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Table of Confenfs
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O. Author's Foreword & Atlcnowletlgments -3
1. Printiples al the Mental Status Exam l
2. Appearante 25
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RAPID PsYcHl.ER SrAFF
LEr'sGol
• Monty & Lil Robinson, for helping with ali aspects of this
venture and for being great parents
• Mark & Nicole Kennedy, fnr taking care of ali the big
things, all the little things, and always helping out
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BRAIN CALIPERS PRINCIPLES OF THE MENTAL STATUS EXAMINATION
Wbat are the components ol the MSE? How do I remember all that?
The MSE can be thought of as a psychiatric "review of A mnemonic can help. The following memory aid not only
S'''llptoms." P. outlined on the previous page, the lists the main areas, but does so in the ordf ,nat they are
assessment of five main areas yields information necessary
usually asked about and presented.
for a differential diagnosis and treatment plan. Expanding
these five a reas gives us the psychological functions that are
assessed and recorded in the MSE. "ABC STAMP LICKER" *
• Sensorium & Cognitive Functioning
Level of consciousness and attentiveness Appearance
Orientation to person, place and time Behavior
Attention Cooperation
Concentration
Memory Speech
Knowledge Thought - form and content
lntelligence Affect - moment to moment variation in emotion
Capacity for Abstract Thinking
Mood - subjective emotional tone throughout the interview
• Perception Perception - in ali sensory modalities
Disorders of sensory input where there is no
stimulus (hallucinations), where a stimulus is Level of consciousness
misperceived (illusions), or of bodily experiences lnsight & Judgment
Cognitive functioning & Sensorium "
• Thinking Orientation
Speech
Memory
Thought Content (what is said)
Attention & Concentration
Thought Form (how it is said)
Reading & Writing
Suicida! or Homicida! ldeation
Knowledge base
lnsight & Judgment
Endings - suicida! and/or homicida! ideation
• Feeling Reliability of the information
Affect (visible emotional state)
Mood (subjective emotional experience)
* From the book:
• Behavior Psychiatric Mnemonics & Clinical Guides
Appearance David J. Robinson, MD
Ps ychomotor agitation or retardation © Rapid Psychler Press, 1996
Degree of cooperation with the interview ISBN 0-9680324-1-9; softcover, 96 pages
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BRAIN CALIPERS
PRINCIPLES OF THé MENTAL STATUS EXAMINATION
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PR/NCIPLES OF THE MENTAL STATUS EXAMINATION
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• Su1c10AL/HoM1c10AL loEATION
with elaboration of material • ELEMENTS OF CoGNITtVE TEsTtNG
from the HPI using closed- (may be convenient to include
ended questions to get these components at this point
more specific informaoon to help gauge the severity of Specialized
reported symptoms) lnvestigations
(if indicated)
ÜiRECT TESTING OF OTHER • GENERAL KNOWLEDGE • Biochemical
MSE CoMPONENTS • PERCEPTION Neuroimaging
lf certain areas aren't • INSIGHT & JuoGMENT Other
amenable to questions • FORMAL CoGNITIVE TESTING
earlier in the interview, MEMORY
specific inquiries must be A TTENTtON & CoNCENTRATtoN
made at sorne point to READING & WRITING
assess these functions ABSTRACT THINKING
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Are there some practica/ examples? How else tan I conteptualize the MSE?
Scenario A • Because the MSE is equivalent to the physical
An elderly male patient had hip surgery two days ago. Since examination in psychiatry, the approach used to
that time, he has been persistently disoriented, disruptive investigate symptoms in physical medicine is a helpful
and agitated. At the outset of the interview, he picks at parallel. A popular outline follows the acronym l.P.P.A.
invisible objects in the air and mumbles to himself.
• lnspection
Evalu_ation: This man is delirious, and the information • Palpation
obtained from him at this point is of questionable reliability. • Percussion
His mental status needs to be assessed first, with questions • Auscultation
involving the following areas:
• Orientation Further "looking into," "touching on," "sounding out," and
• What he's experiencing at the moment (What is he "listening to" is required to fully evaluate psychiatric
picking at? Are there sounds, sights, smells, sensations, symptoms. Unlike the physical exam, the MSE is at least
that are diverting his attention? etc.) partly integrated with the history. Both the physical exam and
• Having him speak up or repeat what he's been saying MSE are recorded separately from the body of the history.
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• The MSE is an evaluation of the patient at the time of the j 35. Listen for what the patient is not telling you.
interview. The findings on an MSE can and do change
(invariably in front of a senior colleague). lt is a record of 314. The last statement a patient makes as you leave the
observations made only during a particular assessment. room is very important.
e The MSE provides an assessment to help monitor 323. The error of missing a diagnosis of dementia in
course and prognosis. lt has a high "test-retest'' value hospitalized patients is common. This occurs because
and reveals important information about clinical course. cognitive mental status evaluations are too often omitted.
e I.ti_e MSE consists of a{elatively standardized approacli . 326. A test of orientation to time must include the day, date,
~
and set of inquiries. HoweV,:er, every instructor will hav8' mQ_nth and ~ar. Orientation to time can remain intact to
h'TS.or her own ra11onale for doing things a certain way. lt everything except the year.
is important to have exposure to as many styles as
possible. Then, assimilate this knowledge into an 398. Do not make the error of accepting the first abnormality
approach that suits you. Different approaches can be foundas the cause fofthePatient's symptoms.
used at different times in different ways; there is no one
"righr approach__ 421. You cannot diagnose what is not in your differential
diagnosis.
• The aim of the MSE is to have completed a thorough
evaluation by the end of the interview. You are free to
develop your own style - as long as you have covered
the main areas, your approach is not "wrong," and you
have latit• de in how this is accomplished. You can *From: A Little Book of Doctors' Rules
always benefit from the ideas of othe.rs. Q.ut critically by Clifton K. Meador, MD
review thejr 511ggestjoos before automatically Hanley & Belfus lnc .. Philadelphia, PA. 1992
incorporating them into your interv1ew style. Reprinted with permission.
16 17
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Summary References
COMPREHENSIVE TEXTBOOK OF PSYCHIA TRY, 6TH EDITION
lt is not prudent to remove vital organs from a woman who H. Kaplan, MD & B. Sadock, MD, Editors
has the delusion of being infested with extraterrestrial Williams & Wilkins, Baltimore, 1995
microbes, eve· if she demands the procedure. Similarly, a
SYNOPSIS oF PsvcHIATRY, 7TH EomoN
man who wants a blood transfusion with type A blood so it
could combine with his own type B blood - to make type AB
H. Kaplan, MD, B. Sadock, MD & J. Grebb, MD, Editors
- would also be denied this procedure. In both these Williams & Wilkins, Baltimore, 1994
examples, the psychotic thought processes elicited in the TEXTBOOK OF PsvcHIATRY, 2No EomoN
MSE have a direct bearing on diagnostic and therapeutic R. Hales, MD, S. Yudofsky, MO & J. Talbott, MD
interventions. American Psychiatric Press lnc., Washington O.e., 1994
An evaluation of mental status is an integral part of any
clinical interview, regardless of whether symptoms are Relerences lor lnteru5ewing Sldlls
obvious or subtle. From the rirst moment of contact with PSYCHIATRIC INTERVIEWING: THE ART OF ÜNDERSTANDING
The psychiatric interview, like the scalpel in surgery, is the VoLUME 1: THE FuNDAMENTALS
instrument that reveals what lies beneath the surface. A well- E. Othmer, MD, Ph.D & S. Othmer, Ph.D
conducted interview is no less reveal1ng thañº an.operation, American Psychiatric Press lnc., Washington O.e., 1994
and i~fill.hai takes an equal amount of time and e~
THE F1RST INTERVIEW - REVISED FOR DSM-IV
~- J. Morrison, MO
The Guilford Press, New York, 1994
The MSE is an "instrument" to measure psychological
functioning like the stethoscope is an instrument for cardiac THE PsvcHIATRIC INTERVIEW IN CuNICAL PRACTICE
or respiratory assessments. Along with the history, physical R. MacKinnon, MD & R. Michels, MD
exam and specialized testing, the MSE is a cornerstone of W.B. Saunders, Philadelphia, PA, 1971
descriptive psychopathology and vital to a psychiatric
assessment PSYCHIATRIC INTERVIEWING: A PRIMER, 2ND EDITION
R. Leon, MD
This book has been written as a guide to conducting a Elsevier Science Publishing Ca .• New York, 1989
thorough MSE and to understanding the significance of the
findings. Justas chords and rhythm are the building blocks BoARDING TIME, 2No EomoN
of music, the details and subtleties of assessing J. Morrison, MD & R. Muñoz, MD
abnormalities in thinking, feeling, perceiving and behaving American Psychiatric Press lnc., Washington, O.e .• 1996
form the backbone of the MSE.
18 19
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• 1was the leading supplier of smoked salman to the city's Dwarf Prototype Conventional Diagnosis
delis until 1 inhaled too many fish-bits into my lungs. Sleepy Narcolepsy, Sleep Apnea,
Substance Abuse (Benzodiazepines)
• Somebody urinated in my genetic pool.
Dope y Organic Brain Syndrome, Alzheimer's
Oisease, Substance Abuse (Alcohol)
• There is a rotund man in a red suit who sees my
therapist befare 1 do. He has a fear of crawling down Bashful Avoidant Personality Disorder,
small ch1mneys on Christmas Eve. 1 think he suffers from Agoraphobia, Schiz· J Personality
santac/austrophobia.
Grumpy Depression, Dysthymia,
Borderline Personality Disorder
• Every now and then a voice commands me to go to the
golf driving range to hit a bucket of chicken. Sneezy Somatoform Disorder, Conversion
Disorder, Substance Abuse (Cocaine)
• My career as an arsonist carne toan end when 1 was
apprehended for trying to start tires in a rainforest. Doc Narcissistic Personality Disorder,
Obsessive-Compulsive Personality
• My imaginary companion parlayed my childhood Disorder, Hypochondriasis
fantasies into a multi-billion dallar burger franchise. Happy Manía, Delirium,
Substance Abuse (Narcotics)
• 1 was never happy being depressed.
Proposed Dwarf Prototypes
• 1 am the world's most unfortunate Multiple Personality
Wise Guy Antisocial Personality Disorder,
victim - each alter has its own personality disorder. Malingering, Factitious Disorder
• 1 lost a bel that 1 could quit gambling. Twinkie Anorexia Nervosa, Bulimia Nervosa,
Histrionic Personality Disorder
• They named a medical syndrome after me. lt's called the Post-Traumatic Stress Disorder,
Frisky
Generation X Triad: alcohol ingestion, príapism and Attention-Deficit/H yperactivity Disorder.
amnesia. Substance Abuse (stimulants)
22 23
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Chapter2
Appearance
• Attire
• Body Habitus
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Diagnostic Criter' 1 are from the DSM-IV. * The implications of these findings are speculative, not
©American Psychiatric Association, Washington. D.C. 1994 diagnostic. They are included only to P'' 1ide an initial
Reprinted with permission. basis for assessment.
26 27
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How do I describe the various aspects ol Due consideration must be given to the circumstances of the
interview. An inpatient who awoke five minutes prior t0 an
appearance? interview warrants a different level of expectation than would
a banker attending an outpatient appointment.
Gender, Race and Age are factual identifying features.
lt is prudent to keep in mind that medica! rP"'~Jrds are legal
Apparent Age is a judgment made by the interviewer documents. Your comments can surface al:lain in a variety of
based on actual age and other factors, the majar settings, with the courtroom being the most common. Also,
determinants being hair and skin condition, style of clothing patients usually have the right to read their medica! records.
and behavior. This is generally recorded as:
a Appears h,"s or her stated age For this reason, déscriptions are best made with regard to
• Appears youngerlolder than the stated age the congruity of patients' attire to the context of the interview,
followed by a description of their dress. For example:
lnterviewers with experience in booths at county fairs or
exhibitions may attempt a more precise estimate ("This is a Right: "This man is dressed as if
40-year-old man who doesn't look a day over 39."). he were prepared for the outdoors.
He had on a fur hat, black jacket
Many factors can contribute to an older-looking appearance, and striped shirt ... "
the most common being:
• Serious and prolonged physical illnesses Wrong: "This rube had on a tres
• Protracted exposure to strong weather elements gauche, fake raccoon fur hat anda
• Alcohol and other substance abuse cheap-looking sweater worn over a
• Chronic and severe psychiatric disorders Bert & Ernie undershirt ... "
• Disadvantaged socioeconomic status
• Homelessness Attire, when taken in context with other signs and symptoms,
can provide useful information. For example:
Attire describes how patients are dressed and how they • Patients in a manic episode may dress flamboyantly, and
ha ve presented themselves for the interview. Attire is a often show a predilection fer the color red
reflection of many factors: socioeconomic status, occupation, • Schizophrenia, depression, dementia and substance
abuse/dependence are common causes for a declining
self-esteem, ability and interest in attending to convention,
interest in, and ability to attend globally to, self-care
etc. Descriptions often include a cornment on the overall
impression or "gestalt" of the attire, and then the details of (attire, grooming, hygiene, etc.)
how patients are dressed. • Patients with personality disorders can reflect their
character traits in their style and choice of clothing
"The patient was meticulously dressed in a tuxedo with a • Anorectic patients often dress in loase, baggy clothing to
top hat and white gloves ... " hide their state of emaciation
• lntravenous drug users rnay wear long-sleeved shirts
"The patient was seductively attired in a spandex outfit ... " and long pants to hide needle marks (called "tracks")
28 29
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Body Habitus refers to the body type or build of patients. A sensitive line of questioning indicating your interest will
To help convey a mental image, descriptions can be made help explore these areas, with the following inquiries being a
using the following terms: guide:
.. Ectomorphic: thin or slight body build • Is the missing/disfigured part a congenital or an acquired
• Mesomorphic: muscular or sturdy build abnormality?
.. Endomorphic: heavy or portly body build • lf congenital, what difficulties did this pose during
development?
An overly muscular build can be relevan! to a psychiatric • lf acquired, was it through an accident? An assault? An
assessment for the following reasons: attempt at self-harm?
e Sorne patients with a histo~y of abuse (of any variety) • What limitations dces this currently impose?
engage in intense physical training to decrease their • Has the patient experienced any losses related to the
vulnerability, or their sense of vulnerability handicap? How has he or she adjusted to the loss?
• Paranoid patients may wish to increase their ability to
physically ward off future attackers Exploring these areas also conveys to patients that you are
e Anabolic steroid abuse should be considered willing to discuss any aspect of their lives, and may create a
greater degree of openness in the interview.
30
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People seek to express themselves through their lt may be that patients with the above-mentioned diagnoses
appearance. Those with tattoos have used their skin as a have a greater likelihood of having tattoos, but the mere
canvas with which to make a permanent and highly personal presence of tattoos should not imply that patients have these
statement. lt is importan! to ask about tattoos, even if they disorders. Larger tattoos in visible areas that have a
are not visible. menacing ar sinister appearance have a higher probability of
being associated with psychiatric conditions.
Questions that you rr.ight ask of patients are:
• What is the tattoo? What does it represent? Tattoo removal can be accomplished in severa! ways:
e · What does the tattoo symbolize to you? • A "cover up" tattoo, which is by necessity larger and
• What was going on in your life when you got the tattoo? usually has a more benign theme
• What made this person/group/event so significan!? • Abrading the. skin with salt. which has a sanding action
• How much time did you spend thinking about the tattoo, • Surgical excision, which can include prior tissue
and what steps did you take befare getting it? expansion
• What gave yo u the ... (confidence/hope/etc.) that you • Laser removal (there is one model called the "Tatu-lazr")
would always feel as strongly towards the ... (person/
organization/etc. )? Body piercing has become common in recent years.
• Have you regretted getting the tattoo? Have you taken Typical sites far this include the nose, eyebrows, cheeks,
any steps to have it removed? lips, tangue, nipples, belly-button and genitals. Like tattoo
wearers, there are devotees who have developed
From these questions, you can learn about: subcultures based on this practice.
• Significant relationships, leve! of commitment, etc.
• Affiliation 1. 'th groups, subcultures, etc. At the time of writing, there are other alternéltive "body art"
• Sexual practices, legal involvement, etc. forms gaining popularity. These include CL_,ings, scarring/
• Impulse control, insight, judgment, etc. scarifícation, and branding. The medica! literature on these
practices is scant. Whereas tattoos can be quite beautiful
Tattoos can serve a number of psychological functions. At and ornate, the potential for significant disfigurement and the
the core, they help define an identity and boost esteem by historical precedents far sorne alternative practices may
strengthening a sen se of self (ego). Whether this serves as a indicate a higher level of psychopathology.
compensation for perceived self-inadequacies needs to be
determined with information from the rest of the interview. lnteresting movie examples of tattoos can be seen in:
• Tattoo (a case of "tattoo rape")
The psychiatric relevance of tattoos has spawned • Blues Brothers (their names are on their fingers)
considerable debate. RASPA & CusAcK associated them with • Cape Fear (1962 original, 1991 remake)
alcohol & drug abuse, and with antisocial & borderline • Raising Arizona (Woody Woodpecker tattoo)
personality disorders. Studies investigating the strength of • lrezumi (Japanese film)
this association are lacking. G1TTLESON looked specifically at • The lllustrated Man (movie and a Ray Bradbury story)
the usefulness of tattoo content, and was unable to correlate • The Night of the Hunter (1955 original, 1991 remake)
a psychiatric diagnosis with the theme of a tattoo. • Heat (1996 film with OeNiro and Pacino!)
34 35
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JIU 111 .,
A Rapid Streening Test for 8. What was Freud's comment to Fliess regarding the
unconscious symbolism of pistachio nuts?
Neuropsychological Fundían*
9. Which color has the lowest frequency in the light
Robert S. Hoffman, MD spectrum, infrared ar ultra violet? And why is tliis?
Purpose: Rapid screening of medica! and psychiatric 1O. How often do Venezuelan armadillos change their
ratients for r . idence of organic mental disorder. This test protective coat?
requires 2 minutes and a pencil.
11. What is the difference between a duck?
Standardization: Norms generated by administration to 50
consecutive patrons of Doggie Diner, West Geary Branch, 12. Why is it hotter in the summer than in the city?
San Francisco.
13. Name ali of Rula Lenska's professional acting credits
lnstructions: lf patient is lying down, have him/her sit up, excluding television commercials.
and vice versa. Remove ali distractions from the room. Ask
the following questions:
Scoring
1. What was the closing bid for ITT common stock at 4 p.m.
last February 12th? Number Correct lnterpretation
2. What is the world indoor speed record for the 100-yard 11 - 13 Mensa membership recommended
dash performed with dog sled and 1O huskies?
7 - 10 Qualified to dine with William F. Buckley
3. How many times did Hughlings Jackson divorce and
remarry? 3-6 Tunes T.V. set to "Babewatch"
6. Who was the inventor of the Unna Boot? o Aberrant tonsils with neoplastic changes
have replaced the entire cerebral cortex
7. What is the pressure per square inch of Mount St. Helens
in full eruption?
• From the Journal of Polymorphous Perversity,
Spring 1986, 3(1) © 1986 Wry-Bred Press, Reprinted with Permission.
42 43
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Chapter 3
· Behavior
Whith aspeds ol behavior are important?
Behavior refers to activity during the interview, and is one of
the cardinal means of determining mental illr~:;s. lt provides
the only outwardly observable manifestation-., of psychiatric
1\ conditions. Patients may be delusional, suicida! or plagued
~'4\
by hallucinations, but th.ese are all interna! experiences to
which a clinician has no direct access. Behavior also reveals
information about other parameters of the MSE, such as
mood, cooperation & reliability, thought content, etc. As with
appearance, the assessment of behavior begins the instant
patients are in visual contact, which may be the only
opportunity to observe certain actions (e.g. tics,
compulsions). The majar aspects of behavior are:
General Observations
• Activity Level
Habits & Mannerisms
Agitation or Retardation
Observation of Specific Movements
• Akathisia (Section 1)
• Automatisms (11)
• Catatonia (111)
• Choreoathetoid Movements (IV)
• Compulsions (V)
• Dystonias (Vla) & Extrapyramidal Symptoms (Vlb)
• Tardive Dyskinesia (VII)
• Tics (VIII)
• Tremors (IX)
• Negative Symptoms (X)
44 45
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Agitation is used to describe physical restlessness, usually Hyperactivity refers to an increased level of physical
with a heightened sense of tension and leve! of arousal. energy. lt is distinguished from agitation by the absence of
Common signs are: inner tension, and by the fact that the extra energy is usually
• Handwringing, finger tapping or fidgeting goal-directed. Patients often speak quickly and at length, and
• Frequent shifts in posture or position may become unusualiy assertive or even aggressive.
• Foottapping or rhythmic leg movements
e1 Frequent changes in the focus of attention This is a common observation among patients with:
8 Decreased ability to concentrate due to the distracting • Manía or hypomania
influence of feeling restless (as opposed to other causes • Attention-DeficiUHyperactivity Disorder (ADHD)
such as a decreased leve! of consciousness, etc.) • Obsessive-Compulsive Personalities (under a deadline)
Agitation can also be used to describe an emotional state or An increased level of activity can also be seen in the
affect, in that patients can bolh feel and appear agitated. following conditions:
Psychomotor refers to movements that are psychically • Catatonic excitement (covered in the section on
determined, as opposed to those caused by externa! catatonia later in this chapter)
sources. For example, a high intake of caffeine can cause • Seizure disorders. particularly in the interictal periods
people to feel restless and agitated. Another common cause after one seizure and befare the onset of another
are those annoying little hairs that stick in back of your neck • Head injuries, delirium or other confusional states
after a haircut. This distinction is important because there • Dissociative states or culture-bound syndromes
are many causes far agitation (see list below). In recognition
of this, the DSM-IV specifies psychomotor agitation in the Akathisia is defined as a state of inner drivenness to keep
diagnostic criteria far manía, hypomania and depression. moving. lt occurs as a side-effect of antipsychotic
medication. Patients often seem ill at ease, move their legs
Agitation is seen in the following conditions: rhythmically or have to get up and walk around the room.
• Substance ingestion/withdrawal, common causes of Akathisia cannot be differentiated from other states of
which are ethanol, benzodiazepines and stimulants agitation by observation alone. lt is a subjective experience,
• General medica! conditions such as hyperthyroidism, and must be inquired about with patients who are on
hypopan:1ihyroidism, dementia and delirium neuroleptics. More information on akathisia ;... 1ncluded in this
• Psychiatric conditions such as schizophrenia, chapter and in ENDINGS - SUICIDAL & HOMICIDAL IDEA TION.
depression, mania/hypomania, any of the anxiety
disorders, and Cluster A & C personality disorders* Restless Legs Syndrome is characterized by
• Agitated depression: patients may experience a mixed uncomfortable sensations in the legs compelling the sufferer
state of manic and depressive symptoms. This is very to keep moving. This usually occurs at the onset of sleep,
unpleasant to endure and more highly correlated with and is classified as a Sleep Disorder (Dyssomnia).
completed suicide than other bipolar mood states Prolonged inactivity, uremia, and anemia (often seen in
pregnancy) are known causes. An autosomal dominam
• Cluster A - Paranoid, Schiz'Jid, Schizotypal inheritance has been found. Benzodiazepines, among
Cluster 8 - Histrionic, Borderline, Antisocial, Narcissistic
Cluster C - Obsessive-Compulsive, Oependent, Avoidant
severa! other medications, provide effective treatment.
50 51
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Psychomotor Retardation refers to a slowness of voluntary In general, mental processes are slowed along with
and involuntary movements. Other terms used to describe movements, with patients reporting that they are unable to
this observation are hypokinesia or bradykinesia, and in think as fast as usual. This needs to be distinguished from
extreme cases the virtual absence of movement is called mental retardation, which is an intellectual deficit or mental
akinesia. This description applies to the initiation, execution subnormality. The distinction is that patients who are
and completion of movement and excludes those who may mentally retarded have permanent learning disabilities, not
have trouble initiating tasks, but can complete them readily ones that will clear with time. Mental retardation is defined as
(such as obsessive-compulsive or dependent personalities) subaverage mental functioning prior to age 18. lt is different
or those who start tasks readily but can't complete them than dementia in that patients with dementia have achieved
(such as patients with dementia or mania). a normal leve! of intelligence and then acquired an illness
causing them to lose their mental faculties. Depression can
Often accompanying the slowed movements are changes in affect cognitive functioning so strongly that the person
voice and prosody of speech (the natural emotional tone or appears demented. This is called pseudodementia, ar: more
inflection of speech). Most people move spontaneously recently, the dementia syndrome of depression. While this
when speaking, often gesturing with their hands to facilitate latter term more accurately reflects the pathology of thP
speech orto accentuate what they are saying. Other typical process, pseudodementia is seen in other conditions and is
movements include adjusting eyeglasses, scratching, still widely used as a descriptive term.
shifting posture, crossing and uncrossing legs, folding and
unfolding arms, etc. Keeping track of patients' repertoire of Causes for decreased or diminished movements are:
spontaneous movements is valuable in assessments. Make • Depression, which is the most common psychiatric
a point of asking about unusual or repetitive actions, or the cause; in past diagnostic nomenclature, there was a
absence of typical movements. Descriptions of behavior subtype of depression called retarded depression
must also be prefaced by an indication of the level of • Schizophrenia, and in particular the presence of
consciousness. You would not be surprised that obtunded or negative symptoms
comatose patients demonstrated severely diminished body • Medication side-effects, especially to antipsychotics
movements (akinesia in these cases), but you'd probably like • Catatonia, explained in detail later in this chapter
to hear about their level of consciousness first. • Dementia, of any cause
• General medica! conditions, in particular illnesses which
Facial expression is another important aspect to observe. have fatigue as a prominent symptom, such as
Check to see if patients convey a sense of what they are hypothyroidism, Addison's disease, mononucleosis,
discussing with appropriate facial expressions. Mask-like or arthritis, Parkinson's Disease, Multiple Sclerosis, etc.
masked fac11s refers to the absence of use of facial
muscles, leading to an appearance reminiscent of a mask. Occasionally, only certain parts of a patient'& Jody may have
diminished or absent movements. Common causes are:
Abulia is a reduced will to take-action or initiate thought, • Pain syndromes, e.g. affecting the use of extremities
often with an indifference to the consequences. Spontaneity • Paralysis of one or more limbs
of speech and response to stimuli are also slowed. • Conversion disorders, defined as a psychogenic
impairment of motor or sensory function
52 53
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yJ -="
(1) Akathisia has been mentioned previously. lt is called (111) Catatonia is a term applied to a diverse number of
neuroleptic-induced when it is caused by antipsychotic postura! and movement disturbances. The motor disorders
medication. fhe usual manifestations are rocking, fidgeting, can include both increased and decreased lf ..~Is of activity.
pacing or generally feeling compelled to keep moving. lt can The term catatonia was developed by Kahlbaum and initially
be quite uncomfortable. Suicides and violence have been was a diagnostic entity on its own. lf Kahlbaum had been a
reported because it was not detected or adequately treated. dog person, he would have called it dogatonia.
lt is caused iatrogenically by initiating or increasing
antipsychotic medication, or by decreasing or stopping In the DSM-IV, catatonia is diagnosable in three forms:
agents which reduce the symptoms. Trying to voluntarily • A subtype of schizophrenia
suppress akathisia-driven movements increases the sense • A specifier for a mood episode
of discomfort. The ~ & B group Carneo has a song called • Due to a general medicar .:0ndition
"Shake Your Pants," which is a succinct description of what it
feels like to have this condition. Catatonia is also found in:
• Periodic catatonia, a rare variant involving an alteration
(11) Automatisms are "automatic" involuntary movements of thyroid function and nitrogen balance
that can range from relatively minar to complex behaviors. • Neurologic illnesses that involve the basal ganglia, ,..
They occur most commonly in epileptic seizures of the frontal lobes, limbic system & extrapyramidal pathways ;•t ·
partial complex or absence type. Automatisms may be the • Syphilis and viral encephalopathies .. ~.
only outward manifestations of a seizure disorder. They are • Head trauma, arteriovenous malformations, etc. ;·
also seen in head injuries, substance ingestion, catatonia, • Toxic states (e.g. alcoholism, fluoride toxicity)
and dissociative and fugue states. By definition, • Metabolic conditions (e.g. hypoglycemia, hyper-
automatisms occur during an altered state of consciousness. parathyroidism)
During automatisms, action.:> can range from purposeful to
disorganized, and mayor may not be appropriate for the This mnemonic lists DSM-IV criteria for catatonia:
situation or the person displaying them. Patients may be
partially aware of their surroundings. They may continue with "WRENCHES"
their actions, but do not seem "quite right" at the time, and
are amnestic for the episode. Typical automatisms are: Weird (peculiar) movements
• Lip-smacking or uttering words (which are understandable)
• Fumbling with clothing (e.g. doing and undoing a button) Rigidity
• Eye blinking or staring with an unwavering stare Echopraxia - copying the body movements of others
• Continuing with activities such as driving a car, or Negativism - automatic opposition to ali requests
repetitive actions such as sorting or cleaning
Catalepsy (waxy flexibility)
Automatisms are occasionally complex actions that result in High level of motor activity
violence towards the self or others, and for this reason also Echolalia - repeating the words of others
have a leg:-' significance and definition.
