Symptomatology

Disorders of thought

Disorders of Thought process

Thought process describes how the patient uses language and puts ideas together. Can be linear or non-linear.

• Circumstantiality
  • Indirect speech that delays reaching the point BUT eventually does
  • The patient gives many unnecessary or trivial details
• Tangentiality
  • Going off on particularly relevant details BUT the patient never reaches the point (patient gives ball park responses)
  • The patient gives a reply that is appropriate to the general topic without actually answering the question.
• Thought block
  • Abrupt cessation of the patient’s train of thought before the thought or idea is reached

Disorders of thought form

Thought form describes the flow and structure of the thoughts expressed by the patient

• Loosening of association
  • No logical connection from one thought to another, as well as there being loss of goal directedness of the thoughts.
• Derailment
  • Gradually deviates without blocking
• Flight of ideas
  • Thought changes rapidly from one idea to another, and is often accompanied by pressured speech
• Clang associations
  • Words are connected by phonetics rather than actual meaning eg. by rhyming
• Perseveration
  • Persistent response to a previous stimulus (question) even when a new stimulus (question) is asked
  • The patient repeats out of context words, phrases or ideas.
• Word salad
  • Incoherent collection of words
• Neologisms
  • New words created by the patient or patient uses common words in an unconventional way
• Echolalia
  • Repetition of words or phrases said by another person (repetitive and persistent, at times mocking)
• Irrelevant answers
  • Patient gives answers that are not in harmony with the questions asked (apparently ignore or not attend to the question)
• Coprolalia
  • Involuntary and repetitive use of obscene language
• Palilalia
  • Repeating the last words or phrases during speech
• Glossolalia
  • The phenomenon of apparently speaking in an unknown language

Disorders of thought content

• Delusions
  • Fixed False beliefs about external reality not consistent with a person’s education, social or cultural background; not changed by reasoning
  • Types of delusions:
    • Grandiose delusion: inflated self-worth, power, knowledge, identity or special relationship to a deity or famous person
    • Religious delusion: believes they have divine powers, receive messages from God, or that they actually are God.
    • Delusion of jealousy/infidelity: delusion that one’s sexual partner is unfaithful despite lacking evidence(Othellos syndrome)
    • Erotomania: that another person usually of higher status is in love with the individual
    • Persecutory/ paranoid: central theme is that the individual (or someone close) is being attacked, harassed, cheated, persecuted, or conspired against
    • Somatic: main content pertains to appearance or functioning of one’s body (Patient sees herself becoming tall, patient feels her brain been taken out and put back in, Cotard’s syndrome, where the patient believes that parts of their body are dying, dead or do not exist)
    • Hypochondriac: belief in one’s illness
    • Nihilistic: extreme pessimism
    • Reference: normal behavior of others refer to himself
    • Delusional perception: a true perception attributed a false meaning
    • Bizarre: involves a phenomenon that a person’s culture would consider completely absurd or implausible
• Overvalued ideas
  • False beliefs but less firmly held and can be reasoned (can occur in normal persons undergoing stressful experiences)
• Obsessions
  • Persistence of an irresistible thought/feeling that cannot be easily eliminated from the mind
  • It is a repetitive, persistent, intrusive, and unpleasant thought or urge that causes severe distress and anxiety.
• Compulsions
  • Ritualistic, repetitive behaviors (e.g., touching, washing) or mental act (e.g., counting, repeating a word silently) carried out in an effort to relieve urges and decrease obsession-related distress.
• Ruminations
  • Type of obsessional thinking involving excessive, repetitive thoughts that interfere with other forms of mental activity
  • Common in OCD and generalised anxiety disorder
• Ideas of reference
  • The belief that random events are uniquely related to the patient
• Suicidal/homicidal ideation
  • Does the patient have a plan?
  • Does the patient have intent?
  • Does the patient have a means?
• Phobias
  • Persistent irrational fears
  • Persistent (≥ 6 months) and intense fear of one or more specific situations or objects (phobic stimuli).
• Poverty of thought
  • Too little ideas
• Overabundance of thought
  • Too many ideas

Disorders of thought alienation/control

• Thought withdrawal
  • External forces remove patient’s thoughts from the mind
• Thought insertion
  • External forces put thoughts into patient’s mind against their wish
• Thought broadcasting
  • Patient’s thoughts are made public without being talked by the patient out loud
• Thought echo
  • Voices repeating the patient’s thoughts

Disorders of perception

Perception is the process by which sensory stimuli are given a meaning.

