The document outlines the learning outcomes and content of a psychiatry lecture on the classification and causes of mental illness. It discusses the classification of mental disorders according to diagnostic manuals like ICD and DSM, as well as the multi-factorial biological, psychological, and social causes of abnormal behavior. It also covers the phenomenology and management of various conditions like psychoses, neuroses, and cognitive disorders.

1. Dr. Zahiruddin Othman
Psychiatry Department, USM
GMT 201; 23rd October 2019

2. Learning outcome
1. Classification of mental illness
a) Know some history on the development of the present nomenclature
b) Outline the general principles of classification of psychiatric illness according the
International Classification of Diseases (ICD) and (DSM IV)
2. Causes of mental illnesses
a) Understand the characteristic symptomatology of specific mental illness
b) Understand the multi-factorial causation of abnormal behavior understood in terms of the
predisposing, precipitating and perpetuating factors
c) Know the biological, psychological and social aspects that contribute to the above
etiological factors discussed in general.
d) Know how to evaluate the severity of abnormal behavior
3. Outline the phenomenology of psychoses, neuroses and cognitive disorders.
4. Outline the principles of management comprising of curative, preventive and
the psycho-social aspects.

3. Classification of Mental Illness
• Ego boundary & reality testing
• Psychoses vs. neuroses
• Etiology
• Primary vs. secondary
• Functional vs. organic vs.
substance-induced disorders
• Endogenous vs. exogenous
depression
• Biological vs. psychological vs.
social causes
• Course of illness
• Manic depressive illness vs.
dementia praecox
• Clinical vs. personality disorders
• Symptoms/syndrome
• Cognitive, psychosis, mood,
anxiety, obsession, somatic,
behavioural
• Classification system
• Categorical vs. dimensional
• Modern classification: ICD & DSM

4. DSM-I
(1952)
DSM-II
(1968)
DSM-III
(1980)
DSM-IIIR
(1987)
DSM-IV
(1994)
DSM-IV-TR
(2000)
DSM-5
(2013)
ICD-9
(1975)
ICD-10
(1992)
ICD-8
(1968)
First DSM. Focus on
diagnosis. Influenced
by psychoanalytic
thinking
No major
changes
compared to
DSM-I
Use of field tested
criteria to achieve
reliability. No
theory of aetiology.
Conservative
revision of
DSM-III.
Text is revised, but
the diagnostic
criteria are not
Latest version. Aim at
incorporating new
genetic and
neurobiological findings.
Timeline of the development of the present nomenclature
ICD-11
(2018)

5. International Classification of Disease (ICD)

6. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)

7. Differences between DSM and ICD
Diagnostic and Statistical
Manual of Mental Disorders,
5th Edition (DSM-5)
International Classification of
Disease (ICD)
Applies to only mental
disorders
Applies to both physical &
mental disorders
Produced singularly by the
American Psychiatric
Association (by invite only)
Produced by World Health
Organization
Approved by the APA Approved by WHO
Predominately used by
researchers worldwide and by
US clinicians
Predominately used by
clinicians outside of the US
Need to pay For free
https://www.who.int/classifications/icd/
ICD10Volume2_en_2010.pdf

8. 1. It is usually severe
2. It involves the total
personality
3. It is usually
accompanied by
impaired reality
testing

9. Characteristic Symptomatology of Specific
Mental Illness
CORE PSYCHOPATHOLOGY CHARACTERISTIC
SYMPTOMS
ASSOCIATED FEATURES

10. Characteristic
Symptomatology
• Aberrant salience hypothesis
(Kapur)
• Loss of ego boundary
• Impaired reality testing
• Overinclusive thinking (Cameron)
• Self-monitoring dysfunction (Frith)

11. Understanding behaviour in the context of the
underlying psychopathology
Difficulty
falling
asleep
• anxiety
Early
morning
awakening
• depression
Reduced
need for
sleep
• mania
Agitation • psychosis
Irritability • Mania
Delusions • Psychosis
Drug-
seeking • Addiction

