Download APPEARANCE AND BEHAVIOUR

HEALTH MINISTRY OF THE REPUBLIC OF KAZAKSTAN
KARAGANDA STATE MEDICAL ACADEMY
M.U.Lubchenko, V.V.Gershman
GENERAL PSYCHOPATHOLOGY
Educational manual.
Karaganda, 2007
УДК 616.89.
ББК 56.14 я 7
L
96
Reviewers:
1. V.B. Molotov-Luchansky – head of the bases of nursins skills department of
KSMA, candidate of medical science, assistant professor
2. R.Sh. Sabirova – dean of psychology and philosophy department of KSU by
Buketov, candidate of psychological science, assistant professor
3. M.G.Abdrachmanova - head of neurology and east medicine department of
KSMA, Doctor of medicine, assistant professor
ГОО
M.U.Lubchenko candidate of medical science, assistant professor of
psycology, psychiatry, narcology department of KSMA
Gershman V.V. assistant of psycology, psychiatry, narcology department of
KSMA
General psychopatology. – Educational manual. – Karaganda. – 2007. – 73 pages
ББК56.14 я 7
The aims of the manual are to provide students with a working knowledge of
general psychopathology, symptoms and syndromes of perceptual disturbances,
thought disorders, disorders of mood and affect, behavioral, memory, intelligence
and consciousness disorders and their diagnostical meaning.
Discussed and approved at the meeting of Methodical Council of KSMA.
Protocol №9 of 10. 05 2007 y.
Confirmed and recommended for edition of Academic Council of KSMA.
Protocol № 10 of 17. 06. 2007 y.
© M.U.Lubchenko,
2
V.V.Gershman. 2007
Content
1.
Sensation and Perception disorders
5
1.1
Illusion
5
1.2
Hallucination
6
1.3
Psychosensory disorders
12
2.
Disorders of Language and Speech
15
2.1
Speech disturbances
15
2.2
Language Disorder
16
2.3
Disorders of thinking
17
2.3.1 Disorders of the stream of thought
17
2.3.2 Disorders of form of thought
18
2.3.3 Disorders of content of thought
21
2.3.4 Disorders of possession of thought
28
3.
Disorders of Mood and Affect
30
4.
Cognitive function
37
4.1
Memory disorders
38
1.2
Intelligence disorders
41
5.
Insight
45
6.
Disorders of self-awareness
46
7.
Disturbed Consciousness
46
8.
Appearance and behaviour
50
8.1
Psychomotor Agitation and Retardation
50
8.2
Catatonic disorders
52
8.3
Spontaneous movements
54
8.4
Seizures
55
9.
Test
58
References
76
3
The word psychiatry is derived from Greek (word psyche that means the
human faculty for thought, judgment, and emotion; the mental life, including both
conscious and unconscious processes; the mind in its totality, as distinguished from
the body + iatreia that means healing) is the branch of medicine concerned with
the investigation, treatment and prevention of diseases and disorders of the mind.
Mental disorder: any clinically significant behavioral or psychological
syndrome characterized by the presence of distressing symptoms, impairment of
functioning, or significantly increased risk of suffering death, pain, disability, or
loss of freedom. Mental disorders are assumed to be the manifestation of a
behavioral, psychological, or biological dysfunction in the individual. The concept
does not include deviant behavior, disturbances that are essentially conflicts
between the individual and society, or expected and culturally sanctioned
responses to particular events. It is important to realise that psychiatry is not
limited to illnesses of purely psychological origin since many physical illnesses
and their treatment cause psychological changes and certain diseases of the mind,
such as Alzheimer's Disease, have a clearly organic basis. Further on, psychiatry is
not limited to the work of psychiatrists. Anxiety is so common that its alleviation is
part of the work of every clinician, whether he be psychiatrist, physician, surgeon
or family practitioner. Up to 30% of patients presenting to their general practitioner
are known to have psychiatric problems, and only 1 in 10 is referred to
psychiatrists. Therefore, every general practitioner must have a working
knowledge of psychiatry. The hospital specialist also finds that many patients
referred to hospital outpatient clinics and are admitted to general medical and
surgical wards have psychiatric symptoms, either as a consequence of underlying
physical disease or because persons with anxiety or depression frequently present
with somatic manifestations of their mood disorder. Hence, there is no clear
dividing line between the work of the psychiatrist and other doctors in clinical
practice, and a basic knowledge of psychiatry is essential for all clinicians.
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1. Sensation and Perception disorders
Sensation is the process by which our senses gather information and send it
to the brain. With all this information coming into our senses, the majority of our
world never gets recognized. Perception is physical sensation given meaning, the
integration of sensory stimuli to form an image or impression, in a manner or
configuration influenced by past experience. The way we perceive our
environment is what makes us different from other animals and different from each
other. Perception may be increased or decreased in intensity. Heightened
perception occurs in delirium, mania, after hallucinogens, and in the rare ecstatic
states that occur as part of acute schizophrenia or “transported” hysterical trances.
Dulled perception occurs in depression and organic delirium. Cenesthesias:
bodily malsensations, often with a paroxistic and fluctuating intensity, which are
idiosyncratically experienced as new and unusual (such as “Unusual bodily
sensations of numbness and stiffness”, “Migrating bodily sensations wandering
through the body”, “Kinaesthetic sensations, pseudomovements of the body”).
Cenesthesias occurs in depression, conversional disorders and schizophrenia.
While mild changes of perception, for example, heightened or dulled perception,
may occur as secondary phenomena to emotional disturbance such as anxiety,
major perceptual disturbances such as illusions and hallucinations are usually
associated with major functional illness or organic disturbances of brain function.
1.1 Illusion
An illusion is sensory stimulation given a false interpretation, that is, a false
perception. Illusions are most likely to occur when the mind is under the sway of
an emotionally determined ideational “set” (eg, vigilance for an intruder), when
sensory clarity is reduced (eg, at night), or when both sets of circumstances are
operating (as when a frightened elderly patient has both eyes bandaged following
ophthalmic surgery). Illusions are common in delirium and may be visual (eg,
fluttering curtains seen as intruders), auditory (eg, a slamming door interpreted as
the report of a pistol), tactile (eg, skin sensations thought to be caused by vermin),
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gustatory (eg, poison detected in the taste of food), kinesthetic (eg, flying), or
visceral (eg, abdominal pain thought to be caused by ground glass). Affective
illusion is associated with and based on changes with mood for example at
midnight a person may take a shadow as a ghost, but in the next moment this may
not be the case. Pareidolic illusion - vivid mental images occurring without
conscious effort when perceiving ill-defined stimuli, e.g. shapes in clouds. It
occurs more in children than in adults, in patient with delirium. Illusions may also
occur in normal life (especially physical and psychological), and pathological in
hysteria, depression, and schizophrenia, particularly when perception is
subordinated to a delusional idea (eg, of guilt or persecution) or an emotion of
great force.
1.2 Hallucination
A hallucination is a false perception that occurs in the waking state in the
absence of a sensory stimulus (Esquirol, 1833). It is not merely a sensory distortion
or misinterpretation, and it carries a subjective sense of conviction. It has the same
qualities as a normal perception i.e. is vivid, solid and compelling. It is not subject
to conscious manipulation. Hallucinations are common and normal, especially in
some people, when falling asleep (hypnagogic) or waking (hypnopompic). Severe
sleep deprivation can cause hypnagogic hallucinosis. Sensory deprivation
experiments have produced visual and auditory hallucinosis in many subjects.
Auditory hallucinations are traditionally associated with a diagnosis of
schizophrenia. In the World Health Organisation’s International Pilot Study of
Schizophrenia (WHO, 1973) auditory hallucinations were reported by 73 per cent
of people diagnosed as having an acute episode of schizophrenia, they still can be
reported by individuals who have been sexually abused, or suffered a bereavement,
as well as by individuals diagnosed as having a manic depressive illness or an
affective psychosis. Hallucinations may also be a prominent feature of the
uncommon schizophrenia-like psychosis associated with epilepsy. Diencephalic
and cortical disease may be associated with hallucinations (usually visual). Tumors
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of the olfactory or basal temporal regions may cause olfactory hallucinosis, for
example, as an aura. Hallucinations, especially visual (though sometimes
vestibular and kinesthetic), are common in the delirium caused by toxins (eg,
drugs, hallucinogens, alcohol, toxins), fever, cerebrovascular disease, and central
degenerative disorders. Although typically associated with psychiatric disorders,
the hallucinatory experience has a wide range of etiologies that may include but is
not limited to the following: neurological insult, seizure and sleep disorders, drug
reactions, substance abuse, grief, stress, as well as metabolic, endocrine and
infectious diseases.
Hallucinations can be auditory, visual, olfactory or gustatory, tactile, or somatic. In form, they may be amorphous, elementary, or complex. They may be experienced as emanating from inner or outer space and, if from outside, from near or
far. Hallucinations may be unsystematized, appearing to have no link to life circumstances, or systematized and part of a causally interconnected delusional world.
Auditory hallucinations may be inchoate (eg, humming, rushing water,
inaudible murmurs), fragmentary (eg, words or phrases such as “fag,""get him,” or
“beastly") or complex. Typically the schizophrenic patient locates complex
hallucinations in inner or outer space, as a voice or voices speaking to or about him
or her. The voice may be soothing, mocking, disparaging, or noncommittal.
Sometimes the voice echoes the patient’s thoughts or comments neutrally on his or
her actions. Sometimes the voice orders the patient to perform actions, or puts
thoughts into his or her head, a notion verging on thought insertion. The voice may
be perceived as coming from the radio or television, from outside the window, or
even from a distant place. In alcoholic hallucinosis, typically, a conspiracy of
threatening whisperers plan to injure the patient, provoking the patient to defend
himself or herself or to take flight. The experience of verbal hallucinations is very
personal. Whilst it is known that a common first reaction to voices is puzzlement,
individuals evolve different ways of interacting with their voices. Certain people,
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for example, experience voices as immensely distressing and frightening and will
shout and swear at them. In contrast, other individuals might find their voices
reassuring and amusing and actually seek contact.
The voices . . . were mostly heard in my head, though I often heard them in the
air, or in different parts of the room. Every voice was different, and each beautiful, and generally, speaking or singing in a different tone and measure, and
resembling those of relations or friends. There appeared to be many in my
head, I should say upwards of fourteen. I divide them, as they styled themselves, or one another, into voices of contrition and voices of joy and honour.
In the case of imperative voices, many individuals desperately resist the
commands, and comply only at times of great pressure, whilst others comply
willingly and fully.
Visual hallucinations vary from elemental flashes of light or color, as in
disorders of the visual pathways and cortex, to well-formed scenes of people,
animals, insects, and things. In delirium, insects or other small objects may be seen
moving on the bed or in the surroundings. Lilliputian hallucinations occur in
delirium and other organic brain syndromes. Visual hallucinations may be
secondary to hypnopompic hallucinations, migraine, seizure disorders, delirium,
encephalitis, post-concussion syndrome, or even non-neurological events such as
transcendental meditation, mystic events, use of hallucinogens, and near death
experiences. Autoscopic hallucinations: These are a blend of visual and
proprioceptive hallucinations. Autoscopic (heautoscopic) hallucinations: first
described by Féré in 1891, a.k.a. phantom mirror image – the experience of seeing
a double of oneself projected into external space. Lhermitte has defined them as
"the visual hallucination of the self". In these cases, the vision is of one's double,
like in a mirror, sometimes repeating one's gestures, and on occasions busy with
other activities, a veritable doppelginger occur in: depressive illness,
schizophrenia, temporal lobe epilepsy (in 30%), parietal lobe lesions. Associated
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with:
decreased
consciousness,
delirium,
visual
imagery,
narcissism,
depersonalization. Negative autoscopy is the experience of looking into a mirror
and seeing nothing at all. In schizophrenia, or under the influence of hallucinogens,
the patient may have the uncanny sense that somebody or something, a presence, is
behind him or her - extracampine hallucination. Extracampine hallucinations
experienced outside of the normal sensory field, e.g. “he’s right behind me walking
everywhere I go”. Occur in: schizophrenia, epilepsy, organic states, hypnagogic
hallucinations in healthy people. Sometimes a schizophrenic patient will report
visual hallucinations (eg, trips in flying saucers) aligned with his or her prevailing
delusions. The visual hallucinations of hysteria or dissociative disorder have a
hallucinatory-like quality and sometimes represent a traumatic event, as when a
war veteran relives a battle incident. Complex audiovisual hallucinations may
occur in temporal lobe epilepsy. Charles Bonnet's syndrome is a clinical entity of
the elderly, first described by the Swiss naturalist, as an account of the visual
hallucinations experienced by his grandfather. He described them as "amusing and
magical visions, coexisting with reason". It is now defined as a persistent recurrent
visual hallucinatory phenomenon of a pleasant nature, with a clear state of
consciousness, compelling, but seen by the patient as unreal. It is associated with
ocular pathology, and tends to be "remarkably crisp and detailed, and at times
lilliputian". In general, visual hallucinosis suggests acute brain disorder rather than
functional psychosis and tends to occur in a setting of confusion or obtundation.
Olfactory and gustatory hallucinations (eg, burning rubber, steak and onions)
may occur in epilepsy. Schizophrenic patients may perceive gas being pumped into
their bedrooms by persecutors or may think they taste poisonous substances in
their food. Melancholic patients may be conscious of the stench of corruption
rising from their unworthy bodies or may complain of the changed, metallic,
tasteless quality of their meals.
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Hallucinations of bodily sensation can be classified in: superficial: thermic
(temperature), haptic (touch), hygric (perception of fluid); kinaesthetic, visceral.
Tactile hallucinations are characteristic of cocaine and amphetamine intoxication,
the patient being distracted by the sensation of insects. Formicative hallucinations
are tactile phenomena found with the abuse of Alcohol, Methylphenidate,
Amphetamines, and Steroids. The patients complain of "bugs" crawling in their
skin, and may vigorously scratch themselves. Schizophrenic patients may detect
the effect on the skin of radioactivity beamed at them from a hostile source.
Somatic hallucinations occur in schizophrenia, whereby genital, visceral,
intracerebral, or kinesthetic sensations are often referred to the influence of
persecutors or machines. The melancholic patient may have the sense of having no
stomach, with food dropping from the throat into a void.
Hypnogogic (going to sleep) and Hypnapompic (on waking) hallucinations can
be visual or auditory and associated with: healthy people, toxic states (e.g. fever,
glue-sniffing), post-infective depressive states, phobic anxiety neuroses. Functional
hallucinations that are generated in the presence of an unrelated external stimulus
of the same modality (usually auditory); can occur in schizophrenia. Reflex
hallucinations
denotes a veridical perception in one modality producing an
hallucination in another, e.g. seeing a doctor writing and then feeling him writing
across one’s stomach. Is a hallucinatory form of synaesthesia. Pseudohallucination:
This is a form of imagery in which sensory experience emanates from within the
patient's mind and is perceived in inner, subjective space. It is vivid, but lacks the
substantiality of normal perception. A patient may complain of "voices" but
describe them in terms as above and recognise that they originate in their own
thoughts. In most cases happened due to schizophrenia.
Hallucinations had first been defined by Jean-Etienne Esquirol in 1838 as
‘perceptions without an object’: “A man who is thoroughly convinced that one of
his sensations corresponds to an actual perception, while no object capable of
triggering such sensation is within the reach of his senses, is in a state of
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hallucination: he is a visionary”, and it was clear for Esquirol that this applied
mostly to visual hallucinations. But at the beginning of the 1850s, a discussion
came to the fore among Parisian psychiatrists as to whether this definition was
appropriate outside a rather limited range of pathological phenomena. Baillarger
reported several cases in which patients had the feeling of being invaded by
thoughts which at certain moments were described as hallucinations without any
sensory quality. This he called hallucinations psychiques (mental hallucinations).
Even though the debates failed to reach a satisfactory conclusion, hallucinations
psychiques became a classical issue, and Jules Séglas, at the beginning of the
1880s, proposed to consider that this delusional experience, which was also called
‘pseudohallucination’, to discriminate it from the official Esquirolian ‘perception
without an object’, should be understood as ‘motor hallucination’, that is, as the
autonomisation of the production of speech. Empirical evidence was soon to
corroborate the idea that verbal hallucinations were generally not mere ‘sensory
disorders’, but motor disorders, as it was shown that in most cases patients were
actually pronouncing in undertones the hallucinations they claimed to be hearing.
This lead gradually to the idea that in a significant number of cases, the ‘motor
hallucinatory mechanism’ was responsible for the formation of a psychotic
syndrome, which became extremely famous in France under the name of psychose
hallucinatoire chronique. In the 1920s, G. G. de Clérambault and V.K. Kandinsky
claimed that most of the psychoses were actually determined by what he termed
automatisme mental, which he suspected to be caused by a superficial ‘serpiginous
lesion of the brain’ According to such conceptions we can differentiate a true
hallucination appears to the subject to be substantial and to occur in external
objective space most common happened in exogenous mental disorders and
pseudohallucination: this is a form of imagery in which sensory experience
emanates from within the patient's mind and is perceived in inner, subjective space.
It is vivid, but lacks the substantiality of normal perception most common
happened in endogenous mental disorders. A patient may complain of "voices" but
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describe them in terms as above and recognise that they originate in their own
thoughts. The example of pseudohallucination
is thought echo: An auditory
hallucination in which the patient experiences his own thoughts as repeated or
echoed or commented on, or even spoken out loud before he thinks them.
Various theories have been put forward to explain the occurrence of
hallucinations. When psychodynamic (Freudian) theories were popular in
psychiatry, hallucinations were seen as a projection of unconscious wishes and
desires. As biological theories have become orthodox, hallucinations are more
often thought of (by psychiatrists at least) as being caused by functional deficits in
the brain. With reference to mental illness, the function (or dysfunction) of the
neurotransmitter dopamine is thought to be particularly important. Psychological
research has argued that hallucinations may result from biases in what are known
as metacognitive abilities. These are abilities that allow us to monitor or draw
inferences from our own internal psychological states (such as intentions,
memories, beliefs and thoughts). The ability discriminate between self-generated
and external sources of information is considered to be an important metacognitive
skill and one which may break down to cause hallucinatory experiences.
1.3 Psychosensory disorders
Metamorphopsias, they may include the following: dysmegalopsia, (alterations
in the form of objects), micropsia and macropsia in which real visual perceptions
are seen smaller or larger than they really are. Micropsia can be accompanied by
teleopsia, in which the minified object is seen far away. In pelopsia objects are
seen as getting closer. Allesthesia modifies the perception of the place where a true
object really is. Palinopsia, is a persistent visual sensation after the object has been
removed from the patient's visual field. These events have more an illusory than
hallucinatory quality, and are frequently associated with either parietal lobe
pathology or as a component of a migrainous aura. Chromatopsias in which the
environment is seen as uniformly tinted with a color. Xanthopsias (yellow vision)
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have been reported with Digitalis use, and purple vision may be seen an antihelminthic treatment.
Depersonalization: An experience in which the patient feels that he himself is
unreal that he is acting as a part rather than being spontaneous and natural, that he
is a shadow of a real person. It is usually describes in terms of being “as if... ” He
feels detached from his experience as though he were viewing them from a long
way off, or through the wrong end of a telescope. In more severe forms of the symptom, the patient feels that he is actually dead, or when he looks in a mirror he cannot see a proper reflection or feels that parts of his body do not really belong to
him or that he is living some entirely different "parallel world" and cannot interact
in this one. The patient retains a measure of understanding although his condition
is abnormal.
I get shaky in the knees and my chest is like a mountain in front of me, and my
body actions are different. The arms and legs are apart and away from me and
they go on their own. That's when I feel I am the other person and copy their
movements, or else stop and stand like a statue. I have to stop to find out
whether my hand is in my pocket or not. frightened to move or turn my head.
Sometimes I let arms roll to see where they will land.
Depersonalization seen in disorders such as depersonalization disorder,
depression, dissociative disorders, hypochondriacal neurosis / hypochondriasis,
temporal lobe epilepsy, schizophrenic disorders, and schizotypal personality
disorder. Some patients do not draw a distinction between depersonalization and
derealization, using depersonalization to include both.

