المحاضرة الاولى من الطب النفسي(مصطلحات)

1. Phenomenology
“Listen to the patient. He is telling you the diagnosis”
(Osler)

2. 2
Phenomenology
 Definition:
- The study of events, either psychological or physical,
without embellishing‫تجميل‬ those events with
explanation of cause of function
- In psychiatry, it involves the observation and
categorization of abnormal psychic events, the
internal experiences of the patient and his consequent
behaviour
- Descriptive psychopathology:
- Empathic evaluation of patient‟s subjective experience

3. 3
Phenomenology
 Symptoms:
- subjective experiences described by the patient
- e.g. Depressed mood, poor concentration
 Signs:
- objective findings observed by the clinician
- e.g. Psychomotor retardation, restricted affect
 Syndrome:
- a group of signs and symptoms that occur together as
a recognizable condition that may be less than
specific than a clear-cut disorder or disease

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Description of symptoms
 Significance:
 symptoms are more likely to indicate mental disorder
if they are intense and persistent.
 Primary and Secondary:
 Temporal:
 Primary – antecedent
 Secondary – subsequent
 Causal:
 Primary – direct expression of the pathological process
 Secondary – a reaction to the primary symptoms

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Description of symptoms
 Form:
 Normally is what the doctor is interested in
 e.g. Voices - internal/external, second/third
person, true voices/implanted thoughts etc.
 Content:
 What the patient is pre-occupied in
 e.g. Voices - what the voices says, his feelings
towards them etc.

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Description of symptoms
 Asking the patient:
 imagine someone asking you:
“Do you have any fixed, false beliefs that are out
of keeping with your culture or educational
background?”
 thus, it is very important to start off with
open-ended question (screening) and then
proceed to close-ended question (specific
symptoms)

8. 8
Description of symptoms
 Asking the patient:
 now imagine you asking the patient:
 Do you have any odd experiences lately?
 Well, like strange sensasations, feelings or thoughts?
 If so, is it in the form of voices that other people cannot
hear?
 ..... And so on....
 Sometimes people hear things when there is
nothing actually there to explain it, like a voice
calling their name. Do you have such an
experience?
 can you tell me more about it?

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Classification of signs and
symptoms in Psychiatry
 Disorders of Perception
 Disorders of Thinking
 Disorders of Mood
 Disorders of Cognition

10. 10

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 Perception:
 the process of becoming aware of what is
presented through the sense organs i.e. the
understanding of a sensory stimulus
 imagery: an experience within the mind,
usually without the sense of reality, can be
called out and terminated by voluntary effort.

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 Alterations in Perception:
 intensity
 noise - louder or softer than normal
 quality
 shape - e.g. macropsia, micropsia, distorted
 food – bitter ‫مر‬
 Two main disorders:
 illusion
 hallucination

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Disorders of Perception
 Illusions
 misperceptions of external (objective) stimuli
 conditions more likely to occur:
 reduced level of sensory stimulation (e.g. at
dusk ‫)الغروب‬
 reduced level of consciousness (e.g. delirious pts.)
 when attention is not focussed on the sensory
modality (e.g. in darkness)
 when there is a strong affective state (e.g. stressed
up / angry)

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Disorders of Perception
 Hallucinations
 sensory perception without an objective
stimulus but with with a similar quality to a
true percept
 experienced as originating in the outside
world and not in the mind (like imagery)
 can be of all sensory modalities:
 visual / auditory / tactile
 gustatory / vestibular / olfactory
 “presence”

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Disorders of Perception
 Hallucinations
 objective space
 perceived via a
sensory modality
 clear, distinct, vivid
 beyond voluntary
control
 no insight (towards
the symptom)
 Pseudohallucinations
 subjective space
 may not be
perceived by a
sensory modality
 unclear, foggy
 within voluntary
control of a person
 there is insight

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Description of hallucinations
 According to complexity
 elementary
 complex
 According to sensory modality
 According to special features
 auditory: 2nd or 3rd person

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Auditory hallucinations
 Elementary / complex
 Voices
 single/multiple
 male/female
 known/unknown person
 person
 1st person: “thought echo” - hearing own thoughts
spoken aloud (Gedankenlautwerden, echo de la pensee)
 2nd person: calling patient by „you‟
 3rd person:calling patient by „he‟ or „she‟

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Auditory hallucinations
 Voices
 commanding / running commentary / arguing with
each other
 timing:
 day / night / all the time
 circumstances when it occurs
 continuous / intermittent / frequency
 theme:
 friendly, derogatory ‫ازدراء‬
 patient‟s response to the voices