12. Mania
Depression

13. Mania and Hypomania Depression
• A distinct period of persistently
elevated, euphoric, or irritable mood
• Inflated self-esteem or grandiosity
• Decreased need for sleep
• More talkative than usual or pressure to
keep talking
• Flight of ideas or subjective experience
that thoughts are racing
• Distractibility
• Increased in goal-directed activity or
psychomotor agitation
• Excessive involvement in pleasurable
activities that have a high potential for
painful consequence
• Depressed mood almost everyday
• Loss of interest or pleasure in all, or
almost all activities
• Significant weight gain or loss
• Decrease or increase in appetite
• Sleeping too much or too little
• Fatigue or loss of energy
• Feeling worthless or excessive or
inappropriate guilt
• Diminished ability to think or
concentrate, or indecisiveness, nearly
everyday
• Recurrent thoughts of death (not just
fear of dying), suicidal thoughts

14. Characteristic Symptomatology of Anxiety Disorders
Panic
Fear
Worry
Thoughts
•Corticostriato-
thalamocortical
circuits
Emotion
• Amygdala
Somatic
•Locus Coeruleus
Behavior
Intensity

15. Causation of Abnormal Behavior
Predisposing Precipitating Perpetuating
Biological History of head injury
Mental retardation
Family history
Past drug abuse
Recent drug abuse
Thyroid disease
Sleep deprivation
Continuing drug abuse
Poor compliance
Poor social rhythm
Psychological Personality disorder
Childhood conflict
Loss of parents
Fail in exam
Loss of income
Grief
Unresolved conflict
Poor acceptance of illness
Social Immigration
Unemployment
Marital conflict
Job stress
Ongoing marital conflict
Interpersonal problem
EXAMPLE

16. Multifactorial
Causation of Mental
Disorders
• Polygenetic inheritance +
environmental factors =
multifactorial
• Multifactorial threshold
model
• Stress act on vulnerability,
if exceeds the threshold 
illness
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1685995/

17. Multifactorial Causation of Schizophrenia

18. Hyperdopaminergic state in
mesolimbic area  positive
symptoms (hallucinations &
delusions)

19. The monoamine receptor
hypothesis of depression
posit that deficient activity
of monoamine
neurotransmitters causes up
regulation of postsynaptic
monoamine
neurotransmitter receptors,
and that this leads to
depression.
Depression
GABAergic agents such as
benzodiazepines may
alleviate anxiety/fear by
enhancing phasic
inhibitory actions at
postsynaptic GABAA
receptors within the
amygdala.
Phobia
Pathological worry
may be caused by
overactivation of
corticostriato-
thalamo-cortical
(CSTC) circuits.
Anxiety

20. Neural Circuitry in Mental Illness

21. PSYCHOLOGICAL
FACTORS
• Psychodynamic Perspective
• Originate from intra-psychic
conflict
• Cognitive-Behavioral Perspective
• Learned maladaptive behavior
patterns
• Humanistic Perspective
• Originates from thinking one must
earn positive regard from others

22. Breathing exercise
Muscle relaxation
Imagery
Aversion therapy
Systematic
desensitization
Exposure/flooding
Classical Conditioning
Token economy
Parent management
training
Addiction
Operant Conditioning
Modelling
Social skill training
Social LearningApplication

23. Sociocultural
Perspective
• Cultures play a role
• Perceive actions as
abnormal, or normal
• Culture-Bound
Syndromes
• Mental disorders only
seen in certain cultures
• Use of folk medicine
Main Puteri di Bachok

24. Culture-Bound
Syndrome
• “CBS is a collection of signs and
symptoms which is restricted to a
limited number of cultures
primarily by reasons of their
psychosocial features” [Prince
1985]
• The condition is usually recognized
and treated by the folk medicine of
the culture
TextbookofCulturalPsychiatry-editedbyDineshBhugraApril2018

25. Figure 1: Attack of acute “genital
disappearance” anxiety during
epidemic of koro in South China, 1985.
Figure 2: Exorcism treatment of koro attack during epidemic
in South China, 1985. Extracting the possessing female fox
spirit from the middle finger of the koro patient.
source

26. Severity of Abnormal
Behavior - evaluation
• Degree of symptoms &
functional impairment
• Assessment
• Clinical
• Interview, observation
• Instrument
• Self-rated, clinician-rated
• Biomarker
• Cortisol, skin conductance, heart
rate variability, etc.
https://www.youtube.com/watch?v=ItjstlkgCUM

27. Phenomenology of
Psychoses, Neuroses and
Cognitive Disorders
• Aims to explain the
basic data of psychiatry
by:
• Defining the essential
qualities of morbid
mental experiences
• Understanding what
the patient is
experiencing

