clinical manifestations of psychiatric disorders 3

Clinical Manifestations of Psychiatric Disorders

Alemayehu Negash MD, PhD, Assistant professor and Consultant psychiatrist,

Chairman (Head), Department of Psychiatry

Issues of considerable concern Need for a Comprehensive Clinical Perspective

A psychiatric disorder may be characterized by

disturbances involving a wide variety of areas in the

patient's life.

i. It may include the

ii. biological,

iii. psychological,

iv. behavioral,

Issues of considerable concern i. interpersonal, and

ii. social spheres.

View the patient from multiple perspectives:

i. biological

ii. Psychological

iii. social

Bio-psycho-social model enables clinicians to consider

psychopathology and its effects on a patient's life

in the broadest possible manner.

Issues of considerable concern the amount of information gathered in a thorough

assessment of a psychiatric disorder is potentially

overwhelming

the clinician's theoretical orientation and other personal

and cultural factors also limit what is perceived.

A phenomenon known as concept-driven perception.

Clinicians tend to perceive primarily those signs and

symptoms that are most in accord with their theoretical

points of view

Issues of considerable concern The intermittent nature of many psychiatric signs

and symptoms leads to

i. the potential unreliability,

ii. selective recall, and

iii. false remembering of patients and others in

reporting symptoms and events;

iv. differing interpretations of elicited information

or observations,

Issues of considerable concern subjective theoretically driven biases - influence the

clinician's perception of signs and symptoms - all

contribute to potential errors in data collection.

To help guard against misinformation and simplistic

understandings and formulations

1. complete assessment of a psychiatric patient

2. consultation with family,

3. friends,

4. co-workers, and other professional observers

Issues of considerable concern The Clinical Challenges

These subjective descriptions of psychiatric

symptoms are inherently

less reliable, or

at least less objective,

not directly measurable and

are not quantifiable data such as blood

pressures, temperatures, and laboratory test

results

Issues of considerable concern

Circumstance

The line between symptoms and signs is often blurrier in

psychiatry than in general medicine

Signs and symptoms are said to be present when the limits

of normal variability are exceeded.

Signs and symptoms are usually not static entities;

They often vary in intensity or even in their existence

depending on the circumstances


The depressed mood of a patient with Major depressive

episode:

may persist regardless of external situations,

the depressed mood in mild reactive depression

may vanish completely during:

e., a psychiatric interview—only to reappear at

other times.

Issues of considerable concern State dependent phenomena : Signs and symptoms that occur

only in specific settings or with certain internal states :

example 1 - certain hallucinations or memories may

be present only during states of drug or

alcohol intoxication in some patients,

example 2 – hives, may erupt as a psychophysiological

response only during states of anger.


Interpersonal context is also important.

1. Some people become violent only when involved in

sadomasochistic relationships or in certain group

settings such as adolescent gangs.

2. In gangs, social pressures for conformity and

expectations for aggressive behavior may provoke

pathological behaviors that might otherwise never be

expressed by gang members individually.

Issues of Significant importance

Cultural Context

Psychiatric signs and symptoms cannot be assessed

independent of an individual's background and culture

Many phenomena often considered to be symptoms of

psychiatric disorders may not be experienced as

psychiatric problems by patients.

Hearing an angel's voice may represent a manifestation of

a psychotic disorder, yet the patient may vigorously dispute

that the experience is not a psychopathological symptom.


These signs and symptoms must all be considered in

context:

Exactly what constitutes normal varies from culture to

culture and from situation to situation.

A behavior or subjective experience that may be defined as

symptomatic in one context may be perfectly acceptable

and within normal bounds in another.


A phenomenon should be considered abnormal only if

it seems deviant within the patient's specific culture

after its full physiological and environmental context is

taken into account and

if it causes personal or interpersonal impairment.

Too often, phenomena prematurely mislabeled as

psychopathology turn out to be perfectly understandable

and nonpathological once the whole situation is appraised.

Issues of considerable concern Conversely, some examiners are disinclined to label certain

phenomena as psychopathological even when they clearly are,

for fear of stigmatizing the patient.

Within cultures, most interpersonal interactions are carefully

regulated by tight sets of rules and controls and constrained by

reasonably well-defined sets of expectations and acceptable

limits.

Even slight deviations from these acceptable limits are quickly

perceived by laypeople, as well as professionals, because

behavioral deviances are often experienced as threats.

Issues of considerable concern Deviations in

amplitude, duration, and intensity

can occur in

facial expressions,

gestures,

postures,

vocalizations,

language, and

other expressions of emotion and thought.


Sign and Symptom Classifications Schemas

Several different classification schemas:

1. State versus trait,

2. primary versus secondary, and

3. form versus content.

Issues of considerable concern The state versus trait distinction refers to whether the

sign or symptom is an enduring characteristic of the

person (“traits”) or time-limited phenomena (Illness-

related).

However, some enduring traits may also be symptoms.

A person who always worries a great deal, chronically

exhibits catastrophic thinking, and feels subjectively

nervous in many different circumstances since early

childhood may have anxiety traits.


If such symptoms of anxiety are present only during a

specific time frame, for example, over a 9-month period in

conjunction with a full depressive syndrome, then they are

best described as state-related symptoms.

At times, trait and state symptoms may be one and the

same.

In one study, patients who had remission of their

depression with treatment still showed relatively high rates

of fatigue and sleep disturbances.

Issues of considerable concern In such circumstances, long-term symptoms of fatigue and

sleep disturbances may be both trait markers of the

depressive disorder as well as symptoms of the acute

depressive episode.

During the acute stages of psychiatric disorders marked by

dramatic state characteristics, it is unwise to infer that any

of the prominent signs or symptoms are enduring traits,

even those usually associated with personality.


Thus, a diagnosis of dependent personality traits based on

an acutely depressed patient's behavior is often incorrect.

Similarly, manipulative behavior in the midst of a

hypomanic or manic episode should not be considered

evidence for enduring manipulative traits unless these

behaviors are also present when the mania has clearly

resolved.

Issues of considerable concern Primary versus secondary symptoms

This scenario may refer to causal relationships between

what is primary and secondary?

1. temporal sequence between the two symptom sets, or

2. inability to more clearly understand the origin of the

various symptoms.

Basing the distinction between primary and secondary on

causality implies that it is actually understood what is

cause and what is effect.

Issues of considerable concern In attention-deficit/hyperactivity disorder (ADHD), for

instance, the attention deficit is believed to be primary,

whereas the hyperactivity is believed to be secondary,

caused by the inability to attend.

Patients who develop severe dependent personality traits

and chronic demoralization only after numbers of

incapacitating psychotic mood episodes might be described

as having primary mood disorders and secondary

personality disorders.

Issues of considerable concern Temporal sequence in the appearance of certain symptomsThis concept is regularly used as the basis for deciding the primacy of

i. certain symptoms,

ii. behaviors, or

iii. disorders,

in trying to determine what is primary and what is

secondary when substance abuse occurs in conjunction

with depression or anxiety symptoms or schizophrenia.

Issues of considerable concern These differences are not trivial.

But they may have treatment implications.

For instance, treating a primary mood disorder in a

substance-abusing patient with a long course of medication

This may be quite different from simply expecting that, with

prolonged sobriety, a secondary mood disorder will resolve

on its own.

Issues of considerable concern However, the primary–secondary distinction with mood and

substance abuse problems, although logical, may not always

be consistent in treatment studies.

Example: in one study, patients with primary alcohol abuse

and secondary depression (whose depressions should

theoretically have responded to simple sobriety) responded

better to antidepressants than to placebo.

Issues of considerable concern Furthermore, it is becoming increasingly clear that the

presence of certain pre-existing psychiatric conditions

(e.g., personality disorders), increases one's vulnerability

for the subsequent development of other psychiatric

disorders such as major depressive disorders.

However, establishing temporal sequence with any

certainty is typically difficult but not impossible.

Issues of considerable concern Ultimately, understanding the contribution of each

element as a thread in the evolution and development of a

given clinical condition is more important than simple

categorical distinctions between primary and secondary

signs, symptoms, and disorders, viewing each element as

exerting impact dynamically affecting

i. the appearance,

ii. manifestations, and

iii.course of the others manifestations


This perspective exerts its own influence on the

pathogenesis and treatment of the specific syndromes and

associated disorders.

This view is particularly important because, despite the

excellent conceptual contributions made by categorical

diagnostic systems (DSM-IV-TR), in clinical practice

distinctions are often vague, and comorbidity among so-

called categorically distinct disorders is often the rule

rather than the exception.


For example, data from the National Comorbidity Study

show that 51 % of the population experience three or more

comorbid psychiatric disorders.

