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PuBLISHING INFORMATION TABLE OF CONTENTS

Table of Confenfs

Ob
O. Author's Foreword & Atlcnowletlgments -3
1. Printiples al the Mental Status Exam l

2. Appearante 25

Rapid Psychler Press 3. Behavior 45

produces books that are: 4. Cooperation & Reliability 89
5.Speeth JJJ
• comprehensively researched 6. 1hought Process 141
• well organized
1. 1hought Content 111
• formatted lar ease of use
8. Suicitlal & Homiritlal ldeation 211
• reasonably priced
9. Afled & Mood 253
• clinitally oriented, and
• include humor that enhances 1O. Perteption 279

eduiation, anti that neither 11. lnsight & Judgment 309

demeans patients nor the efforts 12. Sensorium & Cognitive Fundioning 325
of titase who lreat them 13. The Mini Mental Status Ex.am
& Other Screening Tests 351
14. Reporting the Mental Status Exam 361
lndex 314

Other Rapid Psythler Publications 382

-4
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RAPID PsYcHl.ER SrAFF
LEr'sGol

The Rapid Psythlers

• Brian & Fanny Chapman, both fine and food artists
Brain Calipers
• Dean Avola, marketing wiz with strong ideas, strong
A Guide to a Successlul
advice, anda strong back Mental Status Exam
·Dr. Donna Robinson, promotion and sisterly duties

• Monty & Lil Robinson, for helping with ali aspects of this
venture and for being great parents

• Mary-Ann Mclean & Alex McFadden, for your patience,

enthusiasm, and help in so rnany ways

• Mark & Nicole Kennedy, fnr taking care of ali the big
things, all the little things, and always helping out

• Brad Groshok, for being there at midnight when the

computer crashes, and for making my productivity a priority

• Kathi Sword & Glenn Avola, marketing & graphics support

• Tom Norry, Janice Seaborn, Sue Fletcher & Dr. Sandra

1forthcott, proof and spoof readers

• Sherry Ripa from LithoSource for your expertise and for

helping me coordinate this publication

• Grant & Danny from Admar Graphics for the great

marketing idras and goodies
The care of the human mind is the mvst noble
1 also
wish to acknowledge the following for keeping me
branch of medicine.
company through the hundreds of hours of writing time:
Aloysius Sieffert
• Kenny G, for the best sax playingc l've ever heard
• Richard Eiliot, Dave Koz, Warren Hill, and Ne/son Rangel/ There was no influenza in my young days. We called
for pinch-hitting for Kenny a cold a cold.
• Coca-Cola, for a great tasting, caffeinated beverage Arnold Bennett

-1 1
BR- ·J ( . -cPEfc. · .-.__i.
Notes on Terminology
Individual diagnostic criteria that correspond to findings on
the Mental S'.3tus Examination are reprinted in each chapter.
The numbers that follow the name of the disorder are from
the official coding system used by the DSM-IV and based on
the numerical codes from the lnternational Classification of
Oiseases, Ninth Revision, C:inical Modification (ICD-9-CM).
Thesé numbers are used in record keeping and for statistical
purposes. The appearance of an 'X' indicates that there are
subtypes or specifiers for the disorder and that further
delineation is necessary.
Throughout Brain Calipers, the term "patient" is used to refer
to a person who is suffering and seeking help. The term is
further used to define those who bear pain without complaint
or anger. To me, the terms "client," "consumer," or
"consumer-survivor," reflectan unfortunate trend that is
pejorative towards mental health care, labeling it as if it were
a trade or business instead of a profession. These terms are
also ambiguous, as it is not clear what is being "consumed"
or "survived."
Where possible, the genderless "they" is used to refer to
patients. In situations where this would not suffice, the use of
'he' and 'she' was arbitrarily used in this book.
Finally. the term mental retardation is used because it is an
accurate description, and is the current diagnostic
terminology found in the DSM-IV. While terms "special" and
·'challenged" have become popular substitutes, they are not
suitable for a book on descriptive pathology. Ali people are
"special" in their own way and "challenged" from time to time.
D.J.R.
2 3
rRlillCIPLE:. OF } rl~ Mt:riTAL .,ºTATulE><Ar.11NA) ION
Chapter 1
Principies al the .
Mental Stat11s Examination
What is the Mental Status Examination?
The Mental Statlls Examination (MSE) is the component of
an interview where cognitive functions are tested and
inquiries are made about the symptoms of psychiatric
conditions. lt is a set of standardized observations and
questions designed to evaluate:
• Sensorium
• Perception
• Thinking
• Feeling
• Behavior
The MSE is an integral part of any clinical interview, not just
one that takes place in a psychiatric context. An assessment
of cognitive functioning must be made befare information
from patients can be considered accurate. The MSE records
only observed behavlrr. cognitive abilities and inner
experiences expressed during the interview. The MSE is
conducted to assess as completely as possible the factors
necessary to arrive ata provisional diagnosis, formulate a
treatment plan and follow the clinical course.
The MSE is a portable assessment tool that helps identify
psychiatric symptoms and gauge their severity. With
experience, it is a specific, sensitive, and i· .' ..xpensive
diagnostic instrument. The MSE takes only a few minutes to.
administer and yields information that is crucial to making a
diagnostic assessment and starting a course of treatment.
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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

4 5
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BRAIN CALIPERS
PRINCIPLES OF THé MENTAL STATUS EXAMINATION

Do I have to perlorm an MSE? How tlo I sfarl the MSE?

Yes.~ lt 1s as essential to a complete psychiatric assessment
as the physical examination is to other areas of medicine.
The MSE has been adroitly called the "brain stethoscope." *
Ali psychiatric diagnoses are made clinically in interview
situations. There is no blood test, x-ray or single identifying
fr.;ature for ar _' psychiatric condition. This emphasizes the
necessity of a thorough assessment, of which the MSE is an
essential component.
The MSE is often unpopular for two reasons:
• The questions are difficult to formulate because they are
not asked in other types of interviews or in other areas of
medicine, psychology, nursing, etc.
e The questions appear to be of dubious relevance.
Once these two difficulties are surmounted, the MSE
becomes an enjoyable and interesting aspect of interviewing.
To achieve this level of comfort, it helps to realize that
almost half of the MSE is obtained "free" through observation
and discussion from the initial parts of the interview.
• "Free" parameters • Parameters to ask about
Level of consciousness Orientation
Appearance Cognitive Functioning
Behavior Suicidal/Homicidal Thoughts
Cooperation Knowledge Base
Reliability Perception
Affect Mood
Thought Form Thought Content
fThe American Psychiatric Association listed the MSE as one of the
essential "Domains of Clinical Evaluation"
American Journal of Psychiatry, Vol.152:11, Suppl., p. 72, Nov. 1995
·D. O'Neill, Brain Stethoscopes: The Use and Abuse of Brief Mental
~tatus Schedules; Postgrad. Medica/ J., (69), p. 599-601, Aug. 1993
The MSE begins as soon as the patient is in view. A moment
of observation before the interview begins reveals important
information such as: grooming, hygiene, behavior, gait, level
of interest in and interaction with surroundings, etc.
Other elements of the MSE are obtained as the inteNiew
proceeds. Most interviewers begin an inter ·~w with open-
ended questions and allow patients at least five minutes of
relatively unstructured time to "tell their story."
lnvariably, there are items that will have to be specifically
asked about, which can be done in one of three ways:
• Taking the opportunity when the chance arises in the
interview. This is the most natural approach, allowing the
MSE to be woven into th8 flow of the interview. For
example, many patients will complain of poor memory
and decreased attention span, presenting an ideal
opportunity to test cognitive functioning. The
disadvantage to this method is that is can disrupt the
structure of an interview. For those new to interviewing
and the MSE, this approach may be better left until more
facility has been gained in coping with such tangents.
• Taking note of key points in the history that allow a
smooth transition back to these items. Far example,
"You mentioned before that your vision was blurred. Did
this ever cause you to see something unusual?" This lets
patients know that they have been listened to, while
adhering to a more _structured approach. lf patients say
something that introduces an important area, but at an
inopportune time, say something like, "lt's important far
me to know about that, and we'll get back to it in a few
minutes*, but right now could you tell me more about ... "
*Just remember to ask about it later!!

6 7
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BRAIN CALIPERS
., Asking about these items at the end of the interview.
This too has the advantage of helping preserve the
structure of the interview. Additionally, the two other
more elegant approaches don't always present
themselves. Specific parts of the MSE can be introduced
as follows:
-·. "At this point, l'd like to ask you sorne questions that are
separate from what we've been discussing so far, but
will give me sorne important information about you."
or
"Right now, l'd like to ask you sorne questions to give me
an idea .Jout so:ne aspects of your mental functioning."
or
"l'd like to switch now and ask you a set of questions that
will help me evaluate your ... (thinking, memory, etc.)."
or
"There are sorne others areas that 1 need to formally test
to get an idea al::lout your ... (concentration, attention,
etc.)."
or
"In order to be as thorough as possible, 1 need to ask you
sorne questions about your mental functions and inner
experiences."
N.B. These questions are only suggestions. Ask instructors
or colleagues for their own patented phrases. While
conducting the MSE is essential, it can be done in a variety_
of ways and in any arder. You can draw on the experiences
of others initially, and then eventually develop your own
approach. Specific questions regarding certain sections of
the MSE (e.g. hallucinations and delusions, suicida! or
homicida! thoughts) are included in their respective chapters.
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PR/NCIPLES OF THE MENTAL STATUS EXAMINATION
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How is the MSE different from the history?
Man y parts of the MSE are indeed covered in the body of the
interview. However, it is rare foral/ aspects of the MSE to be
covered without being addressed specifically.
In one extreme case, an interview can consist solely of the
MSE. Patients who are delirious, severely demented or
grossly psychotic cannot provide reliable information.
lnterviews under these circumstances are principally a
record of appearance, behavior, speech, thought form, etc.
On the other hand, someone can answer q11P3tions in a
straightforward, logical manner and demor. ,erate no obvious
abnormalities of behavior, but still have a serious mental ,
illness. Most clinicians can recall a situation where they were
fooled by not pursuing a thorough MSE. The best example of
this situation is a patient who suffers from a delusional
disorder. Other than the theme of the delusion (paranoia,
jealousy, etc.), the interview can be largely unremarkable.
Unless specific inquiries are made about the presence of
these fixed, false ideas, they will be missed.
Other components of the psychiatric history and the MSE
interact dynamically so interviewers learn where to most
profitably direct their inquiries. Considera patient who is
disheveled, wearing a kevlar jacket to ward off gamma
radiation, and conversing with a light bulb using unusual
language. These are the areas to immediately ask about:
• The recen! ingestion of substances
• Serious medical illnesses, head injuries, etc.
• A history of schizophrenia, past psychotic episodes or
previous hospitalization
• Compliance with rE:commended treatment
A representation of the integration of the MSE into the
assessment process is illustrated on the next two pages.
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lntegration ol the MSE and the History

Psychiatric History MSE Component Standard
lnterview
• IOENTIFYINGÜATA • APPEARANCE
• BEHAVIOR
Process
• CHtEF CoMPLAtNT
º ÜRIENTATION
(ask patients for their full
name, if they had difficulty
finding the room/clinic/hospital)
••
Mental
• LEVEL oF CoNsc1ousNEss Status
(this is usually obvious) Exam

• HtSTORY OF PRESENT ILLNESS • COOPERATION

(HPI) 5 - 1O minutes of
relatively unstructured
questions using open-
ended inquiries and other
• SPEECH
• THouGHT FoRM
• THouGHT CoNTENT
(this open format allows
•
facilitating techniques patients to talk about what Physical
concerns them, a valuable Examination &
indicator of thought content)
Routine
lnvestigations
• ExPLORATION oF SvMPTOMs • AFFECT
FROM HPI • Mooo
More focused assessment

•
• 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

ro 11
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Are there some practica/ examples?
Scenario A
An elderly male patient had hip surgery two days ago. Since
that time, he has been persistently disoriented, disruptive
and agitated. At the outset of the interview, he picks at
invisible objects in the air and mumbles to himself.
Evalu_ation: This man is delirious, and the information
obtained from him at this point is of questionable reliability.
His mental status needs to be assessed first, with questions
involving the following areas:
• Orientation
• What he's experiencing at the moment (What is he
picking at? Are there sounds, sights, smells, sensations,
that are diverting his attention? etc.)
• Having him speak up or repeat what he's been saying
How else tan I conteptualize the MSE?
• Because the MSE is equivalent to the physical
examination in psychiatry, the approach used to
investigate symptoms in physical medicine is a helpful
parallel. A popular outline follows the acronym l.P.P.A.
• lnspection
• Palpation
• Percussion
• Auscultation
Further "looking into," "touching on," "sounding out," and
"listening to" is required to fully evaluate psychiatric
symptoms. Unlike the physical exam, the MSE is at least
partly integrated with the history. Both the physical exam and
MSE are recorded separately from the body of the history.

S-:enario B • The MSE can also be considered part of the objective

A woman in her late twenties is seen in the emergency portian of the SOAP approach to recording clinical
department due to intermittent attacks of shortness of breath information.
and whetizing. After answering sorne preliminary questions,
she reveals that these episodes occur only when her Subjective - Cc¡insists of sections from the interview:
neighbors fill her apartment with poison gas. Chief Complaint
History of Present lllness
E 1aluation: -, nis woman is more likely paranoid (for any Past History (Medical ,1d Psychiatric)
number of reasons) than asthmatic. At this point, the MSE Family and Personal History
becomes the principal component of the interview. The next
step might involve exploring her thoughts of being Objective - Recording of observations
persecuted (onset, identity of conspirators, etc.). Mental Status Exam
Physical Examination
In these two brief examples, a full MSE becomes paramount Laboratory Testing
because an understanding of thinking, feeling, behavior,
perception, sensoriur., and cognitive functioning is integral to Assessment- Provisional (or Preferred) Diagnosis
making a correct diagnosis and instituting treatment. Positiva & Differential Diagnoses
findings on the MSE help target areas for further questioning,
investigations, collaborative history, etc., and are a guide to Plan - Further lnvestigations, Short-Term & Long-
clinical course and prognosis. Term Treatment

12 13
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Is the MSE the only examination needed?
Not at ali. The MSE is a component of an interview like Past
Medica/ History or Personal History. The MSE consists of a
range of questions inquiring about the features of certain
mental illnesses and assessing a number of psychological
functions. lt is by no means the end of the investigative or
~_iagnostic process. The MSE assists with hypothesis
generation, and helps determine which further
investigations might be necessary. The following is a list of
commonly used investigations:
Biological
• Routine physical exam and bloodwork, CXR. EKG
• lmaging the CNS via CT or MRI scans, EEG
• Hypothalamic/thyroid/pituitary/adrenal function
• Neurologic testing and possible consultation
• Special tests, e.g. Dexamethasone Suppression Test (DST)
• Evoked Potentials
• Drug and Toxicology screens
• Vision and Hearing tests
Social
• Collateral history from family, general practitioner, etc.
• Activities of Daily Living (ADL) assessment
• Referral to members of multidisc!plinary teams
Psychological
• Personality and lntelligence tests (e.g. MMPl-11,
Rorschach, WAIS-R)
• Neurops1 :hological Test Batteries (e.g. Bender Gestalt,
Luria-Nebraska)
Oiagnostic
There are a vast riumber of diagnostic scales to further
examine findings in interviews (this is acronym manía).
Sorne of the common ones are: PSE-9, SCID 1 & 11, DIS, SAOS,
CIDI, SCAN. HAM-A. HAM- D, 801, BPRS, SAPS, SANS, PANSS,
STAI, BDS, MSRS, & BCRS 1!
14
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'~
Tidbits on lnterviewing
Because psychiatric symptoms and diagnoses are made in
interview situations, developir;g skills in obtaining information
is crucial to this process. Especially relevant to the MSE are
the following:
• A psychiatric interview is nota conversation, but an
aQtive periad af questioning_and observation. Ali aspects
of the person being interviewed are subject to scrutiny:
body odors, unusual movements, grooming habits. etc.
Areas that might be tactfully avoided in social situations
are pursued in assessments to further the understanding
of that person.
• Be interested!l Pursue hints, suggestions and
insinuations. Psychiatric interviews allow the privilege of
asking about personal matters and making repeated
inquiries for further information.
• Exude a neutral, calm and objective manner. Ali aspects
of patients' lives (sexual, religious, fantasy) are relevant.
lnformation involving sensitive areas is best obtained
using a straightforward, nonjudgmental demeanor. Your
task is to understand patients and empathize w!th them.
An attitude of curiosity and acceptance helps to facilitate
this exchange.
• Be flexible. Adjust your tone, vocabulary and types of
quest1onSto suit the patient.
• At regular intervals, take a break to check your
understanding of patients' problems with them. This
cleITTiy conveys your interest. and will often help clarify
which areas need further questioning.
Attend to the comfort of patients. Provide tissues, ashtrays,
water, etc. to see that their needs are met. Taking care of
these preliminary considerations expresses em ath and
helps avoid later interruptions. A listo excellent references
for books on interviewing skills is provided at the end of this
chapter.
15
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Nlental Status Examination Tidbits Dr. Meador's Rules*

9 The MSE is sometimes referred to as the Present State
Examination (PSE).
11 The Mini-Mental State Examination (MMSE) IS NOT the
same as a complete MSE. See the chapter on the
MMSE & ÜTHER ScREENING TESTS far further information.
9 The MSE was originally a component of the neurological
examination.
7. There is no blood or urine test to measure mental function.
There probably never will be.
9. lf in doubt about dementia, do a Mental Status Exam.
31. The interview is the beginning of treatment.
133. Let patients ramble for at least 5 minutes when you first
see them. You will learn a lot. '

• 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
course and prognosis. lt has a high "test-retest'' value
and reveals important information about clinical course.
e I.ti_e MSE consists of a{elatively standardized approacli .
and set of inquiries. HoweV,:er, every instructor will hav8'
h'TS.or her own ra11onale for doing things a certain way. lt
is important to have exposure to as many styles as
possible. Then, assimilate this knowledge into an
approach that suits you. Different approaches can be
used at different times in different ways; there is no one
"righr approach__
• 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
always benefit from the ideas of othe.rs. Q.ut critically
review thejr 511ggestjoos before automatically
incorporating them into your interv1ew style.
323. The error of missing a diagnosis of dementia in
hospitalized patients is common. This occurs because
cognitive mental status evaluations are too often omitted.
326. A test of orientation to time must include the day, date,
~
mQ_nth and ~ar. Orientation to time can remain intact to
everything except the year.
398. Do not make the error of accepting the first abnormality
foundas the cause fofthePatient's symptoms.
421. You cannot diagnose what is not in your differential
diagnosis.
*From: A Little Book of Doctors' Rules
by Clifton K. Meador, MD
Hanley & Belfus lnc .. Philadelphia, PA. 1992
Reprinted with permission.

16 17
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Summary
lt is not prudent to remove vital organs from a woman who
has the delusion of being infested with extraterrestrial
microbes, eve· if she demands the procedure. Similarly, a
man who wants a blood transfusion with type A blood so it
could combine with his own type B blood - to make type AB
- would also be denied this procedure. In both these
examples, the psychotic thought processes elicited in the
MSE have a direct bearing on diagnostic and therapeutic
interventions.
An evaluation of mental status is an integral part of any
clinical interview, regardless of whether symptoms are
obvious or subtle. From the rirst moment of contact with
patients, clioicians begin the orocess of hypothesis
g~~which is refined by further observation,
q,u~ng and in~stiqations.
The psychiatric interview, like the scalpel in surgery, is the
instrument that reveals what lies beneath the surface. A well-
conducted interview is no less reveal1ng thañº an.operation,
and i~fill.hai takes an equal amount of time and e~
~-
The MSE is an "instrument" to measure psychological
functioning like the stethoscope is an instrument for cardiac
or respiratory assessments. Along with the history, physical
exam and specialized testing, the MSE is a cornerstone of
descriptive psychopathology and vital to a psychiatric
assessment
This book has been written as a guide to conducting a
thorough MSE and to understanding the significance of the
findings. Justas chords and rhythm are the building blocks
of music, the details and subtleties of assessing
abnormalities in thinking, feeling, perceiving and behaving
form the backbone of the MSE.
18
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References
COMPREHENSIVE TEXTBOOK OF PSYCHIA TRY, 6TH EDITION
H. Kaplan, MD & B. Sadock, MD, Editors
Williams & Wilkins, Baltimore, 1995
SYNOPSIS oF PsvcHIATRY, 7TH EomoN
H. Kaplan, MD, B. Sadock, MD & J. Grebb, MD, Editors
Williams & Wilkins, Baltimore, 1994
TEXTBOOK OF PsvcHIATRY, 2No EomoN
R. Hales, MD, S. Yudofsky, MO & J. Talbott, MD
American Psychiatric Press lnc., Washington O.e., 1994
Relerences lor lnteru5ewing Sldlls
PSYCHIATRIC INTERVIEWING: THE ART OF ÜNDERSTANDING
S. Shea, MD
W.B. Saunders, Philadelphia, PA, 1988
THE CUNICAL INTERVIEW ÜSING DSM-IV
VoLUME 1: THE FuNDAMENTALS
E. Othmer, MD, Ph.D & S. Othmer, Ph.D
American Psychiatric Press lnc., Washington O.e., 1994
THE F1RST INTERVIEW - REVISED FOR DSM-IV
J. Morrison, MO
The Guilford Press, New York, 1994
THE PsvcHIATRIC INTERVIEW IN CuNICAL PRACTICE
R. MacKinnon, MD & R. Michels, MD
W.B. Saunders, Philadelphia, PA, 1971
PSYCHIATRIC INTERVIEWING: A PRIMER, 2ND EDITION
R. Leon, MD
Elsevier Science Publishing Ca .• New York, 1989
BoARDING TIME, 2No EomoN
J. Morrison, MD & R. Muñoz, MD
American Psychiatric Press lnc., Washington, O.e .• 1996
19
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Generation X Delusions The Dwarl lnventory ol Psychopathology

a 1 served in the regiment commanded by Colonel Sanders
in the Great Chicken War.
o The dots and dashes on the highways are a secret
message in Morse Code that 1 alone must decipher.
The continua! reclassification of diagnostic schemes means
confusion for everyone. This inventory takes a more practica!
approach by amalgamating types of behavior into clusters,
the so-called Dwarf Prototypes. Familiarization is available
to all by way of a short story and training film.

• 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

Which aspects ol appearance are imporlant?

The purpose of recording information about appearance is to
provide a mental picture of the physical characteristics of a
patient. This is done not only to obtain an accurate record,
but to convey to others as closely as possible what it was
like to see the patient. Features of appearance that are
important are:

• Gender & Race

• Actual & Apparent Age

• Attire

• Grooming & Hygiene

• Body Habitus

• Physical Abnormalities & Assistive Devices

• Jewelry & Cosmetics (if remarkable)

• Other notable features (tattoos, bod,· ·-;iercing, scars,

unusual pattern of hair loss, etc.)

24 25
.._J k... ...~-- _.;->aCJ·~.._j·= ..J·=._r=~·=-.;·=..,~~...~r~.:J·=-..J·-=.J·=-.J l,;j w _.... _.. .....Jil __.. _mJ-líl mJ &I al ai •-n•-pm.lhl tJ

What is th~ diagnostic signilicance ol The Psychiatric Physical Exam

observations made regarding appearance? Head & Neck
e Trichotillomania 312.39 • Altered pupil size
• Argyll Robertson pupil
A. Recurrent pulling out of one's hair resulting in noticeable
• Cornea! pigmentation
hair loss.
• Piercing of lips, nose, etc.
& Anorexia Nervosa 307 .1 • Neck mass
A. Refusal to maintain body weight at or above a minimally • Dental caries
• Nasal septal defect
normal weight for age and height (e.g. weight loss leading to
• Arcus Senilis
a maintenance of body weight less than 85% of that
• Parotid Enlargement
expected; or failure to make expected weight gain during a
period of growth, leading to a body weight less than 85% of Skin
that expected). • Tattoos
• Lacerations on
e Major Depressive Episode 296.X knuckles (Russell's sign)
A. (3) Significan! weight loss when not dieting or weight gain • Scars from slashing
(e.g. a change of more than 5% of body weight in a month) • Scars from trauma
• Needle marks/lracks
e Schizophrenia 295.X • Handcuff marks
A. (5) Negative symptoms (see the BEHAVIOR CHAPTER) • Piloerection
Negative symptoms are also part of the criteria for: • Palmar erythema
Schizophreniform Disorder 295.40 • Bruising
• Cigarette burns
Schizoaffective Disorder 295.70
• Gender ldentity Disorder 302.X • Dermatitis or
Excoriated skin
A. (2) In boys, preference far cross-dressing or simulating
female attire; in girls, insistence of wearing only stereotypical • Pretibial Myxedema
masculine clothing (coded as a separate disorder depending • Kaposi's Sarcoma
or whether it occurs in children or adolescents/adults). • Lanugo hair
• Café-au-lait macules
• Histrionic Personality Disorder 301.50 • Red-purple striae
(4) Consistently uses physical appearance to draw attention ·Edema
to self. • Spider angiomata
Possible lmplication*
Drug intoxication/withdrawal
Neurosyphilis, head injury. brain tumor
Wilson's Disease
Personality Disorder
Thyroid disease
Eating Disorder (repeated vomiting)
Cocaine Use
Alcohol Use
Anorexia/Bulimia Nervosa
Personality Disorder
Eating Disorder (dueto self-
induced vomiting)
Borderline Personality Disorder
Antisocial Personality, Substance Use
l.V. drug use/dependence
Antisocial Personality, Paraphilia
Opioid Withdrawal
Alcohol Use
Alcohol Use, Seizure disorder
Dementia, Alcohol Abuse, Neurologic
conditions, Personality Disorder
OCD - compulsive hand washing,
may occur on knees from
cleaning in an kneeling position
Graves' Disease
AIDS, HIV encephalopathy
Anorexia Nervosa
Neurofibromatosis
Cushing's Syndrome/Disease
MAOI use, Anorexia Nervosa
Alcohol Use Disorder

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
appearance?
Gender, Race and Age are factual identifying features.
Apparent Age is a judgment made by the interviewer
based on actual age and other factors, the majar
determinants being hair and skin condition, style of clothing
and behavior. This is generally recorded as:
a Appears h,"s or her stated age
• Appears youngerlolder than the stated age
lnterviewers with experience in booths at county fairs or
exhibitions may attempt a more precise estimate ("This is a
40-year-old man who doesn't look a day over 39.").
Many factors can contribute to an older-looking appearance,
the most common being:
• Serious and prolonged physical illnesses
• Protracted exposure to strong weather elements
• Alcohol and other substance abuse
• Chronic and severe psychiatric disorders
• Disadvantaged socioeconomic status
• Homelessness
Attire describes how patients are dressed and how they
ha ve presented themselves for the interview. Attire is a
reflection of many factors: socioeconomic status, occupation,
self-esteem, ability and interest in attending to convention,
etc. Descriptions often include a cornment on the overall
impression or "gestalt" of the attire, and then the details of
how patients are dressed.
"The patient was meticulously dressed in a tuxedo with a
top hat and white gloves ... "
"The patient was seductively attired in a spandex outfit ... "
28
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Due consideration must be given to the circumstances of the
interview. An inpatient who awoke five minutes prior t0 an
interview warrants a different level of expectation than would
a banker attending an outpatient appointment.
lt is prudent to keep in mind that medica! rP"'~Jrds are legal
documents. Your comments can surface al:lain in a variety of
settings, with the courtroom being the most common. Also,
patients usually have the right to read their medica! records.
For this reason, déscriptions are best made with regard to
the congruity of patients' attire to the context of the interview,
followed by a description of their dress. For example:
Right: "This man is dressed as if
he were prepared for the outdoors.
He had on a fur hat, black jacket
and striped shirt ... "
Wrong: "This rube had on a tres
gauche, fake raccoon fur hat anda
cheap-looking sweater worn over a
Bert & Ernie undershirt ... "
Attire, when taken in context with other signs and symptoms,
can provide useful information. For example:
• Patients in a manic episode may dress flamboyantly, and
often show a predilection fer the color red
• Schizophrenia, depression, dementia and substance
abuse/dependence are common causes for a declining
interest in, and ability to attend globally to, self-care
(attire, grooming, hygiene, etc.)
• Patients with personality disorders can reflect their
character traits in their style and choice of clothing
• Anorectic patients often dress in loase, baggy clothing to
hide their state of emaciation
• lntravenous drug users rnay wear long-sleeved shirts
and long pants to hide needle marks (called "tracks")
29
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-'L-1 ~ &J ~ ~~aJ=:aU~ ._J=._¡=.&J~.J= ._J~.,.j=.J=.J.- 11iLf
Hygiene & Grooming are observations regarding the
leve! of self-care. Hair, attention to facial hair, skin condition,
nails, body odor, oral hygiene and condition of clothing are
the major aspects surveyed. Common terms are:
e Disheveled (ruffled as if by a strong wind)
@ Unkempt (attention to grooming not present initially)
" lmmaculate!ylneatly/adequatelylpoor/y groomed are
other adjectives used
As with attire, the level of grooming and hygiene can help to
make a diagnosis and gauge the severity of the condition.
.. Patients Widl obsessive-compulsive disorder may wash
so frequently that they cause skin damage
• Delusional disorders can affect patients' level of
grooming (e.g. not washing to ward off a feared entity)
• Patients with an obsessive-compulsive or narcissistic
personality disorder are often fastidiously groomed and
spend a disproportionate amount of time attending to
their grooming
11 Chronic, severe m'3ntal illnesses in general reduce the
leve! at which patients maintain their self-care
Body Habitus refers to the body type or build of patients.
To help convey a mental image, descriptions can be made
using the following terms:
.. Ectomorphic: thin or slight body build
• Mesomorphic: muscular or sturdy build
.. Endomorphic: heavy or portly body build
An overly muscular build can be relevan! to a psychiatric
assessment for the following reasons:
e Sorne patients with a histo~y of abuse (of any variety)
engage in intense physical training to decrease their
vulnerability, or their sense of vulnerability
• Paranoid patients may wish to increase their ability to
physically ward off future attackers
e Anabolic steroid abuse should be considered
30
Lf ld_Mí __ .. ... lili ., 18' llJ llJ -.J_ .,¡ ~:AR9ici: 111 11;1
An excess of adipose tissue can be an indication of:
• Metabolic abnormalities (e.g. hypothyroidism)
• Past ar current abuse. Far example, in cases of sexual
abuse, it has been speculated that victims may make
themselves (consciously ar unconsciously) less
attractive to potential perpetrators by gaining weight
• lmpulsivity with food ar alcohol
Additionally, the following unusual body proportions should
be noted:
• Trunca! obesity and wasting of the arms and legs occurs
in Cushing's Disease/Syndrome and n· ,r diseases
• A barre! chest which is disproportionate to the rest of the
body can be caused by emphysema ar chronic
bronchitis, raising the possibility of a neoplastic growth
•
Physical Abnormalities should be noted, as well as the
resulting handicap and need far assistive devices. In social
situations it is often polite and tactful to avoid discussing
handicaps, but exploring these areas during the interview is
important to completing the MSE.
A sensitive line of questioning indicating your interest will
help explore these areas, with the following inquiries being a
guide:
• Is the missing/disfigured part a congenital or an acquired
abnormality?
• lf congenital, what difficulties did this pose during
development?
• lf acquired, was it through an accident? An assault? An
attempt at self-harm?
• What limitations dces this currently impose?
• Has the patient experienced any losses related to the
handicap? How has he or she adjusted to the loss?
Exploring these areas also conveys to patients that you are
willing to discuss any aspect of their lives, and may create a
greater degree of openness in the interview.
31
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J}j,) ~u' a'j ~~J gU ~j
Physical handicaps can be significant for the following
reasons:
• The leve! of adjustment gives a good idea of someone's
overall ability to cope with stressors and losses; the
ability to adapt gives a good indication of insight and
judgment
• Relevance to the etiology of psychiatric disorders. For
example, a child who is continually ridiculed and
ostracized may well develop a paranoid personality
disorder. Other common outcomes can be the
development of depression, dysthymia, anxiety disorders
and substance abuse/dependence.
Jewelry and cosmetic use are extensions of attire and
grooming, resnectively. They can convey a strong and
~_jrsonal sen~e of how patients see themselves and what
they consider important. Examples of the usefulness of
these observations are as follows:
• Make-up can be bizarrely applied by patients with
psychotic conditions, and lavishly by patients who are
manic or i1ave personality disorders (usually borderline
or histrionic)
• Patients with schizophrenia or schizotypal personality
disorder may wear amulets and trinkets to which they
have attached a mystical significance
• The study of rings is a fascinating pastime. More than
just marital status, they can indicate occupation (e.g.
school rings, engineers wear a steel or iron ring on the
fifth finger of their working hand), achievements (if you
ha ve never seen a Super Bowl or World Series ring, they
are worth a look}, organizations (e.g. Freemasons), etc.
• Chains, necklaces, ear and nose rings are often of
significance for personal, cultural and religious reasons
32
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Are tattoos signilicant?
The word "tattoo" is taken phonetically from the Tahitian (or
another Polynesian language) word meaning, "to knock or
strike." The word also has two military meanings: a signa!
(e.g. drumbeat) to return to quarters, oran outdoor display.
Tattooing has been in existence for thousands of years,
extending back at least as far as the time of Ancient Egypt, ~
and quite possibly for much longer befare that.
Captain Cook visited Tahiti in the late 1700's, and made the
first recorded reference in Europe to the word "tattoo." On
subsequent voyages, sailors to these islands became
interested in the beautiful designs and had them applied.
Wearing a tattoo was initially associated \ .n the lower
classes and criminal elements. This association persists
today, though in the intervening centuries the upper classes
and royalty have been no strangers to the art (apparently
including King George V and Winston Churchill's mother!).
T attoos are made by the injection of permanent or indelible
ink into the dermal layer of the skin. Tattoos can be made
professionally with the use e.A an electric needle, or in a more
crude manner by hand (often referred to as "jail-house").
'Tats," as they are commonly known, have achieved an
unprecedented level of popularity. Many celebrities sport
them. They are frequently displayed in movies, and are often
central to the plot. There are conventions, magazines,
associations, and renowned artists that facilitate a culture
unto itself. Tattoos reflecta myriad of significance. For
example, they can signify membership in criminal
organizations (e.g. the Japanese Mafia or Yakuza) or
convictions for certain crimes. Alternatively, they can be
expressions of attachment to a person or lifestyle (e.g.
sexual orientation or sexual practices ).
33
 i :
• :!l. l. ta~,,.:::.iL.t~i'.t=L=iiLJ.....Li-=JLA~.iiil.~~*''·~~M _¡.,.
People seek to express themselves through their
appearance. Those with tattoos have used their skin as a
canvas with which to make a permanent and highly personal
statement. lt is importan! to ask about tattoos, even if they
are not visible.
Questions that you rr.ight ask of patients are:
• What is the tattoo? What does it represent?
e · What does the tattoo symbolize to you?
• What was going on in your life when you got the tattoo?
• What made this person/group/event so significan!?
• How much time did you spend thinking about the tattoo,
and what steps did you take befare getting it?
• What gave yo u the ... (confidence/hope/etc.) that you
would always feel as strongly towards the ... (person/
organization/etc. )?
• Have you regretted getting the tattoo? Have you taken
any steps to have it removed?
From these questions, you can learn about:
• Significant relationships, leve! of commitment, etc.
• Affiliation 1. 'th groups, subcultures, etc.
• Sexual practices, legal involvement, etc.
• Impulse control, insight, judgment, etc.
Tattoos can serve a number of psychological functions. At
the core, they help define an identity and boost esteem by
strengthening a sen se of self (ego). Whether this serves as a
compensation for perceived self-inadequacies needs to be
determined with information from the rest of the interview.
The psychiatric relevance of tattoos has spawned
considerable debate. RASPA & CusAcK associated them with
alcohol & drug abuse, and with antisocial & borderline
personality disorders. Studies investigating the strength of
this association are lacking. G1TTLESON looked specifically at
the usefulness of tattoo content, and was unable to correlate
a psychiatric diagnosis with the theme of a tattoo.
34
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~ U Mlll-\Ja__\¡¡¡¡¡_~_\is,¡¡_y_&d_&.i_i.J "' j.J r.. . cM~lft1L<:y U
lt may be that patients with the above-mentioned diagnoses
have a greater likelihood of having tattoos, but the mere
presence of tattoos should not imply that patients have these
disorders. Larger tattoos in visible areas that have a
menacing ar sinister appearance have a higher probability of
being associated with psychiatric conditions.
Tattoo removal can be accomplished in severa! ways:
• A "cover up" tattoo, which is by necessity larger and
usually has a more benign theme
• Abrading the. skin with salt. which has a sanding action
• Surgical excision, which can include prior tissue
expansion
• Laser removal (there is one model called the "Tatu-lazr")
Body piercing has become common in recent years.
Typical sites far this include the nose, eyebrows, cheeks,
lips, tangue, nipples, belly-button and genitals. Like tattoo
wearers, there are devotees who have developed
subcultures based on this practice.
At the time of writing, there are other alternéltive "body art"
forms gaining popularity. These include CL_,ings, scarring/
scarifícation, and branding. The medica! literature on these
practices is scant. Whereas tattoos can be quite beautiful
and ornate, the potential for significant disfigurement and the
historical precedents far sorne alternative practices may
indicate a higher level of psychopathology.
lnteresting movie examples of tattoos can be seen in:
• Tattoo (a case of "tattoo rape")
• Blues Brothers (their names are on their fingers)
• Cape Fear (1962 original, 1991 remake)
• Raising Arizona (Woody Woodpecker tattoo)
• lrezumi (Japanese film)
• The lllustrated Man (movie and a Ray Bradbury story)
• The Night of the Hunter (1955 original, 1991 remake)
• Heat (1996 film with OeNiro and Pacino!)
35
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lsn't it judgmental ta make inlerences Appearance Tidbits

nbout patients' appearance? • Examiners are often impressed by succinct and detailed
summaries of appearance. This indicates that you were
Appearance is too important a feature to not include when observant and looked for other sources of information
gathering information during the MSE. While inferences can during the interview.
be drawn and hypotheses made regarding certain features, e Race and ethnic background are important factors to
further information is required for confirmation. Diagnosis consider, especially if these are different than your own.
and treatment require more than appearance alone. People Signs and symptoms can have different meanings in
wear particular clothing, jewelry and cosmetics, and adapt other cultures. For example, there are severa! culture-
their grooming styles to express themselves. In clinical bound syndromes which seem as unusual to us as
situations, we strive to interpret more than fashion aspects of our society appear to them. Sorne of these
statements. A wealth of information is available toan are described in the chapter Oíl THOUGHT CONTENT.
experienced observer.

To il:ustrate this, consider the famous Victorian detective Summary

Sherlock Holmes. In the short-story called THE YELLow FAcE,11
he examines a pipe and tells Watson, 'The owner is
obviously a muscular man, left-handed, with an excellent set
of teeth, careless in his habits, and with no need to practice
economy." How Holmes arrives at these conclusions makes
peiect sense once he reveals both his observations and
their significance. You may not know that Holmes' creator,
Sir Arthur Conan Doyle, was himself a physician. lt is also
widely held that Doyle based the character of Holmes on a
lecturer at the University of Edinburgh, Dr. Joseph Bell.
In the 1BOO's gr~at significance was given to appearance
ar,ct the interpretation of certain features. The discipline of
Physiognomy proposed that "the correspondence of
externa! figure with interna! qualities is not the consequence
of circumstances ... but related like cause and effect ...
the form and arrangement of the muscles determine the
mode of thought and sensibifity." *
fiThe Complete Sherlock Holmes, Vol.1, p. 352
Doubleday & Co. lnc., New York
* Lavater's Essays on Physiognomy, 9th Edition
William Tegg & Co., London, England, 1855
With over one-third of our brains involved in the direct or
indirect interpretation of visual images, humans can be said
to be visual creatures. For many, the ultimate truth is
observing, hence the saying, "Seeing is believing."
Appearance in our culture is often a highly significant
statement about who we are, and what we consider
important. Though we do not live in an era where as much
can be gleaned from attire as in Holmes' Victorian England,
a good deal of useful information is still conveyed through
appearance. No psychiatric diagnosis is made, nor is any
treatment recommended purely on the bas; of appearance.
lt is one of the first modes of assessment during an
interview, andas such provides important clues to areas for
further questioning.
Have the curiosity and initiative to ask about aspects of
attire. This aids in the process of hypothesis generation.
To paraphrase Holmes, we cannot theorize without data. Our
job is to try and understand patients; every effort should be
made to keep our opinions and biases from influencing
interviews.

