Psychiatric sheet for postgraduates

‫اﻟﻠﮫم وﻓﻘﻧﻲ ﻹﻧﺟﺎز‬
‫ھذا اﻟﻌﻣل، واﺳﺘﻛﻣﺎل‬
‫ﻣﺎ ﺑدأه أﺳﺘﺎذي‬
‫اﻟدﻛﺘور/ ﻳﺎﺳﺮ رﻳﺎ‬

‫‪Dr. Mohamed Abdelghani‬‬

Updated By Mohamed Abdelghani

I- Psychiatric history

1- Date
2- Informant
3- Source and reason for referral
4- Identifying data of the patient
5- Complaint
6- History of present illness
7- Past illnesses
8- Family history
9- Personal history

1- Date
 Help an appraisal developmant of the case in chronological order.
 May be of great medicolegal importance.

2- Informant
o May be relative, neighbor, friend or police.
o Reliability of the informant must be evaluated.

3- Source and reason for referral
 The source of referral may be the patient himself or a relative or a friend or
the police.
 The reason for referral may be treatment, incompliance of medications or
medicolegal reasons.

4- Identifying data of the patient
i- Name: must be recorded in an obvious place to:
 Facilitate detection of patient sheet.

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 Sex, religion and social class of parents can be known from patient’s
name.
 Unusal name which is not accepted by the patient.
ii- Age:
 Some disease are related to age;
- Senile dementia and Alzheimer’s disease are related to old age.
- Hysteria and psychotic disorders are more common in adulthood.
 Dosage of drugs depends on patient’s age.
 Chronic schizophrenics may experience time standstill ‫.ﺗﻮﻗﻒ ﺗﺎم‬

iii- Sex: although sex can be known from patient’s name, but some names are
confusing like Ragaa, Ismat, etc.
 May be there is gender identity disorder.
 There are diseases related to females like premenstrual dysphoric
disorder, postpartum psychosis.
 Some diseases are more common in males like substance abuse and
antisocial personality disorder, and others are more common in females
like depression and conversion disorder.
iv- Occupation:
1. Indicator of socioeconomic status.
2. Level of intellegence.
3. Some occupations have an influence on patient’s personality.
4. May be aetiology of; intoxication by heavy matals in workers, alcohol
abuse in barmen.
5. Overwork may be cause of nervousness, or symptom of hypomania.
6. Occupational skills may be impaired by patient’s symptoms.
7. Unemployment is associated with psychological distress.
8. Occupation may have a colouring effect on symptomatology as occurs in
occupation delerium.

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v- Marital status:
- Prevalence of mental disorders is as follows; divorced more than single
more than widow more than married.
vi- Residence:
 For follow up of the case.
 Distribution of disease may vary in urban and rural communities.
 Homeless persons may be cause or result of the mental disorder.
vii- Religion: and degree of religiosity must be assessed.

5- Complaint
- The patient complaint:
o Inpatient’s own words.
o State why he or she has come or been brought in for help.
o If the patient is mute, this must be recorded.
- The informant complaint:
 Due to impaired insight of many psychiatric patients, it is
important to take the informant’s complaint.

6- History of present illness
- Comprehensive and chronological picture of the events.
- Onset, precipitating factors, course, duration, severity, effect on patient’s
functions, relation to physical condition, exacerbating events, ameliorating
factors, treatments received and degree of improvement.
- It is prefered to be open-ended questions specially with well-organized patients.

7- Past illnesses
- Past psychiatric episodes; symptoms, extent of incapacity, type of treatment
received, names of hospitals, length of each illness, effect of previous
treatments, and degree of compliance.
- Medical and surgical history, and drugs used in treatment.
- History of substance abuse.
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8- Family history
- Father, mother and sibilings; their relations to each other and to the patient, and
their attitude toward the patient’s illness.
- Financial resources, social class, social norms, religious traditions of the family.
- Psychiatric, neurological, substance use disorders in the family members.

9- Personal history
a- Prenatal and perinatal.
b- Infancy and early childhood.
c- Middle childhood.
d- Adolescence.
e- Young adulthood.
f- Middle adulthood and old age.
a- Prenatal and perinatal
- Full-term pregnancy or premature.
- Vaginal delivery or caesarian.
- Infections and drugs during pregnancy.
- Birth complications.
- Defects at birth.
b- Infancy and early childhood
 Infant-mother relationship.
 Problems with feeding and sleep.
 Significant milestones; standing, walking, first words, two-word.
sentences, and bowel and bladder control.
 Other caregivers.
 Unusual behaviours, e.g. head banging.
c- Middle childhood
o Preschool and school experiences.
o Separations from caregivers.
o Friendships/play.

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o Methods of discipline (‫)اﻟﺘﻬﺬﻳﺐ‬

o Illness, surgery, or trauma.
d- Adolescence
 Onset of puberty.
 Academic achievement.
 Organized activities (sports, clubs)
 Areas of special interest.
 Romantic involvements and sexual history.
 Drug/alcohol use.
 Symptoms (moodiness, irrigularity of sleeping or eating, fights, and
arguments).
e- Young adulthood
 Academic and career decisions.
 Military experience.
 Legal history.
 Work history.
 Marital history and offsprings.
 Religiousity and values.
 Intellectual and leisure activities.
f- Middle adulthood and old age
 Social activities.
 Aspirations. (‫)ﻃﻤﻮﺣﺎت‬

 Major losses.
 Retirement and aging.

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II- Mental state examination

1) Apperance and Behaviour.
2) Emotion.
3) Thinking.
4) Speech.
5) Perception.
6) Sensorium (intellectual functions)=(Cognitive functions).
7) Insight.
8) Judgement.
9) Impulsivity.

(1) Appearance and Behaviour
i. Appearance:
a) Body built:
- height and weight;
o very tall: chromosomal abnormality.
o very thin: anorexia nervosa.
- Body proportions;
 Pychnic (short rounded): more in depressed.
 Asthenic (lean and narrow): more in schizophrenics.
 Atheletic: more in epileptics.
b) Facial appearance:
- Mood: anxious, depressed, happiness.
- Medical conditions with psychiatric importance; thyrotoxicosis, Down’s
syndrome, renal failure and cushing syndrome.
c) General appearance:
 Self care and grooming; hair, nail: may be neglected in schizophrenic, depressed
and addicts.
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 Clothing; colour, appropriateness with age and sex.
ii. Behaviour (Conation):
Sum total of the psyche that includes impulses, motivations, wishes, drives, instincts,
and cravings, as expressed by a person's behavior or motor activity.
a) Social behaviour:
1- Abnormal social contact:
- Decreased in depression and schizophrenia e.g:"poor eye to eye
contact".
- Increased in mania.
2- Inappropriate social behaviour:
e.g. Aggression.
3- Non-social vocalization:
 Schizophrenic and demented patients may talk to themselves.
 In Gilles de la Tourette’s syndrome the patient may utter obscenities.
b) Motor behavior" activity":

i. Quantitative:
1- Decreased in depression.
2- Increased in mania and hypomania.
ii. Qualitative:
1. Abulia: Reduced impulse to act and to think. Occurs as a result of
neurological deficit, depression and schizophrenia.
2. Adiadochokinesia: Inability to perform rapid alternating movements. Occurs
with cerebellar lesions.
3. Adynamia: Weakness and fatigability, characteristic of neurasthenia and
depression.
4. Aerophagia: Excessive swallowing of air. Seen in anxiety disorder.
5. Aggression: forceful, goal-directed action that may be verbal or physical; the
motor counterpart of rage, anger and hostility.
6. Agitated depression: A combination of depressed mood and psychomotor