Stupor - immobility
54 55
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Weird (peculiar) voluntary rnovements given as examples in Rigidity is central to the definition of catatonia (given by S1Ms
the DSM-IV consist of: p. 336), as "a state of increased tone in rnuscles at rest,
abolished by voluntary activities, and thereby distinguished
• lnappropriate or bizarre postures that are often from extrapyramidal rigidity." In the latter condition, muscle
uncornfortable and maintained for extended periods of tone would not be reduced with rnovement.
time (e.g. kneeling or squatting when a chair is
availablP). Most people would find this uncomfortable, Extreme rigidity can lead to muscle breakdown, acute renal
but patients experiencing catatonia appear to be able to failure and in sorne cases, death. This is re' ,red to as lethal
endure this without apparent discomfort. Another catatonia, which can result frorn any forrn of catatonia. This
exarnple is the psychological pillow, in which patients is a medica! emergency and after supportive rneasures, is
lie with their heads elevated without any support. effectively treated with electroconvulsive therapy (ECT).
• Stereotyped movements are repetitive, driven, non- Various types of rigidity can be found:
purposeful actions. These are thought to originate in • Lead pipe: resistance to movement in all directions
something of personal, autistic significance. Examples • Cogwheel: a stop-and-go pattern, seen in Parkinsonism
include body rosking, head banging, self-biting, picking • Clasp Knife: resistance w a certain point, then giving
at one's skin or orífices, hitting one's self, etc. They are way
usually "socially unacceptable" behaviors and have no
adaptive function (except at rock concerts ). Echopraxia is the involuntary repetition of the movements of
others (mimicry would be voluntary). For exarnple, a patient
e Prorninent mannerisms are exaggerated, crude or
who is instructed to touch her left ear when you cross your
unusual behaviors. They are more socially appropriate
arms will not be able to comply, and will instead copy your
than stereotyped movements, but often occur out of
actions as if she were a rnirror image. This has also been
context or have sorne other odd component. For
called echokinesis, echomimia and copying mania. lt also
exarnple, sorne patients rnake a very grand show of
occurs in seizure disorders, tic disorders and dementias.
seeking out new people and
Echopraxia is one of the behaviors seen in automatic
giving thern a prolonged, firm
obedience (covered in this chapter).
handshake accompanied by
repeated nodding, a stern
Negativism refers to the automatic refusal to cooperate.
expression and loud greeting.
Simple requests are strongly opposed forno obvious reason,
• Prorninent grimacing refers to a even in cases where patients would benefit from
particularly hollow smile. This participation (e.g. taking off a warm coat when inside).
humorless baring of the teeth Patients typically either refuse, or do the exact opposite of
with deadened, unblinking eyes what is asked of them. lf patients are given gentle physical
is a seen rnost frequently among encouragement, they will passively resist. A large but as yet
patients with catatonia. unpublished group of parents have proposed that this is a
developmental stage that most teenagers seem to pass
through.
56 57
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Catalepsy (waxy flexibility, flexibilitas cerea) is a There are other catatonic behaviors beyond those listed in
phenomenon whereby patients can be moved into new the DSM-IV. Another group, the automatic behaviors,
postures or positions, and will stay this way for periods of involve instantaneous obedience:
thirty seconds or more. In contrast to catatonic rigidity, • Echopraxia and echolalia have been discussed
patients cannot be moved, those with waxy flexibility • Mitgehen is a German term meaning "going with" and
demonstrate sorne resistance. This condition was so named can be demonstrated by directing patients with a very
because early phenomenologists likened the malleability of light touch - a typical example is to have patients
patients' limbs to that of candle wax. extend an arm, which can be lowered or elevated with a
very light touch even when they are instructed to r'3sist
High level of motor activity, called catatonic excitement, • Mitmachen, German for "making with," is the slow
is an episode of hyperactive behavior consisting of a high- spontaneous return to the original position
pitched "running amok" that ends when the patient collapses • Automaton-like behavior involves patients carrying out
i1 exhaustior :ir when treatment is started. This can requests immediately in stilted, torced f- ,hion
progress to the point of becoming a medica! emergency due • Advertence is the heedful facing of the interviewer when
to fever, dehydration, electrolyte abnormalities, autonomic being addressed, as if ·required by strict discipline
instability and an altered leve! of consciousness. During this
episode, patients may display any of the other movement These conditions should be suspected in situations involving
abnormalities that are part of catatonia: bizarre postures, an excessive and mechanistic leve! of cooperation. They can
grimacing, echopraxia, rigidity, waxy flexibility, etc. be tested by instructing patients not to perform them.
Echolalia is the involuntary repetition of words, such as Negativism has already be0ri mentioned. However, it should
greetings, statements and questions, without patients being be emphasized that such patients actively resist ali attempts
able to express their own thoughts. Again, this differs from to reach them. This is to be differentiated from uncooperative
mimicry in that patients don't do this of their own volition. patients who display a passive-aggressive demeanor and
attempt to undermine or sabotage efforts in an interview.
Stupor is probably the most commonly known catatonic Other aspects of negativism are:
behavior. Patients can show a decrease in movement to the • Gegenhalten, which describes the situation where
point of being mute and akinetic. They may also have a patients resist being moved with a force equal to that
reduced awareness of their environment. A stupor can last being applied
for a prolonged time, and even lead to the point where an • Aversion, which is the opposite of advertence in that
intervention is necessary for nutritional or hygienic reasons. patients automatically shun examiners upon hearing
An episode can end abruptly with a sudden outburst or them speak
irnpulsive act that is not in response to externa! stimuli. A
condition that appears similar is akinetic mutism (also Patients can shift from automatic obedience to negativism
called a coma vigil). lt is a state of unconsciousness where without obvious precipitants; known as ambitendency. A
patients lie mute and unresponsive but may follow objects final feature of catatonia is a facial expression called
with their eyes. A number of vascular, traumatic or schnauzkramp (German for snout cramp), which is a
neoplastic conditions can produce this syndrome. puckering or protruding of the lips and jaw.
58 59
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11
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(IV) Choreoathetoid movements are seen in various (V) Compulsions are defined in the DSM-IV as:
neurologic and psychiatric disorders. The term is an
(1) Repetitive behaviors or mental acts that the person feels
amalgamation of two different movement disorders: driven to perform in response toan obsession, or according
• Choreiform movements are involuntary and appear as to rules that must be applied rigidly
irregular, jerky, spasmodic and quasi-purposeful; they (2) Behaviors ar mental acts aimed at preventing or reducing
are irregularly timed and generally not repeated; these distress or preventing sorne dreaded event or situation;
movements most often affect the face and arms; an however, these behaviors ar mental acts are either not
example would be someone whose hand shot up connected in a realistic way with what they are designed to
towards his face and who incorporated this into an neutralize or prevent, or are clearly excessive
adjustment of his hair
• Athetoid movements are slow, writhing (snake-like), Two points bear emphasizing with this definition:
twisting, and have the appearance of following a pattern; • Compulsions can be entirely mental experiences
any muscle group can be affected; an episode might look (prayers, sayings), though the majority are actions
like someone practicing tai chí, or using a hand to imitate • The "rules that must be applied rigidly" are self-imposed,
an airplane climbing and diving not due to involvement with an organization with a strict
• Ballismus is a larger-amplitude, faster, and more violent code of conduct (e.g. mom. the military. boarding
motion (it has the same word root as ballistics); it usually schools)
occurs on ')ne side of the body (hemiballismus) and
resembles speeded-up athetoid movements (like a Compulsions are also:
punch into the air) • Unwanted and ego-dystonic (insight is preserved)
• Purposeful or semi-purposeful actions performed to
The most common causes for these movements are as lessen anxiety (not performing them increases anxiety)
follows: • Performed consciously (though compulsions are often
• Huntington's Chorea resisted to at least sorne degree, at least initially)
o Sydenham's Chorea (rheumatic fever) • Stereotyped (repeated over and over)
a Wilson's Oisease (hepatolenticular degeneration) • Ritualistic (performed the Rame way each time)
• Multiple Sclerosis • Usually linked to obsessions; e.g. those with obsessional
e Tourette's Disorder doubt. check things; those obsessed with dirt, clean
• Liver or kidney failure things
• Aging/hereditary causes
• Various infarcts, traumas and tumors Compulsions can occur individually, but are usually
preceded by obsessions, (explained in the chapter on
Of particular interest in psychiatry are: THOUGHT CoNTENT). Obsessions are recurrent thoughts.
• Use of antiparkinsonian (dopaminergic) agents images or impulses that are:
• Use of stimulants (e.g. for ADHD) • Recurrent and recognized as excessive or unreasonable
• Use of anticonvulsants (e.g. phenytoin) • Not simply excessive concerns about realistic problems
• Lithium toxicity • Recognized as a product of the person's mind, as
• Tardive Oyskinesia (covered in this chapter) opposed to thoughts being inserted from elsewhere
60 61
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62 63
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The groups of medications that are commonly used to treat (Vlb) Other Extrapyramidal Symptoms (EPS)
these conditions are: The pyramidal tracts are made up of axons that originate in
o Anticholinergic agents the posterior frontal and anterior parietal lobes. Ninety
• Antihistamines percent of the fibers pass through the pyramid of the medulla
e Benzodiazepines and forma tract found laterally in the spinal cord. The group
(Í} r~-blockers of nuclei known as the basal ganglia make up the majar
0 Dopamine agonists component of the extrapyramidal system.
Most acute dystonias seen in current practice are due to The following is a list of extrapyramidal reactions (in their
antipsychotic medication_ However, dystonias have been usual order of occurrence after neuroleptic administration):
well documented in patients with schizophrenia who have • Dystonic reactions (hours to days)
never been exposed to neuroleptic medication. Not only • Akathisia (hours to weeks)
have extrapyramidal reactions been recorded, but a whole • Akinesia or Bradykinesia (days to weeks)
range of motor disorders have been seen, including: • Rigidity (dáys to weeks)
• Posture, tone and gait • Tremors (weeks to months)
a Eye movements and blinking • The Pisa and Rabbit Syndrome (months to years)
• Facial, head, trunk and limb movements
e Speech production Parkinsonism refers to the symptoms but not the presence
0 Purposeful movements relating to completing activities of Parkinson's Disease, which is an idiopathic depletion of
dopaminergic neurons in the basal ganglia and has a
_Dystonias can also be tardive as opposed to acute. Next to sporadic and familia! form.
torticollis, the most common is blepharospasm
(involuntary closure of both eyes), though this often spreads The causes of parkinsonism most relevant to psychiatry are:
to muscles controlling head movements and chewing. • Medication-induced dopamine blockade - neuroleptics,
which are dopamine receptor blockers (and others with
Dystonia itself is a neurologic condition. lt is classified on the this action such as the antidepressant amoxapine and
basis of its etiology, age of onset, and distribution. Dystonia several antiemetics - prochlorperazine,
's differenfü=. ;d from other motor disorders (such as choreo- metoc/opramide, promethazine, trimeth-· '_,enzamide,
athetoid) by the presence of repetitive, patterned and thiethylperazine, trifluopromazine)
sustained movements. Causes of dystonia most relevant to • Medication-induced dopamine depletion, which occurs
psychiatry are: with reserpine and tetrabenazine
• Lesch-Nyhan Syndrome, Rett's Disorder, Reye Syndrome • Uthium, disu/firam, methyldopa and sorne of the calcium
• Huntington's Disease, Wilson's Disease, Parkinson's channel blockers
Disease, Multiple Sclerosis • Toxins such as carbon monoxide, cyanide, ethanol,
• Head trauma or peripheral trauma methanol and MPTP
• Methane ar carbon monoxide poisoning • Head trauma
• Medications - anticonvulsants, bromocriptine, fenfluramine
• Psychogenic
64 65
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I •
because the basal ganglia fails to activate cortical areas 1 acetylcholine ~
I r
•
and the impairment of postura! reflexes. Because of this,
falls are common in patients with parkinsonism.
• Other common signs are stiffness, shutfling or festinating
gait, mask-like facies, drooling, stooped posture and
• With the decreased availability of dopamine, an
ataraxia (indifference towards the environment)
imbalance is created causing the group of disordered
• Drug-induced parkinsonism is clinically indistinguishable
movements known as parkinsonism. This happens
from Parkinson's Disease, and stopping medications is
regardless of the cause of the lessened availability of
the only way of distinguishing the two; in sorne cases,
dopamine. The amount of dopamine may be decreased
patients continue to have parkinsonism as long as three
by the receptor-blocking action of neuroleptics, or by
months after a neuroleptic is stopped and require
idiopathic cell loss in the substantia nigra leading to
antiparkinsonian medication. In sorne cases, patients
degeneration of dopaminergic tracts, which is
may have had subclinical Parkinson's Disease.
e Parkinson's Disease.
Fluoxetine has been reported to cause parkinsonism
4l
About 15% of those on neuroleptics experience
parkinsonism; women are twice as likely to be affected
as men; t' ose over age forty have a higher risk I
,.-,-,--1----.----.--m 1 L
[
• The features of parkinsonism can be confused with the 1
~
acetylchc 1e r
[
~
332.1 as a research diagnosis to be coded on Axis 1
66 67
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Tardive Dyskinesia (TO} is an involuntary movement
2.~ disorder associated with chronic neuroleptic uRe. Tardive
Jr;=r;=r;r;r; r¡ r¡r;:r;:c;r, ':i
refers to the delayed onset, which is from m ,iths to years
~ acetylcholine ~
] after starting medication. Oyskinesia is a distortion of
1.-t- voluntary movement. This condition is composed of choreo-
'YYYYYYYYYYY>- athetoid movements, but is considered separately due to its
' >'
dopamine >-
>' importance in psychiatry. Dyskinesias of other etiologies can
occur in patients taking neuroleptics, and in order to
standardize the findings, the DSM-IV lists research criteria
To correct this mismatch, two strategies are used: for Neuroleptic-lnduced Tardive Dyskinesia 333.82,
which again would be ceded on Axis 1.
1. Pharmacologically increasing the amount of dopamine.
This doesn't work in psychiatry because dopamine agonists A. lnvoluntary movements of the tengue, jaw, trunk or
generalfy worsen the symptoms of psychosis. However, this extremities have developed in association with the use of
is one of the main modes of treating Parkinson's Disease. neuroleptic medication.
2. Pharmacological/y decreasing acetylcholine. This is the
approach taken to treat parkinsonism caused by psychiatric B. The involuntary movements are present over a period of
medications. There are several anticholinergic agents at least 4 weeks and occur in any of the following patterns:
(ACA) available - benztropine, biperiden, procyclidine, (1) Choreiform movements (i.e. rapid, jerky, nonrepetitive)
ethopropazine and trihexyphenidyl. Complications can arise (2) Athetoid movements (i.e. slow, sinuous, continua!)
because neuroleptics themselves have anticholinergic side (3) Rhythmic movements (i.e. stereotypies)
effects. The additive effects can result in adverse peripheral
C. The signs or symptorns in Criteria A and B develop during
reactions (dry mouth, blurred vision, constipation, flushed
exposure to neuroleptic medication or within 4 weeks of
skin, etc.) or central reactions (confusion, restlessness,
withdrawal from an oral neuroleptic or 8 weeks from a depot
impaired memory, hallucinations, incoherence, etc.)
neuroleptic.
Other extrapyramidal symptoms (EPS) are: D. There has been exposure to neuroleptic medication far at
• Pisa Syndrome, so named because patients' posture least 3 months (1 month if age 60 or older).
bears a resemblance to the Leaning Tower of Pisa. lt is a
tardive dystonia that causes a torsion spasm of the E. The symptoms are not due to a neurological or general
torso muscles with the result that patients bend to one medical condition.
side (also called pleurothotonus).
a Rabbit Syndrome, a quick, alternating perioral F. The symptoms are not better accounted for by a
movement that resembles the chewing action of a neuroleptic-induced movement disorder.
rabbit's mouth (like Bugs Bunny eating a carrot), often
with a smacking of the lips. This syndrome is more rapid Diagnostic Criteria are from the DSM-IV.
and regul'. than the oral-facial-buceo-lingual movements ©American Psychiatric Association. Washington, D.G. 1994
Reprinted with permission.
seen in tardive dyskinesia.
68 69
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TO occurs in three areas The risk factors that increase the likelihood of TO are:
Facial & oral movements (present in 75% of those affected) • Advancing age and female sex
1i Facial expressions - frowning, blinking, grimacing • Duration of neuroleptic administration
* Lips and mouth - pouting, puckering, lip smacking e lncreasing neuroleptic dosage
a Jaw - opening and closing, chewing, teeth grinding • Presence of a nonpsychotic disorder
a Tangue - tremar, protrusion, rolling • Drug holidays - these are not "summer trips," but
Extremities 'present in 50% of those affected) planned discontinuations of prescription medication
a Choreoathetoid movements in the upper or lower limbs • Brain damage and other neurologic cor .cions
11 Tremors or rhythmic movements may be present • Severe EPS early in the course of neuroleptic
e Range from rapid, purposeless and spontaneous to slow administration
and complex motions
A research instrument was designed to assess the presence
Trunk (present in 25% of !hose affected) of TO. lt is called the Abnormal lnvoluntary Movement Scale
0 Twisting, rocking or gyrating of the back, neck, shoulders (AIMS) and was developed by the National lnstitute of
or pelvis Mental Health.* The AIMS involves both observation and
Source Adapted from the AIMS Movement Scale asking the patient to particip1te in actions that will assist in
the detection of TO. These activated movements are scored
In the early stages of development, TO can easily be missed on a 5-point scale (from O to 4), allowing quantification anda
and only an observan! interviewer who is looking for the means by which to assess future changes. A summary of the
initial manifestations will notice them. TO is often not protocol for activated movements is as follows:
reported by patients, but by those around them who are
Facial & oral movements
aware of the repetitive movements (often smacking or • Have the patient remove extraneous matter from mouth
chewing). lt can easily be passed off as gum or tobacco
• Open mouth, then protrude tengue
chewing or ill-fitting dentures.
Extremities
The movements of TO are more pronounced during stressful • Ask the patient to sit with hands hanging unsupported
periods (such as interviews) and with use of non-affected over or between knees
body parts. Lessening of the movements is seen during • Tap each finger on the thumb of the same hand
periods of relaxation, use of affected parts, and voluntary • Active flexion and extension of arms
suppression. TD is typically absent during sleep. An increase Trunk
in neuroleptic dosage temporarily improves the symptoms, • Ask the patient to stand up and walk, then turn around
whereas the use of an anticholinergic agent (ACA) worsens • While standing, extend both arms, palms down
sorne forms of TD.
Recall that distraction makes movements in affected areas
In severe cases, TO can also cause irregularities in worse. Observe body parts not currently being evaluated for
speaking, breathing and swallowing. Swallowing air the presence of abnormal movements.
(aerophagia) can lead to chronic belching or grunting. limb .
* National lnstitute of Mental Health: Abnormal lnvoluntary Movement
involvement can leave patients incapacitated. Scale, in ECDEU AssESSMENT MANUAL, Edited by G. W. Rockville, 1976
70 71
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72
73
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1
U
Examples of simple vocal tics are: The DSM-IV lists four tic disorders (the diagnostic criteria are
& Coughing, humming abbreviated):
" Grunting, gurgling
s Throat clearing, clicking Jr clacking Tourette's Disorder 307.23
& Sneezing, sniffing, snorting or snuffling • Both multiple motor and one or more vocal tics have
e Screeching, barking, squealing been present. although not necessarily concurrently
e Whistling, hissing e The tics occur many times a day (usually in bouts),
nearly every day or intermittently throughout a period of
. Examples of complex vocal tics are: more than one year. and during this time there is no tic-
o Sudden utterances of inappropriate syllables or words free period of more than three consecutive months
o Copralalia (saying or shouting obscenities) • Causes marked distress or significant impairment in
• Echolalia (repeating others' phrases - this is also one social, occupational, or other important areas of
of the behaviors in catatonia) functioning
• Palilalia (repeating one's own phrases)
Transient Tic Disorder 307.21
Tics can be present in up to one-sixth of boys and about • Single or multiple motor and/or vocal tics
one-twelfth of girls; they often disappear without • Tics occur many times per day
consequenc". The highest prevalence is in children aged • Duration is between four weeks and one year
seven to eleven. Tics are considered pathological when they Chronic Motor or Vocal Tic Disorder 3(, .. 22
are present nearly every day for at least one month. As with • Duration is longer than one year
other movement disorders, the pathology is thought to occur
at the leve! of the basal ganglia. Tic Disorder Not Otherwise Specified 307.20
• The catch-all diagnosis far other tic conditions
Tics occur in a wide variety of conditions:
• Physiologic tics - mannerism or gestures Motor tics can be subdivided into clonic and tonic forms.
• Primary tic disorders (see next page) Clonic tics are abrupt and simple movements, such as head
o Chromosomal ábnormalities - Down Synd., Fragile X twitching or nose wrinkling. Tonic tics are more sustained
e Medications - i.e. anticonvulsants, neuroleptics. movements and may be painful, such as torticollis.
levodopa; stimulants used for the treatment of ADHD - blepharospasm or prolonged mouth opening.
pemoline, methylphenidate and amphetamine; caffeine
a Head trauma Diagnosing tic disorders may take years. Tics usually start
e Mental retardation - including Pervasive Developmental with eye-blinks, head-jerks or grimaces, which are common
Disorders twitches in children. The tics in Tourette's Disorder are often
& Neurologic conditions - e.g. Huntington's Disease and accompanied by irritability, attentional deficits ora low
Sydenham's Chorea, Wilson's Disease frustration tolerance, which can lead to a misdiagnosis of a
• lnfections - e.g. encephalitis, Creutzfeld-Jakob behavioral disorder (e.g. conduct disorder). Also, there are
• Schizophrenia comorbid conditions that complicate diagnostic issues (e.g.
• Gasoline or carbon monoxide poisoning obsessive-compulsive disorder).
74 75
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m.
~ repetitive
Classification of tremors is made using the following criteria:
• Speed, which is measured in cycles per second, called
Hertz (abbreviated Hz)
• Presence of resting tremors, tremors that appear with
behaviors
movement (action or intention tremors) and tremors
~ _....4
seen when the affected part is held in a sustained
manner (postura! tremors)
• Small (fine) or large (coarse) degrees of movement
stereotyped ) ( habits &
behaviors mannerisms
The causes of tremors which are most relevant to psychiatry
are as follows:
-76 77
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,..__¡ .-'..:..i ..m:_j mtAtN~AuPtds ~ BEHAVIOR
78 79
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BEHAVIOR
80 81
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-
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BEHAVIOR
*' iJ
Summary References
According to the esteemed philosopher Forrest Gump,11 INTRODUCTORYTEXTBOOK oF PsYCHIATRY, 2ND EomoN
"Stupid is, as stupid does." While there are numerous and N. Andreason, MD, Ph.D & D. Black, MD
far-reaching interpretations of his wisdom, in this context he American Psychiatric Press lnc., Washington, O.e. 1995
t ils us that t~,1avior is the principal means of classification.
PsvcHIATRIC D1cT10NARY, 7TH EomoN
No less an authority on psychiatry than Hannibal "The R. eampbell, MD
Cannibal" Lecter behooves us to read Marcus Aurelius: Oxford University Press, New York, 1996
"Of each particular thing, ask: What is in itself, in its own
constitution? What is its causal nature." * DIAGNOSTIC & STA TISTICAL MANUAL OF MENTAL DISORDERS,
4TH EDITION
What others look like is one of the first things we notice -
American Psychiatric Association, Washington O.e., 1994
another is what they're doing. The human brain is exquisitely
attuned to appearance and action; and on this basis one of
CoMPREHENSIVE TEXTBOOK OF PsvcHIATRY, 6TH EomoN
the majar means of recording psychiatric illness is through
H. Kaplan, MD & B. Sadock, MD, Editors
the classification of abnormal behavior.
Williams & Wilkins, Baltimore, 1995
Psychopathology can be categorized from an explanatory
viewpoint (i.e. psychodynamic theory) ora descriptiva one SvN0Ps1s oF PsvcHIATRY, 7TH EomoN
involving the observation of behavior and assessment of the H. Kaplan, MD, B. Sadock, MD & J. Grebb, MD, Editors
inner experiences of patients. Phenomenology is the study Williams & Wilkins, Baltimore, 1994
of events as they occur, rather than by attempting an
explanation. In psychiatry, this involves the translation of TExrnooK OF PsvcHIATRY, 2ND EomoN
aberran! perception, cognition, emotional state and behavior R. Hales, MD, S. Yudofsky, MD & J. Talbott, MD
into the signs and symptoms of mental illness. The key to American Psychiatric Press lnc., Washington o.e., 1994
phenomenological classification is precision. While patients
may "look depressed," "act schizophrenic" or "seem SYMPTOMS IN THE MINO, 2ND EDITION
~ Winston Groom, Forrest Gump, Ooubleday, New York City, 1994 PSYCHOTROPIC ORUGS FAST FACTS, 2ND EDITION
J. Maxmen, MD & N. Ward, MD
• Thomas Harris, The Silence of The Lambs, St. Martin's Press,
W. W. Norton & Co., New York, 1995
NYC. 1988 (he said something slightly different in the movie version)
82 83
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mm
Cannibal . Jay Ryser, M.Ed.
~~-)-
The Feral Child Syndrome (FCS) occurs in humans raised in
.~
t ~.
Ouarterly the wilderness by predatory animals. This scate measures the
symptoms of FCS. Score one (1) for each true statement.
Questions can be scratched into the table at the end of the test.
This month: ..
..
t like being outside.
1 eat with my hands.
An interview with Dr. Hannibal Lecter .. 1 scratch myself wherever and whenever 1 have an itch.
• 1 clean my food befare 1 eat it.
• Large predatory animals frighten me.
• 1 have dirt under my nails.
• 1 answer questions with grunts.
• At the dinner table, 1 point to what 1want in!'>tead of asking.
• 1 think of the outdoors as one big toilet.
• 1 growl when someone tries to steal my fries.
• 1 enjoy lying in warm, sunny places.
• Fire hydrants excite me.
• 1 sleep more when the weather is cold.
• 1 eat meat.
• 1 enjoy having my back and head scratched.
• 1 howl at the full moon.
• 1 sniff my food befare 1eat it.
"lt made incredible sense to me ... • 1 wear a chain around my neck.
if we do become what we eat, then • 1 don't check for traffic befare crossing the street.
• 1 stick my head out of the window in a moving car.
why not consume the wealthiest,
most beautiful and sophisticated
people that we possibly can."
Total: O
Scoring
Other Articles: 15 - 20 You view Wolf Man Jack as kin
10 - 14 You run with the wolves most weekends
~ Liver by the River: A Mississippi Delicacy
7- 9 You occasionally wolf down your food
~ Starve a mosquito - keep your blood & be Vlad you did! 4-6 You own a Steppenwolf album or two
~ Who said fish was brain food? Try the real thing! O- 3 You view Bambi as kin
86 87
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• . . ! . . . ·"l._)
t!)j¡cl
. COOPERATION
ríf ., "
& RELIABILITY
•l
Chapter4
:.
1 Cooperation & Reliability
What lattors determine cooperation and
reliability?
Cooperation from patients is required so that the information
they provide is useful in forming a diagnostic impression.
Without it, we are practicing Veterinary Psychiatry. Sorne
patients can't or won't share information. This aspect needs
to be included in the presentation of the MSE at an early
stage, as it colors the rest of the information obtained. In a
sense, cooperation refers to the quantity of information
given. This doesn't imply that taciturn patients are
uncooperative if questions can be answered succinctly. ·
Cooperation is best gauged by the responses to open-ended
questions, which have no clear end-point. ~ - JSt patients
share information freely and participate readily in the
interview.
• Eye Contact
• Attitude/Demeanor
• Level of Consciousness
• Affect
• Secondary Gain
-----
88 ;
89
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RELIABILl-:Y
1.1
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1
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Attentiveness to the lnterview impacts on the degree Level of Consciousness (LOC) refers to the degree of
nf cooperatic ' and reliability. Patients can be distracted by alertness or leve! of arousal. In typical interv: · ,oJ situations,
externa! (noise) or interna! stimuli (hallucinations) while patients are alert, attentive to their surroundings and
speaking, and may preferentially attend to these events and responsive to questions. This can be recorded in the MSE
not see the point of answering your questions. lnterest can as, "The patient was fully alert and attentive to the interview."
diminish in an interview for any of a number of reasons:
a Borderline or antisocial personalities often become bored Aberrations in the level of arousal are important to include
in interview situations early in recording or reporting the MSE. The reader or
_'8 Narcissistic or histrionic personalities can develop a listener needs to be aware of this at the outset, because an
need (within the interview) for an affirmation of their altered level of consciousnes::o affects the quality of the
specialness or attractiveness information that follows. A diminished LOC immediately calls
a Patients experiencing a manic or hypomanic episode into question the possibility of an organic condition, and
may be so distractible that they cannot attend to the warrants urgent investigation.
questions being asked of them
o Delirious patients drift in and out of lucidity; they may While the LOC can't be "increased," an increased level of
lapse in to a clouded state of consciousness during an attentiveness can be observed, and is referred to as:
interview • Hyperarousal if patients are agitated or anxious
8 Obsessive-Compulsive Disorder can cause patients to • HypeNigilant if they sean the environment or focus
succumb to the intrusive thoughts or the irresistible urge undue attention on minar or irrelevant stimuli
to reduce their state of anxiety; they may engage in a
number of ritualized behaviors Hyperarousal occurs most commonly in the following:
" Other anxiety disorders such as panic disorder can • Mania - patients are often highly distractible, and will
cause a sudden overwhelming distraction far patients shift their attention to any new or competing stimulus
• Patients who are psychotic may experience (e.g. overhead announcements, the color of your name
hallucinations or incorporate interview material into tag, strains of conversations they can overhear, etc.)
delusions, which then reduces their ability to attend to • Anxiety disorders - for example, if patients have a panic
questions attack (Panic Disorder) or flashback (Posttraumatic
Stress Disorder) during the interview, the manifestations
This is recorded in the MSE as patients being attentive/ may include an increased leve! of arousal
inattentive. A further description is given for diminished • Paranoia - patients are typically hypervigilant and alert
attention span. Reasons might include: far evidence that they are being conspired against (e.g.