36 37
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1

id .. ilÍítJ iiJ ilj itllll Á~EA~CE&J &J

Relerences lor inlormation on tattoos Referentes

R. Raspa & J. Cusack INTRooucToRY TExrnooK OF PsvcHIATRY, 2No. EomoN
Psychiatric lmplications of Tattoos Nancy Andreason, MD, Ph.D & Oonald Black, MD
American Family Physician, 41:5, p. 1481-6, May 1990 American Psychiatric Press lnc., Washington, D.C. 1995

J. Appleby THE CLINICAL INTERVIEW USING DSM-IV

Letter to the Editor re: Psychiatric lmplications of VoLUME 1: THE FUNDAMENTALS
Tattoos E. Othmer, MD, Ph.D & S. Othmer, Ph.D
American Family Physician, 43:4, p. 1162/1171, April 1991 American Psychiatric Press lnc., Washington O.C., 1994

N. Gittleson, et al. BoARDlNG TIME, 2No Eo1r10N

The Tattooed Psychiatric Patient J. Morrison, MD & R. Muñoz, MO
British Journal of Psychiatry, Vol. 115, p. 1249-51, 1969 American Psychiatric Press lnc., Washington, O.C., 1996

J. Farrow, R. Schwartz & J. Vanderleeuw CoMPREHENSIVE TEXTBOOK oF PsvcHIATRY, 6rn EomoN

Tattooing Behavior in Adolescence H. Kaplan, MD & B. Sadock, MO, Editors
Am. J. of Diseases of Children, 145:2, p. 184-7, Feb. 1991 Williams & Wilkins, Baltimore, 1995

K. Sperry 5YNOPSIS OF PSYCHIA TRY, 7TH EDITION

Tattoos and tattooing: Part 1 H. Kaplan, MD, B. Sadock, MD & J. Grebb, MD, Editors
Am. J. of Forensic Med. & Path. 12:4, p. 313-9, Oec. 1991 Williams & Wilkins, Baltimore, 1994
Tattoos and tattooing: Part 11
Am. J. of Forensic Med. & Path. 13:1, p. 7-17, Mar. 1992 01AGNOSTIC & 5TATISTICAL MANUAL OF MENTAL DISORDERS,
4TH EomoN
Additionally, the Internet is an excellent source of current American Psychiatric Association, Washington O.C., 1994
information on ali forms of body art. Check out the following:
• http://www.fleshcanvas.com An excellent resource for preparing written reports is:
• http://www.lycaeum.org THE CuNICIAN's THESAURUS, 4rH EomoN
• http://www.cityscape.co.uk E. Zuckerman, Ph.D
• http://www.tattoos.com Clinician's Toolbox, The Guilford Press. New York, 1995
• http://ziris.syr.edu/dj/dj. tatoos
The section especially applicable to report' - d appearance is
' http://wwvv.zelacom.com/-nyctattoo
summarized on p. 97-101.
• http://www.infogo.com/homepage/synth/tattoos.html
• http://www.bme.freeq.com
the rec.arts.bodyart newsgroup for postings and the FAQ's
(frequently asked questions)

38 39
~··
L-
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·• S"fU'FF
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"

4. What starring role brought Wallace Beery to national 2 Dementia

prominence?
1 Anencephaly, or 100% false transmitters
5. What makes this test different from ali other tests? in cortical neurons

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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b• ..!.,,.;
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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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What Í$ the diagnostic signilicance of
observations made regarding behavior?
e Schizophrenia 295.X
A (4) Grossly disorganized or catatonic behavior
lil Majar Depressive Episode 296.X
A. (5) Psychomotor agitation or retardation nearly every day
(observable by others, not merely subjective feelings of
restlessness or being slowed down)
e Manic/Hypomanic Episode 296.X
B. (6) lncrease in goal-directed activity (either socially, at
work or school, or sexually) or psychomotor agitation
" Obsessi'·e-Compulsive Disorder 300.3
A. Compuls1ons - repetitive behaviors (e.g. hand washing,
ordering, checking) or mental acts (praying, counting,
repeating words silently) that the person feels driven to
perform in response toan obsession
e Posttraumatic Stress Disorder 302.X
D. (4) Hypervigilance
D. (5) Exaggerated startle response
• Generalized Anxiety Disorder 300.02
C. (1) Restlessness or feeling keyed up or on edge
C. (5) Muscle tension
• Exhibitionism 302.4
A ... behaviors involving the exposure of one's genitals to
an unsuspecting stranger
• Frotteurism 302.89
A. ... behaviors involving touching and rubbing against a
nonconsenting person
46
~ .... '1a W¡¡¡¡ -.:~ w . . . aJ 9il _, 'ffNHAMR tii 1111
• Narcolepsy 34 7
B. (1) Cataplexy (i.e. brief episodes of sudden bilateral loss
of muscle tone, often in association with intense emotion)
• Kleptomania 312.32
A. Recurrent failure to resist impulses to steal objects that
are not needed for personal use or for their monetary value
• Schizotypal Personality Disorder 301.22
A. (7) Behavior or appearance that is odd, eccentric or
peculiar
A. (9) Excessive social anxiety ...
• Borderline Personality Disorder 301 .83
A. (5) Recurrent suicida! behavior, gestures or threats, or
self-mutilating behavior
• Narcissistic Personality Disorder 30-. .d1
A. (9) Shows arrogant, haughty behaviors or attitudes
• Tourette's Disorder 307.23
A. Both multiple motor and one or more vocal tics have
been present at sorne time during the illness. although not
necessarily concurrently (a tic is a sudden, rapid, recurrent,
nonrhythmic, stereotyped motor movement or vocalization)
• Neuroleptic-lnduced Acute Dystonia 333. 7
A. (1) Abnormal positioning of the head and neck ...
(2) Spasms of the jaw muscles
(3) lmpaired swallowing, speaking, or breathing ...
(5) Tongue protrusion or tongue dysfunction
(6) Eyes deviated up, down, or sideways
(7) Abnormal positioning of the distal limbs or trunk
• Neuroleptic-lnduced Parkinsonism 332.1
A. (1) Parkinsonian tremor
(2) Parkinsonian muscular rigidity
(3) Akinesia
. 47
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Neuroleptic-lnduced Postura! Tremor 333.1

s
A A fine postura! tremar that has developed in association
with the use of a medication
B. The tremar has a frequency between 8-12 cycles per
second
a Neuroleptic-lnduced Tardive Dyskinesia 333.82
B. The involuntary movements occur in a variety of
·patterns:
(1) Choreiform movements
(2) Athetoid movements
(3) Rhythmic movements
a Neuroleptic-lnduced Acute Akathisia 333.99
B. At least one of the following is observed:
(1) Fidgety movements or swinging of the legs
(2) Rocking from foot to foot while standing
(3) Pacing to relieve restlessness
(4) lnability to sit or stand still for at least severa! minutes
Diagnostic Criteria are from the DSM-IV.
©American P<:·1chiatric Association, Washington, 0.C. 1994
.~eprinted with permission.
These behaviors are among the most likely to be observed
in interview situations. However, the contribution of behavior
to diagnosing mental illness goes beyond the specific criteria
listed here. Behaviors that are reported but not seen are
presented in the body of the history, since the MSE is a
record of what happens only during the interview.
Observation of behavior is the critica! element in descriptive
psychopathology. Phenomenology is the study of observed
events, without inferring a cause. This was the initial basis
far classifying mental disorders. The other majar division is
explanatory psychopathology.
N.B. Behavior, movement and activity are used
synonymously in this chapter.
How do I describe the general aspects of
attivity?
Activitylevel is a global description of patients' physical
movements. Individual factors assessed are:
• Posture
• Range and frequency of spontaneous movements
• Cooperation and ability to carry out requested tasks
Activity leve! is generally recorded as:
• lncreased (also referred to as speeded up or agitated)
• Decreased or Slowed (hypokinesis, bradykinesia)
• Within normal /imits (WNL - a key three-letter
abbreviation (TLA))
Even in cases where there are no obvious behavioral
abnormalities, a brief description provides a visual image of
what it was like to be in the interview. Far example:
"Mr. Y.K.K. sat comfortably in the room with his arms fo/ded across his
chest and absent-minded/y fiddled with the zipper on his jacket ... "
"Ms. Scholl sat cross-legged in the cha ir far the d1 - .ion of the
interview and managed to braid her shoe laces dunng that time."
lt may be helpful to classify movements in three ways:
• Conscious voluntary movements - such as getting
up to clean the dirt off the light switch
• Unconscious voluntary movements - such as
adjusting eyeglasses or clearing the throat; habits &
mannerisms fall into this rategory
• lnvoluntary movements - such as tremors or dystonias;
these are usually considered neurological abnormalities
The MSE records only the behavior, not the patients' interna!
experiences. For example, patients who clean light switches
may have a compulsion to do so; patients who frequently
adjust their glasses may have a motor tic; however, only the
action itself is recorded.

48 49
~_¡ ~!3 u .:_,¡JJ~~...:J=-=Lí=.LI==.a'.J="°=~-&J=L!~~·'·.
Agitation is used to describe physical restlessness, usually
with a heightened sense of tension and leve! of arousal.
Common signs are:
• Handwringing, finger tapping or fidgeting
• Frequent shifts in posture or position
• Foottapping or rhythmic leg movements
e1 Frequent changes in the focus of attention
8 Decreased ability to concentrate due to the distracting
influence of feeling restless (as opposed to other causes
such as a decreased leve! of consciousness, etc.)
Agitation can also be used to describe an emotional state or
affect, in that patients can bolh feel and appear agitated.
Psychomotor refers to movements that are psychically
determined, as opposed to those caused by externa!
sources. For example, a high intake of caffeine can cause
people to feel restless and agitated. Another common cause
are those annoying little hairs that stick in back of your neck
after a haircut. This distinction is important because there
are many causes far agitation (see list below). In recognition
of this, the DSM-IV specifies psychomotor agitation in the
diagnostic criteria far manía, hypomania and depression.
Agitation is seen in the following conditions:
• Substance ingestion/withdrawal, common causes of
which are ethanol, benzodiazepines and stimulants
• General medica! conditions such as hyperthyroidism,
hypopan:1ihyroidism, dementia and delirium
• Psychiatric conditions such as schizophrenia,
depression, mania/hypomania, any of the anxiety
disorders, and Cluster A & C personality disorders*
• Agitated depression: patients may experience a mixed
state of manic and depressive symptoms. This is very
unpleasant to endure and more highly correlated with
completed suicide than other bipolar mood states
• Cluster A - Paranoid, Schiz'Jid, Schizotypal
Cluster 8 - Histrionic, Borderline, Antisocial, Narcissistic
Cluster C - Obsessive-Compulsive, Oependent, Avoidant
50
f.,¡ ti o fu
Hyperactivity refers to an increased level of physical
energy. lt is distinguished from agitation by the absence of
inner tension, and by the fact that the extra energy is usually
goal-directed. Patients often speak quickly and at length, and
may become unusualiy assertive or even aggressive.
This is a common observation among patients with:
• Manía or hypomania
• Attention-DeficiUHyperactivity Disorder (ADHD)
• Obsessive-Compulsive Personalities (under a deadline)
An increased level of activity can also be seen in the
following conditions:
• Catatonic excitement (covered in the section on
catatonia later in this chapter)
• Seizure disorders. particularly in the interictal periods
after one seizure and befare the onset of another
• Head injuries, delirium or other confusional states
• Dissociative states or culture-bound syndromes
Akathisia is defined as a state of inner drivenness to keep
moving. lt occurs as a side-effect of antipsychotic
medication. Patients often seem ill at ease, move their legs
rhythmically or have to get up and walk around the room.
Akathisia cannot be differentiated from other states of
agitation by observation alone. lt is a subjective experience,
and must be inquired about with patients who are on
neuroleptics. More information on akathisia ;... 1ncluded in this
chapter and in ENDINGS - SUICIDAL & HOMICIDAL IDEA TION.
Restless Legs Syndrome is characterized by
uncomfortable sensations in the legs compelling the sufferer
to keep moving. This usually occurs at the onset of sleep,
and is classified as a Sleep Disorder (Dyssomnia).
Prolonged inactivity, uremia, and anemia (often seen in
pregnancy) are known causes. An autosomal dominam
inheritance has been found. Benzodiazepines, among
severa! other medications, provide effective treatment.
51
iif .~"' ~-·~1~~.:-~t-:,,lt~ ~-J ,;lr:__-"--'f-~~~.oc: U: iÜ; .;¡¡~· 111:
Psychomotor Retardation refers to a slowness of voluntary
and involuntary movements. Other terms used to describe
this observation are hypokinesia or bradykinesia, and in
extreme cases the virtual absence of movement is called
akinesia. This description applies to the initiation, execution
and completion of movement and excludes those who may
have trouble initiating tasks, but can complete them readily
(such as obsessive-compulsive or dependent personalities)
or those who start tasks readily but can't complete them
(such as patients with dementia or mania).
Often accompanying the slowed movements are changes in
voice and prosody of speech (the natural emotional tone or
inflection of speech). Most people move spontaneously
when speaking, often gesturing with their hands to facilitate
speech orto accentuate what they are saying. Other typical
movements include adjusting eyeglasses, scratching,
shifting posture, crossing and uncrossing legs, folding and
unfolding arms, etc. Keeping track of patients' repertoire of
spontaneous movements is valuable in assessments. Make
a point of asking about unusual or repetitive actions, or the
absence of typical movements. Descriptions of behavior
must also be prefaced by an indication of the level of
consciousness. You would not be surprised that obtunded or
comatose patients demonstrated severely diminished body
movements (akinesia in these cases), but you'd probably like
to hear about their level of consciousness first.
Facial expression is another important aspect to observe.
Check to see if patients convey a sense of what they are
discussing with appropriate facial expressions. Mask-like or
masked fac11s refers to the absence of use of facial
muscles, leading to an appearance reminiscent of a mask.
Abulia is a reduced will to take-action or initiate thought,
often with an indifference to the consequences. Spontaneity
of speech and response to stimuli are also slowed.
52
w:: ,,. 111 · .rir ., . .· ili •· '1,,, "'·~ . ~;;, ..fl\ · •·: .11
In general, mental processes are slowed along with
movements, with patients reporting that they are unable to
think as fast as usual. This needs to be distinguished from
mental retardation, which is an intellectual deficit or mental
subnormality. The distinction is that patients who are
mentally retarded have permanent learning disabilities, not
ones that will clear with time. Mental retardation is defined as
subaverage mental functioning prior to age 18. lt is different
than dementia in that patients with dementia have achieved
a normal leve! of intelligence and then acquired an illness
causing them to lose their mental faculties. Depression can
affect cognitive functioning so strongly that the person
appears demented. This is called pseudodementia, ar: more
recently, the dementia syndrome of depression. While this
latter term more accurately reflects the pathology of thP
process, pseudodementia is seen in other conditions and is
still widely used as a descriptive term.
Causes for decreased or diminished movements are:
• Depression, which is the most common psychiatric
cause; in past diagnostic nomenclature, there was a
subtype of depression called retarded depression
• Schizophrenia, and in particular the presence of
negative symptoms
• Medication side-effects, especially to antipsychotics
• Catatonia, explained in detail later in this chapter
• Dementia, of any cause
• General medica! conditions, in particular illnesses which
have fatigue as a prominent symptom, such as
hypothyroidism, Addison's disease, mononucleosis,
arthritis, Parkinson's Disease, Multiple Sclerosis, etc.
Occasionally, only certain parts of a patient'& Jody may have
diminished or absent movements. Common causes are:
• Pain syndromes, e.g. affecting the use of extremities
• Paralysis of one or more limbs
• Conversion disorders, defined as a psychogenic
impairment of motor or sensory function
53
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yJ -="

(1) Akathisia has been mentioned previously. lt is called
neuroleptic-induced when it is caused by antipsychotic
medication. fhe usual manifestations are rocking, fidgeting,
pacing or generally feeling compelled to keep moving. lt can
be quite uncomfortable. Suicides and violence have been
reported because it was not detected or adequately treated.
lt is caused iatrogenically by initiating or increasing
antipsychotic medication, or by decreasing or stopping
agents which reduce the symptoms. Trying to voluntarily
suppress akathisia-driven movements increases the sense
of discomfort. The ~ & B group Carneo has a song called
"Shake Your Pants," which is a succinct description of what it
feels like to have this condition.
(11) Automatisms are "automatic" involuntary movements
that can range from relatively minar to complex behaviors.
They occur most commonly in epileptic seizures of the
partial complex or absence type. Automatisms may be the
only outward manifestations of a seizure disorder. They are
also seen in head injuries, substance ingestion, catatonia,
and dissociative and fugue states. By definition,
automatisms occur during an altered state of consciousness.
During automatisms, action.:> can range from purposeful to
disorganized, and mayor may not be appropriate for the
situation or the person displaying them. Patients may be
partially aware of their surroundings. They may continue with
their actions, but do not seem "quite right" at the time, and
are amnestic for the episode. Typical automatisms are:
• Lip-smacking or uttering words (which are understandable)
• Fumbling with clothing (e.g. doing and undoing a button)
• Eye blinking or staring with an unwavering stare
• Continuing with activities such as driving a car, or
repetitive actions such as sorting or cleaning
Automatisms are occasionally complex actions that result in
violence towards the self or others, and for this reason also
have a leg:-' significance and definition.
(111) Catatonia is a term applied to a diverse number of
postura! and movement disturbances. The motor disorders
can include both increased and decreased lf ..~Is of activity.
The term catatonia was developed by Kahlbaum and initially
was a diagnostic entity on its own. lf Kahlbaum had been a
dog person, he would have called it dogatonia.
In the DSM-IV, catatonia is diagnosable in three forms:
• A subtype of schizophrenia
• A specifier for a mood episode
• Due to a general medicar .:0ndition
Catatonia is also found in:
• Periodic catatonia, a rare variant involving an alteration
of thyroid function and nitrogen balance
• Neurologic illnesses that involve the basal ganglia, ,..
frontal lobes, limbic system & extrapyramidal pathways ;•t ·
• Syphilis and viral encephalopathies .. ~.
• Head trauma, arteriovenous malformations, etc. ;·
• Toxic states (e.g. alcoholism, fluoride toxicity)
• Metabolic conditions (e.g. hypoglycemia, hyper-
parathyroidism)
This mnemonic lists DSM-IV criteria for catatonia:
"WRENCHES"
Weird (peculiar) movements
Rigidity
Echopraxia - copying the body movements of others
Negativism - automatic opposition to ali requests
Catalepsy (waxy flexibility)
High level of motor activity
Echolalia - repeating the words of others
Stupor - immobility

54 55
h' ~-' ir¡ ~'""~~~~:__6--~ -1)~~-U-~:.A:'-d; Q:
Weird (peculiar) voluntary rnovements given as examples in
the DSM-IV consist of:
• lnappropriate or bizarre postures that are often
uncornfortable and maintained for extended periods of
time (e.g. kneeling or squatting when a chair is
availablP). Most people would find this uncomfortable,
but patients experiencing catatonia appear to be able to
endure this without apparent discomfort. Another
exarnple is the psychological pillow, in which patients
lie with their heads elevated without any support.
• Stereotyped movements are repetitive, driven, non-
purposeful actions. These are thought to originate in
something of personal, autistic significance. Examples
include body rosking, head banging, self-biting, picking
at one's skin or orífices, hitting one's self, etc. They are
usually "socially unacceptable" behaviors and have no
adaptive function (except at rock concerts ).
e Prorninent mannerisms are exaggerated, crude or
unusual behaviors. They are more socially appropriate
than stereotyped movements, but often occur out of
context or have sorne other odd component. For
exarnple, sorne patients rnake a very grand show of
seeking out new people and
giving thern a prolonged, firm
handshake accompanied by
repeated nodding, a stern
expression and loud greeting.
• Prorninent grimacing refers to a
particularly hollow smile. This
humorless baring of the teeth
with deadened, unblinking eyes
is a seen rnost frequently among
patients with catatonia.
56
4" .:.w...:,_:_~~!!!!".::"",',,,_Üli.!!!!ll~~/-.:=~~··,_·'·-=~='>:..:.'·_...líl=·!t."·""---=•='>_··-=·=·';:..•""-•=·
·=.~---=lj{'="--...:llfl.~··:.,"'~=&:"':;fü~·:.:·=·::·~~R lft ft
Rigidity is central to the definition of catatonia (given by S1Ms
p. 336), as "a state of increased tone in rnuscles at rest,
abolished by voluntary activities, and thereby distinguished
from extrapyramidal rigidity." In the latter condition, muscle
tone would not be reduced with rnovement.
Extreme rigidity can lead to muscle breakdown, acute renal
failure and in sorne cases, death. This is re' ,red to as lethal
catatonia, which can result frorn any forrn of catatonia. This
is a medica! emergency and after supportive rneasures, is
effectively treated with electroconvulsive therapy (ECT).
Various types of rigidity can be found:
• Lead pipe: resistance to movement in all directions
• Cogwheel: a stop-and-go pattern, seen in Parkinsonism
• Clasp Knife: resistance w a certain point, then giving
way
Echopraxia is the involuntary repetition of the movements of
others (mimicry would be voluntary). For exarnple, a patient
who is instructed to touch her left ear when you cross your
arms will not be able to comply, and will instead copy your
actions as if she were a rnirror image. This has also been
called echokinesis, echomimia and copying mania. lt also
occurs in seizure disorders, tic disorders and dementias.
Echopraxia is one of the behaviors seen in automatic
obedience (covered in this chapter).
Negativism refers to the automatic refusal to cooperate.
Simple requests are strongly opposed forno obvious reason,
even in cases where patients would benefit from
participation (e.g. taking off a warm coat when inside).
Patients typically either refuse, or do the exact opposite of
what is asked of them. lf patients are given gentle physical
encouragement, they will passively resist. A large but as yet
unpublished group of parents have proposed that this is a
developmental stage that most teenagers seem to pass
through.
57
.u t. i.11 -w_-... -~--u-.u~-.J-u·--.J·--..J--U-u---M·......W
Catalepsy (waxy flexibility, flexibilitas cerea) is a
phenomenon whereby patients can be moved into new
postures or positions, and will stay this way for periods of
thirty seconds or more. In contrast to catatonic rigidity,
patients cannot be moved, those with waxy flexibility
demonstrate sorne resistance. This condition was so named
because early phenomenologists likened the malleability of
patients' limbs to that of candle wax.
High level of motor activity, called catatonic excitement,
is an episode of hyperactive behavior consisting of a high-
pitched "running amok" that ends when the patient collapses
i1 exhaustior :ir when treatment is started. This can
progress to the point of becoming a medica! emergency due
to fever, dehydration, electrolyte abnormalities, autonomic
instability and an altered leve! of consciousness. During this
episode, patients may display any of the other movement
abnormalities that are part of catatonia: bizarre postures,
grimacing, echopraxia, rigidity, waxy flexibility, etc.
Echolalia is the involuntary repetition of words, such as
greetings, statements and questions, without patients being
able to express their own thoughts. Again, this differs from
mimicry in that patients don't do this of their own volition.
Stupor is probably the most commonly known catatonic
behavior. Patients can show a decrease in movement to the
point of being mute and akinetic. They may also have a
reduced awareness of their environment. A stupor can last
for a prolonged time, and even lead to the point where an
intervention is necessary for nutritional or hygienic reasons.
An episode can end abruptly with a sudden outburst or
irnpulsive act that is not in response to externa! stimuli. A
condition that appears similar is akinetic mutism (also
called a coma vigil). lt is a state of unconsciousness where
patients lie mute and unresponsive but may follow objects
with their eyes. A number of vascular, traumatic or
neoplastic conditions can produce this syndrome.
58
l.i ~~-*-la--l':ill.-M-M--llil.-&J.-M.-'til.......IJ.;.:;:.:ÁI~ Id
There are other catatonic behaviors beyond those listed in
the DSM-IV. Another group, the automatic behaviors,
involve instantaneous obedience:
• Echopraxia and echolalia have been discussed
• Mitgehen is a German term meaning "going with" and
can be demonstrated by directing patients with a very
light touch - a typical example is to have patients
extend an arm, which can be lowered or elevated with a
very light touch even when they are instructed to r'3sist
• Mitmachen, German for "making with," is the slow
spontaneous return to the original position
• Automaton-like behavior involves patients carrying out
requests immediately in stilted, torced f- ,hion
• Advertence is the heedful facing of the interviewer when
being addressed, as if ·required by strict discipline
These conditions should be suspected in situations involving
an excessive and mechanistic leve! of cooperation. They can
be tested by instructing patients not to perform them.
Negativism has already be0ri mentioned. However, it should
be emphasized that such patients actively resist ali attempts
to reach them. This is to be differentiated from uncooperative
patients who display a passive-aggressive demeanor and
attempt to undermine or sabotage efforts in an interview.
Other aspects of negativism are:
• Gegenhalten, which describes the situation where
patients resist being moved with a force equal to that
being applied
• Aversion, which is the opposite of advertence in that
patients automatically shun examiners upon hearing
them speak
Patients can shift from automatic obedience to negativism
without obvious precipitants; known as ambitendency. A
final feature of catatonia is a facial expression called
schnauzkramp (German for snout cramp), which is a
puckering or protruding of the lips and jaw.
59
tl.I'
!.. l.
11
'
b ....
L.1 lb' iti ~ ~ ~ et --fil-&¡-Q41rl'1'--D' ta'
(IV) Choreoathetoid movements are seen in various
neurologic and psychiatric disorders. The term is an
amalgamation of two different movement disorders:
• Choreiform movements are involuntary and appear as
irregular, jerky, spasmodic and quasi-purposeful; they
are irregularly timed and generally not repeated; these
movements most often affect the face and arms; an
example would be someone whose hand shot up
towards his face and who incorporated this into an
adjustment of his hair
• Athetoid movements are slow, writhing (snake-like),
twisting, and have the appearance of following a pattern;
any muscle group can be affected; an episode might look
like someone practicing tai chí, or using a hand to imitate
an airplane climbing and diving
• Ballismus is a larger-amplitude, faster, and more violent
motion (it has the same word root as ballistics); it usually
occurs on ')ne side of the body (hemiballismus) and
resembles speeded-up athetoid movements (like a
punch into the air)
The most common causes for these movements are as
follows:
• Huntington's Chorea
o Sydenham's Chorea (rheumatic fever)
a Wilson's Oisease (hepatolenticular degeneration)
• Multiple Sclerosis
e Tourette's Disorder
• Liver or kidney failure
• Aging/hereditary causes
• Various infarcts, traumas and tumors
Of particular interest in psychiatry are:
• Use of antiparkinsonian (dopaminergic) agents
• Use of stimulants (e.g. for ADHD)
• Use of anticonvulsants (e.g. phenytoin)
• Lithium toxicity
• Tardive Oyskinesia (covered in this chapter)
60
ilif_--if. k • 'il.'--:M-líl--61.~-"---......,._ ..•;::,. • .r ltl
(V) Compulsions are defined in the DSM-IV as:
(1) Repetitive behaviors or mental acts that the person feels
driven to perform in response toan obsession, or according
to rules that must be applied rigidly
(2) Behaviors ar mental acts aimed at preventing or reducing
distress or preventing sorne dreaded event or situation;
however, these behaviors ar mental acts are either not
connected in a realistic way with what they are designed to
neutralize or prevent, or are clearly excessive
Two points bear emphasizing with this definition:
• Compulsions can be entirely mental experiences
(prayers, sayings), though the majority are actions
• The "rules that must be applied rigidly" are self-imposed,
not due to involvement with an organization with a strict
code of conduct (e.g. mom. the military. boarding
schools)
Compulsions are also:
• Unwanted and ego-dystonic (insight is preserved)
• Purposeful or semi-purposeful actions performed to
lessen anxiety (not performing them increases anxiety)
• Performed consciously (though compulsions are often
resisted to at least sorne degree, at least initially)
• Stereotyped (repeated over and over)
• Ritualistic (performed the Rame way each time)
• Usually linked to obsessions; e.g. those with obsessional
doubt. check things; those obsessed with dirt, clean
things
Compulsions can occur individually, but are usually
preceded by obsessions, (explained in the chapter on
THOUGHT CoNTENT). Obsessions are recurrent thoughts.
images or impulses that are:
• Recurrent and recognized as excessive or unreasonable
• Not simply excessive concerns about realistic problems
• Recognized as a product of the person's mind, as
opposed to thoughts being inserted from elsewhere
61
,,,j u lilA -......-~...,=-.,,j-~,.j~a.J--,J=--~~=-.J~=-W-...t--M.
A patient's curren! compulsions may or may not be evident
w ....
in interview situations. Sorne patients can endure the anxiety
that stems from suppressing compulsions for the duration of
the time spent being observed. lf compulsions are reported
but not seen, they should be listed in the case presentation
as a present or past psychiatric illness, but not in the MSE.
The most common compulsions are:
e Excessive or ritualized grooming (handwashing,
showering, brushing teeth, etc.)
e Excessive cleaning of objects (e.g. decontamination)
e Rituals of repetition (circling a room in a certain manner,
putting clothes on in a certain arder, etc.)
11 Checking (doors to see if locked, stove to see if turned
off, containers to see if closed, etc.)
a Counting, Touching, Measuring
., Ordering or arranging (usually in a logical sequence,
e.g. size, alphabetical arder, for symmetry and precision)
<i Hoarding and Collecting
111 Asking or Confessing
The following questions can help screen for compulsions:
" Are ther,,- 3ctions that you perform repetitively?
e Do you feel you must perform an act against your will?
a Do you spend time doing something over and over?
., Do you llave a sense of doom about not carrying through
with a certain action?
o Do you, for example, clean, check, count or arrange
things on a repetitive basis?
The DSM-IV stipulates that obsessions or compulsions
involve at least one hour per day. Sorne patients have
multiple compulsions, and a quick "laundry list" of common
ones may help screen far their presence. Compulsions can
change over time. In sorne cases, patients will defend their
compulsions as being proper (e.g. cleaning or washing)
despite the psychosocial cost to them (e.g. marital discord,
losing their job )_
62
ü9 • Mm . ., w .i lílJ. *'- .,,¡, ..,, ..,
~H~R Id
(Vla) Dystonias are involuntary increases in muscle tone,
and are a specific type of extrapyramidal side effect.
Dystonias are manifested as sustained torsions or
contractions of muscles (usually muscle groups) that give
patients a contorted appearance. They generally occur in
three areas:
• As a reaction to antipsychotic medications
e As a consequence of chronic schizophrenia
• As the consequence of a neurologic condition
Acute dystonias usually occur within the first five days of
neuroleptic administration. Young males and patients who
receive high potency neuroleptics (e.g. haloperidol) are at
higher risk far these reactions. Sorne clinicians advocate that
antiparkinsonian agents be used prophylactically to preven!
such reactions in higher-risk groups .
Common dystonias are:
• Oculogyric crisis or spasm: fixed upward gaze or eye
muscles torced into a dysconjugate gaze
• Torticollis or wry neck: a spasmodic contraction of
neck muscles that causes the head to rotate and the
ch in to point to the side opposite the sp< _.n
• Opisthotonos, also known as are de cercle: a spasm in
the neck and back that causes an arching forward; in
severe cases, recumbent patients have only their heels
and their backs of their heads touching the floor
• Laryngospasm: a dystonia of the muscles controlling
the tangue and throat; it can lead to difficulty speaking,
swallowing, and in severe cases, even breathing
These reactions are very uncomfortable and frightening for
patients. The presence of a dystonic reaction requires
immediate intervention. Prolonged reactions are a majar
reason that patients do not comply with their medications.
Untreated, these reactions can last at least an hour.
Fortunately, dystonias can usually be treated effectively and
quickly with antiparkinsonian medications.
63
~,/ w ~y ~tr-~-*F=itJk-iíÍJ~~~-iir-iJ~~ a: ·~
The groups of medications that are commonly used to treat
these conditions are:
o Anticholinergic agents
• Antihistamines
e Benzodiazepines
(Í} r~-blockers
0 Dopamine agonists
Most acute dystonias seen in current practice are due to
antipsychotic medication_ However, dystonias have been
well documented in patients with schizophrenia who have
never been exposed to neuroleptic medication. Not only
have extrapyramidal reactions been recorded, but a whole
range of motor disorders have been seen, including:
• Posture, tone and gait
a Eye movements and blinking
• Facial, head, trunk and limb movements
e Speech production
0 Purposeful movements relating to completing activities
_Dystonias can also be tardive as opposed to acute. Next to
torticollis, the most common is blepharospasm
(involuntary closure of both eyes), though this often spreads
to muscles controlling head movements and chewing.
Dystonia itself is a neurologic condition. lt is classified on the
basis of its etiology, age of onset, and distribution. Dystonia
's differenfü=. ;d from other motor disorders (such as choreo-
athetoid) by the presence of repetitive, patterned and
sustained movements. Causes of dystonia most relevant to
psychiatry are:
• Lesch-Nyhan Syndrome, Rett's Disorder, Reye Syndrome
• Huntington's Disease, Wilson's Disease, Parkinson's
Disease, Multiple Sclerosis
• Head trauma or peripheral trauma
• Methane ar carbon monoxide poisoning
• Medications - anticonvulsants, bromocriptine, fenfluramine
• Psychogenic
64
0 ./ w Wi" .v -~-· lfi( ilif__it _il(__m. lllíEH.ORíti ,.
(Vlb) Other Extrapyramidal Symptoms (EPS)
The pyramidal tracts are made up of axons that originate in
the posterior frontal and anterior parietal lobes. Ninety
percent of the fibers pass through the pyramid of the medulla
and forma tract found laterally in the spinal cord. The group
of nuclei known as the basal ganglia make up the majar
component of the extrapyramidal system.
The following is a list of extrapyramidal reactions (in their
usual order of occurrence after neuroleptic administration):
• Dystonic reactions (hours to days)
• Akathisia (hours to weeks)
• Akinesia or Bradykinesia (days to weeks)
• Rigidity (dáys to weeks)
• Tremors (weeks to months)
• The Pisa and Rabbit Syndrome (months to years)
Parkinsonism refers to the symptoms but not the presence
of Parkinson's Disease, which is an idiopathic depletion of
dopaminergic neurons in the basal ganglia and has a
sporadic and familia! form.
The causes of parkinsonism most relevant to psychiatry are:
• Medication-induced dopamine blockade - neuroleptics,
which are dopamine receptor blockers (and others with
this action such as the antidepressant amoxapine and
several antiemetics - prochlorperazine,
metoc/opramide, promethazine, trimeth-· '_,enzamide,
thiethylperazine, trifluopromazine)
• Medication-induced dopamine depletion, which occurs
with reserpine and tetrabenazine
• Uthium, disu/firam, methyldopa and sorne of the calcium
channel blockers
• Toxins such as carbon monoxide, cyanide, ethanol,
methanol and MPTP
• Head trauma
65
~ .a:J ~-~~~=;ar=~;;rar=&r=-1-=aJ-~~~=~~~~~ ~ w~~~---t.í~--·~~~-~-~~~=4iilJ--~~~~~ ~

Parkinsonism Tidbits Parkinsonism can be understood by looking at the two majar

.¡¡
The features of parkinsonism are listed in the mnemonic neurotransmitters in the basal ganglia, acetylcholine and
"TRAP"- T-tremor, R-rigidity, A-akinesia, P-postural changes. dopamine. The basal ganglia contain the highest
..
Tremar at rest is one of the most common signs of concentration of 0 2 receptors in the brain, which are thought
Parkinsonism. lt has been called a pill-rolling tremor to be the site of action of "traditional" neuroleptics
due to the action of the fingers. The tremor occurs at 3-5 (olanzapine, clozapine, risperr:tal and remoxipride have other
Hz and can also be seen in the facial muscles and legs. sites of action).
In medication-induced parkinsonism, there is usually a
c;:oarser type of tremar. • When they are in balance, no movement disorder is
e Rigidity in EPS is of the lead pipe or cogwheel type; present.
these are descriptions of what it feels like for an
examiner to passively move the limb.
~
Akinesia (or more often, bradykinesia) is present ~ 1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

I •
because the basal ganglia fails to activate cortical areas 1 acetylcholine ~
I r

that are involved in the generation of movement.

Q
Postural changes occur both because of muscle rigidity

•
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
[

negative symptoms of schizophrenia (covered later in

this chapter) and the anergia of depression ,~ ~

• The DSM-IV lists Neuroleptic-lnduced Parkinsonism ; dopamine ~

~
332.1 as a research diagnosis to be coded on Axis 1

66 67
~~ 'l ~*\.~E*~1r=« -7 k lit 6r ~c>I
2.~
Jr;=r;=r;r;r; r¡ r¡r;:r;:c;r, ':i
~ acetylcholine ~
] after starting medication. Oyskinesia is a distortion of
1.-t-
'YYYYYYYYYYY>-
' >'
dopamine >-
>'
To correct this mismatch, two strategies are used:
1. Pharmacologically increasing the amount of dopamine.
This doesn't work in psychiatry because dopamine agonists
generalfy worsen the symptoms of psychosis. However, this
is one of the main modes of treating Parkinson's Disease.
2. Pharmacological/y decreasing acetylcholine. This is the
approach taken to treat parkinsonism caused by psychiatric
medications. There are several anticholinergic agents
(ACA) available - benztropine, biperiden, procyclidine,
ethopropazine and trihexyphenidyl. Complications can arise
because neuroleptics themselves have anticholinergic side
effects. The additive effects can result in adverse peripheral
reactions (dry mouth, blurred vision, constipation, flushed
skin, etc.) or central reactions (confusion, restlessness,
impaired memory, hallucinations, incoherence, etc.)
Other extrapyramidal symptoms (EPS) are:
• Pisa Syndrome, so named because patients' posture
bears a resemblance to the Leaning Tower of Pisa. lt is a
tardive dystonia that causes a torsion spasm of the
torso muscles with the result that patients bend to one
side (also called pleurothotonus).
a Rabbit Syndrome, a quick, alternating perioral
movement that resembles the chewing action of a
rabbit's mouth (like Bugs Bunny eating a carrot), often
with a smacking of the lips. This syndrome is more rapid
and regul'. than the oral-facial-buceo-lingual movements
seen in tardive dyskinesia.
68
a ¡¡¡,: Lid t.j .:¡:j ~ít' Mi" ... , W.t lir '( ..,,/ ¡j/ k '*"" .A...;i llcv Q'
Tardive Dyskinesia (TO} is an involuntary movement
disorder associated with chronic neuroleptic uRe. Tardive
refers to the delayed onset, which is from m ,iths to years
voluntary movement. This condition is composed of choreo-
athetoid movements, but is considered separately due to its
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
for Neuroleptic-lnduced Tardive Dyskinesia 333.82,
which again would be ceded on Axis 1.
A. lnvoluntary movements of the tengue, jaw, trunk or
extremities have developed in association with the use of
neuroleptic medication.
B. The involuntary movements are present over a period of
at least 4 weeks and occur in any of the following patterns:
(1) Choreiform movements (i.e. rapid, jerky, nonrepetitive)
(2) Athetoid movements (i.e. slow, sinuous, continua!)
(3) Rhythmic movements (i.e. stereotypies)
C. The signs or symptorns in Criteria A and B develop during
exposure to neuroleptic medication or within 4 weeks of
withdrawal from an oral neuroleptic or 8 weeks from a depot
neuroleptic.
D. There has been exposure to neuroleptic medication far at
least 3 months (1 month if age 60 or older).
E. The symptoms are not due to a neurological or general
medical condition.
F. The symptoms are not better accounted for by a
neuroleptic-induced movement disorder.
Diagnostic Criteria are from the DSM-IV.
©American Psychiatric Association. Washington, D.G. 1994
Reprinted with permission.
69
Ad .... ....... ~ &1 &..I .J aJ a.A .J &J e.l--..,-w:-w:
TO occurs in three areas
Facial & oral movements (present in 75% of those affected)
1i Facial expressions - frowning, blinking, grimacing
* Lips and mouth - pouting, puckering, lip smacking
a Jaw - opening and closing, chewing, teeth grinding
a Tangue - tremar, protrusion, rolling
Extremities 'present in 50% of those affected)
a Choreoathetoid movements in the upper or lower limbs
11 Tremors or rhythmic movements may be present
e Range from rapid, purposeless and spontaneous to slow
and complex motions
Trunk (present in 25% of !hose affected)
0 Twisting, rocking or gyrating of the back, neck, shoulders
or pelvis
Source Adapted from the AIMS Movement Scale
In the early stages of development, TO can easily be missed
and only an observan! interviewer who is looking for the
initial manifestations will notice them. TO is often not
reported by patients, but by those around them who are
aware of the repetitive movements (often smacking or
chewing). lt can easily be passed off as gum or tobacco
chewing or ill-fitting dentures.
The movements of TO are more pronounced during stressful
periods (such as interviews) and with use of non-affected
body parts. Lessening of the movements is seen during
periods of relaxation, use of affected parts, and voluntary
suppression. TD is typically absent during sleep. An increase
in neuroleptic dosage temporarily improves the symptoms,
whereas the use of an anticholinergic agent (ACA) worsens
sorne forms of TD.
In severe cases, TO can also cause irregularities in
speaking, breathing and swallowing. Swallowing air
(aerophagia) can lead to chronic belching or grunting. limb .
involvement can leave patients incapacitated.
70
..... i.--------~-------*"_.,,,·_.----' •'""#"'""IÜ li.i
The risk factors that increase the likelihood of TO are:
• Advancing age and female sex
• Duration of neuroleptic administration
e lncreasing neuroleptic dosage
• Presence of a nonpsychotic disorder
• Drug holidays - these are not "summer trips," but
planned discontinuations of prescription medication
• Brain damage and other neurologic cor .cions
• Severe EPS early in the course of neuroleptic
administration
A research instrument was designed to assess the presence
of TO. lt is called the Abnormal lnvoluntary Movement Scale
(AIMS) and was developed by the National lnstitute of
Mental Health.* The AIMS involves both observation and
asking the patient to particip1te in actions that will assist in
the detection of TO. These activated movements are scored
on a 5-point scale (from O to 4), allowing quantification anda
means by which to assess future changes. A summary of the
protocol for activated movements is as follows:
Facial & oral movements
• Have the patient remove extraneous matter from mouth
• Open mouth, then protrude tengue
Extremities
• Ask the patient to sit with hands hanging unsupported
over or between knees
• Tap each finger on the thumb of the same hand
• Active flexion and extension of arms
Trunk
• Ask the patient to stand up and walk, then turn around
• While standing, extend both arms, palms down
Recall that distraction makes movements in affected areas
worse. Observe body parts not currently being evaluated for
the presence of abnormal movements.
* National lnstitute of Mental Health: Abnormal lnvoluntary Movement
Scale, in ECDEU AssESSMENT MANUAL, Edited by G. W. Rockville, 1976
71
.tr' áL ~j .:r irl'"" "1.,, ~"' J1t J~ ' .JI,,
llilp' ~. .J;¡~ ilif'"'

Dyskinesias occur in a wide variety of conditions:

i
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i'

(VII) Tics are defined in the DSM-IV as involuntary.