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21. 21
Visual Hallucinations
 elementary (e.g. flashes of light)
 complex
 semi-formed: with some structure
 fully-formed: e.g. human figures, trees
 black and white / coloured
 static / mobile
 stable form / changing design
 size (e.g. lilliputian)
 commonly associated with organicity

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 Olfactory and gustatory hallucinations
 often experienced together
 often unpleasant in nature (e.g. rotten fish, bitter)
 common in temporal lobe epilepsy
 Somatic (tactile and deep)
 tactile (haptic): touched, pricked e.g. insect
crawling under the skin (e.g. formication in
coccaine abuse)
 deep sensation: e.g. viscera being pulled out,
sexual stimulation, electric shock
 Autoscopic hallucination
 seeing own body projected into objective space
(can happen in depression)
 “negative autoscopy” also can occur!

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 Extracampine hallucinations:
 perceiving a sensation from beyond the limits of the
sense organ
 e.g. visions from outside visual field, hearing voices from
far far away
 Reflex hallucinations:
 stimulus in one sensory modality causing a hallucination
in a different sensory modality
 e.g. music causing visual hallucination (LSD abuse)
 Hypnogogic and hypnopompic hallucinations
 occurs at the point of falling to or waking from sleep
 usually brief and elementary
 Feeling of “Presence”
 feeling the presence of „somebody‟ near but realises that
he is non-existent!

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Other Perceptual Disturbances
 Depersonalization: a feeling that his body
parts are abnormal, unreal
 e.g. “my brain becomes big until it fills the room”
 Derealization: a feeling that the external
environment is abnormal, unreal
 e.g. people are 2 dimensional card board figures
 both can occur in tiredness, depression etc.

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Thinking
 Definition:
 a goal directed flow of ideas, symbols or
associations, initiated by a problem/task, leading
to a reality orientated conclusion
 disorders of thinking are usually recognized from
speech and writing
 4 components of thinking:
 form of thought
 flow (stream) of thought
 content
 possession

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Formal Thought Disorder
 Disorder in the form (structure) of thoughts
 3 main subgroups:
 loosening of association
 flights of ideas
 perseveration

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Loosening of Association
 Loss of the normal structure of thinking
 muddled and illogical conversation that cannot be
clarified by further enquiry.
 Several forms:
 Knight‟s move / derailment:
 transition from one topic to another with no logical
connection between the two
 Word salad:
 severe form of derailment affecting the grammatical
structure of speech
 Talking past the point (vorbeireden) / tangentiality:
 touching the point just a little bit before going
 Circumstantiality:
 going round and round before finally reaching the
point

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Flights of Ideas
 Patient‟s thoughts and conversation move quickly
from one topic to another so that one train of
thought is not completed before the another
appears but there is an apparent association
between them (clang (similar sound) or chance
associations)
 3 components have to be there:
 pressure of speech
 shifting topics
 apparent association (can be followed)
NB: if without pressure of speech = PROLIXITY

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Others Formal Thought Disorders
 Perseveration:
 Giving a response beyond the point of relevance i.e. same
answer to each question (stimulus)
 c/f verbal stereotypy (verbigeration): words, sounds or
phrase repeated in a senseless way (no stimulus)

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Disorder of flow (stream)
 Both the amount and the speed of thoughts
are changed
 Different levels:
 muteness
 poverty of thought
 thought block
 volubility:  amount & speed, still can interrupt
 pressure of speech:  amount & speed, cannot
interrupt speech

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Disorders of Content of Thought
 Delusion:
 false belief, unshakeable, inappropriate to a person‟s
educational and social background
 “double orientation”: wholly convinced about the truth of
the delusional belief but the conviction may not influence
his feelings and emotions
 Over-valued ideas:
 ideas held with a lot of emotion (highly charged) but with
some degree of ambivalence and doubts about the belief.
(Emotions are expressed to compensate for the
ambivalence)
 Pre-occupation:
 ideas which comes to mind, again and again and may
prevent the patient from performing his day to day
activities

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Classification of Delusions
 According to fixity:
 complete / partial / over-valued ideas / ideas
 According to onset:
 Primary: autochtonous delusions
 sudden onset (out of the blue‫مكان‬ ‫ال‬ ‫من‬ ) of delusion
 other forms:
 delusional mood: anxiety, foreboding ‫نذير‬ something
to happen (Wahnstimmung)
 delusional perception: false meaning to a normal
percept
 memory: attribute new meaning to old experience
 Secondary: derived from preceding morbid
experience e.g. hallucinations, depressive mood
etc.

