Symptomatology in Psychiatric y

Prof. Hani Hamed Dessoki, M.D.PsychiatryProf. Hani Hamed Dessoki, M.D.PsychiatryActing Dean, Faculty of Applied Mental Health sciencesActing Dean, Faculty of Applied Mental Health sciences

Beni Suef UniversityBeni Suef University

Prof. PsychiatryProf. Psychiatry

Chairman of Psychiatry DepartmentChairman of Psychiatry Department

Beni Suef UniversityBeni Suef University

Supervisor of Psychiatry DepartmentSupervisor of Psychiatry Department

El-Fayoum UniversityEl-Fayoum University

APA memberAPA member

Psychiatric illness

Neurosis1. Normal or mild personality

changes.2. Slightly disturbed thinking.

3. In contact with reality.4. Intact orientation insight.

5. No perceptual disturbances e.g. hallucinations & delusions

Psychosis1. Marked personality changes.

2. Disordered.3. No contact with reality.

4. Lacking.5. hallucinations& delusions

present.

Neurosis is a change in the quantity of lifepsychosis is a change in the quality of life.

References: Gelder M, Gath D, Mayou R. Oxford Textbook of Psychiatry. 2nd edition, 1989. Oxford Medical Publications

Organic disorders

Dementia of Alzheimer’s type

Physical diseases that affect the brain as well

as other organs

Functional disorders

Mood disorders Anxiety disorders

Schizophrenia Others

Classification of psychiatric disorders

References: Gelder M, Gath D, Mayou R. Oxford Textbook of Psychiatry. 2nd edition, 1989. Oxford Medical Publications.

Organic disorders

Dementia (Alzheimer’s type)

Physical diseases that affect the brain

Chronic e.g. caused by AIDS,

cerebrovascular stroke

Acute e.g. caused by infections

DementiaDelirium

Organic disorders

References: Gelder M, Gath D, Mayou R. Oxford Textbook ofPsychiatry. 2nd edition, 1989. Oxford Medical Publications.

Functional disorders

Functional disorders

Mood disorders:• Depression

• Mania

Anxiety disorders:• Anxiety states

• Phobias• Panic attacks

Schizophrenia(Paranoid,Catatonic,

Disorganised,Undeffernciated& Residual)

Others: • Obsessive- compulsive

disorder• Personality

disorders

Types

*Psychotic disorders

*Mood disorders

*Anxiety disorders

*Eating disorders

*Substance use disorders

*Somatoform disorders

*Personalit ydisorders

*Dissociative disorders

*Impulse control disorders

•Etiology of Psychiatric illness????????

Unknown

Biopsychosocial ModelBiopsychosocial Model

The Role of Epigenetic Modulationin Major depression

Champagne et al. 2005; Copyright Elsevier (2005).

Externalenvironment

Maternal care Social experiences

Geneticbackground

EARLY EXPERIENCESEpigenetic modifications 1

AdultFertilization Pre-natal Postpartum Post-weaning

REVERSIBILITYEpigenetic modifications 2

Behavioralphenotype

Maintaining (perpetuating) factorse.g. social factors (poor housing, unhappy

marriage, financial worries)

Predisposing factorse.g. family tendency to

depression

Precipitating factorse.g. life events (bereavement, redundancy,

long term illness)

Psychiaric illness

Social and environmental factors

Psychiatric Symptoms and Signs

•I . Disorders of Perception•II- Disorders of Thinking

•III. Disorders of Speech•IV- Disorders of Emotions

•V. Disorders of Motor Behavior•VI- Disorders of Memory

•VII- Disorders of Attention•VIII- Disorder of Orientation

•IX- Disorders of Consciousness•X- Judgment

•XI- Insight

I . Disorders of Perception

•Perception is the process by which sensory stimuli are given a meaning (i.e., transferring physical stimulation into psychological information). Common disorders of perception are the following:

1 .Illusions:• Misinterpretation of real external sensory stimuli (e.g.,

mistaking a rope for a snake, mirage).• May affect any sensory modality (visual, auditory, etc...).

• May occur in normal or pathological conditions (e.g., delirium).

2 .Hallucinations:Hallucination is a false perception in the absence of any external stimulus.

3.Depersonalization and Derealization:

Types of Hallucinations• According to complexity:• • Elementary (e.g., noises, flashes of

light).• • Complex (voices, music, faces, scenes).• According to sensory modalities :• a. Auditory Hallucinations:• b. Visual Hallucinations:• c. Tactile Hallucinations:• d. Olfactory (smell) and Gustatory (taste)

Hallucinations:• e. Somatic Hallucinations:

Auditory hallucinations• They are the most common type of hallucinations.

