Introduction to Psychiatry
MUDr. Eliška Bartečková, Ph.D.
1 Psychiatry and mental disorders
Psychiatry is a medical specialty focused on the diagnosis, treatment, and prevention of mental, emotional,
and behavioral disorders. As trained physicians, psychiatrists can prescribe medication and often use a
combination of medical and psychotherapeutic approaches.
Psychology, in contrast, primarily studies the mind and behavior. Psychologists employ various therapeutic
techniques to help individuals cope with and overcome emotional and behavioral challenges, but they typically
cannot prescribe medication unless specifically licensed to do so in certain jurisdictions.
While both fields aim to understand the mind and promote mental well-being, psychiatry is rooted in medicine
and medical interventions, whereas psychology focuses on cognitive, emotional, and behavioral processes.
A mental disorder is a syndrome characterized by a clinically significant disturbance in cognition, emotional
regulation, or behavior. This disturbance reflects a dysfunction in the psychological, biological, or
developmental processes underlying mental functioning and is typically associated with significant distress or
impairment in social, occupational, or other important areas of life.
Mental health, on the other hand, refers to a state of well-being in which an individual recognizes their own
abilities, manages the normal stresses of life, works productively, and contributes to their community. Mental
health is not merely the absence of mental disorders but encompasses emotional, psychological, and social
well-being.
2 Diagnosis in psychiatry
2.1 Outline of the diagnostic process in psychiatry
The diagnostic process in psychiatry follows a structured workflow:
1. Symptom Assessment: Information is gathered from multiple sources, including:
- Direct patient interviews
- Observations during consultations
- Third-party reports (family, close friends)
- Indirect mediums (creative activities, diaries, messages, suicide notes)
2. Syndrome recognition: Symptoms are matched to known syndromes. For example, depressive
syndrome may be present in both bipolar disorder and major depressive disorder, requiring further
assessment.
3. Contextual analysis: Factors such as age of onset, duration, and symptom progression help refine the
diagnosis.
4. Paraclinical Examinations: Medical conditions must be ruled out. Common first-line investigations
include:
- Blood tests, urine tests, toxicology screenings
- Brain imaging (CT, MRI)
- EEG (useful for seizure-related conditions)
- Advanced imaging (SPECT, PET, PET-MR) in rare or research cases
2.2 Basics of psychopathology
Psychopathology provides a structured framework for describing symptoms. Psychopathological terms are
used in description of patient state, mental status examination.
Below is a lexicon of key terms organized by domain:
Consciousness Psychomotor Function
Disorientation: Impaired ability to identify time,
place, or persons.
Somnolence: Pathological drowsiness but still
responsive.
Stupor (Sopor in Czech terminology): A state of
unresponsiveness with reduced psychomotor
activity.
Coma: A profound loss of consciousness with no
response to stimuli.
Akinesia: Reduced or absent voluntary movement.
Waxy Flexibility: The maintenance of imposed
postures.
Motor Stereotypies: Repetitive, purposeless
movements (e.g., rocking, tapping).
Echophenomena: Involuntary imitation of another’s
movements (echopraxia) or speech (echolalia).
Agitation: Excessive motor activity often driven by
inner distress.
Stupor (in Czech usage): Lack of movement or
responsiveness without reduced alertness.
Aggression: Behavioral manifestations of physical
or verbal hostility.
Volitional Behavior Emotion and Mood
Abulia: Reduced ability to initiate or sustain goaldirected
activities.
Compulsions: Repetitive behaviors or mental acts
driven by an internal urge, often linked to
obsessions.
Affect: The immediate, observable emotional
expression.
Mood: A sustained emotional state (e.g.,
depressive mood, manic mood).
Anxiety: A diffuse sense of worry or fear.
Anhedonia: A reduced ability to experience
pleasure.
Perception Thought Processes
Hallucinations: Sensory perceptions without
external stimuli (e.g., hearing voices).
Illusions: Misinterpretations of real external stimuli.
Bradyphrenia: Slowed thinking.
Flight of Ideas (racing thoughts): Accelerated
flow of ideas, often seen in mania.
Formal Thought Disorder: Pathological change in
form, flow, and coherence of thinking
Delusions: Fixed false beliefs resistant to contrary
evidence.
Obsessions: Recurrent, intrusive, and unwanted
thoughts.
Attention and Cognition Appetite and Sleep
Hypoprosexia: Reduced ability to maintain
attention.
Distractibility: Shifting focus to irrelevant stimuli.
Hyperphagia: Increased appetite.
Anorexia: Loss of appetite.
Insomnia: Difficulty falling or maintaining sleep.
