Psychiatric symptoms

Symptoms and signs

Symptoms and signs

• Symptoms are the complaints with which a

patient presents to the clinician
• Signs are the ones which the clinician
obtains on examination of the patient.
• In psychiatry, the boundary between
symptoms and signs is not that distinct
because when explored further, a
symptom can become a sign.
 Behavior
Behavior

Intellect
Intellect Affect
Affect
Aspects of psychopathology
• Psychopathology: Descriptive
(phenomenological) and Exparimental
• Signs and symptom categories:
1. Behavior
2. Mood and Affect
3. Talk
4. Thinking
5. Perception
6. Memory
7. Orientation
8. Attention and Concentration
9. Abstraction
10.Inteligence
11.Insight
Disturbance of behavior
A. Quantitative disturbance:
a. Excess motor activity
i. Agitation: the patient is moving around, moving his limbs and head,
wrinkling his fingers and cannot stay for some time in one place. This
sign is found in many psychiatric disorders e.g. mania, agitated
depression, some cases of schizophrenia ,

ii.Restlessness: the patient feels inner tension with some agitation and
cannot standstill. On sitting he sits on the edge of the chair and moves
his body parts like arms, head and neck. This condition found mainly in
anxiety, and akathisia, also in some psychotic state. The differentiation
between restlessness and agitation may be difficult but in restlessness
the condition usually not desired by the patient i.e. out of his control but
agitation is usually are action to the thoughts of the patient.
Disturbance of behavior
A. Quantitative disturbance:
iii. Excitement: Excitement occurs in primary psychiatric
disorders e.g. mania and schizophrenia and in organic
mental disorders e.g. drug addiction and temporal lobe
epilepsy.

iv. Difference between manic and catatonic schizophrenic

excitement
Disturbance of behavior
A. Quantitative disturbance:
Manic excitement Catatonic excitement

Occurs mainly’ in Occurs without

response to provocation. Mostly in response to
environmental stimuli delusion or hallucination

Accompanied with
cheerful or irritable The mood is apathetic
mood

Usually unexpected and

Usually expected and organized
disorganized

Accompanied with other

Accompanied with other
manifestations of
manifestations of mania
schizophrenia
Disturbance of behavior
A. Quantitative disturbance:
b. Diminished Motor activity
i. Partial retardation of motor activity e.g. in cases
of retarded depression or simple schizophrenia.
ii. Complete suppression of motor activity (Stupor):
1. No profound disturbance of consciousness
2. There is complete suppression of motor activity
(speech and movement). The patient does not respond
to any stimulus, neither external (question or painful
stimulus), nor internal (hunger, thirst or distended
bladder).
3. In stupor the patient is arousable but not responsive. It
occurs in psychiatric disorders like depression,
schizophrenia, and hysteria, or in acute organic mental
disorders.
Disturbance of behavior
A. Quantitative disturbance:
1. Stereotypy: means monotonous repetition, which
may be :
i. In movement (e.g. touching the nose, or pacing
up and down the room)
ii. In speech (e.g. some words are repeated).
2. Mannerism: repeated movements, which may
continue for hours or days without cessation, and are
keeping with the thought (e.g. a patient with paranoia
salutes repeatedly in a grandiose manner).
Disturbance of behavior
A. Quantitative disturbance:
3. Perseveration: denotes the repetition of the same act
(a movement, a word, or a phrase in spite of the
patient’s effort or desire to do a new one i.e. inability
to move from one act to the next one (e.g. during a
meal the patient continues to put the spoon in the
plate and up to his mouth, even after the plate gets
empty).
4. Lack of initiation and reduction of spontaneous
movement, lack of volition: the patient has no desire
or will to perform acts.
Disturbance of behavior
A. Quantitative disturbance:
5. Negativism: means automatic resistance to
all stimuli.
i. In muscular field it may show itself as a
resistance to passive movements (e.g. keeping
the arm extended on trying to flex it or as
opposite performances to that asked for (e.g.
looking down when asked to look up).
ii. In speech it consists of total loss of it i.e.
mutism.
iii. Negativism is seen also in the retention of
saliva, urine and feces.
Disturbance of behavior
A. Quantitative disturbance:
6. Resistiveness: in which the patient simply oppose or
resists anything he is asked to do e.g. when he is setting
and is asked to stand up, he will remain setting down.

