Information section

Section pages

• Glossary of terms — abbreviations and clinical terms, including three-language equivalents.
• Appendices A–E — monitoring and examination standards, practical protocols.
• Appendix B — Scales — screening scales: M-CHAT-R, AQ-10, ASRS, SNAP-IV.
• Final recommendations — the key clinical lessons of the book.

Online tests

• Relationship models map — online test based on the book “Phoenix Era” (AZ).
• Self-assessment tests — the test section of the book “The Guilt Virus”.

More on the site

• Klinik Psixiatriya — ICD-11 guide — blog article about the book (AZ).
• Book order — order page for the printed copy (AZ).
• Books — all books on the site.

INTRODUCTION TO PSYCHOPATHOLOGY

Aim of this section

Modern psychiatric classifications — the International Classification of Diseases, 11th Revision (ICD-11), and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) — are based largely on operational diagnostic criteria: the presence of a specified number of symptoms over a specified duration is a prerequisite for diagnosis. This approach increases diagnostic reliability but may obscure the true clinical meaning of symptoms and syndromes.

Classical psychiatry — with Karl Jaspers, Eugen Bleuler, Kurt Schneider and Karl Leonhard in the late 19th and early 20th centuries — developed through a phenomenological and syndromological approach. This approach retains great value in clinical practice today:

Diagnostic criteria count symptoms, whereas syndromology explains the interrelationships and clinical manifestations of symptoms.

Syndromological reasoning is essential for early diagnosis — especially in patients whose criteria have not yet been fully met.

Pathophysiological reasoning is needed to understand why these symptoms are interrelated and which functional system is impaired.

Differential diagnosis is superficial without a syndromological approach.

In this section, psychopathological symptoms are classified by core functional domains, after which common psychopathological syndromes are presented.

The concepts of symptom and syndrome

A symptom is a single manifestation of a disorder (e.g., hallucination, delusion, depressed mood).

A syndrome is a consistent combination of interrelated symptoms specific to a particular nosological entity or recurring across several nosologies.

A nosological entity is a disease distinguished by its etiology, pathogenesis, clinical course, and treatment characteristics (e.g., schizophrenia, bipolar disorder, Alzheimer’s disease).

In clinical practice, the physician typically proceeds from symptoms to syndrome and from syndrome to diagnosis. Accurate syndromological assessment is the foundation of the patient’s examination and treatment.

Classification of psychopathological symptoms

Disorders of consciousness

Quantitative disorders (reduction):

Obnubilation (clouding of consciousness) — a mild reduction of consciousness with slowed reactions

Somnolence — a drowsy state; the patient is easily aroused

Sopor — a disorder of consciousness accompanied by brief arousal only in response to strong stimuli

Coma — complete loss of consciousness; no response to stimuli

Qualitative disorders (involving alteration of the content of consciousness):

Delirium — acute onset, fluctuating consciousness, disorientation, visual hallucinations, and psychomotor agitation. Typical causes are alcohol withdrawal syndrome, infection, intoxication, and hepatic and renal failure.

Oneiric (dream-like) state — fantastic scenes in which the patient feels like a participant

Amential state (amentia; a severe confusional state) — profound disorientation, fragmented thinking, incoherent speech

Twilight state of consciousness — “tunnel-like” narrowing of consciousness, automatic behavior, subsequent amnesia. Typical in epilepsy and dissociative states.

Disorders of perception

Illusions — misperception of a real object (e.g., a shadow on the wall is perceived as a person).

Hallucinations — perception in the absence of a real stimulus. By modality:

Auditory hallucinations — the most common type of hallucination. “Voices” may be commenting, addressing, or commanding; imperative voices carry high risk. This modality is characteristic of schizophrenia.

Visual hallucinations — characteristic of organic disorders (delirium, dementia, intoxication).

Olfactory and gustatory hallucinations — characteristic of temporal lobe epilepsy and schizophrenia.

Tactile hallucinations — cocaine and amphetamine intoxication (“insects under the skin”).

Cenestopathies — vague, strange, painful bodily sensations (e.g., “my brain is boiling”, “something is pulling in my abdomen”, and so on).

Pseudohallucinations, as described by Kandinsky, are perceived by the patient as “internal” (“voices inside my head”), yet still occur without an external stimulus.

Functional hallucinations — arise only in the presence of a real stimulus (hearing a voice in the sound of running water).