autopsychic depersonalization : experiences are felt as foreign

somatopsychic depersonalization : the body or some parts seem not self,
detached, or died

allopsychic depersonalization / derealization: a loss of the sensation of the
reality of one's surroundings; the feeling that something has happened, that the
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world has been changed and altered, that one is detached from one's
environment. It is seen most frequently in schizophrenic disorders.

déjà entendu [Fr. “already heard”] : the feeling that one has heard or
perceived something previously although it is in fact new to one's
experience

déjà éprouvé [Fr. “already tested”] : a feeling that one has previously
engaged in or experienced something when one has not

déjà fait [Fr. “already done”] : a feeling that what is happening has
happened before

déjà pensé [Fr. “already thought”] : a feeling that one has thought the
same thoughts before

déjà raconté [Fr. “already told”] : a feeling when telling someone
about an experience that one had previously related the same
experience either to them or to someone else, when in fact one had
not. 2. a feeling that a long-forgotten event which is being recalled
was told to one before, when it was not

déjà vécu [Fr. “already lived”] . a feeling that a new experience has
been encountered before, in a previous existence

jamais vécu [Fr. “never lived”] : a feeling that a common experience
has never been encountered before

déjà voulu [Fr. “already desired”] : a feeling that one has entertained
the same desires before

déjà vu [Fr. “already seen”] : an illusion in which a new situation is
incorrectly viewed as a repetition of a previous situation

