psychiatric sheet for postgraduates

اللھم وفقني إلنجاز

ھذا العمل، واستكمال

ما بدأه أستاذي

الدكتور/ ياسر ريا

Dr. Mohamed Abdelghani

Updated By Mohamed Abdelghani

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I- Psychiatric history

1- Date

2- Informant

3- Source and reason for referral

4- Identifying data of the patient

5- Complaint

6- History of present illness

7- Past illnesses

8- Family history

9- Personal history

1- Date

Help an appraisal developmant of the case in chronological order.

May be of great medicolegal importance.

2- Informant

o May be relative, neighbor, friend or police.

o Reliability of the informant must be evaluated.

3- Source and reason for referral

The source of referral may be the patient himself or a relative or a friend or

the police.

The reason for referral may be treatment, incompliance of medications or

medicolegal reasons.

4- Identifying data of the patient

i- Name: must be recorded in an obvious place to:

Facilitate detection of patient sheet.


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Sex, religion and social class of parents can be known from patient’s

name.

Unusal name which is not accepted by the patient.

ii- Age:

Some disease are related to age;

- Senile dementia and Alzheimer’s disease are related to old age.

- Hysteria and psychotic disorders are more common in adulthood.

Dosage of drugs depends on patient’s age.

Chronic schizophrenics may experience time standstill توقف تام.

iii- Sex: although sex can be known from patient’s name, but some names are

confusing like Ragaa, Ismat, etc.

May be there is gender identity disorder.

There are diseases related to females like premenstrual dysphoric

disorder, postpartum psychosis.

Some diseases are more common in males like substance abuse and

antisocial personality disorder, and others are more common in females

like depression and conversion disorder.

iv- Occupation:

1. Indicator of socioeconomic status.

2. Level of intellegence.

3. Some occupations have an influence on patient’s personality.

4. May be aetiology of; intoxication by heavy matals in workers, alcohol

abuse in barmen.

5. Overwork may be cause of nervousness, or symptom of hypomania.

6. Occupational skills may be impaired by patient’s symptoms.

7. Unemployment is associated with psychological distress.

8. Occupation may have a colouring effect on symptomatology as occurs in

occupation delerium.


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v- Marital status:

- Prevalence of mental disorders is as follows; divorced more than single

more than widow more than married.

vi- Residence:

For follow up of the case.

Distribution of disease may vary in urban and rural communities.

Homeless persons may be cause or result of the mental disorder.

vii- Religion: and degree of religiosity must be assessed.

5- Complaint

- The patient complaint:

o Inpatient’s own words.

o State why he or she has come or been brought in for help.

o If the patient is mute, this must be recorded.

- The informant complaint:

Due to impaired insight of many psychiatric patients, it is

important to take the informant’s complaint.

6- History of present illness

- Comprehensive and chronological picture of the events.

- Onset, precipitating factors, course, duration, severity, effect on patient’s

functions, relation to physical condition, exacerbating events, ameliorating

factors, treatments received and degree of improvement.

- It is prefered to be open-ended questions specially with well-organized patients.

7- Past illnesses

- Past psychiatric episodes; symptoms, extent of incapacity, type of treatment

received, names of hospitals, length of each illness, effect of previous

treatments, and degree of compliance.

- Medical and surgical history, and drugs used in treatment.

- History of substance abuse.


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8- Family history

- Father, mother and sibilings; their relations to each other and to the patient, and

their attitude toward the patient’s illness.

- Financial resources, social class, social norms, religious traditions of the family.

- Psychiatric, neurological, substance use disorders in the family members.

9- Personal history

a- Prenatal and perinatal.

b- Infancy and early childhood.

c- Middle childhood.

d- Adolescence.

e- Young adulthood.

f- Middle adulthood and old age.

a- Prenatal and perinatal

- Full-term pregnancy or premature.

- Vaginal delivery or caesarian.

- Infections and drugs during pregnancy.

- Birth complications.

- Defects at birth.

b- Infancy and early childhood

Infant-mother relationship.

Problems with feeding and sleep.

Significant milestones; standing, walking, first words, two-word.

sentences, and bowel and bladder control.

Other caregivers.

Unusual behaviours, e.g. head banging.

c- Middle childhood

o Preschool and school experiences.

o Separations from caregivers.

o Friendships/play.


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o Methods of discipline (التهذيب)

o Illness, surgery, or trauma.

d- Adolescence

Onset of puberty.

Academic achievement.

Organized activities (sports, clubs)

Areas of special interest.

Romantic involvements and sexual history.

Drug/alcohol use.

Symptoms (moodiness, irrigularity of sleeping or eating, fights, and

arguments).

e- Young adulthood

Academic and career decisions.

Military experience.

Legal history.

Work history.

Marital history and offsprings.

Religiousity and values.

Intellectual and leisure activities.

f- Middle adulthood and old age

Social activities.

Aspirations. (طموحات)

Major losses.

Retirement and aging.


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II- Mental state examination

1) Apperance and Behaviour.

2) Emotion.

3) Thinking.

4) Speech.

5) Perception.

6) Sensorium (intellectual functions)=(Cognitive functions).

7) Insight.

8) Judgement.

9) Impulsivity.

(1) Appearance and Behaviour

i. Appearance:

a) Body built:

- height and weight;

o very tall: chromosomal abnormality.

o very thin: anorexia nervosa.

- Body proportions;

Pychnic (short rounded): more in depressed.

Asthenic (lean and narrow): more in schizophrenics.

Atheletic: more in epileptics.

b) Facial appearance:

- Mood: anxious, depressed, happiness.

- Medical conditions with psychiatric importance; thyrotoxicosis, Down’s

syndrome, renal failure and cushing syndrome.

c) General appearance:

Self care and grooming; hair, nail: may be neglected in schizophrenic, depressed

and addicts.


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Clothing; colour, appropriateness with age and sex.

ii. Behaviour (Conation):

Sum total of the psyche that includes impulses, motivations, wishes, drives, instincts,

and cravings, as expressed by a person's behavior or motor activity.

a) Social behaviour:

1- Abnormal social contact:

- Decreased in depression and schizophrenia e.g:"poor eye to eye

contact".

- Increased in mania.

2- Inappropriate social behaviour:

e.g. Aggression.

3- Non-social vocalization:

Schizophrenic and demented patients may talk to themselves.

In Gilles de la Tourette’s syndrome the patient may utter obscenities.

b) Motor behavior" activity":

i. Quantitative:

1- Decreased in depression.

2- Increased in mania and hypomania.

ii. Qualitative:

1. Abulia: Reduced impulse to act and to think. Occurs as a result of

neurological deficit, depression and schizophrenia.

2. Adiadochokinesia: Inability to perform rapid alternating movements. Occurs

with cerebellar lesions.

3. Adynamia: Weakness and fatigability, characteristic of neurasthenia and

depression.

4. Aerophagia: Excessive swallowing of air. Seen in anxiety disorder.

5. Aggression: forceful, goal-directed action that may be verbal or physical; the

motor counterpart of rage, anger and hostility.

6. Agitated depression: A combination of depressed mood and psychomotor


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agitation. A common presentation of depressive illness in the elderly.

7. Akathisia: A subjective sense of motor restlessness, relieved by repeated

movement of the affected part (usually the legs). A side-effect of treatment

with neuroleptic drugs.

8. Akinesia: Lack of physical movement, as in the extreme immobility of

catatonic schizophrenia or as an extrapyramidal effect of antipsychotic

medication.

9. Akinetic mutism: Absence of voluntary motor movement or speech in an

apparently alert patient (as evidenced by eye movements). Seen in psychotic

depression and catatonic states.

10. Amimia: Lack of the ability to imitate others.

11. Anergia: subjestive lack of energy.

12. Astasia abasia: Inability to stand or to walk in a normal manner, even though

normal leg movements can be performed in a sitting or lying down position.