Disorders of thinking

Disorders of form (tempo and coherence):

Racing thoughts — observed in manic episodes

Flight of ideas — associations change rapidly, although a connection is retained

Slowed thinking — observed in depression and dementia

Thought blocking — sudden cessation of thought

Tangential thinking — the answer drifts away from the question toward a peripheral topic

Circumstantial thinking — excessive detail

Incoherent (atactic) thinking — grammatical form is preserved, while meaning is disturbed (schizophrenia)

Verbigeration — meaningless repetition of words and phrases

Neologisms — new “coined” words (schizophrenia)

Perseveration — repetition of the same word or idea (organic disorder)

Disorders of content:

Delusion — a false belief that is not supported by evidence and is inconsistent with the cultural context. Types:

- Persecutory delusion — a conviction of being followed and of malicious intent

- Grandiose delusion — exaggerated self-importance, power, and wealth

- Delusion of reference — events in the environment are attributed to oneself

- Delusion of influence — external forces (technical, cosmic, mystical) influence one’s thoughts

- Hypochondriacal delusion — belief in the presence of a severe illness (pathological bodily sensations, etc.)

- Cotard syndrome (delusion of being a living corpse) — the belief that body parts have disappeared or died

- Delusion of jealousy — belief in the spouse’s infidelity

- Erotomania (Clérambault syndrome) — the belief that a well-known person is secretly in love with the patient

Overvalued (dominant) ideas — close to reality, but given excessive importance

Obsessions — intrusive, ego-dystonic (experienced as alien to the self) thoughts

Mood and affect disturbances

Depressed mood — low, sad, hopeless

Manic mood — elevated, euphoric, or dysphoric (irritable)

Dysphoria — irritable, uneasy mood

Anhedonia — loss of the ability to experience pleasure (a core depressive symptom)

Apathy — emotional deficiency, loss of interest

Affective lability — frequent shifts in emotion

Flat affect — weakening of emotional expression (a negative symptom characteristic of schizophrenia)

Inappropriate affect — the emotional response does not correspond to the situation (e.g., the patient responds to the death of a relative with laughter)

Alexithymia — inability to express one’s emotional state in words

Anxiety — a feeling of impending danger, more often accompanied by somatic and autonomic symptoms

Fear — an emotional reaction to a concrete, real danger

Panic — acute, paroxysmal anxiety

Behavioral and motor disturbances

Psychomotor arousal — excited, aimless movements

Psychomotor retardation — slowing of movements, difficulty with initiation

Stupor — a state characterized by motor retardation, mutism

Catalepsy — passive maintenance of a body posture

Waxy flexibility — the limbs yield to gentle pressure and remain in the imposed position

Negativism — acting contrary to requests

Echolalia, echopraxia — repetition of another person’s speech or movements

Stereotypies — repetitive, aimless movements

Mannerism — bizarre performance of ordinary movements

Tics — involuntary muscle contractions

Compulsive behavior — repetitive behavior aimed at reducing obsessions (handwashing, checking)

Memory disturbances

Anterograde amnesia — failure to recall events that occurred after the precipitating event

Retrograde amnesia — failure to recall the period preceding the event

Congrade (concurrent) amnesia — absence of memory for the event itself

Korsakoff syndrome — severe anterograde amnesia, confabulations, and disorientation. Causes: thiamine deficiency and chronic alcoholism.

Confabulations — filling of memory gaps with fabricated content

Hypermnesia — pathological enhancement of memory (in some epileptic states)

Hypomnesia — decreased memory (depression, early dementia)

Attention disturbances

Hypoprosexia — decreased attention

Hyperprosexia — pathological increase in attention (hypochondria, paranoid states)

Distractibility in attention-deficit/hyperactivity disorder (ADHD) and in mania

Stickiness of attention — inability to detach from one topic (organic disorders)

Cognitive disturbances

Mild cognitive impairment — exceeding the normal age-related limits, but not reaching dementia

Dementia — extensive and persistent decline of cognition (memory, language, executive functions, visuospatial cognition)

Agnosia — inability to recognize objects (visual, auditory, and tactile agnosias)

Apraxia — inability to perform previously acquired movements

Aphasia — impairment of speech

Acalculia — impaired calculation ability

Disturbances of will and motivation

Apathy — lack of interest, lack of motivation

Abulia — weakness of will, inability to make decisions

Avolition — absence of motivation for goal-directed behavior

Ambivalence — the simultaneous presence of two contradictory desires

Hypobulia — decreased volitional activity

Hyperbulia — pathologically increased volitional activity

Disturbances of personality and the self

Depersonalization — alienation from oneself, the feeling of not being oneself

Derealization — perception of the environment as fictitious or unreal

Disturbance of the boundaries of the self — merging with the thoughts and feelings of others

