The Neuropsychiatric Mental Status Examination

The Neuropsychiatric Mental Status

By Michael Alan Taylor, M.D. Professor and Chairman Department of Psychiatry and

Behavioral Sciences University of Health Sciences The Chicago Medical School Chicago, Illinois

Springer-Science+Business Media, B.V.

ISBN 978-0-89335-130-4 ISBN 978-94-011-7391-9 (eBook) DOI 10.1007/978-94-011-7391-9

Copyright© 1981 Springer Science+Business Media Dordrecht Originally published by Spectrum Publications, Inc. in 1981 Softcover reprint of the hardcover 1st edition 1981

All rights reserved. No part of this book may be reproduced in any form, by photostat, microform, retrieval system, or any other means without prior written permission of the copyright holder or his license.

Library of Congress Cataloging in Publication Data

Taylor, Michael Alan.

The neuropsychiatric mental status examination.

Includes bibliographical references and index.

1. Neuropsychiatry–Programmed instruction.

I. Title. [DNLM: 1. Mental disorders–Diagnosis– Programmed texts. WM18 T 244n]

RC341. T 39 616. 89’075’076 80-36794

For Christopher and Andrew

Acknowledgments

I wish to thank the following people for their contributions to this work:

Ms. Sierra-Franco’s detailed review of the program structure was of singular help to me. Whatever weaknesses remain in the design are solely my responsibility and undoubtedly exist from my resistance to respond to one of her many perceptive suggestions. Ms. Ingrid Hendricks edited an earlier revision of the manuscript and coordinated its field trials.

Ms. Sandra Mott typed and retyped multiple manuscript drafts and revisions and generally facilitated the process of writing and preparing the book. Ms. Peggy Pfeiffer and Brad Greenspan, M.D. posed for the photographs which were taken by Professor Jack DeBruin, Medical Photo- grapher in the Department of Medical Communication at the University. Ralph Reitan, Ph.D. kindly gave his permission to use test items from his Reitan-Indiana Aphasia Screening Test. The medical students who partic-

ipated in the field trials provided many insightful suggestions and were always encouraging. Ellen Taylor put up with the debris of work and hours of non-communication. She was always supportive and made life a lot easier.

There are almost as many explanations for psychiatric disorders as there are patients with them. Each explanation is intriguing, some of them are systematic, all of them have intellectually powerful champions. Yet their very multitude is a scandal. It provokes the professionally debilitating challenge: Why does every psychiatric explanation satisfy some people and not others? Recently this question has received a simple answer. We cannot satisfactorily explain that which we lack the skill to describe.

To develop the fundamental skill a student must see many patients under the direction of an experienced and involved instructor to whom he can show his results, accept correction and advance in his abilities. But we need a means to amplify the clinical experience, a text to supplement the instructor in bringing forth and strengthening the vocabulary needed to describe the phenomenology, presentations and distinctions amongst psychiatric patients.

A “programmed text” such as this one is a satisfactory means because it can cover rapidly many themes and variations of a vast clinical experi- ence. It can permit the reader to progress at his own speed but bring

a sense of mastery to him as he progresses. He can check his knowledge as he sees patients on the clinical services. This kind of text combined with patient practice is thorough, fast and fun, but should succeed in the important task of rapidly building for the student an authentic set of terms and concepts suitable for both clinical work and research.

Thus, this text approximates an individual instruction method. It supplements it but does not replace it. All phenomenological events need to be seen to be believed, but this step by step conversation with an author that is the strength of the programmed approach finds here a situation that is apt for it.

This book leads to progress not because everything in it is bound to command assent but because it uses the method of breaking complex problems down to smaller elements, fights for clarity, strengthens its reader through the question and answer approach and calls directly for engagement with the teacher and the patient.

I enjoyed this book for still other reasons that emerge from the intentions of the author. This is no “back to basics” book although there are plenty of basics to learn. Rather this book is a piece with the “let’s get down to work” approach that has vitalized the academic psychiatric world in the

Preface

last decade. Its scholarly roots extend back to Kraepelin but reach broadly to encompass empirical work wherever it is found. It presents its information in a way that permits the reader to wrestle with it, check its reasoning and its references and to argue with the author. Here is

a two-fisted “new world” style for the dissemination of information on the characteristics of psychiatric patients that is direct and unabashedly confident, but as well friendly, open to challenge, alive with vigor. It

is a product of a teacher who admires his students and enjoys his subject and is prepared for the benefit of both to show how he thinks. Such an approach wins readers, respect and results. I expect this book to find

a place in teaching programs that want to bring on a phenomenological interest in psychiatry. Since this is a major theme in contemporary work, it should have a large audience.

Although much effort has been expended to develop a reliable and valid nosology of mental disorder, the process of clinical psychiatric diag- nosis remains very much an art. Unfortunately, inspiration and talent, applied without effective technique and divorced from a valid data base are frequently unsuccessful. The inexperienced clinician, almost instinct- ively recognizing the need for technique and data, gropes for a process which will enhance recognition of signs and symptoms and which will or- ganize these phenomena into a usable structure. The phenomenologic ap- proach towards clinical psychiatric diagnosis is one such process. Its rel- iance on a structured examination, objective observation and precise de- finitions of clinical phenomena makes phenomenology an extremely useful tool for the evaluation and subsequent diagnosis of individuals with men- tal disorder.

This book is an introduction to the language, technique and concepts of the phenomenologic school. It is not intended to substitute for a well- taught course in basic psychopathology, nor can it replace hours of pa- tient contact required to become a skilled clinician. It is a beginning.

The book is in two parts. Part I presents basic phenomenologic prin- ciples, the behaviors that comprise the major areas of concern in the men- tal status examination, some suggestion on how to conduct the examination and a brief exposure to behavioral relationships which lead to a clinicial diagnosis. Part II builds upon Part I. It develops and reinforces the items dealing with techniques, elaborates the phenomenologic principles of diag- nosis, presents diagnostic criteria which have been found to be reliable

and valid in the classification of major mental disorder and presents data which aid in the delineation of those disorders.

This is a programmed book and not a comprehensive text. Reading it is not a passive experience. To gain from it, you must participate in the program. Filling in the blanks, drawing lines or circles are all part of the process of helping you learn not just from eye to brain but from hand to brain. Some items will seem absurdly simple and you will be able to rap- idly go through those parts of the program. More difficult parts will take proportionately longer. Some items present new information, some review old information or present old information in new forms. The sequence is important and has been developed so the correct response to any item is either within that item or within previous items. Each page of questions or test items will be followed on the next page by the correct answers to those items. If you make an error, read back into the text until you

find the items that explain the correct response. Do not skip items, for

Introduction

like the good mystery novel, if you read the last page first , the rest are partially ruined.

Unlike standard textbooks, this book cannot be of value if picked up for only a few moments at a time and then discarded for days or longer. Throughout the program, there are natural breaks, and pausing there wi best achieve your learning goals. When starting again, a brief review of past items will help put you in the proper “set” for reading new material. insure the correct response, always read the directions before attemptint to answer.

Although many of the statements in the text are referenced, additionI readings will be required to flesh out the concepts in the program and to document others further.

In my opinion, the best general English language text of adult psych· iatry is the book by Slater and Roth (1969). For the reader who does no; plan to specialize in psychiatry, this survey plus Woodruff, Goodwin and Guze’s small, but well documented primer of Psychiatric Diagnosis (1974) should suffice.

For a more in-depth understanding of the phenomenological approach to psychopathology, Taylor and Heiser (1971) and Taylor (1972) should initially be read, followed by Hamilton’s revisions of Fish’s classic books. For those made of heroic stuff, Kurt Schneider’s seminal work and Karl Jaspers’ great General Psychopathology remain unsurpassed.

Further clinical descriptions, rich in detail and priceless in insight into the early development of clinical psychiatry, can be found in Bleuler’ famous monograph (1950) on schizophrenia and in the more recent fascim- ilies of Kraepelin’s lectures (1968) and treatises on dementia praecox (197 and manic-depressive illness (1976) and Kahlbaum’s monograph on cata- tonia (1973).

For a more in-depth presentation of neuropsychology, the Luria (197: and Golden (1978) texts should suffice as an introduction to the study of higher cortical functions. A discussion of the relationships between high• cortical dysfunction and psychopathology can be found in Pincus and Tuc ker’s (1978) Behavioral Neurology. Slater and Beard (1963), Herrington

( 1969) and Benson and Blumer ( 1975) provide detailed discussions of the behavioral manifestations of coarse brain disease.

Bibliography

Benson, D.F., Blumer, D. (Eds.): Psychiatric Aspects of Neurologic Disease. New York, Grune & Stratton, 1975.

Bleuler, E.: Dementia Praecox or the Group of Schizophrenias, (Trans. Zinkin), Int. University Press, 1950.

Golden, C.J. : Diagnosis & Rehabilitation in Clinical Neuropsychology, Springfield, C.C. Thomas, 1978.

Hamilton, M. (Ed.): Fish’s Clinical Psychopathology, Signs and Symptoms in Psychiatry, Revised Reprints, Bristol, John Wright & Sons, Ltd. , 1974.

Hamilton, M. (Ed.): Fish’s Schizophrenia, Revised Reprints, Bristol, John Wright & Sons, Ltd. , 1976.

Herrington, R.M. (Ed.): Current Problems in Neuropsychiatry: Schizo- phrenia, Epilepsy, the Temporal Lobe. Brit. J. Psychiat. , Special Publication #4, Ashford, Kent. Headley Bros., Ltd., 1969.

Jaspers, K.: General Psychopathology, (Trans. J. Heonig and M.W. Ham- ilton), University Chicago Press, 1968.

Kahlbaum, K.L.: Catatonia, (Trans. Levy, Y. and Priden, T.), Baltimore, Johns Hopkins University Press, 1973.

Kraepelin, E. : Dementia Praecox & Paravhrenia, (Trans Barcley, R .M. ; Ed., Robertson, G.M.), Foes. 1919Edltion, Huntington, New York, R.E. Kruger Publishing Company, 1971.

Kraepelin, E.: Lectures on Clinical Psychiatry, (Johnstone, T. Ed.) New York, Hafner, 1968.

Kraepelin, E. : Manic-Depressive Insanity and Paranoia, New York, Arno Press, 1976.

Luria, A.R.: The Working Brain: An Introduction to Neuropsychology, New York, Basic Books, Inc., 1973.

Pincus, J.H., Tucker, G.J.: Behavioral Neurology, 2nd Edition, New York, Oxford University Press, 1978.

Schneider, K.: Clinical Psychopathology, (Trans. M.W. Hamilton), New York, Grune & Stratton, 1959.

Slater, E. , Roth, M. : Mayer Gross’ Clinical Psychiatry, 3rd Edition, Baltimore, Williams & Wilkins, 1969.

Slater, E., Beard, A.W.: The Schizophrenia-like Psychoses of Epilepsy: 2. Psychiatric Aspects. Brit. J. Psychiat. 109:95-150, 1963.

Taylor, M.A., Heiser, J.: Phenomenology: An Alternative Approach To Diagnosis of Mental Disease. Compr. Psychiatry 12:480-486, 1971.

Taylor, M.A.: Schneiderian First Rank Symptoms and Clinical Prognostic Features in Schizophrenia. Arch. Gen. Psychiatry 26: 64-67, 1972.

Woodruff, R.A., Goodwin, D.W., Guze, S.B.: Psychiatric Diagnosis, New York, Oxford University Press, 1974.

Preface Introduction Part I

Basic Concepts 2 Interview Considerations 8 General Appearance, Motor Behavior

and Catatonia 12 Affect 36 Language Function (Thought Process) 48 Delusions (Apophany) 94 Perception and First Rank Symptoms 108 Cognitive Function 136 Frontal Lobe Cognitive Dysfunction 146 Verbal Memory 162 Parietal Lobe Function 174 Language Disorder 194 Review Section 224 Clinical Evaluations 240 Phenomenologic Mental Status Outline 264 Cognitive Function Evaluation Outline 265 References 266

Part II

Introduction 273 Diagnosis 274 Major Affective Disorder 276 Schizophrenia 302 Diagnostic Criteria-summary 328 Coarse Brain Disease 340 Frontal Lobe Syndromes 356 Temporal Lobe Syndrome 370 Parietal Lobe Syndromes 384

Anxiety States (DSM-Ill Term:

Anxiety Disorders) 402

Minor Depression (DSM-III Term:

Dysthymic Disorder) 434

Obsessional Conditions 440 Hysteria (DSM-Ill Term:

Somatoform Disorders) 444 Sociopathy (DSM-Ill Term: Antisocial

Personality Disorder) 460 Alcoholism 468 Clinical Evaluations 478 References 500

Contents

The Neuropsychiatric Mental Status Examination

THE HUMORLESS SMILE CALLED “GRIMACE” SEEN IN CATATONIC PATIENT

T!-IE SAD EXPRESSION OF DEPRESSION

part I

BASIC CONCEPTS

1.

The mental status examination is the psychiatric equivalent of

the medical specialist’s physical examination. It should be part of

any complete medical evaluation and becomes meaningful only in the context of a complete physical and neurological examination. The mental status examination should include only observations of the patient’s behavior and experiences during the examination (inter- view) period. Historical data including recent hallucinations and sui- cidal thoughts are past, not present experiences, and thus do not belong in the mental status. The goal of the mental status examination is not a psychotherapeutic interaction. It is a specialized evaluation of behavior and its goals are to establish a reasonable treater-patient relationship and a thorough evaluation of the patient’s :-;–c;–~-~-­ .,——-:——:c–~ so that a working diagnosis can be established and a treatment plan developed, executed and monitored.

Failure to limit the mental status examination to the patient’s behavior during the interview makes evaluation of rapid behavioral changes difficult and often leads to erroneous clinical conclusions.

Historical data is, of course, important and must be determined and recorded systematically. This information is then corroborated by the physical examination and the mental status evaluation. These examinations deal with the status of the patient just as the historical examination deals with the patient’s –,–,–

A physician examining a patient with crushing chest pain would not be satisfied with a description of “I had no heart abnormalities last year.” A physician practicing psychiatry should not be satisfied with the examination of a depressed patient who states: “I was not suicidal last year. ”

2.

2

1. present behavior

2. present, past

3

3.

The mental status examination is based on objective observation of the patient’s behavior. Objective observation separ- ates what you observe from what you believe or interpret.

Two examiners are looking at the same patient: The patient is sitting in a corner, talking to himself, masturbating in public, and constantly putting various objects he finds around him in his mouth. He appears completely unaware of the ward activities around him.

One of the examiners is quick to interpret the patient’s behav- ior. He says, “That man’s regressed.” The second examiner who observes carefully sees the following behaviors: abnormal sexual behavior, orality, unusual placidity. These behaviors alert him;

he shows the patient a pen and asks him to name it. The patient can’t name it until he feels it. Only then does the examiner inter- pret his observations to suggest that the patient is suffering from Kluver-Bucy syndrome which indicates bilateral temporal lobe lesions (55). Objective of , not past, behavior

is a basic principle of the phenomenological mental status.

Observations during the mental status exam should separate form (process) from the content of behavior. What a person is talk- ing about, the subject matter, is content. How a person is talk- ing, the fluency and accuracy of his speech, the grammatical cor- rectness of his language is ———–

The form of signs and symptoms is often diagnostic. On the other hand, the of signs and symptoms is rarely

of such diagnostic importance because it reflects individual exper- ience and cultural learning rather than disease process. A bushman with a brain tumor might hallucinate an antelope whereas a Madison Avenue ad man with a similar tumor might hallucinate a bevy of mo- dels. Although the content is interesting, it is the fact that these two gentlemen see things that are not real (hallucinate) which is of prime importance and which indicates a pathological process.

A patient said she heard her mother’s voice coming from her ra- dio, telling her that she was a bad girl and should kill herself. Cir- cle the words and/or phrases that indicate the form of this exper- ience.

A patient said he clearly saw little men running through the streets screaming and waving knives at passersby. He said he was terrified and when the little men approached him, he ran away. Cir- cle the words and/or phrases indicating the form of this experience.

A patient said he felt metal worms crawling under his skin, up his arms and into his face and head. Circle the words and/or phra- ses indicating the form of this experience.

Historical data can also be separated by form and content but the mental status includes only ______________

4.

5.

6.

7.

8. 9.

4

3. present, observation, present

4. form

5. content

6 .

A p a t i e n t s a i d she(!iear~her mother’s~ming f r o m h e r rad~ telling her that she was a bad girl and s ould kill herself.

7.

A patient said he@:early silW)little men running through the streets screaming and wavmg knives at passersby. He said he was terrif- ied and when the little men approached him, he ran away.

8. 9.

A patient said he~metal worms<§’awling under his skin~up his arms and into his ace and head.

Although not stated, it is implied that this experience is perceived as occurring outside of the patient. This, too, is part of the form of this hallucination.

present behavior

5

10.

11.

In addition to relying heavily on objective and separating behavior into and , the phe- nomenologist’s mental status as much as possible utilizes precise terminology.

Precise terminology is necessary for accurate diagnosis. Often psychiatrists disagree about the meaning or usage of common psy- chiatric terms. Some use the term “paranoid” to mean delusional, others to mean suspicious or frightened and some as a synonym for schizophrenia. By avoiding such terms as “paranoid” and using in- stead more terminology, phenomenologists try to reduce areas of confusion and disagreement. The use of precise terminology is as important for the psychiatrist as it is for the in- ternist. Just as the internist would not be satisfied with a descrip- tion of heart sounds as “odd” or “abnormal,” so, too, the psychi- atrist should not be satisfied with descriptions as “bizarre behav- ior,” “incoherent speech,” “paranoid.”

The phenomenologic mental status is based on three principles: objective , the separation of the and __________ of behavior, and terminology.

Below are some words and phrases. Circle those suggesting behavior form:

“I don’t think I’m well” “A clear voice”

“A voice from inside my head” “It says ‘kill yourself”‘

Below are some words and phrases. Circle the words suggest- ing behavior content:

“A clear voice” “The smell of burning flesh” “Little men with knives” “My father’s voice”

Below are some words and phrases. Circle the words suggest- ing behavior form:

Visual hallucination “A green gas”

“A voice from outside my head” “I’m upset about my job”

The following statements are true about the phenomenological mental status except one (circle your answer).

a. Precise terminology of objective observation is essential for a proper examination.

b. What the patient is talking about is not nearly as diagnostically important as how he is talking.

c. Only behaviors during the examination are recorded as part of the mental status.

d. The identily of a hallucinated voice, e.g. , who it is, is impor- tant.

12. 13.

14.

15.

16.

In the following sections, I will describe the major areas of the mental status; how to examine and elicit psychopathology, and how to distinguish different signs and symptoms.

6

10. observations, form, content

11. precise

12. observation, form, content, precise

13.

“I don’t think I’m well” Ci”A clear voiceV c·~voicefrominsidem~ “Itsays’killyourself”‘

14.

“A clear voice”

CLittle men with knives~

“The smell of burnin “My father’s voice”

15.

Visual hallucination

“A voice from outside my head”

“A green gas”

“I’m upset about my job”

16. d. This is not true because it deals with content.

7

INTERVIEW CONSIDERATIONS

17. 18.

As all the patient’s behaviors are important for consideration in the mental status examination, the patient’s general appearance is the first behavioral area to be evaluated,

19.

Inexperienced examiners often express the misconception that they must remain impersonal with patients. The unresponsive “blank screen” approach to interviewing is not appropriate to the men-

tal status examination. When should you first begin evaluating the

20.

It is often helpful to explain your reasons for speaking with the patient and what you are going to do and not do. Patients have

the right to be informed about their condition and treatments, and of your opinions concerning their illness. Within the limits of good judgment, you should uphold this right.

21.

Often the best approach for obtaining the information you need in a mental status examination is to engage the patient in a “conver- sation”. No matter how structured an interview, the maintenance

of a al atmosphere will increase your chan- ces of success (i.e., obtaining enough information to make a work- ing diagnosis and treatment plan). In our society, normal conver- sation between strangers or acquaintances has certain rules. The inexperienced examiner often suspends these rules during a mental status examination. It is surprising how frequently an initial “Hello, I am Dr. So and So” is ignored in favor of a more clinical but less effective opening such as “What’s today’s date?”

22.

A good mental status examination, while in atmos- phere, should not be haphazard. Some structuring is important.

The examiner should, whenever possible, greet the patient out of the examining room and walk with him to the area selected for the interview. The examination begins when you first see the pa- tient, not when you sit down. How the patient greets you, how the patient walks and moves are all part of the first behavioral area of the mental status examination, the patient’s _ _ _ _ _ _ _ _ _

patient? – – – – – – – – – – – – – – – – – – – – – – –

8

17. present

18. general appearance

19. When you first see the patient

20. No answer required

21. conversation

22. conversational

9

23.

24.

Your examination questions and actions should proceed in a log- ical pattern, yet remain responsive to the specific needs and be- haviors of the patient. Your examination goals of establishing a work- ing and developing a treatment and follow-up momtormg of treatment should always be kept in mind.

When you first meet a patient, who is standing sedately in the hall, a pleasant “hello” is a fine opening. However, for the patient who is standing on top of a table and cursing the devils about him,

a “Hello, I’m Dr. So and So, how are you?” does not direct the qual- ity of your statements to the global behavior of the patient. Be-

low are some descriptions of patient’s global behavior. Draw lines between each description and the appropriate opening statement.

25.

26.

Circle those words or phrases consistent with a good mental status examination:

“Hello, I’m Dr. Jones.”

“What’s the matter?”

“I’m Dr. Jones. Let’s sit down and we can talk about this.”

“Stop that. Sit down. want to talk with you.”

Elderly woman, sitting on the floor, crying.

An elderly man, lying in bed, reading.

Middle aged man rushes to you and starts offering one complaint after the other.

A young man, standing in the hall, starts beating him- self with his hands on his chest and head.

1. 2. 3. 4. 5. 6.

conversational atmosphere

unresponsive “blank screen” approach

the examination begins when you first see the patient questions asked in logical pattern

unstructured without sequence

examination goal is to establish a working diagnosis and treat- ment plan

Patients with psychiatric illnesses often ask direct and personal questions. Although responses to personal questions must be lim- ited, patients do have the right to know something about the person examining and testing them, and truthful responses to questions about your education, experience or professional role (e.g., student, resident) are often helpful in maintaining a good relationship with

the patient. Such questions are part of any normal conversation.

In addition to their direct questioning of the examiner, patients

often say or do things that are quite humorous. When it is obvious that you are not making fun of their illness, do not be afraid to laugh. Ii hur,or and responses to questions help achieve the goals of the ez2.mination, they are appropriate. Write a sentence explaining

tl'”!e goals of a mental status examination.

10

23. diagnosis, plan

24.

“Hello, I’m Dr. JonesX” Elderly woman, sitting on the floor crying.

25.

1. 2. 3. 4. 5. 6.

(5onversational atmospher0

unresponsive “blank screen” approach

the examination be ·ns when you first see the patient

26.

The goals of the mental status examination are to establish a rea- sonable treater-patient relationship so that a thorough diagnostic evaluation can be made (a working diagnosis) and a treatment plan developed.

“What’s the matter?” An elderly man, lying in bed, reading.

“I’m Dr. Jones. Let’s s i t – – Middle aged man rushes to you and down and we can talk starts offering one complaint after about this.” the other.

“Stop that. Sit down. I – – – A young man, standing in the hall, want to talk with you”. starts beating himself with his hands

on his chest and head.

uestions asked in logical pattern

unstructured without sequence

examination goal is to establish a working diagnosis and treat- ment plan

11

GENERAL APPEARANCE, MOTOR BEHAVIOR AND CATATONIA

27. 28.

29.

30.

31. 32.

In the mental status examination, the first behavioral area to be evaluated is the patient’s _______________

General appearance includes observations of body type, sex, age, race, nutrition, health, and personal hygiene. Your general impressions of the patient’s manner and state of consciousness are included here. Below are a number of statements. Circle those re- lated to general appearance.

Short and stocky Hostile and suspicious

Says he hears voices Alert

Unkempt

Sleepy and dazed Owns a dress shop Born in 1928

An individual’s state of consciousness refers to his degree of arousal or cortical activation. It is determined early in the examin- ation and is included in the behavioral area: ———

Cortical activation or results from activity which begins in brain stem structures and is projected through the thal- amus to the cortex (48) .

The degree of arousal or cortical _ _ _ _ _ _ will determine the clinical state (levels) of consciousness.

The different states of cortical activation can produce different states (levels) of These include: a) alertness; b) lethargy; c) semicoma; and d) coma.

12

27. 28.

general appearance

29.

general appearance

30.

arousal

31. 32.

activation consciousness

Short and stock Hostile and suspicious Says he hears voices

(Ale~

13

33.

34.

35.

36.

37.

Clinical items such as those below become important as their presence or absence increases or decreases the probabilities of dif- ferent disorders. Draw lines between appropriate items in the

two columns:

Short and stocky Unkempt

Hostile & suspicious Alert

Body type

Manner

Full cortical activation Altered level of arousal Personal hygiene

Sleepy and dazed

Draw lines between appropriate items in the two columns:

Comatose

Alert

Lethargic

Semicomatose

Awake and appropriate answers all questions

Keeps on falling asleep, occassionally fails to respond to examiner’s questions

Unresponsive to questions unless exa- miner shakes patient and shouts

Unresponsive even to painful stimulation

A patient’s manner, or attitude, is also part of general appear- ance behaviors and can provide clues as to the reliability of the in- formation you are trying to obtain. Cooperative/uncooperative, friendlyIsuspicious, open/guarded, submissive/haughty, are de- scriptive terms of some of the more common patient attitudes.

The general appearance of a patient includes state of -“..,..,-,,– or cortical and attitude or In addition, general descriptions such as an author would use to describe a char- acter in a book should be utilized when recording your mental status

examination findings.

Below are two brief descriptions of a patient’s general appear- ance. Such details often have diagnostic importance because they either increase or decrease the probability of a variety of mental conditions. Examine the two descriptions and see if all the general appearance items are covered. Review the general appearance items listed and after each description circle those items, if any, which are missing in each example:

A. The patient is a 32-year-old, cooperative, white, ecto- morphic man (thin, small boned, small framed, little muscle

mass) who appears thin, stoop-shouldered and dazed.

He is unkempt, has nicotine-stained fingers and he moves in a slow, absent-minded fashion.

age, race, sex, body type, state of consciousness, manner, nutrition, health, personal hygiene

B. The patient is a short, stocky, hirsute, long armed, mus- cular 42-year-old woman, whose greasy sweat, frozen face and general bradykinesia (decreased movement) suggest recent use of neuroleptics.

age, race, sex, body type, state of consciousness, manner, nutrition, health, personal hygiene

14

33.

Short and stocky Body type Unkempt– ~Manner

Hostile & suspicio~Full cortical activation

34.

Awake and appropriately answers all questions

35.

no answer required

36.

consciousness, activation, manner

Alert

Sleepy and dazed

Altered level of arousal Personal hygiene

Alert Lethargic

Keeps on falling asleep, occasionally fails to respond to examiner’s questions

Unresponsive to questions unless ex- aminer shakes patient and shouts

37. A. The patient is a 32-year-old, cooperative, white ectomorphic man (thin, small boned, small framed, little muscle mass) who appears thin, stoop-shouldered and dazed. He is unkempt, has nicotine-stained fingers and he moves in a slow, absent- minded fashion.

Unresponsive even to painful stimu- lation

age, race, sex, body type, state of consciousness, manner, nutrition, health, personal hygiene

None circled because all items are described

B. The patient is a short, stocky, hirsute, long-armed, muscular 42-year-old woman, whose greasy sweat, frozen face, and gen- eral bradykinesia (decreased movement) suggest recent use of neuroleptics .

15

38.

39.

Obvious patient characteristics (e.g. , age, sex) are often vital in developing an accurate diagnosis. If you do not consciously

state the obvious, you will often omit the key to the diagnosis. In Item 37.B the facial hair and stocky body build of the patient were clues suggesting her depression was secondary to adrenal hyper- plasia. Proper treatment (in this case surgery) would not have been possible without proper observations leading to an accurate

Look at the photograph at the right. Although you cannot comment on manner and state of consciousness, 1) describe the patient; and 2) what would you say to begin an interview with this patient?

Look at the photograph at the right. Describe the patient’s general appearance.

Following an examination and description of the patient’s –~~~~~~—-,youshouldobservethepatient’s

motor behavior. Motor behavior, like the items of general appear- ance, is observed ———————————–

40.

41.

16

38. diagnosis

39. 1) A young white male, staring fixedly into space. He has an ex- aggerated smile (grimace) without warmth. Remainder of gen- eral appearance items cannot be evaluated from this photograph.

40.

A young, slim, mesomorphic (average build) white male who sits slumped over in a dejected manner staring at the floor. He appears neat and clean. (Further comments about level ot consciousness, manner and cooperativeness will require additional observation.)

41.

general appearance, initially upon meeting the patient

2) “Mr. Jones, what are you doing? Can you look at me? I’d like to speak with you.”

17

42.

43.

44.

45.

46.

47. 48.

49.

50.

51. 52.

Whenever possible, you should meet your patient in a location away from the place of examination so you have to walk with the patient. Carefully watch the patient’s gait and note any abnormal- ities. If there is a problem, ask the patient if he is aware of it and to what he attributes his difficulty in walking.

In addition to observations of gait, the examination should in- clude comments upon: abnormal movements, frequency of movement, rhythm or coordination and motor speed. How would you begin ex- amining these motor behaviors without disrupting your initial at- tempts to establish a relationship with the patient?

The increase in frequency of motor behavior is termed agitation. Pacing, hand wringing, head rubbing, constant shifting of body position, are all examples of increased of motor behav-

ior or ——————-

Any intense mood (anxiety, depression, anger) may be expres- sed in the motor behavior of agitation or ________

The motor expression of an intense mood is termed ~,-,—— Pacing, hand wringing, head rubbing, shifting body positions are all examples of this increased frequency of motor behavior.

General restlessness, shifting body position, hand rubbing or playing with one’s fingers are examples of ————–

Agitation is the motor expression of an intense mood. Circle those words or phrases descriptive of agitation:

Impassive Restless Pacing

Foot tapping Guilt Hand rubbing Immobile

Because of chronic ingestion of neuroleptic compounds, many psychiatric patients exhibit constant foot tapping, jerky pacing, pelvic thrusts and/or repetitive oral movements sw~h as lip smack- ing, or moving the tongue in and out of the mouth. These increased movements are manifestations of a coarse brain disease and have been given the global term tardive dyskinesia (6,20). It should

not be confused with agitation which is the motor manifestation of an———————————–

Agitation can also be confused with the small, jerky hand, head and shoulder movements characteristic of chorea. Agitation can be distinguished from choreiform movement because it is under partial voluntary control and because it is the motor expression of an

The increased frequency of activities (as opposed to frequency of motor behavior or agitation) is termed hyperactivity. When the frequency of activities is decreased, it is termed hypo_________

Increased frequency of motor behavior is termed ——~–:F”:- Increased frequency of activities is termed ————and is usually goal directed.

18

42. No answer required

43. I would meet the patient away from the examination area and walk with him as I observe and perhaps discuss his motor difficulties, if any.

44. frequency, agitation

45. increased frequency of motor behavior 46. agitation

47. 48.

49.

50.

agitation

Impassive (Foot ta~

Immobile

intense mood

intense mood

(RestlesS) Guilt

51. activity

52. agitation, hyperactivity

19

53. 54. 55.

56.

57.

58. 59.

A patient who talks to several people, one after the other, who goes from one place to another in quick succession, is said to be

_ _ _ _ _ active.

A patient who sits for long periods in a corner chair, rarely moving or responding to surrounding action, is said to be _ _ _ active.

In its extreme form, hyperactivity will lead to multiple activities that are never completed and which appear purposeless (non-goal directed). This is called an excitement state. In contrast,

, or decreased frequency of activities, in its extreme form .,…is-c-a”‘”‘ll;-e-d a stuporous state (37, 40 pp. 26-29, pp. 36-40, pp. 79-80).

In extreme hypoactivity or , a patient may stay motionless for hours, staring fixedly or following the examiner about the room with his eyes, unresponsive even to severe pain stimulation

(general analgesia) (37, 40 pp. 36-40, pp. 79-80).

In extreme hyperactivity or , a patient may con- tinually rush about until exhausted. Patients have been known to suffer cardiovascular collapse and even death as the result of ex- treme (37,40) .

Pacing, hand wringing, head rubbing, is not goal directed. It is termed ————

Draw a line between the term in column A and its description(s) in column B. A term can be used more than once.

AB

60.

61. 62.

It is difficult to distinguish severe agitation from a state of excitement or severe because in excitement the pa- tient impulsively interrupts one activity to begin another, thus los- ing apparent goal direction.

When a patient exhibits extreme hyperactivity or or extreme hypoactivity or , the diagnosis of Catatonia must be considered (37,40 p. 36).

Catatonia is a syndrome (2,37) which, in 25 to 50 percent of ca- ses ( 2, 40 p. 36,53, 74) is associated with major affective or mood disorder. In addition to specific motor behaviors to be considered, catatonia is characterized by periods of extreme hyperactivity and

hypoactivity, also termed

Hyperactivity Hypoactivity

Agitation

Restlessness

Dancing, singing, cleaning, washing and telephoning in rapid succession

Pacing the halls

Spree buying, yelling at passersby, writ- ing one dozen letters, moving the furniture out of the house

Sitting in the same position for hours

20

and _ _ _ _ _ _ _ __

53. hyper

54. hypo

55. hypoactivity

56. stupor

57. excitement, hyperactivity

58. agitation

Hypoactivity

Dancing, singing, cleaning, washing and telephoning in rapid succession

Agitation.c:..–~—‘””<–Pacing the halls

60. hyperactivity

61. excitement, stupor 62. excitement, stupor

Spree buying, yelling at passersby, writ- ing one dozen letters, moving the furn- iture out of the house

Sitting in the same position for hours

21

63.

64.

Mutism is a state of verbal unresponsiveness. In association with stupor or excitement, mutism is characteristic of :-:.~,.–,–.,-­

However, other specific motor behaviors should be presen before the diagnosis of is made.

A flat, expressionless face without eye blinking is most charac- teristic of catatonia. Grimacing and other fixed facial postures can occur ( 37). Look at the photographs below . Check the facial exp- ressions consistent with catatonia.

1234

65.

The photograph of face #3 should not be checked in answer to question 64. This is the typical facial expression in major depres- sion. Two outstanding characteristics of a depressed face are: 1. the Omega sign; and 2. Veraguth’s folds (33,58). The Omega sign is a furrowing between the eyebrows that looked to an imaginative clinician of long ago like the Greek letter >l (Omega). Veraguth de- scribed eyelid folds which formed an upward angle at the inner canthus of the eye.

22

63. catatonia, catatonia

64. photographs 1, 2, and 4

1 – blank look

2 – grimace

4 – schnauzkrampf (German. literally: snout cramp)

Note: Number 3 does NOT belong in this category as it is the expression typical of major depression.

65. No answer required.

A posture characteristic of depressive stupor.

23

66.

67. 68.

Catatonic patients, although often verbally unresponsive or -~~—–;-;–‘ can be accurately diagnosed because of the odd positions they assume. This is called posturing.

The tendency of catatonic patients to remain in postures for lor periods is called catalepsy.

Patients often allow an examiner to place them in odd postures despite instructions to the contrary. The initial resistance these patients offer prior to slowly allowing themselves to be postured, reminded early clinicians of a bending candle, thus the term waxy flexibility. Below are photographs of a catatonic “patient” in sev- eral different postures. Since he is maintaining these postures for prolonged periods, he demonstrates

I

When a patient positions his body or body parts in an odd way, he is said to be _________

When a patient remains in the same position or odd posture for a prolonged period of time, he is said to have _________

69. 70. 71.

An odd body position is a ——– position is

A prolonged body

24

66. mute

67. no answer required 68. catalepsy

69. posturing

70 . catalepsy

71. posturing, catalepsy

“Psychological Pillow” is a Catatonic Posture 25

72.

73.

74.

Patients in catatonic stupor can remain motionless or cataleptic for hours. They stare fixedly, and even when subjected to pain stimulation, they remain immobile (general analgesia) . They are also mute or verbally _________

Some cataleptic patients (in a prolonged posture) resist the ex- aminer’s attempts to move their limbs. The patients exert an amoun1 of force equal to that of the examiner: when the examiner pushes the patient’s arm lightly, the patient resists to the same extent. When the examiner pulls the patient’s arm vigorously, the patient resists with equal strength. This phenomenon is called Gegenhalten and is a sign of ___________

Draw lines between appropriate items in the two columns:

75.

76.

Draw lines between appropriate items in the two columns:

Posturing Excitement Waxy flexibility

Stupor Agitation

Severe hyperactivity Psychological pillow

Slow resistance as patient allows examiner to place him in odd posture

Increased motor frequency due to intense affect

Severe hypoactivity often associated with generalized analgesia

Catalepsy Omega sign

Gegenhalten Veraguth folds Grimacing

The furrowed brow of depression

The patient resists being moved with strength equal to that applied

Spending hours in one position The sad eyes of depression

A facial posture

Draw a line between the matching items in the two columns:

Severe hypoactivity

Agitation

Severe hyperactivity

Frantically going from task to task until exhausted

Immobile and unresponsive Rocking, pacing, hand wringing

26

72.

unresponsive

73.

catatonia

74.

Posturing Severe hyperactivity Excitement~Psychological pillow

Waxy flexibility— Slow resistance as patient allows examiner

75.

Catalepsy The furrowed brow of depression

76.

Severe hy~oactivityFrantically going from task to task until exhausted

to place him in odd posture

S t u p o r > < Increased motor frequency due to intense affect

Agitation Severe hypoactivity often associated with generalized analgesia

Omega sig~The patient resists being moved with strength ~-~equal to that applied

Gegenhalten Spending hours in one position Veraguth folds— The sad eyes of depression

G rim acing—– A facial posture

Agitation Immobile and unresponsive Severe hyperactivity Rocking, pacing, hand wringing

27

77.

The motor signs of catatonia remain some of the most fascinatin~ phenomena observed in psychiatric patients. Echo phenomena are part of the catatonic syndrome. Echolalia refers to the patient’s co1 stant repeating of the last phrase or sentence of the examiner. Ect praxia refers to the patient’s copying of the interviewer’s motor be- havior. In the examination of a patient suspected of having cataton the examiner, by raising his arm above his head without comment, can often stimulate the patient to respond in a similar fashion, i.e., exhibiting . The examiner can also ask “When I touch my nose you touch your chest.” If, despite repeated correc · tions, the patient also touches his nose, mimicking the examiner’s

78.

Catatonic patients will often respond to light pressure, even when instructed to the contrary. If you lightly press the patient’s hand and arm upward and the patient responds to the pressure de- spite your instructions not to lift his arm, you have demonstrated the phenomenon of MHgehen (German for “going with”). The coop- eration to light pressure by the examiner followed by a slow return to a previous position is termed Mitmachen (German for “making with”). These phenomena can be considered forms of automatic ob- edience to light pressure and are known by the German terms __________ and _________

79.

Place a check mark in the appropriate box to indicate into which mental status section each behavior item best fits. Check each item only once.

movement, he is exhibiting . The obvious repetition of your sentences is an example of – – – – – – – – –

Body type Echopraxia Mitmachen Agitation Age & Sex Catalepsy Gait

Dress

General Appearance

General Motor Behav~or

Catatonia

28

77.

echopraxia, echopraxia, echolalia

78.

Mitgehen, Mitmachen

79.

General Motor Behavior

I

!(Accepted)

General Appearance Body type I

Echopraxia

Mitmachen

Agitation

Age & Sex I Catalepsy

Gait I Dress I

Catatonia

I I

I

29

GEGENHALTEN

ECHOPRAXIA

30

MITMACHEN

31

80.

Beside each major grouping of behavior~, place the numbers of the appropriate items listed below to indicate into which mental status section each behavior item best fits. Use each item only once. Gen- eral appearance ; General motor behavior _ _ _ _ _ ______; Catatonia ___________

81. 82.

83.

84.

85. 86. 87.

In demonstrating automatic obedience (Mitgehen, Mitmachen) a patient will allow himself to be placed into postures with ______

________ pressure from the examiner.

You are speaking with a patient and suddenly without comment you raise your left arm high in the air. The patient copies your movement. You then also raise your right arm in the air and again the patient repeats the movement. This is an example of _ _ _ _ _

You must tell the patient he should not respond when you want to demonstrate obedience. Otherwise you cannot be sure that the response is not simply the result of a very cooperative patient trying to please you.

When observing catatonic patients over prolonged periods of time, psychiatrists have noted striking non- goal directed, repetitive motor behaviors termed stereotypes. These patients may also exhibit stereotype of speech in which they repeat phrases and sentences

in an automatic fashion, similar to a scratched record. On the other hand, when the patient’s speech is a repetition of your speech, it

is termed —————

A patient standing next to your desk automatically moves your paperweight back and forth from one spot to another. You have observed a behavior termed ______________

Occasionally, the non-goal directed repetitive motor behavior of catatonics is mistakenly called obsessive compulsive behavior. We know, however, that the correct term is ____________

The patient with obsessive compulsive behavior knows the be- havior is “foolish” but feels great anxiety until the compulsion to perform the behavior is obeyed. The patient with automatic repet- itive behavior or has no such awareness of the “foolishness'” of his behavior.

1. Race

2. Hypoactive 3. Mitgehen

4. Echopraxia 5. Agitation

6. Personal Hygiene

7. Gegenhalten

8. Hyperactive

9. State of Consciousness

32

800 General appearance: 1) Race; 6) Personal hygiene; 9) State of consciousness

8lo 82 o

83 o

84 o

85o

86o 87 o

General motor behavior: 2) Hypoactive; 5) Agitation, 8) Hyperactive Catatonia: 3) Mitgehen; 4) Echopraxia; 7) Gegenhalten

light echopraxia

automatic

echolalia

stereotype stereotype stereotype

33

88.

Draw lines between matching items in the two columns:

89.

Draw lines between matching items in the two columns.

90.

Draw lines between appropriate items in the two columns:

91.

Draw lines between appropriate items in the two columns:

92.

You are asked to examine a 27-year-old white male patient whom you find lying in bed, eyes open, staring fixedly at the ceiling.

As you approach, the patient quickly shuts his eyes and the nurse says “You see, I told you he was faking!” Knowing better, you proceed to examine the patient and find that he has no fever, has stable vital signs, and no fpcal neurological signs. When you check his chart, you note that his laboratory tests are also within normal limits and that no systemic cause has been found for his mutism, immobility, and unresponsiveness. In testing the patient for res- ponse to painful stimuli, you observe general analgesia and conclude

Stereotype Echopraxia

The patient repeats your movements

Mitgehen Echolalia

The patient repeats your words

Mitmachen

Despite your verbal instructions to the contrary, the patient lets you posture his arm and when released, slowly moves it back to its original place

Stupor Catalepsy Gegenhalten

Maintaining a posture for long periods Severe hypoactivity

Veraguth folds Omega sign

Furrow between the eyebrows

Waxy flexibility Posturing

Assuming odd body positions

Excitement

Increased non-goal directed motor activity– an expression of intense affect

Agitation Mitgehen Echolalia

Extreme hyperactivity

The patient repeats your words Automatic obedience

Non-goal directed, automatic, repetitive move- ment

Despite your verbal instructions to the contrary, the patient allows you to move his arms with

light pressure

When you attempt to move a patient’s arm, he resists with a force equal to yours

Upward angle of inner canthus of eye in depression

Gradual resistance but allowing placement in odd body postures

that he is in a state of ———————-

34

88.

Stereotype><The patient repeats your movements

Echopraxia Non-goal directed, automatic, repetitive move- ment

Mitgehen The patient repeats your words

Echolalia~Despiteyour verbal instructions to the contrary, the patient allows you to move his arm with

light pressure

Mitmachen—–Despite your verbal instructions to the contrary, the patient lets you posture his arm and when

released, slowly moves it back to its original place

Stupor—-__ _……..-Maintaining a posture for long periods Catalepsy~Severe hypoactivity

Gegenhalten—-When you attempt to move a patient’s arm, he

resists with a force equal to yours

Veraguth folds Furrow between the eyebrows

Omega sign:::,.:><Upward angle of inner canthus of eye in depression

Waxy flexibility Assuming odd body positions

P0sturing~Gradual resistance but allowing placement in odd body postures

Excitemen><tIncreased non-goal directed motor activity– an expression of intense affect

Agitation Extreme hyperactivity Mitgehen——-The patient repeats your words Echolalia—–Automatic obedience

stupor

Catatonia is not acceptable here as not all stuporous patients are catatonic and not all catatonic patients are stup0rous, i.e., immobility with general analgesia is not always present in catatonia.

89.

90.

91.

92.

35

93.

Continually harassed by the medical staff who are now greatly impressed with your knowledge, you are asked to see a 23-year-old black woman who \vas hospitalized because of a “violent” episode in which she ran about the streets screaming, talking to people in a confused manner, and finally collapsing into an unresponsive mute condition. Again, “physical” examination and laboratory tests are within normal limits.

94.

You are now the talk of the entire hospital and colleagues are desperately trying to find a chink in your armor by asking you to see their most perplexing patients. One such patient is a 17-year- old male who has enraged the staff by constantly mimicking what they say and do. When you observe him doing this, you note the automatic quality of his copying of the speech and motor behavior

of others, and you suggest to the staff that the patient is not a “little brat” but may have catatonia and that he is exhibiting echo- lalia and echopraxia. They laugh at you, convinced they’ve finally got you. Undaunted, you approach the patient, introduce yourself, explain that you are going to examine him (he, of course, repeats your words), and then you take hold of his arm and try to move

it but you feel equal resistance. If you pull hard, he resists stron- gly; if you pull weakly, his resistance is equally weak. You note this example of and then are surprised when the patient suddenly sticks out his lips in a snout-like position

and then falls to his knees in a praying attitude. He remains in

this posture for 10 minutes at which time you take hold of his arm and after some initial resistance, you feel a sudden give and then lessening resistance as you place the arm in awkward positions which the patient maintains. You tell your colleagues that you have demonstrated ; that the patient is in a prolonged posture or state 2.nd that the diagnosis is indeed the syndrome of _ _ _ _ _ _ _ __

AFFECT

95.

For n complete mental status examination you must first examine

When you see the patient, she is standing next to her bed, one arm raised above her head. The other arm is placed on her heart. According to the nurse she has remained this way for a long time and you conclude these are examples of and .,..—-..—-~.—,—=-· She does not answer your questions and stares fixedly ahead. You tell her to remain where she is and not to move; then, with your index finger, you apply light pressure to her back and she begins to walk forward. You again tell her, in an author- itative voice, not to move, but with continued light pressure she moves forward. You conclude she also exhibits _ _ _ _ _ _ _ _

Not yet satisfied, you apply light pressure to her raised arm and although you tell her to resist, she allows you to move her arm into a new position. When you remove your index finger, she re- mains in the new posture for a few moments and then slowly returns to her former posture. You note this example of _ _ _ _ _ _ __

and make a diagnosis of—————-,—–

a patient’s . You should next make and

~~-,-.,–,.,—

Affect is the emotional tone underlying all behaviors. 36

carefu~l,_-n-o~t-e_o_f~h~i_s_a_f=f~ect.

93.

posturing, catalepsy, automatic obedience, mitmachen, catatonia.

94.

Gegenhalten, waxy flexibility, cateleptic, catatonia

95.

general appearance, motor behavior

37

96. 97.

Affect has range, amplitude, stability, appropriateness of mood, quality of mood, and relatedness. Mood is only one facet of

98.

The mnemonic device SHAAA may help you recall the different transient expressions of mood. They are _ _ _ _ _ _

99. 100.

Relatively transient expressions of sadness, happiness, anxiety, anger, and apathy are termed . The different types of mood expressed refer to the quality of mood.

101.

The variability of emotional expression over a period of time is the range of affect. Normal of can be compared to the variations and resonances in music. The variability of emotional expression or of can be con- stricted in mental disease.

102.

If a person essentially expresses only one mood over a period of time, regardless of what is taking place around him, his

103.

If a person expresses only sadness, his affective range is

If a person expresses only euphoria, his affective range is In both instances, although the quality of mood

104.

The amplitude of emotions can be graded by the amount of energy a person is expending in expressing a mood. The different qualities of mood, the transient expressions of emotions are associated with differing degrees of amplitude. Thus, the quality of anger can be associated with mild amplitude and is expressed as annoyance or irritability, or it can be expressed with great amplitude as anger

and rage. List the different qualities of mood.

105. 106.

Amplitude of affect states nothing about range of affect, which refers to the of emotional expression.

Mood and affect are not synonymous terms. Normal mood refers to relatively transient expressions of sadness, happiness, anxiety, anger, and apathy. Mood is but a part of an individual’s _ _ _ _

_ _ _ _ _ _ which is a more global function.

______, and _______

In mental illness, the y_uality of may become constant despite changes in the patient’s immediate surroundings. Patients with affective disorders can express a constant mood of sadness, elation, or irritability (18,40 pp. 22-24, 58,71).

of affect is said to be , i.e. , there .i.s.-,-ll'”‘”t·”‘”‘tl,-e_v_a_r.–iability .

is different, the variability over time is the same.

In many patients, affectivity, although intense (with great am· plitude) can be constricted in range. The psychomotor epileptic, for exarr.ple, can shout and rage with great force, never varying his mood until overcome by exhaustion. His range of affect is se- verely but the amplitude of his affect is intense.

38

96. affect

97. affect

98. sadness, happiness, anxiety, anger, apathy

99. moods

100. mood

101. range, affect, range, affect

102. range, constricted

103. constricted, constricted

104. sadness, happiness, anxiety, anger, apathy

105. variability

106. constricted

39

107.

108.

Normal changes in mood occur relatively slowly during the course of the day and are well modulated. Rapid shifts during the time of

a mental status exam are pathological. Shifts in mood quality (e.g. , anger to sadness) and in amplitude (e.g. , mild to intense) refer to the stability of affect. List the different qualities of mood. Can affect be restricted in range and be of high intensity?

Instability of affect termed lability, is most characteristic of mania (18, 40 pp. 22-24, 71) and various coarse brain syndromes

( 14, 15, 23). Draw a line between appropriate items in each column.

109.

Mood appropriateness refers only to the interview situation and is determined in part by the examiner’s own mental state and em- pathic understanding of the patient’s behavior. What you judge to be appropriate becomes the standard by which you evaluate the pa- tient’s behavior. Inappropriateness of mood (laughing in a sad sit- uation) is not a pathognomonic sign (decisive indicator of a spec- ific disorder) and may be simply the reflection of normal anxiety as well as serious illness. Look at the descriptive phrases below and using your empathy (“put yourself in the patient’s shoes”) check those indicating inappropriateness of mood.

The patient screams in terror at a hallucinated voice.

In discussing the recent death of his parents, a patient bursts into tears.

When asked about the events leading to her hospitalization, a patient became angry and said she’d been wrongfully locked up after a fight with her husband.

You may hear colleagues use the term “inappropriate affect.” However, what they really mean is inappropriate _ _ _ _ _ _ _ _

The most difficult facet of affect to describe and rate is related- ness. Relatedness refers to the patient’s ability to express warmth, to interact emotionally and to establish rapport with the examiner. Schizophrenics are notoriously unable to respond in this manner

and often appear cold and unfeeling (12,13,41,42). You might feel you are addressing a computerized voice or taped answering mach- ine rather than a person. When a patient can express warmth and can establish rapport with you, his affect is said to be

When this rapport is missing and the patient appears co,.ld,—::a-::nc:’d..–c:-:cu-=n feeling, his affect is said to be ________

110. 111.

Constricted range of affect Decreased intensity of affect Labile affect

Relatively constant expression of one mood

Moods shift rapidly and frequently during a short period of time

Expression of little emotional energy

40

107.

sadness, happiness, anxiety, anger, apathy (SHAAA) yes

108.

Constricted range of a f f e c t – – – – Relatively constant expression of one mood

109.

No checks. If you believed in the reality of frightening voices, you too would be terrified. Crying at a recent loss is appropriate. If you believed you’d been wrongfully locked up, you too would be angry. Remember, your empathy will determine appropriateness of mood.

110. 111.

mood

related, unrelated

Decreased int~oef anffesctity Moods shift rapidly and freq- uently during a short period

Labile affect Expression of little emotional energy

41

of time

112.

113.

114.

115.

116.

117.

118.

Draw a line between appropriate items in the two columns:

Relatedness

Affect of increased intensity

Quality of mood Inappropriate mood

A strong· mood, such as rage, fear

Ability to express warmth, concern, love

Emotions of anger, happiness, sadness

Sudden explosive laughter without apparent reason

Lack of relatedness is often called flatness of affect or emotional blunting. Although considered crucial for the diagnosis of schizo- phrenia by most authors (12,13,41,42,65,70) the determination of emotional is difficult.

The global impression of emotional blunting can be separated into component parts which are more easily evaluated during a men- tal status examination. This method has been found to be reliable (reproducible) and when used in a rating scale, helpful in diagnos- ing patients with major mental illness ( 3 ). Decreased intensity of affect and the lack of mood variations, or affect, are characteristic of emotional blunting.

In addition to range and intensity of affect, patients with emotional blunting often present with an ex- pressionless face and unblinking eyes and speak in an unvarying monotonous voice.

Emotionally individuals are often seclusive, a- voiding social contact, and indifferent to their surroundings (hos- pital staff, visitors, relatives, physical environs).

“How do you like it here in the hospital?”

“Did you enjoy your visit with your family?”

These are questions which will often produce apathetic respon- ses.

and !motionally blunt~~t~~~~~~d~;l:fre~~~ aT”h_e_y__,h,—a_v_e_a_n_ _ range face, eyes and they speak in an ________

voice.

Emotionally blunted individuals often are indifferent and express little affection for their family and friends. This emotional indiff- erence leaves them unconcerned for their present situation and with- out plans or desires for the future. For example, when asked how they feel about being in the hospital, or how they would feel if they had to remain hospitalized for many months, patients respond, “Well, I suppose I’ll have to,” “It’s o.k. being here,” “Well, I don’t like it, but what can I do?” What is the characteristic affective range and amplitude associated with these responses? What is the character- istic quality of mood?

42

112.Relatedness~Astrongmood,suchasrage,fear Affect of increased Ability to express warmth, concern,

intensity love

Quality of mood—–Emotions of anger, happiness, sadness Inappropriate m o o d – – – Sudden explosive laughter without

113. blunting

114. constricted

115. constricted, decreased

116. blunted

apparent reason

117. constricted, decreased, expressionless, unblinking, monotonous (or unvarying)

118. constricted, decreased, apathy

43

119.

120.

Circle the words or phrases associated with emotional blunting:

121.

Once again, you are asked to see a patient. When you first see her, she is standing in the hall next to the nurses’ station, speak- ing rapidly to several nearby people. When she sees you, she rush- es to meet you, vigorously shakes your hand, laughs, begins to

ask you all sorts of questions, but soon interrupts herself to in- struct the porter who is cleaning the floor, and a nurse who is begin ning to administer medications. You note this example of

; – – – – – ; o ; – ; – and then interrupt her to tell her you’d like to sp-=–e-=–a”k-w~i”‘”‘th” her. She suddenly becomes angry and shouts at you for your bad manners. The medication nurse tells her to stop shouting. This results in the patient bursting into long gales of laughter. Later,

in writing your report, you state that her affective range was not —–.,.—–~~….— and her mood amplitude was . Her moods varied from to and, although appro- priate in quality, were certainly not within the normal limits of intf’n- sity. Her rapid shifts in mood is termed of affect.

1.

Check the words or phrases associated with emotional blunting.

Spending all day in bed away from people but not sad

Apathetic mood

Labile affect

Grandi:lse euphoric mood Monotonous voice

Profound sadness Constricted affective range Expressionless face Friendliness

2. Appearing content to be hospitalized and having no future plans

3. 4.

5. 6.

Joking with the hospital staff

Greeting all the visitors to the ward with a big “Hello”

Crying over the recent death of a friend

Shallow laughter without humor

44

119. (Apathetic mooc!) Labile affect

Grandiose euphoric mood 0onotonous voic~

Profound sadness

Expressionless face Friendliness

120. 1.

Spending all day in bed away from people I but not sad

121.

2. Appearing content to be hospitalized I and having no future plans

3. Joking with the hospital staff

4. Greeting all the visitors to the ward with a big “Hello”

5. Crying over the recent death of a friend

6. Shallow laughter without humor I

hyperactivity, constricted, increased, irritability to euphoria, lability

45

122.

Another patient is first seen sitting quietly outside your office. Even though you say hello and ask her to come in, she remains seat ed, staring ahead until you repeat your introduction upon which she slowly gets up and moves to a chair next to your desk. There are deep furrows between her eyebrows. Her eyes have a sunken appearance, and the inner angle of the upper lids appears to rise. Throughout the interview, the patient remains seated, head bowed. Her only movements are the constant rubbing together of her hands She speaks in a monotonous, slow, plodding fashion, is often close to tears and, despite an attempt at humor on your part, cannot eve1 manage a smile. She says she feels like crying but cannot. She says she feels like a bad person, and that somehow her present con dition is deserved and that people would be better off if she were dead. You find yourself feeling sad for her and concerned about her pained expression. Later, in writing your report, you state that she exhibited motor behavior. Because of her han• rubbing, you feel she showed mild motor Her facial expression, marked by an sign and folds was SIJd.

123.

Write the numbers of the items listed below that best fit the following mental status area:

In describing her a-ffect, you state that her affective range was -~~-; she showed stability of affect and her mood was one

of constant . Do you feel her mood was appropriate?

General Appearance_______________________ General Motor Behavior___________________ Affect________________________________________________ Catatonia______________________________________

1. Stereotype

2. Age, sex, race

3. Nutrition

4. Relatedness

5. Coordination

6. Catalepsy

7. Echolalia, echopraxia 8. Quality of mood

9. Lability

46

10. Mitmachen

11. Range of affect 12. Agitation

122. hypoactive, agitation, Omega, Veraguth, constricted, sadness

Do you feel her mood was appropriate? yes Her profound sadness is consistent with her ideas of guilt. – –

123. General appearance 2. Age, sex, race; 3. Nutrition

General Motor Behavior 5. Coordination; 12. Agitation

Affect 4. Relatedness; 8. Quality of mood; 9. Lability; 11. Range of affect

Catatonia 1. Stereotype; 6. Catalepsy; 7. Echolalia, echopraxia 10. Mitmachen

47

124. Place a check mark in the appropriate box to indicate into whicl mental status section each behavior item best fits.

Hesitant gait Stupor Grimacing Manner Semicomatose Blunting Posturing

Body type Waxy flexibility Agitation

125.

Label each clinical item with the appropriate term:

127.

Thought process is form and differs from thought content. The form of speech is characterized by its rate, pressure, rhythm, idio- syncracy of word usage, tightness of associational linkage and form~ of associational linkage. What the patient is talking about is

thought ________

128.

The way associations are linked together is part of the form

of thought processes and can be of diagnostic importance. What the patient is talking about, thought , reflects cultural and personal life and experience, and with few exceptions, is rarely of diagnostic importance.

General Appearance

General Motor Behavior

Catatonia

Affect

!\’lute man lying in bed, staring at ceiling, averting gaze, general analgesia

Mood shifts rapidly and unexpectedly from anger to laughter and then sadness

Mute woman standing in hall with hands held above her head and clasped in prayer- like manner

Woman rushes about hospital ward, talking to every staff member, greeting all visitors and doing some cleaning. She tries to help other patients but moves on to other tasks before finishing.

LANGUAGE FUNCTION (THOUGHT PROCESS)

126.

You should evaluate a patient’s thought process only after you have evaluated the mental status behavioral areas of

speech:-______

48

124

Hesitant gait Stupor Grimacing Manner Semicomatose Blunting Posturing

Body type Waxy flexibility Agitation

General Appearance

I I

General Motor Behavior

I

/(acceptable)

Catatonia

I I

Affect

125.

Mute man lying in bed, staring at ceiling, averting gaze, general analgesia

Mood shifts rapidly and unexpectedly from anger to laughter and then sadness

Mute woman standing in hall with hands held above her head and clasped in prayer- like manner

Woman rushes about hospital ward, talking to every staff member, greeting all visitors and doing some cleaning. She tries to help other patients but moves on to other tasks bofore finishing.

general appearance, motor behavior, affect.

content

L26.

L27.

128. content

I

I

I I

I

stupor lability of affect

posturing

hyperactivity or excitement

49

129.

Circle the words or phrases suggestive of the form of thought process.

130.

Circle the words or phrases suggestive of the content of though

“He jumps from topic to topic, I can’t follow him” “My boss fired me”

“I hear voices coming from the radiators”

His speech is fast, then slow, then fast again

“I think I am the cause of all this trouble in the U.S.” “It’s my mother’s fault”

Thought content may be diagnostically helpful when it reflects mood. Grandiose ideas of wealth, great power, or high birth are often associated with a manic state ( 40 pp. 19-22, 71). Ideas of guilt, worthlessness, and hopelessness are often associated with its opposite, a major _ ( 40 pp. 75-98, 58).

131.

132. 133.

134. 135.

Unlike the thought content that reflects an altered quality of , strange or “bizarre” ideas are never diagnostic

Racing thoughts

“He talks too much.”

“My son is 12 years old.”

“I am worried about my job.” “He speaks jibberish. It makes

no sense.

“I see lights in the sky.”

a-,–n’d-ca.,_.n-,–o_c_c_u_r~in

many conditions ( 14, 15, 18, 23).

Asking a patient to interpret several proverbs is a poor test

of thought processes ( 5, 56). The answers are never diagnostic and are so culture-dependent as to be useless in a phenomenologic mental status. An examination of the rate, rhythm and pressure of speech, the idiosyncratic usage of words, and the tightness and form of associational linkage are far better guides to the presence or absence of thought process disorder. Write a sentence sum- marizing the difference between thought process form and content.

Although the rate of speech may reflect cultural patterns, severe deviations can be readily observed in mentally ill patients. The rate of speech can be rapid or _______

Slow and/or hesitant speech is characteristic of depressions, altered states of consciousness and certain coarse brain disease in which the ability to select and/or express the proper words is defective (aphasin) (9,16,40 pp.77-80,43,58). Would you be correct if you said that observations on the rate of a person’s speech deals with form, not content? _ _ _ _ _

50

129.

Racing thoughts

“He talks too much!”

“I am worried about my job.”

“He speaks jibberish. It makes no sense.”

130.

“I see lights in the sky.” “He i.alks too much” suggests pressure of speech.

“He speaks jibberish. It makes no sense” suggests a breakdown in linkage or word usage.

“He jumps from to ic to topic, I can’t follow him” “My boss fired me”

“I hear voices coming from the radiators”

His speech is fast, then slow, then fast a ain

“I thmk I am the cause of all this trouble m the U.S.” “It’s my mother’s fault”

“He jumps from topic to topic, I can’t follow him” suggests a break- down in linkage.

“His speech is fast, then slow, then fast again” suggests dysrhyth- mic speech.

“l\ly son is 12 years old.”

“Racing thoughts” suggests the rate of speech and thought.

131. depression

132. mood

133. Thought process form is how a person is talking; thought content is what he is talking about.

134. slow

135. yes

51

136.

137. 138.

139.

140.

Rapid speech is characteristic of anxiety states. When rapid speech is also pressured, it is a cardinal sign of mania (40 pp. 31- 32, 41). Patients with pressured speech talk continuously, as if compelled; it is very difficult to interrupt them. As thought processes are inferred from speech, patients who have rapid and pressured speech often comment that their thoughts are _ _ _ _ _

The rate of thoughts can only be reported by the paitent, but may be inferred from the of

Pressured speech refers to the drive to talk. In its marked form, the patient’s drive to is so great that it becomes difficult to stop or interrupt him. Rapid, pressured speecl is a cardinal sign of ________

The rhythm of speech is not infrequently disrupted by various illnesses. Scanning speech (where word sounds are stretched, producing a slow, sliding cadence) is typical of multiple sclerosis

( 43), mumbled hesitant speech is often heard in patients with Huntington’s chorea (50), while staccato (or abrupt, clipped) speech (both fast and slow) is often a sign of psychomotor epilepsy (15). Once again, it’s not what the patient is saying, but

141.