They mainly occur in psychotic disorders especially schizophrenia.

•  • Varieties:• • Voices talking to the patient (2nd person), i.e.,

addressing or commanding• • Voices talking about the patient (3rd person),

e.g., commenting on his thoughts or actions• • Voices repeating patient's thoughts (echo de

pensee)

b. Visual Hallucinations:

• Most common in organic mental conditions, (e.g., delirium, substance intoxication or withdrawal).

• May occur in schizophrenia, severe mood disorders or dissociative disorders.

c. Tactile Hallucinations:

• False perception of touch.• e.g., phantom limb (from amputated limb);

and crawling sensation on or under the skin in cocaine intoxication and withdrawal.

d. Olfactory (smell) and Gustatory (taste) Hallucinations:

• Most common in organic conditions, e.g., temporal lobe epilepsy.

• May occur in schizophrenia or severe mood disorders.

e. Somatic Hallucinations:

• False sensation of things occurring in the body (mostly visceral). They usually occur in psychotic disorders, particularly schizophrenia.

3.Depersonalization and Derealization:

•Disturbed perception of oneself or the surrounding environment:a. Depersonalization: the person perceives himself, his body or parts of his body as different, unreal or unfamiliar.b. Derealization: the person perceives the external world, objects or people as different, strange or unreal.

•Depersonalization and Derealization may occur in normal people (during stress), in anxiety disorders, mood disorders, schizophrenia, and in organic conditions (e.g., temporal lobe epilepsy).

II- Disorders of Thinking

• These are classified into:• • Disorders of Form of Thinking• • Disorders of Stream of Thinking• • Disorders of Content of Thinking

) A (Disorders of Form of Thinking

• They are also called Formal Thought Disorders.

• They are abnormalities in the logical structure and association of thoughts.

• They lead to failure in producing coherent and logically connected meanings.

• Formal thought disorders usually occur in psychotic disorders and some organic mental disorders.

) A (Disorders of Form of Thinking

• The following are the commonest types.1.Loosening of associations:2. Incoherence:3. Word Salad:4. Verbigeration:5. Perseveration:6. Neologism:7. Clang associations:

)B (Disorders of Stream of

Thinking• These are abnormalities in the progress of

thought including its speed (tempo) and continuity.

• 1. Flight of ideas:• 2- Circumstantiality:• 3 - Blocking:

)C (Disorders of Content of Thinking

• These are abnormalities in the ideas or beliefs contained in thought.

• a. Delusions• b. Obsessions

Delusions:• A delusion is a false belief.• It is based on incorrect inferences about reality. • It is not consistent with the patient's cultural background.• It cannot be corrected by experience or reasoning.Delusions may be:• Fixed (complete conviction all the time) or shakable (lacking full

conviction sometimes).• Systematized (i.e., united by or centered on a single theme or idea

with many connected details) or malsystematized (i.e.. disconnected or shifting from one theme to another).

• Bizarre (i.e., with very strange or absurd content).N.B. Delusions and Hallucinations occur in psychotic disorders

such as:1- Schizophrenia.2- Delusional disorders.3- Psychotic mood disorders.4- Some organic or substance related mental disorders.

)C (Disorders of Content of Thinking

• These are abnormalities in the ideas or beliefs contained in thought.

Types of Delusions (according to theme): 1. Delusion of persecution: 2. Delusion of grandeur (grandiosity): 3. Delusion of reference: 4. Delusion of guilt or self accusation. 5. Nihilistic delusion: 6. Somatic delusion: 7. Hypochondriacal delusion: 8. Delusion of infidelity (delusional jealousy): 9. Erotomania (delusion of love): 10. Delusions of influence & control (Passivity

phenomena):

Delusions of control:•This is a false belief that a person's

thoughts, feelings, actions or will are being controlled by external forces.

• Delusions concerning the possession of thoughts:

i. Thought insertion: ii. Thought withdrawal: iii. Thought broadcasting:

b. Obsessions:• Obsessions are recurrent, persistent

thoughts, impulses or images that cannot be eliminated from consciousness by logic or reasoning although the person is aware that they are unreasonable, absurd and alien to him (ego-dystonic).

Compulsions

• If the thought urges the patient to perform a certain act, repetitive compulsion results, e.g., obsession of dirt leads to compulsive washing. Like obsessions, compulsions are recognized as senseless and alien.

Disorder of content of thoughtDisorder of content of thought•preoccupation of thought

Centering of thought content on a particular idea, associated with a strong affective tone, such as a paranoid trend or a suicidal or

homicidal preoccupation.