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agitation. A common presentation of depressive illness in the elderly.
7. Akathisia: A subjective sense of motor restlessness, relieved by repeated
movement of the affected part (usually the legs). A side-effect of treatment
with neuroleptic drugs.
8. Akinesia: Lack of physical movement, as in the extreme immobility of
catatonic schizophrenia or as an extrapyramidal effect of antipsychotic
medication.
9. Akinetic mutism: Absence of voluntary motor movement or speech in an
apparently alert patient (as evidenced by eye movements). Seen in psychotic
depression and catatonic states.
10. Amimia: Lack of the ability to imitate others.
11. Anergia: subjestive lack of energy.
12. Astasia abasia: Inability to stand or to walk in a normal manner, even though
normal leg movements can be performed in a sitting or lying down position.
Seen in conversion disorder.
13. Atonia: Lack of muscle tone.
14. Automatism: automatic performance of acts generally representing
unconscious symbolic activity. This apparently conscious act occurs in
absence of full consciousness "e.g. during TLE".
15. Bradykinesia: Slowness of motor activity.
16. Bruxism: Grinding of the teeth during sleep. Seen in anxiety disorder.
17. Catalepsy (Waxy flexibility): A motor symptom of schizophrenia in which
the patient's limbs can be passively moved to any posture and then held for a
prolonged period of time. Also known as flexibilitas cerea.
18. Cataplexy: Symptom of narcolepsy in which there is sudden loss of muscle
tone leading to collapse. Usually occurs following emotional stress.
Commonly seen in narcolepsy.
19. Catatonic exitement: agitated, purposeless motor activity, uninfluenced by
external stimuli.
20. Catatonic rigidity: Fixed and sustained motoric position that is resistant to

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change.
21. Catatonic stupor: markedly slowed motor activity, often to the point of
immobility although the patient is well aware of their surroundings..
22. Chorea: random and involuntary quick, jerky, purposeless movement.
23. Command automatism: Condition associated with catalepsy in which
suggestions are followed automatically.
24. Compulsion: uncontrollable impulse to perform an act repetitively.
25. Constructional apraxia: Inability to copy a drawing, such as a cube, clock,
or pentagon, as a result of a brain lesion.
26. Coprophagia: Eating of filth or feces.
27. Dependence: The inability to control intake of a substance to which one is
addicted. Dependence has two components:
 Physiological dependence: is the physical consequences of withdrawal
and is specific to each drug.
 Psychological dependence: is the subjective feeling of loss of control,
cravings, and preoccupation with obtaining the substance.
 For some drugs (e.g. alcohol) both psychological and physiological
dependence occur; for others (e.g. LSD) there are no marked features of
physiological dependence.
28. Diogenes syndrome: Hoarding of objects, usually of no practical use, and the
neglect of one's home or environment. May be a behavioural manifestation
of an organic disorder, schizophrenia, depressive disorder, obsessive-
compulsive disorder; or a certain type of personality.
29. Disinhibition: Loss of the normal sense of which behaviours are appropriate
in the current social setting. Occurs in manic illnesses, the later stages of
dementing illnesses and during intoxication with drugs or alcohol.
30. Dyskinesia: Difficulty in performing voluntary motor activity by
superimposed involuntary motor activity.
31. Dyspraxia: Inability to carry out complex motor tasks (e.g. dressing, eating)
although the component motor movements are preserved.

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32. Dystonia: slow sustained contractions of the trunk or limbs.
33. Echopraxia: Pathological imitation of movements of one person (usually the
examiner) by the patient.
34. Encopresis: Involuntary passage of feces, usually occurring at night or
during sleep.
35. Enuresis: Incontinence of urine during sleep.
36. Extra-pyramidal side-effects (EPSE): Side-effects of rigidity, tremor, and
dyskinesia caused by the anti-dopaminergic effects of psychotropic drugs,
particularly neuroleptics. Unlike in idiopathic Parkinson's disease,
bradykinesia is not prominent.
37. Floccillation: Aimless picking, usually at bedclothes or clothing, commonly
seen in dementia and delirium.
38. Hemiballismus: Involuntary, large-scale, "throwing" movements of one limb
or one body side.
39. Mannerism: ingrained, habitual involuntary movement.
40. Micrographia: Small "spidery" handwriting seen in patients with Parkinson's
disease; a consequence of being unable to control fine movements.
Recognised by comparing their current signature with one from a number of
years previously.
41. Mimicry: Simple, imitative motion activity of childhood.
42. Mitgehen :An extreme form of mitmachen where the patient's limbs can be
moved to any position by very slight or fingertip pressure.
43. Mitmachen: A motor symptom of schizophrenia where the patient's limbs
can be moved without resistance to any position. The limbs return to their
resting state once the examiner lets go, in contrast with catalepsy, where the
limbs remain in their set positions for prolonged time.
44. Motor symptoms of schizophrenia :
 Schizophrenia is associated with a variety of soft neurological signs and
motor abnormalities.
 Motor symptoms include; catatonia, catalepsy, automatic obedience,

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negativism, ambitendency, mitgehen, mitmachen, mannerism,
stereotypy, echopraxia, and psychological pillow.
45. Negativism: motiveless resistance to all attempts to be moved or to all
instructions (or even doing the opposite).
46. Nymphomania: Abnormal, excessive, insatiable desire in a woman for sexual
intercourse.
47. Pantomime: Gesticulation; psychodrama without the use of words.
48. Pica: Craving and eating of nonfood substances, such as paint and clay.
49. Posturing: The maintenance of bizarre and uncomfortable limb and body
positions. Associated with psychotic illnesses and may have delusional
significance to the patient.
50. Psychogenic polydipsia: Excessive fluid intake without organic cause.
51. Psychological pillow: A motor symptom of schizophrenia. The patient holds
their head several inches above the bed while lying and can maintain this
uncomfortable position for prolonged periods of time.
52. Psychomotor agitation: excessive motor and cognitive activity, usually non-
productive and in response to inner tension.
53. Psychomotor retardation: Decrease and slowness of spontaneous voluntary
movement. Usually associated with subjective sense of tiredness and
subjective retardation of thought. Occurs in moderate to severe depressive
illness.
54. Ritual: Formalized activity practiced by a person to reduce anxiety, as in
OCD. OR: Ceremonial activity of cultural origin.
55. Satyriasis: Morbid, insatiable sexual need or desire in a man.
56. Sleep walking (somnambulism): motor activity during sleep.
57. Stereotypy: repetitive fixed pattern of physical action or speech.
58. Tardive dyskinesia: A movement disorder in which there is continuous
involuntary movement of the tongue and lower face. More severe cases
involve the upper face and have choreoathetoid movements of the limbs. It's
associated with long-term treatment with neuroleptic drugs.

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59. Tic: involuntary, spasmodic motor movement.
60. Twirling: Sign present in autistic children who continually rotate in the
direction in which their head is turned.

Commentary sample
 The pt. has an average body built, sitting calm in the chair, properly groomed
with appropriate self care "cleaned hands, nails cut, shaving his beard" with
appropriate clothing and appears healthy.
 He is cooperative, interested and interactive.

(2) Emotion
☺Emotion: is a complex phenomenon involving reactions in 3 distinct components;
a) Affective component: feeling experienced by the subject (e.g joy, anger,
sadness …).
b) Behavioral (expressive) component = "Skeletal & muscular component".
c) Autonomic and endocrine component.
☺Mood: is used to describe the sustained emotional tone and the subjective
(experienced) aspect of emotion.
 Euthymic mood: narmal range of mood, implying absence of depressed or
elevated mood.
☺Affect: short-lived feeling state and may be used to describe the objective
(observable) aspect of emotion.
o Appropriate affect: condition in which the emotional tone is in harmony with
the accompanying idea, thought or speech.
N.B: In clinical practice, both mood and affect are used interchangeably.