Thought withdrawal/insertion — the feeling that one’s thoughts are being taken away or that alien thoughts are being inserted into one’s head (a first-rank symptom of schizophrenia, K. Schneider)

Main psychopathological syndromes

Affective syndromes

Depressive syndrome (depressive triad):

Low mood

Psychomotor retardation

Slowing of thinking (ideational retardation)

Additional symptoms: anhedonia, sleep disturbance, change in appetite, guilt, hopelessness, suicidal ideation

Manic syndrome (manic triad):

Elevated mood

Psychomotor arousal

Rapid thinking (flight of ideas)

Additional symptoms: decreased need for sleep, grandiose ideas, distractibility, risky behavior

Mixed affective syndrome — the simultaneous presence of manic and depressive symptoms (e.g., high activity and deep sadness).

Anxiety syndromes

Generalized anxiety disorder — persistent, generalized anxiety, muscle tension, autonomic symptoms.

Panic syndrome — paroxysmal, acute anxiety, fear of death, autonomic symptoms (tachycardia, shortness of breath, sweating), lasting 10–30 minutes.

Phobic syndrome — fear of a specific object or situation, avoidance behavior.

Obsessive-compulsive syndrome

Obsessions (intrusive thoughts) and repetitive behaviors aimed at reducing them (compulsions). The patient recognizes that these are absurd but is unable to resist them.

Psychotic syndromes

Paranoiac syndrome — systematized delusions (persecutory, referential, grandiose) + anxiety. Hallucinations are atypical or minimal.

Paranoid syndrome — delusional symptoms (persecutory ideas are more typical) + hallucinations (especially auditory) + anxiety.

Paraphrenic syndrome — grandiose fantastic delusions + hallucinations + elevated affect.

Hallucinatory syndrome (hallucinosis) — predominantly hallucinations (auditory or visual), with absent or minimal delusional symptoms.

Kandinsky–Clérambault syndrome (mental automatism syndrome):

Characteristic of schizophrenia.

Ideational automatism — “thought stealing”, “thought insertion”

Sensory automatism — pseudohallucinations

Motor automatism — “forced movements”

Catatonic syndrome — stupor or agitation, waxy flexibility, negativism, mutism, echolalia, echopraxia. Its diagnosis and treatment are of vital importance (see 6A40 and C.8).

Dysphoric syndrome — irritable, angry mood, aggression. Observed in epilepsy, organic brain diseases, and during withdrawal.

Exogenous-organic type syndromes (K. Bonhoeffer)

Syndromes characteristic of exogenous brain damage:

Delirium syndrome — acute, fluctuating level of consciousness, disorientation, visual hallucinations, psychomotor arousal. Etiology: alcohol withdrawal syndrome (severe form — delirium tremens), infections, intoxications, hepatic/renal failure.

Amential syndrome — profound disorientation, confused thinking, fragmented affect, fragmentary hallucinations. Seen in severe somatic diseases.

Twilight state of consciousness — tunnel-like narrowing of consciousness, automatic behavior, subsequent amnesia. Observed in epilepsy and in dissociative (conversion) states.

Korsakoff syndrome — fixation amnesia + confabulations + disorientation. Thiamine deficiency (Wernicke–Korsakoff syndrome), chronic alcoholism.

Asthenic syndrome — fatigue, irritability, reduced memory and attention, headache, sleep disturbance. It is widespread and may be of both organic and psychogenic origin.

Dementia syndromes

Cortical dementia (Alzheimer type) — impairments in memory, language (aphasia), praxis (apraxia), and gnosis (agnosia).

Subcortical dementia (Parkinson’s disease, Huntington’s disease) — slowing, impaired executive functions, depression, but cortical functions are relatively preserved at an early stage.

Frontotemporal dementia — personality change, disinhibition (weakening of inhibition), social inappropriateness + language disorders (semantic or progressive non-fluent aphasia).

Lewy body dementia — characterized by fluctuating cognitive impairment, visual hallucinations, parkinsonism, and rapid eye movement (REM) sleep behavior disorder.

Personality change syndromes

Organic personality change (after frontal lobe damage, etc.) — disinhibition, violation of social rules, emotional lability, lack of planning.

Post-encephalitic syndromes — behavioral, memory, and affective disorders following encephalitis.