142.

Scanning speech can be observed in patients with multiple sclerosis. Mumbled, hesitant speech can be observed in patients with Huntington’s chorea. Staccato speech can be observed in psychomotor epilepsy. These are examples of dysfunction of the

he is saying something that is diagnostically importan~:-7t-.- – – – – – Draw a line between appropriate items in the two columns:

Rapid/pressured speech

Staccato speech

Scanning speech Mumbled speech

Worlds are stretched out in sliding cadence

Overtalkativeness, intrusive speech

Words are clipped and abrupt

Speech sounds as if person had water or marbles in his mouth

_ _ _ of speech.

The idiosyncratic use of words is often a sign of severe mental illness. A word seemingly invested and given meaning by a patient is called a neologism (new words). Some neologisms (e.g., glob, rutophobile, thoe) result from the patient’s inability to utilize the proper sounds of speech ( 9, 16, 17).

52

136.

racing (too fast)

137. 138.

139.

140.

rate, speech talk, mania

how

Rapid/pressured~speech Words are stretched out in cadence

sliding

141.

142.

Staccato speech Scanning speech Mumbled speech

rhythm

no answer required

Overtalkativeness, intrusive speech Words are clipped and abrupt

Speech sounds as if person had water or marbles in his mouth

53

143.

144. 145.

146.

147.

148.

149. 150.

Circle the words or phrases indicating the use of a neologism: “I can’t rutton this shirt”

“Can you give it to him when I say that you will?”

“The orroble hit him”

“I ban’t rit it”

Neurologists call new words resulting from a patient’s inability to utilize proper sounds of speech a form of phonemic paraphasia. We also use the term

Phonemic refers to sound, paraphasia to a form of language disorder. Phonemic paraphasia is the disorder of the sound for- mation of language (9,16,17). Write a sentence defining the phonemic paraphasia termed neologism.

Another form of paraphasia is word approximation, the use of substitute words resulting from a difficulty in finding and/or in naming an object. Difficulty in using the sounds of language can produce another form of paraphasia termed _ _ _ _ _ _ _ paraphasia.

Some patients use known words but give them private meanings. It is difficult to tell where private words end and substitute words or begin. Perhaps

both should be designated by the term paraphasia.

New words or and substitute words or are examples of paraphasia. Psychiatrists als_o_r_e–;f.–e_r_t,-o-.-t”h-e-,–s-e-phenomena as formal thought

disorder. Formal thought disorder is considered a sign of severe brain dysfunction.

In the sentences; “I need to sign some papers. May I use your writer?” the word “writer” is used instead of pen. This is an example of a or word ———-

In the beginning, you may find it hard to “hear” word approx- imations. Your brain will translate “writer” into “pen.” You may therefore believe that if a word or phrase is understandable to you, it is not an example of a paraphasia. Train yourself to listen to what patients say. Do not translate. Do not interpret. Ask

the patient: “What did you call this?” And be alert for other word approximations during the rest of your examination. Circle the words or phrases indicating a paraphasia and indicate whether the paraphasic response is a neologism, a word approximation, or a private usage.

“I was going to the buying place when I became sick. I was quite inbisposed but the helper, the, you know, the treating person wouldn’t put me in the bospirab.

I was very industrial.”

54

143.

144. 145.

neologism

146.

phonemic

147.

word approximations

148.

neologisms, word approximations

149. 150.

paraphasia, approximation

The formation of a new word due to the inability to utilize proper speech sounds.

buying place – word approximation – store

inbisposed – neologism – indisposed

helper/treating person – word approximation – Doctor bospirab – neologism – hospital

industrial – private use of word – upset

55

151.

and was asked

to name it. The answer “box” instead of “square” is a subtle form

152.

Studies of the speech patterns and word usages of psychiatric patients and patients with coarse brain disease have demonstrated that the speech of these two groups is striking·ly similar ( 4, 13,16, 2: Pati:;r;ts with mental illnesE often demonstrate aphasia (4,22,73,75). List tne paraphasias you have learned.

153. 154.

After evaluating a patient’s

and pressure of speech as well a-s—-;-cth.-e_p_r_e_s_e_n_c_e_o”f-any paraphasias,

155.

Eugen Bleuler believed (13) that the apparent disruption of meaningful connections between words or phrases, termed loosening of associations, was a pathognomonic sign of schizophrenia. Was

he commenting upon the content or the form of speech?

156. 157.

To the phenomenologist, the apparent disruption of meaningful connections between words or phrases, termed

is not a pathognomonic sign of schizophrenia. – – – – – – – –

158.

The disruption of meaningful connections between words and phrases, termed , can be graded as word salad, when the loosening occurs between words anc consecutive words seem unrelated in meaning, or as fragmentation, when the loosening occurs between phrases and sentences.

159.

It takes a great deal of practice to train your ear to distinguish the different varieties of thought process disorders from the jumble< speech of many patients. I will illustrate many of these disorders, but only the constant clinical practice can master the technique. Below is a quote from a patient. Is it an example of fragmentation or word salad?

A patient was shown this figure D

of or word approximation. Many “normal”

people demonstrate this particular word approximation.

the tightness and form of thought linkage should next be examined.

The terms “incoherent,” “illogical,” and “irrelevant” are occasionally used to describe the speech of patients. These terms are not used in the phenomenologic mental status exam because they are not precise and only imply that the patient spoke oddly and that you didn’t quite understand it. Evaluating the

of associations and the of associational more precise and diagnostically important.

lil~1k.–a_g_e-.-is-·-

Mild looseness of associations, or the apparent disruption of ~—-,—~between words or phrases, is frequently observed in severely anxious individuals and extreme loosening such as flight of ideas is often seen in mania (40 pp. 14-15).

“I, or what, what, the shy, he, me, she, she, she, she, cold, it.”

56

151. paraphasia

152. neologism (phonemic), word approximation, privote use of words

153. rate, rhythm 154. tightness, form

155. form: tightness of linkage

156. loosening of associations

157. meaningful connections

158. loosening, associations

159. word salad

57

160.

161.

Is the following quote from a patient an example of word salad or fragmentation?

“Then going over the world … then coming down … I’m going’ to meet. .. riding and riding down … How’s it coming, Johnny? … Now, now, going home, going home.”

Draw a line between the appropriate items in the two columns:

162.

163.

The form of linkage of thoughts is the structural arrangement in which associations are linked. The disruption of meaningful connections between words or phrases is termed _ _ _ _ _ _ _ _ _

The next several items will use small squares ( D )to represent associations. They will illustrate several types of disorders of

the form of thought linkage. The psychiatric literature is crammed with terms and concepts of thought disorder. I will discuss only some of them.

Below is an illustration with squares of fragmented speech; each square represents a phrase or sentence. Notice that there is a sequence in the associations, but that some associations are missing, leaving spaces between associations.

The arrow represents the general direction (or flow) of associations which, in this example, are goal directed. In the above example,

if each square represented a word, we would have an example of

In circumstantial speech, even though the associations follow one another (linkage is tight), extra nonessential associ’ltions are added before the goal is eventually reached. On the other hand, speech in which associations do not follow, in which each word is unconnected in any meaningful way from the preceeding and followin words is termed – – – – – – –

164.

Word salad

Word approximation Fragmentation

Neologism

Consecutive words without meaning “You’re a conseparate!”

“I’m sick. I think I have a heat (fever).”

Consecutive phrases unrelated in meaning

58

160. fragmentation

161.

Word S a l a d – – – – Consecutive words without meaning

Word approximation “You’re a conseparate!” Fragmenta;~~:·_-~”I’msick. I think I have a heat (fever)”. Neologism~Consecutive phrases unrelated in meaning

loosening of associations

word salad

162.

163.

164.

word salad

59

165.

In response to the question, “What kind of work do you do?”, a patient replies, “I’ve been working all my life … it’s been

hard, but I’ve never been without a job. Oh yes, we’ve had to

cut corners, but there’s always been food on the table. Now, take this present job—been at it two years now; pay’s O.K., but I don’t like the boss— you know the type, they think they own the world; think just because they give you a measly salary that they can ask you to do anything. Well, they can’t. I’m the doorman, but I’m not cleaning up for anyone!”

If you’re still awake, picture each sentence in one of our little squares with each square numbered in sequence– an arrow representing the general flow of associations and the goal that the patient is trying to reach (in this case, the answer to the question). Write the answers to the following questions:

Is the above an example of word salad?

Does the patient reach the goal? (Does he tell the questioner his work?)

Did the patient need all those details to reach the goal?

Circumstantial speech is characteristic speech of chronic epileptics, alcoholics, borderline retardates, of persons with senile brain changes, and of some oassive-agressive and obsessive-com- pulsive personalities ( 8, 9, 17 pp. 25- 59). It can be pictured thus:

where all the EVEN associations are nonessential

166.

Write a sentence defining circumstantial speech

60

165.

Is the above an example of word salad? No Does the patient reach the goal? (Does

he tell the questioner his work?) Yes Did the patient need all those details to

reach the goal? No

166.

Circumstantial speech refers to tightly linked associations, but with extra, non-essential associations interspersed. The speech takes a circuitous route before reaching its goal.

61

167.

In tangential speech, or talking past the point, although the linkage is tight, the answering associations bypass the goal by going off on a tangent; thus the goal is never reached. This speech is often observed in schizophrenia and in coarse brain disease. Tangential speech can be pictured thus:

168.

In response to the question, “What kind of work do you do?” a patient answers:

169. 170.

Please note that the content in items 166 and 168 is similar but that the is different.

Write a sentence defining tange:1tial speech.

A. “Well, I’ve been working all my life.” (speech stops)

Q. “Yes, but what kind of work do you do?”

A. “Never been without a job” (speech stops)

Q. “I understand that, but I’m interested in the type of work that you do What is it?”

A. “Yes… yes. Can you imagine being out of work?

I watch the news and a lot of people are out of work.” (Same content, still no answer after another three minutes)

GOAL

Again, picture each sentence in one of our little numbered squares, the arrow and the goal. Write the answers to the following questions:

Did the patient reach the goal?

Are the associations meaningful connections or disrupted one from the other? (loosening)

Draw a line between the appropriate items in the two columns:

Paraphasia Circumstantial speech

Tight but extra nonessential linkages that finally reach goal

Tangential speech Fragmented speech

Tight linkages bypassing goal Work approximations

62

Consecutive phrases unrelated in meaning

167. Tangential speech refers to tightly linked associations which bypass the goal by going off on a tangent.

168. Did the patient reach the goal? No

Are the associations meaningful connections or disrupted one from

169. form

the other? (loosening) No

If you answered yes to the second part, look again at the associa- tions: working all life–a lot of people out of work. These associa— tions do connect meaningfully, but they bypass the goal, never reaching it.

170. Paraphasia”- Tight but extra non-essential linkages _. _”-., / that finally reach goal

Circumstantial speevconsecutive phrases unrelated in meaning Tangential speech~ Tight linkages bypassing goal Fragmented speech V/ord approximations

63

171.

Some patients’ thought linkage may sound generally tight, but many associations, particularly at the end of the thought, are re- peated in an automatic manner. This form of speech (a verbal stereotype) was first described by Karl Kahlbaum (37) as character- istic of catatonia, and is called verbigeration.

In response to the question, “What kind of work do you do?” a patient answered:

“I do work, work… I do do, you the work, I do, I do I do I, I, do.”

The above speech can be pictured thus:

Did the patient reach the goal?

A verbal sterotype called is often associated with the syndrome of ——-

The automatic repetition of associations, particularly at the end of thoughts is termed __________

Neurologists refer to automatic repetition of phrases, particularly at the end of thoughts as palilalia (9). Psychiatrists call the same phenomenon _________

In item 171, the patient answered, “I do work, work… I do do, you the work, etc … ” the introduction of the word “you” after “do do” is an association made by sound rather than by the meaning of the words. This is termed a clang association and is typically ob- served in manic states (40 pp. 14-15), although it can also be observed in patients with phonemic paraphasia ( 16, 17). Another form of phonemic paraphasia is ————

The recognition of different forms of thought process disorder has led to attempts to relate specific forms with specific illnesses or syndromes. Thus, verbigeration has been related to _ _ _ _ _ _ _

172. 173. 174.

175.

176.

and clang associations to

states.

64

171. Did the patient reach the goal? No

172. verbigeration, catatonia 173. verbigeration

174. verbigeration

175. neologism

176. catatonia, manic

65

177.

The following table summarizes the observed relationships

between the thought disorders we have examined and several major psychiatric conditions. These thought disorders are not pathognomoni (the tabled relationships are not absolute) but the presence of any

one is suggestive of the condition in which it is more frequently observed.

Chronic Mild-ModeratE l\lania Catatonia Schizophrenia Coarse Brain Disease

Verbigeration

Clang associations X Tangential speech Fragmented speech X Word salad

Word approximations Neolo!Qsms

Circumstantial speech X

X

X

X X X X X X X X X X X X X X

178.

179.

Fragmented speech is the least discriminating of these thought disorders and the experienced phenomenologist will rarely use this concept. Write the definitions of the thought disorders listed in the above table.

Eugen Bleuler considered thought blocking to be a basic sign

of schizophrenia ( 12, 13). Thought blocking describes the sudden absence of all thoughts and mental activity. The patient simply stops and goes “blank” (altered awareness) for several moments in a

manner similar to ·a petit mal absence in epilepsy. In psychotherapy, when a patient stops talking at an emotionally-laden moment, the

term blocking is also used. The latter phenomenon, however, is

not the same as thought where the patient is unaware of an “absence” which appears clinically similar with that observed in epilepsy.

While describing her problems with her mother, a patient sud– denly stopped talking. H.er psychotherapist remarked upon this abrupt cessation of speech upon which the patient blushed, admitted her difficulty and began to relate an incident that occurred between her and her mother a number of years before.

Is this the blocking of thought associated with schizophrenia?

Is this the blocking of thought associated with petit mal epilepsy? Explain your answers.

66

177. Verbigeration: a verbal stereotype in which the patient repeats associations in an automatic manner, particularly

at the end of a thought.

Clang association: association by the sound of words rather than their meaning.

Tangential speech: tightly linked associations going off on a tangent bypassing the goal.

Fragmented speech: the loss of meaningful connections between words phrases, or sentences.

Word salad: the loss of meaningful connections between words.

Word approximations: the use of words or phrases without precise meaning, a paraphasia.

Neologisms: new words formed by the improper use of the sound of words; a phonemic paraphasia.

Circumstantial speech: tightly linked associations but with extra, nonessential associations interspersed. The

speech takes a circuitous route before reach- ing its goal.

178. blocking, petit mal

179. Is this the blocking of thought associated with schizophrenia? No

Is this the blocking of thought associated with petit mal epilepsy? No

Because patient was aware of her “block” which was related to a specific emotional thought.

67

180.

Derailment is a term describing the sudden switch from one line of thought to a new parallel line of thought. Der:1ilment often occurs after an episode of thought blocking or sudden —,.—,—.-.,.,.—– ________________ and can be pictured thus:

B L

c0 KI

N G

When asked the question, “What kind of work do you do?”, a patient answered: “I’m a carpenter, I do … ,” the patient suddenly stopped speaking and stared past the examiner’s shoulder. After a few moments, the examiner touched the patient’s arm and asked, “What’s happening to you now?” upon which the patie11t focused on the examiner and said: “I read that thousands of people are un- employed now …. ” The sudden cessation of mental and motor activity exhibited by this patient is called

181.

182.

183.

184.

The disrupted thought associations on a

the blocking episode is called _________

g

-=-co-=-m=m::-:e:-:n::-:c::-:e::-:m=e=n7t-o””‘f.–::a=n–=-o·ther parallel train of thought, or – – – – – – – although often associated, can occur separately.

When asked: “What kind of work do you do?” a patient responds, “I am a line man, you know, the weather man can’t be olamed for

the weather.” This is an example of . Draw

a slash line where there is a switch in associatiOns.

Draw a line between the appropriate items in the two columns:

The apparent sudden cessation of mental and motor activity of

, the disruption of one train of thought and the

Clang associations Derailment Blocking

Verbigeration (palilalia)

“How high am I, I fly, I fly, Look, look at the sky?”

“It is indisdispu utable, able, a ble, a blbe”

“l\1y brother works in a paper factory, he is a puncher …

The problem in the town is that most people wcrk at the factory and with all the layoffs … ”

Similar to a petit mal absence

68

pa-r-a”ll:-e-.-l_c_o_u_r_s_e–,f.-o”ll.–o-w~i~n

180. absence of thought

181. blocking, derailment

182. blocking, derailment

183. derailment

you know /the weather

184. Clang association— “How high am I, I fly, I fly, look, look at the sky!”

Derailme5Zn”It is a indisdispu utable, able able, a blbe”

Blocking

Verbigeration (palilalia)

“My brother works in a paper factory, he is a puncher…the problem in the town is what most people work at the factory and will all the layoffs…”

Similar to a petit mal absence

69

185.

Write the appropriate name next to each diagram of disordered thought form linkage:

186. 187.

Verbigeration or

alent term) is a form of stereotype of speech and is often seen as part of the syndrome.

188.

Draw a diagram using our small numbered squares, arrow and goal, to illustrate the following:

GOAL ———and———–

Circumstantial speech is often observed among patients with mania. Associations by the sound rather than the meaning of words or associations are also observed in mania.

Circumstantial speech Tangential speech Verbigeration /palilalia Word salad Fragmented speech

70

(its neurological equiv-

185. Circumstantial

Blocking and Derailment Tangential

Verbigeration or palilalia

186. palilalia, catatonic 187. clang

188.

Circumstantial speech

GOAL Tangential speech

Verbigeration /palilalia (Verbigeration may or may not

be goal directed) Word salad Fragmented speech

OJ 00 (§] [R) ITQ}- · GOAL ITJ@)(]] [[j IT§}-·GOAL

0-GOAL

(Please note that fragmented speech and word salad differ only in degree of loss of meaningful connection between associations (i.e., the tightness of linkage has broken down)

71

189. 190.

Many patients with mania exhibit signs and symptoms of catatonia (40 p.36,71,74). Stereotype of speech or _ _ _ _ _ _ _ _ can also be observed among manic patients.

191.

When asked “Wha.t kind of work do you do?”, a patient responds: “I’m a brick layer, been doing it for years, been doing it all my

life, or about. Been a brick layer a long time. I work down on l\1ulberry. A long time. We’re doin’ an office building … 25 stories. It takes a long time to put up a building.” In this example of speech, the linkage is tight, but certain stock phrases and words (“a long time”) are continually repeated. Even when the subject

192.

The constant repetition or return to the same topic, rather

than phrase, is called perseveration of theme. Perseveration of theme can be observed in many depressed patients (40 pp. 75-98,59). On the other hand, perseveration of associations or the automatic

use of “plugged in” or ” –·-··—” words is a significant indicator of coarse brain disease.

193.

If in the diagram below the number 2 indicates repetition of the same phrase ( [I] ) what thought disorder does the diagram represent?

The repetition ·of stoc.K words and phrases, i.e., words or phrases automatically placed into the flow of speech, is termed perseveration. Perseveration is a type of formal thought disorder and is observed in schizophrenics and in patients with coarse brain disease (9,13,14,17,22,23).

Other formal thought disorders I have discussed are shown below. Match them with the examples of speech presented in the column on the right.

Tangential speech Verbigeration I palilalia

That prune has many folds in it, you know , canals, grooves

Neologism

Word approximation Derailment

Private use of words Blocking

The weather button is dangerous. He is organaniziningizinginging. What is my opinion. Well….. .

I grottled it.

What is my opinion? Well, I might have thought about it a long time and you know there are many things to consider, some this way, some that.

I was going to the store, I have a bad leg and it hurts.

is changed, the patient continues to repeat the same phrases auto- matically “plugged” into the new topic. In very mild forms these phrases, termed may be a culture-bound speech

pattern: “You know!”

72

· GOAL

189. 190.

Verbigeration or palilalia Tangential speech

That prune has many folds in it, you know , canals, grooves

191.

perseveration

192.

stock

193.

perseveration

Neologism ~ W d

The weather button is dangerous.

Private use of words B locking/

I grottled it.

~Iwas going to the store, I have

t•

H . …… .

e 1s organamzinmgizmgmging.

What is my opinion? Well, I might have thought about it a long time and you know there are many things to consider, some this way, some that.

or approx1ma 1on

Derai!ment:><;,_~Whatie my opinion. Well..•••.

a bad leg and it hurts.

73

194.

Rambling speech is an example of a thought process associated with coarse brain disease (14,66). It has been heard by almost all party goers, businessmen at long luncheons, skid row passersby, in short, by anyone who has heard the speech of an intoxicated individual. The diagram below pictures rambling speech.

Is it goal directed?_______

Are associations tightly linked?

195.

196.

197.

Non-goal directed, fragmented (loosely linked) speech, or speech, is characteristic of acute coarse brain –:-p:-a:-:r.,.,.ticularly intoxications ( 14, 66). Since it is often

associated with slight to severe speech slurring (depending on

the dryness of the martinis), speech is not difficult to recognize. A staggering gait, or ataxia, is another bedfellow

of speech.

Rambling speech suggests an rather than a chronic process. Drivelling speech, another manifestation of

brain disease, is more characteristic of long -st'””””a-n-d”i.-n-g~d.-y-s’f.-u-nction ( 9, 14 , 16 , 17 , 22, 23) .

Unfortunately, our imaginations are not up to diagramming drivelling speech. Goal? 7 X A 3 9 B B is one possibility. Although associations appear tightly linked, syntax appears preserved and there are no startling stereotypes (verbigeration) or perseverations (stock words). In drivelling speech, as in classical double-talk, sentences (and some words) simply make little sense, the meaning of the speech is lost. When asked, “What kind of work do you do?”, a patient replied: “Never let it be reduced that I’ve not been gaiting the bob. Partially layered and down, I’m not sure. Twenty-five or twenty-six, that’s the work. I’ve had one grunch but the left over there is not the man I saw.” When you hear a patient’s response that you know is in English

but which seems, nevertheless, to be in another unrecognizable language, suspect and listen carefully.

When the syntax of speech is preserved but the words make no sense, neurologists say an individual has jargon agrammatism

( 16, 17). Psychiatrists call this phenomenon _ _ _ _ _ _ _ _ _

There are times when a patient’s response, if taken out of context, shows no evidence of thought disorder, but in context it is totally unrelated to the examiner’s question. The term for this is non-sequitur (Latin for “does not follow”). When “flight of ideas” (to be discussed) are not present, non-sequitur responses are a form of thought disorder observed in schizophrenia as well as coarse brain disease with aphasia ( 9, 16, 17). To the question “How old are you?” a patient responds, “It could be, but I’m not estranged.” This illustrates the _ _ _ _ _ _ _ _ _ _

198. 199.

‘d~is_o_r-d”e-rc-s-,

74

194. Is it goal directed? No Are associations

tightly linked? No

195. rambling, rambling, rambling

196. acute, coarse

197. drivelling

198. drivelling

199. non-sequitur

75

200.

Draw a line between appropriate itmes in the two columns:

201.

202.

Draw a line between matching items in the two columns. Not all items in either column need be matched.

203.

Draw a line between items in the two columns:

Non-sequitur

Drivelling/jargon agrammatism

Perseveration of association

VerbigerationIpalilalia

Draw a line between the appropriate items in the two columns:

Tangential speech Rambling speech

Derailment

Circumstantial speech

Typical of acute intoxications

Non-goal directed, tight associations observed in schizophrenia and in coarse brain disease

Circuitous but eventually goal directed

Often associated with blocking

Clang associations Blocking

Paraphasia

Fragmented speech

Perseveration of associations

Word approximations & neologisms Apparent sudden cessation of mental

and physical activity

Associations by sound rather than by meaning

Double talk

Use of stock words and phrases; associated with coarse brain disease

Drivelling/jargon agrammatism

vr~rbigerationIpalilalia Perseveration of

association

Clang association

“That’s my situation. Situations change and it can’t be helped. My situtation is my problem, I’ve got to situation myself just right.”

“Well, it’s not that either, but with the totally generated it can’t be helped.”

“When was I last well? Hell you ding-dong, you bell, I’m well.

“Its approxiximalalal al al al.”

76

Automatic repetition of words and phrases, particularly at the end of associations.

Totally unrelated response Double-talk

Repetition of stock words in generally goal-directed speech

200. Non-sequitur

Automatic repetition of words and phrases, particularly at the end of associations

203.

Draw a line between items in the two columns: Drivelling/jargon~”That’s my situation. Situations change

DrivellingIjargon agrammatism

Totally unrelated response Double-talk

Perseveration of association

201. Tangentialspeec~Typicalofacuteintoxications

‘202.

Clang associations~Word approximations & neologisms

Blocking _ /

Apparent sudden cessation of mental and physical activity

Paraphasia

AssociatiOns by sound rather than by meaning

Fragmented speech

Double talk

Repetition of stock words in generally goal-directed speech

Rambling speech Non-goal directed, tight associations; ob- served in schizophrenia and in coarse

brain disease Derailment~Circuitousbuteventuallygoaldirected

Circumstantial speech Often associated with blocking

Perseveration o f – – – – U s e of stock words and phrases; assoc- association iated with coarse brain disease

agrammatism

>and it can’t be helped. My situation is my problem, I’ve got to situation myself just right.”

Verbigeration/palilalia “Well, it’s not that either, but with the totally generated it can’t be helped.”

Perseveration of “When was I last well? Hell you ding-dong, association you bell, I’m well.”

Clang association “Its approxiximalalal al al al.”

77

204.

Draw a line between items in the two columns:

205.

Identify each of the examples of formal thought disorcer:

206.

“What’s the point of all this probeout?”

Draw a line between appropriate items in the two columns:

Derailment Neologisms

“That’s rypitcal of him”

Word approximations Private usage of words

“He was going to tell me and I just never got to go. ”

“He callously disregarded my wishes. The situation is callous and I’m very upset.

To callously disregard one is not the way to act.”

“How can I tell about which I am in the middle of. You don’t really think this is the beginning, or the end, or for that matter any of it.”

“I was having this trouble sleeping, the light you know was difficult to read by.”

“Stop it! Stop it! Do you think am generated?”

Word salad Neologisms

Word approximations Non-sequitur

The paraphasia of using “new” word: Answer unrelated to question

Severe form of drivelling speech

78

“I don’t understand a drum of what they’re doing.”

“I was at the engine station on

time but the cars, the engine never showed up.”

The paraphasia that consists of using incorrect words with similar meaning to the correct choice

204.

Draw a line between items in the two columns

205.

“He callously disregarded my wishes. The situation is callous and I’m very upset. To callously disregard one is not the way to act.”

“How can I tell about which I am in the middle of. You don’t really think this is the beginning, or the end, or for that matter any of it.”

“I was having this trouble sleeping, the light you know was difficult

to read by.”

Derailment Neologisms

Word approximations Private usage of words

“That’s rypitcal of him”

“I don’t understand a drum of what they’re doing.”

“He was going to tell me and I just never got to go.”

“I was at the engine station on time but the cars, the engine never showed up.”

“Stop it! Stop it! am generated?”