1 1' · I' 1 " I'
'' tJ
11

e Disorders of the basal ganglia - Huntington's Disease,

Wilson's Disease. Sydenham's Chorea sudden, rapid, recurrent. nonrhythmic, stereotyped,
e Metabolic Conditions - hyperthyroidism, irresistible movements or vocalizations. Tics generally mimic
hypoparathyroidism all or part of a normal movement. and may be seen as
e Medications - levodopa, amphetamines. bromocriptine. "purposeful" in this regard. They can range from simple to
amantadine complex though their duration is often only about one
e Spontaneous Dyskinesias (Senile Chorea) second. Most patients with tics have a unique "repertoire"
that varíes in type, location, degree and frequency with time.
TO is not rare, and is worth taking the time to detect. Up to Tics often occur in paroxysmal bouts.-
5% of younger patients who take neuroleptics far one year
develop at least one sign. This increases to 30% in elderly Patients can voluntarily suppress tics during interviews.
patients. Tu has been reported in schizophrenic patients However, this becomes increasingly difficL11 • ctnd is
who have never taken neuroleptic medication. lt has been associated with escalating discornfort. Prior to a tic
proposed to be a late compfication of schizophrenia that has occurring, patients may experience premonitory urges or
been spuriously associated with neuroleptic administration. sensations. As with compulsions, a feeling of relief comes
Nevertheless. there have been successful lawsuits brought with expressing the tic. Stress, fatigue, new situations or
about because of a lack of informed consent. Until the even boredom can exacerbate tics. Other illnesses,
connection is either more formaffy proved or disproved, it is concentration on other matters, relaxation, alcohol and
prudent to examine patients as carefully as possible prior to orgasm can diminish tics. Like other movement disorders,
giving neuroleptics and at regular intervals (three to six tics are virtually absent durinJ sleep.
months) throughout the period of administration.
Examples of simple motor tics are:
TO Tidbits • Blinking or blepharospasm
• Facial twitches, grimaces, head jerking
•
There are other types of tardive phenomena - tardive
• Abdominal tensing
dystonia, tardive akathisia and tardive Tourette's
• Shrugging or rotation of the shoulders
• The management of TO invofves early detection, use of
• Jerking movements in the extremities
as fittfe neuroleptic medication as possible, and
• Grinding teeth (bruxism)
switching to the newer antipsychotics
• Oculogyric movements
• Severaf medication schemes have been reported as
helping to diminish TO once it is present; this list is Examples of complex motor tics are:
extensive and keeps changing; consuft recent journal • Grooming behaviors
articles for current recommendations (sometimes • Head shaking
referred to as the "flavor of the rnonth") • Jumping or kicking
• Withdrawal dyskinesias can occur as neuroleptic • Hitting or biting oneself
dosages are tapered • Touching or smelling objects
• The proposed mechanism is dopamine receptor super- • Copropraxia (making obscene gestures)
sensitivity (from prolonged blockade) in the basal ganglia • Echopraxia (copying the movements of another)

72
73

-------- .. ··-·· .. ., -

ü ü L i.J :U a-1 i:LJ ..u :aJ iiiLl 1LA lli6l .... -
Examples of simple vocal tics are:
& Coughing, humming
" Grunting, gurgling
s Throat clearing, clicking Jr clacking
& Sneezing, sniffing, snorting or snuffling
e Screeching, barking, squealing
e Whistling, hissing
. Examples of complex vocal tics are:
o Sudden utterances of inappropriate syllables or words
o Copralalia (saying or shouting obscenities)
• Echolalia (repeating others' phrases - this is also one
of the behaviors in catatonia)
• Palilalia (repeating one's own phrases)
Tics can be present in up to one-sixth of boys and about
one-twelfth of girls; they often disappear without
consequenc". The highest prevalence is in children aged
seven to eleven. Tics are considered pathological when they
are present nearly every day for at least one month. As with
other movement disorders, the pathology is thought to occur
at the leve! of the basal ganglia.
Tics occur in a wide variety of conditions:
• Physiologic tics - mannerism or gestures
• Primary tic disorders (see next page)
o Chromosomal ábnormalities - Down Synd., Fragile X
e Medications - i.e. anticonvulsants, neuroleptics.
levodopa; stimulants used for the treatment of ADHD -
pemoline, methylphenidate and amphetamine; caffeine
a Head trauma
e Mental retardation - including Pervasive Developmental
Disorders
& Neurologic conditions - e.g. Huntington's Disease and
Sydenham's Chorea, Wilson's Disease
• lnfections - e.g. encephalitis, Creutzfeld-Jakob
• Schizophrenia
• Gasoline or carbon monoxide poisoning
74
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.... -id u ~-~-~-)a-t.-ti-ti-~-~-E--&-~-M~~
1
U
The DSM-IV lists four tic disorders (the diagnostic criteria are
abbreviated):
Tourette's Disorder 307.23
• Both multiple motor and one or more vocal tics have
been present. although not necessarily concurrently
e The tics occur many times a day (usually in bouts),
nearly every day or intermittently throughout a period of
more than one year. and during this time there is no tic-
free period of more than three consecutive months
• Causes marked distress or significant impairment in
social, occupational, or other important areas of
functioning
Transient Tic Disorder 307.21
• Single or multiple motor and/or vocal tics
• Tics occur many times per day
• Duration is between four weeks and one year
Chronic Motor or Vocal Tic Disorder 3(, .. 22
• Duration is longer than one year
Tic Disorder Not Otherwise Specified 307.20
• The catch-all diagnosis far other tic conditions
Motor tics can be subdivided into clonic and tonic forms.
Clonic tics are abrupt and simple movements, such as head
twitching or nose wrinkling. Tonic tics are more sustained
movements and may be painful, such as torticollis.
blepharospasm or prolonged mouth opening.
Diagnosing tic disorders may take years. Tics usually start
with eye-blinks, head-jerks or grimaces, which are common
twitches in children. The tics in Tourette's Disorder are often
accompanied by irritability, attentional deficits ora low
frustration tolerance, which can lead to a misdiagnosis of a
behavioral disorder (e.g. conduct disorder). Also, there are
comorbid conditions that complicate diagnostic issues (e.g.
obsessive-compulsive disorder).
75
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(IX) Tremors are involuntary movements consisting of

regular, rhythmic oscillations of sorne part of the body. They
l
-.,
tics l compulsions are usually seen in the hands, arms, head, neck, lips, mouth
or tongue, but can also occur in the legs, voice or trunk.

~ 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:

• Stress-induced - situational anxiety, anxiety disorders

(e.g. panic disorder), strong emotion, fatigue,
~0 .e,"='
·O
0.~"' hypothermia
.;s."='"' ·1<.."=' .0
roº ..;:;.Ci
cP
~~
~
0" ~'{;
:o" • Psychotropic medication-induced - lithium, valproic
acid, neuroleptics, Tricyclic Antidepressants (TCAs),
Selective Serotonin Re-uptake lnhibitors 'SSRls)
conscious + + +
• Other medication - dopaminergic medications
voluntary + + + - (levodopa, bromocriptine), ~-adrenergic agonists
(isoproterenol, theophylline ), stimulants (caffeine,
"purposeful" + - - +
amphetamines, cocaine)
complex + + -/+
movements
• Endocrine ~ hyperthyroidism, pheochromocytoma

• Substance Withdrawal - alcohol, benzodiazepines

rhythmic + - -
• Familia! - essential tremur
paroxysmal - - +
• Neurologic conditions - Parkinson's Disease or
parkinsonism, Wilson's Disease, brain tumors, conditions
ritualistic + . - - -/+
affecting the cerebellum
lessen anxiety + - - - e Physiologic tremar
premonitory urge - - +
• Hysterical tremar

-76 77
 ;::e_J aJ ,.J ~ -1 ~ a.J ¡aJ .... Li .... w l.a "- la llll aJ aJ ad al 11.J aJ &l. &l &J
,..__¡ .-'..:..i ..m:_j mtAtN~AuPtds ~ BEHAVIOR

The most likely tremors to be encountered are: (X) Negative Symptoms

a Pill-rolling tremor: a passive or resting tremor where
the thumb is rolled across the other fingers; this is the
classic tremor of parkinsonism
111 Postura! tremar: a physiologic tremor that occurs when
maintaining a position or posture
@ Essential tremor: an action tremor of the hands (but can
include head or voice tremors); this is inherited asan
autosomal dominan! trait in most cases
o Wing-beating tremor: an abduction of the shoulder with
flexion of the elbow; often seen in Wilson's Disease
" Liver flap (asterixis): can be seen in patients with liver
failure; the wrist exhibits rapid flexion-extension
The DSM-IV includes research criteria for Medication-
lnd uced Postura! Tremar. This condition has been most
frequently repo11ed with the use of lithium. lts features
include the following:
• lt is dose-related and can affect up to 50% of patients
• Pre-existing tremors ora family history increase the risk
• lt is most often confined to the fingers, is irregular in
amplitude and rhythm, variable throughout the day,
interferes with hand-writing, and worsens with anxiety
• lt occurs at 8 - 12 Hz
ª lt is often managed with propranolol 10 mg qid
The trernor of parkinsonism (EPS) has the following features:
• lt is present in the hands and wrists
• lt occurs at 4 - 7 Hz and is more rhythmic
... lt occur~ .n abou~ 15% of patients receiving
antipsychotics
• Micrographia is present, as opposed to jagged
handwriting (this can also refer to handwriting that gets
smaller with progress across the line on the page)
• lt is maraged by reducing the neuroleptic dose, using
anticholinergic agents (ACAs), and if necessary,
amantadine or diphenhydramine
Part of developing skills as an interviewer is to not only pay •
attention to what is being saiJ or done. but also to what is not
being said or done. For example, patients who talk about
their families while omitting certain members (like a parent)
often betray the presence of a conflict with that person.
Similarly, there are certain behaviors that are remarkable far
their absence instead of presence.
Many clinicians divide the signs and symptoms of
schizophrenia into positive and negative symptoms, also
referred to as Type 1and Type 11 schizophrenia, respectively.
One way to conceptualize this distinction is that positive
symptoms are added to the picture, negative ones are
deficits in the clinical presentation. Positive symptoms are:
hallucinations, delusions, formal thought disorders and
bizarre or disorganized behavior. A mnemonic for negative
symptoms is:
·"NEGATIVE TRACK"
Negligible response to conventional antipsychotics
Eye contact is decreased
Grooming & hygiene decline
Affective responses become flat
Thought blocking
lnattentiveness
Volition diminished
Expressive gestures decrease
Time - increases the number of negative symptoms
Recreational interests diminish; Relationships decrease
A's - see below far 5 A's
Content of speech diminishes (poverty of thought)
Knowledge - cognitive deficits increase

78 79
b' i'.ii:J a alt'N ~,p;r li)J~' wf:r' ¡Jj-' ~ ri:f ~ ~.,, u ~ ~j (ij ~__, ~ / ~-·' IJ.t/ ~" w Jd' ¡¡;r ilit Jlij rili.j il' liº/ i:t Q'
BEHAVIOR

!"he distinction is importan! for severa! reasons:

• When Kraepelin and Bleuler first described
Behavior Tidbits
• Regressed behavior refers to age-inappropriate
schizophrenia, they made distinctions between
behaviors exhibited by patients; the overall decline may
fundamental (positive) and accessory (negative)
be present as_neediness, poor motivation, emotional
symptoms. By the way, Bleuler suggested the term
lability, diminished self-care, oppositional behavior, etc.
schizophrenia in 1911 to refer to a splitting of the mind.
• Yawning can be an indication of opioid withdrawal (or
Prior to this, Kraepelin called it dementia praecox.
boredom with the interview)
11 Negative symptoms are not usually treated effectively by
• Cigarette smoking is coinmon among patients with
traditional antipsychotic medication, whereas positive
schizophrenia - it is estimated that up to 90% smoke;
symptoms generally do respond. Newer antipsychotics
smoking may alter the metabolism of antipsychotic
(clozapine, olanzapine) appear to treat negative
medications and diminish side-effects
symptoms much more effectively.
• Viscosity refers to the interpersonal "stickiness" seen in
• Of the five "A" criteria for schizophrenia, only one
sorne patients with temporal lobe epilepsy (TLE); they
includes negative symptoms; the DSM-IV requires six
often do not appreciate the subtle signs that others send
months of prodromal or residual symptoms, which
(e.g. to end conversations, switch tapies, etc.) and will
may consist largely or entirely of negative symptoms.
speak al length about one tapie
• Negative symptoms tend to become more prominent
• Perseveration is both a verbal and behavioral
with time and are significantly disabling to patients.
phenomenon, and is defined as an inability to switch
• Statistically, !hose with primarily negative symptoms are
tasks (e.g. patients given the task of standing up will
unrnarried males with an earlier onset, poorer course,
continue to do this when given other instructions )
and higher incidence of other behavioral abnormalities.
11 Patients with dystonia may not be able to let go of your
hand after shaking it
Dr. Nancy Andreason* developed standardized scales to
• Frequent watér drinking may be seen in schizophrenia;
more fully assess the presence of positive and negative
this can lead to water intoxication, seizures from
symptoms. The scale for positive symptoms is called the
hyponatremia, and even death
SAPS (Scale for the Assessment of Positive Symptoms).
• Cataplexy is the sudden involuntary loss of postura!
The other is the SANS (Scale for the Assessment of
muscle tone, and is a feature of narcolepsy (don't
Negative Symptoms; for those who appreciate puns, sans in
confuse it with catalepsy)
French means "without"). The majar headings in this scale
• Aristotle thought the brain cooled the heart (this attitude
are in the following mnemonic:
has never left the specialty of Cardiology)
PLANT mnemonic for the five A's from • George Gilles de la Tourette did not provide the original
aPathy/ Avolition
aLogia the Scale for the Assessment of Nega- description of the illness that bears his name; the honor
Affective Flattening tive Symptoms provided (SANS) by: was bestowed upon him by Charcot; it is speculated that
aNhedonia/Anciality Dr. David Wagner severa! notable historical figures suffered from tics
á ftentional impairment • T ourette was shot in the back by a delt .onal patient,
Indiana University
made a full recovery, and then died years later of tertiary
*The scales are available in majar texts or from Dr. Andreason, e/o Oept. of syphilis
Psychiatry, College of Medicine. University of lowa, lowa City, IA, USA 52242

80 81
w .:.... M BMN~IPE~ ...
-
iLJ ..,¡ &J &J ilJ i!l:! ... .. ... . • -• • •
u 111 i&I "' ., . .. 11
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

anx!ous," more accurate descriptions help classify these A. Sims, MD

observations. The immense range of behaviors that might be Saunders, London, England, 1995
seen in interview situations could fill an entire book. This
chapter provides a basis for not only recognizing certain key NEUROLOGY SECRETS

behaviors, but also understanding their significance to the L. Rolak, MD

diagnosis of various psychiatric illnesses. Hanley & Belfus, Philadelphia, 1993

~ 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
~1
., id lid ild-.-r.1-~ ~&J~ al~Al=..i-&i=ai=lliJ~...~-~u· u WI-· ~=U.-•~•~·--_., 111 ., • rl."IY i111FFti ili

Rabid feral Experiences Scale

Psychler

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:
An interview with Dr. Hannibal Lecter
"lt made incredible sense to me ...
if we do become what we eat, then
why not consume the wealthiest,
most beautiful and sophisticated
people that we possibly can."
Other Articles:
~ Liver by the River: A Mississippi Delicacy
~ Starve a mosquito - keep your blood & be Vlad you did!
~ Who said fish was brain food? Try the real thing!
..
..
t like being outside.
1 eat with my hands.
.. 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.
• 1 wear a chain around my neck.
• 1 don't check for traffic befare crossing the street.
• 1 stick my head out of the window in a moving car.
Total: O
Scoring
15 - 20 You view Wolf Man Jack as kin
10 - 14 You run with the wolves most weekends
7- 9 You occasionally wolf down your food
4-6 You own a Steppenwolf album or two
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.

Of course, a cornucopia of information is not useful unless it

is accurate. In a similar vein, reliability refers to the quality of
data obtained in the interview. The following parameters
provide an assessment of cooperation and reliability:

• Eye Contact

• Attitude/Demeanor

• Attentiveness to the lnterview

• Level of Consciousness

• Affect

• Secondary Gain

-----
88 ;
89
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RELIABILl-:Y
1.1

What is the diagnostic signilicance ol How do 1 describe the various aspects of

cooperntion anti reliability? cooperalion anti reliability?
e Malingering V65.2 Eye Contact is a universal indicator that someone is
The essential feature of malingering is the intentional interested. The eyes have been called the "window to the
production of false or grossly exaggerated physical or soul" beca use of the information they convey. Generally
psychological symptoms motivated by externa! incentives speaking, continuous eye contact indicates cooperation.
Patients may avert their gaze momentarily to think about
e Factitious Disorder 300.1 X details that are not readily available. A sustained aversion of
A. lntentional production or feigriing of physical or gaze can be an indication that sorne a rea of difficulty for the
psychological signs or symptoms patient has been encountered. Poor eye contact may have
B. The motivation for the behavior is to assume the sick role several causes:
C. Externa! incentives for the behavior are absent • Paranoid patients (dueto schizophrenia, a delusional
disorder or personality disorder) often sean the room by
• Antisocial Personality Disorder 301.7 shifting their gaze frequently and may systematically
A. (2) Deceitfulness, as indicated by repeated lying, use of examine the entire area
aliases, or conning others for personal profit or pleasure • Hallucinations (usually auditory or visual) are perceptual
aberrations tha_t can distract patients
• Paranoid Personality Disorder 301.0 • Patients who are shy or have a social phobia may show
A. (1) Suspects, without sufficient basis, that others are fleeting eye contact at the outset of an interview, which
exploiting, harming or deceiving him or her improves as rapport develops
• In sorne cultures, direct eye contact can mean disrespect
• Manic/Hypomanic Episode 296.X • An unwavering gaze can be an act of intimidation, a
A. A distinct period of abnormally and persistently elevated, veiled threat ora challenge to your authority as an
expansive or irritable mood interviewer
P. (5) Distrae :.:>ility
Eye contad is described as continuous/goodlintermittentl
• Major Depressive Episode 296.X fleetinglabsent. lf aberrations are present, describe them in
A. (8) Diminished ability to concentrate, or indecisiveness, detail:
nearly every day ...
"Mr. Gunn avoided direct eye contact for
the majority of the interview but remained
• Dementias (of various etiologies) 290.X
wary of his surroundings. After a cursory •
A. (1) Memory impairment ... inspection of the room, he cast furtive
glanc.es at the heating vent, light switch
Diagnostic Criteria are from the DSM-IV. and overhead speaker. Then he spent a
©American Psychiatric Association, Washington, D.C. 1994 great deal of time staring out the window
Reprinted with permission at a parked vehicle outside the clinic ... "

90 91
 1

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a 11,,,; lar ~ QJ ~ ~ r ÜI"' W' ii~' IÍr' llJ' ti"" f!: . ~,t' .iJ
OOPERATION &
lfr' lir" ldj Sí,,
REllABILITY

Eye Contact Tidbits Attitude/Demeanor towards the interview and interviewer

e Patients with schizophrenia have a high rate of blinking,
which is thought to be due to a hyperdopaminergic state
• SPEMs (smooth-pursuit eye movement) abnormalities
occur in schizophrenia, mood disorders and organic
brain disorders; they also occur ata higher rate in first-
degree relatives of schizophrenics than the general
population and may be a marker for this illness;
saccades are fast eye movements under voluntary
control - e.g. the discrete movements across a line that
the eyes make when reading; saccades are abnormal
when tracking an object moving smoothly across the
visual field (e.g. watching a moving car)
• Wilson's Disease causes an abnormal deposit of
copper in the cornea called a Kayser-Fleischer ring;
sunflower cataracts are also an ocular finding
• A common observation regarding sociopaths is their
cold, unfeeling, "reptilian" gaze; severa! authors have
commented on this both in fiction and medical literature
• An oculogyric crisis is one form of dystonia consisting
of a forced upward gaze; in psychiatric patients this is
almost always due to a reaction to antipsychotic
medications; this occurs in other neurologic disorders
• Wernicke's Triad consists of ataxia, mental changes
(confusion) and ophthalmoplegia; the eye muscle most
commonly affected is the lateral rectus muscle resulting
in a conjugate gaze palsy, though a diverse number of
other ocular abnormalities also occur
• Pin-point pupils can be a sign of opioid use
• lnjected conjunctiva can be a sign of marijuana use
• Glassy eyes may be a sign of substance ingestion,
usually w: .. ; alcohol; or it may in fact be a glass eye!
• Nystagmus is an involuntary oscillating movement of
the eyes consisting of alternating slow and quick
movements; it occurs normally at the extremes of gaze
(called end-point or physiologic nystagmus);
movemer.ts that occur laterally, vertically ar in a rotatory
fashion are almost always a sign of pathology
is another important aspect. Patients may have biases from
previous contact with mental health professionals. Usually,
this becomes obvious early in the interview and can pose a
significant obstacle to obtainirg information. This commonly
happens with patients who:
• Have personality disorders, usually from Cluster B
(typically borderline or antisocial)
• Are under duress to attend the interview (e.g. by a
spouse, business partner, etc.)
• Suffer from chronic conditions that have resulted in
numerous contacts with different caregivers
• Have an agenda (secondary gain) to carry out in the
interview and seek to gain the upper hand at the outset
• Are cognitively impaired due to organic processes or
substance ingestion/withdrawal
e Are in emotional or physical pain
o Are involuntarily committed
Demeanor can be described globally as being cooperative or
uncooperative. Cooperative patients can be further
described as:
• Obsequious/solicitous/effusive
• Seductive/flattering/charming
• Over-inclusive/eager to please
e Entitled/controlling
The manner in which patients are uncooperative requires
elaboration, for example:
• Hostile/defensive
• Suspicious/guarded
• Antagonistic/critical
• Childish/regressed
e Sullen/withdrawn
To illustrate your description, include a quote or observation
from the interview. ·

92 93
 L-~~~~~=~~~~~~--~~~~~-=~=~~-~~M
!-~--' ia
Attentiveness to the lnterview impacts on the degree
nf cooperatic ' and reliability. Patients can be distracted by
externa! (noise) or interna! stimuli (hallucinations) while
speaking, and may preferentially attend to these events and
not see the point of answering your questions. lnterest can
diminish in an interview for any of a number of reasons:
a Borderline or antisocial personalities often become bored
in interview situations
_'8 Narcissistic or histrionic personalities can develop a
need (within the interview) for an affirmation of their
specialness or attractiveness
a Patients experiencing a manic or hypomanic episode
may be so distractible that they cannot attend to the
questions being asked of them
o Delirious patients drift in and out of lucidity; they may
lapse in to a clouded state of consciousness during an
interview
8 Obsessive-Compulsive Disorder can cause patients to
succumb to the intrusive thoughts or the irresistible urge
to reduce their state of anxiety; they may engage in a
number of ritualized behaviors
" Other anxiety disorders such as panic disorder can
cause a sudden overwhelming distraction far patients
• Patients who are psychotic may experience
hallucinations or incorporate interview material into
delusions, which then reduces their ability to attend to
questions
This is recorded in the MSE as patients being attentive/
inattentive. A further description is given for diminished
attention span. Reasons might include:
• Being preoccupied
• A reduced or fluctuating level of consciousness
• Being distracted by activity in and around the interview
• Sudden shifts in affect or mood state
,-he formal te _t of attention in the MSE is covered in the
chapter on CoGNITIVE FuNcT10N1NG & SENSORIUM.
94
b .. • • ~ • .. .. . . \..,JPE&IT109i1r. ;,.Sil1A•íY . , aJ
Level of Consciousness (LOC) refers to the degree of
alertness or leve! of arousal. In typical interv: · ,oJ situations,
patients are alert, attentive to their surroundings and
responsive to questions. This can be recorded in the MSE
as, "The patient was fully alert and attentive to the interview."
Aberrations in the level of arousal are important to include
early in recording or reporting the MSE. The reader or
listener needs to be aware of this at the outset, because an
altered level of consciousnes::o affects the quality of the
information that follows. A diminished LOC immediately calls
into question the possibility of an organic condition, and
warrants urgent investigation.
While the LOC can't be "increased," an increased level of
attentiveness can be observed, and is referred to as:
• Hyperarousal if patients are agitated or anxious
• HypeNigilant if they sean the environment or focus
undue attention on minar or irrelevant stimuli
Hyperarousal occurs most commonly in the following:
• Mania - patients are often highly distractible, and will
shift their attention to any new or competing stimulus
(e.g. overhead announcements, the color of your name
tag, strains of conversations they can overhear, etc.)
• Anxiety disorders - for example, if patients have a panic
attack (Panic Disorder) or flashback (Posttraumatic
Stress Disorder) during the interview, the manifestations
may include an increased leve! of arousal
• Paranoia - patients are typically hypervigilant and alert
far evidence that they are being conspired against (e.g.
microphones. hidden cameras or recorders)
• Substance abuse - this most frequently ·occurs with
stimulants such as cocaine or amphetamines (or their
designer drug derivatives such as "ice"); it can also occur
with caffeine or PCP ingestion
• General medical conditions, such as hy~ :rthyroidism or
pheochromocytoma
95
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A decreased LOC is recorded using to the following terms (of
increasing severity):
.:t Drowsy or lethargic: refers to response with a mínimum
of effort (raised voice or gentle nudging); thought is
slowed and lacks goal-directedness; patients may drift
off to sleep
e ObtundPd: greater efforts are needed to bring arousal to
the poinl where questions can be answered; persistent
efforts (i.e. direct, closed-ended, or even "yes orno"
questions) are required to maintain focus
• Stupor: refers to a state where patients make occasional
returns to a wakeful state; vigorous or even painful
stimulat1on is needed to accomplish this; mild stimuli
may produce groaning or movement away from an
annoying sound or touch
• Coma: is a per~:stent state of unconsciousness
Following the time course of a change in LOC can help
delineate the cause. For example:
• Deteriorating LOC: may mean intracranial bleeding,
edema, or infection; structural lesions; overdoses, etc.
• Fluctuating LOC: this is the hallmark of delirium
• lmproving LOC: possibilities include alcohol or drug
intoxication that lessens with time; a post-ictal state;
concussion; hypoglycemia; a period of_ anoxia; an
ischemic neurologic event; sleep deprivation, etc.
96
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Affect is introduced in this section, and is fully covered in the
chapter on AFFECT & Mooo. Affect is defined as:
e An observable or objective quality of an emotional state
e The moment to moment variability of visible emotions
based on the what is occurring in the interview (externa!
events) or feelings (interna! events)
• The range of reactions to questions/events that would
usually be considered of emotional sig: dcance
A financia! analogy is as follows: affect is the minute to
minute variation in the worth of a company stock, mood is
the general trend overa longer time period. Another analogy
is that affect is like weather and mood is like climate.
In the DSM-IV, the conditions previously referred to as
"Affective Disorders" were renamed "Mood Disorders.'' This
was done to more accurately reflect the nature of the
pathology. The conditions being described (depression,
mania, etc.) are of a sustained nature and are more aptly
described as disorders of mood. While there are no longer
"affective disorders," there are situations where the affective
component of other disorders interferes with the interview.
Sorne patients experience rapid shifts in their emotional state
in interviews, which interferes with the quality and quantity of
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.
Affect is reported in a separate section along with Mood. In
situations where intense affect interferes with obtaining
information, describing this in the CooPERATION & RELIABILITY
section helps put subsequent information in perspective.
97
=--"'
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What is Secondary Gain?
Secondary gain (also called morbid or epinosic gain) refers
to an actual or externa! advantage that patients gain from
being ill. Common examples include:
• Being relieved of occupational responsibilities
• Prescription medication (e.g. opioids. benzodiazepines)
• Avoiding military seNice
• Leverage in personal relationships
• Postponing exams
• Deferring legal proceedings; transfer out of prison or jail
Shelter 2. ;d/or food; financia! gain
In psychoanalytic theory, a symptom functions to decrease
intrapsychic conflict and distress, which is called the
primary gain. The best example of this is a conversion
disorder. Here, a psychological conflict is "converted" into a
physical one that is often a symbolic representation of an
unacceptable impulse. A wife catching her husband in an act
of infidelity develops blindness; a son who wishes to strike
his father converts this impulse into a paralyzed arm.
Tertiary gain is the advantage that others receive from the
patient's illness (e.g. disability income).
~~'ifg
98
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What is the relevante ol this to the MSE?
Any mental disorder can be mimicked by organic conditions
or by someone skilled in the production of psychiatric
symptoms. There is no way of objectively assessing auditory
hallucinations, paranoia, fla'shbacks or any other interna!
experiences. No laboratory test or other investigation can
verify the symptoms reported by patients. For this reason,
mental illnesses are favored by malingerers.
The history of malingering is a history of civilization itself. As
soon as there were unpleasant tasks or sitt•<>~ions, people
found ways out of them by faking illnesses. An account of
malingered psychosis appears in the Bible. Other examples
include the novel "The Good Soldier Schweik" by Jaroslav
Hasek, and the antics of Corporal Klinger on. M*A*S*H.
Malingering can occur in a variety of contexts:
• "Faking bad" - at one end of a continuum is the
exaggeration of actual symptoms; the other end is their
complete fabricatidn
• "Faking good" minimizes or denies current symptoms
• Fabricated or staged events provide a witnessed,
documented or otherwise verifiable record of an injury or
traumatic event which can be used later to feign illness
• Alteration of documentation - altered photocopies,
forged referral notes, stolen letterhead, etc.
• Tampering with diagnostic procedures - scars that are
self-inflicted to look like surgical incisions, blood added
to urine, feces injected to cause septicemia (if you
suspect factitious septicemia, call it skepticemia)
Factitious Disorder is the deliberate production of
symptoms (physical ar psychological} in the apparent
absence of secondary gain. Symptoms are produced so that
patients can assume "the sick role." The motivation is
thought to be for primary gain; however, there may be
secondary gain that is not immediately obvious.
99
 ~ :í.i' ~~;¡\¡-¡-~il:r-.lit-"11'1-~-Ü'
1-i/ ~J
How do 8detect Malingering?
Reliable clues to unveil malingering have been sought for
centuries. There are sorne reports that even experienced
interviewers do little better than chance in making the
distinction. lt should not be your primary goal in an interview
to detect the faking of illnesses. You will cause yourself less
grief by being fooled by a stream of malingerers than you will
by incorrectly confronting one legitimate patient. Additionally,
not ali false information is due to malingering.
Nevertheless, an attitude of "benevolent skepticism" where
there is obvious secondary gain helps keep the possibility of
manufactured symptoms in mind. lt is usually not difficult to
see secondary gain. This is perhaps most prevalent with
incarcerated individuals. Mental illness can mean a transfer
out of the "general population" into medica! segregation,
(.,alled "soft time," a more lenient regimen of prison life. Of
even greater significance is the issue of a mental illness
being responsible for criminal behavior. Such a finding in
court means that the perpetrator is sent to a forensic
psychiatry unit instead of prison. In less obvious situations,
patients often guide the interview to address their agenda, or
even voice their requests and hope to exploit the
compassion of the interviewer.
Signs that patients may be lying are as follows:*
• Anxiety expressed as a high-pitched voice, grammar
mistakes or parapraxes ("slips of the tangue")
• Anxiety expressed as agitation, hand wringing, etc.
• Delays in answering questions or evasive answers
e Discrepancies between facial expression and physical
movement (especially anxious fidgeting)
• Statements that obliquely address the truth e.g. "Would 1 lie
to you?"
N.B. Eye contact and facial expression may-not be reliable
clues to the detection of feigning information
* Adapted from: The Comprehensive Textbook of Psychiatry
100
B llí-k~_j¡f.:_¡I,( lfil rlí .,¡J,Pfii/r,<fli[a< Ji.,,lfli{rr fil' ,,¡,(
& L1P1AN, in The Comprehensive Textbook of
MILLs
Psychiatry, also suggest that certain mental illnesses are
among the most likely to be malingered:
• Mental Deficiency or Retardation
• Cognitive Disorders (e.g. Dementias)
• Amnesia
• Psychosis
delusions
hallucinations
• Posttraumatic Stress Disorder
The authors also include a summary of factors to help
distinguish between real and malingered symptoms for each
of these disorders. They also note that malingering is difficult
to maintain in a lengthy interview and suggest that the
evaluative process should be extended for as long as
possible. In such situations, you can ask patiP1ts to repeat
segments of the history to verify what they c....iid earlier.
While interviewing skills are important in the detection of
malingering, other methods to investigate the veracity of
interview material are:
• lnterviewing patients on separate occasions to
corroborate earlier information
• Obtaining medica! records and/or speaking with prior
contacts of patients
• The Minnesota Multiphasic Personality lnventory,
Second Version (MMPl-2). This test includes the F and K
Scales that can be used individually or in combination to
detect malingering; testing with other objective
personality inventaries has also been reported
o Projective testing with such tests as the Rorschach or
Thematic Apperception Tests
• Sodium amytal and other drug-assisted interviews
• Hypnosis
• Polygraph (lie-detector) testing
Adapted from: Clinical AssAssment of Malingering & Deception
101
t:l w
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iwtail~~ ~ft¡J~ .Jk-.1 ll:.f w .....
In what other situations is false inlormation
provided?
• Confabulation is the "invention of stories" to fill in
memory gaps. Patients are not consciously trying to be
deceptive; they do tllis to avoid calling attention to their
cognitive deficits. This is most commonly seen in
Korsakoff's Psychosis and is due to anterograde
amnesia caused by thiamine deficiency (Vitamin 8 1 )
usually a result of chronic alcohol ingestion.
• Ganser's Syndrome originally referred to episodes of
transient psychosis and clouding of consciousness.
Perhaps it didn't help that Ganser described this in three
prisoners. Currently, the syndrome refers to the situation
where "approximate" answers are given. Far example,
answers like "there are six fingers on a normal hand" or
"five quarters in a dallar" are typical. Controversy
surrounds the accurate nosology of this disorder. In
sorne studies, Ganser-like answers were given by
subjects trying to imitate mental disorders. Other authors
have sh0wn that it occurs in response to stress, head
injuries or other mental illnesses, and that it is not under
voluntary control. There is an overlap of malingering,
dissociative and psychotic symptoms in this syndrome.
• Ego defense mechanisms such as denial or repression
operate to keep certain information beyond conscious
retrieval. Patients may quite legitimately not be aware of
events that are documented in their medical records.
• The severity of disorders impacts on the reliability of
information. Far example, paranoid patients may alter
the history they relate in arder to gain or avoid admission
as a means of coping with their suspicions. While their
real intent is self-preservation, this may only be
achievable (in their minds) by falsifying the data they
present in interviews.
102
... ¡.~~~-~.. -~-.. -w--..--i.-J2!ai1 11 n~~. . ~~ld .
Summary
Cooperation from patients is required for psychiatric
diagnoses to be made. A number of factors can interfere with
patients' volition, anda distinction needs to be made as to
whether someone can'! or won't share information. Patients
who can't cooperate are often severely ill with medical and/or
psychiatric conditions. Those who won't share information
are usually angry at events that take place in or around
interviews. Factors such as involuntary committal, appearing
under duress or the presence of a personality disorder are
common reasons for a willful lack of cooperation. This is
referred to as resistance. lt is a maxim that resistance must
be dealt with befare other aspects of an assessment can
begin. To paraphrase the Borg from Star Trek, not
addressi_ng resistance can be futile!
Whereas cooperation makes reference to the quantity of
information shared, reliability reflects the quality of the data
obtained. Patients can create the illusion of cooperation
while providing little useful information. For ~r excellent
example of this, see the movie The Usual ~Jspects.
An understanding of what secondary gain is available to
patients is important. Psychiatric diagnoses, being
determined exclusively through interviews, are more easily
malingered than physical conditions. Collateral information is
always important to obtain, and may be the only way of
detecting Malingering or Factitious Disorder. These are
important conditions to keep in mind during any assessment,
but are "diagnoses of exclusion." Their presence does not
rule out the possibility of concurrent or future legitimate
medical or psychiatric conditions.
There are other conditions in which information is distorted
for reasons other than deception (e.g. denial in alcohol
abuse or confabulation in cortical blindness, also known as
Anton's Syndrome).
103
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Dr. Meador's Rules Part 11 Referentes

29. Patients with factitious disease do not rernain with the INrnooucroRY TExrnooK oF PsvcHJATRY, 2ND EomoN
physician who rnakes the diagnosis. N. Andreason, MD, Pil.D & O. Black, MD
American Psychiatric Press lnc., Washington. D.C. 1995
60. All patients will lie about something. Sorne will lie about
everything. THE CLINICAL INTERVIEW Us1NG DSM-IV
VoLUME 1: THE FuNoAMENTALS
162. Do not talk toan angry patient about any other subject E. Othmer, MD, Ph.D & S. Othmer, Ph.D
American Psychiatric Press lnc., Washington O.C., 1994
until you understand the source of his or her anger. Take as
long as necessary to diffuse the anger.
PsvcHIATRIC D1cnoNARY, 7rH EomoN
177. lllness behavior attracts attention. Ali illness has sorne R. Campbell, MD
secondary gain. Oxford University Press, New Yorl<, 1996

01AGNosr1c AND STATISTICAL MANUAL oF MENTAL 01soRDERS,

215. F actitious skin lesions do not appear between the
scapulae. 4rn EomoN
American Psychiatric Association, Washington, D.C., 1994
299. Patients who are receiving money for disability rarely
CoMPREHENSIVE TExrsooK oF PsvcH1ATRY, 6TH EomoN
get well. After the first year they never get well even if the
rnoney is less than they could earn working. H. Kaplan, MD & B. Sadock, MD, Editors
Williarns & Wilkins, Baltimore, 1995
333. Think of factitious disorder when there are unusual
CuNICAL AssESSMENT oF MAUNGERING AND OEcEPTION
findings, especially when caring for a physician's spouse or
any health care worker. R. Rogers, Ph.D.
The Guilford Press. New York, 1988
418. lf a patient is clearly lying to you, remernber:
An excellent resource for preparing written reports is:
• The lie is usually directed to "the doctor," not you as a
person. THE CuN1C1AN's THESAURUS, 4TH EomoN
• The facts, like the lies, are irilportant medica! symptorns E. Zuckerman, Ph.D
Clinician's Toolbox, The Guilford Press, New York, 1995
• No patient's lie should be held against the patient or get
you angry The section especially relevant to reporting cooperation and
reliability is in Chapter 13.

From A Little Book oi Doctor's Rules

by Clifton K. Meador. MD
Hanley & Belfus, Philadelphia. 1992
Reprinted with permission.

105
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j

Excerpt lrom a Failing Board Examination Auntie Sigmunda's Angst Column

Q. What brought you to hospital today? Alistair Munro, MD
f .. A silver Tr ...1derbird.
• Dear Auntie
Q. 1 see.
What was the problem that sent you to hospital? Sigmunda:
A. My wife. What is psycho-
oralysis?
Q. Your wife is the problem?
Psychoanalysis, with
A. No, she just sent me here, she says l'm the problem.
/ess of an emphasis
on the anal element.
Q. In what way are you the problem?
A. She says 1 don't co,nmunicate much.
• Dear Auntie
O. What else can you tell me about that? Sigmunda:
A. Nothing really. but she wrote out a list of other problems How complex was
1 have - here. Oedipus?
Whi/e his father was
Q. Why do you need these written out? dying to find out, only
A. l've been having problems with my memory lately. his mother knew far
certain.
Q. How long have you been having memory problems?
A. 1 can't remember. • Dear Auntie Sigmunda:
Can you describe passive-aggressiveness to me?
O. She says that you're ambivalent ... How can such a níce person ask such a schmucky
A. l'm not so sure about that. question?

O. You're too deferential ... • Dear Auntie Sigmunda:

A. You'd have to decide that one, Doc. What is a conversion symptom?
lt occurs when you are born again, but suffer brain damage
Q. She also says something about you being paranoid -
in the birth process.
A. 1 told her not to say anything! 1 can't trust anyone these days.
• Dear Auntie Sigmunda:
Q OK. Tell me, what is your occupation?
A. Lately l've just been pre-occupied. What is sex?
That which comes between fünf and sieben in my homeland.
Q. What kind of work have you done befare?
A. 1 used to be a court jester, but these days l'm nobody's fool. • Dear Auntie Sigmunda:
How does psychoanalysis work?
On/y hams get cured.

108 109

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Chapter5
Speech
Whith aspeds ol speech are imporlant?
Speech

Language Thought Process

Speech refers to verbal expression, which consists of

utterances, words, phrases and sentences.

Language refers to the communication of comprehensible

ideas. Not all speech is language (e.g. vocal tics, campaign
promises). Language can be conveyed by means other than
speech - posture, gestures, expressions, actions and sign
language ali transmit clear meanings without requiring verbal
expression. Language consists of ideas (usualfy expressed
as words) that convey meaning (semantics) and are
properly produced (articulation).
Thought process is the way in which patients produce and
organize their thoughts. Thought is inferred from speech and
language (including writing or signing) because it cannot be
accessed directly.

Many view this distinction as arbitrary and organize speech

and thought process together in the MSE, which is certainly
acceptable. This chapter outlines the mechanical (motor)
aspects and various qualities of speech production that are
not generally included in the discussion of thought process.

