General Symptomatology ….

Chapter 1: General Symptomatology

Outlines:

1-Introduction.

2- Composition of mind.

3- Signs and symptoms of psychiatric disorders.

Disorders of Intellect.
Disorders of thinking.
Disorders of speech.
Disorders of Perception.
Disorders of Memory.
Disorders of Orientation.
Disorders of Attention& Concentration.
Disorders of Consciousness.
Judgment.
Insight.

Disorders of Emotion.
Disorders of Affect.
Disorders of mood.

Disorders of behavior (conation).

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General Symptomatology ….

General symptomatology

 Symptom: is usually defined as subjective experience described by

the patient.
 Sign: is defined as an objective finding observed by the nurse.
 But in psychiatry the word symptom includes subjective and
objective evidence of disease

Composition of mind

The mind is composed of spheres that represent the aspects of mental

functioning. They are related to each other.
 Intellect: it include: the processes of thinking, perception, orientation,
memory, attention& concentration, judgment, insight, general
knowledge, intelligence& consciousness.
 Affect: it denotes the emotional state or condition. It is the inner
Feeling or experience of the individual.
 Behavior: it is the conduct of the individual.

Affect,
mood, or
Intellect, emotion
cognition
or mental
process I A

Behavior or
B conation

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Part (I): Disorders of Intellect

A) Disorders of Thinking: (Form – Stream - Content)

 Formal thought disorders:

(Concrete thinking – Autistic Thinking)

When the order, sequence, attraction, & alternations are lacking,

thoughts do not fulfill their function, & ideas are just put together in a
disconnected & loose manner. This is the basic defect in formal thought
disorder.

Formal thought disorder is a profound basic disorder, in the essence

of the process of thinking & not simply a change of the shape (form) of
thinking. Hence it is not advised to use the expression "disorders of the
form of thinking" The right expression is formal disorder.

Clinical manifestations of formal thought disorder:

1- Concrete thinking: in which the patient use the literal thinking,

without understanding the implicit meaning behind sentences.
Concreteness versus abstractness.
Abstract thinking: in which the patient understand the meaning
behind sentences (normal form of thinking).

How to test the ability to abstract?

By using similarities & proverbs. E.g.
Proverb: people who live in glass houses shouldn't throw stones.
 Abstract thinking: don't criticize others for faults you may have
yourself.
 Concrete thinking: if you throw stones in the house, you could
break a window & shutter the glass.

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2- Autistic thinking: thinking that gratifies unfulfilled desires

but has no regard for reality, egocentric (self-centered), fantasy.
E.g. the difference between a healthy person & a schizophrenic is
that a schizophrenic may not know where fantasy leaves off &
reality begins.
 Concrete & autistic thinking are normal form of thought during early
stage of development.
 N.B. normally during personality development, during autistic stage
(birth to 3or 4 weeks), in which the child is generally unaware of
environment. He is unaware of any difference between his
internal & external world. A form of psychopathology that,
results from inability to progress beyond this stage is severe
autistic schizophrenia. During the stage of concrete operations (8-
11 years) the child is not yet capable of abstract reasoning. He
understands things as he sees them & as they seem to be. But
during formal thought stage (12- adulthood) he develops the ability
to think abstractly.

 Disorders of the stream of thinking (Thought Process):

(Tangentiallity …………………………. Neologism)

Disorders of the stream of thinking are not separable from formal

thought disorder. They are related to the association & the goal
directed sequence as well as to the speed of production, expression,
& succession of thoughts.

1- Tangentiallity: an association disturbance in which the speaker goes

off the topic. When it happens frequently &the speaker does not to
return to the topic (not reach to the goal). E.g. the nurse asked the
client to talk more a b o u t h i s f a m i l y . T h e c l i e n t continuously

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left the topic & talks about boats, animals, his apartment, & so
forth. Each time the nurse tried to help the client to focus, he would
go off on another topic.

2- Circumstantiality: before getting to the point or answering a

question, the person gets caught up in countless details & explanations.

E.g. "Where are you going for the weekend, Harry?"

"Well I first thought of going to my mother's, but that was before I
recommend that she was going to my sister's. My sister is having a
picnic. She always has picnics at the beach. The beach that she goes to
is large & gets crowded. That's why I don't like that beach. So I
decided to go someplace else. I thought of going to my brother's
house. He has a thought of going to my brother's house. He has a large
house on a quiet street...! I finally decided to stay home".