Do you think

~~~~————

“What’s the point of all this probeout?”

Neologism

206. Wordsalad~Theparaphasiaofusing”new”words

Neologisms =’~~><~-~Answer unrelated to question

Word approximations~ Severe form of drivelling speech

Non-sequitur~ The paraphasia that consists of using in- correct words with similar meaning to

the correct choice

79

Perseveration/stock words

=D-=r-=i.:..v-=e=ll=in=g_ _ _ _ _ _ _ _ Derailment

Private usage of words

207.

You have now become familiar with many different forms of thought disorder. Although there are numerous other terms and several other forms of disordered thinking, a presentation of the total is beyond the scope of this book. I do, however, want to describe one more form of thought disorder: Flight-of-ideas. Flight-of-ideas has been described as the cardinal thought disorder of mania ( 40 pp. 14-15, 71). In flight-of-ideas, the patient jumps from topic to topic, lines of thinking are fragmented and multiple lines of thought are common. Associations often appear in response to an <‘Xternal stimulus until interrupted by new stimulated lines

of thought. Severe flight-of-ideas can be pictured with the following diagram:

Careful examination of the confused impression of the diagram shoulc isolate segments which fit the definition of several previously des- cribed disorders of thinking.

This sequence has missing associations, but it is ge;1erally goal directed. If the associations were phrases or sentences, this would be an example of speech. If we isolate the associational line:

We can see tight associations taking a circuitous route and an

If we isolate the association line:

example of

speech.

80

207. fragmented, circumstantial

81

208.

209.

210.

Each of the following is consistent with flight-of-ideas except: (circle answer)

Circumstantial speech Fragmented speech Neologisms

Jumping from topic to topic

Alas, all is not simple in psychiatry! You saw in item 207 that flight-of-ideas becomes a combination of speech and speech. Since fragmented speech is a traditional example of of , the possibility exists that flight-of-ideas and loosening of associations may be variants of the same disordered thought process. The elaboration of this problem is well beyond the digestive tracts of many of us and obviously beyond the scope of this book.

Place an M next to the terms associated with Motor behavior, a T next to the terms associated with Thought process and an A

next to the terms associated with Affect:

Relatedness

Perseveration of association

Non-sequiturs Catalepsy- –

Mood Echopraxia- –

Verbigeration

Tardive dyskinesia

Apathy_ _ Gegenhalten

Paraphasia Drivelling_ _

82

208. 0 eologismi)

209. circumstantial, fragmented, loosening, associations

210. Relatedness A

Perseveration of association T

Non-sequiturs.!_ Catalepsy.!’:!_

Mood A Echopraxia M_

T a r d i v e

dyskinesia~

Apathy~ Gegenhalten~

Drivelling__’!’_

83

211. Place a check mark in the appropriate box indicating the most typical relationships (more than one checked category for any thought disorder is possible):

Drivelling Flight-of-ideas Rambling Perseveration Non-sequiturs Derailment

Clang associations Paraphasia

Tangential speech Circumstantial speech Blocking Verbigeration

Mania

Schizophrenia

Acute Coarse Brain Disease

Chronic Coars Brain Disease

Write the definition of the thought disorders listed above.

84

211.

Drivelling

Flight-of-ideas

Rambling

Perseveration

Non-sequiturs I Derailment I Clang associations I

Paraphasia I Tangential speech I Circu11stantial speech I

Blocking I Verbif'”eration I I

I

Acute Coarse Chronic Coarse Mania Schizophrenia Brain Disease Brain Disease

I

I

I

Although the relationships in this table are not absolute, please note that the pattern of thought disorder is similar for schizophrenia and coarse brain disease. Any interpretation of this similarity will undoubtedly be predetermined by the bias of the viewer.

Drivelling: Associations appear tightly linked and syntax appears pres- erved but the meaning of speech is lost. It is double-talk.

Flight-of-ideas: Jumping from topic to topic, often in response to exter- nal stimuli. Multiple lines of thought can occur.

Rambling: non -goal directed, fragmented speech.

Perseveration: The repetition of stock words and phrases automatically

placed into the flow of speech.

Non-sequiturs: Patient’s response is totally unrelated to the examiner’s

questions.

Derailment: The sudden switch from one line of thought to a new parallel

line of thought.

Clang associations: association by the sound of words rather than meaning. Paraphasia: The use of words or phrases without precise meaning; new

words formed by the improper use of the sound of words (neologism). Tangential speech: tightly linked associations which bypass the goal go-

ing off on a tangent.

Circumstantial speech: tightly linked associations but with extra non-es~

sential associations interspersed. The speech takes a circuitous route

before reaching its goal.

Blocking: Sudden absence of all thoughts and mental activity. Verbigeration: a verbal stereotype in which the patient repeats associa-

funs, particularly at the end of a thought, in an automatic manner.

85

I

I I I I

I I

I

I

I

I

212.

What a person is talking about is helpful in reaching a diagnosi when the content reflects an intense mood. Once you have estab- lished the of a patient’s speech, or how he is speaking, you should determine whether the thought content is helpful in the diagnostic process.

213.

Feelings of hopelessness, worthlessness, helplessness, guilt and thoughts of suicide are often expressed in thought content. T reflect the presence of a sad mood ( 40,58, 65). During the mental status exam, you must determine whether these feelings are presen The following questions can induce the patient to explain his mood.

214.

Thoughts of suicide can be determined by asking the patient the following series of questions:

215. 216.

The presence of ideas of hopelessness, worthlessness, helpless· ness, guilt and suicide reflect the presence of a _ _ _ _ _ _ _ __

1.

“How does the future look?”—“Do you think your difficulties will improve?”

2.

“Do you think your family needs you?”—“Are you a worthwhilE person?”

3. 4.

“Do you think you can do anything about all this?”

“Have you let people down?”—“Are you a bad person?”

1. “Well, with all this going on, you must feel pretty badly. Do you ever get the feeling you’d like to go to sleep and not wake up?”

2. 3. 4.

“Do you ever get the feeling you’d be better off dead?”

“Did you ever wish you could just end it all?”

“Did you ever think of harming yourself? … Of killing yourself? … Have you tried? … Do you feel that way now?”

The details of what a person is hopeless about or guilty about i the thought content. This content becomes diagnostically impm because it reflects an intense mood of sadness. The fact that a tient feels profound sadness and thus feels guilty is diagnostical more important than the detail of the guilty idea. For example, patient said “I’m a terrible person, I masturbated when I was Y’ and now my family’s being punished for it. I’ve let them down. They should kill me.” The patient expressed the details of mas bation and resulting family punishment. These details could ea; have been finding money in the street and not returning it and suiting trouble in the world. It’s the feeling of guilt, manifestE by these details, which is of primary concern in the diagnostic amination.

List the types of feelings associated with a sad mood.

86

212. form

213.

No answer required

214.

No answer required

sad mood

215.

216. hopelessness, worthlessness, helplessness, guilt, suicide

87

217. 218.

219. 220. 221.

A patient responded “Yes” to the question, “Do you ever get the feeling you’d like to go to sleep and not wake up?” This res- ponse suggests he has thoughts of _ _ _ _ _ __

List the thought content being evaluated by each of the follow- ing questions:

1. 2. 3. 4. 5.

“How does the future look?” ————-

“Do you think you can do anything about all this?” _ _ _ _ “Did you ever wish you could just end it all?” ________ “Did you ever think of harming yourself?” __________ “Do you think your family needs you?”

Questions relating to feelings of hopelessness, worthlessness, helplessness, guilt, and suicide determine the presence of ideas which reflect a ——-

Past thought content belongs in the historical part of your eval uation of the patient. In the mental status examination, you want to determine the content.

Next to each of the following descriptions, indicate which thoug disorder it best illustrates:

Q. “Why did you come to the hospital?” A. “I don’t like that food.”

“Don’t frazzle it away.”

“It’s not because of, well you see, the one that he was interested in not being part of the drive.”

“I renigated it.”

Q. “Where do you live?”

A. “I live with my mother.”

Q. “Yes, but where do you live?”

A. “I would rather not be there.

Q. “Yes, but what is your address?” A. “Some people would say that I

live downtown.”

88

217. 218.

219. 220. 221.

suicide

“How does the future look?” hopelessness

“Do you think you can do anything about all this?” helplessness “Did you ever wish you could just end it all?” suicide

“Did you ever think of harming yourself?” suicide

“Do you think your family needs you?” worthlessness

sad mood

present

Non-sequitur

Private use of word – “frazzle” (a paraphasia)

Drivelling/jargon agrammatism

Neologism – “renigated” (a paraphasia)

Tangential speech. The answers follow but never reach the goal.

89

222.

Next to each of the following descriptions, indicate which thoug disorder it best illustrates:

Q. “Do you like it here?”

A. “Well, as you know, I’ve been here over

a week now. I came in on Friday and today is Wednesday. My brother brought me here. There are some patients who I know from last time and, of course, many of the staff – so that when you consider how sick I was at the beginning and now it really isn’t so bad. It’s o.k.”

“He was rejuvennerated ated ated”

“I’ve been here over a week and the time I was in the arf!ly sarge”

“It’s a tough life. Real tough, but I

think I can tough it out. You know I’ve been around and I’ve grown tough-skinned.”

Next to each of the following descriptions, indicate which thoug process disorder it best illustrates:

“You might be right, bright boy … flight boy. What a sight!”

“I don’t know…We were so young…What time is it?…eh?…What went wrong?”

“We went in a driver, you know, a road machine.”

“I’m a persistently active person. I have always persistently done my job…never give up. Perseveration, fortitude, per- sistance is what it takes to get ahead.”

“Why did I do it? How come you ask so many questions? Are you a Doctor? Doctors make a lot of money. I’d like to be rich. The idle rich you know!”

223.

90

222.

Circumstantial speech (question is answered after much unnecessary i11formation)

Verbigeration/palilalia (stereotype of speech) Derailment (occurs after the word “week”) Stock words (perseveration) “tough”

223.

Clang associations (bright – flight – sight)

Rambling speech (never reaches a goal, loosening between associa-

tions)

Word approximations (driver and road machine for car) Stock word/perseveration – persistently Flight-of-ideas (jumps from topic to topic)

91

224.

Next to each of the following descriptions, indicate which thou€ disorder it best illustrates:

“What happened in the Army is my business. I’11 mind my business, you mind yours. Are you sure you work here? Your’re awful nosy! I don’t like questions. I’d rather be outside. I like the out of doors. It’s raining now but it will be nice tomorrow. After the rain falls the sun must shine. In any cloud there’s a silver lining.”

Q. “What happened to you before you were brought here?”

A. “I came here about a week ago. I don’t think I should be here.”

Q. “Well, what happened before you were brought here that made people think you should be hospitalized?”

A. “l\ly sister-in-law is responsible. If it weren’t for her they wouldo’t have come for me.”

92

224. Flight-of-ideas (jumps from topic to topic)

Tangential speech (talks around the point but the answer never

reaches the goal)

93

DELUSIONS (APOPHANY)

225.

226.

227.

228.

.,.–…,—–,—-‘ and Your next task is to examine for apophany or delusional behavior or ideas. Apophany comes from the Greek and means “to become manifest.” Phenomenologists apply the global term apophany to the category of phenomena characterized by false or arbitrary ideas developed with- out adequate proof. The term “delusion” is incomplete in describing behavior form and needs equalifying terms to have more precise meaning. The term “paranoid” has been used to mean everything from a suspicious mood, to delusions of persecution, to schizophre- nia and will not be used in this text.

Although apophanous phenomena are frequently observed in severely ill psychiatric patients, they are not pathognomonic of schiz< phrenia, and are frequently found in patients with affective dis- orders (18,31,33,40 pp. 19-22, pp. 84-85, 65,71) and coarse brain disease (14,15,16,21,23). Ideas of persecution which are apophan- ous are not pathognomonic of schizophrenia. Apophanous is a glo- bal term applied to the category of phenomena characterized by

_ _ _ _ _ _ _ or arbitrary ideas developed without adequate proof.

There are several standard definitions of the term “delusion”:

“a fixed false belief, not in keeping with one’s own cultural environ- ment” (32) and “the making of a relationship without adequate proof” ( 35) are two of the more common ones. Write a sentence defining

the use (or application) of the term apophanous.

Apophanous phenomena are experiences in which the patient mis- connects events, objects, experiences, and endows them with per- sonal significance. They include: delusional mood or atmosphere, delusional ideas, autochthonous ideas and delusional perceptions. Although we will discuss the form of these phenomena individually, each will be characterized by or ideas de- veloped without _______

To review: The phenomenologic mental status requires you to

evaluate a patient’s general _ _ _ _ _ _ _

94

225. appearance, motor behavior, affect, thought processes

226. false

227. Apophanous is a global term applied to a category of phenomena characterized by false or arbitrary ideas developed without ade- quate proof.

228. false, arbitrary, adequate proof

95

229.

230.

231.

During the course of a mental status examination, many patients will reveal delusional ideas when detailing or explaining recent per- sonal history. They will relate the nature of plots against their lives; electric waves coming from the wall; their great power; their special relationship with God; great sins they have committed…. Whenever the examiner suspects a patient’s statements to be

the next question, in essence, should be: “How do

_y_o_u~k,…–n_o_w-..,?”‘”–

When false or arbitrary ideas are accepted as real by patients, they may readily reveal these ideas because they feel them to be obvious to everyone. Some patients who are aware that other peo- ple might think them crazy will be reluctant to reveal strange, but to them true, ideas. Once again, a conversational approach is of- ten the best method of eliciting phenomena.

If during a conversation with a friend about the weather, your friend said, “There are radioactive machines in the wall”, you would not calmly continue your discussion of the weather. You’d be sur- prised, concerned, curious. When a patient tells you such strange things, be surprised, concerned and curious. Say: “That’s very unusual…How can you tell there are machines in the wall?…Who would do such a thing? … Why would anyone want to harm you? … Tell me more about this, I’m very interested in what you just said…” Don’t put the patient on trial, don’t argue, don’t convey the feel-

ing of: “Ho hum, so what else is new?” Questions should continue

(as long as the patient is willing to discuss the matter) until you

can determine the , not just the content of the apo- phanous phenomenon.

Perhaps the mildest form of apophany is termed an apophanous or delusional mood, sometimes also termed delusional atmosphere. This experience is the “feeling” that something is wrong, that things are not right and are sinister. (“Something is going on out there,

I don’t know what it is, but I feel it and I’m afraid.”) It is akin to, but more severe than, the feeling of being watched or the common experience of self-consciousness felt by sensitive persons when en- tering a noisy room full of people who, for a moment, become quiet

to observe the newcomer. Delusional atmosphere or~,..-,-.—-.­ can be observed in almost any serious psychiatric condition, and does not have diagnostic specificity.

232.

233.

234.

Some patients will describe a sinister atmosphere which sur- rounds them. This is a . Others will relate events in such a way that you’ll suspect its presence. It is perfectly proper for you to help the patient verbalize his delusion, as you would any psychopathology. Say: “You must have been

frightened or suspicious…Did you feel that people were watching you … ?” This approach suggests concern; it shows that you know about such things, and are interested in helping.

Frequently, patients with severe mood disorders or perceptual disorders, i.e. , hallucinations, will misconnect experiences in a per·- sonal manner. From their disordered mood or perceptual errors, ideas are made manifest. The phenomenon is termed an apophanous or idea.

96

229. apophanous

230. apophanous

231. form

232. mood

233. delusional mood (apophanous mood)

234. delusional

97

235.

236.

237.

238.

239.

240. 241.

242. 243.

When delusional ideas develop from other psychopathology, i.e., an altered mood, a hallucination, the ideas are secondary in sequence of occurrence and are sometimes called secondary delusional ideas.

As with all apophanous phenomena, secondary delusional ideas are arbitrary and develop without _ _ _ _ _ _ _ __

A depressed patient states that he is a terrible person, full of evil, that he is being punished for his sins and that he is the cause of all the many deaths in the hospital. This patient is expressing ideas which follow from his terribly painful mood. These ideas, particularly his responsibility for hospital deaths, are misconnec- tions of events to his person and are examples of-w…-r”it,–e_a_s_e_n_t:-e-nce

e x p l a i n i n g w h y h i s de’lu—=-s”‘”‘io:-::n:-a”l'”‘””id”e:-a:–:;:t-.:h-:a-:t~h;::-:-e~i'””‘s–:::cr-::-e-:-:sponsible f o r h o s p i – tal deaths is secondary.

A patient states that people are going to kill him because he overheard their conversation. When he ran away, he heard them yell at him, threatening to shoot him. He says he frequently hears them threaten him. Here too, the patient’s idea that he is going

to be killed developed from a hallucination. Another example of

When an apophanous or delusional idea develops from some pre- vious psychopathology, it is referred to as a

delusional idea. When the delusional idea form_s_w-I”‘”‘·t7h_o_u-:-t-o–;b:-v-l”‘”””·o-us development from previous psychopathology, it is termed a primary delusional idea.

An apophanous idea which appears in the patient’s mind with- out obvious development from previous psychopathology is a

. When it ap- pears suddenly and full formed ,-1-;-:.t:-:-is-a-:1-so-t:–e-r_m_e_d-:-a-n autochthonous

delusional idea.

Autochthonous delusional ideas occur and are ——- formed. ——

Ideas that do not develop from any obvious psychopathology are called delusions. But ideas that develop from previous psychopathology such as a disordered mood or perceptual error are delusions.

An autochthonous delusional idea is one form of

delusional idea. ——–

Sudden, fully-formed, primary delusional ideas or …,.–~—–.-~ ideas are similar to the “Eureka” phenomenon. The patient suddenly “knows” the idea is true but can’t explain why, or from where the idea came. For example, one patient said that he was sitting at home eating breakfast when: “It suddenly dawned on me that my family wanted to murder me. I can’t understand why I never thought of

it before, but at breakfast it just came to me.”

98

2350

adequate proof

236o

237 0

238o

239 o

secondary delusional ideas

It is secondary because it develops from other psychopathology,

i.e 0 , depressed mood

secondary delusional ideas

secondary

primary delusional idea

suddenly, fully

240o

241. primary, secondary

242o primary

243o autochthonous

99

244.

245. 246.

247.

248. 249.

250.

Clinical psychiatry is not yet an exact science. Ultimately, the examiner must decide using his clinical judgment, whether an auto- chthonous idea is a personalized misconnection of events and there- fore a primary , or whether the autochth- onous idea is simply a phobic or obsessional thought.

Some primary delusional ideas develop slowly over time. Some primary delusional ideas develop suddenly and fully formed. The latter phenomenon is called ———-

A patient said “The FBI is after me.” When asked how he knew this he said he knew because his garbage was not picked up and he had difficulty unlocking his apartment door. He thought these ev- ents odd and after giving them some thought he concluded that the FBI had done it. This delusional idea is because it does not develop from other psychopathology. It is not -.,-,~,-­ because it developed over time, i.e., it was not sudden and fully formed. –

The late Kurt Schneider, a German psychiatrist, described (60) certain primary delusional ideas which, instead of developing from

a disordered mood or perceptual error, developed from perceptions of real stimuli. Schneider termed these primary delusional ideas de- lusional perceptions. Delusional perceptions are considered primary because they do not develop from any other obvious _ _ _ _ _ _

Delusional perceptions develop from perceptions of real stimuli, _m’in—-,d-.—— delusional ideas develop fully formed in the patient

Secondary delusional ideas often develop from unreal perceptions —perceptions without real stimuli, i.e., hallucinations. The apo- phanous phenomena that develops from a real perception is termed

Circle the examples of secondary delusional ideas:

“The FBI is after me. I can hear their radio cars talking from my TV set.”

“The FBI is after me. I saw agents creeping about my apartment last night. When I chased them, they disappeared.”

“The FBI is after me. I was walking down the street last week and I suddenly knew it. I just knew it.”

“The FBI is after me. I passed a store window and the dummies were all undressed. That was the signal that gave me the idea.”

Note: In today’s world, the statement “The FBI is after me” should not automatically be greeted with skepticism. Would you commit someone B.S”crazy” for saying that there were “bugs” in the Democratic Headquar- ters in Washington and machines in the walls of the White House? Always ask the question “How do you know?” and evaluate the patient’s responses to determine the form of their idea. In the above item, “The FBI is after me” was the content; you were identifying the form of secondary delusion- al ideas.

100

244. delusional idea

245. authchthonous

246. primary, autochthonous

247. psychopathology

248. authchthonous

249. delusional perceptions

250. “The FBI is after me. I can hear their radio cars talking from my TV set.”

“The FBI is after me. I saw agents creeping about my apartment last night. When I chased them, they disappeared.”

“The FBI is after me. I was walking down the street last week and I suddenly knew it. I just knew it.”

“The FBI is after me. I passed a store window and the dummies were all undressed. That was the signal that gave me the idea.

101

251.

Circle the examples of primary delusional ideas:

252. 253.

Write a sentence defining the difference between a primary and a secondary delusional idea.

254. 255.

The term “persecutory delusions” refers only to

It doesn’t tell you whether the delusions are primary-o=-=r-:-:s:-:e:-:c:-:o=-=n=-d”a-=-=ry=-, autochthonous, or delusional perceptions.

256.

Some patients give no initial hint of apophanous phenomena;

but with skilled interviewing, they will reveal multiple delusional ideas. Some patients won’t tell you their “crazy” ideas, but will readily tell you about the trouble with their neighbors, co-workers or family members. Several questions directed to these relationship will often reveal abundant apophanous phenomena.

“The FBI is after me. can hear their radio cars talking from my TV set.”

“The FBI is after me. saw agents creeping about my apartment last night. When I chased them, they disappeared.”

“The FBI is after me. I was walking down the street last week and I suddenly knew it. I just knew it.

“The FBI is after me. I passed a store window and the dummies we· undressed. That was the signal that gave me the idea.”

Circle the examples of secondary delusional ideas:

“I feel dead. I want to cry but I cannot…My guts are rotting. My brain is full of garbage. I am being punished.”

“The voice tells me it is God and I am the annointed; I am Christ; I am all powerful.”

“God is my lover. We have been having sex together for over a year. I can feel him inside of me, lying on top of me. He talks to me. I have a special purpose, I am God’s lover.”

In severe depressions, the content of delusions often revolves around past sins, nihilistic ideas, somatic illness, terrible personal history, or future events (31-33,40 pp. 75-98,58,65). In mania, the content of delusion is often “grandoise,” dealing with great personal power, great wealth, high birth ( 18, 31-33, 40 pp. 22-24, 65, 71). Persecutory delusional ideas can occur in individuals with depression, mania and schizophrenia (12, 13, 18, 31-33,41,42,58,65, 71). Although the content of these apophanous ideas is helpful, their form is of major importance. The fact that they are apophan- ous is significant. Their content is not. Write a sentence defining an autochthonous idea and a delusional perception.

Write a sentence defining apophanous phenomena.

102

251. “The FBI is after me. I can hear their radio cars talking from my TV set.”

“The FBI is after me. I saw agents creeping· about my apartment last night. When I chased them, they disappeared.”

“The FBI is after me. I was walking down the street last week and I sudden! knew it. I ·ust knew it.” This is the primary delusional idea termed: autochthonous.

“The FBI is after me. I passed a store window and the dummies were all undressed. That was the si nal that gave me the idea. This is the primary delusional idea termed: delusional perception.

252. A secondary delusional idea develops from other psychopathology; a primary delusional idea does not develop from other psychopath- ology.

253. “I feel dead. I want to cry but I cannot. ..My guts are rotting. My brain is full of garbage. I am being punished.”

“The voice tells me it is God and I am the annointed; I am Christ. I am all powerful.”

“God is my lover. We have been having sex together for over a year. I can feel him inside of me, lying on top of me. He talks to me. I have a special purpose. I am God’s lover.”

254. content

255. An apophanous autochthonous idea springs fully formed in the pa- tient’s mind. A delusional perception is based on a real stimulus, personalized, and made significant.

256. Apophanous phenomena is a category of phenomena characterized by false or arbitrary ideas developed without adequate proof.

(Note: No one should be totally happy with this definition. We can better define the specific phenomena of apophanous mood and ideas (primary and secondary).

103

257.

Draw lines between appropriate items in the two columns:

258.

Next to each of the following descriptions, indicate which apo- phanous phenomena it best illustrates:

“Something is going on out there. They’re up to something. I can feel it. They’re watching me.”

“I know they are after me. The voices tell me.”

“I know they are after me. The blue shirt you are Wf)aring is the sign.”

“I know they are after me. I was walking down the street and it just came to me. It was a revelation.”

“I know they are after me. It just makes sense; people looking at me, the lights not working at home. They’ve done something to my house. They bugged it.”

Next to each of the following descriptions, indicate which apo- phanous phenomena it best illustrates:

“I feel so bad…as if I’m dead. I want to cry but I can’t. It’s horrible I’m all dried up. It’s hopeless … I’m dead

“There must be machines in the wall. They must have placed them there. I can feel them putting radioactive waves in my body. The waves make me weak and then force me to do things.”

“The President’s in on it. I heard him speaking to my brother last night. He won’t kill me, however, I know his plans now.”

“I know they’re trying to take over … I just know.”

259.

Delusional mood

Autochthonous delu- sional idea

Primary delusional idea

Secondary delusional idea

“I’m going to die tomorrow. Why else would my mail not arrive?”

Sudden fully-formed apophanous idea

“I feel as if someone or something sin- ister is watching me.”

“I’m going to die tomorrow, the voice told me.”

…I’m a corpse.”

104

257. Delusional mood””‘-

” ”

“I’m going to die tomorrow. Why else would my mail not arrive?”

Sudden fully formed apophanous idea

“I feel as if someone or something sinister is watching me.”

258.

“Something is going on out there. They’re up to something. I can feel it. They’re watching me.”

“I know they are after me. The voices tell me.”

“I know they are after me. The blue shirt you are wearing is the sign.”

“I know they are after me. I was walking down the street and it just came to me. It was a revelation.”

“I know they are after me. It just makes sense: people looking at me, the lights not working at home. They’ve bugged it.”

“I feel so bad … as if I’m dead. I want to cry but I can’t. It’s horrible I’m all dried up. It’s hopeless…I’m dead…I’m a corpse.”

“There must be machines in the wall. They must have placed them there. I can feel them putting radioactive waves in my body. The waves make me weak and then force me to do things.

“The President’s in on it.

heard him speaking to my brother last night. He won’t kill me, however, I know his plans now.”

“I know they’re trying to take over…I just know.”

259.

Delusional mood Secondary delusional idea

Delusional perception

Autochthonous delusional idea (one form of primary delusional ideas)

Primary delusional idea

Secondary delusional idea (to a mood)

Secondary delusional idea (to the feeling of waves coming into the body)

Secondary delusional idea (to hallucinated voices)

Primary delusional idea

Autochthonous delusion idea

Primary delusional idea

Secondary delusional—–“I’m going to die tomorrow, the voice idea told me.”

105

260.

Next to each of the following descriptions, indicate which apo- phanous phenomena it best illustrates:

“It’s eerie … as if someone were watching me. People are acting funny. Something is wrong. It’s frightening.”

“I am the king of the world. have so much energy, so many ideas. It’s won-

derful. I’m ecstatic.”

“When the man in the subway yawned, I kn’:)W the train would crash.”

“He’s trying to poison me. The TV keeps telling me over and over again.”

106

260.

“It’s eerie …as if someone were watching me. People are acting funny. Something is wrong. It’s frightening.”

“I am the king of the world. I have power beyond your imagin- ation. I have so much energy, so many ideas. It’s wonderful. I’m ecstatic.”

Secondary delusional idea (to a mood)

“When the man in the subway yawned, I knew the train would crash.”

Delusional perception

“He’s trying to poison me. The TV keeps telling me over and over again.”

Secondary delusional idea (to voices from the TV)

107

Delusional mood

PERCEPTION AND FIRST RANK SYMPTOMS

261.

262.

You have now learned a good deal about the recognition of be- haviors classified under the five mental status headings of:

=—.,.——,.–‘ , and The next area of examination is perceptual

function. Perceptual disturbances are very common among psych- iatric patients. As with other areas of behavior, the form not the content of these disturbances is of diagnostic importance.

Perception is the brain’s interpretation of exogenous and endo- genous stimuli. The stimulus modalities we are interested in are generally the traditional sensory systems of the body: visual, audi- tory, olfactory, gustatory, tactile and visceral. Perception is one major process by which we know the real world and our reality per- ception is a complex process, inadequately understood, but obvious ly influenced by multiple genetic, constitutional, social, environmer tal, and pathological factors. When these factors distort, limit, or otherwise damage the process of perception, a person’s reality per- ception can be said to be disordered. Thus, if a person sees some- thing that is not there, he has had a perception without a stimulus and his reality perception is _________

A hallucination is a disordered perception because it occurs when no has occurred.

A hallucination is an example of disordered

Reality testing refers to the individual’s ability to recognize what perceptions are real–that is, reflecting real stimuli–and what perceptions are not real–that is, distorted interpretations of real stimuli or perceptions which develop without stimulus. Perceptions which develop without stimulus are termed _ _ _ _ _ _ _ _ _ _

263. 264. 265.

108

261. general appearance, motor behavior, affect, thought processes, apophany

262. disordered

263 stimulus

264. reality perception

265. hallucinations

109

266.

267.

268.

269.

270.

271. 272. 273.

The distinction between reality perception and reality testing is clinically important because many psychiatric patients have disturbe reality perception but are aware they are misperceiving and thus have good reality Psychotic patients usually

have both disordered reality and poor reality

As they first begin to respond to treatment, patients

continue to misperceive but begin to become aware of their mis- perceptions. Their improves first.

Your ability to differentiate reality testing from reality percep- tion will give you an early clue to your patient’s beginning response to treatment. Write a sentence defining the difference between real-

ity testing and reality perception.

Hallucinatiolls can occur in all sensory modalities: visual, audi- tory, olfactory, gustatory, tactile, and visceral. Hallucinations or

-:-::–::::-,.—,-.,.—,–,—–.- that occur without sensory ,—,.,..,–,—–.- can happen under a variety of non-pathological conditions such as

fatigue, distractability, and normal pre- and post-sleep states. Nearly 50% of people without any mental disorder have hallucinated at some time in their lives ( 31 pp. 18- 22).

Pseudo, or fRlse hallucination is a term that refers to vague, poorly formed hallucinations or hallucinations which are experienced as occurring in inner subjective space (an “inner voice”). Pseudo- hallucinations occur in many people without mental disorder. Un- fortunately, the prefix “pseudo” is a poor one since these phenom- ena are indeed hallucinations. Their vagueness and lack of inten- sity has lead to their being separated by the term “pseudo” from clear, fully-formed and intense hallucinations ( 62, 63). Write a sen- tence defining a hallucination.

Not infrequently, pseudo-hallucinations occur near sleep-onset. They are called hypnagogic hallucinations. When they occur upon awakening they are called hypnopompic hallucinations. Although they are given different names, these phenomena are most likely manifestations of identical processes. hallucinations occurring as one falls asleep and hallucinations occur- ring as one wakes up, have significance onlywr the diagnosis of altered sleep states (65).

Vague, poorly formed perceptions occurring without real stimuli are termed When they occur as a person falls asleep they are termed _________

A vague, poorly formed hallucination occurring as one falls aslee is termed hypnagogic. A similar phenomena occurring as one

awakes is termed __________

One of the most commonly hallucinated phenomena is termed in- complete auditory hallucinations (42). Incomplete auditory halluc- inations are voices. They are muffled, whispered, often experience4 as coming from inside the head and are usually limited to a few word or phrases. auditory hallucinations occur with great frequency in all psychoses.

110

266. testing, perception, testing, reality testing

267. Reality perception is your ability to accurately interpret exogenous and endogenous stimuli. Reality testing is your ability to determine the accuracy of your perceptions.

268. perceptions, stimuli

269. A hallucination is a perception without a stimulus.

270. hypnagogic, hypnopompic

271. pseudo hallucinations, hypnagogic

272. hypnopompic

273. incomplete

111

274.

275.

276.

277. 278.

279.

280.

281.

Some patients experience unformed hallucinations such as flashes of light, unidentified noises, smells and tastes. These phenomena are termed elementary hallucinations (31,32, 62, 63). A muffled whis- pered voice termed an is not an elementary hallu- cination because even though it IS vague it has form, i.e., the pa- tient identifies it as a voice.

Although not necessarily a manifestation of pathology, unformed hallucinations occur in numerous morbid states (toxic, depressive, epileptic, schizophrenic). These unformed unidentified noises, smells, lights and tastes are termed __________

If a patient complains about a whispered voice that is bothering him at night, but he knows the voice is not real, his reality

– – – is disordered, but his reality remains intact.

A hallucinated whispered voice is an example of an _ _ _ _ _

Not infrequently, patients will hallucinate only immediately after ordinary stimulation in that particular sensory modality. For ex- ample, a patient heard voices only when the electric fan was on. This phenomenon is termed a functional hallucination and can occur in numerous morbid states (depressive, epileptic and schizophrenic) ( 32, 63, 64). Unformed hallucinations, termed halluc- inations, can also occur in these conditions.

Occasionally, patients report hallucinations which occur outside the normal sensory field. They see people behind them or hear voices in another country. This phenomenon is termed an extra- campine hallucination and, like hallucinations occurring immediately after ordinary stimulation (termed ) and un- formed hallucinations (termed ) , can occur in numerous morbid states (toxic, depressive, epileptic, and schizo- phrenic) ( 31).

Draw lines between appropriate items in the two columns:

Elementary hallucination

Hypnagogic hallucination Functional hallucination

A hallucination only after sensory stimulation

Unformed hallucinations

A pseudo-hallucination upon falling asleep

The ability to tell real from false perceptions

Reality testing

Draw lines between appropriate items in the two columns:

Reality perception

Pseudo-hallucination

Incomplete auditory hallu- cination

Hypnopompic hallucination

A vague poorly formed halluci- nation

A brief, whispered voice

A pseudo-hallucination while a- wakening

Ability to accurately perceive sensory stimuli

112

274. incomplete auditory hallucination

275. elementary hallucinations

276. perception, testing

277. incomplete auditory hallucination

278. elementary

279. functional, elementary

280.

Elementary h a llu c in a tio n ;c : A hallucination only after sensory stimulation

281.

Reality perception

A vague poorly formed hallucina- tion.

Hypnagogic hallucination Functional hallucination

Unformed hallucinations

Reality testing

The ability to tell real from false perceptions

Pseudo-hallucination

A brief, whispered voice

Incomplete auditory hallucination

A pseudo-hallucination while awa- kening

Hypnopompic hallucination

Ability to accurately perceive sen- sory stimuli

113

A pseudo-hallucination upon fall- ing asleep

282.

Draw lines between appropriate items in the two columns:

283.

284.

285.

286.

287. 288. 289. 290.

The particular sensory modality of a hallucination can provide

a clue to the nature of a patient’s disorder. The modality of the hallucination is part of its form. The hallucination’s vividness (clarity), perceived source (inside inner subjective space or out- side the self) and duration are also part of its form. What the hallu- cination is about, or its , is rarely of diagnostic significance

The most frequently observed perceptual disturbances among psychiatric patients are visual and incomplete auditory hallucinations ( 13,40-42,71. 72). Although no hallucination is pathognomonic. some are characteristic of specific psychiatric conditions. Visual hallucina tions, for example, including functional and elementary hallucinations are most often manifestations of coarse brain disease, particularly toxic states (31). Muff1ed voices, footsteps, groans, and voices of

short duration termed —..,-~;—–.- —,;——.———; -..,–.–.– are most often associated with manias, depressions and schizophrenia (13,33,40-42,58,65,71,72).

Tactile or somatosensory, haptic or visceral, olfactory and gus- tatory hallucinations are not uncommon among psychiatric patients but unfortunately, many clinicians fail to inquire about the presence of these phenomena. Although they can all occur in affective dis- orders (that is, mania and depressions), and in schizophrenia,

their presence should suggest brain disease ( 13,33, 40-42,58,65,71,72).

A perception when no sensory stimulus has occurred is termed

Extracampine hallucinations Hypnagogic hallucination

Incomplete auditory hallu- cinations

Elementary hallucination

riluff1ed, voices, vague music Flashing lights

Significant only in altered sleep states

A hallucination outside the nor- mal sensory field

A false or misperception of a real sensory stimulus is termed an illusion.

a ~~-.–~­

Misperceptions of real sensory stimuli or can occur

in normals as well as in most psychiatric cond’~it”‘i”o-:::nccsc-.— Misperceptions of real stimuli or –~,——-‘ often occur because

of fatigue or an extremely intense mood.

A frightened person, misperceiving shadows as threatening peo- ple, demonstrates an example of an ___________

Write a sentence defining the difference between a hallucination and an illusion.

114

282. Extracampine hallucinations Muft1ed, voices, vague music Hypnagogic hallucination~Flashinglights

Incomplete auditory hallu- cinations

Elementary hallucination

283. content

284. incomplete auditory hallucinations

285. coarse

286. hallucinations

287. illusions

288. illusions

289. illusion

Significant only in altered sleep states

A hallucination outside the nor- mal sensory field

290. A hallucination is a perception without a stimulus; an illusion is a misperception of a real stimulus.

115

291.

292.

293. 294.

295.

296.

297.

Some perceptions take the form of distortion of the real stimulus Objects can be visualized as smaller or larger than their real size; sounds are perceived as louder or softer than their true intensity

or depth perception is suddenly lost. On the other hand, misinter- pretations of a real stimulus are termed __________

Perceiving objects as becoming larger is termed macropsia. Per- ceiving objects as becoming smaller is termed micropsia. Macropsia and micropsia are examples of perceptual _ _ _ _ _ _ _ _ __

ger

Perceptual distortion can take the form of objects becoming lar- opsia or smaller, opsia.

Macropsia and micropsia are examples of perceptual distortion where objects are perceived as changing in . T~se phenomena come under the general heading of dysmegalopsia and are often experienced in epileptic states ( 15, 23).

Draw lines between appropriate items in the two columns:

Illusion Micropsia

Elementary hallucination Haptic hallucination

“I feel a snake crawling in my stomach”

“Everything suddenly becomes small & far away”

“I was running home and as the trees moved, I thought I saw a giant”

“I see flashes of light”

Draw lines between appropriate items in the two columns:

Haptic hallucination Macropsia

Functional hallucination

Incomplete auditory hallucination

“I see objects becoming suddenly larger”

“I hear a voice only when the water is running from the faucet”

Whispered voices

A visceral perception without a stimulus

As patients relate what has happened to them, many will inad- vertently reveal experiences which are obviously hallucinations:

Example: “I saw a man with a knife standing at the foot of the bed. He disappeared when I turned on the light.”

“I see a shining cross in the sky.”

“God is talking to me now.”

However, in the seriously ill, it is likely that they believe their hallucinations to be real. They have poor

and poor .

In-,_t:,–,1~is-s~i-ct-u-a-,-t~ion,

the exam-

iner must be skilled in obtaining information about hallucinatory experiences.

116

291. illusions

29 2. distortion 293. macro, micro

294.

size

295.

Illusion

“I feel a snake crawling in my stomach”

296.

“I see objects becoming suddenly larger”

297.

reality perception, reality testing

M icropsia—–“”‘-.._,..—-+– “Everything suddenly becomes small and far away”

Haptic hallucination Haptic hallucination

“I see flashes of light”

Macropsia

“I hear a voice only when the water is running from the faucet”

Functional hallucination

Whispered voices

Incomplete auditory hallucination

A visceral perception without a stimulus

117

“I was running home and as the trees moved, I thought I saw a giant”

298.

When examining a patient for apophany, we ask him about “trou- ble with neighbors, co-workers, or family members” which might reveal the patient’s delusional ideas, or perceptions about these or other people. Hallucinatory experiences can, at times, be elicited

in a similar manner. Questions such as: “Have any of the neighbors or any other people been bothering you or trying to harm you?”… “Have you seen any of them following you?” … “Can you hear them talking about you or saying bad things about you?” This will of- ten encourage a patient to describe voices, visions, and other per- ceptual phenomena. The development of good rapport with the patient is vital if you are to obtain adequate information about apo- phanous and perceptual phenomena. Patients will converse with you more readily if you can make them feel that you are concerned, in- terested in their experiences (as if they were real), and that you have heard about such things before. Frequently, a statement like the following is helpful: “I have spoken with other people with sim- ilar experiences (feelings, situations) to yours and they also … ”

You then simply give examples of apophany, hallucinations, or illu- sions and many patients will respond with “Yes, I’ve had that happen to me too.” Details usually follow.

Once this process has begun, the introduction of more obvious “crazy” experiences is less likely to be met with resistance. “Have any of these people (who are talking about you and trying to hurt you) tried to spy on you? … Bug your house with machines? … Do they use the TV or radio? … Do they try to control you? … I know a man who felt that some machine in the wall was controlling his thoughts. Did you ever experience something like that?”

Throughout the conversational examination, the patient should feel that you know about such things and that you know people be- lieve such things, and also that you are simply interested. Should the patient ask you directly, “Do you think I’m right?” the best reply is, “I understand what you’re saying and I know you feel these (frightening) experiences to be true, but I wonder whether there isn’t another explanation.” If the patient says, “No, there isn’t”, go on to the next logical topic. If the patient insists on your opinion, offer the explanation that the experiences are signs and symptoms of an illness. After you’ve said your peace, don’t argue. You’re on the record; you’ve told the patient the truth without at- tacking him. lVJany patients will trust you even more for being truth- ful and disagreeing, than for appeasing them and treating them as

if they’re crazy, or for disregarding their feelings and fighting with them about the validity of their experiences. On rarer occasions,

a fruitful question might be: “Have you recently had any frighten- ing experiences or experiences that you couldn’t explain?” You can then give the patient some examples of voices or visions. One in a hundred patients will respond positively to the questions, “Do you hallucinate? Do you hear voices?”

It is not easy to examine for apophany and perceptual pheno- mena in the manner just described. It takes time, self-control and a bit of acting skill. If you master it even partially, however, it will serve you well.

118

298. (No answer required. Just rest and think about it.)

119

299.

300.

Popular literature, music, and art often express experiences which we observe in patients. Label each pop music phrase with the appropriate phenomenologic term:

“I hear singing and there’s no one there.”

“She dances overhead, on the ceiling near my bed.”

“Lucy in the sky with diamonds

Label each description with the appropriate phenomenologic term:

“It’s frightening– -suddenly everything becomes very small as if I were looking through the wrong end of a telescope.”

“It happens many times during the day. I suddenly smell burn- ing rubber or rotting flesh. I feel dizzy and then it’s all right again.”

“It’s a frightening man. I can see him walking behind me. Sometimes I see him in another city.”

“I can’t make it out. It’s some sort of a noise or hum but I hear it all over the place.”

Next to each of the following descriptions, indicate which per- ceptual disturbance it best illustrates:

“I can hear him talking all the way from California: 1900 miles!”

“It’s horrible. Everything becomes flat and then bigger as if swollen. It makes me sick to my stomach.”

“I woke up in the middle of the night and saw this transparent figure standing over my head.”

“It’s like a buzzing noise. can just make it out.”

301.

120

299.

300.

“I hear singing and there’s no one there.”

“She dances overhead, on the ceiling near my bed.”

“Lucy in the sky with diamonds.”

“It’s frightening—suddenly everything becomes very small as if I were looking through the wrong end of a telescope.”

“It happens many times during the day. I suddenly smell burn- ing rubber or rotting flesh. I feel dizzy and then it’s all right again.”

“It’s a frightening man. I can see him walking behind me. Sometimes I see him in another city.”

“I can’t make it out. It’s some sort of a noise or hum but I hear it all over the place.”

“I can hear him talking all the way from California: 1900 miles!”

“It’s horrible. Everything be- comes flat and then bigger as if swollen. It makes me sick

to my stomach.”

“I woke up in the middle of the night and saw this trans- parent figure standing over my head.”

“It’s like a buzzing noise. can just make it out.”

Incomplete auditory hallucination (auditory hallucination)

Hypnagogic hallucination Visual hallucination

Micropsia (dysmegalopsia)

Olfactory hallucination

Extracampine visual hallucination Elementary auditory hallucination

Extracampine hallucination

Macropsia (dysmegalopsia)

Hypnopompic hallucination Elementary hallucination

301.

121

302.

Next to each of the following descriptions, indicate which per- ceptual disturbance it best illustrates:

“I feel a hand moving in my stomach.”

“I taste metal.”

“I am sitting alone in my room and I suddenly smell burning rubber or rotting flesh.”

“Everything is o.k. until the phone rings or the door bell goes off – then I hear this voice calling me names.”

“Every time I heard a noise

it sounded like a person moving around in the house. It was scary.”

Next to each of the following descriptions, indicate which per- ceptual disturbance it best illustrates:

“I see light rays bouncing off things. It’s like a glow … a haze of light.”

“Just before I fell asleep I saw

this animal jump about in ·the corner of the room.”

“The room suddenly became small and far away. I felt dizzy.”

“I hear this voice. It says my name or mumbles something to me.”

“I feel these things, like worms, crawling about under my skin.”

“The shadow looked like a gorilla.”

Kurt Schneider was the first person to describe systematically the phenomena he labeled first rank symptoms (60). Schneider as- serted that, in the absence of coarse brain disease, the presence

of any one of these phenomena was decisive in the diagnosis of schi- zophrenia. Schneider’s assertion was based on anecdotal clinical observations. He believed these phenomena to be “first rank” only in a clinical sense with no etiological significance. Even though his descriptions and definitions have generated great interest in the phenomenological study of schizophrenia, studies ( 1, 19, 52, 70-72,

74) have demonstrated that although Schneiderian’s first rank symp- toms occur in 60 to 75 percent of rigorously defined schizophren- ics, they are also experienced by individuals with affective disease, particularly during manic episodes. Although no longer “first rank” in the diagnostic sense, first rank symptoms are still useful in det- ermining severe illness.

303.

304.

122

302.

“I feel a hand moving in my stomach.”

Haptic (visceral) hallucination Gustatory (taste) hallucination

303.

“I see light rays bouncing off things. It’s like a glow…a haze of light.”

304.

No answer required

“I taste metal.”

“I am sitting alone in my room and I suddenly smell burning rubber or rotting flesh.”

Olfactory (smell) hallucination

“Everything is o.k. until the phone rings or the door bell goes off – then I hear this voice calling me names.”

Functional hallucination

“Every time I heard a noise it sounded like a person moving around in the house. It was scary.”

Auditory illusion

“Just before I fell asleep I saw this animal jump about in the corner of the room.”

Hypnagogic hallucination

“The room suddenly became small and far away. I felt dizzy.”

Micropsia (form of dysmegalopsia)

“I hear this voice. It says my name or mumbles some- thing to me.”

Incomplete auditory hallucination

“I feel those things, like worms, crawling about under my skin.”

Tactile (somatosensory) hallu- cination

“The shadow looked like a gorilla.”

Visual illusion

123

Elementary hallucination

305.

306.

307.

308.

Although Schneider listed eleven —,—.—–.;– , – – ; ; , – – – – . – symptoms, they can be conveniently categorized under five major headings:

1) Thought broadcasting, 2) Experiences of alienation, 3) Exper- iences of influence, 4) Complete auditory hallucinations, 5) Delu- sional perceptions.

According to Schneider, in thought broadcasting, the patient experiences that as his thoughts occur, they escape from his head aloud into the external world. Some clinicians assume thought

to be a hallucinatory experience, but as Schneider ‘d_e_s_c_r..,ib_e_d-.–ci'”‘”t_a_n-.d_a_s patients relate it,

is the experience, the feeling of losing one’s “”th,…o_u_g…-h–:t-s_t.,..o—-,t…-h_e_o_u_,-t-sl.–..de world. Patients with both thought broad-

casting and auditory hallucinations experience them as different phe- nomena.

Patients will often have secondary delusional ideas involving telepathy, electronic surveillance or power rays that explain the phenomena that their thoughts escape aloud from their heads so that others can hear them. This is termed ————————-

Once a patient has told you about his apophanous ideas and you have been asking detailed questions about “how he knows,” it is a natural sequence to ask about plots involving electronic surveillance, or attempts at telepathy. From this progress to questions such as, “Do you feel that people are reading your mind?…Can others really (literally) hear your thoughts? … You mean it’s like your thoughts were coming out of your head, as loud as my voice?…Come on, you’re kidding me. You mean to say it’s as if your head were like

a radio and everybody here can hear what you’re thinking?” If a patient responds positively to these questions, he is admitting to the first rank syraptom of

Sometimes naive observers object to such a line of questioning. It appears to them that you are “putting words in the mouths of pa- tients.” Don’t let this attitude faze you. You must ascertain wheth- er or not a patient has apophanous ideas in order to arrive at a diag- nosis. The form of these ideas has diagnostic value. Your apparent- ly “leading questions” are in response to statements your patient

has made. If the patient denies experiencing any of the phenomena

I have described, you obviously won’t ask him if his head is “like a radio.”

When a patient expresses the feeling that others can read his mind or says that he believes that people know what he’s thinking by the expression on their faces, we can conclude that he has apo- phanous ideas. These are not sufficient statements, however, to qualify for the experience of others hearing his thoughts coming a- loud out of his head. When a patient was asked what he was plan- ning to do that day, he laughed and then said testily, “You know perfectly well what my plans are; everyone in this room does; you’re hearing them right now … All those machines in the floor are letting everyone hear them.” This is an example of _________________

t309.

124

305.

first rank

306.

307.

308.

broadcasting, thought broadcasting

thought broadcasting

thought broadcasting

309.

thought broadcasting (if you added secondary delusional idea you would also be correct).

125

310.

311.

312.

313. 314.

315.

Many seriously ill patients describe the experience that their body sensations, feelings, impulses, thoughts and actions are im- posed upon them by some external agency; that they are literally “being controlled,” can literally “feel” the controlling force, and th• must passively submit to the experience. Schneider termed this ph nomenon experiences of influence. Patients often develop :;-::-::-cc:-cc-:-:,.— delusional Ideas that explain the nature of their exper- iences of __________

A frightened 19-year-old female student described her teacher as continually “emitting energy waves” which made her think homo- sexual thoughts, and which made her assume “certain sexual” body postures. The student “felt” the teacher “control” her body, “touc: ing her genitals” and vibrating over her skin while she remained still, unable to move or resist. This student was experiencing the Schneiderian symptom of

In experiences of alienation the patient’s feelings, impulses, thoughts or actions are felt not to be his own but to literally belong to someone else. Secondary delusional ideas explaining the nature of this external force are common.

Experiences of alienation are the subjective disowning of one’s feelings, thoughts, or movements, i.e. , “it’s not mine”. In contras experiences of are primary subjective feeling~ of being controlled by some outside force and of involuntary submis- sion.

If it’s yours, but it’s being controlled, it’s an experience of

If it’s not yours, but somehow attached to yom

body, or in your mind, it’s an experience of ___________

Some people refer to the feeling of loss of contact or empathy with family, friends or society as “alienation.” The Schneiderian

is quite different. The patient experiences his….,..fe:-e””‘l”i=n-=g::-:s-,”””””””t”h-=o-,-u'”‘g”‘hc:-t”‘s, or movements as

“foreign,” not part of the self, and as though they “do not belong” to him.

Some patients with large parietal lobe lesions will deny any rela- tionship to certain of their body parts (21). They will say: “That arm is not mine, I don’t know what that thing is but it’s not mine, mine is over there next to it.” While this phenomenon is similar in many ways to the Schneiderian first rank symptom of

, cerebral localization has never been demons-t’r-a-t’e-d””f”o_r_a-ny “fi'””r·-s..,.t_r_a_n….,..k symptom .

126

310. secondary, influence

311. first rank, influence

312. influence

313. influence, alienation 314. experience of alienation

315. alienation

127

316.

A 19-year-old patient complained of concentration difficulties resulting from unwanted thoughts which suddenly appeared in his stream of consciousness but which were “obviously” not his own. He insisted that: “someone keeps putting things in my head … and the pressure is too much.” He spent hours cleaning the ward kit- chen but insisted the cleaning activity was not part of him. He knew he was there while it happened, but the action was “discon- nected” from his “self” like a “foreign body” and was attributed to the “actions of God.” This young man’s complaint is an example of an . Hisbe- lief that God was literally responsible for the actions people said were his is an example of a delusional idea.

The 19-year-old man in the previous item felt that God was put ting thoughts in his head. This is often referred to as thought in- sertion because the inserted thought is experienced as a foreign body, this phenomenon is termed an experience of _ _ _ _ _ _ _

Some patients describe the phenomena of suddenly losing all mental and motor activity, i.e., suddenly going blank as in petit m epilepsy or as observed in the thought disorder termed -..,–,—,,—–,—–· Patients with these experiences will;–s-om-e7tl’·m-e,-s state that someone or something has taken their thoughts away. This experience is often referred to as thought withdrawal and is often literally experienced or felt as the result of some outside forcE (e.g., gamma rays, thought vacuum). In this form, it is an ex- perience of __________

Schneider listed experiencing foreign thoughts being placed in one’s head or thought , having one’s thoughts take away or , and blocking, as separate first rank sym toms. Since there is no evidence that their separation enhances

the selection of more homogenous patient groups, they have been included under the terms experiences of and of

In the presentation of perceptual disorders, you learned about

whispered voices of short duration or —–r;-,–,—.—,–,-,– Schneider described

hallucinated voices which: occurred in clear consciousness, were clearly audible, were experienced as coming from outside the patien head (inner subjective space) and were sustained in duration. He termed these voices phonemes or complete auditory hallucinations.

Phonemes, or auditory hallucinations are pro- longed voices, continually commenting upon the patient’s actions, discussing the patient among themselves or repeating the patient’s thoughts.

The auditory hallucination of a voice continually repeating a pa- tient’s thoughts is an example of a complete auditory hallucination ora ____________

317.

318.

319.

320.

321.

322.

128

316. experience of alienation, secondary

317. alienation

318. blocking, influence

319. insertion, withdrawal, alienation, influence

320. incomplete auditory hallucinations

321. complete

322. phoneme

129

323.

324.

325.

326.

327.

328.

The phenomenon of a voice repeating the patient’s thoughts is also termed thought echo. This should not be confused with the p tient’s experience of his thoughts escaping alouC: from his head wh: is termed

When a patient hears someone repeat his thoughts to him, it is termed thought echo or a

hallucination. When a pat”ie_n_t~ll'””‘”t_e_r-a'”‘llc-y-,f-ee~l;-s his thought escaping aloud from his head, it is termed _______________

In the presentation of apophany, you have learned about pri- mary delusional ideas that develop from real perceptions. SchneidE termed these This is the last form of first rank symptoms.

A delusional perception is based upon the patient perceiVmg a real stimulus, making it significant (“that’s important”), making it personal (“that’s important to me”), and then reaching a conclusior for which you (the empathic examiner) cannot feel a meaningful cor nection between the real stimulus (the “proof”) and the patient’s conclusion (the delusion).

A delusional perception has all of the following· characteristics except:

329.

A patient entered the examiner’s office, frowned and said, “I see, you’re in on it too!” When asked to explain, she reluctantly pointed to the coffee cup on the desk and said, “You see that, don you? Well, isn’t it obvious? You’re in on it! It (the cup) is all th• proof I need to show me you’re with those bastards against me.” This patient perceived a real stimulus, the ; she personalized it: proof that you are against me”; she made the per- ception significant: “You’re in on it,” i.e., made a connection be-

tween the cup ano the idea for which there is no understanding (meaningful connection) and she stated an apophanous phenomenon which is the Schneiderian first rank symptom of _ _ _ _ _ _ _ _ _

Draw lines between matching items in the two columns:

a) b) c) d)

Based upon a real stimulus

The real stimulus is given special meaning by the observer

The content of the conclusion is always persecutory

There is no meaningful connection between the real stimulus an the patient’s conclusion as to its significance.

Thought broadcasting

Phoneme (complete auditory hallucination)

Experience of alienation

“I feel someone putting his thoughts in my head. I feel th(

in there now.”

“My thoughts came out of my head like a radio.”

“Comes from outside my house and yells at me all day long.”

130

323.

thought broadcasting

324.

complete auditory, thought broadcasting

325.

delusional perceptions

326.

no answer required

327. c)

328. cup, delusional perception

329. Thought broadcasting

“I feel someone putting his thoughts in my head. I feel them in there now.”

Phoneme (complete aud hallucination)

“My thoughts came out of my head like a radio.”

Experience of alienation

“Comes from outside my house and yells at me all day long.”

131

330.

Draw lines between matching items in the two columns:

331.

332.

Label the description with all the appropriate phenomenologic terms:

“You know perfectly well what’s happening to me! You and those machines! I know, you’re in it with the rest of them. They’re all trying to hurt me. I can feel that machine pull the thoughts right out of my head. Everyone hears them. What do you mean ‘What are you thinking about?’ You hear them too, you liar!”

Draw lines between appropriate items in rows 1 and 2, and be- tween rows 2 and 3:

Experience of influence Delusional perception Thought echo

“Every time I have a thought that bastard says it back to me

“The machine makes me stand still.”

“The yellow bus didn’t come to- day. I am going to die.”

Thought inser~ion

Phoneme

Blocking

The patient sud- denly becomes silent, immobile & unresponsive

& after a few moments becomes animated again

& begins speak- ing.

Experiences of alienation

A patient stated that a man’s voice constantly talked to her and that it came from a spot on the wall.

Thought withdrawal

A clear, sustained hallucinated voice coming from outside one’s head.

A patient was very upset because someom else’s leg seemed to

be attached to her bod

132

330.

Experience of influence

Thought echo

“Every time I have a thought, that bastard says it back to me.”

“The machine makes me stand still.”

“The yellow bus didn’t come to- day. I am going to die.”

331.

332.

secondary delusional ideas

experiences of influence with an irritable mood thought broadcasting

Thought insertion

The patient s u d – – Thought withdrawal denly becomes

silent, immobile

& unresponsive

Blocking/

& after a few moments becomes animated again

& begins speak- ing.

A patient stated that a man’s voice constantly talked to her and that it came from a spot on the wall.

A clear, sustained hallucinated voice coming from outside one’s head.

A patient was very

upset because someone else’s leg seemed to

be attached to her body.

133

333.

Next to each of the following descriptions, indicate which Schneiderian first rank symptom it best illustrates:

“They’re talking all the time, both of them. They yell at me, say vile things. Can’t shut them up. I hear them now yelling from the other room.”

“The rays come from the television station. They go into the antenna on the roof, into the wires and then through the house and into me. They vibrate and tingle, Sometimes they make me weak and I can’t move. They keep my arms at my side and I can’t overcome it.”

“There are too many things in my head. I can’t think. He keeps put- ting them in there and they move about. The thoughts he puts there jumble things up and I can’t think my own thoughts.”

Next to each of the following descriptions, indicate which Schneiderian first rank symptom it best illustrates:

“A green phone…a green phone! As soon as I saw that I knew what was happening. They’ve infiltrated the government.”

“Sure everyone can hear them. They come out of my head as if someone

is sucking them out. Everytime I think I feel them being sucked out. Everyone hears my thoughts once they’re outside my head.”

“I can’t make a move without that bastard telling me what I’m doing. All day long he talks to me. I think he put a transmitter into a freckle on my back.”

334.

134

333.

“They’re talking all the time, both of them. They yell at me, say vile things. Can’t shut them up. I hear them now yelling from the other room.11

“The rays come from the tele- vision station. They go into the antenna on the roof, into the wires and then through the house and into me. They vibrate and tingle. Some- times they make me weak and I can’t move. They keep my arms at my side imd I can’t overcome it.”

“There are too many things in my head. I can’t think. He keeps putting them there and they

move about. The thoughts he puts there jumble things up and

I can’t think my own thoughts.”

“A green phone…a green phone! As soon as I saw that I

knew what was happening. They’ve infiltrated the government.”

“Sure everyone can hear them. They come out of my head as

if someone is sucking them out. Everytime I think I feel them being sucked out. Everyone hears my thoughts once

they’re outside my head.”

“I can’t make a move without that bastard telling me what I’m doing. All day long he talks to me. I think he put a transmitter into a freckle on my back.”

334.

Complete auditory hallucinationI phoneme

Experience of influence (with sec ondary delusional ideas)

Experience of alienation/ Thought insertion (with a secondary delusional idea)

Delusional perception

Thought broadcasting

Complete auditory hallucination/ phoneme (with a secondary delu-

sional idea of a transmitter in a freckle)

135

COGNITIVE FUNCTION

335.

A complete menta.l status examination must include a thorough evaluation of cognitive function. Numerous investigators (11,57, 73,75, 77) have demonstrated significant cognitive impairment in as many as 60 percent of severely ill psychiatric patients. Although

an evaluation of cognitive functioning should be systematic, the ex- aminer should maintain the flow of the interview by asking question~ or eliciting tasks which clarify the patient’s complaints or difficultie~ Specific questions can be asked however, and the patient can

336.

In this part of the mental status examination, we are concerned with behaviors which reflect known cerebral cortical and subcortical functioning. It usually takes about 20 minutes to evaluate these be- haviors properly. Once this task is completed, you will have ob- tained a reasonably reliable and valid profile of cerebral

function. Some understanding of cerebral anatomical land””m::–a-r’k–:s—-=-a-:-:nd functional regions is essential if the profile of cerebral function is

to be correlated with localization of lesions or area in dysfunction.

337.

In the preceding- sections of this text, we have followed a se- quence of mental status areas which parallels the usual natural se- quence of observations. Thus we begin with an evaluation of

338.

To simplify the material, this section will break with the natural sequence of evaluation and present the mental status of cognition organized by cerebral regions or functional areas rather than by the conversational sequence of a good interview.

be requested to perform structured tasks without fear of losing the rapport vital to proper examination.

______ —-:—,——=-~ and then —,=—c—–.c-c-,—–,-.,—- ——-.—- before we find out about affect and thought pro- cesses, i.e. , we evaluate what we see in the patient before we eval- uate what the patient says.

136

335. No answer required

336. cognitive

337. general appearance, motor behavior

338. cortical

137

339.

A patient’s responses to tests of cognitive functioning must be interpreted in the context of his previous education, cultural back- ground, motivation for doing his best on the tests, and the situatio in which the examination is conducted. Tests of cognitive function are essentially evaluating cerebral function.

340.

If a patient has only an elementary school education or comes from a socially deprived environment, responses to questions regar< ing fund of information and vocabulary must be interpreted with caution. Persons from other countries are also often handicapped when asked to perform certain “American” tests of cognition. Theil responses must therefore be cautiously evaluated. Education, moti- vation, acculturation and native language are all important factors affecting the performance on tests of cognition. Circle the factors below which can affect performance on tests of cognition:

341.

Cerebral

in psychiatric patients. Standard concepts use the terms “delirium’ or “acute organic brain syndrome” to refer to conditions where the cognitive impairment is diffuse and reversible.

342. 343.

A diffuse, coarse brain disorder which develops rapidly, is transient, and reversible is termed a _ _ _ _ _ _ _

344.

Since some patients with so-called acute onset diffuse, reversib conditions termed become chronically ill and some patients

High school drop-out

Extremely tall Lack of interest Literary Divorced

Fluency in language of test

impairment is frequently observed

In contrast to delirious states, dementias are diffuse, coarse brain disorders where the cognitive impairment develops slowly and is

with slow onset diffuse, irreversible conditions termed

recover in part, it is often best, when examining a pati-=e-=n…_,t-,…..,.to::-c::ca::-:u-:- tiously use these terms and evaluate specific functions or cortical regions and whether each is impaired or intact.

138

339. cortical

340. ~Extremely tall

341. cognitive

C:Lack of interes!) Divorced

342. delirium

343. irreversible

344. deliriums, dementias

139

345.

During the examination you will obtain a general impression of the patient’s cognitive ability from your informal observations of the patient’s vocabulary, fund of information and ability to accurat~ relate details and sequence of personal events. Some examiners in- quire whether the patient “remembers” or becomes “confused” abou1 such things as local politicians, current events, national politicians, This line of discussion often leads to the questions:

346.

During the past two decades, rapid, reliable and valid methods have been developed for testing cognitive function. These tests,

in part, focus on the localization of certain cognitive functions in th dominant cerebral hemisphere. Other functions are localized in the non- hemisphere.

347. 348.

For more than 97 percent of individuals, the dominant cerebral hemisphere is the left ( 29,44, 45, 61), the non -dominant cerebral herr isphere is usually the _____________

349. 350.

Non-dominant functioning usually refers to non-symbolic spatial perceptual cognition. In most individuals, these functions are per- formed by the hemisphere ( 44, 45, 47, 61).

“Who is the Mayor?”

“Who is the Governor?”

“What is the capital of this state? … the country?”

“Who is the President?…Before him?…and before him?… What happened to him?…etc.”

These questions and those about the population of the United StateE distances between the West and East coast and recent major news events are all helpful, as is your general impression of the patient’E abilities. Nevertheless, they are crude and should not substitute for methodological testing of specific functions of cerebral ________ regions.

Dominant function usually refers to symbolic cognition and lan- guage related processes (29,44,45,47 ,61, 76). In about 97 percent of individuals, these functions are performed by the _ _ _ _ _ _ hemisphere.

Dominant, non-dominant cerebral function is, in actuality, not a single separation. For our purposes, however, we will assume simplicity and learn to evaluate patient’s cognition as if verbal cog- nition was clearly functioning and non-verbal spatial/perceptual cognition clearly functioning.

140

345. cortical

346. dominant

347. right

348. left

349. right

350. dominant, non-dominant

141

351.

A gross test of cerebral dominance requires the patient to write his name (see below) . The preferred hand held in a “hooked” po- sition above the line of writing suggests the dominant hemisphere

is on the same side as the preferred hand. The preferred hand held below the line of writing (most common) suggests the dominant hem- isphere is on the opposite side to the preferred hand (46).

352. 353.

354.

355.

Same Side Opposite Side Dominant Hemisphere Dominant Hemisphere

When asked to write her name, a patient held her right hand be- low the line of writing. This suggests that her

hemisphere is dominant for language. – – – – – – – – –

Since about 97 percent of people have a dominant left hemisphere and most people also write with their contralateral (opposite) hand, the right one, most people must also write with their right hand ______ the line of writing.

Specialized tests of cerebral dominance involve electroenceph- alographic monitoring and intracarotid injections of sedatives ( 76). For purposes of a mental status examination, the location of the preferred hand to the line of writing (above or below) can determine

the the

hemisphere.

In most individuals, it is

In addition to hand position when writing, information about hand preference for different tasks can aid in determining the dom- inant hemisphere. If you were to test the entire population, how many would you find to be left cerebral dominant? _ _ _ _ _ _ _

142

351. No answer required

352. left 353. below

354. dominant hemisphere, left

355. 97 percent

143

356.

The examiner asked the following questions: “Which hand do you throw a ball with?” “Which hand do you write with?”

“Which hand do you pour liquids with?”

To each question the patient responded: “my right.” In such a clear-cut situation (a pure right-hander), the odds are overwhelm- ing that the patient’s dominant cerebral hemisphere will be contra- lateral to the preferred right hand. If so, what is the writing hand position of such a person? ___________

Between 5 and 10 percent of the population is left handed. Nev- ertheless, of the population is left cerebral dominant. What can you conclude from these figures regarding the cerebral dominance and writing hand position of most left handers? Write down your conclusion.

Draw lines between matching items in the two columns:

357.

358.

359. 360.

361.

Following a stroke, a patient spoke with difficulty. The area of damage most likely was in the hemisphere.

Following a stroke a patient spoke with difficulty and had troublE using his preferred hand, the left. An electroencephalogram showed abnormality in the left temporo-parietal area. This suggests that this person’s dominant hemisphere for language was the

_ _ _ _ , but that unlike most individuals the preferred hand was

_ _ _ _ _ _ _ , not contralateral to the dominant hemisphere.

