) 0·2% (0·2–0·3)
Eating disorders 0·2% (0·1–0·2) 0·1% (0·9–1·4) 0·3% (0·2–0·3)
Prevalence of mental disorders in India, 2017 (Lancet Psychiatry 2020;
7: 148–61. Published Online December 23, 2019)
 Etiology Models
Medical or biomedical model.

Psychoanalytic theories.

Attachment theory.

Evolutionary psychology.
Etiology?
 Bio-Psycho-Social model
Biological (physiological pathology)

Psychological (thoughts, emotions and behaviors such as

psychological distress, fear/avoidance beliefs, current
coping methods and attribution)

Social (socio-economical, socio-environmental, and

cultural factors such as work issues, family circumstances
and benefits/economics)

(The Biopsychosocial model was first conceptualised by George Engel in 1977)

 Biological factors
Prenatal damage
Infection, disease and toxins
Injury and brain defects
Neuro-transmitter systems
Abnormal levels of dopamine activity correspond with
several disorders (reduced in ADHD and OCD, and
increased in schizophrenia).
The dysfunction in serotonin and other  monoamine 
neurotransmitters (norepinephrine and dopamine)
Chronic Substance abuse
Life experience and environmental factors
Poor parenting, abuse and neglect
Adverse childhood experiences
 abuse, poverty, malnutrition, and traumatic experiences
Familial and close relationships
Parental divorce, death, absence, or lack of continuity
Social expectations and esteem
both too low of self-esteem or too high can be detrimental to
an individual's mental health
Communities and cultures
 poverty, unemployment or underemployment, lack of social
cohesion, and migration
 Assessment of Psychiatric Pt.
A psychiatric assessment, or psychological
screening, is the process of gathering information
about a person within a psychiatric service, with the
purpose of making a diagnosis.
The assessment includes social and biographical
information, direct observations, and data from
specific psychological tests.
 It can be a multi-disciplinary process
involving nurses, psychologists, occupational
therapist, social workers, and professional counselors.
 Assessment (Parts)
Demographic Profile including informant and source of
referral.
Chief Complains
 Onset, Course, Duration, Episode,
Precipitating/Predisposing/Perpetuating Factors and Past
Previous T/t. (OCD EPT)
History
 History of Present/Past Illness, Medical illness, Personal
history (including birth complications, childhood
development, parental care in childhood, educational and
employment history, relationship and marital history, and
litigation).
 Assessment (Parts)
The history also includes an enquiry about the
individual's current social circumstances, family
relationships, current and past use of alcohol and
illicit drugs, and the individual's past treatment
history (current and past diagnoses,

Cultural values can influence the way a person and

their family communicates psychological distress and
responds to a diagnosis of mental illness.
 Assessment (Parts)
Mental status examination
What: The MSE is a structured way of describing a patient's current state
of mind.
Domains
General Appearance and Behavior
Consciousness and Orientation
Attention And Concentration
Affect
Thinking
Perception
Memory
Intelligence
Judgment
Insight
General Appearance and Behavior
Gait
Built
Personal Hygiene
Grooming
Psychomotor Activity
Abnormal Movements
Eye To Eye Contact/Gaze
Rapport
Consciousness and Orientation
Definition- State of awareness.
Fully conscious
Altered consciousness
Stupor, Coma.
Disorientation: to time, place and person – Delirium
Denotes Organicity.
Attention And Concentration
Attention: is the amount of effort exerted in focusing
on certain portion of an experience.
Digit Span Test
Concentration: Ability to sustain a focus on one
activity.
Serial subtraction test. (100-7 test)
 Affect and Mood
Affect: Observed expression of emotion, possibly
inconsistent with patients (subjective) description.
Subjective
Objective
Intensity
Range – towards depressed, elevated , anxious or angriness.
Constricted, Flat.
Appropriateness
Relatedness
Mood: Pervasive and Sustained emotion subjectively
experienced & reported and observed by others.
 Speech
Loudness,
Rhythm, 
Prosody, 
Intonation,
Pitch, 
Phonation, 
Articulation,
Quantity,
Rate,
Spontaneity and
Latency of speech.
 Thinking
Thought process
Flow: decreased/average/increased.
Push, Pressure, Uninterruptable. Thought block.
Poverty of Speech.
Form: Grammatical Corrections and Meaningfulness.
Irrelevant, incoherent, loosening/derailment (knight's
move), Flight of Ideas, Word Salad, Neologism, etc.
 Thinking
Thought Content:
Poverty of thought: Minimal content.
Overvalued Ideas: An overvalued idea is an emotionally charged belief.
Delusions: A false belief which can not be corrected by reasoning and not
in the context of socio-cultural background and intelligence of the patient.
Preoccupation: thoughts which have an undue prominence in the
person's mind.
Obsessions: "undesired, unpleasant, intrusive thought that cannot be
suppressed through the patient's volition"
Phobia: "a dread of an object or situation that does not in reality pose any
threat" etc.
Thought Possession:
Thought insertion/withdrawal/broadcasting.
 Perception
Illusions: An illusion is defined as a false sensory
perception in the presence of an external stimulus.
Hallucinations: A hallucination is defined as a sensory
perception in the absence of any external stimulus, and is
experienced in external or objective space.
Pseudo-hallucination: is experienced in internal or
subjective space (for example as "voices in my head") and
is regarded as akin to fantasy.
Derealization: a distortion of the sense of reality.
Depersonalization: a distortion of the sense of self.
Memory
Immediate: Registration and Recall
Recent
Recent Past
Remote
 Judgment
Judgment refers to the patient's capacity to make sound, reasoned and
responsible decisions.
Personal
Social
Test: "what would you do if you found a stamped, addressed envelope lying in
the street?”