jamais vu [Fr. “never seen”] : the sensation that familiar surroundings
are strangely unfamiliar; the illusion that one has never seen anything
like that before
Derealisation: The patient experiences his surroundings as unreal. An
office or a bus or a street seems as a large stage set with actors rather than real
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people going about their ordinary business. Everything seems colourless, artificial
and dead. In the most severe forms of the symptom the patient feels as though the
world was made of "plastic", "as thought it were not really there at all", as though
"people are puppets on strings without any real life of their own". Derealization is
associated with anxiety or dissociative disorders, depression, schizophrenia,
organic brain disorder, and after hallucinogen use. Time may be experienced as
accelerated under the influence of hallucinogens, in mania, or during an epileptic
aura. Time may seem slowed or stopped in depression or epilepsy. In some
conditions, time seems to lack continuity and the subject feels uninvolved in the
temporal stream. This is particularly likely to be encountered in amnestic
syndromes, depression, schizophrenia, or toxic-confusional states.
2. Disorders of Language and Speech
Although a lot of the doctors focuses on the content of that the patient says
and experiences, the form of verbal expression and thinking are also important.
Speech may be too slow and too restricted in severe depression with psychomotor
retardation. Long pauses may occur between words and in replies to questions. In
extreme forms the patient gives monosyllabic replies or even no responses at all, in
which case the patient is described as mute. Accelerated speech is seen in mania,
when it is difficult for the interviewer to get a word in edge-ways. Obsessional
patients may talk circumstantially, set bogged down in the details of their answers,
talking round and round the same points. This contrasts with manic patients, who
are constantly changing from topic to topic and may demonstrate flight of ideas.
Volume and tone of speech: Speech volume is often reduced in depression. Manics
may speak louder than usual. The depressed patient may sigh frequently and
display a mournful cadence. Normal variation in tone of voice may be restricted in
a depressed patient. Non-social speech: muttering, talking out loud or shouting
suggests disinhibition or possibly auditory hallucinations. Approximate answers
seen in hebephrenic schizophrenia, hysterical pseudodementia, Ganser syndrome,
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organic brain disease. Pseudologia fantastica seen in histrionic/ asocial personality
disorder, overlap with Munchausen syndrome
2.1 Speech disturbances
1. Aphonia loss of ability to vocalize
2. Dysphonia impairment with hoarseness, occurs in disease of the vocal cords and
IXth cranial nerve lesions
3. Dysarthria occures in lesions of the brain stem e.g. bulbar/ pseudobulbar palsy,
schizophrenia, personality disorders (perhaps consciously produced)
4. Logorrhoea excessive production of the volume of speech, without pressure of
speech
5. Logoclonia spastic repetition of syllables, occurs in Parkinsonism,
schizophrenia
6. Echolalia repetition of words or phrases that are spoken to him, seen in:
learning disability, dementia, head injury, Tourette’s syndrome
7. Unintelligible speech
a) Dysphasia
b) Paragrammatism – disorder of grammatical construction
c) Private symbolism:
1) neologisms
2) stock words and phrases
3) cryptolalia
4) cryptographia
8. Verbigeration refers to the repetition of words or syllables that expressive
aphasic patients may use while searching for the correct word
9. Paragrammatism any error in grammatical construction in schizophrenic
2.2 Language Disorder
· Clang associations
· associations with the initial syllable in schizophrenia
· associations with the last syllable in mania
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· Verbal stereotypy - repetition of a word or phrase (Stock word) which has no
immediate relevance to the context
2.3 Disorders of thinking
Disorders of thinking can be divided into the following categories:
disorders of the stream of thought (speed and pressure), disorders of form of
thought, disorders of content of thought, disorders of possession of thought.
2.3.1 Disorders of the stream of thought
In this category there is an alteration in either the amount or speed of
thought. At one extreme there is pressure of thought, when ideas arise in unusual
variety and abundance and pass through the mind rapidly. At the other extreme
there is poverty of thought, when the patient has only a few thoughts, which lack
variety and richness, and seem to move through the mind slowly. The experience
of pressure occurs in mania; that of poverty in depressive disorders. Either may be
experienced in schizophrenia. Stream of thought can be interrupted suddenly, the
patient’s mind goes ‘blank’ and an observer may notice an interruption in the flow
of conversation. Minor degrees of this experience are common, particularly in
people who are tired or anxious. In contrast, thought blocking (Snapping off),
which is a particularly abrupt and complete interruption, strongly suggests
schizophrenia. It is another name for. Because thought blocking has this diagnostic
significance it should only be identified if there is absolutely no doubt about its
presence. Unexperienced interviewers often wrongly identify a sudden interruption
in speech as thought blocking. Thought blocking should only be identified when
interruptions in speech are sudden, striking, repeated and when the patient
describes it as an abrupt and complete emptying of the mind. The diagnostic
association with schizophrenia is strengthened if the patient also interprets the
experience unusually, e.g. as having had his thoughts taken away by a machine
operated by a persecutor. The patient may explain it in terms of thought
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withdrawal. It is not caused by distraction and the patient cannot give any
explanation for it, but can describe it.
I may be thinking quite clearly and telling someone something and suddenly
I get stuck. You have seen me do this and you may think I am just lost for
words or that I have gone into a trance, but that is not what happens. What
happens is that I suddenly stick on a word or an idea in my head and I just
can't move past it. It seems to fill my mind; and there's no room for anything
else. This might go on for a while and suddenly it's over.
2.3.2.Disorders of form of thought
Formal thought disorder: there is evidence from the patient's speech or
writing that there is an abnormality in the way their thoughts are linked together.
Thus the abnormality is in the form of their speech rather than it's content. In flight
of ideas the patients thought and conversation move quickly from one topic to
another so that one train of thought is not completed before another one appears.
These rapidly changing topics are understandable because the links between them
are normal, a point which differentiates them from loosening of associations. In
practice the distinction is often difficult to make, especially when the patient is
talking so rapidly. The characteristics of flight of ideas are preservation of the
normal logical sequence of ideas, using two words with a similar sound (clang
association ) or the same word with a different meaning (punning ), rhyming and
responding to the distracting cues in the immediate surroundings. Flight of ideas is
characteristic of mania.
Perseveration is the persistent and inappropriate repetition of the same
thoughts. The disorder is detected by examining the person’s words or actions.
Thus in response to a series of simple questions, the person may give the correct
answer to the first question but continue to give the same answer inappropriately to
18
subsequent questions. Perseveration occurs in dementia but is not confined to this
condition.
Loosening of associations denotes a loss of the normal structure of thinking.
To the interviewer this appears as muddled and illogical conversation that cannot
be understood by further inquiry. There are several types of this abnormality, but
the striking feature in all of them is the general lack of clarity in the patient’s
conversation. This muddled thinking differs from those people with low
intelligence or anxiety. Anxious people give a more coherent account when they
have been put at ease, while those with low intelligence express their ideas more
clearly if the questions are simplified. When there is loosening of associations the
more the interviewer tries to clarify matters the less he understands them.
Loosening of associations occurs most often in schizophrenia.
The problem is insects. . . . My brother used to colect insects. . . . He's now a
man 5 foot 10 inches. . . . Y know, 10 is my favorite number. ... I also like to
dam draw, and watch television.
Loosening of associations can take several forms: Knight’s move or
derailment refers to a transition between topics, either mid-sentence or between
sentences, with no logical connection between the two phrases and no evidence of
such links that are found in flight of ideas. When this abnormality is extreme then
it can disrupt not only the connection between sentences and phrases, but also the
finer grammatical structure of speech. It is then called word salad. Verbigeration is
when sounds, words or phrases are repeated in a senseless way. It is a type of
stereotypy. One effect of loosening of associations is called vorbiereden or talking
past the point. The patient seems to get near to the point but never quite reaches it.
In addition to these disorders of links between ideas, thoughts may become
illogical through the widening of concepts i.e. the grouping together of concepts
that are not normally regarded as closely connected with one another.In derailment
there is a breakdown in association so that thoughts seem to occur with no logical
19
connection between them. The subject is unable to link his ideas and there is a
change in direction of his thinking. In fusion there is some preservation of the
normal chain of associations, but there is a bringing together of heterogeneous
elements. Links are made in the speech which do not progress clearly to the goal of
thought. Schneider’s mixing or muddling represent extreme degrees of fusion and
derailment. Crowding of thought occurs in schizophrenia. His thoughts are
passively concentrated and compressed in his head. The patient may say that his
thoughts are crowded into one part of his head it is a bit like flight of ideas but has
the schizophrenic quality of passivity.
Neologism: An abnormality of speech in which the patient makes up a new
word or phrase or uses existing words or phrases in bizarre ways which have no
generally accepted meaning but which have idiosyncratic meaning to the patient,
e.g. "inner testinal fortitude" used to mean inner strength. Autistic thinking is a
term used to refer to thinking not in accordance with the facts of reality and
emphasizes preoccupation with inner experience. Tangentiality
Replying to
questions in an oblique, tangential or irrelevant manner. e.g. "Where are you from
?", "Well, that's a hard question. I'm from Astana. I really don't know where my
relatives came from, so I don't know if I'm Russian or French". Circumstantial
thinking the slow stream of thought is affected by a defect of intellectual grasp, a
failure of differentiation of the figure ground – there is a great deal of unnecessary
detail which obscures the meaning; occurs in: epilepsy, mental retardation,
obsessional personality. Concrete Thinking – inability to think in an abstract way;
unable to differentiate between primary and secondary meanings of words; ·
abstractions and symbols are interpreted superficially without tact, or awareness of
nuance – the patient is unable to free himself from what the words actually mean.
Obsessive thinking anankasts tolerate ambiguity less readily than normals, they
like to have decisions made, but will delay making a decision until they have
reached a greater degree of certainty than that required by other people, thinking
tends to be under-inclusive, monolithic and segmented symptoms are said to be
20
characteristic of obsessional thinking, other features include insecurity and
sensitivity
2.3.3 Disorders of content of thought
Disorders of content of thought include delusions, preoccupations,
obsessions, compulsions, phobias, plans, intentions, recurrent ideas about suicide
or homicide, hypochondriacal symptoms and specific antisocial urges. Other
disorders of content include overvalued ideas. Sometimes there are slightly
different ways of dividing the different abnormalities of disorders of thought.
Obsessions, compulsions and phobias are sometimes described under the heading
‘disorders of thought control or possession’ rather than disorders of content of
thought.
Obsessions and compulsions. Obsession refers to impulses and thoughts.
Compulsions confined to motor acts. Obsessive phenomena can occur in normal
people, obsessive-compulsive neurosis, anankastic personality disorder, especially
if depressed, schizophrenia, when the obsessions are bizarre, may arise de novo in
the elderly associated with an organic psychosyndrome - the element of resistance
is usually not present. Jaspers in 1963 in his phenomenological analysis identified
five essential characteristics of obsessional symptoms: a) A nonsensical,
meaningless and absurd quality to the thoughts and actions of the obsessive thatis
recognized by the obsessive himself; b) The thoughts and acts having a compelling
force; c) A belief that thoughts and actions can influence events (magical
thinking); d) Need for order; e) Unacceptable impulses.
Have the following characteristics :
1. they must be recognized as the individual’s own thoughts or impulses
2. there must be at least one thought or act that is still resisted unsuccessfully,
even though others may be present which the sufferer no longer resists
3. the thought of carrying out the act must not in itself be pleasurable (simple
relief of tension or anxiety is not regarded as pleasurable)
21
4. the thoughts, images, or impulses must be unpleasantly repetitive
According to Lewis (1936), obsessional thoughts have three essential
features:
1. a feeling of subjective compulsion
2. a resistance to it
3. preservation of insight
Types of obsession
1. Obsessional thoughts / ideas
a) repeated, intrusive thoughts interfering with normal train of thought, causing
distress
b) may be single works, phrases, rhymes, or puns - often violent, obscene
or blasphemous
c) attempts to exclude them lead to distress
2. Obsessional images consist of:
a) obsessional image - depicts repetitively the unwanted intrusive cognition
b) compulsive image - depicts compulsive behaviour either by rectifying an
obsessional image (e.g. seeing corpses in coffins, and then having to imagine the
same people standing); or an independent compulsive image
c) disaster image - compulsive checkers may also ‘see’ the disaster happening, if
they do not turn the gas taps off for example
d) disruptive image - may intrude whilst compulsive rituals are being carried out
and necessitate the ritual being recommenced
3. Obsessive ruminations endless inconclusive internal debates, ruminations are
often pseudophilosophical, irritatingly unnecessary, repetitive and achieve no
conclusion
4. Obsessional doubts concern over actions, e.g. gas not switched off, doors not
closed
5. Obsessional convictions notions that thought equal acts, e.g. if I think about him
he will die, may be delusional in intensity
22
6. Compulsive rituals
a) mental rituals such as counting
b) physical activities like washing and checking
c) may be related to thoughts, or be unconnected
d) hand washing is more common in women
7. Obsessional slowness
slow activity out of proportion to other symptoms.
Affects goal directed activity, automatic activity is still carried out quickly
Obsessional acts: The central features of obsessional or compulsive
behaviour are i) that repeated checking, handwashing or other ritual is experienced
as being carried out against conscious resistance - the patient tries to resist but
cannot; ii) the behaviour is recognised by the patient as being irrational or
senseless. Carrying out the behaviour may reduce tension and anxiety.
Overvalued ideas: A belief that is held tenaciously but without unshakeable
conviction. An overvalued idea is an idea which is in itself comprehensible or
socially acceptable which has come to dominate the patient’s life, and is pursued
by him beyond the bounds of reason; does not have a stereotypic quality (unlike
obsessional rumination), never considered senseless by the patient, tend not to
have a bizarre quality, e.g. preoccupation with the water being over-flurinated.
Associated with: personality disorder (especially paranoid), morbid jealousy,
hypochondriasis, dysmorphophobia, parasitophobia (Ekbom’s syndrome), anorexia
nervosa (intense preoccupation and marked emotional investment in the belief e.g.
the belief of an anorexic girl that she is fat), transsexualism. Hypochondriasis: A
pre-occupation with one's health that is regarded as excessive by an observer. It
consists of worry, beyond the power of the patient to control, that there is disease
or malfunction in the patient, and which is out of proportion to any malfunction
that is actually present. Dysmorphophobia: This is a dissatisfaction and
preoccupation with physical appearance. The patient has a strong feeling that
something is wrong with his appearance. He looks ugly or old, his skin is cracked,
23
his teeth misshapen, his nose too large or crooked. In more severe forms, the
patient actually acts on the idea, for example, has his teeth out or plastic surgery on
his nose. Ideas of reference: In its moderate form this symptom is indicated by self
consciousness. The patient cannot help feeling that people take notice of him (in
buses, in a restaurant or in other public places) and that they observe things about
him that he would prefer not to be seen. He realises that his feelings originate
within himself and that he is no more noticed that other people, but cannot help the
feeling all the same. In its severe form, the patient thinks that people are critical of
him or that they tend to laugh at him. It is important to differentiate an overvalued
idea from a delusion
A major category of disorders of content of thought includes delusions. The
psychiatrist and philosopher Karl Jaspers first defined the three main criteria for a
belief to be considered delusional. These criteria are:

certainty (held with absolute conviction)

incorrigibility (not changeable by compelling counterargument or proof to
the contrary)