7. Automatic obedience: in contrast with negativism there is

abnormal suggestibility; it shows itself as:
i. Echopraxia which is repetition of actions seen (e.g.
when the doctor walks the patient walks too).
ii. Echolalia which is repetition of words heard (e.g.
when the doctor says to the patient: how are you? the
patient answers: how are you?).
Disturbance of behavior
B. Qualitative disturbance:
iii. Waxy flexibility (Flexibilitas cerea) which is the
maintenance of imposed postures however abnormal
they may be (e.g. rising-the head of the patient from the
pillow, or the arm up). The absence of fatigue in such
cases is remarkable.

iv. Catalepsy (posturing) is sometimes used for any form

of sustained immobility.

v. Automatic movements or automatism occur in a

pathological sense, without the subject being aware of
their meaning and even without his being aware of their
happening at all. Automatism may be i) local e.g.
automatic writing or ii) general e.g. in fugue and
Disturbance of behavior
B. Qualitative disturbance:
8. Impulsive action or impulses: consist of sudden
outbursts of activity with little or no provocation, such
as attacking another person (bystander), or breaking a
window.

9. Aggression: means intention to inflect harm to the

others without their permission or even their trial to
avoid this harm, the aggression could be physical,
verbal, or moral. physical aggression like body
injuring, verbal aggression like obscene words, moral
aggression like violation of social or religious norms
that cause harm or embarrassment to others. The non
physical aggression is called hostility.
•  
• Mood: Sustained and pervasive emotion that
colors the person’s perception of the world.
• The patient may report his feelings or the
psychiatrist ask how he or she feels.

• Affect: The patient present emotional

responsiveness that is inferred from his facial
expression.
Disturbance of Affect
A) Quantitative disturbance:
1. Cheerfulness is used for happiness or
gladness. It is pathological when out of the
patient's actual circumstances.
2. Euphoria is a generalized feeling of well being
(not amounting to a definite affect of
gladness).
3. Exaltation means something in addition to
elation, an element of grandeur.
4. Ecstasy is a feeling of happiness, usually
with a mystical coloring.
Disturbance of Affect
A) Quantitative disturbance:
5. Depression is an emotional state characterized by
pervasive lack of interest, difficulty to be in
pleasure (anhedonia) and sadness not in accord
with the patient's actual circumstances.
6. Sadness: it is and emotional state occurs as a
reaction to loss of loved object, the object could
be a person; money or status. Sadness could be
a part of depressed mood when occurs without
cause.
Disturbance of Affect
A) Quantitative disturbance:
7. Anxiety: is an emotional state characterized by
anticipation of danger.
If the source of anticipation is unknown it is called
generalized anxiety,
if the anticipation is from potentially non dangerous
object or situation it is called phobia,
if the anticipation is from consequences of act or
situation it is regarded as. Obsessive fear.
The anxious mood is that of fear accompanied with
restlessness.
Disturbance of Affect
A) Quantitative disturbance:
8. Apathy: is absence of affect, or loss of emotion,
or lack of feel­ing (there is loss of both emotional
expression and experience). Occurs in some
schizophrenics.
9. Indifference: is lack of objective emotional
response. (There is loss of emo­tional
expression, but emotional experience is
preserved). Occurs in schizophrenia. a type of
this called “a belle indifference “ occurs in
hysteria when the patient`s feelings are not in
tune with the problem.happy in spite of his
disability
Disturbance of Affect
A) Quantitative disturbance:
10.Emotional deterioration: is a progressive failure
to show the normal emo­tional responses
(characterized by a childish, easily suggestible,
facile state). Occurs in disorganized
schizophrenias
11. Emotional instability or lability: is inability to
control the emotions and their expression. The
emotional change from one extreme to the
other with no obvious cause (e.g. Laughing and
weeping. it occurs in gross organic disorders,
such as dementia)
Disturbance of Affect
A) Quantitative disturbance:
11. Morbid anger: is an unprovoked transient angry
outburst with violence. (In children and mentally
defectives, it is called 'tantrums'). Occurs in
schizophrenia and personality disorders
Disturbance of Affect
B) Qualitative disturbance:
i. Incongruity or disharmony of affect:
inappropriateness of affect to thought content
(e.g. the patient feels happy while he believes
that he is going to be killed by his enemies).

ii. Ambivalence denotes the simultaneous

existence of contradic­tory emotions (e.g. Love
and hate), or ideas (e.g. being present and
absent at the same time, or present in two
places simultaneously. It occurs in
schizophrenia.
Disorders of Talk
A. Disorders of Stream
1- Slow stream: Slowing of the stream of talk
occurs in different psychiatric disorders
particularly in psychosis and the disturbance
shows different degrees:
a. Lack of spontaneous talk.
b. Delayed response to questions.
c. Short response to questions.
d. No response to questions Mutism.
Disorders of Talk
A. Disorders of Stream
2- Blocking is a sudden stoppage of the
stream of talk, for a while and then it is
resumed without the patient being able to
account for such stoppage. This could occur
in some normal individuals when surprised
and in some schizophrenics.