• Being preoccupied microphones. hidden cameras or recorders)
• A reduced or fluctuating level of consciousness • Substance abuse - this most frequently ·occurs with
• Being distracted by activity in and around the interview stimulants such as cocaine or amphetamines (or their
• Sudden shifts in affect or mood state designer drug derivatives such as "ice"); it can also occur
with caffeine or PCP ingestion
,-he formal te _t of attention in the MSE is covered in the • General medical conditions, such as hy~ :rthyroidism or
chapter on CoGNITIVE FuNcT10N1NG & SENSORIUM. pheochromocytoma
94 95
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A decreased LOC is recorded using to the following terms (of Affect is introduced in this section, and is fully covered in the
increasing severity): chapter on AFFECT & Mooo. Affect is defined as:
.:t Drowsy or lethargic: refers to response with a mínimum e An observable or objective quality of an emotional state
of effort (raised voice or gentle nudging); thought is e The moment to moment variability of visible emotions
slowed and lacks goal-directedness; patients may drift based on the what is occurring in the interview (externa!
off to sleep events) or feelings (interna! events)
e ObtundPd: greater efforts are needed to bring arousal to • The range of reactions to questions/events that would
the poinl where questions can be answered; persistent usually be considered of emotional sig: dcance
efforts (i.e. direct, closed-ended, or even "yes orno"
questions) are required to maintain focus A financia! analogy is as follows: affect is the minute to
• Stupor: refers to a state where patients make occasional minute variation in the worth of a company stock, mood is
returns to a wakeful state; vigorous or even painful the general trend overa longer time period. Another analogy
stimulat1on is needed to accomplish this; mild stimuli is that affect is like weather and mood is like climate.
may produce groaning or movement away from an
annoying sound or touch In the DSM-IV, the conditions previously referred to as
• Coma: is a per~:stent state of unconsciousness "Affective Disorders" were renamed "Mood Disorders.'' This
was done to more accurately reflect the nature of the
Following the time course of a change in LOC can help pathology. The conditions being described (depression,
delineate the cause. For example: mania, etc.) are of a sustained nature and are more aptly
• Deteriorating LOC: may mean intracranial bleeding, described as disorders of mood. While there are no longer
edema, or infection; structural lesions; overdoses, etc. "affective disorders," there are situations where the affective
• Fluctuating LOC: this is the hallmark of delirium component of other disorders interferes with the interview.
• lmproving LOC: possibilities include alcohol or drug
intoxication that lessens with time; a post-ictal state; Sorne patients experience rapid shifts in their emotional state
concussion; hypoglycemia; a period of_ anoxia; an in interviews, which interferes with the quality and quantity of
ischemic neurologic event; sleep deprivation, etc. the information obtained. Of particular relevance is that
patients with Cluster B Personality Disorders (antisocial,
borderline, histrionic & narcissistic) frequently experience
dramatic changes in emotional state as a reaction to the
interviewer. More often than not, these affective changes
involve hostility, irritability or anger. However, affective
changes that accompany flirtation or idealization can be just
as detrimental to the interview.
96 97
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98 99
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1-i/ ~J
& L1P1AN, in The Comprehensive Textbook of
How do 8detect Malingering? MILLs
Psychiatry, also suggest that certain mental illnesses are
among the most likely to be malingered:
Reliable clues to unveil malingering have been sought for
• Mental Deficiency or Retardation
centuries. There are sorne reports that even experienced
• Cognitive Disorders (e.g. Dementias)
interviewers do little better than chance in making the
distinction. lt should not be your primary goal in an interview • Amnesia
to detect the faking of illnesses. You will cause yourself less • Psychosis
grief by being fooled by a stream of malingerers than you will delusions
by incorrectly confronting one legitimate patient. Additionally, hallucinations
not ali false information is due to malingering. • Posttraumatic Stress Disorder
Nevertheless, an attitude of "benevolent skepticism" where The authors also include a summary of factors to help
there is obvious secondary gain helps keep the possibility of distinguish between real and malingered symptoms for each
manufactured symptoms in mind. lt is usually not difficult to of these disorders. They also note that malingering is difficult
see secondary gain. This is perhaps most prevalent with to maintain in a lengthy interview and suggest that the
incarcerated individuals. Mental illness can mean a transfer evaluative process should be extended for as long as
out of the "general population" into medica! segregation, possible. In such situations, you can ask patiP1ts to repeat
(.,alled "soft time," a more lenient regimen of prison life. Of segments of the history to verify what they c....iid earlier.
even greater significance is the issue of a mental illness
being responsible for criminal behavior. Such a finding in While interviewing skills are important in the detection of
court means that the perpetrator is sent to a forensic malingering, other methods to investigate the veracity of
psychiatry unit instead of prison. In less obvious situations, interview material are:
patients often guide the interview to address their agenda, or • lnterviewing patients on separate occasions to
even voice their requests and hope to exploit the corroborate earlier information
compassion of the interviewer. • Obtaining medica! records and/or speaking with prior
contacts of patients
Signs that patients may be lying are as follows:* • The Minnesota Multiphasic Personality lnventory,
• Anxiety expressed as a high-pitched voice, grammar Second Version (MMPl-2). This test includes the F and K
mistakes or parapraxes ("slips of the tangue") Scales that can be used individually or in combination to
• Anxiety expressed as agitation, hand wringing, etc. detect malingering; testing with other objective
• Delays in answering questions or evasive answers personality inventaries has also been reported
e Discrepancies between facial expression and physical o Projective testing with such tests as the Rorschach or
movement (especially anxious fidgeting) Thematic Apperception Tests
• Statements that obliquely address the truth e.g. "Would 1 lie • Sodium amytal and other drug-assisted interviews
to you?"
• Hypnosis
N.B. Eye contact and facial expression may-not be reliable • Polygraph (lie-detector) testing
clues to the detection of feigning information
Adapted from: Clinical AssAssment of Malingering & Deception
* Adapted from: The Comprehensive Textbook of Psychiatry
100 101
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In what other situations is false inlormation Summary
provided?
Cooperation from patients is required for psychiatric
• Confabulation is the "invention of stories" to fill in diagnoses to be made. A number of factors can interfere with
memory gaps. Patients are not consciously trying to be patients' volition, anda distinction needs to be made as to
deceptive; they do tllis to avoid calling attention to their whether someone can'! or won't share information. Patients
cognitive deficits. This is most commonly seen in who can't cooperate are often severely ill with medical and/or
Korsakoff's Psychosis and is due to anterograde psychiatric conditions. Those who won't share information
amnesia caused by thiamine deficiency (Vitamin 8 1 ) are usually angry at events that take place in or around
usually a result of chronic alcohol ingestion. interviews. Factors such as involuntary committal, appearing
under duress or the presence of a personality disorder are
• Ganser's Syndrome originally referred to episodes of common reasons for a willful lack of cooperation. This is
transient psychosis and clouding of consciousness. referred to as resistance. lt is a maxim that resistance must
Perhaps it didn't help that Ganser described this in three be dealt with befare other aspects of an assessment can
prisoners. Currently, the syndrome refers to the situation begin. To paraphrase the Borg from Star Trek, not
where "approximate" answers are given. Far example, addressi_ng resistance can be futile!
answers like "there are six fingers on a normal hand" or
"five quarters in a dallar" are typical. Controversy Whereas cooperation makes reference to the quantity of
surrounds the accurate nosology of this disorder. In information shared, reliability reflects the quality of the data
sorne studies, Ganser-like answers were given by obtained. Patients can create the illusion of cooperation
subjects trying to imitate mental disorders. Other authors while providing little useful information. For ~r excellent
have sh0wn that it occurs in response to stress, head example of this, see the movie The Usual ~Jspects.
injuries or other mental illnesses, and that it is not under
voluntary control. There is an overlap of malingering, An understanding of what secondary gain is available to
dissociative and psychotic symptoms in this syndrome. patients is important. Psychiatric diagnoses, being
determined exclusively through interviews, are more easily
• Ego defense mechanisms such as denial or repression
malingered than physical conditions. Collateral information is
operate to keep certain information beyond conscious
always important to obtain, and may be the only way of
retrieval. Patients may quite legitimately not be aware of
detecting Malingering or Factitious Disorder. These are
events that are documented in their medical records.
important conditions to keep in mind during any assessment,
• The severity of disorders impacts on the reliability of but are "diagnoses of exclusion." Their presence does not
information. Far example, paranoid patients may alter rule out the possibility of concurrent or future legitimate
the history they relate in arder to gain or avoid admission medical or psychiatric conditions.
as a means of coping with their suspicions. While their
real intent is self-preservation, this may only be There are other conditions in which information is distorted
achievable (in their minds) by falsifying the data they for reasons other than deception (e.g. denial in alcohol
present in interviews. abuse or confabulation in cortical blindness, also known as
Anton's Syndrome).
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Chapter5
Speech
Whith aspeds ol speech are imporlant?
Speech
110 111
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Thought and language have a large interplay, but describe e Autism 299.00
different processes. Language is the prinicipal means by A. (2) (a) Delay in, or total lack of, the development of
which thought process is assessed. Animals and preverbal spoken language (not accompanied by an attempt to
humans demonstrate that thought occurs without the ability compensate through alternative modes of communication
to express syntactical language. While humans are such as gesture or mime)
anatomically capable of speech, language is an acquired (b) In individuals with adequate speech, marked
ability. Understandable are uttered by eighteen months, with impairment in the ability to inititate or sustain a conversation
phrases being spoken between two and three years of age. with others
(e) Stereotyped and repetitive use of language or
A decision tree for speech abnormalities is as follows: idiosyncratic language
Medical
speech abnormality present e Delirium 293.0
B. A change in cognition (such as memory deficit,
[~irect] f 1congenital 1 disorientation, language disturbance, etc.)
~hiatric 1 ¡ 1medical1
• Dementia 290.X
A. (2) (a) Aphasia (language disturbance)
Psychiatric
The following aspects of speech are covered in this chapter: • Schizophrenia 295.X
• Primary Language Disorders A. (3) Disorganized speech (e.g. frequent derailment or
• Quality of Speech i ncoherence)
• Prosody
• Brief Psychotic Disorder 298.8
A. (3) Disorganized speech (e.g. frequent derailment or
What is the diagnostic significante ol incoherence)
speech abnormalities? • Manic/Hypomanic Episode 296.X
Congenital/Onset in Childhood B. (3) More talkative than usual or pressure to keep talking
• Mental Retardation 31 X.X • Schizotypal Personality Disorder 301.22
B. Concurrent deficits or impairments in present a<;faptive (4) Odd thinking and speech (e.g. vague, circumstantial,
functioning in ... use of communication metaphorical, overelaborate or stereotyped)
112 113
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What are the primary language disorders? How do I distinguish medica/ from
• Aphasias (alsc called dysphasias) are disturbances in
psychiatric causes al $peech disturbances?
the ability to express and comprehend language. The
pathology is in the brain itself and not in the nerves or This distinction between aphasias and disorders of thought
muscles involved in speech production. Aphasias are process can be difficult because they both affect verbal
manifested as errors in word choice and grammar. The expression. In the case of severe psychiatric disturbances, it
main types of aphasias are outlined later. may not be possible in one interview to make the distinction.
A classic example is the confusion between schizophrenic
• Dysarthria is poorly articulated speech dueto a
speech and aphasia. Additionally, sorne patients can have
dysfunction in the physical ability to produce sounds
(e.g. mouth, tangue, lips, cranial nerves, larynx, throat). both simultaneously; for example, Broca's Aphasia (defined
The speech of dysarthric patients is distorted and later) can be complicated by hypomania or paranoia, and
indistinct. In particular, consonant sounds are difficult to Wernicke's Aphasia can cause depression. The following is
distinguish. Other abnormalities include added, deleted a list of potential distinguishing features:
or substituted sounds.
Parameter Medica! Psychiatric
• Alexia is the inability toread. Dyslexia is defined asan • greater severity +
impairment in learning to read that leads to difficulties • continuous duration +
with spelling and the perception of the shapes of words • abrupt onset +
and letters. Dyslexia is usually a developmental disorder, • older age of onset +
whereas alexia is usually acquired and involves a lesion • related language symptoms +
• word finding difficulties +
in the occipital lobe.
• awareness of difficulty (partial) +
• Agraphia (or dysgraphia) is an inability to write in • loss of repetition, naming +
someone who had acquired this skill. The ability to copy and comprehesion abilities
can persist. The deficits in written language usually
parallel those of verbalization. Speech abnormalities are caused by:
• Agnosia is an inability to recognize objects despite • Cardiovascular accidents (CVAs) in right handers and
intact sensory and intellectual abilities and language most left handers, this involves the left middle cerebral
function. For example, patients can physically describe artery; these are the most common cause
an object but not its function. • Tumors, head trauma, seizures, sleep deprivation
JI Apraxia 1s an inability to perform learned movements as • lnfections - meningitis, encephalitis
a result of disruption of areas controlling motor and • Degenerative disorders - Parkinson's Disease,
language functions. Strength, sensation, coordination Huntington's Disease, Pick's Disease
and comprehension remain intact. Apraxia often occurs
with aphasia. Patients are aware of their difficulties. The major psychiatric conditions that involve speech
abnormalities were listed at the beginning of the chapter
• Anomia is a specific inability to name or label things
along with their specific diagnostic criteria. Other conditions
even though they are familiar. This occurs whether the
object is shown or recalled from memory. such as anxiety and lithium toxicity also affect language
abilities by causing stuttering and dysarthria, respectively.
118 119
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What are tbe specific aphasias? Broca's Aphasia is also called Motor Ap11asia,
Expressive Aphasia and Anterior Aphasia (Broca's Area is
Because of the potential difficulties in distinguishing primary anatomically anterior to Wernicke's). lt is characterized by
language disorders from psychiatric conditions, the aphasias the following features:
will be sumr.1arized here. The reason it is vital to make this e Speech is nonfluent
distinction is that aphasias almost always involve an injury to • Comprehension of writing and speech remains intact
the dominant cerebral hemisphere, which requires urgent • Repetition is impaired
investigation and tre:itment. Psychiatric conditions are less
-medically urgent and involve a differént form of treatment. Nonfluent speech has the following characteristics:
• Slower than average (half to one-third the normal rate)
Aphasias are usually classified as fluent or nonfluent • Abnormal flow with an irregular rhythm
aphasias on the basis of the flow of speech. Further • Frequent extended pauses producing a halting quality
distinction is made using three tests: • The amount of speech is decreased, often with missing
• Comprehension - tested by the ability to follow simple, connecting words (prepositions, conjunctions, pronouns,
and later, complex requests articles ); verb tenses may also be abnormal
• Repetition - tested with simple and complex phrases
• Naming - tested with common and uncommon objects These deficits result in agrammatism, which is speech or
writing that lacks syntax because words are not pul in a
An alternate system divides aphasias into receptive and corred sequence according to the rules of grammar. The
expressive based on the ability to understand and speak. choppy communication style is called telegram or
This poses difficulties for non-neurologists because there are telegrahic style. For example, the following phrase:
frequently features of both in aphasic patients. Rapid Psychler produces humorous and educational publications.
becomes
Paraphasias (paraphasic errors) are the substitution of a
letter or word for the intended word. There are four types: Torpid cycler . .. produces ......... publica/ .... avocation .. .
• Related (approximative) - light is used instead of lamp
• Unrelated (semantic) - caboose is used instead of lamp The agrammatism, halting style and paraphasias that may
• Literal (phonemic) - /ump is used instead of /amp be presentare also shown above. Articulation is usually poor
• Neologistic (jargon) - pi/oknarfis used instead of lamp (dysarthric speech ).
120 121
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Transcortical Motor Aphasia differs from Broca's only Wernicke's Aphasia is also called Sensory Aphasia,
in that repetition remains intact. Echolalia may be present. Receptive Aphasia and Posterior Aphasia. lt is characterized
Patients cannot engage in conversation or directly name by the following features:
something. Comprehension of written and spoken language • Fluency remains intact
2mains lar!=J-•Y intact. • Comprehension is impaired
• Repetition is impaired
122 123
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Transcortical Sensory Aphasia differs from Anomic Aphasia is also called angular gyrus aphasia,
Wernicke's Aphasia only in that repetition remains intact. As amnestic aphasia, nominal aphasia and dysnomia. lt has the
ir Transcortical Motor Aphasia, speech may resemble following features:
echolalia. Naming and comprehension are impaired, as they • Speech remains fluent
are in Wernicke's. • lntact comprehension
• lntact repetition
There is also a Mixed Transcortical Aphasia which has • Variable presence of paraphasias
nonfluent speech and impaired comprehension, but intact • Variable semantic meaning to speech
repetition.
The speech of patients with anomic aphasic; .1as frequent
Conduction Aphasia results from a lesion in the arcuate interruptions while they search for particular words.
fasciculus. This causes a fluent aphasia with the following Generalities such as "thing," "it," "thing-a-ma-jig" occur after
features: pauses. For example:
• lntact comprehension Rapid Psychler produces humorous and educational publications.
• lmpaired repetition
• lmpaired naming beco mes
• Awareness of speech abnormalities You know those peop/e, with the bicyc/e design, they printed it.
• Reading aloud is impaired, while reading silently is not
A specific type of anemia is prosopagnosia, where patients
Paraphasias are generally of the literal type (letter lack the ability to recognize familiar faces. Other deficits
substitution), for example: include being unable to name signs. colors, people's names,
etc. This condition has an overlap with senescent
Rapid Psychler produces humorous and educational publications.
forgetfulness and early dementia. These may be ruled in if
beco mes the following conditions are met:
Rabid Dychler detruses l1amorous and educational clubications. • Paraphasias are not prominent
• Onset is gradual
• Repetition and comprehension are intact
• Pronunciation remains good
The fate of the • Localizing neurologic signs are absent
guy who
discovered Fluent Aphasia Tidbits
Freud's first • The most common language disturbances after closed
slip was from head injuries are Anomic and Wernicke's Aphasias
Victoria's • Patients can become agitated and even paranoid; the
Secret. language disturbance and the absence of physical signs
can resemble the psychosis of mania or schizophrenia
• The motor strip and Wernicke's Area are far enough apart
that physical signs are uncommon with fluent aphasias
124 125
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What oth'er qualities ol speeth are there? Amount of speech varies widely in interview situations.
Mental health professionals spend years learning how to
Aµart from the primary language disorders, there are other obtain and organize salient information, leaving patients
qualities to consider when recording speech abnormalities. considerable leeway in what constitutes a "normal" amount
The features presented in the following section have to do of speech (recorded as responsive, spontaneous, we/1-
with the "mechanical" aspects of speech and for this reason spoken, fluent, or animated). Anxious patients provide a lot
are considered separately from disorders of thought process. of extraneous detail through their desire to simply be helpful.
Conversely, other patients feel inhibited, provide sparse
_Accent & Dialect are terms used interchangeably to answers and offer little information spontaneously.
deseribe regional or cultural differences in pronunciation.
Accent can be used to refer to the speech of patients who Conditions where the amount of speech can be increased:
are not native Engfish speakers (e.g. a French, Swedish or • Mania (see pressure of speech below)
Spanish accent). Dialect can be used to describe regional • Anxiety disorders
variations in those who are native anglophones. • Obsessive compulsive personalities (needless detail)
• Cluster B Personalities (seek to control·· ~ interview)
(here are five majar dialects in the U.S. - New York, New • Temporal lobe epilepsy (may miss social clues)
England, Southern, Appalachian and Western. In Canada, • Fluent aphasias
those from the Atlantic Provinces have a distinct style of Terms used to describe an increased amount of speech are:
speech, while the rest of the country speaks a "middle verbose, loquacious, talkatíve, copious speech, /ogorrhea,
American" dialect. In Great Britain, the skill in distinguishing vocíferous, overabundant ar expansíve.
dialect is finely honed. Britons can not only detect which
hamlet someone is from, they can make an educated guess Conditions where the amount of speech can be decreased:
as to the side of the street. Australians, New Zealanders and • Depression
South Africans spea~ with distinguishable accents. At one • Schizophrenia
English-speaking film festival, an Australian film needed • Catatonia
subtitles! In other regions (e.g. the Caribbean) the rules of
• Avoidant, dependent and schizoid personalities
grammar are different from those in The Chicago Manual of • Dementia (can be verbose in early stages)
Style. However, this does not constiute abnormal speech. • Delirium
Terms used to describe an decreased amount of speech are:
Following is a list of fun and informative guides to becoming
paucity of speech, impoverished, laconic, tacitum, single
a dialectmeister:
word answers or minimally responsive.
H. Mohr How to Talk Minnesotan
Penguin Books. New York. 1987
At one extreme is pressure of speech, where patients are
C. Bowles G'Day - Teach Yourself Australian driven to keep talking, and have an increased rate and
Angus & Robertson Publishers, North Ryde, NSW. Australia, 1987
amount of speech. A key distinguishing factor is that they are
S. Mitchell How to Speak Southern, Bantam Publishing not usually interruptable. At the other extreme is absence of
J. Levine How to Speak New Yorkese, Crown Publishing speech called mutism, which is found in neurologic
conditions and extreme forms of psychiatric illnesses.
126 127
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128 129
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Pitch, as in music, refers to the highness or lowness of the Rhythm, or cadence, varies in normal speech to add
spoken words. Pitch usually varies throughout the course of emphasis and maintain interest, just as in music. Certain
a sentence. For example, it rises when questions are asked types of rhythm disturbances exist:
and falls when authoritative statements are made. Pitch also e Stuttering
changes with emotional state (e.g. rising with anxiety and A. Disturbance in the normal fluency and time patterning of
falling with depression). Puberty lowers the natural speaking speech (inappropriate for the individual's age), characterized
voice of both sexes. In adulthood, pitch changes occur due by frequent occurences of one or more of the following:
to throat diseases, smoking, etc. Of interest is that pitch (1) sound and syllable repetitions
tange can be altered by psychiatric illnesses, especially (2) sound prolongations
(3) interjections
psychosis. lntonation and musicality are other terms used to
(4) broken words
describe the animation present in speech. (5) audible or silent blocking
(6) circumlocutions
A lack of pitch change can occur as a variant of normal (7) words produced with an excess of physical tension
speech. Pitch aprosodias are seen in: (8) monosyallabic whole-word repetitions
• Obsessive-compulsive or schizoid personalities
Diagnostic Criteria are from the DSM-IV.
• Parkinson's Disease or parkinsonism ©American Psychiatric Association, Washington, D.C. 1994
• Depression and dysthymia Reprinted with permission.
• Nondominant hemispherical lesions and aphasias
• People are aware that they stutter; an example is
Unchanging pitch is described as monotonous, f/at, or
expressíonless. Rrrrapid Psychchchler proproproduces huhuhuhumorous
• Cluttering is a nonfluent disruption involving bursls of
Spontaneity is the degree of engagement in the interview. rapid speech containing syntactical errors; the
lnformation volunteered without a question being posed is articulation is poor and the speaker is unaware of the
called spontaneous speech. Latency refers to the time speech abnormalities
i~ terval in wr ~h patients answer questions or connect their
Rapid Psychler produces humorous and educG .:mal publications.
sentences. Generally, there is an inverse relationship
between the two, i.e. patients who lack spontaneity have an beco mes
increased latency prior to speaking. Rap ........ sychpaduce ........ antationo ......... libax ..... tations
lncreased spontaneity and decreased latency occur in: e Scanning speech describes a nonfluent abnormality
• Mania, anxiety where there are irregular pauses between syllables, as if
• Fluent aphasias each syllable were scanned separately prior to being
pronounced; this occurs in multiple sclerosis, chronic
Decreased spontaneity and increased latency occur in: alcoholism & head injuries (especially cerebellar trauma)
• Depression e.g. Ra pid Psych ler pro du ces hu mor ous and edu ca
• Parkinson's Disease or parkinsonism
• Other rhythm disturbances can be seen in psychomotor
• Alcohol or substance intoxication epilepsy (stacatto or machine-gun-like) and the
• Nonfluent aphasias, autism, delirium or dementia mumbling, pedantic speech seen in Huntington's Chorea
130 131
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lnflection, or stress, adds an extra communicative f esting of Aphasius
element to speech, contributing to the pragmatics of When a patient has speech difficulties, formal testing for an
language. As an example, consider how the following aphasia is warranted.
inflection (indicated by italics) changes the meaning of what
is being said: Screen for disability
• hearing impairment, cranial nerve lesions, vision impairment
• substance intoxication, withdrawal, etc.
/'d like to help you out.
(1 will help you, instead of someone élse) J.
Test for writing ability
l'd like to help you out. • agraphia is present to sorne degree in all forms of aphasia
(1 want to help you, but 1can't) • if intact, there is no aphasia, continue if abnormality present
132 133
----~-~-~-~-~~--,-
Summary Referentes
An assessment of speech is integral to the ful! and accurate
CUNICAL NEUROLOGY FOR PsYCHIATRISTS, 4TH EDITION
assessment of psychiatric illness. As outlined at the D. Kaufman, MD
beginning of this chapter, severa! illnesses have specific W. B. Saunders eo., Philadelphia, 1995
criteria related to abnormalities of speech and thought
process. The distinction between these two domains of THE CuN1cAL INTERVIEW Us1NG osM..:1v
evaluation remains arbitrary. The mechanical aspects of VoLUME 1: THE FuNDAMENTALS
· speech disorders, c..¡uality of speech, and prosody were E. Othmer, MD, Ph.D & S. Othmer, Ph.D
presented here because they do not strictly have to do with American Psychiatric Press lnc., Washington O.e .. 1994
the form or process of thought (covered in the next chapter).
PsvcH1Arn1c D1cr10NARY, 7rH Eo1r10N
While higher mammals have means of communication,
R. eampbell, MD
huma ns are unique in their development of syntactical
Oxford University Press, New York, 1996
language. Various qualities of speech convey additional
information. How something is said can be more importan!
DIAGNOSTIC ANO STATISTICAL MANUAL OF MENTAL DISORDERS,
than what is actually said. An assessment of speech
overlaps with a multitude of other mental status parameters:
4TH EDITION
American Psychiatric Association, Washington, O.e., 1994
thought, mood & atfect, intelligence, cooperation, etc.
Aphasias are language deficits that diminish or remove the COMPREHENSIVE TEXTBOOK OF PSYCHIATRY, 6TH EDITION
ability to express and comprehend ideas. Reading, writing, H. Kaplan, MD & B. Sadock, MD, Editors
speaking, naming, repeating and comprehending can ali be Williams & Wilkins, Baltimore, 1995
affected. The main area for speech is called the peri-Sylvian
region, encompassing parts of the frontal and temporal SvN0Ps1s OF PsvcHIATRY, 7TH EomoN
lobes. When patients have difficulties communicating, testing H. Kaplan, MD, B. Sadock, MD & J. Grel;>b, MD, Editors
far an aphasia is warranted. The majar types of aphasias Williams & Wilkins, Baltimore, 1994
and methods to test for them have been outlined.
An excellent resource for preparing written reports is:
Characteristic speech patterns accompany mental illnesses: THE CuN1c1AN's THESAURUS, 4TH EomoN
• Manic patients have an increased amount of speech. E. Zuckerman, Ph.D
which is delivered quickly and often loudly Clinician's Toolbox, The Guilford Press, New York, 1995
• Depressed patients are soft-spoken, slow to answer
questions and often have little to say The section especially relevan! to reporting speech is in
• Psychosis can change a patient's voice and other Chapter 12.
speech '1aracteristics
• Other aspects of speech provide valuable diagnostic
clues, e.g. tics, slurred speech, paraphasias, echolalia
134 135
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Chapter 6
Thought Process
What is thought process?
Speech
Language
140 141
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THOUGHT PROCESS
142 143
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These disorders are listed below in arder of increasing
severity. What is considered normal when it tomes to
thought process?
Process Disturbance Nature of Disturbance
There is a continuum of variation in how thought is
Circumstantiality • words are completely formed
• sentence structure maintained
expressed. People express varying degrees of coherence,
Tangentiality
• linkage between ideas remains light detail and organization at different times. Thought process
• overinclusive of detail or do not must be considered in conjunction with other features of the
directly address the point interview. Someone who is overly anxious may speak
quickly and provide a lot of extraneous detail. A person who
Flight of ideas • words and sentences maintained
• connection between ideas apparent is highly creative may verbalize their flow of thought ("stream
• rapid and frequent shifts in tapie of consciousness") anu appear to have disjointed ideas.