In such individuals, the dynamic interactions and mutual

influences of various signs and symptoms and their

biological underpinnings become impossible to

disentangle.

Issues of considerable concern The categories that currently comprise DSM-IV-TR are not

going to be the last word in the evolving history of

psychiatric diagnosis.

Recent studies show that psychiatric signs and symptoms

may be usefully grouped into psychotic syndromes that

differ in some respects from current DSM-IV-TR

categories.

A large family study of probands with broadly defined

schizophrenia and affective illness and their first-degree

relatives has been conducted in recent decades.

Issues of considerable concern Kenneth Kendler and colleagues found six classes of

psychosis.

These classes of psychosis include

i. classic schizophrenia,

ii. major depression,

iii. schizophreniform disorder,

iv. bipolar schizomania,

– schizodepression, and

– hebephrenia.

Issues of considerable concern The methodology that has been used in their study was a

sophisticated statistical technique called latent class

analysis

These classes bore substantial resemblance to current or

historical nosological constructs

However, several of them differed from DSM-IV-TR

nosological constructs.

Another study found the three factors ordinarily associated

with symptoms of schizophrenia.

Issues of considerable concern These factors represent

1. positive,

2. negative, and

3. disorganized symptom domains,

They found them not to be specific to schizophrenia, as

they were found in other schizophrenia-spectrum

psychoses and in non-schizophrenia-like psychotic

conditions as well.


A dimensional view of psychopathology fits much recent

data better than the categorical view that is inherent in the

DSM-IV-TR.

Personality disorders fit poorly into a categorical scheme.

The frequent “comorbidity” of personality disorders likely

reflects the descriptive overlap rather than the patient

having two distinct disorders.


Similarly, in the DSM-IV-TR, dysthymia and major

depression are seen as two different mood disorders,

Recent studies indicate that they are more likely

manifestations of one disorder that differs in course and

intensity.

Issues of considerable concern Impairments and Adversities

psychiatric

1. signs,

2. symptoms,

3. disorders

create specific impairments and adversities in

affected individuals

Issues of considerable concern specific normal role functions

1. personal

2. social

3. Economic achievement

4. Significant others.

5. Society in general

These functional Roles are affected in

psychiatry

Issues of considerable concern These problems and impairments often cut across

traditional sets of signs and symptoms of which categorical

diagnoses are comprised, affecting, basic abilities to

i. care for oneself

ii. care for one's family,

iii.marital functioning and

iv.child rearing,

Issues of considerable concern v. wage earning,

vi. school performance, and

vii. social behavior.

They constitute the issues with which patients and families

struggle

They need to appear on the problem lists that treatment

plans and specific interventions target.


Studies reveal that the impairments imposed by major

depression are considerable with regard to

1. physical functioning,

2. role limitations, and

3. social functioning.

They must be directly addressed regardless of the

associated DSM-IV-TR diagnoses.

Issues of considerable concern These impairments enter determinations of ratings for Axis

V of the DSM-IV-TR, which addresses the global

assessment of functioning

These impairments are of considerable importance in

evaluating treatment outcomes

Furthermore, the relationship between symptoms and

disorders on one hand and functional impairments on the

other is not always straightforward.

Issues of considerable concern In bipolar and unipolar mood disorders, many patients recover

symptomatically from episodes.

However, they achieve premorbid psychosocial function either

months later or not at all.

Whether this disparity between symptomatic and functional

recovery reflects i. subtle residual symptoms,

unrecognized cognitive disturbances,

personality difficulties, or unknown combination of factors

awaits full explanation

Sins and symptoms in PsychiatryThinking DisturbancesNormal ThinkingThinking is defined as the mental activity and processes used to

imagine,

appraise,

evaluate,

forecast,

plan, create, and will

Sins and symptoms in PsychiatryMost of what is known about thinking derives from the

study of language as the product (and reflection) of

thought.

However a great deal of thinking takes place preferably

and nonverbally (nonverbal language)

Thinking occurs in images, music, and kinesthetic

sensations and in symbols other than linguistic ones.

Attempts to transmit preverbal and nonverbal thought

using only words are frustrating and unsatisfactory.

Sins and symptoms in Psychiatry

Disturbances of Flow (stream) and Form of thought

Current systems for classifying thought abnormalities are

primarily descriptive.

Conventional classification of thought

1. form

2. Flow (stream)

3. content

Sins and symptoms in PsychiatryMany types of abnormal thinking include both form and

content abnormalities.

Delusions are usually classified as thought content

disturbances, however, they are also marked by formal

abnormalities such as

a. rigidity and

b. inflexibility to external influence or

c. to information that clearly contradicts the

delusional idea.


Formal thought disorder typically refers to marked

abnormalities in the

1. form

2. flow or

3. connectivity of thought,

Some clinicians use the term broadly to include any

psychotic cognitive sign or symptom.

Sins and symptoms in PsychiatryNormal variations in the flow and form of thought some peoples’ thinking appears to be

effortless,

rapid and

productive,

goal-directed

creative,

always controlled and

comprehensible

Sins and symptoms in PsychiatryFor others, thinking is

a difficult exercise,

slow,

a painstaking process with low output or

“scattered,” with difficulty staying with a topic or

finishing a single thought.

Sins and symptoms in PsychiatryMost people experience admixtures of these extremes.

Disturbances in the flow and form of thought occur with

regard to

rate,

continuity,

control, and

complexity.

Sins and symptoms in PsychiatryThinking can be unusually slow or (or retarded) .

Patients experiencing retarded thought often describe

feeling that even simple thought requires monumental

effort, as if molasses were cluttering their thinking.

These difficulties are expressed as

slowness in decision making and

long latency of response, increased pause times

when speech is initiated and during speech.

Sins and symptoms in PsychiatrySlowed thought, such as noted in depression, is typically

goal directed but characterized by little initiative or

planning

Thought blocking, seen in schizophrenia, is experienced as

the snapping off or as a sudden break in a train of

thought, as if a wall suddenly comes down, interrupting

thinking (and speaking) in midsentence.

Sins and symptoms in PsychiatryTo an outside observer, without further explanation from

the patient, thought blocking may appear identical to

thought withdrawal,

A thought withdrawal is a disturbance in the control of

thought

In this siuation the patient feels as if some alien force has

intentionally withdrawn the thoughts from consciousness.


The patient's further description and explanation of the

inner experience is necessary to distinguish these two

symptoms.Accelerated Speech

Accelerated rates of thinking, typically accompanied by

fast talking, can be seen as a normal variant.

Sins and symptoms in PsychiatryRapid rates of speech are heavily influenced by

a. cultural and

b. situational factors.

Only sometimes truly rapid thoughts are reflected in

normality.

Pressure of speech

speech that is rapid,

excessive, and

typically loud


Flight of ideas occur when the flow of thought increases to

the point at which the train of thought switches direction

frequently and rapidly.

The associative links between conceptual topics during

flight of ideas are comprehensible to the listener,

But flight of ideas demands considerable effort at times to

understand


Listening to a flight of ideas that is not overwhelmingly

fast can be both a dizzying and enjoyable experience for

the listener,

Such speeches are demonstrated by the successful

performance style of certain contemporary comedians.

Sins and symptoms in PsychiatryPressure of speech is characteristic of

i. mania

ii. hypomania,

iii. stimulant intoxication, and,

iv. occasionally, anxiety

v. schizophrenia (occasionally as well)

Sins and symptoms in PsychiatryContinuity

Disturbances in the continuity of thought take several forms.

A.Circumstantiality:

i. the flow of thought includes many digressive turns and

associations, often including a great deal of

unnecessary detail.

ii. Transcripts of circumstantial thought or speech are

marked by multiple commas, sub clauses, and needless

departures.

Sins and symptoms in Psychiatryiii. However, in circumstantial thought or speech, the speaker

eventually returns to the point that was initially intended

without having to be prompted by the listener.

B. Tangentiality:

The person's thought wanders further and further away

from the intended point, without ever returning

iii. The person may not even remember what the original point

was supposed to be.

iv. Tangentiality is a mild form of derailment .


C. Derailment: A speech where there is a breakdown in associations.

D. Loose associations:

This type of speech is represents more severe derailment.

It is the type of speech where the flows of ideas are no

longer comprehensible to the listener.

Individual thoughts seem to have no logical relation to

one another.

Sins and symptoms in Psychiatry Loose associations are classically a hallmark feature of

schizophrenia.

In extreme cases, the associations of phrases and even

individual words are incomprehensible.

The syntax—the rules of grammar by which phrases are

organized into sentences and words into phrases—may be

disrupted.

E.Word salad:

Describes the stringing together of words that seem to

have no logical association.