Abnormalities of Emotion
A. Abnormal emotional predisposition: long standing disposition (trait):
I- Dysthymia; the person tends to be always sad.
II-Hyperthymia; tends to be overcheerful.
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III- Cyclothymia; tends to swing markedly from happyness to sadness.
IV- Affectless; tends to show no emotional response (indifferent).
B. Abnormal emotional reactions: temporary (changeable) emotional states:
I. Quantitative emotional disorders:

a. Abnormally intensified emotional reactions:

1- Unpleasant mood:
 Depression: pathological feeling of sadness.
 Dysthymia: Chronic, mildly depressed mood and diminished
enjoyment, not severe enough to be considered depressive illness.
 Double depression: A combination of dysthymia and depressive illness.
 Grief.
 Bereavement: Feeling of grief or desolation, especially at the death or
loss of a loved one.
 Mourning: Syndrome following loss of a loved one, consisting of
preoccupation with the lost individual, weeping, sadness, and repeated
reliving of memories.
 Guilt: Emotional state associated with self-reproach and the need for
punishment. Distinguished from shame as shame is a less internalized
form of guilt that relates more to others than to the self.
 Dysphoric mood: an unpleasant mood.
 Anhedonia: loss of interest in, and withdrawal from, all regular and -
pleasurable activities, often associated with depression.
 Alexithymia: a person’s inability to, or difficulty in, describing or being
aware of emotion or mood.
 Anxiety: it is emotional state related to feer but has no justifiable cause
(unreasonable fear) and has 2 components;
- Psychological arousal "Psychic component": feeling of
apprehention and anticipation that danger is about to happen.

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- Physiological arousal "Dysmorphic component": with somatic and
autonomic nervous system manifestations.
Anxiety may be free floating (not attached to any idea) or phobic
(fear is focussed on specific objects and out of proportion to the
real danger, and can't be reasoned and leads to avoidance of feared
situation).
 Irritability: feelin state of reduced control over temper, usually leads to
verbal or behavioral outbursts.
 Intropunitive: Turning anger inward toward oneself. Commonly
observed in depressed patients.
 Agitation: severe anxiety associated with excess and purposeless motor
activity.
 Tension: increased and unpleasant motor and psychological activity.

2- Pleasant mood:
 Elation: Air of enjoyment, euphoria, triumph, intense self-confidence,
or optimism, in manic patients elation has an infectious quality "but
not necessarily pathological".
 Euphoria: generalized sense of well-being, with lack of concern for
physical or mental illness "differs from elation in that it has no
infectious quality and always pathological".
 Exaltation ‫ : زﻫﻮ‬element of grandier in addition to the elation.

 Ecstacy ‫ : ﻧﺸـﻮة‬feeling of intense rapture, in this uplifted mood there is

usually some mystical religious colouring, and the patient feels happy,
peaceful and calm.
 Ineffability: Ecstatic state in which persons insist that their
experience is inexpressible and indescribable.
 Unio mystica: Feeling of mystic unity with an infinite power.
 Expansive mood: a person’s expression of feelings without restraint,
frequently with overestimation of their significance or importance.

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b. Abnormally reduced emotional reaction:
1. Emotional dullness: reduction of emotion is more in expression than in
experience.
2. Emotional indifference: the patient experiences the emotion but shows
no expression of it. "i.e. The severe degree of emotional dullness".
3. Apathy: (absence of affect) the patient neither experiences nor
expresses emotions.
4. Emotional blunting: reduction in both emotional experience and
expression, the extreme degree is apathy.
5. Constricted or ristricted affect: reduction in intensity of feeling tone,
less severe than blunted but clearly reduced.

II. Qualitative emotional disorders:
1- Incongruity (disharmony) of affect: inappropriateness of affect to thought
content.
2- Labile affect ‫ :ﺗﻘﻠـﺐ اﳌـﺰاج‬Fluctuation or instability of emotion, unrelated to

external stimuli. May be found in multiple sclerosis, multiple infarcts
dementia, schizophrenia, biploar disorders.
3- Inappropriate affect: disharmony between the emotional feeling tone and
the idea, thought, or speech accompanying it.
4- Ambivalence: coexistence of two opposing feelings or attitudes toward the
same thing in the same person at the same time. (e.g. love and hate).

☺N.B.: Negative symptoms of schizophrenia:
 The symptoms which reflect impairment of normal function.
 They are: lack of volition, lack of drive, apathy, anhedonia, flattening of
affect blunting of affect, and alogia.
 Believed to be related to cortical cell loss.

☺N.B.: Acathexis (decathexis):
o Lack of feeling associated with an ordinarily emotionally charged subject.

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o In psychoanalysis, it denotes the patient's detaching of emotion from
thoughts and ideas.
o Occurs in anxiety, dissociative, schizophrenic, and bipolar disorders.

☺N.B.: Cathexis: In psychoanalysis, a conscious or unconscious investment of
psychic energy in an idea, concept, object, or person.

☺N.B.: Dyspareunia: Physical pain in sexual intercourse, usually emotionally
caused and more commonly experienced by women; can also result from cystitis,
urethritis, or other medical conditions.

(3) Thinking

Def: Goal-directed flow of ideas, symbols, and associations initiated by a problem or
task and leading toward a reality-oriented conclusion; when a logical sequence
occurs, thinking is normal.

Other terms:

1. Primary process thinking:

 Mental activity directly related to the id and characteristic of unconscious
mental processes.
 Marked by primitive, prelogical thinking and by the tendency to seek
immediate gratification of instinctual demands.
 Includes thinking that is dereistic, illogical, magical.
 Normally found in dreams, abnormally in psychosis.

2. Secondary process thinking:

o The form of thinking is logical, organized, reality oriented, and influenced by
the demands of the environment.
o Characterizes the mental activity of the ego.

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3. Abstract thinking: is the ability to form concepts on the basis of summerizing or
generalizing attributes of some objects or events.
4. Autistic thinking (dereism): Thinking in which the thoughts are largely
narcissistic and egocentric, with emphasis on subjectivity rather than objectivity,
and without regard for reality. Seen in schizophrenia and autistic disorder.
5. Magical thinking: A belief that certain actions and outcomes are connected
although there is no rational basis for establishing a connection (e.g. if you step
on a crack, your mother will break her back). Magical thinking is common in
normal children and psychotic patients.
6. Fantasy (Daydream): fabricated mental picture of a situation or chain of events.

7. Parapraxis (Freudian slip):uncosciously motivated lapse from logic, considered
part of normal thinking.
8. Hyperpragia: Excessive thinking and mental activity. Generally associated with
mania.

Thought disorders
may be classified according to stream, form, possession and content of thought:

I- Stream of thought:
1- Too rapid:
 Logorrhoea; endless trivial talk (pressure of thought).
 Flight of ideas: switches rapidly from one topic to another, however the
train of thought can be followed (d.d: loosening of association).
2- Too slow:

o Various degrees of retardation up to mutism.
o Alogia: Absence of spontaneous speech due to poverty of thoughts . A
negative symptom of schizophrenia and a symptom of depressive illness.
3- Interrupted:
 Thought blocking, "Entgleiten", "snapping off", "thought
deprivation" or "increased thought latency": abrupt interruption

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in train of thought before a thought or idea is finished; after a
brief pause, a person indicates no recall of what was being said
or was going to be said, the patient feels suddenly that his mind
has gone blank.
 Lethologica: Momentary forgetting of a name or proper noun.

II- Form of thought:
It refers to the manner in which thoughts, as reflected in speech, are linked in
language.
Formal thought disorder: disturbance in the form of thought rather than the
content of thought; thinking characterized by loosened associations, neologisms, and
illogical constructs. It's subdivided into:
A. -ve Formal thought disorder: concrete thinking.
B. +ve Formal thought disorder:
1- Loosening of associations = (asyndetic thinking) = (Asyndesis): flow of
thought in which ideas shift from one subject to another in a completely
unrelated way.
2- Incoherence: thought that generally is not understandable; running
together of thoughts or words with no logical or grammatical connection,
resulting in disorganization.
3- Derailment "Entgleisen" or "Knight's move thinking": gradual or sudden
deviation in train of thought without blocking, sometimes used
synonymously with loosening of association.
4- Word salade(Schizophasia): incoherent mixture of words and phrases. It's
the most severe degree of schizophrenic thought disorder in which there is
no connection between words and phrases.
5- Condensation (Fusion or Verschmelzung): fusion of various concepts into
one compound idea.
6- Muddling (Faseln) ‫ : ﻣ ﺰج وﺗﺸ ﻮﯾﺶ‬A feature of schizophrenic thought disorder
caused by simultaneous derailment and fusion. The speech so produced
may be very bizarre.
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7- Perseveration: persisting response (verbal or motor) to a previous
stimulus after a new stimulus has been presented; often associated with
cognitive disorders.
8- Verbigeration: meaningless repetition of specific words or phrases while
unable to articulate the "next" word in the sentence. Seen in expressive
dysphasia.
9- Irrelevant answer: not in harmony with question asked.
10- Circumstanciality: indirect speech that is delayed in reaching the point but
eventually gets from original point to desired goal; characterized by
overinclusion of details.
11- Tangentiality: inability to have goal-directed associations of thought;
speaker never gets from point to desired goal.
12- Evasion ‫ :اﻟﺘﮭ ﺮب‬Act of not facing something; consists of suppressing an
idea that is next in a thought series and replacing it with another idea
closely related to it. Also called paralogia and perverted logic.
13- Echolalia: psychopathological repeating of words or phrases of one
person by another; tends to be repetitive and persistent.
14- Flight of ideas: rapid, continuous verbalizations which produce constant
shifting from one idea to another; ideas tend to be connected, and in the
less severe form a listener may be able to follow them.
15- Neologism: new word created by a patient, often by combining syllables
of other words, for idiosyncratic ‫ ﺷﺨﺼﯿﺔ/ذاﺗﯿﺔ‬pathological reasons.
16- Clang association: association of words similar in sound but not in
meaning; words have no logical connection.