From the information about the patient in item 360 you would pre- dict that when writing he held his hand ____________ the line of writing.

Dominant hemisphere is ipsilateral (same side) to preferred hand

Dominant hemisphere function

Dominant hemisphere is contralateral (opposite) to preferred hand

Non-dominant hemisphere function

Writes with hand below the line of writing

Writes with hand above the line of writing

Language function

Non-verbal function

144

356.

below the line

357.

358.

97% – Many left handers are left cerebral dominant and write in the “hooked” position above the line of writing.

Dominant hemisphere is Writes with hand below the line ipsilateral (same side to~ / o f writing

preferred hand) ~~•’~A

Dominant hemisphere function”‘- Writes with hand above the line

Dominant hemisphere is contralateral (opposite) to preferred hand

/ “”-of writing Language function

Non-dominant hemisphere—-Non-verbal function function

359. left

360. left, ipsilateral

361. above

145

FRONTAL LOBE COGNITIVE DYSFUNCTION

362. 363.

364.

365.

The frontal lobes rostral to (in front of) the motor areas have executive function over other areas of the cerebral

(47 pp. 187-225). ——

Unlike other cortical regions, the differentiation of the frontal lobes into dominant and non-dominant functions is not clear-cut. Although language function is lateralized in the dominant, ustwlly the frontal lobe, other frontal lobe functions appear more diffuse (47 pp. 187-225).

The frontal lobes focus attention (concentration), regulate (or- ganize and program) motor behavior, synthesize information from all other cortical regions, monitor all behaviors and plan new ones

( 47 pp. 270- 279). It is not unlike a futuristic computer that imple- ments and monitors its old programs and develops its own new pro- grams as needed. Unlike other cortical regions most frontal lobe functions cannot be to the right or left lobe.

In the mental status examination, we can evaluate the frontal lobe functions of:

1. Global orientation in clear consciousness

2. Concentration

3. Regulation of motor behavior

4. Language

5. Active perception

6. Judgment and abstract thinking

146

362. cortex 363. left

364. lateralized

365. No answer required

147

366.

All too frequently the inexperienced clinician assumes that “crazy” is a synonym for disoriented and following “Hello,” blurts out. “What’s today’s date, and who is the President?”

Not only is this approach not conversational, but it is not exact- ly the best way of establishing the rapport vitally needed for the examination. Better to wait for the appropriate moment in the con- versation and then ask questions which will provide you with the

necessary information regarding the patient’s global orientation. Often this can be accomplished at the outset of the exam. “How long have you been in the hospital. .. Let’s see, you said you came in on Friday, that means you’ve been here, uh … how many days?” Yes,

a bit of acting is required, but certainly no more than the usual cocktail party or business luncheon dramatics.

Often, in discussing the events of the present illness, a patient will say that he’s confused, not sure of time-sequence, or that he can’t remember. This provides an excellent opportunity to become “concerned” about the patient’s memory and ability to remember dates, places and people. Frequently, helpful are statements such as: “When you say you have difficulty remembering things, do you mean dates? Do you mean where you are?…For example, is your me1 ory problem such that you don’t remember today’s date…the name

of the place we’re in … my name?” Once the patient begins tore- spond to these questions, it appears more natural to ask for more details “just to clarify the difficulty in my own mind.” “The day of the week,” “the year,” “what kind of building are we in?,” all be- come less jarring to your relationship with the patient.

Global orientation refers to one’s precise awareness of place, person and _________

367. 368.

369.

If a patient doesn’t remember your name but knows your job

370.

Concentration or the ability to attend to a task must always be evaluated prior to testing or properly interpreting information about other cognitive function ( 47 pp. 270- 279). If a patient cannot at- tend to a task, he will be unable to perform well on other tests of

function, he’s oriented to person. If it’s a Tuesday and he thinks

it’s a Friday, he’s If he’s in a hospital and he

thinks he’s home, he is

to ———-

As part of your concerned questioning about all the patient’s “difficulties” and possible “confusion” you should acquire informa- tion about the patient’s awareness of:

The date

Day of the week

Month

Year

Season

Building location and name Town or county

State

this information reflects to

and

——— ——–

148

366.

No answer required

367. 368.

time

disoriented to time, disoriented to place

369.

global orientation, place and time

370.

cognition (cortical function)

149

371.

Before beginning any formal testing, the patient should be askec about his subjective feelings, regarding his memory and concen- trating capacities. If he is satisfied, begin with a simple, “Well,

I’m glad to hear that, so I’d just like to ask you a few questions to help me to better understand your situation.” If he is not satisfied, begin with “That must be troublesome (or upsetting). I’d like to find out more about your memory (difficulties).” What would you say to introduce the topic of global orientation? Write down your statements.

372.

When a patient’s anxiety or fatigue is marked, it may interfere with his ability to attend to a task. An altered mood (depression or euphoria), intrusive thoughts or perceptions can also interfere with

373.

A series of numbers stated by the examiner and repeated back- wards by the patient is a test of concentration and not of memory (47 pp. 270-279,66,67,79). The patient’s ability to accurately re- peat in sequence five numbers backward should be considered a nor· mal response. Directions for this task should be clear and the pa- tient’s actual trial preceded by an example: “I’m going to say sev- eral numbers and I’d like you to repeat them for me…If I say: 1, 2 3, I’d like you to say 1, 2, 3.” After the patient’s actual trial with numbers forward, you should say: “I’m now going to say several numbers, and this time I’d like you to repeat them for me backward1

374. 375.

The subtraction of serial sevens or serial threes beginning at 100 is a test of attention to a task, not memory (66). Another test of attention to a task is ___________

376.

Some patients who have difficulty with numbers will be unable

377.

The frontal lobes regulate motor behavior (47 pp. 182-185, pp. 250- 255). When we observe and categorize a patient’s motor behav- ior, we are evaluating the functioning of the

…If I say: 1, 2, 3, what will you say?” You can proceed only af- ter (sometimes with several examples) the patient responds, “3, 2, 1.” A poor performance of this test of concentration could reflect many things. Circle those examples below which could account for concentration problems:

Depression Hallucinations Anxiety

Stupor Euphoria Intrusive thoughts

In testing with serial sevens, directions should, as always, be explicitly stated and an example of two given, using another numbei You should, for example, do it first serially, subtracting twos, and then ask the patient to do the same thing with sevens. No errors and completion close to zero in 90 seconds or less is considered a normal response. An abnormal performance of serial sevens sug- gestsa deficitin————

to perform serial sevens properly or repeat numbers backward.

These tests of can be supplemented by asking the patie1

to spell simple words (world, money, truck) and then spell them

backwards. If the patient has no spelling difficulties, spelling a simple word backwards is also a test of __________

150

371. How long have you been in the hospital? You’ve been here how many days? Today is….. ? You came here when?

374. numbers backwards 375. concentration

376. concentration concentration

377. frontal lobe

OR

When you say you have difficulty remembering things, do you mean dates? For example, do you remember today’s date?

372. concentration

151

378. 379.

380.

381.

382.

Frontal lobe function is reflected in part by an extreme increase in motor activities or or its opposite, very few motOJ

activities or ————————

The removal of the frontal lobes of animals can cause them to show stereotypes, posturing and echopraxias (47 pp. 89-90). Thus an evaluation of the syndrome also partially tests fron- tal lobe function.

Echophenomena are also suggestive of frontal lobe dysfunction. A patient repeating your questions rather than answering them, termed , or a patient reflecting your movements despite your commands to the contrary, termed _______________ may have serious frontal lobe dysfunction.

Equal resistance to an examiner’s attempts to move a limb, termed , is a catatonic feature and also a sign of dys-

function or dysregulation of motor behavior of the

lobe. ————-

Tests of cognitive function include the copying of shapes.

These tests require the patient to make his copy of approximately th

same size, in the middle of a blank sheet of paper and without tak- ing his pencil off the paper. Patients with frontal lobe dysfunction can copy the shape reasonably well, but are unable to keep from repeating their effort until multiple lines distort the shape (motor perseveration). In the drawing below, for example, the patient was asked to copy a circle (47 pp. 182-185) .

383.

384.

c,Patients also can be asked to copy changing visual patterns sue

r-w-w-w .

as ‘e… or

keep from making extra shapes, e.g. , ~

indicates the dysfunction termed motor~ . This is an example of lobe dysfunction.

Frontal lobe motor regulation can also be tested by asking the patient to rapidly tap with his index finger while the heel of his hand is resting upon a flat surface (47 pp. 182-185, pp. 250-255). Standardized methods for evaluation of finger tapping require sev- eral trials but in general dysrhythmic and uncoordinated tapping

or less than 35 taps in 10 seconds suggests frontal lobe dysfunction

Errors in which the patient is unable to

152

~V

378. hyperactivity, hypoactivity 379. catatonic

380. echolalia, echopraxia

381. gegenhalten, frontal

382. No answer required

383. perseveration, frontal

384. No answer required

153

385.

386.

Unlike other frontal lobe functions, fine motor control is later- alized. Thus, the finger tapping of the right hand tests functions in the contralateral or frontal lobe whereas the fin- ger tapping of the left hand tests functions in the contralateral or ___________________ frontal lobe.

Draw lines between matching items in the two columns. The frontal lobe functions in the left hand column can be used more than once.

387.

388.

Circle the words or phrases related to frontal lobe function:

389.

Conccntration Motor regulation Orientation

Knows the year, but not the date

Hyperactivity

Hospitalized patient doesn’t know hospital’s name or location

Echopraxia

Cannot perform serial 7’s

Aware of place, person, and time

Able to attend to a task Able to read

Accurately perceives tactile stim- ulation

Able to spell

Able to regulate fine hand movements

Orientation, concentration, motor regulation, are all frontal lobe functions. Next to each item below, indicate to which frontal lobe function it relates by placing an 0 next to orientation items; a C

next to concentration items; and a

~next to motor regulation items.

1. 2. 3. 4. 5.

6. 7. 8. 9.

Knows the day of the week

Finger tapping dysrhythmic and slow Echopraxia, gegenhalten Hypoactivity or hyperactivity

To the command copy this: ~

Can do serial sevens well

“Where am I?”

Spells world “WORLD” but spells it backwards “ALOW” To the command “Draw a circle” ~

We have evaluated the frontal lobe functions of —-.———— , , and

“‘T”””h-e-,.fr_o_n-t'”””a-,-l–;l,-o”‘”””b-e-also actively synthesizes perceptions (‘a-c’t7iv__e _p_e_r_- ception) (47 pp. 240-244) and engages in abstract thinking (47 pp. 323-340, 48).

154

g responds: ~

the patient

385. left, right

386.

Concentration Knows the year, but not the date Motor reiulation…..-::,….=—- Hyperactivity

387.

Orientation

Aware of(I}lace, person) c!nd umv

Able to@_it_e_n_d-to-a-ta_s_k) Able to read

Hospitalized patient doesn’t know hospital’s name or location

Echopraxia

Cannot perform serial 7’s

Accurately perceives tactile stimulation fine hand move-

388. 1. 2. 3. 4. 5.

6. 7. 8. 9.

Knows the day of the week 0

Finger tapping dysrhythmic and slow M Echopraxia, gegenhalten M Hypoactivity or hyperactivity

To the command copy this:

i

To the command “Draw a circle” @> ~

389. global orientation, concentration, regulation of motor behavior

155

#

!Vi

the patient responds:

M Spells world “WORLD” but spells it backwards “ALOW” c

Can do serial sevens well c “Where am I?” 0

390.

If your patient has no difficulty in naming objects, show him a picture of a simple object upside down. Active perception requires the reversing of the perception to its proper orientation. If the pa- tient is unable to identify the object (such as a hat, candle stick, cup and saucer) turn the picture right-side up. Proper identifica- tion then signifies loss of

and frontal lobe dysfunctio-n-.———

391.

Abstract thinking is the final function to be evaluated in this section. (Language will be evaluated later on.) Begin by telling the patient:

392.

Abstract thinking can also be tested by asking the patient to solve problems. If you have determined that the patient can do simple math you can then ask the following:

393. 394.

If a fully alert patient cannot problem solve or abstract he most likely has dysfunction in what brain area? ___________

“I’d like to ask you about some things and I’d like you to tell me what they have in common or how they are most alike. For example, a cat and a dog are most similar in that they are animals.”

You can proceed only if the patient understands what your expec- tations are. If so, then:

Q. “What is the similarity between an orange and an apple?” A.

Q. “What is the similarity between an airplane and a bicycle?” A.

Q. “What is the similarity between a fly and a tree?” A.

Proper answers to the first two questions suggest normal abstrac- tion. Proper answers to all three questions suggest above average abstraction.

a) “If you had four apples and I had three more than you, how many would I have?”

b) “If you had 18 books and you wanted to put them on two dif- ferent book shelves so that one shelf had twice as many books as the other, how many would be on each shelf?”

c) “If you had a candle 15 inches long and it casts a shadow four times its length, how long is the shadow?”

The matl)ematics in the above problems are not difficult. The real task is to determine the principle involved. This is abstract think- ing and a major function of the lobe.

Draw lines between matching items in the two columns:

Concentration Global orientation Motor regulation

Finger tapping Place, time, person Serial 7’s

156

390. active perception

391. frontal lobe

A. Both are fruit

A. Both are means of transportation A. Both are alive

392. frontal

393. frontal

394. Concentration~ / F i n g e r tapping Global orienta~:~ Place, time, person Motor regulation Serial 7’s

157

395.

Draw lines between matching items in the two columns:

396.

Judgment refers to the ability to evaluate various situations and information and reach an effective conclusion. Unfortunately, the evaluation of judgment is too greatly affected by the examiner’s per- sonal and cultural biases, and is rarely of diagnostic importance. Although psychiatrists are called to assess people’s judgmental capa- cities for legal purposes, the subtleties of the area of “judgment”

in the legal sense is beyond the scope of this book (if not of the profession). Tradition suggests that the evaluation of a patient’s judgment can be achieved by asking the following questions:

A. “What would you do if you found a stamped, addressed and sealed envelope on the street?”

B. “What would you do if you were in a crowded theater and were the first person there to discover a fire?”

C. “What would you do if you were lost in the woods?”

After being subjected to such responses as:

A. “Open it up and look for money…” or “I don’t pick up things off the street!”

B. “Run like hell” …

C. “Are you kidding? I never even go to the park!”

I decided there must be a better way. There is! Decisions concern- ing the patient’s life situations and reality problems offer the best chance to evaluate judgment, e.g. , “What are you going to tell your boss about this?…What are your plans when you leave the hospital? …What advice would you give your daughter about her problem?”

Active perception Motor regulation Abstract thinking

Motor perseveration

Similarities

Recognizing upside down figures

158

395. Active perceptio~Motor perseveration

Motor regulation Similarities

Abstract thinking Recognizing upside down figures

396. No answer required

159

397.

Below are examples of responses to tasks evaluating frontal lobe function. Indicate with an x if the response is abnormal and in each case write where indicated, the function being tested.

“93 . . . 86 . . . 79 . . . 72 . . . 65 . . . 58 . . . 5 1 . . . 44 . . . 37 . . . 30 . . . 23 . . . 16… 9… 2.”

“A flower has a green stem and so does grass.”

“Oh, a cup. I didn’t recognize it when you held it upside

down.”fWWW'”

Response f\A.I\IV..MN

Finger taps (less than 35 taps with index finger in 10 seconds)

Despite instructions to the contrary, patient repeats (copies) examiner’s move- ments.

“THE A R”

“It’s July 1, 1959”

“If I had 4 and you had 3 more than me, you’d have 7.”

“A plane and a bicycle both have wheels.”

“Copy

160

397.

“93… 86… 79… 72… 65 . .. 58 … 51. .. 44 … 37 … 30… 23… 16… 9… 2.”

“A flower has a green stem

and so does grass.” X

“Oh, a cup. I didn’t recog- nize it when you held it

upside down.” X

Concentration Abstract thinking

Active perception Motor regulation

Motor regulation

“Copy ‘W ‘I{lN I”

Response !WWv’vW X

Finger taps (less than 35

taps with index finger in

10 seconds) X

Despite instructions to the contrary, patient repeats (copies) examiner’s move- ments. X

“THE A R”

“It’s July 1,1959.”

“IfI had 4and you had 3 more than me, you’d have 7.”

“A plane and a bicycle both have wheels.”

161

Motor regulation X Concentration

X Orientation

Abstract thinking Abstract thinking

VERBAL MEMORY

398.

399.

400.

401.

Formal memory testing is part of the mental status examination. Information concerning past historical events, family history and re- cent personal events including those of the day of the interview can obviously provide information concerning a patient’s memory capa- city (7). A patient who is unable to accurately relate these details or sequence of events in his personal life should be suspect for hav- ing a memory deficit. List some of the life events which would be helpful indicators for evaluating a patient’s memory.

Memory, however, is not a holistic brain function ( 7, 47, p. 297, 67, 78). Long-term memory (months to years), recent memory (hours to weeks), short-term memory (minutes) and immediate recall can

all be selectively affected in mental illness. Draw lines between ap-

propriate items in the two columns:

Immediate recall Long-term memory Recent memory

Recalling events years back What happened last week

What happened 10 seconds ago

Except in severe bilateral hippocampal dysfunction or an altered state of consciousness, immediate recall is rarely, if ever, impaired. Short-term memory (minutes) is often disturbed in psychiatric pa- tients, particularly those suffering from psychomotor states (recur- rent paroxysms of behavior often associated with temporal lobe dys- function), intoxications and other acute coarse brain processes. Recent memory (hours to weeks) is frequently disturbed in more chronic coarse brain processes while the most established memory patterns or

is often the ‘la_s_,t,–;-t-o’b,_e-d’I,….s…,.t-urbed by illness.

Draw lines between matching lines in the two columns:

Short-term memory Long-term memory Recent memory Immediate recall

Memories of years past

Memories of the last 30 seconds Memories of this morning Memories of the past few minutes

162

398. Birth and marriage dates; numbers and ages of children; iob se- quences, duration and inclusive years; sequence of events and du- ration of present complaints; dates, duration and sequence of past

illnesses.

399. Immediate recall~Recalling events years back Long-term memory What happened last week Recent-term memory What happened 10 seconds ago

400. long-term memory

401. Short-termmem~ryMemoriesofyearspast

Long-term memory Recent memory Immediate recall

Memories of the last 30 seconds Memories of this morning Memories of the past few minutes

163

402.

403. 404.

405.

406.

407.

408.

409. 410. 411.

Once you have established to your satisfaction that a patient is able to concentrate, i.e., attend to a task, you can then proceed with formal memory testing. Memory can be tested utilizing words or drawings (e.g., the Wechsler memory scale) (49,78). The pa- tient is asked to remember several words or word pairs; the words or pairs are stated and the patient asked to repeat immediately the words. This tests immediate assimilation and immediate

Repetition after ten minutes tests – – – – – memory. Reproduction of standard figures can be similarly utilized.

Immediate repetition of a series of words, letters, or numbers tests the memory function of immediate recall. The repetition of a series of words, letters, or numbers backwards tests – – – – –

Long-term memory is best tested by questions concerning past personal and family history. Questions concerning recent personal events, particularly those of the previous day, is the best clinical test of memory.

One reasonable short-term memory test is to ask the patient to remember the following words: blue, chair, swim, glove. Five min- utes later, ask him to recall the words in any order. Be careful, don’t give hints such as: “Do you remember the four words I asked you?” Three or more words recalled correctly should be,considered a normal response. A ten-word test, if time permits, is more relia- ble and valid.

One word of caution: Write the words down or you’re sure to forget them! List all the memory functions we have discussed. This is a test of your memory.

Inability to repeat words, letters or numbers backwards termed poor is different from poor memory. Amnesia refers to the inability to recall past events. (The only time I’ve seen global amnesia in a “psychiatric patient” has been at the movies.)

Decreased memory capacity can take several forms. The inabil- ity to recall past events or can be retrograde (inability to recall events preceding the injury or illness onset) or anterograde (inability to recall events following the injury or illness onset).

The inability to recall events prior to a psychological or physi- cal traumatic event is amnesia, and except for the moment or two immediately priol;’ to the trauma, it is rarely perma- nent.

When a person, hit upon the head, cannot remember the events immediately preceding the blow, he is said to suffer from a mild tra- umatic amnesia.

Anterograde amnesia refers to the inability to recall events fol- lowing the traumatic incident. Inability to recall events preceding the traumatic incident is termed

When a person, hit upon the head, cannot remember the events immediately following the blow, he is said to suffer f!”om a mild trau- matic amnesia.

164

402. recall, short-term

403. concentration

404. recent

405. short-term memory:

406. concentration

407. amnesia

408. retrograde

409. retrograde

410. retrograde amnesia

411. anterograde

immediate recall, short-term memory, recent memory, long-term memory

165

412.

413.

414.

415.

416. 417.

418.

419.

The inability to recall events following a traumatic incident is called amnesia. It results from the faulty registration of new material because of a continuing altered consciousness and acute cerebral dysfunction. Anterograde amnesia is almost always permanent though almost always self-limiting in duration (i.e., ev- ents during the period of amnesia are not recalled, even after the amnesic processes resolve). The longer the period of _ _ _ _ _ _ amnesia, the more severe the dysfunction.

Persons suffering head injury often appear dazed, perplexed, or “out-of-sorts” for several hours or even days following the in- jury. Suddenly, they seem to become their “usual selves” again but insist that they cannot remember clearly what happened since the injury. Such people have had an episode of _ _ _ _ _ _ __ amnesia.

Periods of memory dysfunction often occur in association with

an altered consciousness. An apparent perplexity, dazed appear-

ance or “fuzziness” in response to questions often signals such an

alteration of consciousness. When an altered consciousness follows

a traumatic event and the person upon recovery cannot remember

post-traumatic events, we can say that he had

amnesia. ———

Not infrequently, psychiatric patients appear perplexed, dazed or fuzzy in their responses, but without any evidence of coarse brain·dysfunction. They may appear to have “spotty” recall of events prior to the onset of their illness termed an< difficulty recalling events following the onset of their illness terme< -.,.—~:—-.-but their responses are not as consistent as thosE observed in patients with coarse brain disease. Upon recovery (thE usual course) from this perplexed condition, patients will describe themselves as having been in a clouded, dream-like state. The terr for this is aneroid state.

Clouded, dream-like conditions termed states, occur frequently in acute psychoses. When there is no evidence of head trauma, such a state prognosticates a good recovery (51, 72).

Patients suffering from acute and chronic anxiety syndromes

will often describe periods of detachment in which everything feels

fuzzy around the edges, and in which they feel themselves, as if

in a dream, watching themselves “go through the motions.” This

condition is termed depersonalization and should not be confused

with an altered sensorium or a clouded, dream-like

state. ——-

A person suffering from anterograde amnesia almost always ex- hibits an altered ; a person in an

state appears clouded and perplexed but has

a person in a or detached feeling state has a clear sensorium.

The inability to remember events prior to and following a trau- matic event are termed and amnesia. Some patients, however, can recall “memories”, but these memories turn out to be false.

166

7 no·-:;:-tr:c:-ac:cuc:-:cm-:a~t’ic,.,h,.,i,.,.stoc:cr:-:-y,-;

412.

anterograde, anterograde

413.

anterograde

414.

anterograde

415.

retrograde amnesia, anterograde amnesia

416. 417.

oneroid oneroid

418.

consciousness, oneroid, depersonalized

419.

retrograde, anterograde

167

420.

421.

422.

423.

424.

Some false memories are the result of coarse brain disease (ret- rospective falsification); others are associated with apophanous psy- chosis. False memories associated with delusional ideas are called pseudomemories. These pseudomemories seem to support the pa-

tient’s apophanous notions with “historical” evidence. Only careful history taking, validation from family and friends and your own common sense can determine what are real and what are false or

——————– memories.

Confabulation (making things up) is another form of false

It is falsified memory in response to the questions or

statements of others. Example: A manic patient with grandoise idea; claims that he has had “a telephone conversation with the President of the United States”. When he is questioned about that, he adds: “Actually, he calls me all the time. He and I are old buddies. He always asks my advice on how to deal with the Russians.”

Confabulated memory can be elicited by suggesting false events to the patient who may agree and elaborate. A “Good morning, Mr. Jones. How did you like that party last night? … And how about thE steak we had for breakfast?” can often lead you and the patient down the garden path of confabulation. Confabulation, then, is a most dramatic example of false or ———————–

Confabulated memory is most frequently observed in Korsakoff’s encephalopathy. Fantastic confabulations in which patients relate trips to other planets, flying sans plane across the country, etc.,

is similar to obviously false tall tales and is associated with cortical atrophy in the frontal lobe (69), but can occur in mania, sociopathy and normal children. I assume the last from anecdotal observation, and conclude that confabulation is either normal in children or that my younger son, age six at this writing, is a chronic alcoholic.

Write a sentence describing confabulated memory.

There is a common form of falsification of memory in which an individual feels he has experienced an event before. This is given the French term deja vu (already seen). Jarnais vu (never seen) is another French term for the rarer experience of not recognizing a famili9.r situation. When pathological, deja vu and jamais vu are often related to psychomotor states (15,23). They can also be ob- served in toxic states and some sociopaths ( 65). What is the term for each of the following experiences?

A patient stated that she returned home from work to find that she was “unfamiliar” with her apartment, furniture and personal belong- ings. “I knew it was crazy but I felt as if I had never been there before.”

A patient said that during the past few weeks, several times each day she would experience the overwhelming sensation that what was happening at that moment had happened before.

168

420. pseudo

421.

422.

423.

424.

memory

pseudomemories

Confabulation is the falsification of memory in response to the ques- tions of others.

A patient stated that she returned home from work to find that she was “unfamiliar” with her apartment, furniture and personal belongings. “I knew it was crazy, but I felt as

if I had never been there before.”

A patient said that during the past few weeks, several times each day she would experience the overwhelm- ing sensation that what was happen- ing at that moment had happened before.

Jamais vu

Deja vu

169

425.

Draw lines between matching items in the two columns

426.

427.

428.

Draw lines between matching items in the two columns:

429.

Label each item with the appropriate phenomenologic term. In- dicate with an X which items or patient responses you feel are not normal or reflect illness.

Oneroid state Anterograde amnesia Depersonalization

Amnesia for events following a truum

Clouded, dream-like state

Clear sensorium but detached from self

Pseudomemory Retrograde amnesia

Amnesia for events prior to trauma

False memories associated with apo- phanous ideas

Falsification of memories, often fan- tastic which can be stimulated by examiner’s questions

Confabulation

Draw lines between matching items in the two columns:

Deja vu Jamais vu

Anterograde amnesia Retrograde amnesia

Permanent though circumscribed memory loss

Unfamiliar events experienced as familiar

Amnesia for events prior to trauma

Familiar events experienced as un- familiar

Label each clinical item with the appropriate phenomenologic term. Indicate with an X which items or patient responses you feel are not normal or reflect illness.

When asked to repeat 5 1 0 9, a young woman said, “6 9 5 1.” When asked

to subtract sevens from 100 (after a demonstrated twos from 100) , she said: “100, 93, 89, 87, 65, 58.11 Be- cause of this response, the examiner

did not test —————– The patient complained of feeling “funny,” as if in a dream-like state, as if surrounded by a fog or haze.

Testing for:

When asked to repeat 6 1 0 9 8, a youngmansaid”61098.” He completed serial sevens in 45 seconds.

He was next asked to remember: Blue, chair, swim, glove, and as instructed, repeated them to the examiner. Five minutes later, when asked to repeat the words, he said, “Blue, glove, chair, swim.”

Testing: Testing:

Testing: Testing:

170

425.Oneroidstate~Amnesiaforeventsfollowingatrauma Anterograde amnesia Clouded, dream-like state Depersonalization——Clear sensorium but detached from

426.

Pseudomemory~Amnesia for events prior to trauma Retrograde amnesia False memories associated with apo-

427.

Deja vu Jamais vu

Permanent though circumscribed mem- ory loss

428.

When asked to repeat 5 1 0 9,

a young woman said, “6 9 5 1.” When asked to subtract sevens from 100 (after a demonstrated twos from 100), she said: “100, 93, 89, 87, 65, 58. 11 Because

of this response, the examiner did not test memorY.

X

X

The patient complained of feeling “funny,” as if in a dream-like state, as if surrounded by a

fog or haze.

Oneroid state

429.

When asked to repeat 6 1 0 9 8, ayoungmansaid”61098.” He completed serial sevens in 45 seconds.

Testing: Concentration

Confabulation ——–Falsification of memories, often fan- tastic which can be stimulated by

Retrograde amnesia

Familiar events experienced as unfa- miliar

He was next asked to remember: Blue, chair, swim, glove, and as instructed, repeated them to the examiner. Five minutes later, when asked to repeat the words, he said, “Blue, glove, chair, swim.”

Testing: Immediate recall

171

self

phanous ideas

examiner’s questions

Unfamiliar events experienced as fa- miliar

Amnesia for events prior to trauma

Testing for: Concentration

Testing: Memory

Testing: Short-term memory

430.

Label each item with the appropriate phenomenologic term. To a patient who has been hospitalized for a week:

Dr.: “Good morning, Mr. Caldwell. You look like you’re feeling a little better this morning.”

Pt.: “I’m just great, Doc.”

Dr.: “It must have been that party last night. Did you like the punch?”

Pt.: “Ha, you ain’t kiddin’, it was really good…But I only took a sip , Doc. I don’t drink much you know. ”

Dr. : “I understand. By the way, did they give you the steak for breakfast?”

Pt.: “Sure did … lot of other stuff, too. They’re treatin’ me real nice here.”

A man with a bandage on his forehead said: “What happened? You say today’s Friday? The last thing I remember it was Monday and

I was in the car.”

Label each item with the appropriate phenomenologic term:

“I can’t explain it. I know it’s impossible. But I can’t get away from the feeling that things that are happening to me have all happened before. It’s all familiar.”

“I remember the accident and falling. But I don’t remember what happened just before the accident. I know I was talking, but I don’t remember anything else, not even who I was talking to. ”

“I’ve been everywhere. Why the other day I took a space-ship to Venus. It was extremely hot there. Then I came back here and began building a new skyscraper in the city. Actually I’ve built most of the big buildings in the city.”

431.

172

430. confabulation

anterograde amnesia (since he doesn’t remember the accident, he

431. deja vu

retrograde amnesia

fantastic confabulation

also has retrograde amnesia)

173

PARIETAL LOBE FUNCTION

432. 433.

In most individuals, the dominant parietal lobe is on the

434.

A person who has severe difficulties with verbal or symbolic abilities related to spatial orientation or categorization may have dysfunction in the ______________________

435. 436.

A person who has severe difficulties with non-verbal motor per- ceptual tasks may have dysfunction in the ———–

437. 438.

Disorientation to time, place and grossly suggests frontal lobe dysfunction. Right-left suggests brain dysfunction in the dominant parietal lobe (21,26,34,54).

In general, the left or parietal lobe controls verbal or symbolic abilities related to spatial orientation and categorization while the right or parietal lobe controls non-verbal motor-perceptual abilities ( 21,47 pp. 147-168).

Many psychiatric patients, although oriented to place, are dis- oriented to right and left, and/or their body parts (11). A com- plete mental status examination will include questioning about this cortical function. Any good history will include questions about

the patients’ general health and “somatic” complaints. Ask the pa- tient about weakness, particularly in the arms and legs. The state- ments “Hold out your right arm,” “Show me your left hand” become natural. They maintain the doctor-patient relationship while testing for right-left _________

The patient should also be asked to place his hand to the oppo- site ear or elbow. Several trials should be required involving dif- ferent contralateral body parts. This is a test of

disorientation and thus dominant lo,…b-e—–,.fu-n-c””ti'””o-n-.–

174

432. left

433. dominant , non-dominant

434. left (dominant) parietal lobe

435. right (non-dominant) parietal lobe

436. orientation

437. person, disorientation 438. right-left, parietal

175

439.

When told “Place your left hand on your right ear” a patient hesi tated, looked at both his hands, turned them over several times,

and then with great hesitation placed his left hand on his right ear. This is a mild form of disorientation suggestive of ________________ lobe dysfunction.

440.

Following testing of orientation to body parts and right-left ori- entation a patient should be asked to name each finger of each hand. Failure to accomplish this like right-left disorientation suggests _________________ lobe dysfunction.

441.

Inability to properly identify one’s fingers is called finger ag- nosia and suggests dysfunction in the dominant

,———,–,–..-=-~ (21,26,38,54,68). Psychotic patients often ( 11)

442.

In testing the inability to recognize and name one’s fingers, termed the examiner should first point to each finger and require the patient to name each. This can be followed by holding up your hand and asking the patient to show

you your index finger, ring finger, etc. If there is any doubt abou1 the patient’s responses, the fingers should be numbered, the patient

443.

An examiner pointed to a patient’s fingers one at a time and asked: “What do you call this one?” Beginning with the right thumt the patient responded:

444.

Circle those words or phrases suggestive of dominant parietal lobe dysfunction.

445.

When asked to identify the fingers on his right hand, a patient said “thumb…finger next to thumb…large finger…index finger

have difficulties in naming their fingers.

instructed as to the number of each finger and the tests repeated with the correct number for each finger being the required response

“Thumb … straight finger … middle systems finger … index and outer or end finger.”

This is an example of finger and suggests dysfunction in the dominant ———-

Unable to do serial 7’s

Difficulty in identifying one’s fingers

Difficulty in identifying upside-down objects Difficulty with symbolic categorization

Difficulty with non-verbal motor-perceptual abilities Difficulty in knowing right from left

… smaller index finger.” If this patient has a localized brain lesion, is he likely to do well on tests of right-left orientation?

Is he likely to do well on tests of symbolic or language categorTza— tion? Is he likely to do well on tests of non-verbal motor-percep- tual?- Where is this patient’s lesion likely to be?_ _ _ _ _ __

176

439.

right-left, dominant parietal

440.

441.

442.

443.

444.

dominant parietal

parietal lobe

finger agnosia

agnosia, parietal lobe

Unable to do serial 7’s

Difficulty in identifying one’s fingers

Difficulty in identifying upside-down objects Difficulty with symbolic categorization

Difficulty with non-verbal motor-perceptual abilities

@fficulty in knowing right from lefy no, no, yes, dominant parietal lobe

445.

177

446.

Patients with significant brain dysfunction often have difficulty performing simple motor behaviors even though they have no sen- sory loss, paralysis or muscle weakness. These difficulties are called apraxias. Some apraxias suggest dysfunction in the dominant parietal lobe (16,21,24,25,27,28). What other cognitive difficulties suggest dysfunction in the dominant parietal lobe?

447.

If persons cannot perform simple motor tasks even though they have no sensory loss, paralysis or muscle weakness, they are said

448. 449. 450.

to have ——————-

If a person cannot identify his fingers he is said to have

451.

The inability to demonstrate the use of simple objects such as a key or a hammer is termed an ideomotor apraxia. Many patients with ideomotor apraxia have dominant parietal lobe dysfunction. What other cognitive deficits can be observed in patients with dysfunc- tion in this cortical region?

452.

When asked: “Show me how you would: throw a ball; hammer

a nail; flip a coin; use a key; 11 a patient without sensory deficit or motor weakness was unable to follow the commands although she un- derstood them. This inability to demonstrate the use of simple ob-

453.

In most instances when a patient has difficulty demonstrating the use of objects with both hands and there is no sensory/motor loss the dysfunction is in the dominant (16,21,24, 25). Bilateral (right and left hand) ideomotor apraxia can also re- sult from lesions in fibers running between the dominant temporo- parietal area and the frontal lobe ( 28, 30).

454.

When asked to demonstrate the use of a key, a patient could

only do so by extending his index finger as if it were the key. This is called body-part as object and is a manifestation of ___________ apraxia.

455.

When asked to demonstrate the use of a key, a hammer, and how to flip a coin, a patient was able to do so only when first saying what he was going to do, i.e. “I take the key like this and put it into the lock. Then I turn it this way.” Despite instructions to the contrary, the patient could not demonstrate the use of simple objects without describing what he was going to do. This is called “verbal overflow” and, as “body part as object”, is a manifestation of

Non-recognition (or inability to identify) is an ____________ Non-performance without motor sensory deficit is an _________

Some patients without sensory or motor deficits cannot demon- strate (without props) the use of simple objects (a hammer, a key, flipping a coin, using a straw, blowing out a candle). This inabil- ity is a special form of——————-

jects is —————-

——————- apraxia.

178

446. finger agnosia, right/left disorientation, difficulty with symbolic or language categorization

447. apraxia

448. finger agnosia

449. agnosia, apraxia

450. apraxia

451. finger agnosia, right/left disorientation

difficulty with symbolic or language categorization

452. ideomotor apraxia

453. parietal lobe

454. ideomotor

455. ideomotor

179

456.

457.

458.

459.

460.

461.

When asked to demonstrate the flipping of a coin, a patient with- out sensory or motor deficit mimicked a movement with open palm,

his hand going up and down without flipping his thumb against his index finger. Even when asked to do so, he was unable to flip his thumb against his index finger. This dysfunction suggests a lesion in the hemisphere usually the parietal lobe but also among the fibers running between the parietal and frontal lobes.

When asked to demonstrate the hammering of a nail, a patient without sensory or motor deficit did so by raising and lowering his arm without any wrist movement. When asked to demonstrate the use of a key he did so by sticking out his index finger as the key. This latter performance termed and the lack of wrist movement while demonstrating the use of a hammer, are

examples o f – – – – – – – – – – – – – – – – – – – – –

Write a sentence or two defining or describing the following:

Verbal overflow: Body part as object: Ideomotor apraxia:

Some patients will have ideomotor apraxia of only one hand, usu- ally the left. Often, this is associated with a type of language dis-

order we will learn about later in the program. This unilateral ideo- motor apraxia of the left hand is due to a lesion or dysfunction in the left frontal lobe ( 30) which prevents the information required

to perform the task with the left hand from crossing over into the right hemisphere which regulates movement on the left side.

Ideomotor apraxia of only the left hand suggests a lesion in the

here would prevent information

from crossing over into the other hemisphere.

Ideomotor apraxia of both hands (bilateral) can be due to ale- sion in the fibers connecting the dominant temporo-parietal region to the dominant frontal lobe or, more commonly due to a lesion in the ________

180

re_q_u~i_r_e__,d-:-to_p_e_r’f’o-rm

because a lesion

a motor task

456.

dominant (left)

457.

body part as object ideomotor apraxia

458.

Verbal overflow: The inability to demonstrate the use of simple ob- jects without describing the movements. A form

459.

No answer required

460.

dominant (left) frontal lobe

461.

dominant (left) parietal lobe

of ideomotor apraxia.

Body part as object: The use of a body part, such as a finger, as the object to be demonstrated. A form of

ideomotor apraxia.

Ideomotor apraxia: The inability to demonstrate the use of simple objects despite no sensory or motor deficit.

181

462.

Identify the site of the lesion:

463.

Draw lines between matching items in the two columns:

464.

Patients with parietal lobe dysfunction (particularly in the pos- terior area), may have trouble copying the examiner’s movements (25 47 pp. 147-168). They cannot regulate their body parts in space. Ask your patient to do what you do.

The patient demonstrates finger agnosia, body part as object, verbal overflow, right/left disorientation

The patient demonstrates body part as object in the left hand only, verbal overflow with the left hand only, flips an imaginary coin with an open palm with the left hand only, uses an imaginary hammer without moving his wrist, left hand only

The patient demonstrates good right/left orientation, good finger recognition, bilateral ideomotor apraxia

Unable to demonstrate the use of simple objects despite normal motor strength

Right dominant hemisphere

Unable to name own fingers

Ideomotor apraxia Finger agnosia

Writes name with right hand above line of writing

Writes name with right hand below line of writing

Left dominant hemisphere

1. Right arm extended; 2. then bend arm, hand open, arm raised; 3. then hand closed in a fist. Repeat with left arm (see below).

Inability to copy these simple movements despite normal sensory and motor function indicates parietal lobe dysfunction opposite (contra- lateral) to the arm-hand having difficulty and is a form of _ _ _ _

182

462. dominant (left) parietal lobe

dominant (left) frontal lobe

fibers between dominant temporo-parietal region and frontal lobe

463. Unable to demonstrate the ~Right dominant hemisphere use of simple objects despite

normal motor strength

Unable to name own fingers Ideomotor apraxia

Writes name with right hand Finger agnosia above the line of writing

Writes name with right h a n d – – – Left dominant hemisphere below line of writing

464. apraxia

183

465.

466.

Inability to demonstrate without props the use of simple objects despite normal sensory and motor function is termed

The inability to copy simple movements despite norma’l_s_e_n_s_o_r_y-an—.d

motor function is termed a movement or kinesthetic apraxia.

Identify the site of the dysfunction:

Cannot copy examiner’s hand

and arm movements with right hand, poor verbal categorization, right/left disorientation

Kinesthetic apraxia of right hand, ideomotor apraxia of both hands, finger agnosia of both hands, right/left disorientation

Bilateral ideomotor apraxia, good finger identification, no kinesthetic apraxia, good right/left orientation

Left hand ideomotor apraxia, no kinesthetic apraxia, good right /left orientation, good finger identification

Psychiatric patients often have difficulties copying the outline of simple figures, even though they have no motor weakness and understand the task ( 73, 75). This is called a construction apraxia. When a patient cannot demonstrate the use of a simple object even though he has no motor weakness, this is called an _ _ _ _ _ __ apraxia.

Ideomotor apraxia is a sign of ~~——,- ~–,,.—–· Construction apraxia is a dysfunction in non-verbal motor-percep- tual organization and is therefore a sign of dysfunction in the ——– (10,21,47 pp. 147-168).

467.

468.

469.

Inability to copy the outline of simple figures, termed—,– can be tested by asking the patient to copy sim-

p:-:-‘le,—–,fccig–:u:–r–ce-s-s-u-ch,—-as a square, a cross and a triangle ( 73, 75). When you ask a patient to copy one of the figures say, “I’m going to ask you to copy something. This is not a drawing test, but I’d like you to try your best. Just draw the outline of the picture and once

you start, don’t take your pencil off the paper. !\lake your copy a bit bigger than the picture and place it in the middle of the paper.” Use a different piece of paper for each drawing.

184

465.

ideomotor apraxia

466.

left parietal lobe

left parietal lobe

fibers between dominant (temporo-parietal region and dominant fron

467.

ideomotor

468.

dominant parietal lobe dysfunction (occasionally frontal and fiber tracts between lobes), non-dominant parietal lobe

469.

construction apraxia

tal lobe)

dominant frontal lobe

185

470.

When asked to copy the square, cross and triangle pictured on the left, aDpatient draws figures depicted on the right.

0

D

471.

472.

Place an F for frontal, D-Pfor dominant parietal and N-Pfor non- dominant parietal, next to the appropriate items: –

Construction apraxia Right/left disorientation Finger agnosia Ideomotor apraxia Echopraxia

Identify the example of cortical dysfunction and give localization: Unable to copy a cross

Unable to recognize and name fingers

Unable to copy examiner’s hand and arm movements

Unable to keep from copying examiner’s arm movements

Unable to demonstrate the use of a key with either hand

186

D

~

470.

construction apraxia, non-dominant parietal

471.

472.

Construction apraxia N-P Right/left disorientation D-P Finger agnosia D-P Ideomotor apraxia D-P Echopraxia F

Unable to copy a cross

Unable to recognize and name fingers

Unable to copy examiner’s hand and arm movements

Construction apraxia, non-dominant parietal lobe

Finger agnosia, dominant parietal lobe Apraxia, contralateral parietal lobe

Unable to keep from copying Echopraxia, frontal lobe examiner’s arm movements

Unable to demonstrate the Ideomotor apraxia, dominant parietal use of a key with either lobe

hand

187

473.

474. 475.

476.

477.

A person’s awareness of right and left and the ability to recog- nize and name his body parts is located in the —–;-~c—-:oc–­

. This brain area is also the locale for the abil”‘””‘it,…y—:-to-c-a”‘””lc-u’l-a.,…te—-,(“”21, 26,47 pp. 147-168, 54).

Inability to do simple math (to calculate) is called acalculia and results from dysfunction in the _______________

In testing for inability to do simple math, termed

first ask the patient to write a series of numbers like:-..-7-,’9’,—,.3-,’5=-“, 7,nextaskthepatient”Howmuchis”: 3×3;5×4;7-4;8-5; 3 + 4; 6 + 7; or similar problems. Inability to do this task is indic- ative of ___________

Many patients are able to do very simple math problems but are unable to do problems requiring “carrying” or “borrowing” numbers. To test for this ask the patient to: add 27 + 8; 44 + 57; subtract

31 – 7; 41 – 14; or problems of similar complexity. Inability to do these problems while solving simpler ones like 3 x 3, 7 – 4, indicat- ed dyscalculia. Dyscalculia or the more severe acalculia is a dys- function of the ____________________

Place a check in the box which best matches the dysfunction with the related brain ~’egion:

Dysfunction

Acalculia

Ideomotor apraxic:\

Pinger agnosia

Echopraxia

Poor concen- tration

Construction apraxia

Global dis- orientation

Frontal lobe

Dominant Parietal

Non- Dominant Parietal

188

473. dominant parietal lobe

474. dominant parietal lobe

475. acalculia, acalculia

476. dominant parietal lobe

477.

Dysfunction Frontal Lobe

Acalculia

Ideomotor apraxia /(left hand only)

Finger agnosia

Echopraxia

Poor concen- tration

Construction apraxia

Global disorienta- tion

Dominant Parietal

.;

/Bilateral

/

Non-Dominant Parietal

.;

.; .;

/

189

478. Place a check in the box which best matches the dysfunction

with the related brain region·

Non-Dominant Parietal

Dysfunction

Poor abstract thinking

Can’t copy a cross

Can’t do serial 7’s

Can’t demon- strate use of simple objects

:::an’t do simple math

Can’t keep from mimicking exa- miner’s move- ments

Can’t name fingers

Doesn’t know right from left

Frontal lobe

Dominant Parietal

479.

480. 481. 482.

The dominant parietal lobe is the way station between visual perception and language; thus reading and writing as well as mathe- matical abilities are located in this brain region (21,28,47 pp. 147- 168). List all of the functions you have learned including those mentioned above, associated with the dominant parietal lobe.

Inability to write or difficulty writing is termed agraphia or dys- graphia (the less severe form). Inability to calculate or difficulty calculating is termed o r———

Inability to read or difficulty reading is termed alexia or dys- lexia (the less severe form). Inability to write is termed ____or——–

When you test for reading difficulties termed

or ask the patient to read aloud sim—,p’le_s_e–,n”‘””‘t,–e_n_c,-e_s_

and then do what it says. For example, “Put this paper in your pocket.” Any error should be considered pathological and warrants further evaluation. Proper testing of reading and comprehension requires more elaborate standardized tests.

190

478.

Dysfunction

Poor abstract t h i n kin~~:

Can’t copy a cross

Can’t do serial 7’s

Can’t do simple math

Can’t keep from mimicking exa- miner’s move- ments

Can’t name

fin~~:ers

Doesn’t know ri~~:ht from left

Can’t demon- strate use of simple objects

Frontal Lobe

I I

I

,I (left hand only)

Dominant Parietal

I

I I

/Bilateral

Non- Dominant Parietal

I

479. calculations, writing, reading, recognizing and naming body parts, right/left orientation, regulation of contralateral body parts in space, kinesthetic practic function, motor programs for using simple objects (ideomotor practic function)

480. acalculia, dyscalculia

481. agraphia, dysgraphia 482. alexia, dyslexia

191

483.

484.

485.

When you test for writing difficulties termed “””7.””~—–,-,——,.-: ask the patient to copy a simple sentence such as “John went to the store for a loaf of bread.” Inability to write words or to write in script (loss of that ability) should be considered pathological and warrants further evaluation.

The final dominant parietal lobe function we will consider in this section is recognition and naming of relationships, or categorization (47 pp. 147-168). Ask the patient to identify the following individ- uals:

“Your father’s brother” “Your brother’s father”

Try it yourself! Inability to properly recognize the relationships suggests dysfunction in the dominant parietal lobe.

Place a check in the box which best matches the dysfunction

with the related brain region:

Non-Dominant Parietal

Dysfunction

Acalculia

Poor concentration

Construction apraxia

Agraphia

Ideomotor apraxia

Echopraxia

Can’t do similar- ities

Finger agnosia

Can’t define rela- tionships

Dyslexia

Can’t identify upside-down objects

Can’t copy exa- miner’s hand positions, both hands

Can’t do serial 7’s

Frontal Lobe

Dominant Parietal

192

483. agraphia, or dysgraphia

484. my uncle, my father

485

Dysfunction

Acalculia

Poor concentration

Construction apraxia

Agraphia

Ideomotor apraxia

Echopraxia

Can’t do simila- rities

Finger agnosia

Can’t define re- lationships

Dyslexia

Can’t identify upside-down objects

Can’t copy exa- miner’s hand positions, both hands

Can’t do serial 7’s

Frontal Lobe

I

I(left hand only) I

Dominant Parietal

I

I

/(Bilateral)

I

I I

Non-Dominant Parietal

I

I

I

I

I I

193

LANGUAGE DISORDER

486.

Since thought process is inferred from a person’s speech, when we describe “thought disorder” we are really describing language and/or speech disorder. There are numerous schema for classifying language disorder and the following brief integration with “thought disorder” will utilize the classification described by Jason Brown

(17 ).

487.

You have previously learned that many psychiatric terms have their neurological equivalent. Thus, the psychiatric term drivelling speech, where the syntax is intact but the meaning is lost, is called by the neurologist and stereotyped repetitive speech is called by the psychiatrist and by the neurologist.

488.

Schema of language disorder are based upon the functional type of the disorder and/or its “localizing” value. Whatever system is used, it is rare for a patient to have a pure form. In psychiatric patients with major mental illness, complex forms of language dys- function indicating widespread cerebral dysfunction is the rule rather than the exception. Thus, the use of new words termed

489.

The language schema we will use separates language into poster- ior (temporo-parietal) and anterior (frontal) systems. As both deal with symbolic function, the language system is in the – – – – – – – hemisphere, usually the ——–

490. 491.

The hemisphere is dominant in better than percent of the general population.

is often observed with the use of substitute words t:-e_r_m_e_d-;— . Both are forms of para-

phasic speech .

The organization of language in the left hemisphere can be

separated into and

systems.

194

486. No answer required

487. jargon agrammatism, verbigeration, palilalia

488. neologisms, word approximations

489. dominant, left

490. left, 97

491. posterior, anterior

195

492. 493. 494. 495.

The posterior language system relates to the left temporo-parieta brain region. The language system relates to the left frontal lobe.

496.

Wernicl<e’s language disorder or Wernicke’s

suggests dysfunction in the posterior language s-y-st.,…e-m-.—-;;T'”‘h,.,…is_r_e–

497.

The posterior language system involves disorder described as semantic, nominal and phonemic. This type of language disorder

498. 499.

The posterior language system involves disorder described as _________, and _________

500.

Match the words or phrases in the two columns:

501.

Drivelling speech, word approximations, derailment, non-sequi- tive speech, are all examples of ———,– language disorder and suggests dysfunction in the brain regions of the

502.

Nominal disorder refers to a deficit in naming objects (nominal aphasia) and a deficit in the use of nouns so that speech is often “empty” and “circumlocutory.” In contrast, when the meaning of speech is lost we use the term disorder.

The posterior language system is localized in the posterior tempo roparietal brain regions of the cerebral hemisphere. In most individuals, this is located on the _ _ _ _ _ _ _

The posterior language system relates to the brain regions. This system is functionally separated into semantic, no- minal and phonemic language functions.

The left temporo-parietal brain region includes an area termed Wernicke’s area. Language disorders from this region are sometimes termed Wernicke’s language disorder or more properly Wernicke’s aphasia. Wernicke’s aphasia indicates dysfunction in the

_____ language system. —-

lates to the brain regions in the ——— hemisphere.

is localized in the brain regions of the hemisphere.

– – – – –

Semantic disorder refers to dysfunction of the meaning of speech It includes jargon agrammatism or the psychiatric term

nonsequitive speech, semantic paraphasia (word substit.-:u-:t”io=n’)-oc::-r::-

and speech where associ- ations suddenly skip–t.,-o_a_n_e_w_a_n_d-::–o”””f::-te-n-paralleled topic. This

last form is given the psychiatric term ————

Drivelling speech Derailment

Semantic paraphasia (word substitution

Word approximation Non-sequitur

Responses unrelated to questions

——- hemisphere.

196

Meaning of speech is broken followed by a new train of thought

Syntax is retained but meaning of speech is lost.

492. 493. 494. 495.

496.

497.

498. 499.

500.

501.

502.

anterior dominant, left

temporo-parietal posterior

aphasia, temporo-parietal, left (dominant)

temporo-parietal, left (dominant)

semantic, normal, phonemic

drivelling, word approximations, derailment

Drivellings~eechSemanticparaphasia(wordsubstitution)

Derailment

Word approximation Non-sequitur

semantic temporo-parietal left (dominant)

semantic

Meaning of speech is broken followed by a new train of thought

Responses unrelated to questions

Syntax is retained but meaning of speech is lost.

197

503. 504.

505. 506.

507. 508.

509.

510.

511. 512. 513.

“Empty” and “circumlocutory” speech with a deficit in the use of nouns suggests language disorder.

Word approximations less severe than the semantic type, a:; weir as inability to name objects, is observed in language disorder.

Inability to name objects is termed anomia. It is a form of _ _ _ _ _ _ _ language disorder.

Place an S next to the word or phrase suggestive of semantic language disorder and an Nnext to the word or phrase suggestive of nominal language disorder.

Drivelling speech Anomia

Circumlocutory speech

Derailment

Jargon agrammatism Non-sequitive speech

Anomia and “empty” speech suggest language dis- order. Drivelling and derailment sugges.,-t______ language

disorder.

Phomenic language disorder along with nominal and semantic language disorder functionally represent the ~::-::-p-:,.,–:—-‘language system located in the brain regions of the _ _ _ _ _ hemisphere.

Phonemic language disorder refers to a deficit in the use of sounds to make spoken language. Associations by sound rather tha: meaning, termed and new words, termed , produced because the sounds have been altered are observed in this form of language disorder.

Match the words or phrases in the two columns:

Semantic aphasis Nominal aphasia

Phonemic aphasia

Neologisms, clang associations

Drivelling, derailment, non-sequitive speech

Anomia, loss of use of nouns

Wernicke’s aphasia, also termed fluent/receptive/sensory apha- sia, is for our purpose equivalent to posterior aphasia which in- cludes: types.

Fluent, receptive or sensory aphasia are terms equivalent to Wernicke’s aphasia and suggest dysfunction in the

brain region. ——-

If a man is unable to speak with meaning, uses “circumlocutory, empty” speech and an occasional new word, he most likely has dys- function in his brain region. The terms for this group of aphasias are Wernicke’s aphasia, _ _ _ _ _

———–‘ and _________

198

503. nominal 504. nominal

505. nominal

506. Drivelling speech S Derailment S

Anomia N – – Jargon agrammatism S Circumlocutory speech N Non-sequitur speech S

507. nominal, semantic

508. posterior, temporo-parietal, left

509. clang associations, neologisms

510. Semantic aphasixN eologism s, clang associations

Nominal aphasia Drivelling, derailment, non-sequitive speech

Phonemic aphasia Anomia, loss of use of nouns

511. semantic, nominal, phonemic

512. temporo-parietal

513. dominant temporo-parietal, fluent, receptive, sensory

199

514.

Which of the following statements about posterior language dis- order is incorrect?

515.

516. 517.

518.

519.

520.

521.

522.

523.

Paraphasias: word approximations, neologisms, jargon agram- matisms (drivelling speech) are characteristic of

lan-g,–u_a_g-:-e,–,–d”i~s-o-,-r~d’e-,r.,—.

Sensory aphasia or _ _ _ _ _ _ _ aphasia results from dysfunc- tion in the areas.

The best clinical “test” of language ability requires careful list- ening to how the patient is speaking. Once again, you must focus upon not _________

If a patient refers to a pen as “a writer,” a key as “a lock or opener” a watch as “a timer,” a comb as “you know, to fix your hair with,” he is using word The presence of these paraphasias indicates dysfunction in brain areas and dysfunction of the posterior language system. Which of the subtypes of the posterior system does the above example best fit?

Word approximations, neologisms, tangential speech (talking

past the point), drivelling (jargon agrammatisms) are all observed

in patients with demonstrable lesions in the dominant posterior tern-

a. b. c. d.

Posterior language disorder correlates with dysfunction in the dominant temporo-parietal brain regions.

Posterior language disorder incompasses the terms: Wernicke’s aphasia, receptive aphasia, sensory aphasia, fluent aphasia.

Posterior language disorder includes the subtypes semantic, nominal, phonemic.

Phonemic disorder refers to the meaning of speech whereas no- minal disorder refers to the use of proper nouns.

aphasia, a term equivalent to

poro-parietal brain area. Encompassing terms for these disorders

are _______, or _______

apha-s~i-a-.———

As part of a language evaluation, ask each patient to name sim- ple objects such as a pen, a watch, a key, a comb and then the smaller parts of these objects (e.g., penpoint, watchband). Inabil- ity to name objects or parts of objects is termed ________

Anomia is associated with Wernicke’s aphasia and thus indicates

dysfunction in the~——–,——–,-·

Another term for this language dysfunction is

Inability to understand spoken words, termed word deafness,

as is the inability to name simple objects, termed

are indications of aphasia and su_g_g_e_s7t-d’y-s”fc-uc-n-c–,t–.’ion

in the brain region.

A test of posterior language function is also a partial test of

_____ aphasia.

function in the

brain region.

200

514. d. Phonemic disorder refers to the sound of speech.

515.

516. 517.

518.

519.

520.

521.

Wernicke’s, posterior

Wernicke’s (receptive, fluent), dominant temporal/temporo-parietrl form, content

approximations, dominant temporo-parietal, nominal

Wernicke’s, fluent, receptive, sensory

anomia

dominant temporo-parietal brain regions, posterior, nominal

522. anomia, nominal, dominant temporo-parietal

523. dominant temporo-parietal

201

524.

The terms Wernicke’s.! fluent, sensory or receptive aphasia refe to posterior language disorder which can be further divided into

525. 526.

An individual who exhibits jargon speech, anomia or neologisms has dysfunction in the Anterior language disorder suggests dysfunction in the ——– ——–

527.

Patients with anterior language disorder often speak in a “tele- graphic” pattern in which small words and word endings are elimi-

528.

During an examination, a patient was unable to speak fluently. Her speech was dysrhythmic and slow and she had great difficulty in “getting words out.” When she did speak, her speech was “tele- graphic.” This speech pattern is characteristic of – – – – – – = , . language disorder and suggests a lesion in the The term for this pattern is Broca’s aphasia.

529.

Anterior language disorder frequently results in a reduction in the amount of fluency of speech. This non-fluent aphasia, also termed aphasia, can take the form of uncontrolled auto- matic repetition of syllables in the middle of and at the end of words or phrases. The psychiatric term for this anterior language dis- order is . Its equivalent neurologic term is

530.

Circle the words or phrases which best describe Broca’s aphasia

, ,and . Anterior i-=-a=n-=g-=u::-:a=-g”‘”e=–=d”‘i'”=s-=-o·rder which relates to dysfunction in the dominant fran· tal lobe can also be separated into subtypes.

Patients with anterior language disorder often have difficulty

in articulation. Their speech is slow, labored and distorted in rhythm and pronunciation. A patient with this speech pattern may have dysfunction in the __________________

nated from the flow of speech. Patients with anterior language dif- ficulties will have trouble with the fluency of their speech and in repeating spoken speech. What are some other characteristic speech patterns of patients with dominant frontal lobe dysfunction?

Speech is fluent

Poor articulation of words Neologisms

Speech is non-fluent Word approximations Labored speech Jargon agrammatism

Small words and word endings missing

202

524. semantic, nominal, phonemic

525. 526.

dominant temporo-parietal region, dominant frontal lobe dominant frontal lobe

527.

slow, labored speech, difficulty in articulation, distortion in rhythm and pronunciation.

528.

anterior, dominant frontal lobe

529.

Broca’s, verbigeration , palilalia

530.

Speech is fluent (speech is non-fluent) (Poor articulation of wor!iS}word approximations

Neologisms (!.abored speeiii)

Small words and word Jargon agrammatism endin s missin

203

531. 532. 533. 534.

Often, motor aphasia is a term used interchangably with Broca’s aphasia. Is motor aphasia fluent or non-fluent?———

535.

Psychiatric patients rarely have classical Broca’s aphasia; how- ever, patients with intoxications or chronic brain syndromes will often exhibit motor speech dysfunction ( 9, 16). This can be tested by asking the patient to repeat phrases such as: “No ifs, ands or buts,” “Methodist Episcopal,” “Massachusetts Avenue.” Patients with anterior language dysfunction will have difficulty with the above phrases often leaving out a word or two: “No ifs or buts,” m the endings of words: “No if an buts,” or adding syllables that

don’t belong: “Methodist Episcacapal.” Difficulties in repetition such as the above, suggest dysfunction in the inferior, posterior area of the _____________________

536.

Non-fluent aphasia can present with poverty of speech to the point of mutism. General motor behavior can also be reduced in frequency. This speech “arrest” disorder, as Broca’s aphasia, is a form of anterior language disorder and thus can result from dys- function in the ——

537.

The combination of paucity of speech with Broca’s type respon- ses can also be observed in patients with bilateral frontal lobe dys- function. This presentation has been termed transcortical motor aphasia and, as Broca’s ~phasia, is a form o f———- ———— (9,16,17).

538.

Place an A next to those words and phrases indicative of ante- rior languagedisorder and a ~next to those words and phrases in-

Broca’s aphasia, also termed motor aphasia, results from dys- function in the —–

Broca’s aphasia, also termed motor aphasia, is language disordeJ in the language system.

Broca’s area is located in the posterior, inferior region of the outside surface (lateral) of the dominant frontal lobe ( 16, 17). Des- cribe the speech pattern of this aphasia.

dicative of posterior language disorder.

Motor aphasia Receptive aphasia Non-fluent aphasia Wernicke’s aphasia Nominal aphasia Phonemic aphasia

Sensory aphasia

Fluent aphasia Transcortical motor aphasia Broca’s aphasia

Speech arrest

Semantic aphasia

204

531. 532. 533. 534.

535.

non-fluent

dominant frontal lobe

anterior

slow, labored, poor articulation, loss of small words and word end- ings, telegraphic, non-fluent

536.

537.

538.

dominant frontal lobe

anterior language disorder

Motor aphasia A Receptive aphasia P Non-fluent aphasia-A Wernicke’s aphasia P Nominal aphasia P – Phonemic aphasia~

Sensory aphasia P

Fluent aphasia P – Transcortical motor aphasia A Broca’s aphasia A – Speech arrest A –

Semantic aphas1a ~

dominant frontal lobe

205

539.

In the space provided, write all the terms that describe each example of language disorder.

540.

In the space provided, write all the terms that describe each example of language disorder:

541.

The relationships between the dominant frontal, temporal, and parietal lobes in the organization of verbal or symbolic function are extremely complex. Disconnections between areas and combination lesions can lead to a variety of syndromes ( 28,30 ) . This material is beyond the scope of this text.

“I couldn’t rerubish it”

“Not happy … not content …not satisfied here… home”

“It could always be, but I’m not the indicator that one would need to require it •II

111.•••o .1.••o o.II

“It’s episodada…da …da.•.cal”

“It’s a door-turner, a twister, a door mover-on.”

“Open door…in open door … street.”

“….Harold go….car….”

“The rotarator tribbled its output.”

“I can’t find the cover- upper to the pot.11

206

539.

“I couldn’t rerubish it”

“Not happy…not content. .. not satis- fied here•..home”

“It could always be, but I’m not the indi- cator that one would need to require it”

“1…… 1……”

“It’s espsodada… da … da … cal”

“It’s a door-turner, a twister, a door mover-on.”

“Open door…in open door … street. ”

” … Harold go … car … ”

“The rotarator tribbled its output.”

“I can’t find the cover-upper to the pot.”

No answer required

Neologism, phonemic language disorder. Wernicke’s aphasia, posterior language disorder, fluent aphasia, sensory aphasia, receptive aphasia

Broca’s aphasia, motor aphasia, anterior language disorder, non-fluent aphasia

Drivelling, jargon agrammatism, semantic language disorder, Wernicke’s aphasia, posterior language disorder, fluent apha- sia, sensory aphasia, rzceptive aphasia

Paucity of thought, speech arrest, ante- rior language disorder, motor aphasia, non-fluent aphasia

Verbigeration, palilalia, anterior language disorder, motor aphasia, non-fluent apha- sia

Word approximations, nominal language disorder, Wernicke’s aphasia, posterior language disorder, fluent aphasia, sen- sory aphasia, receptive aphasia

Broca’s aphasia, motor aphasia, anterior aphasia, non-fluent aphasia

Transcortical aphasia (speech arrest, Broca’s combination), motor aphasia, an- terior aphasia, non-fluent aphasia

Neologisms, phonemic language disorder, Wernicke’s aphasia, receptive aphasia, sensory aphasia, fluent aphasia, posterior aphasia

Word approximation (for “lid”), nominal aphasia, posterior aphasia, Wernicke’s aphasia, receptive aphasia, sensory apha- sia, fluent aphasia

540.

541.

207

542.

Draw lines between matching items in the two columns:

543.

544.

545.

546.

547.

Draw lines between matching items in the two columns:

Anomia

Spelling apraxia Alexia

Acalculia

“How much is 85 – 27 ?”

“What is the name of this object?” “Spell cross”

“Read this”

Apraxia Agnosia Alexia Acalculia

Unable to recognize objects Unable to read

Unable to do math

Unable to perform simple motor tasks despite normal motor and sensory function

Fill in the blanks with the appropriate terms:

The inability to name objects is————–

The inability to read is——————- The inability to compute simple numbers is _ _ _ _ _ _ _ _ __

The inability to write words is ————-

Fill in the blanks with the appropriate terms:

The inability to recognize objects is ___________

This function can be specifically sublabeled: the inability to recog- nize letters is letter the inability to recognize num-

bers is number ———·

Circle the terms indicating dominant hemisphere dysfunction:

Construction apraxia Spelling apraxia Ideomotor apraxia Acalculia

Anomia

Alexia Agraphia Letter agnosia

When you are testing for dominant and non-dominant dysfunc- tion, give directions clearly and precisely. Don’t give hints such as “What is the name of this geometric figure?” Simply say “What is the name of this shape” or “Please copy this shape.”

208

542.

543.

544.

545.

Anomia~”How much is 85 – 27?”

agnosia 546.

547.

No answer required

Spelling apraxia Alexia

Acalculia

“What is the name of this object?” “Spell cross”

“Read this”

Apraxi~Unabletorecognizeobjects

Agnosia Alexia Acalculia

Unable to read

Unable to do math

Unable to perform simple motor tasks

despite normal motor and sensory function

The inability to name objects is anomia

The inability to read is __.::a~le::::x~ia::__”7″””_–:—-.—–.-.—— The inability to compute simple numbers is acalculia

The inability to write words is –=a.:.<gz.:r:..:a::;;p:..:hc:.;l:.:·a’———–

The inability to recognize objects is agnosia . This function can be specifically sublabeled: the inability to recognize letters is letter agnosia ; the inability to recognize numbers is number

209

548.

Review the following tasks and responses. Which hemisphere(s) is(are) affected in this patient?

TASKS

a. Name these shapes

(square, cross, tri- angle)

b. Copy the shapes b. (cross, square,

triangle)

c. Write the name of c. each shape

Review the following tasks and responses. Which hemisphere(s) is(are) affected in this patient?

549.

550.

Calculate 85 – 27 =

Review the following tasks and responses. Which hemisphere(s)

TASKS

a. Name these shapes (square, cross, tri- angle)

b. Read this. “He is a friendly animal, a fam- ous winner of dog shows.”

RESPONSES

a. Box, cross, pyramid

b. “He is a famous animal, a friendly winner of dog shows.”

RESPONSES a. “Box”, “Time”

b.

c.

c.

%~~ 1g

is(are) affected in this patient? TASKS

a. Name these (square, clock)

b. To calculate 85 – 27.

c. To place the left hand on the right ear.

d. “Show me how you hammer a nail.”

‘{5

210

; %J _ ‘ {

c. Left hand placed on left ear, even

when told it was incorrect. d. Unable to perform

548. both

549. dominant

550. left (dominant)

211

551. Check the appropriate box that best matches each behavior witt its most likely cortical functional region:

Behavior

Loss of recent memory

Can’t copy simple shapes Can’t do serial 7’s Global dis- orientations Can’t do sim- ple math Jargon agram- matism Telegraphic speech

Can’t remem- ber four items, concentration intact

Can’t concen- trate

Can’t demon-

strate the use of simple objects Copies examiner’s movements, des- pite instructions

to the contrary Disoriented to left-right

Uses multiple over- lapping lines when copying a circle Can’t name simple objects

Frontal

Dominant Parietal

Non-Dominant Parietal

Dominant Temporal

212

1

I I

551. Behavior

Frontal

Dominant Parietal

Non-Dominant Dominant

Loss of recent memory

Cant copy simple shapes Can’t do

serial 7’s Global dis- orientations Can’t do s1m- ple math

I I

Jargon agram- matism Telegraphic speech

I

Can’t remem-

ber four items, concentration intact

Can’t concen- trate

Can’t demon- strate the use

of simple objects Copies examiner’s movements, des- pite instructions to the contrary

I

Disoriented to

I

I

left-ri~~:ht

Uses multiple over- lapping lines when copying a circle Can’t name simple objects

I

I I

.

I

I

213

Parietal

Temporal

I

552.

Place the number of the appropriate item on the proper brain region:

553.

You noticed that in the last item there were no tasks or behav- iors for the right

or for both —–1.–o-…b-es. These areas are difficult to test without special equipment.

1. 2. 3. 4. 5. 6. 7. 8. 9.

10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

Active perception (identification of upside-down objects) Wernicke’s area

Broca’s area

Ability to copy (reconstruct) objects

Ability to orient oneself to right/left Ability to do simple math

Ability to concentrate

Abstract thinking

Reading and writing

Memory

Recognition and categorization of symbolic relationships “Methodist Episcopal”

Naming s:imple objects

Regulating motor behavior (no perseveration)

Regulating motor behavior (no echopraxia)

Ability to demonstrate use of objects

Ability to recognize and name body parts (i.e. -fingers) Global orientation

Usually the dominant hemisphere

214

552.

LEFT FRONTAL: 1.

3. 7. 8.

12. 14. 15.

RIGHT FRONTAL: 1.

Active perception (identification of upside- down objects)

Broca’s area

Ability to concentrate

Abstract thinking

“Methodist Episcopal”

Regulating motor behavior (no perseveration) Regulating motor behavior (no echopraxia)

Active perception (identification of upside- down objects)

LEFT PARIETAL:

7. Ability to concentrate

8. Abstract thinking

14. Regulating motor behavior (no perseveration) 15. Regulating motor behavior (no echopraxia)

