Signs and Symptoms of Psychiatric Disorders
gSigns and Symptoms of Psychiatric Disorders
1. Introduction
Psychiatrists need to:
Collect clinical data objectively and accurately.
Organize and communicate data systematically and balanced.
Have intuitive understanding of each patient as an individual.
Skills are developed by:
Listening to patients.
Learning from experienced psychiatrists.
Textbooks provide information and procedures to develop the first capacity.
Intuitive understanding cannot be learned directly from a textbook.
Skill in examining patients depends on knowledge of symptom and sign definitions.
Misclassification leads to inaccurate diagnoses.
Psychiatrists decide if symptoms and signs fall into a pattern observed in other psychiatric patients (a syndrome).
Diagnosis involves combining observations about the patient’s present state with their history.
Identifying a syndrome helps to:
Predict prognosis.
Select effective treatment.
Direct the psychiatrist to relevant knowledge about causes, treatment, and outcome in similar patients.
Diagnosis and classification are discussed in the next chapter and in chapters dealing with various psychiatric disorders.
Chapter 3 discusses how to elicit and interpret symptoms, integrate information to arrive at a syndromal diagnosis, and create a rational approach to management and prognosis.
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2. General Issues of Psychiatric Disorders
General issues to be considered: methods of studying symptoms and signs, and the terms used to describe them.
2.1. Psychopathology
Study of abnormal states of mind.
Two approaches:
Descriptive
Experimental (discussed in later chapters).
2.2. Descriptive Psychopathology
Objective description of abnormal states of mind.
Avoid preconceived ideas or theories.
Limited to describing conscious experiences and observable behavior.
Also called: phenomenology or phenomenological psychopathology (though not synonymous).
More than just symptomatology.
Aims to elucidate the essential qualities of morbid mental experiences.
Requires:
Ability to elicit, identify and interpret symptoms.
Key element of clinical practice.
'Fundamental professional skill of the psychiatrist'.
Karl Jaspers: German psychiatrist and philosopher.
Allgemeine Psychopathologie (General Psychopathology), published in 1913.
Most complete account of the subject.
2.3. Experimental Psychopathology
Seeks to explain abnormal mental phenomena.
Psychodynamic psychopathology (Freud):
Explains causes of abnormal mental events in terms of unconscious mental processes.
Example: Freud explained persecutory delusions as evidence of repression and projection in the unconscious mind.
Focuses on empirically measurable and verifiable conscious psychological processes.
Uses experimental methods like cognitive and behavioral psychology and functional brain imaging.
Cognitive theories of delusions, panic attacks, and depression.
Conducted in the context of syndromes in which the symptoms occur.
2.4. Symptoms and Signs
In general medicine, there's a clear distinction between symptom and sign.
In psychiatry, it's different.
Few 'signs' in the medical sense.
Most diagnostic information comes from the history and observations of the patient’s appearance and behavior.
'Sign' in psychiatry may refer to:
A feature noted by the observer (e.g. responding to hallucination).
A group of symptoms interpreted as a sign of a particular disorder.
'Symptoms and signs' often used interchangeably with 'symptoms'.
2.5. Subjective and Objective
In general medicine:
Subjective = symptoms
Objective = signs
In psychiatry:
'Objective' refers to features observed during an interview.
Psychiatrist uses 'objective' to compare with the patient’s description of symptoms.
Example: evaluating depression
Subjective: low mood, tearfulness
Objective: poor eye contact, psychomotor retardation, crying
'Subjective and objective evidence of depression' provides stronger evidence than either alone.
'Not objectively depressed' recorded if behavior and manner appear normal despite subjective complaints.
Psychiatrist explores reasons for discrepancy and decides on diagnostic conclusions.
Objective signs are accorded greater weight.
Depressive disorder may be diagnosed with sufficient objective evidence, even if the patient denies subjective feelings.
The significance of complaints of low mood may be questioned if there are none of the objective features associated with the diagnosis.
2.6. Form and Content
Useful to distinguish between form and content when describing psychiatric symptoms.
Form:
The type of experience (e.g., auditory hallucination).
Content:
The specifics of the experience (e.g., voices calling them a homosexual).
