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Signs and Symptoms
of
Mental Disorders
Dr.issam Bannoura : MD JB Psychiatry
Clinical tutor, Bethlehem Mental Hospital
Psychiatry can be practiced only, if the psychiatrist develops two
distinct capacities: One of the capacity to collect clinical data objectively,
and accurately by history taking, and examination of mental state, and to
organize the data in a systemic and balanced way. The other is the
capacity for intuitive understanding of each patient, as an individual. Both
capacities can be developed by accumulation experience of talking to
patient.
Once the psychiatrist has elicited a patient signs and symptoms , he
needs to decide how far these phenomena , resemble or differ from those
of other psychiatric patient.
Psychopathology:
That means abnormal state of mind, and denotes three distinct
approaches:
1.phenomenological psychopathology: which is concerned with objective
description of abnormal state of mind, it concerned with conscious
experience and observable behavior.
2.psychodinamic psychopathology: it goes beyond description , and seeks
to explain the causes of abnormal state of mind, by postulating
unconscious mental process.
3.experimental psychopathology: abnormal phenomena , are examined by
inducing a change in one of the phenomena , and observing changes in
the other.
The significance of individual symptoms
A single symptom does not necessarily indicate mental disorder, it is
necessary grouping of symptoms into syndrome. Symptoms are more
likely to indicate, mental disorder, when they are intense and persistent.
Primary and secondary symptoms
The term is used in describing symptoms, but has two meanings:
-Temporal: primary means antecedent, and secondary means subsequent.
-Causal: primary means a direct expression of the psychological process,
and secondary means a reaction to the primary.
Disorders of perception
A- Illusion: illusions are misperception of external stimuli, they are
more likely when the general level of sensory stimulation is
reduced. They are also mire likely when level of consciousness is
reduced. For example it happens in delirious patients, and
frightened persons.
B- Hallucinations: a hallucination is a percept experienced in the
absence of an external stimulus, with similar quality to a true
percept. Hallucinations are not restricted to the mentally ill, some
people experience them when tired, and during the transition
between sleep and wakening ( they are called hypnogogic if
experienced while falling asleep, and hypnopompic if experienced
during awakening ).
Types of hallucinations
1. According to complexity:
-Elementary: such as bangs, whistles and flashes
-Complex: such as hearing voices, or music, or seeing faces
and scenes.
2. According to sensory modality:
a- Auditory: occasionally called phonemes. and they may be:
- Second person hallucination, they seem to address the
patient directly (e.g. you are going to die), or give
command (e.g. hit him). They mostly suggest depressive
disorder, or other mental, or organic disorder.
- Third person hallucination: voices which appear to be
talking to each other, referring to the patient as third person
(e.g. he is a homosexual). They are associated particularly
with schizophrenia but may be experienced in other mental
or organic disorders.
- Voices which anticipate echo, or repeat the patient’s
thoughts also suggests schizophrenia.
b- Visual hallucinations:
- Lilliputian: they are visual hallucinations of dwarf figures
- Extracampian: are experienced as located outside the filed
of vision.
Visual hallucinations may occur in hysteria, affective
disorders and schizophrenia, but should always raise the
possibility of organic disorder
c- Olfactory and gustatory hallucinations are frequently
experienced together, as unpleasant taste or smell, they may
occur in schizophrenia, or severe depressive disorder, but
they should also suggest temporal lobe epilepsy or irritation
of olfactory bulb or pathways by a tumor.
d- Somatic hallucinations (tactile or of deep sensation).
- tactile called haptic, as sensation of being touched, pricked
or strangulated.
- of deep sensation as feeling of viscera being pulled, or of
sexual stimulation, or electric shock.
They are weakly associated with particular disorders, but
they may suggest schizophrenia. The sensation of insects
moving under the skin may suggest cocaine abuse (cocaine
bugs).
e- other hallucinations:
- autoscopic hallucination: is the experience of seeing ones
body projected into external space, may suggest temporal
lobe epilepsy, or other organic disorder.