Post-concussion syndrome — after head trauma: headache, dizziness, fatigue, irritability, impaired concentration.

CLINICAL INTERVIEW AND ASSESSMENT OF MENTAL STATUS

Objectives of the clinical interview

The psychiatric clinical interview serves a threefold purpose:

Diagnostic — to collect information, identify symptoms, establish a diagnosis

Therapeutic — to establish a therapeutic relationship (rapport), provide support to the patient, and activate (psychotherapeutic) mechanisms

Evaluative — risk assessment (suicide, harm to others), functional level, psychosocial environment

The initial interview usually lasts 45–90 minutes. In emergency situations it is shorter, but the key points (risk, decision) must still be covered.

Structure of the clinical interview

Preparation

Review of documents (referral, previous medical records)

Room: quiet, private, safe (an emergency call button, if possible)

Time: sufficient time should be allocated

Recommendation: meet the patient alone; if required, an accompanying person (in case of suspected involuntary hospitalization, see the section “Legal and ethical aspects”)

Opening

Greet the patient, introduce yourself, explain the purpose:

“Hello, I am Dr. [name], a psychiatrist. The purpose of this meeting is to understand your condition and to determine together how best to help you. Our interview may take about 45 minutes.”

Information about confidentiality:

“Our conversation is confidential. However, in the event of a serious threat to you or someone else, I am obliged to pass this information on to the appropriate persons — this is a legal requirement. If necessary, we will discuss this together with you.”

Open-ended question:

“What is troubling you? Can you tell me why you have come here?”

Complaints and history of the present illness

Complaints — in the patient’s own words (a quotation where possible)

Onset — when and under what circumstances did it begin?

Course — changes in symptoms (improvement, worsening, fluctuation)

Triggering factors — stressors, losses, medications, substances

Functional impact — effect on work, relationships, and daily activities

Previous treatment attempts — which medications were taken and how effective they were

Psychiatric history

Previous diagnoses

Previous hospitalizations (time, institution, duration)

Previous medications (effectiveness, side effects)

Previous psychotherapy

History of suicide attempts (time, method, seriousness of intent)

Medical history

Chronic diseases

Surgical interventions

Craniocerebral trauma (with loss of consciousness)

Epileptic seizures

Endocrine disorders (especially thyroid diseases)

Current medications (psychotropic side effects)

Allergies

Substance use history

Alcohol — frequency, amount, withdrawal symptoms

Tobacco — smoking, daily amount, age of initiation

Prescription/non-prescription medications (especially benzodiazepines, opioids)

Illicit substances (cannabis, opioids, stimulants, hallucinogens)

Behavioral addictions (gambling, gaming, internet, shopping)

Family history

Mental disorders in first- and second-degree relatives

Suicides

Substance use

Chronic diseases (possible genetic component)

Personal and social history

Birth and early development

Childhood environment, family dynamics

Traumatic experiences (abuse, exposure to violence, loss)

Education

Work history

Relationship history, marital status, children

Social support system

Legal history (criminal prosecution, conviction)

Military service (especially if there is combat experience)

Sexual and reproductive history

Premorbid personality

Character traits before the illness

Style of forming relationships

Response to stress, behavior

Assessment of mental status

The Mental Status Examination (MSE) — the main clinical tool of psychiatry — is a systematic recording of what is seen and heard during the interview.

Standard structure of the mental status examination

1. Appearance and behavior

Age, appearance

Clothing, hygiene, grooming

Facial expression, gestures, behavior

Attitude towards the interview (cooperation, resistance, aggressiveness)

Eye contact

Psychomotor activity

2. Speech

Rate (fast, normal, slow)

Volume (loudness)

Quantity (increased, decreased, mutism)

Clarity, coherence

3. Mood and affect

Mood — the sustained emotional state reported by the patient (“How do you feel?”)

Affect — the emotional expression observed during the interview

Range of affect (broad, restricted, flat)

Congruence of affect with mood and topic

4. Thought

Form — tempo, coherence, blocking, tangentiality, circumstantiality

Content — delusions, obsessions, phobias, suicidal/homicidal ideation

5. Perception

Hallucinations (modality, content)

Illusions

Depersonalization, derealization

6. Cognition

Clarity of consciousness

Orientation (time, place, person)

Attention, concentration

Memory (immediate, short-term, long-term)

Abstract thinking (proverb interpretation, similarity)

Executive functions

Calculation

General level of knowledge

7. Insight and judgment

Insight — the patient’s awareness of their illness (present? absent? partial?)