Hypersomnia: Excessive sleepiness.
Self-Harm and Suicidality Insight
Suicidal Ideation: Thoughts of self-harm or
suicide.
Non-Suicidal Self-Injury (NSSI): Self-harm without
intent to die.
Anosognosia: Lack of awareness or denial of
illness, common in psychotic disorders.
2.3 Syndromes in psychiatry
A syndrome is a cluster of symptoms that consistently appear together. Symptoms form syndromes, which,
when combined with context, result in a diagnosis.
Notable psychiatric syndromes include:
Dementia Syndrome: Cognitive deficits, memory impairment, and functional decline (e.g., Alzheimer’s
disease).
Delirium: Acute disturbance in attention and cognition, often reversible and associated with medical
conditions, substance use, or withdrawal. Often accompanied by paranoia, delusions, and hallucinations.
Catatonic Syndrome: Motor disturbances ranging from stupor to excessive movement, posturing,
stereotypy, and echolalia. Seen in schizophrenia, mood disorders, and neurological conditions (e.g., limbic
encephalitis).
Withdrawal Syndrome: Symptoms emerging when discontinuing a substance, with clinical presentation
varying by substance.
Paranoid Syndrome: Dominated by delusions of persecution or grandeur, usually without hallucinations.
Hallucinatory Syndrome: Persistent hallucinations, often auditory, without pronounced delusional content.
Paranoid-Hallucinatory Syndrome: Combination of paranoia and hallucinations, characteristic of
schizophrenia.
Depressive Syndrome: Persistent sadness, anhedonia, weight changes, and hopelessness, often seen in
major depressive disorder.
Manic Syndrome: Elevated mood, increased energy, impulsivity, often in bipolar disorder.
Obsessive Syndrome: Intrusive thoughts (obsessions) and repetitive behaviors (compulsions).
2.4 Context
Several contextual factors influence diagnosis:
Age of Onset: Some disorders have characteristic ages of onset (e.g., ADHD in childhood, late-onset
depression in the elderly).
Course of Disorder:
- Remitting: Episodes with full recovery in between (e.g., major depressive disorder).
- Remitting with Deterioration: Declining baseline function with each episode (e.g., schizophrenia,
bipolar disorder).
- Chronic: Persistent symptoms without remission (e.g., generalized anxiety disorder).
- Chronic with Exacerbations: Ongoing disorder with periodic worsening (e.g., schizophrenia,
bipolar disorder).
- Single Episode: A one-time occurrence with no recurrence (e.g., acute psychotic disorder).
- Chronic with Diminishing Symptoms: Symptoms decrease over years (e.g., ADHD, borderline
personality disorder).
- Chronic with Deterioration: Symptoms progressively worsen over time (e.g., dementia).
Temporal Sequence of Symptoms: Symptom progression helps differentiate disorders. For example, in
depression with psychotic features, depressive symptoms typically appear first, followed by psychosis.
2.5 Diagnostic manuals
Diagnostic manuals standardize mental health conditions for consistency in diagnosis and treatment. These
manuals define specific diagnostic criteria — clusters of symptoms (syndromes) and contextual factors —
that must be met for a diagnosis.
Commonly used diagnostic manuals include:
ICD-10: International Classification of Diseases, 10th Revision (widely used in Europe).
DSM-5: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (primarily used in the U.S. and
research).
ICD-11: The updated version of ICD-10, currently being implemented.
3 Etiopathogenesis of psychiatric disorders
3.1 Biopsychosocial model
The biopsychosocial model provides a multidimensional framework for understanding mental health,
incorporating interactions between biological, psychological, and social factors. Rather than viewing
psychiatric disorders through a single-cause lens, this model emphasizes how various factors contribute,
interact, and influence each other over time.
Three primary domains define this model:
- Biological factors – Genetics, brain chemistry, neurodevelopment, and physical health.
- Psychological factors – Personality traits, emotional regulation, cognitive patterns, and coping
mechanisms.
- Social factors – Societal influences, relationships, economic status, cultural norms, and access to
healthcare.
Within this model, psychiatric disorders are understood through the "Three P's", which categorize factors
influencing mental health:
- Predisposing factors – Increase vulnerability to a disorder.
- Precipitating factors – Trigger the onset of symptoms.
- Perpetuating factors – Maintain or worsen the condition over time.
While some disorders have well-documented risk factors, the exact interplay of these factors varies
significantly between individuals. This variation highlights the importance of personalized assessment and
treatment.