- reflex hallucination: for example the sound of music may
provoke visual hallucination that may occur after talking
drugs such as LSD or rarely in schizophrenia.
- as already mentioned hypnopompic and hypnogogic
hallucinations occur at the point of waking or falling asleep.
C- Pseudo hallucination:
They are vivid mental images that may be within the mind, or the
experience of perceiving something from the external world, but
recognized as unreal, they have no diagnostic significance because
patients are often uncertain themselves.
Disorders of thinking
They are usually recognized from speech and writing, they denote for
groups of phenomena:
A- Disorders of the stream of thought.
B- Disorders of the form of thought.
C- Particular kinds of thoughts-delusions
-obsessions
D- Abnormal believes about possession of thoughts
Disorders of the stream of thoughts
Both amount and speed of thoughts are changed, they may be:
1-pressure of thought, when ideas arise in unusual variety and abundance,
and pass through the mind rapidly. They suggest mania and may be
experienced in schizophrenia or organic disorder.
2- poverty of thought, when patient has only few thoughts, occurs in
depressive disorders, and may be in schizophrenia or other organic
disorders.
3. thought blocking, when stream of thought interrupted suddenly, the
patient experiences as his mind going blank, this experience strongly
suggests schizophrenia specially when interruptions in speech are
sudden, striking and repeated.
Disorders of the form of thought(formal thought disorder)
It can be divided into three subgroups:
1-flight of ideas : the patients thoughts and conversation move quickly
from one topic to another, so that train of thoughts is not completed
before another appears, but the links between topics are normal. They
are characteristic of mania.
2. loosening of association: that denotes a loss of the normal structure of
thinking, the patient changes the topics with no connection between
them, the interviewer appears as muddled and illogical. It can takes
several forms:
a- knights move or derailment refers to transition from one topic to
another between sentences or in mid sentences, with no
relationship between the two topics.
b- word salad or verbigeration, refers to a kind of stereotypy in which
sounds, words, or phrases are repeated in senseless way.
c- talking past the point, when the patient seems always about to get
near the matter, but never quite reach it.
Loosening of association occurs most often in schizophrenia.
3.Preseveration: is the persistent and inappropriate repetition of the same
thoughts, occurs in dementia but not confined to this condition.
Particular kinds of abnormal thoughts
 DELUSIONS
 OBSESSIONS
Delusions
A delusion is fix false belief that is firmly held on inadequate
grounds, can’t be altered by evidence of the contrary, and isn’t a
conventional belief that the person might be hold, upon his educational or
cultural background.
Delusions must be distinguished from overvalued ideas
(Wernicke1900) which are preoccupying belief, they are neither
delusional nor obsessional in nature, which comes to dominate a persons
life for many years, and may affect his actions (e.g. a person whose
mother and sister suffered from cancer, he may preoccupied with the
conviction that cancer is contagious.
Delusion is called complete when the belief is firmly held, with total
conviction, other delusion develop more gradually, called partial
delusions, similarly partial delusion may appear during recovery. Partial
delusion usually followed or preceded by full and complete delusion.
A primary delusion is one that appears suddenly, without any mental
events leading to it. But secondary delusions can be understood as
derived from some preceding morbid experience, such as hallucination or
delusion. The accumulation of secondary delusions may result a
delusional system and sometimes called systematized.
Systematized delusions may be bizarre (impossible), or nonbizarre
(possible).
When there is a mood from which a delusion arises, it is called
delusional mood. When familiar percept has new significance, for the
patient, it is called delusion perception. Finally , some delusions concern
past rather than present event, and are known delusional memory.
Occasionally , a person who lives with a deluded patient, comes to
share his delusions, this condition is known as shared delusions .