impossibility or falsity of content (implausible, bizarre or patently untrue)
Delusion: A false belief inappropriate to the patient's socio-cultural background
and firmly held in the face of logical argument or evidence on the contrary. It is not
modified by experience or reason. In someone who is partially improved on
treatment, delusions may be expressed with a degree of doubt, although it is clear
that they have previously believed them with delusional intensity. A delusion is
identified on the above characteristics of its form - the content of a delusion can
vary widely (see below). Jaspers originally made a distinction between primary
and secondary delusions. According to Jaspers, the primary delusions (sometimes
called true delusions, autochthonous idea) are distinguished by a transformation of
meaning, so that the world, or aspects of it, are interpreted in a radically different
way by the delusional person. To others, this intepretation is 'un-understandable' in
24
terms of the normal mental causality, mood, environmental influences and other
psychological or psychopathological factors. Jaspers describes four types of
primary delusion:
1.
delusional intuition - where delusions arrive 'out of the blue', without
external cause.
2.
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.
3.
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.
4.
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 realises
that this person was laughing because the man has animals living inside him.
Stages in the development of a delusion (Fish, Conrad)
1. Trema – delusional mood
2. Apophany – search for a new meaning
3. Anastrophy – heightening of the psychosis
4. Consolidation – formation of a new cognitive set based on the new meanings
5. Residuum – eventual autistic state
Delusions - secondary: A delusion which emerges understandably from other
pathological experiences or preoccupations e.g. hallucinations or a prevailing
affect. They may be either mood congruent or mood incongruent. For example, a
person becomes depressed, suffers very low mood and self-esteem, and
subsequently believes they are responsible for some terrible crime which they did
not commit.
25
Delusions of Assistance: The patient believes that someone or some
organisation, force or power is trying to help him. This delusion may arise as an
explanation for the experiences which are expressed as delusions of reference.
Delusions of Assistance may be simple (people make signs to the patient in order
to persuade him to be a better person, because they want to help him) or
complicated (angels organise everything so that the patient's life is directed in the
most advantageous way).
Delusions of Catastrophe: The patient feels a sense of impending doom, that
something awful is going to happen, but doesn't know what. He can only be
temporarily reassured and the feeling is out of proportion to any possible cause.
Affect is usually depressed. If the symptom is more intense, the patient has a
delusional conviction that the world is about to end and that some enormous
catastrophe has occurred or is going to occur, that the world is decayed, dirty, and
rotten. Also called Nihilistic Delusions.
Delusions of Control (Passivity): The essence of the symptom is that the patient
experiences his will as replaced by that of some other force or agency. The basic
experience may be elaborated in various ways - the patient believes that someone
else's words are coming out of his mouth, or that he writes down is not his own, or
that he is the victim of possession, a zombie, a robot, controlled by someone else's
will, even his body movements and feelings being willed by some other power.
Thought insertion and withdrawal are also delusions of passivity.
The inmates, here, hate me extremely because 1 am sane. . . They talk
to me telepathically, continuously and daily almost without cessation,
day and night. (Inmates and employees talk to me telepathically, daily,
and continuously without cessation, day and night). . . .By the power of
their imagination and daily and continuously, they create extreme pain
in my head, brain, eyes, heart, stomach and in every part of my body.
Also by their imagination and daily and continuously, they lift my
26
heart and stomach and they pull my heart, and they stop it, move it,
twist it and shake it and pull its muscles and tissues . . . they force one
another to talk orally and to send their voices to my head, forehead,
temples and heart. ... By telepathy and imagination, they force me to
say orally whatever they desire, whenever they desire and as long as
they desire. I never said a word of my own. I never created a thought
or image of my own.
Delusions of Grandiosity (Grandeur): The patient thinks he has special
abilities or is an important person. He may be chosen by some Power or by Destiny
for a special mission or purpose because of his unusual talents. He thinks he is able
to read people's thoughts or that he is particularly good at helping them, that he is
much cleverer than anyone else, that he has invented machines, composed music,
solved mathematical problems etc, beyond most people's comprehension. The
patient believes he is famous, rich, titled or related to prominent people. He might
believe that he has been adopted and that his real parents are royalty, etc.
Delusions of Guilt: The patient thinks he has brought ruin to his family by
being in his present condition and that his symptoms are punishment for not doing
better. He may have a fluctuating awareness that his feelings are an exaggeration
of normal guilt. In the more severe form of symptom, the patient has the conviction
that he has sinned greatly, or committed some terrible crime, or brought ruin to the
world. He may feel that he deserves punishment even death or hell fire because of
it. This symptom appears to be grounded in a depressed mood.
Delusions of Infidelity (Morbid Jealousy): The patient without good reason
thinks that his sexual partner is unfaithful to him. In the more intense form the
patient seeks for evidence and interprets innocent patterns of events as proof of
accusations of unfaithfulness.
27
Delusions of Persecution: The patient believes that someone or some
organisation, force or power is trying to harm him in some way, to damage his
reputation, to cause him bodily injury, to drive him mad or to bring about his
death. The symptom may take many forms from a direct belief that people are
hunting him down to complex and bizarre plots of every kind, science fiction, and
elaboration.
Delusions of Reference: Delusions of reference consist of a further
elaboration of ideas of reference so far as other people / events are involved. Thus
what is said may have a hidden meaning or someone makes a gesture that the
patient construes as a deliberate message. Situations may seem to be created which
have a special meaning to the patient. Things seem to be arranged to test him out,
objects are arranged so that they have a special significance for him, street signs,
advertisements, the TV and radio or different patterns of colour seem to have been
put there in order to give him a message.
The presence of a delusion usually indicates that the patient is suffering from
some type of psychotic illness or reactive psychosis.
2.3.4 Disorders of possession of thought
Healthy people take for granted the fact that their thoughts are their own. They
also assume that thoughts are private experiences that can be known to other
people if spoken aloud, or revealed by facial expression, gesture, or action. Patients
with delusions about the possession of thought can be affected in several ways:
Those with delusions about thought insertion believe their thoughts have been
implanted by an outside agency. This is different from a person who has
obsessional thoughts because, no matter how unpleasant the thoughts are, they
realize they are their own. Obsessional .thoughts are ‘home made but disowned’.
The patient with delusion of thought insertion will not accept that the thoughts he
28
possesses originate from his own mind. In the most typical case the alien thoughts
are said to have been inserted into the mind from outside. In such a case there is
usually an explanatory delusion as well. The symptom is very significant
diagnostically and so the greatest care must be taken never to identify it as present
without good evidence and a written example. False positive ratings may arise due
to the following:
1. Some patients of inadequate intellectual level or poor verbal ability, are
unable to grasp what is being asked.
2. Symptoms such as inefficient thinking, motor pressure and brooding may
cause confusion, but in none of these are alien thoughts experienced as being
inserted into the brain.
3. Auditory pseudo-hallucinations may be very difficult to distinguish and
sometimes the patient is unable to say whether the experience is a voice or a
thought.
4. The patient may explain the experience of the thought insertion in delusional
terms. However, if the patient merely complains that he is being influenced
or even simply that his thoughts are being read, this is not thought insertion.
5. An elated patient may speak as if his thoughts are coming from elsewhere.
But in such cases the patient knows they are his thoughts.
Patients with delusions of thought withdrawal believe that thoughts have been
taken out of their mind. This delusion usually accompanies thought blocking. In
delusions of thought broadcasting the patient believes that his unspoken thoughts
are known to other people in some way. Some people believe their thoughts can be
heard by other people (Gedankenlautwerden). All three of these symptoms occur
more commonly in schizophrenia than in any other disorder.
Mayer Gross outlined the boundaries of obsessions with delusions and
overvalued ideas. Recently this issue was reviewed by Kozak and Foa (Table 1).
(Table 1)
29
The boundaries of obsessions with delusions and overvalued ideas.
Obsession
Subjective
compulsion
Overvalued idea
feeling
Delusion
of Non-intrusive, unresisted False
over-riding acceptable idea pursued
internal resistance
personal
based
on
beyond bounds of reasons reference
of
beliefs
incorrect
external
reality
Absurd, ego dystonic
Ego syntonic
Unshakeable
conviction
Resistance
Strong
effective
component
Less
than
delusional
intensity
3.Disorders of Mood and Affect
Feeling: a positive or negative reaction to some experience” The subjective
experience of emotion. Emotion: a stirred up state due to physiological changes
which occurs as a response to some event and which tends to maintain or abolish
the causative event. The emotion is designated by the content of consciousness
which has evoked the physiological changes. Affects: waves of emotion in which
there is a sudden exacerbation of emotion usually as a response to some event
(sthenic affects: anger, rage, hate and joy; asthenic affects: anxiety, horror,
shame, grief and sadness). Affectivity: the total emotional life of the individual.
Affect: an objective assessment of a patient's mood during interview. It may appear
low and unreactive (i.e. lack of normal variation over time) or may appear elated in
mania. Labile affect is apparent if the range of affect varies widely and rapidly e.g.
from being elated to crying then abruptly to laughing again, all within a few
minutes. Mood: the emotional state prevailing at any given time. “The dominant
30
hedonic tone of the moment”: Deese. Mood state: a lasting disposition, either
reactive or endogenous, to react to events with a certain kind of emotion. Mood:
The patient's subjective assessment of how they have been feeling in themselves,
prior to and during the interview. This should be described in the patient's own
words and contrasts with the assessment of their affect by the interviewer.
Anxiety an unpleasant affective state with the expectation, but not the
certainty of something untoward happening (‘a fear for no adequate reason’). A
commonly experienced mood state. To be pathological it must cause distress to the
patient or others, be beyond the voluntary control of the patient, and be out of
proportion to any real threat to the patient. Anxiety or fear seen in schizophrenia
can be understood as a natural reaction to the delusions and hallucinations.
‘Acute anxiety states’: exaggerated states of normal fear.
‘Anxious disposition’: a low threshold for the development of anxiety.
Phobias - fears restricted to a specific object, situation or idea. It can be
classified: agoraphobia : intense, irrational fear of open spaces, characterized by
marked fear of being alone or of being in public places where escape would be
difficult or help might be unavailable. acarophobia : irrational fear of mites or of
other minute animate (insects, worms) or inanimate (pins, needles) objects,
sometimes accompanied by fear of parasites crawling beneath the skin.
aerophobia : irrational fear of drafts or fresh air, often connected with the idea of
harmful airborne influences. cancerphobia / cancerophobia : irrational fear of
cancer. claustrophobia : irrational fear of being shut in; fear of enclosed spaces,
such as elevators and tunnels, MRI machines, tight ties, rings, or belts.
eremophobia : irrational fear of being alone. erotophobia : fear of love, especially
of sexual feelings and activity. erythrophobia : irrational fear of the color red,
often accompanied by fear of blood (hematophobia). hydrophobia : irrational
fear of water. mysophobia : irrational fear of dirt and contamination. necrophobia
: irrational fear of death or of dead bodies. neophobia : irrational fear of novel but
31
non-threatening situations such as meeting a stranger or entering a new room.
nyctophobia : irrational fear of darkness. pharmacophobia : irrational fear of
drugs or medicines. phobophobia : irrational fear of one's own fears or of
acquiring a phobia. social phobia: fear and avoidance of social or performance
situations in which the individual fears possible embarrassment, defeat and
humiliation, e.g., fears of speaking, performing, or eating in public. zoophobia :
irrational fear of animals
Panic: A sudden, intense experience of anxiety which is accompanied by
prominent physical, autonomic and psychosensorial
symptoms. Subjective
manifestations: malaise, self-annihilation experiences. Somatic symptoms: dyspnea
or sensation of fatigue / asphyxia, palpitations, dizziness, vertigo, faintness,
shakiness, tremors, nausea or abdominal disturbance, paresthesias of light and
sound sensations, chills or heat => sweating, hyperthermia, pollakiuria, diarrhea,
tachycardia, polypnea, forced inspiration, increased systolic blood pressure.
Psychological or psychosensorial symptoms: acceleration of thoughts, impaired
distance perception, slowing down of time course, maintenance of self-control,
sometimes
interruption
of activities
and
escape, feelings
of unreality
(depersonalization, derealization), fears of dying, fears of going crazy, fears of
losing control.
Depressed mood state. ‘Vital hypochondriacal’ depression (Schneider):
the type of depression in which ‘precordial anxiety’ (a sense of oppression in the
chest associated with anxiety) occurs. Morbid anxiety often occurs in association
with morbid depression and gives rise to the clinical picture of agitated
depression. Depression four broad categories of signs and symptoms:

affective symptoms : loss of interests, habits (family, job, hobbies, friends) and
vital force, moral pain and shiness, irritability, irrequietude, anxiet, taedium
vitae, desperation, apathy, depersonalization, anhedonia: A loss of ability to
experience pleasure or enjoyment. It may be described as a symptom but can
32
also be observed through the course of an interview, as a loss of reactivity of
affect and a lack of expression of pleasure when speaking of usual interests and
enjoyment, excessive guilt;

cognitive symptoms can take two forms: qualitative and quantitative.With
qualitative cognitive symptoms, patients' thoughts reflect the depression - the
patient thinks in a depressed manner. Thoughts can become coloured with
feelings of hopelessness, helplessness, and pessimism. The person can feel
excessively and unreasonably quilty about things. They may also experience a
loss of self-esteem and self confidence. These qualitative symptoms are
extremely dangerous as they contribute to the suicidal behaviour of the
depressed person. In fact, the depressive symptom most highly correlated with
suicidal behaviour in depression is hopelessness. Desire of death and suicide
can be congruous / secondary (guilt, ruine) or uncongruous / primary
(persecution) due to delusional disorders. The quantitative cognitive symptoms
involve disturbances of attention, concentration and memory. Many patients
complain of memory problems, and deficits are documented with
neuropsychological testing. These quantitative cognitive symptoms can greatly
contribute to the adverse effects on the person's performance at work that are
often a consequence of depression;

psychomotor symptoms : psychomotor retardation, early morning awakening,
weight loss, lack of reactivity to the environment, slowing, abulia, adynamia,
asthenia, reduced and fragmented mimic;