3- Looseness of association: (illogical & haphazard connections

between ideas) thinking is haphazard, illogical, & confused,
connections in thought are interrupted. Seen; mostly in schizophrenic
disorders. E.g. "Can't go to the zoo, no money. Oh... I have a hat,
these members makes no sense, man… hat's the problem?"

4- Flight of ideas: rapid jumping from one idea to another. The

connection between ideas is through stimuli from last idea or
external stimuli

E.g. "say babe how's it going...going to my sister's to get some

money...money, honey, you got any bread... bread & butter, staff of
life, ain't life grand?..."

5- Clang association: the meaningless rhyming "words. E.g. "Eat, beat,

heat, seat...."

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6- Incoherence or word salad: a mixture of words & phrases that

have no meaning. E.g. "I'm fine... apple pie... no sale... cellar
door . . . take it slow . . . furniture store. Coherence: Mixtures of words
& phrases have meaning. i.e. logical speech.

7- Blocking: sudden cessation of a thought in the middle of a sentence.

Person is unable to continue his train of thought. Often sudden new
thoughts crop up unrelated to the topic. Can be disturbing to the
individual. E.g. "I was going to get a new dress for the...I forgot
what I was going say"

8- Perseveration: psychopathological repetition the same word or idea

in response to different questions. E.g.
N: How are you doing, Harry?
H: fine nurse, just fine.
N: Did you go for a walk?
H: fine nurse, just fine.
N: Are you going out today?
H: fine nurse, just fine.

9- Pallalia: it is the pathological repetition of the last word said.

E.g. the patient said to the nurse: "my name is Ahmed, Ahmed, Ahmed..."

10- Echolalia: repeating the speech of another person.

E.g. the nurse said to the client, "Tell me your name." the client
responded, "tell me your name".

11- Irrelevant answer: answer that is not in harmony with question

asked.
E.g. N: How are you doing?
H: my name is Ali.

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12- Pressure of speech: forceful energy heard in manic individual's

frantic, jumbled speech as she struggles to keep pace with racing
thoughts. E.g. vomiting of talk.

13- Poverty of speech: speech that is brief & uncommunicative.

14- Retardation of speech: refers to slow speech & prolonged latent

period before response. E.g. slowing of speech.

15- Neologism: (creation of new words) words a makes up that only

have meaning for the person himself.
E.g. "I'm afraid to go to thxe hospital because the norks are looking for
me there."

 Disorders of the content of thought:

(Delusions – Obsession – Preoccupation – Suicidal Ideation)

1- Delusion: it is false fixed belief, not consistent with patient's

educational & cultural background that cannot be corrected by
logic or reasons.

Types of delusion:

A. According to systematization:
1- Systematized delusions: (well knit) when they form a coherent
system & appear to be logical. E.g. paranoid delusions.
2- Unsystematized delusions: group of delusions that are not
related to each other or they are in haphazard relation.

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B. According to categorization:

1- Paranoid delusions: it is an intense & strongly defended

irrational suspicious belief, includes the following:
Delusion of grandeur: false belief that one is a very powerful &
important person.
Delusion of persecution: false .belief that one is chased by others.
Delusion of reference: false belief that the behavior of others-refers
to oneself (by people in street, radio, T.V, & newspaper are referring to him).
Delusion of jealousy: conviction that one's spouse has some definite
relation with someone else
Delusion of infidelity: false belief derives from-pathological
jealousy that one's lover is unfaithful (it's an extreme of the jealousy
delusion.
Erotic delusion: false belief that there is a love story between
oneself & famous person.
Litigious delusion: patient writes complains & sends them
to responsible person.

2- Delusions of influence: (Delusions of control) includes the

following:
Delusion of thought insertion: false fixed belief that thoughts
are inserted into one's mind by other people or agencies.
Delusion of thought withdrawal: false fixed belief that thoughts
are withdrawn or taken from one's mind by other people or agencies.
Delusion of thought broadcasting: false fixed belief that one's
thoughts are broadcasted all over the world.
Delusion of being controlled: false fixed belief that one is
being controlled by others or agencies.

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3- Depressive delusions; includes the following:

Delusion of self-blame (guilt or sin): in which the patient believes
that he is wicked, full of sins & unfit to live with other
people (un worthiness)
Delusion of poverty: false belief that one lost everything in life.