Delusional themes
1-persecutary delusions: are often called paranoid. Many writers applied
the term paranoid to grandiose, erotic, jealous, and religious delusions,
for this reason it is preferable to avoid the term paranoid. Persecutory
delusion are most commonly concerned with persons, or organizations,
that are to be trying to inflect harm on the patient, damage his
reputation or poison him, they can occur in schizophrenia, severe
affective disorders, and organic disorders.
2-delusions of reference: are concerned with the idea that objects,
events, or people have a personal significance for the patient . they
occur in schizophrenia, severe affective disorders, and organic
disorders.
3-grandiose delusions: or expansive delusions, are beliefs of
exaggerated self importance, and may be of grandiose ability which
occur in mania, may be in schizophrenia, or in organic disorders.
4-delusions of guilt and worthlessness: are found in depressive illness,
and the person concerned of shame and guilt, for what he had done in
the past.
5-nihilistic delusions: are beliefs about the nonexistence of some person
or thing, concerning failures of body function, that he had to die, and the
patient’s career is finished. They are associated with severe depressive
illness (cotard’s syndrome ).
6-hypochondriacal delusions: are concerned with illness, such as cancer
venereal disease, and they belief they are ill, they occur in
schizophrenia, delusional disorder, or organic disorders.
7-religious delusions: are delusions with religious content, many appear
in schizophrenia, affective disorders, or organic disorders.
8-delusions of jealousy: are more common among men, and are
concerned with doubts about the spouse’s fidelity. They occur in
delusional disorder (morbid jealousy) and in schizophrenia.
9-erotomanic delusions: are more common in women, are concerned
when a female has a belief that she is in love with a famous person,
they occur in delusional disorder(erotomania) or in schizophrenia.
They may called sexual or amours delusions.
10-delusions of control: the patient believes that his actions, impulses
or thoughts, are controlled by an outside agency, they suggest
schizophrenia, and may occur in affective disorders.
Delusions concerning the possession of thoughts
11-delusions of thought insertion: are a person’s belief that some of his
thoughts, are not of his own, and have been implanted by an outside
agency.
12-delusions of thought withdrawal: are beliefs, that thoughts of the
patient, have been taken out of the mind.
13-delusions of thought broadcasting: the patient believes that
unspoken thoughts are known to other people, through radio, telepathy,
or through other way.
The last three delusions, concerning the possession of thought, are
more common in schizophrenia, than in other disorders.
Obsessional and compulsive syndromes:
Obsessions are recurrent persistent thoughts, impulses, or images, that
enter the mind, known to be silly, senseless, unreal, they are generally
about matters which the person finds distressing and unpleasant, the
presence of resistance is important.
Obsessions can occur in several forms:
1-obsessional thoughts: are repeated words, or phrases, which are
usually
upsetting the patient.
2-obsessional ruminations: are repeated worrying themes of a more
complex kind, for example about the ending of the word.
3-obsessional doubts: are repeated themes expressing uncertainty about
previous actions.
4-obsessional impulses: are repeated urges to carry out actions, that are
usually aggressive. The person who has urges to pick up knife, may
develop fear of knives(obsessional phobia)
.
Thoughts about illness of fearful kind, or dread of illness such as
cancer, are called illness phobia.
Themes of obsessions can be grouped into six categories:
Dirt, contamination, aggression, order line, illness, sex, and religion.
Compulsions: are repeated purposeful behaviors, performed as
stereotyped way, they are accompanied by a sense that they must be
carried out, and by an urge of resistance. Usually the result of repeated
compulsive rituals, the person has slow performance and delay, the
condition called obsessional slowness.
Compulsive rituals are of many kinds:
-checking are concerned with safety.
-cleaning are concerned with dirt and contamination.
-counting
-dressing.
Phobias
A phobia is a persistent irrational fear of, and wish to avoid a specific
abject, activity, or situation.
Phobias may be:
1-simple: irrational fear of simple objects, or situations, such as high
places, spiders…etc.
2-social: irrational fear of social situations.
2-agoraphobia: irrational fear to be away from home and in situations a
person cannot escape easily.