110 111
~j ~~ ~4í1.t.:· ~~~-ilf__.,4l~-ilr-"f Q iil' ~~~ ·~~~:...ál:...91~~~_)5.éHf¡''
0
/ 91
Thought and language have a large interplay, but describe
different processes. Language is the prinicipal means by
which thought process is assessed. Animals and preverbal
humans demonstrate that thought occurs without the ability
to express syntactical language. While humans are
anatomically capable of speech, language is an acquired
ability. Understandable are uttered by eighteen months, with
phrases being spoken between two and three years of age.
A decision tree for speech abnormalities is as follows:
speech abnormality present
[~irect] f 1congenital 1
~hiatric 1 ¡ 1medical1
The following aspects of speech are covered in this chapter:
• Primary Language Disorders
• Quality of Speech
• Prosody
What is the diagnostic significante ol
speech abnormalities?
Congenital/Onset in Childhood
• Mental Retardation 31 X.X
B. Concurrent deficits or impairments in present a<;faptive
functioning in ... use of communication
o Expressive Language Disorder 315.31
A. The seores obtained from standardized individually
administered measures of expressive language are
substantially below those of nonverbal intelligence ...
• Stuttering 307.0 (explained in detail on p.131)
112
e Autism 299.00
A. (2) (a) Delay in, or total lack of, the development of
spoken language (not accompanied by an attempt to
compensate through alternative modes of communication
such as gesture or mime)
(b) In individuals with adequate speech, marked
impairment in the ability to inititate or sustain a conversation
with others
(e) Stereotyped and repetitive use of language or
idiosyncratic language
Medical
e Delirium 293.0
B. A change in cognition (such as memory deficit,
disorientation, language disturbance, etc.)
• Dementia 290.X
A. (2) (a) Aphasia (language disturbance)
Psychiatric
• Schizophrenia 295.X
A. (3) Disorganized speech (e.g. frequent derailment or
i ncoherence)
• Brief Psychotic Disorder 298.8
A. (3) Disorganized speech (e.g. frequent derailment or
incoherence)
• Manic/Hypomanic Episode 296.X
B. (3) More talkative than usual or pressure to keep talking
• Schizotypal Personality Disorder 301.22
(4) Odd thinking and speech (e.g. vague, circumstantial,
metaphorical, overelaborate or stereotyped)
• Histrionic Personality Disorder 301.50
(5) Has a style of speech that is excessively impressionistic
and lacking in detail
Diagnostic Gritería are from the DSM-IV.
©American Psychiatric Association, Washington, D.C. 1994
Reprinted with permission.
113
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What are tbe primary language disorders?
In arder to understand the primary language disorders it is
helpful to review the areas of the brain involved in speech
production. The brain is lateraiized, with the areas
responsible for speech being found in the dominant cerebral
her.1isphere. Lateralization is related to hand dominance:
• Right-handers make up 90% of the population and
almost ali have the speech center on the left side
• Among left-handers, about two-thirds have a dominant
left cerebral hemisphere; the remainder have right-sided
or bilateral dominance
• Gauging handedness by using the writing hand is about
85% accurate in determining dominance, while
footedness is about 98% accurate; in addition to asking
about writing, find out which hand the patient would peel
a patato or throw a ball with; the dominant foot is the one
used for kicking
• Handedne~s is a hereditary trait, but the hand used for
writing can be changed (e.g. by hand/arm accidents or
teachers opposed to the use of the left hand)
• Left handers have traditionally been discriminated
against: in Latín, left is called sinister, no one besides a
Boy Scout shakes with the left hand, and as a cultural
tip, there are certain areas of the world where you would
probably not want to shake left hands with people
The cerebrum has four lobes: frontal, temporal, parietal and
occipital. The areas involved in speech are found around the
Sylvian fissure (also called the peri-Sylvian area) which
separates the temporal from the frontal lobe. The Sylvian
fissure is also called the lateral cerebral sulcus. Broca's
area is in the frontal lobe and controls the motor expression
of speech. Wernicke's area is in the superior part of the
temporal lobe and controls the center far the receptive or
sensory aspects of speech. These areas are connected by a
group of neurons called the arcuate fasciculus. · •
114
a..<IS~H .o.á -"
U
B - Broca's Area
Frontal Lobe
Brodmann Area 44
W • Wernicke's Area
Superior Temporal Gyrus
Brodmann Area 22
AF • Arcuate Fasciculus
There are many classification systems far specifying
locations in the brain. One of the most practica! ones far
psychiatric considerations was developed by Korbinian
Brodmann, which divides the brain into 47 areas based on
differences in cortical regions. lf the human brain were
designed by Vasily Kandinsky, it might well have the
geometric shapes shown in the above illustration.
While the dominant hemisphere (usually lef. controls most
of the functions of speech, the right hemisphere provides an
integrative function. In arder to "get the whole picture," or see
"the forest and the trees," or understand a FAR SIDE cartoon,
the nondominant hemisphere must be functioning. Other
nondominant functions include the inflection, rhythm and
emotional components of language. lnterestingly, second
and later languages and obscenities are not controlled by the
dominant hemisphere. Dama~es to the corpus callosum
(the neurons connecting the two halves of the brain) can
result in a number of language abnormalities.
Additionally, the following cranial nerves (CN) are required
far the comprehension and production of speech:
• CN 5 - control of articulation via jaw muscles
• CN 7 - control of articulation via facial muscles
• CN 8 - (cochlear part) carries auditory information
CN 9, 10, 11 & 12- control the soft palate, pharynx,
larynx and tongue to implement speech
115
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speech abnormality present Whith conditions affect the ucquisition ol

la~red 'f congenital
normal language slcills?

j psychiatric 1 j medica! 1 • Mental Retardation is a combination of significantly

subaverage intellectual functioning and limitations in
adaptation occurring before age 18. The IQ falls below
Based on the decision tree above, obtaining information to 70-75, which takes into account the error of 5 points on
answ~r the following questions starts the formal assessment testing. Mild to moderate retardation affects learning to
of speech abnormalities: the point that mental abilities are arrested at about the
• Is the patient's speech abnormal? level of grade six. Vocabulary is accordingly limited.
• In what way is it abnormal? Findings include repeated verbalizations and the use of
Abnormal speech patterns form the basis of the rest of behavior to express feelings (e.g. tossing things).
this chapter and the THOUGHT PROCESS chapter
• Autism is characterized by delayed social relationships
and language, and resistance to change in the
• Was the patient's speech ever normal?
environment. Common findings include echolalia and
A list of conditions affecting speech development and the
the reversa! of pronouns. For example, "You want" is
,speech patterns of certain illnesses follows later.
verbalized instead of "I want." Neologisms (made up
words with idiosyncratic meanings) are also common.
• Is anything e/se abnormal in addition to speech?
Words and sentences may be used once and then
• reading
dropped from the vocabulary for days to weeks. Odd
• writing/drawing these are specific tests
voice quality and rhythm patterns have also been noted.
• comprehension that can be carried out
• repetition in the MSE to further • Pervasive Developmental Disorders
• Rett's Disorder - encephalopathy beginning between 6 to 24
• copying define the deficits in the months in otherwise normal infant girls
• naming· patient's presentation • Asperger's Disorder - currently defined in the DSM-IV as
• response to directions impaired social interaction and stereotyped behaviors, but in the
past been described as also having language deficits
Given that speech is encoded thought, the chance to hear • Heller's Syndrome (Childhood Disintegrative Disorder) -
has a typical onset between ages 3 to 4 years and involves a loss
patients speak gives us valuable clues about their mental
of previously acquired language skills
functioning. lt is notan unusual experience to have a patient
present for an interview who is shabbily dressed and acting • Tourette's Disorder involves vocal and motor tics
which are apparent on average by age seven and must
in an eccentric manner. While you are busy (prematurely)
be present by age eighteen. Vocal tics can take severa!
considering sorne heavy-duty diagnosis, you are taken
forms, such as repeated words or phrases (out of context
aback by the persori's intelligence and eloquent speech.
to the situation) and coprolalia (the involuntary
Conversely, patients can be demented, delirious or mentally
utterance of obscene words ). Coprolalia can occur alone
retarded and appear neatly groomed with no obvious
or as an interruption during a sentence.
behavioral abnormalities.

116 117
:A.1 la U - . . -..i.-..i-&J-il.J-f¡;j_ll:J_aJ-aJ--aJ-U=-itJ--LJ·
What are the primary language disorders?
• Aphasias (alsc called dysphasias) are disturbances in
the ability to express and comprehend language. The
pathology is in the brain itself and not in the nerves or
muscles involved in speech production. Aphasias are
manifested as errors in word choice and grammar. The
main types of aphasias are outlined later.
• Dysarthria is poorly articulated speech dueto a
dysfunction in the physical ability to produce sounds
(e.g. mouth, tangue, lips, cranial nerves, larynx, throat).
The speech of dysarthric patients is distorted and
indistinct. In particular, consonant sounds are difficult to
distinguish. Other abnormalities include added, deleted
or substituted sounds.
• Alexia is the inability toread. Dyslexia is defined asan
impairment in learning to read that leads to difficulties
with spelling and the perception of the shapes of words
and letters. Dyslexia is usually a developmental disorder,
whereas alexia is usually acquired and involves a lesion
in the occipital lobe.
• Agraphia (or dysgraphia) is an inability to write in
someone who had acquired this skill. The ability to copy
can persist. The deficits in written language usually
parallel those of verbalization.
• Agnosia is an inability to recognize objects despite
intact sensory and intellectual abilities and language
function. For example, patients can physically describe
an object but not its function.
JI Apraxia 1s an inability to perform learned movements as
a result of disruption of areas controlling motor and
language functions. Strength, sensation, coordination
and comprehension remain intact. Apraxia often occurs
with aphasia. Patients are aware of their difficulties.
• Anomia is a specific inability to name or label things
even though they are familiar. This occurs whether the
object is shown or recalled from memory.
118
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How do I distinguish medica/ from
psychiatric causes al $peech disturbances?
This distinction between aphasias and disorders of thought
process can be difficult because they both affect verbal
expression. In the case of severe psychiatric disturbances, it
may not be possible in one interview to make the distinction.
A classic example is the confusion between schizophrenic
speech and aphasia. Additionally, sorne patients can have
both simultaneously; for example, Broca's Aphasia (defined
later) can be complicated by hypomania or paranoia, and
Wernicke's Aphasia can cause depression. The following is
a list of potential distinguishing features:
Parameter Medica! Psychiatric
• greater severity +
• continuous duration +
• abrupt onset +
• older age of onset +
• related language symptoms +
• word finding difficulties +
• awareness of difficulty (partial) +
• loss of repetition, naming +
and comprehesion abilities
Speech abnormalities are caused by:
• Cardiovascular accidents (CVAs) in right handers and
most left handers, this involves the left middle cerebral
artery; these are the most common cause
• Tumors, head trauma, seizures, sleep deprivation
• lnfections - meningitis, encephalitis
• Degenerative disorders - Parkinson's Disease,
Huntington's Disease, Pick's Disease
The major psychiatric conditions that involve speech
abnormalities were listed at the beginning of the chapter
along with their specific diagnostic criteria. Other conditions
such as anxiety and lithium toxicity also affect language
abilities by causing stuttering and dysarthria, respectively.
119
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What are tbe specific aphasias?
Because of the potential difficulties in distinguishing primary
language disorders from psychiatric conditions, the aphasias
will be sumr.1arized here. The reason it is vital to make this
distinction is that aphasias almost always involve an injury to
the dominant cerebral hemisphere, which requires urgent
investigation and tre:itment. Psychiatric conditions are less
-medically urgent and involve a differént form of treatment.
Aphasias are usually classified as fluent or nonfluent
aphasias on the basis of the flow of speech. Further
distinction is made using three tests:
• Comprehension - tested by the ability to follow simple,
and later, complex requests
• Repetition - tested with simple and complex phrases
• Naming - tested with common and uncommon objects
An alternate system divides aphasias into receptive and
expressive based on the ability to understand and speak.
This poses difficulties for non-neurologists because there are
frequently features of both in aphasic patients.
Paraphasias (paraphasic errors) are the substitution of a
letter or word for the intended word. There are four types:
• Related (approximative) - light is used instead of lamp
• Unrelated (semantic) - caboose is used instead of lamp
• Literal (phonemic) - /ump is used instead of /amp
• Neologistic (jargon) - pi/oknarfis used instead of lamp
Nonfluent Aphasias Fluent Aphasias
• Broca's • WernickE:f s
• Transcortical Motor • Transcortical Sensory
·Global • Conduction
• Anomic
Paraphasias and tangential speech (talking beyond the
point and not returning to it) are seen in aphasias.
120
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Broca's Aphasia is also called Motor Ap11asia,
Expressive Aphasia and Anterior Aphasia (Broca's Area is
anatomically anterior to Wernicke's). lt is characterized by
the following features:
e Speech is nonfluent
• Comprehension of writing and speech remains intact
• Repetition is impaired
Nonfluent speech has the following characteristics:
• Slower than average (half to one-third the normal rate)
• Abnormal flow with an irregular rhythm
• Frequent extended pauses producing a halting quality
• The amount of speech is decreased, often with missing
connecting words (prepositions, conjunctions, pronouns,
articles ); verb tenses may also be abnormal
These deficits result in agrammatism, which is speech or
writing that lacks syntax because words are not pul in a
corred sequence according to the rules of grammar. The
choppy communication style is called telegram or
telegrahic style. For example, the following phrase:
Rapid Psychler produces humorous and educational publications.
becomes
Torpid cycler . .. produces ......... publica/ .... avocation .. .
The agrammatism, halting style and paraphasias that may
be presentare also shown above. Articulation is usually poor
(dysarthric speech ).
Broca's =
"broken"
telegraphic
speech
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

Fluent aphasias have the following characteristics:

"Transcortical • lntact articulation and a normal rate of speaking
MotorWays ... • Complete sentences with proper syntax
we cornprehend • Speech consists of paraphasias and jargon
your order and • Neologisms, and words that are used because they
will repeat it back sound the same (clang z:ssociations), are common
to you." • Circumlocution occurs when a word is substituted for
the problematic word, ora description is given of an
object, or its use is verbalized instead of the item itself

Wernicke's Aphasia contains more paraphasias than does

Global Aphasia is an extreme form of nonfluent aphasia
Broca's. lf the speech of a patient with Wernicke's Aphasia
that results when the dominant hemisphere is so severely was muffled or in the background, it would not sound
damaged that language function ceases. Patients can make unusual until you heard the actual semantic content, which is
a few utterances that are devoid of semantic content. virtually unintelligible. For ~xample:
Vascular and traumatic lesions are the most common
Rapid Psychler produces humorous and educational publications.
causes. Extensive physical deficits accompany this severe
type of aphasia. be comes
Quick pedalers are the make of knowing whatever might not fraught.
Nonfluent Aphasia Tidbits
• Most injuries to Broca's Area are extensive and damage Patients with Wernicke's
nearby structures, so that Broca's Aphasia is often Aphasia are unaware of the non-
accompanied by right hemiparesis (motor cortex) and sensical nature of their speech
homonymous hemianopsia (visual field defect) and may speak continuously.
• The middle cerebral artery supplies this region
• Awareness of these deficits persists and can cause
depression Wernicke's =
• The frontal lobes are responsible for many higher "wordy"
functions; damage can cause a frontal lobe syndrome speech
that affects behavior, emotions, speech, thought form
and content, and lack of initiative (abulia)

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?
Aµart from the primary language disorders, there are other
qualities to consider when recording speech abnormalities.
The features presented in the following section have to do
with the "mechanical" aspects of speech and for this reason
are considered separately from disorders of thought process.
_Accent & Dialect are terms used interchangeably to
deseribe regional or cultural differences in pronunciation.
Accent can be used to refer to the speech of patients who
are not native Engfish speakers (e.g. a French, Swedish or
Spanish accent). Dialect can be used to describe regional
variations in those who are native anglophones.
(here are five majar dialects in the U.S. - New York, New
England, Southern, Appalachian and Western. In Canada,
those from the Atlantic Provinces have a distinct style of
speech, while the rest of the country speaks a "middle
American" dialect. In Great Britain, the skill in distinguishing
dialect is finely honed. Britons can not only detect which
hamlet someone is from, they can make an educated guess
as to the side of the street. Australians, New Zealanders and
South Africans spea~ with distinguishable accents. At one
English-speaking film festival, an Australian film needed
subtitles! In other regions (e.g. the Caribbean) the rules of
grammar are different from those in The Chicago Manual of
Style. However, this does not constiute abnormal speech.
Following is a list of fun and informative guides to becoming
a dialectmeister:
H. Mohr How to Talk Minnesotan
Penguin Books. New York. 1987
C. Bowles G'Day - Teach Yourself Australian
Angus & Robertson Publishers, North Ryde, NSW. Australia, 1987
S. Mitchell How to Speak Southern, Bantam Publishing
J. Levine How to Speak New Yorkese, Crown Publishing
126
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Amount of speech varies widely in interview situations.
Mental health professionals spend years learning how to
obtain and organize salient information, leaving patients
considerable leeway in what constitutes a "normal" amount
of speech (recorded as responsive, spontaneous, we/1-
spoken, fluent, or animated). Anxious patients provide a lot
of extraneous detail through their desire to simply be helpful.
Conversely, other patients feel inhibited, provide sparse
answers and offer little information spontaneously.
Conditions where the amount of speech can be increased:
• Mania (see pressure of speech below)
• Anxiety disorders
• Obsessive compulsive personalities (needless detail)
• Cluster B Personalities (seek to control·· ~ interview)
• Temporal lobe epilepsy (may miss social clues)
• Fluent aphasias
Terms used to describe an increased amount of speech are:
verbose, loquacious, talkatíve, copious speech, /ogorrhea,
vocíferous, overabundant ar expansíve.
Conditions where the amount of speech can be decreased:
• Depression
• Schizophrenia
• Catatonia
• Avoidant, dependent and schizoid personalities
• Dementia (can be verbose in early stages)
• Delirium
Terms used to describe an decreased amount of speech are:
paucity of speech, impoverished, laconic, tacitum, single
word answers or minimally responsive.
At one extreme is pressure of speech, where patients are
driven to keep talking, and have an increased rate and
amount of speech. A key distinguishing factor is that they are
not usually interruptable. At the other extreme is absence of
speech called mutism, which is found in neurologic
conditions and extreme forms of psychiatric illnesses.
127
L ~ ~ ~N "i/P~ ~ ~ ~ ~ lt @:! ti b b tl b ti '11.
Articulation refers to the clarity with which words are
spoken. This is not a disorder of wordfinding or grammar.
Words can be poorly pronounced dueto:
• Slurring (drug toxicity, e.g. lithium, alcohol ingestion)
• Poorly fitting dentures (resembles tardive dyskinesia)
• Missing teeth (edentulous)
• Chewing gum
• Central and peripheral neurologic conditions
• lmpaired hearing
• Tardive dyskinesia
• Accents from non-native speakers
• Lisps
• Altered level of consciousness
• Phonation difficulties by decreased resonance of the
mouth, nose and throat
Terms used to describe this are: garbled, slurred, mumbled,
clipped, choppy, unc/ear ar poor diction.
Modulatio'1 is the loudness or softness of speech. Sorne
patients are naturally louder when they speak, while others
add emphasis at various points in the interview. Conditions
where patients speak louder than normal include:
• Mania
• Psychosis (of any cause)
• Cluster B Personalities
• Dementia
• Delirium
• Hearing impairment or deafness
• Substance intoxication or withdrawal
Conditions where modulation is reduced include:
• Depression
• Medica! disorders (e.g. hypothyroidism, diseases of the
larynx or recurrent laryngeal nerve, hyperacusis)
• Personality disorders (e.g. Avoidant, Schizoid)
• Paranoia (in personalities, delusions or schizophrenia)
• Substance intoxication or withdrawal (e.g. hallucinogens)
128
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What is Prosody?
Prosody is the term that refers to the emotional or affective
components of speech. Prosody is used to describe the
rhyming meter in poetry. The narrators of "spoken books"
provide an excellent example of prosody. Here, one person
uses different aspects of speech to: convey action or
thought, give each character an identifiable voice, and
generally speak in a way that keeps listeners interested.
Disorders of prosody are called aprosodias. Just as aphasic
speech is accompanied by writing difficulties, aprosodias
occur with a loss of nonverbal communication. The gestures
and facial expressions that constitute the paralinguistic
aspects of speech are missing. The nondominant (usually
right) hemisphere has the major contribution to prosody.
Patients with aprosodias are unable to detect the emotional
aspects of the speech they hear. The difficulties with
reception may be more pronounced with pr ,erior non-
dominant hemispheric lesions. Anterior les1ons are thought
to cause greater difficulties with the expressive component.
This anterior/posterior pattern is similar to that of aphasias.
Prosody can be tested as follows:
• Having patients say the same phrase under contrasting
emotional conditions. For example, saying, "/'ve got to
gel out of here" dueto (a) a boring movie, then (b) a fire
• Having patients listen to you say the same phrase with a
different affective component
• Reviewing pictures of emotionally charged situations
Prosody can be can be assessed according to the following
components:
• Pitch/intonation/musicality
• Spontaneity/latency
• Rhythm/cadence
• Stress/inflection
129
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Pitch, as in music, refers to the highness or lowness of the
spoken words. Pitch usually varies throughout the course of
a sentence. For example, it rises when questions are asked
and falls when authoritative statements are made. Pitch also
changes with emotional state (e.g. rising with anxiety and
falling with depression). Puberty lowers the natural speaking
voice of both sexes. In adulthood, pitch changes occur due
to throat diseases, smoking, etc. Of interest is that pitch
tange can be altered by psychiatric illnesses, especially
psychosis. lntonation and musicality are other terms used to
describe the animation present in speech.
A lack of pitch change can occur as a variant of normal
speech. Pitch aprosodias are seen in:
• Obsessive-compulsive or schizoid personalities
• Parkinson's Disease or parkinsonism
• Depression and dysthymia
• Nondominant hemispherical lesions and aphasias
Unchanging pitch is described as monotonous, f/at, or
expressíonless.
Spontaneity is the degree of engagement in the interview.
lnformation volunteered without a question being posed is
called spontaneous speech. Latency refers to the time
i~ terval in wr ~h patients answer questions or connect their
sentences. Generally, there is an inverse relationship
between the two, i.e. patients who lack spontaneity have an
increased latency prior to speaking.
Rhythm, or cadence, varies in normal speech to add
emphasis and maintain interest, just as in music. Certain
types of rhythm disturbances exist:
e Stuttering
A. Disturbance in the normal fluency and time patterning of
speech (inappropriate for the individual's age), characterized
by frequent occurences of one or more of the following:
(1) sound and syllable repetitions
(2) sound prolongations
(3) interjections
(4) broken words
(5) audible or silent blocking
(6) circumlocutions
(7) words produced with an excess of physical tension
(8) monosyallabic whole-word repetitions
Diagnostic Criteria are from the DSM-IV.
©American Psychiatric Association, Washington, D.C. 1994
Reprinted with permission.
• People are aware that they stutter; an example is
Rrrrapid Psychchchler proproproduces huhuhuhumorous
• Cluttering is a nonfluent disruption involving bursls of
rapid speech containing syntactical errors; the
articulation is poor and the speaker is unaware of the
speech abnormalities
Rapid Psychler produces humorous and educG .:mal publications.
beco mes
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

l'd like to help you out. ""

Assess degree of fluency
(1'11 help you. but 1won't do it far you) • nonfluent speech is telegraphic (mainly nouns and verbs)
• fluent speech contains jargon, paraphasias, neologisms
l'd like to help you out. • assess various qualities of speech and prosody
(l '11 help you, but not your narley friend)
Fluent Nonfluent
l'd like to help you out.
(Get out! How did you get in?) "'
Assess degree of comprehension
• use sequential motor tasks of increasing complexity
lrony and sarcasm (both indispensable elements of • use a series of questions requiring a yes or no answer
language) are added by inflection. Patients with aprosodias Comprehension lntact Comprehension lmpaired
miss the finer messages conveyed with stresses in speech.
In many instances. non-native speakers, patients with
subnormal intelligence and those who are concrete in their Assess ability to repeat i
• start with complex sentences first 1
thinking will also miss the meanings conveyed by inflection. • use a series of questions requiring a yes or no answer
This does not consitute an aprosodia.
Repetition lntact Repetition lmpaired
_ _ __J
\
Speech Tidbits
Spoonensms are a type of paraphasia (closest to a Assess ability to name obje' ,;
literal or phonemic type) involving a tranposition of the • start with an object; if unable to answer, give clue as to use
• if still unable to answer, give first syllable as a clue
first letters or sounds of a word; Spooner ( 1844-1930) is
• if still unable to answer, offer a list containing the item
said to have proposed a toast to the "Queer Old Dean"
instead of the "Dear Old Queen"
• Patients with Broca's Aphasia retain their ability to cuss, Assess ability to read
usually when frustrated by their language difficulties; this • test reading silently and aloud
indicates there is another locus/aspect to the control of • ask questions to evaluate degree of comprehension
• there are often similar defects in reading and speaking
speech

132 133

Summary
An assessment of speech is integral to the ful! and accurate
assessment of psychiatric illness. As outlined at the
beginning of this chapter, severa! illnesses have specific
criteria related to abnormalities of speech and thought
process. The distinction between these two domains of
evaluation remains arbitrary. The mechanical aspects of
· speech disorders, c..¡uality of speech, and prosody were
presented here because they do not strictly have to do with
the form or process of thought (covered in the next chapter).
While higher mammals have means of communication,
huma ns are unique in their development of syntactical
language. Various qualities of speech convey additional
information. How something is said can be more importan!
than what is actually said. An assessment of speech
overlaps with a multitude of other mental status parameters:
thought, mood & atfect, intelligence, cooperation, etc.
Aphasias are language deficits that diminish or remove the
ability to express and comprehend ideas. Reading, writing,
speaking, naming, repeating and comprehending can ali be
affected. The main area for speech is called the peri-Sylvian
region, encompassing parts of the frontal and temporal
lobes. When patients have difficulties communicating, testing
far an aphasia is warranted. The majar types of aphasias
and methods to test for them have been outlined.
Characteristic speech patterns accompany mental illnesses:
• Manic patients have an increased amount of speech.
which is delivered quickly and often loudly
• Depressed patients are soft-spoken, slow to answer
questions and often have little to say
• Psychosis can change a patient's voice and other
speech '1aracteristics
• Other aspects of speech provide valuable diagnostic
clues, e.g. tics, slurred speech, paraphasias, echolalia
134
----~-~-~-~-~~--,-
Referentes
CUNICAL NEUROLOGY FOR PsYCHIATRISTS, 4TH EDITION
D. Kaufman, MD
W. B. Saunders eo., Philadelphia, 1995
THE CuN1cAL INTERVIEW Us1NG osM..:1v
VoLUME 1: THE FuNDAMENTALS
E. Othmer, MD, Ph.D & S. Othmer, Ph.D
American Psychiatric Press lnc., Washington O.e .. 1994
PsvcH1Arn1c D1cr10NARY, 7rH Eo1r10N
R. eampbell, MD
Oxford University Press, New York, 1996
DIAGNOSTIC ANO STATISTICAL MANUAL OF MENTAL DISORDERS,
4TH EDITION
American Psychiatric Association, Washington, O.e., 1994
COMPREHENSIVE TEXTBOOK OF PSYCHIATRY, 6TH EDITION
H. Kaplan, MD & B. Sadock, MD, Editors
Williams & Wilkins, Baltimore, 1995
SvN0Ps1s OF PsvcHIATRY, 7TH EomoN
H. Kaplan, MD, B. Sadock, MD & J. Grel;>b, MD, Editors
Williams & Wilkins, Baltimore, 1994
An excellent resource for preparing written reports is:
THE CuN1c1AN's THESAURUS, 4TH EomoN
E. Zuckerman, Ph.D
Clinician's Toolbox, The Guilford Press, New York, 1995
The section especially relevan! to reporting speech is in
Chapter 12.
135
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fUNNYSTUFF
" 11

More Spoonerisms Psychiatrit Near-Misses

• Our Lord is a shoving leopard.

• lt is kisstomery to cuss the bride.

• 1 believe you're occupewing my pie. May 1 sew you to

another sheet?

• When trq soldiers return from France. we will have the

hags flung out.
schizofemia
o 1 keep my icicle well-boiled.

• You have tasted two worms at this school.

• The Navy has an impressive number of cattle ships and

bruisers.

• To the headmaster's secretary: "Is the bean dizzy?"

• 1don't like to eat parrots and keys.

• lt nevers pains, but it roars.

• 1 tossed my lemper miss thorning.

• lf only they would get me low.

• 1 commended a student for fighting a liar in the kitchen.

• You hissed my mystery lecture. prominent

• 1'11 take mine in a mere bug.
vegeta ble sig ns

• Brown lettuce makes a sad bailad

~
Source (from !he ILL - lntrepid Linguist Library):
Donald Chain Black, Spoonerisrns, Sycophants & Sops
Dell Publishing, New York, 1988
Richard Lederer, Get Thee to a Punnery
Dell Publishing. New York, 1988

138 139
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Chapter 6

Thought Process
What is thought process?

Speech

Thought Process Thouf'h: Content

Language

• Speech refers to any form of verbal expression. With

aphasias, speech is produced with deficits in fluency,
repetition, comprehension, prosody, etc.

• Language is the exchange of comprehensible ideas,

and describes the communicative value of speech.

• Thought content describes what is being talked about.

This is covered in detail in the next chapter.

• Thought process or thought form refers to the way in

which ideas are produced and organized. This is an
assessment of how patients are communicating. The
degree of connection and the flow of thought are
disrupted in many psychiatric illnesses. When this
occurs it is referred to as a thought disorder. The way
ideas are linked together is as important as their content.
Beca use thought cannot be accessed directly, it is
assessed vía speech, writing, and behavior.

140 141
id lirM """ 8'1N~LIPT'Js .¡_' .J ""'1 .i .1 .1 ei iid,' .¡· w ~ ~ ~ ~ ~ ~ d ~ • d ~ d d ~ u ~
THOUGHT PROCESS

What is the cliagnostic signilicance of What constitutes a disorder ol thought

abnormalities in thought process? process?
Because language is encoded thought, the DSM-IV The following parameters are used to describe thought
combines the assessment of speech and thought process. process:
The diagnostic criteria that specifically include speech were • Goal directedness
outlined in the last chapter. Without repeating the individual • Tightness of associations between words, phrases,
'""Gritería, the disorders are: sentences and paragraphs
• Mental Retardation 317 /318.X • Rate, pressure & rhythm
• Expressive Language Disorder 315.31 • ldiosyncracy of word usage
• Stuttering 307.0
• Autism 299.00 Thought process is easiest to assess when patients are
11 Delirium 293.0 given open-ended questions. Here, they must decide:
• Dementia 290.X • What is important to say
• Schizoaffective Disorder 295. 70 • How directly they answer questions
• Schizophreniform Disorder 295.40 • How much detail to give, and when to move on
• How to move on to another topic, and the degree of
Diagnostic criteria that specifically include thought process connectedness to what was just being discussed
are as follov·s:
• Schizophrenia 295.X In a closed-ended style of interview, disorde,. ~ of thought
A. (3) Disorganized speech (e.g. frequent derailment or process may not be elicited. However, once it is apparent
incoherence) that a thought disorder is present, greater structure in an
interview may be the only way of moving on to salient areas.
• Brief Psychotic Disorder 298.8
A. (3) Disorganized speech (e.g. frequent derailment or The individual disorders of thought process are:
incoherence) • Circumstantiality
• T angentiality
• Manic Episodc/Hypomanic Episode 296.X
• Flight of ideas
B. (4) Flight of ideas_ or subjective experience that thoughts
• Rambling
are racing
• Loose Associations
• Schizotypal Personality Disorder 301.22 • Thought Derailment
(4) Odd thinking and speech (e.g. vague, circumstantial, • Thought Blocking
metaphorical, overelaborate or stereotyped) • Fragmentation
• Verbigeration
Diagnostic Criteria are frorn the DSM-IV. • Jargon
©American Psychiatric Association, Washington, D.C. 1994 • Word Salad
Reprinted with permission. • lncoherence

142 143
~·· iliJ J1r ~·--~/-~r ilj~~,,-~,--~.--,r--ti,·--11,-11,,__w~ [4·· '1~:~:~~.L.·~-~11.~•~~-JGl.r-~"'*"55_,_ •
These disorders are listed below in arder of increasing
severity.
Process Disturbance Nature of Disturbance
Circumstantiality • words are completely formed
• sentence structure maintained
Tangentiality
• linkage between ideas remains light
• overinclusive of detail or do not
directly address the point
Flight of ideas • words and sentences maintained
• connection between ideas apparent
• rapid and frequent shifts in tapie
Rambling
• clusters of sentences remain goal-
directed, interspersed with groups
that are not goal-directed
Loose Associations • words and sentences maintained
• phrases and sentences still properly
constructed
• connection between ideas is not
obvious, unclear or nonsensical
Thought Derailment • syntax intact, speech suddenly
Thought Blocking shifts (derailment) or stops (blocking)
• may or may not return to previous
topic, unaware of what is happening
Fragmentation • words intact, phrases become
disconnected from each other
Verbigeratiun • repetition of words and phrases
Jargon • syntax intact, speech meaningless
Word Salad • words remain intact, ali syntax lost
lncoherence • words are unintelligible, speech is
garbled or dysarthric
144
What is considered normal when it tomes to
thought process?
There is a continuum of variation in how thought is
expressed. People express varying degrees of coherence,
detail and organization at different times. Thought process
must be considered in conjunction with other features of the
interview. Someone who is overly anxious may speak
quickly and provide a lot of extraneous detail. A person who
is highly creative may verbalize their flow of thought ("stream
of consciousness") anu appear to have disjointed ideas.
Sorne people make great leaps in thinking befare verbalizing
anything, and the connections between their statements may
need to be explained.
lt is valuable to record segments of the interview to illustrate
your opinion of the patient's thought process. At the end of
the interview, make a judgment about the overall ability of
the patient to communicate his or her difficulties. The
following descriptions are commonly used:
• Tightness of thought
well-organizedltangentíal/loose/y connectedlíncoherent
• Flow of speech
spontaneouslhesítantlínterruptedlhaltíng
• Directness of responses
ínformatíve and relevantlembellíshedlmarkedly overínclusíve
• Flow of ideas
logícal and wíth varíabílíty/restrícted/repetitive
• Vocabulary
descriptivelrestríctedlídiosyncratíc use of words
• Flow of information
good exchange/adequate/vague/disorganized
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

liow do I go off on a tangent? How do I get booked on a flight _;f ideas?

Definition: Tangential speech can be followed and remains
logical. Proper words and grammar are used. The
distinguishing factor is that the person does not arrive at the
point or answer the question. Tangentiality helps move a
conversation along, but in an interview situation it can be a
sign of pathology. The severity and frequency of tangential
speech needs to be gauged to determine if it impacts on the
quality of the interview. Tangential replies stay in the
"ballpark" of the answer. Patients in whom tangentiality is not
pathological can refocus their replies to the question at hand.
Definition: Flight of ideas is non-goal directed speech that
"takes off' in a tangential manner. Patients are usually
distractible, and change their topic every sentence or two.
Speech remains logical, and the connections between ideas
are still recognizable. Patients don't elaborate on their ideas
befare moving onto something else. Their statements
contain proper words and gra(, 1mar. Flight of ideas differs
from tangential speech in that tapie changes are more
abrupt, more frequent, and often prompted by a word in the
previous sentence.

Diagrammatic Representation: Diagrammatic Representation:

º$'<.
r-=:.-r-G-0-\-..}-VC---\....-N\-N
~~
p...- e-e-o-~ ~'v

-
~'::,"
. • X'
x·0
-
c.;"5<;
~<Q

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
in the summer because the sunlight makes the paint fade.
Most commonly seen in:
• Personality disorders where verbal communication is
maintained mainly for the sake of feeling connected to
someone, e.g. histrionic and dependent personalities
• Cognitive disorders such as delirium or dementia
• Hypomania, anxiety disorders
• SubstancP ingestion and abuse (alcohol, stimulants,
marijuana, etc.)
• Schizophrenia; though other disorders of thought
process are more typical of this illness
-
;:v
-Example: Name the Seven Dwarfs
Happily, 1 don't think on such a small level. Small things
come in good packages. 1 cut myself opening my mail
yesterday, it still stings. 1 got stung by a bee last summer,
but it's only fair, since 1 eat honey. 1 have breakfast every
morning because it is the most important meal of the day.
l like to eat three squares when 1 can, but not out of the can.
Cans keep food around for years, but not if you take the
label off. 1 bought a labeling machine, and now everything in
my house has a proper name. 1 like to addre~!" my property
on a first name basis. Ah, the joys of owner~.iip.
continued ~

148 149
 ' '

_J _, _j ",,__)~~_J._ __:j'- __J'- _j- _j-_J-_j~..J--1-..-- Li iaj-llií:a---U---bi-til-lliif-lll!i-l/lfJ-MJ__.,__l.., UG.PR.ESS.. &J

An examination of these sentences reveals discernible

connections between them, with a word acting as a trigger
for the abrupt and frequent changes in topic.
Happily, 1don't think on such a small leve!.
Who are the loose associations?
Definition: Association refers to the logical connection or
"tightness" between ideas. In loase associations, a

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.

1 cut myself opening my mail yesterday.

]?
1 like to eat three squares when 1 can, but not out of
]?
J
the can. 1 have breakfast every morning.

Cans keep food around for years.

Cans keep food around for years, but not
if you take the label off.
oon'
Most commonly seen in:
e Mania and hypomania; flight of ideas with pressured
speech is one of the cardinal signs of a manic episode
• In severe mania, patients speak in an uninterruptable
monologue heading off on irrelevant tangents
• Patients often pickup on something around them to start
their flight of thought; in this example, "happily" was used
as a partial answer to the question, since Happy is one
of the Seven Dwarts ©
• Flight of ideas can also be seen in psychotic disorders
(e.g. schizophrenia, brief psychotic disorder, drug
induced psychosis), delirium and dementia
]?
1 address my property personally. ]?
There is no logical connection between these sentences.
Loosening of associations is characteristic of the thought
process during psychosis (in schizophrenia and other
psychotic disorders ). However, mania can become so
severe that the connections between ideas becomes lost.
Rambling describes speech composed of clusters of related
sentences that are goal directed, then become interspersed
with loosely associated statements. lt is characteristic of an
acute, coarse brain disorder (often alcohol related).
Rambling is not as severe as loosening of associations, but
lacks the logical connections seen in flight of ideas.

150 151
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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
i . ··.)
..,,;·· '""
!/

iJ u ;Li U1'N •Aíf.CIP'i&d,' &l.' ...... .... .,_, •· - 111:'· .... -· - - •· • · - · .... - · 1111 .... ... Sii •iTllf!ll.iJG .>R<:M!.·ss . . -

A Comparison al Fluent Thought Process Thought bloclcing and derailment?

Disorders
Definition: Thought blocking is the sudden involuntary

./
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.

Derailment occurs when speech begins again about another

topic after a few seconds. Patients do not usually know what
they were speaking about before the block, and are unaware
- 2
of the switch in tapie. Their speech is otherwise fluent and is
1. Goal-directed, logical thought that both addresses the grammatically correct.
point and answers the question directly.
Diagrammatic Representation:
2. Circumstantial thought contains a mass of digressions,
B
subsidiary clauses and "talking around" the point. People are A•B•C•D•E•F•G•H-1-J
L
often aware of their wordiness and that their style of thought o
e j · P·Q·R·S·T·U·V·W·X·Y·Z
impedes reaching the goal.
K
..
3. Tangential thought is not goaldirected, though it starts
out being relevant and generally stays in the vicinity of the
1
N
1
r DERAiLMENT 1
G
topic. The point or question is not ultimately addressed,
which distinguishes this from circumstantiality. lf the thought
process does not reach the goal and is overly detailed, it can Example: How about those Orioles?
be described as both tangential and circumstantial. 1think they're the team this year! They made sorne important
changes ...... l've got to catch a midnight train to Georgia.
4. Flight of ideas takes off more quickly and radically than
tangential speech. Rapid, uncensored associations are Most Commonly Seen in:
made due to increased distractibility and the pressure to • Thought blocking is one of the negative symptoms of
keep talking. This is a form of accelerated speech. schizophrenia and is considered a form of alogia
• Thought derailment is one of the positive symptoms of
5. Loosening of associations is the loss of meaningful schizophrenia and is considered one of the factors
connections between words and phrases. Transitions are not contributing to a positive formal thought disorder
based on logical connections between ideas . • Delirious patients can also demonstrate these signs

. 152 153
'j ......,¡
_; .:::.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

What is the whole story on lragmentation? Is there a verb in verbigeration?

Definition: Fragmentation is the loss of meaningful
co11nections between words and phrases. The speech lacks
focus and does not bring about closure. lt consists of
phrases that are unrelated in meaning. The phrases
themselves still have proper syntax and are composed of
understandable words. This type of abnormality is similar to
Broca's Aphasia in its broken delivery, However, in
f¡agmentation, the speech contains the connecting words,
articulation is intact, and pauses are not notably long (recall
these are features of Broca's Aphasia).
Diagrammatic Representation:
A·B·C·D·E ... l·J·K ... O·P•Q•R•S•T ... Y•Z
Example:
1have to .... what is my ... gone today .... near and far ..
all or nothing at ali .. flip, flap and fly ... whiter shade of pale
Most Commonly Seen in:
• Fragmentation is not specific for any particular condition,
it can be seen in any psychotic disorder, psychotié mood
disorder, dementia, delirium, etc.
Definition: Verbigeration, also known as palilalia, is the
automatic repetition of words or sounds. Similar to
behavioral stereotypies, verbigeration is considered a
stereotypy of language. The tightness of associations in the
speech may otherwise be intact.
Diagrammatic Representation:
A·B•C•C•C•C .... B•C•C•C•C ....
Example: Where did you park you car?
1 parked it, it, it, it ..... parked it, it, it, it
Most commonly seen in:
• Catatonia (dueto schizophrenia, mood disorders or
organic brain syndromes)
Perseveration
Definition: Perseveration is the automatic repetition of a
verbal response despite changing questions. Perseveration
can also be a motor disorder where the same action persists.
The repeated group of words is called a stock phrase.
Diagrammatic Representabon:

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
~-·· fll, .JJ--4fr-~~~~,.L..~~-itF--lJ~'~~~,/ ilj Lt
What is jargon or driveling ?
Definition: Jargon, also called jargon agrammatism,
double-talk or driveling, is composed of speech that has
lost its communicative value. The syntax is preserved in this
disorder and speech remains fluent. This is the type of
speech that is typical of Wernicke's Aphasia. The repetition
of stock phrases (perseveration) or syllables (verbigeration)
.is not prominent in driveling.
Diagrammatic Representation:
A•C•D•C ... U·W·O ... P•E•X•D•U•R•P•L•E ...
Example: What was McMaster Medica! School like?
In verbatim oval often inside making sudden. When system
phones, try delayed transparency. Principies fourth at one.
Most commonly seen in:
• Any of the causes of Wernicke's Aphasia (e.g. strokes,
tumors, head injuries)
• Chronic psychotic conditions with a severe course
Incoherente
lncoherence can be caused by:
• Severe dysarthria causing indecipherable mumbling
(which may be due to a dystonic reaction of the jaw
muscles)
" Extensive numbers of made-up words (neologisms)
• Prívate use of words (words that exist but are used in an
incorrect way)
• Severe loosening of associations such as word salad
(see next page)
156
1
'" w.j llr (f/ a¡.•. •r· fi7 .r li:TH~H-~0-~ a( tJJ
How do I toss a word salad?
Definition: Word salad is an extreme form of loosened
associations, to the point that words have no connection to
one another. lt is as if a sentence were placed in a food
processor and the diced words were tossed in a bowl. Sorne
folks have had similar e):periences with word processors and
been forced to eat their words. The speech in word salad is
incomprehensible, and resembles the incoherence of a
global aphasia. The articulation in word salad remains
intact, delivery is usually fluent and the prosody of speech is
present.
Word salad differs from fragmentation in that there is no
connection at ali between individual words (recall the
phrases and sentences were unconnected in fragmentation).
Word salad differs from jargon in that there is no
preservation of syntax, though the speech in both disorders
is equally meaningless.
Diagrammatic Representation:
A•X •Q•D•B•E•B•O•P•A·O·L •S•U•X•P•O•R•V· T·X •X •W•V· T •Z
Example: So, just what are those secret herbs and
spices?
at, to, but, not, when, if, that, my, never, fuller, clip, original
Most commonly seen in:
• Chronic schizophrenia with a severe course
• Advanced dementias, severe delirium
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
process disorders?
• Clang Associations
• Echolalia
• Neologisms
• Non sequiturs
• Prívate use of words
• Pressure of speech
• Rate
• Rl1ythm
Clang associations are made on the basis of sound, not
syntax or logical flow. This most commonly occurs by
rhyming the last word in a sentence. In sorne cases, this is
considered a type of phonemic or literal paraphasia where
patients are compelled to substitute a word that sounds
similar to one they just used. An example is:
1 have to go, you know. To and fro befare !he snow starts to blow.
Clang associations are most commonly seen in mania, but
also occur in aphasias, schizophrenia and dementias.
Echolalia has been mentioned earlier in the BEHAv10R
CHAPTER. lt is the automatic repetition of someone else's
3peech. Eci .ulalia is seen in:
• Catatonia
• Transcortical motor aphasias
• Transcortical sensory aphasias
• Dementias
Echolalia is distinguished from perseveration in that the
words repeated are the interviewer's (not the patient's as in
perseveration). Echolalia is distinguished from palilalia
(verbigeration) in that whole phrases and sentences are
repeated, not just the last word or syllable.
Neologisms are words or p11rases made up by patients
that have idiosyncratic meanings for them. Neologisms may
be formed by the improper use of the sound of words or
other perceptual abnormalities. They are also called jargon
paraphasias. In ps;chiatric disorders, neologisms occur in a
syntactically correct place in a patients speech, as if they
were words the interviewer didn't know. Ask about unfamiliar
terms; you'll either detecta neologism or learn a new word.
Additionally, neologisms sound as if they could be words.
For example, which in the following list are actual words?
• jolmet
• jingo
• meltom
o monad
o rocer
o regulus
The first, third and fifth words are neologisms. The created
word has a meaning that only the patient understands.
Jolmet might be the border surrounding a sheet of stamps;
meltom could be the ground on an electrical plug. No sense
can be made from these words by breaking them down into
their components. For example, if phonesiaV. is defined as
the act of dialing a number and forgetting who you were
calling, this is an understandable amalgamation
=
(phone + amnesia phonesia). Such terms were developed
and published by the comedian Rich Hall. 1-' called them
sniglets (defined as a word that doesn't exist, but.should).
Neologisms can appear in any of the disorders of thought
form listed in this chapter. They are most commonly seen in
schizophrenia, but can occur in any type of psychotic
disorder, dementia, and a number of the aphasias. Patients
are not generally aware that they have used a neologism.
They are usually cooperative in defining the term once it has
been pointed out to them.
n R. Hall, Sniglets, Macmillan Publishing Co., New York, 1984

158 159
i&· ~ k br-~~~-ki.-·~;_;~:-~-D._;a~·.tl-Q~~·-
That's irrelevant. What's a non sequitur?
Non-sequitur is a Latin term meaning does not follow. lt
has the same word root as sequence. Non sequ:turs occur
as a function of normal speech and thought. lf someone gets
an idea or is suddenly reminded of something (e.g. get milk),
he or she will blurt out something apart from what was just
being discussed. The reply itself demonstrates proper
·· grammar and syntax, and is not otherwise remarkable
except for not addressing the question.
Non sequiturs can also be a sign of pathology. Generally,
they are said to occur whenever the answer is unrelated to
the question, whether interpreted literally or abstractly.
Consider the following question:
Q. What is the capital of France?
1. Paris
2. The franc
3. The letter F
4. Wine
Which of the following answers is a non-sequitur? At first
glance, only (1) may seen correct. However, since capital
can also refer to money and capital letters, only (4) is an
unrelated response.
Non sequiturs can be seen as part of severa! abnormalities
of thought form:
• Circumstantial speech
• Tangential speech
• Loosening of associations
• Flight of 'deas
• Derailment (with a short period of blocking)
As such, they are nonspecific signs of illness, but are
reported to be more common in schizophrenia, dementias,
aphasias and coarse brain injuries.
160
¡¡ . ~· t'f. ...Ji¡':_& G CJf 14. j, fi¡:' (;{THf;;1é;Hj/itRcjjfss t[ ll
How do 1lceep a word prívate around here?
Private use of words refers to the incorrect use of an
existing word. Syntax remains correct, but the word is used
out of context. lt is also called a literal or semantic
paraphasia. The word substiiuted for the correct one is
unrelated either in sound or function. For example:
Yesterday 1visited my friend gerund.
Gerund is a word, but its use here is of a private nature. lt
was not substituted for Gerrard, which might have been
either a related (approximative) or literal (phonemic) aphasia.
l'm under a lot of pressure of speech
The rate of speech, or more correctly the rate of thought, is
another disorder of tho~ght process. A rapid rate of speech
is a variant of normal, and is frequently seen when patients
are anxious (either situational or dueto an anxiety disorder).
Pressured speech has a rapid rate with an uninterruptable,
intrusive quality, as if patients are compelled to keep talking.
This is also called pressure of ideas or thought pressure.
Diagrammatic Representation:
• an average rate of speech covers this sentence in 4 seconds
Rapid Psychler produces humorous and educational publications.
• pressured speech takes 2 seconds and keeps going (and going)
~ ~plXlt.res h..mroJs ard eckaOCnal pjiJ:a&ns. Usirg hmrrisa key ...
Pressure of speeéh is one of the principal s1gns of manic or
hypomanic episodes and is accompanied by the sensation of
racing thoughts. The combination is expressed verbally as
flight of ideas. These features can also occur in anxiety
states, use of stimulants and hyperthyroidism.
161
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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 .