III- Possession of thought:
1. Thought withdrawal: delusion that thoughts are being removed from a
person’s mind by other persons or forces.

2. Thought insertion: delusion that thoughts are being implanted in a person’s
mind by other persons or forces.

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3. Thought broadcasting: delusion that a person’s thoughts can be heared by
others, as though they were being broadcast over the air.

IV- Content of thought:
A. Poverty of content:
- Thought that gives little informationbecause of vagueness, empty
repetitions, or obscure phrases.
B. Overvalued idea:
- Unreasonable, sustained false belief, maintained less firmly than a
delusion.
- Dysmorphophobia: A type of over-valued idea where the patient
believes one aspect of his body is abnormal or conspicuously deformed.
C. Preoccupation or trend of thought:
 Centering of thought content on a particular idea, associated with a strong
affective tone, such as paranoid trend or a suicidal or homicidal
preoccupation.
N.B.1: Egomania: pathological self-preoccupation.
N.B.2: Monomania; preoccupation with a single object.
D. Hypochondria "Hypochondriasis":
o Exaggerated concern about health that is based not on real organic
pathology but on unrealistic interpretations of physical signs or sensations
as abnormal.
E. Obsession:
 Pathological persistence of an irresistible thought, feeling, idea, image or
impulse that can not be eliminated from consciousness by logical effort;
associated with anxiety and against one's will.
 Patterns of obsessions:
- Dirt and contamination.
- Aggression.
- Orderliness.
- Illness.
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- Sex.
- Religion.
N.B.: Anancasm: Repeated or stereotyped behavior or thought usually used as
a tension-relieving device; used as a synonym for obsession and seen in
obsessive-compulsive (anankastic) personality.
F. Rumination:
o A compulsion to engage in repetitive and pointless thinking about a single
idea or theme, usually of a pseudo-philosophical nature, "as in OCD".
G. Compulsion:
 Pathological need to act on an impulse that, if resisted, produces anxiety.
 Repititive behaviour occurs in response to an obsession and performed
according to certain rules, with no true end in itself other than to prevent
something from occurring in the future.
 Coprolalia: compulsive utterance of obscene words.
 Trichotillomania: The compulsion to pull one's hair out.
 Kleptomania: Pathological compulsion to steal.
 Dipsomania: Compulsion to drink alcoholic beverages.
H. Delusion:
o False fixed belief, based on incorrect inference about external reality, not
consistent with patient’s intelligence and cultural background; cannot be
corrected by reasoning.
o Delusion is classified into:
 Primary delusions: are the direct result of psychopathology.
 Secondary delusions: arise in response to other primary psychiatric
conditions.

i. Primary delusions: subdivided according to:
 The method by which they are perceived as having arisen:
If the patient is asked to recall the point when they became aware of
the delusion, they may report that:

22


o The belief arose: "out of the blue" (autochthonous delusion): fully
formed 1ry delusion that arises suddenly with out explanation
. "‫"اﻟﻤﺮﯾﺾ ﻓﺠﺄة ﯾﻌﺘﻘﺪ أﻧﮫ ورث أرﺿﺎ ﻛﺜﯿﺮة ﺗﻮﻓﺮ ﻟﮫ اﻟﻤﺎل اﻟﻼزم ﻻﺳﺘﺮﺟﺎع أﻣﻮاﻟﮫ اﻟﺘﻲ ﺳﻠﺒﮭﺎ ﻣﻨﮫ اﻵﺧﺮون‬
o On seeing a normal percept (delusional perception).
o On recalling a memory (delusional memory).
o On a background of anticipation, odd experiences, and increased
awareness (delusional mood).
 Broad classes based on their content:
 12 types of primary delusion are commonly recognised:
persecutory delusions, grandiose delusions, delusions of control,
delusions of thought interference, delusions of reference, delusions
of guilt, delusional misidentification, hypochondriacal delusions,
delusional jealousy, delusions of love, nihilistic delusions, and
delusions of infestation.
N.B1.: Delusional memory: A primary delusion which is recalled as arising as a
result of a memory (e.g. a patient who remembers his parents taking him to hospital
for an operation as a child becoming convinced that he had been implanted with
control and monitoring devices which have become active in his adult life).
N.B2.: Delusional mood "Delusional atmosphere": A primary delusion which arises
following a period of an abnormal mood state characterised by anticipatory anxiety, a
sense of "something about to happen", and an increased sense of the significance of
minor events. The development of the formed delusion may come as a relief to the
patient in this situation.
N.B3.: Delusional perception: A primary delusion which arises as a result of a real
perception (e.g. a patient who, on seeing two white cars pull up in front of his house
became convinced that he was therefore about to be wrongly accused of being a
paedophile). The percept is a real external object, not a hallucinatory experience.

23


ii. Secondary delusions: subdivided according to:
a- The dominant theme:
1. Health:
- Hypochondriacal delusions.
2. Financial status:
- Delusion of poverty: a person’s false belief that he or she is
bereft or will be deprived of all material possessions.
3. Moral worth:
- Delusion of self-accusation "D. Of self reproach, sin or
guilt": false feeling of remorse and guilt.
4. Relation to others "Paranoid delusions" include:
- Delusion of persecution: a person’s false belief that he is
being harassed, or persecuted "e.g. watched, followed,...".
- Delusion of grandeur: a person’s exaggerated conception of
his importance, power, or identity.
- Delusion of reference: a person’s false belief that the
behaviour of others refers to himself " e.g. people refer to
him, talk about him, laugh at him,...".
- Delusion of control (Passivity phenomena): false feeling that
a person’s will, thoughts, or feelings are being controlled by
external forces.
5. Others:
- Nihilistic delusion: false feeling that self, others, or the world
is nonexistent or coming to an end or no longer exist. A
feature of psychotic depressive illness.
- Somatic delusion "Hypochondriacal delusions": A delusional
belief that one has a serious physical illness (e.g. cancer,
AIDS). Most common in psychotic depressive illnesses.
- Cotard syndrome: a combination of severely depressed mood
with nihilistic delusions and/or hypochondriacal delusions.