4- Somatic delusions: includes the following:

Hypochondriacal delusion: false belief that one has a serious
physical illness in the area below the thoracic cage that is not based
on real organic pathology 'E.g. cancer stomach.
Nihilistic delusion: false belief that a-part of one's body doesn't
exist or he is dead or there is no world. E.g. the patient said "I have
no brain".

2- Obsession: Obsessive thoughts are intrusive thoughts invading

the conscious awareness against the" resistance of the person in
an involuntary way that they are unnecessary & absurd. If the
patient's resistance succeeds to temporarily or partially control
this intrusion, tension accumulates until it reaches an
intolerable degree that compels the individual to yield & act out
the obsessive behavior.
N.B.-the difference between delusion & obsession is that the latter is
more absurd & the patient is aware of the absurdity & resists it most of
the time.

Content of obsessional thoughts:

A- Dirt and contamination for example, the idea that the hands are
contaminated with bacteria.
B- Aggressive action for example the idea that the person may harm
another person, or shout angry remarks.

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C- Orderliness for example, the idea that objects have to be arranged in a

special way or clothes put on in a particular order.
D- Illness, for example the idea that the person may have a cancer (ideas
of contamination may also refer to illness. For example that a disease
may result from the feared bacterial contamination).
E- Sex usually thoughts or images of practices that the person finds
disgusting.
F- Religion for example blasphemous thoughts, or doubts about the
fundamentals of belief (e.g., does god exist?) or about the adequacy or
completeness of a religious practice such as confession.

3- Preoccupation: Centering of thought content around a

particular idea associated with strong affective tone.

4- Suicidal ideation: It is a recurrent idea affecting the individual to

put an end by himself to his own life.

Follow, Part (I): Disorders of Intellect

B) Disorders of Perception: (Hallucinations – Illusion – Unreality states)

1- Hallucination: False perception without external stimuli.

Etiology of hallucination: hallucination can have organic or a
functional etiology.
 Organic hallucination: as in hepatic coma, pyrexia, etc...
 Functional (psychogenic) hallucination: as in schizophrenia or
other psychiatric disorders.
 Normal hallucination: considered non-pathological, & include:
 Hypnagogic: occurs during falling asleep.
 Hypnopampic: occurs during awakening from sleep.

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Types of hallucination: it affects the five senses:

A. Visual: seeing things that are not there.

E.g. during alcohol withdrawal he kept shouting, "I see snakes on the
wall".

B. Auditory: hearing voices when none are present.

E.g. "I keep hearing my mother's voice telling me I'm bad. She died
a year

C. Olfactory: smelling smells that do not exist. .g. "I smell my

stomach rotting".

D. Tactile (haptic): feeling touch sensations in the absence of stimuli.

E.g. A paranoid man feels electrical impulses "from outer space entering his
body & controlling his mind.

E. Gustatory: experiencing taste in the absence of stimuli.

E.g. A paranoid woman tastes poison in her food while eating at her
son's wedding.

2- Illusion: False perception with an external stimulus.

N.B it may affect any of the special senses (auditory, olfactory,
etc...). E.g. an individual sees a rope & perceives that it is a snake,
thus it is the subject of a visual illusion.

3- Unreality states:

A- Depersonalization: a phenomenon whereby a person experiences

a sense of unreality or self-estrangement. E.g. one may feel that
one's extremities have changed; that one is seeing oneself from a
distance or that one is in a dream.

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B- Derealization: the false perception by a person that his or her

environment has changed. E.g. everything seems bigger or
smaller, or familiar objects have become strange & unfamiliar.

Follow, Part (I): Disorders of Intellect

C) Disorders of Memory

Memory is function by which information stored in the brain and is

later recalled to consciousness.

Levels of memory:
A. Immediate: reproduction or recall of perceived material within
seconds to minutes.
B. Short term memory (recent): recall of events over past few days.
C. Recent past memory: recall of events over past few months.
D. Long term memory (remote): recall of events in distant past.

Disorders of memory:

1- Amnesia: is loss of memory, & may be partial or complete. The

following are the different types of amnesia:-
 Anterograde amnesia: loss of memory for recent events.
 Retrograde amnesia: loss of memory for remote e vents.
 Total amnesia: loss of memory for recent: & remote events.
 Circumscribed (gap) amnesia: loss of memory for limited time.