.. lncreased rate needs to be distinguished from pressure of

spéech. Patients who have a rapid rate of speech are
interruptible, do not appear compelled to keep speaking, and
may be anxious or have medica! illnesses. When asked to
do so, they are able to slow down their rate of speech.

Rhythm Disturbances were covered on p. 131 in the

prosody section of the SPEECH CHAPTER. Psychspeak Neurospeak
Driveling speech ++ Jargon agrammatism
Thought Process Tidbits Neologisms ++ Phonemic paraphasias
• lt can be quite difficult to distinguish word salad from Prívate use of words ++ Semantic paraphasias
Wernicke's Aphasia Verbigeration ++ Palilalia
• lf the associations between someone's thoughts seem
foosened, poin~ out !he shift in topic and ask what the
Thought Process Disorder vs. Aphasia
connection was between the two ideas A thought process disorder generally doesn't interfere with:
• Patients demonstrate loosening of associations when
• Reading
writing as well as speaking • Naming
• Although loase associations are considered a cardinal
• Writing
• Repeating
sign of schizophrenia, they are also seen in cognitive
• Copying
disorders (delirium & depression), mood disorders
(especially severe mania or psychotic depression) and
However, patients may be too disorganized to fully
drug intoxication or withdrawal states
.. Thought insertion or thought withdrawal (defined in
participate. In thought process disorders, neologisms are
symbolic (replace a noun or verb), repeated, and used in a
the chapter on THOUGHT CoNTENr) can affect the process
syntactically correct way. In aphasias, they can replace any
of thought by increasing or decreasing (respectively) the
number of ideas to express word (nonsymbolic), are not repeated, and occur randomly.
• Condensation is a disorder of thought process in which
Aphasias cause the deletion of connecting words (articles,
prepositions, conjunctions, etc.), so speech consists mainly
severa! concepts are expressed in a unified form; this
of nouns and verbs. Patients with thought disorders
occurs rr ·inly in schizophrenia and substance abuse
generally speak fluently with preserved syrt"",x and prosody.

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
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Thoughts on the Move Malapropisms

A malapropism is the unintentional choice of a word that
alters ( or contradicts) the meaning of a statement. They are
named after the character Mrs. Malaprop from Sheridan's
comedy called The Riva/s. For example, she referred to
another character as the "pineapple of politeness" when she
racing thoughts meant to say the "pinnacle." Other humorous substitutions
were the word "illiterate" far "obliterate," and "ineffectual" for
"intellectual." Here are sorne others:

• Homer wrote the Oddity, in which Penelope was the :ast

hardship that Ulysses endured on his journey.

• Adults enjoy adultery more than infants enjoy infancy.

• Julius Caesar extinguished himself on the battlefields of

Gaul.

thought derailment • Mr. and Mrs. Bobbiwash request the honor of your
presents at the marriage of their daughter ...

• Ro me wasn't burned in a day.

• Am 1 my brother's brother?

• The flooding was so bad they had to evaporate the city.

• Socrates died from an overdose of wedlock.

• Gravity was invented by Isaac Apple.

flight of ideas
• The package was sent by partial post.

• Hamlet's son was named Piglet.

"~~~---~~~ • 1 musterded my courage and set forth on a quest ...

168
169
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Chapter 1
Thought Content
What is thought tontent?

Speech

Thought Process Thought Content

Language

Thought content refers to what patients talk about in the

substance of the interview. While it may be t~mpting to say,
"Ms. C.Y. answered the questions 1 asked .. er," an interview
is guided by the content of the answers given. Further
questions are refined by the information patients provide.

One of the key reasons the beginning of an interview is left

unstructured is to allow an assessment of thought content.
Special attention should be given to what patients talk about
spontaneously, elaborate on, and what themes develop as
they speak. This acts as a type of projectíve test because
patients talk about what is important to them, and "project"
their concerns in the interview. As stressors or symptoms
are elicited, exploration along the lines of who, what, where,
when, why & how (W-5 + H) help guide the flow of relevant
material while also allowing patients the chance to continue
speaking in a relatively unrestricted manner. lnterviews that
consist of a closed-ended or laundry-list approach restrict
this flow of spontaneous information.

170 171
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What is the diagnostic signilicance ol
abnormalities in thought content?
A number of disorders are diagnosed largely or completely
on the basis of thought content.
• Schizophrenia 295.X
• Brief Psychotic Disorder 298.8
¡,- Schizophreniform Disorder 295.40
• Schizoaffective Disorder 295. 70
A. (1) Delusions
• Delusional Disorder 297.1
A. Nonbizarre delusions
• Shared Psychotic Disorder (Folie a Deux) 297.3
A. A delusion develops in an individual in the context of a
clase relationship with another person who has an
established delusion
• Major Depressive Episode 296.X
A. (7) ... excessive or inappropriate guilt (which may be
delusional) ...
• Manic Episode/ Hypomanic Episode 296.X
P. (1) lnflatec' self-esteem or grandiosity
• Specific Phobia 300.29
A. Marked and persistent fear that is excessive or
unreasonable, cued by the presence or anticipation of a
specific object or situation.
• Social Phobia 300.23
A. A marked and persistent fear of one or more social or
performance situations in which the person is exposed to
unfamiliar people or to possible scrutiny by others ...
172
j
• Obsessive-Compulsive Disorder 300.3
A. Obsessions:
(1) Recurrent and persistent thoughts, impulses, or images
that are experiencec!, at sorne time during the disturbance,
as intrusive and inappropriate and that cause marked anxiety
or distress
(2) The thoughts, impulses, or images are not simply
excessive worries about real-life problems
(4) The person recognizes that the obsessional thoughts,
impulses, or images are a product of his or her own mind
Compulsions:
(1) Repetitive behaviors or mental acts that the person feels
driven to perform in response to an obsession, or according
to rules that must be applied rigidly
• Posttraumatic Stress Disorder 309.81
B. (1) Recurrent and intrusive distressing recollections of the
event, including images, thoughts, or perceptions
• Hypochondriasis 300.7
A. Preoccupation with fears of having, or the idea that one
has, a serious disease based on the person's
misinterpretation of bodily symptoms
• Paranoid Personality Disorder 301.0
A. (1) Suspects, without sufficient basis, that ~:hers are
exploiting, harming or deceiving him or her
(2) Is preoccupied with unjustified doubts about the loyalty
of trustworthiness of friends or associates
(7) Has recurrent suspicions, without justification,
regarding the fidelity of spouse or sexual partner
• Schizotypal Personality Disorder 301.22
A. (1) Ideas of reference (excluding delusions of reference)
(2) Odd beliefs or magical thinking that influences
behavior and is inconsistent with subcultura! norms
(4) Odd thinking and speech
(5) Suspiciousness or paranoid ideation
173
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Borderline Personality Disorder 301.83

o
A. (9) Transient, stress-related paranoid ideation ...
What constitutes a disorder of thought
content?
• Antisocial Personality Disorder 301.7
A. (7) Lack of remarse, as indicated by being indifferent to or As indicated in the diagnostic criteria listed in the previous
rationalizing having hurt, mistreated, or stolen from another section, thought content is considered abnormal when it
contains any of the following elements:
o Narcissistic Personality Disorder 301.81
• Delusions
A (1.) Has a grandiose sense of self-importance
Paranoid
(2) Is preoccupied with fantasies of unlimited success, Grandiose
power, brilliance, beauty or love Jealous
(3) Believes that he or she is "special" and unique and can Erotomanic
only be understood by, or should associate with, other Somatic
special or high status people (or institutions) Passivity and Control
Other Common Delusions
(5) Has a sense of entitlement Culture-Bound Delusions
(8) Is often envious of others or believes that others are Syntonicity & Congruence
envious of him or her
• Overvalued Ideas
• Avoidant Personality Disorder 301.82 • Obsessions
A. (4) Is preoccupied with being criticized or rejected in • Phobias
social situations • Suicida! Thoughts
• Homicida! Thoughts
• Dependent Personality Disorder 301.6
A. (8) Is unrealistically preoccupied with fears of being left to To paraphrase a famous quote, the ebb and flow of thoughts
take care of himself or herself have a direct effect on emotional health. Patients
experiencing delusions, obsessions or phobias seek
• Obsessive-Compulsive Personality Disorder 301.4 attention because their lives, or the lives of those around
A. (1) Is preoccupied with details, rules, lists, arder, them, are significantly disrupted by these disturbances in
organization, or schedules to the extent that the major point thought content. On the other hand, sorne patients are adept
of the activity is lost at concealing such experiences and make them difficult to
(4) Is overconscientious, scrupulous, and inflexible about elicit, especially in a first interview. The degree of awareness
Matters of m ~ality, ethics, or values of abnormal thoughts (called insight) varíes widely. lmpaired
(8) Shows rigidity and stubbornness or absent insight is usually a sign of a mon. ,erious
disturbance and/or worse prognosis. Additionally, abnormal
thoughts evoke a variable affective response in patients.
Diagnostic Criteria are from the DSM-IV.
©American P5ychiatric Association. Washington, D.C. 1994 Because of the seriousness of suicida! and/or homicidal
Reprinted with permission. thoughts, they are presented in the next chapter.

174 175
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What is a delusion?
.Jelusions a; e one of the cardinal symptoms indicating a
serious mental illness, though they are not specific to any
particular condition. Delusions have been reported in well
over fifty psychiatric and general medical conditions.
The word itself comes from the Latin delirare which means
·lunacy. Literally translated, the word means, "to become
urihinged," "to go out of the furrow," orto deviate from a
straight line (using tlie roots de (from)'and lira (furrow or
track)). Though delusion and delirium have the same word
root, they describe different conditions.
A delusion is defined as a fixed, false belief that:
l'J Is inconsistent with cultural or subcultural norms
• Is inappropriate for the person's level of education
• Is not altered with proof to the contrary (incorrigibility)
• Preoccupies the patient to such a great extent that he or
she finds it difficult to avoid thinking or speaking about it
• Is not resisted by the patient
• Ranges from implausible to impossible
• Places the patient at the center of events
• Is a self-evident truth to the person (subjective certainty)
The content of delüsions ranges from fragmented to
systematized, and from .situations that are possible (non-
bizarre) to those that are impossible (bizarre). In cases
where a patient appears to have q discrete, plausible, but
false belief (e.g. someone is reading my mail), it may only be
possible to establish if this is a delusion with additional
\COrollary) information. Cultural differences can also account
for "unusual" ideas, and it behooves us to check into this
possibility. In order to distinguish a delusion from other
aberrations of thought content, it is crucial to establish that it
is indeed fixed. For example, someone who is confabulating
(or is being misleading) will change sorne part of the history
·vhen askec! J repeat the details.
176
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How do delusions start?
In arder for delusions to develop, sorne cor .1nation of
predisposing factors needs to be present. Examples include:
• lmpairment of brain functioning
• A personality disorder (causing a distortion of reality)
• An inability to manage stress which impacts on a genetic
vulnerability (diathesis) to decompensate; this is called
the stress-diathesis model of mental illness
Specific factors thought to be operative are:
• Delusional intuition (autochthonous delusions):
describes the sudden arrival of an idea which
automatically becomes a belief; this is similar to a
"eureka" experience which comes "out of the blue,"
and illustrates the self-evident aspect of a delusion in
that if a patient believes it, it must be true ("Make it so.").
• Delusional perception: refers to an abnormal
significance ascribed to a real stimulus; for example, a
patient will hear an air-conditioner start and assume she
is about to be exposed to poison gas (note: this occurs in
someone who was not previously paranoid)
• Delusional atmosphereldelusional mood: describes
the experience in which the environment appears altered
so everything seems unusual, ominous or even
threatening; the surroundings seem peculiar and a
significant event is felt to be imminent; frequently
patients are apprehensive until an understanding (though
arbitrary and false) of the situation can be reached
• Delusional memory/retrospective delusions: refers to
the faulty recollection of memories in a way that adds
"proof' to current beliefs
Delusions that start de novo as a result of the above (or
other factors) are called primary delusions. Secondary
delusions arise out of a mood state, perceptual abnormality
(including sensory deprivation or impairment), social factors,
or other pre-existing psychopathology.
177
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Delusions often contain a kernel of trut/J or are based on a

key experience. The subsequent handling of this experience
What is the psychodynamic understanding
is overly personalized, extended, and held to an extreme of delusions?
leve! of conviction which is not amenable to logic. Far
example, a patient who suffers from delusional infestation Delusions serve important psychological functions for
with parasites initially may have had !ice. Another patient patients in whom they occur. They can be understood in
who claims e: romantic connection to a movie star may well terms of fulfilling an unconscious wish or psvcliological need.
11ave met that person or joined her fan club, but then One of the best explanations of delusions i~ .hat they
extrapolates this connection into an erotomanic delusion. displace onto the environment specific feelings (such as
hate) that are unacceptaqle on a conscious leve!.
Delusional patients have an altered process of reasoning.
Apophony (from the Greek "to become manífest") is the Historical information about delusional patients often reveals
phenomenon in whích arbitrary or false ideas are considered repeated experiences with hostility in early relationships.
fact without adequate proof. Events and objects become This becomes internalized as a model for future
imbued with a personal, autistíc sígnificance (also called the relationships, and in adulthood, this hostility is projected onto
residuum). Apophony is also used to refer to the attribution the externa! world. This helps satisfy an interna! emotional
of new meaníngs for psychological events (líke delusional need, but results in false convictions about the environment.
perception or atmosphere outlíned on the previous page ).
Delusions are maintained because they help bolster the low
Delusional patients also make sweeping inferences based self-esteem of patients. In a primitive way, delusions provide
on small amounts of information (called generalization). meaning to the lives of those who suffer from them. Patients
They do not use their knowledge or experience to modify who were previously isolated, hopeless and felt they had
their beliefs. Social Attribution Theory propases that little purpose in life could have something to rally around.
delusional patients excessively ascribe negative events to Common delusional themes can be related to Erickson's
externa! factors. A patient who passes through a radar trap Life Cycle Stages:
(without speeding) is convinced this was arranged so the Theme of Delusion
Sta ge Central lssue
police could monitor his actions. Conversely, positive events • Basic Trust vs. Safety Paranoia
are thought to occur purely far interna! reasons. A patient Basic Mistrust
wins a hospital raffle because she has a divine connection. Bodily Functions Somatization
• Autonomy vs.
and this is a reward for her continued efforts. · Shame & Doubt
• lnitiative vs. Achievement Grandiosity
Delusions become a psychological compromise which Guilt
makes sense of the interna! chaos and externa! reality with • lndustry vs. Achievement Grandiosity
which patients must contend (called consolidation). This is lnferiority
the central tenet in the theory of adaptation, which posits • ldentity vs. Love Jealousy & Erotomania
t~at symptoms are formed in mental illnesses as a means of Role Diffusion
survival. The content of delusions is not random, but a highly • lntimacy vs. Lo ve Jealousy & Erotomania
personalized representation of the patient's inner world. lsolation

178 179

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How do I ask about delusions?
Formulating questions about delusions constitutes one of the
rnost difficult tasks during interviews. As opposed to patients
with phobias or obsessions, delusional patients usually don't
recognize that they are ill. Asking, "So, are you delusional?"
probably won't work, so more refined means are required.
.Watch far themes during the interview:
Despite the complexity of mental illnesses, most delusions
fall into a small number of themes (paranoid, somatic,
grandiose, jealous, etc.).
Questions to help detect the presence of de/usions:
• "What's been on your mind recently?"
• "Do you spend a lot of time thinking about one or two things?"
• "Do you have sorne ideas that you hold very strongly?"
• "Do others frequently disagree with your views on things?"
• "When ye;u aren't busy with something, what do you think about?"
• "What are the things that are most importan! to you?"
Because del_usions dominate thinking (and also mood and
behavior to a large extent), these questions are likely to
revea! an aspect of delusional thinking if it is present. When
patients mention something that could be of a delusional
nature, respond with curiosity. An interested, conversational
manner will elicit more information.
Questions to examine (potential/y) delusional material:
• ''l'm interested in what you just said, what else can you tell me
about that?"
11 "How do you know?"
• "How did all this start?"
• "Why would someone want to do this to you?"
• "What's happened so far?"
• "How do you account for wh::it has taken place?"
Regardless of skill, delusions can't always be elicited.
Patients with an awareness that others don't share their
ideas (preserved insight) or who have been hospitalized
because of delusions may conceal their thoughts.
180
Ir
How do I deal with delusions onte they are
expressed?
lt is important to bear in mind that delusions represent the
truth to patients who experience them. Your reactions (verbal
and behavioral) have a large degree of influence over what
patients are willing to share. As mentioned, an inquisitive
approach that outlines the extent of the delusional thinking is
optimal. Novice interviewers often make one of two mistakes
(sorne make both) when uncovering delusional material:
• Adopting a nonchalant, lackluster demeanor, as if not to
frighten the patient by showing too mue: .11terest
• Sitting bolt upright with a widened stare, sharpened
pencil and demonstrating an unprecedented leve! of
interest in the interview material
Guidelines for handling delusions are as follows:
• Don't interrogate patients - a rapid-fire approach will
usually miss delusions in the first place; an undue
degree of interest or chariJe in interviewing style may
have an idiosyncratic meaning for the patient (e.g. you
become part of the delusion because of your interest)
• Don't argue with patients - no delusion was ever cured
by logic or any degree of proof to the contrary; it can be
very tempting to "enlighten" patients or point out the
obvious contradictions or weaknesses in their
understanding of events
• Empathize with patients to preserve rapport and to
facilitate sharing more information
• Tactfully avoid being the "judge of reality" and telling
patients whether or not you agree with them
• lf pressed to render an opinion, try something like:
• "l'm keeping an open mind."
• "I can't decide without more information."
• "My job is to understand what your views are."
181
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Persetutory (Paranoid) Delusions
Paranoia, literally ~ranslated from Greek, means "a mind
beside itself." These are the most common delusions,
regardless of which disorder the patient has. Paranoia exists
on a spectrum in psychiatric illnesses:
Normal Paran o id Delusional Paranoid
Vigilance Personality Disorder Schizophrenia
Projection is the main ego defense involved in paranoia. In
persecutory delusions, an interna! threat is substituted with
an externa! one. An externa! agency (individual or group) is
accused of acting against the patient. Patients often have a
knack of m;:: 1~ing the. projections "fit" the group being accused
(e.g. fear of being "framed" by a group of criminals).
Paranoid patients are hypervigilant, and miss little that goes
on around them. Their difficulties arise out of the automatic
assumption that others are conspiring against them (also
called delusional misinterpretation).
Paranoid Themes:
• Being followed
• Being monitornd (tape recorded, videotaped, etc.)
• Having.things stolen, particularly while the patient is
away from home
• Being poisoned or drugged
• Having one's reputation ruined or integrity maligned
• Prejudice, slights, obstruction from long-term goals
• Querulous paranoia is the continua! involvement of the
legal system to remedy perceived injustices
• Repeated difficulties with authority figures
• Criticism of those seen as weaker or needy
• Searching intensively to confirm suspicions to the
exclusion of more reasonable ccinclusions
182
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Grundiose Delusions/Delusions of Grandeur
Grandiose delusions involve impossibly great wealth, fame,
power, physical abilities, etc. They even extend beyond the
range of human abilities and achievement to include
supernatural powers or omnipotence. Patients will tell you,
sometimes in the same breath, about their accumulated
billions, clase relationships with the rich and famous, and
plans for the global takeover of sorne business.
Grandiose delusions bear a similarity to persecutory
delusions in that everything that happens around the patient
must have something to do with that person. This is called
self-referential grandiosity.
In sorne instances, patients have the expectation that they
are in training far a secret mission. In this sense, their beliefs
are somewhat opposite the persecutory tyr .n that the
patient is now involved as a clandestine operative.
In psychiatric conditions, grandiose delusions are seen in
schizophrenia and mania. The narcissistic personality
disorder has an overlap with the self-aggrandizing aspects of
these delusions. However, narcissistic personalities are not
delusional, and consider themselves capable of feats (only)
within the realm of human ac~ievement. Differentiation of
narcissism from the nonbizarre delusions in a delusional
disorder may be more difficult.
Grandiose Themes:
• Entitlement and privilege
• Endowing people or machines with special powers
• Religion or royalty
• Making attempts to contact famous people
• Having great but unrecognized talents
• Taking credit far one or severa! remarkable discoveries
183
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Delusions of Jealousy
This is generally considered to be the unfounded conviction
that one's spouse or loved one is being unfaithfuL However,
the term delusion of infidelity is more specific to this
condition. Morbid or malignan! jealousy can be used to
describe situations where jealousy is the predominant
content without the sexual component.
What makes it difficult to distinguish a delusion from justified
jcalousy is that infidelity is usually a discreet process. lt can
be almost impossible for the accused person to prove his or
her fidelity. Many times, the continued accusations drive the
partner away and into another relationship. In a sense, this
makes the crime fil the punishment through the process of
projective identification. Here, patients induce others to
behave in a way that justifies their suspicions. This can also
be thought of as a self-fulfí/líng prophecy. Additionally, the
accused partner is often more attractive or outgoing, which
adds substance to the claims of infidelity.
The delusion frequently starts with projected libidinal wishes
on the part cf the patient. He or she may desire another
1over, and by projecting these (unacceptable) urges outward,
blames the spouse/partner for harboring them. The patient
may have been promiscuous, and automatically assumes
the current partner will be as well. Another common finding is
that the patient is overly dependent on the partner, and may
wish for complete possession.
This condition can occur in males when they become
impotent or have homosexual urges for the men with whom
the partner is supposedly involved. Delusional jealousy is
also seen in alcohol abusers and after head injuries. lt is
notoriously difficult to treat, often remaining stable for years.
This delusion is among the most likely to cause patients to
take action against the partner and/or others involved.
184
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Erofomanic Delusions
Erotomanía is another love-centered delusion. Here, patients
are convinced that so meo ne is secretly in lave with them.
The object of this delusion is often a famous, rich or powerful
person. lt occurs more frequently in women, and has been
called "Old Maid's lnsanity." Other terms for the condition are
de Clérambault's Syndrome and psychose passionelle.
Patients with this delusion can be an extreme nuisance to
public figures. They will devote extraordinary time and
energy to get the attention of the object of their desires. Such
patients may commit crimes (break & enter, kidnap-ping),
blackmail or even make false accusations of sexual assault
or paternity in order to make contact with the person.
They arbitrarily assign significance to unremarkable events
as a sign of the continuing lave of their target. For example,
if a political figure wears a blue suit when giving a speer,h, it
is a clear indication to the delusional patient that'a bond
exists. Paradoxical conduct refers to the situation where ali
efforts to deny a romantic link are interpreted by the patient
as further proof that the secret connection ey;.--:s.
There is sorne debate regarding the course of these
delusions and the danger to the person involved. Sorne
authors report erotomanía is short-lived, andas an actual
relationship becomes more less and less likely with time,
patients select another attachment. Other authors report that
this delusion can not only continue for years, but there have
been instances where patients commit suicide and/or
homicide upon confronting the person to whom they are
attracted.
A related delusion, called the phantom lover syndrome, is
the conviction of being loved by someone who doesn't exist,
but is identified asan "ordinary person."
185

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Somatic Delusions
Soma tic delusions can involve iflness ar bodily functions.
Monosymptomatic hypochondriacal delusions (take a
breath befare you say this out loud) are encapsulated beliefs
patients have about certain aspects of their bodies. The most
common varieties are:
• Delusions of odor - patients are convinced they have
.a foul smell about them that cannot be removed; bad
breath (halitosis) or body odor are the most common foci
for delusions; such patients do not ex peri en ce
consistently unpleasant smefls apart from their own
bodies and do not have olfactory hallucinations
• Delusions of infestation/Dermatozoic Delusions -
these usually involve micro-organisms (germs, microbes,
parasites) or small but visible infectious agents that
inhabit the interna! organs or skin; snakes, rodents and
insects are other frequent agents of infestation
• Delusions of appearance (body dysmorphism) -
involve an exaggerated or entirely fabricated physical
defect; patients are convinced they are disfigured and
that this is immediately obvious to any observer
Somatic delusions can range from possible (a blood
infection) to bizarre (a missing heart). Again, they are often
centered around an actual, but mild illness or discomfort.
Hypochondriasis, body dysmorphic disorder and conversion
disorder hav"' an overlap with this condition but are
distinguished by not being of delusional intensity.
Somatic delusions are most commonly seen in depression
and schizophrenia. However, other psychotic disorders,
alcohol and cocaine withdrawal, temporal lobe epilepsy and
strokes can also be accompanied by these convictions.
Frequently, patients will have seen many physicians and
"doctor shop" to find someone who believes them and is
willing to exhaustively investigate their symptoms.
186
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Delusions of Passivify or Control
Schneider (Kurt, not J.M.) proposed that there were
particular symptoms that were of pragmatic value in
diagnosing schizophrenia (called pathognomonic
findings). He enumerated eleven specific findings and
called these first-rank symptoms. There are also second-
rank symptoms which Schneider thought could be used on
their own to diagnose schizophrenia.
Of the eleven symptoms, eight involve delusions that cause
the patient to feel under the control of externa! forces and
respond passively (passivity experiences). The others are
hallucinations and are covered in the PERCEPTION CHAPTER.
Experiences of Thought Control
• Thought Broadcasting - patients experience their
thoughts as automatically being broadcast to others or
lost to the externa! world (as if by television or radio)
• Thought lnsertion - thoughts are placed into the
patient's head from an outside source
• Thought Withdrawal - thoughts are removed or stolen
from the patient's head befare they can be expresserl
Experiences of lnfluence
• lnsertion of Sensation/Somatic passivity -
submission to an externa! controlling force
• lnsertion of Feelings - "made" or torced feeling
• lnsertion of Impulses - submission i an impulse
• lnsertion of an Outside Will - passivity of volition
Delusional Perception
This is the attribution of a false (delusional) meaning toan
ordinary event (also covered on p. 177).
First-rank symptoms remain an important component of
many diagnostic systems fo~ 3chizophrenia, but they have
not been found to be sensitive or specific for the diagnosis.
187

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Other Delusions
Despite thei;- great variety, delusions fall into a relatively
compact set of themes. As indicated earlier, delusions often
relate to early developmental needs, issues, struggles and
milestones. Commori themes involve: nonexistence, one's
body, one's self and the outside world. Delusions are given
.the suffix "manía" to denote an exaggerated interest in, or
preference for something, but also implies a behavior oran
action. Other aspects of thought content are given the suffix
"philia" indicating a disposition towards something. For
example, pyromania refers to fire setting and pyrophilia
refers toan excessive interest in tires.
Sorne Common Delusions
• Animal Metamorphosis - cat (galeanthropy), dog
(cynanthropy), wolf (lycanthropy)
• Cacodaemonomania - poisoned by an evil spirit
• Caesarmania - delusion of grandiose ability (or
inventing a garlic-laden salad)
• Capgras' Syndrome - an identical looking impostor
has replaced someone significant to the patient
• Delusion of Reference - ascribing personal meaning
to common events; often involves the TV, newspapers or
radio as having special messages just for the patient, but
can include idiosyncratic associations (a bird flew by,
therefore my car is low on oil); if held to a lesser degree
of conviction, these are called ideas of reference
• Doppelganger - having an imaginary companion
~ Dorian Gray - the person stays the same age while
everyone else ages
• Enosimania - guilt, unworthiness for having committed
sorne catastrophic deed
• a
Folie deux ~ a delusion is transferred from a
psychotic person to a recipient who accepts the belief
• Folie induite - transfer of a delusion to someone who
is already psychotic; a delusion added to a pre-existing one
188
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• Fregoli's Syndrome - a persecutor impersonates
people the patient knows (the opposite of Capgras')
• lncubus - a demonic lover
• lntermetamorphosis - a familiar person (usually a
persecutor) and a misidentified stranger share both
physical and psychological attributes
• Magical Thinking - believing that an event will occur
simply by wishing it so, as if by magic
• Messianic - being God (also called theomania)
• Mignon - being of royal lineage
• Nihilism - nonexistence; loss of organs, body or
everything; damnation; sense of death or disintegration;
also called Cotard's Syndrome
• Phantom Boarder - unwelcome delusional house guests
• Poverty - loss of all wealth and property
• Reduplicative Paramnesia - thinking that people,
places or body parts have been duplicated (heutoscopy
is also the delusion of having a double)
• Wahnstimmung (G8rman) - delusions of persecution
Culture-Bound Syndromes
A sampling of delusions from other cultures ...
• Brain Fag - belief that the brain can suffer fatigue from
overuse (Yes, this is what it is called. Sorne sources record this
as "brain fog")
• Koro - belief the penis or vulva will recede into the
body and cause death (differentiate this from kuru which is a
slow virus infection causing neurologic degeneration)
• Rootwork/mal puesto - belief that ene can subject
others, or be subjected to, hexes, spells or curses
• Taijin kyofusho - the belief that one's .._,..dy or its parts
and functions are offensive to others
• Windigo - delusion that one can be transformed into a
giant monster that eats human flesh
• Zar - delusional possession by a spirit
189
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Mootl Congruence & Ego Syntonicity.
The terms ' :ood-congruent and mood-incongruent are
applied to delusions and hallucinations (psychotic features)
that occur with mood disorders.
The themes of depression are guilt, worthlessness, death,
failure, hopelessness, punishment, illness, etc. lf the content
of delusions in depressed patients forms along these lines,
the term mood-congruent is applied.
In manic episodes, mood-congruent delusions follow the
themes of power, brilliance, wealth, longevity, achievement,
special relationships or connections, knowledge, etc.
Manic patients with delusions of nihilism, poverty or
inadequacy have mood-incongruent delusíons, as would
depressed patients with delusions of grandeur, omnipotence
or relationships to famous people. Mood-incongruent
delusions are a poor prognostic sign and may indicate that a
schizoaffective or schizophrenifarm disorder is present.
The term ego-syntonic is used to refer to symptoms that
are not foreign or distressing to patients. Patients do not
experience delusional thoughts as disturbing. The delusional
beliefs become accepted as reality, and are therefore ego-
syntonic. For example, paranoid patients are not disturbed
by continua! thoughts of persecution. lnstead, they accept
that the world is this way and are ever vigilant far evidence to
confirm that they are being conspired against.
Ego-syntonicity is central to the definition of a personality
disorder. Here, a patient's attitudes and actions are not
subjectively distressing. Problems are created instead far
those who must relate to the patient. Similarly, because a
delusional patient doesn't challenge his or her convictions, it
is those around the patient who suffer the consequences.
190
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Overvalued Ideas
An overvalued idea differs from a
delusion in the following ways:
• lt is less firmly held
• The content is less absurd
• lt is not systematized *
Beliefs become ove1Va/ued in that they
preoccupy the patient's thinking and affect behavior.
Examples of overvalued ideas are superstítíons or magical
thinkíng. A superstitious (as opposed to delusional) patient
will concede that walking under a ladder isn't real/y likely to
change his luck, but he feels better not doing such things.
Situations where delusions seem probable but are not clearly
present are often recorded in the MSE as overvalued ideas.
Delusional Tidbits
• Movies/plays that contain delusional themes are: CAr
PEOPLE (galeanthropy); UNFAITHFULLY YouRs & OrHELLO
(delusion of infidelity); INVASION OFTHE Boov SNATCHERS
(Capgras); RoseMARY's BABY (Cacodaemonomania)
• Many attempts have been made to relate the theme of a
delusion to a specific illness - for example, nihilistic
delusions to depression or thought broadcasting to
schizophrenia; while certain illnesses are more
commonly linked to specific delusions, this association is
not reliable enough to be an indication of diagnosis
• * Systematization refers to the degree to which
delusions are organizad; chronically psychotic patients
can develop elaborate delusional systems which remain
stable over time while incorporating new parameters into
the scheme or matríx of the delusion
• Systematized delusions are most often seen in illnesses
with a chronic psychotic component; fleeting or unstable
delusions are more typical of organic cognitiva disorders
191
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What is an obsession? Obsessive Themes

An obsession is a thought, impulse, or image that is: Like delusions, obsessions tend to fall into a relatively small
o Recurrent and persistent number of themes:
• Unwanted (called ego-alien or ego-dystonic)
Theme Obsession
e Not simply an exaggerated degree of concern over
• Cleanliness Contamination
current problerns
• Order Symmetry, Precision
• Recogn' 'ed as a product of the patient's own mind;
• Sex & Aggression Assault, Se; .al Assault,
obsessions are generated from within as opposed to
Homicide, lnsults
from without (as in thought insertion)
• Doubt Safety, Catastrophe,
• Not able to be controlled by the person's will
Unworthiness
• Recognized as absurd and irrational (preserved insight)
e Resisted, at least at sorne point to sorne degree
Another scheme for classifying obsessions is as follows:
• Accompanied by a sense of anxious dread
• lntellectual Obsessions - involving philosophical or
o Usually paired with a compulsion to decrease anxiety
metaphysical questions surrounding life, the universe &
everything; destiny; curvE:d space; gravity waves, etc.
While obsessions are a cardinal symptom of Obsessive-
• lnf1ibiting Obsessions - doubts or prohibitions about
Cornpulsive Disorder (OCD), they are also seen in:
actions which may be harmful to others; the patient may
• Depression - obsessive thoughts about death, illness,
become withdrawn or isolated to ensure such actions do
a bleak future, self-deprecation, negative view of others
not occur
• Psychotic disorders - the prodrome of schizophrenia
• lmpulsive Obsessions - urges to steal, collect (hoard),
(schizophreniform disorder) can include obsessions,
or count (arithomania)
causing the patient to perform unusual rituals
• Other anxiety disorders - such as phobias, where the
patient is tormented by thoughts of the feared object or How do 1ask about obsessions?
situation when not confronted by it
• Obsessive-Cornpulsive Personality Disorder (OCPD)- Obsessions are recognized by patients as absurd and
shares sorne features with OCD distressing, yet they are not expressed as dominantly in
• Hypochondriasis - preoccupation with serious illness interviews as are delus1ons. Suggestions far inquiries are:
• Body Dysrnorphic Disorder - intrusive thoughts of • Do you experience repetitive thoughts that you can't
irnage distortion stop? Do they feel like your own thoughts?
• Impulse control disorders • Are you ever forced to think something against your will?
• Temporal lobe epilepsy
• Tourette's disorder Another approach is to ask specific questions involving the
• Organic mental disorders - traumatic head injuries, majar themes of obsessions:
carbon monoxide poisoning, disorders of the basal • Do you have intrusive thoughts about ... (contamination,
ganglia, cardiovascular accidents hurting someone, having to count something, etc.)?

192 193

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What are the psychodynamic aspects of
obsessions?
As mentioned on the last page, obsessions tend to fall within
a small number of themes, with aggression, cleanliness and
arder being the most prominent. In Freud's psychosexual
stages of development, these are the issues that domínate
the anal phase. Control and autonomy are the key
·outcomes from this stage. Freud linked obsessive behaviors
to difficulties during the anal stage of development, and
defined the anal triad as consisting of parsimoniousness,
orderliness and obstinacy (mnemonic - P.0.0.)
r"oilet training is usually the first intrusion of socialization into
an infant's otherwise unrestrained existence. Achieving
continence involves submitting to parental expectations on
demand, and then being judged on the outcome. When
children fail at the task, overambitious or demanding parents
evoke feelings of being bad and dirty. lssues of cleanliness,
timeliness, stubbornness and control can reasonably be
seen as linked to this stage of development. Failing to
produce on schedule, with an immediate perception of
disappointment, arouses feelings of anger and aggression.
Ego defenses are used to defend against the expression of
unfulfilled dependency wishes and strong feelings of anger
directed at caregivers.
Ambivalence develops as a result of the simultaneous
existence of longing (love) and aggressive wishes (hate).
This conflict of opposing emotions paralyzes the patient with
doubt and indecision, and can result in the doing-undoing
pattern seen with obsessions and compulsions.
Magical thinking is also a component of OCD in that the
obsession is given great power, and is deemed to have more
of a connection to events than is realistic. For example,
having thoughts of a disaster does not make it occur.
194
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• lsolation (of affect) separates or strips an idea from its
accompanying feeling or affect. This is the predominant
defense contributing to the obsessive component. An
idea is made conscious, but the feelings are kept within
the unconscious. When this defense is used to a lesser
degree, three others mechanisms may be used:
• lntellectualization - excessive use of abstract thinking
• Moralization - morality isolates contradictory feelings
• Rationalization - justifying unacceptable attitudes
• Undoing involves an action, either verbalization or
behavior, that symbolically makes amends for conflicts,
stresses or unacceptable wishes. This is the
predominant defense contributing to t~- '· compulsive
component.
• Reaction Formation transforms an impulse into a
diametrically opposed thought, feeling or behavior. This
is frequently seen as a "counterdependent" attitude in
which patients (primarily with obsessive-compulsive
personalities) eradicate dependency on anyone.
Similarly, maintenance o" a calm exterior guards against
an awareness of angry feelings. For example,
orderliness is a reaction formation against the childhood
desire to play with feces orto make a mess.
• Displacement redirects feelings from a conflict or
stressor onto a symbolically related, but less threatening,
person or object. "Kicking the dog" or "shooting the
messenger" are examples of this defense.
Anger or aggression towards caregivers becomes
unconsciously forbidden, so substitutes (canine and
otherwise) are targeted for these feelings. This is also the
predominant defense involved in the formation of a phobia.
While the presumed etiology of OCD and OCPD are blended
here, a comparison of their differing features is presented on
the next page.
195
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OCD vs. OCPD Obsession Tidbits

Although similar in name, these are phenomenologically " Preoccupations are another component of thought
distinct conditions. Key features thi':lt help distinguish content; they differ from obsessions in that they are a
between the two are: willful return to thinking or conversing about a topic

Feature OCD OCPD e Ruminations are another term for intellectual

Central Recurren!, intrusive Enduring preoccupation obsessions; here, people "chew" (mull over) their "cud"
Concept thoughts and/or with perfection, orderliness (thoughts) but achieve no resolution; there is an irritating
behaviors/mental acts and interpersonal control and unnecessary quality (both in time and intensity) to
this type of thought, which is another manifestation of
Subjective Ego-dystonic; Ego-syntonic until clase ambivalence
Experience recognizes irrationality relationships are affected
of mental events and or defenses break down • Compulsions can also be mental acts, and be properly
behavior
considered as component of thought content, e.g.
lmpact on Time consuming; Defends traits and methods praying, counting or repeating words silently
daily routine interferes with as being effective and
ability to function justified by productivity • Although obsessions or compulsions can be present
alone, in the vast majority of patients, br "·, are present
Mentation Aware of forced Thoughts lack quality
nature of thoughts. of intrusiveness; behavior • Another way to elicit obsessional thoughts is to ask
recognizes them as a occurs automatically, most about common compulsive behaviors: counting,
product of own mind; processes remain
checking, cleaning, touching, ordering, arranging, etc. lf
resists compulsions unconscious
these are present, ask what motivates these actions
Mani- Often involves themes Pervasive throughout
festations • Although this disorder is ego-dystonic, patients
frequently take years to come to psychiatric attention; it
Anxiety Marked; anxious dread No! usually evident may be that patients recognize the absurd nature of
obsessions and have difficulty sharing them
Etiology Growing evidence Psychosocial influences
for genetic factors predominate • Many patients see other specialists for problems related
to the sequelae of their compulsions - skin, gum and
OCD and OCPD were initially formulated as one disorder,
joint problems appear to be especially common
hence the similarity in name. There are conflicting opinions
about the degree to which OCPD exists prior to the onset of • The people at the OssEss1vE-CoMPULs1vE FouNoATION
OCD. Currently, there is more evidence against this must be saluted for their sense of humor; these are
association. OCD is associated with other Cluster C actual badges they have printed:
personality disorders (most often Avoidant & Dependent) • Compulsive people do it over and over.
more frequently than with OCPD. • What if?
• Every member counts!