Intelligence
General fund of knowledge:
Simple
Arithmetic: Addition, Subtraction, Multiplication and Division.
Abstract:
Multidimensional thinking with ability to use metaphors and hypothesis
appropriately.
Insight
The person's understanding of his or her mental illness
6 levels
 1. Complete denial of illness
 2. Slight awareness of being sick and needing help, but denying it at the same
time
 3. Awareness of being sick but blaming it on others, on external factors, or on
organic factors
 4. Awareness that illness is caused by something unknown in the patient
 5. Intellectual insight: admission that the patient is ill and that symptoms or
failures in social adjustment are caused by the patient's own particular irrational
feelings or disturbances without applying this knowledge to future experiences
 6. True emotional insight: emotional awareness of the motives and feelings
within the patient and the important persons in his or her life, which can lead to
basic changes in behavior.
 Scales and Psychological testing in
Assessment
 Hamilton Rating Scale for  Rorschach test
Depression (HAM-D)  Thematic apperception test
 Montgomery-Åsberg Depression
 Draw-A-Person test
Rating Scale (MADRS)
 Young Mania Rating Scale (YMRS)  Sentence completion test
 Positive and Negative Syndrome  Picture Arrangement Test
Scale (PANSS)  Seguin Form Board Test
 Mini-mental state examination  Bhatia Battery Test
 Hamilton Anxiety Scale (HAM-A)  Melin’s intelligence test for
 Yale–Brown Obsessive Compulsive children
Scale (Y-BOCS)
 ADHD Rating Scale
 Alcohol Use Disorders
Identification Test
Classification of mental disorders
psychiatric nosology or psychiatric taxonomy.

Chapter V of the tenth International Classification of

Diseases (ICD-10) produced by the World Health
Organization (WHO);

The Diagnostic and Statistical Manual of Mental

Disorders (DSM-5) produced by the American
Psychiatric Association (APA).
 ICD - 10
F00: Organic, including symptomatic, mental disorders
F10: Mental and behavioural disorders due to use of psychoactive
substances
F20: Schizophrenia, schizotypal and delusional disorders
F30: Mood [affective] disorders
F40: Neurotic, stress-related and somatoform disorders
F50: Behavioural syndromes associated with physiological disturbances
and physical factors
F60: Disorders of personality and behaviour in adult persons
F70: Mental retardation
F80: Disorders of psychological development
F90: Behavioural and emotional disorders with onset usually occurring in
childhood and adolescence
In addition, a group of "unspecified mental disorders".
Physical Examination
 Lab Tests in Psychiatry
Routine Tests.
Co-morbid Physical Illnesses. (DM, TB, etc)
Associated Condition. (ALD, COPD)
Rule out Imitating Illnesses. (Thyroid dysfunctions,
Anemia, SSPE)
Rule out Organic illness. (Imaging)
Drug Monitoring.
Drug Side Effects.
 Treatments
Pharmacological Non Brain Psycho- Hormonal
Pharmacological Stimulation Surgeries Therapy

