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Психопатология.

Signs and symptoms in psychiatry.

The objective of our classes today is the study of the psychopathology problems. Signs
are objective, symptoms are subjective. Signs are the clinician*s observations, such as
noting a patient*s agitation; symptoms are subjective experiences, such as a person*s
complaint of feeling depressed.

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Thought process. The pattern of a patient” speech allows the examiner to note the
quality of the thought process, including its flow, logic and associations.
Abnormalities of the thinking process include the following:

a. The first one is loose associations. This abnormality involves the shifting of
ideas from one to another with no logical connection, accompanied by a lack of
awareness on the part of the patient that these ideas are not connected. The
patients” thoughts are difficult for the examiner to follow.
b. The second one is tangential thinking. The patient wanders off the subject as
new bur related words are spoken. Usually it is possible to follow the patients”
thoughts, but the patient often loses track of the interviewer’s question.
c. The third one is circumstantiality. As with tangential thinking the patient loses
the point of what he is saying but stays within the general topic area. Irrelevant
details cause digressions in conversation. These digressions are mild if the patient
is merely anxious, but they can be severe if he is delirious and distractible.
d. Blocking. This problem occurs when the thinking process stops altogether and
the mind goes blank. It is found in acute anxiety and schizophrenia.
e. Perseveration. This repetition of the same words or phrases occurs despite
the interviewer’s direction to stop.
f. Echolalia. This problem is the direct repetition of the interviewer’s words.
g. Flight of ideas. This process, which is seen in mania, is characterized by rapid
speech with quick changes of ideas that may be associated in some way, such as
by the sound of the words. It may also involve loose associations.
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Next we will speak of content of thought.

Content of thought. Disturbances in thought content include delusions and

obsessions.

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Delusions are fixed, false beliefs that are outside the patient’s culture. For example,
a patients” belief that his thoughts are being broadcast outside his head is a
delusion, but a belief in Santa Claus is not. Delusions may be paranoid (or
persecutory), grandiose, nihilistic, somatic or bizarre. Delusions cannot be changed
by reasoning and are inconsistent with the beliefs of the patients* cultural group. In
some cases delusions may be so individualistic that no cultural connections can be
made. Delusions may be relatively circumscribed or may pervade all aspects of
patients* life and thinking. In some cases delusions may appear relatively trivial to
patients, but, more commonly, they become an organizing force in patients* lives.
Delusions may be simple in their organization or highly complex and systematized.
Sexual, religious and philosophical content of delusions are common. Because
delusions are fixed, false beliefs, they cannot be corrected by the physician.
Contradiction of the patients” delusional belief may cause the patient to become
angry and stop the interview. The physician should not pretend to agree with the
delusions but should take a neutral position and continue the examination.

There are different contents of delusion.

◊ Delusions of persecution are beliefs that others are trying to harm, spy
on, influence, or humiliate patients or interfere with their affairs.
Persecutory delusions are frequently pervasive and actively incorporate
features of patients* lives. Delusions of persecution involve the belief that
some person or object has special significance or power (e.g., a disk jockey
is sending special commands to the patient).
◊ Delusions of reference are beliefs that random events in the environment
have special meaning and are directed specifically at patients (e.g., talking
by strangers, television, or radio about patients, random events such as
accidents that have been designed to harm or influence patients). Ideas of
reference differ from delusions of reference in intensity rather than form.
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◊ Delusions of influence are beliefs that patient’s thoughts and actions are
controlled by outside forces. In extreme cases, patients feel as if they were
robots without thoughts and actions of their own. Patients may feel that
body parts, frequently the genitals, are manipulated by unseen forces.
Likewise, patients may feel as if their thoughts have been removed and
replaced by alien thoughts.
◊ And thought broadcasting involves thoughts leaving a patients” head and
going directly to objects in the environment. Patients may experience this as
a physical sensation. For those who have not experienced this
phenomenon, thought broadcasting is difficult to understand.
◊ But grandiose delusions are more common in patients with mania than in
those with schizophrenia. However, schizophrenic patients may feel as
though they are central figures in the complex delusional systems in the
environment. Patient’s feelings of having special knowledge, special
relationships with important figures or of poising a treat to conspiracies may
all be considered grandiose. These grandiose delusions are differentiated
from the expansive and positive grandiose delusions that are typical of
mania.
◊ Somatic delusions in schizophrenic patients typically include feelings that
the body has been manipulated or altered by outside forces. These somatic
delusions must be differentiated from the somatic delusions of other
disorders (e.g., having cancer or a decaying body), which are typical of
major depression with melancholic features. Patients with somatic delusions
may feel that: an electronic device has been placed in their body, that their
body is under the control of others or portions of their body are not their
own.

And now some words about obsessions.