196 197
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Everything you always wanted to lcnow
about pbobias, but were alraid to ask
Phobias are marked and persistent fears that are:
• Viewed by the patient as excessive and unreasonable
(phobias are ego-dystonic with preserved insight)
• Clearly circumscribed (the person has clearly
demarcated objects or situations that are feared)
• lnvariably accompanied by a sense of anxiety upon
exposure or the thought of exposure to the object(s) or
situation(s)
• Capable of causing sufficient distress that patients go to
great lengths to the avoid anxiety-provoking stimulus
• Of generally benign objects or situations; for example,
fears of a rabid doberman ora dangerous neighborhood
are justified; fears of tomatoes or numbers are not
The DSM-IV contains the categories of specific phobias
and social phobias, which can be remembered with the
following mnemonic:
"ASP & BOAS"*
Animal type - e.g. killer chihuahuas or goldfish
Situational type - e.g. bridges, tunnels, flying, drh(ing, etc.
People (social phobia) - e.g. public speaking
Blood/lnjection - e.g. seeing blood or having procedures
Other - used when other categories simply won't do
Agoraphobia - avoidance of places where escape or
getting help are difficult
Surroundings - elements in the natural environment such
as storms, water, heights, etc.
• Far !hose unfamiliar with reptilian suborder ophidia, an asp is a venomous
snake (viper) and also makes an excellent ScRABBLE word: this mnemonic is
helpful because snakes are a common phobia (even for Indiana Jones).
198
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Jlgorapbohia
Agoraphobia is a condition that deserves special mention.
The word is derived from Greek and means "fear of the
marketplace." The DSM-IV defines itas:
• Anxiety about being in places or situations from which
escape might be difficult (or embarrassing) or in which
help may not be available in the event of having an
unexpected or situationally predisposed Panic Attack or
panic-like symptoms. (p. 396)
Agoraphobia is a common phobia and the one that causes
the greatest impairment of social and occupational
functioning. In the DSM-IV, agoraphobia is considered in
conjunction with panic disorder. Generally, patients who
experience repeated panic attacks become "phobic" of the
places where attacks occur, or where help or escape are
difficult to arrange. Patients who have a moderate to severe
course of panic disorder frequently have at least sorne
degree of agoraphobia.
Patients with agoraphobia curtail their activities significantly.
They make constant demands on friends anrl family
members to accompany them on outings. ·, ;1ey frequently
need to be seated near the exit on a bus or in a movie
theater. Their continua! demands can lead to strained
relationships. Such patients can become housebound if
others cannot oblige their requests or if the illness becomes
too severe. Agoraphobia is frequently complicated by other
phobias, obsessions and overvalued ideas (superstitions).
Additionally, depressive disorders and substance abuse
often complicate the lives of agoraphobics.
Agoraphobia is coded in the DSM-IV in two ways:
• Panic Disorder with Agoraphobia
• Agoraphobia Without History of Panic Disorder
199
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How do I ask about phobias? What are the psychodynamic aspects of

Phobias are not usudlly difficult to ask about because they
are ego-dystonic and patients recognize them as excessive.
Unless patients have agoraphobia, or fear something in the
room, they are not likely to be anxious (dueto the phobia)
during the interview. Phobias may well be the most common
psychiatric condition. with estimates ranging as high as 25%
of the population. The presence of phobias can also be
inferred through behavior. For example, someone who
avoids the public acceptance of an award may have a social
phobia or agoraphobia.
Suggestions for questions to screen far the presence of
phobias are as follows:
Specific Phobias:
• Do you have strong fears about certain objects or
situations?
• Are there objects or situations that make you intensely
anxious if you cannot avoid them?
• Do you make special efforts to avoid certain objects or
situations?
Social Phobias:
• Do you have strong or persistent fears about being
humiliated in public?
• Do you have strong or persistent fears that you will do
something embarrassing in front of strangers?
Agoraphobia:
• Do you require special arrangements to be made for you
to be comfortable when outside your home?
• Do you have such a strong sense of anxiety that
someone must be with you befare you can leave your
house?
phobias?
A phobia is the end result of a long (theoretical) chain of
events. Herr Freud and his contribution of Ego Psychology
provide an understanding of how phobias are generated.
Freud incorporated his early findings into what became
known.as his structural theory, introduced with the
publication of The Ego and the Id in 1923. This model has a
triparlite structure containing the id, ego and superego.
Present from birth, the id is completely unconscious and
seeks gratification of instinctual (mainly sexual and
aggressive) drives. The superego forms from an
identification with the same-sex parent at the resolution of
the oedipal conflict. lt suppresses instinctual aims and
serves as the moral conscience, dictating both what should
and should not be done. The superego is largely
unconscious, but has a conscious element.
The fundamental concept in Ego Psychology is that of
conflict among these three agencies. The id, ego and
superego battle for expression and discharge of sexual and
aggressive drives. This conflict produces anxiety, specifically
called signa! anxiety. This anxiety alerts the ego that a
defense mechanism is required, conceptualized as follows:
The id seeks expression of an imp• · e
""
The superego prohibits the impulse from being expressed
~
This conflict produces signa! anxiety
""+
An ego defense is unconsciously recruited to decrease !he anxiety

• To what degree do you limit your activities beca use of A neurotic symptom (phobia) is formed
anxiety?

200 201
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CC::iNTENT
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The following ego defenses are involved in the development

of phobias: Phobias.
s Displacement- here, the sexual or aggressive conflict
is transferred from the person who evokes it to an
unconnected, irrelevant object or situation; this new @ Anginaphobia - fear of narrowness
stimulus becomes associated with strong feelings • Anuptophobia - fear of staying single
(rnarked anxiety) simply because of its presence • Cherophobia - fear of g..:.:>d news
• Dementophobia - fear of insanity
-• Symbolization - this is similar to displacement except • ; Ergophobia - fear of work
that the phobic object or situation is symbolically • ' Gelophobia - fear of laughing
connected with the conflict; as in the classic stimulus- • Genuphobia - fear of knees
response theory, a neutral stimulus (the phobic object) • Glossophobia - fear of talking
can be paired with an anxiety-provoking experience, • Gymnophobia - fear of naked bodies
resulting in a permanent emotional association of the two • Herpetophobia - fear of lizards
• latrophobia - fear of doctors
The classic struggle associated with phobias is castration • Kainophobia - fear of newness
anxiety, which develops out of a child's oedipal conflict (in • Kenophobia - fear of empty spaces
boys, sexual urges towards the mother and aggressive • Kleptophobia - fear of stealing
urges towards the father). The phobic stimulus may be • Logophobia - fear of words
unconnected with castration anxiety (the ego defense of • Methyphobia - fear of alcohol
displacement) or more directly associated (the ego defense • Mnemonophobia - fear of memories
of symbolization). Far example, fear of father can be • Musophobia - fear of mice
displaced onto or symbolized by watches (because he wore • Myxophobia - fear of slime
a watch on his spanking hand). Other anxieties are also • Neopharmaphobia - fear of new drugs
recognized as stemming from these early experiences - far • Osmophobia - fear of smells
example, agoraphobia as an adult version of separation • Panphobia - fear of everything
anxiety. • Pentheraphobia - fear of mother-in-law
• Phobophobia - fear of fear itself
Fear vs. Anxiety • Polyphobia - fear of many things
• Psychophobia - fear of the mind
Anxiety is a sense of uneasiness ar distress with both • Sinistrophobia - fear of things "of the left"/left-handed
mental and physical components, and is a reaction to unreal • Sitophobia - fear of food or eating
or imagined dangers. Fear is a similar reaction, but to known • Sophophobia - fear of learning
r~ actual dar.:.;,ers. The German word angst (meaning fear) • Tridecaphobia - fear of the number 13
was mistranslated as anxiety in Freud's early writing. Sorne
psychiatric literature doesn't distinguish between the two From: The Encyclopedia of Phobias, Fears and Anxieties
because fear may have a repressed, unconscious aspect. R. Doctor, Ph.D. & A. Khan
Facts on File. lnc., New York, 1989

202 203
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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

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS,

• Oelusions are fixed. false beliefs that are ego-syntonic 4TH EDITION
and become accepted as reality by patients who suffer American Psychiatric Association, Washington, D.C., 1994
from them. Delusions can be of a bizarre nature
(physically impossible) or nonbizarre (possible though CoMPREHENSIVE TEXTBOOK oF PsYCHIATRY, 6TH EomoN
unlikely). These beliefs often dominate the thinking of H. Kaplan, MD & B. Sadock, MD, Editors
patients, and, being a cardinal sign of psychosis, are the Williams & Wilkins, Baltimore, 1995
most serious of the disorders of thought content
• Obsessions are unwanted, persistent, intrusive thoughts SvN0Ps1s oF PsvcHIATRY, 7rn EolTION
that are ego-dystonic. Patients recognize them as H. Kaplan, MD, B. Sadock, MD & J. Grebb, MD, Editors
originating from their own minds (in thought insertion, Williams & Wilkins, Baltimore, 1994
patients perceive the ideas as coming from elsewhere).
SYMPTOMS IN THE MINO, 2ND EDITION
• Phobias are fears of neutral objects or situations that
patients recognize as exaggerated. Unless patients are A. Sims, MD
W.B. Saunders Co., Philadelphia, 1995
anticipating or actually confronting the object/situation,
phobias are not intrusive thoughts THE NEUROPSYCHIATRIC MENTAL STATUS EXAMINATION
• Perceptual abnormalities are discussed in Chapter 1O.
M. Taylor, MD
However, disorders of perception can contribute to PMA Publishing Corp., New York, 1981
abnormalities of thought content. A patient who
hallucinates about the Four Horsemen of the Apocalypse DELUSIONS:
may well have persistent fears of persecution, which INVESTIGA TIONS INTO THE PSYCHOLOGY OF ÜELUSIONAL REASONING
could be of delusional intensity. Abnormal perceptions P. Garety, Ph.D & D. Hemsley, Ph.D
may provide the "kernel" of truth or actual experience Maudsley Monographs 36
which the delusion is built around. Additionally, the term Oxford University Press lnc., New York, 1994
illusion is frequently used in a conversational manner to
describe delusions, e.g. "Ms. N.B. is under the il/usíon P. Steinberg, MD
that she is of noble lineage." Personal Communication, 1996

204 205
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UNlllY SfuFF

e Yesterday the dríed Wheatína in my bowl spelled out the

New lmproved Delusions * words: "YOU ARE A NEBBISH!"
1.1 There is a plot to turn my Rolaids into rodents which gnaw
Robert S. Hoffman, MD at my stomach liníng
e When Walter Cronkíte says, "That's the way ít is," he is
As a service to mental health practitioners who are bored by
referring to the fact that 1mainlíne Preparation H
the narrow range of standard delusional material presented • Scíentists from the Smíthsonian lnstítute are carbon
by their patients, the following list of alternatives has been dating my undershorts
~eveloped and may be assigned to new patients on a • The reason my hair is frizzy is that a crazed Beverly Hills
rotating schedule. lt is hoped that utilization of this list in dermatologist has replaced my original haír wíth that of
clinical practice will minimize the frequency of professional Sam Jaffe
burnout endemic to our field. • While 1 sleep, a dybbuk in the form of Joyce Brothers
enters my bed and interprets my parapraxes from the
• There is an evil force which steals upon me al night, previous day
removes ~iy belly button lint, and replaces it with tapioca • People in the street think l'm a close friend of Truman
pudding Capote
• A six-foot-five accountant forces me to floss my teeth every • When my wife says she has a headache, she really does
20 minutes or 1'11 be audited • This isn't really my wife yellíng at me; it's Ethel Merman in
• My county board of supervisors has arranged for mold to disguise, and she's setting my prívate thoughts to Jule
grow on my paté de fois gras in lewd patterns Styne tunes
• Member~ of the Kate Smith Fan Club, belíeving me to be • They have altered my bathroom mirror so 1just seem to
her, are removing used Kleenex from my bathroom as look like Ernest Borgnine with a hangover
mementos • My electric blanket is controlled by the IRS: if they can't
• Barbara Mandrell and the Mandrell Sisters are singing burn me on withholding, th?y can fry me in bed
"special" songs which are causing excess haír growth in my • 1was not born in the usual way; 1was created by Disney
nostrils Studios
• Every night my ex-wife· makes me drool on my pillow by • The real reason for most natural disasters is that, years
beaming radioactive waves al me with her Genie garage ago, 1 removed the tag from my new Beautyrest mattress
door opener • 1can't concentrate because Big Bird keeps singing to me
• 1have a special influence on the Federal Government: about the number "4"
every time 1pass gas, Nancy Reagan changes her dress • The reason 1sound uneducated is that William F. Buckley
o Hell's Angels hold Tuppe1Ware parties under my bed Jr. is stealing the larger words from my vocabulary
• The reason my hearing is impalred is that Mr. Goodwrench • 1have discovered the Fountain of Youth, but 1can't market
has installed genuine GM oíl filters in my auditory canals the stuff because it comes in the form of prune juice
o Since Richard D'Oyly Carte has taken control of my stereo, • lf anyone in the United States flushes their john, 1get
1can listen to nothing but H.M.S. Pinafore scalded in the shower
• No matter what 1cook for dinner, it always comes out as
Mrs. Paul's Fish Sticks
• When 1 try to pull one Kleenex out of the dispenser, Yuri • Excerpted from the Journal of Polymorphous Perversity
Andropov pushes out two dozen more Spring, 1984 1(1) © 1984 Wry-Bred Press, Reprinted with Permission

208 209
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""'ENDtNGs"' - :>utCIDAL
~ G ~ ~ ~
&. HoMtCIDAl IDEATION
~

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.

Suicida! and homicida! ideation are virtually universal in

being grounds for involuntary committal. This !s in
recognition that the majority of those who c. . mmit suicide
suffer from a mental disorder prior to their passing.

Conversely, most violent crime is not perpetrated by those

who are psychiatrically ill. The provision of civil commitment
on the grounds of harm to another is made to detain those
who have a "defect in reasoning." This is frequently due to a
formal thought disorder, such as perceptual aberrations (e.g.
hallucinations) or (most often) paranoid delusions. Patients
who have plans to harm someone as a result of a mental
illness require protection, as do their intended victims.

Mental health professionals are continually faced having to

predict the likelihood of future violence. Patients' intentions
to harm themselves or someone else impacts at the start of
a treatment plan. (Do 1admit this person to hospital? Should
he or she be involuntarily committed?)

. 210 211
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~---~~~---~---~~~~~

What is the tliagnostic signilicance of How do I evaluate the various aspeds ol

suicida/ & homicida/ ldeation? suicida/ ideation?
o Majar Depressive Episode 296.X The following mnemonic covers the key elements in
A. (9) Recurrent thoughts of death (not just fear of dying), assessing suicida! risk:
recurrent suicida! ideation without a specific plan, ora
suicide attempt ora specific plan far committing suicide
"SADDLE SORE WOMAN" *
• Posttraumatic Stress Disorder 309.81
C. (7) Sense of a foreshortened future (e.g., does not expect Social isolation
to have a career, marriage, children, ora normal life span) Age
Disturbed interpersonal relationships (DIRs)
• Borderline Personality Disorder 301.83 Drug use/abuse
A. (5) Recurrent suicida! behavior, gestures, or threats, or
Lethality of method
self-mutilating behavior
Ethanol wse
• Antisocial Personality Disorder 301.7
A. (7) Lack of remarse, as indicated by being indifferent to or Sex (gender)
rationalizing having hurt, mistreated, or stolen from another Occupation
Repeated attempts
• lntermittent Explosive Disorder 312.34 Event - acute precipitant
A. Several discrete episodes of failure to resist aggressive
impulses that result in serious assaultive acts or destruction Will - created or altered
of property
Organic condition - chronic medical illnesc
Mental illness
• Sexual Masochism 302.83
A. Overa period of at least 6 months, recurrent, intense Antidepressants
sexually arousing fantasies, sexual urges, or behaviors Note written
involving the act (real, not simulated) ... of being humiliated,
beaten. bound or otherwise made to suffer
• Sexual Sadism 302.84
... in which the psychological or physical suffering (including
humiliation) of the victim is sexually exciting to the person
• From the book:
PSYCHIATRIC MNEMONICS & CLINICAL GUIDES

Diagnostic Criteria are from the DSM-IV David J. Robinson, MD

©American Psychiatric Association, Washington, D.G. 1994 © Rapid Psychler Press, 1996
Reprinted with permission. ISBN 0-9680324-1-9; softcover, 96 pages

212 213

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Social lsolation, in general, refers to a sense of
unconnectedness with others. This can be in terms of marital
status, occupation, or even patients' view of themselves.
Suicide rates are higher for people who live alone, which
includes those who are widowed, divorced, separated or
have never been married. Many people who live alone prefer
the solitude and freedom from distraction that this provides.
Befare listing this as a risk factor, it is important to know if it
á patient's choice to live alone, and how great a departure
this is from desired living arrangements.
Relationships are to a large degree protective against self-
harm. However, someone may be married, living with a
partner or involved in a relationship and still feel estranged.
People change with time, and new interests are not always
jointly pursued. The quality of relationships is a key factor to
ask about when suicida! thoughts are expressed.
Cultural factors also impact on the degree of isolation
patients might feel. Certain regions have consistently high
rates (Eastern Europe, Scandinavia, Japan). Significantly
lower rates are seen in lreland, the Mediterranean, and the
Middle East. The U.S. and Canada have rates in the middle
of this range (1 O to 15 per 100,000 people per year).
Within certain countries, rates vary according to
demographic features such as race, religion, urban/rural
location, immigration and socioeconomic status:
• Whites have higher rates than Blacks
• Protestar ; have higher rates than Catholics or Muslims
e Rates are higher in cities than in less populated areas
• lmmigrants have higher rates
• Higher socioeconomic strata have higher rates
lt has been proposed that there is a greater sense of
belonging and cohesion in groups with lower suicide rates.
Social isolation can be the result of other factors (e.g. alcohol
or drug abuse, personality difficulties, etc.).
214
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""ENDtNGs" - SutCIDAL & HoMtCIDAL IDEATION
Age is a factor because certain age groups are statistically
correlated with a higher risk of completed suicide. As a
general rule, the prevalence of suicide increases with age.
This trend clearly develops i11 men starting at about age 45,
and climbs continually, with a peak at age 75. Women have
a later onset, starting around age 55 and exhibit a less
dramatic rise with age. The elderly have a suicide rate triple
that of younger peo¡Jie, and commit one-quarter of ali
suicides, but encompass only one-tenth of the population.
There is an important exception to this trend. The suicide
rate among males aged 15-24 is disproportionately high
(especially among whites). In this age group, suicide is
consistently reported to be either the second or third most
common cause of death (with accidents and homicide being
the other causes). While no clear reason has been
established, it has been suggested that the prevalence of
alcohol and drug abuse is a significant factor. Peer pressure
and exposure to media depictions of suicide are also thought
to be relevant factors.
Disturbed Interpersonal Relationships (DIRs)*
Disruptions in meaningful relationships provide perhaps the
best answer as to why people take their lives. DIRs are one
of the most common, if not the major cause of visits to
emergency rooms for emotional reasons.
DIRs in particular refer to:
• The threat of rejection or abandonment
• Loss of approval, acceptance, affection or attachment
To understand why DIRs can impel someone to wish to
commit suicide, it is necessary to review sorne of the
psychology of self-destructive behavior.
* 1 am indebted to Dr. John H. Mount of London, Ontario, Ganada for
his excellent work and teaching on this tapie, which is summarized in
this section.
215
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HoMICIDAL loEATION
&I
'"'""""" \.ALll'tRS

Freud thought suicida! urges stemmed from frustrations that
develope-. during childhood. Everyone carries an
internalized representation of their caretakers (usually
parents). This is referred to asan introjected object (in
psychodynamic theories. object means person). In situations
where parents were, or were perceived to be, harsh,
depriving, distant, etc., a strong sense of abandonment
ensues. Strong feelings, even murderous wishes,
accompany this sense of being unwanted. Later in life, this
.. conflict is arousecl again when people don't feel loved by
those clase to them. DIRs reawaken correspondingly strong
feelings in adults on both conscious and unconscious levels.
Since Freud's initial ideas, a good deal of work tias gane into
understanding earfy experiences and how they influence
relationships later in life. One school of thought is called
Attachment Theory, which was pioneered by John Bowlby.
Withdrawing, or the flight response, can involve:
• Building interpersonal walfs to diminish e ,otional pain
• Developing work habits that compensate far other
deficiencies, often called an "institutional" work style
• Regressing to the need for earlier means of gratification
where others aren't needed (often with "oral" habits like
smoking, drinking alcohol, excessive food consumption)
The fight response involves aggression. Anger can be used
destructively against the self, causing the emergen ce of
suicida! feelings. Anger directed at others brings about a
potent sense of guilt. Along with this sense of guilt is its
unconscious analog - the fear of, or need for, punishment.
Causation of Psychological Sympfoms
innate need for close attachment -+ lf satisfied (PIR)-+©

The central concept in Attachment Theory is that clase,

positive attachments are a fundamental human need. In this "'
lf frustrated (DIR)-+®
theory, the quafity of early attachments largely determines
the success of future relatioriships. Deprivation of early
attachments or the loss (or threatened loss) of positive
attachments to caretakers creates a vulnerability resulting in
"'
Decreased self-esteem
adverse psychological reactions. The outcome of these
reactions can be a diverse array of emotional conditions,
• • "' +
~
including personality disorders, substance abuse or suicide. Aggression Self-
Creative Withdrawal
(fight) Destructive
Effort (flight)
A diagrammatic representation of t11e Causation of Acts
(learning) • personality
Psychologicaf Symptoms according to Attachment Theory "'1' • overdoses
styles
appears on the next page. Guilt • lacerations
• personality
disorders • promiscuity
• work styles "'1' • gambling
lf the innate need for attachment is satisfied by Pleasurable •suicide
Interpersonal Relationships (PIRs), normal development • earlier Fear of/ attempts
pleasures
occurs. lf these needs are frustrated by DIRs, the drop in need for •suicide
self-esteem brings about one of three consequences. The punishment
'1ealthiest º'"'lcome is that of a creative effort which can be
artistic or the desire to learn more about emotional life. Source: J. H. Mount, MD. Personal Communication, 1995

216 217
~- ~
llRAINLAL-¡p1ERS ""'_j
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Drug use/abuse is highly correlated with the likelihood of
acts of self-harm. lt has been estimated that the presence of
chemical dependence increases the risk of completed
suicide by five times that of someone who is not using drugs.
The lethality of the drugs used (or available) needs to be
taken into ~ ..msideration. Those with the greatest potential to
cause death are:
• Amphetamines
• · Barbiturates
• Cocaine
• Opioid3
In sorne cases, the term drugs denotes illicit substances
(street drugs), whereas medications refers to substances
obtained via prescription. lt is important to ask about both
prescription and nonprescription drug use, though ali but
cocaine from the above list can be obtained by a physician's
arder. Cocaine is still used medically as a vasoconstrictor,
but is only available in aqueous form in hospitals."
The greatest risk appears to be through combining drugs of
abuse (including alcohol). A common situation involves using
certain drugs to modulate or prolong highs, reduce
distractions, and avoid the dysphoria of "crashes."
The prevalence of drug use among adolescents and young
adults is thought to be a majar contributor to the increased
rates of suicide seen in this age group.
The presence of certain factors involving the use of
substances increases the risk of suicide:
• Early age of onset
• Chronic use
• Past overdoses
• Family history of substance abuse
• Male gender
218
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.....,.ENDINGS" - Su1c1DAL &
.. .. . ., .,
~
HoMtCIDAL IDEATtON
Lethality of the method is another factor that bears on the
risk of suicide. In general, the more lethal the means, the
more likely it will be carried out.
Males tend to use violent methods, such as firearms, knives,
jumping and hanging. Females are more likel" '.o take
overdoses, drown, or asphyxiate themselves.
In particular, the availability of firearms has been shown to
have an impact on the suicide rate.
Ethanol use can lead to problems during intoxication or
withdrawal states. (This can be considered as part of
"chemical dependency ," but a "OWel was needed for the
mnemonic.)
Alcohol deserves special mention because it is the
substance most often associated with acts of violence.
Ethanol causes disinhibition and removes the self-restraint
that would otherwise be present. The combination of
impaired judgment and a greater propensity to take action
can have dire consequences. lt is common in emergency
rooms to have intoxicated patients who are combative or
self-destructive, yet become entirely different when saber.
Alcohol increases the toxicity of substances that are co-
ingested. Unlike opioids and benzodiazepines, there is no
readily available agent to reverse the effects of alcohol.
Ethanol use is also commonly a consequence of other
factors. Patients with mood disorders or anxiety disorders
appear to be particularly likely to seek solace by imbibing.
Alcohol use obscures accurate statistics on suicide.
Accidents involving single motor vehicles or pedestrians may
be suicides, but the use of alcohol makes the issue of
intention less clear. Deaths by drowning, overdose, falling,
etc., similarly raise the question of suicide vs. accident.
219
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
BRA/N CALIPERS
Sex (gender) is unevenly distributed in terms of attempted
vs. completed suicides. In all age ranges, males commit
suicide more frequently than females. The ratio varies from
2: 1 to almos! 1O:1 depending on the age group and race.
Two factors help explain !he gender discrepancy. As outlined
in the 'L' (lethality) section, males use more lethal methods.
The time ·course of an overdose, asphyxiation or drowning
allows an intervention to be made. Only seconds to minutes
are available with more lethal means (only Superman can
stóp a speeding bullet). Secondly, males have a higher
prevalence of chemical dependency. In North America, the
ratio of m2;,es to females with alcohol problems is at least
4:1. In other areas of the world it is considerably higher.
Depression, however, is strongly correlated with completed
suicides and is more prevalent in females by a factor of
about 2:1. Schizophrenia is widely rega_rded to have a later
onset and milder course in females. lt is thought that
estrogen serves a protective function in "schizophrenia.11
Given that estrogeri patches have been used to treat severe
post-partum depression, :t may be that the course of mood
disorders is somewhat different on a gender basis as well. *
Occupation in general is a protective factor. Higher socio-
economic status is associated with higher risk (t~ough a
recent change in status is also a risk factor). A possible
explanation is that a higher level of occupation generally
requires increased responsibility. lf things go awry, affected
individuals may face consequences from many avenues.
Professionals, and in particular physicians, are generally
above national averages. Recent studies have indicated that
female physicians have rates triple the national average for
women over age 25.
~ l'./l.V. Seeman & M. Lang, The Role of Estrogens in Schizophrenia Gender
Differences, Schizophrenia Bul/etin, Vol.12, no.2, p.185-194, 1990
·E. Frank, L.L. Carpenter & D.J. Kupfer. Sex Differencos in Recurrent
Depression: Are There Any That Are Significant?, American Joumal of
Psyc/Jiatry, Vol.145, No.1, p.41-45. 1988
220
11 ,,
ENDINGs - Su1c10A1. & HoM1c10A1. loEATION
Repeated attempts at self-harm increase the risk of a
completed suicide. A distinction needs to be made between
past serious, unsuccessful attempts and chronic thoughts of
suicide or gestures of self-harm. The latter occurrence is
called parasuicide and refers to chronic self-mutilation,
persistent thoughts or threats of suicide, or nonlethal
attempts.
• The highest statistical category for completed suicides
are older males who are socially isolated, use a method
of high lethality and have either a mood disorder or are
chemically dependent.
• Attempters tend to be younger women who have sorne
social supports, use methods that are unlikely to be fatal
(and likely to be discovered), and have a personality
disorder or adjustment disorder. \.
Women attempt suicide more frequently than men, though
men complete more suicides. Most attempts occur in
younger age groups, which iB che opposite picture to
completed suicides. Attempts are made impulsively,
whereas completed suicides are more often planned, and
take place in settings with a low chance of discovery or
rescue. Among attempters, a personality disorder has been
reported to be the most common diagnosis, with borderline
and antisocial personality disorder being the most prevalent.
With borderlines in particular, parasuicidal behavior can
become a way of life as a means to manipulate others.
Despite the above distinctions, those who attempt suicide
have a large number of demographic variables and risk
factors in common with those who complete suicide.
Engaging in any type of self-harming behavior increases the
risk of an eventual suicide. Even in cases where it seems
obvious that parasuicidal behavior is employed for
secondary gain, complications can arise. For example, drugs
may be taken with alcohol or in new combinations that
enhance their lethality.
221
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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
Mental lllness is the strongest risk factor associated with
suicide. Over 90% of those who take their own lives have a
diagnosable mental condition at the time of death. The
presence of a mental illness is estimated to increase the risk
of committing suicide tenfold.
The majority of patients who commit suicide have seen a
physician within six months of their death. and frequently
·within one month. Other studies have found that a high
percentage of patients who took their lives had been given a
prescription for a psychotropic medication.
Among psychiatric disorders, mood disorders and alcohol
abuse (respectively) are the conditions that have the highest
association with suicide.
Mood Disorders are thought to be present in at least half,
and potentially up to three-quarters of those who commit
suicide. lt has also been estimated that 15% of those with
mood disord~rs will go on to take their own lives. Within the
spectrum ot mood disorders, the diagnoses resulting in the
highest morbidity are:
• Depressions with psychbtic features
• Bipolar mixed states (the coexistence of maníc and
depressive symptoms; of particular concern is that the
energy of mania can cause patients to act on the suicida!
thoughts brought about by depression)
lt has not been condusively shown that there is a difference
in suicide rates between unipolar and bipolar patients. The
risk of self-harm is greatest at the beginning or end of a
mood disturbance. The period just after hospital discharge is
also associated with higher risk of an attempt. Mood
disorders are somewhat more common among the elderly
who commit suicide. Personality disorders and chemical
dependence are more common in the younger age groups.
lnsomnia, anhedonia and poor concentration are the most
common mood symptoms associated with suicide· risk.
224
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"'ENDINGs" - SutetDAL & HoMtcmAL loEATION
Schizophrenia is the third most common psychiatric
diagnosis among those who have suicided. lt is estimated
that 10% of those with this condition may take their lives.
Within this diagnosis, the risk is higher:
• Among young male~. and relatively early in the course of
the illness
• In those with high premorbid achievement and high
personal expectations
• After the recovery from a psychotic episode, during the
Postpsychotic Depressive Disorder of Schizophrenia
(DSM-IV, p. 711)
• In those with an awareness of the overall prognosis
• In those with the additional risk factors of social isolation
and substance abuse
Command hallucinations or persecutory delusions have not
been highly correlated with suicide potential.
Personality Disorders are also frequently diagnosed in
suicida! patients (in particular, the antisocia: ;nd borderline
personalities from Cluster B; suicide is three times the
societal rate in prison populations ). These personality
disorders are associated with substance abuse, impulsivity,
and poor social integration and adjustment. Paranoid
personalities may harm themselves or others as a way of
preempting what they consider to be an inevitable attack.
Anxiety Disorders have recently been found to have an
association with suicide risk. In particular, posttraumatic
stress disorder and the presence of panic attacks (which can
occur in a variety of disorders) were seen as having a
correlation with future suicide.
Alcohol and substance abuse have been previously
mentioned as risk factors. A combination of these disorders
(comorbidity) with other psychiatric illnesses places patients
at particularly high risk.
225
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Antidepressants can factor into the assessment of

suicidality. There is a typical recovery sequence of
What other aspecfs of suicidal risk need to
depressive symptoms (assuming efficacy and compliance): he assessed?
With Tricyclic Antidepressants (TCAs): Another important factor is family history. There are studies
• lnsomnia and appetite may improve within 7 days that demonstrate a genetic inheritance for suicide risk
With Selective Serotonin Reuptake lnhibitors (SSRls): independent of other majar risk factors (mood disorders,
• Energy and interest may improve within 7 days schizophrenia and alcoholisrn). Twin studies have shown a
higher concordance rate far suicide in monozygotic (MZ)
·· The overall recovery tends to follow a pattern of vegetative twins than dizygotic (DZ) twins. Additionally, adoption
symptoms recovering first, followed by cognitive functions, studies have found increased rates of completed suicide
and lastly, mood symptoms and suicida! thoughts. This can among the biological relatives of adopted-away offspring,
place patients in the situatio:i where they have a return of furthering the speculation of a genetic contribution.
energy concurrent with thoughts of self-harm.
Patients who, particularly under the age of ten, lost a parent
Since this section is brought to you by the letter 'A,' two other to suicide are at an increased risk themselves through the
'A' words deserve mention. Akathisia is a motor process of identification with the deceased person. These
restlessness or "squirreliness" that causes patients to feel occurrences seem to break the "taboo" of suicide in families,
driven to keep moving. This most often occurs after the use and, in a sense, transmit that suicide is OK when things get
of antipsychotic medications, thciugh others such as Prozac® tough. This is one of the ways that the tragedy of suicide
have been reported as a cause. Akathisia can be very perpetuates itself. Patients who have lost parents to suicide
distressing, and sorne patients have taken their lives rather may not only suffer from anniversary reactions, but also be
than endure this unpleasant feeling. This is most likely to involved unconsciously in a self-destructive process at the
happen when akathisia is misinterpreted as a worsening of same age as the parent who died.
the psychosis, depression or anxiety., Of note, the treatment
The general level of stress can push people to the point that
far akathisia involves benzodiazepin~s or a ~-blocker, not
suicide is seen as an escape. In our individualized and
the anticholini:!rgic medications that work for other
technological society, the cumulative weigh, Jf moderate
::xtrapyramiüal side-effects.
stressors can be too much for sorne people. In 1967, HoLMES
The presence and severity of other adverse effects to
& RAHE developed a stress scale which assigned a specific
value of Life Change Units (LCU) to particular events. This
medication should be recorded. For example, most
scale was revised by Rahe
psychiatric medications: • Death of a spouse or a farnily
& Miller in 1994. Though mernber
• Result in weightgain
the ranking of the events • Divorce/Separation
• Diminish the interest in, and ability to engage in, sexual
relations
has changed since the • Serious medica! illness
events themselves are the • Being fired or retiring frorn work
• Cause at least mild difficulties in cognitive functions • Marriage or reconciliation
same. ~
? • Change in family situation (i.e .
These factors can dramatically lessen quality of life. (pregnancy/relative moving in)

226 227
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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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BRAIN CALIPERS
Are there ways ol measuring the potential
1.Jsk far srúcide?
• Beck Hopelessness Scale
Aaron T. Beck developed a scale for the presence and
extent of lwpe/essness; this is a self-report questionnaire
that includes 20 questions that gauge the extent to which
patients have pessimistic views about their future.
•· Scale for Suicida! ldeation & Suicide lntent Scale
Both of these instrumAnts were also developed by Beck.
A.T. Beck. O. Schuyier & l. Herman, Development of Suicida! lntent
Scales, in The Prediction of Suicide, Charles Press, 1974
• Risk Estimator Scale for Suicide
Developed by Motto, this rating system incorporates 15
variables found to be statistically significant in a study that
looked at the completed suicides in a group of patients who
were depressed and/or had expressed suicida! ideation.
J.A. Motto, D.C. Heilbron & R.P. Juster, Development of a Clinical
Jnstrument to Estimate Suicide Risk, American Joumal of
Psychiatry, Vol. 142, p. 680-6, 1985 ·
• Rorschach ("lnkblot") Test
Using criteria developed by Exner for
scoring the responses,
this test may have a predictive value for people at risk.
J.E. Exner, The Rorschach: A Comprehensiv'e System,
Third Edition, Wiiey, New York, 1993
• lndex of Potential Suicide
This may be given as a self-report test oras an interview.
There are 50 items that are given a score between 1 to 5.
This test was developed by Zung, who has also produced a
depression rating scale.
W.W.K. Zung, lndex of Potential Suicide: a rating scale for suicide
prevention, in The Prediction of Suicide, Charles Press, 1974
• Suicide Probability Scale
This is a widely used instrument developed by Cull & Gill.
J.G. Cull & W.S. Gill, Suicide Probability Scale Manual
Western Psychological Servíces, Los Angeles, CA, 1986
• Reasons hr Living lnventory
Th1s is another commonly used self-report scale.
230
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"'ENDINGs" - Su1c1DAL & HoM/CIDAL loEATION
Why is it sometimes difficult to interview or
deal with suicida/ patients?
Assessing and treating suicida! patients is among the most
stressful aspects of being a mental health professional. A
suicide in psychiatry is the equivalent of a patient dying on
the table in surgery. The suicide of a patient has been
reported to cause stress in caregivers equal to the loss of a
spouse. Suicida! patients bring about specific difficulties and
challenges.
Suicida! patients engender strong reactions in people around
them, especially those that have to do something (e.g. speak
with them at length, bring them to hospital), including
professionals who have to treat them. In the case of
caregivers, strong countertransference feelings may arise,
defined as the total emotional reaction to a patient. Because
we are all human, we will experience certain feelings in
response to our patients. One of the hallmarks of a
seasoned interviewer in dealing with patients is to recognize
and effectively use countertransference, instead of denying it
or simply acting on it. One's emotional reaction to patients
yields fertile ground for further exploration, and in many ways
is essential for a more complete understanding of patients.
People become suicida! through a complex series of events,
especially in cases of borderline patients. Here, patients
have difficulty being alone, experience hostility as their main
affect, and unconsciously engage in sado-masochistic
relationships because that is what they are used to giving
and receiving. Suicida! patients use relatively primitive
defense mechanisms, which also make them difficult to deal
with. This can result in what has been called
countertransference hate* in response to suicida! patients,
defined specifically as a mixture of malice and aversion.
*J.T. Maltsberger & D.H. Buie, Countertransference Hat~ '·1 the Treatment of
Suicida! Patients, Arch. of General Psychiatry, Vol. 30. ¡:.. 625-633, May, 1974
231
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BRAIN CALIPERS
These feelings can arise for a variety of reasons:
o As professionals, we have dedicated many years to the
pursuit of knowledge and expertise in our field; it can be
frustrating to deal with patients who have simply given up
• Suicida! patients represent an emergency requiring
urgent attention; this causes a majar disruption in one's
schedult: rhat inconveniences other patients
e The religious or philosophical views of treaters regarding
suicide can differ with those expressed by patients;
thoughts of self-harm may be seen as a moral weakness
o Mental health workers derive esteem from seeing their
patients recover and do well; it can be a blow to one's
professional or personal esteem to have a patient
consider suicide
• Suicida! patients elicit a strong need to do something to
help; an idealistic motivation is to hea/ al/, know al/ and
/ove al/, often referred to as a "narcissistic snare"
e Patients can be passive about their intentions and not
reveal them until asked directly or repeatedly; sorne
expect interviewers to be able toread minds, which for
something as serious as suicide is likely to bring about
negative reactions in those conducting the interview
• Patients can remind us of our own unresolved conflicts
about suicide (such as losses we have experienced due
to suicide, ora turbulent time when it was considered)
o Primitive ego defenses can be used by patients to affirm
that they are "bad" and th3t suicide is the right thing to
do; far example, under the right set of circumstances
(e.g. provocation), almos! any interviewer can become
irritated, at which point patients are prone to use this
reaction as proof of their worthlessness or undesirability
a Suicida! ideation is often used by malingerers to gain
admission to hospital for social reasons (3 square meals
and a rectangular bed); it is always a difficult decision to
deny patients admission even if they have a clear gain in
fabricating suicida! thoughts and the interviewer has a
high index of suspicion of being manipulated
232
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.llENDINGS" - SUICIDAL & HOMIC/DAL IDEATION
How do I retognize countertranslerente
reactions?
Maltsberger outlined these countertransference reactions:
• Repression: in this defense, therapists remain unaware
of their reaction by acting out their lack of •-iteres! as
daydreaming, restlessness or drowsine~..;; yawning or
clock watching also conveys disinterest in patients
• Turning against the self: involves feelings of
inadequacy about one's abilities and suitability for the
job; feelings of incompetence and a desire to be
punished can turn the interview into a penance
• Reaction formation: turns the feelings of hatred into the
opposite by becoming too involved in patients' lives,
often with fantasies of omnipotence and rescue
• Projection: is hatred turned back against the patient. In
this situation, one may have the fantasy of wanting to kili
the patient; since this impulse is unacceptable to the
interviewer, it is projected back onto the patient as if to
say, "I don't want to kili you, you want to kili yourself'
• Distortion or Denial: the patient is considered hopeless
and is often prematurely sent away
How do I deal with these reactions?
• First, recognize that you are an emotional being, and that
you will have strong reactions to patients; denying these
reactions can lead to abandonment or sadistic treatment
• Always take the safe route when dealing with suicida!
patients; it is much better to have an early discharge
after further assessment
• Arrange transfer of care in cases of extreme reactions
• Seek out supervision to discuss your reactions; use this
as an opportunity to learn about the patient and yourself.
Remember that countertransference gives you first-hand
experience of how others feel around the patient
233
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BRAIN CALIPERS "EuotNGs" - SutctoAL & HoMtctoAL loEATION