Sins and symptoms in PsychiatryF. Verbigeration

describes the disappearance of understandable speech,

replaced by strings of incoherent utterances

G. Clang association:

This type of speech refers to a sequence of thoughts

stimulated by the sound of a preceding word.

For example, a manic patient said, “I'll kill with a drill or a

pill—God, I'm ill—what swill.”

Sins and symptoms in PsychiatryH. Echolalia:

The patient repeats a sentence just uttered by the examiner.

I. palilalia,

Repetition of only the last uttered word or phrase.

This symptom is found most often in chronic schizophrenia.

J. Perseveration:

In perseveration, a sentence or phrase is repeated,

sometimes several times over, after it is no longer relevant.


In these abnormalities the flow of thought or speech

appears to get stuck

Perseveration is commonly seen in delirium and other

organic mental disorders.

K.Stereotypy

This thought abnormality refers to the constant repetition of

a phrase or a behavior in many different settings,

irrespective of context


Both stereotypy and Perseveration are two other

associative thought or speech abnormalitiesassociative thought or speech abnormalities

Disturbances in the control of thoughtDisturbances in the control of thought1. delusional passivity experiences and

2. obsessional thinking.

In delusional thought passivity, patients experience

their own thoughts as being under the control of

other forces.


Thought passivity Phenomena:

Thought insertion - thoughts are experienced as having

been placed within the patient's mind from the outside;

Thought withdrawal - thoughts are taken out of the patient’s

mind;

Thought broadcasting - patients experience their thoughts as

escaping their minds to be heard by others.

Sins and symptoms in Psychiatry These experiences are often combined with specific

delusions – Delusions of control -, seemingly to

explain the passivity experiences.

Several of these phenomena were included by

Schneider among the so-called first-rank symptoms of

schizophrenia.

Today, these symptoms are viewed more broadly as

nonspecific psychotic symptoms

Sins and symptoms in Psychiatry Schneiderian first-rank symptoms are more likely to

be seen in schizophrenia but not pathognomonic of the

disorder.

Obsessional thinking:Obsessional Thinking is

i. stereotyped,

ii. repetitive,

iii. persistent thinking

iv. that is recognized as one's own thoughts.

Sins and symptoms in PsychiatryObsessional patients do not experience their thoughts as

being controlled by outside forces (ego-dystonic thoughts).

Patients can, with great effort, stop thinking the

obsessional thoughts but cannot prevent them from

recurring.

Patients experience only partial control over the

obsessional thoughts.


Characteristic of obsessions are

a. the subjective experience of compulsion

b. the resistance to it and

c. Intense anxiety that mounts if compulsions

are not performed

In classic obsessional thinking, insight is retained

Some obsessions are bizarre are and patients know that

these thoughts are irrational and their own.


Insight into obsessional thinking is more variable at times

becoming delusional.

Obsessions may be pervasive enough to dominate the

patient's consciousness.

Obsessions

1. may be simple,

2. a sequence of words, or

3. elaborate,


1. enumerating the possible consequences of a

past behavior and

2. elaborating a cascading sequence of typically

catastrophic events.

Typical obsessional themes in OCD involve preoccupations with

1. dirt and contamination,

2. fear of harming others,

3. symmetry, and


4. those related to health and

5. appearance.

Disturbances in Thought Contents

Pathological beliefs and convictions form the core of

thought content disturbances.

Considerations of abnormality regarding beliefs and

convictions must take the person's culture into account

E.g, religious hallucinations:


With regard to intensity of conviction distorted beliefs :

Ideas of reference overvalued ideas

delusions.

Abnormal beliefs and delusions are, in most circumstances,

diagnostically nonspecific.

Delusions are commonly seen in

mania,

depression,

schizoaffective disorder,


4. delirium,

5. dementia, and

6. substance-abuse-related syndromes,

7. schizophrenia and delusional disorders.

Overvalued ideas - unreasonable and sustained abnormal

beliefs that are held beyond the bounds of reason.

Patients with overvalued ideas have little or no insight into

the fact that their ideas are very unlikely to be valid;

Sins and symptoms in PsychiatryNevertheless, the ideas themselves are not as patently

unbelievable as most delusions.

The distorted body images of body dysmorphic disorder

exemplify overvalued ideas.

Morbid jealousy and

preoccupation with a spouse's possible infidelity


Delusions

Delusions are fixed, “false” beliefs, strongly held and

Incorrigible in the face of refuting evidence, that are not

consonant with the person's

educational,

social, and

cultural background.


Thus, delusional thoughts can only be understood or

evaluated with at least some knowledge of patients'

interpersonal worlds, such as their involvements with

religious or political groups.

One of the mind's functions is to generate beliefs,

including myths and meaning systems.

They are most noticeable when shared untestable beliefs

form the basis for group cohesion, as in religions and

cults.


Some groups adhere to their cherished beliefs despite the

abundance of plausible contrary evidence—for example,

the fundamentalist sects that take the biblical creation

story literally.

In the face of contrary evidence or grave personal threat,

individuals often cling to their primary beliefs as matters

of faith (i.e., alternative, non-refutable bases for

understanding).


The strong faith with which religious, political, and

nationalistic convictions are held, even at the cost of

death, shows the power that untestable beliefs can

have on behavior.

These beliefs provide the individual with a sense of personal and group identity and with ways of understanding reality.

Potential mental health advantages of religious beliefs

have been demonstrated.

Sins and symptoms in PsychiatryTherefore, the subjective experience of a delusion is no

different from the subjective experience of believing that

the earth is round or that one's spouse is the same person

that one married on his or her wedding day.

Because of the identical experience of delusions and other

strongly held beliefs, it is generally impossible to argue a

patient out of a delusional belief.

Subjectively, delusions are indistinguishable from

everyday beliefs.


The content of delusions is highly influenced by culture.

Centuries ago, delusions of persecution often concerned

persecution by the devil and had religious connotations.

persecutory delusions today often take on contemporary

technological, political, and social perspectives.


Although delusions are diagnostically nonspecific, some

types of delusions are more prevalent in one disorder than

another.

Examples,

1. delusions of control and

2. delusional percepts are often seen in schizophrenia,

they also occur, albeit less frequently, in psychotic mood

disorders.


Similarly, classic mood-congruent delusions, with

grandiose themes seen in mania or delusions of poverty

characteristic of depression, may also be seen in

schizophrenia.

Sins and symptoms in PsychiatryCharacteristics of Delusions

1. Simple vs. complex

2. Complete vs. partial

3. Systematized vs. non-systematized

4. Primary (autochthonous) vs. secondary

5. Persecutory vs. non-persecutory

6. Bizarre Vs nonbizarre

7. How they affect behavior

Classic Types of Delusions

Delusions of persecution Delusions of grandeur Delusions of influence Delusion of having sinned Nihilistic delusions Somatic delusions Delusion of doubles (doppelganger) Delusional jealousy (Othello syndrome) Delusional mood Delusional perception Delusional memory

Delusions of erotic attachment (Clérambault's

syndrome)

Delusions of replacement of significant others

(Capgras syndrome)

Delusions of disguise (Frégoli's phenomenon)

Shared delusions (folie á deux, folie á trios, folie á

famille)

Sins and symptoms in PsychiatrySystematized delusions are usually restricted or

circumscribed to well-delineated areas and are ordinarily

associated with a clear sensorium and absence of

hallucinations.

They are often isolated from other aspects of behavior.

Non-systematized delusions usually extend into many

areas of life, and new data—new people and situations—are

constantly incorporated to further support the presence of

the delusion.


The patient usually has concurrent mental confusion,

hallucinations, and some affective lability.

Patient with a closed systematized delusional system may

go about life relatively unperturbed

The patient with a non-systematized delusion frequently

has poor social functioning and often behaves in response

to the delusional beliefs.

Complete delusions are those held utterly without doubt.


Partial delusions are those in which the patient entertains

doubts about the delusional beliefs.

Such doubts may be seen

during the slow development of a delusion,

as the delusion is gradually given up, or

intermittently throughout its course.


An autochthonous delusion is one that takes form in an

instant, without identifiable preceding events, as if full

awareness suddenly bursts forth in an unexpected flash of

insight like a bolt from the blue.

These delusions may be quite elaborate.

Delusional percept (delusional perception) refers to the

experience of interpreting a normal perception with a

delusional meaning, one that has enormous personal

significance to the patient


Delusional atmosphere or delusional mood is a state of

perplexity, a sense that something mysterious or odd is

going on that involves the patient but in unspecified ways

Ordinary events may take on heightened significance, but

the delusional interpretations are fleeting, although the

strange feeling stays.

Typically, after a period, full-blown delusions develop,

replacing the delusional mood.


