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Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
Psychiatric sheet for postgraduates
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Psychiatric sheet for postgraduates

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  • 1. ‫اﻟﻠﮫم وﻓﻘﻧﻲ ﻹﻧﺟﺎز‬‫ھذا اﻟﻌﻣل، واﺳﺘﻛﻣﺎل‬ ‫ﻣﺎ ﺑدأه أﺳﺘﺎذي‬ ‫اﻟدﻛﺘور/ ﻳﺎﺳﺮ رﻳﺎ‬ ‫‪Dr. Mohamed Abdelghani‬‬
  • 2. Updated By Mohamed Abdelghani I- Psychiatric history1- Date2- Informant3- Source and reason for referral4- Identifying data of the patient5- Complaint6- History of present illness7- Past illnesses8- Family history9- Personal history1- 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. 2
  • 3. Updated By Mohamed Abdelghani  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 ﺗﺎم‬iii- Sex: although sex can be known from patient’s name, but some names areconfusing 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. 3
  • 4. Updated By Mohamed Abdelghani 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. 4
  • 5. Updated By Mohamed Abdelghani8- 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. 5
  • 6. Updated By Mohamed Abdelghanio Methods of discipline (‫)اﻟﺘﻬﺬﻳﺐ‬o 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. 6
  • 7. Updated By Mohamed Abdelghani II- Mental state examination1) 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 Behaviouri. 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. 7
  • 8. Updated By Mohamed Abdelghani  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 persons 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 8
  • 9. Updated By Mohamed Abdelghani 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 patients 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 9
  • 10. Updated By Mohamed Abdelghani 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 ones 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. 10
  • 11. Updated By Mohamed Abdelghani32. 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 Parkinsons 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 Parkinsons 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 patients limbs can be moved to any position by very slight or fingertip pressure.43. Mitmachen: A motor symptom of schizophrenia where the patients 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, 11
  • 12. Updated By Mohamed Abdelghani 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. Its associated with long-term treatment with neuroleptic drugs. 12
  • 13. Updated By Mohamed Abdelghani 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 EmotionA. Abnormal emotional predisposition: long standing disposition (trait): I- Dysthymia; the person tends to be always sad. II-Hyperthymia; tends to be overcheerful. 13
  • 14. Updated By Mohamed Abdelghani 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. 14
  • 15. Updated By Mohamed Abdelghani - 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 cant 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 ‫ : زﻫﻮ‬element of grandier in addition to the elation.  Ecstacy ‫ : ﻧﺸـﻮة‬feeling 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. 15
  • 16. Updated By Mohamed Abdelghani 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 ‫ :ﺗﻘﻠـﺐ اﳌـﺰاج‬Fluctuation or instability of emotion, unrelated to 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. 16
  • 17. Updated By Mohamed Abdelghani o In psychoanalysis, it denotes the patients 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 ofpsychic energy in an idea, concept, object, or person.☺N.B.: Dyspareunia: Physical pain in sexual intercourse, usually emotionallycaused and more commonly experienced by women; can also result from cystitis,urethritis, or other medical conditions. (3) ThinkingDef: Goal-directed flow of ideas, symbols, and associations initiated by a problem ortask and leading toward a reality-oriented conclusion; when a logical sequenceoccurs, 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. 17
  • 18. Updated By Mohamed Abdelghani3. 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 disordersmay 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 18
  • 19. Updated By Mohamed Abdelghani 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 inlanguage. Formal thought disorder: disturbance in the form of thought rather than thecontent of thought; thinking characterized by loosened associations, neologisms, andillogical constructs. Its 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 "Knights 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. Its 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 ﻮﯾﺶ‬A feature of schizophrenic thought disorder caused by simultaneous derailment and fusion. The speech so produced may be very bizarre. 19
  • 20. Updated By Mohamed Abdelghani 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 ﺮب‬Act 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/ذاﺗﯿﺔ‬pathological 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. 20
  • 21. Updated By Mohamed Abdelghani 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 ones will.  Patterns of obsessions: - Dirt and contamination. - Aggression. - Orderliness. - Illness. 21
  • 22. Updated By Mohamed Abdelghani - 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 ones 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: 22
  • 23. Updated By Mohamed Abdelghani o The belief arose: "out of the blue" (autochthonous delusion): fully formed 1ry delusion that arises suddenly with out explanation . "‫"اﻟﻤﺮﯾﺾ ﻓﺠﺄة ﯾﻌﺘﻘﺪ أﻧﮫ ورث أرﺿﺎ ﻛﺜﯿﺮة ﺗﻮﻓﺮ ﻟﮫ اﻟﻤﺎل اﻟﻼزم ﻻﺳﺘﺮﺟﺎع أﻣﻮاﻟﮫ اﻟﺘﻲ ﺳﻠﺒﮭﺎ ﻣﻨﮫ اﻵﺧﺮون‬ 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 aresult of a memory (e.g. a patient who remembers his parents taking him to hospitalfor an operation as a child becoming convinced that he had been implanted withcontrol and monitoring devices which have become active in his adult life).N.B2.: Delusional mood "Delusional atmosphere": A primary delusion which arisesfollowing a period of an abnormal mood state characterised by anticipatory anxiety, asense of "something about to happen", and an increased sense of the significance ofminor events. The development of the formed delusion may come as a relief to thepatient in this situation.N.B3.: Delusional perception: A primary delusion which arises as a result of a realperception (e.g. a patient who, on seeing two white cars pull up in front of his housebecame convinced that he was therefore about to be wrongly accused of being apaedophile). The percept is a real external object, not a hallucinatory experience. 23
