Clinical manifestations of psychiatric disorders 3
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Transcript of 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
Issues of considerable concern
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.
Issues of considerable concern
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.
Issues of considerable concern
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.
Issues of considerable concern
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.
Issues of considerable concern
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.
Issues of considerable concern
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.
Issues of considerable concern
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
Issues of considerable concern
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.
Issues of considerable concern
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.
Issues of considerable concern
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.
Issues of considerable concern
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.
Issues of considerable concern
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.
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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
Sins and symptoms in Psychiatry
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
Sins and symptoms in Psychiatry
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 .
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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,
Sins and symptoms in Psychiatry
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
Sins and symptoms in Psychiatry
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:
Sins and symptoms in Psychiatry
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,
Sins and symptoms in Psychiatry
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
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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).
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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).
Sins and symptoms in Psychiatry
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.
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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.
Sins and symptoms in Psychiatry
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
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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.
Sins and symptoms in Psychiatry
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.
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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).
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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.
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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.
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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.
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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.
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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.
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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
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• 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
Sins and symptoms in Psychiatry
• 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
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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.
Sins and symptoms in Psychiatry
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.
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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.
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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.
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The dates reported by disoriented individuals may
have personal significance such as those of
important
i. births,
ii. marriages, or
iii. deaths.
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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.
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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.
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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.
Sins and symptoms in Psychiatry
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.
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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
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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.
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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.
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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.
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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
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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
Sins and symptoms in Psychiatry
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.
Sins and symptoms in Psychiatry
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.
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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
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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,
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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.
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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.
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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.
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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.
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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.
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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.
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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,
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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.
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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
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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
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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
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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.
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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
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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.
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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.
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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.
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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,
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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
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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
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Diminished libido,
1.erectile dysfunction, and
2.anorgasmia
are also common sequelae of many psychotropic
agents, especially those with a strong serotonergic
action
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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.
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In psychiatric disturbances, motor abnormalities can
involve
generalized overactivity or
underactivity or
manifest in a wide range of specific
disorders of movement.
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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.
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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.
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It is commonly seen in
mania,
hypomania, and
anorexia nervosa and
as part of ADHD and
in response to stimulating drugs and
medicines.
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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.
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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
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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,
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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.
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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.
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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
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Stereotypies are
repetitious,
bizarre,
seemingly non-goal-directed,
complex organized gestures or postures
that are believed to have private meanings to the
patient.
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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.
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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
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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.
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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).
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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,
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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,
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tongue protrusions,
facial grimacing,
hopping, and
twitches.
Complex tics may merge into complex compulsive
behaviors such as squatting, deep knee bends, and
retracing steps.
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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.
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