Delusional memory is the memory of an event that is

clearly delusional.

As an example, a patient “remembered” that his fourth-

grade teacher slipped lysergic acid diethylamide (LSD) into

his apple juice; this memory served to explain his psychotic

disorder.

The elaboration of false memories and their subsequent

fixed belief may assume delusional proportions.


Patients vary considerably in the extent to which they take

action in response to delusional thoughts.

Just as patients can experience delusions of their thoughts

being controlled (thought passivity), they may similarly

experience their feelings, behaviors, and will as controlled

by outside forces.

These delusions of control (or passivity experiences)

occasionally result in dramatic self-destructive or

aggressive behaviors


Example: The murderer who called himself Son of Sam.

This psychotic killer murdered a series of people in New

York and claimed that he was the powerless agent of a force

that required him to commit the acts.


Olfactory delusions that one emits a foul odor are common

in social anxiety syndromes, in which individuals are

particularly concerned about potentially embarrassing

themselves and others.

Shared delusions may occur in couples (folie à deux) and

in families (folie à famille).


Some Classic Types of Delusions

1. Delusions of persecution

2. Delusions of grandeur

3. Delusions of influence

4. Delusion of having sinned

5. Nihilistic delusions

6. Somatic delusions

7. Delusion of doubles (doppelganger)

Sins and symptoms in Psychiatry8. Delusional jealousy (Othello syndrome)

9. Delusional mood

10. Delusional perception

11. Delusional memory

12. Delusions of erotic attachment (Clérambault's syndrome)

13. Delusions of replacement of significant others (Capgras

syndrome)

14. Delusions of disguise (Frégoli's phenomenon)

15. Shared delusions (folie á deux, folie á trios, folie á famille)

Sins and symptoms in Psychiatry Disturbances of Judgment

Judgment includes a complex and diverse group of

mental functions.

It consists of

1. analytical thinking,

2. social and ethical action tendencies, and

3. depth of understanding or insight.

Sins and symptoms in PsychiatryAnalytical thinking includes the capacity to discriminate

and to weigh the pros and cons of potential alternative

actions.

Social and ethical action tendencies are closely related to

culture and upbringing.

Sins and symptoms in PsychiatryInsight may reflect

1. intelligence,

2. learning,

3. cognitive style, and

4. the capacity to integrate intellectual knowledge

with emotional awareness.


Impairments of judgment occur in many psychiatric

disturbances.

–Anxiety states,

– intoxications,

–fatigue, and

–even group pressures may cause temporary

impairments of judgment in otherwise normal

individuals.

Sins and symptoms in PsychiatryIn mood disorders, judgment may be

1. impaired by either an exaggerated evaluation of risk

or failure in depression or

2. conversely, of inadequate appreciation of risk or

danger in mania.

Organic brain damage and psychotic disorders may

chronically impair any aspect of judgment in any person,

regardless of premorbid character.

Sins and symptoms in PsychiatryPoor role models and deviant social backgrounds may lead

to social and ethical action tendencies quite different from

those of the examiner (e.g., someone raised in a criminal

environment ).

Judgment may be impaired in one dimension and

spared in others.

Individuals may retain sound ethical judgment

when their analytical capacities fail.

Sins and symptoms in PsychiatryLikewise, they may retain excellent analytical abilities for

non-personal matters, although lacking insight into

personal situations or behaviors.

Thus, some people who can provide socially appropriate

responses to traditional mental status examination

questions, such as what one would do in a movie theater if

fire broke out.

Sins and symptoms in PsychiatryOn the other hand, they might at the same time be

incapable of accurately assessing crucial clinical or more

personal matters specifically related to one's capacity to

provide informed consent.

such failures in judgment include

1. the pros and cons of receiving treatment;

2. regarding judgments necessary to provide

oneself with food, clothing, and shelter; or

3. insight into one's state of health or illness.

Sins and symptoms in PsychiatryThe term insight is seen usually in the context of self-awareness

a.Basic insight: a superficial awareness of one's

situation. In evaluating insight into one's psychiatric

condition, basic insight allows an individual to

acknowledge the presence of an illness.


b. A deeper level of insight is operating when the

patient has an intellectual appreciation of what is going on

Example: “I have hallucinations and delusions,

and my doctors have told me that I have

schizophrenia and must take medication.”

b. Still deeper levels of insight reflect more

complete cognitive and emotional appreciation of

a situation


e.g., “I realize that I have schizophrenia, that it

impairs my judgment and social function at times, and

that I will have to take medications if I am to minimize

my symptoms and try to make the most of my life. I

feel profoundly disappointed about this affliction

because it prevents me from achieving some of the

goals I've always wished for.


continued

Nevertheless, I have do my best to get over my

disappointment and hurt feelings so that I can get

whatever I can out of life.”)

Lack of insight correlates with poor outcome in

1. schizophrenia and bipolar disorder,

2. medication noncompliance, and

3. suicidality.

Sins and symptoms in PsychiatryImprovement of psychosis does not necessarily correlate

with improved insight.

Impaired insight may be associated with frontal lobe

abnormalities.

Insight is seriously impaired in

mania

schizophrenia and,

contrary to earlier beliefs, may be lacking in OCD.

Sins and symptoms in PsychiatryJudgment may be impaired by several factors, including

a. cognitive clouding (as in disturbances of

consciousness, e.g., intoxication, so that one's

usual analytical abilities are impaired),

b. self-deception, and

c. impulsivity.

Sins and symptoms in PsychiatrySelf-deception refers to the almost universal tendency to

hide certain issues about the external world or about

oneself from various levels of awareness.

Self-deception - a coping strategy, fostering or maintaining

comfortable perspectives about the world and avoiding

confrontation with issues and realities that inevitably stir

up painful conflicts or the need for difficult actions,

thereby preserving emotional calm.

Sins and symptoms in PsychiatryStudies suggest that self-deception allows us to act and to

be perceived as more convincing in the service of

particular goals, as in romantic relationships or business

dealings.

Therefore, although “kidding ourselves” may sometimes

reflect impaired judgment, it may at times also yield certain

important strategic advantages.

Sins and symptoms in PsychiatryImpulsive judgment describes a tendency to avoid taking

the time and thought to fully understand and integrate all of

the facts and levels of awareness required for optimal

decision making.

Impulsive judgment may occur only with certain issues or

situations such as how

one picks investments,

signal an impaired state (such as intoxication), or

reflect a pervasive character trait.

Sins and symptoms in PsychiatryRapidly made judgments (so-called snap judgments) may

not be maladaptively impulsive, even when they involve

very important areas of life.

Rapid decisions can be

very accurate,

highly adaptive, and

even life-saving,

especially if made against a background of great experience,

wisdom, and forethought concerning the area requiring the

decision.


Disturbances in Perception

ILLUSION

Perceptual distortions in estimating size, shape, and

spatial relations especially when one is fatigued or

excessively aroused.

Illusions are misinterpretations of real sensory stimuli:

Example - when a child in a dark bedroom at night sees

monsters emanating from shadows on the walls.

Sins and symptoms in PsychiatryPareidolia are playful and imaginative voluntary

illusions that can be seen when one looks at ambiguously

defined or evanescent images such as clouds or flames in a

fireplace.

Both the onset and termination of these perceptions are

entirely voluntary.

Trailing is another visual illusion.

It is the perception that an object moving steadily in space

is followed by temporally distinct, after-images of itself.

Sins and symptoms in PsychiatryThe effect is that of a series of stroboscopic photos.

This phenomenon may occur

1. with fatigue

2. is typically seen with marijuana and mescaline

intoxication,

3. during withdrawal from SSRIs, or,

4. less commonly, in association with nefazodone

(Serzone).


Hallucinations

Hallucinations are perceptions that occur in the absence of

corresponding sensory stimuli.

Hallucinations are ordinarily subjectively indistinguishable

from normal perceptions.

Hallucinations are often experienced as being private

So others are not able to see or hear the same perceptions.


The patient's explanation for this is typically

delusional.

Hallucinations can affect any sensory system and

sometimes occur in several concurrently.

When perception is altered, combinations of

illusions and hallucinations, and often delusions as

well, are frequently experienced together.

Sins and symptoms in PsychiatryIn some studies, 90 percent of patients with hallucinations

also have delusions,

~35% of patients with delusions also have hallucinations.

Children and early adolescents are more likely to have

hallucinations in the absence of delusions.

~ 20% of patients have mixed sensory hallucinations (mostly auditory and visual) that may accompany functional, as well as organic, conditions.

Sins and symptoms in PsychiatryA given external stimulus may evoke very different

perceptual distortions in different people.

It has been estimated that between 10 and 27 percent of the

general population has experience memorable

hallucinations, most commonly visual hallucinations.