24


Seen in psychotic depressive illness particularly in elderly
people.
- Delusion of infidility (delusional jealousy): false belief
derived from pathological jealousy about a person’s lover
being unfaithful.
- Othello syndrome (Ey syndrome): A monosymptomatic
delusional disorder where the core delusion has the content of
delusional jealousy.
- Erotomania (delusions of love): delusional belief, more
common in women, that someone is deeply in love with them
(De Clerambault syndrome).
- Delusions of infestation: A delusional belief that one's skin is
infested with multiple, tiny mite-like animals. It may be seen
in acute confusional states (particularly secondary to drug or
alcohol withdrawal), in schizophrenia or in dementing
illnesses.
- Ekbom syndrome: A monosymptomatic delusional disorder
where the core delusion is a delusion of infestation.
- Folie a deux: Mental illness shared by two persons with a
close relationship, usually involving a common delusional
system. Arises as a result of a psychotic illness in one
individual with development of a delusional belief, which
comes to be shared by the second. The delusion resolves in
the second person on separation, the first should be assessed
and treated in the usual way. If it involves three persons, it is
referred to as folie a trois, and so on. Also called shared
psychotic disorder.
- Delusional elaboration: Secondary delusions which arise in a
manner as the patient attempts to find explanations for
primary psychopathological processes (e.g. a patient with

25


persistent auditory hallucinations developing a belief that a
transmitter has been placed in his ear).
- Delusional misidentification: A delusional belief that certain
individuals are not who they externally appear to be. A rare
symptom of schizophrenia or of other psychotic illnesses. It
includes:
 Fregoli syndrome: A type of delusional
misidentification in which the patient believes that
strangers have been replaced with familiar people.
 Capgras syndrome: A type of delusional
misidentification in which the patient believes that a
person known to them has been replaced by a
"double" who is to all external appearances identical,

but is not the "real person".
- Delusions of thought interference: A group of delusions
which are considered first-rank symptoms of schizophrenia.
They are thought insertion, thought withdrawal, and thought
broadcasting.
- Pseudocyesis (A false pregnancy): May be hysterical or
delusional in nature and can occur in both sexes although
more commonly in women. A nonpregnant patient has the
signs and symptoms of pregnancy, such as abdominal
distention, breast enlargement, pigmentation, cessation of
menses, and morning sickness.
- Couvade syndrome: A conversion symptom seen in partners
of expectant mothers during their pregnancy. The symptoms
vary but mimic pregnancy symptoms and so include nausea,
vomiting, abdominal pain, and food cravings. It is not
delusional in nature; the affected individual does not believe

26


they are pregnant (compared with pseudocyesis). This
behaviour is a cultural norm in some societies.
b- The number of themes:
e.g. monomania.
c- The degree of systematization:
o Bizarre delusion: False belief that is patently absurd or fantastic.
o Systematized (non bizarre) delusion: false belief united by single
event or theme. Its content is usually within the range of possibility.
d- The degree of fixation:
 Fleeting "changable": more in Bizarre delusion.
 Fixed "stable": more in Systematized (non bizarre) delusion.
e- The congruity of mood:
 Mood-congruent delusion: delusion with mood-appropriate content.
 Mood incongruent delusion: delusion with content that has no
association to mood or is mood neutral.
I. Phobia:
 Persistent, irrational, exaggerated, and invariably pathological dread of a
specific stimulus or situation; results in a compelling desire to avoid the
feared stimulus.
 Subdivided into:
a. Social phobia: dread of public humiliation, as in fear of public
speaking, performing or eating in public.
b. Specific phobia: circumscribed dread of a discrete ‫ ﻣﻤﯿ ﺰ‬object or
situation. It includes:
1. Agoraphobia: dread of open places.
2. Claustrophobia: dread of closed places.
3. Acrophobia: Dread of high places.
4. Zoophobia: Abnormal fear of animals.
5. Ailurophobia: Dread of cats.

27


6. Algophobia: Dread of pain.
7. Needle phobia: Pathological fear of receiving an injection.
8. Erythrophobia: Abnormal fear of blushing.
9. Xenophobia: Abnormal fear of strangers.
10. Panphobia: Overwhelming fear of everything.

(4) Speech
Ideas, thoughts, feelings are expressed through language; communication through the
use of words and language.

Speech abnormalities
I. Quantitative:
1- Amount of speech:
 Increased: (volubility, logorrhoea, tachylogia, verbomania or verbal
diarrhoea): Excess speech; Symptom of mania.
 Decreased (poverty of speech or laconic speech); the extreme diminution
of speech is mutism.
2- Rate of speech: too fast (pressure of speech), or too slow (bradylalia).
3- Pauses in speech: shortened pauses, or prolonged pauses.
4- Loudness of voice: excessive loud, or soft speech.
II. Qualitative:
1- Dysarthria: disorder of articulation of speech.
2- Lalling: babish articulation.
3- Aphonia: loss of the ability to phonate "vocalize".
- Causes:
i. Structural:
 Vocal cord lesions.
 9th cr. n. lesion.
 Higher centres lesions.
28


ii. Functional:
- Conversion.
- To differentiate between both; ask the pt. to cough: if he does, it's
functional.
4- Stuttering: repitition of syllable; stut-tut-tuttering.
5- Stammering: lrolonged stress on a letter; stammmmering.
6- Cluttering: fluency disturbance involving an abnormally rapid rate and erratic
rhythm of speech that impedes intelligibility; the affected individual is usually
unaware of communicative impairment.
7- Logoclonia :Symptom of Parkinson's disease where the patient gets "stuck" on
a particular word of a sentence and repeats it.
8- Dyslalia: Faulty articulation caused by structural abnormalities of the
articulatory organs or impaired hearing.
9- Bradylalia: Abnormally slow speech. Common in depression.
10- Echolalia: repitition of words or phrases heard.
11- Glossolalia: "Speaking in tongues": Unintelligible jargon that has meaning to
the speaker but not to the listener. Occurs in schizophrenia, dissociative and
neurotic disorders and accepted as a sub-cultural phenomenon in some
religious groups.
12- Aculalia: Nonsense speech associated with marked impairment of
comprehension. Occurs in mania, schizophrenia, and neurological deficit.
13- Cryptolalia: A private spoken language.
14- Coprophrasia "Coprolalia": involuntary use of vulgar or obscene language;
seen in Tourett’s disorder.
15- Paraphasia: Abnormal speech in which one word is substituted for another,
the irrelevant word generally resembling the required one in morphology,
meaning, or phonetic composition, such as clover instead of hand, or treen
instead of train. Seen in organic aphasias and in mental disorders such as
schizophrenia.

29


16- Word approximation: Use of conventional words in an unconventional way
(e.g., handshoes for gloves and time measure for clock); distinguished from a
neologism, which is a new word whose derivation cannot be understood.
17- Holophrasia: Using a single word to express a combination of ideas. Seen in
schizophrenia.
18- Aphasia: inability of the formulation of speech.
- Types:
(i) Sensory or receptive aphasia (fluent aphasia): due to defect of
perception:
1. Visual: visual agnosia.
2. Auditory: auditory agnosia.

(ii) Motor or expessive aphasia(nonfluent aphasia): due to defect of
execution:
1. Verbal aphasia: lesion in Broca’s area (area 44).
2. Agraphia: lesion in exner’s area (area 45).
(iii) Jargon’s aphasia: due to defect of association (area 37 or
association fibers), the patient can speek but the words are
meaningless.
19- Global aphasia: Combination of grossly nonfluent aphasia and severe fluent
aphasia.
20- Nominal aphasia: Aphasia characterized by difficulty in giving the correct
name of an object.
21- Acataphasia: Disordered speech in which statements are incorrectly
formulated. Patients may express themselves with words that sound like the
ones intended, but are not appropriate to the thoughts.
22- Dysprosody: Loss of normal speech melody (prosody). Common in depression.
.‫وﺗﻌﻨﻲ ﻋﺪم ﺗﻤﺎﺷﻲ اﻟﺼﻮت ﻣﻊ ﺳﯿﺎق اﻟﻜﻼم ﻣﻦ ﺣﯿﺚ اﻹﯾﻘﺎع وﻣﺴﺘﻮى ارﺗﻔﺎع واﻧﺨﻔﺎض اﻟﺼﻮت‬
23- Stock phrases/stock words: Feature of schizophrenic speech disorder. The use
of particular words and phrases more frequently than in normal speech and
with a wider variety of meanings than normal.
30


24- Metonymy: Speech disturbance common in schizophrenia in which the affected
person uses a word or phrase that is related to the proper one but is not
ordinarily used; for example, the patient speaks of consuming a menu rather
than a meal.
Commentary sample
 In depression: the pt. talks very little, his speech is slow with long pauses and
low voice.
 In mania: the pt. talks too much, too fast, continously and with loud voice.
(5) perception
- Def.: Process by which a person interprets sensory stimuli.
- Also, it means sensation plus meaning.
- If the sensory stimuli located in the environment, the perception called exteroception.
- If in the body, it is called interoception.
- If on a poorly located mental stage, it is called introspection ‫.اﻻﺳﺘﺒﻄﺎن/ﻓﺤﺺ اﻟﺬات‬
N.B.: Apperception: Awareness of the meaning and significance of a particular
sensory stimulus as modified by one's own experiences, knowledge, thoughts, and
emotions.