Seen in conversion disorder.

13. Atonia: Lack of muscle tone.

14. Automatism: automatic performance of acts generally representing

unconscious symbolic activity. This apparently conscious act occurs in

absence of full consciousness "e.g. during TLE".

15. Bradykinesia: Slowness of motor activity.

16. Bruxism: Grinding of the teeth during sleep. Seen in anxiety disorder.

17. Catalepsy (Waxy flexibility): A motor symptom of schizophrenia in which

the patient's limbs can be passively moved to any posture and then held for a

prolonged period of time. Also known as flexibilitas cerea.

18. Cataplexy: Symptom of narcolepsy in which there is sudden loss of muscle

tone leading to collapse. Usually occurs following emotional stress.

Commonly seen in narcolepsy.

19. Catatonic exitement: agitated, purposeless motor activity, uninfluenced by

external stimuli.

20. Catatonic rigidity: Fixed and sustained motoric position that is resistant to


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change.

21. Catatonic stupor: markedly slowed motor activity, often to the point of

immobility although the patient is well aware of their surroundings..

22. Chorea: random and involuntary quick, jerky, purposeless movement.

23. Command automatism: Condition associated with catalepsy in which

suggestions are followed automatically.

24. Compulsion: uncontrollable impulse to perform an act repetitively.

25. Constructional apraxia: Inability to copy a drawing, such as a cube, clock,

or pentagon, as a result of a brain lesion.

26. Coprophagia: Eating of filth or feces.

27. Dependence: The inability to control intake of a substance to which one is

addicted. Dependence has two components:

Physiological dependence: is the physical consequences of withdrawal

and is specific to each drug.

Psychological dependence: is the subjective feeling of loss of control,

cravings, and preoccupation with obtaining the substance.

For some drugs (e.g. alcohol) both psychological and physiological

dependence occur; for others (e.g. LSD) there are no marked features of

physiological dependence.

28. Diogenes syndrome: Hoarding of objects, usually of no practical use, and the

neglect of one's home or environment. May be a behavioural manifestation

of an organic disorder, schizophrenia, depressive disorder, obsessive-

compulsive disorder; or a certain type of personality.

29. Disinhibition: Loss of the normal sense of which behaviours are appropriate

in the current social setting. Occurs in manic illnesses, the later stages of

dementing illnesses and during intoxication with drugs or alcohol.

30. Dyskinesia: Difficulty in performing voluntary motor activity by

superimposed involuntary motor activity.

31. Dyspraxia: Inability to carry out complex motor tasks (e.g. dressing, eating)

although the component motor movements are preserved.


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32. Dystonia: slow sustained contractions of the trunk or limbs.

33. Echopraxia: Pathological imitation of movements of one person (usually the

examiner) by the patient.

34. Encopresis: Involuntary passage of feces, usually occurring at night or

during sleep.

35. Enuresis: Incontinence of urine during sleep.

36. Extra-pyramidal side-effects (EPSE): Side-effects of rigidity, tremor, and

dyskinesia caused by the anti-dopaminergic effects of psychotropic drugs,

particularly neuroleptics. Unlike in idiopathic Parkinson's disease,

bradykinesia is not prominent.

37. Floccillation: Aimless picking, usually at bedclothes or clothing, commonly

seen in dementia and delirium.

38. Hemiballismus: Involuntary, large-scale, "throwing" movements of one limb

or one body side.

39. Mannerism: ingrained, habitual involuntary movement.

40. Micrographia: Small "spidery" handwriting seen in patients with Parkinson's

disease; a consequence of being unable to control fine movements.

Recognised by comparing their current signature with one from a number of

years previously.

41. Mimicry: Simple, imitative motion activity of childhood.

42. Mitgehen :An extreme form of mitmachen where the patient's limbs can be

moved to any position by very slight or fingertip pressure.

43. Mitmachen: A motor symptom of schizophrenia where the patient's limbs

can be moved without resistance to any position. The limbs return to their

resting state once the examiner lets go, in contrast with catalepsy, where the

limbs remain in their set positions for prolonged time.

44. Motor symptoms of schizophrenia :

Schizophrenia is associated with a variety of soft neurological signs and

motor abnormalities.

Motor symptoms include; catatonia, catalepsy, automatic obedience,


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negativism, ambitendency, mitgehen, mitmachen, mannerism,

stereotypy, echopraxia, and psychological pillow.

45. Negativism: motiveless resistance to all attempts to be moved or to all

instructions (or even doing the opposite).

46. Nymphomania: Abnormal, excessive, insatiable desire in a woman for sexual

intercourse.

47. Pantomime: Gesticulation; psychodrama without the use of words.

48. Pica: Craving and eating of nonfood substances, such as paint and clay.

49. Posturing: The maintenance of bizarre and uncomfortable limb and body

positions. Associated with psychotic illnesses and may have delusional

significance to the patient.

50. Psychogenic polydipsia: Excessive fluid intake without organic cause.

51. Psychological pillow: A motor symptom of schizophrenia. The patient holds

their head several inches above the bed while lying and can maintain this

uncomfortable position for prolonged periods of time.

52. Psychomotor agitation: excessive motor and cognitive activity, usually non-

productive and in response to inner tension.

53. Psychomotor retardation: Decrease and slowness of spontaneous voluntary

movement. Usually associated with subjective sense of tiredness and

subjective retardation of thought. Occurs in moderate to severe depressive

illness.

54. Ritual: Formalized activity practiced by a person to reduce anxiety, as in

OCD. OR: Ceremonial activity of cultural origin.

55. Satyriasis: Morbid, insatiable sexual need or desire in a man.

56. Sleep walking (somnambulism): motor activity during sleep.

57. Stereotypy: repetitive fixed pattern of physical action or speech.

58. Tardive dyskinesia: A movement disorder in which there is continuous

involuntary movement of the tongue and lower face. More severe cases

involve the upper face and have choreoathetoid movements of the limbs. It's

associated with long-term treatment with neuroleptic drugs.


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59. Tic: involuntary, spasmodic motor movement.

60. Twirling: Sign present in autistic children who continually rotate in the

direction in which their head is turned.

Commentary sample

The pt. has an average body built, sitting calm in the chair, properly groomed

with appropriate self care "cleaned hands, nails cut, shaving his beard" with

appropriate clothing and appears healthy.

He is cooperative, interested and interactive.

(2) Emotion

☺Emotion: is a complex phenomenon involving reactions in 3 distinct components;

a) Affective component: feeling experienced by the subject (e.g joy, anger,

sadness …).

b) Behavioral (expressive) component = "Skeletal & muscular component".

c) Autonomic and endocrine component.

☺Mood: is used to describe the sustained emotional tone and the subjective

(experienced) aspect of emotion.

Euthymic mood: narmal range of mood, implying absence of depressed or

elevated mood.

☺Affect: short-lived feeling state and may be used to describe the objective

(observable) aspect of emotion.

o Appropriate affect: condition in which the emotional tone is in harmony with

the accompanying idea, thought or speech.

N.B: In clinical practice, both mood and affect are used interchangeably.

Abnormalities of Emotion

A. Abnormal emotional predisposition: long standing disposition (trait):

I- Dysthymia; the person tends to be always sad.

II- Hyperthymia; tends to be overcheerful.


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III- Cyclothymia; tends to swing markedly from happyness to sadness.

IV- Affectless; tends to show no emotional response (indifferent).

B. Abnormal emotional reactions: temporary (changeable) emotional states:

I. Quantitative emotional disorders:

a. Abnormally intensified emotional reactions:

1- Unpleasant mood:

Depression: pathological feeling of sadness.

Dysthymia: Chronic, mildly depressed mood and diminished

enjoyment, not severe enough to be considered depressive illness.