Antipsychotic Psychoanalysis Cranial Implanted Hormone

drugs or Electrical Cortical Suppression
neuroleptics, Psychotherapy Stimulation Stimulator (ICS),
(CES), Estradiol
Antidepressant, Behavior Therapy Deep Brain administration
Electroconvulsiv Stimulation
Mood Stabilizers, Cognitive e Therapy (DBS), Androgen
Therapy (ECT), Administration
Antianxiety or and Vagus Nerve
Anxiolytic/ Stimulation
Hypnotic, and Transcranial (VNS).
Magnetic
Psychostimulants Stimulation Cingulotomy
(TMS).
Leukotomy
 Forensic Psychiatry
Forensic psychiatry is the implication of psychiatry
knowledge in untangling the legal issues and a key of
better administration of justice.
 The case of R vs. M’ NAGHTEN this case opens the
door for the defence of insanity in the year of 1843,
 In the year of 1964 the renowned foreign
psychiatrist Dr Lawrence Z. Freedman introduced the
term Forensic psychiatry is a sub-speciality of
psychiatry.
 Forensic Psychiatry
Section 84 provides unsoundness of mind as a defence was inserted in
Indian Penal Code.
Section – 328 to 339 of code of criminal Procedure 1973 gives provision as
to the accused person of unsound mind.
Persons with disability (equal opportunities, protection of rights, full
participation) Act, 1995 (PDA-95)
National Trust Act, 1999 (encourage people with autism, cerebral
palsy, mental retardation and various disabilities to live as independently
and as close to the society )
Hindu Marriage Act , 1955. 
● As a result of unsoundness of mind, neither party is incapable of giving
legitimate consent. 
● Even if they are capable of consenting, they must not suffer from psychiatric
illnesses of such a kind or to such a degree that they are unfit for procreation.
● Do not suffer from repeated fits of madness.
The Mental Health Care Act, 2017
 Decriminalization of attempted Suicide
Section 309 IPC. Attempt to commit suicide: Whoever attempts
to commit suicide and does any act towards the commission of such
offence, shall be punished with simple imprisonment for a term
which may extend to one year or with fine, or with both.
Section 309 of the Indian Penal Code was set to be limited in effect
by the Mental Health Care Bill, 2013. The Mental Health Care Bill
was introduced to the Rajya Sabha on 19 August 2013 and provides,
in article 124, that “Notwithstanding anything contained in section
309 of the Indian Penal Code, any person who attempts to commit
suicide shall be presumed, unless proved otherwise, to be suffering
from mental illness at the time of attempting suicide and shall not
be liable to punishment under the said section.”
 Ethics in Psychiatry
Medical ethics is an applied branch of ethics which
analyzes the practice of clinical medicine and related
scientific research.
The committee members which comprises Prof. J. S.
Neki, Prof. D. N. Nandi, Prof. A. K. Agarwal, Dr. V. N.
Vahia and Dr. J. K. Trivedi and others formulated the
code of ethics in ANCIPS Cuttack 1989.
 Ethics in Psychiatry
The fraud and abuse of psychiatry must be dealt on a serious note to
maintain highest possible ethical and professional standards.
such as upgrading, Ganging, Touting, Self advertisement,
 unavailability, publishing research or report to press,
unethical drug trials, teaching unprepared topics,
not upgrading self through CMEs,
selling of sample medicines,
prescribing unscientific drug formulations,
practicing quackery, dichotomy or fee-splitting,
offering or receiving kickbacks,
steering the patient to a particular pharmacy,
non-capping, out of proportion, and illegitimate claim for
professional services)
 Major Psychiatric Establishments
National Institute Of Mental Health And Neuro
Sciences, Bengaluru. (1847-Bangalore Lunatic Asylum; 1974-
formation of the National Institute of Mental Health and Neuro
Sciences (NIMHANS)
Central Institute Of Psychiatry, Kanke, Ranchi. (The
British established this hospital on 17th May 1918 k/a Ranchi European
Lunatic Asylum.)
Institute Of Mental Health And Hospital, Agra. (Agra
Lunatic Asylum, was established in September 1859)
Institute Of Human Behavior And Allied Sciences,
Delhi. (1993)
Indian Psychiatric Society
Founded on 7th January 1947
The organization holds its origins in 1929 when Col
Berkley Hill founded The Indian Association of
Mental Hygiene
The IPS began in 1947 with 15 founder members and
has now grown to a membership of above 7000
specialists. The IPS currently represents the largest
society of mental health professionals in India & works
on health advocacy, social activism, policy formulation
& medical research in the field of mental health. 
  National Mental Health Programme
(NMHP) in 1982
NMHP has 3 components:
Treatment of Mentally ill
Rehabilitation
Prevention and promotion of positive mental health.
Aims
Prevention and treatment of mental and neurological disorders and their
associated disabilities.
Use of mental health technology to improve general health services.
Application of mental health principles in total national development to
improve quality of life.
Strategies
Integration mental health with primary health care through the NMHP
Provision of tertiary care institutions for treatment of mental disorders
Eradicating stigmatization of mentally ill patients and protecting their rights
Thank You