The large majority of self-reported hallucinations in

community studies, particularly auditory hallucinations,

have been associated with

a. depressive and

b. substance use disorders rather than frank

psychotic disorders.

Sins and symptoms in Psychiatryand are common

Hypnagogic are visual hallucinations that occur during the

moments immediately preceding falling asleep.

Hypnopompic hallucinations are visual hallucinations

occur during the moments immediately or preceding

transition from sleep to wakefulness.

Both occur in normal people and are also characteristic

symptoms of narcolepsy.

Sins and symptoms in PsychiatryIn acute bereavement,

1.up to 50 percent of grieving spouses have reported

hallucinating the voice or presence of the deceased,

2. and after amputations, phantom limb hallucinations are

common.

3.Patients who become visually impaired often develop

complex visual hallucinations hallucinations with preserved

insight and with preserved cognitive status, (the so-called

Charles Bonnet syndrome).

Sins and symptoms in PsychiatryA parallel phenomenon is the emergence of hallucination,

including musical hallucinations in individuals with

acquired deafness.

Hallucinations vary according to

1. sensory modality,

2. degree of complexity of the hallucinated experience,

3. the levels of conviction about their reality,

4. the clarity of their contents,

Sins and symptoms in Psychiatry the location of their sources of origin,

the degree of volitional control over them, and

the degree to which the hallucination

influences the person's behavior.

Auditory hallucinations range in complexity:

a. hearing noises buzzing sounds

b. hearing unstructured sounds

c. muffled whispers,

d. ongoing multi-person discussions about the patient.


The simple auditory hallucinations are more

commonly associated with

1. organic psychoses such as delirium,

2. complex partial seizures, and

3. toxic and metabolic encephalopathies.

Auditory hallucinations are classically associated with

schizophrenia (seen in 60 to 90 percent of patients) but are

also frequently seen in psychotic mood disorders.

Sins and symptoms in PsychiatryTwenty percent of manic patients and less than 10 percent of

depressed patients experience auditory hallucinations.

Three types of auditory hallucinations commonly are associated

with schizophrenia:

1. audible thoughts described as hallucinated voices that speak

aloud what the patient is thinking,

2. voices that give a running commentary on the patient's actions,

3. hearing two or more voices arguing with each other, often about

the patient, who is referred to in the third person.


They are also seen less commonly in patients with

psychotic depressions and mania.

Auditory hallucinations in schizophrenia are frequently

mood neutral, hallucinations in patients with mood

disorders are characteristically consistent with their mood.

In psychotic depression, the voices may be unrelievedly

critical and sadistic, whereas in mania the voices often

refer to the patient's specialness.

Sins and symptoms in Psychiatry Command hallucinations order patients to do things.

Often, the commands are benign reminders about everyday

tasks: “Pick up your shoes” or “Clean off the table.”

However, the voices may also be frightening or dangerous,

commanding acts of violence toward the self or others such

as, “Jump off the roof; you're not worth anything,” or, “Pick

up the knife and kill your mother.”

These voices vary in

a. insistence and persistence, and

b. patients differ in their capacities to ignore these commands.

Sins and symptoms in PsychiatryPatients with marked passivity may be helpless in the face

of command hallucinations and may feel impelled to carry

out the orders.

Even though one study did not find command hallucinations

to be associated with a higher risk of harm to the patient or

others, the presence of command hallucinations and the

patient's ability to resist must be assessed carefully.

Sins and symptoms in PsychiatryAlthough visual hallucinations are generally assumed to

characteristically reflect organic disorders, they are seen in

one-fourth to one-half of schizophrenic patients, often—but

not always—in conjunction with auditory hallucinations.

Visual hallucinations occur in a wide variety of neurological

and psychiatric disorders, including toxic disturbances, drug

withdrawal syndromes, focal CNS lesions, migraine

headaches, blindness, schizophrenia, and psychotic mood

disorders.

Sins and symptoms in PsychiatryVisual hallucinations:

flashes of light or

geometrical figures,

elaborate visions such as a flock of angels.

Stimulation of one sensory modality sometimes evokes

perceptual distortions in another (Reflex hallucination).

Marijuana and mescaline intoxication, for example, have

been associated with synesthesia, an experience in which

sensory modalities seem fused.

Sins and symptoms in PsychiatryThis is also a normal experience for many people.

Music may be experienced visually, the sound

fusing with visual illusions; a tactile sensation may

be experienced as a color (e.g., a hot surface may

“feel red”).

In certain religious subcultures, visual hallucinations

may be experienced as normal.

Sins and symptoms in PsychiatryIn one fundamentalist Pentecostal church, worshipers

danced themselves into a frenzy, and, without using any

drugs, several participants shared visions of the Virgin

Mary at the altar.

Sins and symptoms in PsychiatryAutoscopic hallucinations

They are hallucinations of one's own physical self.

Such hallucinations may stimulate the delusion that

one has a double (doppelganger).

Reports of near-death, out-of-body experiences in

which individuals see themselves rising to the

ceiling and looking down at themselves in a

hospital bed may be autoscopic hallucinations.

Sins and symptoms in Psychiatry Lilliputian hallucinations,

The individual sees figures in very reduced size, such as

midgets or dwarfs.

Haptic hallucinations involve touch.

Simple haptic hallucinations, such as the feeling that bugs

are crawling over one's skin (formication), are common in

alcohol withdrawal syndromes and in cocaine intoxication.


Some tactile hallucination like having intercourse

with God, are highly suggestive of schizophrenia

But they may also occur in tertiary syphilis and

other conditions and may, in fact, be stimulated by

local genital irritation.

Sins and symptoms in PsychiatryOlfactory and gustatory hallucinations have most

often been associated with organic brain disease,

particularly with the uncinate fits complex partial

seizures.

Olfactory hallucinations may also be seen in psychotic

depression, typically as odors of

a. decay,

b. rotting, or

c. death.

Sins and symptoms in Psychiatry pseudohallucination

1. perceptions experienced as coming from within the mind

(i.e., not at the boundary or outside the mind).

2. Using this definition, loud voices that are alien, ascribed to

other beings, but which the patient knows are actually

within the mind rather than out in space, are

pseudohallucinations.

3. The term has also been used to describe hallucinatory

experiences whose validity the patient doubts.

Sins and symptoms in PsychiatryA better term for this second phenomenon is partial

hallucination, analogous to partial delusion

Functional hallucinations are rare hallucinations that occur

only in connection with a specific external perception, for

example, in the presence of a sound, such as running

water, a color, or a particular place.

Ictal hallucinations,

They occur as part of seizure activity and are typically

brief, lasting only seconds to minutes, and stereotyped.


unlike illusions, the hallucinated sounds are not

elaborations of the perception but are simply

triggered only in that specific context.

They may be simple images, such as flashes of

light, or elaborate ones, such as visual recollections

of past experiences.


While the hallucinations are being experienced, the

patient ordinarily experiences altered

consciousness or a twilight sleep.

Migrainous hallucinations

They are reported by approximately 50% of

patients with migraine.

Sins and symptoms in PsychiatryMost are simple visual hallucinations of geometrical patterns,

but fully formed visual hallucinations, sometimes with

micropsia and macropsia, may also occur.

This complex has been called the Alice in Wonderland

syndrome after Lewis Carroll's descriptions of the world in

Through the Looking Glass, which mirrored some of his own

migrainous experiences.

In turn, these phenomena closely resemble visual hallucinations

induced by psychedelic drugs such as mescaline.

Sins and symptoms in Psychiatry A flashback

It is an intense visual re-experience of highly charged past

events, which are often replays of hallucinations.

They are typically associated with heavy use of

hallucinogens, such as LSD and mescaline,

They often occur months after the last drug ingestion.

The images may be simple or complex geometrical

patterns, or


These images may consist of previously

experienced elaborate drug-induced

hallucinations.

Flashback phenomena may be state dependent.

In PTSD, some complex, intrusive flashback-like images

may attain a hallucinatory vividness.

Sins and symptoms in PsychiatryImages often include horrifying memories of traumatic

events that may force themselves repeatedly into

consciousness until they are acknowledged and worked

through.

Hallucinosis is a state of active hallucination occurring in

someone who is alert and well oriented.

This condition is seen most often in alcoholic withdrawal,

but it may also occur during acute intoxications and other

drug-mediated states.