Sorne people make great leaps in thinking befare verbalizing
Rambling anything, and the connections between their statements may
• clusters of sentences remain goal-
directed, interspersed with groups need to be explained.
that are not goal-directed
lt is valuable to record segments of the interview to illustrate
Loose Associations • words and sentences maintained your opinion of the patient's thought process. At the end of
• phrases and sentences still properly the interview, make a judgment about the overall ability of
constructed the patient to communicate his or her difficulties. The
• connection between ideas is not following descriptions are commonly used:
obvious, unclear or nonsensical
• Tightness of thought
Thought Derailment • syntax intact, speech suddenly well-organizedltangentíal/loose/y connectedlíncoherent
Thought Blocking shifts (derailment) or stops (blocking)
• may or may not return to previous • Flow of speech
topic, unaware of what is happening spontaneouslhesítantlínterruptedlhaltíng
• Directness of responses
Fragmentation • words intact, phrases become
disconnected from each other
ínformatíve and relevantlembellíshedlmarkedly overínclusíve
• Flow of ideas
Verbigeratiun • repetition of words and phrases logícal and wíth varíabílíty/restrícted/repetitive
• Vocabulary
Jargon • syntax intact, speech meaningless descriptivelrestríctedlídiosyncratíc use of words
Word Salad • words remain intact, ali syntax lost • Flow of information
good exchange/adequate/vague/disorganized
lncoherence • words are unintelligible, speech is
garbled or dysarthric
144 145
=-1 - ,,.__¡...-.*'-1,- ~- .=!·- ...__J~ ~- ...._J- J.Li- ,,¿j~Al-...J'-..J-¡,¡j u u·~·-1..1·~1·-iu·,-~.-~.-,;¡j.~J,-~..!.!.,~cJ~aii'ss _¡¡,:¡ ¡,;'J
-=--1 ,;,.:__¿
Thought is normally goal-directed. In arder to visualize the Get fo the point - what is circumstantiality?
various disorders of thought process, the following
representation will be used: Definition: Circumstantial speech contains an overly
detailed amount of information that provides a lot of
A•B•C•D•E•F•G•H-1--J•K•L•M•N•O•P•Q•R•S•T•U•V•W•X•Y•Z
,. digressive, extraneous detail m arder to give everyone within
listening distance a firm grasp on all of the relevan! or even
where: quasi-relevant factors so that the point, when reached, is
• each letter represents a word clearly made with substantive evidence. The preceding
º· the alphabetical sequence indicates proper syntax sentence is an exarnple of circumstantiality. lt could just as
• progression from left to right indicates a logical sequence easily be defined as speech that contains an excessive
amount of detail but does finally reach the point.
The following propaganda statement can be schematized
using the above substitution of letters. Diagrammatic Representation:
Rapid Psychler produces humorous and educational publications.
+
A "'
B "'e "'
D "'
E "'
F
A•B•C•D•E•F•G•H-+
• a succinct reply gets right to the point
""'
noun "'
verb "' "'
adjective conj. adjective "' "'
no un ~·\·J·K ·L •!14
,,_.o· º1\1.o
For example, a thought process disorder might substitute
incorrect words, though they are in proper syntax. $)
{<;'<.
.
':-()
Q
(Ji-
~
-
Rapid Cycler publishes books about making quick bicycle repairs. ~
OJ
..;:
•
-1
. .
"'
G "'
H "' "' "' "' "' "'
J K L M N
• a circumstantial reply involves
understandable words used in a
The words have different letter designations because they proper grammatical sequence,
but with unnecessary detail
are different than those in the original statement. Since the • a distinguishing feature of the
grammar is correct, the letters are in proper sequence. soliloquy is that !he point is finally
made or the question answered
In another type of thought disorder, a sentence that didn't
follow the rules of grammar would appear as follows: Most commonly seen in:
• Normal situations; endemic in digressive professors,
Rapido Cyc''!rista but clear hofic around then upward hairball.
salespeople, politicians and most lawyp··
"' "'
X "'
V "'
~ - "'
P .¡,U "'T z
"' • Obsessive-Compulsive and. narcissistic personalities
Q
• Temporal lobe epilepsy
Here, the improper syntax is indicated by the non-sequential • Hypomania, anxiety disorders
listing of the letters. Because hofic isn't a word, it was • Substance ingestion & abuse (alcohol, stimulants, etc.)
represented by a funky symbol. This will be the designation • Cognitive disorders (delirium, dementia, mental
for neologisms (explained in detail later in this chapter). retardation)
146 147
'1
~ ~ ~ .!il•N -~/Pi¡¡,' • i;rf it1í ;n1 \Jt!i a jtj· w & ili· ilb' Wh; (b. ¡,, ','
U::'.
/¡, .. ~
~" /L. ~· ~· s.Ji.. :ii.fi. :d. TH~GHlfi•ROIU'ss .iJ.J. iJ!I
-
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. • X'
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-
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Example: Where did you buy your car?
My car has 4 cylinders. lt gives me good gas mileage in the
city but not much passing power on the highway. 1 live near a
highway and have a garage for my car. 1 keep it inside even -Example: Name the Seven Dwarfs
in the summer because the sunlight makes the paint fade. Happily, 1 don't think on such a small level. Small things
come in good packages. 1 cut myself opening my mail
Most commonly seen in: yesterday, it still stings. 1 got stung by a bee last summer,
• Personality disorders where verbal communication is but it's only fair, since 1 eat honey. 1 have breakfast every
maintained mainly for the sake of feeling connected to morning because it is the most important meal of the day.
someone, e.g. histrionic and dependent personalities l like to eat three squares when 1 can, but not out of the can.
• Cognitive disorders such as delirium or dementia Cans keep food around for years, but not if you take the
• Hypomania, anxiety disorders label off. 1 bought a labeling machine, and now everything in
• SubstancP ingestion and abuse (alcohol, stimulants, my house has a proper name. 1 like to addre~!" my property
marijuana, etc.) on a first name basis. Ah, the joys of owner~.iip.
• Schizophrenia; though other disorders of thought
process are more typical of this illness continued ~
148 149
' '
J 'mall
disintegration of meaningful connections between ideas
occurs. Proper words, phrases and sentenr- .; are still used.
J
Small things come in good packages. Eugene Bleuler coined the term schizophrenia to mean a
schism (divide) between thought, emotion and behavior.
pookage' Bleuler outlined four terms that started with 'A' as cardinal
1 cut myself opening my mail yesterday, symptoms of schizophrenia. They are affective flattening,
it still stings.
autism, ambivalence and associational disturbances.
}1;ng
Example:
J
1 gol stung by a bee las! summer, bu! it's only fair,
since 1eat honey. lf the example paragraph théJt illustrated flight of ideas is
used, but every second sentence deleted (with sorne further
eeting
editing), the following series of statements remain:
J
1 have breakfast every morning because it is the
most importan! mea! of the day.
oating
Happily, 1don't think on such a small level.
150 151
. i¡· .. . ·' '
A,., J/~_,, _j\,..-.B,.,.iL ,;;;;11-.< .~ :-J.,,,,,,, :J""j -..i.,,.:J
i 1
J"'=' :.J~-
•
_:,¡'""'' .Ji:i;c"" ""'~j
¡( ',, ,,. ,,
J~1"' ~[}</ lf:';;-· ~;~,,,,, t1..:.<;v' ~·;-· ¡0¡¡¡':;--' ...,\--
. ' ,. ,., 1
,.;}.:·'
11 11 1 ,,
a.i''' ilt.i:"· .;,..• ü·•' .W/
" !' •• 11
.~ liil&i
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!/
iJ u ;Li U1'N •Aíf.CIP'i&d,' &l.' ...... .... .,_, •· - 111:'· .... -· - - •· • · - · .... - · 1111 .... ... Sii •iTllf!ll.iJG .>R<:M!.·ss . . -
./
interruption of thought (and speech). lt is not the same
experience as requiring more time to formulate an idea or
---5 being too emotionally overwhelmed to continue. Thought
blocking is described as having the idea removed from
consciousness or losing the train of thought. A similar
~·3 ------------ interruption in thinking and movement occurs during petit mal
(absence) seizures.
. 152 153
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_; .:::.o....J.•::...:.J.:.::..:.. ......1-....J-__¡'---J'-.-J'-~'--i--J'--••.J'~w ~rad .u. w--w.t .............__.. ·~ .__.¡__.¡.-=--J,.__a;J, lfl. Tt11!f.JGt•º RW~ss 1J 111
Are we having pun yet? C ... C ... C ... C ... C ... C ... C ... C
Example: Where did you park your car?
A pun is a play on words made humorous by involving Garage.
double meanings or similar sounding-words, e.g. How long have you been in town?
Santa's helpers are subordinate clauses. Garage.
Buddhist to a hot dog vendor: "Make me one with everything." Where should the administrator's office go?
Garage.
Continua! punning can be a disorder of thought process in
which sorne patients are compelled to use words for their Most commonly seen in:
sounds or alternate meanings (such as homonyms). In flight • Mood disorders, schizophrenia, catatonia and frontal
of ideas, the connections between words or ideas may be lobe damage dueto trauma, alcohol, strokes, tumors,
based on their multiple or abstract meanings. various dementias, etc.
154 155
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'" w.j llr (f/ a¡.•. •r· fi7 .r li:TH~H-~0-~ a( tJJ
What is jargon or driveling ? How do I toss a word salad?
Definition: Jargon, also called jargon agrammatism, Definition: Word salad is an extreme form of loosened
double-talk or driveling, is composed of speech that has associations, to the point that words have no connection to
lost its communicative value. The syntax is preserved in this one another. lt is as if a sentence were placed in a food
disorder and speech remains fluent. This is the type of processor and the diced words were tossed in a bowl. Sorne
speech that is typical of Wernicke's Aphasia. The repetition folks have had similar e):periences with word processors and
of stock phrases (perseveration) or syllables (verbigeration) been forced to eat their words. The speech in word salad is
.is not prominent in driveling. incomprehensible, and resembles the incoherence of a
global aphasia. The articulation in word salad remains
Diagrammatic Representation: intact, delivery is usually fluent and the prosody of speech is
A•C•D•C ... U·W·O ... P•E•X•D•U•R•P•L•E ... present.
Example: What was McMaster Medica! School like? Word salad differs from fragmentation in that there is no
In verbatim oval often inside making sudden. When system connection at ali between individual words (recall the
phones, try delayed transparency. Principies fourth at one. phrases and sentences were unconnected in fragmentation).
Word salad differs from jargon in that there is no
Most commonly seen in: preservation of syntax, though the speech in both disorders
• Any of the causes of Wernicke's Aphasia (e.g. strokes, is equally meaningless.
tumors, head injuries)
• Chronic psychotic conditions with a severe course Diagrammatic Representation:
156 157
..._, ~
"'""'"" ia.....-~.~..-1 - ..a.,.¡.~..J.-JttJ-~--1-Ai-~---.-w w w-w-w --H'---tii -aJ-af..--1.-aJ.-*4.THllJ/!!!.fd'Ro·~ f;;/ AJ
What are the other components ol thought Neologisms are words or p11rases made up by patients
that have idiosyncratic meanings for them. Neologisms may
process disorders? be formed by the improper use of the sound of words or
other perceptual abnormalities. They are also called jargon
• Clang Associations
paraphasias. In ps;chiatric disorders, neologisms occur in a
• Echolalia
syntactically correct place in a patients speech, as if they
• Neologisms
were words the interviewer didn't know. Ask about unfamiliar
• Non sequiturs
terms; you'll either detecta neologism or learn a new word.
• Prívate use of words
Additionally, neologisms sound as if they could be words.
• Pressure of speech
For example, which in the following list are actual words?
• Rate
• Rl1ythm
• jolmet
• jingo
Clang associations are made on the basis of sound, not • meltom
syntax or logical flow. This most commonly occurs by o monad
rhyming the last word in a sentence. In sorne cases, this is o rocer
considered a type of phonemic or literal paraphasia where o regulus
patients are compelled to substitute a word that sounds
similar to one they just used. An example is: The first, third and fifth words are neologisms. The created
word has a meaning that only the patient understands.
1 have to go, you know. To and fro befare !he snow starts to blow. Jolmet might be the border surrounding a sheet of stamps;
meltom could be the ground on an electrical plug. No sense
Clang associations are most commonly seen in mania, but can be made from these words by breaking them down into
also occur in aphasias, schizophrenia and dementias. their components. For example, if phonesiaV. is defined as
the act of dialing a number and forgetting who you were
Echolalia has been mentioned earlier in the BEHAv10R calling, this is an understandable amalgamation
CHAPTER. lt is the automatic repetition of someone else's =
(phone + amnesia phonesia). Such terms were developed
3peech. Eci .ulalia is seen in: and published by the comedian Rich Hall. 1-' called them
• Catatonia sniglets (defined as a word that doesn't exist, but.should).
• Transcortical motor aphasias
Neologisms can appear in any of the disorders of thought
• Transcortical sensory aphasias
form listed in this chapter. They are most commonly seen in
• Dementias
schizophrenia, but can occur in any type of psychotic
disorder, dementia, and a number of the aphasias. Patients
Echolalia is distinguished from perseveration in that the
are not generally aware that they have used a neologism.
words repeated are the interviewer's (not the patient's as in
They are usually cooperative in defining the term once it has
perseveration). Echolalia is distinguished from palilalia
been pointed out to them.
(verbigeration) in that whole phrases and sentences are
repeated, not just the last word or syllable. n R. Hall, Sniglets, Macmillan Publishing Co., New York, 1984
158 159
i&· ~ k br-~~~-ki.-·~;_;~:-~-D._;a~·.tl-Q~~·- ¡¡ . ~· t'f. ...Ji¡':_& G CJf 14. j, fi¡:' (;{THf;;1é;Hj/itRcjjfss t[ ll
That's irrelevant. What's a non sequitur? How do 1lceep a word prívate around here?
Non-sequitur is a Latin term meaning does not follow. lt Private use of words refers to the incorrect use of an
has the same word root as sequence. Non sequ:turs occur existing word. Syntax remains correct, but the word is used
as a function of normal speech and thought. lf someone gets out of context. lt is also called a literal or semantic
an idea or is suddenly reminded of something (e.g. get milk), paraphasia. The word substiiuted for the correct one is
he or she will blurt out something apart from what was just unrelated either in sound or function. For example:
being discussed. The reply itself demonstrates proper
·· grammar and syntax, and is not otherwise remarkable Yesterday 1visited my friend gerund.
except for not addressing the question.
Gerund is a word, but its use here is of a private nature. lt
was not substituted for Gerrard, which might have been
Non sequiturs can also be a sign of pathology. Generally,
either a related (approximative) or literal (phonemic) aphasia.
they are said to occur whenever the answer is unrelated to
the question, whether interpreted literally or abstractly.
Consider the following question: l'm under a lot of pressure of speech
Q. What is the capital of France?
1. Paris The rate of speech, or more correctly the rate of thought, is
2. The franc another disorder of tho~ght process. A rapid rate of speech
3. The letter F is a variant of normal, and is frequently seen when patients
4. Wine are anxious (either situational or dueto an anxiety disorder).
Which of the following answers is a non-sequitur? At first Pressured speech has a rapid rate with an uninterruptable,
glance, only (1) may seen correct. However, since capital intrusive quality, as if patients are compelled to keep talking.
can also refer to money and capital letters, only (4) is an This is also called pressure of ideas or thought pressure.
unrelated response.
Diagrammatic Representation:
Non sequiturs can be seen as part of severa! abnormalities • an average rate of speech covers this sentence in 4 seconds
of thought form:
Rapid Psychler produces humorous and educational publications.
• Circumstantial speech
• Tangential speech • pressured speech takes 2 seconds and keeps going (and going)
• Loosening of associations
~ ~plXlt.res h..mroJs ard eckaOCnal pjiJ:a&ns. Usirg hmrrisa key ...
• Flight of 'deas
• Derailment (with a short period of blocking)
Pressure of speeéh is one of the principal s1gns of manic or
hypomanic episodes and is accompanied by the sensation of
As such, they are nonspecific signs of illness, but are racing thoughts. The combination is expressed verbally as
reported to be more common in schizophrenia, dementias, flight of ideas. These features can also occur in anxiety
aphasias and coarse brain injuries. states, use of stimulants and hyperthyroidism.
160 161
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'--'- --i _J _J.' ..J.., .,_j·. '· ..u.. -J. '¡
..u. ""'-'1 ...._1 ..J. . i 1 • 'i 1 ¡ 1
ad '""lia:t ~~--ta =.J~aJ.-=&J.,=SJ,=-f~~-·pR.t,EsSaj
....,_J
ILi
""' W. .i
What is the rate ol speech today?
Psychiatry vs.. Neurology
The ratee: .,;peech (and thought) can vary widely in
psychiatric illnesses. Rate tends to vary with amount of
speech and loudness. In mania, patients speak quickly, have
a lot to say, and say it loudly. Depressed patients speak in
an opposite manner .
162
163
~·' .Jic/ ~-~~:j;riJ:-ih~~·4.._·~¡f~~~ti~i!A'.L~t-'1¡~l¡,; ;JJ.f. / arJi'.~-&~"~:~.~tJ:,!_íill::_íÚJ'.~~~11¡4loidJ~ iJ ' lJ /
Summary References
A formal thought disorder is one of the cardinal signs of CuNICAL NEUROLOGY FOR PsvcHIATRISTS, 4TH EomoN
psychosis, with the other being perceptual abnormalities. D. Kaufman, MD
Thought can be disordered because of its content or W. B. Saunders Co., Philadelphia, 1995
l>ecause of f1 w it is organized. Thought can only be
1ndirectly assessed via speech, sign language, writing and THE CuN1CAL INTERVIEW Us1NG DSM-IV
behavior. The form or process of thought involves the VoLUME 1: THE FuNDAMENTALS
following parameters: E. Othmer, MD, Ph.D & S. Othmer, Ph.D
• Goal directedness American Psychiatric Press lnc., Washington D.C., 1994
• Tightness of associations between words, phrases,
sentences and paragraphs PsYCHIATRIC 01cTIONARY, 7TH Eo1T10N
• Rate, pressure & rhythm R. Campbell, MD
• ldiosyncracy of word usage Oxford University Press, New York, 1996
Speech can occur in complete sentences with good DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL D1SORDERS,
articulation and proper syntax even if a patient is psychotic. 4TH EDITION
lt is the flow and production of thought that reveals the American Psychiatric Association, Washington, D.C., 1994
impairment. Patients are generally unaware of their thought
processes and cannot conceal these disorders as they might CoMPREHENs1ve TexrnooK oF PsvcHIATRY, 6TH Eo1T10N
hallucinations or delusions. H. Kaplan, MD & B. Sadock, MD, Editors
Williams & Wilkins, Baltimore, 1995
Disorders of thought process show a wide range of
variability, from moderate overinclusiyeness to the SYNOPs1s oF PsYCHIATRY, 7rH EomoN
meaningless production of words. In sorne disorders, H. Kaplan, MD, B. Sadock, MD & J. Grebb, MD, Editors
patients will use words based on their sound instead of Williams & Wilkins, Baltimore, 1994
meaning. While certain types of thought process disorders
are usually associated with certain conditions, there is no SYMPTOMS IN THE MINO, 2ND EDITION
finciing pathognomonic far any psychiatric illness. lmportant A. Sims, MD
conditions to investigate in patients with thought process W.B. Saunders Co., Philadelphia, 1995
disorders are:
• Epilepsy (especially temporal lobe or partial-complex) THE NEUROPSYCHIATRIC MENTAL STATUS EXAMINATION
• Dementias M. Taylor, MD
• Degenerative neurologic conditions PMA Publishing Corp., New York, 1981
• Substance abuse, dependence anp withdrawal
• Strokes (cardiovascular accidents)
• Mental retardation
164 165
1~
1~
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thought derailment • Mr. and Mrs. Bobbiwash request the honor of your
presents at the marriage of their daughter ...
• Am 1 my brother's brother?
168
169
( 1 N' bH' VIV "\f I
"_j L .ii..1 -;;.,_. - ,¡¡.J'-liW - ,iU. - kJ.-ciW -.&.J ~Al- liW~~ -.#1.:J -&l ~.... ~ ~.-1.~.-~n -~':1-~H - ... -.-IJd-iliJ-ilíJ;-al.-A.l;-..,-a,, *'1
Chapter 1
Thought Content
What is thought tontent?
Speech
Language
170 171
Jl¡j ¿l k~'"~~~_;_~~E-b-~~~~-U~ iJr/ lr IJ"· 6'~) ~~, , . '1' ~j ~, lt Jr· *t:Hoit1'r~rÍíli &J_, iJ
j
• Shared Psychotic Disorder (Folie a Deux) 297.3 • Posttraumatic Stress Disorder 309.81
A. A delusion develops in an individual in the context of a B. (1) Recurrent and intrusive distressing recollections of the
clase relationship with another person who has an event, including images, thoughts, or perceptions
established delusion
• Hypochondriasis 300.7
• Major Depressive Episode 296.X A. Preoccupation with fears of having, or the idea that one
A. (7) ... excessive or inappropriate guilt (which may be has, a serious disease based on the person's
delusional) ... misinterpretation of bodily symptoms
172 173
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' si' -,._j,
1
..,.u, .J .,¡ -J. ..J. &! ~ i!i.i llo;.1 11..d Wf lid. w ll..l'. ~. Id ad. El 111.1 al.ft.uJ/lbm•loNlíl~r &1 tJ
174 175
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;:¡j;t iíll.1,
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tj{J,
,.,, ;;,;-.¿ ~'ii"' '... ,; ... ., ii"/ i>·../_,;../ .¡.,,~
i ¡¡¡¡g;-Q--.-lillJl.-;1J,-&-.l."'----U--U.
ih/
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'"'ª
0w."""'"VJ.-=-ta.--W.-ta.-.,.~m.-SJ.~:S.~•~•;- .1
,.;-/
r:..._..w
fi:1'
.,
176 177
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&1 L .,_. - - . i . -.....-iJllW.-Ji.J.-:ilJ,-:Jl.J.-it.J-íJ.-ild.~J!iJ~tu.--iu-=fd "' w --b--W ---4w -aw ·---*" -&1--4U--4JJ--11J~~e!:!-11Jt!... &-J' .,
178 179
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Ji/ ahl' ~Yt-~~~oL.:Ji~~:"'-~:Ibi.;::.._U-~~~j]~~~,~.e ~-; i'.A) iUilj ~"~1~J Al', ~'.k1 .....Jit:.J1Jt.Ji·:__j¡r f/ff0 erilr~,fil_ ti; Ir
How do I ask about delusions? How do I deal with delusions onte they are
Formulating questions about delusions constitutes one of the expressed?
rnost difficult tasks during interviews. As opposed to patients
with phobias or obsessions, delusional patients usually don't lt is important to bear in mind that delusions represent the
recognize that they are ill. Asking, "So, are you delusional?" truth to patients who experience them. Your reactions (verbal
probably won't work, so more refined means are required. and behavioral) have a large degree of influence over what
patients are willing to share. As mentioned, an inquisitive
.Watch far themes during the interview:
approach that outlines the extent of the delusional thinking is
Despite the complexity of mental illnesses, most delusions
optimal. Novice interviewers often make one of two mistakes
fall into a small number of themes (paranoid, somatic,
(sorne make both) when uncovering delusional material:
grandiose, jealous, etc.).
• Adopting a nonchalant, lackluster demeanor, as if not to
Questions to help detect the presence of de/usions: frighten the patient by showing too mue: .11terest
• "What's been on your mind recently?" • Sitting bolt upright with a widened stare, sharpened
• "Do you spend a lot of time thinking about one or two things?" pencil and demonstrating an unprecedented leve! of
• "Do you have sorne ideas that you hold very strongly?" interest in the interview material
• "Do others frequently disagree with your views on things?"
• "When ye;u aren't busy with something, what do you think about?"
Guidelines for handling delusions are as follows:
• "What are the things that are most importan! to you?"
• Don't interrogate patients - a rapid-fire approach will
Because del_usions dominate thinking (and also mood and usually miss delusions in the first place; an undue
behavior to a large extent), these questions are likely to degree of interest or chariJe in interviewing style may
revea! an aspect of delusional thinking if it is present. When have an idiosyncratic meaning for the patient (e.g. you
patients mention something that could be of a delusional become part of the delusion because of your interest)
nature, respond with curiosity. An interested, conversational • Don't argue with patients - no delusion was ever cured
manner will elicit more information. by logic or any degree of proof to the contrary; it can be
very tempting to "enlighten" patients or point out the
Questions to examine (potential/y) delusional material: obvious contradictions or weaknesses in their
• ''l'm interested in what you just said, what else can you tell me understanding of events
about that?"
• Empathize with patients to preserve rapport and to
11 "How do you know?"
facilitate sharing more information
• "How did all this start?"
• Tactfully avoid being the "judge of reality" and telling
• "Why would someone want to do this to you?"
• "What's happened so far?" patients whether or not you agree with them
• "How do you account for wh::it has taken place?" • lf pressed to render an opinion, try something like:
• "l'm keeping an open mind."
Regardless of skill, delusions can't always be elicited. • "I can't decide without more information."
Patients with an awareness that others don't share their • "My job is to understand what your views are."
ideas (preserved insight) or who have been hospitalized
because of delusions may conceal their thoughts.
180 181
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irli.i' 1!11;,L~Ail_~-._-..,_~_,_-,._--.,-a--..1.... _, •
\
1Ll
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What makes it difficult to distinguish a delusion from justified Patients with this delusion can be an extreme nuisance to
jcalousy is that infidelity is usually a discreet process. lt can public figures. They will devote extraordinary time and
be almost impossible for the accused person to prove his or energy to get the attention of the object of their desires. Such
her fidelity. Many times, the continued accusations drive the patients may commit crimes (break & enter, kidnap-ping),
partner away and into another relationship. In a sense, this blackmail or even make false accusations of sexual assault
makes the crime fil the punishment through the process of or paternity in order to make contact with the person.
projective identification. Here, patients induce others to
behave in a way that justifies their suspicions. This can also They arbitrarily assign significance to unremarkable events
be thought of as a self-fulfí/líng prophecy. Additionally, the as a sign of the continuing lave of their target. For example,
accused partner is often more attractive or outgoing, which if a political figure wears a blue suit when giving a speer,h, it
adds substance to the claims of infidelity. is a clear indication to the delusional patient that'a bond
exists. Paradoxical conduct refers to the situation where ali
The delusion frequently starts with projected libidinal wishes efforts to deny a romantic link are interpreted by the patient
on the part cf the patient. He or she may desire another as further proof that the secret connection ey;.--:s.
1over, and by projecting these (unacceptable) urges outward,
blames the spouse/partner for harboring them. The patient There is sorne debate regarding the course of these
may have been promiscuous, and automatically assumes delusions and the danger to the person involved. Sorne
the current partner will be as well. Another common finding is authors report erotomanía is short-lived, andas an actual
that the patient is overly dependent on the partner, and may relationship becomes more less and less likely with time,
wish for complete possession. patients select another attachment. Other authors report that
this delusion can not only continue for years, but there have
This condition can occur in males when they become been instances where patients commit suicide and/or
impotent or have homosexual urges for the men with whom homicide upon confronting the person to whom they are
the partner is supposedly involved. Delusional jealousy is attracted.
also seen in alcohol abusers and after head injuries. lt is
notoriously difficult to treat, often remaining stable for years. A related delusion, called the phantom lover syndrome, is
This delusion is among the most likely to cause patients to the conviction of being loved by someone who doesn't exist,
take action against the partner and/or others involved. but is identified asan "ordinary person."
184 185
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What are the psychodynamic aspects of • lsolation (of affect) separates or strips an idea from its
accompanying feeling or affect. This is the predominant
obsessions? defense contributing to the obsessive component. An
idea is made conscious, but the feelings are kept within
As mentioned on the last page, obsessions tend to fall within the unconscious. When this defense is used to a lesser
a small number of themes, with aggression, cleanliness and degree, three others mechanisms may be used:
arder being the most prominent. In Freud's psychosexual • lntellectualization - excessive use of abstract thinking
stages of development, these are the issues that domínate • Moralization - morality isolates contradictory feelings
the anal phase. Control and autonomy are the key • Rationalization - justifying unacceptable attitudes
·outcomes from this stage. Freud linked obsessive behaviors
to difficulties during the anal stage of development, and • Undoing involves an action, either verbalization or
defined the anal triad as consisting of parsimoniousness, behavior, that symbolically makes amends for conflicts,
orderliness and obstinacy (mnemonic - P.0.0.) stresses or unacceptable wishes. This is the
predominant defense contributing to t~- '· compulsive
r"oilet training is usually the first intrusion of socialization into component.
an infant's otherwise unrestrained existence. Achieving
continence involves submitting to parental expectations on • Reaction Formation transforms an impulse into a
demand, and then being judged on the outcome. When diametrically opposed thought, feeling or behavior. This
children fail at the task, overambitious or demanding parents is frequently seen as a "counterdependent" attitude in
evoke feelings of being bad and dirty. lssues of cleanliness, which patients (primarily with obsessive-compulsive
timeliness, stubbornness and control can reasonably be personalities) eradicate dependency on anyone.
seen as linked to this stage of development. Failing to Similarly, maintenance o" a calm exterior guards against
produce on schedule, with an immediate perception of an awareness of angry feelings. For example,
disappointment, arouses feelings of anger and aggression. orderliness is a reaction formation against the childhood
Ego defenses are used to defend against the expression of desire to play with feces orto make a mess.
unfulfilled dependency wishes and strong feelings of anger
directed at caregivers. • Displacement redirects feelings from a conflict or
stressor onto a symbolically related, but less threatening,
Ambivalence develops as a result of the simultaneous person or object. "Kicking the dog" or "shooting the
existence of longing (love) and aggressive wishes (hate). messenger" are examples of this defense.