28. Abnormal
Perception
Sensory
DISTORTION
Change in intensity
Hyperacusis
Visual
hyperaesthesia
Change in quality
Micropsia
Macropsia
Dysmegalopsia
Change in the
associated feelings
Derealization
Depersonalization
Sensory
DECEPTION
Hallucination Pseudo-
hallucination
Illusion
Completion
Affect
Pareidolia

29. Pareidolia

30. Hallucination - Definitions
• A perception without an object (Esquirol, 1838)
• Hallucinations proper are false perceptions which are not in any way
distortion of real perceptions but spring up on their own as
something quite new and occur simultaneously with and alongside
real perception (Jasper, 1962)
• An hallucination is an exteroceptive or interoceptive percept which
does not correspond to actual object (Smythies, 1956)

31. Hallucinations
Complexity
Elementary Complex
Voices
Music
Modality
Auditory
Addressing the
patient as …
Thought
spoken aloud
Second Person
Third Person
Content
Commanding
Commenting
Discussing/
Arguing
Visual Other
Tactile
Olfactory
Gustatory
Thought spoken aloud
(gedankenlautwerden) or
thought echo (echo de la pensée)

32. Visual hallucinations
Psychosis
Delirium and
dementia
Charles Bonnet
syndrome
Seizure & Migraine Drugs
Charles Bonnet Syndrome is
a condition that often affects
people with macular
degeneration or diabetic eye
disease.

33. phantom mirror
image –
experience of
seeing oneself
and knowing
that it is oneself
Autoscopy
a hallucination is
provoked by
external
stimulus. Both
hallucination and
the normal
percept are
experienced in
the same
sensory modality
simultaneously
Functional
hallucination
same as
functional
hallucination
except the
percept and
hallucination
occur in different
modality
Reflex hallucination
Concrete
awareness –
hallucinations
experienced
outside the
limits of sensory
field
Extracampine
hallucination
Hallucination
upon entering
sleep
Hypnagogic
hallucination
An hallucination
in which things,
people, or
animals seem
smaller than
they would be in
real life
Lilliputian
hallucination
Hallucinations
doppelganger

34. Perception / Hallucination Pseudo-
hallucination
Fantasy / Imagery
Experience Concrete, tangible, objective, real Pictorial, subjective
Location Outer objective space Inner subjective space
Definition Definite outline, complete sound Indefinite, incomplete
Vividness Full, fresh, bright Dim or neutral
Constancy Retained Evanescent
Independence from volition Cannot be dismissed, recalled or
changed at will
Requires voluntary creation
Insight Has quality of perception Fantasy has quality of idea
Behavioral relevance Relevant to emotions, needs and
actions
Not relevant
Sensory modality Could experience object in another
modality
Could not
Existence Object exists independent of
observer
Depends on observer for
existence

35. DISORDER OF
THINKING
FORM
Flight of ideas
Perseveration
Loosening of
associations
FLOW
(stream)
Pressure of
thought
Poverty of
thought
Thought
blocking
CONTENT
Delusions
Obsessions
POSESSION
Thought
insertion
Thought
withdrawal
Thought
broadcasting
Oxford Textbook of Psychiatry, Second Edition, 1989 https://www.youtube.com/watch?v=r09c87UmeYo

36. A Model of Associations

37. Circumstantiality
Unnecessary
trivial details
Unnecessary trivial details
Unnecessary
trivial details
Goal finally
reached

38. Flight of Ideas
• Weakened determining
tendency (the flow of thinking
towards its goal) by
• Clang associations
• Punning
• Rhyming
• Distracting cues from immediate
surroundings
• Characteristic of mania

39. LOOSENING OF ASSOCIATION
• Denotes loss of the normal structure of
thinking
• Appears as muddled and illogical
conversation to the interviewer
• Examples
• Knight’s move (derailment), word salad,
verbigeration
• Occurs most often in schizophrenia

40. DELUSIONS AND OTHER ERRONEOUS IDEAS
“form”
Overvalued
idea
Delusion
“understandability”
Primary
Secondary
Content / theme
Persecutory
Grandiose
Jealousy

41. Conrad’s Stage Model of Beginning Schizophrenia
Trema
• Delusional mood
Apophany
• Searching for a
new meaning
Anastrophy
• Heightening of
psychosis
Consolidation
• Forming a new
world based on
new meanings
Residuum
• Eventual autistic
state
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800156/