Disorders of perception
I. Sensory distortion:
 Changes in the perceived intensity or quality of a real external stimulus.
 Associated with organic conditions and with drug ingestion or withdrawals.
 It may be quantitative or qualitative:
(a) Quantitative sensory distortion:
1- Hypersensitivity: e.g. hyperacusis (low sound is heard very loud).
2- Hyposensitivity: hypoanaesthia or anaesthesia.
(b) Qualitative sensory distortion:

- e.g. Xanthopsia (visual sensations are tinged with yellow colour after
poisoning with sulphonamides or digitalis).

31


II. Sensory deception:
- Disorders in perceptual recognition which take place at the higher level than
the processing of primary sensory information.
- Examples: hallucination, pseudohallucination, illusion, and agnosia.

(A) Hallucination:
- False sensory perception not associated with real external stimuli.
- Classification of hallucinations:
 According to complexity:
1- Elementary (unformed) hallucination: e.g. whistles, flashes of
light.
2- Complex (formed) hallucination: e.g. voices, faces, or scenes.
 According to sensory modality:
1- Auditory; hearing noises or voices, most common in psychotic
disorders.
2- Visual; seeing flashes of light, faces, or scenes, most common
in delerium and substance-related disorder.
3- Olfactory hallucination, most common in epilepsy.
4- Gustatory hallucination, most common in medical disorders
e.g.: Uncinate seizures.
5- Tactile (haptic): false perception of touch or or surface
sensation.
6- Somatic; false sensation of things occurring in or to the body,
most often of visceral origin (Cenesthetic hallucination).
 According to associated mood:
1- Mood-congruent hallucination: hallucination in which the
content is consistent with either a depressed or a manic mood
(depressed patient hears voices saying that he is a bad person:
a manic patient hears voices saying that the patient is of
inflated worth, power and knowledge).
32


2- Mood-incongruent hallucination: hallucination in which the
content is not consistent with either a depressed or a manic
mood (in depression, hallucinations not involving such themes
as guilt, deserved punishment or inadequacy: in mania,
hallucinations not involving themes as inflated worth, power).
 According to special characteristics:
1- In auditory hallucination:
- Voices may be:
(a) Talking to the patient directly (Second-person
hallucination).
(b) Commanding voice, instructing the patient towards a
particular action (Command hallucination or
teleological hallucination).
(c) Talking to one another referring to the patient as he or
she (Third-person hallucination) = (Running
commentary) = (Voices heard arguing).
(d) Speeking the patient’s thoughts as he is thinking them;
voices anticipate what the pt. will think
(Gedankenlautwerden).
(e) Repeating the patient’s thoughts immediately after he
has thought them; voices repeat what the pt. thinks,
immediately after he has thought them (Echo de la
pensee).
2- Imperative hallucination:
- A combination of command hallucination, and
passivity of action in which the hallucinatory
instruction is experienced as irresistible.

33


3- Extracampine hallucination:
- Hallucinations come from outside the field of
perception (e.g. a patient in Edinburgh "hearing"
voices seeming to come from a house in Glasgow).
- In visual hallucination; hallucinations come from outside
the field of vision; e.g. behind the patient.
4- Negative hallucination:
- Failure to perceive things are present; occurs during
dissociative states.
5- Refex hallucination (Synaesthesia):
- Stimulus in one sensory modality, results in a hallucination
in another; e.g. music may provoke visual hallucination,
"tasting sounds" or "hearing colours").
- This may occur with hallucinogenic drug intoxication
"LSD" and in epileptic states.
6- Autoscopic hallucinations "Autoscopy or Phantom mirror image":
- Visual hallucination or pseudohallucination of oneself for
short periods.
- Though rare, it may occur in sensory deprivation, temporal
lobe epilepsy, near death experience, and psychiatric
disorders.
- If the experience accompanied by the conviction that the
person has a double it is called doppelganger.
7- Hypnagogic hallucination:
- Occurs at the point of falling asleep.
- It may occur briefly in healthy peolple and persistently in
narcolepsy.
34


8- Hypnopompic hallucination:
- Occurs at the point of waking.
- It may occur briefly in healthy peolple and persistently in
narcolepsy.
9- Formication:
- A form of tactile hallucination in which there is the
sensation of numerous insects crawling over the surface of
the body.
- Occurs in alcohol or drug withdrawal, particularly from
cocaine.
10- Hallucinosis:
- State in which a person experiences hallucinations without
any impairment of consciousness.

(B) Pseudohallucinations:
 Similar to hallucinations but do not meet all the requirements of the
definition.
 A false perception which is perceived as occurring as part of one's
internal experience, not as part of the external world.
 They may be described as having an "as if" quality or as being seen with
the "mind's eye".
 Additionally, hallucinations experienced as true hallucinations during the
active phase of a patient's illness may become perceived as pseudo-
hallucinations as they recover.
 They can occur in all modalities of sensation and are described in
psychotic, organic, and drug-induced conditions as well as occasionally
in normal individuals; "The hallucinations of deceased spouses
35


commonly described by widows and widowers may have the form of a
pseudo-hallucination".
 Ther are of two types: perceived type and imaged type:

Pseudo-hallucination Pseudo-hallucination
Hallucination Imagery ‫اﻟﺘﺨﻴﻞ‬
(perceived type) (imaged type)

- Appears in - Appear in - Occurs in inner - Occurs in inner
external space. external space. space. space.

- Three - Detailed photo-
- Flattened and - Flattened and lacks
dimentional graphic reproduction
lacks vividness. vividness.
and vivid. of objects seen.

- Independent
- Independent of - Independent of the - Under control of
of the will.
the will. will. will.

- Insight: lost - Recognized as not
- Recognized as
(accepted by - Recognized as not true "product of
not true
the subject as true. individual’s own
perception.
real). mind".

(C) Agnosia:
- From Greek word “agnostos”: (unkown).
- It is inability to recognize and interpret the significance of sensory
impressions.
- It includes:
1- Visual agnosia: the object can’t recognized by sight, due to lesion
in occipital areas 18,19.

36


2- Picture agnosia (simultagnosia): inability to comprehend more
than one element of a visual scene at a time or to integrate the
parts into the whole.
3- Auditory agnosia: failure to recognize familiar sounds although
hearing is not impaired, due to lesion in area 22.
4- Asteriognosis: inability to recognize objects by touch, due to
cortical sensory loss.
5- Spatial agnosia: Inability to recognize spatial relations.
6- Anosognosia: Inability to recognize a physical deficit in oneself
(e.g., patient denies paralyzed limb).
7- Prosopagnosia: Inability to recognize familiar faces that is not
caused by impaired visual acuity or level of consciousness.
8- Somatopagnosia(ignorance of the body and autotopagnosia):
Inability to recognize a part of one's body as one's own.

(D) Illusion:
 Misinterpretation of an external stimulus.
 It occurs pathologically in delerim and as a normal phenomenon
used by experts in camouflage, fashion designers, or experimental
psychologist.
 According to the type:
1- Affect illusion:
- A combination of heightened emotion and misperception
(e.g. whilw walking in the dark, seeing a tree moving in
the wind as an attacker).
2- Completion illusions:
- Rely on our brain's tendency to "fill-in" missing parts of an
object to produce a meaningful percept and are the basis
for many types of optical illusion.
 Both these types of illusions resolve on closer attention.

37


3- Pareidolic illusions:
- Are meaningful percepts produced when experiencing a
poorly defined stimulus, (e.g. seeing faces in a fire or
clouds).
 According to the sensory modality:
1- Auditory: e.g. the yowling of a cat may be heard by a mother
as the cry of her child.
2- Visual: e.g. a tree in the dark night may be seen by a
frightened man as a threatening ghost.