This conflict of opposing emotions paralyzes the patient with
doubt and indecision, and can result in the doing-undoing Anger or aggression towards caregivers becomes
pattern seen with obsessions and compulsions. unconsciously forbidden, so substitutes (canine and
otherwise) are targeted for these feelings. This is also the
Magical thinking is also a component of OCD in that the predominant defense involved in the formation of a phobia.
obsession is given great power, and is deemed to have more While the presumed etiology of OCD and OCPD are blended
of a connection to events than is realistic. For example, here, a comparison of their differing features is presented on
having thoughts of a disaster does not make it occur. the next page.
194 195
1
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• To what degree do you limit your activities beca use of A neurotic symptom (phobia) is formed
anxiety?
200 201
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Summary Referentes
Delusions THE CLINICAL INTERVIEW Us1NG DSM-IV
VoLUME 1: THE FuNDAMENTALS
E. Othmer, MD, Ph.D & S. Othmer, Ph.D
American Psychiatric Press lnc., Washington D.C., 1994
Obsessions Perception
PsvcHIATRIC D1cT10NARY, 7rn Eo1TION
R. Campbell, MD
Phobias Oxford University Press, New York, 1996
204 205
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Chapter8
"Endings"
Suicida/ & Homicida/ ldeation
While these two components technically belong in the
THOUGHT CoNTENT chapter, the seriousness of their presence
warrants a separate discussion. Asking about these areas is
often fraught with apprehension because of the delicacy
required in phrasing questions and the consequences of
either being present. Yet the findings in the history or
previous parts of the MSE pale in significance if the patient
or someone else is going to come to harm.
. 210 211
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Social lsolation, in general, refers to a sense of Age is a factor because certain age groups are statistically
unconnectedness with others. This can be in terms of marital correlated with a higher risk of completed suicide. As a
status, occupation, or even patients' view of themselves. general rule, the prevalence of suicide increases with age.
Suicide rates are higher for people who live alone, which This trend clearly develops i11 men starting at about age 45,
includes those who are widowed, divorced, separated or and climbs continually, with a peak at age 75. Women have
have never been married. Many people who live alone prefer a later onset, starting around age 55 and exhibit a less
the solitude and freedom from distraction that this provides. dramatic rise with age. The elderly have a suicide rate triple
Befare listing this as a risk factor, it is important to know if it that of younger peo¡Jie, and commit one-quarter of ali
á patient's choice to live alone, and how great a departure suicides, but encompass only one-tenth of the population.
this is from desired living arrangements.
There is an important exception to this trend. The suicide
Relationships are to a large degree protective against self- rate among males aged 15-24 is disproportionately high
harm. However, someone may be married, living with a (especially among whites). In this age group, suicide is
partner or involved in a relationship and still feel estranged. consistently reported to be either the second or third most
People change with time, and new interests are not always common cause of death (with accidents and homicide being
jointly pursued. The quality of relationships is a key factor to the other causes). While no clear reason has been
ask about when suicida! thoughts are expressed. established, it has been suggested that the prevalence of
alcohol and drug abuse is a significant factor. Peer pressure
Cultural factors also impact on the degree of isolation and exposure to media depictions of suicide are also thought
patients might feel. Certain regions have consistently high to be relevant factors.
rates (Eastern Europe, Scandinavia, Japan). Significantly
lower rates are seen in lreland, the Mediterranean, and the Disturbed Interpersonal Relationships (DIRs)*
Middle East. The U.S. and Canada have rates in the middle Disruptions in meaningful relationships provide perhaps the
of this range (1 O to 15 per 100,000 people per year). best answer as to why people take their lives. DIRs are one
of the most common, if not the major cause of visits to
Within certain countries, rates vary according to emergency rooms for emotional reasons.
demographic features such as race, religion, urban/rural
location, immigration and socioeconomic status: DIRs in particular refer to:
• Whites have higher rates than Blacks • The threat of rejection or abandonment
• Protestar ; have higher rates than Catholics or Muslims • Loss of approval, acceptance, affection or attachment
e Rates are higher in cities than in less populated areas
• lmmigrants have higher rates To understand why DIRs can impel someone to wish to
• Higher socioeconomic strata have higher rates commit suicide, it is necessary to review sorne of the
psychology of self-destructive behavior.
lt has been proposed that there is a greater sense of
belonging and cohesion in groups with lower suicide rates. * 1 am indebted to Dr. John H. Mount of London, Ontario, Ganada for
Social isolation can be the result of other factors (e.g. alcohol his excellent work and teaching on this tapie, which is summarized in
this section.
or drug abuse, personality difficulties, etc.).
214 215
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riJ *lu
HoMICIDAL loEATION
&I
'"'""""" \.ALll'tRS
Freud thought suicida! urges stemmed from frustrations that Withdrawing, or the flight response, can involve:
develope-. during childhood. Everyone carries an • Building interpersonal walfs to diminish e ,otional pain
internalized representation of their caretakers (usually • Developing work habits that compensate far other
parents). This is referred to asan introjected object (in deficiencies, often called an "institutional" work style
psychodynamic theories. object means person). In situations • Regressing to the need for earlier means of gratification
where parents were, or were perceived to be, harsh, where others aren't needed (often with "oral" habits like
depriving, distant, etc., a strong sense of abandonment smoking, drinking alcohol, excessive food consumption)
ensues. Strong feelings, even murderous wishes,
accompany this sense of being unwanted. Later in life, this The fight response involves aggression. Anger can be used
.. conflict is arousecl again when people don't feel loved by destructively against the self, causing the emergen ce of
those clase to them. DIRs reawaken correspondingly strong suicida! feelings. Anger directed at others brings about a
feelings in adults on both conscious and unconscious levels. potent sense of guilt. Along with this sense of guilt is its
unconscious analog - the fear of, or need for, punishment.
Since Freud's initial ideas, a good deal of work tias gane into
understanding earfy experiences and how they influence Causation of Psychological Sympfoms
relationships later in life. One school of thought is called
Attachment Theory, which was pioneered by John Bowlby. innate need for close attachment -+ lf satisfied (PIR)-+©
216 217
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HoMtCIDAL IDEATtON
The lethality of the drugs used (or available) needs to be Males tend to use violent methods, such as firearms, knives,
taken into ~ ..msideration. Those with the greatest potential to jumping and hanging. Females are more likel" '.o take
cause death are: overdoses, drown, or asphyxiate themselves.
• Amphetamines
• · Barbiturates In particular, the availability of firearms has been shown to
• Cocaine have an impact on the suicide rate.
• Opioid3
Ethanol use can lead to problems during intoxication or
In sorne cases, the term drugs denotes illicit substances withdrawal states. (This can be considered as part of
(street drugs), whereas medications refers to substances "chemical dependency ," but a "OWel was needed for the
obtained via prescription. lt is important to ask about both mnemonic.)
prescription and nonprescription drug use, though ali but
cocaine from the above list can be obtained by a physician's Alcohol deserves special mention because it is the
arder. Cocaine is still used medically as a vasoconstrictor, substance most often associated with acts of violence.
but is only available in aqueous form in hospitals." Ethanol causes disinhibition and removes the self-restraint
that would otherwise be present. The combination of
The greatest risk appears to be through combining drugs of impaired judgment and a greater propensity to take action
abuse (including alcohol). A common situation involves using can have dire consequences. lt is common in emergency
certain drugs to modulate or prolong highs, reduce rooms to have intoxicated patients who are combative or
distractions, and avoid the dysphoria of "crashes." self-destructive, yet become entirely different when saber.
The prevalence of drug use among adolescents and young Alcohol increases the toxicity of substances that are co-
adults is thought to be a majar contributor to the increased ingested. Unlike opioids and benzodiazepines, there is no
rates of suicide seen in this age group. readily available agent to reverse the effects of alcohol.
Ethanol use is also commonly a consequence of other
The presence of certain factors involving the use of factors. Patients with mood disorders or anxiety disorders
substances increases the risk of suicide: appear to be particularly likely to seek solace by imbibing.
• Early age of onset
• Chronic use Alcohol use obscures accurate statistics on suicide.
• Past overdoses Accidents involving single motor vehicles or pedestrians may
• Family history of substance abuse be suicides, but the use of alcohol makes the issue of
• Male gender intention less clear. Deaths by drowning, overdose, falling,
etc., similarly raise the question of suicide vs. accident.
218
219
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
BRA/N CALIPERS 11 ,,
ENDINGs - Su1c10A1. & HoM1c10A1. loEATION
Sex (gender) is unevenly distributed in terms of attempted Repeated attempts at self-harm increase the risk of a
vs. completed suicides. In all age ranges, males commit completed suicide. A distinction needs to be made between
suicide more frequently than females. The ratio varies from past serious, unsuccessful attempts and chronic thoughts of
2: 1 to almos! 1O:1 depending on the age group and race. suicide or gestures of self-harm. The latter occurrence is
Two factors help explain !he gender discrepancy. As outlined called parasuicide and refers to chronic self-mutilation,
in the 'L' (lethality) section, males use more lethal methods. persistent thoughts or threats of suicide, or nonlethal
The time ·course of an overdose, asphyxiation or drowning attempts.
allows an intervention to be made. Only seconds to minutes
are available with more lethal means (only Superman can • The highest statistical category for completed suicides
stóp a speeding bullet). Secondly, males have a higher are older males who are socially isolated, use a method
prevalence of chemical dependency. In North America, the of high lethality and have either a mood disorder or are
ratio of m2;,es to females with alcohol problems is at least chemically dependent.
4:1. In other areas of the world it is considerably higher. • Attempters tend to be younger women who have sorne
social supports, use methods that are unlikely to be fatal
Depression, however, is strongly correlated with completed (and likely to be discovered), and have a personality
suicides and is more prevalent in females by a factor of disorder or adjustment disorder. \.
about 2:1. Schizophrenia is widely rega_rded to have a later
onset and milder course in females. lt is thought that Women attempt suicide more frequently than men, though
estrogen serves a protective function in "schizophrenia.11 men complete more suicides. Most attempts occur in
Given that estrogeri patches have been used to treat severe younger age groups, which iB che opposite picture to
post-partum depression, :t may be that the course of mood completed suicides. Attempts are made impulsively,
disorders is somewhat different on a gender basis as well. * whereas completed suicides are more often planned, and
take place in settings with a low chance of discovery or
Occupation in general is a protective factor. Higher socio- rescue. Among attempters, a personality disorder has been
economic status is associated with higher risk (t~ough a reported to be the most common diagnosis, with borderline
recent change in status is also a risk factor). A possible and antisocial personality disorder being the most prevalent.
explanation is that a higher level of occupation generally With borderlines in particular, parasuicidal behavior can
requires increased responsibility. lf things go awry, affected become a way of life as a means to manipulate others.
individuals may face consequences from many avenues.
Professionals, and in particular physicians, are generally Despite the above distinctions, those who attempt suicide
above national averages. Recent studies have indicated that have a large number of demographic variables and risk
female physicians have rates triple the national average for factors in common with those who complete suicide.
women over age 25. Engaging in any type of self-harming behavior increases the
~ l'./l.V. Seeman & M. Lang, The Role of Estrogens in Schizophrenia Gender
risk of an eventual suicide. Even in cases where it seems
Differences, Schizophrenia Bul/etin, Vol.12, no.2, p.185-194, 1990 obvious that parasuicidal behavior is employed for
secondary gain, complications can arise. For example, drugs
·E. Frank, L.L. Carpenter & D.J. Kupfer. Sex Differencos in Recurrent
Depression: Are There Any That Are Significant?, American Joumal of may be taken with alcohol or in new combinations that
Psyc/Jiatry, Vol.145, No.1, p.41-45. 1988 enhance their lethality.
220 221
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BRAIN CAL/PERS "ENotNGs" - Su1c10AL & HoMtCIDAL lvEATION
Events of an acute nature increase the risk of suicide. The Wills and Notes indicate that planning was involved in the
presence of loss is central to precipitants that lead to suicida! attempt, which is correlated with an increased risk of
behavior. This can be perceived or actual loss of love, completion. Patients who wísh to "tidy up their affairs" may
esteem, wealth, health, fame, etc. The most common events have wills created or altered. Many patients rnake reference
leading to the wish to die are disturbances in interpersonal to their will, orto changes in ít, prior to a suicide attempt.
relationships (DIRs ).
Generally, notes either actas a way of telling others what the
Searching for the "final straw" is a .vatuable endeavor when person thought of them, oras a plea to those left behind to
.. assessing suicida! patients. lt is important to understand why understand why the suicide occurred. Notes are not always
the patient made an attempt or is considering suicide at this conspicuousty placed. They may be mailed or concealed so
point in time. There is alrnost always an explanation for why they are not prematurely discovered. Sorne patients also
patients do not want to go on living. purchase burial plots or gíve away their possessions as part
of their suicide plan.
Most people at least transiently consider suicide at sorne
point. Traumatic events like the death of a spouse, child or Organic conditions (general medical conditions) can be
oarent frequ- ntly cause suiviving parties to consider whether risk factors due to their seriousness or ch ro· .;ity. This is
cheir own lives are worth continuing. one of the reasons why suicide is more frequent in the
• 20% of adults have had persistent thoughts of suicide elderly. A list of conditions associated with increased risk is
over a two-week period as follows:
• 10% of adults have rnade a plan as to how they would
com.rnit suicide Central Nervous System Cardiovascular
• 3% of adults have made an attempt at suicide. • Dementia (of any type) • Unstable angina
• Head injuries
• Degenerative Conditions Gastrointestinal
In situations where a precipitant is not obvious, consideration • Peptic ulcer
(e.g. Multiple Sclerosis,
of three other factors may help shed sorne light: Parkinson's Disease, • Cirrhosis
Huntington's Disease) • lnflammatory bowel
1. In sorne cases, people react to a symbolic loss rather disease
• Epilepsy
than an actual one. Exploring the meaning of apparently • Strokes • Porphyria
minor losses can help identify the source of the precipitant.
Renal
Cancer
• Dialysis dependence
2. People may not be consciously aware of what influences • Particularly !hose that
them. F or example, watching a movie or hearing a song can grow quickly or are Endocrine
advanced al the time of • Cushing's Disease
bring about associations that evoke painful memories. discovery
HIV seropositivity or AIDS
3. Anniversary reactions occur on the dates of major Musculoskeletal • Especially with
losses. Sorne patients may be completely unaware of why • Amputations encephalopathy
they are suicida! at a certain point in time. An exploration of • Chronic pain
• Paralysis (para or quad) Progressive Autoimmune
dates significant to that person may revea! the cause. Disorders
222 223
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BRAIN CALIPERS
"'ENDINGs" - SutetDAL & HoMtcmAL loEATION
Mental lllness is the strongest risk factor associated with Schizophrenia is the third most common psychiatric
suicide. Over 90% of those who take their own lives have a diagnosis among those who have suicided. lt is estimated
diagnosable mental condition at the time of death. The that 10% of those with this condition may take their lives.
presence of a mental illness is estimated to increase the risk
of committing suicide tenfold. Within this diagnosis, the risk is higher:
• Among young male~. and relatively early in the course of
The majority of patients who commit suicide have seen a the illness
physician within six months of their death. and frequently • In those with high premorbid achievement and high
·within one month. Other studies have found that a high personal expectations
percentage of patients who took their lives had been given a • After the recovery from a psychotic episode, during the
prescription for a psychotropic medication. Postpsychotic Depressive Disorder of Schizophrenia
(DSM-IV, p. 711)
Among psychiatric disorders, mood disorders and alcohol • In those with an awareness of the overall prognosis
abuse (respectively) are the conditions that have the highest • In those with the additional risk factors of social isolation
association with suicide. and substance abuse
Mood Disorders are thought to be present in at least half, Command hallucinations or persecutory delusions have not
and potentially up to three-quarters of those who commit been highly correlated with suicide potential.
suicide. lt has also been estimated that 15% of those with
mood disord~rs will go on to take their own lives. Within the Personality Disorders are also frequently diagnosed in
spectrum ot mood disorders, the diagnoses resulting in the suicida! patients (in particular, the antisocia: ;nd borderline
highest morbidity are: personalities from Cluster B; suicide is three times the
• Depressions with psychbtic features societal rate in prison populations ). These personality
• Bipolar mixed states (the coexistence of maníc and disorders are associated with substance abuse, impulsivity,
depressive symptoms; of particular concern is that the and poor social integration and adjustment. Paranoid
energy of mania can cause patients to act on the suicida! personalities may harm themselves or others as a way of
thoughts brought about by depression) preempting what they consider to be an inevitable attack.
lt has not been condusively shown that there is a difference Anxiety Disorders have recently been found to have an
in suicide rates between unipolar and bipolar patients. The association with suicide risk. In particular, posttraumatic
risk of self-harm is greatest at the beginning or end of a stress disorder and the presence of panic attacks (which can
mood disturbance. The period just after hospital discharge is occur in a variety of disorders) were seen as having a
also associated with higher risk of an attempt. Mood correlation with future suicide.
disorders are somewhat more common among the elderly
who commit suicide. Personality disorders and chemical Alcohol and substance abuse have been previously
dependence are more common in the younger age groups. mentioned as risk factors. A combination of these disorders
lnsomnia, anhedonia and poor concentration are the most (comorbidity) with other psychiatric illnesses places patients
common mood symptoms associated with suicide· risk. at particularly high risk.
224 225
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What are the psychological lactors present How do I ask about thoughts of suicide?
in suicida/ ideation? There is often a great deal of hesitation in asking patients
about the presence of suicida! thoughts. A common fear is
Freud postulated that suicida! urges start out as aggressive
that merely posing such questions will cause patients to
wishes towards an interna! representation of someone to
become suicida!, or that patients will take itas a suggestion.
whom the patient is attached (usually a parent). Murderous
Although tact and timing are required, neither of the above
wishes (or even rage) can then be directed against the self.
situations actually occurs. Consider the following interview:
In this way, violence towards the self or others is seen as
"having a common cause (as demonstrated in the diagram Patient: "In the last month, l've lost my wife, my best friend,
outlining !he Causation of Psychological Symptoms). my job, my truck and my dog. My life is like a Country &
Western song - 1jusi don't know what to do next."
The central feature in the thought processes of suicida!
Student: "Have you considered suicide?"
individuals has been shown to be hopelessness.
lrrespective of diagnosis, the absence of hope far the future Patient: "Do you think that's what 1 should do?
is a key indicator of long-term suicide risk. Other factors that {A better way of phrasing !he question is, "Has this situation been so
difficult for you that you've had thoughts your life wasn't worthwhile?")
have been seen to have prognostic significance are: guilt,
shame, humiliation and desperation.
Patients expect to be asked about suicida! thoughts, and are
frequently relieved to be able to speak about them. Here are
F2ntasies commonly expressed by suicida! patients involve
sorne suggestions on how to ask about suicidal thoughts:
the following themes:
• Are there times when you feel like your difficulties are too
• Rebirth or reunion with a deceased person
• Escape from situations perceived as hopeless or too much for you?
• Do you ever feel like life is too much for you to bear?
painful to endure
• Have you thought that things would be easier if you
• Retaliation or revenge
• Self-punishment or sacrifice weren't around?
• Have you ever worked out a plan for taking your lite?
• Atonement or restitution
What did you have planned?
• A means of gaining or maintaining control in situations
• Do you find your life devoid of happiness or things that
where patients are, or see themselves as, powerless
interest you? Is this so bad you wish you could die?
• Do you have thoughts right at the moment about wanting
Anomie was a term used by Durkheim to refer to a lack of
to take your life? Do you feel suicida! riph~ now?
social control The quality of the relationship to society has
• What happened the last time you felt th,,:; way?
Leen used to classify types of suicides:
• Egotistic Suicide is a lack of integration with society
A positive response to any of these inquiries necessitates an
and a sense of no longer feeling subject to its norms
immediate investigation of the plans the person has made
• Anomic Suicide involves a perceived lack of "collective
and the presence of other risk factors. lt is important to
arder" in society where hopes cannot be realized
• Altruistic Suicide is committed for the benefit of society· distinguish past from present suicida! thoughts.
228 229
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Are there ways ol measuring the potential Why is it sometimes difficult to interview or
1.Jsk far srúcide? deal with suicida/ patients?
• Beck Hopelessness Scale Assessing and treating suicida! patients is among the most
Aaron T. Beck developed a scale for the presence and stressful aspects of being a mental health professional. A
extent of lwpe/essness; this is a self-report questionnaire suicide in psychiatry is the equivalent of a patient dying on
that includes 20 questions that gauge the extent to which the table in surgery. The suicide of a patient has been
patients have pessimistic views about their future. reported to cause stress in caregivers equal to the loss of a
•· Scale for Suicida! ldeation & Suicide lntent Scale spouse. Suicida! patients bring about specific difficulties and
Both of these instrumAnts were also developed by Beck. challenges.
A.T. Beck. O. Schuyier & l. Herman, Development of Suicida! lntent
Scales, in The Prediction of Suicide, Charles Press, 1974 Suicida! patients engender strong reactions in people around
• Risk Estimator Scale for Suicide them, especially those that have to do something (e.g. speak
Developed by Motto, this rating system incorporates 15 with them at length, bring them to hospital), including
variables found to be statistically significant in a study that professionals who have to treat them. In the case of
looked at the completed suicides in a group of patients who caregivers, strong countertransference feelings may arise,
were depressed and/or had expressed suicida! ideation. defined as the total emotional reaction to a patient. Because
J.A. Motto, D.C. Heilbron & R.P. Juster, Development of a Clinical we are all human, we will experience certain feelings in
Jnstrument to Estimate Suicide Risk, American Joumal of
response to our patients. One of the hallmarks of a
Psychiatry, Vol. 142, p. 680-6, 1985 ·
seasoned interviewer in dealing with patients is to recognize
• Rorschach ("lnkblot") Test and effectively use countertransference, instead of denying it
Using criteria developed by Exner for
scoring the responses, or simply acting on it. One's emotional reaction to patients
this test may have a predictive value for people at risk. yields fertile ground for further exploration, and in many ways
J.E. Exner, The Rorschach: A Comprehensiv'e System,
is essential for a more complete understanding of patients.
Third Edition, Wiiey, New York, 1993
• lndex of Potential Suicide People become suicida! through a complex series of events,
This may be given as a self-report test oras an interview. especially in cases of borderline patients. Here, patients
There are 50 items that are given a score between 1 to 5. have difficulty being alone, experience hostility as their main
This test was developed by Zung, who has also produced a affect, and unconsciously engage in sado-masochistic
depression rating scale. relationships because that is what they are used to giving
W.W.K. Zung, lndex of Potential Suicide: a rating scale for suicide
and receiving. Suicida! patients use relatively primitive
prevention, in The Prediction of Suicide, Charles Press, 1974
defense mechanisms, which also make them difficult to deal
• Suicide Probability Scale with. This can result in what has been called
This is a widely used instrument developed by Cull & Gill. countertransference hate* in response to suicida! patients,
J.G. Cull & W.S. Gill, Suicide Probability Scale Manual
defined specifically as a mixture of malice and aversion.
Western Psychological Servíces, Los Angeles, CA, 1986
• Reasons hr Living lnventory *J.T. Maltsberger & D.H. Buie, Countertransference Hat~ '·1 the Treatment of
Th1s is another commonly used self-report scale. Suicida! Patients, Arch. of General Psychiatry, Vol. 30. ¡:.. 625-633, May, 1974
230 231
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Causation ol Psychological Symptoms expression is inwards, expression is outwards,
causing harm to the self causing harm to others
innate need for clase attachment -+ lf satisfied (PIR)-+©
~
Apter11 et al. looked at the use of various ego defenses in the
lf frustrated (DIR)-+® above scheme. This study found support for the widely held
view that the risk of violence and the risk of suicide are ~
~ highly correlated. The defenses found to be significant in
Decreased self-esteem modulating the expression of violence are:
~ Suicide Risk Violence Risk
Repression Denial
t • + Regression Projection & Displar 0 -nent
~
Creative Withdrawal Aggression Self
Effort (flight) (fight) Destructive • Repression keeps impulses within. Regression occurs
(learning) Acts with a greater number of life stressors, which have been
• personality ~
styles found to be higher in suicida! patients than violent ones.
~
• personality homicide • Denial obscures or obliterates reality. Projection
disorders suicide externalizes the source of a threat. Displ~cement
• work styles redirects intense feelings towards a substitute target.
• earlier
pleasures In combination, the defenses that increase the risk of
violence do so by making threats appear externa!.
1 A. Apter, et al. Defense Mechanisms in Risk of Suicide and Risk of
Source: J. H. Mount, MD, Personal Communication, 1995 Violence, American J. of Psychiatry, Vol. 146:8, p. 1027-1031, August 1989
240 241
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How do I ask about violen# intentions? Are there methods for the pretlidion of
Patients may not be open and honest about their intentions
dangerousness?
in this regard. For this reason, the other factors listed in this
chapter serve as a guide for the possibility of violence. The topic of predicting future vfolence encompasses an
Additionally, current stressors of a financia! or interpersonal extensive literature. lt is a common component of forensic
nature are common precipitants for taking action against assessments, and such predictions are frequently sought in
others. The best predictor of future violent behavior is a legal proceedings. There is a lively debate regarding the
· history of past violent behavior. Here are samples of ability to accurately predi et the likelihood offuture harm to
questions that can be asked: . others. Test instruments are certainly becoming more refined
• Have you had thoughts about wanting to get revenge on and valuable. However, much like the weather, the longer
someone? Did you ever develop a plan? the term of the prediction, the less accurate it is likely to be.
• Are you currently having any ideas about wanting to hurt
someone? Do you have a particular person in mind? Risk factors can be divided into majar categories:
• History of aggressive behavior (e.g. childhood history,
• What would you do if you met a person you didn't like?
• Do you have access to guns, knives or other weapons? record of assaults, etc.)
• Developmental factors (psychopathology in parents,
• What would it take for you to want to harm or kili
head injury, rebelliousness against authority, etc.)
someone?
• Presence of majar psychiatric illness
• Personality traits (poor impulse control, inability to
Do psycbiatric patients lrequently brealc the examine own behavior, emotional lability, etc.)
law? The following is a partial list of scales used in the
lt is a long-standing perception that the mentally ill are assessment of violence and the prediction of its recurrence:
dangerous and prone to committing criminal acts. Teplin 11 • Overt Aggression Scale
undertook a study of police-citizen contacts. She found that • Past Feelings and Acts of Violence Scale
contact between police and people with serious mental • The Multidimensional Anger lnventory
disorders made up only 5% of the incidents reported to the • Buss-Durkee Test
police. Those who were involved were more likely to be • Bender Gestalt
doing something harmful to themselves than to others. No • Wechsler Memory Scale
correlation between the presence of mental illness and the • Minnesota Multiphasic Personality lnventory (MMPl-11)
·ype of crim:, committed was found. She concluded that (scored on the Overcontrol/ed Hostility e-· a/e)
psychiatric patients commit crimes at a leve! proportionate to • Legal Dangerousness Scale
their numbers in the population. Previous studies included
other variables associated with higher crime rates, such as Projective tests score responses related to violent content,
age, socioeconomic status and prior criminal record. and can make a prediction of potential violence. The two
~ L Teplin. The Criminality of the Mentally 111: A Dangerous Misconception most commonly used tests are the Rorschach (lnkblot)
American Journal of Psychiatry, Vol. 142 5, p. 593-99, 1985 Test and the Thematic Apperception Test.