The following table illustrates examples of how these factors interact:
Biological Psychological Social
Predisposing Factors genetics vulnerability,
congenital diseases
early life trauma,
personality traits
growing up in an
impoverished
environment, cultural
norms favoring
maladaptive strategies
Precipitating Factors physical illness, injury,
medication with
psychiatric side effects
(corticosteroids)
significant life stressors,
other psychiatric
disorder
loss of social support,
moving to a new country
or city
Perpetuating Factors chronic pain or disability
substance abuse
maladaptive coping
strategies (e.g.
avoidance in phobias)
ongoing social isolation,
stigmatization
3.2 Relevance of neurotransmitter systems in psychiatry
In biological psychiatry, neurotransmitter systems play a central role in mental health. Neurotransmitters are
chemical messengers that facilitate communication between neurons, regulating mood, cognition,
perception, and behavior. Dysregulation in these systems is associated with various psychiatric symptoms,
and many treatments aim to modulate neurotransmitter activity to restore balance.
Key neurotransmitter imbalances can manifest in mood instability, anxiety, psychosis, and cognitive
impairment.
Below is an overview of major neurotransmitters, their functional domains, and associated disorders:
Neurotransmitter Examples of relevant
symptom domains
Examples of relevant
disorders
Serotonin (5-HT) mood, appetite, sleep mood disorders, anxiety
disorders, obsessive-compulsive
disorder
Dopamine (DA) salience signaling, reward,
motivation, volition
primary psychotic disorders,
mood disorders, catatonia
Norepinephrine (NE) alertness, energy mood disorders, attention deficit
and hyperactivity disorder
(ADHD)
Gamma-Aminobutyric Acid
(GABA)
primary inhibitory
neurotransmitter
anxiety disorders, catatonia
Glutamate main excitatory
neurotransmitter, learning,
memory
cognitive disturbances,
depressive disorder, primary
psychotic disorders
Acetylcholine cognitive processes,
especially memory and
attention
Alzheimer’s disease
4 Basic epidemiology of psychiatric disorders
Epidemiology is the study of the distribution, determinants, and frequency of diseases in populations. In
psychiatry, epidemiology helps quantify:
- Prevalence – The proportion of a population affected by a disorder at a given time.
- Incidence – The rate of new cases occurring over a specific period.
- Risk factors – Biological, psychological, and social elements that increase vulnerability to
psychiatric conditions.
Psychiatric disorders vary widely in prevalence, with some being common, others less frequent, and a few
rare:
- Common Disorders: Major depressive disorder (MDD), anxiety disorders, and substance use
disorders. These contribute significantly to the global burden of disease, often measured by Years
Lived with Disability (YLD).
- Less Common Disorders: Bipolar disorder, obsessive-compulsive disorder (OCD), and
schizophrenia, which have lower prevalence but still impose substantial morbidity.
- Rare Disorders: Conditions such as Dissociative Identity Disorder (DID) or early-onset psychosis
variants, which affect a small fraction of the population.
The epidemiology of psychiatric conditions is shaped by a combination of:
- Genetic factors (e.g., hereditary predisposition to schizophrenia or bipolar disorder).
- Personal history (e.g., childhood trauma, adverse experiences).
- Environmental factors (e.g., socioeconomic stress, migration, war, disasters).
5 Basics of treatment in Psychiatry
The treatment of psychiatric disorders is multifaceted, aiming to alleviate symptoms, improve quality of life,
and enhance daily functioning. Depending on the underlying cause, interventions may focus on:
- Addressing medical conditions that contribute to psychiatric symptoms.
- Modulating brain function through pharmacological or stimulation-based methods.
- Developing coping strategies through psychotherapy and psychosocial interventions.
A comprehensive approach often involves a combination of these modalities, tailored to the patient's
individual needs.
5.1 Causal Treatment of Underlying Cause
When psychiatric symptoms arise from identifiable and treatable medical conditions, the primary strategy is
to correct the underlying cause. These conditions are often classified as secondary (organic, “due to”)
psychiatric disorders.
A classic example is delirium, a frequent occurrence in general hospital settings, characterized by acute
confusion due to causes such as:
- Infections (e.g., pneumonia, urinary tract infections).
- Metabolic imbalances (e.g., hypoglycemia, electrolyte disturbances).
- Medication side effects (e.g., corticosteroids, anticholinergics).
Treating the root cause—whether through infection management, metabolic correction, or medication
adjustments—typically resolves psychiatric symptoms.
5.2 Biological Treatments
5.2.1 Pharmacotherapy
Psychotropic medications play a central role in psychiatric treatment, targeting neurotransmitter systems to
regulate mood, cognition, perception, and behavior.
