2.symptoms and signs of psychiatric disorders (1) (1).ppt

Oman Medical CollegePsychiatry Department

Course CoordinatorDr. Mohamed MitwallyAssociate Professor of [email protected]

AffectIntellectBehavior

Disturbance of behaviorA. Quantitative disturbance:

Excess motor activityAgitation: the patient is moving around, moving his limbs and head, wrinkling his fingers and cannot stay for some time in one place. This sign is found in many psychiatric disorders e.g. mania, agitated depression, some cases of schizophrenia ,

Restlessness: the patient feels inner tension with some agitation and cannot standstill. On sitting he sits on the edge of the chair and moves his body parts like arms, head and neck. This condition found mainly in anxiety, and akathisia, also in some psychotic state. The differentiation between restlessness and agitation may be difficult but in restlessness the condition usually not desired by the patient i.e. out of his control but agitation is usually are action to the thoughts of the patient.

Excitement: Excitement occurs in primary psychiatric disorders e.g. mania and schizophrenia and in organic mental disorders e.g. drug addiction and temporal lobe epilepsy.

Difference between manic and catatonic schizophrenic excitement



Manic excitement Catatonic excitement Occurs mainly in response to environmental stimuliOccurs without provocation. Mostly in response to delusion or hallucination Accompanied with cheerful or irritable mood The mood is apathetic Usually expected and organized Usually unexpected and disorganized Accompanied with other manifestations of maniaAccompanied with other manifestations of schizophrenia

b. Diminished Motor activity Partial retardation of motor activity e.g. in cases of retarded depression or simple schizophrenia. Complete suppression of motor activity (Stupor): No profound disturbance of consciousness There is complete suppression of motor activity (speech and movement). The patient does not respond to any stimulus, neither external (question or painful stimulus), nor internal (hunger, thirst or distended bladder). In stupor the patient is arousable but not responsive. It occurs in psychiatric disorders like depression, schizophrenia, and hysteria, or in acute organic mental disorders.


1. Stereotypy: means monotonous repetition, which may be :In movement (e.g. touching the nose, or pacing up and down the room) In speech (e.g. some words are repeated).2. Mannerism: repeated movements, which may continue for hours or days without cessation, and are keeping with the thought (e.g. a patient with paranoia salutes repeatedly in a grandiose manner).


3. Perseveration: denotes the repetition of the same act (a movement, a word, or a phrase in spite of the patients effort or desire to do a new one i.e. inability to move from one act to the next one (e.g. during a meal the patient continues to put the spoon in the plate and up to his mouth, even after the plate gets empty). 4. Lack of initiation and reduction of spontaneous movement, lack of volition: the patient has no desire or will to perform acts.


5. Negativism: means automatic resistance to all stimuli.In muscular field it may show itself as a resistance to passive movements (e.g. keeping the arm extended on trying to flex it or as opposite performances to that asked for (e.g. looking down when asked to look up). In speech it consists of total loss of it i.e. mutism. Negativism is seen also in the retention of saliva, urine and feces.


6. Resistiveness: in which the patient simply oppose or resists anything he is asked to do e.g. when he is setting and is asked to stand up, he will remain setting down.

7. Automatic obedience: in contrast with negativism there is abnormal suggestibility; it shows itself as: Echopraxia which is repetition of actions seen (e.g. when the doctor walks the patient walks too). Echolalia which is repetition of words heard (e.g. when the doctor says to the patient: how are you? the patient answers: how are you?).


Waxy flexibility (Flexibilitas cerea) which is the maintenance of imposed postures however abnormal they may be (e.g. rising-the head of the patient from the pillow, or the arm up). The absence of fatigue in such cases is remarkable.

Catalepsy (posturing) is sometimes used for any form of sustained immobility.

Automatic movements or automatism occur in a pathological sense, without the subject being aware of their meaning and even without his being aware of their happening at all. Automatism may be i) local e.g. automatic writing or ii) general e.g. in fugue and somnambulism.