Example 1:
A patient hears voices calling him a homosexual (auditory hallucination-form) (content-homosexual).
Example 2:
Voices saying she is about to be killed auditory hallucination (form-auditory hallucination) (content-being killed).
Example 3:
Repeated intrusive thoughts that he is homosexual but realizes these are untrue (form-intrusive thoughts) (content-homosexual).
Form is critical when making a diagnosis.
Hallucinations indicate psychosis.
Obsessive thoughts suggest obsessive-compulsive disorder.
Content is important in management.
The content of a delusion may suggest the patient could attack a supposed persecutor.
Patients prioritize discussing the content and its implications, while psychiatrists ask about the form.
2.7. Primary and Secondary
Two meanings:
Temporal: Which occurred first
Causal: Arising directly from the pathological process vs. arising as a reaction to a primary symptom.
Terms are used more often in the temporal sense.
If one symptom is likely a reaction to another, it is described as secondary (causal sense).
Also used in descriptions of syndromes.
2.8. Understanding and Explanation
Jaspers contrasted two forms of understanding:
Verstehen ('understanding'): Appreciate the patient’s subjective experience.
Requires intuition and empathy.
Erklären ('explanation'): accounts for events in terms of external factors (e.g. his recent redundancy)
Requires knowledge of psychiatric etiology.
2.9. The Significance of Individual Symptoms
Psychiatric disorders are diagnosed when a defined group of symptoms (a syndrome) is present.
Almost any single symptom can be experienced by a healthy person.
Even hallucinations are experienced by some otherwise healthy people.
Delusion alone may be evidence of psychiatric disorder if unequivocal and persistent.
A single symptom indicates a need for a thorough search for other symptoms and signs.
Rosenhan (1973) study:
Eight ‘patients’ presented with hearing the words ‘empty, hollow, thud’.
All were admitted and diagnosed with schizophrenia.
Despite denying other symptoms and behaving normally.
Illustrates the importance of descriptive psychopathology and reliable diagnostic criteria.
2.10. The Patient’s Experience
Symptoms and signs are only part of psychopathology.
Also concerned with the patient’s experience of illness.
How the psychiatric disorder changes his view of himself, his hopes, and his view of the world (verstehen).
Depressive disorder may have a very different effect on a person who has lived a satisfying and happy life and has fulfilled his major ambitions compared with a person who has had many previous misfortunes but has lived on hopes of future success.
Psychiatrist has to understand the patient like a biographer understands his subject (life-story approach).
Learned by taking time to listen to patients.
Reading biographies/literature that provide insights into how experiences shape personality can help.
2.11. Cultural Variations in Psychopathology
Core symptoms of serious mental disorders are present in culturally diverse individuals.
Cultural differences in how symptoms present and the meanings attributed to them.
Depression can present with prominent somatic symptoms in Asian populations.
Delusions in sub-Saharan African populations may center upon being cursed.
Cultural differences also affect the patient’s subjective experience of illness.
In some cultures, psychiatric disorder effects are ascribed to witchcraft.
Mental illness can be greatly stigmatized, affecting the patient’s view of himself and his future.
3. Disturbances of Emotion and Mood:
Much of psychiatry is concerned with abnormal emotional states, particularly disturbances of mood and other emotions, especially anxiety.
Clarifying two areas of terminology:
The term ‘mood’ can either be used as a broad term to encompass all emotions (e.g. ‘anxious mood’) or in a more restricted sense to mean the emotion that runs from depression at one end to mania at the other.
‘mood disorders’ are those in which depression and mania are the defining characteristics whereas disorders defined by anxiety or other emotional disturbances are categorized separately.
The term ‘affect’ is now usually used interchangeably with the term ‘mood’ in the more limited meaning of the latter word.
In the past, mood referred to a prevailing and prolonged state, while affect was linked to a particular aspect/object and was more transitory.
Emotions and mood may be abnormal in three ways:
Their nature may be altered
They may fluctuate more or less than usual
They may be inconsistent with the patient’s thoughts or actions, or with his current circumstances.
3.1. Changes in the Nature of Emotions and Mood
Can be towards anxiety, depression, elation, or irritability and anger.