242 243
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"'ENDINGs" - Su1c1DAL. & HoM1C1DAL. IDEATtON
What arr the legal requirements regarding involving civil commitment), with increased '''"'els of
supeNision and restraint (chemical and/or ~:.ysical). lt has
violent patients? still not been established how victims should be warned (e.g.
visit, phone call, letter, police). Other considerations involve
Confidentiality is one of the hallmarks of the helping the anxiety caused to the intended victim, and the possibility
professions. Mental health professionals in particular have of that person taking preemptive action. Obtain opinions from
access to the most personal information about patients. colleagues, supeNisors and legal counsel in such situations. •
Confidentiality is a professional's obligation to keep
information from third parties. Privilege is a patient's right to Individual jurisdictions have different rulings regarding the
··prevent information from being used in legal settings. ethical disclosure of medica! mformation. The other major
Medica! records can be used in court, and as such are not exceptions to breaki~g confidentiality involve:
entirely confidential. Judges have a wide degree of discretion • Emergencies - in situations that threaten life, limb or
available to them in deciding what evidence to allow. vital organ, it is usually possible to release information
Therapists and/or their records can be subpoenaed. • Civil commitment - the police or legal authorities can
be given the iriformation required to detain a patient
In 1976, a decision was made in a California court that set • lncompetence - in situations where a patient cannot
the standard far the duty to warn third parties when they are give consent for the release of information, a substitute
in danger. T_atiana Tarasoff was murdered by a man she'd decision maker can do so
spurned. The perpetrator had indicated his intention to harm • Child abuse or reportable medica! conditions -
her to his therapist. The therapist informed his supervisor notifying agencies that receive information about abused
and the police. However, because no serious action had or potentially abused children is something clinicians can
taken place at the time of the warning, no legal action was do without fear of repercussion, even if the abuse is not
taken. This decision resulted in two legal implications in actually occurring; also, certain communicable diseases
treating potentially violent patients. Known as Tarasoff 1& 11, are reportable to public health authorities
these are legal requirements that therapists have a duty to
warn and a duty to protect potential victims. Breach of Violente Tidbits
confidentiality is indicated only when there is an identified • Children who are abused have a greater likelihood of
victim, and the potential for harm to them is of a serious becoming violent as adults
nature. The American Psychiatric Association guidelines • Proper documentation which records both the
also permita breach of confidentiality where the suicide of a information supplied and the decision-making process is
patient can only be stopped by a psychiatrist's notification of essential
the police, and in cases where someone responsible for the • Use your own feelings in the assessment of potentií=11ly
safety of others (e.g. an airline pilot) is demonstrating violent patients, regardless of the presence or absence
markedly impaired judgment. of risk factors; if you feel uneasy, take precautions
• Medications used to treat "violence" are rationally
In such situations, warnings to the potential victim and the prescribed to treat the underlying conditir...-; for rapid
r :::ilice are inc..,cated. Under the duty to protect aspect, control of violent outbursts, neuroleptics dnd
patients should be managed on an inpatient basis (usually benzodiazepines (e.g. lorazepam) are often given
244 245
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HoM1c1DAL IDEATION
. .,
Summnrv Referentes
Suicide is an act of deliberate self-harm that requires INTRODUCTORY TEXTBOOK OF PsvcHIATRY, 2ND EomoN
immediate intervention. Regardless of one's cultural, N. Andreason, MD, Ph.D & D. Black, MD
rhilosophica· 1r personal views, the evidence to date shows American Psychiatric Press lnc., Washingtor 8.C. 1995
that the overwhelming majority of patients who commit
suicide suffer from a majar mental disorder at the time of THE CuNICAL INTERVIEW Us1NG DSM-IV
death. Patients need protection and treatment during these VoLLIME 1: THE FuNDAMENTALS
periods. E. Othmer, MD, Ph.D & S. Othmer, Ph.D
American Psychiatric Press lnc., Washington D.C., 1994
Numerous risk factors for suicide were outlined to give an
appreciation of which patients might be at an elevated risk PsvcH1A rn1c D1cT10NARY, 7TH EomoN
even befare suicida! ideation is asked about. R. Campbell, MD
Oxford University Press, New York, 1996
Questions do not cause patients to consider suicide. Rather,
avoiding the tapie because of uneasiness leaves suicida!
D1AGNosr1c AND STATISTICAL MANUAL OF MENTAL D1soRDERS,
patients undetected. The absence of expressed thoughts of
4TH EDITION
suicide is not evidence of their absence. Questions directly American Psychiatric Association, Washington O.C., 1994
addressing suicida! intent at the time of the interview are
essential. Any degree of positive response requires an CoMPREHENSIVE TEXTBOOK OF PsvcH1ATRY, 6TH Eo1T10N
immediate inquiry into the presence of a plan, lethality of H. Kaplan, MD & B. Sadock, MO, Editors
method, impulse control, etc. Cumulatively, almost 1% of the
Williams & Wilkins, Baltimore, 1995
population commits suicide.
TEXTBOOK OF PSYCHIATRY, 2ND EDITION
Violence towards the interviewer or others is another
R. Hales, MD, S. Yudofsky, MD & J. Talbott, MD
psychiatric emergency. At so;ne point. most clinicians are
American Psychiatric Press lnc., Washington O.C., 1994
assaulted in treatment settings or have a patient who
expresses the wish to harm someone.
PsvcHornop1c DRuGs: FAsT FAcTs, 2ND EomoN
Suicide and homicide represent a significant cause of J. Maxmen, MD & N. Ward, MD
morbidity and mortality, especially in younger age groups. W.W. Norton, New York, 1995
Various instruments have been developed to assess the AMERICAN PsvcHIATRIC Assoc1ATION ANNUAL REVIEW, VoLUME 6
potential for violence to the self or others. The predictive W. Reíd, MD & G. Balis, MD
value of such tests is hotly debated in legal settings. In Chapter 21: Evaluation of the Vio/ent Patient
clinical settings, there is no substitute for a thorough American Psychiatric Press lnc., Washington D.C., 1987
interview, mental status examination and caution when either
of these outcomes is a possibility.
246 247
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Chapter 9
Affect & Mood
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A. (7) Shows emotional coldness, detachment or flattened
A. A distinct period of abnormally and persistently elevated,
expansive, or irritable mood ... affectivity
254 255
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Appropriateness is the degree to which visible emotions Congruence between affect and other factors in the MSE
match thought content. This is also gauged by the degree to is another important consideration. The association between
which you can empathize with patients. affect and the following parameters is important to observe:
• Mood
Affect is either appropriate or inappropriate to the topic being
Affect may or may not be congruent to the mood state a
discussed. F1r example, a patient who smiles when
patient reports. For example, depressed P'- .ants may still
discussing the death of a parent may be seen as displaying
smile, joke and discuss Caribbean cruises. Lack of congruity
an inappropriate affect. lf you later learn that this parent was
may mean malingering or a factitious disorder, the presence
..abusive or estranged ( and left a large inheritance ), then this
of two separate conditions (e.g. mood and personality
person's smile is more understandable and the expressed
disorder), substance use, schizoaffective disorder ora
emotion is more appropriate to the situation.
psychotic component to a mood disorder.
lnappropriate affect occurs most frequently in schizophrenia, • Appearance
particularly the disorganized or hebephrenic subtype. Emotional disturbances are c<ten manifested in various
Schizophrenia causes patients to lose the ability to relate to aspects of appearance because patients have little time or
others, and instead display a detached, mechanical interest in attending to these finer points:
demeanor. Their emotional responses are not what would
normally be expected for the topics being discussed. Grooming & Attire - depressed patients often neglect their
Patients can demonstrate what is called a sil/y or fatuous self-care, are dishéveled, and often dress in dark colors;
affect. This occurs when patients exhibit qualities such as: manic patients dress flamboyantly (often in red) and use
giggling, laughing, grinning, rhyming, punning, mocking poor judgment in picking new looks or styles; schizophrenic
interviewers, playing with objects and other childlike actions. patients may make bizarre alterations and become unkempt.,
Facial Expression is a key component of affective response.
lnappropriate affect is also seen in: Unvarying movements are seen in depression and
• Malingering - the emotional component of a patient's schizophrenia; in manía and personality disorders,
presentation doesn't "add up" to the verbalized problems expressions can be overly dramatic and exaggerated.
• Substance use - intoxication or withdrawal can cause
patients to be inappropriately jovial or unconcerned with • Behavior
medical problems, criminal charges, etc. Posture indicates interest, self-importance, control, etc.
• Conversion Disorder - la bel/e indifférence describes a Manic, narcissistic and antisocial patients strut and sit
distinct lack of concern for reported neurologic deficits upright; depressed patients slouch and lean on things, etc.
• Depression - when patients have decided to attempt Body Movement/Gesticulation also indicates affective tone.
suicide, they can become unconcerned or untroubled by Depressed patients move infrequently and slowly; manic
their preexisting problems patients emphasize their feelings with rapid and exaggerated
~ Delirious and demented patients can seem unusually movements and have trouble restraining their activities.
concerned about trivial matters (or the converse) Hands and lower limbs may give away clues about
• Antipsychotics - affective flattening can occur through someone's feelings. Keep an eye on the entire body to
the parkinsonif}n sideeffects of these medications monitor reactions to questions (sweating, trembling, etc.).
260 261
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Speech also conveys information about aftective state. What are the various aspects ol mood?
lnflection provides modulation and emphasis, making
speech interesting to hear. This is reduced in depression,
Mood is evaluated according to the following parameters:
schizophrenia or obsessive-compulsive personalities; it is
e Type or quality
ir1creased in manía or Cluster B personalities.
• Reactivity
Prosody also conveys the emotional aspects of speech (this • lntensity
was covered in the SPEECH CHAPTER). e St~bility/duration
• Pattern
Affect Tidbits Quality of mood is the patient's reported em0tional state
e lt is relati· ;ly common for patients to either not be aware
of, or not verbalize their emotional state; in these (therefore, you must ask!). The DSM-IV incl..;Jes the
situations, use your observations to obtain more following as pathological mood types:
information. e.g. "Mr. Janes, you looked upset when you o Depressed
described your struggle to keep ahead of the neighbors." • Euphoric
e lt is also important to inquire about incongruence • Angry/lrritable
between thought content and affect, e.g. "Mr. Smith, you • Anxious
mentioned that you were going into debt trying to keep
up with Mr. Jones, but you smiled when you said this ... " Depressed mood occurs when patients feel less energetic,
hopeful or capable than what is usual for them. This mood
• Psychotic patients who display silly or inappropriate
state can be described by any of a number of qualifying
affect may be responding to interna! stimuli, such as
hallucinations (e.g. voices telling them jokes or ridiculing terms, such as:
the interview) or delusions (e.g. ali psychiatrists are sad, blue, worthless, guilty, flat, hol/ow, miserable, gloomy,
cross-dressers) glum, forlorn, morase, troubled, exhausted, somber,
brooding, unhappy, subdued, withdrawn, etc.
• Affect originates in the limbic system (hippocampus,
amygdala, cingulate gyrus, anterior thalamus, mamillary
bodies ); disease processes that occur in these areas can There are a large number of 'd' words that are used to
cause affective changes (e.g. strokes, tumors, multiple describe these mood disturbances (amaze your friends!):
sclerosis, meningitis); the hippocampal-amygdala down, dejected, despondent, demoralized, dysphoric,
complex is reduced in size in schizophrenia; neurologic despairing, dour, dispirited, drained, doleful, downcast,
disorders affecting the limbic system and basal ganglia down in the dumps, desperate, defeated, dreary,
commonly present with depression disappointed, disillusioned, diminished, dissatisfied,
disaffected, dysfunctional, disconso/ate & downhearted
• ÜTHMER propases that affect has 3 functions:
• se/f-perception: providing an emotional value judgment
• communication: expression of feelings is made known Because depression is used to refer to mood disorders,
to others these mood states are frequently referred to as dysphoric,
• motivation: affect is one of the key elements leading to which means a state of unhappiness or feeling ill at ease.
the initiation of action
262 263
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BRAIN CALIPERS
AFFECT & Mooo
Depressed mood is a diagnostic criterion for the following Euphoric mood occurs when patients feel energized,
disorders: elated or ecstatic. This is of a greater degree than what is
s Depressive Disorders experienced when patients are "up" ar in a "good mood."
a Depressed Phase of Bipolar Mood Disorders Sorne of the terms used to describe euphoric mood are:
a Cyclothymia up, flying, grand, uninhibited, omnipotent, buoyant, jovial,
e Dysthymia racing, driven, on top of the world, indestructible, etc.
• Adjustrnent Disorder with Depressed Mood
Similar to the 'd' words of depression. there are severa! 'e'
_Transient depressions in mood also occur as a variant of words for euphoria:
normal even when there is no obvious precipitant ("cosmic" energized, elevated, elated, entertaining, exalted, extreme,
depression). The diagnosis of a mood disorder rests on the expansive, extraordinary, ecstatic, effervescent & ebu/lient
presence of associated features, severity (degree of social
and occupational impairment) and duration. Majar Euphoric mood is seen in:
depressive episodes can be a complication of any other • Manic or hypomanic phases of bipolar mood disorders
psychiatric condition. The term double depression refers to • Schizophrenia (most often the disorganized type)
an episode of depression complicating a dysthymic disorder. • Substance abuse (particularly with stimulants)
• Dementia and delirium
The DSM-IV also contains research criteria for the following
proposed conditions (in Appendix 8): postpsychotic There has been less empirical support for such conditions
depressive disorder of schizophrenia, minar depressive as: brief hypomanic disorder, minar manic episode, or
disorder, recurrent brief depressive disorder, and an hypomanic personality. When patients are e·xperiencing a
alternate set of criteria (Criteria B) for dysthymia. dysphoric mood, they frequently seek help for the way they
feel. When patients are euphoric, they rarely present for
Depressed mood can be such a long-standing experience for assistance and generally have to be brought to attention
patients that it becomes a character trait. The DSM-IV also because of the impact their rnood state has had on other
lists research criteria for a depressive personality disorder. In people or on social/occupational functioning. Many bipolar
the past (DSM-11), Asthenic Personality Disorder was used to patients are "attached" to their highs and value the increased
refer to patients who exhibited: lassitude, abulia, anhedonia productivity and sense of well-being that accompany them.
and an inability to withstand expectable stresses.
Euphoric mood often occurs with changes in:
Depressed mood is often accompanied by changes in: • Appearance (unusual or bizarre changes)
• Appearance (decline in self-care) • Behavior (rapid, continua! movements)
e Behavior (few spontaneous movements) • Speech (speak loudly, have a great deal to say, etc.)
• Speech (speak softly, have little to say, etc.) • Affect (expanded range, labile, intense)
• Affect (restricted range, variable intensity) • Thought content (grandiose themes)
• Thought content (morbid themes) • Thought form (flight of ideas, pressure of speech)
• Thought form (increased latency of responses) • Cognitive functions may be enhanced (creativity or word
• Diminished cognitive functioning association) or diminished because of distractibility
264 265
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Angry/lrritable moods do not constitute discrete · Anxious mood can occur normally, especially if patients
disorders, but are frequent complications of other conditions. are unfamiliar with or intimated by the interview process. lt is
Sorne of the following terms are used to describe these to be expected that patients will be anxious about such areas
mood states: as diagnosis. prognosis and treatment implications. Anxiety
annoyed, miffed, pissed off, seething, sharp, disgruntled, is pathological when it is pervasive or present to a degree
cranky, indignant, incensed, be/licose, smo/dering, that interferes with social or occupational functioning.
exasperated, furious, ill-tempered, easily provoked, etc.
Terms used to describe an anxious mood are:
These mood states frequently accompany the following fearful, tense, on edge, worried, nervous, uptight, frazzled,
conditions: petrified, uneasy, rattled, terrified, para/yzed, panicky, etc.
• Mania or hypomania
• Cluster B personality disorders Beca use the term "anxiety" is also used to refer to anxiety
• lntermittent Explosive Disorder disorders, these mood states are frequently referred to as
• Disorders where paranoia is prominent apprehensive.
• Substance use, particularly withdrawal syndromes
• Delirium & dementia Anxiety is prominently seen in:
• Head trauma • Generalized anxiety disorder
• Various neurologic conditions • Phobic Disorders
• Temporal lobe (partial-complex) epilepsy, particularly in • Obsessive-compulsive disorder
the interictal or postictal periods • Posttraumatic stress disorder
• Panic disorder
''ritability is ciefined as being easily provoked to anger. The • Adjustment disorder with anxiety
DSM-IV lists irritability as a one of the three mood states in
mania or hypomania. lrritability is usually seen as the mood As with other dysphoric mood states, anxiety can complicate
disorder increases in severity. As with depression, anger or any other psychiatric condition and is prominent in a number
irritability can accompany any psychiatric condition, and are of general medica! conditions (hyperthyroidism, cardiac
not of diagnostic significance in themselves. arrythmias, pheochromocytoma, etc.).
Angry/irritable mood is often accompanied by changes in: Apprehensive mood is often accompanied by changes in:
o Appearance (glaring, menacing facial expressions) • Appearance (widened star3, tense facial expressions)
e Behavior (muscle tension, threatening movements, • Behavior (tremer, quick or jerky movements)
posturing) • Speech (tremulous, rapid)
e Speech (harsh tone of voice) • Affect (intense, restricted; may settle with time)
• Affect (intense, restricted, may be labile) • Thought content (threatened, impending doom,
o Thought content (openly challenging, hostile, sarcastic, exaggeration of potential dangers, ruminative, etc.)
difficulty with authority, uncooperative) • Thought form (decreased latency of response, jumbled,
• Thought form (terse, decreased latency of response) tangential or circumstantial thoughts)
• Cognitive or perceptual aberrations • Cognitive performance (often diminished by anxiety)
266 267
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Reactivity is the cegree to which mood is altered by lntensity refers to the degree to which the mood is
externa! factors. Mood can be shifted by events, the expressed. Like affect, mood has depth, amount and
environment or interactions with others. Manic patients often amplitude. Two patients can experience depressed mood
escalate in mood with stimulation. Depressed patients may with a similarly flat affect and restricted range of emotional
feel worse in the morning and have their spirits lift as the day expression. One patient may appear lethargic, withdrawn
progresses. Similarly, anxious or angry patients have a and show little interest in the interview. The other patient
waxing and waning of their mood under certain conditions. may have problerns with concentration, lowered self-esteem
and be able to convey the degree to which this episode has
In the past, depression was divided into endogenous and interfered with his or her life. The difference between these
--reactive types based on the presence of a (presumed) patients is the depth or intensity of their mood state.
precipitant. Reference to this distinction is still made in texts
and by more "experienced" clinicians. A careful history will Stability or duration describes the length of time the mood
almost always revea! a prec!pitant to a depressive episode. disturbance exists without significant variation. Mood
Frequently it is an event of outwardly minar (but symbolically disorders are required to have a specific time course:
majar) si~nificance. For example, hearing a song on the
radio or watching the Lawrence Welk Show rnay bring back • Major Depressive Episode 2 weeks
memories that serve as a reminder of a lost loved one. • Manic Episode 1 week
• Dysthymic Disorder 2 years
• Cyclothymia 2 years
The endogenous aspect has been carried forward into a
subtype of depression called the melancholic features The rapid cycling subtype of bipolar disorders involves four
specifier. In this type of depression, there is a lack of mood or more cycles of mania/hypomania and depression in the
reactivity to usually pleasurable stimuli. last year. A cycle is the recovery (full or partial) from the
most current rnood disturbance (for at least two rnonths ), or
Another subtype of depression called the atypical features
a switch to the opposite mood polarity.
specifier, contains two criteria related to mood reactivity:
• Mood reactivity, where rnood brightens in response to There is no clear means of distinguishing a sustained affect
actual or 11oténtially positive events from a reactive rnood. Certain conditions (€ ;. personality
A long-standing pattern of interpersonal rejection disorders, substance abuse) where there is a good deal of
sensitivity (not limited to episodes of mood disturbance) variation in the moment-to-moment expression of emotion
resulting in significant social or occupational impairment can occur comorbidly with mood disorders. To complicate
matters, there is a type of bipolar mood disorder called a
Depressed patients with melancholic features have a greater mixed state where the criteria for mania and depression are
likelihood of response to medication or ECT than patients met simultaneously. As a general guide, emotional changes
without these features. Atypical features occur more occurring over:
frequently in women and younger patients. Frequently, only
seconds minutes hours days weeks months
a partial recovery froin these episodes is reported. Atypical
features may indicate a bipolar depression or a seasonal
indicate disorders of affect indicate disorders of mood
pattern (either in the present or future episodes ).
268 269
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Manic Major Depressive Episode Another area fraught with difficulty is distinguishing mania/
hypomania from the elevated mood states that most people
Hypomanic
E"'"'m'o
De pressive Sx.
VV
.lajor Depressio ..
• Depressive syrnptoms are of
significan! duration & severity; usual
course is a full recovery, but rnay
have future episodes, (exarnple
here shows recurrent episodes)
report from time to time. The following questions may help
make this distinction:
• Was your mood ever so high that friends or family
members thought you needed to get h'>;J?
• Did you get yourself into serious financia!, legal or
Manic Dysthymic Disorder
relationship trouble when your mood was high?
Hypomanic • Depressive syrnptoms are not
• Did your mood ever become so elevated that you
Euthymic severe enough for an MDE
thought you had sorne supernatural powers, special
---
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Proposed DSM-V Geriatric Organicity
Mental Evaluation Reporl
®®®
Mr. Happy Mr. Sad Mr. Hyper
~
Mr. Worry Wart
The following questionnaire was developed using
variables that have demonstrated a high empirical
correlation with early cerebral organic changes.
Leisure Activities
O Spying on the neighbors
® @ ® @
O Comparing talk shows
O Watching the flashing "12:00" on the VCR
~
-- O Bingo
Ms. Miserable Ms. Ooubtful Mr. Vigilan! Ms. Grumpy Favorite Beverage
O Sundowner(Tequila, Grenadine, Milk of Magnesia, Tums)
O Phi/'s Screwdriver (Vodka, Extra-Pulp Orange Juice, Geritol}
O Holy Wallbanger (Galliano, Cod Liver Oil, Nytol, Rolaids)
G) @
Mr. Complainer Mr. Angry
®
Mr. Know-lt-All Mr. Shy
O /.C.B.M. (lpecac, Cascara, Bran, Metamucil}
Judgment
This sign means:
El
O This should be the gross tonnage of your vehicle
O The speed limit is the square root of this number
O Anyone this age or older owns the road
@ @ ó
fJ @ Reading Material
O Cereal packages
Mr. Libido
O Crime page of local newspaper
Ms. Flirt Ms. Needy Ms. Bizarre
O National Enquirer
O Reader's Digest Large Type Books (the biglittle picture)
®® ~ @
Pharmatologit Fitness
O Shares heartworm table! with dog
~ O Sprays roaches with ántiperspirant
O Has five year supply of vitamins A to Z
Mr. Faker Ms. lnnocent Mr. Scrambled Mr. Bad O Medicine cupboard contains Absorbine Sr.
276 277
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BRAIN CALIPERS PERCEPTION
Chapter 10
Perception
What factors are involved in perception?
Perception is the process of experiencing the environment,
and recognizing or making sense of the stimuli received via
sensory input, which follows this pathway:
sense organs
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Wbat are tbe various aspects al Hallucinations are given the following terms according to the
perception? sensory modalities in which they occur:
282
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PERCEPTION
Auditory hallucinations are the most common type in The DSM-IV includes these first-rank symptoms as being
psychiatric conditions. In general, they occur as distinctly highly characteristic of schizophrenia. In general, two of the
hefüd voices that speak clearly formed words, sentences or following symptoms are required to make the diagnosis:
even conversations. In organic conditions, they are more like • Delusions
elementa01 hallucinations, involving sounds such as ringing, e Hallucinations
grating or humming, and are often indistinct. • Disorganized speech
• Grossly disorganized or catatonic behavior
Auditory hallucinations are most commonly reported in • Negative symptoms
psychotic illnesses and are one of the cardinal symptoms of
scliizophrenia. They are also among the criteria for However, only one of these criteria is needed if:
schizophreniform disorder, schizoaffective disorder, brief • The delusions are of a bizarre nature
psychotic disorder, and psychotic disorders dueto general • Hallucinations consist of a voice keeping upa running
medica! conditions. commentary on the person's behavior or thoughts, or two
or more voices conversing with each other
Schneiders's first-rank symptoms were covered initially in Diagnostic Criteria are from the DSM-IV.
the chapter on THOUGHT CoNTENT. Seven of the eleven were ©American Psychiatric Association, Washington, D.C. 1994
delusions, and one was delusional perception (the Reprinted with permission.
attribution of a false or delusional meaning to an ordinary
event). This is as far as the DSM-IV goes in making any symptom
pathognomonic far this illness. There are still time factors,
The remaining three are auditory hallucinations: associated functional impairments and important exclusion
• Audible thoughts, where patients hear their thoughts factors involved in diagnosing schizophrenia.
said out loud, as if they were echoes. In sorne situations,
patients will continue speaking to those around them Patients are usually able to describe their "voices" in sorne
expecting that they have shared the experience of these detail. They are aware of the gender of the hallucinatory
audible thoughts. In other instances, patients will hear speaker and whether or not they recognize the voice. Often it
voices commenting on what they have just thought ar are is someone they know or someone that has passed away. In
about to think. sorne instances, patients are instructed by a voice to perform
.. Voices arguing or discussing (or both). Here, two or an act; this experience is called a command hallucination.
more hallucinatory voices speak about the patient in the The repetitive nature of these commands can be too much to
third person. These discussions or arguments pertain to bear and patients may eventually follow them.
the patient (i.e. they are not hallucinatory weather
forecasts ). and are often critica! or derogatory. The classical description of auditory hallucinations is that
• Voices giving a running commentary. This is similar they are experienced as originating "outside" the person's
to the ab ..:. o1e experience. Again, these comments center head, as if from a completely separate entit• fhis is in
on the patient and are usually focused on an activity. Fer contrast to obsessions, which are recognized as coming
example, aµditory hallucinations of this nature often from the patient's mind. Sorne patients are more insightful,
comment on actions just before/after or during the event. and are aware that the voices come from within.
284 285
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Auditory hallucinations are usually derogatory and critica! Visual Hallucinations are the next most prevalent type
twoards patients. Carrying around this cacophony of encountered in psychiatric illnesses. lt is more common to
insulting, belittling comments is one of the tortures of mental have visual and auditory hallucinations occurring together
illness. Fortunately, hallucinations are one of the positive than it is to have visual hallucinations alone. f\ne such
.>ymptoms 1.. e. they are added to the clinical picture), and combination involves auditory hallucinationL. with partial or
are among the most responsive to antipsychotic medication. inferred visual hallucinations. For example, a patient who
hears a voice coming from the coat rack may also see or
Auditory hallucinations can be of sounds other than voices. "might have" seen arms gesturing as "it" was speaking.
Commonly, these include: machine-like sounds, music, lsolated visual hallucinations should prompt a thorough
animal vocalizations or other sounds of nature. investigation for an organic cause (either a general medica!
condition or the effects of a substance ).
Mood disorders can also be complicated by delusions and
hallucinations. In ps/chotic depression or mania, the mood When visual hallucinations occur exclusively in psychiatric
disturbance is present initially, and the psychotic features conditions, they are almost always due to psychotic
begin as the condition worsens. disorders.
lnterestingly, patients who are congenitally deaf and later Visual hallucinations can be simple or complex. They can be
develop schizophrenia report the same type of auditory as brief as a "vision" or as involved as having a visit from
hallucinations as those with normal hearing. Abe Lincoln. With an occipital lobe infarction, psychedelic
and geometric shapes are formed. In peduncular
Auditory hallucinations in organic conditions tend not to be hallucinosis, complex shapes are formed and tend to occur
as distinct or have the same duration as those in psychiatric in the evening. Frequently, patients have concomitant
illnesses. lmportant medica! conditions to corisider are: disturbances in their sleep-wake cycle and are not always
• Delirium adverse to the interesting variety of images. Extracampine
• Dementia hallucinations involve experiences (seeing, hearing, etc.)
• Temporal lobe epilepsy beyond the normal sensory range (e.g., being able to look
• Migraine Headaches (especially of the basilar artery) out the window and see someone in another state).
• Salicylate (aspirin) toxicity
• Méniére's Disease Visual hallucinations can also form, orbe part of, delusional
• Antibiotic administration (e.g. streptomycin) thinking. A patient who experiences a raging Viking leaping
• Sensory deprivation (e.g. hearing loss, cataracts) out of her hospital closet may develop delusions of
• Poorly adjusted hearing aids (may pick up voices from persecution. Paranoid patients commonly "see" their
others beyond the normal range of hearing) persecutors in various public places or just outside their
• Lesions of the tempero-parietal region (e.g. strokes, homes. In the delusion of an imaginary companion, or a
tumors, herpes encephalitis) double (doppelganger) ora phantom boarder, patients
• Vascular lesions of the pons may actually claim to have seen such an entity. In
• Cerebellopontine angle tumors reduplicative paramnesia, patients may not only believe,
• Acoustic neuromas ( occur in neurofibromatosis) but actually claim to see duplicated body parts.
286 287
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The medica! differential diagnosis for visual hallucinations is Olfactory hallucinations are far less common than the
as follows: auditory or visual types. and their presence (along with
• Release hallucinations occur after damage along the gustatory and tactile hallucinations) warrants a medica!
hemispheric part of the visual pathways, involving the investigation. These hallucinations can occur in:
temporal, parietal or occipital lobes; they often occur with • Patients with psychotic disorders
visual field defects • Patients with coexisting psychiatric disorders and
• Palinopsia is the persistence of a visual image after it is temporal lobe epilepsy
removed; this occurs with occipital lobe lesions • Patients with comorbid psychiatric and other general
l letal ha'"Jcinos;s can occur during seizures, and may medica! problems
contain images of past events _
• Anton's Syndrome (cortical blindness) occurs with Unfortunately, olfactory hallucinations rarely involve
lesions of the cortical visual center; patients deny their fragrances like rose petals. The most common smells are
blindness and confabulate visual images, often described as burning rubber, rotting garbage or very strong
displayi;ig a strong affective componen! body odors. These smells often are of personal relevance to
• Migraine headaches occur with scotomas consisting of patients, and they can describe associations to the odor.
graying of the visual field, blurring of the center of vision,
flashing zigzag lines, crescents of brilliant colors, or Smell is the sense most close1y linked to memory, and these
distortion of objects; these last up to twenty minutes hallucinations are often accompanied by strong affects. The
• The aura of a classic migraine can cause visual olfactory association areas are in the frontal lobes and limbic
hallucinations without going on to cause a headache system (hypothalamus and amygdala).
o Various dementias, Pick's disease, etc.