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Classification of Delusions
 According to special features:
 Systematised delusion:
 chronic, presence of nucleus, well knitted, inter-
connected, layered and well-encapsulated.
 Non-systematised delusion
 Shared delusion:
 folie a deux (two person, including patient)
 folie a mass (> than two person)
 According to theme

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Themes of Delusion
 Persecutory (paranoid):
 others/organizations trying to inflict harm on him
 Delusion of Reference:
 idea that objects/events/people have a personal
significance for patient e.g. TV programmes, news
 Grandiose (expansive):
 beliefs of exaggerated self-importance
 e.g. wealth, special powers, beauty
 Religious:
 delusions with religious content
 e.g. chosen to be prophet, communicating directly to God

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Themes of Delusion
 Amorous Delusion
 more common in women
 (? stalking in men)
 De Clerambault‟s Syndrome
 being loved by a man who is unaccessible, high status,
never spoken before, unable to reveal his love for her
 Delusion of Jealousy:
 common in men
 delusion of unfaithfulness of spouse (infedility)
 spying, checking on spouse, examine for sexual
secretions

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Themes of Delusion
 Delusion of Guilt and Worthlessness:
 e.g. minor past faults will be exposed, being
sinful, deserves to be punished
 Nihilistic Delusion
 belief about non-existence of some person / thing
+ pessimistic ideas e.g. career is gone
 Cotard’s Syndrome: failures of bodily functions
e.g. bowels are rotting ‫متعفنه‬ etc.
 Hypochondriacal Delusions
 belief of ill health despite contrary medical
evidence
 usually of a particular theme & may have
relative/friend suffering the supposed illness

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Other Disorders of Thought Content
 Obsessions:
 recurrent persistent thoughts, impulses or images that
enter the mind despite efforts to exclude them
 subjective sense of struggle to resist them
 recognized as his own (not implanted)
 regarded as untrue and senseless
 Compulsions:
 repetitive, purposeful behaviours performed in a
stereotyped way, accompanied with subjective sense
that it must be carried out and an urge to resist
 most common: cleaning, counting, dressing

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Description of Obsessions
 Six common themes:
 dirt & contamination
 aggressive thoughts:
e.g. striking others
 orderliness: how things /
work need to be arranged
/ done
 illness: e.g. dread about
cancer
 sex: e.g. perverse sexual
acts
 religion: doubts about
fundamental belifs e.g.
“Does God exist?”
 Five forms:
 thoughts: intrusive
words or phrases,
upsetting e.g.
blasphemous phrases
 rumination: worrying
themes e.g. ending of the
world
 doubts: uncertainty
about previous action
(realizes done)
 impulses: urges to carry
out actions: dangerous or
embarrassing
 obsessional phobia

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Disorders of Thought Possession
 Thought Insertion:
 delusion that some thoughts have been implanted
by outside agency
 Thought Withdrawal:
 delusion that thoughts have taken out of his mind
(may accompany/explain thought block)
 Thought Broadcasting:
 delusion that his unspoken thoughts are known to
other people

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Disorders of Emotion
 Mood:
 The emotional „tone‟ prevailing at any given time.
A „mood state‟ will last over a longer period
 Affect:
 Synonymous with „emotion‟ and also meaning a
short-lived feeling state. Related to cognitive
attitudes and understanding, and to physiological
sensations

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Abnormal Emotional Predisposition ‫قابليه‬
 Found in disorders of personality and signifying a
consistent tendency to particular stereotyped
expressions. Thus a person may be::
 Dysthymic - always tending to be sad and miserable
 Hyperthymic – always tending to be overcheerful,
unrealistically optimistic
 Cyclothymis – tending to marked swings of mood from
cheerful to unhappy
 Affectless – emotionally cold and indifferent

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Abnormal Emotional Reactions
 Anxiety - a fear with no adequate cause. Fear and anxiety may be
normal experiences, but are regarded as pathological if they are
excessive, prolonged, or if they interfere markedly with normal life.
Usually accompanied by somatic and autonomic changes.
 Depression – feeling of misery, inner emptiness, hopelessness and
helplessness, accompanied by morbid preoccupations. May be normal
in the bereaved, but are regarded as pathological if excessive,
prolonged and accompanied by disturbances of appetite, sleep,
concentration, etc., or by depressive delusions.
 Euphoria and ecstasy – excessive and unrealistic cheerfulness and a
feeling of extreme wellbeing.
 Apathy – the loss of all feeling. No emotional response can be elicited.