Motor and catatonic signs
1-tics: are irregular repeated movements involving a group of muscles.
2-mannerisms: are repeated movements that have some functional
significance (e.g. saluting).
3-stereotypies: movements that are regular (unlike tics) and without
obvious significance (e.g. rocking to and fro).
4-posturing: is the adoption of unusual bodily postures for long time.
5-negativism: when they do the opposite of what is asked.
6-echopraxia: is the imitation of the interviewer’s movements
automatically, even when asked not to do so.
7-echolalia: is the repetition of the interviewer’s speech, and talk.
8-ambitendance: when they alternate between movements, for example
putting hands to shake and withdrawing it, and so on.
9-waxy flexibility: (catatonia) or catalepsy, when parts of the body can
be placed for long period at the same position.
Depersonalization and derealization
Depersonalization is a change of self awareness, that a person feels
himself unreal or lifeless.
Derealization : objects usually appear unreal, and people appear
lifeless.
The symptoms have been reported after sleep deprivation, sensory
deprivation, tiredness, as an affect of hallucinogenic drugs, and may be
associated with generalized anxiety disorder, dissociative disorder,
phobic disorders, depressive disorders, and schizophrenia.
Disorders of mood
Mood: is the long term emotional state.
Affect: is short term or present emotional state.
Changes in the nature of mood can be towards: anxiety, depression,
elation, anger, and irritable mood.
Apathy: total loss of emotions, and inability to feel pleasure.
Blunted or flattened affect: when the emotions are reduced, rather than
lost.
Labile affect: when emotions change in a rapid and abrupt way.
Disorders of memory
Failure of memory is called amnesia.
Short term memory: or primary memory, has two stores:
-immediate memory being stored for 15-20 seconds.
-recent memory in which information can be stored for hours.
Long term memory has been selected for more permanent storage.
Memory is affected by several kinds of psychiatric disorders, specially
organic mental disorders.
In some neurological and psychiatric disorders, patients have a
disturbance of recall or recognize events that have been known(jamais
vu) . or unknown events seem to be already seen(déjà vu)
Anterograde amnesia is poor memory for the interval between the ending
of unconsciousness and full conscious
Retrograde amnesia is inability to recall events, before the
onset of unconsciousness, some causes of
unconsciousness are head injury, and ECT.
Disorders of consciousness
Consciousness is awareness of the self and the environment. The
level of consciousness can vary between the extremes of alertness and
coma.
Coma: the patient shoes no mental activity or respond even to strong
stimuli.
Sopor: the person can be aroused only by strong stimulation.
Clouding of consciousness: the patient is drowsy and reacts
incompletely to stimuli(muddled thinking).
Confusion: means inability to think clearly.
Stupor: refers to condition in which the patient is immobile, mute,
motionless, but appears to be full conscious.
Disorders of attention and concentration
Attention is the ability to focus on the matter, concentration is the
ability to maintain that focus.
Attention and concentration may be impaired in a wide variety of
psychiatric disorders, including depressive disorder, mania, anxiety,
schizophrenia and organic disorders.
Insight
Insight may be defined as awareness of one’s own medical
condition. Most psychotic patients have no insight, e.g. schizophrenic and
manic patients do not consider themselves ill.
To consider insight, it is better to ask four separate questions:
1. is the patient aware of the phenomena?
2. does he recognize that phenomena is abnormal?
3. does he consider that they are caused by mental illness?
4. does he need treatment?
The answers to these questions are informative, and the doctor can
know if the patient, has insight into his illness, and is likely to cooperate
with treatment.
Standard criteria for rating symptoms
Standardized methods of interviewing have been developed in which
standard questions are used and criteria are provided to decide whether a
symptom is present or absent. Among the best known schemes are:
1- SCAN schedule of clinical assessment in neuropsychiatry.
2-SCID the structured clinical interview for diagnosis.
3-CIDI the composite international diagnoses and interview.
Further reading Oxford textbook of psychiatry-1996 -