• Illusions
  • Misinterpretation of real external sensory stimuli
  • May affect any sensory modality (visual, auditory etc.)
  • Can occur in normal or pathological conditions (eg. delirium)
• Hallucinations
  • False perception in the absence of any external stimulus
  • Auditory hallucinations
    • Common in psychotic disorders
    • Second person: voices addressing OR commanding the patient
    • Third person: voices are talking about the patient OR commenting on the patient’s actions without addressing him/ her directly
    • Echo de pensee (Thought echo): voices repeating the patient’s thoughts
  • Visual hallucinations: common in delirium, substance intoxication and withdrawal, schizophrenia, severe mood disorders, OR dissociation disorders
  • Tactile hallucination: phantom limb, crawling sensation (”Creepy crawlies”)
  • Olfactory and gustatory hallucinations: occurs in temporal lobe epilepsy, schizophrenia, and mood disorders
  • Somatic hallucinations: false sensation of things occurring in the body (mostly visceral, seen in schizophrenia)
• Depersonalization and Derealization
  • Depersonalization: persons perceives himself, his body or parts of his body as different, unreal, or unfamiliar
  • Derealization: person perceives the external world, objects, or people as different, strange or unreal
  • Can occur in stress, anxiety disorders, mood disorders, schizophrenia, dissociative disorders and temporal lobe epilepsy

Disorders of Speech

• Poverty of speech
  • Scanty use of words, lacking in details and is very brief
• Pressured speech
  • Talks a lot and rapidly, and may be difficult to follow
• Stuttering
  • Hesitation and involuntary repetition of certain words which may lead to markedly impaired speech fluency
• Apraxia
  • Tongues and lips aren’t able to move in the correct way to produce sounds
• Motor and sensory aphasia
  • A language disorder where the individual’s ability to understand and use verbal or written language is impaired.
  • Examples of types: Type Location of the lesion Type Clinical features Broca’s aphasia (Motor/ expressive aphasia/non-fluent aphasia) Broca area (inferior frontal gyrus) Non-fluent Telegraphic and grammatically incorrect speech. Comprehension is largely spared, and the patient is aware of their difficulty in speech Wernicke’s aphasia (receptive aphasia/ fluent aphasia) Wernicke’s area (superior temporal gyrus) Fluent Fluent speech that lacks sense. Comprehension is impaired, and the patient is typically unaware of their deficits. Reading and writing are often severely impaired. Global aphasia Broca area, Wernicke’s area and arcuate fasciculus Non-fluent Severe impairment of speech production and comprehension Anomic aphasia Not easily pinpointed Fluent Isolated difficulty in finding words Conduction aphasia Arcuate fasciculus, but Broca and Wernicke’s area are preserved Fluent Subtle impairment, mostly in the ability to repeat words and phrases
• Coprophasia
  • Use of markedly obscene or vulgar language
• Alogia
  • Inability to speak due to mental deficiency or dementia
• Dysarthria
  • Motor speech disorder in which the muscles that used for speech are weakened, paralyzed or damaged due to neurological injury leading to slow or slurred speech
• Dysprosody
  • Loss of the normal melody of talk eg. the use of a constant low-pitch in a patient with depression