  • 24. Updated By Mohamed Abdelghaniii. 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. 24
  • 25. Updated By Mohamed Abdelghani 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 ones 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 25
  • 26. Updated By Mohamed Abdelghani 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 26
  • 27. Updated By Mohamed Abdelghani 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 ﺰ‬object 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. 27
  • 28. Updated By Mohamed Abdelghani 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) SpeechIdeas, thoughts, feelings are expressed through language; communication through theuse of words and language.Speech abnormalitiesI. 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. 28
  • 29. Updated By Mohamed Abdelghani ii. Functional: - Conversion. - To differentiate between both; ask the pt. to cough: if he does, its 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 Parkinsons 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. 29
  • 30. Updated By Mohamed Abdelghani16- 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 اﻟﻜﻼم ﻣﻦ ﺣﯿﺚ اﻹﯾﻘﺎع وﻣﺴﺘﻮى ارﺗﻔﺎع واﻧﺨﻔﺎض اﻟﺼﻮت‬23- 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. 30
  • 31. Updated By Mohamed Abdelghani 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 ‫.اﻻﺳﺘﺒﻄﺎن/ﻓﺤﺺ اﻟﺬات‬ N.B.: Apperception: Awareness of the meaning and significance of a particular sensory stimulus as modified by ones 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). 31
  • 32. Updated By Mohamed AbdelghaniII. 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). 32
  • 33. Updated By Mohamed Abdelghani 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. 33
  • 34. Updated By Mohamed Abdelghani3- 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. 34
  • 35. Updated By Mohamed Abdelghani 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 ones 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 "minds eye".  Additionally, hallucinations experienced as true hallucinations during the active phase of a patients 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 35
  • 36. Updated By Mohamed Abdelghani commonly described by widows and widowers may have the form of a pseudo-hallucination".  Ther are of two types: perceived type and imaged type: Pseudo-hallucination Pseudo-hallucination Hallucination Imagery ‫اﻟﺘﺨﻴﻞ‬ (perceived type) (imaged type)- Appears in - Appear in - Occurs in inner - Occurs in innerexternal space. external space. space. space. - Three - Detailed photo- - Flattened and - Flattened and lacks dimentional graphic reproduction lacks vividness. vividness. and vivid. of objects seen.- Independent - Independent of - Independent of the - Under control of of the will. the will. will. will.- Insight: lost - Recognized as not - Recognized as (accepted by - Recognized as not true "product of not truethe subject as true. individual’s own perception. real). 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. 36
  • 37. Updated By Mohamed Abdelghani 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 ones body as ones 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 brains 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. 37
  • 38. Updated By Mohamed Abdelghani 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. 38
  • 39. Updated By Mohamed Abdelghani5. 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 ones 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. 39
  • 40. Updated By Mohamed Abdelghani (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 Oriented 5 Obeying orders 5 To speech 3 Confused 4 Localizing 4 To pain 2 Words 3 Flexing 3 None 1 Sounds 2 Extending 2 None 1 None 1 40
  • 41. Updated By Mohamed AbdelghaniDisorders 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. 41
  • 42. Updated By Mohamed Abdelghaniviii- 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. 42
  • 43. Updated By Mohamed Abdelghani 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. 43
  • 44. Updated By Mohamed Abdelghani 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 memory1. 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. 44
  • 45. Updated By Mohamed Abdelghani3. 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. 45
  • 46. Updated By Mohamed Abdelghani  Most often associated with organic pathology as in Korsakoff syndrome, dementia or following alcohol blackout. (c) False memory: - A persons 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. 46
  • 47. Updated By Mohamed Abdelghani 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). 47
  • 48. Updated By Mohamed Abdelghani 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: ‫ﻋﺼﻔﻮر ﻓﻲ اﻟﯿﺪ ﺧﯿﺮ ﻣﻦ ٠١ ﻋﻠﻰ اﻟﺸﺠﺮة‬ 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 (‫ )ﻣﺠ ﺎز- ﻛﻨﺎﯾ ﺔ‬and hypotheses appropriately. 48
  • 49. Updated By Mohamed Abdelghani 2- Concrete thinking:  Literal thinking with limited use of metaphor without understanding nuances of meaning.  One-dimensional thought. G. Reading and Writing1. 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. 49
  • 50. Updated By Mohamed Abdelghani (7) Insight Def. : Its the patient’s degree of awareness and understanding about being ill. Or; the ability to recognise that ones 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. ‫ﻋﺎرف ﻛﻞ ﺣﺎﺟﺔ ﻋﻦ ﺣﺎﻟﺘﮫ ﻟﻜﻦ ﺗﻨﻘﺼﮫ اﻟﻨﯿﺔ ﻟﻠﺘﻐﯿﺮ ﻣﻦ أﺟﻞ ﻣﺴﺘﻘﺒﻞ أﻓﻀﻞ‬ 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 ‫ ﺗﺠﺮﯾﺒﻲ‬actions 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  Its the ability to assess a situation correctly and to act appropriately in the situation. 50
  • 51. Updated By Mohamed Abdelghani 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. 51
  • 52. Updated By Mohamed Abdelghani Micellaneous definitionsGanser 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 Munchausens 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. 52
  • 53. Updated By Mohamed AbdelghaniAbreaction:  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. 53

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