Below is an overview of major drug classes, their mechanisms, and examples:
Class Usual Mechanism Examples
Anxiolytics & Sedatives Enhance GABA activity
Modulate calcium channels
(pregabaline)
Benzodiazepines (diazepam,
clonazepam)
Z-compounds (zolpidem,
zopiclone)
Others (pregabaline)
Antidepressants Modulate monoaminergic
neurotransmission (conventional
antidepressants)
NMDA antagonism (ketamine)
MAOI (moclobemide)
TCA (amitriptyline, imipramine)
SSRI (sertraline, escitalopram)
SNRI (duloxetine, venlafaxine)
SARI (trazodone)
DNRI (bupropion)
NaSSA (mirtazapine)
MASSA (agomelatine)
SMS (vortioxetine)
Antipsychotics Block dopamine receptors
(Some block also serotonin
receptors)
Typical:
Sedative (chlorpromazine),
Incisive (haloperidol)
Atypical:
D2/D3 antagonists (amisulpride),
SDA (risperidone, paliperidone),
MARTA (clozapine, olanzapine),
Partial dopamine agonists
(aripiprazole, brexpiprazole)
Mood Stabilizers Various Anticonvulsants (valproate,
carbamazepine, lamotrigine)
Others (lithium)
Cognitive enhancers Various Acetylcholinesterase inhibitors
(donepezil, rivastigmin)
Glutamate modulators
(memantine)
Stimulants Increase
dopamine/norepinephrine
amphetamines, methylphenidate,
atomoxetine
5.2.2 Stimulation Methods
When pharmacotherapy alone is insufficient, neuromodulation techniques can be employed:
Electroconvulsive Therapy (ECT)
- Highly effective for severe psychiatric conditions, including treatment-resistant depression, psychotic
depression, and catatonia.
- Induces a controlled therapeutic seizure via brief electrical stimulation under anesthesia.
- Despite historical stigma, modern ECT is safe, well-tolerated, and often life-saving.
Repetitive Transcranial Magnetic Stimulation (rTMS)
- Non-invasive brain stimulation using magnetic pulses.
- Used primarily for treatment-resistant depression.
5.2.3 Other Biological Interventions
- Bright-light therapy – Used in Seasonal Affective Disorder (SAD).
- Nutritional support – Ensuring adequate vitamins and minerals can play a role in holistic treatment.
5.3 Psychotherapy
Also termed as "talk therapy", psychotherapy is a method where mental health professionals help patients by
talking through strategies for understanding and dealing with their disorder. Types include Cognitive
Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), psychodynamic therapy, interpersonal
therapy, and others. It can be applied in individual, couple, family, or group settings.
It's worth noting that many patients benefit from a combination of these treatments, especially for complex or
chronic disorders. The choice of treatment depends on the nature of the disorder, its severity, the patient's
preference, and other individual factors.
6 Basic legal aspects in Psychiatry
Hospitalization and treatment are usually performed with the informed consent of the patient. However,
psychiatric disorders can influence the judgment of patients and their behavior. In some situations, the
patient or his surroundings can be in danger due to psychiatric conditions. In such cases, the patient's
autonomy is impaired and psychiatric hospitalization and treatment aim to return this autonomy. In the Czech
Republic, there are several situations when hospitalization without a patient's consent is permitted. These
situations are described in Act 372/2011 on Health Services and on Conditions of their Provision. The most
relevant situations are as follows:
The patient may be hospitalized without their consent if:
1. they endanger themselves or others in the imminent and serious manner and shows signs of
mental disorder or suffers from it, or is under the influence of an addictive substance unless the
threat to the patient or to others can be avoided otherwise, or
2. their health condition requires the provision of urgent care and at the same time, it does not allow
them to provide consent.
Furthermore, the patient may only be provided urgent care without his/her consent, in the case:
1. where the health condition does not allow the patient to provide this consent
2. of a treatment of serious mental disorder if, in the absence of treatment, it is likely to cause
serious damage to the patient’s health.
7 Basic groups of psychiatric disorders
This section outlines the major diagnostic groups of psychiatric disorders based on ICD-11, including their
typical age of onset, course, and treatment approaches. While these general trends apply to average cases,
individual variability exists within each disorder and among patients.
7.1 Neurodevelopmental Disorders
Description: Developmental deficits causing impairments in personal, social, academic, or occupational
functioning.
Examples: Autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD).
Age of Onset: Early childhood.
Course: Chronic; some symptoms may improve with age and intervention.
Treatment: Behavioral therapy, stimulant medications (for ADHD), individualized educational support.
7.2 Primary Psychotic Disorders
Description: Disorders characterized by distorted perception of reality, including hallucinations and
delusions.