Primary (autochthonous)

vs. secondary

Persecutory vs. non-

persecutory

How they affect behavior

Characteristics of Delusions

Simple vs. complex

Complete vs. partial

Systematized vs.

non-systematized


• Delusions of persecution

• Delusions of grandeur

• Delusions of influence

• Delusion of having sinned

• Nihilistic delusions

• Somatic

Some Classic Types of Delusions

• Delusion of doubles

(doppelganger)

• Delusional jealousy

(Othello syndrome)

• Delusional mood

• Delusional perception

• Delusional memory


• Delusions of disguise

(Frégoli's phenomenon)

• Shared delusions (folie

á deux, folie á trios,

folie á famille)

• Delusions of erotic

attachment (Clérambault's

syndrome)

• Delusions of replacement

of significant others

(Capgras syndrome)

Sins and symptoms in PsychiatryDisturbances of Consciousness

Consciousness can be defined as subjective

awareness of the self and environment.

Reflective consciousness cannot occur until

complex higher-order brain systems evolve

Sins and symptoms in Psychiatry The complex higher-order brain systems’ major

functions are to monitor

i. the experiences,

ii. activities, and

iii. results of activities of those lower-order

brain systems


Lower order functions deal directly with appraising and

responding to the external and internal environments.

Such higher-order metasystems require the presence of

memory so that current and immediate impressions can

be checked and compared against past experiences.

These metasystems may use a variety of sensory

mechanisms to detect and signal their sensations or

perceptions of various events.


Some of these sensors may correspond to feeling

states, and

some may correspond initially to preverbal thought-

like mechanisms that contain the capacity to

develop and recognize abstract categories and,

ultimately, conceptual language-based thought.


Disturbances of OrientationOrientation - one's awareness of

1. time,

2. place, and

3. person.

Accurate orientation requires the integrity of

attention, perception, memory, and ideation.

Sins and symptoms in Psychiatry Impairments occur primarily in

organic mental disorders such as.

1. structural and

2. toxic metabolic brain abnormalities and

3. occasionally in dissociative and

4. psychotic states.


Normal individuals vary tremendously in their

attention to the details of time.

Some people have reliable built-in clocks by which

they can awaken themselves at precise times.

They accurately gauge the passage of time with

mysterious accuracy, even in the absence of external

cues—in a psychotherapy session, for example.


Benign disorientation to time is common.

After a few days in a hospital bed, most people do not

know exactly what the day or date is because they are

not attending to or receiving their usual cues.

Others have difficulty making judgments about time

and may develop pathological lateness or habitually

schedule more activities than could ever be

accomplished in the available time.


Poor time judgments Poor time judgments may be seen in a variety of

psychiatric disorders, such as ADHD, or as an

independent problem.

Pathological time disorientation can be mild or

severe, with inaccuracies of estimation ranging

from days to years.


The dates reported by disoriented individuals may

have personal significance such as those of

important

i. births,

ii. marriages, or

iii. deaths.


Disorientation to place often signifies a greater

degree of cognitive impairment than disorientation

to time

This is because spatial cues are generally more

available for spatial orientation and obvious than

temporal (time) cues

Therefore, disorientation to place rarely occurs in

the absence of time disorientation.


Disoriented people may know, more or less, the

type of place that they are in without knowing the

specific place.

Disturbances of Memory

Memory is not a unitary phenomenon.

Capacities to remember vary for the different

senses and perceptions.


One person may have exceptional musical memory,

with the capacity to remember and reproduce whole

musical pieces after one hearing,

However, he may be incapable of remembering

people's names or telephone numbers.

Exceptionally detailed verbal memories have been

associated with obsessional cognitive styles.


When individuals with extraordinary memories

complain of memory loss, ordinary memory tests

may be inadequate to detect their deficits, since

their relative memory loss may have reduced their

capacities to a point within the range of most

normal people.


Memory functions have been divided into three

stages:

1. Registration,

2. retention, and

3. recall.

Registration (or acquisition) refers to the capacity to

add new material to memory.

Sins and symptoms in PsychiatryThe material may be sensory, perceptual, or conceptual

and may come from the environment or from within the

person.

For new material to be acquired,

1. the person must attend to the information presented,

2. this information must then be registered through the

appropriate sensory channels and

3. then be processed or cortically organized and

consolidated.


Retention is the ability to hold memories in storage.

Large numbers of neurons are believed to be

involved in the storage of a specific memory

Recall is the capacity to return previously stored

memories to consciousness.


Newly registered material is transferred

incrementally from immediate to short-term

memory to long-term memory.

Immediate memory lasts for 15 to 20 seconds

short-term memory lasts (or recent memory) for

several minutes up to 2 days (the time involved in

new learning and its early consolidation), and

long-term (or remote) memory for longer periods.


Different physiological processes mediate each of

these stages of memory.

Because of this, processes that affect immediate or

short-term memory often spare long-term memory.

Disturbances in Registration

Registration and short-term memory retention are

usually impaired in disorders that affect vigilance

and attention

Sins and symptoms in PsychiatryThese disorders include

head trauma,

delirium,

intoxications,

psychosis,

spontaneous or induced seizures,

anxiety, depression, and

fatigue.


A variety of other metabolic and structural brain

disturbances can affect short-term memory as well,

Such particular lesions affect the

1. mammillary bodies,

2. hippocampus,

3. fornix, and

4. closely associated areas


Patients with impaired attention and concentration

may not be able to retain or recollect these items

from short-term memory.

Such patient are able to demonstrate immediate

recall

Benzodiazepine use has been associated with

working memory difficulties, especially in the

elderly.


Some short-acting, high-potency benzodiazepines

used as sleeping pills may be particularly

troublesome in this regard.

Disturbances in RetentionThe retention of memories is impaired in

1. posttraumatic amnesia

2.dementia of the Alzheimer's type and

3.Wernicke-Korsakoff syndrome.


Wernicke-Korsakoff syndrome ordinarily results

from chronic thiamine deficiency seen with

alcoholism,

It is associated with pathological alterations in the

mammillary bodies and thalamus.

Sins and symptoms in PsychiatryDisturbances in Recall

Disturbances in recall can occur even when memories

have been registered and are in storage.

At times, inability to recall may signify that the

memory traces themselves have disappeared and are no

longer retrievable.

However, difficulties in recall can occur separately, as

in the everyday event of forgetting the name of a

person or object, only to spontaneously remember it

hours or days later.


In normal forgetting, more remote events are less

well remembered than recent ones, and important

events are most vividly retained in memory.

Some demented patients may lose memories for all

events occurring after a specific date or event, as if

the slate has been wiped clean, but retain earlier

memories.


Amnesias are syndromes in which short-term and long-

term memory are impaired within a state of normal

consciousness.

As a result, memory disturbances in delirium should,

strictly speaking, not be considered amnestic

syndromes.

Patients who receive ECT frequently have anterograde

amnesias during the course of the treatments; the

amnesia gradually fades over numbers of weeks.

Sins and symptoms in PsychiatryRetrograde amnesia is an impairment in recalling

memories that were established before a traumatic

event, extending backward in time for variable periods.

As memory is regained, the more remote memories

usually return first.

A patient originally amnestic for the 3-month period

before an accident may ultimately be left with amnesia

for events only a day or an hour just before the accident.


In organically caused retrograde amnesias, remote

memories are usually intact, although amnesia may

exist for more recent events.

Anterograde amnesia is the inability to register or

learn new information (and therefore to form new

memories) from a specific event onward

It typically follows head trauma, states of cerebral

physiological imbalance, or drug effects.


Some individuals may progressively erase

memories so that they recall only earlier and earlier

events.

This contrasts with psychogenic (functional)

amnesia, in which the periods of forgotten events

may be more spotty or selective.

Hypermnesia, unusually detailed and vivid

memory, may occur in gifted people


Déjà vu is the sense that one has previously seen or

experienced what is transpiring for the first time

it is a false impression that the current stream of

consciousness has previously been recorded in

memory.

Related phenomena are déjà entendu, a sense that

one has previously heard what is actually being

heard for the first time


déjà pensé, a feeling that one has at an earlier time

known or understood what is being thought for the

first time.

Experiences of jamais vu, jamais entendu, and

jamais pensé involve feelings that one has never

seen, heard, or thought (respectively) things that,

in fact, one has.


These phenomena are all common in everyday life

but may increase in states of

fatigue or

intoxication and

in association with complex partial seizures or

other psychopathological states.

Sins and symptoms in Psychiatry Disturbances of Mood

Mood is defined as a sustained or prevailing

subjective feeling tone or range of tones.

Affect is the moment-to-moment feeling state

Affect sometimes rapidly shifts in response to a

variety of thoughts and situations, that the clinician

can observe


Emotions have been defined as moods and

affects that are connected to specific ideas or

to the physical concomitants of moods and

affects.

Moods, affects, and emotions can be described by a

number of important qualities.