3- Rapid stream occurs mainly in mania and

some schizophrenics
Disorders of Talk
B. Disorders of Expression
a.Irrelevant answers to questions. When the patient is
asked a question he responded by answer not related
to that question.
b.Over inclusions: the patient talk is much abbreviated
and not giving the necessary details.
c. Derailment: the patient deviates in his talks to
subjects away from the main topic.
d.Circumstantiality: there are much unnecessary
details, but the subject in view at the beginning is
ultimately reached.
Disorders of Talk
C. Disorders of Association
i. Vagueness ( the paragraphs of the story
are not harmonious)
ii. Flights of ideas ( the sentences of the
paragraph are not harmonious)
iii. Incoherence ( the words of the sentence
are not harmonious)
iv. Neologism ( the letters of the word in the
word are not harmonious)
 Disorders of Thinking
Stream
Expression
Content
Form
Possession.

The first and second is the same as those •

.discussed under talk
Disorders of Thinking
Content (delusions)
Delusions: false, fixed beliefs which is not
accepted by individuals of the same social,
cultural or educational background and not
corrected by logic reasoning.

If the belief is false but is widely accepted by individuals of

the same culture and education it is called culture bound
belief, if it could be corrected by logic reasoning it is called
idea and not delusion.
Disorders of Thinking
Content (delusions)

Delusions may be
I.Systematized (well knit) when they form a
coherent system and appear to be logical, or

II.Non-Systematized when they are fleeting and

appear to have no logical connection
Disorders of Thinking
Content (delusions)
Types of delusions:
Delusion of grandeur: in which the patient imagines
that he is great individual, very rich, strong,
intelligent, etc.
Delusion of persecution in which the patient thinks
that he is chased (run after) by certain people, or his
food is poisoned by them.
Delusion of reference in which the patient believes
that everything in the environment is referring to him
(e.g. people talking in the street. newspapers, radio, television, etc. are
referring to him).
Disorders of Thinking
Content (delusions)
Delusion of influences (Passivity feeling) in which the
patient says that he is under the influence of electricity,
wireless, hypnotism or telepathy, utilized by some
other person. Such delusions include such diverse
ideas as a) that the patient's thoughts are being read
b) his limbs are moved without his control or consent
by some invisible agency.
Delusion of self ‑ reproach (self blame) or sin: in which
the patient feels that he is wicked, full of sins and unfit
to live or mix with other people (feeling of
unworthiness).
Disorders of Thinking
Content (delusions)
Delusion of poverty in which the patient believes that he
lost all his money, property and everything in life.
Nihilistic delusion in which the patient declare that he
does not exist (dead) and that there is no world.

Hypochondriacal delusion in, which the patient is

convinced that he has a physical disease (e.g. cancer
stomach) in, the absence of any evidence thereof.
Disorders of Thinking
Content (delusions)
Depersonalization: the patient feels that he is no longer
himself; he can no longer believe in his own existence.
When he looks in the mirror he feels himself changed
throughout in comparison with his former state. He feels
unreal, strange, lifeless, detached and automatic. (2)

Derealization: the patient feels that the outer world has

changed the people, streets and houses look different and
unusual. He wonders whether his friends are the same
people as they were, or whether indeed they exist at all.
Disorders of Thinking
Content (obsessions)
Obsessions
Feeling of compulsion to repeat physical or
mental act, the patient realizing that it is silly
and meaningless, resisting it and the
resistance is accompanied by increasing inner
tension which is relieved by repeating again.

The patient fights for his delusions and

resists his obsessions
Disorders of Thinking
content (overvalued ideas)
The overvalued idea refers to a solitary, •
abnormal belief that is neither delusional
nor obsessional in nature, but which is
preoccupying to the extent of dominating
.the sufferer's life
Disorders of Perception
Hallucinations
• Perception of non existed stimulus
• Types
– Visual
– Auditory
– Olfactory
– Tactile
– Gustatory
Disorders of Perception
Hallucinations
• Normal (physiological)
– Hypna-gogic
– Hypna-bombic
• Pathological
– Primary psychiatric disorders
• Schizophrenia
• Rarely in depression, mania, paranoid disorder.
– Organic mental disorders
• Delirium, Drug dependence, TL epilepsy, Brain
tumors. Encephalitis
Disorders of Perception
Illusions
• False perception of an external stimulus
• Types:
– Visual
– Auditory
– Olfactory
– Tactile
– Gustatory
Disorders of Perception
Illusions
• Physiological:
– Intense emotions, change of set, lack of perceptual
clarity
• Pathological:
– Primary mental disorders
• Schizophrenia
– Organic mental disorders
• Delirium
• Epilepsy
• Brain tumors
• Encephalitis
 Disorders of Memory