Double depression: A combination of dysthymia and depressive illness.

Grief.

Bereavement: Feeling of grief or desolation, especially at the death or

loss of a loved one.

Mourning: Syndrome following loss of a loved one, consisting of

preoccupation with the lost individual, weeping, sadness, and repeated

reliving of memories.

Guilt: Emotional state associated with self-reproach and the need for

punishment. Distinguished from shame as shame is a less internalized

form of guilt that relates more to others than to the self.

Dysphoric mood: an unpleasant mood.

Anhedonia: loss of interest in, and withdrawal from, all regular and -

pleasurable activities, often associated with depression.

Alexithymia: a person’s inability to, or difficulty in, describing or being

aware of emotion or mood.

Anxiety: it is emotional state related to feer but has no justifiable cause

(unreasonable fear) and has 2 components;

- Psychological arousal "Psychic component": feeling of

apprehention and anticipation that danger is about to happen.


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- Physiological arousal "Dysmorphic component": with somatic and

autonomic nervous system manifestations.

Anxiety may be free floating (not attached to any idea) or phobic

(fear is focussed on specific objects and out of proportion to the

real danger, and can't be reasoned and leads to avoidance of feared

situation).

Irritability: feelin state of reduced control over temper, usually leads to

verbal or behavioral outbursts.

Intropunitive: Turning anger inward toward oneself. Commonly

observed in depressed patients.

Agitation: severe anxiety associated with excess and purposeless motor

activity.

Tension: increased and unpleasant motor and psychological activity.

2- Pleasant mood:

Elation: Air of enjoyment, euphoria, triumph, intense self-confidence,

or optimism, in manic patients elation has an infectious quality "but

not necessarily pathological".

Euphoria: generalized sense of well-being, with lack of concern for

physical or mental illness "differs from elation in that it has no

infectious quality and always pathological".

Exaltation زهو : element of grandier in addition to the elation.

Ecstacy نشـوة : feeling of intense rapture, in this uplifted mood there is

usually some mystical religious colouring, and the patient feels happy,

peaceful and calm.

Ineffability: Ecstatic state in which persons insist that their

experience is inexpressible and indescribable.

Unio mystica: Feeling of mystic unity with an infinite power.

Expansive mood: a person’s expression of feelings without restraint,

frequently with overestimation of their significance or importance.


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b. Abnormally reduced emotional reaction:

1. Emotional dullness: reduction of emotion is more in expression than in

experience.

2. Emotional indifference: the patient experiences the emotion but shows

no expression of it. "i.e. The severe degree of emotional dullness".

3. Apathy: (absence of affect) the patient neither experiences nor

expresses emotions.

4. Emotional blunting: reduction in both emotional experience and

expression, the extreme degree is apathy.

5. Constricted or ristricted affect: reduction in intensity of feeling tone,

less severe than blunted but clearly reduced.

II. Qualitative emotional disorders:

1- Incongruity (disharmony) of affect: inappropriateness of affect to thought

content.

2- Labile affect Fluctuation or instability of emotion, unrelated to : تقلـب املـزاج

external stimuli. May be found in multiple sclerosis, multiple infarcts

dementia, schizophrenia, biploar disorders.

3- Inappropriate affect: disharmony between the emotional feeling tone and

the idea, thought, or speech accompanying it.

4- Ambivalence: coexistence of two opposing feelings or attitudes toward the

same thing in the same person at the same time. (e.g. love and hate).

☺N.B.: Negative symptoms of schizophrenia:

The symptoms which reflect impairment of normal function.

They are: lack of volition, lack of drive, apathy, anhedonia, flattening of

affect blunting of affect, and alogia.

Believed to be related to cortical cell loss.

☺N.B.: Acathexis (decathexis):

o Lack of feeling associated with an ordinarily emotionally charged subject.


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o In psychoanalysis, it denotes the patient's detaching of emotion from

thoughts and ideas.

o Occurs in anxiety, dissociative, schizophrenic, and bipolar disorders.

☺N.B.: Cathexis: In psychoanalysis, a conscious or unconscious investment of

psychic energy in an idea, concept, object, or person.

☺N.B.: Dyspareunia: Physical pain in sexual intercourse, usually emotionally

caused and more commonly experienced by women; can also result from cystitis,

urethritis, or other medical conditions.

(3) Thinking

Def: Goal-directed flow of ideas, symbols, and associations initiated by a problem or

task and leading toward a reality-oriented conclusion; when a logical sequence

occurs, thinking is normal.

Other terms:

1. Primary process thinking:

Mental activity directly related to the id and characteristic of unconscious

mental processes.

Marked by primitive, prelogical thinking and by the tendency to seek

immediate gratification of instinctual demands.

Includes thinking that is dereistic, illogical, magical.

Normally found in dreams, abnormally in psychosis.

2. Secondary process thinking:

o The form of thinking is logical, organized, reality oriented, and influenced by

the demands of the environment.

o Characterizes the mental activity of the ego.


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3. Abstract thinking: is the ability to form concepts on the basis of summerizing or

generalizing attributes of some objects or events.

4. Autistic thinking (dereism): Thinking in which the thoughts are largely

narcissistic and egocentric, with emphasis on subjectivity rather than objectivity,

and without regard for reality. Seen in schizophrenia and autistic disorder.

5. Magical thinking: A belief that certain actions and outcomes are connected

although there is no rational basis for establishing a connection (e.g. if you step

on a crack, your mother will break her back). Magical thinking is common in

normal children and psychotic patients.

6. Fantasy (Daydream): fabricated mental picture of a situation or chain of events.

7. Parapraxis (Freudian slip):uncosciously motivated lapse from logic, considered

part of normal thinking.

8. Hyperpragia: Excessive thinking and mental activity. Generally associated with

mania.

Thought disorders

may be classified according to stream, form, possession and content of thought:

I- Stream of thought:

1- Too rapid:

Logorrhoea; endless trivial talk (pressure of thought).

Flight of ideas: switches rapidly from one topic to another, however the

train of thought can be followed (d.d: loosening of association).

2- Too slow:

o Various degrees of retardation up to mutism.

o Alogia: Absence of spontaneous speech due to poverty of thoughts . A negative symptom of schizophrenia and a symptom of depressive illness.

3- Interrupted:

Thought blocking, "Entgleiten", "snapping off", "thought

deprivation" or "increased thought latency": abrupt interruption


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in train of thought before a thought or idea is finished; after a

brief pause, a person indicates no recall of what was being said

or was going to be said, the patient feels suddenly that his mind

has gone blank.

Lethologica: Momentary forgetting of a name or proper noun.

II- Form of thought:

It refers to the manner in which thoughts, as reflected in speech, are linked in

language.

Formal thought disorder: disturbance in the form of thought rather than the

content of thought; thinking characterized by loosened associations, neologisms, and

illogical constructs. It's subdivided into:

A. -ve Formal thought disorder: concrete thinking.

B. +ve Formal thought disorder:

1- Loosening of associations = (asyndetic thinking) = (Asyndesis): flow of

thought in which ideas shift from one subject to another in a completely

unrelated way.

2- Incoherence: thought that generally is not understandable; running

together of thoughts or words with no logical or grammatical connection,

resulting in disorganization.

3- Derailment "Entgleisen" or "Knight's move thinking": gradual or sudden

deviation in train of thought without blocking, sometimes used

synonymously with loosening of association.

4- Word salade(Schizophasia): incoherent mixture of words and phrases. It's

the most severe degree of schizophrenic thought disorder in which there is

no connection between words and phrases.

5- Condensation (Fusion or Verschmelzung): fusion of various concepts into

one compound idea.