Disturbance of behaviorB. Qualitative disturbance:

8. Impulsive action or impulses: consist of sudden outbursts of activity with little or no provocation, such as attacking another person (bystander), or breaking a window.

9. Aggression: means intention to inflect harm to the others without their permission or even their trial to avoid this harm, the aggression could be physical, verbal, or moral. physical aggression like body injuring, verbal aggression like obscene words, moral aggression like violation of social or religious norms that cause harm or embarrassment to others. The non physical aggression is called hostility.

Disturbance of behaviorB. Qualitative disturbance:

Mood: Sustained and pervasive emotion that colors the persons perception of the world. The patient may report his feelings or the psychiatrist ask how he or she feels.

Affect: The patient present emotional responsiveness that is inferred from his facial expression.

Cheerfulness is used for happiness or gladness. It is pathological when out of the patient's actual circumstances.Euphoria is a generalized feeling of well being (not amounting to a definite affect of gladness).Exaltation means something in addition to elation, an element of grandeur. Ecstasy is a feeling of happiness, usually with a mystical coloring.

Disturbance of AffectA) Quantitative disturbance:

Depression is an emotional state characterized by pervasive lack of interest, difficulty to be in pleasure (anhedonia) and sadness not in accord with the patient's actual circumstances.Sadness: it is and emotional state occurs as a reaction to loss of loved object, the object could be a person; money or status. Sadness could be a part of depressed mood when occurs without cause.


Anxiety: is an emotional state characterized by anticipation of danger. If the source of anticipation of unknown it is called generalized anxiety, if the anticipation is from potentially non dangerous object or situation it is called phobia, if the anticipation is from consequences of act or situation it regarded as. Obsessive fear. The anxious mood is that of fear accompanied with restlessness.


Apathy: is absence of affect, or loss of emotion, or lack of feeling (there is loss of both emotional expression and experience). Occurs in some schizophrenics. Indifference: is lack of objective emotional response. (There is loss of emotional expression, but emotional experience is preserved). Occurs in schizophrenia. a type of this called a belle indifference occurs in hysteria when the patient feelings are not in tune with the problem.happy in spite of his disability


Emotional deterioration: is a progressive failure to show the normal emotional responses (characterized by a childish, easily suggestible, facile state). Occurs in disorganized schizophreniasEmotional instability or lability: is inability to control the emotions and their expression. The emotional change from one extreme to the other with no obvious cause (e.g. Laughing and weeping. it occurs in gross organic lesions of the brain e.g. the pseudo bulbar syndrome.


Morbid anger: is an unprovoked transient angry outburst with violence. (In children and mentally defectives, it is called 'tantrums'). Occurs in schizophrenia and personality disorders


Incongruity or disharmony of affect: inappropriateness of affect to thought content (e.g. the patient feels happy while he believes that he is going to be killed by his enemies).

Ambivalence denotes the simultaneous existence of contradictory emotions (e.g. Love and hate), or ideas (e.g. being present and absent at the same time, or present in two places simultaneously e.g. in Sohar and Salalah). It occurs in schizophrenia.

Disturbance of AffectB) Qualitative disturbance:

1- Slow stream: Slowing of the stream of talk occurs in different psychiatric disorders particularly in psychosis and the disturbance shows different degrees: Lack of spontaneous talk. Delayed response to questions.Short response to questions.No response to questions Mutism.

Disorders of TalkA. Disorders of Stream

2- Blocking is a sudden stoppage of the stream of talk, for a while and then it is resumed without the patient being able to account for such stoppage. This could occur in some normal individuals when surprised and in some schizophrenics.

3- Rapid stream occurs mainly in mania and some schizophrenics Disorders of TalkA. Disorders of Stream

Irrelevant answers to questions. When the patient is asked a question he responded by answer not related to that question.Over inclusions: the patient talk is much abbreviated and not giving the necessary details.Derailment: the patient deviates in his talks to subjects away from the main topic.Circumstantiality: there are much unnecessary details, but the subject in view at the beginning is ultimately reached.