Associated with events in the person’s life, but may arise without apparent reason.
Accompanied by other symptoms/signs.
Anxiety: autonomic overactivity and increased muscle tension
Depression: gloomy preoccupations and psychomotor slowness
3.2. Changes in the Way Emotions and Mood Vary
Increased variation: lability of mood; extreme variation is sometimes called emotional incontinence.
Reduced variation: blunting or flattening (used interchangeably); severe flattening is sometimes called apathy.
Emotion can also vary in a way that is not in keeping with the person’s circumstances and thoughts, and this is described as incongruous or inappropriate. Example: a patient may appear to be in high spirits and laugh when talking about the death of his mother.
3.3. Clinical Associations of Emotional and Mood Disturbances
Seen in essentially all psychiatric disorders.
Central feature of mood and anxiety disorders.
Common in eating disorders, substance-induced disorders, delirium, dementia, and schizophrenia.
3.4. Anxiety
Normal response to danger.
Abnormal when severity is out of proportion to the threat, or when it outlasts the threat.
Closely coupled with somatic, autonomic, and psychological components.
Mild-to-moderate anxiety enhances performance, but very high levels interfere with it.
Components:
Psychological. Feelings of dread and apprehension, restlessness, narrowing of attention, worrying thoughts, increased alertness (with insomnia), and irritability
Somatic. Muscle tension and respiration increase and may be experienced as muscle tension tremor, or the effects of hyperventilation
Autonomic. Heart rate and sweating increase, the mouth becomes dry, and there may be an urge to urinate or defaecate; Avoidance of danger
A phobia is a persistent, irrational fear of a specific object or situation
Phobic people feel anxious not only in the presence of the object or situation but also when thinking about it (anticipatory anxiety).
3.4.1. Clinical Associations
Phobias are common among healthy children, becoming less frequent in adolescence and adult life.
Phobic symptoms occur in all kinds of anxiety disorder, but are the major feature in the phobic disorders.
3.5. Depression
Normal response to loss or misfortune.
Abnormal when out of proportion to the misfortune or unduly prolonged.
Coupled with lowering of self-esteem, pessimistic/negative thinking, and loss of pleasure (anhedonia).
Characteristic expression/appearance: downturned mouth, furrowed brow, dejected posture.
Level of arousal reduced (psychomotor retardation) or increased (restlessness/agitation).
3.5.1. Clinical Associations
Can occur in any psychiatric disorder.
Defining feature of mood disorders.
Common in schizophrenia, anxiety, obsessive–compulsive disorder, eating disorders, and substance-induced disorders.
Can be a manifestation of an organic disorder.
3.6. Elation
Extreme degree of happy mood, coupled with increased feelings of self-confidence, increased activity, and increased arousal.
Occurs most often in mania and hypomania.
3.7. Irritability and Anger
Irritability: a state of increased readiness for anger.
Of little value in diagnosis.
Important in risk assessment/management, as they may result in harm.
May occur in anxiety disorders, depression, mania, dementia, and drug intoxication.
4. Disturbances of Perception
Specific perceptual disturbances are symptoms of severe psychiatric disorders.
4.1. Perception and Imagery
Perception:
Awareness of what is presented through sense organs.
Data is acted on by cognitive processes that reassemble them and extract patterns.
Cannot be terminated by an effort of will.
Imagery:
Awareness of a percept generated within the mind.
Can be called up and terminated by an effort of will.
Lacks the sense of reality that characterizes perception.
Eidetic imagery: intense, detailed visual imagery with a ‘photographic’ quality.
Pareidolia: imagery persists despite the presence of a percept.
Anxious people may experience sensations as more intense than usual and depressed patients may experience perceptions as dull and lifeless.
4.2. Illusions
Misperceptions of external stimuli.
Occur when sensory stimulation is reduced and attention is not focused on the relevant sensory modality.
More likely when the level of consciousness is reduced or when a person is anxious.
Have no diagnostic significance but need to be distinguished from hallucinations.
4.3. Hallucinations
A percept is experienced in the absence of an external stimulus to the corresponding sense organ.