6- Muddling (Faseln) م�زج وتش�ویش : A feature of schizophrenic thought disorder

caused by simultaneous derailment and fusion. The speech so produced

may be very bizarre.


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7- Perseveration: persisting response (verbal or motor) to a previous

stimulus after a new stimulus has been presented; often associated with

cognitive disorders.

8- Verbigeration: meaningless repetition of specific words or phrases while

unable to articulate the "next" word in the sentence. Seen in expressive

dysphasia.

9- Irrelevant answer: not in harmony with question asked.

10- Circumstanciality: indirect speech that is delayed in reaching the point but

eventually gets from original point to desired goal; characterized by

overinclusion of details.

11- Tangentiality: inability to have goal-directed associations of thought;

speaker never gets from point to desired goal.

12- Evasion التھ�رب: Act of not facing something; consists of suppressing an

idea that is next in a thought series and replacing it with another idea

closely related to it. Also called paralogia and perverted logic.

13- Echolalia: psychopathological repeating of words or phrases of one

person by another; tends to be repetitive and persistent.

14- Flight of ideas: rapid, continuous verbalizations which produce constant

shifting from one idea to another; ideas tend to be connected, and in the

less severe form a listener may be able to follow them.

15- Neologism: new word created by a patient, often by combining syllables

of other words, for idiosyncratic شخصیة/ذاتیة pathological reasons.

16- Clang association: association of words similar in sound but not in

meaning; words have no logical connection.

III- Possession of thought:

1. Thought withdrawal: delusion that thoughts are being removed from a

person’s mind by other persons or forces.

2. Thought insertion: delusion that thoughts are being implanted in a person’s

mind by other persons or forces.


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3. Thought broadcasting: delusion that a person’s thoughts can be heared by

others, as though they were being broadcast over the air.

IV- Content of thought:

A. Poverty of content:

- Thought that gives little informationbecause of vagueness, empty

repetitions, or obscure phrases.

B. Overvalued idea:

- Unreasonable, sustained false belief, maintained less firmly than a

delusion.

- Dysmorphophobia: A type of over-valued idea where the patient

believes one aspect of his body is abnormal or conspicuously deformed.

C. Preoccupation or trend of thought:

Centering of thought content on a particular idea, associated with a strong

affective tone, such as paranoid trend or a suicidal or homicidal

preoccupation.

N.B.1: Egomania: pathological self-preoccupation.

N.B.2: Monomania; preoccupation with a single object.

D. Hypochondria "Hypochondriasis":

o Exaggerated concern about health that is based not on real organic

pathology but on unrealistic interpretations of physical signs or sensations

as abnormal.

E. Obsession:

Pathological persistence of an irresistible thought, feeling, idea, image or

impulse that can not be eliminated from consciousness by logical effort;

associated with anxiety and against one's will.

Patterns of obsessions:

- Dirt and contamination.

- Aggression.

- Orderliness.

- Illness.


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- Sex.

- Religion.

N.B.: Anancasm: Repeated or stereotyped behavior or thought usually used as

a tension-relieving device; used as a synonym for obsession and seen in

obsessive-compulsive (anankastic) personality.

F. Rumination:

o A compulsion to engage in repetitive and pointless thinking about a single

idea or theme, usually of a pseudo-philosophical nature, "as in OCD".

G. Compulsion:

Pathological need to act on an impulse that, if resisted, produces anxiety.

Repititive behaviour occurs in response to an obsession and performed

according to certain rules, with no true end in itself other than to prevent

something from occurring in the future.

Coprolalia: compulsive utterance of obscene words.

Trichotillomania: The compulsion to pull one's hair out.

Kleptomania: Pathological compulsion to steal.

Dipsomania: Compulsion to drink alcoholic beverages.

H. Delusion:

o False fixed belief, based on incorrect inference about external reality, not

consistent with patient’s intelligence and cultural background; cannot be

corrected by reasoning.

o Delusion is classified into:

Primary delusions: are the direct result of psychopathology.

Secondary delusions: arise in response to other primary psychiatric

conditions.

i. Primary delusions: subdivided according to:

The method by which they are perceived as having arisen:

If the patient is asked to recall the point when they became aware of

the delusion, they may report that:


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o The belief arose: "out of the blue" (autochthonous delusion): fully

formed 1ry delusion that arises suddenly with out explanation

ث أرضا كثیرة توفر لھ المال الالزم السترجاع أموالھ التي سلبھا منھ اآلخرون" ."المریض فجأة یعتقد أنھ ور

o On seeing a normal percept (delusional perception).

o On recalling a memory (delusional memory).

o On a background of anticipation, odd experiences, and increased

awareness (delusional mood).

Broad classes based on their content:

12 types of primary delusion are commonly recognised:

persecutory delusions, grandiose delusions, delusions of control,

delusions of thought interference, delusions of reference, delusions

of guilt, delusional misidentification, hypochondriacal delusions,

delusional jealousy, delusions of love, nihilistic delusions, and

delusions of infestation.

N.B1.: Delusional memory: A primary delusion which is recalled as arising as a

result of a memory (e.g. a patient who remembers his parents taking him to hospital

for an operation as a child becoming convinced that he had been implanted with

control and monitoring devices which have become active in his adult life).

N.B2.: Delusional mood "Delusional atmosphere": A primary delusion which arises

following a period of an abnormal mood state characterised by anticipatory anxiety, a

sense of "something about to happen", and an increased sense of the significance of

minor events. The development of the formed delusion may come as a relief to the

patient in this situation.

N.B3.: Delusional perception: A primary delusion which arises as a result of a real

perception (e.g. a patient who, on seeing two white cars pull up in front of his house

became convinced that he was therefore about to be wrongly accused of being a

paedophile). The percept is a real external object, not a hallucinatory experience.


24

ii. Secondary delusions: subdivided according to:

a- The dominant theme:

1. Health:

- Hypochondriacal delusions.

2. Financial status:

- Delusion of poverty: a person’s false belief that he or she is

bereft or will be deprived of all material possessions.

3. Moral worth:

- Delusion of self-accusation "D. Of self reproach, sin or

guilt": false feeling of remorse and guilt.

4. Relation to others "Paranoid delusions" include:

- Delusion of persecution: a person’s false belief that he is

being harassed, or persecuted "e.g. watched, followed,...".

- Delusion of grandeur: a person’s exaggerated conception of

his importance, power, or identity.

- Delusion of reference: a person’s false belief that the

behaviour of others refers to himself " e.g. people refer to

him, talk about him, laugh at him,...".

- Delusion of control (Passivity phenomena): false feeling that

a person’s will, thoughts, or feelings are being controlled by

external forces.

5. Others:

- Nihilistic delusion: false feeling that self, others, or the world

is nonexistent or coming to an end or no longer exist. A

feature of psychotic depressive illness.

- Somatic delusion "Hypochondriacal delusions": A delusional

belief that one has a serious physical illness (e.g. cancer,

AIDS). Most common in psychotic depressive illnesses.

- Cotard syndrome: a combination of severely depressed mood

with nihilistic delusions and/or hypochondriacal delusions.


25

Seen in psychotic depressive illness particularly in elderly

people.

- Delusion of infidility (delusional jealousy): false belief

derived from pathological jealousy about a person’s lover

being unfaithful.

- Othello syndrome (Ey syndrome): A monosymptomatic

delusional disorder where the core delusion has the content of

delusional jealousy.

- Erotomania (delusions of love): delusional belief, more

common in women, that someone is deeply in love with them

(De Clerambault syndrome).

- Delusions of infestation: A delusional belief that one's skin is

infested with multiple, tiny mite-like animals. It may be seen

in acute confusional states (particularly secondary to drug or

alcohol withdrawal), in schizophrenia or in dementing

illnesses.

- Ekbom syndrome: A monosymptomatic delusional disorder

where the core delusion is a delusion of infestation.