2- Paramnesia: it denotes false recall.

 Falsification: patient adds false details to a true memory.
 Confabulation: patient fills the gaps in his memory by fabrication.

3- Hypermnesia: it is -excessive memory, the patient mentions

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even unnecessary details.

4- De Ja vu phenomena (already seen): in which new situation

is experienced as previously.

5- Ja mais vu phenomena: in which familiar situation is experienced

as novel.

Follow, Part (I): Disorders of Intellect

D) Disorders of Orientation

Orientation is the ability to relate the self correctly to time, place &
person.
 Disorientation: confusion & impaired ability to identify time,
place & person.

Follow, Part (I): Disorders of Intellect

E) Disorders of Attention & Concentration

- Attention is the ability to focus awareness on certain important

or relevant aspects of an experience, activity or task
- Concentration is the ability to sustain or maintain that focus
awareness& perception to particular stimulus.

 Distractibility: inability to maintain attention; shifting from one

area or topic to another with minimal provocation.

 Selective inattention: - Inattention only to stimuli that generate

anxiety.

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 Hyper vigilance (hyperprosexia):

- Excessive attention and focus on all internal and external stimuli.
- Prominent in delusional or paranoid states and mania.

Follow, Part (I): Disorders of Intellect

F) Disorders of Consciousness

Conscious individual is:

 Aware of himself & of his environment.
 Capable of responding properly to stimuli.
Between conscious & unconscious there are various degrees of
disturbed consciousness, some of them are:

1- Confusion: there is dimming or clouding of consciousness. All

mental processes slow:
 Intellect: thinking is difficult
 Affect: apathy.
 Behavior: no initiation with fatigue & laziness

2- Delirium: there is clouding of consciousness. The mental functions

show quantitative changes.
 Intellect: hallucination, illusion, & disorientation.
 Affect: fear & apprehension.
 Behavior: restlessness.

3- Stupor: there is complete suppression of motor activity, the patient

doesn't respond to any stimuli neither external, nor internal.

4- Twilight state: (Dream like state): is a state of restricted

consciousness including ideation perception & associated emotional

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state.

5- Somnolence: Abnormal drowsiness (Pathological sleepiness or

drowsiness from which one can be aroused to a normal state of
consciousness).

6- Fugue: it involves memory loss, as psychogenic amnesia, but it also

includes traveling away from home or from one's usual work
locale. Therefore, fugue involves flight as well as forgetfulness.

Follow, Part (I): Disorders of Intellect

G) Disorders of Judgment

Judgment is the ability to assess a situation correctly & act

appropriately within that situation.
Impaired judgment is diminished ability to understand a situation
correctly and to act appropriately.

Follow, Part (I): Disorders of Intellect

H) Disorders of Insight

Generally insight is the ability to understand the objective condition

of his illness. As well as the true cause or meaning of a situation.
In psychiatry: It refers to the patient's conscious recognition of his condition:
1- He or she is disturbed or ill.
2- His or her illness is psychiatric in nature.
3- He or she should seek professional help.
4- He or she should cooperate with the offered treatment.
 Full or partial awareness of these aspects indicates the degree of his
insight.

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 A patient with no insight will have poor judgment towards his

social, financial, & domestic problems.
Part (II) Disorders of emotion (Affect – Mood)

 Emotion is a complex feeling state with psychic, somatic and

behavioral components (occurred when affect and mood change
stirring up the activity of the autonomic nervous system).
 Clinical study and evaluation of emotion is concerned with two main
aspects:
1- Affect:
 Usually used to indicate emotional expression, i.e., the external
observed expression of emotion.
 Also used to indicate the subjective and immediate "short lived" or
transient experience of emotion.

2- Mood: is a "pervasive & sustained emotion that, in the extreme,

markedly colors the person's perception of the world".

Part (II): Disorders of Emotions

A) Disorders of Affect

1- Inappropriate affect (incongruity): it is a disharmony of affect

& ideation.

2- Flat affect: Absence or near absence of any signs of emotional

expression or responsivity. In which the patient show mild expression to
situation.

3- Blunted affect:
In which the patient show mild expression to situation but
under severe pressure.

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4- Pleasurable affect:

 Euphoria: it is a heightened, feeling of psychological well

being inappropriate to apparent events.