5. Ability to orient oneself to right/left 6. Ability to do simple math

9. Reading and writing

11. Recognition and categorization of symbolic relationships

13. Naming simple objects

16. Ability to demonstrate use of objects

17. Ability to recognize and name body parts

RIGHT PARIETAL: 4.

LEFT TEMPORAL: 2. 9. 10. 13.

i.e. – fingers)

Ability to copy (reconstruct) objects

Wernicke’s area

Reading and writing (accepted) Memory

Naming simple objects

Left hemisphere usually the dominant hemisphere. 553. non-dominant temporal lobe, occipital

215

554.

555.

Even though the right (non-dominant temporallobe) and both occipital lobes are difficult to test and are sometimes referred to as the “silent area,” patients can be asked to perform several tasks which will at least screen for dysfunction. What functions of the dominant temporal lobe have you learned?

Occipital lobe function can be tested by evaluating visual acuity in all quadrants of the visual fields. This is part of every complete physical examination, but it tests only the primary visual cortex and not the visual associational areas also located in the occipital lobe. Once you have established that a patient’s visual acuity is intact (with or without corrective lenses) show him a card similar to the following (you can make up your own or purchase standard cards). Ask the patient to “choose the best match for the missing part in the pattern.” (The correct answer is the third pattern, in the top row on the right.) (47 pp. 107-127)

Another method involves the use of camouflaged figures such as this one. Ask the patient to tell you “what he sees in the picture.”

An individual with intact visual perception should be able to extract the figure from the camouflage. Once extracted, the inability to namt

the figure is an example of tion in the

107-127).

and suggests dysfunc- (47 pp.

216

554. posterior language, verbal memory

555. anomia, dominant temporal-parietal region

217

556. 557.

The non-dominant temporal lobe, usually on the–,-,=–:;-:–:=– side of the brain, perceives rhythm and music (47 pp. 128-146).

To test for non-dominant temporal lobe function, ask the patient to sing simple songs or repeat your singing of songs (e.g. , “Happy Birthday”). Another test of non-dominant temporal function is to ask the patient the following:

“I am going to tap on the desk, I want you to tell me how many taps I make.”

Then proceed: –, — , —- . If the patient responds accurately, say: “I am going to tap on the desk; I want you to tap on the desk exactly the way I do.”

Then proceed. The dots represent short or soft sounds, the bars represent longer or louder sounds .

••-‘••’••9••’

Inability to repeat the rhythm or numbers of your taps or to “sing along” suggest dysfunction in the .–.—…,.,.– ,..——- _____ How would you test for occipital lobe function?

Verbal memory and language functions are located in the

: perception of music and rhy-

558.

559.

———-

~thc=m~a=r~e~l~o~c~a~t~e~d-lr·n~t~h~e~——-

Inability to identify camouflaged figures suggests

_ _ _ _ _ _ _ dysfunction; inability to identify rhyth=m—-:csu=g-==g-=-e-,sts ——– ___________ lobe dysfunction.

21’8

556. right

557.

non-dominant temporal lobe, test patient for visual acuity, ability to identify patterns and perceive camouflaged objects.

558.

dominant temporal lobe, non-dominant temporal lobe

559.

occipital lobe, non-dominant temporal

219

560.

Place the number of the appropriate item on the proper brain region:

Left Hemisphere

Right Hemisphere

1. Global orientation

2. Calculations

3. Name 4 objects

4. Identify hidden objects

5. Copy cross

6. Repeat rhythm and musical tones

7. Draw circle

8. Finger identification

9. Serial 7’s

10. Identification of upside-down objects

11. Right-left orientation

12. Echophenomena

13. Demonstrate use of simple objects

14. “Methodist Episcopal” 15. Writing

16. Recognition and categorization of relationships

17. Verbal memory

18. Wernicke’s area

19. Broca’s area

20. Abstract thinking

220

560.

Right Hemisphere

LEFT FRONTAL:

LEFT PARIETAL:

1. Global orientation 7. Draw circle

9. Serial 7’s

LEFT TEMPORAL: 3. 17. 18.

LEFT OCCIPITAL: 4.

Name 4 objects Verbal memory Wernicke’s area

Identify hidden objects

10. Identification of upside down objects 12. Echophenomena

14. “Methodist Episcopal”

19. Broca’s area

20. Abstract thinking

2. Calculations

3. Name 4 objects

8. Finger identification

11. Right-left orientation

13. Demonstrate use of simple objects

15. Writing

16. Recognition and categorization or relationshipE

RIGHT FRONTAL: 1. Global orientation 7. Draw circle

9. Serial 7’s

10. Identification of upside down objects 12. Echophenomena

20. Abstract thinking

RIGHT PARIETAL: 5. Copy cross

RIGHT TEMPORAL: 6. Repeat rhythms and musical tones RIGHT OCCIPITAL: 4. Identify camouflaged objects

221

561. Check the appropriate box that best matches ~ach behavior with its most likely cortical functional region: Non- Non-

Behavior

Motor perseve- ration

Poor short- term memory Finger agnosia

. Construction apraxia

Cannot identify camouflag-ed obiects Cannot do similarities

Poor serial 7’s

Cannot repeat rhythms & songs Aealculia

Ideomotor apraxia (both hands) Right/left dis- orientation Cannot recognize or categorize relationships Anomia

Agraphia Echopraxia Dyslexia

Word approxi- mations

Dominant Dominant Dominant ‘Dominant

Frontal Temporal Parietal Temporal Parietal Occipital

222

561. Behavior

Motor perse- veration Poor short- term memory

IFinger agnosia Construction apraxia

Cannot identify camouflaged objects Cannot do similarities

Poor serial 7’s Cannot repeat rhythms & songs Acalculia Ideomotor apraxia (both hands) Right/left dis- orientation Cannot recognize or categorize relationships Anomia

Agraphia EchOl>raxia Dyslexia

Word approxi- mations

j

I

I

I I

I I

I I I

I I

Non- Non- Dominant ~ominant Dominant Dominant

Frontal Temporal Parietal Temporal Parietal Occipita

I I

I

j

I

223

I

I

REVIEW SECTION

562.

563.

The phenomenological mental status examination utilizes three basic principles of clinical method. In addition to separating form from content, they are and – – – –

Place a check mark in the appropriate box to indicate which men- tal status heading each clinical item best fits:

General General Thought Appearance Motor Behavior Catatonia Affect Disorde~·

Clang associations Hyperactivity Posturing Flight-of-ideas Verbigeration Intense affect Lability of mood Euphoria Tangential speech Irritability Sadness

Unkempt clothes

224

562. objective observation, precise terminology

563.

General General Thought Appearance Motor Behavior Catatonia Affect Disorder

Clang Associations I Hyperactivity I

Posturing

Flight-of-ideas I Verbigeration I I Intense affect I Lability of mood I Euphoria I Tangential speech

Irritability I Sadness I Unkempt clothes I

225

I

I

564. Place a check mark in the appropriate box to indicate which men tal status heading each item fits. More than one check per item is

possible.

Apophany

Violence

Inappropriate mood Thought disorder Poor personal hygiene Tardive dyskinesia Agitation

Loose associations Illusions Hallucinations Persecutory delusions Catalepsy

Mania

Catatonia

Schizophrenia

Coarse Brain Disease

226

564.

Mania Catatonia

I I I I I I I I I I I I I I I I I I I I I I I I

Coarse Schizophrenia Brain Disease

I I I I I I I I I I I I I I I I I I I I I I I I

Apophany

Violence Inappropriate mood Thought disorder Poor personal hygiene Tardive dyskinesia Agitation

Loose associations Illusions Hallucinations Persecutory delusions Catalepsy

There are no pathognomonic signs of the major psychoses.

227

565.

Place a check mark in the appropriate box to indicate which men- tal status heading each clinical item best fits. More than one check mark per item is possible.

Percep-,

General Motor Thought tual 1st Ranl Appearance Behavior Affect Process Apophany Dysfunc. Sympto

Delusional perception Delusional mood Hyperac- tivity Incomplete auditory hallucina- tion Flight-or- ideas Irritabi- lity Autochtho- nous delus~ ional ideas I Clang asso- ciations

Euphoria Depression Posturing

228

565. I

General Motor Thought tual 1st Rank

Delusional perception Delusional mood Hyperac- tivity Incomplete auditory hallucina- tion Flight-of- ideas Irritabi

lity Autochtho.: – nous <ielus- ional ideas Clang asso- ciations

.; .;

.;

Euphoria Depression Posturing

.;

Percep- Appearance Behavior Affect Process Apophany Dysfunc. Symptom

I

.;

.; .;

I

229

.;

.;

.;

566. Place a chec.K mark in the appropriate box to indicate which men- tal status heading each clinical item best fits.

Thin

Agitated

Echolalia

Grimacing

Dishevelled

Labile affect

Anxiety

Rambling speech

Non-sequiturs

Irritability

Clouded con- sciousness Perseveration of association (stock words)

567.

Circle all the thought disorder terms best associated with schizophrenia:

General General Thought Appearance Motor Behavior Catatonia Affect Disorder

Non-sequiturs Circumstantial speech Blocking

Flight-of-ideas Paraphasia Tangential speech

230

566.

General General Thought I Appearance Motor Behavior Catatonia Affect Disorder

Thin

Agitated Echolalia Grimacing Dishevelled Labile affect Anxiety Rambling speech Non- sequiturs Irritability

I

I

Clouded con- sciousness Perseveration of association (stock words)

I

567. ~on-sequituEV ~Circumstantial speech

~Flight-of-ideas (tangential spee~

I

231

.;

I

.;

I

I

I

.;

.;

568.

Label with the appropriate terms the following behaviors:

569.

Label with the appropriate term(s) the following behaviors:

A. “Why are you in the hospital?”

“What’s the trouble? It’s been a long time…I can tell you that, trouble, trouble, the whole world is troubled not just me, so wr should I complain? Think of all those other people.”

B. “What’s a nice girl like you doing in an address like this?”

C. “Doctor, I’m dead. I don’t care what they (staff) say—even if I can move and talk, I know I’m dead, it has to be so, I just know it.”

Label with the appropriate terms the following behavior:

“My husband is trying to poison me, he is unfaithful; the radio keeps re- porting his activities to me.”

“Hello, Doc—How am I today? Today?—I’m fine, I feel great, g-great, g-great, ate, ate, ate, ate.”

570.

232

568. Picture A: Omega Sign, veraguth folds, a sad facial expression Picture B : Posturing, a cataleptic state – catatonia

569. A. Tangential speech with perseveration: talks past the point, does not answer the question and perseverates the stock word “trouble.”

B. Word approximation (“address” for “place”). C. Primary delusional idea

570. Secondary delusional idea, verbigeration/palilalia

233

571.

Label each description with the appropriate phenomenologic term(s):

572.

Label each description with the appropriate phenomenologic term(s):

573.

Label each description with the appropriate phenomenologic terr

“It’s frightening– -suddenly every- thing becomes very small as if I were looking through the wrong end of a telescope.”

“It happens many times during the day. I suddenly smell burn- ing rubber or rotting flesh. I feel dizzy and then it’s all

right again.”

“They’re all in on it. They’re trying to kill me, then they’re going to wipe out the country. It’s all over, I can tell. The radio and TV say it; the ma- chines in my room say it.”

“Doctor, you’ve got to do some- thing. She spends all day stand- ing in the middle of the room, looking at the ceiling. She won’t answer me…”

” … Then, suddenly, she’ll start to clean the house, sew clothes, go shopping. It’s as if she’s do- ing everything at once.”

“…When I try to talk to her, she becomes angry, yells, curses, threatens me. Then, almost in the next second, she laughs, and then cries.”

“It’s a frightening man. I can see him walking behind me. Some- times I see him in another city. ”

“I can’t make it out. It’s some sort of a noise or hum but I hear it all over the place.”

“Well, if the place pictures like a next moment I can’t be written

in sections.”

“Yeah. I know…a kid could do something like that. .. I’m tired, my mouth is dry … What time is it. .. Did you read in the papers … ”

234

571. Micropsia, olfactory hallucination, secondary delusional idea

572. Catalepsy and posturing, hyperactivity, lability of affect

573. extracampine hallucination; elementary auditory hallucination; drivelling; rambling speech

235

574.

Label each item with the appropriate phenomenologic term:

“I don’t know. I just feel funny. Detached…nervous, sort of. .. like I’m going through the motions, watching myself.”

“It’s horrible. Everything becomes large, then small. People’s faces become large and distorted.”

“I can’t stand it. ·Every time the phone rings or the door bell rings, that son of a bitch turns on the machine and the voice scr·eams at me. ”

“You know. You hear it too. Everyone must. They’re talk- ing all the time … (Shouting at the ceiling) . Stop it, stop it! They never stop. They talk about me all the time…Of course, as loud as your voice, you idiot. They’re talking

so loud it drives me crazy.”

Place a P next to the items suggesting perceptual dysfunction, an 0 next to-·the items suggesting memory dysfunction, and a Y next to the items suggesting an abnormality of motor behavior. –

575.

576.

Beside each heading, place the numbers of the appropriate items below:

1. 2. 3. 4. 5. 6.

Mitmachen

Illusion

Anterograde amnesia Haptic hallucination Functional hallucination Echopraxia

7. Deja vu

8. Extracampine hallucination 9. Catalepsy

10. Hypnagogic/hypnopompic 11. Confabulation

12. Waxy flexibility

Memory

Thought process

1. Euphoria

2. Retrograde amnesia

3. Delusional perception

4. Derailment

5. Expansive mood

6. Confabulation

7. Perseveration

8. Autochthonous idea

Affect

Apophany

9. Paraphasia

10. Appropriate mood 11. Jamais vu

12. Non-sequiturs

13. Delusional mood 14. Verbigeration

15. Pseudomemory

16. Relatedness

236

574. depersonalization; macropsia and micropsia (dysmegalopsia); functional auditory hallucination; phoneme or complete auditory hallucination

575. Mitmachen Y Illusion P

Deja vu 0

Extracampine hallucination P Catalepsy Y Hypnagogic/hypnopompic P Confabulation 0

Waxy flexibility Y

Anterograde amnesia 0 Haptic hallucination P Functional hallucination P Echopraxia Y

Affect 1. 5, 10, 16 Thought process 4, 7, 9, 12, 14 Apophany 3, 8, 13

576. Memory 2, 6, 11, 15

237

577.

Draw lines between matching items in the 2 columns (items on the right can be used more than once).

578.

Unable to read

Draw lines between matching items in the two columns:

579.

Check off the tests of dominant parietal lobe function: “Show me how you thread a needle.”

“What finger is this?”

“Copy the outline of this object.”

“How do you use a key?”

“Subtract 29 from 66.”

“Spell earth backwards.”

“Hold out your right hand … Put your right hand on your left ear.”

Unable to name own fingers

Unable to demonstrate use of key, hammer or flipping a coin with both hands

Unable to copy the outline of a key

Unable to perform a non-verbal spatial task

Dominant Parietal Lobe Non-Dominant Parietal Lobe

Apraxia Agnosia

Acalculia Agraphia

Unable to recognize previously known objects

Unable to write a sentence to dictation but able to copy a sentence

Unable to do sirr.ple math

Unable to perform simple motor tasks despite normal muscle strength

238

577.

Unable to name own fin~rers

Dominant Parietal Lobe Non-Dominant Parietal Lobe

578.

Unable to read——–….J Apraxia

Agnosia

Unable to recognize previously known objects

579.

“Show me how you thread a needle.~ “What finger is this?” I “Copy the outline of this object.”

“How do you use a key?” I “Subtract 29 from 66.” I “Spell earth backwards.”

Unable to demonstrate use of key, hammer or flipping a coin with both hands

Unable to copy the outline of a key

Unable to perform a non-verbal spatial task

Acalculia —–:7″”=——“”””:— Unable to do simple math

Agraphia Unable to perform simple motor tasks despite normal muscle

“Hold out your right hand … put your right hand on your left ear.”

I

239

Unable to write a sentence to dictation but able to copy a sentence

strength

CLINICAL EVALUATIONS

Excerpts from clinical cases will be presented in the final section of Part I. As each patient is described, you will be asked to identify behaviors and make clinical comments.

CASE I

A 43-year-old white, medium- built man • dressed in a leather suit is brought into the emergency room by the police. He has been running through the street waving a large knife and attacking buildings.

When you first observe him, the handcuffed This patient’s general motor

patient is being held in a chair as he shouts behavior is characterized

unintelligible phrases, makes comments to the emergency room staff, and occasionally bursts into intense satanic laughter.

When released from his handcuffs, the patient rapidly paces around the examining room, commenting on every item, yelling to any staff member who passes by the open door.

Throughout the interview, the patient’s

manner is exalted, agressive, and on

occasion, suspicious. He appears alert.

He frequently laughs loudly, expresses

great joy, expounds on the feeling of great

power and “superhuman” strength but, upon are

questioning, becomes suddenly irritable and to th:-e-e,–x-,a-m,–I.,….n-a–ct””io-n-si,..,-.tuation angry. His speech is rapid. He speaks and their sudden appearance constantly and can be interrupted only with and disappearance suggest

difficulty.

a of affect. His speech is both rapid and ________

240

by

The most severe form of this

.

-c-an~l~e~a-d>Lt~o-c~a~r~dyi~o-v~a~scular

collapse and death.

motor state is termed

and

This patient’s affective

is expanded.

“‘H”i=-s–:a:c;f””f”‘e-=crte-::-d.,.–.ic::n:-.t:-:-:ensity is

His moods

of _______ and ____

CASE I

This patient’s general motor behavior is characterized by hyperactivity. The most severe form of this motor state is termed excitement and can lead to cardiovascular collapse and death.

This patient’s affective range is expanded. His affective intensity is increased . His moods of euphoria and anger are

inappropriate to the examination situation and their sudden appearance and disappearance suggest a lability of affect. His speech is both rapid and pressured

241

You are unable to keep him on the topic; An example of _ _ _ _ __ he is constantly jumping from subject to

subject. To the question, “What do you

mean by ‘great power’?”, he replies:

“Power is as power does; I am the resur-

rection, ha, I want an erection… rejection. An example of

– – – – – –

Did you know my girlfriend wanted to be a psychiatrist? … She works for a law firm … Those bastards … They keep the price of everything up … No-fault insurance would be the best. The best, the best, the

associations.

best, est, est, est!

The patient also says: “God speaks to me,

An example of _ _ _ _ __

He tells me what to do. I hear him all the time; I feel his power.”

Possible delusional

Possible first rank -sy_m_p–:t_o_m-of’

Your responses to the patient’s last statement should be (list all the questions to determine form):

CASE II

A 30-year-old, thin woman is hospitalized because she has thrown herself in front of

a subway train in a suicide attempt. She

has sustained only superficial injuries. Admission physical and all laboratory findings are within normal limits.

When you first see her, the woman ru~hes to you, grabs you by your white coat and begins to moan, whine and plead: “Help me, help me…What am I to do? I can’t go on like this.”

The descriptions would be placed under the mental status heading of _ _ _ _ _

Once in your office, the patient continues

to pace back and forth, wringing l:er hands, patting her breasts, shaking her head and trembling. When you ask her to sit down, she complies for a few minutes but soon becomes restless, constantly moving her hands, rocking back and forth, and finally rising and again beginning her pacing.

This patient has moderate

to severe motor – – – – – –

Her photograph is on the previous page. Observe it carefully. How would you describe her?

Her expression is character~ istic of with

She is somewhat unkempt. Throughout the interview she continues to whine; tries on numerous occasions to cry without success; looks and says she is in great distress; that life is hopeless; that she is going to die; that she is a bad person; that she is very fearful and sad.

Her range cf affect is

242

experience of – – – – – –

obvious

and ——.,fo’ld’s-.—

mten_s…,i”‘”ty-1.-.S—- but hei The quality of her mood is

An example of flight-of-ideas .

An example of __c::..:l”‘a-“n”‘g’–__associations.

An example of verbigeration

Possible delusional idea

Possible first rank symptom of experience of _ ___ci::n.::fl=uc::e.::n:..:c:..:ec.:·_ _

“Do you mean you hear God’s voice?… As loudly as you hear mine?… Where does the voice come from?… Does he speak to you all the time? Does anyone else talk to you like that? Is it like an energy wave? Does

it make you do things even when you don’t want to?..•You mean you actu- ally feel the wave on your body?”

CASE II

These past descriptions would be placed under the mental status heading of general appearance

This patient has moderate to severe motor _ _ _ca:;gi~·=t=ac:ti:.:”o:n.:._ _ _ _ Her expression is characteristic of depression with obvious

s=:i:.~:gl.:n.:.

omega _ _ _

_ _ _ _ and veraguth folds.

Her range of affect is constricted but her intensity is increased. The quality of her mood is sad and anxious.

243

She can offer no explanation for her fears or feelings of hopelessness (going to die) and guilt (bad person) . She just feels it to be so.

She says she is convinced that people are suffering for her sins, even people whom she had never met. She feels this to be true because she feels so disgusting that her “badness” must affect others.

She says she still feels like killing herself and would do so if we left her alone. She says that she feels worse in the morning, particularly at 2 or 3 a.m., and that she hears strange noises in her room. The noises sourid like footsteps, breathing, or creaks and groans; but they are muffled and sometimes just noises. They frighten her, and fortunately, she does not hear them during the day. She denies hearing them during the interview.*

She had delusional ideas, which develop from her mood, therefore, they are

She is describing vague hallucinations also termed

hallucinations.

*NOTE: Since she does not experience the noise phenomena during the examination, this information should not be written in the mental status evaluation but rather illThe history under the heading Present Illness.

244

Secondary delusional ideas (secondary to her mood) .

She is describing vague hallucinations also termed pseudo and elementary hallucinations.

245

CASE III

A 24-year-old man is brought to the emer- gency room by his mother because of his increasing seclusiveness and “odd” behavior.

Throughout his admission interview, he sits Although not conclusive,

quietly staring straight ahead, but when spoken to, he does look at the examiner and responds.

this does suggest that his consciousness is – – – – – –

His movements are slow and somewhat awk- ward. His facial expression remains un- changed throughout the examination and generally gives no hint of emotion.

His general motor behavior can be characterized as

The patient speaks in a soft, monotonous voice which remains unchanged throughout the interview.

This suggests a…,.,.,.——- l’f,nge of affect w1th

On several occasions, he suddenly stops speaking, stops moving, and simply stares off into space. He seems unaware of these periods which last only a few seconds. On several occasions, these episodes are followed by a different train of thought.

A classical example of

and

When he is asked aoout the events that led

to his mother’s bringing him to the hospital, An example of

he keeps repeating that the problem was his school where he had too many eight o’clock groups. When you realize that the patient means eight o’clock “classes” and you bring this to his attention, the patient becomes mildly irritated and says, “Well, you don’t have to be so fickled about it!”

The word

“fick:;l-=:e-:;d””~is=-=a:—-

He says that his reason for secluding himself in his room is that his mother and father are surrounded by a green foul-smelling gas that makes him sick to his stomach. When you open the door so that the patient can see

The patient is describing his mother in the waiting area, he says that b o th ——–

he can still see and smell the gas. You tell and ——–;-;,..– him that you cannot see or smell the gas , . His that it certainly is an unusual situation; and reality

you ask the patient whether he has any idea is alsop–0-o-r-.- – – – – – – about what is happening, why it happens,

and who or what is behind it all. The patient gives you a shallow smile (the only time during the:interview) and says that you know perfectly well what he thinks since

you can hear his thoughts. You deny this, question the patient more closely and learn

The patient is experiencing

that he is experiencing his thoughts coming

out of his head so that everyone can hear them.

246

moderately ——-

——-intensity.

e-r=r_o_r_s~in=-s-p-ee-c~h~s-uggest .-~-~—mnguage

dysfunction.

. These

CASE III

Although not conclusive, this does suggest that his consciousness is clear

His general motor behavior can be characterized as moderately hypoactive

This suggests a _.::..co-‘-n::.:.::;s.::..tr:..;i:..:c:.cct.=.e..;.d,__ _ _ range of affect with __d=-e=-c=-r=-e::.:a:::s:::e:::d=—– intensity.

A classical example of _ _b_c___lo_c_k_i_n_.g”——- and _ _d_e_r_a_il_m_en_t_ _ _

An example of word approximation (a paraphasia).

The word “fickled” is a neologism. These errors in speech suggest post- erior language dysfunction.

The patient is describing olfactory and visual hallucinations. His reality testing is also poor. – – –

The patient is experiencing thought broadcasting.

247

The patient also says that it is obvious that These are

machines in the wall are generating a force and that the gas surrounding his parents is connected in some fashion to the machines.

During cognitive testing, the patient re- members 5 numbers forward and 4 back- wards. He remembers 3 of 4 words asked of him and subtracts sevens from 100 with- out error in 63 seconds.

His fund of information is good and when asked: “What do an orange and an apple have in common?”, he says: “They’re both fruit.”

When asked: “What do a car and a boat have While this response suggests in common?” , he says: “They’re both means adequate abstract thinking,

of transpalation.”

When you ack him to copy a cross and spell it, he does the following:

~Coss

When you ask him to copy a triangle and spell it, he does this:

He calculates 85 – 27 this way:

-2’7 p:-’37

A 35-year-old white man is transferred from an outlying health facility to the gen- eral hospital’s psychiatric unit because of an episode of “violent” behavior and for “catatonic schizophrenia”.

the word “transpalation” sug- gests and dysfunction in the

These test responses sug- gest cerebral dysfunction: (circle one): Non-dominant, dominant, bilateral

CASE IV

ff5″

248

delusional …-id”‘””e_a_s-.—–

Are any of these test responses abnormal? What function

are 1hey testing?

Vlhat cortical regi,_o_n_a-re—-,t””h_e_y_

testing?_ _ _ _ _ _ _ __

Is this a good response?_ _

These are secondary delusional ideas.

Are any of these test responses abnormal? no What function are they testing? concentratioo What cortical region are they testing? frontal lobes

Is this a good response? ~

While this response suggests adequate abstract thinking, the word “trans- palation” suggests phonemic language disorder and dysfunction in the dominant temporo-parietal region.

These test responses suggest: Non-dominant, Dominant,~

CASE IV

249

The patient had been working up to the day of his hospitalization. Always a quiet and shy person, he had become increasingly aloof at work, speaking in a mumbled

almost unrecognizable English and moving in an “odd manner”. He was seen by a local practitioner, given a neuroleptic drug (chlorprom:1zine), and returned to work. That same day he suddenly tried to rape

a passer-by: he was restrained and trans- ferred for hospitalization.

Admission mental status examination re- veals a six-foot, well-built, neat white male, looking somewhat older than his stated age. The patient appears anergic (tired and without energy to initiate activity), occasionally perplexed but at· other times alert.

He walks to the examining room in a slow, stilted fashion, often hesitates, holding one foot several inches off the ground before he takes a step. His gait is slightly broad-based and, as he walks, he holds his arms stiffly at his sides with his hand and fingers hyperextended.

His hand and arm positions become normal when he stops, but occasionally his hand suddenly supinates (turns palm upward) in a short, rapid movement which, when he notices it, he then extends into a seemingly voluntary act.

The patient speaks slowly in a monotone voice as thought his mouth were filled with marbles. There is no hint of anger. When questioned, he smiles in an automatic, pro- longed, and exaggerated nonhumorous fashion.

His mood seems mildly sad, at other times apathetic, but with little emotional expres- sion. His emotional tone never varies

from this description.

Is this gait normal?

This is an example of “chorea”. Can you find any examples to justify the admission diagnosis of “catatonia”? If so, under- line. Are these signs of agitation? Is he hypoactive

or hyperactive?

This facial expression is an P.xample of a _______

‘fhis description illustrates

250

a

affect and a intensity of

range of

a’f”‘f~ec-t:-.—-

Is this gait normal? No His odd hand positions as he walks is also not normal motor behavior

Can you find any examples to justify the admission diagnosis of “catatonia”? No Are these signs of agitation? No Is he hypoactive or hyperactive?

HYpoactive

An example of a grimace.

This description illustrates a constricted range of affect and a decreased intensity of affect.

251

When questioned, the patient takes several

moments before answering and often his

thoughts simply trail off unfinished. When Is this an example of

this is pointed out, he picks up the same train of thought. When asked about the rape attempt, he replies, “I was working there for two years.” When asked about the medicine he has been given he says, “My family comes from Alabama. ” His sentences are always short. He never volunteers information and never speaks unless spoken to.

The patient is able to repeat four numbers forward and three backwards. His re- sponses to a serial 7’s task is, “93, 97… 97 … “. His response to a serial 3’s task iS, II 97, 93, 87, 80, 70 • • •II

He is unable to give details about his family or of the past year of his life.

Some of his responses to cognitive test items are:

derailment?- – – –

He reads “John went to the store to get a loaf of bread” as “John when to get a bread”. He cannot name “key.” He cannot demon- strate how to use a key.

Is his dysfunction: (circle one):

,dominant, non-dominant, both

252

What type of thought disorder is this?

Are these responses within normal range?__________

Here the patient has responded to tests of

Is this an example of derailment? No It does suggest possible anterior language dysfunction in his paucityof thinking. More data are needed.

These are examples of non-sequiturs, a form of formal thought disorder. This also suggests possible posterior language disorder.

Is this within the normal range? No (5 forward and 4 backward and correct subtraction in 90 seconds are considered normal)

Here the patient has responded to tests of concentration.

Is his dysfunction (circle one): dominant, non-dominant ,Q?otii)

253

CASE V

A 45-year-old man is brought to a psy- chiatric clinic by his wife because of his “strange behavior” which developed sud- denly during the past two days.

The patient had been a heavy drinker for most of his adult life but suddenly stopped drinking a year prior to this episode. He has no previous psychiatric history except that throughout his married life, he has had well-circumscribed periods in which

he came home from work, hardly spoke with his family, ate supper, and then either went immediately to sleep (often sleeping until

the next morning) or simply sat in his

chair staring at the newspaper, apparently without reading it. These episodes of

one to two weeks’ duration would suddenly lift, and he would be again his usual out- going, energetic, infectiously happy-go- lucky self.

Two days prior to his clinic visit, while apparently sleeping, he suddenly sat up in bed, pointed to the window (second floor) and began shouting that there was someone watching him. He woke his wife and two children and accused them of plotting to harm him, and of being un- faithful and evil.

These are most likely

He spent the remainder of the night pacing all over the house, speaking rapidly to himself.

He slept throughout the following day, but that night he again became “agitated.•. confused” and frightened the family. They brought him to the clinic the next morning.

On examination, the patient is a middle- aged endomorphic (thick-boned, stocky, obese) neatly dressed man.

He moves slowly, stares ahead, making little eye contact with the examiner. His face is expressionless. His speech is

slow and he rarely speaks unless spoken to. He says he is going to die.•. that they are out to get him for his past sins… that he is a “worthless person” and de- serves his fate. You hospitalize him.

At home, he was agitated or

254

apophanous or

i d e a s . I s there_e_n_o_u_g..,..h–

inflilrmation to be sure of this? Explain your answer.

hyperactive; now he’s

. Slowec “”m_o..,.to-r-….b-e”‘h_a_vro-.–r-,-s-p_eec_h and

a paucity of thoughts is often referred to as psy- chcmotor retardation.

CASE V

These are most likely apophanous or delusional ideas. Is there enough information to be sure of this? No, because he must first be asked: “How do you know these things to be true?” and then the form of the primary

or secondary nature of the phenomena must be established.

At home, he was agitated or hyperactive; now he is hypoactive. Slowed motor behavior, speech, and a paucity of thoughts is often referred to as psychomotor retardation.

255

~everal hours after admission, the patient

is found in bed, unresponsive to all but the

most painful stimuli. He appears anesthe-

tized although he has received no medi-

cation. After much prodding, he finally

opens his eyes and in a thick-tongued

voice says: “Get thee from me, Satan.” He

then falls back and does not respond for

hours. His vital signs are stable and except associated finding. for his general analgesia, physical exam is

normal.

Later in the day, the patient suddenly Wakes up and begins to sing. He follows this with some good-natured joking with the staff. He smiles, laughs, tries to teach them how to dance, and tries to help them do their work.

At this time, his affective

He races from patient to patient, staff mem- This extreme form of

ber to staff member, location to location,

in an effort to carry out what he feels to

be important tasks. Before he can finish

any one of them, he is off on another

“mission.” His speech is rapid. He speaks

to everyone, interrupts private conver-

sations, cannot be stopped or interrupted, also . Rapid

and only laughs and laughs when harshly spoken to by irritated patients and staff. He sings, whistles, dances, clowns for hours, finally collapsing on his bed once again in an uncommunicative analgesic state.

The following day, the patient becomes irritable. He begins shouting and shaking his fist in a threatening manner at both patients and staff. When placed in a seclusion room, he stands in one spot, staring out the window and speaking in a continuous flow. He can easily be ap- proached, but he keeps on staring ou: ·:·he window even when he respond,:; to ques- tions. He says that there are machines

in the ceiling that are constantly shouting to him.

The machines are loud and speak about events taking place in the hospital. He also says that there are other machines “out there” which are emitting gamma rays that spray his body and that this

is the reason he is standing in one spot. The rays are doing “something” to his muscles “forcing” them to remain “stiff.”

pressured speech is a cardinal sign of . His

256

This extreme -.—–:—-.– active state is also termed

. General analgesia is not an uncommon

intensity was his mood

——-

-a”ls-o__,.t_e_r_m_e_d.—–activity is ——-

In addition to the rapidity of his speech, his speech is

intense

euphoric mood is another cardinal sign of _ _ _ _ _ _

This auditory phenomenon is

called a

It is a Schneiderian

or a

This phenomenon is termed an

and

This extreme hypoactive state is also termed stupor. General analgesia is not an uncommon associated finding.

At this time, his affective intensity was increased; his mood euphoric.

This extreme form of hyper activity is also termed excitement.

In additiOn to the rapidity of his speech , his speech is also pressured. Rapid pressured speech is a cardinal sign of mania. His intense affect and euphoric mood is another cardinal sign of mania.

This phenomenon is called a phoneme or a complete auditory hallucination.

It is a Schneiderian First Rank Symptom.

This phenomenon is termed an experience of influence.

257

When not specifically questioned, he says the following as he stares out the window: “I see the sun. It’s shining. It’s shining. All those trees green…grass…yellow light; it’s bright, it’s bright but not night. I see the sun. Cars are fast.

Associations by sound are called associ- ations.

They are coming for me. They are coming

for me, me, me, me, me, me, me! Watch

out! Watch out! Slow down! You can’t

go that fast. .. stop it, stop it. Is he dead?

No, there he is. I see him…The sun is on The overall speech form of

his car. . . It’s not too far, far, far, far away, far away.” Then he laughs.

multiple interwining themes and jumping from topic to topic is termed ___________

CASE VI

A 45-year-old white man, formerly a uni- versity professor of statistical mathematics,

is brought to the hospital by his family following air evacuation from England where he had gone because he believed that he had a professorship at Oxford. The British authorities sent him back to the United States because there was no record of him

at Oxford and because they observed some of his psychopathology.

Throughout the mental status examination the patient’s facial expression remains unblinking and without reflection of any mood. He denies missing any friends or relatives and says: “They’re o.k …. they’re on their own.” When asked about his feelings

His overall affective re- sponses suggest emotional

about being hospitalized, he says blandly:

“I suppose I have to get it over with.” His plan for the future is to “apply for a position.”

When you ask about the events in England and during his trip back to the U.S…

he is vague in his answers and cannot

give details of events during the past three weeks. He says he applied for many positions, received replies and “has positions.”

A defect of ____________

When asked “how come” he was hospitalized in England and then sent back to the U.S. he says: “It’s just that I came to the position and applied for the position”.

These responses are talking past the point or

When pressed about the reason he is hospi-

talized he becomes mildly irritated and says: stock word and is thus an “I’ve written many papers, positions, and example of a ____________ that’s just the way it is,”

258

This automatic repetition of words is termed__________

The word “position” is a

Associations by sound are called clang associations.

This automatic repetition of words is termed verbigeration or palilalia.

The overall speech form of multiple intertwining themes and jumping from topic to topic is termed flight of ideas.

CASE VI

These behaviors suggest emotional blunting.

A defect of recent memory.

These responses are talking past the point or tangential speech. The word “position” is a stock word and is thus an example of a perseveration.

259

When asked about events which took place

several years back, he is unable to give his A deficit in

birth date, his wedding date, or the age of ——- his relatives. He says he is “38 or 39” and

he denies any memory difficulty.

You inquire further about the patient’s age.•An example of

– – – – – –

Then you ask math questions. The patient cannot subtract or add numbers that in- volve borrowing or carrying. He is unable to do serial 7’s. Despite having a Ph.D.

and dysfunction.

in mathematics, he is not troubled by his failure and says: “I did other mathematics in my position.”

Poor concentration suggests dysfunction.

Then you ask him about physical weakness, which he denies. (Previous physical examination has revealed no weakness).

Despite your repeated instructions to touch his nose when you touch your chest, the patient touches his chest.

Demonstrating -=–~-­ and dysfunction in the -.,.-,—–,—, which regulat_e_ _ motor behavior.

When you question the patient about his fingers and ask him to name them, the patient says (from thumb outward) “Thumb, I don’t know … straight finger? … index finger … I don’t know … end finger.”

a n d_ _ _ _ _ _ dysfunction.

—– Hecallsapen”apencil,”despitebeingtoldExamplesof~~–____

it is incorrect. He calls a watch “a clock” and cannot be more specific. He calls a key “a you know … ” (and demonstrates its use with a poking, non-turning gesture).

and dysfunction in –……..,.–.. T h e s e a r e –

The patient copies a cross in the following manner:

Is this abnormal? If so, what is the dysfunction called and where is it located?

260

An example of

examples of

disorder of the

subtype. ——

language

A deficit in long-term memory.

An example of dyscalculia (or acalculia) and dominant parietal lobe dys- function

Poor concentration suggests frontal lobe dysfunction.

Demonstrating echopraxia and dysfunction in the frontal lobes which reg- ulate motor behavior. – –

An example of finger agnosia and dominant pariet~lobe dysfunction.

Examples of word approximations and dysfunction in the dominant tem- poro-parietal—re-gion. These are examples of posterior language disorder of the semantic subtype. –

Is this abnormal? yes

If so, what is the dysfunction called and where is it located? Construction apraxia, non-dominant parietal lobe.

261

Shade in the areas of probable dysfunction in this patient. List them.

Left Hemisphere

Right Hemisphere

262

Left Hemisphere Right Hemisphere

Dominant and non-dominant frontal Dominant and non-dominant parietal Dominant temporal

263

PHENOMENOLOGIC MENTAL STATUS OUTLINE

I. General Appearance

III. Affect

V. Apophany

Age, race, sex, body type

State of consciousness, manner, General health, hygiene, grooming

II. Motor Behavior

Gait

Rate, rhythm, activity, Catatonic features

Range, intensity, stability

Quality of mood, appropriateness of mood, relatedness

IV. Thought Processes

Rate, rhythm and pressure of speech

Word use

Tightness and form of associational linkage Thought content

Delusional mood

Delusional ideas (primary, secondary) Autochthonous ideas

Delusional perceptions

VI. Perceptual Disturbances

Illusions

Pseudo hallucinations

Elementary, functional, extracampine hallucinations True hallucinations

Dysmegalopsia

VII. First Rank Symptoms

Thought broadcasting

Complete auditory hallucinations (Phonemes) Delusional perceptions

Experiences of influence

Experiences of alienation

VIII. Cognitive Function

Global orientation Judgment

Fund of information Abstract thinking Practic functions Gnostic functions Mnestic functions Other

264

COGNITIVE FUNCTION EVALUATION OUTLINE

Cortical Region A. Frontal Lobes

Task

Dysfunction

B. Dominant Parietal Lobe

1. Calculations

2. Finger identification 3. Right-left orientation 4. Reading

5. Writing

6. Demonstrate use of

Acalculia

Finger agnosia Right-left disorientation Alexia (dyslexia) Agraphia (dysgraphia) Ideomotor apraxia

C. Non-dominant Parietal Lobe

1. Copy outline of simple shapes

Construction apraxia

D. Dominant Temporal Lobe

Lateral Temporo- parietal region

1. Name simple objects 2. Speech

Anomia

Wernicke’s aphasia

Deep

1. Recall word series

2. Relate recent events 3. Recall past events

Short-term memory Recent memory . Long-term memory

E. Non-Dominant Temporal Lobe

1. Repeat rhythms

2. Repeat and recognize

Poor rhythm perception Amusia

F. Occipital Lobes

1. Identification of camouflaged objects

Poor visual perception

1. Global orientation 2. Draw circle

3. Serial 7’s

4. Similarities

Disorientation

Motor perseveration Poor concentration Poor abstract thinking

5. Identification of upside Disability in active

down objects

6. Echophenomena

7. “No ifs, ands or buts”

perception Echopraxia Broca’s aphasia

“Methodist Episcopal” 8. Repeat word series

(dominant lobe only) Immediate recall

simple objects

musical tones

265

(all verbal memory)

1.

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269

part II

INTRODUCTION

In Part I, we concentrated on the Mental Status Examination, that as- pect of the diagnostic process which is perhaps the most difficult because its success depends upon your ability to observe and define the behaviors of patients.

Part II of the text takes you through the rest of the diagnostic pro- cess, with emphasis on the differential diagnosis, a process of refinement which is achieved by synthesizing the information you derive from your observation of the patient and from the patient’s history. The ability to rule out and categorize a variety of subtle signs will lead you to the best possible diagnosis. In psychiatry, there are no pathognomonic signs;

your ability to arrive at an intelligent diagnosis is therefore dependent upon a multiplicity of information. The more precise the information you gather, the more accurate your diagnosis.

Much of Part II requires a thorough understanding of Part I. You will be reminded, at strategic points in the text, to review areas in Part

I about which you might feel uncertain. Part II makes increasingly great- er demands on your diagnostic skills as your proficiency and confidence grow.

The DSM-III term “organic mental disorder” will not be used in this text as it implies the existence of “inorganic” or metaphysical brain syndromes, a notion which is contrary to basic biology and the generally accepted idea that the brain is the organ of behavior and that all behavior- pathological, deviant and normal-reflects brain function. As a substitute for the DSM-III term, I will use “coarse brain disease” to label clinical conditions which have demonstrable etiology or pathophysiology. These brain disorders are “coarse” in that their pathology is measurable with present technology. They contrast with other mental disorders in which the pathology is not yet measurable and in which the etiology or patho- physiology is unknown.

273

DIAGNOSIS

1. 2.

In phenomenology, the fundamentals in the diagnostic process are objective precise , and the separation of

—————– fro~ ——————

The key to clinical diagnosis is the process of changing probabi- lities. Each bit of historical and mental status information continually and gradually alters the probability of the patient having particular conditions. Each datum decreases the likelihood of some disorders and increases the likelihood of others. At the end of the process, the most likely diagnosis is selected. Since there are no pathognomonic signs

in psychiatry, nor conclusive laboratory tests for mental illness, the process of data collection: objective observation, precise terminology, content separated from form, becomes extremely important. You have learned about this process in Part I; to know it and use it you must practice it. Part II will provide much of the data needed to determine the probabilities of several major diagnostic conditions.

3.

Objective observation cannot be overemphasized. Even the small- est mannerism, physical characteristic, word usage or other behavior can be an essential diagnostic clue. For example: A patient was refer- red to a psychiatrist because of his deteriorating productivity at work and because he spent increasing amounts of time in bed, complaining of loss of interest. During the initial phases of the examination, the man demonstrated no abnormalities. However, when he described his work (as a clerk-typist), he said, “Well, I had some trouble…you know … ” and then made typing movements. Further testing of lang- uage functioning revealed other deficits in word finding, naming of objects·, reading and taking dictation. The patient had a localized treatable lesion involving the

. The lesion mig–;h,–t,.–,-h_a_v__e _g_o_n__e _u_n–,detected if the examiner “‘h-a’d-n::-o-t,..–,-nc-:o-:.:t’icc-ed the small clue of the patient’s typing movements. Pay attention to details—they can help you in your diagnostic choices and decrease the morbidity and mortality of your patients.

274

1. 2.

observation, terminology, form, content No answer required

3.

dominant cerebral hemisphere or dominant temporo-parietal region

275

4.

Psychiatric diagnostic systems generally separate five major groups of disorders: the so-called functional psychoses: major affective dis- order and schizophrenia, the organic brain syndromes (coarf\e brain disease), the neuroses, the personality and behavior disorders, and the

psychophysiological disorders. The latest classification system of the American Psychiatric Association (DSM-III ) ( 13), has reorganized this traditional nosology, scattering the neuroses among the other categories adding new categories and renaming psychophysiological disorders: “Psychological factors affecting physical illness.” As nosologies change with the rapidity and logic of hemline height, I will confine Part II to a description and characterization of traditional dh;orders, making referen’ only to their DSM-III counter term. In the first half of the text, I

discussed the more dramatic mental conditions indirectly, and we will begin with them again here. Keep in mind, however, that most people seeking counsel or treatment for mental symptoms do not have major men disease.

Major Affective Disorder

5.

6.

7.

8. 9.

10.

11.

Many investigations have demonstrated that people suffering from depressive and/or manic episodes can be separated phenomenologically into several disease groups. We will limit our focus to two broad groups: bipolar (two poles) and unipolar (one pole) affective disease (92,178).

Bipolar and affective diseases are characterized by a primary disturbance in mood. They are both periodic in course, and episodes usually end in remission. Most patients return to their premorbid level of function ( 88, 177).

When a person suffers from recurrent depressions, i.e. , only one mood pole, he is said to have unipolar affective disease. When a per- son suffers from recurrent depressive and manic episodes, i.e. , both mood poles, he is said to have ——— _________

Some patients have only recurrent manic episodes. Even though they suffer from only one mood pole disorder, i.e. , mania, they are nevertheless said to have affective disease.

Recent research (8,9) suggests that individuals with recurrent manic episodes and no depressions have a variant of bipolar disorder. Individuals who have only depressive episodes are said to have

The major affective disorders can be separated into -:::–‘0″‘7″‘~-c–c:-:c–:;- and disorders. These are common conditions and women are affected more frequently than men by almost two to one

(54,78,141,177).

Bipolar patients suffer from both and _ _ _ _ _ _ episodes. Unipolar patients suffer from only recurrent _ _ _ _ _ _ episodes.

276

4.

No answer required

5.

No answer required

6.

unipolar

7.

bipolar affective disease

8. 9.

bipolar

unipolar disorder.

10.

bipolar and unipolar

11. manic, depressive, depressive

277

12.

The major affective diseases, i.e. , and

_ _ _ _ diseases, are more common amon-g,-_-_-_-_-_-_-_-_-_-_-_-_- _ _ than

13. 14.

The sex ratio difference for major affective disorder for females to males is ———-

15.

Several studies suggest that among individuals with affective dis- order 85 percent have the unipolar form and 15 percent have the bi- polar form ( 10, 178). In both instances, the sex most frequently af- fected is______

16. 17. 18.

Of 100 patients with affective disorder, how many should have the bipolar form and how many should have the unipolar form?

19.

In Part I, item #122, you commented upon the observations of a patient who suffered from a severe depression. She has returned a- gain and is first seen sitting quietly outside your office. Even though you say hello and ask her to come in, she remains seated, staring ahea< until you repeat your introduction upon which she slowly gets up and moves to a chair next to your desk. There are deep furrows between her eyebrows. Her eyes have a sunken appearance, and the inner angle of the upper lid appears to rise. Throughout the interview, the patient remains seated, head bowed. Her only movements are the con- stant rubbing together of her hands. She speaks in a monotonous, slow, plodding fashion, is often close to tears and, despite an attempt at humor on your part, cannot even manage a smile. She says she

feels like crying, but cannot. She says she feels she is a bad person, and that somehow her present condition is deserved and that people would be better off if she were dead. You find yourself feeling sad for her, and concerned about her pained expression. Later, in writing your report, you state that she exhibited motor behav- ior. Because of her hand rubbing, you feel she showed mild motor

among ——–

When all reported figures are averaged, approximately 2 percent of the general population is at risk (chances of getting disorder) for major affective disorder (unipolar and bipolar combined) ( 141 pp. 76- 78, 151). Thus, during their lifetime, two out of every

people you know should theoretically develop affective di_s_o-rd-,-er-.–.-I.,-t is very common.

Of 85 unipolar and 15 bipolar patients, approximately how many of each group will be male and how many female?

Rank the following four patient categ<‘>ries by placing a number from 1 to 4 next to each, indicating its relative frequency of occur- rence, e.g. , 1 =the most common; 4 =the least common.

:~~~~:~~!ea~es ~~f~~::;;:!~~-es-~~~~======

. Her facial expression, marked by an -s.,…ig_n_,_a_n_d.—– folds, was sad. In describing her-a’f”‘fe-=-c-=-t’,–

you state that her affective range was , she showed

—-;<”

_ _ .,–.,.——lability and the intensity of her mood

____

was one of constant , but to what was being discussed. Because of your emotional response to her, you felt

her affect was ———

278

12. bipolar, unipolar, women, men

13. 2to1 14. 100

15. female

16. 85 unipolar, 15 bipolar

17. Using the 2: 1 ratio, of 85 unipolar, 57 will be women and 28 males. Of the 15 bipolars, 10 will be female and 5 male.

18. Bipolar Males 4 Unipolar Males 2 Bipolar Females 3 Unipolar Females 1

19. hypoactive, agitation, Omega, Veraguth, constricted, no increased, sadness, appropriate, related

If you had difficulty with this question, you should review Part I again. You must be able to identify psychopathology before you can master the diagnostic process.

279

20.

21.

22. 23.

24.

25.

26.

27.

28. 29.

The characteristic aspects of major depression are a constricted range of with a mood. Anxiety is an- other mood associated with depression.

Since depressed people often are intensely sad and/or anxious, it is not surprising that their intense mood is sometir<1es expressed in in- creased frequency of motor behavior termed

A marked decrease in activities and a slowing of movements or

– – – – – – – – – – is also characteristic of depressed individuals.

Circle the behaviors characteristic of a major depression:

Omega sign Anxiety Hypoactivity

Singing Hyperactivity Veraguth’s folds

Constricted affect Agitation

Flight-of-ideas

A severely depressed patient can sometimes stay motionless for hours, staring fixedly or following the examiner about the room with his eyes, unresponsive even to severe pain stimulation (general anal- gesia) . This extreme hypoactivity is termed _ _ _ _ _ _ _ _ _

Thought content is helpful in reaching a diagnosis when the con- tent reflects an intense mood. Once you have established the

of a patient’s speech or how he is speaking, you should ‘d-e7te_r_m_l…-.n-e-w’hether the thought is helpful in the diag-

nostic process.

Feelings of hopelessness, worthlessness, helplessness, guilt and thoughts of suicide are often expressed in thought content. They re- flect the presence of a sad mood. During the mental status examina- tion, you must determine whether these feelings are present. Below write several of the questions you might ask to determine these feel- ings:

Depressed people are often suicidal and indeed have a mortality rate much greater than the general population ( 72,160, 162). Below write several questions you might ask to determine a patient’s suici- dal feelings:

The characteristic motor presentation of depression is either

:;-::–:::-::-::::-::-:::-::—::—- or . When decreased motor activity is severe, a can develop.

The slowed speech, E.!owed responses to environmental stimuli and decreased motor behavior observed in many depressed patients is call- ed psychomotor retardation. Although seemingly paradoxical, psycho- motor retardation, hypoactivity, and agitation can be observed in the same patient.

280

20. affect, sad 21. agitation

22. hypoactivity 23.

24. stupor

25. form, content

26. “How does the future look?”—“Do you think your difficulties will improve?”

“Do you think your family needs you?” — “Are you a worthwhile person?”

“Do you think you can do anything about all this?”

“Have you let people down?” — “Are you a bad person?”

27. “Well, with all this going on, you must feel pretty badly. Do you ever get the feeling you’d like to go to sleep and not wake up?”

“Do you ever get the feeling you’d be better off dead?” “Did you ever wish you could just end it all?”

“Did you ever think of harming yourself?…Of killing yourself?… Have you tried?…Do you feel that way now?”

28. agitation, hypoactivity, stupor

29. No answer required

281

30.

The slowing down of speech, motor behavior, and general unresponsiveness of depressed patients, known as

31.

Circle the words or phrases characteristic of depression:

32.

The mood disturbance of some depressed patients can become so severe that feelings of hopelessness, worthlessness and guilt become the thought content of delusional ideas. Since these delusional ideas develop from a mood disorder, they are said to be

In contrast, autochthonous delusional ideas which

other psychopathology are said to be ———-

33.

Depressed patients not infrequently believe that they are terrible people, responsible for public tragedies or the deaths of others or that they have committed unpardonable sins, are doomed, are going to die or be killed or that they are already dead. Some believe they have a horrible disease such as a brain tumor or multiple cancers. Others think that some of their body parts are rotting away or that they have garbage in their intestines. These ideas develop from a profound mood disorder and are therefore called – – – – – – – – –

34.

Some depressed patients have perceptual disturbances. The con- tent of the misinterpreted real stimuli, which is known as .,–,,….-;-“7″””–,—.’ reflects their depression. Noises and shadows become frightening figures or demons ready to punish them for their sins.

35.

Many depressed patients hallucinate. They hear “incomplete” voices calling them names or stating their sins. They smell their “evil” or taste their decay. Hallucinations and delusions are not uncommon among individuals with a major depression ( 8, 9, 88, 177) and the pre- sence of these signs should not discourage you from a diagnosis of de- pression in the presence of a sufficient number of other symptoms.

As many of these delusions in depressive illness develop from the pro- found mood of sadness, they are said to be ———

36. 37.

Unlike the mental status examination, which only focuses upon .,—,–.-c-..-:-:-:- behavior, the diagnostic process must also consider his- torical information or behavior.

, can become so severe that patients beco_m_e_m_u_t,_e-,– ‘b-e-,d;-r-.id….,d;-e-n-and immobile, unresponsive even to painful stimuli,

but at times able to follow people with their eyes. This uncommon condition is called a depressive _ _ _ _ _

Sad or anxious mood Stupor

Euphoria Omega sign

Hyperactivity

Constricted range of Affect

Feelings of hopeless- ness, worthlessness, guilt

Suicide

Flight-of-ideas

Patients with a major depression are most often seen within a few weeks to a few months of the onset of the episode. Because of the morbidity risks by sex in the general population, the majority of de- pressed patients will be ——–

282

Grandiose delusional ideas

d-.-o-n-o””””‘t,—-,d,….e_v_e.,.lo_p___,f~r-om

30.

psychomotor retardation, stupor

32.

33.

secondary, primary

secondary delusional ideas

34. illusions

35. secondary

36. present, past 3 7 . women

283

38.

39.

40.

41.

42.

43.

44.

Although all age groups, including children, can become depres- sed, it is rare for an individual to have a first depressive episode be- fore age 15, or after age 60. Peak onset years are between 40 and 60

(141 pp. 72-74, p. 88, 177). The probabilities are strong that the majority of depressed patients you will encounter will be middle-aged and female. What is the likelihood of these depressions being associa- ted with manic episodes? Explain your answer.

Circle the items which increase the probability that your patient is suffering from a major depression:

Omega sign

Euphoria

Male

Feelings of hopelessness

Hyperactivity Flight-of-ideas

Depressed patients will almost always have a sleep disturbance. Early morning (2 or 3 a.m.) waking and inability to fall asleep again

is most typical, but any significant insomnia is consistent with the diag- nosis of major depression. Another characteristic feature of major depression is a peak onset of between years of age.

Loss of sleep is typical of depression. Characteristically, patients have insomia. Patients generally feel worse during the early morning and somewhat better in the late afternoon or early evening. This 24-hour mood cycle (worse in the morning; better in

the evening) is termed a “diurnal” mood swing.

Loss of appetite, or anorexia, with weight loss (greater than

5 pounds) is also extremely common in major depression as is a

general loss of interest in daily activities. Although some characteristic depressive behaviors are historical data and thus not part of the

mental status examination, their evaluation is essential for any diagnostic determination.

Place a D next to the items characteristic of depression:

Weepy and anxious

Life is not worth living

“I could conquer the world” 50-year-old woman

Delusion of guilt

Teenager

Can’t sleep

Doesn’t feel like eating Euphoric

Suicide attempt

Depressed patients often have multiple physical complaints: head- aches, backaches, generalized weakness, heaviness in arms and legs, constipation, and tiredness are commonly reported. These symptoms are common in many systemic illnesses and in some coarse brain disor- ders. A psychiatric examination and evaluation are not complete with- out a complete physical examination and appropriate laboratory eval- uation to insure the absence of other diseases with behavioral symp- toms.

284

Psychomotor retardation Age 48

Female

Recent suicide attempt

38.

small – only 15% of affective disorders are bipolar

39.

(Omega sign) Euphoria

40.

40and60

41.

early morning

42.

No answer required

Male ~F-=ec::m=al=e””-__,,..-.,..~-..,—… (]’eelings of hopelessnes§) Recent suicide attempt

Hyperactivity Flight-of-ideas

43. Weepy and anxious D

Life is not worth living D “I could conquer the world”

Teenager

Can’t sleep D

Doesn’t feel like eating D Euphoric

Suicide attempt D

44.

No answer required

50-year-old woman D Delusion of guilt D

285

45.

The key to clinical diagnosis is the process of changing probabi- lities. When all of the following clinical criteria are satisfied, the pro-

bability is enormous (26,74,85,126,132,136,137) that the patient is suffering from a major depression.

1. Sad or anxious mood

2. Three of the following (a through f)

a. early a.m. waking (insomnia)

b. diurnal mood swing (worse in the a.m.)

c. anorexia with greater than 5 pound weight loss in 3 weeks

d. psychomotor retardation or agitation

e. suicidal thoughts or behavior

f. feelings of guilt, self-reproach, hopelessness, worthlessness

3. No coarse brain disease or use of steroids or reserpine in the past month, no systemic illness known to cause depressive symptoms.

The probabilities are also great that most individuals with the a- bove condition will be and age. Approximately what percent of the general population is at risk for affective disor- der? ______

In the following case vignette, circle the words or phrases which relate to the diagnostic criteria for depression. Are sufficient criteria for depression satisfied? If not, which one(s) is/are missing?

A 47-year-old woman is hospitalized because of increasing appre- hension, fears of impending death, and thoughts that devils are bothering her. She sees no hope for her condition and feels she is a worthless person. For the 10 days prior to admission, she did not sleep and spent her days pacing. There was no weight loss, no change in her mood throughout the day, and no evidence of systemic illness.

In the following case vignette, circle the words or phrases which relate to the diagnostic criteria for depression. Are sufficient criteria for depression satisfied? If not, which one(s) is/are missing?

A 26-year-old woman was hospitalized because of sadness, trouble falling asleep, loss of appetite with a 7 pound weight loss and ideas that she “was a prostitute” and “sinful.” She felt people had

“bad thoughts” about her, that she was worthless, that there was no hope. Her sadness was worse during the early part of the day. On the day of admission, she attempted suicide.

In the following case vignette, circle the words or phrases which relate to the diagnostic criteria for depression. Are sufficient criteria for depression satisfied? If not, which one(s) is/are missing?

A 46-year-old woman is referred to you because she took an over- dose of analgesics. She appears agitated, worried and anxious. An Omega sign is present. She is emaciated, and admits losing

60 pounds in the last 6 months. She expresses worry about a “lump” in her left axilla and says she has cancer. When you ask her about her suicide attempt, she says, “I didn’t think there was any alternative.” All physical examination findings and laboratory findings are within normal limits and her history is negative for drug abuse and for evidence of systemic illness, including cancer.

46.

47.

48.

286

45. female, middle, 2%

Yes, enough criteria are met to satisfy the diagnosis of depression. 47.

No, there is no statement regarding physical examination, laboratory findings and medical or drug abuse history.

48.

287

49.

In the following case vignette, circle the words or phrases which relate to the diagnostic criteria for depression. Are sufficient criteria for depression satisfied? If not, which one(s) is/are missing?

A 33-year-old woman sought consultation because of insomnia (par- ticularly in the early a.m.) which had persisted for two months. Her appetite had been poor, but no weight loss was evident. She described feeling “moody,” particularly in the morning, feeling

like crying, losing sexual desire, and feeling that the future “looks frightening.” Physical examination and laboratory findings were within normal limits, and her history was negative for drug abuse and for evidence of systemic illness.

Affective disorders can be separated into and –~– groups. Individuals in both groups suffer from major de- pression, however, the patients also experience episodes of mania.

The depression of bipolar patients is clinically similar to that of unipolar patients ( 6, 7). Only the presence or absence of past -,…,-::-::;,..-,..–,…,..-:-.,.,..-,;- episodes will determine the polarity of an individual pa- tient’s disorder. Of those individuals whose first episode is a depres- sion, approximately 5 percent will become bipolar .(44,98,176).

As is true for depression, the hallmark of mania is an altered mood. In mania, euphoria and irritability are most commonly observed. Labi- lity of affect is also frequently observed leading to rapid shifts from excessive jocularity to anger and occasionally to sudden bursts of tears and expressions of profound sadness. In depression, the common moods

When all the following clinical criteria are satisfied, the probability is enormous that the patient is experiencing a Planic episode (8,9,24, 153,157,177,178) and thus has affective disease.

50.

51.

52.

53.

are and ———

54.

In the following case vignette, circle the words or phrases which relate to the diagnostic criteria for mania. Are the criteria for mania satisfied? If not, which one(s) is/are missing?

A 22-year-old college student was found in his dormitory, mute and unresponsive. Later that night at the infirmary, he became agitated, hyperactive, assaultive and verbally overproductive. When hospitalized, he also exhibited a euphoric, as well as irri- table, mood. His rate and pressure of speech was increased and he had flight-of-ideas. He had delusional ideas of grandiosity and admitted to hearing a whispered voice.

1. 2. 3. 4. 5.

Hyperactivity

Rapid/pressured speech

Euphoric or irritable mood

No emotional blunting-

No coarse brain disease, no psychostimulant drug abuse in the prior month, no systemic illness known to cause manic symptoms

288

49.

50.

51.

52.

53.

Yes

bipolar, unipolar, bipolar

manic

sadness, anxiety

bipolar

,54.

No. There is no discussion of the presence or absence of coarse

brain disease, psychostimulant drug abuse or possible systemic condi- tions. This patient does satisfy all the other criteria, but without

a physical examination und careful history, even the best mental status examination is incomplete.

289

55.

In the following case vignette, circle the words or phrases which relate to the diagnostic criteria for mania. Are the criteria for mania satisifed? If not, which one( s) is/are missing?

A 33-year-old woman is hospitalized because she has been hearing voices and believes she is “the center of the world.” She is agi- tated, hyperactive and demonstrates several mannerisms, stereo- types and a moderate degree of posturing. Her mood is euphoric, her affect full, her speech rapid and pressured. She has a though disorder. Physical examination and laboratory findings are

within normal limits and her history is negative for drug abuse and for evidence of systemic illness.

In the following case vignette, circle the words or phrases which relate to the diagnostic criteria for mania. Are the criteria for mania satisfied? If not, which one(s) is/are missing?

A 48-year-old woman was transferred from another hospital because of depressed mood, an attempted suicide, early morning insomnia, crying spells and anorexia. She did not respond to electroconvul·· sive treatment. On admission, she was hyperactive and agitated. She became hostile, her speech was rapid and pressured. Her physical examination revealed hirsutism, masculinized body build, decreased muscle strength and tone and mild hypertension.

In the following case vignette, circle the words or phrases which relate to the diagnostic criteria for mania. Are the criteria for mania satisfied? If not, which one( s) is/are missing?

A 53-year-old woman was hospitalized because of agitation, con- stant “giddy laughter” and the thought that there was a plot to kill her family. She had put bandanas around the chairs at home and put objects in the windows as “symbols” to passers by. While she was being admitted, she sang, danced and joked. Her speech was rapid and pressured and she spent the first few days of hospital- ization going from one activity to the next. Physical examination and laboratory findings were within normal limits and her history was negative for drug abuse and for evidence of systemic illness.

Draw lines to match the diagnostic criteria with the disorder: Hyperactivity

56.

57.

58.

Mania Depression

Early morning waking Psychomotor retardation Euphoria or irritable mood Sad or anxious mood Feelings of guilt

Suicidal thoughts

290

55.

56.

57.

No. Although all the inclusion criteria are met, the exclusion criteria are not complete. She has evidence of possible systemic illness and, upon further evaluation, adrenal hyperplasia was demonstrated.

Yes. The thought disorder was “flight-of-ideas.” The rest is com- plete.

Yes. Singing and dancing, decorating self and objects, delusions of persecution are all consistent with the diagnosis of mania.

58. Hyperactivity

Early morning waking

Mania Psychomotor retardation ——–::;>””;~~Euphoria or irritable mood

Sad or anxious mood Depression…,..E::—–Feelings of guilt

Suicidal thoughts

291

59.

60. 61.

62.

63.

Place an Mnext to the manic items and a Dnext to the depressive

64.

65.

Draw lines between matching items in the two columns:

items: – Rapid/pressured speech_ _ Euphoria

Suicidal thoughts

Irritable mood

Feelings of hopelessness_ _

Psychomotor retardation

Sad mood Hyperactivity_ _ Early a.m. waking_ _

A patient who talks to several people, one after the other, who goes from one place to another in quick succession, is said to be ________. This is a classical sign of _________

In Part I, you learned that catatonia is a syndrome which, in 25 to 50 percent of cases, is a manifestation of major affective disease.

In addition to specific motor behaviors we have considered, catatonia is characterized by periods of extreme hyperactivity and hypoactivity, also termed and ———-

Mutism, stupor or (!Xcitement, although characteristic of , are not pathognomonic (diagnostic) signs. Other specific motor behav· iors should be present before the diagnosis of is made. List those motor behaviors.

Draw lines between matching items in the two columns:

Posturing Excitement Waxy flexibility

Stupor Agitation

Severe hyperactivity Psychological pillow

Slow resistance as patient allows examiner to place him in odd pos- ture

Increased motor frequency due to intense affect

Severe hypoactivity often associ- ated with generalized analgesia

Catalepsy Omega sign

Gegenhalten Veraguth folds Grimacing

The furrowed brow of depression

The patient resists being moved with strength equal to that applie’

Spending hours in one position The sad eyes of depression

A facial posture

Draw a line between the matching items in the two columns:

Severe hypoactivity Tardive dyskinesia Severe hyperactivity

Excitement

Stupor

Drug induced brain damage

292

59. Rapid pressured speech M

Psychomotor retardation D Sad mood D – Hyperactivity M

Early a.m. waking__Q_

Euphoria M

Suicidal thoughts D Irritable mood M –

– Feelings of hopelessness D

60. hyperactive, mania ol. excitement’ stupor

62. catatonia, catatonia

Catatonic motor behaviors: echopraxia, stereotype, automatic obed-

ience (Mitgehen, Mitmachen), catalepsy, posturing, waxy flexibility

63.Posturing~Severehyperactivity

Excitement Psychological pillow

Waxy flexibility Slow resistance as patient allows examiner

to place him in odd posture Stupor——————–Increased motor frequency due to intense

Omega sign

The patient resists being moved with strength equal to that applied

,~~affect

Agitation Severe hypoactivity often associated with generalized analgesia

64. Catalepsy=s<The furrowed brow of depression

Gegenhalten Veraguth folds Grimacing

Spending hours in one position The sad eyes of depression

A facial posture

65. Severe hypoactivity;(Excitement

Tardive dyskinesia Stupor

Severe hyperactivity Drug induced brain damage

293

66.

Draw lines between matching items in the two columns:

67.

Draw lines between matching items in the two columns:

68.

69.

70.

71.

Veraguth’s folds Omega sign

Waxy flexibility Posturing

Furrow between the eyebrows

Upward angle of inner canthus of eyes in depression

Assuming odd body positions

Slow resistance but allowing placement in odd body postures

Stereotype Echopraxia Mitgehen Echolalia

The patient repeats your movements

Non-goal directed automatic, re- petitive movement

The patient repeats your words

Despite your verbal instructions to the contrary, the patient al- lows you to move his arm with light pressure

Despite your verbal instruction to the contrary, the patient lets you posture his arm and when released, slowly moves it back to its original place

Maintaining posture for long periods

Severe hypoactivity Draw lines between matching items in the two columns:

Mitmachen

Stupor

Catalepsy

Draw lines between matching items in the two columns:

Excitement

Agitation Mitgehen Echolalia

Increased non-goal directed mo- tor activity—an expression of intense affect

Extreme hyperactivity

The patient repeats your words Automatic obedience

In Part I, you learned that circumstantial speech, clang associa- tions and flight-of-ideas are frequently observed in manic patients. Stereotype of speech, the automatic repetition of words or sounds at the end of a phrase termed , is observed in catatonia and thus also in mania.

Verbigeration is characterized by

It is a form of verbal stereotypy and is-o”f”te_n_s_e_e_n_a_s_p_a_r–;t-o””f–;t-.,.h_e_

—–,-,—-,—-.-syndrome. Circumstantial speech is often observed among patients with mania. Associations by the sound rather than the meaning of words, termed associations are also observed in mania.

294

66. Stereotype><The patient repeats your move- ments

Echopraxia Non-goal directed, automatic, repetitive movement

Mitgehen~Thepatientrepeatsyourwords

E c h o l a l i a – – – – Despite your verbal instruction to the contrary, the patient allows you to move

his arm with light pressure

67. Mitmachen——–D espite your verbal instruction to the contrary, the patient lets you posture

his arm and when released, slowly moves it back to its original place

Stupor——M aintaining posture for long periods C atalepsy—–Severe hypoactivity

68. Veraguth’s folds~Furrow between the eyebrows

Omega sign~ —-Upward angle of inner canthus of eyes

in depression

Waxy flexi~Assuming odd body positions

Posturing Slow resistance but allowing placement in odd body postures

69. Excitemen><Increased non-goal directed motor activity —an expression of intense affect

Agitation Extreme hyperactivity Mitgehen~Thepatientrepeatsyourwords E c h o l a l i a – – – – Automatic obedience

70. verbigeration

71. stereotyped repetitions of phrases, words or sounds usually at the end of a sentence (neurological term is palilalia); catatonic, clang

295

72. 73.

As many patients with mania exhibit signs and symptoms of cata- tonia, stereotypy of speech, termed , can also be ob- served among manic patients.

74.

or ———

Circle the behaviors typical of mania

75.

Draw lines from the condition to the clinical items which reflect diagnostic criteria. Not all clinical items need be used.