- Folie a deux: Mental illness shared by two persons with a

close relationship, usually involving a common delusional

system. Arises as a result of a psychotic illness in one

individual with development of a delusional belief, which

comes to be shared by the second. The delusion resolves in

the second person on separation, the first should be assessed

and treated in the usual way. If it involves three persons, it is

referred to as folie a trois, and so on. Also called shared

psychotic disorder.

- Delusional elaboration: Secondary delusions which arise in a

manner as the patient attempts to find explanations for

primary psychopathological processes (e.g. a patient with


26

persistent auditory hallucinations developing a belief that a

transmitter has been placed in his ear).

- Delusional misidentification: A delusional belief that certain

individuals are not who they externally appear to be. A rare

symptom of schizophrenia or of other psychotic illnesses. It

includes:

Fregoli syndrome: A type of delusional

misidentification in which the patient believes that

strangers have been replaced with familiar people.

Capgras syndrome: A type of delusional

misidentification in which the patient believes that a

person known to them has been replaced by a

"double" who is to all external appearances identical,

but is not the "real person".

- Delusions of thought interference: A group of delusions

which are considered first-rank symptoms of schizophrenia.

They are thought insertion, thought withdrawal, and thought

broadcasting.

- Pseudocyesis (A false pregnancy): May be hysterical or

delusional in nature and can occur in both sexes although

more commonly in women. A nonpregnant patient has the

signs and symptoms of pregnancy, such as abdominal

distention, breast enlargement, pigmentation, cessation of

menses, and morning sickness.

- Couvade syndrome: A conversion symptom seen in partners

of expectant mothers during their pregnancy. The symptoms

vary but mimic pregnancy symptoms and so include nausea,

vomiting, abdominal pain, and food cravings. It is not

delusional in nature; the affected individual does not believe


27

they are pregnant (compared with pseudocyesis). This

behaviour is a cultural norm in some societies.

b- The number of themes:

e.g. monomania.

c- The degree of systematization:

o Bizarre delusion: False belief that is patently absurd or fantastic.

o Systematized (non bizarre) delusion: false belief united by single

event or theme. Its content is usually within the range of possibility.

d- The degree of fixation:

Fleeting "changable": more in Bizarre delusion.

Fixed "stable": more in Systematized (non bizarre) delusion.

e- The congruity of mood:

Mood-congruent delusion: delusion with mood-appropriate content.

Mood incongruent delusion: delusion with content that has no

association to mood or is mood neutral.

I. Phobia:

Persistent, irrational, exaggerated, and invariably pathological dread of a

specific stimulus or situation; results in a compelling desire to avoid the

feared stimulus.

Subdivided into:

a. Social phobia: dread of public humiliation, as in fear of public

speaking, performing or eating in public.

b. Specific phobia: circumscribed dread of a discrete ممی�ز object or

situation. It includes:

1. Agoraphobia: dread of open places.

2. Claustrophobia: dread of closed places.

3. Acrophobia: Dread of high places.

4. Zoophobia: Abnormal fear of animals.

5. Ailurophobia: Dread of cats.


28

6. Algophobia: Dread of pain.

7. Needle phobia: Pathological fear of receiving an injection.

8. Erythrophobia: Abnormal fear of blushing.

9. Xenophobia: Abnormal fear of strangers.

10. Panphobia: Overwhelming fear of everything.

(4) Speech

Ideas, thoughts, feelings are expressed through language; communication through the

use of words and language.

Speech abnormalities

I. Quantitative:

1- Amount of speech:

Increased: (volubility, logorrhoea, tachylogia, verbomania or verbal

diarrhoea): Excess speech; Symptom of mania.

Decreased (poverty of speech or laconic speech); the extreme diminution

of speech is mutism.

2- Rate of speech: too fast (pressure of speech), or too slow (bradylalia).

3- Pauses in speech: shortened pauses, or prolonged pauses.

4- Loudness of voice: excessive loud, or soft speech.

II. Qualitative:

1- Dysarthria: disorder of articulation of speech.

2- Lalling: babish articulation.

3- Aphonia: loss of the ability to phonate "vocalize".

- Causes:

i. Structural:

Vocal cord lesions.

9th cr. n. lesion.

Higher centres lesions.


29

ii. Functional:

- Conversion.

- To differentiate between both; ask the pt. to cough: if he does, it's

functional.

4- Stuttering: repitition of syllable; stut-tut-tuttering.

5- Stammering: lrolonged stress on a letter; stammmmering.

6- Cluttering: fluency disturbance involving an abnormally rapid rate and erratic

rhythm of speech that impedes intelligibility; the affected individual is usually

unaware of communicative impairment.

7- Logoclonia :Symptom of Parkinson's disease where the patient gets "stuck" on

a particular word of a sentence and repeats it.

8- Dyslalia: Faulty articulation caused by structural abnormalities of the

articulatory organs or impaired hearing.

9- Bradylalia: Abnormally slow speech. Common in depression.

10- Echolalia: repitition of words or phrases heard.

11- Glossolalia: "Speaking in tongues": Unintelligible jargon that has meaning to

the speaker but not to the listener. Occurs in schizophrenia, dissociative and

neurotic disorders and accepted as a sub-cultural phenomenon in some

religious groups.

12- Aculalia: Nonsense speech associated with marked impairment of

comprehension. Occurs in mania, schizophrenia, and neurological deficit.

13- Cryptolalia: A private spoken language.

14- Coprophrasia "Coprolalia": involuntary use of vulgar or obscene language;

seen in Tourett’s disorder.

15- Paraphasia: Abnormal speech in which one word is substituted for another,

the irrelevant word generally resembling the required one in morphology,

meaning, or phonetic composition, such as clover instead of hand, or treen

instead of train. Seen in organic aphasias and in mental disorders such as

schizophrenia.


30

16- Word approximation: Use of conventional words in an unconventional way

(e.g., handshoes for gloves and time measure for clock); distinguished from a

neologism, which is a new word whose derivation cannot be understood.

17- Holophrasia: Using a single word to express a combination of ideas. Seen in

schizophrenia.

18- Aphasia: inability of the formulation of speech.

- Types:

(i) Sensory or receptive aphasia (fluent aphasia): due to defect of

perception:

1. Visual: visual agnosia.

2. Auditory: auditory agnosia.

(ii) Motor or expessive aphasia(nonfluent aphasia): due to defect of

execution:

1. Verbal aphasia: lesion in Broca’s area (area 44).

2. Agraphia: lesion in exner’s area (area 45).

(iii) Jargon’s aphasia: due to defect of association (area 37 or

association fibers), the patient can speek but the words are

meaningless.

19- Global aphasia: Combination of grossly nonfluent aphasia and severe fluent

aphasia.

20- Nominal aphasia: Aphasia characterized by difficulty in giving the correct

name of an object.

21- Acataphasia: Disordered speech in which statements are incorrectly

formulated. Patients may express themselves with words that sound like the

ones intended, but are not appropriate to the thoughts.

22- Dysprosody: Loss of normal speech melody (prosody). Common in depression.

وتعني عدم تماشي الصوت مع سیاق الكالم من حیث اإلیقاع ومستوى ارتفاع وانخفاض الصوت.

23- Stock phrases/stock words: Feature of schizophrenic speech disorder. The use

of particular words and phrases more frequently than in normal speech and

with a wider variety of meanings than normal.


31

24- Metonymy: Speech disturbance common in schizophrenia in which the affected

person uses a word or phrase that is related to the proper one but is not

ordinarily used; for example, the patient speaks of consuming a menu rather

than a meal.

Commentary sample

In depression: the pt. talks very little, his speech is slow with long pauses and

low voice.

In mania: the pt. talks too much, too fast, continously and with loud voice.