Examples: Schizophrenia, delusional disorder.
Age of Onset: Late teens to early 30s.
Course: Remitting with deterioration; chronic with exacerbations.
Treatment: Antipsychotic medications, psychosocial interventions.
7.3 Catatonia
Description: A behavioral syndrome marked by abnormal movement or lack of movement, often linked to
other psychiatric or medical conditions.
Examples: Catatonic schizophrenia, mood disorders with catatonia.
Age of Onset: Variable.
Course: Dependent on underlying cause.
Treatment: Benzodiazepines, electroconvulsive therapy (ECT) in severe cases.
7.4 Mood Disorders
Description: Disorders that disrupt mood regulation, leading to emotional distress or instability.
Examples: Major depressive disorder, bipolar disorder.
Age of Onset: Late teens to early adulthood.
Course: Remitting or chronic.
Treatment: Antidepressants, mood stabilizers, antipsychotics, psychotherapy.
7.5 Anxiety Disorders
Description: Disorders characterized by excessive fear or anxiety, which may be situational or generalized.
Examples: Generalized anxiety disorder (GAD), panic disorder, phobic disorders.
Age of Onset: Childhood to adulthood.
Course: Chronic with exacerbations; some cases remit.
Treatment: Cognitive behavioral therapy (CBT), anxiolytics, antidepressants.
7.6 Obsessive-Compulsive Disorders
Description: Disorders characterized by intrusive obsessive thoughts and repetitive compulsive behaviors.
Examples: Obsessive-compulsive disorder (OCD).
Age of Onset: Adolescence or early adulthood.
Course: Chronic with exacerbations; some cases remit.
Treatment: CBT, selective serotonin reuptake inhibitors (SSRIs).
7.7 Stress-Related Disorders
Description: Disorders resulting from exposure to acute or chronic stressors.
Examples: Acute stress reaction, adjustment disorder, post-traumatic stress disorder (PTSD).
Age of Onset: Any age following a traumatic or stressful event.
Course: Variable; PTSD can be chronic if untreated.
Treatment: Psychotherapy (e.g., trauma-focused CBT), medication for comorbid symptoms.
7.8 Dissociative Disorders
Description: Disruptions in the integration of consciousness, memory, identity, or perception.
Examples: Dissociative identity disorder (DID), functional neurological (conversion) disorders.
Age of Onset: Most commonly in childhood.
Course: Chronic; can improve with therapy.
Treatment: Psychotherapy (mainstay treatment).
7.9 Eating Disorders
Description: Disorders involving disturbances in eating behaviors and body image.
Examples: Anorexia nervosa, bulimia nervosa.
Age of Onset: Adolescence or early adulthood.
Course: Chronic, but recovery is possible with treatment.
Treatment: Multimodal approach – nutritional rehabilitation, psychotherapy, and sometimes
pharmacotherapy.
7.10 Disorders of Bodily Distress and Bodily Experience
Description: Disorders primarily involving distressing, medically unexplained physical symptoms.
Examples: Somatic symptom disorder, illness anxiety disorder.
Age of Onset: Variable.
Course: Typically chronic.
Treatment: Psychotherapy, physical rehabilitation approaches.
7.11 Substance-Related Disorders
Description: Disorders associated with the use, intoxication, withdrawal, and addiction to psychoactive
substances.
Examples: Alcohol use disorder, opioid use disorder, stimulant use disorder.
Age of Onset: Typically adolescence or early adulthood.
Course: Chronic; some cases remit with treatment.
Treatment: Detoxification, counseling, and pharmacological support (e.g., medications for withdrawal
management or relapse prevention).
7.12 Neurocognitive Disorders
Description: Disorders affecting cognitive function, including memory, attention, and executive functioning.
Examples: Dementia, delirium.
Age of Onset:
- Dementia typically occurs in older adults
- Delirium can occur at any age, more commonly in the elderly.
Course:
- Dementia is progressive and irreversible.
- Delirium is acute and often reversible if the underlying cause is treated.
Treatment:
- Dementia: Symptomatic treatment, cognitive support, caregiver interventions.
- Delirium: Address underlying cause, supportive care.
7.13 Personality Disorders
Description: Enduring maladaptive patterns of behavior, cognition, and emotional regulation that deviate
from cultural expectations.
Examples: Borderline personality disorder (BPD), antisocial personality disorder.
Age of Onset: Symptoms typically emerge in adolescence or early adulthood.
Course: Chronic; some (e.g., BPD) may improve over time.
Treatment: Psychotherapy (e.g., dialectical behavior therapy for BPD).