42. Primary delusions
Jaspers describes four types of primary delusion:
• delusional intuition - where delusions arrive 'out of the blue', without external
cause. [autochthonous delusion]
• delusional perception - where a normal percept is interpreted with delusional
meaning. For example, a person sees a red car and knows that this means their
food is being poisoned by the police.
• delusional atmosphere - where the world seems subtly altered, uncanny,
portentous or sinister. This resolves into a delusion, usually in a revelatory fashion,
which seems to explain the unusual feeling of anticipation. [delusional mood]
• delusional memory - where a delusional belief is based upon the recall of
memory or false memory for a past experience. For example, a man recalls seeing
a woman laughing at the bus stop several weeks ago and now realizes that this
person was laughing because the man has animals living inside him.

43. Delusional atmosphere/mood
• ‘Wherever you are looking, everything looks unreal.’
• ‘People went down the street like in a puppet theatre’
• ‘People look confusing... they are almost like they’re made up...
People that I know... have masks on or they’re disguising themselves.
It’s like a big play... like a big production story’
• ‘When you go somewhere, everything seems already set up for you
like in a theatre – it’s really eerie, and you get terribly frightened’

44. Overvalued Idea
• An acceptable, comprehensible idea pursued by the patient beyond
the bound of reason
• Neither delusional or obsessional, but preoccupying to the extent of
dominating the sufferer’s life
• Associated with strong affect and abnormal personality
• Disorders with overvalued ideas;
• Paranoid state, Morbid jealousy, Hypochondriasis, Dysmorphophobia,
Parasitophobia (Ekbom’s syndrome), Anorexia nervosa, Transsexualism and
etc

45. Obsession vs. Delusion
Obsession
• Repetitive
• Intrusive
• Purposeless
• Logical (magical thinking)
• Ego-dystonic
• Rejected/resisted
Delusion
• Intrusive
• Purposeful
• Illogical
• Ego-syntonic
• Accepted by patient

46. Definitions of delusion
• Overriding rigid convictions which create a self-evident, private, and
isolating reality requiring no proof
• A false unshakeable belief which arises from internal morbid
experience. It is out of keeping with the patient’s educational and
cultural background (Hamilton, 1978)
• A judgment which cannot be accepted by other people of the same
class, education, race and period of life as the person who
experienced it (Stoddart,1980)

47. Theme of delusions
Delusion of
reference
Delusion of control Grandiose delusion
Persecutory
delusion
Delusion of
jealousy
Delusion of love
Delusion of
infestation
Nihilistic delusion Delusion of guilt
Delusional
misidentification
https://www.youtube.com/watch?v=ZEbWFEB1GFg

48. Dimensions of Delusional Severity
Extent of
preoccupation
PRESSURE
Extent of
departure from
culturally
determined
consensual
reality
BIZARRENESS
Degree to which
patient is
convinced of the
reality of the
delusion
CONVICTION
Degree to which
the beliefs are
NOT internally
consistent,
logical and
systematized
DISORGANIZATION
Extent of
involvement of
areas of
patient’s life
EXTENSION

49. Catatonic behavior
• Bizarre movements
• Echolalia / echopraxia
• Command automatism
• Extreme resistance
• Excitement
• Negativism
• Posturing
• Waxy flexibility
• Stupor

51. Behavioral and Psychological Symptoms of Dementia
Most distressing Moderately distressing Manageable
PSYCHOLOGICAL
Delusions
Hallucinations
Depressed mood
Sleeplessness
Anxiety
BEHAVIORAL
Physical aggression
Wandering
Restlessness
PSYCHOLOGICAL
Misidentifications
BEHAVIORAL
Agitation
Culturally inappropriate behavior
and disinhibition
Pacing
Screaming
BEHAVIORAL
Crying
Cursing
Lack of drive
Repetitive questioning

52. Principles of Management
Acute (in-patient) Maintenance (out-patient)
Objective Remission of symptoms Maintain stability & regain function
BIOLOGICAL Pharmacotherapy
Electroconvulsive therapy (ECT)
Bright light therapy
Transcranial Magnetic Stimulation (TMS)
Psychosurgery
PSYCHOLOGICAL Psychoeducation
Token economy
Cognitive-behavioural therapy (CBT)
Psychodynamic psychotherapy
Supportive psychotherapy
Cognitive remediation therapy
Behavioural therapy
SOCIAL Occupational therapy Support group
Group therapy
Supported employment
MENTARI

53. ECT
BLT TMS