vegetative symptoms : insomnia, including difficulties falling asleep, frequent
awakening during the night or very early morning awakening (this last sleep
disturbance, known as terminal insomnia, is most characteristic of severe
depression) or hypersomnia, inapettency or hyperphagy, reduction of libido,
constipation, headache, daily or seasonal alternance (usually worse at morning,
better at evening in case of endogenous depression).
33
Endogenous depression : a type of depression caused by somatic or
biological factors rather than environmental influences, in contrast to a Reactive
depression. Patients usually not self-reproachful but tend to blame others for their
illness. Morbid thinking is not present. Threats of suicide are not infrequent, even
suicidal attempts are made. Often anger and resentment are ill-controlled. They
enjoy sympathy. The loss of weight, loss of interest and loss of libido are not
common. Sleep is almost invariably disturbed. ‘Smiling depression’: Unless they
are overwhelmed by their miseries or suffering from psychomotor retardation,
depressives can produce the communicatory smile. These patients smile with their
lips, but not with their eyes. They are particularly sensitive about ideas of guilt and
are often extremely disturbed by commiseration, so that they become obviously
depressed or even burst into tears when the examiner sympathizes with them.
Atypical clinical picture: shows depression
expressed with features of mood
reactivity/overreactivity to positive events, hyperphagia, hypersomnolence, severe
fatigue/leaden paralysis, chronic oversensitivity to rejection, masked depression).
Verstimmung (‘ill humored mood state’): irritable, angry depressive states,
patients are not only unhappy themselves, but make others unhappy as a result of
their unpleasant, aggressive behaviour, the borderline between reactive depression
and Verstimmung is not well marked. Seen in: disturbed adolescents; abnormal
personalities, particularly ‘psychopaths’; morbid depression (often the expression
of an abnormal personality, occasionally result of a mixed affective state;
schizophrenia; organic states; mania (pt. is irritable, querulous and awkward);
epilepsy (may occur when there have been no fits for sometime and often improve
after the pt. has a fit).
Ictal moods in temporal lobe epilepsy are most commonly of depression and
anxiety, and less commonly of euphoria or extremely unpleasant feelings.
Organic neurasthenia: mild anxiety mixed with depression and irritability,
occurring in mild acute and chronic coarse brain disease.
34
Morbid euphoria (undue cheerfulness and elation) and elation Seen in:
mania, organic states, schizophrenia (occasional).
Mania include four broad
categories of signs and symptoms: affective symptoms, cognitive symptoms,
psychomotor symptoms, vegetative symptoms. Heightened mood, exaggerated
optimism and self-confidence, increased physical and mental activity and energy,
excessive irritability, aggressive behavior, decreased need for sleep without
experiencing fatigue, grandiose delusions, inflated sense of self-importance, racing
speech, racing thoughts, flight of ideas, impulsiveness, poor judgment,
distractibility, reckless behavior, in the most severe cases, delusions and
hallucinations are the symptomes of mania. The manic, in contrast with the general
paretic, does not have well-held grandiose delusions. Lesions of the hypothalamus
may produce clinical pictures resembling mania with flight of ideas. Euphoria
classically occurs in disseminated sclerosis. Euphoria and a general passive attitude
are characteristic features of the amnestic syndrome. Moria (Witzelsucht): silly
euphoria with lack of foresight and general indifference; found in frontal lobe
lesions, particularly when the orbital surface is damaged.
Ecstasy A sense of extreme well-being associated with a feeling of rapture,
bliss and grace. It is not associated with overactivity and flight of ideas. Visions of
religious themes and voices of Higher Beings may be seen and heard. Seen in:
happiness psychosis, schizophrenia, epilepsy
Dissociation of affect a lack of manifestation of anxiety or fear under
conditions where this would be expected. It is said to be an unconscious defense
reaction against anxiety. The term covers a different forms of behaviour; plain
denial of anxiety, Belle indifference: seen in hysteria – the patient has gross
symptoms and severe disabilities but is undisturbed by his suffering.
Perplexity A state of puzzled bewilderment. Seen in: anxiety, mild clouding
of consciousness, acute schizophrenia
Irritability a liability to outbursts. A state of poor control over aggressive
impulses directed towards others, most frequently to those nearest and dearest.
35
May be a trait of personality (the explosive personality) and it occurs in morbid
states. It is very commonly a manifestation of the tension accompanying anxiety. It
appears episodically in women as part of the premenstrual syndrome. It may occur
in any organic state, but is rarely seen in the amnestic syndrome.
‘Apathetic hebephrenia’ (Leonhard): chronic schizophrenia in which patient
describes his frightful experiences with an indifferent air, have no drive, no interest
in anything, is difficult to employ and hangs about the hospital completely
indifferent to his lot. The anergic state seen in depression is not apathy because the
patient is not completely indifferent; it is rather that he is too preoccupied with his
miseries. Chronic organic states, particularly those in which the frontal lobes are
affected, may be associated with apathy. Emotional indifference and a lack of
activity, often associated with a lack of activity, often associated with a sense of
futility. Seen in: traumatic depersonalization, situations of hopelessness.
Parathymia (inadequacy or blunting of affect): in its mildest forms, shows
itself as a (recently acquired) insensitivity to the subtleties of social intercourse, a
complete loss of all emotional life so that the pt. is indifferent to his own wellbeing and that of others. Blunted affect: There is a diminution of emotional
response and a very limited range of emotional expression even when emotive
subjects are spoken about. This is evident to the interviewer but not necessarily to
the patient.
Incongruity of affect: A loss of the direction of emotions, so that an
indifferent event may producer a severe affective outburst, but an event which is
emotionally charged to the examiner has no effect on the patient’s emotional
expression. Is not necessarily a primary disorder of affect; FTD would lead to a
distortion of the schizophrenic’s comprehension of his environment, so that
although the affect expressed might appear incongruous to the outsider, it might be
congruous with the patient’s thoughts.
36
Stiffening of affect: The emotional expression is congruous at first, but it
does not change as the situation changes. See in Schizophrenia
In chronic hebephrenia the abnormality of emotional expression may occur
against a background of an enduring mood state, such as silly euphoria, careless
indifference, querulous ill-humor and autistic depression. Some chronic paranoid
schizophrenics discuss their delusions with elation, depression or irritability; but
outside their delusions they show some emotional blunting.
Compulsive (forced) affect: The expression of emotion in the absence of
any adequate cause. Lability of affect: the patient has difficulty in controlling his
emotions. Seen in: abnormal personalities, as appreciation-needing and irresolute
psychopaths, some normal subjects, organic states, like organic neurasthenia,
morbid depression, mania
Affective incontinence: there is complete loss of control over emotions. In
mild cases, pt. breaks into tears when a very slightly emotionally charged topic is
mentioned, when the symptom is marked he breaks into tears when spoken to and
has no feelings of sadness. Seen in: organic states, like cerebral arteriosclerosis,
disseminated sclerosis, attacks of forced laughing occur most commonly in
disseminated sclerosis.
Delusional mood: The patient feels that his familiar surroundings have
changed in a puzzling way which he may be unable to describe. He may simply
say that everything seems odd, strange, and that he cannot understand what is
happening. He may experience this as ominous or threatening or simply appear
puzzled and perplexed.
4. Cognitive function
Cognition refers to the mental processes of appraisal, judgement, memory
and reasoning. Cognitive function may be impaired in organic or functional
psychiatric disorder with deficits in one or more of the following areas: orientation,
memory for recent events, learning of new information, attention and
37
concentration, comprehension, calculation, the ability for abstract thinking and
judgement. The patient who can give a clear and accurate history is unlikely to be
cognitively impaired. However, a discrepancy between an individual's previous
level of functioning assessed from their educational and work record and their
present performance at work or at home should raise the suspicion of impairment.
Attention: The ability to selectively focus on stimuli relevant to the task in
hand. Disorders of selective attention can be due to dissociative states, Alzheimer’s
disease,
depression,
schizophrenia.
Hypoprosexia:
distraction,
difficult
concentration, attention deficit (depression, concsiousness disorders, mental
retardation, dementia). Hyperprosexia: a condition in which the mind is occupied
by one idea to the exclusion of others, e.g. in mania.
Orientation: This refers to orientation for time (day of the week, date, year),
place (where the interview is being held, what town/city) and persons (personal
details). Time sense may be assessed by asking about time of day, duration of
interview, how long they have been in hospital. Orientation is typically affected in
amnestic syndrome, dementia and where a reduced conscious level is present.
Concentration: The ability to maintain attention on the task in hand,
measured by such tasks as reciting the months of the year in reverse order or
spelling a word e.g. 'world' backwards.
4.1 Memory disorders
Memory the capacity to record, retain, and retrieve information.
Psychogenic amnesias Anxiety amnesia - seen in: psychogenic reactions, morbid
anxiety, particularly in depressive illnesses. Katathymic amnesia – a set of ideas
which are disturbing when conscious are repressed in an attempt to avoid the affect
which they would otherwise produce. Seen in: hysteria, normal persons. Hysterical
(dissociative amnesia) – there is a complete loss of memory and loss of identity,
38
but the pt. can carry out complicated patterns of behaviour and is able to look after
himself. It is often associated with a fugue or wandering state.
Organic amnesias: Acute coarse brain disease: Poor memory is due to
disorders of perception and attention and the failure to make a permanent trace.
Retrograde amnesia: amnesia which embraces the events just before the injury; is
the result of disturbance of the short-term memory.
Post-traumatic amnesia: the period between loss of consciousness and the
appearance of full awareness and memory; duration is directly related to the
severity of the head injury.
Anterograde amnesia: the pt. is apparently fully conscious, but has no memory for
the events which occur; is the result of a failure to make permanent traces. Seen in:

Alcoholic ‘blackout’