•overvalued idea False or unreasonable belief or idea that is sustained beyond the

bounds of reason. It is held with less intensity or duration than a delusion but is usually associated with mental illness

•hypochondria Exaggerated concern about health that is based

not on real medical pathology, but on unrealistic interpretations of physical signs or sensations as

abnormal.

•delusion False belief, based on incorrect inference about external reality, that

is firmly held despite objective and obvious contradictory proof or evidence and despite the fact that other members of the culture do

not share the belief.

•bizarre delusion False belief that is patently absurd or fantastic (e.g., invaders from

space have implanted electrodes in a person's brain). Common in schizophrenia. In nonbizarre delusion, content is usually within the

range of possibility

•mood-congruent delusion Delusion with content that is mood appropriate

(e.g., depressed patients who believe that they are responsible for the destruction of the world).

•mood-incongruent delusion Delusion based on incorrect reference about external reality, with

content that has no association to mood or is mood inappropriate

•obsession Persistent and recurrent idea, thought, or impulse that cannot be

eliminated from consciousness by logic or reasoning; obsessions are involuntary and ego-dystonic

•phobia Persistent, pathological, unrealistic, intense fear

of an object or situation; the phobic person may realize that the fear is irrational but, nonetheless,

cannot dispel it.

Disorder of streamDisorder of stream•poverty of content of speech

Speech that is adequate in amount but conveys little information because of vagueness, emptiness, or

stereotyped phrases

•pressured speech Increase in the amount of spontaneous speech; rapid,

loud, accelerated speech, as occurs in mania, schizophrenia, and cognitive disorders

•blocking Abrupt interruption in train of thinking before a thought or

idea is finished; after a brief pause, the person indicates no recall of what was being said or was going to be said (also known as thought deprivation or increased thought

latency). Common in schizophrenia and severe anxiety

Disturbance of process and formDisturbance of process and form•Impaired reality testing

Fundamental ego function that consists of tentative actions that test and objectively evaluate the nature and limits of the environment; includes the

ability to differentiate between the external world and the internal world and to accurately judge the relation between the self and the environment

•illogical thinking Thinking containing erroneous conclusions or internal contradictions;

psychopathological only when it is marked and not caused by cultural values or intellectual deficit

•irrelevant answer Answer that is not responsive to the question.

•loosening of associations Characteristic schizophrenic thinking or speech disturbance

involving a disorder in the logical progression of thoughts, manifested as a failure to communicate verbally adequately;

unrelated and unconnected ideas shift from one subject to another.•tangentiality

Oblique, digressive, or even irrelevant manner of speech in which the central idea is not communicated

•derailment Gradual or sudden deviation in train of thought

without blocking; sometimes used synonymously with loosening of association.

•incoherence Communication that is disconnected,

disorganized, or incomprehensible

•neologism New word or phrase whose derivation cannot be understood;

often seen in schizophrenia .•word salad

Incoherent, essentially incomprehensible, mixture of words and phrases commonly seen in far-advanced cases of

schizophrenia•flight of ideas

Rapid succession of fragmentary thoughts or speech in which content changes abruptly and speech may be incoherent. Seen

in mania.•circumstantiality

Disturbance in the associative thought and speech processes in which a patient digresses into unnecessary details and

inappropriate thoughts before communicating the central idea. Observed in schizophrenia, obsessional disturbances, and

certain cases of dementia

III. Disorders of Speech1- Volubility :2- Poverty of speech:3- Poverty of content of speech (poverty of

thought):4- Stuttering and stammering:5- Dysarthria:6- Aphasia: Motor aphasia (expressive): Sensory aphasia (receptive): Nominal aphasia:7- Mutism:

IV- Disorders of Emotions

• Emotion is a complex feeling state with psychic, somatic and behavioral components.

• The clinical study and evaluation of emotion is concerned with two main aspects:

• A-Mood: a sustained and pervasive emotional tone subjectively experienced and reported by the patient and observed by others (e.g., depression, elation, anger).

• B- Affect: usually used to indicate the subjective and immediate "short lived" or transient experience of emotion. It also refers to the external expression or observed aspect of emotions.

A- Disorders of Mood:• Disorders of mood may be unpleasant or

pleasant.