(5) perception

- Def.: Process by which a person interprets sensory stimuli.

- Also, it means sensation plus meaning.

- If the sensory stimuli located in the environment, the perception called exteroception.

- If in the body, it is called interoception.

- If on a poorly located mental stage, it is called introspection االستبطان/فحص الذات.

N.B.: Apperception: Awareness of the meaning and significance of a particular

sensory stimulus as modified by one's own experiences, knowledge, thoughts, and

emotions.

Disorders of perception

I. Sensory distortion:

Changes in the perceived intensity or quality of a real external stimulus.

Associated with organic conditions and with drug ingestion or withdrawals.

It may be quantitative or qualitative:

(a) Quantitative sensory distortion:

1- Hypersensitivity: e.g. hyperacusis (low sound is heard very loud).

2- Hyposensitivity: hypoanaesthia or anaesthesia.

(b) Qualitative sensory distortion:

- e.g. Xanthopsia (visual sensations are tinged with yellow colour after

poisoning with sulphonamides or digitalis).


32

II. Sensory deception:

- Disorders in perceptual recognition which take place at the higher level than

the processing of primary sensory information.

- Examples: hallucination, pseudohallucination, illusion, and agnosia.

(A) Hallucination:

- False sensory perception not associated with real external stimuli.

- Classification of hallucinations:

According to complexity:

1- Elementary (unformed) hallucination: e.g. whistles, flashes of

light.

2- Complex (formed) hallucination: e.g. voices, faces, or scenes.

According to sensory modality:

1- Auditory; hearing noises or voices, most common in psychotic

disorders.

2- Visual; seeing flashes of light, faces, or scenes, most common

in delerium and substance-related disorder.

3- Olfactory hallucination, most common in epilepsy.

4- Gustatory hallucination, most common in medical disorders

e.g.: Uncinate seizures.

5- Tactile (haptic): false perception of touch or or surface

sensation.

6- Somatic; false sensation of things occurring in or to the body,

most often of visceral origin (Cenesthetic hallucination).

According to associated mood:

1- Mood-congruent hallucination: hallucination in which the

content is consistent with either a depressed or a manic mood

(depressed patient hears voices saying that he is a bad person:

a manic patient hears voices saying that the patient is of

inflated worth, power and knowledge).


33

2- Mood-incongruent hallucination: hallucination in which the

content is not consistent with either a depressed or a manic

mood (in depression, hallucinations not involving such themes

as guilt, deserved punishment or inadequacy: in mania,

hallucinations not involving themes as inflated worth, power).

According to special characteristics:

1- In auditory hallucination:

- Voices may be:

(a) Talking to the patient directly (Second-person

hallucination).

(b) Commanding voice, instructing the patient towards a

particular action (Command hallucination or

teleological hallucination).

(c) Talking to one another referring to the patient as he or

she (Third-person hallucination) = (Running

commentary) = (Voices heard arguing).

(d) Speeking the patient’s thoughts as he is thinking them;

voices anticipate what the pt. will think

(Gedankenlautwerden).

(e) Repeating the patient’s thoughts immediately after he

has thought them; voices repeat what the pt. thinks,

immediately after he has thought them (Echo de la

pensee).

2- Imperative hallucination:

- A combination of command hallucination, and

passivity of action in which the hallucinatory

instruction is experienced as irresistible.


34

3- Extracampine hallucination:

- Hallucinations come from outside the field of

perception (e.g. a patient in Edinburgh "hearing"

voices seeming to come from a house in Glasgow).

- In visual hallucination; hallucinations come from outside

the field of vision; e.g. behind the patient.

4- Negative hallucination:

- Failure to perceive things are present; occurs during

dissociative states.

5- Refex hallucination (Synaesthesia):

- Stimulus in one sensory modality, results in a hallucination

in another; e.g. music may provoke visual hallucination,

"tasting sounds" or "hearing colours").

- This may occur with hallucinogenic drug intoxication

"LSD" and in epileptic states.

6- Autoscopic hallucinations "Autoscopy or Phantom mirror image":

- Visual hallucination or pseudohallucination of oneself for

short periods.

- Though rare, it may occur in sensory deprivation, temporal

lobe epilepsy, near death experience, and psychiatric

disorders.

- If the experience accompanied by the conviction that the

person has a double it is called doppelganger.

7- Hypnagogic hallucination:

- Occurs at the point of falling asleep.

- It may occur briefly in healthy peolple and persistently in

narcolepsy.


35

8- Hypnopompic hallucination:

- Occurs at the point of waking.

- It may occur briefly in healthy peolple and persistently in

narcolepsy.

9- Formication:

- A form of tactile hallucination in which there is the

sensation of numerous insects crawling over the surface of

the body.

- Occurs in alcohol or drug withdrawal, particularly from

cocaine.

10- Hallucinosis:

- State in which a person experiences hallucinations without

any impairment of consciousness.

(B) Pseudohallucinations:

Similar to hallucinations but do not meet all the requirements of the

definition.

A false perception which is perceived as occurring as part of one's

internal experience, not as part of the external world.

They may be described as having an "as if" quality or as being seen with

the "mind's eye".

Additionally, hallucinations experienced as true hallucinations during the

active phase of a patient's illness may become perceived as pseudo-

hallucinations as they recover.

They can occur in all modalities of sensation and are described in

psychotic, organic, and drug-induced conditions as well as occasionally

in normal individuals; "The hallucinations of deceased spouses


36

commonly described by widows and widowers may have the form of a

pseudo-hallucination".

Ther are of two types: perceived type and imaged type:

Hallucination

Pseudo-hallucination

(perceived type)

Pseudo-hallucination

(imaged type)

Imagery التخيل

- Appears in

external space.

- Appear in

external space.

- Occurs in inner

space.

- Occurs in inner

space.

- Three

dimentional

and vivid.

- Flattened and

lacks vividness.

- Flattened and lacks

vividness.

- Detailed photo-

graphic reproduction

of objects seen.

- Independent

of the will.

- Independent of

the will.

- Independent of the

will.

- Under control of

will.

- Insight: lost

(accepted by

the subject as

real).

- Recognized as

not true

perception.

- Recognized as not

true.

- Recognized as not

true "product of

individual’s own

mind".

(C) Agnosia:

- From Greek word “agnostos”: (unkown).

- It is inability to recognize and interpret the significance of sensory

impressions.

- It includes:

1- Visual agnosia: the object can’t recognized by sight, due to lesion

in occipital areas 18,19.


37

2- Picture agnosia (simultagnosia): inability to comprehend more

than one element of a visual scene at a time or to integrate the

parts into the whole.

3- Auditory agnosia: failure to recognize familiar sounds although

hearing is not impaired, due to lesion in area 22.

4- Asteriognosis: inability to recognize objects by touch, due to

cortical sensory loss.

5- Spatial agnosia: Inability to recognize spatial relations.

6- Anosognosia: Inability to recognize a physical deficit in oneself

(e.g., patient denies paralyzed limb).

7- Prosopagnosia: Inability to recognize familiar faces that is not

caused by impaired visual acuity or level of consciousness.

8- Somatopagnosia(ignorance of the body and autotopagnosia):

Inability to recognize a part of one's body as one's own.

(D) Illusion:

Misinterpretation of an external stimulus.

It occurs pathologically in delerim and as a normal phenomenon

used by experts in camouflage, fashion designers, or experimental

psychologist.

According to the type:

1- Affect illusion:

- A combination of heightened emotion and misperception

(e.g. whilw walking in the dark, seeing a tree moving in

the wind as an attacker).

2- Completion illusions:

- Rely on our brain's tendency to "fill-in" missing parts of an

object to produce a meaningful percept and are the basis

for many types of optical illusion.

Both these types of illusions resolve on closer attention.