Delirium

Twilight state due to epilepsy

Pathological drunkenness

Organic brain disorders.
Transient global amnesia:
-
A sudden onset of retrograde amnesia covering a period of a few days upto
several years
-
Perception and personal identity remain normal.
-
An anterograde amnesia continues until recovery (upto several hours).
-
The amnesia subsequently shrinks to a period of half to five hours.
-
In some patients there is evidence of ischemia in the territory of the
posterior cerebral circulation.
-
The immediate cause is probably from bilateral temporal or thalamic
lesions.
Subacute coarse brain disease: The patient may have a retrograde amnesia
which stretches back over years before the onset of the disease; is due to
destruction of memory traces.
39
The amnestic state:
-
There are 3 faults: difficulty in forming permanent traces, difficulty in recall
and thought disorder.
-
There is disorientation for place and time, euphoria and confabulation.
-
Is related to damage to the floor and walls of the third ventricle and those
parts of the brain, eg. temporal lobes, closed linked to them.
-
There is a complete loss of ‘impressibility’ (registration of new memories)
in some patients.
-
The disorder of thinking is an inability tom change set, called tramline
thinking. Once thought is proceeding in a given direction it continues in that
direction for an unnecessarily long time, and instead of being corrected by the
incoming information it distorts the information that is getting registered and
makes recall difficult.
Chronic coarse brain disease:
-
The amnesia extends over many years.
-
Ribot’s law of memory regression: in dementing illnesses the memory for
recent events is lost before the memory for remote events.
Amnesic (or amnestic, dysmnesic, dysmnestic or Korsakov’s) syndrome is
characterized by prominent impairment of recent and remote memory with
preservation of immediate recall in the absence of generalized cognitive
impairment. Anterograde amnesia is associated with an impaired ability to learn
and disorientation for time. If the underlying pathology improves this can result in
a lessening of the extent of the retrograde amnesia. Confabulation, whereby gaps in
memory are unconsciously filled with false memories, is often a feature. Other
cognitive functions are usually normal, as perception. The course and prognosis are
those of the primary pathology; if the latter is treatable, then complete recovery of
the memory impairment is possible. The most common cause is deficiency of the
vitamin thiamine owing to alcohol abuse.
40
DISTORTION OF MEMORIES (paramnesias). Confabulations A false
description of an event, which is alleged to have occurred in the past. Seen in
organic states, hysterical psychopaths, amnestic syndrome, and chronic
schizophrenia. Some chronic schizophrenics confabulate, producing detailed
descriptions of fantastic events which have never happened. Leonhard suggests
that these pts. have a special form of FTD which he calls ‘pictorial thinking’.
Bleuler preferred to them ‘memory hallucinations’, since the memories are false
and unchangeable. But the ‘hallucinatory flashbacks’ which occur in temporal lobe
epilepsy may better merit the designation ‘memory hallucinations’.
4.2 Intelligence disorders
Intelligence: The capacity to understand the world, think rationally, and use
resources effectively when faced with challenges. Intelligence tests are used to
measure intelligence. They provide a mental age (the typical intelligence level
found for people at a given chronological age) which, when divided by a person’s
chronological age (physical age) and then multiplied by 100, gives an IQ, or
intelligence quotient score. Specific tests of intelligence include the StandfordBinet test, the Wechsler Adult Intelligence Scale – Revised (WAIS – R), and the
Wechsler Intelligence Scale for Children - Revised (WISC – R). In addition to
intelligence tests, other standardized tests take the form of achievement tests
(which measure level of knowledge intelligence a given area) and aptitude tests (
which predict ability intelligence a given area). Some researchers suggest that there
are two kinds of intelligence: fluid intelligence and crystallized intelligence. Fluid
intelligence: The ability to deal with new problems and encounters. Crystallized
intelligence: The store of specific information, skills, and strategies that people
have acquired through experience. Gardner’s theory of multiple intelligences
proposes that there are seven spheres of intelligence: musical, bodily-kinesthetic,
logical-mathematical, linguistic, spatial, interpersonal, and intrapersonal. At the
furthest extreme, Guilford’s structure-of-intellect model theorized that there are
41
150 separate mental abilities. Information-processing approaches suggest that
intelligence should be conceptualized as the way in which people represent and use
material cognitively. Rather than focusing in the structure of intelligence, they
examine the processes underlying intelligent behavior. One example of an
information-processing approach is Sternberg’s triarchic theory of intelligence,
which suggests three major aspects to intelligence: componential, experiential, and
contextual.
Mental Retardation ( Developmental Disability) is characterized both by a
significantly below-average score on a test of mental ability or intelligence and by
limitations in the ability to function in areas of daily life, such as communication,
self-care, and getting along in social situations and school activities. Failure to
develop cognitive abilities and achieve an intelligence level that would be
appropriate for their age group. Mental retardation is sometimes referred to as a
cognitive or intellectual disability. Children with mental retardation can and do
learn new skills, but they develop more slowly than children with average
intelligence and adaptive skills. Aggression, self-injury, and mood disorders are
sometimes associated with the disability. Mental retardation may be caused by an
inherited abnormality of the genes (about 5%), such as fragile X syndrome,
phenylketonuria, Down syndrome etc., prenatal illnesses and issues (fetal alcohol
syndrome, drug abuse), maternal infections and illnesses (glandular disorders,
rubella, toxoplasmosis, and cytomegalovirus, hypertension or toxemia), birth
defects that cause physical deformities of the head, brain, and central nervous
system, hyperthyroidism, and bacterial infection (meningitis) or (encephalitis),
traumatic brain injury and environmental factors (malnutrition) etc. There are
different degrees of mental retardation, ranging from mild to profound. A person's
level of mental retardation can be defined by their intelligence quotient (IQ), or by
the types and amount of support they need.
42
Mild mental retardation. Approximately 85% of the mentally retarded population
is in the mildly retarded category. Their IQ score ranges from 50-69, and they can
often acquire academic skills up to the 6th grade level. They can become fairly
self-sufficient and in some cases live independently, with community and social
support.
Moderate mental retardation. About 10% of the mentally retarded population is
considered moderately retarded. Moderately retarded individuals have IQ scores
ranging from 35-49. They can carry out work and self-care tasks with moderate
supervision. They typically acquire communication skills in childhood and are able
to live and function successfully within the community in a supervised
environment such as a group home.
Severe mental retardation. About 3-4% of the mentally retarded population is
severely retarded. Severely retarded individuals have IQ scores of 20-34. They
may master very basic self-care skills and some communication skills. Many
severely retarded individuals are able to live in a group home.
Profound mental retardation. Only 1-2% of the mentally retarded population is
classified as profoundly retarded. Profoundly retarded individuals have IQ scores
under 20. They may be able to develop basic self-care and communication skills
with appropriate support and training. Their retardation is often caused by an
accompanying neurological disorder. The profoundly retarded need a high level of
structure and supervision.
2. Impairments or deficits for that age group in functioning in at last two of the
following areas: A. Communication; B. Health; C. Leisure time; D. Safety; E.
School; F. Self-care; G. Social; H. Taking care of a home; I. Work
3. The onset of impairment must be before the age of eighteen.
43
Dementia is a slow, progressive decline in mental function in which
memory, thinking, judgment, and the ability to learn are impaired. The most
common cause of dementia is Alzheimer's disease. Other common causes are
Lewy body dementia and destruction of brain tissue by strokes, which results in
vascular dementia (multi-infarct dementia). Less common causes include
Parkinson's disease, infections such as AIDS, normal-pressure hydrocephalus, and
drug or alcohol abuse. Rare causes of dementia are Pick's disease and CreutzfeldtJakob disease, including its variant form, which is thought to result from
consuming contaminated meat. Dementia may also result from brain damage due
to a head injury or from cardiac arrest (sudden stopping of the heart's pumping).
Because dementia usually begins slowly and worsens over time, it may not be
identified at first. Memory, especially for recent events, is one of the first mental
functions noticeably to deteriorate. As dementia worsens, the ability to keep track
of time and the ability to recognize people, places, and objects are reduced. People
with dementia typically have problems finding and using the right word and have
difficulty with abstract thinking (such as working with numbers). Emotions may be
changeable, unpredictably and rapidly switching from happiness to sadness.
Changes in personality are also common. Often, a particular personality trait
becomes increasingly exaggerated: People who were always concerned with
money become obsessed with it, or people who were often worried become
constant worriers. Sleep patterns are often abnormal. Some people with dementia
hide their deficiencies well. They avoid complex activities such as balancing a
checkbook, reading, and working. People who do not modify their lives may
become frustrated with their inability to perform daily tasks. They may forget to do
important tasks or may perform them incorrectly; for example, they may forget to
pay bills or to turn off the lights or stove. People with dementia may become
withdrawn and less capable of controlling their behavior, sometimes acting
disruptively (for example, by yelling, throwing, hitting, or wandering). Several
effects of dementia contribute to these actions. Because people with dementia have
44
difficulty in understanding what they see and hear, they may misinterpret an offer
of help as a threat and lash out. Because their short-term memory is impaired, they
cannot remember what they are told or have done. They repeat questions and
conversations, demand constant attention, or ask for things (such as meals) they
have already received. Because they cannot express their needs clearly or at all,
they may yell when in pain or wander when lonely or frightened. About 10% of
people with dementia also have a psychosis, with hallucinations, delusions, or
paranoia. Eventually, people with dementia become unable to follow conversations
and may become unable to speak. In its most advanced forms, dementia results in a
near-complete destruction of the brain's ability to function. People become totally
dependent on others, and many become bedridden. Eventually, people may have
difficulty swallowing food without choking. Death often results from an infection,
such as pneumonia.
5. Insight
· ‘A correct attitude to morbid change in oneself’ (Lewis, 1934)
· Concept is multidimensional, incorporates both current and retrospective
components, and is usually not an ‘all-or-none’ phenomenon (David, 1990)
· Medication compliance and awareness of illness are separate but overlapping
constructs which contribute to insight (David, 1990)
· David (1990) divides insight into 3 dimensions :
1. awareness of disease
2. correct labelling of abnormality
3. willingness to take treatment
· Amador et al., 1993 :
1. recognition of illness (signs, symptoms, etc.)
2. attribution of illness (attribution of illness phenomena to a mental disorder)
3. awareness of treatment
45
4. awareness of social consequences of illness, e.g. disability, involuntary
commital to hospital, response/ concern of relatives.
6. Disorders of self-awareness
According to Jaspers, self-experience has four aspects :
1. Awareness of the existence of activity of the self
2. Awareness of the unity of the self at any one time
3. Awareness of the continuity of self-identity through time
4. Awareness of the self as distinct from the outside world
Disorders of self
· disorders of awareness of activity
· passivity phenomena
· loss of feeling
· nihilistic delusions
· disorders of unity of self
· autoscopy - refers to seeing oneself
· doppelganger
· multiple personality states
· disorder of boundaries of self - usually seen in schizophrenia, but is seen in states
of ecstasy
· Depersonalisation:
· sense of awareness of existence as a person is altered or lost
· the actions of others seem contrived
· Disorders of body image: organic disorder of body image (Paraschemazia) found after non-dominant strokes, anorexia nervosa, dysmorphophobia, hysteria,
hypochondriasis, schizophrenia.
7. Disturbed Consciousness
Consciousness: a state of awareness of the oneself and the environment. ·
Clouding of consciousness - disorientation in time, place, person, disturbances of
46
perception and attention, and subsequent amnesia. Drowsiness - further reduction
in level of consciousness, with unconsciousness if unstimulated, but can be
stimulated to a wakeful state. Sopor - further loss of responsiveness, can only be
aroused by considerable stimulation. Coma - profound reduction of conscious level
with very little or no response to stimulation.
Consciousness can be changed in three ways:
a. Dream-like changes of consciousness
b. Lowering of consciousness
c. Restriction of consciousness
Dream-like changes of consciousness: Dream-like (Oneiroid) state the
patient is disorientated, confused and experiences elaborate hallucinations, usually
visual (although sometimes auditory or tactile). There is an impairment of
consciousness and marked emotional change, the patient may appear to be living in
a dream world, the most common in schizophrenia. Is difficult to differentiate
from delirium.
Delirium is characterized by acute generalized psychological dysfunction
that usually fluctuates in degree. There is impairment of consciousness, often
accompanied by abnormal perceptions (illusions and/or hallucinations) and mood
changes (anxiety, lability or depressed mood). Delirium can result from poisoning,
psychoactive substance-use withdrawal, intracranial causes, endocrinopathies,
metabolic disorders, systemic infections and postoperatively. Delirium can occur
in patients suffering from physical illnesses, particularly hospital inpatients:
. general medical and surgical wards: delirium occurs in approximately 10%
. surgical intensive care units: 20–30%
. severely burned patients: approximately 20%.
Prodromal symptoms include: perplexion, agitation, hypersensitivity to light
and sound. Features of delirium itself include the following:
47
. Impairment of consciousness. The level of consciousness fluctuates, often being
worse at night. The pt. disoriented for time and place, but not for person.
Disordered thinking. Amnesia.
. Mood changes. The patient may be anxious, perplexed, agitated or depressed,
with a labile affect.
. Abnormal perceptions. Transient illusions and visual, auditory and tactile
hallucinations may occur. Visual hallucinations – usually of small animals,
associated with fear or even terror; or Lilliputian hallucinations which may be
associated with pleasure. Auditory hallucinations – commonly elementary, rarely
continuous voices, organized auditory hallucinations take the form of odd
disconnected words or phrases. Other hallucinations of touch, pain, electric
feelings, muscle sense and vestibular sensations often occur.
.
When the underlying physical illness is severe, insomnia is marked.
‘Occupational delirium’: when the pt. is restless and carries out the actions of his
trade. ‘subacute delirious state’ (toxic confusional state): milder degrees of
delirium, where pt. may have a general lowering of the consciousness during the
day and be incoherent and confused, while at night delirium occurs with visual
hallucinations and restlessness. There may also be some restriction of
consciousness so that the mind is dominated by few ideas, attitudes, and
hallucinations.
Lowering of consciousness (torpor): Patient is apathetic, generally slowed
down, unable to express himself clearly and may perseverate. After some weeks
there appears a remarkable partial recovery and the patient is left with a mild
organic defect. Seen in: severe infections, like typhoid and typhus, arteriosclerotic
disease, following a cerebrovascular accident.
Restriction of consciousness:
There is some lowering of the level of
consciousness, and the awareness is narrowed down to a few ideas and attitudes
which dominate the patient’s mind. ‘twilight state’ (Westphal): there is a - a
restriction of the morbidly changed consciousness, a break in the continuity of
48
consciousness, relatively well ordered behaviour. Twilight State commonly last
from one to several hours, but can last for weeks, characterized by:
1. abrupt onset and end
2. variable duration
3. unexpected violent acts or emotional behaviour
It may present as dream-like absent-minded behaviour, or slowness of
reaction and muddling of comprehension. Psychomotor retardation is commonly
profound, with marked perseveration in speech and action. Affective (panic, terror,
anger, ecstasy) and perceptual (hallucinations, usually visual and vivid and
complex) phenomena are common. Tend to terminate in a tonic-clonic seizure is
more commonly than automatisms. Memory is often fragmented, but a vivid
recollection of the hallucinations may be retained. Simple, hallucinatory,
orientated, perplexed, psychomotor, excited and expansive twilight states have
been described. Generally organic in origin, commonest twilight state is the result
of epilepsy. ‘Hysterical twilight state’: the restriction of consciousness resulting
from unconscious motives. Seen in severe anxiety. ‘Fugues’: wandering states
with some loss of memory. Seen in: depression, hysterical fugue: more common in
subjects who have previously had a head injury with concussion. Automatism a
state of clouding of consciousness which occurs during, or immediately after, a
seizure during which the individual retains control of posture and muscle tone, and
performs simple or complex movements and actions without being aware of what
is happening, the behaviour is sometimes inappropriate and may be out of
character for the individual i.e. action without awareness when environmental
cues may some extent determine the detailed patterns of behaviour, accompanied
by continuous electrical disturbance of the EEG, aura are common, majority are
brief, lasting from a few seconds to several minutes, associated with psychomotor
epilepsy originating in the medial temporal lobes, violence is rare, amnesia is
common.
49
8. Appearance and behaviour
8.1Psychomotor Agitation and Retardation
Psychomotor Agitation: a disorder of motor activity associated with mental
distress which is characterised by a restricted range of repetitive, non-progressive
("to and fro"), non-goal directed activity. The motor activity is particularly, but not
exclusively, directed to the upper limbs, but may also involve repetitive vocal
activity such as repeated questioning. In moderate degree it is shown by fidgeting
of various parts of the body and an inability to sit still. In severe degree it is
expressed by pacing up and down, wandering about, inability to sit down for vary
long time. It can be due to mania, agitated depression, catatonia, hysteria, delirium,
dementia frontal lobe lesions. Grandiosity: The patient's behaviour and speech
indicate a belief that he is superior to others and/or the interviewer. It may be
associated with actual delusions of grandiosity but the evidence for grandiosity
comes from the patient's overall demeanor and conversation. For example,
indicating that speaking to the interviewer is rather beneath him, or that he does not
wish to be involved with the general "riff raff" of patients on the ward. Mannerism:
Mannerisms are odd, repeated voluntary movements, usually specific to the
patient, often suggesting a special meaning or purpose. For example, saluting or
bowing down to greet someone. In catatonic schizophrenia.
Psychomotor Retardation: a disorder of motor activity characterised by a
reduction in the amount of purposeful movement. The patient sits abnormally still
or walks abnormally slowly or takes a long time to initiate movement. There is a
reduced amount of spontaneous movement. There are long pauses in their speech
before the patient answers the questions,each word follows very slowly after the
one before. With restricted quantity of speech the patient uses the minimum
necessary words, does not use extra sentences or unprompted additional comments,
so that it is extremely difficult to keep on the conversation. In more severe forms
50
the patient completely fails to answer. Questions have to be repeated and answers
are restricted to a minimum. Subjectively the patient may complain of their
thoughts being slowed up or reduced. It can be due to depression, altered
consciousness.
Disinhibition: A loss of social conventions which leads to behaviour which
is inappropriate to the social setting, such as overfamiliarity, type of clothing,
sexual behaviour and speech. Most often in schizophrenia and personality
disorders.
Stupor: An altered state in which the patient does not move, speak or
respond to external stimuli but in which consciousness appears to be maintained
(lucid) or altered. Consciousness can be inferred from purposeful eye-movements
that follow external objects. Severe stupor with altered consciousness seems to
have a better prognosis. It may have a variety of psychiatric, and neurological
causes, occurs in:
· schizophrenia (30 %)
· depression (25 %)
· psychological trauma
· mania
· organic brain lesions (20 %):
· diencephalon and upper brain stem
· frontal lobe
· basal ganglia
· the ‘locked in’ syndrome is due to lesions in the ventral pons
· spontaneous resolution occurs in 30 % of cases
· stupor has a mortality of 20 % (perhaps due to encephalitis).
51
8.2 Catatonic disorders
Catatonic disorders are a group of symptoms characterized by disturbances
in motor (muscular movement) behavior that may have either a psychological or a
physiological basis. The well-known of these symptoms is immobility (stupor),
which is a rigid positioning of the body held for a considerable length of time.
Patients diagnosed with a catatonic disorder may maintain their body position for
hours, days, weeks or even months at a time. Alternately, catatonic symptoms may
look like agitated, purposeless movements that are seemingly unrelated to the
person's environment. The condition itself is called catatonia. A less extreme
symptom of catatonic disorder is slowed-down motor activity. Often, the body
position or posture of a catatonic person is unusual or inappropriate; in addition, he
or she may hold a position if placed in it by someone else. Catatonic symptoms in
patients with schizophrenia were first described by the psychiatrist Karl Ludwig
Kahlbaum in 1874. Kahlbaum described catatonia as a disorder characterized by
unusual motor symptoms. His description of individuals with catatonic behaviors
remains accurate to this day. Kaulbaum carefully documented the symptoms and
the course of the illness, providing a natural history of this unusual disorder. The
catatonic subtype of schizophrenia is, fortunately, rare today. Depression with
catatonic features. People who are severely depressed may show disturbances of
motor behavior resembling those of patients diagnosed with catatonic
schizophrenia. These depressed persons may remain virtually motionless, or move
around in an extremely vigorous but apparently random fashion. Extreme
negativism, elective mutism (choosing not to speak), peculiar movements, and
imitating someone else's words or phrases (echolalia) or movements (echopraxia)
may also be part of the symptomatic picture. These behaviors may require
caregivers to supervise the patient, to insure that he or she does not hurt him- or
herself or others. As the depression begins to lift, the catatonic symptoms are
diminished. Catatonic disorders due to a ganeral medical conditions. Persons with
52
catatonic disorder due to a medical condition show symptoms similar to those of
catatonic schizophrenia and catatonic depression, except that the cause is believed
to be physiological. Such neurological diseases as encephalitis may cause catatonic
symptoms that can be temporary or lasting. Psychiatric symptoms caused by
physiological illnesses can appear early in the course of an illness. For this reason,
it is important to consider possible physical causes when catatonic symptoms
appear. Persons with catatonic symptoms of physical origin generally show greater
self-awareness or insight, and more distress about their symptoms than those
suffering from schizophrenia. This difference can help clinicians distinguish
between patients whose catatonic symptoms stem from psychiatric causes versus
those whose symptoms have a medical origin.