Experienced as originating in the outside world or from within the person’s body (rather than as imagined).
Cannot be terminated at will.
Generally indicate significant psychiatric disorder.
Occur in some otherwise healthy people.
Common when falling asleep (hypnagogic) or waking (hypnopompic).
Common in narcolepsy.
Some bereaved people experience hallucinations of the dead person.
Can occur after sensory deprivation, in people with blindness/deafness, in neurological disorders affecting visual pathways, in epilepsy, and in Charles Bonnet syndrome
4.3.1. Types of Hallucinations
Described by complexity and sensory modality.
Elementary hallucination: bangs, whistles, flashes of light.
Complex hallucination: hearing voices/music, seeing faces/scenes.
Auditory hallucinations: noises, music, or voices.
Voices may be clear/indistinct and speak words/phrases/sentences.
Second-person hallucinations: address the patient directly.
Third-person hallucinations: talk to one another, referring to the patient as 'he' or 'she'.
Voices anticipate patient thoughts (Gedankenlautwerden/thought echo) or repeat them immediately after (écho de la pensée).
Visual hallucinations: elementary or complex.
Lilliputian: hallucinations of dwarf figures.
Extracampine: hallucinations located outside the field of vision.
Olfactory and gustatory hallucinations: smells and tastes are often unpleasant.
Tactile hallucinations (haptic): sensations of being touched, pricked, or strangled.
Formication: movements just below the skin, attributed to insects or worms burrowing through the tissues.
Hallucinations of deep sensation: feelings of viscera being pulled upon or distended, or of sexual stimulation or electric shocks.
Autoscopic hallucination: seeing one’s own body projected into external space.
Out-of-body experience: sensory deprivation.
Near-death experience: after a near-fatal accident or heart attack; conviction that the person has a double (Doppelganger).
Reflex hallucination: stimulus in one sensory modality results in a hallucination in another.
4.3.2. Clinical Associations of Hallucinations
Occur in diverse disorders: schizophrenia, severe mood disorder, organic disorders, and dissociative states.
Auditory hallucinations: only clearly heard voices have diagnostic significance; third-person hallucinations are strongly associated with schizophrenia and such voices may be experienced as commenting on the patient’s intentions or actions or may make critical comments.
Voices with derogatory content suggest severe depressive disorder, especially when the patient accepts them as justified; in schizophrenia, the patient more often resents such comments
Voices that anticipate, echo, or repeat patient thoughts also suggest schizophrenia.
Visual hallucinations should always suggest the possibility of an organic disorder, although they also occur in severe affective disorders, schizophrenia, and dissociative disorder; autoscopic hal- lucinations also raise suspicion of an organic disorder, such as temporal lobe epilepsy.
Hallucinations of taste and smell are infrequent and May occur in schizophrenia, severe depressive dis- orders, and temporal lobe epilepsy, and in tumours affecting the olfactory bulb or pathways.
Tactile and somatic hallucinations are suggestive of schizophrenia, especially if they are bizarre in content or interpretation.
Sensation of insects moving under the skin (formication) occurs in people who abuse cocaine.
4.4. Pseudohallucinations
Similar to hallucinations but do not meet all requirements of definition/implications.
Two distinct meanings:
Sensory experience that does not seem to the patient to represent external reality, being located within the mind rather than in external space; in this way, pseudohallucinations resemble imagery although, unlike imagery, they cannot be dismissed by an effort of will.
Sensory experience appears to originate in external world but seems unreal
It is usually sufficient to decide whether a perceptual experience is a ‘true’ hallucination or not, since it is only the former which carries diagnostic significance.
4.5. Abnormalities in the Meaning Attached to Percepts
Delusional perception: a delusion arising directly from a normal percept.
Disorder of thought.
5. Disturbances of Thoughts
Among the most diagnostically significant symptoms in psychiatry; merits detailed description.
Two kinds of phenomena:
Disturbance of thoughts themselves: a change in the nature of individual thoughts; the category of delusion is particularly important.
Disturbance of the thinking process and linking together of different thoughts: may affect speed/form of the relationship between thoughts; can occur even if individual thoughts are unremarkable.