III. Disorders of self-awareness (depersonalization):
o A person’s subjective sense of being unreal, strange, or unfamiliar.
o It is one of dissociative disorders and the insight is preserved.
o It is often accompanied by derealization which is a subjective sense that the
environment is strange or unreal; a feeling of changed reality.

IV. Other perceptual disturbances:
1. Flashbacks:
- Exceptionally vivid re-experiencing of remembered experiences.
- Flashbacks of the initial traumatic event occur in PTSD and flashbacks
to abnormal perceptual experiences initially experienced during LSD
intoxication can occur many years after the event.
2. Cenesthesia:
- Change in the normal quality of feeling tone in a part of the body.
3. Macropsia:
- False perception that objects are larger than they really are.
4. Micropsia:
- False perception that objects are smaller than they really are. Sometimes
called lilliputian hallucination.

38


5. Trailing phenomenon:
- Perceptual abnormality associated with hallucinogenic drugs in which
moving objects are seen as a series of discrete and discontinuous images.
6. Globus hystericus:
- The sensation of a "lump in the throat" occurring without oesophageal
structural abnormality or motility problems. A symptom of anxiety and
somatisation disorders.
7. Mirror sign:
- Lack of recognition of one's own mirror reflection with the perception
that the reflection is another individual who is mimicking your actions.
Seen in dementia.
8. Splitting of perception:
- Loss of the ability to simultaneously process complimentary information
in two modalities of sensation (e.g. sound and pictures on television).
Rare symptom of schizophrenia.
9. Hyperesthesia:
- Increased sensitivity to tactile stimulation.
10. Hypesthesia:
- Diminished sensitivity to tactile stimulation.
11. Acenesthesia:
- Loss of sensation of physical existence.
12. Ageusia (dysgeusia):
- Lack or impairment of the sense of taste. Seen in depression and
neurological deficit.
13. Causalgia:
- Burning pain that can be organic or psychic in origin.

39


(6) Cognitive and intellectual functions "Cognitive functions"

A. Consciousness.
B. Orientaion.
C. Attention and concentration.
D. Memory.
E. Intellegence.
F. Abstract thought.
G. Visuo-spatial ability.
H. Reading and writing.
I. General knowledge.

Commentary sample
The pt. is fully conscious, well oriented with time, place and persons, attentive,
concentrating, with intact memory "immediate, recent, recent past and remote",
of average intelligence and general knowledge and good abstraction.

A. Consciousness
- It is the awareness of self and environment.

- Glasgow coma scale is used to evaluate the level of consciousness from 3-14.

Eye opening Verbal response Motor response

Spontaneous 4 Oriented 5 Obeying orders 5

To speech 3 Confused 4 Localizing 4

To pain 2 Words 3 Flexing 3

None 1 Sounds 2 Extending 2

None 1 None 1

40


Disorders of Consciousness
i- Confusion:
- Disturbance of consciousness manifested by impaired orientation in relation
to time, place or person.
ii- Drowsiness:
- A state of impaired awareness associated with a desire or inclination to
sleep.

iii- Dreamy state:
- Altered state of consciousness, likened to a dream situation, which develops
suddenly and usually lasts a few minutes; accompanied by visual, auditory,
and olfactory hallucinations.
- Commonly associated with temporal lobe lesions.
iv- Trance:
- Sleep-like state of reduced consciousness and activity.
v- Somnolence:
- Abnormal drowsiness which one can be aroused to a normal state of
consciousness.
vi- Clouding of consciousness:
- Disturbance of consciousness in which the person is not fully awake, alert,
and oriented.
- Occurs in delirium, dementia, and cognitive disorder.
vii- Delirium:
- Restless, confused, disoriented reaction associated with fear and
hallucinations.

41


viii- Stupor:
- Lack of reaction to, and unawareness of surroundings with absence of
movement and mutism where there is no impairment of consciousness.
- Functional stupor occurs in a variety of psychiatric illnesses.
- Organic stupor is caused by lesions in the midbrain (the "locked-in"
syndrome).
ix- Twilight state:
- Disturbed consciousness with hallucination.
x- Coma
- Profound unconsciousness in which a person cannot be roused, with minimal
or no detectable responsiveness to stimuli.
xi- Psychogenic unresponsiveness (coma vigil)
- Not true coma but a dissociative disorder in which the patient appears
unresponsive but is physiologically awake.
- Can be tested by letting the patient’s hand to fall toward his face.
xii- Delirium tremens:
- Also called alcohol withdrawal delirium.
- The clinical picture is acute confusional state secondary to alcohol
withdrawal.
- Usually, occurring 72 to 96 hours after the cessation of heavy drinking.
- Distinctive characteristics are marked autonomic hyperactivity (tachycardia,
fever, hyperhidrosis, and dilated pupils).
- It also accompanied by confusion, withdrawals, visual hallucinations, and,
occasionally, persecutory delusions and Lilliputian hallucinations.
xiii- Hypnosis:
- Artificially induced alteration of consciousness characterized by increased
suggestibility.
42


B. Orientation
- It is the awareness of the one self in relation to time, place and persons.

- Disorientation may indicate cognitive impairment caused by organic mental
disorders but psychogenic factors may also cause disorientation, e.g. in mood
disorders, anxiety disorders, dissociative disorders and factitious disorder.

- In disorientation, sense of time is impaired before sense of place and the patient
improves in reverse order.

- Double orientation: some patients believe they are in two different places at the
same time.

C. Attention and Concentration
- Attention is the ability to focus on certain stimuli while concentration is the
ability to sustain attention.
- It is tested clinically by substracting serial 7s from 100 (or simpler substraction
e.g. serial 4s from 25) and in less educated patients to tell the months of the year
or the days of the week in a reverse order.

Disorders of attention

1- Distractibility:
- Inability to concentrate attention; in which attention is drawn to
unimportant or irrelevant external stimuli.

2- Selective inattention:
- Blocking out only those things that generate anxiety "as a defense
mechanism".

3- Hypervigilance:
- Excessive attention and focus on all internal and external stimuli.
- Usually, secondary to delusional or paranoid states.
43


4- Trance:
- Focused attention and altered consciousness.
- Usually, seen in hypnosis, dissociative disorder, and ecstatic religious
experiences.

5- Disinhibition:
- Removal of an inhibitory effect that permits persons to lose control of
impulses as occurs in alcohol intoxication.

6- Hypnosis:
- Artificially induced modification of consciousness characterized by
heightened suggestibility.

D. Memory
- It is the process of acquisition (registration), retention (storage), and retrieval
(reproduction) of information.
- Retrieval helped by a presentation of a cue is termed “recognition” while retrieval
in the absence of such a cue is termed “recall”. Recall is more difficult than
recognition.

Levels of memory

1. Immediate memory:

- Retrieval of perceived material within seconds or minutes. It is checked by
asking patients to repeat 6 digits forward and then backward.

2. Recent memory:

- Retrieval of events over past few days. It is checked by asking patients about
their appetite and then about what they had for breakfast or for dinner the
previous evening.

44


3. Recent past memory:

- Retrieval of events over past few months. It is checked by asking patients
about important news events from the past few months.

4. Remote memory:

- Retrieval of events in distant past. It is checked by asking patients about
information from their childhood that can be later verified.

Disorders of memory

I. Quantitative disturbance of memory:
1- Amnesia:
- Partial or total inability to recall past experiences.
- May be of organic or emotional origin.
- May be:
(a) Anterograde: amnesia for events occurring after a point in time
"e.g.: head injury".
(b) Retrograde: amnesia for events occurring before a point in time.

2- Hypermnesia:
- Exaggerated degree of retention and recall.
II. Qualitative disturbance of memory:
1- Paramnesia:
- Falsification of memory by distortion of recall.
- It includes:
(a) Faulse reconnaissance: false recognition.
(b) Confabulation:
 Unconscious filling of gaps in memory by imagined or untrue
experiences that a person believes but they have no basis in
fact.