Ambitendence: this is a fluctuation between two alternatives, e.g. the
patient begins to take the hand the examiner offers him, and then withdraws
his own hand and then makes to put it forward again etc.

Echolalia & Echopraxia: these are the imitation of words and phrases or
actions, respectively, using the tone of voice and inflexion or actions of the
person copied.

Flexibilitas cerea: this is a condition in which the muscles of the limb
become fairly rigid and the arm if moved passively moves without jerking.
If an arm is raised into a certain position, the patient will hold it for at least
15 seconds.

Mitgehen: this is excessive co-operation in passive movements. The patient
can be pushed into uncomfortable postures by fingertip pressure from the
examiner.

Negativism: this occurs when the patient consistently does the opposite to
what he is asked, e.g. when asked to open his hand, he will close it tighter.

Posturing: the patient maintains odd, bizarre or uncomfortable positions for
a long time, e.g. lying in bed with his head raised several centimetres above
the pillow.
53
8.3 Spontaneous movements
Spontaneous movements, i.e. habitual, non-goal directed:
1) Tics - sudden involuntary twitching of groups of muscles, particularly facial
2) Static tremor - of hands, head, or upper trunk
3) Spasmodic torticollis - involves spasm of neck muscles with twisting of head,
which may become permanent
4) Chorea - abrupt, random jerky movements resembling fragments of goaldirected behaviour
5) Athetosis - slow, semi-rotary writhing movements
6) Orofacial dyskinesia - restless movements of tongue, mouth, and facial muscles
7) Akathisia: a disorder of motor activity that is often a side-effect of antipsychotic
(or sometimes antidepressant) medication. It is characterised by excess movement,
typically of the lower limbs, feelings of restlessness and subjective distress.
8) Tardive dyskinesia: a disorder of motor activity, usually as a side-effect to long
term antipsychotic treatment. It is characterised by slow, writhing movements
mainly of the mouth, tongue and face but may also affect other areas.
9) Stereotypy: A repeated, simple, purposeless and involuntary motor act, such as
rocking to and fro in a chair, rubbing one's head round and round in one's hands,
nodding one's head or grimacing. It occurs in: organic brain disorders (Pick’s
desease), epilepsy, catatonic schizophrenia
54
8.4 Seizures
International Classification of Seizures (1981), excluding infantile and
childhood epilepsies, which is based on clinical features rather than aetiology
(Table 2).
(Table 2)
International Classification of Seizures (1981)
Partial
seizures
locally)
(beginning Simple partial seizures (consciousness is
not impaired):
— with motor symptoms
— with somatosensory or special
sensory symptoms
— with autonomic symptoms
— with psychic symptoms
Complex partial seizures (consciousness
is impaired):
— star ting as a simple par tial seizure
— impaired consciousness at onset with
or without automatism
Partial seizures becoming generalized
Generalized seizures (convulsive or Absence:
non-convulsive)
— simple (petit mal)
— complex
Myoclonic
Clonic
Tonic
Tonic–clonic (grand mal)
Atonic
Adolescent epilepsies
Early morning myoclonus associated
with tonic–clonic seizures
55
Myoclonus and simple absence
Progressive myoclonic epilepsies
Unclassified epilepsy seizures (because
of incomplete data)
Simple partial seizures consist of motor, sensory, or psychomotor
phenomena without loss of consciousness. In jacksonian seizures, focal motor
symptoms begin in one hand and then "march" up the extremity. Other focal
attacks can first affect the face area and spread down the body to involve an arm
and sometimes a leg. Some partial motor seizures begin with raising the arm and
turning the head toward the moving part. Some proceed to generalized
convulsions.
In complex partial seizures, the patient loses contact with the surroundings
for 1 to 2 min. At first, the patient may stare, perform automatic purposeless
movements, utter unintelligible sounds without understanding what is said, and
resist aid. Mental confusion continues another 1 or 2 min after motor components
of the attack subside. These seizures may develop at any age, and structural
pathology (eg, mesial temporal sclerosis, low-grade astrocytomas) should be ruled
out. Complex partial seizures most commonly originate in the temporal lobe but
may originate in any lobe of the brain.
Complex partial seizures are not characterized by unprovoked aggressive
behavior. However, if restrained during a complex partial seizure, a patient may
lash out at the person restraining him, as may a patient in a postictal confused state
after a generalized seizure. Between seizures, patients with temporal lobe epilepsy
have a higher incidence of psychiatric disorders than does the general population;
33% may have psychologic difficulties, and 10% may have symptoms of
schizophreniform or depressive psychoses.
Generalized seizures cause loss of consciousness and motor function from
the onset. Such attacks often have a genetic or metabolic cause. They may be
primarily generalized (bilateral cerebral cortical involvement at onset) or
56
secondarily generalized (local cortical onset with subsequent bilateral spread).
Types of generalized seizures include infantile spasms and absence, tonic-clonic,
atonic, and myoclonic seizures.
Infantile spasms are primarily generalized seizures characterized by sudden
flexion of the arms, forward flexion of the trunk, and extension of the legs.
Seizures last a few seconds and are repeated many times a day. They occur only in
the first 3 year of life and then are replaced by other types of seizures.
Developmental abnormalities are usually apparent.
Absence seizures (formerly called petit mal) consist of brief, primarily
generalized attacks manifested by a 10- to 30-sec loss of consciousness and eyelid
flutterings at a rate of 3/sec, with or without loss of axial muscle tone. Affected
patients do not fall or convulse; they abruptly stop activity and resume it just as
abruptly after the seizure, with no postictal symptoms or even knowledge that an
attack has occurred. Absence seizures are genetic and occur predominantly in
children. Without treatment, such seizures are likely to occur many times a day.
Seizures often occur when the patient is sitting quietly and can be precipitated by
hyperventilation. They rarely occur during exercise.
Generalized tonic-clonic seizures typically begin with an outcry; they
continue with loss of consciousness and falling, followed by tonic, then clonic
contractions of the muscles of the extremities, trunk, and head. Urinary and fecal
incontinence may occur. Seizures usually last 1 to 2 min. Secondarily generalized
tonic-clonic seizures begin with a simple partial or complex partial seizure.
Atonic seizures are brief, primarily generalized seizures in children. They
are characterized by complete loss of muscle tone and consciousness. The child
falls or pitches to the ground, so that seizures pose the risk of serious trauma,
particularly head injury.
Myoclonic seizures are brief, lightning-like jerks of a limb, several limbs, or
the trunk. They may be repetitive, leading to a tonic-clonic seizure. There is no loss
of consciousness.
57
In status epilepticus, seizures follow one another with no intervening periods
of normal neurologic function. Generalized convulsive status epilepticus may be
fatal. It may result from extra-rapid withdrawal of anticonvulsants. Confusion may
be the only manifestation of complex partial or absence status epilepticus, and an
EEG may be needed to diagnose seizure activity.
9.Test
1Patients may show psychomotor retardation, which is manifest as a slowing or
loss of spontaneous movement and reactivity. Psychomotor agitation or
restlessness also can be observed in some patients. It is most likely ___________
- A. depression
- B. obsessive-compulsive disorder
- C. mania
- D.Parkinson’s desease
2.Patients report a dysphoric mood state, which may be expressed as sadness,
heaviness, numbness, or sometimes irritability and mood swings. They often report
a loss of interest or pleasure in their usual activities, difficulty concentrating, or
loss of energy and motivation. It is most likely ___________
- A. obsessive-compulsive disorder
- B. depression
- C. mania
- D.Parkinson’s desease
3.Their thinking often is negative, frequently with feelings of worthlessness,
hopelessness, or helplessness. It is most likely ___________
- A. depression
- B. obsessive-compulsive disorder
- C. mania
58
- D. phobia
4.If your patien’s got periods of several days when his/her mood is especially
energetic or irritable, and/or she/he needs less sleep, unusually talkative, thoughts
come and go faster than usual
- A. hypomanic episodes
- B. obsessions
- C.depression
- D. phobia
5.The thought content of patients usually is consistent with their dysphoric mood.
Patients often report feeling overwhelmed or inadequate, helpless, worthless, or
hopeless. Thought content always should be assessed for hopelessness, suicidal
ideation, or homicidal/violent ideation or intent. It is most likely ___________
- A. obsessive-compulsive disorder
- B. phobia
- C. mania
- D. depression
6.If your patien’s got periods of several days when his/her mood is especially
energetic or irritable, and/or she/he feels like you’re doing or saying things that are
unlike your usual self, thoughts come and go faster than usual
- A. hypomanic episodes
- B. obsessions
- C.depression
- D. phobia
7."Loss of memories for events that happened after brain damage"
refers to?
59
- A confabulation
- B retrograde amnesia
- C organic amnesia
- D anterograde amnesia
8. Someone who suffers brain damage and cannot remember anything that
occurred before the brain damage is experiencing
- A anterograde amnesia
- B retrograde amnesia
- C dyslexia
- D schizophrenia
9. Words are associated together inappropriately because of their meaning or
rhyme so that speech loses its aim and the patient wanders far from the original
theme. The patient jumps from topic to topic but with recognizable links such as
rhyming, punning or environmental distractions. Is called
- A Flight of ideas
- B Loosening of associations
- C Neologism
- D Thought blocking
10. The patient's speech is muddled, illogical, difficult to follow and cannot be
clarified. The patient talks fairly freely but so vaguely that no information is given
in spite of the number of words used. In severe form grammar may be affected
such that speech becomes completely incomprehensible (word salad). Is called
- A Flight of ideas
- B Loosening of associations
- C Neologism
- D Pressure of speech
60
11. An abnormality of speech in which the patient makes up a new word or phrase
or uses existing words or phrases in bizarre ways which have no generally accepted
meaning but which have idiosyncratic meaning to the patient, e.g. "inner testinal
fortitude" used to mean inner strength. Is called
- A Flight of ideas
- B Loosening of associations
- C Neologism
- D Pressure of speech
12. The patient talks rapidly with few, if any, pauses, and is difficult to interrupt.
There seems to be undue pressure to get the words out, he speaks too fast, his voice
is too loud and unnecessary words are added. Is called
- A Flight of ideas
- B Loosening of associations
- C Neologism
- D Pressure of speech
13.The patient feels that he himself is unreal that he is acting a part rather than
being spontaneous and natural, that he is a shadow of a real person. In more severe
forms of the symptom, the patient feels that he is actually dead, or when he looks
in a mirror he cannot see a proper reflection or feels that parts of his body do not
really belong to him. It’s most likely
- A Anhedonia
- B Depersonalization
- C Derealisation
- D Incongruity of affect
14.The patient has a strong feeling that something is wrong with his appearance.
He looks ugly, or old, his skin is cracked, his teeth misshapen, his nose too large or
61
crooked. In the more severe forms, the patient actually acts on the idea, for
example, has his teeth out or plastic surgery on his nose.
- A Anhedonia
- B Anxiety
- C Blunted affect
- D Dysmorphophobia
15. A recurrent, distressing idea, impulse or image that enters the mind against
conscious resistance, e.g. about things being dirty or contaminated, or doubt about
something being true or done correctly. It is experienced as being the patient's own
thought. Is called
- A Obsessional idea
- B Delusion
- C Overvalued ideas
- D None of all above
16. A belief that is held tenaciously but without unshakeable conviction. There is
intense preoccupation and marked emotional investment in the belief e.g. the belief
of an anorexic girl that she is fat. Is called
- A Obsessional idea
- B Delusion
- C Overvalued ideas
- D None of all above
17. A false belief inappropriate to the patient's socio-cultural background and
firmly held in the face of logical argument or evidence to the contrary. It is not
modified by experience or reason. Is called
- A Obsessional idea
- B Delusion
62
- C Overvalued ideas
- D None of all above
18. The patient feels a sense of impending doom, that something awful is going to
happen, but doesn't know what. He can only be temporarily reassured and the
feeling is out of proportion to any possible cause.
- A Delusions of Catastrophe
- B Delusions of Grandiosity
- C Delusions of Guilt
- D Delusions of Infidelity
19. The patient has a delusional conviction that the world is about to end and that
some enormous catastrophe has occurred or is going to occur, that the world is
decayed, dirty, and rotten.
- A Delusions of Catastrophe