Disorders of TalkB. Disorders of Expression

Vagueness ( the paragraphs of the story are not harmonious)Flights of ideas ( the sentences of the paragraph are not harmonious) Incoherence ( the words of the sentence are not harmonious)Neologism ( the letters of the word in the word are not harmonious)

Disorders of TalkC. Disorders of Association

Disorders of ThinkingStreamExpressionContentForm Possession.

The first and second is the same as those discussed under talk.

Delusions: false, fixed beliefs which is not accepted by individuals of the same social, cultural or educational background and not corrected by logic reasoning.

If the belief is false but is widely accepted by individuals of the same culture and education it is called culture bound belief, if it could be corrected by logic reasoning it is called idea and not delusion.Disorders of ThinkingContent (delusions)

Delusions may be Systematized (well knit) when they form a coherent system and appear to be logical, or

Non-Systematized when they are fleeting and appear to have no logical connection

Disorders of Thinking Content (delusions)

Types of delusions:Delusion of grandeur: in which the patient imagines that he is great individual, very rich, strong, intelligent, etc.Delusion of persecution in which the patient thinks that he is chased (run after) by certain people, or his food is poisoned by them.Delusion of reference in which the patient believes that everything in the environment is referring to him (e.g. people talking in the street. newspapers, radio, television, etc. are referring to him).

Disorders of ThinkingContent (delusions)

Delusion of influences (Passivity feeling) in which the patient says that he is under the influence of electricity, wireless, hypnotism or telepathy, utilized by some other person. Such delusions include such diverse ideas as a) that the patient's thoughts are being read b) his limbs are moved without his control or consent by some invisible agency.Delusion of self reproach (self blame) or sin: in which the patient feels that he is wicked, full of sins and unfit to live or mix with other people (feeling of unworthiness).


Delusion of poverty in which the patient believes that he lost all his money, property and everything in life.Nihilistic delusion in which the patient declare that he does not exist (dead) and that there is no world.

Hypochondriacal delusion in, which the patient is convinced that he has a physical disease (e.g. cancer stomach) in, the absence of any evidence thereof.


Depersonalization: the patient feels that he is no longer himself; he can no longer believe in his own existence. When he looks in the mirror he feels himself changed throughout in comparison with his former state. He feels unreal, strange, lifeless, detached and automatic. (2)

Derealization: the patient feels that the outer world has changed the people, streets and houses look different and unusual. He wonders whether his friends are the same people as they were, or whether indeed they exist at all.


ObsessionsFeeling of compulsion to repeat physical or mental act, the patient realizing that it is silly and meaningless, resisting it and the resistance is accompanied by increasing inner tension which is relieved by repeating again.

The patient fights for his delusions and resists his obsessions

Disorders of ThinkingContent (obsessions)

Perception of non existed stimulusTypes Visual Auditory Olfactory Tactile Gustatory

Disorders of PerceptionHallucinations

Normal (physiological)Hypna-gogic Hypna-bombicPathological Primary psychiatric disorders Schizophrenia Rarely in depression, mania, paranoid disorder.Organic mental disordersDelirium, Drug dependence, TL epilepsy, Brain tumors. Encephalitis

Disorders of PerceptionHallucinations

False perception of an external stimulusTypes:Visual Auditory Olfactory Tactile GustatoryDisorders of PerceptionIllusions

Physiological:Intense emotions, change of set, lack of perceptual clarityPathological:Primary mental disordersSchizophrenia Organic mental disordersDelirium Epilepsy Brain tumors Encephalitis Disorders of PerceptionIllusions

RegistrationRetention Recall & Recognition Any failure of one of these functions is regarded as memory disordersDisorders of Memory

Anterograde amnesia when there is loss of memory for recent events.Retrograde amnesia when there is loss of memory for remote events. Total amnesia when there is loss of memory for all events, recent and Remote. Circumscribed amnesia when there is loss of memory for a limited time (amnesic gap).