Sins and symptoms in PsychiatryA number of important qualities of Moods

and Affects:

Intensity - shallow to deep,

Range - broad to narrow[or flat]),

stability - rigid to labile,

reactivity to external events - none to much,


Periodicity - periodic to aperiodic

congruence with thought content - (congruent or

appropriate to incongruent,

speed of resolution - rapid to slow and

viscosity - short-lived to persistent.


The individual's lifelong predominant mood is one

component of temperament.

Thus, for example, one may be described as having

a calm, cheerful, irritable, depressive, anxious, or

sensitive temperament.


Functions of moods, affects, and emotions

They serve as internal and external signal systems.

They signal the state of the individual to others and

often elicit necessary help and support from the

environment.

E.g., A baby's face communicates its state of need,

tension, or contentment, thereby recruiting

appropriate maternal interventions.


Moods also have an infectious quality and serve as

important ways of influencing others.

As adults, much of our most important interpersonal

communications is transmitted nonverbally through

cues that signal the observer about our moods.

Positive words communicated by a angry or rude

face lead listeners to perceive an angry message

regardless of our spoken words.


Therefore, when we act cheerfully toward others,

they, in turn, are more likely to feel cheerful and to

reciprocate that cheerfulness.

Internal Functions of Mood

1.Internally, moods, affects, and emotions let

individuals know how well or how poorly they are

doing.

Sins and symptoms in Psychiatry This allows them, for instance, to establish the

distance between actual self-appraisal and desired

self-expectations.

For example, individuals who desire to master

important goals and feel that they have a reasonably

good chance of doing so ordinarily experience

pleasant emotional states in relation to these goals.


If something intervenes to prevent them from

reaching these goals so that there is an actual gap

between their desires and the likelihood of success,

then they may feel hopeless.

2.In addition to serving as signal systems, emotional

states of nonspecific tension, arousal, or anger

usually imply that some action is necessary to

secure their discharge or release.


Emotional states and their expression are regulated

by biological, psychological, and cultural

influences.

Emotional or affective lability, characterized by

rapidly shifting emotions that seem unattached to

the situation are typically occurs

1.premenstrually in some women,


2. with varying periodicity in cyclothymic

individuals and

3. in those with cluster B personality disorders, and

4. in relation to need states such as hunger, sleep

deprivation, and sexual frustration.

5. Mood shifts have also been related to

environment-related physiological influences

such as seasonal changes in light.


Somatic Disturbances in Psychiatric Illness

Nearly all psychiatric disorders manifest some

change in basic physiological function

The severity of the disruption in normal function

may provide clues to the amount of physiological

malfunction seen in the primary underlying Axis I

psychiatric illness


A. Sleep Disturbances

About one-third of each day's activities are spent

sleeping

Therefore, it is not surprising that psychiatric

disturbances are frequently manifested by an

alteration in normal sleep.

These alterations may be in

Sins and symptoms in Psychiatrythe presence of abnormal events occurring while

sleeping

the primary psychiatric disturbance,

medications used in psychiatric treatment, or

the use of other prescribed agents or substance use.

Finally, use of caffeine, in excess or in the evening


the timing,

the amount, and

the quality of sleep and

Insomnia is usually defined by its subjective

component as the sensation of not sleeping well or

enough.

Sins and symptoms in PsychiatryInsomnia is a common, often chronic, symptom or

sign of many different psychiatric disorders,

including

substance abuse,

depression,

generalized anxiety disorder,

panic, mania (in which the diminished sleep does

not always provoke a complaint), and


acute schizophrenia.

It may also occur as a consequence of aging or

as a symptom or disorder not associated with other

psychopathology.

Insomnia may also result from the ingestion of

substances that alter the normal sleep–wake cycle:

Sins and symptoms in Psychiatry alcohol

stimulants, and

discontinuation of sedative-hypnotics.

Much attention is often paid to

distinguishing patterns of insomnia, such as

difficulty falling asleep

middle or

Sins and symptoms in PsychiatryTerminal insomnia (early morning awakening), or

Linking specific patterns to a specific disorder like

melancholic depression with terminal insomnia

Hypersomnia, characterized by either excessive nighttime

sleep or excessive sleepiness during the day, is less common

than insomnia.

It, too, however, may reflect a number of different

pathological states.

Some depressed patients, especially those with a history of

mania or hypomania, may exhibit hypersomnia.


Hypersomnia may also be seen during

stimulant withdrawal,

with excessive use of sedatives or

tranquilizers, or

in conjunction with a variety of medical

disorders.

Sins and symptoms in Psychiatry Narcolepsy is experiencing by the patient a sudden

attacks of irresistible sleepiness.

This symptom that may be part of a broader syndrome

that includes

1. cataplexy - sudden attacks of generalized muscle

weakness leading to physical collapse in the presence of

alert consciousness,

2. sleep paralysis - waking from sleep with a sensation of

being totally paralyzed that may persist for minute


c. hypnagogic hallucinations - vivid visual

hallucinations that occur at the point of falling

asleep

Narcoleptic attacks are often precipitated by

unusual states of arousal (e.g., cataplexy may

immediately follow unrestrained laughter or

orgasm).

Daytime sleepiness may reflect sleep apnea.

Sins and symptoms in PsychiatryIn sleep apnea, typically middle-aged patients

demonstrate severe snoring, often first reported by

their bed partners and periods when breathing

stops.


Soring results from soft palate

abnormalities that cause intermittent

airway obstruction throughout the night;

patients awake repeatedly to find

themselves gasping for air.

Associated daytime fatigue is common in

sleep apnea.

Sins and symptoms in Psychiatry Periodic hypersomnia also occurs in Kleine-Levin

syndrome

This condition typically affect young men in which

periods of sleepiness alternate with

confusional states,

ravenous hunger, and

protracted sexual activity.

Intervals of days, weeks, or months may pass between

these episodes.


Somnambulism, or sleepwalking, and sleep

terror disorder (night terror) are two sleep

disorders characterized, respectively,

by aimless wandering

with incomplete arousal and

by acute anxiety and physiological arousal without

awakening.


Both Somnambulism, or sleepwalking, and sleep

terror disorder (night terror) typically begin in

childhood

Sleepwalking may be also initially precipitated by

some psychotropic medications.

Nightmares are a common complaint, often

associated with traumatic events, anxiety disorders,

and mood disorders,


Not uncommonly nightmare occurs as an occasional

event in otherwise healthy individuals.

Vivid dreams and nightmares may also be a

medication side effect

Appetite and Weight Disturbances

A significant change in appetite and weight can be

seen in both medical and psychiatric illness.

Sins and symptoms in PsychiatryAnorexia may occur in the

latter stages of chronic medical illness and

frequently seen in depression,

grief, and

some anxiety disorders.

Anorexia may be secondary to alterations in taste

sensation, as a function of psychiatric disturbance

or medication side effect.

Sins and symptoms in PsychiatryIn eating disorders, such as anorexia nervosa,

patients may resist hunger to restrict food intake to

achieve a physiologically unrealistic low weight.

i. Binge eating, of up to several thousand

calories per episode,

ii. as an attempt to self-soothe and

iii. emotionally self-regulate during times of

increased tension and anxiety and


iv. as a key feature of bulimia nervosa or of

binge-eating disorder.

Increased appetite:

as a side effect of many psychotropics

in some hypothalamic disorders or

in bilateral temporal lobe dysfunction such as

Klüver-Bucy syndrome,

Sins and symptoms in PsychiatryKlüver-Bucy syndrome

emotional placidity,

hypersexuality,

hyperorality, and

other related symptoms

Sins and symptoms in PsychiatryEnergy Disturbances

Normal energy levels vary considerably among

people.

Some people fatigue easily and are perceived by

themselves and others as having “weak

constitutions,”

Others appear to have almost boundless energy and

much less need for sleep.

Sins and symptoms in PsychiatryBoth medical and psychiatric disorders can cause

fatigue

Fatigued patients, having been labeled depressed or

neurotic by their physicians, are referred to

psychiatrists after routine workup has ruled out

1. anemia,

2. hypothyroidism,

3. sleep apnea, and

4. other frequent somatic causes.

Sins and symptoms in PsychiatryDisturbances in Sexual Drive

As with energy, the normal range of sexual drives is

common.

Some individuals are naturally lusty, whereas others

have limited sexual desire.

Diminished sexual drive with impotence or decreased

libido is seen in a wide variety of neurological,

metabolic, and other somatic conditions.

Sins and symptoms in PsychiatryAmong neurological disorders, complex partial

seizures are commonly associated with

hyposexuality,

Among patients suffering from complex partial

seizures 50 percent of have hyposexuality.