• Huntington's disease Olfactory hallucinations accompany hallucinations in other
• Eye problems - injury, retina! detachment, surgery modalities, as well as delusions. For example, the raging
• Narcolepsy Viking who carne out of the closet may have had a certain
• Substance intoxication or withdrawal scent about him in addition to sounds, etc. Patients with
somatic delusions ("l'm rotting inside") may have
Visual Hallucination Tidbits accompanying olfactory hallucinations. Paranoid patients
• Oneiroid states (from Greek, meaning dream) occur in who believe they are being subjected to poisonous gases
schizophrenia and delirium. The patient experiences can hallucinate the smell of a noxious substance being piped
vivid hallucinations which can range from terrifying to in through their heating or air-conditioning.
engrossing. Oneiroid states can become an "alternate" or
dream world where patients keep track of this state and Olfactory hallucinations occur in the following· conditions:
reality at the same time • Temporal Lobe Epilepsy- often form the aura of a
• The Charles Bonnet Syndrome is a rare condition seizure, particularly if the focus is in the uncus (uncinate
consisting of formed, complex, repetitive visual seizures)
hallucinations (that are recognized as such); there are no • Migr~ine Headaches. as part of aura (but overall, they
symptoms of other psychiatric conditions, no clouding of are more common in temporal lobe epilepsy)
consciousness and no hallucinations in other modalities • Diseases involving the frontal lobes or limbic system
288 289
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BRAIN CALIPERS
PERCEPTION
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Pseudohallucinatians & degree ol insight
into perceptua/ disortlers How do I aslc about perceptual disorders?
296
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(!)
Have you ever heard something and not been sure
where :. was corning from? Perceptual Disorders in Substanr~ Use
8
Did you ever hear something that sounded like a voice
and not know who was talking? Perceptual disorders occur frequently during both the
intoxication and withdrawal states of substance use
lf the presence of any perceptual abnormality can be syndromes. A summary is as follows:
establishe::J, treat this as you would any other symptom and
get as much detail as possible. The questions in this section lngestionllntoxication
are geared at exploring auditory hallucinations because they • Hallucinogens consist of LSD, mescaline (peyote) and
are the most comrnon type encountered in psychiatric psilocybin (mushrooms). These substances act on
disorders. In general, questions should assess duration, serotonergic neurons to produce any and all of the
quality, intensity, variation, associated events, etc. possible disturbances in perception. Of note are the
• Did you recognize whose voice it was? blending of senses (called synesthesias) where, for
• Did the voice/voices tell you to do something? example, a color has an associated taste and smell. The
• Did you comply? Why or why not? Hallucinogen Persisting Perception Disorder (flashbacks)
involves spontaneous, transient experiences of
The question, "Did the voice seem to come from inside or geometric shapes, micropsia, macropsia, spoken words
outside your head?" is often asked. The significance of this and false perceptions of movement. Hallucinogens can
is that true auditory hallucinations are considered to originate also cause a trailing phenomenon, where moving
outside the self, e.g. from radio towers or microwave ovens. "objects are seen as a series of disconnected images (as
However, true hallucinations can also be perceived as if lit by a strobe light).
coming from within. Another way of asking this question is to • Cannabis use is frequently accompanied by a
inquire whether the experience felt like a product of the heightened awareness of externa! stimuli. Experiences
person's mind (i.e. obsessions or images) or whether it was are more vivid and new details may appear to the user.
a completely foreign or externa! experience. Derealization and depersonalization can also occur, and
time often appears to slow down.
Questions about other hallucinations can be posed as • Phencyclidine (PCP) is chemically distinct from LSD
follows: and considered individually in the literature on substance
• Have you ever experienced a taste that wasn't due to disorders. This drug can cause very marked behavior
something you were eating? disturbances due (in part) to perceptual aberrations.
• Have you smelled something that didn't fit with the Depersonalization, auditory and visual hallucinations,
situation you were in at the time? tactile hallucinations of tingling and warmth, and
• Have you ever experienced a strong/bad taste or smell distortions of time and space are common.
that you couldn't account for? • Amphetamines, MOMA and cocaine can cause
• Have you had sensations in your body that felt like they psychotic episodes, with visual hallucinations.being the
were dueto unseen forces? (e.g. being touched or predominant disturbance of perception. Because other
moved b:; something, ants crawling on your skin, interna! positive symptoms also occur, this psychc-•;c state can
organs being shifted, etc.) be indistinguishable from paranoid schizophrenia.
298 299
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FUNNYSTUFF
1had been seeing a therapist for three years ... Modecate Modulate catatonia easily.
lmap lnjectable management program
Orap Oral pacifier
Prozac Prometes zest and activity
Mellaril Mellowed out and resting at last
Serentil Serene until dawn
Ativan Anticipation vanquishes me
Halcion Halcyon "daze" isn't only nostalgia
Anafranil Am not afraid of new pills
306
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ftJ
Chapter 11
lnsight & Judgment
What lactors deteTmine insight and
judgment?
lnsight refers to the knowledge and awareness of the
parameters involved in an event, process ar decision. In
mental health, this term is used to describe:
• The awareness of having an illness
• An understanding of the factors contributing to the illness
• An appreciation that various signs and symptoms are
part of a disease process
308
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What is the diagnostic signilicance ol What are the components ·ol insight?
delicient insight or judgment?
lnsight is a complex function requiring the integration of
lnsight and judgment can be impaired in any psychiatric higher mental functions. The following components can be
disorder. Deficient awareness and poor decision making used to help determine the level of insight:
regarding illnesses are common findings in ali types of • Acknowledgment of the illness (diagnosis, subtype,
clinical conditions, but are perhaps found more frequently in course features, etc.)•
.Psychiatric than in medica! illnesses. • Consequences and repercussions of being ill
• Awareness of own thoughts, feelings, motivations, etc.
The DSM-IV contains severity and course specifiers far ali • Attention to subtleties and the symbolic aspects of
psychiatric disorders. These specifiers are listed after the behavior
diagnosis and are based on: • The ability to see the effects of one's actions on others
• The current illness only • Comprehension that treatment may be able to reduce,
• The number and intensity of signs and symptoms control or alleviate symptoms
• The degree of social and occupational impairment
lnsight is an important aspect of determining a patient's
The specifiers are: capacity for giving informed consent. An assessment of
• Mild - few, if any symptoms in excess of those required medica! competence focuses on many of the above issues,
to make the diagnosis, and result in no more than minar and the following considerations are very helpful in
impairment in social or occupational functioning determining the degree of insight:
• Moderate - between mild and severe • Choices are based on rational reasons
• Severe - man y symptoms in excess of those required • Understanding the rationale for proposed treatment
to make the diagnosis, or severa! symptoms that are • Ability to identify, recognize and survey alternatives
particularly severe or result in marked impairment in • Ability to commit to a choice
social or occupational functioning
Adequate insight is vital for compliance with a treatment
Disorders including a "with poor insight" specifier are: regime. Compliance is much more likely when patients can
• Obsessive-Compulsive Disorder - if for most of the time appreciate the benefits of continuing with various forms of
during the current episode, the obsessions and treatment. This also emphasizes the importance of
compulsions are not seen as excessive or unreasonable educating patients and families about psychiatric disorders.
• Hypochori:Jriasis - if for most of the time during the
current ep1sode, the individual does not recognize that lnsight is variable, and changes with mood ~.ate, degree of
the concern about having a serious illness is excessive thought disorder, drug intoxication, degree of time since
or unreasonable medication was taken, etc. Although an interview assesses
the awareness of an illness, patients can have varying
Diagnostic Criteria are from the DSM-IV.
insight into different aspects of their lives. Deficient insight in
©American Psychiatric Association, Washington, D.C. 1994
Reprinted with permission. certain areas is referred to as a blind spot.
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INstGHT & JuoGMENT
The ego is the mediator between i) the id and superego, and An ego defense can be considered a compromise which
ii) the person and reality. The ego has both conscious and allows expression of the impulse in a disguised form. All
unconscious elements. The following are considered to be defenses protect the ego from the instinctual drives of the id
the conscious roles of the ego: and are unconscious processes.
• Perception (sense of reality) Freud directed most of his attention to repression, which he
• Reality testing (adaptation to reality) considered the primary ego defense. Repression is defined
• Motor control as expelling and withholding an idea or feelirr: from
• lntuition conscious awareness. He thought other deft;,1ses were used
··• M~mory only when repression failed to dirninish the anxiety. Anna
• Affect Freud expanded the total number of defenses to nine in her
• Thinking and learning 1936 book, The Ego and the Mechanisms of Defense. Since
•Control of instinctual drives (delay of immediate then, many more defense mechanisms have been identified.
gratification) Akin to the theories of Life Cycle Development, there is a
• Synthetic functions (assimilation, creation, coordination) progression in the use of ego defenses with maturity.
• Language and comprehension
George Vaillant catalogued de-1enses into tour categories:
Narcissistic, lmmature, Neurotic and Mature. These
The fundamental concept in Ego Psychology is that of defenses are explained in standard reference texts.
conflict among these three agencies. The id, ego and
superego battle for expression and discharge of sexual and Narcissistic Defenses Mature Defenses
aggressive drives. This conflict produces anxiety, specifically Denial Altruism
called signal anxiety. This anxiety alerts the ego that a Distortion Anticipation
defense mechanisrn is required, which is the unconscious Primitive ldealization Asceticism
Projection Humor
role of the ego. The events can be conceptualized as
Projective ldentification Sublirnation
follows: Splitting Suppression
+ Reaction Formation
Repression
Schizoid Fantasy
Sornatization
A character trait or psychiatric symptom is formed
Sexualization
Undoing
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References
Valiant, Prince George The Hierarchical Structure of Ego Defenses A flagrant hypochondriac, Kranklin pioneered the field of
Medieval Psychology; Round Table Press, Serf City, New England Psychosomatic Medicine in order to give legitimacy to his
wildly varied complaints. He changed the face of Psychiatry
From Lilliputian 10 Kohutian: The Advancement of Self Through
(and his own too) when he unwittingly self-administered ECT
Selfish Psychology
Chapter 1: Heinz 57 Manual of Therapeutic lnterventions during a particularly intense fit of compulsive indignation.
Mirror, Mirror on the Wall Press; New York
322 323
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CoGNITIVE FuNcr10N1NG & SENSORIUM
ChapteT 12
Cognitive Functioning & Sensorium
Whith aspects ol cognitive lunctioning and
sensorium are tested?
The areas usuafly tested in an MSE conducted in a standard
interview are:
• Level of Consciousness/Alertness
• Orientation
• Attention & Concentration
• Memory - Registration
lmmediate
Recent
Remote
• lntelligence Estimation
• Knowledge Base/Fund of lnformation
• Capacity to Read and Write
• Abstraction/Concrete Thinking
• Visuospatial Ability
324 325
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Disorientation to Place
Ouestions about orientation to place can be asked in an Attention & Concentration
indirect manner, such as:
• Did you have any trouble finding the clinic today? Attention is the ability to direct mental energy when fully
• Where did you ... (park your car, get off the bus, etc.)? alert. lt is a conscious, willful focusing of cognitive processes
• l've never heard of ... (oatient's address), how would 1 while excluding competing stimuli (such as mood state,
get there from the hospital? thoughts, perceptions, ecc.). Concentration is the sustained
• Mr. B.O., if you were at the intersection of Cedar and focus of attention for a period of time. While these terms are
Elm, how would (or wood) you get to Oak Street? interrelated, they are still evaluated separately. For example,
·· ·• .What is the nearest main intersection to the hospital? patients with mild to moderate dementia can attend to tasks
but have deficits in their ability to concentrate. ·
Delirium is the most common reason for patients to lose
track of where they are and why they are in hospital. Ouestions about attention and concentration are fairly easy
Frequent misinterpretations of location are that they are in a to introduce into the MSE as patients frequently complain of
hotel, jail, laboratory or army barracks (which, at times, difficulties in these areas. When this arises, you have the
seems to be the majar extended functions of hospitals). option of either performing tests of concentration at that time,
or using the patient's complaints as a segue later in the
lf patients are unable to give adequate answers to questions interview. For patients who don't specifically complain about
like those above, ascertain where they think they are and diminished concentration, the topic can be introduced as:
what happens in the building: • Ms. Nebular, it is common for people who have the kinds
.. What tyr. J of building are you in now? of problems with ... (repeat presenting d;"~culties) to
have difficulties with their concentration.
lf they know it is a hospital/clinic/office, ask if they know the
name. lf they don't know this, try asking about: lf the patient agrees that she's had trouble, say that you
• What goes on in this building? would like to test this more formally. For patients who do not
• Do you think this is a school, library, bank ... ? endorse such difficulties, you can say something like:
• Ms. Nebular, 1would like to do as thorough an
Disorientation to Person assessment as possible, and this involves sorne
Disoriented patients are rarely so impaired that they lose screening tests to check yo 1 ir level of concentration.
track of their own identity. This occurs in severe delirium, Would you be agreeable to proceeding with this?
head injuries (especially involving the frontal lobes ),
profound dementia and dissociative disorders. Orientation to Attention is assessed by checking the person's digit span.
person can be tested at the beginning of the interview by This isn't the size of their hands, but the number of numbers
asking patients to state their full name (as if you needed to they can recall both forwards and backwards. Introduce this
check that yoú were speaking to the right person or had a by saying that you want them to repeat a list of numbers.
profound interest in the person's middle na me). Another Once you've read the list, you can signal this by lowering the
approach is to have patients write their name and the date at tone of your voice with the last digit. Another method is to
the top of a piece of paper at the start of the interview. keep your head down and only make contact with the patient
332
333
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tiRAIN CALIPERS 'CoGNITIVE FuNCTIONtNG & SENSORIUM
at the end of the sequence. This gives you the advantage of Alternative numerical tests are:
being able to write the numbers down as you recite them • Subtracting serial 3's starting at 20
(the patient is NOT allowed to write the numbers down). • Serial additions
• Starting at another number using a different inteNal of
Read off the numbers so that there are pauses of about one subtraction (e.g. 103 - 8)
second between them. Avoid adding emphasis (prosody) to
the numbers as you read them. Numbers that are grouped lt is both a strength and weakness of the serial sevens test
too closely or with sorne rhythm can give a spuriously good that both concentration and arithmetic ability are tested. For
result. For example, many companies have developed a this reason, other tasks involving concentration over 30 to 60
jingle so that their phone numbers are more memorable. seconds are sometimes used. For patients who have had
Another consideration is to avoid using numbers in a repeated admis.sions to.hospital, the serial sevens test
sequence (5-6-7-8) or exclusively odd or even numbers. becomes too familiar to be valid (sorne patients will even ask
when you want them to do this test if it isn't requested). For
This test is given for numbers both in a forward and such patients, a different interval of subtraction is warranted.
backward direction. lt may help to start with an example to A more advanceo testinvolves alternating between serial
illustrate what you're expecting. You can usually start by seven subtractions and reciting the months backwards.
testing 4 numbers recited in a forward fashion. Most adults
have digit recall spans of between 5 to 7 numbers forward While the serial sevens test is commonly employed, it
and 4 to 6 numbers backward, without errors, and completed suffers from a lack of standardization. There are no uniform
within 30 seconds. guidelines regarding:
• Time between individual subtractions
Digit span is impaired in patients with: dementia, delirium, • Time for the total test
frontal lobe lesions, head injuries, marked medication side- • How many subtractions should be recorded
effects, anxiety disorders and mania/hypomania. lt is also • The number of errors allowed
unusual to r-we a greater span backwards than forwards,
and this should prompt an investigation for an organic cause. The CoMPREHENs1ve TexrsooK oF PsvcHIATRY, $ecoNo EomoN
(1975) suggests that 30 seconds be allowed between
Concentration is most frequently tested with serial seven successive subtractions. A study* done using'subjects with
subtractions. Again, patients are not allowed to use any aid above-average levels of education had the following findings:
in this test, including counting with their fingers. You can • Only 42% made errorless subtractions
introduce this as follows: • 19% made one error, 14% made two errors
• l'd like you to start with the number 100 and subtract 7;
then, from this number, subtract 7 and keep going as far This test is frequently abandonad by patients lacking at least
as you can. high school education and by those with "math phobia" (or, in
the DSM-IV, Mathematics Disorder 315.1.)
lt may be necessary to give the patient an example of what
* The Serial Sevens Subtraction Test
you want by doing the first subtraction, so that the first effort A Smith, Ph.D.
he or she makes is attempting 93 - 7. ArchivesofNeurology, Vol. 17., p. 78, July 1967
334 335
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Other tests that can be used in interviews involve: Memory- General Principies
• Reciting the moriths of the year backwards
• Naming the Seven Dwarfs Memory is one of the key elements that define a person as
• Spelling words composed of five or six letters backwards an individual. Our memories are a library of knowledge and
experience that influence the interpretation of the present.
Brain areas involved: attention and concentration are also Memory is essential far a vast array of functions ranging
"global" brain functions and involve many of the same from basic motor skills to complex intellectual tasks. lt has
structures required to maintain alertness; the frontal lobes an integral function in perception, thought, feeling and
··(left,. right and bilateral) are of particular importance in
behavior.
concentration.
The study of memory encompasses an extensive and
Standardized Tests: include visual, verbal and auditory detailed body of literature. A brief review is provided here to
tests of concentration. Sorne examples follow: aid in the accurate specification of memory problems
• Trailmaking Test Part A (Trails A) involves connecting discovered on the MSE. Memory is at the center of higher
25 circled, randomly spread numbers in ascending arder; cognitive functions:
Trailmaking Test Part B (Trails B) is more complicated,
and involves alternating between numbers and letters
(e.g. 1 - A - 2 - B - 3 - C). Because of the "shifting
cognitive sets" between letters and numbers, this is a
more sensitive test. Both tests are performed with a
pencil and paper and are unaffected by aphasias. ~
• The Stroop Test involves tour parts: (i) reading the
names of colors printed in black on white cards; (ii)
reading the names of colors printed in a different color,
such as the word red printed in green ink; (iii) naming the
co.lors of dots; (iv) reading the cards from part (ii) again, ~
but this time naming the color of the ink
• The Concentration Endurance Test requires the
regh;•ration
patient L mark a certain target letter in the midst of
distracting letters and symbols; this particular test uses
the letters d and p with single and double quotation
marks above and below the letter; far example, the letter
d with two marks (one above and one below, two above
or two balow) can be the target
• There are several Cancellation Tests; one is the Digit
Symbol Subtest of the Wechsler Adult lntelligence Scale
(WAIS); symbols are paired with digits and patients are
asked to fill in blanks next to the symbols
~
336 337
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after the occurrence of an event; this is also called
continuous or forward amnesia
retrograde amnesia event anterograde amnesia
Declarative memory is factual and directly accessible to ~- - -
consciousness. lt is also called "knowing that" or "knowing - • time
what" memory. This type of memory can be acquired in a
short time and is the form most impaired in amnesia. Memory can be impaired at the level of:
• Encoding - perceptions are not properlv "encoded" by
,rocedural ;.iemory refers to acquired skills and habits. lt is an inability to attend to the delivery of infcmation
also called "knowing how" memory. This type of memory • Storage - after memories are encoded, they must be
evolves after many trials, and remains largely intact in consolidated and maintained to allow retention
various forms of amnesia (for both learned and new tasks ). • Retrieval - deficits in recalling consolidated material
338 339
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Testing ol Memory in tbe MSE one out of three. You can vary the number of words used to
suit the educational status, degree of alertness and level of
The most common test of verbal rnernory involves word cooperation of the patient being interviewed.
recall. Thi~ ;s used to test immediate memory (registration)
and short-term memory (recent rnemory). The patient is lf a patient cannot rernember all of the items, it is a cornrnon
given a list of three to five words and asked to repeat them practice to prompt thern. This can be done initially by stating
approximately five minutes later. the category of the missing item(s) (e.g. Was ita color? ...
A brand of soap?). lf this doesn't work, presenta list of other
The words chosen should have the following characteristics: words which include the missing item(s). This provides
8 · They should be unrelated to each other (e.g. don't use
patients with more help than listing the category, failing this
red, white & blue; sax, drums & rock 'n rol!) prompt may indicate a more serious impairment. Make sure
e They should not be something in the room or shown to you don't mention the missing '.tem too close to the
the patient (e.g. a set of keys, coins, chairs, light bulbs) beginning of the list, and don't add any inflection to your
• They should be unrelated to the person's vocation or voice far the correct word. Again, there is no established
interests (e.g. don't ask a mechanic to remember a lug standard with which to assess performance of short-term
nut, cam shaft and exhaust manifold) memory. lf the patient requires prompting ora word list,
record this as such.
Sorne popular combinations involve a color, quality and item
Keepirig an eye on the time is important. Report the duration
not in the room (green, honesty, postcard). This test is
as accurately as possible between registration and testing.
presented to the patient as follows:
Typically, this is recorded as, "Mr. T. was able to register ali
"Arnold, l'd like to formally test your rnemory now. l'm going to give
you three items to rernember. l'd like you to repeat thern so 1 know three items and recall two of three at about four minutes'
you've learned thern, and then l'm going to ask you to repeat them in time. He was able to recall the third with prompting. Patients
a few minutes. The words are bench press, dumbbe/I f/y and arm-curl. with Korsakoff Syndrome have anterograde amnesia, but
Can you please repeat thern far me now? · intact registration anda variable short-term memory. Testing
such patients too quickly will miss this important deficit.
Of course, if Arnold was a body-builder, these wouldn't be
good choices of items for him to rernember. lf patients are This test is often included at the beginning of the cognitive
notable to register these items, repeat them once. lf they evaluation. In many interviews (such as the Psychiatry &
have trouble a second time, this may indicate a cognitive Neurology Board exams) there are only thirty minutes
deficit, and further testing of concentration is warranted. allotted for the whole exam, and five minutes for the entire
Registration tests the same cognitive abilities as digit span. MSE may be all that is available. Frequently, interviewers
There is no clear rationale for why numbers are used in one forget to ask patients to recall these items. lt is prudent to get
area and words in another. in the habit of writing them down, because:
• This ensures you won't forget what they were
Sorne clinicians use four or five words for this test. Again, • You get a visual cue to ask the patient to repeat them
there is no standard of what is considered average. Missing
one itern out of four or five is less significant than missing lt is embarrassing when patients ask (invariably at the end of
an exam) if you still want them to repeat the thme items.
340
341
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A ILi AJ. tttd1N°t1AuP"fiis ...:! .a.! .J .J --1 .J CoGNITIVE FuNCTIONING & SENSORIUM
Other tests of verbal short-term memory involve: Long-term memory can be assessed in terms of recent
• A name, address and zip code of a fictitious person events (hours to days) or remate (years to decades). This
• A short "story" of three to four sentences having about 25 can be tested in a practicar manner in interviews by giving
points of information; an intact response involves patients questions to which you can verify the answer. For
remembering in the vicinity of 15 details example, the following information is usually readily
e Word lists of about 15 items which can be related or available:
unrelated; intact recall is considered to be somewhere in • Date of birth
the vicir ·ty of 50% of the words, which declines as age • Address, zip code and phone number
increases; a standardized test assessing this is the Rey o Previous appointments or hospitalizations
·Auditory-Verbal Learning Test (RAVLT) • Medication type and dosage
• Recollection of your name (as long as you gave it)
Short-term memory can also be assessed by using visual
design reproduction tests. One such test involves copying Remate memory can be distingui·shed from fund of
a design from memory that was placed in front of the patient knowledge by testing for personal details. Various other
for O - 30 seconds. These designs are usually an forms of personal information can be elicited, but need to be
amalgamation of severa! geometric shapes. corroborated to exclude the po&sibility of confabulation (the
falsifícation of memory in response to questions ).
A variation on this is to give patients the chance to study a
certain number of shapes, and then select them from a Brain areas involved in memory:
larger group presented for a fíxed period of time (e.g. 30 • Verbal memory dominant temporal lobe
seconds) later. A standardized • Visual memory nondominant temporal lobe
_... o
Examples of shapes
assessment is the Rey Visual that can be used • Registration frontal & temporal lobes
Design Learning Test (RVDL T), • Short-term memory hippocampus (consolidation and
which consists of two parts: retrieval); temporal lobe
• Showing patients 15 geometric (storage); medial dorsal thalamic
••
shapes and having patients nuclei (storage)
~
draw them from memory association cortex of temporal
• Long-term memory
lobe (medial temporal region)
• Having patients select the 15
designs they have seen from a
larger group of 30
V Structures involved in memory:
• Hippocampus - has connections to the thalamus and
The Weschler Memory Scale has a Visual Reproduction temporal lobe; part of the limbic system
subtest. Auditory sh.ort-term memory can be tested with a • Amygdala - involved in the integration of memories
rhythm tapped by the examiner and repeated by the patient. and the recognition of faces; part of the limbic system
This assessment has been formalized and is called the • Mamillary bodies - implicated in the pathology of
Seashore Rhythm Test, which is a component of the larger Korsakoff's Syndrome; part of the hypothalamus
Seashore Test of Musical Ability. • Pulvinar - needed for memory retrieval; part of the
thalamus
342 343
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COGNITIVE f UNCTIONING & SENSORIUM
Estimation ol /ntel/igence
Knowledge Base/fund of lnlormation
lnte//igence is a mu/ti-faceted group of mental abi/ities
invo/ving: Another component of assessing cognitive function is to test
• The assimi/ation and reca// of factual information a patient's knowledge base. This can be estimated by
• logical reasoning incidental factors during the interview or may need to be
• Problem-solving skil/s more fully explored if cognitive deficits are discovered in
other areas of testing. Head injuries and dernentia are the
• The use of abstraction, genera/ization and symbolization
• lntegration of parts into a who/e most cornmon causes of permanent knowledge deficits. The
pseudodementia of depression can give the appearanca of
Three distinct types of inte//igence have been described: impaired cognitive functioning because patients tend to
mechanical, abstract and socia/. lnte//igence is usual/y answer with "I don't know" responses. When pressed to
reported asan intelligence quotient (l.Q.) respond, they often can, if sufficient time is allowed.
344
345
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BRAIN CALIPERS
CoGNITIVE FuNCTIONING & SENSORWM
346 347
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M1N \.ALIPn's CoGN1r1vE FuNcnoNING & SENSORIUM
348 349
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ILI c!uNll~c fi,'ltm..~1NG~ SE~ORl!f.t
l.
Tidbits Relerences
• The Rule of Ribot states that the language one learns THE CuNICAL INTERVIEW Us1NG DSM-IV
first is the one that is more automatic, and is better
VOLUME 1: THE FUNDAMENTALS
preserved if one is rendered aphasic; alternatively, E. Othmer, MD, Ph.D & S. Othmer, Ph.D
Pitres' Law states the language most recently learned American Psychiatric Press lnc., Washington D.C., 1994
and used is the one that is best preserved in aphasia
e The most common early cognitive changes in dementing PsvcHrA TRIC DrcnoNARY, 7TH EomoN
illnesses are diminished ability to concentrate and
R. Campbell, MD
impaired problem-solving ability; later problems involve Oxford University Press, New York, 1996
orientation (though leve! of consciousness remains
intact), reasoning, perception and memory DIAGNOSTIC ANO 5TATISTICAL MANUAL OF MENTAL 01SORDERS,
• Memory impairment in dementia is most prominent far
4TH EDITION
recen! events; as the illness progresses, impairment American Psychiatric Association, Washington, D.C., 1994
becomes more marked c;nd involves distant memories
• Acalculia or dyscalculia is the inability to perform CoMPREHENSIVE TEXTBOOK oF PsvcHIATRY, 2No EomoN
arithmetic operations H. Kaplan, MD & B. Sadock, MD, Editors
e Agnosia is the inability to recognize an object despite Williams & Wilkins, Baltimore, 1975
having intact sensory pathways
• Asterognosis is the inability to recognize an object SYMPTOMS IN THE MINO, 2ND EDITION
when it is held in the hand (with eyes closed)
A. Sims, MD
• Gerstmann's Syndrome involves the parietal lobes and W.B. Saunders Co., Philadelphia, 1995
consists of left-right disorientation, acalculia, agraphia
and an inability to localize fingers A CoMPENDIUM OF NEUROPSYCHOLOGICAL TEsrs:
• The Klüver-Bucy Syndrome involves the temporal AoMINISTRATION, NoRMS & CoMMENTARY
lobes and consists of visual and auditory agnosia, O. Spreen, Ph.D & E. Strauss, Ph.D.
aphasia, dementia, apathy and hypersexuality Oxford University Press, New York, 1991
Summary SvN0Ps1s oF PsvcHtA TRY, 7TH Eo1r10N
f esting of cognitive functioning and sensorium is the last H. Kaplan, MD, B. Sadock, MD & J. Grebb, MD, Editors
majar area of evaluation in the MSE. These functions are of Williams & Wilkins, Baltimore, 1994
critica! importance to a patient's ability to function
autonomously in society. Posing questions to test these THE CLINICAL AssESSMENT OF MEMORY
areas can be a chatlenge to work into the interview. D. Reeves, Ph.D & D. Wedding, Ph.D
However, many of the impairments are not evident in other Springer Publishing Company, New York, 1994
parts of the interview or MSE, and need to be specifically
evaluated. Abnormal findings in this section usually require
further investigation.