5.1. Delusions
A belief that is firmly held on inadequate grounds, that is not affected by rational argument or evidence to the contrary, and that is not a conventional belief that the person might be expected to hold given their educational, cultural, and religious background.
Intended to separate delusions from other abnormal thoughts and strongly held beliefs found among healthy people.
Another characteristic feature is having a marked effect on the person’s feelings and actions. Since the behavioural response to the delusion may itself be out of keeping or even bizarre, it is often this that first brings the person to psychiatric attention, and leads to the delusion being elicited.
Occasionally, a delusion can have little influence on feelings and actions.
Double orientation: separation of delusion from feelings and actions occurs in chronic schizophrenia.
5.1.1. Types of Delusions
Categorized by characteristics or theme of the delusion
Primary and secondary delusions
Delusional mood
Delusional perception
Delusional memory
Shared delusions
Delusional themes
5.1.1.1. Primary and Secondary Delusions
Primary or autochthonous delusion: appears suddenly and with full conviction but without any mental events leading up to it; not all primary delusional experiences start with an idea.
Secondary delusions: derived from a preceding morbid experience (hallucinations, low mood, or an existing delusion); some seem to have an integrative function, making the original experiences more comprehensible to the patient and others seem to do the opposite increasing the sense of persecution or failure; may accumulate until there is a complicated and stable delusional system
5.1.1.2. Delusional Mood
When a patient first experiences a delusion, he responds emotionally; the change of mood may precede the delusion and is often a feeling of foreboding the german term for this antecedent mood is called Wahnstimmung (the mood from which a delusion arises).
5.1.1.3. Delusional Perception
The attaching of a new significance to a familiar percept without any reason to do so.
The perception is normal, and it is the delusional interpretation that is abnormal.
5.1.1.4. Delusional Misidentification
The delusional misidentification of oneself or of specific other people.
5.1.1.5. Delusional Memory
Delusional interpretation is attached to past events; it can be genuine or autochthonous and can arise suddenly (the memory itself is the delusion) or arise with a past memory and delusion arises ( the memory is normal but a delusional interpretation is placed upon it).
5.1.1.6. Shared Delusions
One person shares there delusions with another.
Known as shared delusions or folie à deux, the second person’s delusional conviction recedes after separation.
5.1.1.7. Delusional Themes
Group delusions according to their main themes.
* the term ‘paranoid’ has a wider meaning (Lewis, 1970). It was used in ancient Greek writings to mean the equivalent of ‘out of his mind’ although for historical reasons it is preferable to retain the broader meaning of the term, the narrower usage is now more common, as sanctioned in the diagnostic cat- egory of paranoid personality disorde * ‘persecutory’ is preferable when the narrow sense of paranoid is required to avoid ambiguities.Persecutory delusions are concerned with persons or organizations that are thought to be trying to inflict harm on the patient, damage his reputation, or make him insane however, the patient’s attitude to the delusion may point to the diagnosis.
Delusions of reference are concerned with the idea that objects, events, or people that are unconnected with the patient have a personal significance for him or to actions or gestures made by other people which are thought to convey a message about the patient, may also relate to grandiose or reassuring themes.
Delusions of control (passivity phenomena) is a patient who has a delusion of control believes that his actions, impulses, or thoughts are controlled by an outside agency such symptoms of schizophrenia are usually present as well.
Delusions concerning the possession of thought are thoughts that become known to other people only if they are spoken aloud, or revealed in writing or through facial expression, gesture, or action.
Thought insertion is the delusion that certain thoughts are not the patient’s own but are implanted by an out- side agency and the thoughts are not his own, but have been inserted into his mind.
Thought withdrawal is the delusion that thoughts have been taken out of the mind and feels abrupt and complete emptying of his mind.
Thought broadcasting is the delusion that unspoken thoughts are known to other people or that their thoughts can be heard out loud by other people.
Grandiose delusions are beliefs of exaggerated self- importance; the patient may consider himself to be wealthy, endowed with unusual abilities, or a special person such expansive ideas occur particularly in mania, and in schizophrenia.
Bizarre delusions are Delusions with highly improbable content (e.g. of con- trol by aliens who communicate via birds); are often given particular weight in the diagnosis of schizophrenia.