- B Delusions of Grandiosity
- C Delusions of Guilt
- D Delusions of Infidelity
20. The patient thinks he has special abilities or is an important person. He may be
chosen by some Power or by Destiny for a special mission or purpose because of
his unusual talents. The patient believes he is famous, rich, titled or related to
prominent people.
- A Delusions of Catastrophe
- B Delusions of Grandiosity
- C Delusions of Guilt
- D Delusions of Infidelity
21. The patient thinks that he is much cleverer than anyone else, that he has
invented machines, composed music, solved mathematical problems etc, beyond
63
most people's comprehension. He might believe that he has been adopted and that
his real parents are royalty, etc.
- A Delusions of Catastrophe
- B Delusions of Grandiosity
- C Delusions of Guilt
- D Delusions of Infidelity
22. The patient has the conviction that he has sinned greatly, or committed some
terrible crime, or brought ruin to the world. He may feel that he deserves
punishment even death or hell fire because of it.
- A Delusions of Catastrophe
- B Delusions of Grandiosity
- C Delusions of Guilt
- D Delusions of Infidelity
23. The patient without good reason thinks that his sexual partner is unfaithful to
him. In the more intense form the patient seeks for evidence and interprets
innocent patterns of events as proof of accusations of unfaithfulness.
- A Delusions of Catastrophe
- B Delusions of Grandiosity
- C Delusions of Guilt
- D Delusions of Infidelity
24. The patient believes that someone or some organisation, force or power is
trying to harm him in some way, to damage his reputation, to cause him bodily
injury, to drive him mad or to bring about his death.
- A Delusions of Catastrophe
- B Delusions of Grandiosity
- C Delusions of Guilt
64
- D Delusions of Persecution
25. Which of the following statements about dementia is not correct?
- A Acute onset
- B Insidious onset
- C Clear consciousness
- D Global impairment of cerebral functions (e.g. recent memory, intellectual
impairment and personality deterioration with secondary behaviour abnormalities)
26. Which of the following statements about dementia is not correct
- A Clear consciousness
- B Global impairment of cerebral functions (e.g. recent memory, intellectual
impairment and personality deterioration with secondary behaviour abnormalities)
- C Progressive course (static course in head injury and brain damage)
- D Fluctuating course with lucid intervals
27. Elwood is convinced that aliens from the planet Saturn have taken up residence
in his attic and have planted monitoring devices in his head at night while he is
sleeping. Although he has thoroughly searched his attic and found no evidence of
their activities. His beliefs represent __________.
- A hallucinations
- B neologisms
- C delusions
- D obsessions
28. Korsakoff's syndrome (alcohol amnestic disorder), characterized by
- A anterograde and retrograde amnesia, disorientation, poor recall, and
impairment of recent memory, coupled with confabulation.
65
- B lesions in the mammillary bodies and thalamic nuclei may be the result of
vitamin deficiencies or the direct toxic effects of alcohol. Recovery is variable.
- C in more than one-half of the patients, elements of Korsakoff's syndrome are
permanent.
- D all of the above
29. Which of the following is not a characteristic of hallucinations
- A a misinterpretations of a real stimuli
- B a perception which occurs in the absence of any external stimulus
- C it can occur in any sensory modality and is experienced as originating in real
space, not just in thoughts
- D are usually associated with drug use (particularly hallucinogenic drugs), sleep
deprivation, psychosis or neurological illness
30. ________
________
are particularly associated with psychotic disorders
such as schizophrenia, and hold special significance in diagnosing these conditions
- A auditory hallucinations
- B olfactory (smell) hallucinations
- C gustatory (taste) hallucinations
- D somatic hallucinations
31. Formication
- A is a form of haptic hallucinations
- B associated with the sensation of touch
- C it is commonly seen in delirium tremens, amphetamine psychosis, and cocaine
intoxication.
- D all of the above
32. Hypnogogic / hypnopompic hallucinations:
66
- A hallucinations which are experienced whilst falling asleep haptic
hallucinations, associated with the sensation of touch
- B bodily sensations e.g. insects crawling under the skin
- C hallucinations which are experienced whilst waking up, respectively.
- D an unpleasant or different taste often interpreted as being the result of food
being
poisoned
33. Which of the following is not a characteristic of pseudohallucination
- A this is a form of imagery in which sensory experience emanates from within
the patient's mind
- B is perceived in inner, subjective space
- C it is vivid, but lacks the substantiality of normal perception
- D is percieved in external spase
34. A fluctuation between two alternatives, e.g. the patient begins to take the hand
the examiner offers him, and then withdraws his own hand and then makes to put it
forward again etc. is called
- A Ambitendence
- B Echolalia & Echopraxia
- C Posturing
- D Psychomotor Agitation
35. The imitation of words and phrases or actions, respectively, using the tone of
voice and inflexion or actions of the person copied is called
- A Ambitendence
- B Echolalia & Echopraxia
- C Posturing
- D Psychomotor Agitation
67
36. Excessive co-operation in passive movements. The patient can be pushed into
uncomfortable postures by fingertip pressure from the examiner is called
- A Ambitendence
- B Mitgehen
- C Psychomotor Retardation
- D Psychomotor Agitation
37. This occurs when the patient consistently does the opposite to what he is asked,
e.g. when asked to open his hand, he will close it tighter.
- A Negativism
- B Echolalia & Echopraxia
- C Posturing
- D Psychomotor Agitation
38. The patient maintains odd, bizarre or uncomfortable positions for a long time,
e.g. lying in bed with his head raised several centimetres above the pillow.
- A Negativism
- B Echolalia & Echopraxia
- C Posturing
- D Psychomotor Agitation
39. A loss of social conventions which leads to behaviour which is inappropriate to
the social setting, such as overfamiliarity, type of clothing, sexual behaviour and
speech is called
- A Disinhibition
- B Rapport
- C Stereotypy
- D Tardive dyskinesia
68
40.A repeated, simple, purposeless and involuntary motor act, such as rocking to
and fro in a chair, rubbing one's head round and round in one's hands, nodding
one's head or grimacing is called
- A Disinhibition
- B Rapport
- C Stereotypy
- D Tardive dyskinesia
41. The patient's behaviour and speech indicate a belief that he is superior to others
and/or the interviewer; it may be associated with actual delusions of grandiosity is
called
- A Grandiosity
- B Mannerism
- C Psychomotor Agitation
- D Psychomotor Retardation
42. Odd, repeated voluntary movements, usually specific to the patient, often
suggesting a special meaning or purpose. For example, saluting or bowing down to
greet someone.
- A Grandiosity
- B Mannerism
- C Psychomotor Agitation
- D Psychomotor Retardation
43. A reduction in the amount of purposeful movement. The patient sits
abnormally still or walks abnormally slowly or takes a long time to initiate
movement. There is a reduced amount of spontaneous movement.
- A Grandiosity
- B Mannerism
69
- C Psychomotor Agitation
- D Psychomotor Retardation
44. A loss of ability to experience pleasure or enjoyment is called
- A Anhedonia
- B Anxiety
- C Blunted affect
- D Panic
45. A diminution of emotional response and a very limited range of emotional
expression even when emotive subjects are spoken about is called
- A Anhedonia
- B Anxiety
- C Blunted affect
- D Panic
46. Emotion expressed is not in keeping with that which is expected or appropriate
to what is being spoken of
- A Anhedonia
- B Depersonalization
- C Derealisation
- D Incongruity of affect
47. A sudden, intense experience of anxiety which is accompanied by prominent
physical, autonomic symptoms, such as dry mouth, sweating, palpitations,
hyperventilation, G-I disturbance, etc.
- A Anhedonia
- B Anxiety
- C Blunted affect
70
- D Panic
48. Which of the following statements about delirium is not correct?
- A Acute onset
- B Disorientation, bewilderment, anxiety, poor attention
- C Clouding of/impaired consciousness, e.g. drowsy
- D Clear consciousness
49. Which of the following statements about delirium is not correct?
- A Acute onset
- B Disorientation, bewilderment, anxiety, poor attention
- C Clouding of/impaired consciousness, e.g. drowsy
- D Irreversible
50. Which of the following statements about delirium is not correct?
- A Clear consciousness
- B Perceptual abnormalities (illusions, hallucinations)
- C Reversible
- D Clouding of/impaired consciousness, e.g. drowsy
51. Anxiety or panic attack in situations that include being outside the home alone,
being in a crowd or standing in line, being on a bridge, or traveling on a bus, train,
or automobile— that is,
- A agoraphobia
- B claustrophobia
- C mysophobia
- D nyctophobia
52. Irrational fear of being shut in; fear of enclosed spaces, such as elevators and
tunnels, MRI machines, tight ties, rings, or belts— that is,
71
- A agoraphobia
- B claustrophobia
- C mysophobia
- D nyctophobia
53. An anxiety disorder characterized by fear and avoidance of social or
performance situations in which the individual fears possible embarrassment,
defeat and humiliation, e.g., fears of speaking, performing, or eating in public—
that is,
- A social phobia
- B claustrophobia
- C mysophobia
- D nyctophobia
54. Mysophobia – is
- A irrational fear of animals
- B irrational fear of dirt and contamination
- C irrational fear of darkness.
- D irrational fear of speaking
55. Nyctophobia – is
- A irrational fear of animals
- B irrational fear of dirt and contamination
- C irrational fear of darkness.
- D irrational fear of speaking
56. Increased physical and mental activity and energy is to symptoms of mania as
_________________ is to depression
- A decreased energy, fatigue, being "slowed down"
72
- B excessive irritability, aggressive behavior
- C grandiose delusions, inflated sense of self-importance
- D heightened mood, exaggerated optimism and self-confidence
57. Racing speech, racing thoughts, flight of ideas is to symptoms of mania as
_________________ is to depression
- A normal, slow, monotonic, or lacking in spontaneity and content speech
- B heightened mood, exaggerated optimism and self-confidence
- C excessive irritability, aggressive behavior
- D decreased need for sleep without experiencing fatigue
58. Grandiose delusions, inflated sense of self-importance is to symptoms of mania
as _________________ is to depression
- A often negative thinking, frequently with feelings of worthlessness,
hopelessness, or helplessness
- B recurring thoughts of death or suicide
- C feelings of guilt
- D all of the above
59. Which of the following is not a symptoms of depression
- A irritability, anger, worry, agitation, anxiety
- B inability to concentrate, indecisiveness
- C inability to take pleasure in former interests, social withdrawal
- D grandiose delusions, inflated sense of self-importance
60. Depression and mania have three broad categories of signs and symptoms.
These are:
- A mood, physical, cognitive
- B mood, cognitive, consciousness
73
- C physical, cognitive, consciousness
- D mood, intellegence, consciousness
61. Which of the following is a characteristic of atypical presentations of
depression
- A fatigue, headache, abdominal distress, or change in weight
- B sadness or low mood
- C diminished interest or pleasure, feelings of worthlessness
- D persistent sad, anxious, or "empty" mood, feelings of hopelessness, pessimism
62. Which of the following is a characteristic of atypical presentations of
depression
- A elderly persons may present with confusion or a general decline in functioning.
- B sadness or low mood
- C diminished interest or pleasure, feelings of worthlessness
- D persistent sad, anxious, or "empty" mood, feelings of hopelessness, pessimism
63. Which of the following is a characteristic of atypical presentations of
depression
- A children may present with initially misleading symptoms such as irritability,
decline in school performance, or social withdrawal
- B sadness or low mood
- C diminished interest or pleasure, feelings of worthlessness
- D persistent sad, anxious, or "empty" mood, feelings of hopelessness, pessimism
64. Which of the following is true about pseudodementia
- A this decline in cognitive functioning, which, on formal testing, appears to arise
from impaired concentration or motivation,
- B is referred to, more currently, as dementia of depression
74
- C should remit with successful treatment of the depressive episode
- D all of the above
65. Patients may show psychomotor retardation, which is manifest as a slowing or
loss of spontaneous movement and reactivity. Psychomotor agitation or
restlessness also can be observed in some patients. It is most likely ___________
- A depression
- B obsessive-compulsive disorder
- C mania
- D Parkinson’s desease
Test’s answers
1- A
2-B
3–A
4–A
5–D
6–A
7–D
8–B
9–A
10 - B
11 – C
12 – D
13 – B
14 – D
15 – A
16 – C
17 – B
18 – A
19 – A
20 - B
21- B
22 – C
23 – D
24 – D
25 - A
26 – D
27 – C
28 – D
29 – A
30 - A
31 – D
32 – A
33 – D
34 – A
35 – B
36 – B
37 – A
38 – C
39 – A
40 - C
41 – A
42 – B
43 – D
44 – A
45 – C
46 – D
47 – D
48 – D
49 – D
50 – A
51 – A
52 – B
53 – A
54 – B
55 – C
56 – A
57 – A
58 – D
59 – D
60 – A
61 – A
62 – A
63 – A
64 – D
65 – A
75
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