45


 Most often associated with organic pathology as in Korsakoff
syndrome, dementia or following alcohol blackout.
(c) False memory:
- A person's recollection of an event that did not actually
occur.
- In false memory syndrome, persons erroneously believe that
they sustained an emotional or physical (e.g., sexual) trauma
in early life.
(d) Déjà vu:
 Illusion of visual recognition in which a new situation is
incorrectly regarded as a repetition of a previous memory.
(e) Jamais vu:
- False feeling of unfamiliarity with a real situation that a
person has experienced.
- An everyday experience but may also occur in temporal lobe
epilepsy, schizophrenia, and anxiety disorders.
(f) Déjà entendu:
 As Déjà vu but concerns auditory recognition.
(g) Déjà pensé:
- False recognition that a thought has been previously
entertained.
(h) Retrospective falsification:
 Previous experience is remembered, but in a distorted way.
(i) Anomia:
- Inability to recall the names of objects.

2- Blackout "Palimpsest" ‫:ﻓﻘﺪان ﻣﺆﻗﺖ ﻟﻠﺬاﻛﺮة‬
- Amnesia experienced by alcoholics about behavior during drinking
bouts.
- Usually, indicates that reversible brain damage has occurred.

46


III. Others:
1- Fugue:
 A dissociative reaction following a severe external stressor (e.g. marital
break-up) in which the affected individual develops global amnesia and
may wander to a distant location.
 Consciousness is unimpaired and after resolution there is amnesia for the
events which occurred during the fugue.
2- Neurological amnesia:
 Auditory amnesia: loss of ability to comprehend sounds or speech.
 Tactile amnesia: loss of ability to judge the shape of objects by touch.
 Verbal amnesia: loss of ability to remember words.
 Visual amnesia: loss of ability to recall or to recognize familiar objects
or printed words
.

E. Intelligence
- Ability to understand, recall, mobilize, and constructively integrate previous
learning in meeting new situation.

Intelligence disturbances

1- Mental retardation:

- Lack of intelligence sufficient to interfere with social and occupational
performance.
- Degrees of mental retardation:
 Mild "Moron" (IQ from 50 to 70).
 Moderate "Imbecile" (IQ from 35 to 50).
 Severe (IQ from 20 to 35).
 Profound "Idiot" (IQ below 20).

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2- Dementia:

o Organic and global deterioration of intellectual functioning without
clouding of consciousness.

3- Pseudodementia:

- Clinical features resembling a dementia not caused by an organic
condition.
- Most often caused by depression (dementia syndrome of depression).

4- Acalculia:

o Loss of ability to do calculations; not caused by anxiety or impairment in
concentration.
o Occurs with neurological deficit and learning disorder.

F. Abstraction
- It is the ability to deal with concepts.

- It is tested clinically by asking the pt. to:

o Explain proverb: ‫ﻋﺼﻔﻮر ﻓﻲ اﻟﯿﺪ ﺧﯿﺮ ﻣﻦ ٠١ ﻋﻠﻰ اﻟﺸﺠﺮة‬

o Define abstract words: e.g.: envy, love or hate, .....

o D.D. between similar meaninges: e.g.: dwarf & short.

- Types of thinking according to abstraction:

1- Abstract thinking:

 Ability to appreciate nuances of meaning.

 Multidimensional thinking with ability to use metaphors (‫ )ﻣﺠ ﺎز- ﻛﻨﺎﯾ ﺔ‬and
hypotheses appropriately.
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2- Concrete thinking:

 Literal thinking with limited use of metaphor without understanding
nuances of meaning.

 One-dimensional thought.

G. Reading and Writing
1. Alexia:

- An acquired reading disability, where reading ability had previously been
developed.

- Usually, occurring in adulthood conditions.

2. Dyslexia:
- Developmental reading disability.

3. Bradylexia:
- Inability to read at normal speed.

4. Dysgraphia:

- Difficulty in writing.

5. Cryptographia:
- A private written language.

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(7) Insight
Def. : It's the patient’s degree of awareness and understanding about being ill.

Or; the ability to recognise that one's abnormal experiences are symptoms of
psychiatric illness and that they require treatment.

Levels of insight

1. Complete denial of illness.
2. Slight awareness of being sick and needing help but denying it at the same
time.
3. Awareness of being sick but blaming it on others, on external factors, or on
organic factors.
4. Awareness that illness is due to something unknown in the patient.
5. Intellectual insight: admission that the patient is ill and that symptoms or

failures in social adjustment are due to the patient’s own particular irrational
feelings or disturbances without applying this knowledge to future experiences.
‫ﻋﺎرف ﻛﻞ ﺣﺎﺟﺔ ﻋﻦ ﺣﺎﻟﺘﮫ ﻟﻜﻦ ﺗﻨﻘﺼﮫ اﻟﻨﯿﺔ ﻟﻠﺘﻐﯿﺮ ﻣﻦ أﺟﻞ ﻣﺴﺘﻘﺒﻞ أﻓﻀﻞ‬
6. True emotional insight: emotional awareness of the motives and feelings within
the patient and the important persons in his life, which can lead to basic
changes in behavior.
o Reality testing:
- Fundamental ego function that consists of tentative ‫ ﺗﺠﺮﯾﺒﻲ‬actions that test and
objectively evaluate the nature and limits of the environment.
- It includes the ability to differentiate between the external world and the
internal world and to accurately judge the relation between the self and the
environment.

(8) Judgement

 It's the ability to assess a situation correctly and to act appropriately in the
situation.

50


 Tested clinically by asking the pt. what will he do in imaginary situaion; e.g.:
seeing a fire.

 Types of judgement:
(a) Critical judgement: ability to assess, discern, and choose among various
options in a situation.
(b) Automatic judgement: reflex performance of an action.
(c) Impaired judgement: diminished ability to understand a situation correctly
and to act appropriately.

(9) Impulsivity

- It is important to assess the patient capability of controlling sexual, aggressive,
and other impulses.

- This is to measure the patient’s potential danger to self and others.

- Impulse control can be estimated from:

o Information in the patient’s recent history.

o The behavior observed during the interview.

51


Micellaneous definitions
Ganser symptom (Vorbeigehen) or (Vorbeireden):
- The production of "approximate answers" as the patient gives repeated wrong
answers to questions (e.g. "what is the capital of Scotland? Paris").
- Occasionally associated with organic brain illness or more commonly seen as
a form of malingering (e.g. in prisoners awaiting trial).

Malingering:
o Deliberately falsifying the symptoms of illness for a secondary gain (e.g. for
compensation, to avoid military service, or to obtain an opiate prescription).

Priapism:
 A sustained and painful penile erection, not associated with sexual arousal.
 A rare side-effect of antidepressant medication "Trazodone".
 If not relieved can cause permanent penile damage.

Pseudologia phantastica:
- Disorder characterized by uncontrollable lying in which patients elaborate
extensive fantasies that they freely communicate and act on.
- There may be a grandiose or over-exaggerated flavour to the accounts
produced.
- A feature of Munchausen's disease.

Russell sign:
o Skin abrasions, small lacerations, and calluses on the dorsum of the hand
overlying the metacarpophalangeal and interphalangeal joints found in patients
with symptoms of bulimia.
o Caused by repeated contact between the incisors and the skin of the hand
which occurs during self-induced vomiting.
52


Abreaction:
 A process by which repressed material, particularly a painful experience or a
conflict, is brought back to consciousness.
 In this process, the person not only recalls, but also relives the repressed
material, which is accompanied by the appropriate affective response.

Acting out:
- Behavioral response to an unconscious drive or impulse that leads to temporary
relief of inner tension.
- Relief is attained by reacting to a present situation as if it were the situation
that originally gave rise to the drive or impulse.
- Common in borderline states.

Anaclitic:
o Depending on others, especially as the infant on the mother.
o Anaclitic depression in children results from an absence of mothering.

Androgyny:
 Combination of culturally determined female and male characteristics in one
person.

53

Psychiatric sheet for postgraduates

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Psychiatric sheet for postgraduates