38

3- Pareidolic illusions:

- Are meaningful percepts produced when experiencing a

poorly defined stimulus, (e.g. seeing faces in a fire or

clouds).

According to the sensory modality:

1- Auditory: e.g. the yowling of a cat may be heard by a mother

as the cry of her child.

2- Visual: e.g. a tree in the dark night may be seen by a

frightened man as a threatening ghost.

III. Disorders of self-awareness (depersonalization):

o A person’s subjective sense of being unreal, strange, or unfamiliar.

o It is one of dissociative disorders and the insight is preserved.

o It is often accompanied by derealization which is a subjective sense that the

environment is strange or unreal; a feeling of changed reality.

IV. Other perceptual disturbances:

1. Flashbacks:

- Exceptionally vivid re-experiencing of remembered experiences.

- Flashbacks of the initial traumatic event occur in PTSD and flashbacks

to abnormal perceptual experiences initially experienced during LSD

intoxication can occur many years after the event.

2. Cenesthesia:

- Change in the normal quality of feeling tone in a part of the body.

3. Macropsia:

- False perception that objects are larger than they really are.

4. Micropsia:

- False perception that objects are smaller than they really are. Sometimes

called lilliputian hallucination.


39

5. Trailing phenomenon:

- Perceptual abnormality associated with hallucinogenic drugs in which

moving objects are seen as a series of discrete and discontinuous images.

6. Globus hystericus:

- The sensation of a "lump in the throat" occurring without oesophageal

structural abnormality or motility problems. A symptom of anxiety and

somatisation disorders.

7. Mirror sign:

- Lack of recognition of one's own mirror reflection with the perception

that the reflection is another individual who is mimicking your actions.

Seen in dementia.

8. Splitting of perception:

- Loss of the ability to simultaneously process complimentary information

in two modalities of sensation (e.g. sound and pictures on television).

Rare symptom of schizophrenia.

9. Hyperesthesia:

- Increased sensitivity to tactile stimulation.

10. Hypesthesia:

- Diminished sensitivity to tactile stimulation.

11. Acenesthesia:

- Loss of sensation of physical existence.

12. Ageusia (dysgeusia):

- Lack or impairment of the sense of taste. Seen in depression and

neurological deficit.

13. Causalgia:

- Burning pain that can be organic or psychic in origin.


40

(6) Cognitive and intellectual functions "Cognitive functions"

A. Consciousness.

B. Orientaion.

C. Attention and concentration.

D. Memory.

E. Intellegence.

F. Abstract thought.

G. Visuo-spatial ability.

H. Reading and writing.

I. General knowledge.

Commentary sample

The pt. is fully conscious, well oriented with time, place and persons, attentive,

concentrating, with intact memory "immediate, recent, recent past and remote",

of average intelligence and general knowledge and good abstraction.

A. Consciousness

- It is the awareness of self and environment.

- Glasgow coma scale is used to evaluate the level of consciousness from 3-14.

Eye opening Verbal response Motor response

Spontaneous 4

To speech 3

To pain 2

None 1

Oriented 5

Confused 4

Words 3

Sounds 2

None 1

Obeying orders 5

Localizing 4

Flexing 3

Extending 2

None 1


41

Disorders of Consciousness

i- Confusion:

- Disturbance of consciousness manifested by impaired orientation in relation

to time, place or person.

ii- Drowsiness:

- A state of impaired awareness associated with a desire or inclination to

sleep.

iii- Dreamy state:

- Altered state of consciousness, likened to a dream situation, which develops

suddenly and usually lasts a few minutes; accompanied by visual, auditory,

and olfactory hallucinations.

- Commonly associated with temporal lobe lesions.

iv- Trance:

- Sleep-like state of reduced consciousness and activity.

v- Somnolence:

- Abnormal drowsiness which one can be aroused to a normal state of

consciousness.

vi- Clouding of consciousness:

- Disturbance of consciousness in which the person is not fully awake, alert,

and oriented.

- Occurs in delirium, dementia, and cognitive disorder.

vii- Delirium:

- Restless, confused, disoriented reaction associated with fear and

hallucinations.


42

viii- Stupor:

- Lack of reaction to, and unawareness of surroundings with absence of

movement and mutism where there is no impairment of consciousness.

- Functional stupor occurs in a variety of psychiatric illnesses.

- Organic stupor is caused by lesions in the midbrain (the "locked-in"

syndrome).

ix- Twilight state:

- Disturbed consciousness with hallucination.

x- Coma

- Profound unconsciousness in which a person cannot be roused, with minimal

or no detectable responsiveness to stimuli.

xi- Psychogenic unresponsiveness (coma vigil)

- Not true coma but a dissociative disorder in which the patient appears

unresponsive but is physiologically awake.

- Can be tested by letting the patient’s hand to fall toward his face.

xii- Delirium tremens:

- Also called alcohol withdrawal delirium.

- The clinical picture is acute confusional state secondary to alcohol

withdrawal.

- Usually, occurring 72 to 96 hours after the cessation of heavy drinking.

- Distinctive characteristics are marked autonomic hyperactivity (tachycardia,

fever, hyperhidrosis, and dilated pupils).

- It also accompanied by confusion, withdrawals, visual hallucinations, and,

occasionally, persecutory delusions and Lilliputian hallucinations.

xiii- Hypnosis:

- Artificially induced alteration of consciousness characterized by increased

suggestibility.


43

B. Orientation

- It is the awareness of the one self in relation to time, place and persons.

- Disorientation may indicate cognitive impairment caused by organic mental

disorders but psychogenic factors may also cause disorientation, e.g. in mood

disorders, anxiety disorders, dissociative disorders and factitious disorder.

- In disorientation, sense of time is impaired before sense of place and the patient

improves in reverse order.

- Double orientation: some patients believe they are in two different places at the

same time.

C. Attention and Concentration - Attention is the ability to focus on certain stimuli while concentration is the

ability to sustain attention.

- It is tested clinically by substracting serial 7s from 100 (or simpler substraction

e.g. serial 4s from 25) and in less educated patients to tell the months of the year

or the days of the week in a reverse order.

Disorders of attention

1- Distractibility:

- Inability to concentrate attention; in which attention is drawn to

unimportant or irrelevant external stimuli.

2- Selective inattention:

- Blocking out only those things that generate anxiety "as a defense

mechanism".

3- Hypervigilance:

- Excessive attention and focus on all internal and external stimuli.

- Usually, secondary to delusional or paranoid states.


44

4- Trance:

- Focused attention and altered consciousness.

- Usually, seen in hypnosis, dissociative disorder, and ecstatic religious

experiences.

5- Disinhibition:

- Removal of an inhibitory effect that permits persons to lose control of

impulses as occurs in alcohol intoxication.

6- Hypnosis:

- Artificially induced modification of consciousness characterized by

heightened suggestibility.

D. Memory

- It is the process of acquisition (registration), retention (storage), and retrieval

(reproduction) of information.

- Retrieval helped by a presentation of a cue is termed “recognition” while retrieval

in the absence of such a cue is termed “recall”. Recall is more difficult than

recognition.

Levels of memory

1. Immediate memory:

- Retrieval of perceived material within seconds or minutes. It is checked by

asking patients to repeat 6 digits forward and then backward.

2. Recent memory:

- Retrieval of events over past few days. It is checked by asking patients about

their appetite and then about what they had for breakfast or for dinner the

previous evening.


45

3. Recent past memory:

- Retrieval of events over past few months. It is checked by asking patients

about important news events from the past few months.

4. Remote memory:

- Retrieval of events in distant past. It is checked by asking patients about

information from their childhood that can be later verified.

Disorders of memory

I. Quantitative disturbance of memory:

1- Amnesia:

- Partial or total inability to recall past experiences.

- May be of organic or emotional origin.

