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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 -