Judgment — the ability to make decisions (e.g., “How would you get out of a burning building?”)

8. Risk assessment

Suicide risk is assessed separately below.

Heteroaggressive risk — intention to harm others

Level of self-care — ability to live independently

Sample mental status protocol

MENTAL STATUS

Appearance and behavior: a 32-year-old man, appears his age, hygiene is maintained.
Clothing is appropriate for the season. He cooperates with the interview, but initially
appears anxious. Eye contact is reduced. Motor activity
is somewhat increased.

Speech: the rate is somewhat increased, the volume is normal, and the quantity is increased.
It is clear, but at times it deviates from the topic.

Mood: “I feel anxious … for the past two weeks I have been unable to fall asleep” (quotation).

Affect: the range is restricted; against a background of anxiety it is congruent with the topic. At times dysphoric components are observed.

Form of thought: at times tangential, but returns to the main content.
There is no blocking.

Content of thought: persistent anxiety regarding work and financial situation.
There are no delusions. Suicidal ideation is absent. No heteroaggressive
ideation.

Perception: hallucinations are denied. There is no depersonalization,
derealization.

Cognition: consciousness is clear. The patient is correctly oriented to time, place, and person. Moderate difficulty with attention and concentration
(2 errors on the “saying the word WORLD backwards” task). Memory is clinically
intact. Abstract thinking is preserved.

Insight: present — the patient accepts their symptoms as an illness,
and is motivated for treatment.

Judgment: preserved.

Risk assessment: suicide risk is low (no suicidal ideation, no plan, no previous attempt, support system is present).
There is no heteroaggressive risk. Self-care is fully preserved.

Suicide risk assessment

This must be done in every psychiatric interview. Research shows that “asking about suicide does not provoke it” — on the contrary, not asking makes it impossible to detect the risk.

Asking openly but in a stepwise manner

“How often do these thoughts occur?”

- “Have you thought about how to do it?” (plan)

- “Do you have the means at hand?” (availability of means)

- “Have you ever attempted it?” (previous attempts)

- “What keeps you going now?” (protective factors)

“Do you sometimes feel very bad? Have you thought that life has no meaning?” (passive suicidal ideation)

“Do you think about harming or killing yourself?” (active suicidal ideation)

If the answer is positive, risk factors are assessed:

Suicide risk factors

Static (unchanging):

Previous suicide attempt (the strongest predictor — it increases the risk of suicide in the following year approximately 50–100-fold compared with the general population (source: NICE, self-harm risk assessment))

Family history of suicide

Sex (male — completed suicide, female — attempt)

Age (older men are at the highest risk; adolescents represent the second peak)

Legal history

Traumatic childhood

Dynamic (changeable):

Active suicidal ideation, plan, intent

Access to means (firearm, poison)

Recent loss (spouse, job, health)

Isolation

Hopelessness (can be measured with the Beck Hopelessness Scale)

Active psychiatric disorder (depression, psychosis, borderline personality disorder (BPD), substance use)

Active intoxication

Sleep disturbance (chronic)

Protective factors:

Social support

Family responsibilities (children)

Religious and spiritual beliefs

Engagement in treatment

Future plans, hopes

Risk levels and clinical decisions

C-SSRS scale

The Columbia-Suicide Severity Rating Scale (C-SSRS) is an evidence-based, internationally recommended tool. The screening version of the scale consists of 6 questions and takes approximately 5 minutes.

Safety plan

It is prepared jointly with the patient at low–moderate risk:

Early warning signs (e.g., maladjustment, isolation, low mood)

Internal coping strategies (e.g., walking, music, physical exercise)

Social distraction (whom to see and where)

People who can provide support (name, telephone number)

Clinical help numbers (clinic, crisis line)

Ensuring the safety of the environment (removal of means, e.g., a firearm is handed over to a relative)

Assessment of heteroaggressive risk (harm to others)

The following should be asked during the interview:

“Do you think about harming or killing someone else?”

In the case of a positive answer:

Is there a specific target?

Is there a plan?

Are the means accessible?

Previous aggressive behavior?

High-risk indicators:

Specific victim + plan + means

Active psychotic symptoms (especially imperative hallucinations, persecutory delusions)

Antisocial personality disorder

Current intoxication

History of previous violence

In high-risk cases, hospitalization and warning of the potential victim (the Tarasoff principle — a US precedent).