• Unpleasant moods• Dysphoric mood:

Irritable mood: • Depression:

Anhedonia• Fear

Anxiety• Free-floating anxiety

Tension• Phobia

Pleasant Moods:

• 1-Euphoria• 2- Elation• 3- Ecstasy:

B- Disorders of Affect:

• These are disturbances related to observed expression of emotions. They include the following disorders:

• 1. Constricted or restricted affect• 2. Blunted affect• 3. Flat affect (apathy)• 4.Inappropriate affect (incongruity of affect)• 5. Lability of affect (emotional incontinence)• 6. Swings of affect• 7. Ambivalence

V. Disorders of Motor Behavior

1- Tics2- Mannerisms3- Stereotypy4- Psychomotor retardation5- Psychomotor agitation6- Excitement7- Lack of Volition (Avolition)8- Catatonic Symptoms

8 -Catatonic Symptoms

a. Catalepsy: b. Catatonic Posturingc. Catatonic rigidityd. Waxy flexibility e. Catatonic Stupor: f. Catatonic Excitement: g. Negativismh. Automatic obedience i. Echolaliaj. Echopraxia

VI- Disorders of Memory

• Memory is the psychological function by which information stored in the brain is later recalled in consciousness.

• Clinically, 4 levels of memory are described:Immediate MemoryRecent (short-term) Memory Recent Past Memory Remote (Long-term)

Disorders of Memory:A- Amnesia 1. Anterograde 2. Retrograde 3. Circumscribed amnesia (amnestic gap)B- HypermnesiaC- Paramnesia• It is falsification or distortion of recalled memories.

Common types: 1- Confabulation 2- Retrospective Falsification 3- Deja vu 4- Jamais vu

VII- Disorders of Attention

• Attention is the ability to focus awareness on certain important or relevant aspects of an experience, activity or task. Concentration is the ability to sustain or maintain that focus.

• Disorders of Attention: 1. Distractibility 2. Selective inattention 3. Hypervigilance (hyperprosexia)

VIII- Disorder of Orientation

• Orientation is awareness of time, place and persons.

• Disorientation : disturbed orientation to time, place or persons. It is usually related to disturbed consciousness.

IX- Disorders of Consciousness• Consciousness is the general state of awareness

of the self and the environment.• Common disorders of consciousness are:1- Clouding of Consciousness:2- Stupor:3- Coma:4- Dream-like state (oneroid or twilight state):5- Somnolence:N.B.: Most symptoms indicating disturbances inconsciousness, orientation, memory, and attentionhighly suggest an "Organic Mental Disorder".

X- Judgment

• Judgment is the ability to assess a situation rationally and to act appropriately within that situation. Judgment has several aspects (cultural, social, moral, etc...) that should be considered in order to be assessed by the clinician.

XI- Insight

•In psychiatry, insight refers to the• patient's conscious recognition of his

condition, i.e., awareness that:1 - he is disturbed or ill

2 -his illness is psychiatric in nature3 -he should seek professional help

4 -he should cooperate with the offered treatment

•Full or partial awareness of these aspects indicates the degree of his insight.

SchizophreniaSchizophrenia• Emil Kraepelin “Dementia Praecox’ (1896)Emil Kraepelin “Dementia Praecox’ (1896)• Blueler “Schizophrenia”Blueler “Schizophrenia”• Onset: adolescence or young adulthoodOnset: adolescence or young adulthood• DSM-IV review:DSM-IV review:

– Positive symptoms (delusions, hallucinations, Positive symptoms (delusions, hallucinations, disorganized speech or behavior)disorganized speech or behavior)

– Negative symptoms (catatonia, affective flattening, Negative symptoms (catatonia, affective flattening, withdrawal, or avolition)withdrawal, or avolition)

– Social-occupational disturbanceSocial-occupational disturbance– 6+ months6+ months

Fundamental symptoms (4 As)Fundamental symptoms (4 As)• Association (dissociations in thought process)Association (dissociations in thought process)

• AmbivalenceAmbivalence

• AutismAutism

• Affective disturbanceAffective disturbance

Schizophrenia: Kurt Schneider Schizophrenia: Kurt Schneider (1887-1967)(1887-1967)

• First-rank symptomsFirst-rank symptoms

• Broad concept Broad concept (boundaries)(boundaries)

• Operationalisation of Operationalisation of symptomssymptoms

• PhenomenologyPhenomenologyFirst-rank symptoms

First-rank symptomsFirst-rank symptoms• Thought echoThought echo

• Auditory hallucinations (voices)Auditory hallucinations (voices)– Two or more voices conversing with one anotherTwo or more voices conversing with one another– Maintaining a running commentary on the person’s thoughts or behaviourMaintaining a running commentary on the person’s thoughts or behaviour

• Thought withdrawalThought withdrawal

• Thought insertionThought insertion

• Thought broadcastingThought broadcasting

• Delusions of control, influence or passivityDelusions of control, influence or passivity

• Delusional perceptionDelusional perception