Suidde Tidbits Which conditions are most lrequently

e Suicide is the 8th leading cause of death; every day in
the U.S. and Canada over 100 people take their lives
0 2 out of every 3 suicide victims are white males
e Many studies have replicated the autopsy finding of
diminished central nervous system serotonin in violent
suicides. This is measured via a serotonin metabolite
called 5-HIAA (recall serotonin is 5-hydroxytryptamine -
5-HT) Of particular note in these studies was the violent
aspect of suicides. These findings were most strongly
correlate ; with the lethality of the suicide method.
Evidence also exists for dysregulation of dopaminergic
and noradrenergic systems.
e Ritual suicides are part of certain cultures:
hara-kiri is stabbing of the abdomen by a sword and was a
practice of Japanese warriors when disgraced; in Star Trek,
Klingons do the same thing (called Hegh'bat)
suttee was a Hindu custom in which a wife sacrificed herself
on the funeral pyre of her deceased husband
dadaism was a nir.:listic artistic movement that began in
Switzerland in 1916 as a consequence of W.W.I. lt was based on
anarchy and irrationality; several followers arbitrarily committed
suicide for the sake of defying society
psychic suicide occurs when individuals will themselves to death
without externa! means (e.g. a voodoo curse)
o Failing to ask about current suicida! ideation is one of the
ways of automatically failing an examination
11 In examinations, if a patient indicates she is suicida!,
take personal charge of attending to her safety at the end
of the exam (unless the examiners do so); it may be an
exam to you, but it's her life
• 8 to 25 attempts are made for each completed suicide
• Despite the efforts of many volunteers, suicide
prevention centers have not been shown to lower rates
• Suicide, particularly on an inpatient basis, is one of the
most common reasons for malpractice suits
associated with violence?
lt is important to keep in mind that any patient with any
diagnosis can become violent.
The following mnemonic covers the most common
conditions associated with the risk for violence:
"MADS & BADS" *
• Manía - at risk dueto impulsivity, granc..osity, high
energy level and possible psychotic symptoms
• Alcohol - dueto intoxication (disinhibition) or
withdrawal (altered perception, irritability)
• Dementia - poor judgment and disinhibition
• Schizophrenia - most common with the paranoid
subtype; command hallucinations or delusions also
elevate the risk
• Borderline Personality Disorder - intense anger and
unstable emotions can be part of a rage reaction when
abandonment is perceived
• Antisocial Personality Disorder - disregard for the
safety of others; sadistic enjoyment of suffering
• Delirium - hallucinations and delusions can cause
violent reactions (usually in a disorganized fashion)
• Substance Abuse - intoxication, particularly with
hallucinogens and PCP (phencyclidine)
* From the book:
Psychiatric Mnemonics & Clinical Guides
David J. Robinson, MD
© Rapid Psychler Press, 1996
ISBN 0-9680324-1-9; softcover, 96 pages

4
234 235
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Within any diagnosis, the risk for violence is elevated with

the presence of any of the following factors:
"ARM PAIN" (Risk lar Violence)
Altered state of consciousness (e.g. delirium, intoxication)
Repeated assaults - history of violence
· Male sex
Paranoia (schizophrenia, manía, delusional disorder)
Age - more likely to be violent if younger and impulsive
lncompetence - brain injury, mental retardation, psychosis
Neurologic disease - Huntington's Chorea, Dementia
Violence itself is not a DSM-IV diagnosis. lt is considered a
Condition 7.iat May Be a Focus of 6/inical Attention, is
categorized as Adult Antisocial Behavior(V71.01 ), and
describes illegal and/or immoral crimes against society.
Con.fusion can be caused by the use of the word antisocial,
because in this context it refers to acts committed in the
absence of a mental disorder, not due to an Antisocial
Personality Disorder.
Violence is an epidAmic in North American society, with an
estimated prevalence of uµ to one-fifth of the population
becoming victims. Crime statistics show that most violent
crimes are committed:
• Between people that know each other
• Between males, especially with drug involvement
• With handguns (this factor also increases suicide rates)
There are two types of violence that are of concern in
interview situations:
• Violence directed towards others
• Violence directed at you and/or other interviewers
How do I protect mysell in interviews?
Studies of violence against clinicians have shown that at
least one-third óf psychiatrists and psychiatric nurses have
been assaulted at least once. For unknown reasons, social
workers and psychologists are attacked less frequently.
Most attacks occur in emergency rooms or on inpatient units.
While this may make outpatient appointments seem
appealing, assaults in these settings usually have a degree
of premeditation and are more likely to involve a weapon.
A psychiatric interview in the emergency room seeks to
answer the question, "Why is the patient here now?"
The focus is to obtain information that helps determine the
appropriate disposition. Befare seeing patients, assess the
acuteness of the situation so that this remains the patient's
emergency, and not yours.
In the Emergency Department:
• Attend to your safety first; you can't make an accurate,
objective assessment if you are in jeopardy
• Be aware of the security arrangements available and
make use of them liberally
• See if the police or security are in attendance or nearby
• Read the emergency recc.,rd thoroughly
• Skim the patient's hospital file for other information
• Determine how the patient was brought to the hospital
(e.g. police, friends, on own); being brought in by others
increases the risk of violence
• Find out if the patient is intoxicated, restrained, or being
held involuntarily (ali of these increase the risk of
aggressive acts)
• See if bloodwork has been drawn (e.g. far drug toxicity,
medica! conditions ); is an overdose or head trauma
suspected? (both reduce the leve! of self-restraint)
• See if someone is available to provide collateral history
• See if other staff members have additional information

236 237

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When seeing patients:
• Don't challenge patients' beliefs, especially when starting
the interview; maintain your composure
e Give explanations for your actions; demonstrate
openness
e Respect the autonomy of patients
• Stress that thoughts and feelings are to be verbalized,
not acted upon
a Allow adequate, even arnple space for patients
• Sit close to the exit to facilitate your escape if necessary
• Do not block the door should patients bolt
e Seating arrangements can be discussed with patients
e Introduce others and explain their purpose in the room
• Be attuned to your feelings; don't react with anger or
sarcasm
s Do not discuss disposition (i.e. admission or outpatient
management) until you have enough information to make
a solid decision
e ldentify and explore resistance to cooperation
e lnterview rooms should never be locked when in use
• Rooms can be customized for safety - desks bolted
down, emergency alarms, unbreakable glass, removal of
heavy objects, etc.
• Crisis inter :ention strategies should be practiced -
physical, chemical, non-violen! (verbal), etc.
• lf necessary, insist that someone else be present
(clinical or security staff) in the interview
• Don't act heroically - go to the trouble of attending to
your safety and comfort
• Do not be influenced by goading from patients, other
staff, colleagues or supervisors
• lf physical restraint becomes necessary, avoid
participating if adequate personnel are present;
remember that you need to preserve your rapport with
patients, and participating in a restraint will likely ruin
this; no matter how psychotic or clouded patients are,
they usually remember those present when they were
restrained
238
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& HoMtCIDAL IDEATtON
Wby do patients berome violent?
Violence towards others, like that directed at the self, is a
complex phenomenon with bio-psycho-social contributions:
Biological
• Genetic factors exist for many conditions associated with
violence (e.g. personality disorders); the XYY
chromosome type has been linked into an increased risk
of violen ce, though a number of studies have been
unable to validate this finding
• Head injuries increase the chance of poor judgment and
diminished impulse control, as does intoxication or
withdrawal from alcohol and other substances
• Lowered serotonin levels (measured by the presence of
the metabolite 5-HIAA) are associated with a generalized
increased risk of violence towards the self or others
• Patients with mental retardation can self-mutilate, and
may become aggressive if efforts are made to stop them:
• the de Lange Syndrome (also known as the
Amsterdam type of mental retardation). consisting of any
of a number of usually obvious physical abnormalities
• the Lesch-Nyhan Syndrome, is an aut'" .orna!
recessive trait causing abnormal purine metabolism
Sociocultural
• Violence is more common in urban settings, and is
particularly endemic in downtown or "inner city" areas '
• Debate exists as to whether racial factors exist outside of
socioeconomic factors
• Poverty, or at least econom:::: inequality between
perpetrator and victim, is frequently cited as a risk factor
• Marital discord increases the likelihood of violent action
• The availability of guns increases the likelihood of a
serious injury or fatal outcome; societies or areas with
more strict gun control have lower rates of violence
239
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BRAIN CALIPERS
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HoM1c1DAL IDEATION
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Psychological Taking a closer look at the lower right-hand aspect of this

lrrespective of the contributions from genetic or sociocultural diagram, the process can be illustrated as follows:
factors, anyone can become violent under certain
circumstances. Suicide or murder often have similar an event that diminishes self-esteem triggers the "fight"
response, leading toan aggressive drive or impulse
beginnings. As reported in the sociocultural section, factors
that lower self-esteem. such as poverty or the breakup of a ~
relationship, are common determinants of violent behavior.
The chart below illustrates this. One of the results of biological, sociocultural an? psychological -+ -
factors operat1ve - • - ••
diminished self-esteem can be the fight response, resulting
in a sense of rage which can be variably dealt with: ~
• Consciously or unconsciously
expression modified by various mental processes,
• By a number of different defense mechanisms · particularly ego defenses
• As action taken against the self or others ~~~~~~~~~-

~
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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BRAIN CALIPERS
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How do I ask about violen# intentions?
Patients may not be open and honest about their intentions
in this regard. For this reason, the other factors listed in this
chapter serve as a guide for the possibility of violence.
Additionally, current stressors of a financia! or interpersonal
nature are common precipitants for taking action against
others. The best predictor of future violent behavior is a
· history of past violent behavior. Here are samples of
questions that can be asked:
• Have you had thoughts about wanting to get revenge on
someone? Did you ever develop a plan?
• Are you currently having any ideas about wanting to hurt
someone? Do you have a particular person in mind?
• What would you do if you met a person you didn't like?
• Do you have access to guns, knives or other weapons?
• What would it take for you to want to harm or kili
someone?
Do psycbiatric patients lrequently brealc the
law?
lt is a long-standing perception that the mentally ill are
dangerous and prone to committing criminal acts. Teplin 11
undertook a study of police-citizen contacts. She found that
contact between police and people with serious mental
disorders made up only 5% of the incidents reported to the
police. Those who were involved were more likely to be
doing something harmful to themselves than to others. No
correlation between the presence of mental illness and the
·ype of crim:, committed was found. She concluded that
psychiatric patients commit crimes at a leve! proportionate to
their numbers in the population. Previous studies included
other variables associated with higher crime rates, such as
age, socioeconomic status and prior criminal record.
~ L Teplin. The Criminality of the Mentally 111: A Dangerous Misconception
American Journal of Psychiatry, Vol. 142 5, p. 593-99, 1985
242
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., .. ., .,
HoMtCIDAL IDEATION
., .,
Are there methods for the pretlidion of
dangerousness?
The topic of predicting future vfolence encompasses an
extensive literature. lt is a common component of forensic
assessments, and such predictions are frequently sought in
legal proceedings. There is a lively debate regarding the
ability to accurately predi et the likelihood offuture harm to
. others. Test instruments are certainly becoming more refined
and valuable. However, much like the weather, the longer
the term of the prediction, the less accurate it is likely to be.
Risk factors can be divided into majar categories:
• History of aggressive behavior (e.g. childhood history,
record of assaults, etc.)
• Developmental factors (psychopathology in parents,
head injury, rebelliousness against authority, etc.)
• Presence of majar psychiatric illness
• Personality traits (poor impulse control, inability to
examine own behavior, emotional lability, etc.)
The following is a partial list of scales used in the
assessment of violence and the prediction of its recurrence:
• Overt Aggression Scale
• Past Feelings and Acts of Violence Scale
• The Multidimensional Anger lnventory
• Buss-Durkee Test
• Bender Gestalt
• Wechsler Memory Scale
• Minnesota Multiphasic Personality lnventory (MMPl-11)
(scored on the Overcontrol/ed Hostility e-· a/e)
• Legal Dangerousness Scale
Projective tests score responses related to violent content,
and can make a prediction of potential violence. The two
most commonly used tests are the Rorschach (lnkblot)
Test and the Thematic Apperception Test.
243
 d ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ 61 "lil(l j¡J
~
tsRAIN CALIPERS
What arr the legal requirements regarding
violent patients?
Confidentiality is one of the hallmarks of the helping
professions. Mental health professionals in particular have
access to the most personal information about patients.
Confidentiality is a professional's obligation to keep
information from third parties. Privilege is a patient's right to
··prevent information from being used in legal settings.
Medica! records can be used in court, and as such are not
entirely confidential. Judges have a wide degree of discretion
available to them in deciding what evidence to allow.
Therapists and/or their records can be subpoenaed.
In 1976, a decision was made in a California court that set
the standard far the duty to warn third parties when they are
in danger. T_atiana Tarasoff was murdered by a man she'd
spurned. The perpetrator had indicated his intention to harm
her to his therapist. The therapist informed his supervisor
and the police. However, because no serious action had
taken place at the time of the warning, no legal action was
taken. This decision resulted in two legal implications in
treating potentially violent patients. Known as Tarasoff 1& 11,
these are legal requirements that therapists have a duty to
warn and a duty to protect potential victims. Breach of
confidentiality is indicated only when there is an identified
victim, and the potential for harm to them is of a serious
nature. The American Psychiatric Association guidelines
also permita breach of confidentiality where the suicide of a
patient can only be stopped by a psychiatrist's notification of
the police, and in cases where someone responsible for the
safety of others (e.g. an airline pilot) is demonstrating
markedly impaired judgment.
In such situations, warnings to the potential victim and the
r :::ilice are inc..,cated. Under the duty to protect aspect,
patients should be managed on an inpatient basis (usually
244
~ •l!J w ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ liÍ' •
"'ENDINGs" - Su1c1DAL. & HoM1C1DAL. IDEATtON
involving civil commitment), with increased '''"'els of
supeNision and restraint (chemical and/or ~:.ysical). lt has
still not been established how victims should be warned (e.g.
visit, phone call, letter, police). Other considerations involve
the anxiety caused to the intended victim, and the possibility
of that person taking preemptive action. Obtain opinions from
colleagues, supeNisors and legal counsel in such situations. •
Individual jurisdictions have different rulings regarding the
ethical disclosure of medica! mformation. The other major
exceptions to breaki~g confidentiality involve:
• Emergencies - in situations that threaten life, limb or
vital organ, it is usually possible to release information
• Civil commitment - the police or legal authorities can
be given the iriformation required to detain a patient
• lncompetence - in situations where a patient cannot
give consent for the release of information, a substitute
decision maker can do so
• Child abuse or reportable medica! conditions -
notifying agencies that receive information about abused
or potentially abused children is something clinicians can
do without fear of repercussion, even if the abuse is not
actually occurring; also, certain communicable diseases
are reportable to public health authorities
Violente Tidbits
• Children who are abused have a greater likelihood of
becoming violent as adults
• Proper documentation which records both the
information supplied and the decision-making process is
essential
• Use your own feelings in the assessment of potentií=11ly
violent patients, regardless of the presence or absence
of risk factors; if you feel uneasy, take precautions
• Medications used to treat "violence" are rationally
prescribed to treat the underlying conditir...-; for rapid
control of violent outbursts, neuroleptics dnd
benzodiazepines (e.g. lorazepam) are often given
245
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. .,
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
potential for violence to the self or others. The predictive
value of such tests is hotly debated in legal settings. In
clinical settings, there is no substitute for a thorough
interview, mental status examination and caution when either
of these outcomes is a possibility.
AMERICAN PsvcHIATRIC Assoc1ATION ANNUAL REVIEW, VoLUME 6
W. Reíd, MD & G. Balis, MD
Chapter 21: Evaluation of the Vio/ent Patient
American Psychiatric Press lnc., Washington D.C., 1987

246 247

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BRAIN CAUPERS
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250 251
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l:;RAIN CALJPERS AFFECT & Mooo

Chapter 9
Affect & Mood

What are the lactors involved in assessing

emotional states?
The assessment of emotional states and their disorders is
another fundamental domain of the mental status exam. The
quality of one's existence is to a large degree determined by
the vicissitudes of feelings experienced. Disorders of
emotion constitute sorne of the most common and severe
illnesses in psychiatry. The components that are assessed
are called affect and mood.

Affect (pronounced with emphasis on the first syllable)

refers to the visible, externa! or objective m~ · Jestations of a
patient's emotional state. lt is a record of momentary
dynamic changes in the expression of emotional responses.
Both interna! (e.g. memories, ideas) and externa! (e.g.
aspects of the environment) events can change affect.

Mood is the person's internal feeling state. lt is described by

the patient (subjective) and refers to the pervasive emotional
tone displayed throughout the inteNiew. Mood changes are
less connected to interna! or external stimuli and occur less
spontaneously. Mood is considered the "emotional
background" whereas affect is the "emotional foreground" of
the inteNiew. Affect can be likened to one's degree of
satisfaction with the various courses of a mea!, with mood
being the overa!! enjoyment of the whole evening.

lt is important to assess these areas separately as they have

different implications. Additionally, their degree of
congruence is of relevance in formulating a diagnosis.

252 253
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BRAIN CALIPERS . AFFECT & Mooo

• Obsessive Compulsive Disorder 300.3

What is the diagnostic signilicance al C. The obsessions or compulsions cause marked distress
affective and mood changes?
• Simple and Social Phobic Disorders 300.2X
• Schizophrenia & Schizoaffective Disorder 295.X A. Marked and persistent fears ...
A. (5) Negative symptoms (e.g. affective flattening) B. Exposure to the phobic stimulus almost invariably
provokes an immediate anxiety response ...
• Majar Depressive Episode 296.X D. The phobic situation is avoided or endured with intense
A. (1.) Depressed mood most of the day ... anxiety or distress
A. (2) Markedly diminished interest or pleasure in ali
activities • lntermittent Explosive Disorder 312.34
A. (6) Fatigue or loss of energy nearly every day ... A. Severa! discrete episodes or failure to resist aggressive
A. (7) Feelings of worthlessness or excessive or impulses causing assault or destruction of property
inappropriate guilt ...
• Pyromania 312.33
• Dysthymic Disorder 300.4 B. Tension or affective arousal befare the act
A. Depressed mood most of the day ...
B. (3) Low energy or fatigue • Pathological Gambling 312.31
8 (4) Low self-esteem A. (4) Restlessness or irritability when attempting to cut
B. (6) Feelings of hopelessness down or stop gambling

• Manic Episode & Hypomanic Episode 296.X • Schizoid Personality Disorder 301.20
A. (7) Shows emotional coldness, detachment or flattened
A. A distinct period of abnormally and persistently elevated,
expansive, or irritable mood ... affectivity

~ Posttrau;,iatic Stress Disorder 309.81 • Schizotypal Personality Disorder 301.~2

C. (5) Feelings of detachment or estrangement from others A. (5) lnappropriate or constricted affect
C. (6) Restricted range of affect
• Antisocial Personality Disorder 301.7
D. (2) lrritability or outbursts of anger
A. (4) lrritability and aggressiveness ...
D. (5) Exaggerated startle response
• Borderline Personality Disorder 301.83
o Acute Stress Disorder 308.3
A. (6) Affective instability due to a marked reactivity of mood
B. (1) A subjective sense of numbing, detachment, or
A. (7) Chronic feelings of emptiness
absence of emotional responsiveness
A. (8) lnappropriate intense feelings of anger or difficulty
• Generalized Anxiety Disorder 300.02 controlling anger
C. (1) Restlessness or feeling keyed up or on edge
• Dependent Personality Disorder 301.6
C. (2) Being easily fatigued
A. (6) Feels uncomfortable or helpless when alone ...
C. (4) lrritability

254 255
 1 &¡"' ii;;( ii<l" a;1 ier 1tl,, aa,, ~ &r' il') it, "",; 11/ ti .
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e Histrionic Personality Disorder 301.50
A. (3) Displays rapidly shifting and shallow expression of
emotions
A. (6) Shows self-dramatization, theatricality and
exaggerated expression of emotion
e Narcissistic Personality Disorder 301.81
A. (1) Has a grandiose sense of self-importance
A. (8) Is often envious of others ...
A (9) Shows arrogant, haughty behaviors or attitudes
s Post Psychotic Depressive Disorder of
Schizophrenia (considered a criteria set for further
study in Appendix B of the DSM-IV)
There are certainly more emotional symptoms in other
disorders. This is not intended to be a complete cataloguing
of affective and mood criteria from the DSM-IV. The purpose
of this extended listing was to demonstrate that there is an
emotional component to every psychiatric disorder.
Diagnostic Criteria are from !he DSM-IV.
©American Psychiatric Association, Washington, D. C. 1994
Reprinted with permission.
Mootl Disorder vs. Affettive Disorder
The DSM-IV changed the category of affective disorders to
mood disorders, which more accurately describes the
findings in these conditions. Mood disturbances are of a
sustained natu~~ and not usually abruptly altered by interna!
or externa! stimuli. Disorders of affect exist within many of
the other conditions listed above. A notable example is the
Cluster B personality disorders (borderline, narcissistic,
histrionic and antisocial) where emotions can (and do!)
change rapidly. dramatically and frequently in response to
interna! and external cues. A number of other illnesses
typically present with wide fluctuations in expressed emotion.
256
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AFFECT & Mooo
What are the various aspetls ol affect?
Affect is evaluated according .o the following parameters:
e Type or quality
o Range or variability
o Degree or intensity
e Stability or mobility
o Appropriateness
• Congruence to: • mood
• appearance
• behavior
• speech
Type or quality is the predominan! emotion expressed.
There are nine principal types of affect:
• happiness • sadness • fear/anxiety
• surprise • shame • anger
• interest • disgust • contentment
Range refers to the degree to which visible emotions vary
throughout the interview. During the assessment. a patient's
"normal" affective tone would consist of a combination of a
number of the above emotional qualities.
At sorne point in the interview, a patient would be expected
to smile, frown, appear interested and show sorne
manifestation of emotion. Since there is no "standard"
degree of affect that can be measured, this area of
evaluat!on is subjective and varies between interviewers.
A narrow or restricted range of affect describe patients who
express one or two emotional states. This can be seen in
mood disorders (manic patients can have a narrowly high
range), schizophrenia, paranoid disorders, temporal lobe
epilepsy and obsessive-compulsive personalities.
A wide or expanded range, where severa! emotions are
expressed, is seen in Cluster B personality disorders,
dementia, delirium, and substance intoxication & withdrawal.
257
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Stability refers to the duration of an affect.1e response.

..Degree is the extent or intensity to which emotions are
expressed. This can also be called amount or amplitude,
and is a measure of the energy expended in conveying
feelings. Affective expression occurs along a continuum:
Low lntensity Normal
flattened appropriate
constricted responsive
detached adequate
Another way of describing intensity of affect is the force of
the expression. Much like a good actor conveys depth to a
role, intense affect arouses Pmotional responses in those
present. You can use your own reactions as a gauge.
Patients can have an intense affect with a narrow range
(e.g. manía or depression). Conversely, a wide range of
expression with low intensity is also seen (e.g. histrionic
personalities or delirious patients lack a certain degree of
conviction to their affective states). Blunted affect is a term
often used to describe low or flattened intensity. S1Ms uses
the term to describe a lack of emotional sensitivity to others.
A flattened intensity of affect can be seen in schizophrenia,
conversion disorder (la belle indifférence), dementia, and
obsessive & schizoid personalities. A heightened degree of
affect can be seen in manía, narcissistic and borderline
rersonalities :nd anxiety disorders. Depression has a
variable presentation: sorne patients convey intense distress
while others are muted and appear apathetic.
Sorne emotions exist only as long as a facial expression or a
single tear, others are pervasive throughout the interview.
Normally, there are shifts in affect during interviews. These
periods are sustained for a few moments and appropriate to
the context of the interview. For example: anxiety at the
outset, sadness when speaking about recent difficulties,
anger at the dog for eating something, happiness when
discussing a new computer, etc .
lf changes in affect are small or nonexistent (called fixed or
immobile) during the interview, this observation is more a
consideration of mood. However, affect still retains the
quality of being how the patient is objectively appears to the
High lntensity
exaggerated
interviewer, and is recorded as such. The term Jabí/e
dramatic describes affective changes that occur rapidly and
passionate frequently. These changes can take place in either the
intensity or range of affect.' For example, a patient may be
moved from tears to euphoria within seconds (range) or from
mild to intense irritation (degree).
Reactivity of affect refers to the degree to which externa!
factors influence emotional expression. For example,
features of the interview process or interviewer can cause a
reaction in patients. Another parameter of lability is whether
or not patients appear to be in control of their emotions. In
general, patients with mood disorders, substance intoxication
or withdrawal and dementias have little to no control over
their affective state. Patients with personality disorders have "
a greater degree of control. Lability of affect is commonly
seen in the following conditions:
• Mania (affect can vary rapidly, e.g. from elated to
irritable; expansive to hostile)
• Cluster B personalities (this is one of the defining
aspects of histrionic & borderline person::il;ties)
• Delirium & dementia
• lntoxication with drugs or alcohol
• Impulse control disorders

258 259

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BRAIN CALIPERS
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Appropriateness is the degree to which visible emotions
match thought content. This is also gauged by the degree to
which you can empathize with patients.
Affect is either appropriate or inappropriate to the topic being
discussed. F1r example, a patient who smiles when
discussing the death of a parent may be seen as displaying
an inappropriate affect. lf you later learn that this parent was
..abusive or estranged ( and left a large inheritance ), then this
person's smile is more understandable and the expressed
emotion is more appropriate to the situation.
lnappropriate affect occurs most frequently in schizophrenia,
particularly the disorganized or hebephrenic subtype.
Schizophrenia causes patients to lose the ability to relate to
others, and instead display a detached, mechanical
demeanor. Their emotional responses are not what would
normally be expected for the topics being discussed.
Patients can demonstrate what is called a sil/y or fatuous
affect. This occurs when patients exhibit qualities such as:
giggling, laughing, grinning, rhyming, punning, mocking
interviewers, playing with objects and other childlike actions.
lnappropriate affect is also seen in:
• Malingering - the emotional component of a patient's
presentation doesn't "add up" to the verbalized problems
• Substance use - intoxication or withdrawal can cause
patients to be inappropriately jovial or unconcerned with
medical problems, criminal charges, etc.
• Conversion Disorder - la bel/e indifférence describes a
distinct lack of concern for reported neurologic deficits
• Depression - when patients have decided to attempt
suicide, they can become unconcerned or untroubled by
their preexisting problems
~ Delirious and demented patients can seem unusually
concerned about trivial matters (or the converse)
• Antipsychotics - affective flattening can occur through
the parkinsonif}n sideeffects of these medications
260
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AFFECT
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Congruence between affect and other factors in the MSE
is another important consideration. The association between
affect and the following parameters is important to observe:
• Mood
Affect may or may not be congruent to the mood state a
patient reports. For example, depressed P'- .ants may still
smile, joke and discuss Caribbean cruises. Lack of congruity
may mean malingering or a factitious disorder, the presence
of two separate conditions (e.g. mood and personality
disorder), substance use, schizoaffective disorder ora
psychotic component to a mood disorder.
• Appearance
Emotional disturbances are c<ten manifested in various
aspects of appearance because patients have little time or
interest in attending to these finer points:
Grooming & Attire - depressed patients often neglect their
self-care, are dishéveled, and often dress in dark colors;
manic patients dress flamboyantly (often in red) and use
poor judgment in picking new looks or styles; schizophrenic
patients may make bizarre alterations and become unkempt.,
Facial Expression is a key component of affective response.
Unvarying movements are seen in depression and
schizophrenia; in manía and personality disorders,
expressions can be overly dramatic and exaggerated.
• Behavior
Posture indicates interest, self-importance, control, etc.
Manic, narcissistic and antisocial patients strut and sit
upright; depressed patients slouch and lean on things, etc.
Body Movement/Gesticulation also indicates affective tone.
Depressed patients move infrequently and slowly; manic
patients emphasize their feelings with rapid and exaggerated
movements and have trouble restraining their activities.
Hands and lower limbs may give away clues about
someone's feelings. Keep an eye on the entire body to
monitor reactions to questions (sweating, trembling, etc.).
261
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Speech also conveys information about aftective state.
lnflection provides modulation and emphasis, making
speech interesting to hear. This is reduced in depression,
schizophrenia or obsessive-compulsive personalities; it is
ir1creased in manía or Cluster B personalities.
Prosody also conveys the emotional aspects of speech (this
was covered in the SPEECH CHAPTER).
Affect Tidbits
e lt is relati· ;ly common for patients to either not be aware
of, or not verbalize their emotional state; in these
situations, use your observations to obtain more
information. e.g. "Mr. Janes, you looked upset when you
described your struggle to keep ahead of the neighbors."
e lt is also important to inquire about incongruence
between thought content and affect, e.g. "Mr. Smith, you
mentioned that you were going into debt trying to keep
up with Mr. Jones, but you smiled when you said this ... "
• Psychotic patients who display silly or inappropriate
affect may be responding to interna! stimuli, such as
hallucinations (e.g. voices telling them jokes or ridiculing
the interview) or delusions (e.g. ali psychiatrists are
cross-dressers)
• Affect originates in the limbic system (hippocampus,
amygdala, cingulate gyrus, anterior thalamus, mamillary
bodies ); disease processes that occur in these areas can
cause affective changes (e.g. strokes, tumors, multiple
sclerosis, meningitis); the hippocampal-amygdala
complex is reduced in size in schizophrenia; neurologic
disorders affecting the limbic system and basal ganglia
commonly present with depression
• ÜTHMER propases that affect has 3 functions:
• se/f-perception: providing an emotional value judgment
• communication: expression of feelings is made known
to others
• motivation: affect is one of the key elements leading to
the initiation of action
What are the various aspects ol mood?
Mood is evaluated according to the following parameters:
e Type or quality
• Reactivity
• lntensity
e St~bility/duration
• Pattern
Quality of mood is the patient's reported em0tional state
(therefore, you must ask!). The DSM-IV incl..;Jes the
following as pathological mood types:
o Depressed
• Euphoric
• Angry/lrritable
• Anxious
Depressed mood occurs when patients feel less energetic,
hopeful or capable than what is usual for them. This mood
state can be described by any of a number of qualifying
terms, such as:
sad, blue, worthless, guilty, flat, hol/ow, miserable, gloomy,
glum, forlorn, morase, troubled, exhausted, somber,
brooding, unhappy, subdued, withdrawn, etc.
There are a large number of 'd' words that are used to
describe these mood disturbances (amaze your friends!):
down, dejected, despondent, demoralized, dysphoric,
despairing, dour, dispirited, drained, doleful, downcast,
down in the dumps, desperate, defeated, dreary,
disappointed, disillusioned, diminished, dissatisfied,
disaffected, dysfunctional, disconso/ate & downhearted
Because depression is used to refer to mood disorders,
these mood states are frequently referred to as dysphoric,
which means a state of unhappiness or feeling ill at ease.

262 263
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BRAIN CALIPERS
Depressed mood is a diagnostic criterion for the following
disorders:
s Depressive Disorders
a Depressed Phase of Bipolar Mood Disorders
a Cyclothymia
e Dysthymia
• Adjustrnent Disorder with Depressed Mood
_Transient depressions in mood also occur as a variant of
normal even when there is no obvious precipitant ("cosmic"
depression). The diagnosis of a mood disorder rests on the
presence of associated features, severity (degree of social
and occupational impairment) and duration. Majar
depressive episodes can be a complication of any other
psychiatric condition. The term double depression refers to
an episode of depression complicating a dysthymic disorder.
The DSM-IV also contains research criteria for the following
proposed conditions (in Appendix 8): postpsychotic
depressive disorder of schizophrenia, minar depressive
disorder, recurrent brief depressive disorder, and an
alternate set of criteria (Criteria B) for dysthymia.
Depressed mood can be such a long-standing experience for
patients that it becomes a character trait. The DSM-IV also
lists research criteria for a depressive personality disorder. In
the past (DSM-11), Asthenic Personality Disorder was used to
refer to patients who exhibited: lassitude, abulia, anhedonia
and an inability to withstand expectable stresses.
Depressed mood is often accompanied by changes in:
• Appearance (decline in self-care)
e Behavior (few spontaneous movements)
• Speech (speak softly, have little to say, etc.)
• Affect (restricted range, variable intensity)
• Thought content (morbid themes)
• Thought form (increased latency of responses)
• Diminished cognitive functioning
264
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AFFECT & Mooo
Euphoric mood occurs when patients feel energized,
elated or ecstatic. This is of a greater degree than what is
experienced when patients are "up" ar in a "good mood."
Sorne of the terms used to describe euphoric mood are:
up, flying, grand, uninhibited, omnipotent, buoyant, jovial,
racing, driven, on top of the world, indestructible, etc.
Similar to the 'd' words of depression. there are severa! 'e'
words for euphoria:
energized, elevated, elated, entertaining, exalted, extreme,
expansive, extraordinary, ecstatic, effervescent & ebu/lient
Euphoric mood is seen in:
• Manic or hypomanic phases of bipolar mood disorders
• Schizophrenia (most often the disorganized type)
• Substance abuse (particularly with stimulants)
• Dementia and delirium
There has been less empirical support for such conditions
as: brief hypomanic disorder, minar manic episode, or
hypomanic personality. When patients are e·xperiencing a
dysphoric mood, they frequently seek help for the way they
feel. When patients are euphoric, they rarely present for
assistance and generally have to be brought to attention
because of the impact their rnood state has had on other
people or on social/occupational functioning. Many bipolar
patients are "attached" to their highs and value the increased
productivity and sense of well-being that accompany them.
Euphoric mood often occurs with changes in:
• Appearance (unusual or bizarre changes)
• Behavior (rapid, continua! movements)
• Speech (speak loudly, have a great deal to say, etc.)
• Affect (expanded range, labile, intense)
• Thought content (grandiose themes)
• Thought form (flight of ideas, pressure of speech)
• Cognitive functions may be enhanced (creativity or word
association) or diminished because of distractibility
265
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BRAIN CAUPERS
Angry/lrritable moods do not constitute discrete
disorders, but are frequent complications of other conditions.
Sorne of the following terms are used to describe these
mood states:
annoyed, miffed, pissed off, seething, sharp, disgruntled,
cranky, indignant, incensed, be/licose, smo/dering,
exasperated, furious, ill-tempered, easily provoked, etc.
These mood states frequently accompany the following
conditions:
• Mania or hypomania
• Cluster B personality disorders
• lntermittent Explosive Disorder
• Disorders where paranoia is prominent
• Substance use, particularly withdrawal syndromes
• Delirium & dementia
• Head trauma
• Various neurologic conditions
• Temporal lobe (partial-complex) epilepsy, particularly in
the interictal or postictal periods
''ritability is ciefined as being easily provoked to anger. The
DSM-IV lists irritability as a one of the three mood states in
mania or hypomania. lrritability is usually seen as the mood
disorder increases in severity. As with depression, anger or
irritability can accompany any psychiatric condition, and are
not of diagnostic significance in themselves.
Angry/irritable mood is often accompanied by changes in:
o Appearance (glaring, menacing facial expressions)
e Behavior (muscle tension, threatening movements,
posturing)
e Speech (harsh tone of voice)
• Affect (intense, restricted, may be labile)
o Thought content (openly challenging, hostile, sarcastic,
difficulty with authority, uncooperative)
• Thought form (terse, decreased latency of response)
• Cognitive or perceptual aberrations
266
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AFFECT & Mooo
· Anxious mood can occur normally, especially if patients
are unfamiliar with or intimated by the interview process. lt is
to be expected that patients will be anxious about such areas
as diagnosis. prognosis and treatment implications. Anxiety
is pathological when it is pervasive or present to a degree
that interferes with social or occupational functioning.
Terms used to describe an anxious mood are:
fearful, tense, on edge, worried, nervous, uptight, frazzled,
petrified, uneasy, rattled, terrified, para/yzed, panicky, etc.
Beca use the term "anxiety" is also used to refer to anxiety
disorders, these mood states are frequently referred to as
apprehensive.
Anxiety is prominently seen in:
• Generalized anxiety disorder
• Phobic Disorders
• Obsessive-compulsive disorder
• Posttraumatic stress disorder
• Panic disorder
• Adjustment disorder with anxiety
As with other dysphoric mood states, anxiety can complicate
any other psychiatric condition and is prominent in a number
of general medica! conditions (hyperthyroidism, cardiac
arrythmias, pheochromocytoma, etc.).
Apprehensive mood is often accompanied by changes in:
• Appearance (widened star3, tense facial expressions)
• Behavior (tremer, quick or jerky movements)
• Speech (tremulous, rapid)
• Affect (intense, restricted; may settle with time)
• Thought content (threatened, impending doom,
exaggeration of potential dangers, ruminative, etc.)
• Thought form (decreased latency of response, jumbled,
tangential or circumstantial thoughts)
• Cognitive performance (often diminished by anxiety)
267
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Reactivity is the cegree to which mood is altered by
externa! factors. Mood can be shifted by events, the
environment or interactions with others. Manic patients often
escalate in mood with stimulation. Depressed patients may
feel worse in the morning and have their spirits lift as the day
progresses. Similarly, anxious or angry patients have a
waxing and waning of their mood under certain conditions.
In the past, depression was divided into endogenous and
--reactive types based on the presence of a (presumed)
precipitant. Reference to this distinction is still made in texts
and by more "experienced" clinicians. A careful history will
almost always revea! a prec!pitant to a depressive episode.
Frequently it is an event of outwardly minar (but symbolically
majar) si~nificance. For example, hearing a song on the
radio or watching the Lawrence Welk Show rnay bring back
memories that serve as a reminder of a lost loved one.
The endogenous aspect has been carried forward into a
subtype of depression called the melancholic features
specifier. In this type of depression, there is a lack of mood
reactivity to usually pleasurable stimuli.
Another subtype of depression called the atypical features
specifier, contains two criteria related to mood reactivity:
• Mood reactivity, where rnood brightens in response to
actual or 11oténtially positive events
A long-standing pattern of interpersonal rejection
sensitivity (not limited to episodes of mood disturbance)
resulting in significant social or occupational impairment
Depressed patients with melancholic features have a greater
likelihood of response to medication or ECT than patients
without these features. Atypical features occur more
frequently in women and younger patients. Frequently, only
a partial recovery froin these episodes is reported. Atypical
features may indicate a bipolar depression or a seasonal
pattern (either in the present or future episodes ).
lntensity refers to the degree to which the mood is
expressed. Like affect, mood has depth, amount and
amplitude. Two patients can experience depressed mood
with a similarly flat affect and restricted range of emotional
expression. One patient may appear lethargic, withdrawn
and show little interest in the interview. The other patient
may have problerns with concentration, lowered self-esteem
and be able to convey the degree to which this episode has
interfered with his or her life. The difference between these
patients is the depth or intensity of their mood state.
Stability or duration describes the length of time the mood
disturbance exists without significant variation. Mood
disorders are required to have a specific time course:
• Major Depressive Episode 2 weeks
• Manic Episode 1 week
• Dysthymic Disorder 2 years
• Cyclothymia 2 years
The rapid cycling subtype of bipolar disorders involves four
or more cycles of mania/hypomania and depression in the
last year. A cycle is the recovery (full or partial) from the
most current rnood disturbance (for at least two rnonths ), or
a switch to the opposite mood polarity.
There is no clear means of distinguishing a sustained affect
from a reactive rnood. Certain conditions (€ ;. personality
disorders, substance abuse) where there is a good deal of
variation in the moment-to-moment expression of emotion
can occur comorbidly with mood disorders. To complicate
matters, there is a type of bipolar mood disorder called a
mixed state where the criteria for mania and depression are
met simultaneously. As a general guide, emotional changes
occurring over:
seconds minutes hours days weeks months
indicate disorders of affect indicate disorders of mood

268 269
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" ., .
Patterns of Mood Disturbances How do I ask about mood symptoms?
Manic Bipolar Disorder Type 1
Hypomanic Mood symptoms are usually distressing to patients and they
• Manic and Depressive Episodes
Euthymic • Depressive Episodes in sorne speak about them or display them readily in interviews.
patients are brief or nonexistent Since mood is a subjective pt1enomenon, patients need to be
Depressive Sx.
• No separate diagnostic category asked about their emotional state.
Major Depression exists for Unipolar Mania
• How have you been feeling lately?
Manic
• How would you describe your mood right at the moment?
Bipolar Disorder Type 11
• l'd like you to rate your mood on a scale from 1 to 10. lf 1
Hypomanic
• Hypornania with Major Depressive is the worst you've ever felt, and 1O is the best, what
Euthymic Episodes; the irnplications of the
distinction frorn Bipolar Type 1 are
score would you give yourself right now?
Depressive Sx. • How did you feel in response to ... (sorne event)?
still being investigated
Major Depression
Sorne patients (particularly obsessive personalities) will
Manic Rapid Cycling Type answer feeling questions with thinking answers e.g. "I feel
Hypomanic
• 4 or more episodes of Mania,
the Orioles will win the World Series," or "I feel like a pizza,"
Euthymic Hypomania, Mixed, or MDE in 1 year are not statements of mood.
• Recovery for 2 rnonths between
Depressive Sx.
episodes, or a switch to a rnood lt may be necessary to point out a patient's reactions as a
Ma;~r Depression episode of opposite polarity
mea ns of eliciting information about mood, e.g. "You looked
very sad when you were talking about being ripped off at the
Manic Cyclothymic Disorder drive-thru, how did you feel at that time?" As with affect,
Hypomanic
incongruities between observable signs and the reported
Euthymic A A AA • Depressive syrnptoms do not
necessarily meet the criteria for a
mood state need to be explored, e.g. "You indicated it was
Depressive Sx. V YVY Dysthyrnic Disorder and are not as
severe as an MDE; highs can be upsetting far you to miss SEINFELD last week, but you said
Major Depression hypornanic in intensity this with a grimace on your face."

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
---

• sorne patients do develop a

Depressive Sx. coexisting MDE; this is then called a connections to important people, or revolutionary ideas?
Major Depression Doubl~ Depression

270 271
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BRAIN CALIPERS AFFECT & Mooo

Mood Tidbits llelerences

,. Anhedor..a is the absence of enjoyment from acts that
THE CUNICAL INTERVIEW USING DSM-IV
are usually pleasurable
VoLUME 1: THE FuNOAMENTALS
• Anomie is a (real or imagined) lack of integration into
E. Othmer, MD, Ph.D & S. Othmer, Ph.D
society, leaving few social supports for the person
American Psychiatric Press lnc., Washington O.e., 1994
• Apathy is a "lack of feeling" characterized by diminished
energy and interest in the environment; such patients are
PsvcH1ATR1c D1cnoNARY, 7TH EomoN
unemotional and listless; apathy has been described as
R. eampbell, MD
a mood state and occurs with frontal lobe damage,
Oxford University Press, New York, 1996
schizophrenia, dApression, and substance abuse (e.g.
sedatives, marijuana, etc.)
01AGNOSTIC ANO STATISTICAL MANUAL OF MENTAL 01SORDERS,
o Alexithymia is the inability to sense and describe mood
4TH EDITION
states; patients are "disconnected" from their feelings
American Psychiatric Association, Washington, O.e., 1994
and describe them in terms of somatic sensations or
behavior; this is seen in schizophrenia, posttraumatic
CoMPREHENSIVE TExrsooK oF PsvcHIATRY, 6TH EomoN
stress disorder, somatoform disorders and strokes
H. Kaplan, MD & B. Sadock, MD, Editors
• Euthymia is the word used to describe normal mood
Williams & Wilkins, Baltimore, 1995
• The criteria used to diagnose the dysphoric mood states
of depression, cyclothymia & dysthymia are different
SYMPTOMS IN THE MINO, 2ND EDITION
• The distinction between mania and hypomania is made
A. Sims, MD
on the basis of degree; if the symptoms are severe
W.B. Saunders eo., Philadelphia, 1995
enough to interfere with work or relationships, orto
warrant hospitalization, mania is diagnosed
THE NEUROPSYCHIATRIC MENTAL STATUS ExAMINATION
• Always explore what patients mean when they use
M. Taylor, MD
jargon ora self-diagnosis; "depression" can mean quite
PMA Publishing Corp., New York, 1981
different things to different people; make further inquiries
to make sure you understand what the patient means
An excellent resource for preparing written reports is:
Summary THE CLINICIAN'S THESAURUS, 4TH EOITION
E. Zuckerman, Ph.D
As Mr. Spock or Data from Star Trek can attest, emotions elinician's Toolbox, The Guilford Press, New York, 1995
are one of the quintessential aspects of being human. Affect
and mood indicate what is importan! to patients. Emotions The section especially relevant to reporting Affect and Mood
motívate behavior, alter perception and change thinking_ is in Chapter 15.
Disorders of feelings are among the most common and
severe conditions in psychiatry_ Both a subjective (mood)
and objective rattect) assessment of a patient's emotional
~tate are requ1red in the MSE.