Delusions of guilt beliefs are found most often in depressive illness themes are that a minor infringement of the law in the past will be discovered and bring shame upon the patient, or that his sinfulness will lead to retri- bution on his family.
Nihilistic delusions are beliefs that some person or thing has ceased, or is about to cease, to exist; examples include a patient’s delusion that he has no money, that his career is ruined, or that the world is about to end and often it is of bodily function (often that the bowels are blocked), and are often referred to as Cotard’s syndrome.
Hypochondriacal delusions believes, wrongly and in the face of all medical evidence to the contrary, that he is suffering from a disease such delusions are more common in the elderly.
Mood-congruent and mood-incongruent delusions: it is said to be mood- congruent (Hypochondriacal and nihilistic delusions in psychotic depression, and grandiose delusions in mania), in contrast a delusion that is out of keeping with the prevailing mood is mood incongruent, and is suggestive of schizophrenia ( applies to hallucinations as well).
Delusions of jealousy are Not all jealous ideas are delusions; less intense jealous preoccupations and obsessions are common and may lead to aggressive behavior and continues to find evidence supporting his beliefs; his search will continue.
Sexual or amorous delusions are Sexual delusions are occasionally secondary to somatic hallucinations felt in the genitalia; a person with amorous delusions believes that she is loved by a man who is usually inaccessible to her, and often of higher social status.
5.2. Obsessional and Compulsive Symptoms
5.2.1. Obsessions
Recurrent, persistent thoughts, impulses, or images that enter the mind despite efforts to exclude them; conviction that to think something is to make it more likely to happen; recognized by the person as his own and not implanted from elsewhere; they are generally about matters that the patient finds distressing or otherwise unpleasant and are often, but not always, accompanied by compulsions.
Resistance is important because it distinguishes obsessions from delusions, and this diminishes when obsessions have been longstanding further more, when obsessions are very intense, patients may become less certain that they are false.
Obsessional thoughts repeated and intrusive words or phrases that are upsetting to the patient; Obsessional ruminations are repeated worrying themes of a more complex kind; Obsessional doubts are repeated themes expressing uncertainty about previous actions and the person realizes that the degree of uncertainty and consequent distress is unreasonable; Obsessional impulses are repeated urges to carry out actions, usually ones that are aggressive, dangerous, or socially embarrassing and the person has no wish to carry it out resists it strongly, and does not act on it; Obsessional phobias. is an obses- sional symptom associated with avoidance as well as anxiety; Obsessional slowness is that many obsessional patients per- form actions slowly because their compulsive rituals or repeated doubts take time and distracts them from their main purpose.
Many can be grouped into on or other of 6 categories:
dirt and contamination
aggression
orderliness
illness
sex
religion.
5.2.1.1. Compulsions
Repetitive and seemingly purposeful behaviours that are performed in a stereotyped way (hence the alternative name, ‘compulsive rituals’) in response to an obsession; The compulsion usually makes sense given the content of the obsession
Compulsions may cause problems for several reasons:
* They may cause direct harm (e.g. dermatitis from excessive washing). * They may interfere with normal life because of the time they require. * Although the compulsive act transiently reduces the anxiety associated with the obsession, in fact the com- pulsions help to maintain the condition.Many types are particularly common
Checking rituals are often concerned with safety
Cleaning rituals often take the form of repeated hand washing, but may involve household cleaning.
Counting rituals usually involve counting in some spe- cial wayoften silent, so an onlooker may be unaware of the ritual
In dressing rituals the person lays out clothes, or puts them on, in a particular way or order.
5.3. Overvalued Ideas
First described by Wernicke; A comprehensible and understandable idea which is pursued beyond the bounds of reason with content are usually understandable when the person’s background is known themes generally culturally common and acceptable
a small degree of insight and willingness to at least entertain alternative views, even though this is not persistent and the patient always returns to and retains the belief.
distinguished from obsessions since there is no sense of intrusiveness or senselessness of the thought, nor is there resistance to it.
6. Disturbances of Thinking Processes
6.1. Disturbances of the Stream of Thought
The amount and speed of thinking are changed.