350 351
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1tJ • &1 1111
So/id Moments in
Concrete Thought A TEXTBOOK OF
ÜBJECT LISTS
• lf a sing'~ dog can have
FOR
200 puppies, imagine
how many she'd have if MENTAL
she were married? STATUS
• lf it's a penny for your EXAMS
thoughts, but you have
to put your two cents in, Assistance for
who's making the extra those stressfu/
penny? times when your
e Careto join me? Why, are you coming apart? memory is worse
• l'd like to get into that drawer. Don't bother, you won't fil. than the patient's
• When l was your age, there was no history to study.
• My girlfriend was faithful to the end, unfortunately 1was
the quarterback.
A.M. Nesia
• 1 heard they were going to hang me in effigy, so 1 made
sure 1didn't go there.
• 1carne from Humble Beginnings, a village of about 400
people. Later, 1was driven to Poverty, which was just
down the road. A TEXTBOOK OF
• You can take a horse to water, but a pencil must always NUMBER LISTS
be lead.
FOR
• My doctor diagnosed me with kleptomania. She said 1
should take something for it. MENTAL
• Asked of John Dillinger, "Why do you rob banks?" STATUS
"Because that's where the money is." EXAMS
• lt only rained twice last week, first for. three days, and
then for four. Assistance for
• When 1 send my grandmother a postcard, 1write slowly those times when
because 1know she can't read very fast. you don 't want
" l feel like a hot dog. You don't look like one. to use your own
• Why don't sharks eat comedians? They taste funny. phone number
• How many psychiatrists does it take to make chocolate
chip cookies? Four. One to do the baking and three to
pee/ the Smarties. ® A. Calculia
354
355
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BRAIN CALIPERS
MMSE & SCREENING TESTS
Chapter 13
The Mini-Mental Status Exam
& Other Screening Tests
356 357
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MMSE & ScREENING TEsrs
Registration
• Lis! 3 objects at one-second intervals, then ask
the patient to repeat all 3; give one point for each
corree! answer given on the first trial; repeat this /1
until the patient can recite ali 3 items 13
Recall
• Ask the patient to recite the above 3 items 13
Language
• Show the patient a watch and a pen and ask the
patient to name these items 12 /1
• Ask the patient to repeat the following statement:
"No ifs, ands or buts." /1
358
359
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lnstructions lar Administering the MMSE Critique of the MMSE
Orientation The fallowing scenario plays itself out over and over:
• Ask for the date, then ask specifically for parts omitted (e.g. season,
lt is the first day of a rotation in psychiatry for a group of
ye ar)
• Ask patients to tell you exactly where they are now, then ask for the
clinical clerks. One of thf'.: keener students grabs a chart to
parts omitted (state, country, etc.) review the presenting history befare seeing the patient After
Registration having sorne idea what to ask about, she tries to recall the
• Ask if you may test memory, then list 3 unrelated objects in a clear format of a psychiatric interview. "Not much different than a
voice with about 1 second between each item. After giving the list standard interview," she muses, "except for this weird thíng
once, ask the patient to repeat this lis! and score 1 point for each item
called the mental status exam." Somewhere, somehow she
on this tria!. Because you will be testing recall later, continue to give
patients the list of objects until they can repeat them fully. lf patients comes across a copy of the MMSE, and her confusion
are unable to repeat these items after 6 trials, they cannot be disappears. She presents the case thoroughly, and when it
rr.eaningfully tested. comes time to present the mental status. she smiles and
Attention & Concentration says, "On the mental status exam. the patient scored 26."
• Ask patients to begin with 100 and count backwards by 7. Stop after
5 subtractions (93, 86, 79, 72, 65 ). Score the total number of correct
The majar pitfall of the MMSE is that it is NOT the same as a
answers. lf patients can't or won't perform this task, ask them to spell
the word "world" backwards. complete mental status exam. The similarity in names is
The score is the number of letters in corree! order, e.g., dlrow = 5, certainly part of the confusion. The MMSE was designed to
dlorw = 3, dolrn·-= 2, dolwr = 1, world =O be a r?pid screening instrument far cognitive i111pairment,
F.ecall and has three main clinical applications:
• Ask patients to recall the 3 words you previously asked them to • lt tests features that are often omitted in traditional
remember. Score 0-3.
Language
mental status exams, such as reading, writing, copying,
• Naming: Show patients a wrist watch and ask what it is. Repeat for a repetition, following commands, and detailed orientation
pen or pencil. Score 0-2. • The test score can serve as a screening tool far
• Repetition: Ask the patient to repeat the sentence after you. Allow dementia and delirium (i.e. a score less than 24 indicates
only one tria!. Score O or 1. impaírment)
• 3-Stage command: Use blank paper and repeat the command. Score • lt provides a quantitative score to follow the day-to-day
1 point for each part correctly executed.
• Reading: On a blank piece of paper print the sentence "Clase your
progress of a patient in hospital
eyes," in letters large enough for patients to see clearly. Ask them to
read it and do what it says_ Score 1 point only if the eyes are closed. The MMSE does not include most of the features assessed
• Writing: Give patients a blank piece of paper and ask them to write a by a thorough MSE. While it can certainly be a useful
sentence for you. Do not dictate a sentence, it is to be written addition to the MSE, it is by no means a replacement. The
spontaneously. lt must contain a subject and verb and be sensible. MMSE is the most popular cognitive screening instrument
Corree! grammar and punctuation aren't necessary.
and has a large body of literature supporting its use. The
Copying
On a clean piece of paper, draw intersecting pentagons, each side validity of MMSE seores has been demonstrated through
about 1 in., and the patient to copy it exactly as it is. All 10 angles positive correlations with performance on intelligence tests
must be present and the pentagons must intersect to score 1 point and with deficits found on brain imaging.
Tremar and rotation are ignored.
360 361
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BRAIN CALIPERS
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ScREENING TEsrs
~· ~
362 363
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No TES fuNNY SruFF
o
1. Traffic Cop 2. Family Therapist
3. Narcissist 4. Umpire
5. Gambler 6. First Aider
7. Advertising Executive 8. Optimist
9. Member of Defensa Staff 1O. Organic Chemist
364 365
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BRAIN ···' -.iJ
CALIPERS llLJ REPORTING THE MSE
Chapter 14
Reporting the MSE
The general format of a verbal or written psychiatric report
follows this outline:
• ldentifying Data
• Presenting Complaint
• History of Present lllness
• Past Psycfüatric History
• Medical History .·
• Substance Use History
• Personal History ·
• Family History
• Mental Status Examination
• Provisional Diagnosis & Differential
• Treatment Plan
366 367
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REPORTING THE MSE
P. S. is a 33-year-old, single. unemployed male brought to the N. P. is a 50-year-old male real-estate agent who presented to the
emergency department after accosting patrons for cigarettes in a clinic seeking counseling to deal with the loss of his dog, business,
shopping center. and mistress.
• Appearance: tattered jeans. soiled sneakers and a sweater which Mr. P. is an immaculately groomed man who appears younger than
seemed '· o heavy for the warm weather; unshaven with his stated age. Of particular note were his gold ring'-- .ailored suit and
unwashed hair and had tobacco-stains on his hands manicured nails. He initially sat in the chair behind me desk
• Behavior: restless during the interview, stood up twice to look in (designated far the interviewer) but was unruffled when asked to
the ashtray, but was able to be directed back to his seat; fidgeted move. He sat comtortably throughout the interview and spontaneously
constantly with his lighter and appeared distracted preened his hair and adjusted his tie on severa! occasions. He
• "Cooperation: moderately interested in !he interview; information emphasized his speech with dramatic gestures of his hands.
limited but considered reliable; eye contact was intermittent
• Speech: spontaneous and fluent, spoke in a low voice and had He spoke spontaneously and made a special effort ·to enunciate his
occasional difficulty naming people, places, and events words clearly. As he talked about his losses, there were pauses of up
• Thought Content: answered questions grudgingly with little to twenty seconds befare answerinq questions. There was a good
elaboration; spontaneously spoke about the injustices he'd deal ot prosodic variation to his speech and he had an engaging
suffered by "!he system" and specified how today's events were manner of speaking. He included a considerable amount ot detail to
part of a scheme to persecute him; this belief was strongly held emphasize a limited number ot points. He seemed appreciative of the
throughout !he interview and unwavering in intensity chance to speak and át times needed redirection to matters relevan!
• Thought Process: his thoughts were logically connected with a to the interview. He focused principally on his los ses and how he felt
restricted flow of ideas and one episode of thought derailment betrayed by everyone and everything in his life. In particular, he
• Affect & Mood: his emotional expression ranged from mildly thought he had been too trusting and too generous with those around
sullen to moderately irritable; he became hostile when he was told him. He denied thinking there was a conspiracy against him. His
he would have to remain in !he hospital; he described his mood emotions were intense, encompassed a range from tears to laughter,
as pissed off and reported it as a one out of ten and were appropriate to the tapie being discussed. His mood was
• Perception: experienced continua!, clearly formed auditory predominantly described as "hopeless" and he thoughl this was one of
hallucinations throughout the interview which told him he was the lowest times ot his lite. He had briet episodes ot hearing his
stupid to get detained at the hospital and he should find a way to mistress whisper his name when she wasn't in the room, but denied
· get released immediately; he did not report perceptual other experiences consistent with hallucinations or illusions. There
disturbances in other sensory modalities were no thoughts ot harm to others, but he had fleeting suicida!
• Suicide/Homicide: no thoughts or plans for self-harm; he wishes wishes. He understood he wouldn't always teel this upset and had
to assault one of the officers who brought him in hope for his tuture. He was willing to attend weekly appointments and
• lnsight & Judgment: impaired, denies he was bothering anyone or did not teel he would act on this thoughts ot lite not being worth living.
that has any need for hospitalization or treatment
• Cognition: Orientation was not tormally tested as Mr. P. found the clinic, had his
alert and fully conscious throughout the interview watch set properly, and carried a newspaper. He related historical
oriented to person, day, date, month, year, season and place information in considerable detail. Despite his complaints ot being
able to register three objects on the second attempt and recall unable to concentrate, he was able to register five items and recall
two of them four minutes later (despite prompting, he couldn't them at about tour minutes' time. He could recall seven digits forward
recall the third); remate memory was impaired for historical details and five backward. Serial sevens were correct to five subtractions. He
obtained from hospital record (dates and events) was able toread, write, and copy a diagram without difficulty. He had
digit span five forward, four backward; attempted two serial seven an overly personal interpretation ot proverbs, and related them back to
subtractions, both were incorrect (97, 87), then stopped this task wisdom that he should have possessed. He had an in-depth
declined to answer questions testing general knowledge, knowledge ot current events and historical information.
abstraction ability, proverb interpretation or hypothetical situations
368 369
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Appearance, Behavior & Cooperation - unkempt, slightly obese Ms. M. E. 's appearance was that of a woman who looked her stated
woman dressed in a hospital gown with food stains on the front, hair age and was dressed in mismatched clothes, consisting of a suit
was dyed brown severa! weeks ago, prominent right facial droop and jacket, leotards and hiking boots. In the interview, her behavior
right hemiparesis; she looked at areas in the room where there was involved refusing to be seated, and speaking only if she was allowed
nothing occurring and was talking out loud prior to the introduction of to walk around the room. She rummaged through her purse at the
the interviewers; picked in the air al unseen objects and then knocked beginning of the interview and then wrote out severa! lisis for the
over the items on her bedside table, struggled continuously against remainder of lhe time. She was superficially cooperative with the
her waist rest 'int; had a wide-arnplitude resting tremaron her left assessment and said she'd talk as long as she co;, "write her lists
side; she was unable to focus on the interview and did not appear to and if the interview didn't last more than ten minutes. She was
comprehend the reason for the consult or that there was anything considered reliable, but biased towards minimizing her activities.
amiss; her leve! of consciousness varied from alert at the beginning of
the interview to somnolent (but still rousable) at the end. Her speech was loud, rapid and pressured, but remained
understandable and had proper syntax. Prosody was exaggerated,
Speech, Thought & Perception - nonfluent speech, did not appear regardless of the content. Thought process involved connections
to comprehend many of the statements made to her and could not that were generally logical. On two occasions she was unable to
repeat them when asked; expressed speech was dysarthric, halting repeat the questions posed to her, orto relate the connection between
and had an irregular rhythm; she spoke at times in stock phrases, them and what she was just sayin:;: The content of her thoughts had
examples of which wer<J: to do with her plans to start at a senior management level in the
Fortune 500 company of her choice after graduation. She had
"Check's in the mail."
developed powerful insights inlo the business world and offered the
"No thanks."
interviewer an autographed copy of her term paper.
"1'11 see"
Al other times, longer phrases were out of grammatical sequence and Her affect was forceful and exuberant, and remained consistently high
contained mainly verbs and nouns; she seemed impervious to the for the interview. She described her mood as energetic and that she'd
questions put to her and made replies that were not relevan! to what never felt better, and gave herself a nine out of ten (she says she'd be
was asked; she appeared to be experiencing perceptual disturbances a ten after graduation). She denied any perceptual problems. She
that contained at leas! visual and auditory hallucinations (based on her stated she felt well and couldn't see why others were concerned. On
reaction to nonexistent stimuli); unable to ascertain information about this basis, her insight and judgment were both deemed irnpaired.
other experiences.
Testing of her cognitive functions revealed that she was completely
Affect & Mood - labile with considerable intensity; she was startled oriented. She was able to register tour items and recalled them at
by the appearance of the interviewers and began to cry; later was around five minutes. However, she could nol recite the interviewer's
terrified by the hallucinatory experiences, bu! after knocking her name or her exam schedule, so her long-term memory was
bedside items on the floor, she was calm enough to drift off to sleep. considered impaired. Her attention and concentration were intact for
six numbers forward and four backward. She performed three serial
lnsight & Judgment - not testable at the time of the interview. subtractions correctly and then told a story about the number
seventy-nine. She was able to enumerate a considerable list of
Cognitive Functions - notable to answer any questions regarding similarities and differences, many of which demonstrated a high
orientation despite wall calendar in clear view; responses to other level of abstraction. Her knowledge base was consisten! with her
questions were either nonsensical or too garbled to understand. leve! of education and her intelligence seemed above average.
370 371
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BRA/N CALIPERS REPORT/NG THE MSE
.. Her appearance is that of a woman appearing older than her age, Serial ?'s Concrete Tangential Labile
Mood
dressed in a housecoat and slippers, She is thin, has an odor of Champion Thinker Speech
•
poor hygiene and old scars on her left wrist and forearm.
She sat throughout the interview in an immobile position with her
hands at her sides and her head slumped forward on her chest.
There were no spontaneous movements when speaking.
e
Paranoid
~
Rigid
181
Completely
~
Financially
• She was uncooperative with the interview and said she wanted to
Ideas Thinking Oriented Competen!
be left alone. The information she shared did not seem reliable.
• Her speech was fluent and syntactically correct. There was a
latency of severa! seconds befare replying to questions. She
spoke in a monotonous manner with no variability in prosody.
~ ~
® $
• Her thought process showed intermittent loosening of Thought Thought Flight Thought
associatic :. with periods of rambling when asked open-ended Broadcasting lnsertion of Ideas Blocking
•
questions.
The content of her thought involved delusions of persecution and
infestation. On a recent trip overseas, she inadvertently knocked
over the display of a merchant who was selling rare cultural
w !'I Q 1 0
artifacts. This merchant put a "curse" on her, and the patient has Visual Auditory Olfactory Gustatory
been coping poorly and declining since that time. She is Hallucination Hallucination Hallucination Hallucination
convinced she has a type of flesh-eating organism inside her. .............._
.. She has passive wishes to die, but denies that she'd do anything
to harm herself. There are no thoughts of harm to others. ~ ~ b 6
• Her affect was flat ,md showed no range during the interview. She
felt doomed and hopeless and described her mood as depressed. Nihilistic Soma tic Tactile Erotomanic
• She described perceptual abnormalities in the form of tactile Delusions Fixation Hallucination Delusion
(beetles crawling on her skin) and cenesthetic (!he lining of her
fJ Px_
' D
intestines was being gnawed away) hallucinations. She was also
constantly harassed by the voice of the merchant.
a Her insight and judgment were both considered impaired on the
basis of the bizarre delusions. her inability to understand that she Wide Range Knew Loud Thought
is ill, and because she needed others to bring her in for help. of Affect Corree! Age Speech Derailment
• Cognitive testing revealed that she was only oriented to person,
month, year and season. She knew she was in a hospital, bu! not
which one. She was able to register only one object after two
tries, and was not able to recall this after three minutes' time. Her
~
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Well Dressed
~
Knowledge
li
Knowledge
digit span was intact only for three numbers forward and two Bizarre
Delusions & Groomed lntact Deficient
numbers backward. She did r:ot attempt the serial sevens test.
She was able to follow a written command and wrote a sentence
("I am going to die for what 1 did."). In response to many questions
she replied, "I don't know." Testing of similarities and differences 8 fJ ¡ 9fJI
revealed concrete thinking and highly idiosyncratic replies.
372 373
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BRAIN CAilPERS
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INDEX
lndex Apophany
Apparent Age
Apraxia
178
28
118
Abnormal lnvoluntary Movement Scale (AIMS) Articulation 111, 128
70 - 71 Asterognosis 350
Abstraction/Abstract Thinking Attachment Theory 216
346 - 47
Abulia Allention-DeficiUHyperactivity Disorder (ADHD)
52, 122
Acalculia
350 51,60, 74
Accent & Dialect Allentiveness
126 94,333
Acronyms - See Mnemonics Altire 28
Activity Leve! Attitude & Demeanor
49 93
Acule Stress Disorder Arcuate Fasciculus 114
254, 280, 327
Affect Autism
50, 79, 97, 253,257-260 113,117,142
Age Automatic Behaviors
28,215 59
Agitation Automatisms
50 54
Psychomotor Basal Ganglia
50 65,67, 72, 192,262
Agnosia Blepharospasm
118,350 64, 73, 75
Agoraphobia Body Dysmorphic Disorder
198 - 200, 293 186, 192
Agraphia Body Habitus
118 30
Akathisia Brain Stethoscope
48, 51, 54, 65, 72,226 6
Akinesia Brief Psychotic Disorder
52, 65, 66 113, 142, 150, 172, 280
Akinetic Mutism Broca's
58
I exia Aphasia
118 119, 121, 13?, 154
Alexithymia Are a
272 114 - 15
A logia Brodmann Areas
153 115,301
Amnesia Castration Anxiety 202
Anterograde Catalepsy
102,339, 341 58,81,291
Retrograde Cataplexy
339 81,291,297
Angst Catatonia
202 51, 53- 55, 127, 155, 158
Anhedonia Excitement
272 51,58
Anniversary Reactions Lethal
222, 227 57
Anomia Periodic
118 55
Anomie Stupor
228, 272 58
Anorexia Nervosa Choreoathetoid Movements
26, 29 60,69, 70
Anosognosia Circumlocution
295 123, 131
Anxiety Disorders Circumstantiality
50, 94, 95, 119, 127 130, 148, 144, 147, 152, 160
192, 222, 254, 265 Clang Associations 123, 158
Apathy Clock Drawing
272 349
Aphasias Cluttering of speech
118, 120, 133, 158, 159 131
Ano mi e Compulsions
125 61,62, 76
Conduction Types
124 62
Global Concentration
122, 157 333
Mixed Confabulation
124 102,103,288,343
Transcortical Motor Conversion Disorders
122, 158 53, 186,258
Transcortical Sensory Countertransference
124, 158 231
(see also Broca's & Wernicke's) Cranial Nerves 115
374
375
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INDEX
Judgment
316 - 318
Kleptomania
47 Negative Symptoms 53, 66, 79, 80
Korsakoffs Psychosis Schedule for the Assessment of Negative Symptoms
102
Knowledge Base
345 80
Language Negativism
111 57,59
Laryngospasm Neologisms
63 117, 123, 146, 156, 159, 163
Leve! of Consciousness Neuropsychological Tests
95, 96,330
Lite Cycle Stages (Erickson's) Bender Gestalt
179, 315 14
Limbic System Luria-Nebraska
262 14
Lithium Non-sequiturs
60, 78, 119, 128 160
J.oose/Loosening of Associations Obsessions
144, 151 - 2, 156, 160, 162 61, 192-97
Majo( Depressive Episode Obsessive-Compulsive Disorder
26,29,46, 50, 53, 90,97, 127, 46, 75,94, 173, 255
Oculogyric Crisis 63,92
128, 130, 134, 162, 172, 186,
192, 212, 254, 261, 264, 327 Oneiroid State(s) 288
Malingering Ophthalmoplegia
90, 99, 102, 103 92
Macropsia Opisthotonos
294 63
Mania/Hypomania Orientation
29,46,50, 51, 90,94,95,97, 331, 332
113, 125, 127, 128, 130, 134, Overvalued Ideas 191
142.147-48, 150-51, 161- Palilalia 155, 158, 163
162, 172, 183, 254, 261 - 62, Panic Disorder 94,95,225,267,280
265, 327 Paraphasias 120, 158, 159, 161, 163
Mannerisms 56 Parapraxes 100
Melancholia/Melancholic Features 268 Parkinsonism 47, 57, 65 - 67, 130
Memory 337- 343 Pathological Gambling 255
immediate 337, 338 Perception 279
recen! 337, 338 Perseveration 81, 155, 158
remate 337, 338 Personality Disorders
Mental Retardation - see Retardation, Mental Clusters (listed) 50
Metamorphosia 294 General 29, 190
Micropsia 294 Antisocial 50,90,94,97, 128, 174,212,
Mini-Mental Status Exam (MMSE) 16, 345, 348, 357 - 62 221, 225, 255
Mixed State(s) 50, 224, 269 Avoidant 50, 127,128, 174, 196
Mnemonics & Acronyms Borderline 47,50,94,97, 128, 174,212,
Catatonic Signs & Symptoms 55 221,225,255,281,293
IPPA Dependen!
13 50, 127, 148, 174, 196, 255
Menta' :;tatus Exam 5 Histrionic 26, 50, 94, 97. 113, 128, 148,
Negative Symptoms 79 256, 281, 2 J
Phobias 198 Narcissistic 50, 47, 94, 97, 128, 147, 174,
SANS
80 256
SOAP 13 Obsessive-Compulsive 50, 51, 127, 130, 147, 174,
Suicida! Risk Factors 213 192, 196, 258, 293
Violent;e Factors 235,236 Paranoid 50,90,91, 173,225
Modulation (of speech) Schizoid
128 50, 127, 128, 130,255,258 ¿
Mood Schizotypal
253, 263 - 67, 270 32, 47, 50, 113, 142, 173, 255,
Mood Congruence/lncongruence
190, 261, 280 281, 293
Narcolepsy Pervasive Developmental Disorders
47, 288, 291 117
Phenomenology 48,82
378
379
~ wt ~ ~~i¡uPiJ__ IQ_j¡ ~ líQ ~ 91 li' Q liQ lit Q U fi' fÁ i.Í 11 EJ IJ j1 mJ ~ j( 91,Nfx .t IÍ
Phobias/Phobic Disorders 91, 172, 195, 198, 200- 3, 79,80, 91, 113, 119, 125, 127.
255,267 142, 148, 150-51.153, 155,
Physical Examination Findings 27 157 - 59, 162, 172, 183, 186,
Physical Abnormalities 31 192, 220, 225, 254, 260 - 62
Physiognomy 36 280,285,327
Pisa Syndrome 65, 68 Schizophreniform Disorder 26, 142, 172, 192
Pitch of speech 130 Secondary Gain 93,98
Positive Symptoms 79, 80, 153, 286 Seizures/Seizure Disorders 51
Posttraumatic Stress Dii:.order 46, 95, 173, 212, 225, 254, Semantics 111
267,280,327 Serial Seven Subtractions 334,335
·"Postures 56 Sexual Sadism & Masochism 212
Pressure of speech 127. 161 Shared Psychotic Disorder 172
Primary Gain 98, 99 Short-term Memory - see Recen! Memory
Private use of words 156, 161, 163 Similarities Test 347
Privilege 244 Social Jsolation 214
Prosody of speech 52, 129,262 Speech 111
Prosopagnosia 125,295 Rate 162
Proverbs/Proverb lnterpretation 347 Spontaneity of s¡;cech 130
Pseudodernentia 53 Stereotyped Movements/Stereotypies 56, 76
Pseudohallucinations 296 Stuttering 112, 131, 142
Psychopathology, descriptive 82 Substance Abuse/Dependence 29, 50, 95, 147-48, 150- 51,
Psychopathology, explanatory 48,82 162, 218 - 19, 225, 299, 300,
Psychological Pillow 56 326
Pu ns 154 Systen:iatization of Delusiom: 191
Pyromania 255 Tangential Speech 120, 148, 152, 160
Rabbit Syndrome 65,68 Tardive Dyskinesia 48, 60, 68 - 72, 128
Racing Thoughts 161 Tattoos & Body Piercing 33- 35, 38
Rambling 144, 151 Tertiary Gain 98
Rapid Cycling Specifier (Mood Disorders) 269 Thought Blocking 144, 153
Reactive Depression 268 Thought Derailment 144, 153, 160
Reduplicative Paramnesia 189,287 Thought lnsertion 204
Registration - See lmmediate Memory Tics 73- 76
Resistance 103 TLA 49
Restless Legs Syndrome 51 Torticollis 63, 64, 75 •
Retardation Tourette's Disorder 47, 72, 75, 81, 117, 192
Psychomotor 52 Tremor(s) 48,65,66, 77, 78
Mental 53, 74, 112, 117, 142, 147, Trichotillomania 26
239,326 Verbigeration 144, 155, 158, 163
Rhythm of speech 131 Visuospatial Ability 348
Rigidity 57,58 Wernicke's
Clasp Knifr 57 Aphasia 119, 123, 15A, 162
Cogwheel 57,66 Area 114, 125
Lead Pipe 57,66 Triad 92
Scanning speech 131 Word Salad 144, 157,162
Schizoaffective Disorder 26, 142, 172, 280
Schizophrenia 9,26,29,32,46,50,53, 74,
380 381
~ L L ~ L ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ M ~ ~ ~ ~ MM M ~ M
BRAIN CALIPERS 0THER RAPID PSYCHLER PRODUCTS
382 383
~~w~~~~~~~~~~-~·~••••••~~~~~~~~~
BRAIN CALIPERS
OrHER RAPID PSYCHLER PRooucrs
Features include:
• Explanations of diagnostic and theoretical principies
• Thorough coverage of each personality disorder
• Summaries of past personality disorders
• DSM-IV diagnostic criteria
• Caricatures by Brian Chapman
DAVID J. ROBINSON MD • Satirical articles from the Psycholllogical Bulletin
384 385
~¡ l. ~ B. .1N 6ift1P.. .. ... .. .. .. .. .. .. .. .. . ~ ~ .... !i L
~ ~ ~ ~
OrHER
~·
RAPID
M M ~ ~-
PsYCHLER PRooucrs
MM
Disordered Personalities
Presentation Set
Color presentation graphics are available
Psycho-
as 35mm slides and overheads. 11
*Part 1 - Axis 11 Diagnoses - Color versions of the
··ilf ustrations at the beginning of each chapter (with
lllogical
headings):
1. Schizoid
3. Paranoid
2. Schizotypal
4. Antisocial
Bulletin
5. Borderli: ·'-' 6. Narcissistic
7. Histrionic 8. Dependen!
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11. Passive-Aggressive 12. Asthenic
13. Cyclothymic 14. Explosive
15. Self-Defeating & Masochistic Personalities
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28. Ego Defenses 29. Organic Personality Disorder • Kevorkian's Organs
30. Medica! vs. Psychiatric Perspectives
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386
387
'1 ~ lt..*N .._,,._ *t fil' *" • e • • • lt iJ d' w IJ' 11' • ti" í( lf 11( ., •l l'ij lf
lí 1( ¡(PRooucrs
OrHER RAPID PsvcHLER
& CLINICAL GUIDES Not since Lazarus carne up with the BASIC ID to help us
remember his multimodal approach has there been such
a book to help mental health professionals deal with the
vast amount of material in a comprehensive way.
Robinson uses humor to help us learn, remember, and
ultimately to help our clients and patients better, and to
make the H.M.O. process less onerous. 1recommend this
to P.H.O.s, M.S.W.s and suggest P.0.0. they purchase
this book A.S.A.P."
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Eastern New Mexico University.
• Clinical Disorders
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David J. Robinson MD 96 pages, soft-cover, ISBN 0-9680324-1-9
388 389
·~ L \.1 '--1 L; ~ Ira.e ~ ~ ~ ~ ~ ~ ~ -.., lw ~ k. b .. t. '- IW a, IM llJ IJ ~ 11 9' 11 1M
- fjRA/N C.ALIPER5 0THER RAPID PSYCHLER PROOUCTS
THERAPY
Lubertus Berrens
illus1ra1~d by
WaUher M. E1jkeleslam
~ & ~ ~~9ll~HfHS
The anthology of articles and caricatures from the Science Friction is a collection of (real !) articles from
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192 pages, soft-cover, ISBN 0-9680324-4-3
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390 391
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