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Obsessions are persistent, intrusive thoughts, ideas, or impulses. The patient realizes
that the ideas do not make sense and are not being imposed from outside (i.e.,
delusion). An example is a man who is always fighting an impulse to run down the hall
of the office building through a plate glass window at the end. He knows that this action
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is potentially life threatening, and he does not want to hurt himself, but he cannot stop
thinking about it and feeling anxious. Other common obsession include fears of
contamination and unrealistic fears about physical health, as seen in hypochondriasis.

The individual expresses either obsessions or compulsions. Obsessions are defined by

the following 4 criteria:

1. Recurrent and persistent thoughts, impulses, or images are experienced at some

time during the disturbance as intrusive and inappropriate and cause marked
anxiety and distress.
2. The thoughts, impulses, or images are not simply worries about real-life
problems.
3. The person attempts to suppress or ignore such thoughts, impulses, or images or
to neutralize them with some other thought or action.
4. The person recognizes that the obsessional thoughts, impulses, or images are a
product of his/her own mind (not imposed from without as in thought insertion).

At some point during the course of the disorder, the person recognizes that the
obsessions are excessive or unreasonable. This does not apply to children. The
obsessions cause marked distress; are time consuming (take >1 h/d); or significantly
interfere with the person's normal routine, occupational or academic functioning, or
usual social activities or relationships. The typical interview questions may be:

o Have you ever been bothered by thoughts that do not make any sense
and keep coming back to you even when you try not to have them?

o When you had these thoughts, did you try to get them out of your head?
What would you try to do?

o Where do you think these thoughts are coming from?

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And now about perceptual disorders.

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Perceptual disorders include a variety of distortions of sensory experiences and their

interpretation. Recent data suggest that a fundamental perceptual defect in
schizophrenia is the inability to habituate and suppress extraneous environmental
stimuli or internal thought processes. However, it must be emphasized that no
perceptual disturbance is pathognomonic of schizophrenia. Perceptual distortions may
occur in healthy people as well as in patients with mood disorders or organic mental
syndromes.

Perceptual disorders include hallucinations, illusions and others.

1. Hallucinations are sensory experiences that occur without corresponding

environmental stimuli
◊ Auditory hallucinations range from unformed buzzing sounds to complex
voices holding conversations. The most characteristic auditory hallucinations of
schizophrenia include hearing voices speaking about a patient in the third
person, hearing voices making derogatory comments about the patient, and
hearing one voice telling the patient to commit some action. The voices may be
muffled or distinct, familiar or unfamiliar, single or multiple, and of either sex.
Patients may hear their own voice spoken aloud.
◊ Command hallucinations are a special form of auditory hallucinations in
which voices tell a patient to commit some action. In some patients, these
hallucinations are so persistent that they become difficult to resist. Patients who
hear command hallucinations telling them to harm themselves or others must
be considered dangerous.
◊ Visual hallucinations are also experienced by schizophrenic patients,
although they are more common in other disorders, particularly organic mental
disorders. These hallucinations may be simple, but they are most
characteristic of schizophrenia when they are complex and related to a
patient’s delusional system (e.g., a visit from aliens).
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◊ Other hallucinations may be tactile, gustatory, olfactory (frequently an
unpleasant and indescribable odor), or somatic. Like visual hallucinations,
these hallucinatory experiences also occur in other disorders (e.g., olfactory
hallucinations in complex partial seizures). In schizophrenic patients, they are
frequently connected to delusional systems.
2. Illusions are misperceptions or misidentifications of identifiable environmental
events or objects that may occur in any sensory modality. Illusions are common in a
variety of disorders and occur in normal individuals as well. In schizophrenic patients,
illusions may be variants of a normal experience given a delusional explanation.
3. “Deja vu” feelings are defined as those in which unfamiliar situations feel
strangely familiar. These illusions also occur as a normal phenomenon and in several
forms of epilepsy.
4. “Jamais vu” feelings are defined as those in which familiar situations feel novel
and unfamiliar. These illusions also occur in several forms of epilepsy.
5. Hypersensitivity to light, sound, or smell is common in schizophrenia and to
other disorders such as migraine headaches, depression.
6. Distorted perceptions of time also occur in a variety of conditions such as
dissociative states and anxiety.
7. Depersonalization and derealization are alterations in an individual’s
perception of reality. With depersonalization, the patient feels detached and views
himself as strange and unreal. Changes in body perception of one’s own body or the
body of others also occur. Derealization involves a similar alteration in the patient’s
sense of reality of the outside world. Objects in the outside world may seem altered in
size and shape, and people appear dead or mechanical. Misperceptions of movement,
perspective, and size, which are typical of organic conditions and anxiety, also occur in
schizophrenia.
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MOOD.

The emotional state that the patient experiences internally is known as mood, and the
outward expression of the patient’s internal emotional state is known as affect. The
interviewer notes whether the patient’s mood and affect are the same. For example, a
patient who has a depressed mood is likely to appear sad and quiet and to speak softly
and slowly.