In pressure of thought, ideas arise in unusual variety and abundance and pass through the mind rapidly
In poverty thoughts, the patient has few thoughts, and these lack variety and richness and seem to move slowly through the mind
Pressure of thought occurs in mania; pov- erty of thought occurs in depressive disorders are also known as pressure jof speech or poverty of speech.
6.2. Thought Block
Sometimes the stream of thought is interrupted suddenly.
The patient feels that his mind has gone blank, and an observer notices a sudden interruption in the patient’s speech.
In thought blocking, the interruptions are sudden, striking, and repeated, and are experienced by the patient as an abrupt and complete emptying of his mind.
The diagnostic asso- ciation with schizophrenia is stronger when the patient interprets the experience in an unusual way.
6.3. Disorders of the Form of Thought
Recognized from speech and writing, but is sometimes evident from the patient’s behaviour .
Several kinds can be divided, but none of the associations is strong enough to be diagnostic.
Perseveration is the persistent and inappropriate rep- etition of the same thoughts; occurs in, but is not limited to, dementia and frontal lobe injury.
Flight of ideas is that thoughts and speech move quickly from one topic to another so that one train of thought is not carried to completion before another takes its place.
Loosening of associations denotes a loss of the normal structure of thinking; the interviewer the patient’s discourse seems mud- dled, illogical, or tangential to the matter in hand; seen most often in schizophrenia.
In talking past the point (Vorbeireden) the patient seems always about to get to the endpoint of the topic in question, but then skirts around it and never, in fact, reaches it.
Knight’s move or derailment refers to a transition from one topic to another, either between sentences or in mid- sentence, with no logical relationship between; seen mostly in schizophrenia.
Verbigeration is said to be present when speech is reduced to the senseless repetition of sounds, words, or phrases and if extreme, the disorder is called word salad.
6.4. Other Disorders of Thinking
Overinclusion refers to a widening of the boundaries of concepts, such that things are grouped together which are not normally regarded as closely connected.
Neologisms are words or phrases invented by the patient, often to describe a morbid experience should ask the patient what he means by it and neologisms occur most often in chronic schizophrenia.
7. Depersonalization and Derealization
Depersonalization is a change of self- awareness such that the person feels unreal, detached from his own experi- ence, and unable to feel emotion
Derealization is a similar change in relation to the environment, such that objects appear unreal and peo- ple appear as lifeless two- dimensional ‘cardboard’ fig- ures
the ‘as if’ quality is a useful discriminator. Depersonalization and derealization are experienced quite commonly by healthy people
They occur in anxiety disorders, post traumatic stress disorder, depressive disorders, schizophrenia, and temporal lobe epilepsy is also a rarely used diagnostic category of depersonalization– derealization syndrome.
8. Motor Symptoms and Signs
Abnormalities of social behaviour, facial expression, and posture occur frequently in mental disorders of all kinds motor symptoms and signs can also be side effects of medication; motor slowing and agitation, which are important features of depres- sive disorder, are discussed in Chapter 9.
With the exception of tics, the specific symptoms listed here are mainly observed in schizophrenia, particularly catatonic schizo- phrenia Tics are irregular repeated movements involving a group of muscles— for example, sideways movement of the head or the raising of one shoulder.
Mannerisms are repeated movements that appear to have some functional significance— for example, saluting.
Stereotypies are repeated movements that are regular (unlike tics) and without obvious significance (unlike mannerisms)— for example, rocking to and fro.
Catatonia is a state of increased muscle tone that is abolished by vol- untary movement.
Catalepsy (waxy flexibility, flexibilitas cerea) is a term used to describe the tonus in catatonia when a patient’s limbs can be placed in a position in which they then remain for long periods while at the same time muscle tone is uniformly increased.
Posturing is the adoption of unusual bodily postures continuously for a long time; the posture may appear to have a symbolic meaning or may have no apparent significance
Grimacing has the same meaning as in everyday speech; Schnauzkrampf (snout cramp or spasm) denotes pouting of the lips to bring them closer to the nose.
Negativism is when patients do the opposite of what is asked, and actively resist efforts to persuade them to comply.
Echopraxia occurs when