Psychiatric disorders known for diminished

sexual drive include depressive disorders,

schizophrenia, and substance abuse


Diminished libido,

1.erectile dysfunction, and

2.anorgasmia

are also common sequelae of many psychotropic

agents, especially those with a strong serotonergic

action


Increased sexual activity may be seen in some

1. neurological,

2. medical

3. psychiatric, and

4. drug-induced disorders.

Manic patients frequently exhibit hypersexual

interests and behaviors to an unusual degree.

Sins and symptoms in PsychiatryHypersexuality is occasionally seen in conjunction

with epileptic syndromes or

In patients who have had diencephalic injuries.

Altered sexuality, including

fetishism sadomasochism,

pedophilia, and

other paraphilias, may be seen as isolated

psychiatric syndromes.

Sins and symptoms in PsychiatryInappropriate sexual behaviors may signal early

brain disease or psychosis.

Cross-dressing may occur in

transvestites,

transgenderists,

transsexuals, or,

occasionally, in other psychiatric

conditions.

Sins and symptoms in PsychiatryDisturbances in Motor ActivityMotor behavior is normally

finely coordinated,

purposeful, and

adaptive, and

necessary activities are usually carried out

efficiently.


In psychiatric disturbances, motor abnormalities can

involve

generalized overactivity or

underactivity or

manifest in a wide range of specific

disorders of movement.


Many motor disturbances are seen in psychiatric

disorders.

Some form part of the core symptoms of the

disorders;

1.some occur in disorders that, bridge neurology and

psychiatry (such as Tourette's syndrome);

2.others are acute or chronic medication side effects.

Sins and symptoms in Psychiatry Overactivity

Restlessness and agitation are diffuse increases in

body movement, usually noted as

fidgeting,

rapid and rhythmic leg or hand tapping, and

jerky start-and-stop movements of the

entire body accompanied by inner tension.


Restlessness accompanies psychiatric conditions of

high emotional arousal or confusion, such as

i. toxic states,

ii. deliria,

iii. mania,

iv. agitated depressive disorders,

v. anxiety disorders,

Sins and symptoms in Psychiatryvi. many medical disorders such as

hyperthyroidism.

vii. In some depressive states, agitation is often

accompanied by pacing and hand wringing.

vi.In generalized overactivity, patients seem to have

increased physical energy,

vii.It is distinguished from agitation by its lack of inner

tension and by more purposeful movements.


It is commonly seen in

mania,

hypomania, and

anorexia nervosa and

as part of ADHD and

in response to stimulating drugs and

medicines.


In catatonic excitement, patients exhibit

disorganized and overactive behaviors, including

frantic jumping,

thrashing of limbs, and

seemingly senseless menacing or attacking

behaviors.

Sins and symptoms in PsychiatrySuch excitement is seen in

1. mania,

2. periodic catatonia,

3. catatonic forms of schizophrenia, and

4. some culture-bound syndromes such as amok.

Confusional excitement is a state of restlessness

and generalized purposeless activity seen in ictal

states, some acute intoxications, and deliria.


Decreased Motor Activity

Global reductions in motor activity—motor

retardation—are seen in a variety of physical

disorders, such as

1. hypothyroidism,

2. Addison's disease,

3. some infectious and postinfectious

conditions, including


1. CFS and postpolio syndrome, and

2. other fatiguing conditions,

3. as well as in some

4. organic mental disorders,

5. intoxications,

6. schizophrenias, and

7. depressive disorders.

Sins and symptoms in PsychiatryPoverty of movement (akinesia, or more properly,

hypokinesia) may occur

in schizophrenia and

as a neuroleptic side effect.

depression

Changes in the voice frequently accompany the

reduced motor activity in schizophrenia and

depression,


In both disorders normal inflection is replaced by

monotonous tone and prolonged speech latency.

In stuporous states,

patients remain immobile,

their eyes are open, and

they are apparently awake (conscious).

Sins and symptoms in PsychiatryConversion reactions are

functional

Non-physiological,

Psychogenic

impairments in sensory or motor functions.


Common motor forms include various paralyses and

pareses, including

limb paralyses,

ataxias, and

aphonias.

In globus hystericus, the patient is unable to

swallow.

Sins and symptoms in PsychiatryPatients with astasia-abasia have marked unsteadiness

of gait.

Sensory conversion reactions include

blindness,

deafness,

anesthesia, and

analgesia.

Some hyperesthesias and pain syndromes may also

originate as conversion symptoms.


Catatonic Activity

Catatonia refers to a broad group of movement

abnormalities usually associated with

schizophrenia

Other disorders that develop catatonia

1. mania,

2. depression,

3. periodic catatonia

Sins and symptoms in PsychiatryMany neurological disorders especially those

involving the

i. basal ganglia,

ii. limbic system,

iii. diencephalon, and

iv. frontal lobes,

v. systemic metabolic disorders

vi. toxic drug states


Stereotypies are

repetitious,

bizarre,

seemingly non-goal-directed,

complex organized gestures or postures

that are believed to have private meanings to the

patient.


Examples:

1. continuously and repeatedly crossing

oneself or

2. blessing others in a religious gesture,

3. waving in a stylized manner, and

4. making disrespectful gestures.


The stereotypical behaviors commonly seen in

autistic children (constant spinning or rocking)

may provide

i. self-soothing,

ii. steady sensory input

that helps the patients reduce the degree to which they

are disturbed by the ordinarily unpredictable and

uncontrollable stimulation from the environment


Bizarre posturing may also be seen in catatonia.

One chronic schizophrenic patient routinely stood

for hours on one leg with his arms in the air like a

crane.

In echopraxia, the patient imitates the examiner's

movements and in echolalia imitates speech, as if in

mimicry.


Some catatonic patients exhibit waxy flexibility.

waxy flexibility maintaining unusual postures in

which they have been posed for prolonged periods

of time.

Negativism may take the form of refusing to behave

in a prescribed manner or resisting passive

movement

Sins and symptoms in Psychiatry MutismMutism may result from a variety of peripheral muscle and CNS conditions and from functional disorders. Mutism may occur in profound depression, catatonic states, and conversion reactions. Elective mutism is occasionally seen in acute adjustment disorders and some personality disturbances.

Sins and symptoms in PsychiatryMotor Disturbances and Movement DisordersTremor

Tremors are involuntary oscillating movements of

the limbs or head,

They may occur at rest or with movement.

Physiological tremors, which are minimal at rest

and increase with activity, are characterized by

small amplitudes and high frequencies.

Sins and symptoms in PsychiatryThey are characteristic of

anxiety,

fatigue, and

toxic or metabolic disorders,

caffeinism or

hyperthyroidism, and

psychiatric medications, (lithium, valproate, and

stimulating antidepressants).


Coarse tremors, with larger amplitudes and lower

frequencies, are seen in Parkinson's disease and

cerebellar disease.

Asterixis is a large-amplitude flapping tremor of

the hands seen in hepatic disease.

Parkinsonian symptoms and signs may be seen in

psychiatric disorders, particularly in patients taking

antipsychotic medications.

Sins and symptoms in PsychiatrySymptoms include

akinesias with a marked decrease in normally

spontaneous fidgeting,

Blepharospasm

Blepharospasm is a rapid and violent repetitive,

spasmodic movement of the eyelids.

are often a side effect of antipsychotic or

other medications

are also common in neurological disorders,


Stiff gait with diminished arm swing,

pill-rolling non-intention tremors (which seem to

be less common in drug-induced parkinsonism,

compared with the idiopathic type),

expressionless soft and monotonous speech,

micrographical handwriting, and

cogwheel rigidity.

Sins and symptoms in Psychiatry Tics

Tics are rapid, repetitive, often spasmodic jerking

involuntary movements that serve no apparent

purpose.

The person may try to disguise or hide the tic in a

seemingly purposive movement, and the movement

may ultimately be shaped into a mannerism.

Sins and symptoms in PsychiatryTics are the central feature of tic disorders, are

associated with other disorders, and may occur as a

consequence of stimulant use.

Tourette's disorder is characterized by a chronic

shifting array of motor and vocal tics.

Sins and symptoms in PsychiatryThe tics may include

grunts,

coughs,

clicks, or

sniffs,

Motor symptoms may include

eye blinking,


tongue protrusions,

facial grimacing,

hopping, and

twitches.

Complex tics may merge into complex compulsive

behaviors such as squatting, deep knee bends, and

retracing steps.


Coprolalia, characterized by sudden verbal outbursts of

obscenities, occurs in less than one-third of Tourette's

patients.

Mental coprolalia is an associated feature in which

obscene words or phrases suddenly intrude into

consciousness in an ego-dystonic manner.

Obsessive–compulsive symptoms, as well as attention-

deficit symptoms, are also common in Tourette's

syndrome.

clinical manifestations of psychiatric disorders 3

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