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Depth and range of emotional expression are the following:

1. Labile affect describes sudden shifts in emotional state. The patient may laugh
one minute and cry the next without a clear stimulus.
2. Flat affect describes a shallow and blunted emotional state. Facial expression
and voice lack spontaneity.
3. The symptoms of Depression are:
◊ Depressed mood most of the day, nearly every day
◊ Markedly diminished interest or pleasure in all, or almost all, activities of
the day
◊ Insomnia or hypersomnia nearly every day
◊ Significant weight loss or weight gain not dieting (more than 5% of body
weight in 1 month)
◊ Psychomotor agitation or retardation nearly every day
◊ Fatigue or loss of energy nearly every day
◊ Feelings of worthlessness or excessive or inappropriate guilt (which may
be delusional) nearly every day
◊ Diminished ability to think or concentrate, or indecisiveness nearly every
day
◊ Recurrent thoughts of death, recurrent suicidal ideation without a specific
plan, or a suicide attempt or a specific plan for committing suicide
4. The main symptoms of Mania are:

◊ Abnormally and persistently elevated, expansive or irritable mood

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◊ Inflated self-esteem or grandiosity
◊ Decreased need for sleep (feels rested after only 3 hours of sleep)
◊ More talkative than usual or pressure to keep talking
◊ Distractibility (i.e., attention too easily drawn to unimportant or irrelevant
external stimuli)
◊ Increase in goal-directed activity (e.g., socially, at work or school, or
sexually) or psychomotor agitation
◊ Excessive involvement in pleasurable activities that have a high potential for
painful consequences (e.g., the person engages in unrestrained buying
sprees, sexual indiscretions, or foolish business investments).
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Motor activity.

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Motor activity may change. Some alterations in motor activity and behavior may be
associated with the pharmacologic treatment of schizophrenia.

1. Quantitative changes. The amount of activity and its “driven” quality ranges from the
extremes of agitation in excited catatonic states and acute psychotic exacerbations to
the withdrawn and inactive states associated with catatonic stupor and chronic
institutionalization. Acathisia, bradykinesia, and tardive dyskinesia are commonly
associated with the effects of neuroleptic medications rather than with schizophrenia.
Catatonic stupor is a state of dramatic motor inactivity in which patients may, if
untreated, be immobile for weeks or months at time. Patients may be unable to initiate
eating, drinking, or elimination. As patients recover, it is clear that they have been aware
of events in the environment. Patients in catatonic stupor may require aggressive
medical care to avoid dehydration, electrolyte disturbances, and infections. In some
cases, catatonic stupor may change abruptly to catatonic excitement. Medical illnesses,
and affective disorders are the most common causes of catatonia.
Catatonic excitement, a hypermetabolic state, is a psychiatric emergency. A patient’s
activity and speech may be excessive, driven, and purposeless. Patients in this state
may be violent. Before pharmacologic treatment and electroconvulsive therapy were
available, patients in this state frequently died of acute hyperthermia.
2. Qualitative changes. Psychopharmacologic interventions frequently confuse the
clinical picture of movement abnormalities by adding features of parkinsonian
movement difficulties and the choreoathetotic movements of tardive dyskinesia. Even
without pharmacologic treatment, patients with schizophrenia may exhibit a variety of
movement abnormalities (e.g., increased flexor muscle tone, unusual mannerism,
bizarre gestures).
a. Catatonic posturing is demonstrated by patients who assume strange postures and
hold them for long periods.
In catatonic rigidity, patients resist being moved from their unusual rigid postures.
In waxy flexibility, patients” limbs may be moved like wax, and they hold the newly
assumed position for long periods of time.
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b. Echopraxia is the behavioral equivalent of echolalia. Patients involuntarily mimic
the movements of another person.
c. Automatic obedience refers to the following of directives in an unquestioning,
robot-like manner.
d. Mannerism and grimacing refers to patients” artificial and stilted appearance.
Inappropriative silliness is evident, particularly in hebephrenic patients and patients
with frontal lobe damage, and is frequently accompanied by unusual mannerism.
Particular mannerism may have special meanings that are connected to delusions or
hallucinations. Grimacing movements may be subtle or pronounced but may be
mistaken for the orofacial dystonias of tardive dyskinesia.
e. Stereotyped behaviors (stereotypy) involves the purposeless repetitive movements
(or verbalizations) seen in a variety of conditions. These movements may involve the
entire body such as rocking or may involve repetition of complex gestures. The
movements may have magical significance or may be purposeless to the patient.
f. Perseveration is involuntary repetition of a task. For example, patients who are
asked to copy a series of circles may continue to copy the figures until they run off the
page. Patients may repeat an answer to a question until asked to stop. Perseveration
is also seen in patients with organic mental syndromes, particularly in those with
damage to premotor areas.