Diagnosis
of a mental disorder shouldn’t be made on the basis of an individual
symptom. Therefore, for proper diagnosis symptoms should be intense and
persistent.
A syndrome should be established i.e. Signs and symptoms should portray a recognizable pattern.
Psychiatric signs and symptoms fall into groups referred to as systems of psychological functioning.
These include:-
1) Perception
2) Thinking
3) Speech
4) Motor activity
5) Memory
6) Orientation
7) Consciousness
8) Cognitive (intellectual functioning)
9) Mood /Affect
Different psychiatric disorders may affect each of the above systems as discussed in this chapter:
A: Disorders of perception
Perception is the process of becoming aware of what is presented through the sense organs.
Response to stimuli from five senses or relating various sensory impressions with previous experiences and knowledge.
1. Illusion
Misperceptions of external stimuli e.g. mistaking a stick for a snake. They occur:-
When the general level of sensory stimulation is reduced e.g. at dusk one may perceive the outline of a bush as that of a man.
When
the level of consciousness is reduced e.g. acute organic syndrome. In
strong affective states e.g. anxiety state one may see a cloud like an
angel coming towards them.
When attention is not focused on sensory modality.
Also in depression.
May occur in normal persons but are pathological if they persist or become excessive.
2. Hallucinations
Mental impressions of sensory vividness without adequate external stimuli.
A
perception is experienced in the absence of an external stimulus to the
sense organs and with a similar quality to true perception. It is not
restricted to mentally ill patients only as normal people may experience
hallucinations especially when tired.
Also, occur in healthy
people during the transition between sleep and waking. While falling
asleep – called hypnagogic hallucinations and While awakening –
hypnopompic hallucinations.
Hallucinations occur in:-
~Severe
affective disorders e.g. during strong feelings or conflicts which
cannot be controlled by ordinary coping/defense mechanisms e.g excessive
fear/ intense religiosity etc.
~Schizophrenia.
~Organic disorders e.g. lesions of the sensory centers.
~Toxic states e.g. alcohol intoxication.
~Dissociative disorders
~Sometimes in healthy people.
Hallucinations have two very important qualities:
1) experienced as a true perception, not imagery
2) seems to come from the outside world (except for somatic hallucinations).
Hence experiences that possess only one of these qualities, are pseudohallucinations.
Types of Hallucinations
Grouped according to:-
1)Complexity
2)Sensory organ affected
Based on Complexity:
1. Elementary hallucinations
Such experiences as bangs, whistles, a flash of light.
2. Complex
E.g. hearing voices or music, seeing faces & scenes
Based on Sensory system affected
1. Auditory hallucinations
Hearing voices that don’t exist. Voices may command one to do violent acts e.g. kill or commit suicide. May occur in depression.
2. Tactile hallucinations
Based on Sensory system affected
Also called haptic hallucinations or somatic hallucinations.
✓Sensations
of being touched, pricked, or strangled usually occur in organic states
e.g. marked cocaine toxicosis – called “cocaine bugs” and
schizophrenia.
Subtype- sexual hallucinations-special type of
tactile hallucination. E.g. Male schizophrenics may complain of erection
& orgasm being forced into them. Female schizophrenics –may have
the sensation of being raped.
3. Visual hallucinations
Seeing figures/images that are not present. May occur in:-Intense fear and organic psychosis
4. Gustatory hallucinations
Tasting strange things in the mouth which are actually not present.
Occurs in:- Schizophrenics and Major/epilepsy
5. Olfactory hallucinations
Perceiving peculiar non-existent smells. Occur in:-Temporal epilepsy, Depression, Schizophrenia.
Unclassified
Reflex hallucinations
Where
a stimulus in one sensory modality results in hallucinations in another
e.g. sound of music provokes visual hallucinations.
3. Depersonalization/Derealization
Alterations in the perception of one’s reality
Depersonalization:
The patient feels detached and views himself/herself as strange and
unreal. It's the change of self-awareness that the person feels unreal.