LEGAL AND ETHICAL ASPECTS

Fundamentals of Azerbaijani psychiatric legislation

In the Republic of Azerbaijan, psychiatric care is regulated by the following laws:

Law of the Republic of Azerbaijan “On Psychiatric Care” of 12 June 2001 (with subsequent amendments; the latest revision dates to 2024)

Law of the Republic of Azerbaijan “On Psychological Assistance”

Law of the Republic of Azerbaijan “On Protection of Public Health” of 26 June 1997

Constitution of the Republic of Azerbaijan (in particular Article 28 – the right to liberty)

Civil Procedure Code of the Republic of Azerbaijan (procedure for involuntary hospitalization)

Criminal Code and Criminal Procedure Code of the Republic of Azerbaijan (compulsory medical measures)

Types of psychiatric care

According to Article 5 of the Law “On Psychiatric Care”, psychiatric care is provided in three forms:

Voluntary psychiatric care

Informed consent

Under Article 1.0.6 of the Law, informed consent is the statement by the patient or their legal representative that they voluntarily accept a decision on treatment and that they understand the information provided to them about the goals and benefits of treatment, the scope, duration, and method of treatment measures, the probable risks, as well as the possibility of refusing treatment and discontinuing it.

Requirements for informed consent:

In written form (entered into the medical record)

Full information must be provided (benefits, risks, alternatives, right to refuse)

The patient must comprehend (complicated by comorbid cognitive impairment and intoxication)

Voluntary — without pressure

For patients under 16 years of age — consent of the legal representative

Patient rights (Article 23 of the Law)

To receive information about one’s health status and treatment

To meet with close relatives or, at one’s choice, other persons and to maintain telephone contact with them

To use money and other material assets freely

The right to correspondence

To perform religious rites freely

To file complaints (including to the Commissioner for Human Rights (Ombudsman))

Involuntary hospitalization

Legal grounds

Article 11 of the Law (grounds for involuntary hospitalization):

If the nature of the mental disorder requires that examination and treatment be carried out solely … only in a psychiatric inpatient setting, involuntary treatment … is applied if the following grounds exist:

11.1.1. the person with a mental disorder poses a direct danger to themselves and (or) to others;

11.1.2. the person’s incapacity as a result of a mental disorder, i.e., the inability to independently satisfy their basic vital needs;

In simple terms: “danger, incapacity, or the risk of deterioration if untreated”. The text of the law: “11.1.3. the failure to provide inpatient care to a person with a severe mental disorder causes irreparable harm to their health and makes treatment impossible”.

Involuntary hospitalization procedure

Stage 1: Initial Assessment

The psychiatrist (emergency psychiatric care team, admission department) examines the patient and establishes the grounds for involuntary hospitalization.

Stage 2: Admission to the Inpatient Unit (Emergency)

The patient is actually admitted. Within 48 hours, a commission of psychiatrists (comprising no fewer than 3 physicians) must conduct an assessment.

Stage 3: Decision of the Commission

If the commission concludes that involuntary hospitalization must be continued, an application is filed with the court within 24 hours.

Stage 4: Court Decision

The court reviews the case within 5 days (in accordance with the Civil Procedure Code). The patient (if their health condition permits), the legal representative, the prosecutor, and the psychiatrist take part. The court decides on the continuation or termination of involuntary hospitalization.

Stage 5: Periodic Assessment

During the period of involuntary hospitalization, the patient must be examined by a commission of psychiatrists at least once a month during the first six months (Article 28.2).

Clinical indications

Absolute indications for involuntary hospitalization:

Active suicidal behavior (an attempt or a specific plan and means)

Active homicidal intent (a specific target + plan + means)

Severe psychotic disorganization (self-care is impossible)

Imperative hallucinations (with harmful intent)

Severe mania (impairment of self-care, risks of harm)

Relative indications (clinical judgment):

Severe depression with psychotic symptoms

Anorexia nervosa in a severe somatic condition (body mass index (BMI) < 15)

Mixed affective episode

Aggressive behavior in the context of psychosis

Compulsory medical measures

Article 12 of the Law regulates compulsory medical measures:

Grounds for application: persons who committed a crime in a state of insanity or who developed a mental disorder after committing the crime

Only on the basis of a court decision

Determined by Articles 21 and 93–99 of the Criminal Code and Articles 468–487 of the Criminal Procedure Code (CrPC)

Carried out in specialized psychiatric inpatient facilities

Types (according to the CrPC):

Compulsory treatment in general-type psychiatric inpatient facilities

Compulsory treatment in specialized psychiatric inpatient facilities

Compulsory treatment in specialized psychiatric inpatient facilities under intensive observation