Manics are often impulsive, intrusive and importunate. They have boundless energy, need little sleep, but have little perseverance. They will go on buying sprees or begin fanciful projects, but will fail to complete the required work because they quickly lose interest and begin a new task. They continually interrupt interactions between others, constantly making demands or repeating the same statements which they insist you hear again. Their mood is often _ _ _ _ _ _

Flight-of-ideas Memory loss Labile affect Hyperactivity Impulsiveness Overtalkativeness

Psychomotor retardation Elation

Hypoactivity

Irritability

Mania

Psychomotor retardation

Depression

Early a.m. wakening Irritability

Head decoration Hyperactivity Suicidal

296

Shyness

Feelings of guilt and self-reproacl Verbigeration

Rapid/pressured speech

Diurnal mood swing (worse in a.m Emotional blunting

Euphoria

Sadness

Anorexia with more than 5 pound weight loss

Complete auditory hallucinations

72. verbigeration (or palilalia)

73. euphoric, irritable

74. <£Iight-of-idea”S) Memor loss Labile affect

Hyperactivity Impulsiveness

75.

~otor retardation Elation

Hypoactivity

UrritabilQi:) Shyness

Feelings of guilt and self-reproach Verbigeration

Rapid/pressured speech

Diurnal mood swing (worse in a.m.) Emotional blunting

Psychomotor retardation

Euphoria

Sadness

Anorexia with more than 5 pound weight loss

Early a.m. wakening Irritability

Head decoration Hyperactivity Suicidal

Complete auditory hallucination

Mania

297

76.

Read the following case ·vignette. Underline the words or phrase! which relate to specific diagnostic criteria for mania and/or depressior Check those which are positive. Write your diagnosis below.

77.

Read the following case vignette. Underline the words or phrases which relate to specific diagnostic cieteria for mania and/or depressior and check those which are positive. Write your diagnosis below.

78.

Read the following case vignette. Underline the words cr phrases which relate to specific diagnostic criteria for mania and/or depression and check those which are positive. Write your diagnosis below.

79.

Read the following case vignette. Underline the words or phrases which relate to specific diagnostic criteria for mania and/or depression and check those which are positive. Write your diagnosis below.

A 69-year-old woman was hospitalized stating “I am a bad woman …the police are after me…they want to see me dead…I’m just

rotten, that’s all.” She had a history of insomnia, crying epi- sodes and complaining of feeling “terrible” in the morning but bet ter as the day progressed. Her appetite had been good and her weight stable. At times, she felt she would be better off not awakening in the morning. Physical examination and laboratory findings were within normal limits and her history was negative for drug abuse and/or evidence of systemic illness.

A 39-year-old man was hospitalized because of assaultiveness, irritability and severe agitation, and for saying: “I am a messen- ger of God…I have the secret for the cure of cancer because God told me.” On admission, he was in a state of excitement.

He was hyperactive and euphoric. His affective intensity was in- creased, his affect labile, shifting from irritability to euphoria to sadness with tears. His speech was rapid and pressured, he had flight-of-ideas. Physical examination and laboratory findings were within normal limits and his history was negative for drug abuse and for evidence of systemic illness.

A 49-year-old man was found by the police carrying a bow and arrow and pretending to be “Robin Hood.” When seen in an emer- gency room, he was hyperactive and agitated, irritab’le and threat ening. His speech was loud, rapid and pressured. He felt

he was a “natural born leader,” and for this reason law enforce- ment agencies were after him. Physical examination and labora- tory findings were within normal limits and his history was nega- tive for drug abuse and for evidence of systemic illness.

A 50-year-old woman sought consultation because she found her- self unable to make herself “do things.” She described recent “nervous and funny” feelings. She wanted to stay in bed all day, had trouble falling asleep and awakened early. She felt better in the morning and worse as the day progressed. During the past month she lost 20 pounds. She had suicidal thoughts. Physical examination and laboratory findings were within normal limits and her history was negative for drug abuse and for evidence of sys- temic illness.

298

/

76. A 69-year-old woman was hospitalized stating “I am a bad woman…

the police are after me … they want to see me dead … I’m just rotten that’s all.” She had ~istory of inso’ilinia, crying ‘e’pisodes and com- plaining of feeling “terrible” in the morning but better as the day progressed. Her appetite had been good and her weight stable. At times, she felt she would be better off not””l:wakening in the morning. Physical examination and laboratory findings were within normal lim- its and her history was negative for drug abUSe and/or evidence of systemic illness.

Depression

She demonstrates sadness (crying spells) plus insomnia, a diurnal mood swing and suicidal tendencies (better off not awakening). She satisfies the exclusion criterion.

77. A 39-year-old man was hospitalized because of assaulti~enessand irritability, severe agitation and for saying: “I am a messenger of God… I have the secret for the cure of ,91ncer because God ):old me.” On admis~on, he was in a state of excitement. He was hyp~ractive and euplioric. His affective intensity was increased, his affect lab- ile, shifting from irritability to euphoria to sadness with tears. His speech was’fapid and pressured, he had flight-of-ideas. Physicaeexamination and laboratory findings were within normal lim- its and his history was negative for drug abuse and for evidence of systemic illness.

Mania

78. A 49-year-old man was found by the police carrying a bow and arrow and pretending to}le “Robin Hood.” When.;:seen in an emergency room, he w}s hyperactive and agitated, irritable and threatening.

His speecli was loud, rapid and pressured. He felt he was a “natural born leader,’~nd for this reason law enforcement agencies were af- ter him. Physical examination and laboratory findings were within normal limits and his history was negative for drug abuse and for evidence of systemic illness.

Mania

79. A 50-year-old woman sought consultation because she found heryelf unable to make herself “do things.” She described recent “nervous and funny” feelings. She wanted to stay in bed all day, had tro’Gble falling asleep-‘and awakelied early. She felt better in the morninf!/ and worse as the day progres!,)ed. During the past month sh~.Jost 20 pounds. She had suicidal”‘thoughts. Physical examination and laboratory findings were within normal limits and her history was negative for drug abuse and for evidence of systemic illnes_~·

Depression

Her diurnal mood swing is the opposite of the classical description of depression. Nevertheless, sufficient signs and symptoms are present for the diagnosis. If you missed this one because of the reversed di- urnal mood, remember: there are no pathognomonic signs.

299

80.

Patients with major affective disorder can be divided into those with only recurrent depressions, i.e., disease and those with recurrent manias or with both manias and depressions, i.e. , ________ disease.

81. 82. 83.

Which sex is at greater risk for affective disorder? (write your answer below)

84.

It is not unusual for bipolar patients to exhibit depressive signs or symptoms during the course of a manic episode. Lability of affect is very common and a manic patient can quickly switch from a happy, singing, dancing, joking period to one of remorseful crying and hope lessness. Sometimes this shift is spontaneous, although a well-timed question from the examiner, “You know, you suddenly look sad…are you going to cry?” can bring on a flood of tears and statements abou1 guilt, worthlessness and hopelessness on the heels of a string of loud coarse jokes, puns and laughs. List all the diagnostic criteria we have used for mania.

Which age group is at greatest risk for affective disorder? (writ• your answer below)

The following behaviors have all been observed in patients with demonstrable affective disorder. Circle those which satisfy by defi- nition or description diagnostic criteria for depression or mania and place a D next to each circled depressive criterion and an M next to

each circled manic criterion: Irritability

– Feeling down in the dumps

Incomplete auditory hallu- cinations

Fecal smearing

Assaultive

Thought broadcasting

Mutism, posturing, catalepsy

Sits in a chair all day

Doing too many things at once in a rapid impulsive manner

When moves, does so slowly

Singing/dancing

Anxious mood

Jumping from topic to topic Impulsive

Talking too much and too fast

Repeats examiner’s questions

Would like to go to sleep and not wake up

Intrusive

Feelings of being dead

300

Feels worse in morning; better in evening

80. unipolar, bipolar

81. the female sex

82. middle age (40 to 60)

83. (Irritability) M

Incomplete auditory hallucinations Assaultive

Thought broadcasting

(Feeling down in the dumpy D Fecal smearing

Mutism, posturing, catalepsy Feels worse in morning; better

84.

Criteria for Mania: (all of the following)

(§”ts in a chair all d 0 D

·n evenin

Doing too many things at once in

All the non-circled items are consistent with the diagnosis of affect- ive disorder, particularly mania.

1. Hyperactivity

2. Rapid/pressured speech

3. Irritable/euphoric mood

4. No emotional blunting

5. No coarse brain disease, no psychostimulant drug abuse in prior

month, no systemic illness known to cause manic symptoms

301

a rapid impulsive manner M Singing ancing

(Anxious mooiD D

Jumping from topic to topic

Impulsive

(?eelings of being dea4) D

85.

List all the diagnostic criteria we have used for depression. Al- though there is always room for improvement, and other sets of cri- teria (50,147) (similar but not identical) are in use, those you have learned are reasonably reliable and have been partially validated by clinical treatment response ( 1, 5, 8, 9, 154, 157) , laboratory data ( 2, 4, 12,153,156), and family illness pattern (5,151,154).

Schizophrenia

86.

There are a number of differing points of view about the signs and symptoms which define schizophrenia as a syndrome. Some psy- chiatrists (94) even say that schizophrenia cannot be defined accord- ing to criteria and is not a disease or a syndrome.

However, many researchers have felt the need to develop sets of criteria to differentiate the behaviors seen in affective diseases from those produced by other conditions and from those observed in schi- zophrenics. The criteria which you will learn to use in this section are reasonably reliable and have the advantage of having been, in part, validated by laboratory data ( 2, 3,153, 156) clinical presentation ( 5, 152, 154), treatment response ( 5, 154) and family illness patterns (5,152,154).

The number of people called “schizophrenic” decreases dramatic- ally when diagnostic criteria for schizophrenia are refined and subjec- ted to tests for reliability and validity ( 159).

Under the relatively old standard diagnostic criteria for schizo- phrenia, nearly 40 percent of all psychiatric admissions were labeled schizophrenic (166). (Some hospitals obviously using the grab-bag approach achieved a 100 percent score!) With the more refined and relatively new research diagnostic criteria, the diagnosis of schizo- phrenia is made in only 5 to 10 percent of all acute psychiatric admis- sions (159). This suggests a dramatic drop in the estimated morbidity risk (EMR) for schizophrenia in the general population: from 1 per- cent to 0. 3 percent ( 141 pp. 11-12, 159). For affective disorders, the EMR is about percent. Compare this figure with those for schizc phrenia. Which diagnosis are you most likely to make most frequently?

In hospitals that use the diagnostic criteria I will be discussing

(or similar criteria), the diagnosis of affective disorder is made in about 25 percent of acute admissions. Schizophrenia is diagnosed in 5 to 10 percent of the admissions (110,151,159). In England and Scot- land where comparison studies have been made (38,89), affective dis- ease is also the more frequent diagnosis. Many U.S. hospitals have much looser criteria (or different concepts); in those hospitals, the figures mentioned above are reversed. What is the estimated general population morbidity risk for affective disorder and for schizophrenia using modern research criteria?

87.

302

85. Criteria for Depression (all of the following)

86.

2, affective disorders

87.

2 percent for affective disorder, 0. 3 percent for schizophrenia

1. Sad or anxious mood

2. Three of the following:

a. early a.m. waking

b . diurnal mood swing (worse in a.m.)

c. more than 5 pound weight loss in 3 weeks

d. psychomotor retardation/agitation

e. suicidal thoughts/behavior

f. feelings of guilt, self-reproach/hopelessness/worthlessness.

3. No coarse brain disease or use of steroids or reserpine in the past month, no systemic illness known to cause depressive symptoms

303

88.

The criteria for schizophrenia are the following:

All four are required:

1. No diagnosable affective disorder

2. No coarse brain disease or hallucinogenic stimulant drug use or systemic illness known to cause psychiatric symptoms

3. Clear consciousness

4. One of the following is required

a. Emotional blunting

b. Formal thought disorder

c. First rank symptom (any one)

Which of the above criteria is most similar to those used for depres- sion and mania?

We have defined pathognomonic to mean a sign or symptom that occurs in only one condition. There are no pathognomonic signs in psychiatry. Thus, although the required presence of emotional

_ _ _ _ _ _ ,formal and—–,-,—- —-;—-;-=-:-:——-.. symptoms (required as inclusion criteria) increase the probability of valid diagnosis for schizophrenia, you must also consi- der the criteria which preclude the diagnosis (exclusion criteria) be- cause other disorders, such as temporal lobe epilepsy (42) also can present with schizophrenic symptoms.

The inclusion criteria for the diagnosis of schizophrenia are

—-,———-‘ and ———— symptoms.

In Part I, we discussed how the global impression of emotional blunting can be separated into component parts which are more easily evaluated during a mental status examination. Constricted range and decreased intensity are two component parts of emotional blunting. List as many others as you can recall:

The facial appearance in patients with emotional blunting is char- acterized by: ————-

Patients with emotional blunting speak in an unvarying ——- voice.

Patients with emotional blunting are often seclusive, avoiding so- cial contact and are indifferent to their surroundings (hospital staff,

visitors, relatives, physical environs).

“How do you like it here in the hospital?” “Did you enjoy your visit with your family?”

These are questions which will often produce apathetic responses.

range and a

face, voice.

89.

90.

91.

92. 93. 94.

Emotionally blunted individuals have a

intensity of affect. They have an

——e y e s and they speak in a

304

88. 2. Coarse brain disease, drugs and systemic illness can each produce manic, depressive and schizophrenic syndromes.

89. blunting, thought disorder, first rank

90. emotional blunting, formal thought disorder, first rank

91. expressionless face, unblinking eyes, monotonous voice, no expressed concern for loved ones

92. an expressionless, unblinking look

93. monotonous

94. constricted, decreased, expressionless, unblinking, monotonous or unvarying

305

95.

96.

97.

Emotionally blunted individuals often are indifferent to, and ex- press little affection for their family and friends. This emotional in- difference leaves them unconcerned for their present situation and without plans or desires for the future. When asked how they feel a- bout being in the hospital, or how they would feel if they had to re- main hospitalized for many months, patients respond, “Well, I suppose I’ll have to,” “It’s o.k. being here,” “Well, I don’t like it, but what can I do?”. Once again, list as many characteristics of emotional blunting as you can.

Circle the words or phrases associated with emotional blunting.

Apathetic mood

Labile affect

Grandiose, euphoric mood Monotonous voice

Profound sadness Constricted affective range Expressionless face Friendliness

Check the words or phrases associated with emotional blunting.

Spending all day staring at the T.V. , has little to do with other patients

Appears indifferent to being hospitalized and has no future plans

Stays by himself, but is not sad

Greets all the visitors to the ward with a big “Hello”

Wants to help the hospital staff, is liked by all

Cries when a fellow patient suffers a heart attack

Laughs shallowly without humor

306

95. constricted range, decreased intensity of affect, expressionless face, unblinking eyes, monotonous or unvarying voice, indifferent to and

without affection for family and friends, unconcerned for their present situation, without plans or desires for the future.

96. qpathetic mooV Profound sadness

abile affect Constricted affective range

97.

Grandiose, euphoric mood Ex ressionless face @onotonous voi<§) Friendliness

Spending all day staring at the T.V. , has little

to do with other patients I

Appears indifferent to being hospitalized and has I no future plans

Stays by himself, but is not sad I Greets all the visitors to the ward with a big

“Hello”

Wants to help the hospital staff, is liked by all

Cries when a fellow patient suffers a heart attack

Laughs shallowly without humor I

307

98.

In Part I we discussed formal thought disorder and how the pre- sence of these phenomena increases the probability of the diagnosis

of schizophrenia. Make a written list of the formal thought disorders and when appropriate, draw the little “box-diagrams” to depict each. Define the formal thought disorders that do not lend themselves to the diagrammatic description.

308

98. A. Verbigeration (palilalia)

[}JI}]QJ[TI[II~ .Goal

Stereotyped repetition of assoc- iations at end of phrase or sen- tence.

.Goal

New words

Imprecise but closely related word, e.g., “writer” for “pen”

Double talk. Syntax is intact but speech has no meaning.

(sudden switch from one associa- tional line to a new parallel line)

Verbal response totally unrelated to stimulus question or statement

Automatic usage of stock words or phrases often without meaningful connections to associational stream of thought.

B. Talking past the point (tangential speech)

c. Neologisms

D. Word approximations

E. Drivelling speech (jargon agrammatism)

F. Derailment

G. Non-sequitur H. Perseveration

[!][!I@I}]II](KJ(]]~ .Goal If you had difficulty with 97 and 98, please go back to Part I and

review the section on Thought and Speech.

309

99.

In Part I, we discussed the first rank symptoms of Kurt Schneider List these and briefly define each.

100.

101. 102.

103.

104.

Patients often have secondary delusional ideas involving telepathy, electronic surveillance, or power rays, to explain how their thoughts escape aloud from their heads so that others can hear them. This is the phenomenon of ________ ———

When a patient tells you something the content of which suggests apophany, you should ask the basic question ” ?”

Once a patient has told you some of the details of his apophanous ideas, you can progress smoothly to the examination of first rank symp· toms. If a patient responds positively to the question “You mean to

say that you feel your thoughts leaking out of your head and they

are as loud as my voice?” , he is admitting to the first rank symptom of

A 33-year-old man said his wall paper was filled with “radioactiv- ity” which “took over” his body and made him do things against his

will. He was experiencing the Schneiderian

_________ symptom of ———–

An irritable 35-year-old man complained that someone had bitten him in his leg and that the bite had injected “things” into his body which he could “feel” in his head and chest. These “things” were mak- ing noise and preventing him from concentrating. This man’s com- plaint is an example of an . His belief that someone had placed these 11things” in him by b1tmg him

on the leg is an example of a

delusional idea.

310

99. A.

Phonemes (complete auditory hallucinations)

Clearly audible voices, sustained and perceived as coming from “outside” the self. ·

B. Thought broadcasting

The subjective, literal experience of feeling one’s thoughts escap- ing aloud from one’s head into the air for all to hear.

C. Experiences of influence

The subjective, literal experience of feeling oneself being con- trolled by some “outside” force or agency.

D. Experiences of alienation

The subJective, literal experience of feeling parts of one’s body, or thoughts or feelings as being foreign bodies in no way connec- ted to the self.

E. Delusional perceptions

The interpretation of a real perception into a personalized sig- nificant but arbitrary meaning. There is no meaningful connec- tion between the real perception and the conclusion.

If you had any difficulty with this question, please return to Part I and review the section on First Rank Symptoms.

100. thought broadcasting

101. “How do you know?”

102. thought broadcasting

103. first rank, experience of influence

104. experience of alienation, secondary

311

105.

The 35-year-old man in the previous item also clearly heard voices coming from the “things” in his head and chest. These voices constan ly commented upon his actions and often repeated his own thoughts. This is an example of a –

106.

Draw lines between matching items in the two columns:

107.

As we discussed in Part I, schizophrenia and affective disorders have several symptoms in common. Hallucinations, delusions, catatonic motor features and first rank symptoms can occur in both groups of patients (5,24,88,109,143,147,152,154,157,158,177). To assure a more distinct separation of groups and thus a higher probability of diag-

108.

Match the clinical item to the disorder in which it is most commonly observed by placing a check mark in the appropriate box (more than one checked category for any thought disorder is possible).

Thought broadcasting Phoneme

“Someone is putting his thoughts in my head.”

Experience of alienation

Complete auditory hallucination

nostic accuracy for each patient, the schizophrenic exclusion criterion of: “no diagnosable affective disorder” is used. If the patient has suf ficient symptoms to satisfy the criteria for depression or mania, it is preferable to diagnose affective disorder even when there are some signs of schizophrenia present. It is always better to be a therapeutic optimist and first treat the condition with the better outcome (affective disease). Research data support the validity of the precedence of af- fective symptoms over schizophrenic symptoms (1, 3, 5-7,24, 25,87, 90, 96,110,150,154,155,157,158,176).

Drivelling Flight-of-ideas Perseveration Non-sequiturs Derailment

Clang associations Paraphasia Tang-ential speech Circumstantial speech Blocking- Verbigeration

312

Mania

Schizophrenia

“My thoughts came out of my hea• like a radio.”

105.

complete auditory hallucination or phoneme

106.

Thought broadcasting Phoneme

“Someone is putting his thoughts in my head.”

107.

No answer required

108.

Mania

Schizophrenia

Experience of alienation

Complete auditory hallucination

Drivelling- Flight-of-ideas Perseveration

Non- sequiturs Derailment

Clang- associations Paraphasia

Tang-ential speech Circumstantial speech Blocking- Verbil;reration

.;

“My thoughts came out of my head like a radio.”

I

I wnn Ingnt- l

of-ideas I I

I

I

I I

313

I I

I

109.

Circle the words or phrases satisfying any of the diagnostic criteJ for schizophrenia:

110.

Circle the words or phrases satisfying any of the diagnostic critei for schizophrenia:

111.

Circle the words or phrases satisfying any of the diagnostic criter for schizophrenia:

112.

Circle the words or phrases that would exclude the diagnosis of schizophrenia :

113.

Are sufficient criteria for the diagnosis of schizophrenia satisfied in the following case vignette? If not, which one( s) is/are not satis- fied and why?

Hyperactivity

Emotional blunting Psychomotor retardation

Flight-of-ideas

First rank symptoms

No coarse brain disease Euphoric

Delusions and hallucinations

Talking past the point (tangential speech)

Irritability Perseveration Agitation

Thought broadcasting Feelings of hopelessness

Delusional perception

Seizures

No affective disease Labile affect Experience of influence Head trauma

Comatose

Warm and friendly Catalepsy Paraphasia Phoneme

Thought disorder Encephalitis

Clouded consciousness LSD use

Lack of emotional warmth, drive or interest

Neologism

Brain tumor

Memory deficit with adequate con· centration

A 43-year-old man was hospitaliz8d because of t:>epeated calls to the police. During admissions, he insisted that his house was go- ing to be bombed. When you examine him, he is ll.lert and cooper- ative. He is mildly irritable, expresses no warm feelings concern- ing his family and does not relate to you. He has multiple delu- sional ideas. His speech includes talking past the point, several neologisms, paraphasia and several episodes of derailment. Pseu- domemories are present, but no other memory disturbances can

be observed. He exhibits no signs of affective disorder, physical examination and laboratory findings are within normal limits and he has no history of drug abuse or systemic illness.

314

109.

Hyperactivity

Flight-of- ideas

@ s 1 rank symptoms)

Delusions and hallu- cinations

Talking past the point (tangential speech)

Irritability (ferseveration)

A ‘tation

Delusional perception

~motional blunting) Psychomotor retardation

C.No coarse brain disease) Euphoria

(Thought broadcasting) Feelings of hopelessness

(Lack of emotional warmth, drive or interesf Seizures

Comatose (Neologism) Brain tumor

Memory deficit with adequate concentration

110.

111. (No affective diseasi) Labile affect

~perience of influenc”V Heaa trauma

112. (i\larm and friendly) Catalepsy

Paraphasia Phoneme

113. Yes. Even though he has no first rank symptoms, his formal thought disorder and emotk•nal blunting, in clear consciousness and in the absence of coarse brain, systemic disease or affective disorder satis- fy sufficient criteria for the diagnosis of schizophrenia.

315

114.

Are sufficient criteria for the diagnosis of schizophrenia satisfied in the following case vignette? If not, which one(s) is/are not satis- fied and why?

A 44-year-old woman was hospitalized because she became bellige- rent. She is untidy but alert, paces, rocks and constantly moves her fingers. Her affect is constricted and profoundly blunted.

She has a paucity of speech, rarely responding with more than

one or two words. There is no evidence of formal thought disorde or first rank symptoms of Schneider. There are no signs of affec- tive disease or memory dysfunction. Physical examination and laboratory findings are within normal limits and there is no his- torical evidence of coarse brain disease, drug abuse or systemic il While hospitalized she remains, except for brief periods of irritabil aloof, placid and generally unresponsive to staff, other patients, c ward activities.

Are sufficient criteria for the diagnosis of schizophrenia satisfied in the following case vignette? If not, which one(s) is/are not satis- fied and why?

A 20-year-old man is hospitalized because of threatening behavior. He is easily “upset.” He often laughs for no obvious reason, also snarls and makes gestures like those of a dog. He has attempted to bite people.

115.

116.

Are sufficient criteria satisfied for the diagnosis of schizophrenia in the following case vignette? If not, which one(s) is/are not satis- fied and why?

A 40-year-old woman is hospitalized because of her constant com- plants to the police that she’s been hearing voices in her attic. When examined, she is alert and cooperative, though mildly irrita- ble. She speaks in a monotone, has little emotional spontaneity

and relates poorly to the examiner. Affective range is restricted, intensity decreased and little warmth can be elicited, even when

she talks about her children. She describes several clear voices coming out of her attic which persist throughout the day. She attributes this to some person sending a ray to her TV antenna. Her speech is stilted (overly formal, somewhat dysrhythmic). Para phasias are present. There is no evidence of affective disorder OI memory dysfunctions. Physical examination and laboratory findingE are within normal limits and there is no evidence of drug abuse, coarse brain disease or history of systemic disease.

On initial examination, he was mute, immobile and analgesic. Cata· lepsy was present. A second examination performed when he is alert and no longer stuporous reveals him to have severe emotion- al blunting, paraphasic speech, and complete auditory hallucina-

tions. Physical examination reveals evidence of an old craniotomy. The patient had had a head injury as a child and suffered a sub- dural hematoma which required evacuation.

316

114. Yes. In the absence of coarse brain disease, medical illness and af- fective disease, the presence of severe emotional blunting, even with- out formal thought disorder or first rank symptoms, shows a high probability that this patient has schizophrenia.

115. No. He has emotional blunting and formal thought disorder, but the exclusion criteria are not satisfied. This is an example of secondary or symptomatic schizophrenia. That is, the patient has the syndrome but with an obvious etiology (head injury).

The schizophrenia we have been discussing contrary to this case is idiopathic. No one knows the etiology.

116. Yes. Sufficient criteria are satisfied for the diagnosis of schizo- phrenia.

317

117.

Match the diagnostic criteria with the diagnosis by writing the let· ter of the criterion in the space provided next to the appropriate dis- order.

118.

Match the diagnostic criteria with the diagnosis by writing the let- ter of the criterion in the space provided next to the appropriate dis- order.

a. Feels terrible in a.m. , better in afternoon

b. Cries all the time

Mania ———————– c. No emotional rapport d. Euphoric

Depression —————— e. Delusional idea of being evil

Mania ———————–· Depression__________________

Schizophrenia _____________

a. Formal thought disorder b. AnxiousIsad mood

c. Psychomotor retardation d. No coarse brain disease e. First rank symptoms

f. No systemic illness known to produce similar picture

g. No drug abuse in month prior to symptom onset

h. Euphoria

i. Hyperactivity

Schiziphrenia _______________

f. Tangential speech

g. Jargon agrammatism

h. Hyperactivity

i. Slowed speech/motor behavior j. Talks too much and too fast

318

117.

Mania d, f, g, h,

a. Formal thought disorder b. Anxious/sad mood

c. Psychomotor retardation d. No coarse brain disease e. first rank symptoms

f. No systemic illness known to produce similar picture

g. No drug abuse in month prior to symptom onset

h. Euphoria

i. Hyperactivity

a. Feels terrible in a.m. , better in afternoon

b. Cries all the time

c. No emotional rapport

d. Euphoric

e. Delusional idea of being evil f. Tangential speech

g. Jargon agrammatism

h. Hyperactivity

i. Slowed speech/motor behavior j. Talks too much and too fast

118.

Depression b, c, d, f, g Schizophrenia a, d, e, f, g

Mania Depression Schizophrenia

a, b , e, c, f, g

d, h,

319

119.

Match the diagnosis criteria with the diagnosis by writing the let- ter of the criterion in the space provided next to the appropriate dis- order.

120.

k. Hyperactive

Over the years, schizophrenia has been classified into subgroups

121.

The variety of subgroups in the traditional view of schizophrenia reflects an attempt to identify the most characteristic feature of the subgroup. Thus, although observed to share many signs and symptom with other schizophrenics, “catatonic schizophrenics” were unlike othel schizophrenics in that they exhibited predominant catatonic features.

M a n ia ———— d. Anorexia with weight loss of 10 lbs. in 2 weeks

Depression _________ Schizophrenia _ _ _ _ _ _ _ _

e. Early a.m. insomnia

f. Speech rapid and pressured g. Not emotionally blunted

h. No coarse brain disease

i. Suicidal

j. Feels hopeless and worthless

labeled: “paranoid,” “catatonic,” “hebephrenic,” “simple, 11 “chronic,” “undifferentiated” and “schizo-affective” types (37). There is a grow- ing body of evidence that the “schizo-affective” type should not be considered part of schizophrenia (3,30,36,106,119,146,154,155,161,163 172, 173). Some researchers consider it a separate condition ( 172, 173) and others (30,36,106,119,146,161), including myself, consider most people with the diagnosis of “schizo-affective type” to have affective disorder. This theoretical problem will only be resolved by the clarif- ication offered by further data. For our purposes, the definite diag- nostic criteria we use and our therapeutic optimism suffice. A person who has signs and symptoms which satisfy the criteria for affective dis order does not, by definition, satisfy the criteria for schizophrenia and should be treated for affective disease. Individuals whose signs and symptoms approach but do not satisfy either set of criteria should first be treated for the condition with the best prognosis, i.e., affec- tive disorder.

There is no evidence th:1t patients ‘3atisf:,’ing the above criteria schizophrenia can be successfully separated into subgroups. They eitl have the condition or they don’t! A patient who satisfies the criteria f, schizophrenia is diagnosed as schizophrenic. Variations of other clinic; phenomena are secondary and not pathognomonic (152,159). List the criteria for schizophrenia.

320

a. Irritable, laughs and cries b. Neologisms

c. Thought broadcasting

119.

a. Irritable, laughs and cries

120.

No answer required

121.

All four required:

a, f, g, h, k Depression d, e, g, h , i,

c. Thought broadcasting

Mania

d. Anorexia with weight loss of 10 lbs. in 2 weeks

Schizophrenia

b , c, h

e. Early a.m. insomnia

f. Speech rapid and pressured g. Not emotionally blunted

h. No coarse brain disease

i. Suicidal

j. Feels hopeless and worthless k. Hyperactive

1. No diagnosable affective disorder

2. No coarse brain disease or hallucinogenic stimulant drug use or

systemic illness known to cause psychiatric symptoms

3. Clear consciousness

4. One of the following is required

a. Emotional blunting

b. Formal thought disorder

c. First rank symptom (any one)

321

b . Neologisms

122.

In the following case vignette, underline the words and/or phrase! which satisfy any diagnostic criterion. Are there enough criteria satis- fied to make a diagnosis? If so, what is your diagnosis?

A 39-year-old man was hospitalized because he had been banging on his neighbors’ doors in the early morning hours. He complainec to police that he couldn’t sleep because the neighbors were “heck- ling” him and “dictating” his every movement and action by a “jolt in the skull.” When you see him, the patient is cooperative and

fully alert. After initial irritability, he does not exhibit any mood His affect is restricted in range and he expresses little warmth.

He is concerned about his neighbors and “some wise guys” who are “out to kill” him, and he feels it is unfair that he has been hospi- talized. He has little interest in his wife (f.·om whom he is sepa- rated) or his two children. “They made their beds,” he says.

The patient often responds to questions by talking about the same subject but not to the point. Occasionally his answers are unre- lated to the questions. On those occasions, he uses the same words and phrases in his answer in an automatic fashion. He says that people are talking to him all the time. Their voices, some- times whispered, sometimes very loud, are being “plugged” into his ear. There is no evidence of sadness, euphoria, motor dis- turbance or coarse brain disease. Physical examination and labo- ratory findings are within normal limits and his history is negative for drug abuse or systemic illness.

In the following case vignette, underline the words and/or phrases which satisfy any diagnostic criterion. Are there enough criteria satis: to make a diagnosis? If so, what is your diagnosis?

A 49-year-old woman was hospitalized because she was repeatedly screaming “I don’t know what I’ll do…” and for staying in bed

all day staring at the ceiling, crying, not eating and not sleeping at night. When you examine her, she is lying in bed, fully alert but dishevelled and dirty. She refuses to speak, turns away from you and hides her head. A little while later she is somewhat more cooperative. Her movements and speech are markedly slowed. There is no agitation. Her affect is restricted in range and inten- sity. Her mood is sad. She says “there is no use, I can’t be helped…leave me alone, I want to die.” She admits to hearing a muffled voice and occasionally seeing shadowy threatening figures. Physical examination and laboratory findings are within normal limits and she has no history of drug abuse or systemic illness.

123.

322

122. A 39-year-old man was hospitalized because he had been banging on his neighbors’ doors in the early morning hours. He complained to police that he couldn’t sleep because the neighbors were “heckling” him and “dictating” his every movement and action by a “jolt in the skull.” When you see him, the patient is cooperative and fully alert. After initial irritability, he does not exhibit any mood. His affect is restricted in range and he expresses little warmth. He is concerned about his neighbors and “some wise guys” who are “out to kill” him and he feels it is unfair that he has been hospitalized. He has little interest in his wife (from whom he is separated) or his two chil~ “They made their beds,” he says. The patient often responds to questions by talking about the same subject but not to the point. Occasionally his answers are unrelated to the questions. On those occasions, he uses the same words and phrases in his answer in an automatic fashion. He says that people are talking to him all the time. Their voices, sometimes whispered, sometimes very loud, are being “plugged” into his ear. There is no evidence of sadness, euphoria, motor disturbance or coarse brain disease. Physical examination and

laboratory findings are within normal limits and his history is negative for drug abuse or systemic illness.

Yes.

Schizophrenia

He satisfies all the exclusion criteria and exhibits emotional blunting (some irritability can be present), formal thought disorder (talking past the point, or tangentiality, non-sequiturs, perseveration), first

rank symptoms (experience of control, phonemes).

123. A 49-year-old woman was hospitalized because she was repeatedly screaming “I don’t know what I’ll do…” and for staying in bed all day staring at the ceiling, crying, not eating and not sleeping at night. When you examine her, she is lying in bed, fully alert but dishevelled and dirty. She refuses to speak, turns away from you and hides her head. A little while later she is somewhat more coop- erative. Her movements and speech are markedly slowed. There is no agitation. Her affect is restricted in range and intensity. Her mood is sad. She says “there is no use, I can’t be helped…leave me alone, I want to die.” She admits to hearing a muffled voice and occasionally seeing shadowy threatening figures. Physical examina- tion and laboratory findings are within normal limits and she has no history of drug abuse or systemic illness.

Yes

Major Depression

The exclusion criteria are satisfied. She exhibits a sad mood, feel- ings of hopelessness, a desire to commit suicide and insomnia.

Although the classical sleep pattern of early a.m. wakening is most characteristic in a major depression, it is not uncommon for patients to have sleeping difficulties throughout the night.

323

124.

In the following case vignette, underline the words and/or phrase which satisfy any diagnostic criterion. Are there enough criteria satis- fied to make a diagnosis? If so, what is your diagnosis?

A 43-year-old man was hospitalized because he was becoming pro- gressively more seclusive and was putting metal screws into his legs. When you asked him about this he said “shorts …. electron- ics” and then became unintelligible. His sleep was disturbed but there was no weight loss or appetite change. The patient was co- operative and fully alert. His motor behavior was normal except for some facial tics. He often closed his eyes. He scratched his body in a purposeless way. His affective range and intensity wer

decreased. He was mildly irritable and apathetic. He was un- concerned about being hospitalized or about the welfare of his fam ily. He had no future plans. His speech was not pressured; it was mumbled and consisted mostly of nouns. When asked how he felt, he said “tipper, shorts….electronics…a blanket head is not yellow … ” His memory was intact. Physical and laboratory findings were within normal limits and his history was negative

for drug abuse and systemic illness.

In the following case vignette, underline the words and/or phrase’ which satisfy any diagnostic criterion. Are there enough criteria satisfied to make a diagnosis? If so, what is your diagnosis?

A 50-year-old woman sought consultation because of “nervousness’ and because she had thoughts about killing herself. During the preceding month she had lost interest in her work, spent progres- sively more time in bed, had difficulty sleeping throughout the night and had lost 20 pounds. There was no diurnal change in these behaviors. When examined, she was fully alert and cooper- ative. Her motor behavior was decreased in frequency and slow. Her affect was restricted, her mood sad. Physical examination and laboratory findings were within normal limits and her history was negative for drug abuse and systemic illness.

125.

324

124.

A 43-year-old man was hospitalized because he was becoming progres- sively more seclusive and was putting metal screws into his legs.

125.

He often closed his ey~s. He scratched his body in a purposeless

way. His affective range and intensity were decreased. He was

mildly irritable and apathetic. He was unconcerned about being hos- pitalized or about the welfare of his family. He had no future plans.

His speech was not pressured; it was mumbled and consisted mostly

of nouns. When asked how he felt, he sa1d “tipper, shorts….elec- tronics…a blanket head is not yellow…” His memory was intact. Physical and laboratory findings were within normal limits and his histor~ was negative for drug abuse and systemic illness.

Yes

Schizophrenia

He satisfies the exclusion criteria and exhibits formal thought disorder (drivelling speech/jargon agrammatism) and emotional blunting.

A 50-year-old woman sought consultation because of “nervousness”

and because she had thoughts about killing herself. During the pre- ceding month she had lost interest in her work, spent progressively more time in bed, had difficulty sleeping thr<?.U.S’.J:l~!_!!1~.!8:!!t and

had lost 20 pounds. There was no diurnal change in these behaviors. When examined, she was fully alert and cooperative. Her motor behav- ior was decreased in frequency and slow. Her affect was restricted, her mood sad. Physical examination and laboratory findings were within normal limits and her history was negative for drug abuse and systemic illness.

Yes

Major Depression

She satisfies the exclusion criteria and exhibits sadness and anxiety, psychomotor retardation, insomnia, weight loss and suicidal thoughts.

When you asked him about this he said “shorts.•.electronics” and then became unintelligible. His sleep was disturbed but there was no weight loss or appetite change. The patient was cooperative and fully alert. His motor behavior was normal except for some facial tics.

325

126.

In the following case vignette, underline the words and/or phrasE which satisfy any diagnostic criterion. Are there enough criteria satisfied to make a diagnosis? If so, what is your diagnosis?

A 25-year-old man was hospitalized because he was extremely agi- tated, overtalkative and “incoherent.” He was not sleeping and had lost “a great deal of weight.” He was dishevelled but fully alert. He talked continuously and was unable to sit still. He spoke rapidly in a dramatic matter, jumping from topic to topic. His mood was euphoric. During his first few days in the hospital he was constantly engaging staff members in conversation, asking the same questions over and over again. He danced and sang in the hallways. He decorated his head with bits of paper and cloth He ran from one ward activity to another, rarely completing a tasl before starting a new one. He said people communicated with him by their movements and the clothing they wore; that a nurse usin green ink was a sign that he was the “Son of God”; that God spoke to him through the rays of the sun. The patient spoke on several occasions for minutes on end using words that rhymed wit sun: “I am the son, see the sun, see a bun, hi hon’, hi honey bun … ” Physical and laboratory findings were within normal lim- its and he had no history for drug abuse, coarse brain disease, o systemic illness.

In the following case vignette, underline the words and/or phrase which satisfy any diagnostic criterion. Are there enough criteria satisfied to make a diagnosis? If so, what is your diagnosis?

A 28-year-old woman was hospitalized because she kept saying “God is punishing me. I am a bad girl.” During the few weeks before admission she became increasingly restless, did not sleep well, ate excessively and smoked constantly (which was unusual for her). She began to complain that people were talking about her being a “bad mother.” She said God spoke to her. The voice was described as clear, coming from above and constant. At time! she seemed fearful and hid behind furniture; at other times she giggled and laughed for no apparent reason and walked about witl: cigarette ashes on her head. Just prior to hospitalization she was observed hopping and jumping about, then holding her arms and hands in a strange prolonged position and then kneeling down to pray. When you first examined her, she became angry, agitated and threw things about the room. Later, she walked up and down the corridors, disrobing, masturbating, screaming, punching dom talking to the walls, going from one activity to the next, interrup1 ing conversations, talking non-stop and rapidly. Physical exam- ination and laboratory findings were within normal limits and she

had no history of coarse brain disease, drug abuse or systemic illness.

127.

326

126.

A 25-year-old man was hospitalized because he was extremely agitated, overtalkative and “incoherent.” He was not sleeping and had lost “a great deal of weight.” He was dishevelled but fully alert. He talked continuously and was unable to sit still. He spoke rapidly in a dra- matic manner, jumping from topic to topic. His mood was euphoric. During his first few days in the hospital, he was constantly engaging staff members in conversation, asking the same questions over and over again. He danced and sang in the hallways. He decorated his head with bits of paper and cloth. He ran from one ward activity to another, rarely completing a task before starting a new one. He said people communicated with him by their movements and the clothing they wore; that a nurse using green ink was a sign that he was the “Son of God”; that God spoke to him through the rays of the sun.

127.

A 28-year-old woman was hospitalized because she kept saying “God

is punishing me. I am a bad girl.” During the few weeks beforead- mission she became increasingly restless, did not sleep well, ate ex- cessively and smoked constantly (which was unusual for her). She began to complain that people were talking about her being a “bad mother.” She said God spoke to her. The voice was describeClas ~coming from above and constant. At times she seemed fearful and hid behind furniture; at other times she giggled and laughed for

no apparent reason and walked about with cigarette ashes on her

head. Just prior to hospitalization, she was observed hopping and jumping about, then holding her arms and hands in a strange prolonged position and then kneeling down to pray. When you first examined

her, she became angry, agitated and threw things about the room. Later, she walked up and down the corridors, disrobing, masturbat- ing, screaming, punching doors, talking to the walls, going from one activit to the next, interru tin conversations, talkin non-stop

and rapidly. Physical examination and laboratory indings were with- in normal limits and she has no history of coarse brain disease, drug abuse or systemic illness.

The patient spoke on several occasions for minutes on end using words that rhymed with sun: “I am the son, see the sun, see a bun, hi

hon’, hi honey bun •.. ” Physical and laboratory findings were within normal limits and he had no history for drug abuse, coarse brain disease or systemic illness.

Yes

Mania

He satisfies the exclusion criteria and exhibits rapid/pressured spee~h, euphoria and hyperactivity. He also has flight-of-ideas and clang associations.

His possible delusional perception, delusional ideas, auditory halluci- nations, head decoration, singing, dancing, impulsive, intrusive and importunate behaviors are all seen in manic episodes ( 24, 88, 96, 157, 177).

Yes

Mania

She satisfies exclusion criteria and exhibits rapid/pressured speech, hyperactivity (an excitement state) and an irritable mood. Her cata- tonic features, nudity, agitation, violence, public masturbation

are all observed in severe mania (24, 86,98,157, 177).

327

DIAGNOSTIC CRITERIA – SUMMARY

128.

The following table was presented in Part I and summarizes the observed relationships between the thought disorders we have ex- amined and several major psychiatric conditions. These thought disorders are not pathognomonic (the tabled relationships are not absolute), but the presence of any one is suggestive of the condi- tion in which it is most frequently observed.

Chronic Mild-Moderate Mania Catatonia Schizophrenia Coarse Brain Disease

Verbigeration

Clang assoc- iations

Tangential speech

Fragmented speech

Word salad

Word approx- imations

Neologisms

Circumstantial speech

X

X

X

X

X

X X

X X XX X X

X X X X

X

Circle the thought disorders which satisfy the diagnostic criteria you have been studying for schizophrenia.

328

128. Chronic Mild-Moderate Mania Catatonia SchizoJlhrenia Coarse Brain Disease

Verbigeration X lXJ X

Clang assoc- h…tions

Tangential speech

X

Fragmented

speech X X X X

Word salad 00 X

Word approx- ® imations

X Neologisms lXJ X

Circumstantial

speech X X

Phenomena in the Catatonic column are not circled because although they fit the diagnosis of “Catatonia,” we have learned that catatonia is not a disease, but a syndrome associated with affective disorder, schiZophrenia and coarse brain disease.

329

®

X

129.

Place a check mark in the appropriate box to indicate into which mental status section each behavior item best fits. Circle the check~ which satisfy diagnostic criteria and put the first letter of the assoc· iated disorder next to the circled check (M -Mania, D – Depression, S – Schizophrenia) .

Tardive dyskinesia Stupor

Grimacin~r

Manner

Clear consciousness

Bluntin~r

Posturing-

Body type Waxy flexibility Ag-itation

130.

Place a check mark in the appropriate box to indicate into which mental status section each behavior item best fits. Circle the checks which satisfy diagnostic criteria and put the first letter of the asso- ciated disorder (M -Mania, D -Depression, S -Schizophrenia)

next to the circled check.

Clang association

Hyperactivity

Posturing-

Flight-of-ideas

Verbig-eration

Intense affect

Lability of mood

Euphoria

Tangential speech

Irritability Sadness Unkempt clothes

General General

Appearance Motor Behavior Catatonia Affect

General General Thought Appearance Motor Behavior Catatonia Affect Disorder

330

129.

General General

Appearance Motor Behavior Catatonia Affect

Tardive dyskinesia Stupor

Grimacing

Manner

y

Clear consciousness Blunting

Posturing

Body type

V>s y

{

\.OS

Waxy flexibility Agitation

y

130.

General

Clang association Hyperactivity Posturing Flight-ot”-ideas Verbigeration Intense affect Lability of mood Euphoria Tangential

\..OM

{ {

I !.

speech Irritability Sadness Unkempt clothes

~ 0s \,OM

.i

I

(acceptable) .;

~D

General

Appearance Motor Behavior Catatonia Affect Disorder

{

~D

If you circled any of the others (except “unkempt clothes”) and in- dicated an “M” or “D”, you would have been correct in the sense that these phenomena are often seen in affective disease. However, they are not specific diagnostic criteria.

331

I .1._

(OS

V)M

Thought

Place a check mark in the appropriate box to indicate into which mental status section each behavior item best fits. Circle the checkf which satisfy diagnostic criteria and put the first letter of the assoc iated disorder (M – Mania, D – Depression, S – Schizophrenia) next to the circled check.

131.

Thin

Agitated

Echolalia

Grimacing

Dishevelled

Labile affect

Anxiety

Rambling speech

Non-sequiturs

Irritability

Clouded con- sciousness

Perseveration of associations

General General Thought Appearance Motor Behavior Catatonia Affect Disorder

332

131.

Thin

Agitated Echolalia Grimacing Dishevelled Labile affect Anxiety Rambling speech Non-sequiturs Irritability Clouded con- sciousness Perseveration of

associations

General General Thought Appearance Motor Behavior Catatonia Affect Disorder

I

.,

I

“-i}D

.,

I

Clouded consciousness although not a criterion does exclude the diagnosis of the major psychoses: depression, mania and schizo- phrenia.

333

J.. COD

!,Q_S

\.,OM

G)s

i..

Place a check mark in the appropriate box to indicate into which mental status section each behavior item best fits. Circle the checks which satisfy the diagnostic criteria and put the first letter of the associated disorder (M – Mania, D – Depression, S – Schizophrenia) next to the circled check.

Gen. Motor Thought Appearance Behavior Catatonia Affect Disorder Apophany

Hyperactive

Flight-of- ideas

Posturing

Delusional perception

Heavy body build

Singing and dancing-

Secondary delusional ideas

40-year-old woman

Clang associ iations

132.

Euphoria

Self-expo- sure

334

132.

Euphoria Self-expo-

sure Hyperactive Flight-of-

ideas Posturing Delusional

perception Heavy body

build Singing and

dancing Secondary delusional

ideas 40-year-old

woman

Clang associ iations

Gen. Motor Thought Appearance Behavior Catatonia Affect Disorder Apophany

I

I

I

— —

Q)s

I I

I

I

acceptable

(0M

Again, though the other phenomena are not diagnostic criteria, they can occur most frequently in affective disorder, particularly mania.

335

I

I

~M

133.

Place a check mark in the appropriate box to indicate into which mental status section each behavior item best fits. Circle the check: which satisfy diagnostic criteria and put the first letter of the assoc iated disorder (M – Mania, D – Depression, S – Schizophrenia) next to the circled check .

Delusional perception

Delusional mood

Delusional ideas

Hyperac- tivity

Incomplete auditory hallucina- tion

Flight-of- ideas

Irritability

Autochtho- nous delu-

sional ideas

Clang asso6- iations

Euphoria Sadness Posturing

General Appear-

ance

Percep-1 First Motor Thought tual Dys- Rank

Behavior Affect Process Apophany fu;1ct. Symptom

336

133.

Delusional perception

Delusional mood

Delusional ideas

General Appear-

ance

Percep- Motor Thought tual Dys-

Behavior Affect Process Apophany funct. Q s

First

Rank Symptom

Q s

Hyperacti- vitv

QM

Incomplete auditory hallucina- tion

I

Flight-of- ideas

Irritability Autochtho-

nous delu- sional ideas Clang assoc-

iations Euphoria Sadness Posturing

[(.{)M

WM

!,.OD

I

I

337

I I

I I

134. Place a check mark in the appropriate box to indicate into which mental status section each behavior item best fits. More than one check per symptom is possible.

Delusions

Violence

Inappropriate mood

Thought dis- order

Poor personal hygiene

Tardive dys- kinesia

Agitation

Loose assoc- iations

Illusions

Hallucinations

Persecutory delusions

Bizarre be- havior

Mania Catatonia Schizophrenia Coarse Brain Disease

338

134.

Mania Catatonia Schizophrenia Coarse Brain Disease Delusions -1 I I I

Violence I I I I

Inapproprmte

mood I .; I I

Thought dis-

order I j I j

Poor personal

hygiene j j j j

Tardive dys- kinesia

Aintation Loose assoc-

iations Illusions Hallucinations Persecutory

delusions Bizarre

behavior

IIII

I .; IIII

I .; I I

I I I I

I I

I j

.; j j

I

This item demonstrates the relative worthlessness of imprecise terms and descriptions. Precise description of each of the phenomena might have allowed you to assign them to particular columns. In diagnosis, the same principle applies. The more precise your descriptions, the more likely you are to make a correct diagnosis.

339

II

COARSE BRAIN DISEASE

135.

The DSM-III term “organic mental disorder” will not be used

in this text as it implies the existence of “inorganic” or metaphysical brain syndromes, a notion which is contrary to basic biology and

the generally accepted idea that the brain is the organ of behavior and that all behavior–pathological, deviant and normal-reflects

brain function. As a substitute for the DSM-III term, I will use “coarse brain disease” to label clinical conditions which have demonstrable etiology or pathophysiology. These brain disorders are “coarse” in that their pathology is measurable with present technology. They contrast with other mental disorders in which

the pathology is not yet measurable and in which the etiology or pathophysiology is unknown.

About one out of five patients hospitalized on an acute psychia- tric inpatient service has coarse brain disease ( 159,166, 169). In acute general medical surgical units approximately one out of nine patients has coarse brain disease (111,169,170), usually a subacute delirium. By convention, a delirium refers to a process which is .-…–.–.-.—- in onset, and unlike the dementias, its response to treatment is usually ________

The variety of acute and chronic coarse brain syndromes is too great to be completely detailed in this text. I will discuss only a few conditions, more as illustrations of the diagnostic process than as comprehensive presentations of differing disorders. I will not discuss the coarse brain disease affecting children. This important area is beyond the scope of this book. It deserves a volume of its own.

Pathological processes resulting in coarse brain disease can pre- sent as delirium, localized syndromes, or dementia. These condi- tions are not pathognomonic; single etiology can present as all three during the course of the illness. Although a detailed mental status, neurological and physical examination can narrow the possibilities,

a detailed history and laboratory investigation are essential for rea- sonable diagnostic accuracy (169).

136.

137.

340

135. rapid, good

136. No answer required

137. No answer r<!quired

341

138.

Many non-etiological factors influence the picture of a coarse brain disease process. Thus a single morbid process can produce a localized brain syndrome, an acute diffuse brain syndrome termed

_ _ _ _ _ _ _ _ , and a chronic diffuse brain syndrome termed

139.

Both the speed at which the morbid process involves the brain and the extent of the process can determine whether a neuro-virus, for example, will produce an acute diffuse process termed a

140.

Individual predisposition (vulnerability) can also determine the clinical presentation resulting from a morbid process. In a clinical presentation in which the brain vulnerability is great or the morbid process severe, an acute, diffuse process termed a

will often develop. ——-

141.

During the daylight hours, many delirious patients appear to

be without psychopathology. At night, however, what during the day was a mildly tired, somewhat restless patient becomes a confused agitated nursing problem that brings house staff running from all corners of the building. A search for mild hints of delirium during the day can save you and the patient a sleepless night. Circle the words and phrases below indicating non-etiological factors which

can influence the clinical picture of a coarse brain disease process:

142. 143.

The degree of cortical arousal will determine the clinical state or level of consciousness. List these different clinical levels:

144.

Patients with a reduced level of consciousness often appear perplexed and their eyes wander and fail to focus. When the deli- rium is pronounced they may also be lethargic. Write a brief des- cription of the behaviors of a lethargic patient.

145.

Delirious patients often appear confused and delayed in their responses. These behaviors reflect an underlying _ _ _ _ _

_r_a___,,._c_al…-iz_e_d~s-;n~r~~~~ic diffuse process termed _ _ _ _ _ _ _ _ _ 0 10

Rapidly spreading morbid process

Middle class

Localizing morbid process

Age and nutritional status of patient

Divorced with one child

Insidious onset

In all patients who are delirious, some degree of reduced cor- tical arousal (i.e. , alteration in level of consciousness) is present

( 43,45, 46, 170). Check the descriptions below which are consistent with an altered state of cortical arousal (i.e., level of consciousness:

Unresponsive even to painful stimulation Awake and appropriately answers all questions

Keeps falling asleep, occasionally fails to respond to examiner’s questions

Unresponsive to questions unless examiner shakes patient and shouts

342

138.

delirium, dementia

139.

140.

delirium, dementia

delirium

Age and nutritional status of patient**_.——-

Divorced with one child

* speed of process

** individual’s vulnerability *** localizing process

142. 143.

alertness, lethargy, semi-coma, coma

_/_Unresponsive even to painful stimulation

_ _ Awake and appropriately answers all questions

I Keeps falling asleep, occasionally fails to respond to examiner’s –questions

I Unresponsive to questions unless examiner shakes patient and –shouts

They have difficulty staying awake, keep on falling asleep and occa- sionally fail to respond to examiner’s questions.

Alteration in cortical arousal or reduced level of consciousness.

144.

145.

343

(Localizing morbid process*~ (!nsidious onsev

146.

147.

148.

149.

150.

151. 152.

An alteration in the level of consciousness makes the processin of incoming stimuli difficult. Delirious patients commonly misinter- pret the events about them, and are often suspicious and frightenE Because of their reduced level of consciousness, they often appear _______ and . Their responses are often

The following behaviors are observed in patients with an alter tion in consciousness except (circle your answer):

a. Perplexed

b. Lethargic and sleepy c. Confused

d. Rapid reaction time e. Delayed reaction time

Any intense mood can lead to increased frequency of motor be- havior termed . Delirious patients who are often anxious and occasionally terror-striken often demonstrate restlessness and an occasional severe increase in motor behavior, i.e.,

Because of their reduced,….,.=–.-,—–~~-~-,——~~—~ delirious patients often have difficulty listening to, retaming and understanding data. A deficit in immediate recall, short-term, and recent memory is common. Mrs. Jones who “just can’t seem to fol- low” your instructions regarding her medication schedule or dress- mg changes, etc., may not be a “bad patient.” Evaluate her cog- nitive functioning! One out of nine Mrs. Joneses on an acute gen- eral medical surgical unit is suffering from some coarse brain mor- bid process.

Circle the words or phrases characteristic of a delirious state.

Lethargic

Restless

Omega sign

Delayed reaction time Agitated

Emotional blunting

Perplexed and suspicious Talks too much

Confused

Sleepy

Fully awake

Recent memory deficit

_______ , or fail to occur at all.

Three days after bowel surgery, over the course of a day, a patient becomes restless. She picks at her bed clothes and constan lytriestogetoutofbed. Mostlikelyshehasa——-

In conjunction with restlessness and agitation and a picture of “confusion,” patients with acute diffuse cerebral dysfunction or a –~,—=-o—o– often exhibit signs of sympathetic nervous system arousal. Their pulse is rapid; they are cold and clammy (periphera vasoconstriction and increased sweating) ; they may hyperventilate; and they may have increases in blood pressure. Although cold – clamminess – rapid pulse – lethargy often signal “shock,” they just as frequently imply ———

344

146.

perplexed, lethargic, confused, delayed

147.

a. Perplexed

b. Lethargic and sleepy c. Confused

148.

agitation, agitation

149.

level of consciousness

150.

(Perplexed and suspicio~ Talks too much

151. 152.

delirium, delirium

0

Rapid reaction time e. Delayed reaction time

Omega sign

Emotional blunting delirium

Fully awake

~ecent memory defic~

345

153.

154.

155.

Delirious patients often misinterpret stimuli. A group of doctor~ and nurses discussing another patient become a conspiring group

out to harm the delirious patient; shadows become menacing figures; changes in the daily routine become threats. Secondary delusional ideas can develop. Misinterpretation of actual real stimuli termed

_ _ _ _ _ _ _ , and perceptions without real stimuli termed

are not uncommon. Delirious patients hallucin-ate in all -se_n_s_o_r_y_m_o_d-o-alities. The most common sensory modality involved is visual.

The perception of vague unformed sounds or lights without a real stimulus is an . A hallucination that only occurs when a particular sensory modality is stimulated is a These phenomena are not in- frequently observed in delirious patients.

Circle the words or phrases characteristic of a delirious state.

156.

157.

158.

159.

A 68-year-old man is brought to your clinic by his family becausE he has been shouting, not sleeping and saying “odd things that do not make sense.” The patient enters the examining room furtively, looking about him in a perplexed manner. Although his eyes are widely open and his pupils somewhat dilated, he fails to focus on you as you speak. He is sweating and pale and unable to sit still. Des- pite a note by a physician that says the patient is “schizophrenic” you suspect a _________________

Delirious patients are often irritable, anxious, or suspicious. The moods often shift rapidly. This rapid shifting from one muod to another, or , is characteristic of many coarse brain disease processes.

The patient in item #156 said odd things and did not make any sense when he spoke. The characteristic speech of delirium is un- connected associations which are non-goal directed. This is called

Generally irreversible

Restless

Diffuse

Severe anxiety

Acute

Elementary and functional hallucinations

Cannot focus well on incoming stimuli

Localized lesion

Deficit in short-term memory Chronic

Sympathetic arousal

Deficit in recent memory

disorder.

Diagram this thought process

Because of their reduced level of consciousness, delirious pa- tients almost always exhibit some cognitive dysfunction associated with the frontal lobes. Concentration and global orientation are us- ually affected. Write a sentence on how you would test for concen- tration and global orientation.

346

153. illusions, hallucinations

154. elementary hallucination (pseudo hallucination acceptable, but not as accurate)

functional hallucination

If you had any difficulty with this question, please review the per- ceptual function section in Part I, starting with item 261.

0annot focus well on incoming stimu~ Localized lesion

(Deficit in short-term memo!:V Chronic

Sympathetic arousal

156. Delirious state. (Upon examination, you discover the patient has had a myocardial infarction; he is hospitalized and treated; he should recover from both his infarction and his delirium.)

157. 158.

159.

lability of affect rambling speech

(Fragmented speech is an accep- table answer, but not as accu- rate)

GOAL

Concentration is tested by asking the patient to do serial 7’s, recall numbers forwards and backwards or spell simple 5-letter words back wards; global orientation is tested by asking the patient to give the date, day of the week, year, locale.

347

160.

Write an !VI next to each item most characteristic of mania, an S next to each ffem most characteristic of schizophrenia, aD next to- each item most characteristic of depression and a DLnextto each

161.

Write an !VI next to each item most characteristic of mania, an S next to each Hem most characteristic of schizophrenia, a D next to each item most characteristic of depression and a DLnextto each iter

162.

Write an !VI next to each item most characteristic of mania, an S next to each Hem most characteristic of schizophrenia, a D next to each item most characteristic of depression and a DL nextto each

163.

164.

An acute, diffuse, usually reversible coarse cortical disease proc w.ith some degree of reduced cortical arousal is termed a , – – – – – – – A chronic, diffuse, usually irreversible coarse cortical disease proce is termed a ________

When a person insidiously develops a diffuse cortical brain dys- function which is relatively unresponsive to treatment, he is said

to have a . This implies that pre-morbidly the person was functioning reasonably well but that since the onset of the mor- bid process deterioration of function has occurred.

item most characteristic of delirium. Early a.m. insomnia

Neologisms

Hyperactivity

Sympathetic arousal Euphoria

Perplexity

– Rambling speech

Flight-of-ideas Delusions of guilt First rank symptoms Lethargy _ _

Visual hallucinations

most characteristic of delirium.

Diurnal mood swing (worse in a.m.)

Clang associations Elementary hallucination Thought broadcasting Hopelessness

Singing and dancing

Recent memory deficit

Paraphasias Psychomotor retardation Not alert

Disorientation

item most characteristic of delirium. Emotional blunting

Intrusive and importunate Suicidal

Confused

Telling jokes and punning

– Omega sign

Unfocused stare

Bright cheerful expression Talks too much

Can’t do serial 7’s

348

160. Early a.m. insomnia D Neologisms S

Hyperactivi~M

Rambling speech DL Flight-of-ideas M – – Delusions of gu~D First-rank symptoms-s Lethargy DL – – Visual hallucinations DL

Recent memory deficit DL

Paraphasias S Psychomotor retardation D Not alert DL

Disorientation DL

Omega sign D

Unfocused stare DL

Bright cheerful expression ~

Talks too much M Can’t do serial ~DL

Sympathetic arousal DL

Euphoria M Perplexity DL

161. Dbrnal mood swing (worse in a.m.)

– –

Clang associations

Elementary hallucinations DL Thought broadcasting S Hopelessness D

Singing and dancing ~

162. Emotional blunting S Intrusive and importunate M Suicidal D

Confused—-rlL

Telling jokes and punning

163. delirium, dementia

164. dementia

M

M

D

349

165.

166.

167.

168.

169.

170.

The following statements characterizing dementia are all true except (underline your answer):

a. insidious onset with chronic course b. diffuse cortical dysfunction

c. relatively unresponsive to treatment d. premorbid function is poor

e. premorbid function is good

A dementia can occur at any age. We are considering only some of the dementias which develop after puberty. Despite the etiology and age of onset, dementias have several common characteristics

(139,169,171). List them.

Circle the words or phrases most characteristic of dementia:

Insidious Reversible

Loss of previous Secondary to neoplasm function

Localized

Circle the words or phrases most characteristic of dementia:

Acute Chronic

Acute onset

Multiple cortical areas involved

Usually irreversible Insidious onset

Age-related

Involving only the frontal lobe

Poor functioning since birth

Widespread

Place a DE next to the items most characteristic of dementia and

a DL next tothe items most characteristics of delirium. You may have to indicate an item for both.

Insidious onset Reversible Irreversible

Diffuse

Loss of prior function Acute

In major depression, slow speech and a paucity of thought are characteristic. In mania speech and

—-~~~ ,.-,,.—,——- are characteristic o’f,…–;cth’e–;t-.-h_o_u-g’h-,t,– process. In delirium is charac- teristic of the thought process disorder. In demenha as in schizo- phrenia, thought disorder is most often observed.

350

165. d

166. insidious onset, chronic course, widespread cognitive dysfunction, relatively unresponsive to treatment, premorbid function is good

167. ~Acute Localized

168. Acute onset

Multiple cortical areas involved

Insidious onset

169. Insidious onset DE Reversible DL

Irreversible DE

Reversible

Secondary to neoplasm

Age-related

Involving only the frontal lobe Poor functioning since birth

Diffuse DL,DE

Loss of prior function DL ,DE Acute DL – – –

Again, keep in mind that the characterization of delirium as acute and reversible and dementia as chronic and irreversible is not with- out many exceptions.

170. rapid, flight of ideas (too many thoughts), rambling speech, formal

351

171.

172.

173. 174.

175.

In major depression, a restricted affect with a mood that is

or is characteristic. In mania, an expanded,

..-la”””‘b-i'”‘”l-e-a”””‘f”‘f’ect with moods of or is charac- teristic. In deliriUm, the mood most often seen is severe – – – – although irritability, suspiciousness and lability of affect are

not uncommon. In schizophrenia and often in dementia

is the characteristic defect in affect. Demen-=-t-ed_,—– -p-at-:-:i;-e-n7ts-c-an also exhibit lability of affect.

The motor behavior seen in major depression is characteristically . In mania, a major diagnostic motor sign is

– – – – – – – In delirium, often secondary to an intense mood, motm·

…,—-.,..—,—-, is seen. Although schizophrenics and people with dementia tend to be awkward, and there are some characteristic gait and other motor disturbances associated with individual dementing processes, neither schizophrenia nor dementia has a characteristic motor sign.

In major depression, mania and schizophrenia, orientation and memory functions are usually intact. In delirium and dementia, or- ientation and memory function are ____________

Part of the sad facial expressions of patients with major depres- sion are the sign and . Manics often look bright-eyed, ecstatic; their skin 1s tight and flushed. People in a delirium appear . The sign of emotional blunting in schizophrenia is a face that is and =–::-:::–.::–=-=-~~–· People who are demented may, like schizophre- mcs, have a face. People with dementia may also have abnormal muscle tone ( 139, 171) (which should always be thoroughly tested). These patients can exhibit a sagging facial expression when decreased tone is present.

The thought content associated with a major depression reflects feelings of , , and

. Manics often (but not always) have grandiose “id”e::c:a::c:s:-::o”‘f-g=·r=e::c:a:–.t:-::cw=e-=alth, power, or stature. There is no characteristic

content in schizophrenia, delirium or dementia. nBizarren content is not diagnostic.

352

171.

sad, anxious, euphoria or irritability, anxiety, emotional blunting

172.

173.

hypoactive (slowed), hyperactivity, agitation

usually disturbed

174. Omega, Veraguth’s folds, perplexed, expressionless, unblinking, expressionless

175. hopelessness, worthlessm•ss, guilt, suicide

353

176. Complete the following chart by writing in each appropriate box the most characteristic clinical behaviors in each mental status area for each disorder.

General Appearance

Motor Behavior

Affect

Thought Processes

Thought Content

Memory and Orientation

Depression Mania Schizophrenia Delirium Dementia

354

176. Area

General Appearance

Motor Behavior

Affect

Thought Processes

Thought Content

Memory and Concentration no deficit

Depression

sad face

Omega sign Veraguth’s ecstatic

folds

slow hypoactive agitated

sad or anxious

hyper- active

euphoric

agitated

labile anxious

rambling none

deficit

irritable restricted labile

slow; paucity of

thought

guilt hopeless-

ness worthless-

ness suicide

fast; flight-of-

ideas grandiosity

mild or no deficit

mild or

Mania Schizophrenia Delirium Dementia

bright-eyed unblinking

perplexed unblinking expression-

flushed

expression- less face

none

blunted

formal thought disorder

none

ruild or no deficit

less face

none sometimes

gait or tonicity disturb- ance

blunted or labile

formal thought disorder

none

deficit

expansive

355

FRONTAL LOBE SYNDROMES

177.

Coarse brain disease can present as an acute, diffuse, usually reversible process with some degree of reduced cortical arousal known as , a chronic, diffuse, usually irreversible process or , or a localized syndrome which can be either acute or chronic and which often results in significant behavioral changes

and occasionally alteration of mood.

178.

In Part I you learned to evaluate cognitive function and relate specific dysfunctions to specific cortical regions. Localized brain disease will often result in syndromes composed of specific

_ _ _ _ _ dysfunction, specific changes and some alteration.

Please review the sections on cognitive functions of the various lobes, Part I (items #335-397) before you proceed to this section.

Frontal

Temporal

LATERAL (OUTSIDE) SURFACE_OF BRAIN. LEFT HEMISPHERE FOR REFERENCE TO ITEMS 177-281

356

Brain Stem

177. delirium, dementia

178. cognitive, behavioral, mood

357

179.

Unlike major depression, mania and schizophrenia, tnere are no established, reliable and valid criteria for delirium and dementia. DSM-III criteria (13) approach this standard, but further testing is needed. List the criteria for the following:

Major Depression Mania Schizophrenia

180.

The frontal lobes rostral to (in front of) the motor areas have executive function over other areas of the cerebral cortex (77 pp. 79-99, pp. 176-225). Unlike other cortical regions, the differentia- tion of the frontal lobes into dominant and non-dominant functions

is not clear-cut. Although language function is localized in the ~-~-~-· usually the frontal lobe, other frontal lobe functions appear more diffuse.

358

179.

Major Depression

1. Sad or anxious mood

2. Three of the following (a

through f)

a. early a.m. waking

b. diurnal mood

swing (worse in a.m.)

c. greater than 5 lb. weight

loss in 3 weeks d. psychomotor

retardation or

agitation e. suicidal

thoughts or

behavior

f. feelings of guilt , self-

reproach, hope- lessness, worth- lessness

3. No coarse brain disease or use of steroids in the past month; no systemic illness known to cause depressive symptoms.

180. dominant, left

Mania

1. Hyperactivity

2. Rapid/pressured speech

3. Irritable/euphoric mood

4. No emotional blunting

5. No coarse brain disease, no psy- chostimulant drug abuse in prior month, no systemic illness known to cause manic symptoms.

Schizophrenia

1. No diagnosable affec- tive disorder

2. No coarse brain disease or hallucinogenic or stimulant drug use

or systemic illness known to cause psychiatric symp- toms

3. Clear consciousness, memory and orienta- tion intact (if one