 Elation: it is feeling of happiness with air of confidence &

enjoyment associated with increased motor activity.

 Exaltation: it is intense elation with feelings of grandeur &

sarcasm.

 Ecstasy: it is feeling of intense happiness with mysterious air. It

is met with in mystical experience, epilepsy, schizophrenia, &
under the effect of drugs e.g. hashish.

5- Depressive affect:

 Grief or mourning: it is a feeling of sadness appropriate to a real

loss.

 Depression: it is a psychopathological feeling of sadness.

- Its mental state also involves feeling of loneliness, despair, low Self-esteem,
self-reproach, psychomotor retardation or agitation.

6- Inadequate affect:

 Apathy: it is the absence of both emotional experience & expression.

 Indifference; it is the absence of emotional expression but

experience is present.

7- Ambivalence: The holding, at the same time, of two opposing

emotions, attitudes, ideas, or wishes toward the same person, situation,

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or object.

Follow, Part (II): Disorders of Emotions

B) Disorders of Mood

Normal range of mood is called Euthymic Mood (implying absence of

abnormal or pathological moods).

1- Dysphoric mood:
- An unpleasant mood; a mood of general dissatisfaction and
restlessness.

2- Irritable mood:
- Easily annoyed and provoked to anger.

3- Anhedonia:
- Lack of the ability to experience pleasure and loss of interest in all
regular pleasurable activities.

4- Labile mood: Having rapidly shifting emotions, unstable.

5- Anxiety, apprehension, & fear:

1-Anxiety: a state of feeling uneasiness, uncertainty resulting from

a real or perceived threat whose actual source is unknown or
unrecognized.

Types of anxiety:
a) Free floating anxiety: it is a severe, generalized, &
pervasive fear not attached to any idea.
b) Tension: unpleasant feeling associated with physical &
psychological tightness.
c) Panic: Acute, episodic attacks of severe anxiety and dread
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associated with severe autonomic manifestation and feeling of

impending death. That produces disorganization of the
personality, loss of rational thought, & inability to
communicate, along with specific physiological changes.

2- Apprehension: intense fear of any non-fearful stimulus. Fear of

external danger, e.g. car accident.

3- Fear: Unpleasant emotional state in response to a realistic threat

or danger.

6- Phobia: Fear related to particular object or situation. The person is

aware of the irrationality. Although aware that cats would not harm
her, Mary was deathly lid of cats & refused to visit her sister & friends
who had cats.

Part (III): Disorders of behavior

1- Hyperactivity: it includes.

A) Agitation: it's some form of hyperactivity characterized by

pacing and accompanied with restlessness.
B) Excitement: it is severe form of hyperactivity, excessive
purposeless motor activity and the patient may destruct himself or
others.

2- Psychomotor retardation: Extremely slow and difficult

movements that in the extremes can entail complete inactivity and
incontinence.

3- Repetitive activities:

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a) Stereotypy: it is a monotonous repetition of certain movement

without purpose. That are regular (unlike tics) and without obvious
functional significance (unlike mannerisms).

b) Mannerism: it is a repeated movement, which isn't monotonous and

keeping with the personality character.

c) Perseveration: the involuntary repetition of the same thought, phrase,

or motor response (e .g brushing teeth, walking).

d) Waxy flexibility: it is the maintenance of imposed postures however

abnormal they may be (as if made of wax). (e.g. raising the head of
the patient from the pillow, or the arm up). The absence of fatigue in
such cases is remarkable.

e) Catalepsy (posturing): it is sustained immobility. The patient initiates

the position by himself.

f) Tics: Involuntary, irregular, repeated movements involving a group of

muscles (e.g., raising shoulder or turning the head). Often related to
stress or anxiety, rarely organic disease.

4- Echopraxia: imitating the movements of another person.

5- Negativism: frequent opposition to suggestion, e.g.:

 In motor sphere→ when asked to look up, he looked down.
 In speech sphere→ when he asked question, he didn't answer.
 In visceral sphere→ retention of saliva, urine or feces.

6- Automatic obedience: the performance of all simple commands in

a robot-like fashion may be present in catatonia.

7- Impulsiveness: is an action that is sudden, abrupt, unplanned, & directed

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toward immediate gratification.

8- Compulsion: uncontrollable impulse to perform an act repetitively.

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