Disorders of emotions

• Mood
  • Prolonged duration (several days; reported)
• Affect
  • Seen at the moment by interviewer
• Blunting
  • Loss of normal emotional sensitivity to experiences
• Catastrophic reaction
  • An extreme emotional and behavioral over-reaction to trivial stimulus
• Flattening
  • Loss of the range of normal emotional responses
• Incongruity
  • Mismatch between the emotional expression and the associated thought
• Lability
  • Superficial, rapidly changing and poorly controlled emotions

Disorders of motor behavior

• Catatonia
  • Occurs when the pathological mental state is expressed in motor anomalies.
  • Examples include:
    • Catatonic Stupor: movement and speech ceases and the patient is unresponsive to the spoken word or even to painful stimuli. There is usually also the failure to take food or fluid. Therefore, the life of the patient may be in danger and active treatment is essential.
    • Catatonic Posturing: the patient assumes a posture which is then maintained.
    • Catatonic Rigidity: a posture is maintained against the interviewer’s attempts to move the limbs or the whole patient.
    • Waxy Flexibility: the interviewer can change the position of the patient’s limbs, and in the process the limbs feel to the interviewer as if they are made of wax. (The new posture is usually then maintained for at least a few seconds and sometimes minutes.)
    • Negative or Contrary Catatonia: the patient does the opposite of what is expected. The most commonly described is when the patient extends their hand to the clinician, the clinician responds by extending his/her hand, and as this action is performed, the patient withdraws his/hers.
    • Other Catatonic Symptoms include catatonic excitement in which there is extreme activity, including potential violence, and automatic obedience.
• Catalepsy
  • Muscular rigidity and fixed posture regardless of external stimulus, as well as reduced sensitivity to pain
  • Rigidity, waxy flexibility,
• Cataplexy
  • Transient and sudden muscle weakness and loss of muscle tone
• Mannerisms
  • Habitual involuntary movements
• Stereotypies
  • Repetitive, abnormally frequent, non-goal oriented movements
• Tics
  • A sudden, involuntary vocalization or contraction of a small group of muscles that is recurrent and nonrhythmic
• Psychomotor agitation
  • A state of restlessness accompanied by purposeless movements
• Psychomotor retardation
  • A slowing down or inhibition of mental and physical activity, manifested as slow speech with long pauses before answers, slowness in thinking, and slow body movements
• Apraxia
  • Difficulty performing targeted, voluntary movements despite having intact motor function and the willingness to perform the movement.
• Echopraxia
  • Imitation of another person’s movements

Disorders of memory

• Amnesia
  • Loss of memory
• Retrograde amnesia
  • Amnesia of events or information acquired prior to the incident
• Anterograde amnesia
  • Amnesia of events or information acquired after the incident
• Para amnesias
  • Falsification of memory by distortion of recall; may occur in some patients going thro stressful life experiences eg terminal illness, bereavement, after alcohol abuse
• Jamais vu
  • False feeling of unfamiliarity with a real situation that a person has experienced
• Déjà vu
  • llusions of visual recognition in which a new situation is incorrectly regarded as a repetition of previous memory
• Confabulation
  • Unconscious filling of gaps in memory by imagined or untrue experiences that a person believes but that are not true, without the intention of deceiving the interviewer

Disorders of attention

• Distractibility
  • Inability to concentrate, that is, attention is easily diverted to other activities that are irrelevant
• Trance
  • A dream-like state when attention is focused on one thing and the person seems oblivious of his surrounding
• Selective inattention
  • One blocks away from consciousness things that generate anxiety
• Hyper vigilance
  • Excessive attention is concentrated on a stimulus

Disorders of consciousness

• Coma
  • Deep/profound unconsciousness. Score low on the Glasgow Coma Scale.
• Stupor
  • Lack of response and unawareness of surrounding
• Delirium
  • A dream-like change in consciousness often accompanied by an impaired reality testing. The patient may be anxious, restless, confused, and experience hallucinations
• Drowsiness
  • A state of impaired awareness associated with a desire or inclination to sleep
• Somnolence
  • Abnormal drowsiness