Legal status of the clinical psychologist

Pursuant to the Law of the Republic of Azerbaijan “On Psychological Assistance”, the scope of activity and the limits of authority of the clinical psychologist:

Scope of the psychologist’s activity

The right to provide psychological assistance — psychological counseling, psychodiagnostics, psychocorrection, psychotherapeutic interventions (if the relevant qualification is held)

The words “psychologist”, “psychological”, “psychoanalysis”, “psychodiagnostics”, “psychotherapy” may be used only by persons entitled to provide psychological assistance in accordance with the conditions of the Law (Article 3.2).

Limits of the psychologist’s authority

Outside the psychologist’s authority:

Making a psychiatric diagnosis (only a psychiatrist)

Prescribing medication (only a physician)

Making a decision on involuntary hospitalization

Issuing medical opinions (forensic psychiatric examination, etc.) (only a psychiatrist)

The clinical psychologist’s work with a patient at risk of suicide — steps

When a patient expresses suicidal ideation, the clinical psychologist must take the following steps:

Risk assessment — Columbia-Suicide Severity Rating Scale (C-SSRS) or a clinical interview (see the section above)

Low–moderate risk: a safety plan is drawn up, close monitoring is carried out, and the patient is referred to a psychiatrist

High risk — the patient is not left alone; immediate referral to a psychiatrist or the emergency psychiatric service (contact the Baku Mental Health Center; emergency medical service – 103, police – 102)

Documentation — the assessment, the decision, and the steps taken must be recorded in writing

Confidentiality issue — when there is a threat to life, confidentiality is limited (general principles of the law)

Sample document: a referral letter from a psychologist to a psychiatrist

[Clinic letterhead]
Date: ___________

Dear Psychiatrist,

The patient under my clinical psychological care
[name, surname, patronymic], date of birth __________,
consulted me on [date], and during the interview
expressed active suicidal ideation.

Clinical picture:
- suicidal ideation: [active/passive, plan present/absent, means available/unavailable]
- Mood: [description]
- History of suicide attempt: [present/absent, details]
- Psychiatric history: [previous diagnoses, medications]

Based on the symptoms noted above, I state that the patient requires urgent psychiatric assessment,
and I consider that a psychiatric evaluation is necessary.

I request that you examine the patient and make
an appropriate decision.

Respectfully,
[Psychologist’s name and surname]
[Specialty, certificate number]
[Signature, seal]
[Contact number]

Minor patient

When working with patients younger than 14 years (Law “On Psychological Assistance”):

Psychological assistance is provided only with the consent of the legal representative

However, if child abuse or suicidal behavior is detected, it must be reported in the cases prescribed by law (the Law “On the Rights of the Child”; to the parent or the relevant authorities)

Special rules of confidentiality in child psychotherapy — agreed upon in advance

Confidentiality and its boundaries

General principle

Information obtained in the patient–physician relationship is confidential. This is enshrined in the Law “On the Protection of Public Health” and the Law “On Psychiatric Care”.

Circumstances in which a breach of confidentiality is permitted

With the patient’s written consent

Written request from law enforcement agencies (within the framework of a criminal investigation)

A court decision

When there is a threat to the life and health of the patient or others (Tarasoff principle — duty to warn and protect)

Information about minor patients is provided to parents (within the framework of the law)

Collegial consultation (within a multidisciplinary team)

Tarasoff principle (duty to warn and protect)

US precedent: if a patient expresses an intention to harm a specific person, the physician has a duty to warn that person. Although this is not directly enshrined in Azerbaijani legislation, the general principles (the right to life, public safety) imply it.

Minor patients

Age limits

Psychiatric care for patients under 16 years of age is provided with the consent of the parent (legal representative), in accordance with Article 5.2 of the Law “On Psychiatric Care”

Over 16 years of age: with the patient’s own consent (however, informing the parent is generally recommended)

Patients over 18 years of age make decisions concerning psychiatric care independently

Child protection protocols

In case of suspected child abuse (sexual, physical, psychological), neglect, or factitious disorder imposed on another (FDIA), the physician has a duty to report. Institutions to contact:

Social Services Agency

Commissioner for Human Rights (Ombudsman)

Police (in dangerous situations)

The aggressive patient and safety measures

Legal framework

Article 37.4 of the Law “On Psychiatric Care” regulates the use of special measures:

For the purpose of ensuring the safety of psychiatrists providing psychiatric care, other specialists, and nursing and junior medical staff, they are granted the right to use special measures (physical restraint of a person with a mental disorder, temporary isolation of that person, and the use of special restraint clothing).