• Registration
• Retention
• Recall & Recognition

Any failure of one of these functions is

regarded as memory disorders
Disorders of Memory
Types of Amnesia

1. Anterograde amnesia when there is loss of

memory for recent events.
2. Retrograde amnesia when there is loss of
memory for remote events.
3. Total amnesia when there is loss of memory
for all events, recent and Remote.
4. Circumscribed amnesia when there is loss of
memory for a limited time (amnesic gap).
Disorders of Memory
Paramnesia (False Recall)

1. Confabulation: when the patient fills the gaps in his

memory by fabrication i.e. by giving im­aginary accounts
of his activities (Thus a bed ridden patient will describe a
walk which he asserts he has just taken). It usually
occurs in organic diseases Korsakov’s syndrome which
is typically seen in alcoholism).

2. Falsification (illusion of memory): when the patient adds

false details and meanings to a true memory. It occurs in
organic and psychiatric diseases (e.g. paranoid states).
Disorders of Memory
Hypermnesia

 excessive memory,
 the patient mentions even small unnecessary
details.
 It is present in
1- some normal people (geniuses)
2- some mental disorders (hypomania
and paranoia).
 Clinical exam of of Memory

• Immediate recall:
– (5-7 digits or home address immediately)
• Short-term recall:
– (5-7 digits or home address at 5 min)
• Recent:
– what patient did past several days
• Recent past:
– what patient did past few months, present President, recent
news events
• Remote:
– Childhood events, past Presidents, historical events (years)
Disorders of Memory
Clinical significance

• Anxious patient may complain of poor

memory because of defective registration
• In Korsakoff’s syndrome there is failure of
retention so the patient has disturbed
immediate recall
• In dementia the recall of recent events is
disturbed.
 Orientation

• Realization of:
– Time
– Place
– Persons
– Situation.
• Disturbed in acute organic brain disorders.
 Attention and Concentration
• These terms are used for describing the
experience that certain objects are in the
center of consciousness, whilst others lie
more towards the periphery.
 Attention may be disturbed in various
ways
• difficult to arouse the attention of the patient.
– a) states of disturbed consciousness (e.g. confusion)
b) self‑absorption due to depression or schizophrenia.
• Difficult to maintain or keep the attention of the
patient due to distractibility.
• Distractibility is a disorder of attention in which
the patient gives attention to every passing
stimulus
 Types of Attention
• Active (voluntary)
• Passive (involuntary).
• In organic disease: active attention is often
good, while passive attention is poor i.e. object
in the center of consciousness is observed,
while those towards the periphery are not.
• In Psychogenic diseases (e.g. schizophrenia)
the patient does not pay attention to what the
doctor says to him and at the same time he pays
attention to what the nurses talk about.
 Abstraction

• Abstraction: is the patient's ability to

derive a general principle from a specific
example.
• Abstract thinking is affected in psychosis
particularly schizophrenia and mental
retardation
Factors affecting Abstraction

– level of education.
– Culture
– cerebral dysfunction. Abstraction
deficits are particularly common
with frontal lobe disorders.
 Clinical Assessment of Abstraction
1- Similarities
– Similarities require the patient to identify the class or category of
which two items are members (e.g., rose and tulip, bicycle and
train, watch and ruler).
2- Differences
– Differences require the patient to identify the salient distinguishing
feature between two similar items (e.g., child and midget, canal and
river, lie and mistake)
3- Idioms
– Idioms are metaphorical statements or aphorisms that require the
patient to generalize to a larger meaning (e.g., "seeing eye to eye,"
"level headed," and "eyes peeled")
4- Proverbs.
– Proverbs are usually double metaphors that require the patient to
ignore the immediate meaning and derive a lesson or maxim (e.g.,
"don't cry over spilled milk," "people who live in glass houses
shouldn't throw stones," "the tongue is the enemy of the neck").
 Intelligence
• The ability to benefit from previous
experiences and to get maximum benefit
from available data
• Intelligence is affected in mental retardation
 Assessment of Intelligence

• Clinical assessment • Psychometry

– During interview – WAIS
– Mathematical problem – WISC
solving. – SB
– Proverb test
– General information.
 Insight & Judgment

• Insight: is the degree of realization the

patient has of his own condition.
• Judgment: is the ability to grasp the
meaning of a situation and hence react to
it appropriately.
• Insight and judgment are disturbed in
psychotic conditions e.g. schizophrenia
and mania.