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Abnormal Expression of Emotion
 Denial or dissociation of affect - as seen in hysteria ( la belle indifference) or
occasionally in situations of extreme danger.
 Emotional indifference – as may be seen in „psychopathic‟ disorder. Expected
emotional response is not shown to others.
 Perplexity – anxious and puzzled bewilderment. Seen in early schizophrenia
and confusional states.
 Emotional incongruity – the abnormal presence or absence of emotions, e.g.
fatuous euphoria in situation which would normally evoke a depressed mood.
The criterion of „understandibility‟ is therefore employed, i.e, the mood is not
understandable to the „normal‟ person. Characteristic of acute schizophrenic
disorder.
 Blunting – insensitivity to the emotions of others, and a dulling of the normal
emotional responses. Seen in chronic schizophrenia

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Abnormal Expression of Emotion
cont,…
 Emotional lability – rapid fluctuations of emotion. The emotions may be
appropriate in a less intense form, but the rapidchange is not. Seen in organic
disorders, brain stem lesions, mania, some personality disorders.
 Emotional incontinence – an extreme form of emotional lability, with complete
loss of controll over the emotions. Seen in organic disorders, especially
pseudobulbar palsy..
 When examining the disorders of emotion, look for:
1. The quality of emotion: anxiety, sadness, cheerfulness, suspiciousness,
irritability, apathy
2. The appropriatness of the emotion to what is beingsaid and to behaviour
3. The constancy of the emotion at interview and whatfactors appear to influence
it..

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Disorders of Consciousness
 Reduced levels of consciousness are seen in :
1. Clouding of consciousness – disorientation in time, place, person,
disturbances of perception and attention and subsequent amnesia.
2. Drowsiness – further reduction in level of consciousness, but can be
stimulated to a wakeful state.
3. Stupor – further loss of responsivness, can only be aroused by
considerable stimulation. Awareness of environment is often
maintained in depressive or catatonic stupor, but not in organic stupor.
4. Coma – profound reduction of conscious level with very little or no
response to stimulation.

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Motor behavior (conation)
1. Echopraxia: pathological imitation of movements of one person by another
2. Catatonia: motor anomalies (stupor or excitement) in some disorders
a. Catalepsy: general term for an immobile position that is constantly maintained
b. Catatonic excitement: agitated, purposeless motor
c. activity,uninfluenced by external stimuli
c. Catatonic stupor: markedly slowed motor activity, often to a point of
immobility and seeming unawareness of
surroundings

49. 49
• Catatonic rigidity: voluntary assumption of a rigid posture,
held against all efforts to be moved
• Catatonic posturing: voluntary assumption of an inappropriate or bizarre posture,
generally maintained for long periods of time
• Cerea flexibilitas (waxy flexibility): the person can be molded into a position that is
then
maintained that is then maintained; when the
examiner moves the person‟s
limb he feels as if it were made of wax

50. 50
3 Negativism: motiveless resistance to all attempts to follow instructions, request or directions
4. Cataplexy: temporary loss of muscle tone and weakness precipitated by a variety of emotional states
5. Stereotypy: repetitive fixed pattern of physical action or speech
6. Mannerism: ingrained, habitual involuntary movement
7. Command automatism: automatic following of suggestions (also called automatic obedience)
8. Mutism: voicelessness without structural abnormalities

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9. Overactivity
a. Psychomotor agitation: excessive motor and cognitive overactivity,
usually nonproductive and in response to
anxiety
B Hyperactivity (hyperkinesis): restless, destructive activity,
often associated with some underlying brain pathology
Tic: involuntary, spasmodic motor movement
Sleepwalking (somnambolism): motor activity during sleep
Akathisia: subjective feeling of muscular tension secondary to
antipsychotic or other medication, which can cause restless,
pacing, repeated sitting and standing; can be mistaken for psychotic agitation
Compulsion: uncontrollable impulse to perform an act repetitively
Ataxia: failure of muscle coordination; irregularity of muscle action
Polyphagia: pathological overeating
1 Hypoactivity (hypokinesis): decreased motor and cognitive activity,
as in psychomotor retardation; visible slowing of thought, speech, and
movements

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1Circumstantiality: indirect speech that is delayed in reaching the point
but eventually gets from original point
to desired goal; characterized by an over inclusion of details
and parenthetical remarks
1Tangentiality: inability to have goal-directed association of thought; patient never
gets from desired point to desired goal
Echolalia: psychopathological repeating of words or phrases of one person by another;
tends to be repetitive and persistent, may be spoken with mocking or staccato intonation
Corprolalia: compulsive utterance of obscene words
Glossolalia:neologisms that simulates coherent speech; the expression of a revelatory message
through unintelligible words ( also known as speaking in tongues); not considered a disturbance
in thought if associated with practices of specific religions
1Dysprosody: loss of normal speech melody (called prosody)
Dysarthria: difficulty in articulation, not in word finding or in grammar

53. Reference
 Oxford Textbook of Psychiatry (Third
Edition) Gelder et al
 Sypmtoms in the Mind: An Introduction
to Descriptive Psychopathology (Second
Edition) Andrew Sims