Rules of application:

Only when there is a genuine threat

The least restrictive means must be chosen

Time-limited

Must be documented in the medical records

The facility administration must be notified

Principles of de-escalation

Before physical restraint:

A calm, friendly approach

Listening to the patient’s concerns

Offering a choice (for example, “Would you like to sit in a separate room to calm down, or to take medication?”)

Verbal de-escalation

Only when these methods fail is pharmacological or physical restraint applied

Pharmacological restraint (emergency sedation, ES)

First choice — oral medications with the patient’s consent:

Lorazepam 1–2 mg, orally

Olanzapine 5–10 mg by mouth (orally disintegrating tablets (ODT) are effective)

Risperidone 1–2 mg, orally

In the absence of consent or cooperation — intramuscular (IM):

Olanzapine 10 mg IM (lorazepam IM — at least 1 hour later)

Haloperidol 5 mg IM + lorazepam 2 mg IM (classic combination; ECG/QTc first)

Aripiprazole IM 9.75 mg

Caution: olanzapine IM + parenteral benzodiazepine — the combination may cause respiratory depression. Olanzapine IM must not be used simultaneously with parenteral benzodiazepines; if such use is necessary, an interval of at least 1 hour is observed between them and the patient is monitored for respiratory depression.

Sample documents

Protocol for referral for involuntary hospitalization

REFERRAL FOR INVOLUNTARY HOSPITALIZATION
Date: __________ Time: __________

Patient information:
- First name, surname, patronymic: _____________________
- Date of birth: _____________________
- Address: _____________________
- Identity card/ID: _____________________

Interview conditions:
- Location: _____________________
- Source of referral: _____________________
- Legal representative present? Yes/No; name: _____________________

Clinical picture:
[Complaints, history, description of mental status]

Diagnosis (ICD-11): _____________________

Grounds for involuntary hospitalization, “Law “On Psychiatric Care”
Care” (Article 11):
☐ 11.1.1 The patient poses a danger to themselves or others
☐ 11.1.2 The patient is unable to meet basic vital needs
☐ 11.1.3 Risk of severe deterioration of the condition without treatment

Specific indicators:
[Suicide risk, homicidal ideation, level of care, etc.]

Decision: The patient is admitted involuntarily to [name of institution]
psychiatric inpatient unit.

Next steps:
- Examination by a commission of psychiatrists within 48 hours
- After the decision of the commission, an application is submitted to the court within 24 hours

Psychiatrist: _____________________
Certificate number: _____________________
Signature: _____________________
Seal: _____________________

Suicide risk safety plan (developed together with the patient)

SAFETY PLAN
Patient: _____________________ Date: _____________

1. Early warning signs (signals that matter to me):
- _____________________
- _____________________
- _____________________

2. My internal self-management strategies (coping strategies) (only those I can do on my own):
- _____________________
- _____________________
- _____________________

3. People and places that will distract me:
- _____________________
- _____________________

4. People I can ask for help (name, phone):
- _____________________
- _____________________

5. Clinical help (24 hours):
- My clinic: _____________________ (phone: ______)
- Baku Mental Health Center (emergency): _____________
- Emergency medical services (Azerbaijan): 103
- Police: 102

6. Making my home environment safe:
- Means that pose a risk: _____________________
- Plan for their removal: _____________________

Signatures:
Patient: _____________________
Psychiatrist: _____________________

Ethical principles

International principles (International Code of Medical Ethics, World Psychiatric Association (WPA), Declaration of Madrid)

Autonomy — the patient’s right to make decisions

Beneficence — acting in the patient’s interest

Non-maleficence (primum non nocere — first, do no harm)

Justice — equal treatment of all patients

Clinical dilemmas

Conflict between autonomy and the principle of beneficence:

The patient refuses treatment, but their decision-making capacity is in doubt

Solution: decision-making capacity is formally assessed; if capacity is absent, a legal representative is involved; if capacity is present, the patient’s refusal is respected (provided that the patient is not dangerous)

Confidentiality vs. public safety:

As indicated above — where there is a threat to life, confidentiality is limited

Multiple role relationships:

The roles of patient, employee, and friend must not be mixed

A strict framework — professional relations only

Gifts and financial relationships:

Not accepting significant gifts from patients

Avoiding financial or business relationships