or both are impaired, this must be due solely to inattentiveness or poor concentration.

4. One of the following:

a. emotional blunting b. formal thought dis-

order

c. first rank symptoms

(any one)

359

181.

In Part I, you learned to evaluate seven frontal lobe functions. There were:

1. Global orientation

2. Concentration

3. Active perception

4. Motor regulation

5. Language

6. Judgment

7. Abstract thinking

What are the tasks you would ask of a patient to evaluate these functions?

List the frontal lobe functions which can be evaluated during the mental status examination.

1. 2. 3. 4. 5. 6. 7.

In addition, the frontal lobes also regulate the functioning of other cortical areas. They initiate, moderate and terminate complex higher cortical functions.

Circle the mental status tests of frontal lobe function:

182.

183.

184.

Echophenomena Copy simple shapes Serial 7’s

Calculations

“No ifs ands or buts” Recall words series

Similarities Writing

Repeat rhythrr

Draw lines between matching items in the two columns:

Identification of upside down objects

Serial 7’s

“No ifs ands or buts” Similarities

Draw circle

Motor regulation

Language Concentration Active perception Abstract thinking

360

181. 1. 2. 3. 4.

5.

6. 7.

182. 1. 2. 3. 4.

Determine the date, place

Do serial 7’s

Identify upside-down objects

Perform motor tasks and observe the presence of perseveration, inertia

Observe for the presence of Broca’s aphasia (non-fluent, slow labored, dysarthric speech)

Determine quality of patient’s solution to real-life problems Test for ability to understand similarities or problem solve.

Global orientation Concentration Motor regulation Judgment

5. Language

6. Active perception 7. Abstract thinking

183. (ichophenomena) Copy simple shapes

Calculations

CNo ifs ands or buts”3)

Recall word series

(Similarities) Writing

Repeat rhythms

184.

Identification of upside down objects

Serial 7’s Similarities

Motor regulation

Language Concentration Active perception Abstract thinking

(Serial 7’V

361

185.

Individuals with frontal lobe dysfunction often exhibit profound behavioral changes in addition to their inability to perform well on specific mental status tasks. Two major frontal lobe syndromes havE been described: the convexity syndrome (affecting lateral or out- side surfaces) and the orbito-frontal syndrome (affecting medial/or- bital surfaces) (21,77,99 pp. 187-225, pp. 318-322, 115 pp. 131-134) The behaviors in these syndromes are often complex, but they re- flect deficits in the basic functions of the frontal lobe and they can be elicited for diagnostic purposes. Once again, list the seven frontal lobe functions.

1. 2. 3. 4. 5. 6. 7.

In Part I, I said that the frontal lobe acts like a futuristic com- puter which not only implements and monitors old programs but de- velops new programs as needed. This active planning requires drivE ambition, desire and the ability to follow through on these motiva-

tions. Althoug·h much of the energy and mood for this active plan- ning originates in lower brain structures (limbic system and reticula:

activating system), it is expressed through the frontal lobes. Thus frontal lobe dysfunction can present as a loss of active planning, a loss of drive, ambition, desire and the ability to follow through on these motivations. Emotional blunting is an example of this loss and although it is a major diagnostic criterion for it also re- flects frontal lobe dysfunction and is the most obvious and frequent behavioral manifestation of the convexity (lateral surface) syndrome (21, 77, 115).

The individual with lateral frontal lobe dysfunction termed the —–~-c-o-,-,~,…— _ _ _ _ _ _ _ _ _ appears apathetic and bland without initiative.

Patients with the convexity syndrome often demonstrate a pau- city of thought and a coarsening of personality characterized by an insensitivity to the feelings of others, being overly stubborn and

set in one’s ways and with a loss of concern for personal appearance manners, present circumstances or future prospects. The convexity syndrome correlates with dysfunction in the _ _ _ _ _ _ _ _ _ _

Lateral frontal lobe dysfunction producing the –,.–….,..,.—,,.—-, is characterized by a ________ of affect and

a-~~~~~~—-_-_-_-_ of personality.

In its typical form, the frontal lobe convexity syndrome is char- acterized by affective and personality . In its less common form, the frontal lobe convexity syndrome is also characterized by catatonia and/or incontinence of urine and feces.

186.

187. 188.

189. 190.

362

185. 1. Global orientation 2. Concentration

3. Motor regulation 4. Judgment

5. Language

6. Active perception 7. Abstract thinking

186. schizophrenia

187. convexity syndrome

188. lateral frontal lobe

189. convexity syndrome, blunting, coarsening

190. blunting, coarsening

363

191.

192. 193.

Circle the words or phrases consistent with a frontal lobe con- vexity syndrome:

194.

The orbito-frontal syndrome usually reflects dysfunction in the medial and orbital surfaces of the frontal cortex (see the cutaway diagram A of the brain). In diagram B indicate where you might expect to find a lesion resulting in a frontal lobe convexity syndrome

AB

195.

Medial Surface of Lateral Surface of Right Hemisphere Left Hemisphere

In the frontal lobe convexity syndrome the characteristic affec- tive change is . In the orbito- frontal syndrome, euphoria and irritability are most characteristic.

Catalepsy

Paucity of thought “No ifs ands or buts”

Euphoria Unkempt and unclean Construction apraxia Overly stubborn Emotional blunting

The two major frontal lobe syndromes are the orbito-frontal syn- drome (medial) and th e ———— _______

().

The cross-hatched area in the diagram would most likely result

in which frontal lobe syndrome?

364

191.

Euphoria

Unkempt and unclean Overly stubborn

192. 193.

convexity syndrome (lateral)

convexity (lateral) frontal lobe syndrome

194.

195.

emotional blunting

Construction apraxia (¥motional bluntinV

365

196.

The euphoria seen in the orbito-frontal syndrome is often shal- low, foolish and silly in quality. In Part I you learned a German term for this mood:

197. 198.

Witzelsucht is the typical mood of the ———– ——–syndrome.

199.

Patients with dysfunction in the medial-orbital areas are often unable to regulate their motor behavior. This can take the form of intrusive and importunate behavior, hyperactivity, echophenomena or rapid/pressured speech. (If you add this to flight-of-ideas, eu- phoria and irritability, you have a nice description of mania.) What criterion for mania helps to distinguish a patient who is suffering from manic-depressive illness from one with an orbito-frontal syn- drome? (Hint: Think of the diagnostic criteria for mania.)

200.

The fact that patients with mania, depression, and schizophrenia exhibit signs and symptoms similar in form to those resulting from coarse brain disease, should not be surprising in light of studies indicating that patients with those psychiatric conditions have demonstrable brain dysfunction ( 2, 4, 51,76, 84, 115,136, 153,156, 164,167). Although we have evidence for brain dysfunction in these patients, no one knows the etiology of these conditions. What coarse frontal lobe syndrome is likely to be confused with schizophrenia? ——-and with mania? _________

201.

Place a C next to the words or phrases characteristic of a frontal lobe convexiTy syndrome and an 0 next to the words or phrases characteristic of an orbito-frontaf syndrome.

Individuals with significant frontal lobe dysfunction often exhibit a deficit in their ability to concentrate and attend to stimuli. They become easily distracted by irrelevant stimuli. This inability to at- tend to stimuli or to persevere in a task can lead to uncontrolled as- sociations. The patients will jump from topic to topic, commenting upon everyone and everything in the immediate vicinity. This fam- iliar thought disorder is . Although it is associated with the disgnosis of it can also be observed in indiv- iduals with disease of medial-orbital areas of the frontal lobe.

Apathy

Witzelsucht Unkempt/unclean Catalepsy

“No ifs ands or buts” Hyperactive

Flight-of-ideas

Paucity of ideas Distractible

Intrusive and importunate Overly stubborn

366

Irritable

196. Witzelsucht

197. orbito-frontal

198. flight-of-ideas, mania

199. 1.

No evidence of coarse brain disease. (Also, no evidence of stimulant drug use in the past month, or systemic illness known to cause similar abnormal changes).

2. The moods of mania are associated with a full affect, whereas the moods of the orbito-frontal syndrome are shallow and are associated with some emotional blunting.

200. convexity, orbito- frontal

201. Apathy C Witzelsucht 0

Flight-of-ideas 0

Paucity of ideasC”” Distractible 0 – – Intrusive and importunate 0 Overly stubborn C

Unkempt/unclean C Catalepsy C

“No ifs ands or buts” Hyperactive 0

C

Irritable 0

367

202. Identify the frontal lobe syndrome.

A 21-year-old man was brought to you by his parents for con- sultation because he sat in front of the television set throughou the day, had become progressively uncommunicative and was neglecting his personal hygiene. When examined, he sat in a stooped position, looking blankly at the floor. His face was wit! out expression and he moved in a slow stiff manner. His hair was dishevelled, his clothes dirty and mucus stained. He pick- ed his nose constantly during the examination. He was not em- barrassed by his appearance, had no interests, did not seem

to mind being examined and had no future plans. He spoke in short choppy sentences. When asked who else lived at home, he responded “mother, father, brother.” He rarely used con- junctions or pronouns in his speech.

203. Identify the frontal lobe syndrome.

A 54-year-old woman was hospitalized on a psychiatric ward be- cause of assaultiveness. Following admission, she paced the halls engaging everyone she saw in conversation. When you tried to speak with her, she did not reply, but as soon as you moved on to another patient, she interrupted you with statemen1 about her life, your appearance, the ward and other patients. Once she started to speak, you could interrupt her only with great difficulty. She then became angry, yelled and cursed at you. On one occasion, she tried to hit you but was restrained. On other occasions she laughed and joked but with little humor. She made silly comments about her hospitalization, although she thought her children had “railroaded” her. Despite your instrw tions to the contrary, she repeated your movements. She was disoriented. Her electroencephalogram and CT scan were

both abnormal.

368

202. Convexity

203. Orbito-frontal

369

TEMPORAL LOBE SYNDROME

204.

You have learned about two frontal lobe syndromes, the and the

205.

Psychomotor epilepsy refers to a seizure process which manifests itself in transient behavioral changes. Temporal lobe epilepsy is one kind of psychomotor epilepsy specifically involving a seizure process in one or both of the temporal lobes. Thus, whereas all temporal lobe epilepsies are psychomotor, all psychomotor epilepsies are not temporal lobe in origin ( 19,20, 56, 149). We will limit ourselves tOThe temporal lobe syndromes (19,20,42,58,99 pp. 142-146, 115 pp. 29-45, 143,144).

206. 207. 208. 209.

Temporal lobe seizures are of short duration (usually seconds, occasionally minutes). Since they usually produce behavioral changes they are one form of seizures.

210.

When untreated, temporal lobe epilepsy tends to be recurrent. These recurrent seizures have a characteristic duration, level of consciousness and memory function. What are they?

————— . poral lobe also produces a distinct syndrome.

In addition to their duration, temporal lobe seizures produce an alteration in consciousness. This alteration is behav- iorally manifested by a clouded or perplexed appearance.

The characteristic duration of a temporal lobe seizure is Consciousness is and usually manifested

by a or appearance.

Patients with temporal lobe epilepsy typically have some memory disturbance for the seizure and for events immediately preceding and following the seizure. Although the memory deficit may span several minutes or even hours, the usual seizure can be measured in

370

~D,_.–y-s”‘fc–u””n-c–:t-.-io–:n,—:-ir-,-t,..,h-e—,t-e-m-

204.

convexity syndrome, orbito-frontal syndrome

205.

No answer required

206. 207. 208. 209.

psychomotor

short

short, altered, clouded, perplexed seconds

210.

short duration, altered consciousness, memory deficit for the seiz- ure and for events immediately preceding and following the seizure

371

211.

212.

213.

When a temporal lobe seizure is “typical” it presents little diag- nostic difficulty. Some temporal lobe seizure disorders, however, are preceded by prolonged behavioral changes, a prodromal period, and/or followed by a postictal (post seizure) period, each of which can last days or weeks. The total episode thus may easily last a month and can be confused with schizophrenia, or less commonly with mania. The typical seizure pattern, however, is characterized

by —————————————————

214. 215.

216.

Temporal lobe seizures are of duration, involve an in consciousness, result in some disturbance of

————- and without treatment are

Which of these precludes the diagnosis of schizo-p–.-h_r_e_n..,.ia-?”.

During a temporal lobe fit patients often exhibit motor automa- tisms. Common motor automatisms are chewing and swallowing movements or lip smacking. Patients may also suddenly get up and walk around the room. Occasionally, more complicated behaviors are observed. Patients may pour a glass of water,

write something, or put on an article of clothing. During this period the patient is unresponsive and his speech is arrested or stilted and stereotyped with stock words. Will the patient recollect these behaviors? Without adequate treatment, will these behaviors most likely occur again? What will be the usual duration of the behaviors?____________

The chewing and swallowing movements and lip smacking often seen during temporal lobe fits are called ___________________

During a temporal lobe fit and while exhibiting motor automatism~ the patient is to your questions. When the fit is over he has no of the incident.

Place an X over the brain area most likely involved in a patient who exhibits motor automatisms, stock words and unresponsiveness for several moments and then cannot remember these events.

372

—-

211. a short duration, alteration of consciousness, memory loss and re- current episodes

212. short, alteration, memory, recurrent

alteration of consciousness, memory loss (acceptable as it “suggests” coarse brain disease).

213. no, yes, short

214. motor automatisms

215. unresponsive, recollection

216.

373

217.

Place an X over the brain area most likely involved in a patient who is apathetic, quiet, unkempt and who when asked to repeat “No ifs ands or buts” says: “No ifs buts.”

218.

The time period preceding the temporal lobe fit: the prodrome period, and the time following the fit: the postictal period, are usually much longer in duration than the actual seizure. Although patients often are unable to remember (are amnestic for) the fit, they can remember some of the events during the prodromal and postictal periods. Behaviors during these periods appear strange

to the observer; they are often the cause of psychiatric hospitali- zation (143). Although transient, the behaviors observed during the psychomotor fit also can lead to psychiatric hospitalization. You have learned that stock words and motor often occur and that during the fit the patient is to external stimuli.

Mood changes are associated with the temporal lobe syndrome. Sudden fear or violent angry outbursts can occur. These moods can develop during the period preceding the seizure; the

—.,—.–‘ or during the period following the fit; the _ _ _ _ _ _ period.

Some evidence (16,51,52,62) suggests that psychomotor fits developing from seizures in the non-dominant temporal lobe are as- sociated with depressive-like and manic-like episodes, whereas psy- chomotor fits developing from seizures in the dominant temporal lobe are associated with schizophrenic-like episodes. Usually the domin- ant temporal lobe is th e ————-

A patient with a depression secondary to seizure activity in the non-dominant temporal lobe most likely will have a lesion in the __________ hemisphere.

A patient with a schizophrenic-like illness secondary to a seizure disorder most likely will have a lesion in the hemisphere.

219.

220.

221. 222.

374

217.

218. automatisms, unresponsive

219. prodrome, postictal

220. left

221. right

222. left (dominant)

375

223.

Perceptual disturbance and apophanous phenomena can also occur in association with pre- and post-seizure periods. Olfactory, tactile, visual and elementary auditory hallucinations are not uncom- mon. Patients also describe seeing whirling and moving lights and changing colors; they may experience a darkening of vision and a loss of three dimensional vision. Dysmegalopsia, when objects be- come larger, known as , or smaller, known as —————–, is also characteristic.

224.

Following a seizure, some epileptics suddenly leave their home and drive or walk a significant distance, occasionally to another town or city. This “automatic” travel occurs in an altered state of consciousness and is called a fugue. As this fugue occurs after the fit it is part of the period. Not all fugue states, however, reflect temporal lobe epilepsy.

225. 226.

Memory disturbances are also commonly observed in temporal lobe epileptics. False familiarity or , false unfamil- iarity or , and anterograde amnesia are typical.

227.

Draw lines between matching items in the two columns. Items on the left can be used more than once.

Draw lines between matching items in the two columns. Items on the left can be used more than once.

Convexity syndrome Temporal lobe epilepsy Orbito-frontal syndrome

Altered consciousness, memory disturbance, motor automatisms

Orbito-frontal syndrome Convexity syndrome Temporal lobe epilepsy

Broca’s aphasia, emotional blunting, coarsening of personality

376

Hyperactivity, over-talkativeness, distractibility , irritable

Rage reactions, stock words, forced thinking, unresponsive, recurrent

Apathetic, shallow moods, coars- ening of personality

Macropsia, jamais vu, amnesia, transient episodes

Lateral surface of frontal lobe, paucity of ideas, overly stubborn

Importunate, intrusive, flight-of- ideas

Perplexed, clouded, unresponsive, fugue states

223. macropsia , micropsia

224. postictal

225. 226.

deja vu , jamais vu

227.

Orbito-frontal syndrome Convexity syndrome Temporal lobe epilepsy

Broca’s aphasia, emotional blunting, coarsening of personality

Convexity syndrome Temporal lobe epilepsy Orbito-frontal syndrome

Altered consciousness, memory distur- bance, motor automatisms

377

Hyperactivity, over-talkativeness, distractibility, irritable

Rage reactions, stock words, forced thinking, unresponsive, recurrent

Apathetic, shallow moods, coarsening of personality

Macropsia, jamais vu, amnesia, tran- sient episodes

Lateral surface of frontal lobe, paucity of ideas, overly stubborn

Importunate, intrusive, flight-of-ideas

Perplexed, clouded, unresponsive, fugue states

228.

Next to the appropriate word or phrase, place aT if it suggests a temporal lobe syndrome, a C if it suggests a frontai lobe convex- ity syndrome or an Qif it suggests an orbito-frontal syndrome.

229.

In Part I you learned about a thought disorder in which associa- tions are tightly linked, but take a circuitous route, filled with un- necessary associations, before reaching the goal. This disorder, termed , is often observed in chronic temporal lobe epileptics as part of their permanent, non-seizure behavior (16). This thought disorder is observable between, not during seizures.

230.

Patients with chronic temporal lobe epilepsy develop other per- manent behavioral changes in addition to circuitous speech, termed . One such behavior is a loss of sexual drive, as

231.

An individual with recurrent transient episodes of odd behav- iors for which he has partial or complete memory deficit and who has lost interest in sex should be suspected of having – – – – – – –

232.

Hypergraphia is a term to describe a voluminous increase in the amount one writes. Chronic temporal lobe epileptics can become hypergraphic. Frequently they maintain detailed notes or diaries

of each day’s experiences, their symptoms and thoughts about per- sonal and world events. This writing is characterized by its per- severative, stilted style and by its endless use of unnecessary de- tail to make a point. This last characteristic is similar to the speech problem of these patients which is termed ———-

233.

Patients with temporal lobe epilepsy without previous (premor- bid) interest, can develop a perseverative fascination for vague phi- losophical and/or abstract religious topics. Over a period of a few years, interests can metamorphose from a few beers and a baseball game to the metaphysical universe and the nature of man. Rumina- tions on these subjects are typically without meaning. When these ruminations are recorded in an endless series of notebooks, the pa- tient is said to also exhibit_____________

234.

Permanent changes in one’s pattern of speech, writing, thinking, and sexual activity can be observed in chronic temporal lobe epilep- tics. What are these changes?——————–”

Anterograde amnesia Apathy

Deja vu

Rage

Dysmegalopsia

Stock words or forced thinking Broca’s aphasia

Flight-of-ideas _ _ Importunate, intrusive Perplexed and clouded

Hyperactivity

Poor personal hygiene

b;:-:-o””‘th;-:-:f”‘r::-:e::-:q::-:u-e::-:n::-:c::-:y::::-:-o::-:i’f sexual activity and interest in sex diminish. De- creased motor activity is termed hypoactivity, decreased sexual activ- ity is termed sexuality.

378

228. Anterograde amnesia T

Dysmegalopsia T

Stock words or forced thinking T Broca’s aphasia C

Flight-of-ideas –a–

Importunate, intrusive 0 Perplexed and clouded T

229.

circumstantial speech

230.

circumstantial speech, hypo

231.

temporal lobe epilepsy

232.

circumstantial

– – Poor personal hygiene C

Apathy C Deja vu —;y;- Rage T – –

Hyperactivity 0

233. hypergraphia

234. circumstantial speech, hypergraphia, over-abstract thinking, hyposexuality .

379

235.

Draw lines between matching items in the two columns. Items on the left can be used more than once.

236.

Next to the appropriate word or phrases, place a T if it suggests a temporal lobe syndrome, a C if it suggests a frontal lobe convexity syndrome, or an Qif it suggests an orbito-frontal syndrome.

Lip-smacking__ Witzelsucht

237.

Identify the most likely area of cortical dysfunction.

A 28-year-old man was brought to the hospital by the police because he tried to break all the windows in a building across from his house. When the police found him, he was standing quietly and confused. Later that day, he had no recollection of the event but said this kind of experience had happened to him before.

Temporal lobe epilepsy Convexity syndrome Orbito-frontal syndrome

Stock words, forced speech, deja vu, dysmegalopsia, rage reaction

Non-fluent aphasia, apathy, un- kempt, urinary incontinence

Circumstantiality, perceptual changes, transient odd behaviors

Prodrome, depression with non- dominant dysfunction, episodes of unresponsiveness.

Hypergraphia, religious conversion, hyposexuality

Hyperactivity, flight-of-ideas, distractibility , poor concentration

Transient

Fugue state

Urinary incontinence Paucity of ideas Hyposexuality Dysmegalopsia Unkempt, unclean Hyperactivity Hypergraphia

Overly stubborn

Stock words, forced speech Catalepsy

Perplexed and clouded

Loss of drive and ambition

Deja vu, jamais vu

Amnesia for the event

Flight-of-ideas

Distractibility and poor concentration

380

235. Temporal lobe epilepsy Stock words, forced speech, deja vu, dysmegalopsia, rage reaction

Convexity syndrome –¥~~-Non-fluent aphasia, apathy, unkempt, urinary incontinence

Orbito-frontal syndrome

Circumstantiality, perceptual changes, transient odd behaviors

Prodrome, depression with non-dominant dysfunction, episodes of unresponsive- ness

Hypergraphia, religious conversion, hyposexuality

Hyperactivity, flight-of-ideas, distract- ibility, poor concentration

Witzelsucht 0

Overly stubborn C

Stock words, forced speech T Catalepsy C

Perplexed and clouded T

Loss of drive and ambition C Deja vu, jamais vu T

Amnesia for the event T Flight-of-ideas 0 Distractibility and poor concentration 0

236. Lip smacking T Transient T – –

Fugue state T Urinary incontinence Paucity of ideas C Hyposexuality T – – Dysmegalopsia -or- Unkempt, unclean Hyperactivity 0 Hypergraphia T

C

C

237. temporal lobe – from the above information, it is impossible to de- termine right or left.

381

238.

Identify the most likely area of cortical dysfunction.

A 23-year-old man is referred to you because of episodic sad- ness, insomnia, anorexia with weight loss, and suicidal thought! His fourth such episode occurred six months ago. Between these episodes, he is generally in good health and feeling his usual self except for transient periods of confusion during whic· he nods his head in a rhythmic automatic fashion and smiles

in an odd way. His family says that during these episodes he is unresponsive.

Identify the most likely area of cortical dysfunction.

A 22-year-old man is brought to the clinic by his parents becaw for the past year he has done nothing but sit in his room and listen to records. He leaves his room only to eat and go to the bathroom. He is slow moving, dirty, and dishevelled. He is apathetic and denies any interest in anything other than listen- ing to his records. His speech is slow, labored, and he has a paucity of thoughts.

Identify the most likely area of cortical dysfunction.

A 39-year-old man who sought hospitalization because he contin- ually heard voices, coming from the ceiling, which discussed

his activities. These voices upset him and he contemplated sui- cide to “end their noise.” Upon further questioning, he said that he was also disturbed by sudden, brief periods when he was unable to move his body but was forced (by some outside “power”) to speak and write things. His sister stated that she had observed these episodes and that when one occurred, her brother’s speech was incomprehensible and he was unresponsive to her efforts to communicate with him.

239.

240.

382

238. temporal lobe – probably non-dominant (because of associated de- pression)

239. convexity syndrome – lateral frontal lobe

240. temporal lobe epilepsy. Most likely in the dominant hemisphere because of associated speech disturbances and signs of a schizo- phrenic-like clinical picture.

383

PARIETAL LOBE SYNDROMES

241.

242.

243.

244.

The parietal lobe is functionally organized to simultaneously synthesize symbolic, perceptual and motor processes. In general, the left or parietal lobe controls verbal or symbolic abilities related to orientation and categorization whereas the right or parietal lobe controls non-verbal motor perceptual abilities ( 40, 99 pp. 147-186, 115 pp. 135-137).

Dominant cerebral function generally refers to symbolic or ~-~-~-~~– functions. Tests for specific dominant cerebral functions include:

Naming objects or testing fo r———- Writing or testing for ——— Reading or testing for ———- Calculating or testing fo r———-

Mental status cognitive function tasks to evaluate dominant parietal lobe function include———-

———-‘ and ______

In individuals with coarse brain disease, cortical dysfunction can range from a mild difficulty to the total absence of a particular function. The presence of acalculia, agraphia, finger agnosia and right-left disorientation point to a lesion in the -~~~—~­ –.—–,—,–::—:=-~””””‘lobe. This condition is called Gerstmann’s syndrome (40,57,112).

384

241. dominant, non-dominant

242. verbal anomia

agraphia alexia acalculia

243. calculations, finger identification, right-left disorientation, reading, writing

244. dominant parietal

385

245.

Patients with dominant parietal lobe dysfunction often have difficulty grasping information as a whole or understanding difficult sentences (40,99 pp. 147-186). These patients lose the ability to organize and categorize. Sentences (thoughts) that require cate- gorizing (“figuring out”) are meaningless to patients suffering from this syndrome.

246.

When told “Place your right hand on your lrft elbow,” a patient hesitated, looked at both his hands, with great hesitation, he placed his left hand on his right ear. This response indicates the dysfunction of and is suggestive of

247.

An examiner pointed to a patient’s fingers one at a time and asked: “What do you call this one?” Beginning with the right thumb, the patient responded: “Thumb … straight finger … second straight finger … index and outer or end finger.” This is an example of and suggests dys- function in the ——- ________ ——–

248. 249. 250.

Right/left disorientation and finger agnosia are two of four signs composing Gerstmann’s syndrome. What are the other two?

251

Patients with non-dominant parietal lobe dysfunction may have difficulty in dressing themselves, making their beds, or feeding· themselves. This inability to perform simple tasks is called a

252. 253.

Patients with non-dominant parietal lobe dysfunction can have difficulty recognizing faces ( 17, 107) . What are some other diffi- culties due to non-dominant parietal lobe dysfunction?

The following task tests the ability to organize and categorize: Name these individuals: 1. “Your father’s brother”

2. “Your brother’s father”

Testing for Gerstmann’s syndrome also evaluates dominant parietal lobe function. If Gerstmann’s syndrome is present, what dysfunctions would you expect to observe? (write them down)

________ lobe dysfunction.

The lobe that simultaneously synthesizes non-verbal motor-

perceptual abilities is the ———- ———- lobe.

The inability to copy simple shapes is termed –,—..—— and the inability to do simple tasks (such as

kinesthetic apraxia. These deficits are often

‘dr-r_e_s-sm,-.g~),…..,.i-s-;t-e-rmed

observed in patients with non-dominant parietal lobe dysfunction (40,99 pp. 147-186).

The non-recognition of faces is termed prosopagnosia. It reflects dysfunction in the ————-

386

245. acalculia, agraphia, finger agnosia, right-left disorientation

246. right-left disorientation, dominant parietal

247. finger agnosia, dominant parietal lobe.

248. dysgraphia, dyscalculia

249. non-dominant parietal

250. construction apraxia

251. kinesthetic (dressing) or motor apraxia

252. constructional apraxia, kinesthetic apraxia

253. non-dominant parietal lobe

387

254.

255.

256.

257. 258.

259.

260.

261.

Finger agnosia is the non-recognition of one’s fingers and is associated with dysfunction in the – – – – –

i.,…s_a_s_s_o-c”ia-t,…e-d..-w”””‘i”‘”t,_h.dy~~:n~~~~r~ofh-e”‘”‘it'”‘io_n_o_f;;-l<f””a_c_e_s_t;-ermed

Patients with prosopagnosia have difficulty recognizing —–,—:-::….,..—-;:–· They may develop secondary delusional ideas concerning this “non-recognition” and may call family members

and/or friends impostors or doubles and members of a “plot.”

A 27-year-old man said his mother was an impostor; that some- one had “switched” her because her face was “different” from his

“real” mother. This non-recognition, term ed–..——- has been given the psychiatric term Capgras’ syndrome.

The psychiatric term for the delusional idea that a familiar person is really an impostor is syndrome.

Many individuals with Capgras’ syndrome actually have non- recognition of faces, term ed———-‘ reflecting dysfunction in the ———- ———-

– – – – – – (11,17 ,75,107).

Non-recognition of faces termed , is associated with dysfunction in the

. The p sychiatc:l’l::..•c-::—:tc-:e”‘r::m:–:.fr:o-::r-t”‘h””‘I”s”–=c-::-:ondition , when “it,….is_a_s_s_o_c-.ia-t.,..e-d.–w-I'”‘·t…-h secondary delusional ideas of familiar persons

being “impostors” is ———-

In addition to construction apraxia, dressing apraxia and prosopagnosia, patients with a dysfunction in the .,-,,.-;;——-

lobe often guess in an uncontrollable manner -w’h_e_n–,t7h_e_y_a_r_e_u-nable to recognize a correct perception. This

replacement of direct correct perceptions by uncontrollable guesses is termed paragnosia ( 40) .

The following exchange took place between a patient and an examiner:

E: “Where are we now?”

P: (Looking about the emergency room) “I’m at McDonalds’.” E: “No, that’s not right.”

P: “A library?”

E: “No.”

P: “A post office or a bus terminal?”

This replacement of a direct perception by uncontrollable guesses is termed a ———-

388

254.

dominant parietal lobe, prosopagnosia, non-dominant parietal lobe

255.

256.

257. 258.

259.

260.

261.

faces

prosopagnosia

Capgras’

prosopagnosia, non-dominant parietal lobe

prosopagnosia, non-dominant parietal lobe, Capgras’ syndrome

non-dominant parietal

paragnosia

389

262.

The following exchange took place between a patient and an examiner:

E: “You live with your parents?”

P: “My father, yes. I don’t know who she is.”

E: “What do you mean … Who she is? Isn’t she your mother?”

P: “No way! Somebody else is inside of her. She’s not the same. Her face is tilted or something.”

This failure to recognize his mother’s face is termed

The idea that someone else is inside her is the psychiatri_c_s-:-y-n–:;d,–r_o_m_e_

termed . The most likely area of cortical dysfunction is the _______________

Another form of non-recognition associated with non-dominant parietal lobe dysfunction is the inability of an individual to recog- nize his own illness. This is termed anosognosia (168). Non- recognition of faces is termed and non-recognition with wild guessing is termed ——–

Denial, or non-recognition of illness, is termed anosognosia. It is associated with dysfunction in th e ——-

Check off tests of non-dominant parietal lobe function: “Copy this object.”

“What finger is this?”

“Put your shirt on.”

“Hold out your right hand … Put your right hand on your left ear.”

Check off tests of dominant parietal lobe function: “Copy the object.”

“Hold out your left hand…put your left hand on your right elbow.”

“Put your shoes on.” “What finger is this?”

263.

264. 265.

266.

390

262.

prosopagnosia, Capgras’ syndrome, non-dominant parietal lobe

263.

264. 265.

266.

prosopagnosia, paragnosia

non-dominant parietal lobe

“Copy this object.” I “What finger is this?”

“Put your shirt on.” I

“Hold out your right hand … Put your right hand on your left ear.”

“Copy the object.”

“Hold out your left hand … put your left hand on your right elbow.”

“Put your shoes on.” “What finger is this?”

I I

391

267.

The following exchange took place between a patient and an examiner:

268.

Patients with parietal lobe dysfunction may have trouble copying the examiner’s movements. Ask the patient to do what you do.

269.

Psychiatric patients often have difficulties copying simple figures even though they have no motor weakness. This is called

270. 271.

Kinesthetic apraxia and construction apraxia are signs of dysfunction in the ———- ————

E: “How long has your left arm been paralyzed?”

P: “It’s not paralyzed! It’s o.k.”

E: “I don’t understand. You can’t move it, can you?”

P: “I pulled a muscle.”

E: “But you can’t move it at all, not even your fingers!” P: “It’s just temporary. I’ve not been sleeping.”

E: “You think you can’t move it because you’re tired?” P: “Yes.”

E: “There’s nothing really wrong?”

P: “Nothing.”

This patient’s inability to recognize his paralyzed left arm is termed —————–

1. Extend left arm’ ~

2, Bend •=at elbow, hand open.~

3. Keep arm bent and make a fist.~

4. Repeat with right arm ~

Inability to imitate these simple movements may indicate parietal lobe dysfunction opposite or contralateral to the arm/hand having difficulty (99 pp. 147-186). If a patient repeats your movements, despite instructions to the contrary, it is called

and indicates lobe dysfunct”‘”io-n–.———

. When a patient cannot perform a simple mot_o_r-ct;-a-s’k__e_v_e_n–.t.-h-o-ugh he has no motor weakness,

he demonstrates a ———-

Capgras’ syndrome is associated with the non-dominant parietal lobe dysfunction concerning non-recognition of faces or – – – – – –

392

267. anosognosia

268.

echopraxia, frontal

269.

construction apraxia, kinesthetic (motor) apraxia

non-dominant parietal lobe

270.

271. prosopagnosia

393

272. 273. 274.

275.

276.

Inability to recognize one’s illness, termed

is associated with non-dominant parietal lobe dy,..,s”‘fr::u-=n-:c”””tl”·o-n:-.—

The substitution of a recognized perception by wild guesses is termed _________

The presence of anosognosia, prosopagnosia, paragnosia, construction apraxia, and kinesthetic apraxia strongly suggest dysfunction in which cortical region? _ _ _ _ _ _ _ _ _

Place a D-P for dominant parietal and N-P for non-dominant parietal next to the appropriate items:

Construction apraxia Right-left disorientation Finger agnosia

Capgras’ syndrome_ _

Anosognosia _ _

Kinesthetic apraxia Paragnosia Acalculia Dysgraphia

Identify the example of cortical dysfunction and give local- ization:

Unable to copy a cross

Wild guesses replacing direct perception

Unable to recognize and name fingers

Unable to put left hand on right ear

Unable to imitate examiner’s hand and arm movements

Unable to keep from imitating examiner’s arm movements

Unable to dress oneself

394

272. anosognosia

273. paragnosia

274. non-dominant parietal lobe

275. Construction apraxia N-P Right-left disorientation D-P Finger agnosia D-P Capgras’ syndrome N-P Anosognosia N- P

276. Unable to copy a cross

Wild guesses replacing direct perception

Unable to recognize and name fingers

Unable to put left hand on right ear

Unable to imitate examiner’s hand and arm movements

Unable to keep from imita- ting examiner’s arm movement

Unable to dress oneself

Kinesthetic apraxia N-P Paragnosia N-P Acalculia D-P Dysgraphia D-P

Construction apraxia, non-dominant parietal

Paragnosia, non-dominant parietal

Finger agnosia, dominant parietal

Right/left disorientation, dominant parietal

Kinesthetic (motor) apraxia, contra- lateral parietal

Echopraxia, frontal

Kinesthetic (motor) apraxia, non- dominant parietal

395

277.

278.

Inability to do simple math (to calculate) is termed _ _ _ _ _ _ and results from .dyi~fr:~~~nofo~~es..–ig_n_s_c-om_p_o_s1..–.n-g _ _ _ _ _ _ _ _ syndrome. What are the other three?

Check the appropriate box to indicate the brain region that

relates best to each dysfunction

Non-Dominant Parietal

Dysfunction Acalculia

Ideomotor apraxia Finger agnosia Echopraxia

Poor concentration

Construction apraxia

Global disorientation Poor active perception

Frontal Lobe

Dominant Parietal

396

277. acalculia, dominant parietal lobe, Gerstmann’s, finger agnosia, right/left disorientation, dysgraphia

278.

Dysfunction

Frontal Lobe

Dominant Parietal

Non-Dominan Parietal

Acalculia

Ideomotor apraxia Finger agnosia Echopraxia

Poor concentration Construction apraxia Global disorientation Poor active perceptio~

I I I

I!”‘ (if lefj hand on y)

I I

I I

397

I

279.

Check the appropriate box to indicate the brain region that best relates to each dysfunction.

Dysfunction

Non-recognition of faces

Acalculia

Poor concentration Broca’s aphasia Construction apraxia Agraphia

Kinesthetic (dressir:g, motor) apraxia

Echopraxia

Can’t do similarities

Finger agnosia

Can’t define relation- ships

Motor perseveration

Dyslexia

Can’t identify up- side-down objects

Can’t copy examiner’s hand positions – both hands

Can’t do serial 7’s Paragnosia Anosognosia

Dominant Parietal Lobe

Non-Dominant Parietal Lobe

Frontal Lobe

398

279. Dominant Non-Dominant Dysfunction Frontal Lobe Parietal Lobe Parietal Lobe

Non-recognition of faces Acalculia

Poor concentration Broca’s aphasia Construction apraxia Agraphia

Kinesthetic (dressing, motor) apraxia

Echopraxia

Can’t do similarities

Finger agnosia

Can’t define relation- ships

Motor perseveration Dyslexia

Can’t identify upside- down objects

Can’t copy examiner’s hand positions – both hands

Can’t do serial 7’s Paragnosia Anosognosia

I I

I

I

I I

I I

I I

I

I

I

I

I I

I I

399

I

280.

Identify the area of cortical dysfunction. List any cerebral dysfunctions you observe.

A 51-year-old woman was hospitalized because she called the police continuously complaining that strange people were “landing” on the beaches near her house in “an invasion”.

She also complained that there was someone masquerading as her son who came to her house and tried to convince her

there was no invasion. Although she was standing in an active nursing station, her successive answers, when she was asked where she was, were: “post office…shopping center… library … ” When she was told she was in a hospital, she laughed and said she was “never very good at geography and places”.

Identify the area of cortical dysfunction. List any cerebral dysfunctions you observe.

A 48-year-old man, college graduate, was hospitalized because of a false idea that he had murdered three people. When examined, he was unable to identify his fingers except for his thumbs. He could not do arithmetical problems involving carrying or borrowing steps; when asked to place his right hand on his left elbow, he placed his right hand on his right knee and repeated this error despite being told he was in- correct. He was able to print but he could no longer write in long hand.

281.

400

280. non-dominant parietal lobe

Capgras’ syndrome or prosopagnosia, paragnosia, anosognosia

281. Gerstmann’s syndrome – dominant parietal lobe

finger agnosia, dyscalculia, right/left disorientation, dysgraphia

401

ANXIETY STATES (DSM-III TERM: ANXIETY DISORDERS)

282.

In a general medical practice nearly one-third of all patients seek help because of symptoms of anxiety (91 p. 31, 116). The morbidity risk for anxiety states in the general population has been estimated at 5% (35, 91 p. 31) , making them one of the

more common psychiatric conditions. The estimated general population morbidity risk for affective disorders is _ _ _ _ _ _ _ and for schizophrenia is ——-

283.

Anxiety is a fundamental mode of physiological response associated with emergency avoidance or attack ( 91, 143 pp. 85- 103). Pathological anxiety, i.e., the anxiety states, is a group of disorders for which of the general population is

at risk.

284.

In man, at least, anxiety is both psychic, i.e., a subjective experience of a dysphoric mood, and somatic, i.e. , with systemic signs and symptoms. The terms anxiety neurosis and anxiety states are synonymous. We will use the latter. What percent

285. 286.

In man, anxiety is both the subjective experience of a dysphoric mood, i.e. , anxiety, and the systemic signs and symptoms of anxiety, i.e., anxiety.

of the general population is at risk for these states?

What percentage of patients coming to a general medic””‘a:-;1–cp=-=ra=-c””‘t”‘i””‘ti'””o-:::n-.,er has complaints consistent with anxiety? _ _ _ _ _

Acute anxiety is mediated by catecholamines, specifically adren- aline pathways. As yet, there is no known biochemical (physiologi- cal) understanding of chronic anxiety. An individual suffering from an acute anxiety attack experiences both the subjective experience of anxiety, anxiety, and the physiologi-

cal manifestation of a hyperadrenahne state known as anxiety (91,116).

– – – – – –

402

282. 2%, 0.3%

283. 4%

284. 5, 33

285. psychic, somatic 286. psychic , somatic

403

287.

288.

289.

290. 291.

Acute anxiety attacks can occur under stressful conditions in individuals without prior psychiatric history. When the stressful condition is resolved, the anxiety syndrome will also disappear

and may never recur ( 35,91, 116, 175). The individual will remain symptom-free. This pattern of anxiety (or panic reaction) may not

be an illness, but rather a response to stress inherent in all of us, with some individuals having greater liability, i.e. , vulnerable to stress. As in all acute anxiety attacks, these stress reactions are biochemically mediated by ———–

Some acute anxiety attacks are merely exacerbations of chronic anxiety. Individuals with this pattern of symptoms will recover from the acute anxiety attacks but will remain ill with signs of chronic anxiety. The clinician cannot distinguish the isolated, stress-induced acute anxiety attack from the acute anxiety

attack that is an exacerbation of a chronic condition (35,91,116, 117,143 pp. 85-103,175). Both types of acute attacks are clinically identical and both are biochemically mediated by

_ _ _ _ _ _ (91,116).

Some researchers (117) list 11 symptoms which are most fre- quently associated with acute anxiety. An intense anxious mood often associated with feeling of impending doom or death, a smothering or drowning feeling or air hunger, and a discomfort, tightness or pain in one’s chest are three of the most common, and at least two of these three should be present to satisfy the diagnosis: acute anxiety attack. Can you clinically distinguish an acute anxiety attack which is an isolated stress response from one that is an exacerbation of a chronic condition?

An intense anxious mood, air hunger and chest discomfort suggest the diagnosis of an _______ ——-

To satisfy the diagnosis: acute anxiety attack, a patient should exhibit at least two of three major signs of anxiety. List these three signs:

1. 2. 3.

404

28 7.

adrenaline (catecholamine)

288.

adrenaline (catecholamine)

289.

No

290. 291.

acute anxiety attack

Intense anxious mood

1.

2. Air hunger

3. Chest discomfort

405

292.

Three major signs of acute anxiety are:

and . To satisf; the diagnosis: acute anxiety atta~k, an additional three of the following eight signs should also be present.

293.

You are working at the emergency room and a 30-year-old man is brought in on a stretcher. He is breathing rapidly, trembling, holding his head and saying, “I’m going to die, I’m going to die.” He complains of chest tightness, air hunger, a tightness in his throat and a coldness and numbness in his hands and feet. His heart rate is 120 bpm, respirations 34 pm, blood pressure 140/85 mm Hg. His EKG, all laboratory tests and other physical findings are all within normal limits. The most likely diagnosis is acute anxiety attack. Circle the information which satisfies the criterion “two out of three.” Underline the information which satisfies the criterion “three out of eight.”

Circle the words or phrases characteristic of acute anxiety.

294.

295.

Emotional blunting Diurnal mood swing Dizziness

Fear of impending doom Inward shakiness Vascular throbbing

Paresthesias Delusional mood Euphoria

1.

2. 3. 4. 5. 6.

7. 8.

Lump in throat

Dizziness and/or faintness

Weakness and/or fatigue

Inward “shakiness”

Tremor

Paresthesias (pins and needles in fingers, toes and about the mouth)

Tachycardia (rapid heart beat) and/or palpitations Vascular throbbing (usually with headaches)

Circle the words or phrases characteristic of acute anxiety.

Smothering feeling Fatigue

Lump in throat Tachycardia

Verbigeration

Air hunger

Clang associations Delusional perception

Tremor Flight-of-ideas Faintness Chest pain

406

292.

intense anxious mood, air hunger, chest discomfort

293.

You are working at the emergency room and a 30-year-old man is brought in on a stretcher. He is breathing rapidly, trembling, hold- ing his head and saying, “I’m oing to die, I’m going to die.” He complains of chest t1 htness, air hun er, a tightness in his throat and a coldness and numbness in his hands, and feet. His heart rate is 120 bpm, respirations 34 pm, blood pressure 140/85 mm Hg. His EKG, all laboratory tests and other physical findings are all within normal limits.

294.

295.

Emotional blunting

Diurnal mood swing @izzinesi)

Fear of impendin Inward shakiness Vascular throbbing

Verbigeration (Air hunger_)

Clang associations Delusional perception

(Paresthesia§) Delusional mood Euphoria

407

296.

Underline the three signs, two of which must be present to satisfy the first diagnostic criterion for acute anxiety attack. Then circle the eight signs, three of which must be present to satisfy

the second diagnostic criterion for acute anxiety attack.

297.

298.

Intense anxious mood, air hunger, and chest discomfort are signs of acute anxiety. List the additional eight signs, three of which should also be present to satisfy the diagnosis of acute anxiety attack.

List the 11 clinical signs associated with the diagnosis of acute anxiety attack. Circle those signs from which two of three are required and underline those signs from which three of eight are required.

Because anxiety is a fundamental physiological response associated with “flight/fight” mechanisms, many ofthe physical

signs and symptoms of anxiety in their milder form have adaptive value in stress situations. In its severe form, anxiety is experienced subjectively as a feeling of dysphoria, termed psychic anxiety and as physical symptoms termed anxiety.

Anxiety is a normal physiological response to stress and is

299.

300.

associated with the

mechanism.

1. 2. 3. 4. 5. 6. 7. 8. 9.

10. 11.

Dizziness Tachycardia

Chest discomfort Vascular throbbing Air hunger

Tremor

Inward shakiness Intense anxious mood Lump in throat Paresthesias Weakness

408

296.

1. ~=:;.=~;:–.., 2.

3.

4.

5. 6. 7. 8. 9.

10. 11.

297. 1. 2. 3. 4.

Lump in throat

Dizziness and/or faintness Weakness and/or fatigue Inward “shakiness”

6.

7. 8.

298. 1. 2. 3. 4. 5. 6. 7. 8. 9.

10. 11.

Paresthesias (pins and needles in fingers, toes and about the mouth)

Tachycardia (rapid heart beat) and/or palpitations

Vascular throbbing (usually with headaches).

Intense anxious mood

Air hunger

Chest discomfort

Lump in throat

Dizziness and/or faintness Weakness and/or fatigue Inward “shakiness” Tremor

Paresthesias (pins and needles in fingers, toes and about the mouth)

Tachycardia (rapid heart beat) and/or palpitations

Vascular throbbing (usually with headaches).

5. Tremor

299. somatic

300. flight/fight

409

301.

Acute anxiety is biochemically mediated by

302.

In preparation for a flight/fight response, the organism re- quires optimal functioning:

303.

Peripheral vasoconstriction, resulting in pale and/or cold

skin, insures reduction of possible blood loss during an emergency, flight/fight situation. Two other adrenaline responses insuring optimal vision are:

304. 305.

During flight/fight peripheral vasoconstriction insures :–.–~– This may cause the skin to look

306.

During a flight/fight situation, what happens to the body’s blood?

307. 308.

During a flight/fight situation, what happens to the eyes?

309.

Increased adrenaline, released under stress, also results in increased cardiac rate and output and increased respiratory rate. Thus, more blood can be pumped to the working muscles and more oxygen provided for fuel. What other changes occur in the vascular system?

310.

In preparation for flight or fight the organism needs to be fully alert. Muscle tone increases (sometimes causing tremors) to pre- pare for action. What else happens to the muscles?

This compound has specific effects on many

bod~y:-o::cr=-g=a::cn=s–:w::-ht=:Ic””‘h~

results in clinical signs we associated with somatic anxiety. How- ever, the subjective feeling of dysphoria, termed

anxiety is not clearly related to any known

biochem—-.-ic-al..-s-u~b;–st.,…r-a–=t-e-.-

Bulging eyes (exophthalmos) and dilated pupils (mydriasis) insure optimal vision.

As in most somatic signs of anxiety, exophthalmos and mydriasis are responses to the com poun=d’———-

——–and feel ——–

In addition to insuring a reduction of blood loss via the process of , blood is also shunted to the larger muscles preparing them for emergency action.

In hopes of bluffing the enemy, mammals try to increase their apparent size by standing their hair “on end” (pilerection). Hu- mans, with the same number of hair follicles as apes, but with fine hair, also pilerect their hair when stressed. We term this “goose bumps” or “goose flesh” and it is another sign of the body’s preparation for ——–

410

301. adrenaline, psychic

302. adrenaline

303.

304. 305.

306.

exophthalmos (bulging eyes) , mydriasis (dilated pupils)

reduced blood loss, pale, cold peripheral vasoconstriction

It is shunted to large muscles and peripheral vasoconstriction occurs.

They bulge and the pupils are dilated.

307.

308. flight/fight

309. Blood is shunted to the larger muscles and away from the periphery via peripheral vasoconstriction.

310. Blood is shunted to the larger ones.

411

311.

312.

313.

314.

315.

Circle those words or phrases consistent with a state of preparedness for flight/fight.

316.

317.

Additional adrenaline responses include sweating, dry mouth, urgency and/or urinary incontinence, increased intestinal motility, and diarrhea. They are obviously not all adaptively advantageous and occur in the extreme when an effective —.—–,.——,…..-, preparation and reaction cannot take place. In humans, this in- effective response is associated with the mood of anxiety.

Sweating and a dry mouth are often experienced when anxiety is great. Because of the other adrenaline responses you have learned about, will the skin feel hot and moist or cold and moist?

Tachycardia Sleepiness Goose flesh Rapid breathing Dilated pupils

Flushed Pallor

Muscle tremors Pin-point pupils Wide-eyed

Draw lines to match the items in the two columns.

Peripheral vasoconstriction Increased muscle tone Mammalian bluff

More fuel to work

Goose bumps

Pale and cold

Tremors

Increased rate of breathing and increased heart rate

Now you will no longer be surprised to see a pale anxious patient who is rapidly and continuously looking about the room in a wide-eyed, alert manner; you will recognize the trembling and “goose flesh” in a situation.

There are several other clinical signs which can occur in acutely anxious patients. Adrenaline increases cardiac

and . This can lead to transient hypertension

(systolic), irregular heart beat (cardiac arrhythmias), palpitations (feeling one’s heart beat) and vascular throbbing often with head- aches.

Circle the signs and symptoms which result from the cardio- vascular changes associated with a flight/fight situation.

Tachycardia Lethargy

Flushed skin

Pale skin Exophthalmos Pilerection Muscular tremors

Palpitations

Irregular heart beat

Diarrhea

Cold skin

Transient systolic hypertension Mydriasis

Vascular throbbing

412

311.

(Jtachycar~

Sleepiness (Goose flesh)

(Rapid breathing) (Dilated pupil-v

F l u s h e d

Q’ano0

Muscle tremors Pin-point pupils

(Wide-eye~

312.

313.

314.

315.

Peripheral vasoc~nstriction Goose bumps Increased muscle tone Pale and cold Mammalian bluff Tremors

More fuel to w o rk ——— Increased rate of breathing and

flight/fight

rate, output

0ac~ycardia)

Lethargy

Flushed skin (!ale sk§)

Exophthalmos Pilerection Muscular tremors

QalpitationS) (Irregular heart be~

Diarrhea

(cold skllY

(Transient systolic hypertens~

Mydriasis

(vascular throbbing)

316. flight/fight

317. cold and moist

413

increased heart rate

318.

Increased intestinal motility with cramping and diarrhea and increased urinary output (because of increased cardiac output)

with urgency and urinary incontinence can occur when anxiety

levels are extremely high. Thus, although the flight/fight mechan- ism has great adaptive value, it can in some individuals be subverted into acute anxiety attacks which can become recurrent. What per- cent of the general population is at risk for such a disorder?

319.

List the diagnostic criteria for acute anxiety. Two of the following three:

Three of the following eight:

320.

Circle all the signs associated with acute anxiety.

What percent of general medical practice patients seek help fo__r _ _ _ symptoms consistent with this disorder? Can you clinically distinguish the spontaneous isolated acute anxiety attack from the acute anxiety attack which is an exacerbation of a chronic anxiety state? _______

Abdominal cramps Lethargy

Goose flesh

Bed wetting

Dry mouth

Clouded consciousness Air hunger

Chest discomfort Dysmegalopsia Vascular throbbing Diarrhea

Sleepiness

“Runny nose” Dilated pupils Hypertension Rapid breathing Muscle tremors Dizziness

Paucity of thought Cold, moist skin Palpitations Wide-eyed Witzelsucht

414

318. 5%, 33%, No

319. Two of the following three: Three of the following eight:

Intense anxious mood Air hunger

Chest discomfort

320. 0bdominal crampv Lethargy

“Runny nose” (Dilated pupily Hypertension

(Goose flesh) (Bed wettinj) (pry moutli)

Rapid breathing (Muscle tremo~ Q>izzineS§)

Clouded consciousness Air hunger

Paucity of thought

Dysmegalopsia (Vascular throbbin”V (niarrhe}i)

Witzelsucht

Sleepiness

415

Dizziness Tachycardia Vascular throbbing Tremor

Inward shakiness Lump in throat Paresthesias Weakness

321.

322.

323. 324. 325.

For convenience’s sake (rather than on the basis of data) we can divide chronic anxiety states into two groups: 1) the phobic anxiety states and 2) the simple anxiety states. Phobic anxiety states are associated with an exaggerated fear usually of a non- dangerous object or situation. Simple anxiety states are termed as such because they are present without phobias. The pathological mechanisms underlying chronic anxiety are not known. Acute anxiety is mediated by the pathways.

Chronic anxiety states can be divided into conditions with or without an associated exaggerated fear (usually of a non-dangerous object or situations). Such an “exaggerated fear” is termed a

Chronic anxiety states can be divided into _ _ _ _ _ _ _ -s.,-ta…,t,…e-s-.—- states and ——– ——–

Chronic anxiety states associated with exaggerated fears (usually of a non-dangerous object or situation) are termed

Phobic anxiety states can be separated into:

1. Specific animal phobias

2. Specific situationa! phobias

3. Phobic-anxiety-depersonalization syndrome (PAD).

4. Agoraphobia

Specific animal and situational phobias differ only in content not in form and will be considered together. Both conditions can present as acute anxiety attacks but only when the affected indi- vidual is in proximity to the phobic object or situation. They are chronic only in the sense that even after many years the affected individual will always develop severe anxiety when in the phobic setting. Describe the signs you might find in a phobic person in proximity to the phobic object or situation.

Acute animal and acute situational phobias differ from each other only in . Write the definition of a phobia.

Acute animal phobias are exaggerated fears of such animals as: dogs, cats, horses, rabbits, mice, snakes, flies, and spiders. In

a room where the phobia-producing animal is caged and totally harmless, the phobic patient nevertheless responds with acute anxiety. The patient is aware of the exaggeration of his response, knows it is unwarranted, perceives it as a symptom but cannot

do anything about it other than avoid the object or situation. Acute situational phobias are exaggerated fears of situations such as public speaking or riding a train, car, plane, or boat or being in

a high place or a small space. Here also, the patient is aware of

the unwarranted exaggeration of his response, perceives it as a symptom but cannot stop the anxiety response when placed in the phobic situation or when the phobic situation is anticipated (47, 91,103,104,122,175).

326. 327.

416

321. catecholamine (adrenaline)

322. phobia

323. phobic anxiety, simple anxiety

324. phobic anxiety states

325. 1.

2. 3. 4. 5. 6. 7. 8. 9.

10. 11.

Intense anxious mood often associated with the feeling of impen- ding death or doom

Smothering or drowning feeling, or air hunger

Chest discomfort, tightness or pain

Lump in throat

Dizziness and/or faintness Weakness and/or fatigue

Inward “shakiness”

Tremor

Paresthesias

Tachycardia and/or palpitations Vascular throbbing

326. content. A phobia is an exaggerated fear, usually of a non-danger- ous object or situation.

327. no answer required

417

328.

329.

330.

331.

332.

333.

Acute animal and situational phobias often begin in childhood between the ages of 5 and 7 (47,103-105,122,175). Usually they resolve spontaneously; occasionally they persist into adult life (47,104,122,175). What is the phobic patient’s attitude about his phobia?

Specific animal and situational phobias are most often circum- scribed, i.e., there is little exaggerated anxiety outside the phobic situation ( 104, 122). At what age is the onset of these conditions most likely to occur?

An individual with a specific animal or situational phobia is

most frequently free from unusual anxiety when away from the phobia inducing object or situation. Only in proximity to the phobic object or situation does the individual develop exaggerated anxiety. Because of their restricted nature which are object or situation- specific, these phobias are said to be _ _ _ _ _ _ _

Individuals with specific animal or situational phobias rarely are fearful of more than one object or situation. They rarely have more than one phobia, they are monophobic ( 104, 122). Because they have little unusual anxiety, except in the phobic situation, their phobias are said to be _______

Individuals with a single isolated exaggerated fear are said to be . If their anxiety is limited to the phobic object or situation, 1t is said to be . In tests of physiological response to stress, anxiety levels at rest and psy- chological profiles, individuals with specific animal or situational phobias cannot be differentiated from normal controls ( 47, 91,103, 104,122). These phobias have an excellent response to treatment (47,91,103-105,122).

Each of the following statements about individuals with specific animal and situational phobias is true except (underline your answer):

334.

Circle the words or phrases most characteristic of specific animal and situational phobias:

a)

b)

c) d) e)

They exhibit little excessive anxiety away from the phobic object or situation

Physiologically and psychologically they cannot be differentiated from normal controls

Their phobias are treatment responsive

Their phobias usually developed around ages 5 to 7 They usually have several phobias

Good response to treatment Abnormal psychological profile Often monophobic

Circumscribed

Often begins in later life

Anxiety symptoms different from normal anxiety

418

328. He realizes it is an exaggerated or unwarranted fear but he cannot stop the anxiety response except by avoiding the phobic object or situation.

329. childhood, ages 5 to 7

330. circumscribed

331. circumscribed

332. monophobic, circumscribed

333. a) b) c)

d) e)

They exhibit little excessive anxiety away from the phobic object or situation

Physiologically and psychologically they cannot be differentiated from normal controls

Their phobias are treatment responsive

Their phobias usually developed around ages 5 to 7 They usually have several phobias

334. (§”ood response to treat-ment) Abnormal psychological profile

(often monopho§

(circumscribe~

Often begins in later life

Anxiety symptoms different from normal anxiety

419

335.

336.

337. 338.

339.

Agoraphobia is a phobic anxiety state which appears to be qualitatively different from the circumscribed monophobic and easily treatable and

c :-= :-:——- phobms (35,47,91,122,143 pp. 85-103, 145, 175).

Agoraphobia literally means “fear of the marketplace” (47,102- 105,122, 145). It has come to mean an exaggerated fear of any open (out-of-doors) space. Specific animal and situational phobias

typically develop around ages to . In contrast, agora- phobia usually develops between the ages of 15 and 35. The peak decade is 20 to 30 (47,102-105,122,143 pp. 85-103,145).

Specific animal/situational phobias characteristically develop in childhood. Agoraphobia characteristically develops between ages ____ to with a peak between ages 20 and 30.

An individual who becomes phobic around age 25 is more likely to have which condition (circle one)?

Specific animal phobia Specific situational phobia Agoraphobia

The typical agoraphobic can often describe the exact moment

of onset of the condition: “I was going shopping, and I suddenly felt weak…I thought I was going to fall or faint and had to go home.” Several further trips out-of-doors with similar reactions and growing anxiety usually follow this rather benign onset. Within a year, most such individuals are house-bound, fearful of leaving for any reason, and panic-stricken if forced by circumstances to travel even one or two blocks. Unlike individuals with specific animal and situational phobias, agoraphobics continue to have high levels of anxiety (generalized anxiety) even when home, away from the phobic situation. Thus their anxiety is not limited and their phobia cannot be said to be ———

The sex distribution is not strikingly skewed in individuals with specific animal and situational phobias. However, more than two-thirds of agoraphobics are women (128). What is the phobic situation for agoraphobics?

Individuals with the specific animal and situational phobias can/cannot (circle one) be differentiated from the normal controls on physiological tests of resting anxiety levels, nor in their response to stress and psychological profile, whereas agoraphobics are markedly different from the norm, significantly more anxious

at rest, less adaptable to repeated stress and more “neurotic”

and “introverted” on psychological testing ( 47, 102-105,122,143 pp. 85-103, 145). To top off a bad picture, their response to treatment is poor (47,102,105,122,143 pp. 85-103,145,165).

340.

341.

420

335. specific animal, situational

336. 5, 7

337. 15 to 35

338. specific animal phobia specific situational phobia

cagoraphobfi0

339. circumscribed

340. fear of any open, out-of-door space

341. cannot

421

342.

Circle those words or phrases most consistent with agoraphobia:

343.

344.

Although the content varies from individual to individual, people with specific animal/situational phobias characteristically have only one phobia. They are . Although agoraphobics are also monophobic their phobic content is always

and their anxiety is not ———-

Place an A next to the words or phrases characteristic of agoraphobia and an s next to the words or phrases characteristic of specific animal (or situationa!) phobia:

345.

Both agoraphobics and individuals with specific animal or situational phobias can develop acute anxiety attacks. These acute attacks are indistinguishable in these two patient groups and only a careful history will determine the diagnosis. What are the char- acteristics of specific animal/situational phobias that differentiate them from agoraphobics? Write down the distinguishing features for each condition in the following categories: (1) sex ratio,

(2) age of onset, (3) generalization of anxiety, (4) content of phobias, ( 5) physiological and psychological profile, and ( 6) re- sponse to treatment.

The last phobic state we will consider is called phobic-anxiety- depersonalization (PAD) syndrome. The sex-ratio is similar to agoraphobia, 75 percent of the people suffering from PAD are

Like individuals with agoraphobia, people with PAD syndrome can be differentiated from the normal control on physiological measures of resting anxiety, response to repeated stress, and psy- chological profile (102,129,143 pp. 85-103,145). These differences from the norm are in contrast to phobics who cannot be distinguished from controls.

346.

347.

Female

Onset 5 to 7 Generalized anxiety

Psychologically and physiologically abnormal

Circumscribed anxiety Onset 15 to 35

Onset in childhood

Fear of spiders_ _ Poor treatment response

2/3 are women

Much generalized anxiety

Circumscribed

Fear of public speaking_ _

Good treatment response_ _ _

Fear of open spaces

Differs physiologically from norm

Peak onset 20 to 30

Good response to treatment

Male

Poor response to treatment

422

342. ~

@eneralized anxie_!V Good response to treatment

343.

monophobic, fear of open space, circumscribed

344.

S

Fear of public speaking S

345.

346. female

Circumscribed anxiety Onset 5 to 7 (Peak onset 20 to 3V

(onset 15 to 35) Male

Psychologically and physiologically abnormal

Poor response to treatment

Onset in childhood S

Fear of spiders S

Poor treatment response A 2/3 are women A

Much generalized anxiety ~

Circumscribed

1. Sex ratio almost equal

2. Onset in childhood ( 5 to 7

1.

2/3 women

Onset in young adulthood

( 15 to 35, peak 20 to 30) Generalized anxiety

Content always fear of open spaces

Physiologically and psycho- logically different from nor- mal controls

Unresponsive to treatment

years)

3. Circumscribed anxiety

4. Content varies yet

2.

monophobic

5. Physiologically and

3. 4.

psychologically same as

5. 6.

normal controls

6. Responsive to treatment

347. specific animal/situation

423

Good treatment response–s- Fear of open spaces A – – Differs physiologically from norm A

348. 349.

Unlike specific animal and situational phobias, agoraphobia and PAD syndromes most frequently begin between the ages of _ _ _

350. 351.

for

In the PAD syndrome, the P stands for _____, the Astands and the Dfor ——

352.

Sometime after the initial “shock” and depersonalization episode, the person with PAD syndrome develops increasing daily tension. This anxiety is generalized and pervasive. Periodic, acute anxiety attacks is not an uncommon course. As this anxiety is generalized, PAD syndrome, as well as agoraphobia, differs markedly from simple animal/situational phobias where the anxiety i s – – – – – – – –

353.

In the PAD syndrome phobias usually develop. Multiple phobias (situational or animal) are common, are often transient, and are neveJ the core complaint. Since patients with PAD syr;drome have multiph! phobias they differ markedly from simple animal/situational phobics who have a disorder termed ———

354.

The PAD syndrome course can be diagrammed as follows:

and

(102,129,143 pp. 85-103, 145).

Onset of agoraphobia and PAD syndrome before puberty or after is extremely rare, and when it occurs you should always

age

first consider other neuropsychiatric and systemic conditions.

The typical PAD syndrome begins with a stress event, resulting in sudden intense anxiety or “emotional shock” (fainting is common). This is followed by a period of depersonalization of varying duration, sometimes hours or days, sometimes weeks or months during which the patient feels “detached,” “as if in a dream,” “foggy around the edges,” “as if in slow motion,” “above in the air watching myself.” Exacerbations of depersonalization will then occur periodically throug out the course of the illness. From its name, you could also ex-

pect two other chronic or exacerbating behaviors. They are

——- and ————

Phobias

Anxiety and acute attacks

Depersonalization

episodes l Stress event

As you might expect, the PAD syndrome is extremely debilitating. The individual with this chronic illness often cannot work, cannot socialize, and is never without discomfort. As with agoraphobia, the PAD patient’s response to treatment is ( 102,143 pp. 85-103, 129, 145, 165).

424

348. 15, 35 349. 35

350. phobic, anxiety, depersonalization 351. phobias, anxiety

352. circumscribed

353. monophobic

354. poor

425

355.

356.

PA!J syndrome is familial (it runs in families) with 20 percent of patients having a positive family history (47,102,129,141 pp. 103-106 143 pp. 85-103, 145). As in agoraphobia, the usual age of onset range is to with the peak decade being to

Complete the following table by checking the appropriate box to match the clinical statement to the syndrome with which it is most likely associated. Some clinical statements can be checked more than once.

Onset in childhood

Physiologically abnormal

Good treatment response

Little generalized anxiety

Monophobic

Episodes of depersonal- ization

Episodes of acute anxiety Poor treatment response Circumscribed anxiety Approximately 70-80%

are women

Onset in early adulthood Psychic and somatic anxiety Much generalized anxiety

357.

358.

The anxiety state called neurasthenia has many synonyms. Some of these are “neurocirculatory asthenia,” “cardiac neurosis,” “effort syndrome,” “anxiety neurosis,” “DaCosta’s syndrome,” “vasoregu- latory asthe;:da,” “nervous tachycarc!ia,” “vasomotor neurosis,”

“nervous exhaustion,” “irritable heart,” and “soldier’s heart.” This multitude of names describes a single syndrome which I will arbit- rarily call neurasthenia. As neurasthenia is usually not associated with phobias, it is called a “simple” anxiety state (27:35:117,143 pp.

85-103, 175). The three phobic anxiety states you have learned are:

Neurasthenia is characterized by almost daily anxiety (psychic and somatic), fatigue or easy fatigability and occasional acute anx- iety attacks. Why is neurasthenia called a “simple” anxiety state?

Specific Animal/ PAD

Agoraphobia

Situational Phobia

Syndrome

426

355. 15,35; 20,30

356.

Specific Animal/ PAD

Situational Phobia Syndrome Agoraphobia

Onset in childhood

Physiologically abnormal

Good treatment response v’

Little generalized anxiety I

Monophobic v’ I Episodes of depersonal-

ization I

I

Episodes of acute anxiety v’ Poor treatment response

Circumscribed anxiety I Approximately 70-80%

are women

Onset in early adulthood

Psychic and somatic anxiety v’ Much generalized anxiety

I I

357. simple animal/situational, agoraphobia, PAD syndrome

358. Because it is usually not associated with phobias

427

I v’ v’ v’

I I I I v’ v’ v’ v’

359.

Neurasthenia usually develops after puberty (15 to 35 years mos1 commonly) (35,117,143 pp. 85-103,165,175) it is familial (34,140,141 pp. 103-106,174) and is more common in women (female:male ratio is 2: 1) ( 93). This age of onset range, family history pattern and sex ratio is similar to and ——–

360.

Individuals with neurasthenia can be differentiated from normal controls on physiological tests of resting anxiety levels, response to stress and psychological profile ( 27,47, 91, 116, 117, 143 pp. 85-103, 122). This differentiation from the normal population is similar to that of agoraphobics and patients with PAD syndrome. In what otheJ ways are neurasthenics similar to these other patient groups? Be specific.

361.

Individuals with neurasthenia respond poorly to treatment (47, 104,105,122,143 pp. 85-103). Although without phobias, neurasthen: is more like the PAD syndrome and agoraphobia than specific ____________/ phobias.

362. 363. 364.

Patients with daily anxiety and fatigue termed . – – – – . – – . – often perform poorly under stress or exercise and have a reduced physical work capacity (91,116,117).

365.

What is the most likely diagnosis for this patient?

The response to treatment of specific animal and situational pho- bias is ; agoraphobia, PAD syndrome and neurasthenia have a response to treatment.

90 percent of patients with simple animal/situational phobias res- pond well to treatment (47,103-105,122,145); whereas only 25 to 40 percent of patients with agoraphobia, PAD syndrome and neurastheni respond well to treatment (27,47,102-105,122,129,143 pp. 85-103, 145,165). This separation of responsivity is not surprising as the animal/situational phobics are physiologically and psychologically –.—–;–..,. whereas the latter group of disorders are physiologically and psychologically _________

A 27-year-old woman was shopping on a crowded street when she suddenly felt “light-headed” and had to lean on the wall of a build- ing. She suddenly became fearful that if she started walking again, she would again become “light-headed,” stumble and be “pushed to the ground by the crowd.11 Although she returned home without further incident, over a period of time, she became increasingly fearful of stepping out of doors and after a few months was limited to walking a few blocks to the local grocery store, or to travelling by car if someone else drove. At home she described being tense and restless with frequent headaches and palpitations. She had two “attacks” of hyperventilation associated with extreme fear and “air hunger.” Physical examination and laboratory data were within nor- mal limits except for slight rapidity of speech and a tremor in the upper lip. The mental status examination was within normal limits.

428

359. agoraphobia, PAD syndrome

360. Same age of onset range: 15-35

Same sex ratio: mostly female 70-80% Familial

Generalized anxiety

Associated with acute anxiety attacks

361. animal/ situational

362. neurasthenia

363. good, poor

364. normal, abnormal

365. agoraphobia

429

366.

What is the most likely diagnosis for this patient?

A 24-year-old man, without previous psychiatric history or signifi- cant medical history was brought to an emergency room because, while reading at home he suddenly developed a pounding in his chest, a tightness or lump in his throat, trouble breathing, a shaky feeling, blurred vision, dizziness, headache, “nervousness” and a feeling that he was going to die. On examination he was tremulous, sweating, had dilated pupils (reactive), cold extremities, tachycardia and systolic hypertension. The remainder of the physical and lab- oratory results were within normal limits.

What is the most likely diagnosis for this patient?

A 42-year-old woman was seen in consultation because of her intense fear when in the presence of any small furry animal (a rat, mouse, hamster). When she was not in proximity to such animals, she was without unusual anxiety and functioned well. She denied any other complaints .

What is the most likely diagnosis for this patient?

A 54-year-old woman was seen in the emergency room because she complained of “uncomfortable breathing,” chest tightness, blurred vision, tachycardia and “nervousness” of 2 hours’ duration. Phy- sical examination and laboratory findings were all within normal lim- its except for a sinus tachycardia of 108. She admitted to several of these “attacks” per year for the past 30 years. She also gave a history of being tired most of the time and of having a “nervous heart.”

What is the most likely diagnosis for this patient?

A 24-year-old woman received word that her husband was injured in an automobile accident. Upon hearing the news she felt faint and

fell to the floor without losing consciousness. Although her husband’s injuries were minor, she experienced a dizzy felling “almost dream- like” for several days. One week later, she was found at home lying on the floor for no apparent reason. She said she was frightened. During the next six months she became progressively less able to perform her housework. She was tense and restless, cried easily,

and on occasion woke up during the night extremely frightened, com- plaining of difficulty in breathing. She became fearful of her child- ren’s pet canary saying “it will poke me in the eye”; she also was fearful of riding in a car or of taking a bus. She experienced addi- tional “dream-like … unreal” episodes. Physical examination and lab- oratory findings were within normal limits.

What is the most likely diagnosis for this patient?

A 7-year-old boy was walking down the street when a sudden crash severely startled him. As he turned towards the sound, he saw

that an automobile had struck a policeman’s horse and knocked it to the ground. The boy cried and said he was “frightened” and was taken home where he soon felt better. Despite no unusual behavior at home, at school or at play, he continued to complain of fearfulness whenever he saw a horse on television, in a book or in the street.

367.

368.

369.

370.

430

366.

acute anxiety attack

367.

368.