Derealization:
Alteration of sense of the reality of the environment or outside world.
Familiar objects/places/persons seem to have changed in shape and size.
NB: Depersonalization is directed towards self while derealization is directed towards the outside world.
Occurs in:-Depression, Anxiety states, Schizophrenia, Hysteria.
B: Disorders of thinking/ Thought disorders
Thinking is the most highly organized function of the brain.
Combines experiences with perceptions and knowledge which is stored as memory.
Thoughts are understood through speech and writing.
Hence disorders of thought are closely related to disorders of speech.
Subtypes
I: Disorders of the sequence of thought/thought process
concerned with speed and amount of speech.
a) Flight of ideas/ accelerated thinking.
Evidenced
by overproductive speech characterized by rapid shifting from one topic
to another & fragmenting of ideas. Eventually, speech becomes
incoherent.
Thoughts follow so rapidly that the expression of an idea
is incomplete; Occurs in:-Mania, Organic states esp. due to
hypothalamic lesions, excited schizophrenics
b). Retardation/inhibition of thought/poverty of thought
The stream of thought is slowed down.
Speech is slow & difficult.
Occurs in; severe depression, organic states & schizophrenia.
I: Disorders of sequence of thought/thought process
c). Perseveration of thought
Mental operations persist beyond their relevance. Thoughts or themes repeated though not currently relevant.
The patient is not able to break away from the theme.
Also considered a speech disorder common in organic states e.g. Dementia and sometimes in schizophrenia
d). Circumstantial thinking/ Circumstantiality.
Inclusion of excessive and unnecessary details which are not essential to the subject under discussion.
Speech is indirect and delayed to reach the goal.
Occur commonly in:-Mania/hypomania, Organic mental states, Schizophrenics, Obsession personalities
I: Disorders of sequence of thought/thought process
e). Pressure of thought
The patient is compelled to think in an unusually rapid manner.
Thoughts are abundant & varied.
Common in mania, anxious patients & sometimes schizophrenia.
f). Thought blocking
The sudden halt in the train of thought or in the middle of a sentence.
Commonly occur in Mania and anxiety states
g). Tangentiality/Tangential thinking
Same as circumstantiality but the final goal is not reached as the patient loses track of the original idea.
h). Fragmented thinking/loosening of association.
Same as flight of ideas but the topics/ideas are illogical. Common in: schizophrenia, organic disorders.
II: Disorders of thought content
a). Delusions
Fixed,
usually false beliefs which are incompatible with one’s socio-cultural
or educational background, and they cannot be explained on the basis of
reality.
The main feature is that it’s firmly held on
inadequate grounds i.e. the belief is not arrived at through the normal
process of logical thinking
Types of delusions
Based on onset
1. Primary delusions
Appears suddenly and with full conviction but without any mental events leading up to it.
Special primary delusions may include delusional perception and delusional memory.
2. Secondary delusions
Derived
from some preceding morbid/abnormal experience e.g. hallucinations.
Someone who has auditory hallucinations may eventually believe that he
is being followed or a person who is profoundly depressed may believe
that people think he is worthless.
Based on: theme/content
1. Persecutory delusions. Subjects believe that others are plotting against them. He thinks he is the subject of persecution common in:-
Paranoid schizophrenia, depression (severe), Organic states, Abnormal personalities
2. Grandiose delusions: Also called expansive delusions or delusions of grandeur.
The
subject believes that he or she is some important person e.g. Jesus,
Pope, President, Almighty God, etc or endowed with unusual abilities.
May also think that he is related to some important people e.g. MPS,
royal family, etc. common in Mania, and Schizophrenia
3. Nihilistic delusions
The belief that one is dead & everything around him has stopped working.
May also believe that some portion of his or hers is non-existence
Chiefly occurs in severe depression.
4. Re