- May be:

(a) Anterograde: amnesia for events occurring after a point in time

"e.g.: head injury".

(b) Retrograde: amnesia for events occurring before a point in time.

2- Hypermnesia:

- Exaggerated degree of retention and recall.

II. Qualitative disturbance of memory:

1- Paramnesia:

- Falsification of memory by distortion of recall.

- It includes:

(a) Faulse reconnaissance: false recognition.

(b) Confabulation:

Unconscious filling of gaps in memory by imagined or untrue

experiences that a person believes but they have no basis in

fact.


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Most often associated with organic pathology as in Korsakoff

syndrome, dementia or following alcohol blackout.

(c) False memory:

- A person's recollection of an event that did not actually

occur.

- In false memory syndrome, persons erroneously believe that

they sustained an emotional or physical (e.g., sexual) trauma

in early life.

(d) Déjà vu:

Illusion of visual recognition in which a new situation is

incorrectly regarded as a repetition of a previous memory.

(e) Jamais vu:

- False feeling of unfamiliarity with a real situation that a

person has experienced.

- An everyday experience but may also occur in temporal lobe

epilepsy, schizophrenia, and anxiety disorders.

(f) Déjà entendu:

As Déjà vu but concerns auditory recognition.

(g) Déjà pensé:

- False recognition that a thought has been previously

entertained.

(h) Retrospective falsification:

Previous experience is remembered, but in a distorted way.

(i) Anomia:

- Inability to recall the names of objects.

2- Blackout "Palimpsest" فقدان مؤقت للذاكرة:

- Amnesia experienced by alcoholics about behavior during drinking

bouts.

- Usually, indicates that reversible brain damage has occurred.


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III. Others:

1- Fugue:

A dissociative reaction following a severe external stressor (e.g. marital

break-up) in which the affected individual develops global amnesia and

may wander to a distant location.

Consciousness is unimpaired and after resolution there is amnesia for the

events which occurred during the fugue.

2- Neurological amnesia:

Auditory amnesia: loss of ability to comprehend sounds or speech.

Tactile amnesia: loss of ability to judge the shape of objects by touch.

Verbal amnesia: loss of ability to remember words.

Visual amnesia: loss of ability to recall or to recognize familiar objects

or printed words

.

E. Intelligence

- Ability to understand, recall, mobilize, and constructively integrate previous

learning in meeting new situation.

Intelligence disturbances

1- Mental retardation:

- Lack of intelligence sufficient to interfere with social and occupational

performance.

- Degrees of mental retardation:

Mild "Moron" (IQ from 50 to 70).

Moderate "Imbecile" (IQ from 35 to 50).

Severe (IQ from 20 to 35).

Profound "Idiot" (IQ below 20).


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2- Dementia:

o Organic and global deterioration of intellectual functioning without

clouding of consciousness.

3- Pseudodementia:

- Clinical features resembling a dementia not caused by an organic

condition.

- Most often caused by depression (dementia syndrome of depression).

4- Acalculia:

o Loss of ability to do calculations; not caused by anxiety or impairment in

concentration.

o Occurs with neurological deficit and learning disorder.

F. Abstraction

- It is the ability to deal with concepts.

- It is tested clinically by asking the pt. to:

o Explain proverb: على الشجرة ١٠عصفور في الید خیر من

o Define abstract words: e.g.: envy, love or hate, .....

o D.D. between similar meaninges: e.g.: dwarf & short.

- Types of thinking according to abstraction:

1- Abstract thinking:

Ability to appreciate nuances of meaning.

Multidimensional thinking with ability to use metaphors )كنای�ة) -مج�از and

hypotheses appropriately.


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2- Concrete thinking:

Literal thinking with limited use of metaphor without understanding

nuances of meaning.

One-dimensional thought.

G. Reading and Writing

1. Alexia:

- An acquired reading disability, where reading ability had previously been developed.

- Usually, occurring in adulthood conditions.

2. Dyslexia:

- Developmental reading disability.

3. Bradylexia:

- Inability to read at normal speed.

4. Dysgraphia:

- Difficulty in writing.

5. Cryptographia:

- A private written language.


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(7) Insight

Def. : It's the patient’s degree of awareness and understanding about being ill.

Or; the ability to recognise that one's abnormal experiences are symptoms of

psychiatric illness and that they require treatment.

Levels of insight

1. Complete denial of illness.

2. Slight awareness of being sick and needing help but denying it at the same

time.

3. Awareness of being sick but blaming it on others, on external factors, or on

organic factors.

4. Awareness that illness is due to something unknown in the patient.

5. Intellectual insight: admission that the patient is ill and that symptoms or

failures in social adjustment are due to the patient’s own particular irrational

feelings or disturbances without applying this knowledge to future experiences.

لتغیر من أجل مستقبل أفضلعارف كل حاجة عن حالتھ لكن تنقصھ النیة ل

6. True emotional insight: emotional awareness of the motives and feelings within

the patient and the important persons in his life, which can lead to basic

changes in behavior.

o Reality testing: - Fundamental ego function that consists of tentative تجریبي actions that test and

objectively evaluate the nature and limits of the environment. - It includes the ability to differentiate between the external world and the

internal world and to accurately judge the relation between the self and the environment.

(8) Judgement

It's the ability to assess a situation correctly and to act appropriately in the

situation.


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Tested clinically by asking the pt. what will he do in imaginary situaion; e.g.:

seeing a fire.

Types of judgement:

(a) Critical judgement: ability to assess, discern, and choose among various

options in a situation.

(b) Automatic judgement: reflex performance of an action.

(c) Impaired judgement: diminished ability to understand a situation correctly

and to act appropriately.

(9) Impulsivity

- It is important to assess the patient capability of controlling sexual, aggressive,

and other impulses.

- This is to measure the patient’s potential danger to self and others.

- Impulse control can be estimated from:

o Information in the patient’s recent history.

o The behavior observed during the interview.


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Micellaneous definitions

Ganser symptom (Vorbeigehen) or (Vorbeireden):

- The production of "approximate answers" as the patient gives repeated wrong

answers to questions (e.g. "what is the capital of Scotland? Paris").

- Occasionally associated with organic brain illness or more commonly seen as

a form of malingering (e.g. in prisoners awaiting trial).

Malingering:

o Deliberately falsifying the symptoms of illness for a secondary gain (e.g. for

compensation, to avoid military service, or to obtain an opiate prescription).

Priapism:

A sustained and painful penile erection, not associated with sexual arousal.

A rare side-effect of antidepressant medication "Trazodone".

If not relieved can cause permanent penile damage.

Pseudologia phantastica:

- Disorder characterized by uncontrollable lying in which patients elaborate

extensive fantasies that they freely communicate and act on.

- There may be a grandiose or over-exaggerated flavour to the accounts

produced.

- A feature of Munchausen's disease.

Russell sign:

o Skin abrasions, small lacerations, and calluses on the dorsum of the hand

overlying the metacarpophalangeal and interphalangeal joints found in patients

with symptoms of bulimia.

o Caused by repeated contact between the incisors and the skin of the hand

which occurs during self-induced vomiting.


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Abreaction:

A process by which repressed material, particularly a painful experience or a

conflict, is brought back to consciousness.

In this process, the person not only recalls, but also relives the repressed

material, which is accompanied by the appropriate affective response.

Acting out:

- Behavioral response to an unconscious drive or impulse that leads to temporary

relief of inner tension.

- Relief is attained by reacting to a present situation as if it were the situation

that originally gave rise to the drive or impulse.

- Common in borderline states.

Anaclitic:

o Depending on others, especially as the infant on the mother.

o Anaclitic depression in children results from an absence of mothering.

Androgyny:

Combination of culturally determined female and male characteristics in one

person.

psychiatric sheet for postgraduates

Health & Medicine