369.

specific animal phobia

acute anxiety attack and neurasthenia

phobic-anxiety-depersonalization syndrome

370.

specific animal phobia

431

371.

Many patients with signs and symptoms of anxiety are not suf- fering from an anxiety state but from a systemic illness or another psychiatric condition. Below is a list of some of the conditions as- sociated with the presence of anxiety. A description of each is be- yond the scope of this book, but before you diagnose anxiety state, keep these other possibilities in mind, and remember that a psych- iatric examination includes a physical examination and a complete his- tory of systems.

Depression Pheochromocytoma Cerebral arteriosclerosis Temporal lobe epilepsy Angina

Presenile dementias Caffeine sensitivity Mononucleosis

Thyroid disease

Early essential hypertension Parkinson’s disease Post-concussion syndrome Cardiac arrhythmias

432

Influenza Hepatitis

371. no answer required

433

MINOR DEPRESSION (DSM-111 TERM: DYSTHYMIC DISORDER)

372.

Earlier in Part II you learned the criteria for major depression. What are they?

Major depression when associated with mania is termed -..,….—-.—., affective disorder. Major depression without any history of mania is termed affective disorder.

Major depression refers to the condition also called endogenous depression. In contrast to major depression,

depression refers to the conditions also called _n_e_u_r-,-o”””‘t'””‘i_c_o_r_r_e_a_c-,.t.i.v. _e_

depression. These terms should be considered only as clinical la- bels and not as indicators of etiology.

Psychiatrists who use the term neurotic/reactive depression, i.e., depression, usually mean an abnormal psychological response in a vulnerable individual ( 143 pp. 77-81). What this vul- nerability is, whether it exists, what stimuli are required for the re- sponse and what the mechanism is of this response are all unknown factors. I will consider only the clinical presentation of the condition ( 48, 74, 85, 126, 128) .

Endogenous or depression and neurotic/reactive or depression cannot be separated by the presence or absence o-“f_a_p_r_e-c’ipitating event (53). However, the symptom content of neu-

rotic/reactive depressions often reflects the present life situations of the patient.

373. 374.

375.

376.

434

372. (All required)

1. Sad or anxious mood

2. Three of the following:

early a.m. waking

dirunal mood swing (worse in the a.m.) more than a 5 lb. weight loss in 3 weeks retardation/agitation

suicidal thoughts/behavior

A. B. C. D. E. F.

month, no systemic illness known to cause depressive symptoms.

373. bipolar, unipolar

374. minor

375. minor

376. major, minor

feelings of guilt/self-reproach/hopelessness/worthlessness 3. No coarse brain disease or use of steroids or reserpine in past

435

377.

378. 379.

380.

381. 382.

383. 384.

Without treatment, the average duration of an endogenous or depression is 9 months. Without treatment, the average “”””d_u_r-a””‘t”‘”io-n-of a neurotic/reactive or depression is 4 to 6

weeks.

The sleep pattern in major depression is classically

awakening. In contrast, the sleep pattern in mfnor depres-

-sir-o-=n–;-:is,-difficulty in falling asleep.

The eating pattern in major depression is clinically —-:—–:—:-:– -..,.,.—–,..-, with associated weight • In contrast, the eating pattern in minor depression is classically a normal or in- creased appetite with weight gain.

Anorexia with more than a 5 lb. weight loss and early a.m. wak- ening are characteristic of depression. Normal or increa- sed appetite and inability to fall asleep (initial insomnia) are charac- teristic of depression.

One characteristic of a major depression is: feeling worse in the –;—–;—…,..- and better in the . Minor depressions do not have this diurnal mood swing.

Patients with major depression rarely exhibit mood changes in response to environmental stimuli. They remain sad. Patients with minor depression will often have a lifting of their mood in response to the environment, i.e., their mood reacts to changes in the environment. They have a diurnal mood swing.

Patients with minor. depression rarely exhibit the profound psy- chomotor retardation or severe agitation often seen in patients with ______ depression.

Draw lines to the phrases in column B with the condition in col- umn A.

AB

Early a.m. wakening

Minor depression Major depression

Weight gain

Initial insomnia

Anorexia and weight loss Diurnal mood swing Psychomotor retardation

436

377. major, minor

378. early a.m. 379. anorexia, loss

380. major, minor

381. a.m., evening 382. do not

383. major 384.

Early a.m. awakening Minor depression –=—–,.,.c_- Weight gain

Initial insomnia

Major depression~=——Anorexia and weight loss

Please keep in mind that “classical” or “characteristic” pattern does not mean always and is not pathognomonic.

437

Diurnal mood swing

Psychomotor retardation

385.

Major or minor depression?

A 28-year-old woman was hospitalized because she ingested an over- dose of aspirin in a suicide attempt. She described a long-standing dissatisfaction with her work and a three-week-old feeling of pes- simism and helplessness. She was anxious and was unable to fall asleep at night. Although she said she was not hungry, she had gained 7 lbs. during the past month. Her anxiety was associated wi angry spells which occurred throughout the day. In the hospital she was demanding, manipulative, and often angry with the staff for not meeting her demands.

Major or minor depression?

A 34-year-old man came to an emergency room complaining that he was fearful of killing himself because his wife wanted a divorce. HiE wife told him this three weeks ago and since then he had been unabl’ to fall asleep, go to work or think about anything else. He gained several pounds during this period.

Major or minor depression?

A 44-year-old woman was seen in consultation because of inability

to work. She expressed a feeling of sadness, she had no energy

or interest ‘and she felt that her life was over. She could not eat, lost 10 lbs. d}lring the past month and was unable to sleep. She del cribed feeling somewhat better in the late afternoon or evening.

386.

387.

438

385. minor

386. minor

387. major – However, systemic illness, coarse brain disease and drug usage must be evaluated before a definitive diagnosis can be made.

439

OBSESSIONAL CONDITIONS

388.

Obsessions are persistent, distressing and unwanted thoughts or impulses which the sufferer knows are foolish, but which cannot be resisted. Compulsions are acts resulting from obsessions. An individual with an obsessional condition may repeat the same act over and over again. When asked about it, he will invariably say he is troubled by “having” to do it, but if he tries not to act upon his ob- sessive thought, his anxiety becomes too great and he succumbs.

In contrast, some patients who have repetitive behavior do so in an automatic fashion. They do not find these behaviors distressing and unwanted and do not think of them as foolish. Such a behavior is termed and is a feature of the syndrome termed

389.

390. 391.

392. 393.

Unwanted, persistent and distressing thoughts, i.e.,

, are signs of a rare condition occurring in less than 5 per-

-,-ce_n_,t,–of”all psychiatric patients (61). It occurs about equally in both sexes (79,86,118).

When an individual acts upon his obsessional thoughts and im- pulses, he is said to have a ——-

Most obsessional conditions begin before age 25 ( 79, 86). Just as in the anxiety states, it is rare to see an individual whose obses- sional condition (or any “neurotic” condition for that matter) began after age ______

Obsessional conditions have an early onset and are chronic (79, 86, 118). As they occur in less than 5 percent of all psychiatric pa- tients, they are fortunately also

Obsessional conditions have an onset of illness, are chronic and rare. They seem to be familial but the data are unclear (22,80,127).

440

388. stereotype, catatonia (If you had difficulty with this question, please review the section on catatonia in Part I, items 61 through 94)

389. obsessions

390. compulsion 391. 35

392. rare 393. early

441

394.

The fact that a person has an obsessive thought is more signif- icant than what his thought is about. The content of the obsession or compulsion is not nearly as important as the _________ of the psychopathology.

395.

Obsessive thoughts often involve a fear of hurting oneself or another person; a fear of being hurt in a particular manner; a fear of contamination or disease; a fear of saying distressing, obscene, blasphemous or nonsensical words or phrases. Ruminations (obses- sivq thoughts) about common daily activities such as dressing or hou maintenance are also characteristic of the condition. The more the person tries to resist these thoughts the more anxious he becomes until finally he must act (93). Such acts are called _ _ _ _ _ __

396.

Most normal children and many healthy adults have some obses- sional behaviors: following a set routine for “good luck,” avoiding sidewalk cracks, rechecking things already well checked. There is no standard demarcation line between the range of normality of these behaviors and the abnormal. But individuals with obsessional con- ditions will invariably have significant levels of anxiety, occasionally phobias, and, not infrequently, major or minor depressions (59, 86, 118, 148). Write the definition of an obsession:

397.

Circle the obsessions:

398.

Circle the compulsions:

Write the definition of a compulsion:

“I keep thinking I’m going to put a pencil in my eye.”

“I can’t get that tune out of my head.”

“I checked the lock three times to be sure.”

“I’m afraid that if I don’t pick up my clothes, something ter- rible will happen.”

“I touch my nose, then my elbow, and swallow. Then I feel better.”

“Every time I see a string, I pick it up and put it in my pocket, for fear that if I don’t I will die.”

“I check the door 5 times , the windows 5 times, under my bed 5 times and in the closet 5 times If I lose count I must do it over again.”

“I keep thinking I’m going to harm someone. It’s frightening but also silly.”

“If I don’t call for the weather report every day I get frighten1

“I know its foolish, but I keep thinking something is going to fall on my head and hurt me.”

442

394.

form

395.

396.

397.

398.

compulsions

An obsession is a persistent, distressing and unwanted thought or impulse.

A compulsion is an act resulting from an obsession.

“I keep thinking I’m going to put a pencil in my eye.”

“I checked the lock three times to be sure.”

“I touch my nose, then my elbow, and swallow. Then I feel better.”

“Every time I see a string, I pick it up and put it in my pocket,

for fear that if I don’t I will die.”

“I keep thinking I’m going

to harm someone. It’s frightening but also silly.”

“I know its foolisb. but I keep thinking something is going to fall on my head and hurt me.”

“I’m afraid that if I don’t pick up my clothes, something ter- rible will happen.”

“I check the door 5 times, the windows 5 times, under my bed 5 times and in the closet 5 times. If I lose count I must do it all over again.”

“If I don’t call for the weather report every day I get frightened.”

443

HYSTERIA (DSM-III TERM: SOMATOFORM DISORDERS)

399.

Hysteria is a term dating back several hundreds of years. It refers to the concept of “wandering uterus.” (Today, it is often used by male physicians and psychologists to describe a female pa- tient who annoys them.) In addition to being sexist, the term and concept are controversial because they often indiscriminately refer to the following conditions ( 66,143 pp. 103-119):

400.

A hysterical reaction usually refers to a condition characterized by severe agitation, severe anxiety, and a lot of screaming ( 68, 121′) • In all other clinical manifestations, the condition appears identical to a severe acute anxiety attack. What are the signs of an acute anx- iety attack? (List them)

401.

Conversion hysteria, also known as conversion reaction, or con- version symptom, are medically unexplained symptoms affecting the voluntary musculature or the organs of a special sense (e.g., eyes, ears). They often suggest neurological disease but no tissue path- ology can be demonstrated. Examples include: paralysis, blindness, deafness, aphonia (inability to speak) , difficulty in breathil1g, “fits,” “spells,” anesthesia, amnesia, and unconsciousness ( 68, 121). Con- version hysteria should not be confused with the term “hysterical reaction” which is characterized by severe and severe _____ and a lot of screaming.

1.

Hysterical reaction (similar if not indistinguishable from an acute anxiety attack)

2. 3. 4.

Conversion hysteria (conversion reaction) Hysterical personality

Briquet’s syndrome

444

399. no answer required

400. 1.

Intense anxious mood often associated with the feeling of impen-

ding doom or death

2. Smothering or drowning feeling or air hunger

3. Chest discomfort, tightness or pain

4. Lump in throat

5. Dizziness and/or faintness

6. Weakness and/or fatigue

7. Inward “shakiness”

8. Tremor

9. Paresthesias

10. Tachycardia and/or palpitations 11. Vascular throbbing

401. agitation, anxiety, screaming

445

402.

Unexplained systemic symptoms such as headaches, backaches and other pains should not be included under the heading: conver- sion symptoms. “Conversion” phenomena are characterized by symp- toms affecting the musculature and organs of

403. 404.

Conversion symptoms suggest neurological disease. Can tissue pathology be demonstrated?

405.

There are a group of systemic medical conditions (e.g., ulcera- tive colitis, asthma, peptic ulcers, eczema) termed psychophysiolo- gical disorders (83) (the old term is psychosomatic, the new term is: “psycholqgical factors affecting physical illness”) which are dys- functions with demonstrable tissue pathology. How does this con- trast with conversion symptoms? Write your answer.

406.

Organ symptoms most often associated with psychophysiological disorders are those innervated by the autonomic nervous system (e.g., smooth involuntary muscles of bowels, blood vessels, skin) (123). How does this contrast with the organs most often associated with conversion symptoms? Write your answer.

407.

A “psychological/emotional” or physiological vulnerability to chro- nic stress has been hypothesized as a major causative factor in the development of psychophysiological disorders, hence the prefix “psy- cho.” These systemic illnesses are often associated with high daily (generalized) levels of psychic and somatic anxiety and patients

with these conditions can present with acute anxiety attacks (83,123, 130,135). What are the diagnostic criteria for such attacks?

408.

Psychophysiological disorders can be distinguished from conver- sion symptoms by the organs affected and the tissue pathology ob- served. What specifically are these differences between the two con- ditions?

409.

Most individuals receiving the diagnosis of “hysterical personality’ are women ( 28 ,180). Onset for these behaviors usually occurs before age 15 ( 28,68, 68 ,121,180). “Hysterical personality” is not “hyster- ical reaction” which is characterized by severe , se- vere , and a lot of and which ap-

pears identical to acute anxiety.

As in most of the so-called “neurotic” disorders, more women than men are affected with conversion symptoms ( 71) . The usual body parts (organs) affected a re ————–

446

402. voluntary, special sense

403. no

404. 405.

406.

407.

voluntary musculature, organs of special sense

Conversion symptoms have no demonstrable tissue pathology.

In conversion symptoms the organs of special sense and the volun- tary musculature are most often involved.

408.

( 1) Psychophysiological disorders affect organs innervated by the autonomous nervous system whereas conversion symptoms involve organs of special sense and the voluntary musculature; and

(2) Tissue pathology has been demonstrated only for psychophysio- logical disorders.

Two of the following three: Three of the following eight:

1. Intense anxious mood 2. Air hunger

3. Chest discomfort

1. Tachycardia

2. Tremor

3. Vascular throbbing 4. Inward “shakiness” 5. Lump in throat

6. Paresthesias

7. Dizziness

8. Weakness

409. anxiety, agitation, screaming

447

410.

Individuals with hysterical personalities are said (28) to be:

1. Dramatic and histrionic

2. Egocentric and vain

3. Passive and manipulative

4. Sexually provocative

5. Dependent and demanding

6. Emotionally labile and excitable but shallow

7. Obsessive-compulsive

These behaviors are constant and usually begin before the age of

The term hysterical personality does not imply either a hyster- ical reaction or a conversion symptom, although many psychiatrists believe these conditions occur more frequently in individuals with a hysterical personality than among the general population (21>,71,180). A hysterical reaction is similar to an

-=-=—–::—–:—:· A conversion sympto::m=-s:::uc:-g=g::-ec:-s’ts=-=a:– – – – – – – – disease for which no pathology can be demonstrated.

A 22-year-old woman comes to see you because she is having difficulties at work and with her fiancee. She relates her life events in a dramatic and histrionic manner. When you suggest an altern- ative to her handling of a situation she becomes angry and then bursts into tears. This behavior quickly abates as she becomes awarE that you are unresponsive to her outburst. She then proceeds to cross her legs in a seductive manner. Circle the most likely diag- nosis:

a) Hysterical reaction

b) Conversion reaction

c) Psychophysiological disorder d) Hysterical personality

Although often described as “dramatic,” ”histrionic” and “ex- citable” individuals with hysterical personalities also are described

as emotionally shallow with fleeting moods. What is the characteristic age of onset of these behaviors and which sex is affected most fre- quently?

Obsessive-compulsive behaviors have been described as part of the hysterical personality. What is the difference between an obses- sion and a compulsion?

Individuals with hysterical personalities are described as sexually

provocative. They are also described as emotionally

with moods. ——-

Individuals with hysterical personalities are said to be passive, but also manipulative. They are also sexually———

411.

412.

413.

414. 415. 416.

448

410.

15

411.

acute anxiety attack , neurological

412.

d

413.

before age 15, women

414. 415. 416.

An obsession is a persistent, distressing and unwanted thought or impulse.

A compulsion is an act resulting from an obsession.

shallow, fleeting provocative

449

417.

418.

419.

420.

Circle the words and/or phrases characteristic of a hysterical personality.

Blind without pathology Stubborn

Dramatic and histrionic Intellectual

Egocentric and vain Sexually provocative Passive and manipulative Shy

Circle the words and/or phrases characteristic of a hysterical personality.

Altruistic Obsessive-compulsive Emotionally labile

Asexual

Moods fleeting and shallow

Dependent and demanding Mature

Dramatic

Independent

Excitable

Individuals with a hysterical personality tend to exhibit more frequently than others, behaviors which look like neurological disease of the voluntary musculature or organs of special sense

but for which no pathology can be demonstrated. These behaviors are called ——–

Draw lines to match the phrases in column B with the condition in column A. Conditions in column A can be used more than once.

AB

Conversion hysteria

Hysterical reaction

Psychophysiological disorder

Hysterical personality

Voluntary muscles and organs of special sense involved but no pathology demonstrated

Agitation, screaming and anx- iety

Egocentric, dramatic and excitable behaviors

Involuntary muscles involved

Ulcerative colitis, asthma, pep- tic ulcer

Mimics neurological symptoms but no medical explanation for symptoms

Dysphoria, air hunger, pares- thesias, tremor, tachycardia and inward shakiness

Manipulative, sexually provoc- ative, dependent and demand- ing

450

417.

Blind without pathology

Stubborn

(Dramatic and histriorl§)

Intellectual Altruistic

c§”bsessive-compulsi~

(Emotionally lab® Asexual

(Moods fleeting or shall~

conversion symptoms (or conversion reaction or conversion hysteria)

418.

419.

(Egocentric and va]D (Sexually provocati~

(Passive and manip~ Shy

(Dependent and demandin~ M a t u r e

(DramatiC) Independent

420.A B

Conversion hysteria——– Voluntary muscles and organs of special sense involved but no

pathology demonstrated

Hysterical reaction.—~—– Agitation, screaming and anx- iety

Egocentric, dramatic and ex- citable behaviors

Ulcerative colitis, asthma, pep- tic ulcer

Mimics neurological symptoms but no medical explanation for symptoms

Dysphoria, air hunger, pares- thesias, tremor, tachycardia and inward shakiness

Manipulative, sexually provoca- tive, dependent and demanding

Psychophysiological”””‘=::::::::::–“1,—4.<::::____ Involuntary muscles involved

disorder

Hysterical personality

451

(Excitable)

421.

Although the reliability and validity of the concept of “hysteri- cal personality” is unclear, Briquet’s syndrome (DSM-111 term: “Somatization Disorder”) has been shown to be a specific condition (66,68,70,73,95,114). Many individuals with the label “hysterical personality” satisfy diagnostic criteria for Briquet’s syndrome (73). For the research diagnosis of Briquet’s syndrome, the patient must have 25 medically unexplained chronic symptoms, for a “definite” diagnosis, or 20 to 24 symptoms for a “probable” diagnosis in at least 9 of the 10 following groups ( 114, 121).

Group 1

Headaches

Sickly most of life

Group 2

Blindness Paralysis Anesthesia

Aphonia

Fits or convulsions Unconsciousness Amnesia

Deafness Hallucinations Urinary retention Ataxia

Other conversion

symptoms

Group 3

Fatigue

Lump in throat Fainting spells Visual blurring

Weakness Dysuria

Group 4

Breathing difficulty Palpitation

Anxiety attacks Chest pain Dizziness

Group 5

Anorexia Weight loss Marked fluctu-

ations in weight Nausea

Abdominal bloating Food intolerances Diarrhea Constipation

Group 6

Abdominal pain Vomiting

Group 7

Dysmenorrhea Menstrual

irregularity Amenorrhea Excessive bleeding

Group 8

Sexual indifference Frigidity

Dyspareunia

Other sexual difficulties Vomiting nine months

of pregnancy, or hos- pitalized for hyperem- esis gravidarum

Group 9

Back pain

Joint pain

Extremity pain

Burning pains of the sexu

organs, mouth, or rectu Other bodily pains

Group 10

Nervousness

Fears

Depressed feelings Need to quit working or

inability to carry on regular duties because of feeling sick

Crying easily

Feeling life was hopeless Thinking a good deal

about dying Wanting to die Thinking of suicide Suicide attempts

Briquet’s syndrome is thus characterized by multiple symptoms in multiple organ systems for which there are no “medical” explanations. What other condition have you studied in which organ symptoms occur without medical explanation?

452

421. Conversion reactions

453

422.

423. 424.

List the behavior associated with the label “hysterical personal- ity.”

1. 2. 3. 4. 5. 6. 7.

The “definite” diagnosis of Briquet’s syndrome requires the pre- sence of medically unexplained symptoms in at least

– – – – of 10 organ systems groups.

The diagnosis of hysterical personality and Briquet’s syndrome

is much more commonly made in which sex? Both con- ditions have an early onset with most behaviors present before age 15.

454

422, 1. dramatic and histrionic 2. egocentric and vain

3. passive and manipulative

4. sexually provocative

5. dependent and demanding

6. emotionally labile, excitable but shallow 7. obsessive-compulsive

423. multiple ( 25) , 9 424. women

455

425.

Briquet’s syndrome is a disorder resulting in

426.

Studies suggest that about 2 percent of the female population has diagnosable Briquet’s syndrome (180). Associated conversion symptoms are common (71), but conversion symptoms are also seen in many other psychiatric and systemic conditions (49). Moreover, in any large series of cases of conversion symptoms, only a minority have Briquet’s syndrome. Althought multiple hospitalizations, sur- gical procedures, and dramatic symptoms are common among women with Briquet’s syndrome, a medical explanation for these symptoms _ _ _ _ _ be demonstrated.

symptoms in multiple

Below are the

categories must occur for a defin-

….,…..—- symptoms in itive research diagnosis.

Group 1

Group 4

Group 8

Headaches

Sickly most of life

Breathing difficulty Palpitation

Anxiety attacks Chest pain Dizziness

Sexual indifference Frigidity

Dyspareunia

Other sexual difficulties Vomiting nine months of

Group 2

Blindness Paralysis Anesthesia Aphonia

Fits or convulsions Unconsciousness Amnesia

Group 5

pregnancy, or hospital- ized for hyperemesis gravidarum

Deafness Hallucinations Urinary retention Ataxia

Other conversion

in weight

Nausea

Abdominal bloating Food intolerances Diarrhea Constipation

Back pain

Joint pain

Extremity pain

Burning pains of the sexual

symptoms

organs, mouth, or rectum Other bodily pains

Group 3

Abdominal pain Vomiting

Nervousness

Fears

Depressed feelings Need to quit working

Fatigue

Lump in throat Fainting spells Visual blurring Weakness Dysuria

Group 7

or inability to carry on regular duties be- ceuse of feeling sick

Anorexia

Weight loss

Marked fluctuations

Group 9

Group 6

Group 10

Dysmenorrhea Menstrual irreg-

ularity Amenorrhea Excessive

Crying easily

Feeling life was hopeless Thinking a good deal

bleeding

about dying Wanting to die Thinking of suicide Suicide attempts

456

10_c_a..,.t_e_g_o_r1~.e-s-….m-w..,h’i,..ch

425. multiple, organ systems, 25, 9

426. cannot

457

427.

428.

Briquet’s syndrome runs in families (1.1,179). About 20 percent of first-degree female relatives of patients also have the condition. This risk is many times greater than the percent seen in the general female population.

Draw lines to match the phrase in column B with the condition

429.

Draw lines to match the phrase in column B with the condition

in column A. AB

430.

Draw lines to match the phrase in column B with the condition

in column A. AB

in column A. A Briquet’s syndrome

Hysterical reaction

Hysterical personality Conversion symptom

B

Unexplained loss of function in organs of special sense

Multiple symptoms in multiple systems

Acute anxiety attack

Egocentric, dramatic, manipula- tive, demanding and excitable

Briquet’s syndrome Hysterical personality Hysterical reaction

Conversion symptom

Paralysis without medical cause 25 symptoms in 9 system groups

Tachycardia, “air hunger”,

fear of impending doom, agitation

Sexually provocative, obsessive- compulsive, passive and mani- pulative

Briquet’s syndrome Hysterical personality Hysterical reaction

Conversion syndrome

“Fits and spells” without medical cause

Multiple hospitalizations, multi- ple surgery, familial

Difficulty breathing, dizziness, vascular throbbing, fear, tremors, systolic hypertensions

Histrionic, vain, dependent, emotionally labile

458

427.

2%

428.

Briquet’s syndrome Hysterical reaction

Unexplained loss of function in organs of special sense

Conversion symptom

Egocentric, dramatic, manipula- tive, demandin:Jg and excitable

429.A B

Briquet’s syndrome Paralysis without medical cause Hysterical personality 25 symptoms in 9 system groups

Hysteria! reaction—…..:>…,.—.,~— Tachycardia, “air hunger”, fear of impending doom, agita-

Conversion symptom Sexually provocative, obsessive- compulsive, passive and mani-

430.A B

Briquet’s syndrome “Fits and spells” without medical cause

Hysterical personality Multiple hospitalizations, multi- ple surgery, familial

Hysterical reaction—–,””‘-::— Difficulty breathing, dizziness, vascular throbbing, fear, tre-

Conversion syndrome

Histrionic, vain, dependent, emotionally labile

459

Multiple symptoms in multiple systems

Acute anxiety attack

tion

pulative

mors, systolic hypertensions

SOCIOPATHY (DS!\1-III TERM: ANTISOCIAL PERSONALITY DISORDER)

431.

The adult personality can be defined as the affective and cog- nitive behaviors of the physiologically mature individual. An abnor- mal personality (i.e., personality disorder) implies (1) a deviation from the average personality (a mathematical, not a biological reality) or (2) a morbid process (a disease) resulting in a particular affect- ive and cognitive pattern of behavior which alters the usual person-

432. 433.

Personality refers to and

ior patterns in the physiologically mature ind”iv….,i”d”‘u,…,a”‘l-.—-

behav-

434.

Psychiatry has not yet been successful in identifying personal- ity deviations with or without true illness and has not yet determined a scientifically reliable and valid category of personality deviation. One exception is Briquet’s syndrome, another is sociopathy. Socio- pathy (also known as psychopathic personality, sociopathic person- ality, antisocial personality) is a pattern of affective and cognitive behaviors characterized by: recurrent antisocial, delinquent and criminal behavior beginning before age 20 (often before puberty) (31,124).

ality. In other words, some personalities are on the fringes of nor- mal personality patterns, just as some people without illness are on the fringe of normal height (very tall or very short). When these fringe personality patterns result in discomfort to the individual or society, the individual is labeled abnormal, deviant or disordered, although no illness is present. Other personality patterns may be the result of disease (just as some people are on the fringe of normal height because of pituitary or other lesions).

Using the above model of affective and cognitive behavior pat- terns (personality) we would conclude that an individual with a very forceful assertive, outgoing personality although differing from the norm (and therefore statistically abnormal) most likely, is or is not (circle one ) suffering from an illness.

Personality patterns can be on the fringes of the normal range of behaviors. By definition, these patterns are statistically ________ but not necessarily due to illness.

460

431. is not

432. affective, cognitive

433. deviant (abnormal)

434. no answer required

461

435. 436. 437. 438. 439.

440.

441. 442.

443.

444.

445.

The adult personality is the pattern of -.—-…——- and .,-,…,–,..,..,.–….—-behaviors in the physiologically _ _ _ _ _ _ individual.

Sociopathy is a pattern of affective and cognitive behaviors, be- ginning before age 20 which is characterized by recurrent antisocial, delinquent and behavior ( 31, 124).

In one series of studies, nearly 80 percent of male felons exhib- ited recurrent antisocial and delinquent behavior before age 20. These were diagnosable individuals ( 63-65).

Sociopathy is characterized by recurrent ,

::-::c::——‘ and age _______

Sociopathy, or early onset recurrent and,

behavior beginning before

, behavior has been reported

in”‘:—;1″5′””‘=p-e-,r-=-ce-=-n=-t:.:-:o””f’m=ale and 3 percent of female psychiatric patients (181) and may have a range of from 2 to 9 percent in the general population (64,97).

Sociopathy begins in childhood or early adolescence. It is ex- tremely rare for sociopathic behavior patterns to develop after age

Briquet’s syndrome is most commonly seen in women. In contrast, sociopathy is most commonly seen in ——-

Sociopathic behaviors include recurrent childhood difficulties such as fighting, running away from home, failure in school, and truancy ( 31, 124). In which sex would you expect to most frequently observe these behaviors?

Sociopaths often have a history of childhood hyperactivity (108, 124) . However, keep in mind that not all adult sociopaths were hy- peractive children and that most hyperactive children do not become sociopaths. In addition to hyperactivity, sociopaths usually have difficulties in the home and at school. What are these difficulties?

Sociopaths have stormy interpersonal histories. This includes poor job history, early heterosexual experiences with early marriage but a high divorce rate, adult promiscuity and a high prevalence of prostitution and homosexuality (31′,33, 124). These behaviors are usually present before the age of _ _ _ _ _ _

Sociopaths have an increased prevalence of conversion symptoms

( 71), Briquet’s syndrome ( 33,101, 124) and alcoholism (31, 33,101, 124). Their I.Q.’s have been reported to be low-normal or borderline (33, 39, 97) and they are described as cold and callous (31, 120, 133). From the list of their behaviors, what would you predict to be their relationships with legal authority?

462

435. affective, cognitive, mature

436. criminal

437. sociopathic

438. antisocial, delinquent, criminal, 20

439. antisocial, delinquent, criminal

440. 20

441. men 442. males

443. running away, school failure, and truancy

444. 20

445. Poor – with a history of trouble with the police; criminality

463

446.

Circle the behaviors below which are associated with sociopathy:

447. 448.

A 50-year-old woman developed for the first time recurrent anti- social behavior, lost her job, and left her family. Is she likely to have sociopathy? Explain your answer:

Sociopathic behaviors include (31,33,39,63-65,97 ,108, 120,124, 133,181):

1. Childhood hyperactivity (Keep in mind that not all adult socio- paths were hyperactive children, and that not all hyperactive children become sociopaths).

2. Early fighting.

3. Poor school adjustment (failure, truancy)

4. Running away from home in childhood and adolescence

5. Early heterosexual experiences, early marriage

6. Adult promiscuity, high divorce rate, high prevalence of pros- titution and homosexuality

7. Poor job history

8. Increased prevalence of conversion symptoms, Briquet’s syn- drome and alcoholism

9. Low-normal or borderline I.Q.

10. Trouble with the police

11. Cold and callous affect

To sum up: Sociopaths exhibit recurrent ___________ ______ and behavior.

There appears to be a strong relationship between sociopathy and Briquet’s syndrome (33,101,124). The family illness patterns

of the two conditions are similar and in a group of individuals selec- ted for one of these disorders you will find a greater than expected number who also demonstrate the other condition ( 33,63-65,67, 101). Sociopathy and Briquet’s syndrome may be the same disorder expres- sed differently in the two sexes; sociopathy being more common in ——–and Briquet’s syndrome more common in ____

Sociopathy is familial (i.e., more family members of sociopaths have sociopathy than you would expect from general population fig- ures). The families of sociopaths also have more than expected ill members with Briquet’s syndrome. When ill, the male family members usually have , and the female family members usu- ally have (29,32,41,63,64,67,69,124,134).

449.

450.

Increased risk for alcoholism Egocentric

Briquet’s syndrome Phobias

Obsessive-compulsive behaviors

Increa;:;c:cl risk for conversion symptoms

Cold and callous Psychophysiological disorder

464

446.

(!ncreased risk for alcoholi~ Egocentric

447. 448.

No. More common in men and almost always begins before age 20. antisocial, delinquent, criminal

449.

males, females

450.

sociopathy, Briquet’s syndrome

Griquet’s syndroiDV

Phobias Psychophysiological disorder

465

451. Circle the words or phrases characteristic of sociopathy.

Early fighting Warm and friendly Poor job history Criminality

High I.Q.

Truancy

Alcoholi10-n

Hallucinations and delusions

452. Circle the words or phrases characteristic of sociopathy.

Catatonic motor features Shy and introverted High divorce rate Thought disorder

Running away from home Delinquency

Conversion symptoms Cold and callous

453. Circle the words or phrases characteristic of sociopathy.

School failure Onset at age 30 Verbigeration Criminality Familial

Childhood hyperactivity Prostitution

Early marriage

More common in females

466

451. 6arly fightinj) Warm and friendly

High I.Q. (TruancY) 0-lcoholisr€)

Hallucinations and delusions

(Running away from ho~ (Delinquenc!) (Conversion sympto~

(cold and callou~

@hildhood hyperactiVl§’) (ProstitutiOly

~rly marriagv

More common in females

452.

Catatonic motor features

Shy and introverted (High divorce ra}i)

Thought disorder

453. {School failure) Onset at age 30

Verbigeration @riminality) (Familial)

467

ALCOHOLISM

454.

455.

Alcoholism refers to excessive use of alcohol resulting in medical,

social, interpersonal, vocational or legal problems. We have discusse,

psychiatric conditions where the risk for alcoholism is increased.

These are

and ——————————–

Alcoholism is usually progressive and chronic, occasionally with exacerbation and remissions. However, not all heavy drinkers are alcoholics because by definition: alcoholism is excessive drinking which results in physical, social and/or industrial dysfunction. Cir- cle the descriptions which fit the above definition of alcoholism:

456.

457.

The risk for alcoholism in the general male population is 3 to 5 percent and in the general female population is 1 percent (18, 55, 100, 138,142). The risk is highest among the young, urban dwellers, low

socioeconomic groups, Black Americans and non-Baptists (23,125). France and the Soviet Union are countries with particularly high alcoholism rates ( 131). Write the definition of alcoholism.

Sociopathy and alcoholism are associated with the

sex. Affective disorder is associated with the —–s-ex-.

Lost job because of drinking

Consuming a six- pack of beer a day

Three highballs after work , sev- eral mixed drinks on weekends

Two martinis before lunch and dinner and a brandy at night

Cirrhosis of the liver in a heavy drinker

Constant family ar- guing over husband’s drinking

Arrested for public intoxication

Loss of driver’s license because of driving while intoxicated

468

454. affective disorder, sociopathy

455.

Two martinis before lunch and dinner and a brandy at night

Consuming a six- pack of beer a day

Loss of driver’s license because of driving while intoxicated

Three highballs after work, sev- eral mixed drinks on weekends

arguing over husband’s drinking

456. Excessive drinking resulting in physical, social and/or industrial dys- function.

457. male, female

469

458.

459.

The usual onset of alcoholism in males is in the teens or early 20’s. For females, it is somewhat later. An onset after age 45 is unusual ( 113). You should consider the presence of other conditions, particularly affective disorders in individuals with onset

of alcoholism .

There appear to be clinical stages of alcoholism ( 15,81,82). These stages do not imply causation, nor does the individual patient pass through all stages in sequence (60). Staging is merely a method of clinical shorthand. A Stage I alcoholic will respond positively to most of the following questions:

1. Has your family ever objected to your drinking?

2. Have you ever thought you drank too much in general?

3. Have others ever said you drank too much for your own good?

4. Have you ever felt guilty about drinking?

5. Do you have a drink almost every day?

6. Have you ever lost friends because of drinking?

Behaviors consistent with a positive response to most of the above questions usually begin in the teens or early and are most often seen in the sex.

Family objection, self-concern, statements of concern from others, guilt feelings about drinking, daily drinking and loss of friends due to drinking are all the positive responses of a stage alcoholic. – –

Circle the words or phrases associated with Stage I alcoholism.

460.

461.

462.

Loss of friends due to drinking Daily drinking

Liver disease

Family objections to drinking

DT’s

Guilt about drinking Drinking before breakfast Drinking hair tonic

Circle the words or phrases associated with Stage I alcoholism.

Self-concern about drinking too much

Drunk driving Family objections

Benders

Statements of concern from others

Memory loss

470

458.

late

459.

20’s, male

460.

461.

462.

(Loss of friends due to drinking) (Daily drinking)

Liver disease

~mily objections to drinkin?;)

Drunk driving C!amily objectiofiV

DT’s

@uilt about drinkillj)

Drinking before breakfast Drinking hair tonic

Benders

Statements of concern from others

Memory loss

471

463.

A Stage II alcoholic will respond positively to most of the follow- ing questions:

1. Did you every get into trouble at work because of drinking?

2. Did you ever lose your job on account of drinking?

3. Did you ever have trouble with driving a car because of drink- ing? (accident, speeding, suspended or lost license)

4. Have you ever been arrested, even for a few hours, because of drinking and/or disturbing the peace?

5. Have you ever gone on benders? (48 hours of drinking assoc- iated with default of usual obligations. This must have occurred more than once).

Behaviors consistent with a positive response to most of these ques- tions are associated with the sex, onset in or early

, medical, social and interpersonal problems which are _u_s_u-al'”‘l_y_c_,h,-ro-nic .

Circle the words or phrases characteristic of alcoholics or high risk for alcoholism.

464.

465. 466.

467.

Male

Farmer Schizophrenia Young

Elderly Non-Baptist Sociopathy French

Urban dweller Affective disorder Black American

Trouble at work, loss of job, trouble with driving, arrest due to drinking and benders are all positive responses to questions of a stage alcoholic.

Circle the word or phrase associated with stage II alcoholism:

Trouble at work Liver disease Benders

DT’s

Arrested because of drinking Car accident after drinking

Place an I next to the words or phrases characteristic of stage I alcoholism and a II next to the words or phrases characteristic of stage II alcoholism.-

Benders

Family objections to drinking

Arrested for drinking

Loss of job due to drinking

Feels guilty about drinking

Loss of friends due to drinking

Drunk driving

Others complain of drinking

472

463. male, teens, 20’s

464. @ale) Farmer

Elderly (Non-Bapti@ ( Sociopathp

DT’s

(!\rrested because of drink~

(Car accident after drinkinV

Feels guilty about drinking _I_

Schizophrenia

(Young) ®ench)

(Urban dwelle”V (Affective disorde~ Qnack AmericaJ0

465. II

466. (Trouble at worlD Liver disease

(Bendery

467.

Benders II

Family objections to drinking

Arrested for drinking __!.!__ Loss of job due to drinking II

473

I

Loss of friends due to drink- ing _I_

Drunk driving __!.!__

Others complain of drinking

468.

A stage III alcoholic, in addition to responding positively to stage I and II questions, will also respond positively to the following:

1. Have you ever wanted to stop drinking and couldn’t?

2. Have you ever tried to control your drinking, by trying to drink only under certain circumstances?

3. Did you ever drink before breakfast?

4. Did you ever drink unusual things such as hair tonic, paint sol- vent and rubbing alcohol?

Behaviors consistent with a positive response to most of these ques- tions are associated with (circle the appropriate words or phrases):

469.

470.

471.

Inability to stop drinking, trying to control drinking by only drinking at certain times, drinking before breakfast and drinking unusual things such as hair tonic are all positive responses of a stage

alcoholic.

Circle the words or phrases associated with stage III alcoholism.

Male

Middle aged Rural

Black American Baptist

Medical problems Sociopathy

Female 20’s

Upper socioeco- nomic class

Farmer Schizophrenia Legal problems

Teenager

Urban dweller Affective disorder

Non-Baptist Russian/French Socioeconomic problems

Drinking before breakfast

Loss of friends because of drinking

Wanting to stop drinking but unable

Benders

Family objections to drinking Drinking unusual things

Drunk driving

Place a I next to the words or phrases characteristic of stage I alcoholism, aII next to the words or phrases characteristic of stage II alcoholism and a III next to the words or phrases characteristic of stage III alcoholism.

Benders

Family objection to drinking

Wants to stop drinking but can’t

Loss of driver’s license because of drinking

Drinking before breakfast Drinking paint solvent

Loss of job because of drinking Guilt feelings about drinking

474

468. (Male) Middle aged

Rural

C}llack Americ8:il) Baptist

(Medical problem~ (sociopathy)

Female

Gfu

Upper socioecono- mic class

Farmer

Schizophrenia (Legal probleffib

(Teenagei)

(Urban dweller) (Affective disord@)

(Non-Bapti0 (Russian/Fren£E> (Socioeconomic proble”iiiV

469. III

470. (Drinking before breakfasi)

Loss of friends because of drinking

Wanting to stop drinking but unable

Benders

471. Benders II

Family objections to

drinking I

Wants to stOp”””””drinking

but can’t III

Loss of driver’s license

because of drinking .!!_

Family objections to drinking (Drinking unusual thingV

Drunk driving

Drinking before breakfast III Drinking paint solvent III –

Loss of job because of drinking II Loss of friends over drinking I –

Guilt feelings about drinking I – Trying to limit drinking to certain cir-

cumstances III

475

472.

A stage IV alcoholic, in addition to responding positively to ques- tions about stage I through III, will also respond positively to the fol- lowing questions:

473. 474.

Fighting when drinking, DT’s, liver disease, memory loss when drinking and impotence when drinking are all associated with stage —– alcoholism.

1. Have you ever gotten into fights when drinking?

2. Have you ever had memory losses when drinking (blackouts)?

3. To men only: Have you ever experienced impotence associated with drinking?

4. Have you ever had DT’s, shakes, liver disease or other medical complications of drinking?

Behaviors consistent with a positive response to most of the questions are associated with (circle the appropriate words or phrases):

Female Teenager Farmer

Black American

Male

Early 20’s Baptist

Legal problems

Sociopathy French Non-Baptist

Age 70

City dweller

Place the proper stage number (I, II, III, IV) next to the char- acteristic behavior of that stage:

Fighting when drinking Drunk driving __

Benders

Unable to stop drinking

Liver disease due to drinking

Loss of friends because of drinking

Loss of job because of drinking

Blackouts when drinking

DT’s

Impotence when drinking Drinking before breakfast

Family objections to drinking __

Guilt feelings about drinking

Arrested because of drinking

Drinking hair tonic

Trouble at work because of drinking

Trying to control circum- stances of drinking

Others object to drinking

476

Affective dis- order

472. Female

(Teanag~

F a r m e r

(Black Americ~

@V ~ (Early 2§ (French)

B a p t i s t (Non-Bapti~ ~egal probleiiiS)

Age 70

473. IV

474. Fighting when drinking IV Drunk driving II – Loss of friends because of

drinking I

Loss of job because of

drinking II

DT’s IV –

Family objections to

drinking I

Guilt feelingsabout

drinking _I_

Drinking hair tonic III Trying to control circum- stances of drinking _!!!

Benders II

Unable to—stop drinking III Liver disease due to drinking

IV

Blackouts when drinking IV Impotence when drinking IV Drinking before breakfastll Arrested because of drinking

III

Trouble at work because of drinking !!.._

Others object to drinking _I_

477

CLINICAL EVALUATIONS

You can now put your accumulated knowledge to practical use: You have just been asked to examine the following nine patients. They were referred to you because everyone is amazed by your diag nostic skills. Proceed with the patients the way you did in the last section of Part I.

CASE I

A 39-year-old white man is brought to the emergency room by the police because he became assaultive and agitated, and when confronted, he said: “I am a messenger of God…I have a secret for the cure of cancer because God told me.”

The patient appears in good physical health, has good personal hygiene and is alert. His gait is normal, but he demon- strates increased frequency of motor be- havior, termed , and during your examination he becomes involved

in several surrounding events in the emergency room.

The patient’s eyes are open wide and are bright. His facial skin is taut, flushed and he has a perpetual smile upon his face, altered only by an angry expression when you appear not to understand him.

His affect is expanded in –,-.,-,.— increased in , and his mood, reflected in his facial expression, is

His last statement is a idea. Because it de-

velops from an auditory hal- lucination it is _ _ _ _ _

This behavior is termed

478

CASE I

A 39-year-old white man is brought to the emergency room by the police because he became assaultive and agitated, and when confronted, he said “I am a messenger of God…I have a secret for the cure of cancer because God told me.”

The patient appears in good physical health, has good personal hygiene and is alert. His gait is normal, but he demon- strates increased frequency of motor be- havior, termed agitation, and during your examination he becomes involved

in several surrounding events in the emergency room.

The patient’s eyes are open wide and are bright. His facial skin is taut, flushed and he has a perpetual smile upon his face, altered only by an angry expression when you appear not to understand him.

His affect is expanded in range, increased in intensity, and his mood, reflected in his facial expression, is euphoric (and angry).

His last statement is a delusional idea. Because it develops from an auditory hallucination it is secondary.

This behavior is termed hyperactivity.

479

He is very concerned about his present situation, expresses warm feelings for his family, and elaborates plans for

the future.

His speech is rapid and he is difficult to interrupt. Occasionally he intrudes into the conversations of other staff members in the emergency room.

His thoughts jump from topic to topic and at times he appears to be carrying on two trains of thought simultaneously.

He expresses his idea that he is God’s messenger and admits to hearing God’s voice which comes to him frequently during the day, from above, and is clear and often continuous.

The patient is unable to do serial 7’s or spell the word “world” backwards.

All other cognitive functions appear within normal limits.

Physical examination and laboratory findings are within normal limits and there is no history of coarse brain disease, systemic illness or drug abuse.

List these criteria:

These suggest that he does not have – – – – – – –

An exarr.ple of _ _ _ _ _ ./

An example of _ _ _ _ _

An example of _ _ _ _ _

o_n_e_o_f.—-;t-;-h_e_ _ _ _ which is ——

An example of difficulty in

which is

dysnfu_n_c7tl~.o-n-.

This man satisfies the diag- nostic criteria for

480

a-1.-:s::-:o—=-a-m:c:-:e-::a-::s-:-u-::r::-:e—:-o”F”f

______

He is very concerned about his present situation, expresses warm feelings for his family, and elaborates plans for

the future.

His speech is rapid and he is difficult to interrupt. Occasionally he intrudes into the conversations of other staff members in the emergency room.

His thoughts jump from topic to topic and at times he appears to be carrying on two trains of thought simultaneously.

He expresses his idea that he is God’s messenger and admits to hearing God’ voice which comes to him frequently during the day, from above, and is clear and often continuous.

The patient is unable to do serial 7’s or spell the word “world” backwards.

All other cognitive functions appear within normal limits.

Physical examination and laboratory findings are within normal limits and there is no history of coarse brain disease, systemic illness or drug abuse.

These suggest that he does not have emotional blunting

An example of rapid/pressured speech. – –

An example of flight-of-ideas.

An example of complete audi- tory hallucination or phoneme which is one of the first-rank

symptoms of Schnei~

An example of difficulty in concentration which is also a measure of frontal lobe dysfunction.

This man satisfied the diag- nostic criteria for mania.

List these criteria:

1. Hyperactivity

2. Rapid/pressured speech

3. Irritable/euphoric mood

4. No emotional blunting

5. No coarse brain disease, no psychostim-

ulant drug abuse in prior month, no systemic illness know to cause manic symptoms.

481

CASE II

A 27-year-old white man is brought

to see you because after a family argu- ment, he broke a mirror and a window.

The man is somewhat uncooperative and belligerent. He is thin, wears braces

on his teeth, is unshaven and is untidy. He is alert. He exhibits a fixed, un- blinking expression (he has not received neuroleptics) . His gait is normal and he is not agitated or hyperactive, nor does he exhibit catatonic motor behaviors.

Except for irritability, he expresses no mood or variability in his affect. He does not express any feelings for his parents or his only sibling, denies any interests and expresses no future plans.

Although his speech is stilted, he is difficult to interrupt; but his speech is not rapid.

On occasion he responds to your questions with unrelated statements.

He uses the word “drotter” in a private way.

The patient describes seeing “imaginary” girl friends in his mind’s eye. He des- cribes them as wearing maroon dresses and glasses.

He says that on occasion they speak to him and “control” his thoughts.

Their speech is whispered and comes from inside his head.

And they control his thoughts by some “mechanism” which produces a “tingling” sensation in his brain forcing him to think certain thoughts.

Physical and laboratory findings are within normal limits. There is no history or evidence of coarse brain disease, drug abuse or systemic illness.

These suggest _ _ _ _ _

An example of _ _ _ _ _

An example of_ _ _ _ __

This non-vivid perceptual symptom is termed a visual

An example of _ _ _ _ _ _

An example of —–,~­ – – – – – – – , one of the

Your diagnosis is

482

CASE II

A 27-year-old white man is brought

to see you because after a family argu- ment, he broke a mirror and a window.

The man is somewhat uncooperative and belligerent. He is thin, wears braces

on his teeth, is unshaven and is untidy. He is alert. He exhibits a fixed, un- blinking expression (he has not received neuroleptics). His gait is normal and he is not agitated or hyperactive, nor does he exhibit catatonic motor behaviors.

Except for irritability, he expresses no mood or variability in his affect. He does not express any feeling for his parents or his only sibling, denies any interests and expresses no future plans.

Although his speech is stilted, he is difficult to interrupt; but his speech is not rapid.

On occasion he responds to your questions with unrelated statements.

He uses the word “drotter” in a private way.

The patient describes seeing “imaginary” girl friends in his mind’s eye. He des- cribes them as wearing maroon dresses and glasses.

He says that on occasion they speak to him and “control” his thoughts.

Their speech is whispered and comes from inside his head.

And they control his thoughts by some “mechanism” which produces a “tingling” sensation in his brain forcing him to think certain thoughts.

Physical and laboratory findings are within normal limits. There is no history or evidence of coarse brain disease,

drug abuse or systemic illness.

These suggest emotional blunting.

An example of non-sequiturs.

An example of neologism

This non-vivid perceptual symptom is termed a visual pseudo-hallucination

An example of incomplete auditory hallucination.

An example of experience of influence, one of the first- rank symptoms of Schneider.

Your diagnosis is schizo- phrenia

483

List the criteria :

CASE III

A 46-year-old white woman, a former nurse, is hospitalized saying “I can’t evacuate my bowels.” She claims to have been well until about a year prior to admission. At that time she began experiencing constipation, poor appe- tite, weight loss of 20 pounds, initial and middle insomnia and feeling “down in the dumps.” She denies any cry- ing, diurnal mood variation or sui- cidal ideation.

When you ask her what she thinks the problem is, she points to her abdomen and says “it’s blocked up.” She states that she has not moved her bowels at all for six months.

You examine her. She is under- nourished, yet alert. Her face is mask- like and she persistently nods her head

in a rhythmical fashion, unrelated to

your questioning. Her mouth periodically grimaces. She repeatedly puts her hand up to her neck or smooths down her

hair. When you ask about this behavior she replies “it’s a habit.”

Her motor movements are slow (motor retardation).

These symptoms suggest

Are they sufficient for the diagnosis? _ _ _ _ _ _ _

484

Repetitive automatic behavior! are termed ——-

Are enough symptoms now present for a diagnosis?

List the criteria:

1. No diagnosable affective disorder

2. No coarse brain disease or hallucinogenic

stimulant drug use or systemic illness

known to cause psychiatric symptoms.

3. Clear consciousness, memory and orient-

ation intact. (If one or both are impaired, this must be due solely to inattentiveness or poor concentration) .

4. One of the following:

a. emotional blunting

b. formal thought disorder

c. first rank symptoms (any one).

CASE III

A 46-year-old white woman, a

former nurse, is hospitalized saying

“I can’t evacuate my bowels.” She claims to have been well until about

a year prior to admission. At that time she began experiencing constipation, poor appetite, weight loss of 20 pounds, initial and middle insomnia and feeling “down in the dumps.” She denies any crying, diurnal mood variation or suicidal ideation.

When you ask her what she thinks the problem is, she points to her abdomen and says “it’s blocked up.” She states

that she has not moved her bowels at all for six months.

You examine her. She is undernourished, yet alert. Her face is mask-like and she persistently nods her head in a rhythmical fashion, unrelated to your questioning. Her mouth periodically grimaces. She repeatedly puts her hand up to her neck or smooths down her hair. When you ask about this behavior she replies “it’s a habit.”

Her motor movements are slow (motor retardation).

These symptoms suggest major depression.

Are they sufficient for the diagnosis? ~

Repetitive automatic behaviors are termed stereotypes

Are enough symptoms now present for a diagnosis? No

(We still have not observed her mood or de- termined the presence or absence of coarse brain disease, drug abuse or systemic illness).

485

The patient’s affect is restricted in

, low in and is

-st,…a”””b-:1-e-.–,s=he shows mild concern about her bowel problems but is otherwise apathetic. She is not concerned about being hospitalized and says she would be willing to stay six months to “find out” about her “bowels” but she has no future plans. She expresses no warm feelings for anyone and relates poorly to you.

Her speech is slow in rate, with long, almost blank, pauses between ques- tion and answer.

Despite your efforts to change the subject she continually returns to statements concerning her bowels. She does not have thought disorder. She denies any perceptual distur- bances or- first rank symptoms of

She is aware that she is in a hos- pital, knows its name, but can only tell you it is the early part of the month. She knows the year.

When asked to draw a circle with each hand, she responds:

dght hon”O

She is – – – – – – – – –

Combined with her motor re- tardation, she exhibits

retardation.

Can you now make the diag- nosis Major Depression?_

This is – – – – – – – – –

This is mild

These responses are exampleE of———–

This is a test for –.Is:-.:h-e-=r response normal? _ _ _ _ _

This is an example of

When askeQd to identify the fol- lowing object, she does so but only after turning her head to

theside.

She cannot do serial 7’s or serial 3’s and cannot spell the word “world” backwards.

left h a n d \ )

486

The patient’s affect is restricted in range, low in intensity and is stable. She shows mild concern about her bowel problems but is otherwise apathetic. She is not con- cerned about being hospitalized and says she would be willing to stay six months

to “find out” about her “bowels” but

she has no future plans. She expresses no warm feelings for anyone and relates poorly to you.

Her speech is slow in rate, with long, almost blank, pauses between question and answer.

Despite your efforts to change the subject, she continually returns to statements concerning her bowels.

She does not have thought disorder. She denies any perceptual disturbances or first rank symptoms of Schneider.

She is aware that she is in a hospital, knows its name, but can only tell you it is the early part of the month. She knows the year.

When asked to draw a circle with each hand, she responds:

right han~

When asked to identify the following object, she does so but only after

turning her

and cannot spell the word “world” backwards.

She is emotionally blunted.

Combined with her motor re- tardation, she exhibits psy- chomotor-retardation. – –

Can you now make the diag- nosis Major Depression? No

(She does not have a sad or anxious mood)

This is perseveration of theme.

This is mild disorientation.

These responses are examples of motor perseveration.

This is a test for active per- ception. Is her response

n o r m a l ? N _ c . . . : o _ _ _

This is an example of poor concentration. – –

Qh e a d t o t h e s i d e .

487

When you ask her to place her hand on her nose when you place your hand on your chest, she repeatedly, despite instructions to the contrary, places her hand on her chest.

This is an example of

She cannot identify her fingers and has right-left disorientation. Al- though she is a registered nurse, she says she cannot write script, and is only able to print with difficulty.

These behaviors are consis- tent with dysfunction in the

Her efforts to copy simple figures result in the following:

known as ——– syndrome.

sc;>u.AJ<E TRJ AtV6-L£

She can name them and spell the names . She is able to repeat a four word series. She can recall two words after 5 minutes.

A test of

A test of – – – –

She is unable to remember dates and sequences of important events prior to six months ago.

An example of poor _ _ _ _ Your diagnosis is?

Her physical examination and laboratory data are within normal limits. There is no history of drug abuse, but other in- formants describe her illness as dating back several years.

488

The last four tasks suggest she has ———

Along with

they make u-p–,t’h_e_c_o_n_d-.r.it'”‘”io_n_

These are examples of

and reflect dysfunction in the ___________

When you ask her to place her hand on her nose when you place your hand on your chest, she repeatedly, despite instructions to the contrary, places her hand on her chest.

This is an example of echopraxia.

She cannot identify her fingers and has right-left disorientation. Although she is a registered nurse, she says she can- not write script, and is only able to print with difficulty.

These behaviors are consis- tent with dysfunction in the dominant parietru lobe.

Along with acalculia they make up the condition known as Gerstmann’s syndrome.

Her efforts to copy simple figures result in the following:

She can name them and spell the names. She is able to repeat a four word series. She can recall two words after 5 minutes.

A test of immediate recall.

A test of short-term memory.

She is unable to remember dates and sequences of important events prior to six months ago.

An example of poor long-term memory.

Her physical examination and laboratory data are within normal limits. There is no history of drug abuse, but other in- formants describe her illness as dating back severru years.

Your diagnosis is? Dementia

TRIA t\JG-L£.

489

The last four tasks suggest she has frontru lobe dysfunc- tion.

These are examples of con- struction apraxia and reflect dysfunction in the non-domi- nant parietal lobe.

CASE IV

A 33-year-old white woman comes to see you because “I haven’t been sleeping.”

For the past two months she has had difficulty falling asleep and staying asleep. Her appetite has been poor for the past two days but she denies any weight loss.

She describes feeling especially “moody” in the morning, that she has lost her sexual drive and that she always feels like crying but cannot do so. She states the future “looks frightening”

and “bleak.”

Her husband states that she has also been saying that she was afraid their son was “going blind” although there was no reason for this fear, and that during the past week she was telling him “I’m a whore…I’m no good…You’re doing things to me.”

You observe her to be neat and alert, but unfriendly, at times uncooperative, and somewhat suspicious. She moves slowly, is unsmiling, looks sad and has creases between her eyebrows which you recognize as an

o—o—· At times sh_e_p_u-,t_s____

her head down on her arms and says “it’s useless.”

Her affect is restricted in -.-:—~­ mood is sad, dejected, suspicious and slightly hostile.

She speaks slowly in a soft voice, fre- quently failing to complete her sen- tences.

She suddenly states that the man living with her is “fatter” than her real husband and is “someone else.”

This behavior combined with her motor behavior is recog-

490

nizable ———

This you know to be syndrome, also called_ _ _

, or non-recog- -n”‘”‘it,..io_n_o-…f….,fa-ces and associated

with dysfunction in the area of the brain known as the

CASE IV

A 33-year-old white woman comes to see you because “I haven’t been sleeping.”

For the past two months she has had difficulty falling asleep and staying asleep. Her appetite has been poor for the past two days but she denies any weight loss.

She describes feeling especially “moody” in the morning, that she has lost her sexual drive and that she always feels like crying but cannot do so. She states the future “looks frightening”

and “bleak.”

Her husband states that she has also been saying that she was afraid their son

was “going blind” although there was no reason for this fear, and that during

the past week she was telling him “I’m a whore … I’m no good… You’re doing things to me.”

You observe her to be neat and alert, but unfriendly, at times uncooperative, and somewhat suspicious. She moves slowly, is unsmiling, looks sad and has creases between her eyebrows which you recognize as Omega sign. At times she puts her head down on her arms and says “it’s useless.”

Her affect is restricted in range, mood is sad, dejected, suspicious and slightly hostile.

She speaks slowly in a soft voice, fre- quently failing to complete her senten- ces.

She suddenly states that the man living with her is “fatter” than her real hus- band and is “someone else.”

This behavior combined with her motor behavior is recog- nizable as psychomotor re- tardation.

This you know to be Capgras’ syndrome, also called pros- opagnosia, or non-recogni- tlon of faces and associated with dysfunction in the area of the brain known as the non-dominant parietal lobe.

491

She has no thought disorder and denies perceptual disturbances and

Schneiderian ———-

She cannot concentrate and cannot properly copy a cross or a key but the remainder of her cognitive testing

is within normal limits.

An example of _ _ _ _ _

Physical examination and laboratory

data are within normal limits. There is

no evidence of coarse brain disease although she does have some cognitive dysfunction as you have already observed.

There is no history or evidence of drug abuse.

Your diagnosis is ______________ List the criteria:

CASE V

A 27-year-old white woman called the police and said “I want to kill myself.” The police responded and brought her to see you.

She says she has wanted to kill herself for a long time. She finds life to be empty, but has never had “sufficient courage” to act. She complains of initial insomnia, but no weight loss or diurnal mood change. She has worked until the present as a waitress.

Can you make a diagnosis at this time? – – – – – – – –

492

She has no thought disorder and denies perceptual disturbances and Schneiderian first rank symptoms.

She cannot concentrate and cannot properly copy a cross or a key but the remainder of her cognitive testing is within normal limits.

Physical examination and laboratory data are within normal limits. There is no evidence of coarse brain disease although she does have some cognitive dysfunction as you have already ob- served.

There is no history or evidence of drug abuse or systemic illness.

Your diagnosis is major depression.

An example of construction apraxia.

List the criteria:

1. Sad or anxious mood

2. Three of the following (a through f)

a. early a.m. waking

b. diurnal mood swing (worse in the a.m.) c. greater than 5 pound weight loss in

3 weeks

d. psychomotor retardation or agitation e. suicidal thoughts or behavior

f. feelings of guilt, self-reproach,

hopelessness, worthlessness

3. No coarse brain disease or use of steroids

or reserpine in the past month, no systemic illness known to cause depressive symptoms.

Poor response to items testing cortical function indicates cortical dysfunc- tion. However, the implication of dysfunction does not imply coarse dis- ease.

CASE V

A 27-year-old white woman called the police and said “I want to kill myself.” The police responded and brought her to see you.

She says she has wanted to kill herself for a long time. She finds life to be empty,

but has never had “sufficient courage”

to act. She complains of initial insomnia, but no weight loss or diurnal mood change. She has worked until the present as a waitress.

Can you make a diagnosis at this time? No

493

She makes no eye contact and cries frequently during your examination. Her mood is sad, but occasionally it lifts and she smiles. After talking

to you for a while, she says (through her tears) that you may be able to help her. She is physically healthy.

CASE VI

A 25-year-old white woman comes to see you with the complaint “I feel like driving my car into a telephone pole.” She also complains of being unable to walk without aid, of stag- gering for the past week and of hav- ing severe headaches.

She also complains of being “depressed,” of poor appetite (has lost 2 or 3 pounds), of episodes of insomnia alternating with hypersomnia and, for the past five days, she has been suffering from what her relatives describe as possible “grand

mal seizures.” Two days prior to seeing you she remained “unconscious”

for about 10 minutes. She has no aura and no recollection of these episodes.

She says her staggering is severe

and is associated with weakness, nausea and vomiting. She has no other history of possible neurological disease.

She says she has a history of “border- line” hyperthyroidism,” but that she doesn’t require medication.

She had pancreatitis several years ago and still has abdominal pain and diar·- rhea. Her physician told her that her pancreatitis led to “secondary hydrone- phrosis,” and she occasionally gets kidney infections from this, manifested by frequency, urgency and some burn- ing on micturition.

She says she also has had a chronic vaginal discharge, vaginal pruritis and dyspareunia. In the past she had “gonorrhea” and pelvic inflammatory disease which required surgery. She says she has chronic back pain and vaginal burning because of this.

Does she satisfy criteria for a major depression?.—- A minor depression?

Your neurological examination, EEG and cognitive evaluation are all within normal limits.

If you are a bit enthusiastic and do a CAT-scan, brain scan and lumbar puncture, they too are within normal limits.

494

A recent IVP was normal. So is the urinalysis you request.

Her pelvic examination shows no pathology.

She makes no eye contact and cries fre- quently during your examination. Her mood is sad, but occasionally it lifts and she smiles. After talking to you for a while, she says (through her tears) that you may be able to help her. She is physically healthy.

CASE VI

A 25-year-old white woman comes to see you with the complaint “I feel like driving my car into a telephone pole.” She also complains of being unable to walk without aid, of stag- gering for the past week and of hav- ing severe headaches.

She also complains of being “depressed,” of poor appetite (has lost 2 or 3 pounds) , of episodes of insomnia alternating with hypersomnia and, for the past five days, she has been suffering from what her relatives describe as possible “grand

mal seizures.” Two days prior to seeing you she remained “unconscious” for about 10 minutes. She has no aura and no recollection of these episodes.

She says her staggering is severe and is associated with weakness, nausea and vomiting. She has no other

history of possible neurological disease.

She says she has a history of “border- line” hyperthyroidism,” but that she doesn’t require medication.

She had pancreatitis several years

ago and still has abdominal pain and diarrhea. Her physician told her that her pancreatitis led to “secondary hydrone- phrosis,” and she occasionally gets kidney infections from this, manifested by fre- quency, urgency and some burning on micturition.

She says she also has had a chronic vag- inal discharge, vaginal pruritis and dys- pareunia. In the past she had “gonor- rhea” and pelvic inflammatory disease which required surgery. She says

she has chronic back pain and vaginal burning because of this.

Does she satisfy criteria for

a major depression? No (does

not have 3 of 6 criteria) A minor depression? Yes

Your neurological examination, EEG and cognitive evaluation are all within normal limits.

If you are a bit enthusiastic and do a CAT-scan, brain scan and lumbar puncture, they too are within normal limits.

495

A recent IVP was normal. So is the urinalysis you re- quest.

Her pelvic examination shows no pathology.

– –

She also states that she is allergic to

several medications and has “asthma” which causes her periodic discomfort characterized by chest pain, breathing difficulties, palpitations, dizziness and fearfulness.

Physical examination and other laboratory data are within normal limits.

Your diagnosis is ———-

CASE VII

A 41-year-old black man is brought into

the emergency room because of “agitation,” and because he was “unmanageable” at home.

Your examination reveals him to be in poor nutrition, unkempt and unclean. His gait is unsteady and he is restless. He looks anxious. His breath smells of alcoJ1ol.

The patient’s affect is increased in _ _ _ _ _

and increased in -….-..,—,–,—:—-,-

His mood is appropriate but he is irritable. His speech is slurred and on occasion his thoughts miss the point and some assoc- iations do not seem to follow in sequence (loosening between associations) .

This is an example of ——–speech.

There is no perceptual disturbance

or apophany. There are no first rank symptoms evident.

List the first rank symptoms you would look for:

He cannot concentrate.

What tasks would you ask him to do to determine his concentrating ability?

Recent memory is impaired. He is disoriented.

How would you test for this? Your diagnosis is _ _ _ _ _

496

She also states that she is allergic to

several medications and has “asthma” which causes her periodic discomfort characterized by chest pain, breathing difficulties, palpitations, dizziness and fearfulness.

Physical examination and other laboratory data are within normal limits.

Your diagnosis is definite Briquet’s Syndrome.

CASE VII

A 41-year-old black man is brought into

the emergency room because of “agitation,” and because he was “unmanageable” at home.

Your examination reveals him to be in poor nutrition, unkempt and unclean. His gait is unsteady and he is restless. He looks anxious. His breath smells of alcohol.

The patient’s affect is increased

in range and increased in intensity.

His mood is appropriate but he is irritable. His speech is slurred and on occasion his thoughts miss the point and some assoc- iations do not seem to follow in sequence (loosening between associations) .

There is no perceptual disturbanceor apophany. There are no first-rank symptoms evident.

He cannot concentrate.

Recent memory is impaired. He is disoriented.

This is an example of ramb- ling speech. —–

List the first-rank symptoms you would look for:

1. Phonemes (complete aud- itory hallucinations)

2. Thought broadcasting

3. Experiences of influence

4. Experiences of alienation

5. Delusional perceptions

What tasks would you ask him to do to determine his con- centrating ability?

1. Serial 7’s

2. Word “world” spelled

backwards

3. Numbers repeated forward

and backwards

How would you test for this?

remembering 4 words after 5 minutes.

Your diagnosis is (delirium) alcohol intoxication.

497

CASE VIII

An 18-year-old black man comes to see you because “I don’t feel right.”

He complains of periodic “anxiety” followed by short periods (60-90 seconds) for which he does not remember the de- tails, but is told he becomes “blank”

and then smacks his lips and “flops”

his arms. After these episodes he feels tired and has a headache.

He has a history of head injury.

Physical examination and routine laboratory data are within normal limits.

CASE IX

A 25-year-old white woman comes to see you because “I think I am going to kill my mother.”

She states she has been having recurrent thoughts of wanting to strangle her mother for the past three years. She says these thoughts frighten her and

are “stupid” but she can’t help herself. Most recently she has also had thoughts, persistent and unwanted, that she should throw liquids (water, milk, cold coffee) at peoples’ faces. She always feels mortified afterwards. Yesterday, when thinking about strangling her mother, she actually raised her hand. She became frightened and decided to come and see you.

Besides a mild decrease in range of affect and some physiological signs of anxiety, her mental status is within normal limits.

Physical examination and laboratory data are also within normal limits.

What other specialized diag- nostic tests do you think might be helpful?

What is the most likely diag- nosis?

498

What is the most likely diag- nosis?

CASE VIII

An 18-year-old black man comes to see you because “I don’t feel right.”

He complains of periodic “anxiety” followed by short periods ( 60- 90 seconds) for which he does not remember the de- tails, but is told he becomes “blank”

and then smacks his lips and “flops”

his arms. After these episodes he

feels tired and has a headache.

He has a history of head injury. Phy- sical examination and routine laboratory data are within normal limits.

CASE IX

A 25-year-old white woman comes to see you because “I think I am going to kill my mother.”

She states she has been having recurrent thoughts of wanting to strangle her mother for the past three years. She says these thoughts frighten her and are “stupid” but she can’t help herself. Most recently she has also had thoughts, persistent and un- wanted, that she should throw liquids (water, milk, cold coffee) at peoples’ faces. She always feels mortified afterwards. Yesterday, when thinking about strangling her mother, she actually raised her hand. She became frightened and decided to come

and see you.

Besides a mild decrease in range of affect and some physiological signs of anxiety, her mental status is within normal limits.

Physical examination and laboratory data are also within normal limits.

What other specialized diag- nostic tests do you think might be helpful? electroencephalogram

What is the most likely diag- nosis?

psychomotor epilepsy ( tem- poral lobe)

499

What is the most likely diag- nosis?

Obsessive Compulsive Dis- order

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