Disorders of MemoryTypes of Amnesia

Confabulation: when the patient fills the gaps in his memory by fabrication i.e. by giving imaginary accounts of his activities (Thus a bed ridden patient will describe a walk which he asserts he has just taken). It usually occurs in organic diseases Korsakovs syndrome which is typically seen in alcoholism).

Falsification (illusion of memory): when the patient adds false details and meanings to a true memory. It occurs in organic and psychiatric diseases (e.g. paranoid states).

Disorders of MemoryParamnesia (False Recall)

excessive memory, the patient mentions even small unnecessary details. It is present in 1- some normal people (geniuses) 2- some mental disorders (hypomania and paranoia).Disorders of MemoryHypermnesia

Immediate recall: (5-7 digits or home address immediately)Short-term recall: (5-7 digits or home address at 5 min)Recent: what patient did past several daysRecent past: what patient did past few months, present President, recent news eventsRemote: Childhood events, past Presidents, historical events (years)Clinical exam of of Memory

Anxious patient may complain of poor memory because of defective registrationIn Korsakoffs syndrome there is failure of retention so the patient has disturbed immediate recallIn dementia the recall of recent events is disturbed.Disorders of MemoryClinical significance

Realization of:Time Place PersonsSituation.Disturbed in acute organic brain disorders.Orientation

These terms are used for describing the experience that certain objects are in the center of consciousness, whilst others lie more towards the periphery.Attention and Concentration

difficult to arouse the attention of the patient. a) states of disturbed consciousness (e.g. confusion) b) selfabsorption due to depression or schizophrenia.Difficult to maintain or keep the attention of the patient due to distractibility.Distractibility is a disorder of attention in which the patient gives attention to every passing stimulusAttention may be disturbed in various ways

Active (voluntary) Passive (involuntary).In organic disease: active attention is often good, while passive attention is poor i.e. object in the center of consciousness is observed, while those towards the periphery are not.In Psychogenic diseases (e.g. schizophrenia) the patient does not pay attention to what the doctor says to him and at the same time he pays attention to what the nurses talk about.

Types of Attention

Abstraction: is the patient's ability to derive a general principle from a specific example.Abstract thinking is affected in psychosis particularly schizophrenia and mental retardation

Abstraction

level of education. Culture cerebral dysfunction. Abstraction deficits are particularly common with frontal lobe disorders.Factors affecting Abstraction

1- SimilaritiesSimilarities require the patient to identify the class or category of which two items are members (e.g., rose and tulip, bicycle and train, watch and ruler).2- Differences Differences require the patient to identify the salient distinguishing feature between two similar items (e.g., child and midget, canal and river, lie and mistake) 3- Idioms Idioms are metaphorical statements or aphorisms that require the patient to generalize to a larger meaning (e.g., "seeing eye to eye," "level headed," and "eyes peeled")4- Proverbs.Proverbs are usually double metaphors that require the patient to ignore the immediate meaning and derive a lesson or maxim (e.g., "don't cry over spilled milk," "people who live in glass houses shouldn't throw stones," "the tongue is the enemy of the neck").

Clinical Assessment of Abstraction

The ability to benefit from previous experiences and to get maximum benefit from available dataIntelligence is affected in mental retardation

Intelligence

Clinical assessmentDuring interviewMathematical problem solving.Proverb testGeneral information.PsychometryWAISWISCSB

Assessment of Intelligence

Insight: is the degree of realization the patient has of his own condition. Judgment: is the ability to grasp the meaning of a situation and hence react to it appropriately. Insight and judgment are disturbed in psychotic conditions e.g. schizophrenia and mania.Insight & Judgment

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2.symptoms and signs of psychiatric disorders (1) (1).ppt

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