272 273
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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
~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ u ~ ~ u ~ b ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
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

An object in the environment causes a sensation; upon

interpretation by the brain, it becomes a perception.
Disorders of perception in psychiatry involve false
associations or the de novo arrival of a percept without a
stimulus. Disorders of the sense organs are important
organic considerations, but are beyond the scope of this
book. While imagination can bring about perceptions in any
sensory modality. there is normally no difficulty in disting-
uishing these from real stimuli. Patients experience per-
ceptual abnormalities as clearly as they do reality. but have
lost the ability to make a clear distinction between the two.

278 279
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ORAIN \..ALIPERS
j j j lt-' Mj •. J

PERCEPTION
a) li )M
.!

What is tbe Jiagnostic signilicance ol • Hypochondriasis 300.7

A. Preoccupation with fears of having, or the idea that one
perceptual abnormalities? has, a serious disease based on the person's
misinterpretation of bodily symptoms
e Delirium (of any etiology) 293.0
B. . .. the development of a perceptual disturbance ... • Factitious Disorder with Predominantly
Psychological Symptoms 312.34
• Schizophrenia & Schizoaffective Disorder 295.X
A. (2) Hallucinations • Depersonalization Disorder 300.6
A. Persisten! or recurrent experiences of feeling detached
• Brief Psychotic Disorder 298.8 from, and as if one is an outside observer of, one's mental
A. (2) Hallucinations processes or body.

• Delusional Disorder 297 .1 • Schizotypal Personality Disorder 301.22

B. . .. tactile and olfactory hallucinations may be present if A. (3) Unusual perceptual experiences, including bodily
they are related to the delusional theme illusions

• Mood-Congruent & Mood-lncongruent Psychotic • Borderline Personality Disorder 301.83

Features (delusions and hallucinations) can complicate A. (9) Transient stress-related paranoid ideation or severe
mood disorders dissociative symptoms

• Panic Dísorder 300.X • Histrionic Personality Disorder 301.50

(9) Derealization or depersonalization A. (7) Is suggestible, i.e. easily influenced by others or
circumstances
• Acute ~1:ress Disorder 308.3
B. ( 1) A subjective sen se of numbing, detachment, or Diagnostic Criteria are from the DSM-IV.
absence of emotional responsiveness ©American Psychiatric Association, Washington, D.C. 1994
Reprinted with permission.
B. (2) A reduction in awareness of the surroundings
B. (3) Derealization
B. (4) Depersonalization General Medica/ Conditions associated with
• Posttraumatic Stress Disorder 309.81
perteptual ahnormalities
• Dementia (of any etiology)
B. (1) Recurrent and intrusive distressing recollections of the
• Temporal Lobe (Partial-CoíT1plex} Epilepsy
event, including images, thoughts or perceptions ...
• Migraine headaches
B. (3) Acting or feeling as if the traumatic event were
• Brain tumors
recurring (... including illusions, hallucinations and
• Narcolepsy
dissociative flashback episodes ... )
• Thalamic/peduncular lesions
C. (5) Feelings of detachment or estrangement from others
• Substance intoxication/withdrawal

280 . i 281
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l i ti

Wbat are tbe various aspects al Hallucinations are given the following terms according to the
perception? sensory modalities in which they occur:

Sen se Name of hallucination

Disorders of perception occur in the following forms:
e Hallucinations • sight visual
• lllusions • sound auditory
e
Disturbances of self and environment • smell clfactory
depersonalization • tas te gustatory
derealization • touch somatic
• Disturbances of quality or size
micropsia Hallucinations occur on a continuum of intensity. Brief,
macropsia poorly formed experiences are called incomplete,
dysmegalopsia unformed or elementary hallucinations. Examples are
• Disturbances in the intensity of perception flashes of light, whispered sounds, faint odors or tas tes, or
hyperacusis the sensation of being gently nudged.
visual hyperaesthesia
• Disturbances of experience Functional hallucinations require another stimulus or
déja vu percept to be present first - far example, hearing the opera
jamais vu singer Lorenzo Panzerotti sing about pasta every time the
shower runs. In a functional hallucination, the singer is only
heard when the water is running, and his singing is not
Wbat are hallucinations? simply a misinterpretation of the sound of the shower. The
running water can still be discerned. The hallucination and
Hallucinations are perceptions that occur when there is no original percept occur in the same sensory modality {i.e. the
actual stimulus present They are the most severe of the running water causes an auditory hallucination, not a visual
disorders of perception. Additional features of hallucinations one of Panzerotti consuming pasta).
are that they:
e Occur in ali sensory modalities Sorne patients experience
e Can be simple or complex hallucinations in one form that
Seem as vivid as real experiences are triggered by a stimulus from
• Occur spontaneously and are beyond the will or control a different sensory modality.
of the patient These are called reflex
• Are often intrusive (as are obsessions) hallucinations. With the above
• Are interna! experiences attributed to externa! sources example, a running shower
• Occur s1multaneously with real stimuli would produce a gustatory
• Serve sorne psychological function far patients, and hallucination of a rich spaghetti
often revea! information of psychodynamic relevance sauce or the tactile hallucination
of oodles of noodles.

282
283

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BRAIN CALIPERS
Auditory hallucinations are the most common type in
psychiatric conditions. In general, they occur as distinctly
hefüd voices that speak clearly formed words, sentences or
even conversations. In organic conditions, they are more like
elementa01 hallucinations, involving sounds such as ringing,
grating or humming, and are often indistinct.
Auditory hallucinations are most commonly reported in
psychotic illnesses and are one of the cardinal symptoms of
scliizophrenia. They are also among the criteria for
schizophreniform disorder, schizoaffective disorder, brief
psychotic disorder, and psychotic disorders dueto general
medica! conditions.
Schneiders's first-rank symptoms were covered initially in
the chapter on THOUGHT CoNTENT. Seven of the eleven were
delusions, and one was delusional perception (the
attribution of a false or delusional meaning to an ordinary
event).
The remaining three are auditory hallucinations:
• Audible thoughts, where patients hear their thoughts
said out loud, as if they were echoes. In sorne situations,
patients will continue speaking to those around them
expecting that they have shared the experience of these
audible thoughts. In other instances, patients will hear
voices commenting on what they have just thought ar are
about to think.
.. Voices arguing or discussing (or both). Here, two or
more hallucinatory voices speak about the patient in the
third person. These discussions or arguments pertain to
the patient (i.e. they are not hallucinatory weather
forecasts ). and are often critica! or derogatory.
• Voices giving a running commentary. This is similar
to the ab ..:. o1e experience. Again, these comments center
on the patient and are usually focused on an activity. Fer
example, aµditory hallucinations of this nature often
comment on actions just before/after or during the event.
284
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PERCEPTION
The DSM-IV includes these first-rank symptoms as being
highly characteristic of schizophrenia. In general, two of the
following symptoms are required to make the diagnosis:
• Delusions
e Hallucinations
• Disorganized speech
• Grossly disorganized or catatonic behavior
• Negative symptoms
However, only one of these criteria is needed if:
• The delusions are of a bizarre nature
• Hallucinations consist of a voice keeping upa running
commentary on the person's behavior or thoughts, or two
or more voices conversing with each other
Diagnostic Criteria are from the DSM-IV.
©American Psychiatric Association, Washington, D.C. 1994
Reprinted with permission.
This is as far as the DSM-IV goes in making any symptom
pathognomonic far this illness. There are still time factors,
associated functional impairments and important exclusion
factors involved in diagnosing schizophrenia.
Patients are usually able to describe their "voices" in sorne
detail. They are aware of the gender of the hallucinatory
speaker and whether or not they recognize the voice. Often it
is someone they know or someone that has passed away. In
sorne instances, patients are instructed by a voice to perform
an act; this experience is called a command hallucination.
The repetitive nature of these commands can be too much to
bear and patients may eventually follow them.
The classical description of auditory hallucinations is that
they are experienced as originating "outside" the person's
head, as if from a completely separate entit• fhis is in
contrast to obsessions, which are recognized as coming
from the patient's mind. Sorne patients are more insightful,
and are aware that the voices come from within.
285

u ~ u ~ ~ ~ u u u u u u ~ ~ ~ ~
BRAIN CALIPERS
Auditory hallucinations are usually derogatory and critica!
twoards patients. Carrying around this cacophony of
insulting, belittling comments is one of the tortures of mental
illness. Fortunately, hallucinations are one of the positive
.>ymptoms 1.. e. they are added to the clinical picture), and
are among the most responsive to antipsychotic medication.
Auditory hallucinations can be of sounds other than voices.
Commonly, these include: machine-like sounds, music,
animal vocalizations or other sounds of nature.
Mood disorders can also be complicated by delusions and
hallucinations. In ps/chotic depression or mania, the mood
disturbance is present initially, and the psychotic features
begin as the condition worsens.
lnterestingly, patients who are congenitally deaf and later
develop schizophrenia report the same type of auditory
hallucinations as those with normal hearing.
Auditory hallucinations in organic conditions tend not to be
as distinct or have the same duration as those in psychiatric
illnesses. lmportant medica! conditions to corisider are:
• Delirium
• Dementia
• Temporal lobe epilepsy
• Migraine Headaches (especially of the basilar artery)
• Salicylate (aspirin) toxicity
• Méniére's Disease
• Antibiotic administration (e.g. streptomycin)
• Sensory deprivation (e.g. hearing loss, cataracts)
• Poorly adjusted hearing aids (may pick up voices from
others beyond the normal range of hearing)
• Lesions of the tempero-parietal region (e.g. strokes,
tumors, herpes encephalitis)
• Vascular lesions of the pons
• Cerebellopontine angle tumors
• Acoustic neuromas ( occur in neurofibromatosis)
286
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PERCEPTION
Visual Hallucinations are the next most prevalent type
encountered in psychiatric illnesses. lt is more common to
have visual and auditory hallucinations occurring together
than it is to have visual hallucinations alone. f\ne such
combination involves auditory hallucinationL. with partial or
inferred visual hallucinations. For example, a patient who
hears a voice coming from the coat rack may also see or
"might have" seen arms gesturing as "it" was speaking.
lsolated visual hallucinations should prompt a thorough
investigation for an organic cause (either a general medica!
condition or the effects of a substance ).
When visual hallucinations occur exclusively in psychiatric
conditions, they are almost always due to psychotic
disorders.
Visual hallucinations can be simple or complex. They can be
as brief as a "vision" or as involved as having a visit from
Abe Lincoln. With an occipital lobe infarction, psychedelic
and geometric shapes are formed. In peduncular
hallucinosis, complex shapes are formed and tend to occur
in the evening. Frequently, patients have concomitant
disturbances in their sleep-wake cycle and are not always
adverse to the interesting variety of images. Extracampine
hallucinations involve experiences (seeing, hearing, etc.)
beyond the normal sensory range (e.g., being able to look
out the window and see someone in another state).
Visual hallucinations can also form, orbe part of, delusional
thinking. A patient who experiences a raging Viking leaping
out of her hospital closet may develop delusions of
persecution. Paranoid patients commonly "see" their
persecutors in various public places or just outside their
homes. In the delusion of an imaginary companion, or a
double (doppelganger) ora phantom boarder, patients
may actually claim to have seen such an entity. In
reduplicative paramnesia, patients may not only believe,
but actually claim to see duplicated body parts.
287
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The medica! differential diagnosis for visual hallucinations is
as follows:
• Release hallucinations occur after damage along the
hemispheric part of the visual pathways, involving the
temporal, parietal or occipital lobes; they often occur with
visual field defects
• Palinopsia is the persistence of a visual image after it is
removed; this occurs with occipital lobe lesions
l letal ha'"Jcinos;s can occur during seizures, and may
contain images of past events _
• Anton's Syndrome (cortical blindness) occurs with
lesions of the cortical visual center; patients deny their
blindness and confabulate visual images, often
displayi;ig a strong affective componen!
• Migraine headaches occur with scotomas consisting of
graying of the visual field, blurring of the center of vision,
flashing zigzag lines, crescents of brilliant colors, or
distortion of objects; these last up to twenty minutes
• The aura of a classic migraine can cause visual
hallucinations without going on to cause a headache
o Various dementias, Pick's disease, etc.
• Huntington's disease
• Eye problems - injury, retina! detachment, surgery
• Narcolepsy
• Substance intoxication or withdrawal
Visual Hallucination Tidbits
• Oneiroid states (from Greek, meaning dream) occur in
schizophrenia and delirium. The patient experiences
vivid hallucinations which can range from terrifying to
engrossing. Oneiroid states can become an "alternate" or
dream world where patients keep track of this state and
reality at the same time
• The Charles Bonnet Syndrome is a rare condition
consisting of formed, complex, repetitive visual
hallucinations (that are recognized as such); there are no
symptoms of other psychiatric conditions, no clouding of
consciousness and no hallucinations in other modalities
288
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PERCEPTION
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Olfactory hallucinations are far less common than the
auditory or visual types. and their presence (along with
gustatory and tactile hallucinations) warrants a medica!
investigation. These hallucinations can occur in:
• Patients with psychotic disorders
• Patients with coexisting psychiatric disorders and
temporal lobe epilepsy
• Patients with comorbid psychiatric and other general
medica! problems
Unfortunately, olfactory hallucinations rarely involve
fragrances like rose petals. The most common smells are
described as burning rubber, rotting garbage or very strong
body odors. These smells often are of personal relevance to
patients, and they can describe associations to the odor.
Smell is the sense most close1y linked to memory, and these
hallucinations are often accompanied by strong affects. The
olfactory association areas are in the frontal lobes and limbic
system (hypothalamus and amygdala).
Olfactory hallucinations accompany hallucinations in other
modalities, as well as delusions. For example, the raging
Viking who carne out of the closet may have had a certain
scent about him in addition to sounds, etc. Patients with
somatic delusions ("l'm rotting inside") may have
accompanying olfactory hallucinations. Paranoid patients
who believe they are being subjected to poisonous gases
can hallucinate the smell of a noxious substance being piped
in through their heating or air-conditioning.
Olfactory hallucinations occur in the following· conditions:
• Temporal Lobe Epilepsy- often form the aura of a
seizure, particularly if the focus is in the uncus (uncinate
seizures)
• Migr~ine Headaches. as part of aura (but overall, they
are more common in temporal lobe epilepsy)
• Diseases involving the frontal lobes or limbic system
289
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BRAIN CALIPERS
Gustatory Hallucinations involve more than just having
unusual taste in matters. These are the least common type
and occur under a similar range of conditions as do olfactory
hallucinations. Patients who believe they are being poisoned
may experience unusual tastes. Like olfactory hallucinations,
these are rarely pleasant, often being described as metallic,
acid, bitter or sorne bizarre combination of tastes (such as
corn, wood or paint-flavored ice-cream).
Psychotropic medication can have an effect on taste
sensation. Lithium (metallic), zopiclone (metallic) and
disulfiram (garlic-like) are common examples.
Somatic Hallucinations are made up of three types:
• Tactilt: hallucinations involve disorders of bodily
sensation. Examples include:
• formication (from Latín, meaning ant; mind you don't
substitute the 'm'), which is the sensation of ants or
other insects crawling on the skin
• haptic - the sensation of being touched, such as by a
phantom
• hygric - which involves shifts in fluid ("Ali my lymph is
in my head")
• thermal - temperature related ("My ears are burning")
• Kinesthetic hallucinations are sensations of moving
body parts such as joint position, body rotation, etc.
• Cenesthetic or visceral hallucinations are those
involving interna! organs ("My spleen has aligned itself
along the axis of the equator")
Like the other types of hallucinations, these are most
common in psychotic conditions, temporal lobe epilepsy and
migraine headaches. They are often paired with either
somatic delusions or delusions of control. Because
delusions are often based on a kernel of truth, psychotic
patients may be describing actual perceptions in a distorted
or bizarre fashion. Thus, even the most unusual description
warrants an initial investigation.
290
M h ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
PERCEPTION
Other Hallucinations
Hypnagogic hallucinations occur while falling asleep, and
hypnopompic hallucinations occur while awakening.
These experiences occur in a large percentage of the
population and are not considered pathological in isolation.
They can also occur during periods of illness where
dehydration, fever or sedating medications are given.
These hallucinations are usually visual, but can be auditory
or tactile. While their duration is brief, they can occur as
complex hallucinations.
Hypnagogic and hypnopompic hallucinations occur in
narcolepsy. This condition involves irresistible sleep attacks
that:
• Cause cataplexy, which is a sudden and complete loss
of muscle tone (differentiate this from catalepsy)
• Often occur at times of intense emotional expression
• Have sleep-onset REM periods (these start within 1O
minutes of falling asleep instead of the normal 90 min.)
• Cause excessive daytime somnolence
Most adults have had the exporience of hearing their names
called, only to find there was no one there. Other brief,
familiar sounds (footsteps, doors closing) are also commonly
experienced and are not pathological.
Bereavement is the reaction to, and grieving process
endured after, the death of a loved one. This period is often
filled with "hallucinatory" experiences involving the deceased
person. For example, the creaking of a rocking chair or
seeing the person in a crowd are often reported.
Three other qualities can affect perception and lead to
hallucinations where no mental illness exists:
• Vivid imagination
• High degree of impressionability
• Sensory deprivation
291
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BRAIN CALIPERS
What is an lllusion?
An illusion is a misperception of an existing stimulus. Actual
percepts are exaggerated, distorted or altered so that they
appear as something different to the person, but remain
within the existing sensory modality (e.g. an object which is
seen does not become transformed into a sound). As with
.. hallucinations, illusions occur in each sensory modality.
lllusory experiences are affected by particular factors:
• The need far closure and to make sense of the
environment; here, illusions "fill in the blanks" left by
inattention or uncertainty; far example, misreading a
word or being oblivious to a spelling mistake because the
reader "knew what was meant" in the passage.
• Emotional state or expectation; a person who is
frightened by walking alone at night is more likely to see
a menacing figure in the shadows than if he were with
someon8 else or walking the same route in daylight.
• Pareidu1ia, a type of imagery that persists when looking
at a real object; the illusion and real stimulus exist
simultaneously, but the pareidolic illusion is recognized
as unreal. A common example of this is seeing faces or
shapes in clouds. Such illusions can be so striking that
they require little imagination to visualize.
The DSM-IV only mentions illusions as a criterion far one
disorder (schizotyp.o:I personality disorder). Most major texts
provide scant information on the significance of illusions.
They are mentioned most frequently in relation to substance
intoxication or withdrawal. lt may be that these conditions
divert a patient's attention so that misperceptions of the
environment become more common. Another factor which
has not been established is the significance of the degree of
distortion. For example, would a person be considered more
ill if he or she misperceived a mannequin, ora mushroom, as
a person?
292
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PERCEPTION
Disturbances of Self and Environment
Depersonalization is a change in the perception of self,
causing the individual to feel as if he or she has beco me
unreal. Derealization is a change in the awareness or the
perception of the externa! world. lt may be difficult to make a
clear distinction between the two perceptions because
patients may feel themselves blending into the surroundings
during an episode of depersonalization.
These conditions have the following associated features:
• They are unpleasant. and cause anxiety or dysphoria
• Patients retain an awareness that their experience is
unreal (as opposed to dissociation)
• Typical descriptions involve leaving one's body or
somehow being outside of one's self; "looking down at
myself from the ceiling" or "watching myself in a movie"
are common ways of relating these experiences
A theme of inadequacy is frequently reporté .. Patients feel
as if they have become barren, deficient or incompetent.
Often there is a distortion of time, which can seem either
accelerated or slowed down.
These experiences are common among psychologically
healthy people. An estimated 40% of the population may be
intermittently affected. lt has been suggested that this is an
automatic mechanism triggered by stressful situations.
In the DSM-IV, there is a distinct condition called
Depersonalization Disorder. Depersonalization also occurs
in schizophrenia, mood disorders and anxiety disorders,
particularly agoraphobia. lt is also seen in personality-
disordered patients who lack a strong sense of self {weak
ego bouridaries), feel incomplete and are overly insecure.
These traits are most commonly seen in borderline,
histrionic, schizotypal and obsessive personalities.
293
'" 1 ..._. ...J Bm eJ
IN
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ALIPERS
llLi .J ..J ...J .J ..J .A LJ ~ ...4
Disturbances ol quality or size
While these disturbances are technically illusions, they are
often referred to separately. and are included here for
completeness.
• Micropsia is the perception of seeing things as being
smaller than their actual size (like looking backwards
through a set of binoculars); Macropsia is the perception
of objects seeming larger than their actual size.
Collectively, these can be termed metamorphosia.
• Dysmegalopsia is the perception of seeing one side of
an object as being larger than the other (something like
the faces in a Picasso painting).
e Lilliputian hallucinations involve seeing little creatures,
who may also be speaking and walking on the patient
causing tactile sensations. The word comes from the
celebrated work by Jonathan Swift called GuLUVER's
TRAVELs (written in 1726). In the land of Lilliput, Gulliver
is a giant. Lilliputian is also used to describe small-
mindedness or being petty. Later in his travels, Gulliver
happens upan a land of giants, called Brobdingnag. The
terms gargantuan or brobdingnagian may be used by
erudite people to mean macropsia. AucE rN WoNDERLAND
(lewis C~rroll) and THE PICKWICK PAPERS (Charles
Dickens) also contain accounts of metamorphosia.
Disturbances in the intensity ol perception
In these alte,·ations, sensory input is either augmented or
diminished in intensity. For example, hyperacusis occurs
when sounds are experienced as louder than they actually
are (hypoacusis is tt'le opposite). Smell, touch, taste and
sight (called visual hyperesthesia when enhanced) can all
be affected similarly.
294
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PERCEPTION
kJ rtJ
Disturbances ol experience
Déja vu is a French term meaning "already seen" or "there's
nothing new in that." lt is used to denote a feeling of
familiarity to situations that are novel. Jamais vu, meaning
"never seen," is applied to situations that are familiar but
strike the person as something they have not experienced.
These phenomena occur in people without mental illnesses
and in a variety of medica! and psychiatric disorders. The
most common organic cause is temporal lobe epilepsy.
Schizophrenia is the psychiatric diagnosis most often
associated with frequent or severe experiences of this kind.
When pathological, these disturbances are called
identifying paramnesias. They can cause difficulty with the
veracity of memory. Patients may not be able to accurately
recall if an event occurred or not (as if it may have happened
in a dream and the person can't be certain).
Time perception can also be altered. Patients experiencing
déja vu may think that little orno time has passed because
experiences seem familiar to them.
An autoscopic hallucination refers to the exnerience of
seeing oneself as if in a mirror image, or proj;.;Cted onto the
externa! world. Recognition is intact, and the image is
correctly identified by the person. The opposite can also
occur, called negative autoscopy or heautoscopy. Here,
the person looks in the mirror and sees nothing (which may
make him a vampire!).
These conditions can be a feature of parietal lobe lesions,
which can also cause other abnormalities of perception:
• Anosognosia - unawareness of physical illness, or
nonrecognition of one side of the body (hemi-inattention)
• Prosopagnosia - inability to recognize familiar faces
295
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Pseudohallucinatians & degree ol insight
into perceptua/ disortlers
Pseudohallucinations retain the quality of a perception
without a stimulus; however, the person recognizes that the
event is not actual/y occurring. True hallucinations appear to
be concrete, real and happening apart from the patient (in
their externa! or objective space ). Pseudohallucinations
occur in subjective, inner space. Patients refer to the "inner
eye" or "inner ear" as perceiving the stimulus, which is
usual/y auditory or visual. Pseudohallucinations can be vivid
and formed. The "pseudo" part refers to preserved insight on
the patient's part; it does not refer to poorly formed
perceptions (called elementary hallucinations). In other
words, these experiences are "pseudo" because there is an
awareness of their false origin, not because of vague stimu/i.
In these situations, the patient's reality perception is
impaired, but reality testing remains intact.
Pseudoha//ucinations are perceived as being distinctfy
rJifferent from fantasy/vivid imagery and true hallucinations.
They are not indicative of any particular condition and can
occur in patients who have ha//ucinations (e.g. due to
psychotic disorders) or those who may have fleeting
perceptual disturbances (e.g. persona/ity disorders).
0THMER outlines five stages of insight into perceptual
disturbances:
• Stage 1
No current disturbances; insight into their
o origin, and that they are pathological
Stage 2
No current disturbances; patient remains
convinced that were actually occurring
• Stage 3 Recent experience of perceptual
disturbances; unwilling to discuss them
6
Stage 4
Discusses perceptual experiences and stil/
has them but refrains from taking action
• Stage 5 Acts on perceptuaf disturbance (e.g.
command ha//ucinations)
296
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PERCEPTION
* *' ~
How do I aslc about perceptual disorders?
1 Perceptual disturbances, along with disorders of thought
¡
,
content, are usually the most difficult to ask about in
interviews. There is an underst;nding among laypeople that
1 delusions and hallucinations make one "crazy," and sorne
patients become offended by questions in these areas.
f
· In sorne cases, behavior is altered because patients are
responding to hallucinations - for example, looking abruptly
at an area of the room or being distracted by having to attend
to your voice and the hallucinations simultaneously. In other
situations, patients simply won't share their experiences, or
have command haflucinations to say nothing to interviewers!
When asking about perceptual disturbances, indicate you
know they occur and that you are prepared to discuss them:
• "Mr. Domo, a lot of people with difficulties like yours have
sorne other symptoms as well. In order to be thorough,
f'd like to ask you about sorne of these things so 1have a
complete understanding of what's been happening."
These questions are afso good "openers:"
• Have you had any unusual experiences?
• Have things been happening around you that seem
puzzling or don't make sense?
One of the distinguishing features of hallucinations is that
they seem as real as (orare more vivid than) actual
perceptions. A key point in establishing this is the lack of
corroboration (i.e. others do not experience them). At this
point, patients either share their experiences w; 1 you, or will
ask you to be more specific about what you mean:
• Have you heard a voice from someone not in the room?
• Have you seen something that others couldn't see?
• Ha ve you had experiences such as ... (example of a
hallucination) that others didn't share?
2~7
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t;jRAIN l:ALIPERS
d. ..... d u u .. ii u t.I
(!)
Have you ever heard something and not been sure
where :. was corning from?
8
Did you ever hear something that sounded like a voice
and not know who was talking?
lf the presence of any perceptual abnormality can be
establishe::J, treat this as you would any other symptom and
get as much detail as possible. The questions in this section
are geared at exploring auditory hallucinations because they
are the most comrnon type encountered in psychiatric
disorders. In general, questions should assess duration,
quality, intensity, variation, associated events, etc.
• Did you recognize whose voice it was?
• Did the voice/voices tell you to do something?
• Did you comply? Why or why not?
The question, "Did the voice seem to come from inside or
outside your head?" is often asked. The significance of this
is that true auditory hallucinations are considered to originate
outside the self, e.g. from radio towers or microwave ovens.
However, true hallucinations can also be perceived as
coming from within. Another way of asking this question is to
inquire whether the experience felt like a product of the
person's mind (i.e. obsessions or images) or whether it was
a completely foreign or externa! experience.
Questions about other hallucinations can be posed as
follows:
• Have you ever experienced a taste that wasn't due to
something you were eating?
• Have you smelled something that didn't fit with the
situation you were in at the time?
• Have you ever experienced a strong/bad taste or smell
that you couldn't account for?
• Have you had sensations in your body that felt like they
were dueto unseen forces? (e.g. being touched or
moved b:; something, ants crawling on your skin, interna!
organs being shifted, etc.)
298
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PERCEPTION
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Perceptual Disorders in Substanr~ Use
Perceptual disorders occur frequently during both the
intoxication and withdrawal states of substance use
syndromes. A summary is as follows:
lngestionllntoxication
• Hallucinogens consist of LSD, mescaline (peyote) and
psilocybin (mushrooms). These substances act on
serotonergic neurons to produce any and all of the
possible disturbances in perception. Of note are the
blending of senses (called synesthesias) where, for
example, a color has an associated taste and smell. The
Hallucinogen Persisting Perception Disorder (flashbacks)
involves spontaneous, transient experiences of
geometric shapes, micropsia, macropsia, spoken words
and false perceptions of movement. Hallucinogens can
also cause a trailing phenomenon, where moving
"objects are seen as a series of disconnected images (as
if lit by a strobe light).
• Cannabis use is frequently accompanied by a
heightened awareness of externa! stimuli. Experiences
are more vivid and new details may appear to the user.
Derealization and depersonalization can also occur, and
time often appears to slow down.
• Phencyclidine (PCP) is chemically distinct from LSD
and considered individually in the literature on substance
disorders. This drug can cause very marked behavior
disturbances due (in part) to perceptual aberrations.
Depersonalization, auditory and visual hallucinations,
tactile hallucinations of tingling and warmth, and
distortions of time and space are common.
• Amphetamines, MOMA and cocaine can cause
psychotic episodes, with visual hallucinations.being the
predominant disturbance of perception. Because other
positive symptoms also occur, this psychc-•;c state can
be indistinguishable from paranoid schizophrenia.
299

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Withdrawal
• Alcohol hallucinosis (called Alcohol-lnduced Psychotic
Disorder with Hallucinations in the DSM-IV) consists of
auditory hallucinations that are critica!, derogatory and
threatening. These hallucinations occur in a clear
sensoriurn and are distinct from alcohol withdrawal
deliriL. il. They usually disappear within severa! days.
The quality of the voices can be identical to those
described in Schneider's first-rank symptoms.
e. Alcohol withdrawal leading to delirium tremens (DTs} is
most often accompanied by visual (e.g. lilliputian) and
tactile (e.g. formication) hallucinations.
• Cocaine withdrawal can also lead to the tactile
hallucination of formication. Visual hallucinations can
also occur, bvt the most common psychotic disturbances
are paranoid delusions.
• Benzodiazepine and barbiturate withdrawal can lead to
a state of delirium which is indistinguishable from the
DTs. Usually the hallucinations are visual in nature, but
they can also be tactile or auditory.
In practice, alrnost any substance of abuse can cause
perceptual abnorrnalities as part of an intoxication effecU
delirium, or withdrawal effect/delirium. These particular
exarnples are listed to illustrate that distortions of perception
are common in substance abuse syndromes. lt remains a
fascinating challenge for ps~1 chiatric research that various
states of intoxication or withdrawal can be clinically
indistinguishable from major psychiatric illnesses.
Prescription rnedication is also capable of causing
perceptual disturbances in patients. This happens frequently
in situations where patients are quite ill dueto blood loss,
dehydration, etc. Drug-drug interactions may also be
responsible. Sorne medications in particular are capable of
causing these perceptual disturbances, e.g. opioids,
atropina, nitrous oxide anesthesia, anticholinergics,
sympathomimetics, bromocriptine, L-dopa, etc.
300
&t..· ~;¡¡,"' Ó•_,, l'.... •~• a:1-" illlr' •r.·' ,,,¡~/ a<i/ llli(J'' &.1/ ª·' ,.
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w w - .... - - - - - - - .. PERCEPTION - - 111 -
Psythodynami' Aspetts of Perteption
Hallucinations can be thought of as serving important
psychologicat functions for patients. Like delusions,
hallucinations represent projections onto the environment of
a "voice" belonging either to patients or thei" ,aretakers
(internalized objects). While psychotic disorders are being
delineated as "brain" diseases, there remain important
psychosocial contributions. Convincing evidence for this is
that the concordance rate of schizophrenia for identical
(monozygotic) twins is almost exactly 50%. Clearly, there are
environmental factors influencing the expression and course
of psychiatric disorders.
A majar area of psychosocial contribution is expressed
emotion (EE), defined as criticisrn, overinvolvement and
hostility on the part of caretakers (usually parents). Psychotic
patierits frequently experience auditory hallucinations of
criticism which appears to be a reliving of childhood.
Frequently, the voices can be identifted as those of parents
or other significant 'figures from their past.
Neurodynamic Aspetts
CT scans showing lateral ventricular enlargement have been •
a consistent finding in schizophrenia. Additionally, MRI
scans have found reductions in temporal lobe size and that
specific temporal subcortical nuclei are affected (e.g. limbic
system - amygdala & hippocampus). lt is of significance
that these structures are adjacent to the body of the lateral
ventricle. The terminal area far the. auditory pathway is the
transverse gyrus of Heschl (Brodmann area 41) in the
temporal lobe. This provides a possible explanation for the
major perceptual disturbance of schizophrenia (auditory
hallucinations) in that demonstrable pathology has been
found in the auditory association area of the temporal lobe
{which also contains visual association areas ).
301
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PERCEPTION
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BRAIN CALIPERS

Perception Tidbits References

e Hallucinatory voices are sometimes called phonemes;
the term is also used to denote the audible components
(speech units) of words; phonemic aphasias were
covered in the SPEECH CHAPTER
• Hallucinations that occur in conjunction with delusions
are often difficult to isolate; for example, a somatic
delusion and a haptic hallucination may be clinically
indistinguishable because there is no way of determining
the prese:nce of hallucinations
• Hallucinations are one of the most easily faked
symptoms in factitious disorder and malingering
• lt is importan! to not corroborate hallucinatory
experiences, regardless of how adaman! patients are
about their vividness; sorne patients ask for a reafity
check and depend on your candor
• Mood-congruent/incongruent hallucinations occur as a
specifier for psyr:hotic mood disturbances; like delusions,
hallucinations that are congruent with depression involve
themes of punishment, nihilism. etc.
• Patients with histrionic personalities have a cognitive
style that is impressionistic and diffuse; hysterical
misapperception is a term used to describe a (sensory)
perceptual disturbance based on vague, fleeting and
global attention to events
• Hypochondriasis is the preoccupation with having a
serious illness based on the misinterpretation or
misperception of bodily signs or symptoms
Summary
The human brain needs stimulation in order to develop
properly and to maintain a coherent sense of self and the
world. Perception provides new information, which changes
feelings, thoughts and behavior. Perceptual abnormalities
occur in many illnesses and are one of the hallmarks of
psychosis and other serious psychiatric conditions.
THE CLINICAL INTERVIEW UsING DSM-IV
VOLUME 1: THE FUNDAMENTALS
E. Othmer, MD, Ph.D & S. Othmer, Ph.D
American Psychiatric Press lnc .. Washington O.e .. 1994
PsvcHIATRIC D1cr10NARY, 7TH Eo1r10N
R. eampbell, MD
Oxford University Press, New York, 1996
01AGNOSTIC ANO STATISTICAL MANUAL OF MENTAL 01SORDERS,
4TH EDITION
American Psychiatric Association, Washington, o.e .• 1994
CoMPREHENSIVE TExrsooK oF PsvcHIATRY, 6rH EornoN
H. Kaplan, MD & B. Sadock, MD, Editors
Williams & Wilkins. Baftimore, 1995
SYMPTOMS IN THE M1No, 2ND EomoN
A. Sims, MD
W.B. Saunders eo, Philadelphia, 1995
THE NEUROPSYCHIATRIC MENTAL STATUS EXAMINATION
M. Taylor, MD
PMA Publishing eorp., New York, 1981
HALLUCINATloNs 1N CuNICAL PsvcHIATRY
G. Asaad, MD
Brunner/Mazel, New York, 1990
CLINICAL NEUROLOGY FOR PsvcH1ATR1srs, 4TH EomoN
D. Kaufman, MD
W.B. Saunders Co., Philadelphia, 1995
J. Mount, MD & P. Steinberg, MD
Personal Communication. 1996

302 303
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FUNNYSTUFF

What's Your Perteption? Pharmaco-Acronymania

Have you ever wondered where drug names come from?
How come we don't have any fun names for psychiatric
drugs like Duvoid for urinary hesitancy, or Fastin, an
anorexiant? Why can't we have HallucinHalten as an
antipsychotic, or WorryBuster for an anxiolytic? Or could it
be that there are subliminal messages contained in the
names of medications ...
Librium Liberally given to rummies
Haldol Had last disagreement with orderly
Largactil Largely acting impulsively

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

Marplan M.D.'s alternate plan

Elavil Elation and vitality

... until 1realized 1 was just-hallucinating
Dartal Darn it wasn't long-acting

Zoloft Zenith of lofty heights

Risperdal Risk of relapse perished altogether

Effexor Effective in xenophobia reduction

306
307
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I NSIGHT & J UDGMENT
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

Judgment is the opinion ar conclusion arrived at by a patient,

and generally refers to:
• A decision
• Whether or not a certain action took place, and why
• Weighing the consequences of doing ar not doing
something

lnsight is a cognitive awareness, and techni .illy a

component of thought content. Judgment involves both a
cognitive awareness (decision) and an action (behavior).

lntact insight and judgment are the end result of many

factors: intelligence, accurate perception (of both internar
and externa! ev'ents), absence of significant mood states, the
ability to understand and communicate ideas, intact cognitive
abilities, impulse control, capa~ity for abstract thinking, etc.

lnsight and judgment are crucial factors in determining the

success of therapeutic interventions and prognosis.

308
309
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What is the diagnostic signilicance ol
delicient insight or judgment?
lnsight and judgment can be impaired in any psychiatric
disorder. Deficient awareness and poor decision making
regarding illnesses are common findings in ali types of
clinical conditions, but are perhaps found more frequently in
.Psychiatric than in medica! illnesses.
The DSM-IV contains severity and course specifiers far ali
psychiatric disorders. These specifiers are listed after the
diagnosis and are based on:
• The current illness only
• The number and intensity of signs and symptoms
• The degree of social and occupational impairment
The specifiers are:
• Mild - few, if any symptoms in excess of those required
to make the diagnosis, and result in no more than minar
impairment in social or occupational functioning
• Moderate - between mild and severe
• Severe - man y symptoms in excess of those required
to make the diagnosis, or severa! symptoms that are
particularly severe or result in marked impairment in
social or occupational functioning
Disorders including a "with poor insight" specifier are:
• Obsessive-Compulsive Disorder - if for most of the time
during the current episode, the obsessions and
compulsions are not seen as excessive or unreasonable
• Hypochori:Jriasis - if for most of the time during the
current ep1sode, the individual does not recognize that
the concern about having a serious illness is excessive
or unreasonable
Diagnostic Criteria are from the DSM-IV.
©American Psychiatric Association, Washington, D.C. 1994
Reprinted with permission.
What are the components ·ol insight?
lnsight is a complex function requiring the integration of
higher mental functions. The following components can be
used to help determine the level of insight:
• Acknowledgment of the illness (diagnosis, subtype,
course features, etc.)•
• Consequences and repercussions of being ill
• Awareness of own thoughts, feelings, motivations, etc.
• Attention to subtleties and the symbolic aspects of
behavior
• The ability to see the effects of one's actions on others
• Comprehension that treatment may be able to reduce,
control or alleviate symptoms
lnsight is an important aspect of determining a patient's
capacity for giving informed consent. An assessment of
medica! competence focuses on many of the above issues,
and the following considerations are very helpful in
determining the degree of insight:
• Choices are based on rational reasons
• Understanding the rationale for proposed treatment
• Ability to identify, recognize and survey alternatives
• Ability to commit to a choice
Adequate insight is vital for compliance with a treatment
regime. Compliance is much more likely when patients can
appreciate the benefits of continuing with various forms of
treatment. This also emphasizes the importance of
educating patients and families about psychiatric disorders.
lnsight is variable, and changes with mood ~.ate, degree of
thought disorder, drug intoxication, degree of time since
medication was taken, etc. Although an interview assesses
the awareness of an illness, patients can have varying
insight into different aspects of their lives. Deficient insight in
certain areas is referred to as a blind spot.

310 311
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How is the degree ol insight determined? What are ego defenses?

Because insight occurs along a continuum, there are three Ego defenses, also called defense mechanisms, serve to
levels or degrees that are used to describe the awareness protect an individual from unpleasant thoughts or emotions.
patients have of their illnesses. By definition, these are unconscious processes that result
from interactions between the id, ego and superego.
Full lnsight Everyone uses ego defenses to sorne degree, and these
• Recognizes signs and symptoms are part of an illness mechanisms clearly have adaptive aspects. For example,
• Able to modify behavior sorne degree of denial of an illness often helps patients cope
e Cooperates fully with treatment with a limited amount of stress at a time and not feel
overwhelmed. ln=many psychiatric disorders, ego defenses
Partial lnsight operate on a pathological level, with the end result being that
Ql Recognizes that there are problems. but does not patients have limited insight into their illnesses, relationships,
attribute this to an illness need for treatment, etc.
" May understand that others see them as ill
e Variable ability to modify behavior Where do ego defenses come lrom?
e Variable cooperation with treatment
Their "headquarters" resides in Freud's structural theory,
lmpaired/No lnsight introduced with the publication of The Ego and the Id in
• Denial of illness or that there are problems 1923. This model consists of a tripartite structure containing
., Has no capacity to understand the concerns of others the id, ego and superego. To recap, the id is completely
a Poor compliance with treatment unconscious and seeks gratification of instinctual drives. The
superego forms from an identification with the same-sex
How do I ask about insight? parent at the resolution of the oedipal conflict.
lt becomes the
Many of these considerations are dealt with in the body of moral conscience
the interview. In situations where the degree of insight needs and dictates what
to be specifically addressed, the following questions can is proscribed
help: (should not be
• Is it your opinion that you have an illness? done) as well as
• How do you account for the difficulties you are having? what is prescribed
• Have you had experiences that you think aren't normal? (should be done).
• What does (name of condition) mean to you? The superego
• What factors are important for you to recover? is largely
• What will happen if you don't follow through with the unconscious, but
treatmen• proposed for this condition? has a conscious
What would help you feel better? element.

312 313
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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

The id seeks expression of an impulse Neurotic Defenses lmmature Defenses

+ Controlling
Displacement
Acting Out
Blocking
The superego prohibits the impulse from being expressed
Dissociation Hypochondriasis
~ Externalization ldentification
This conflict produces signa! anxiety lnhibition lntrojection
~ lntellectualization Passive-Aggressive Behavior
An ego defense is unconsciously recruited lsolation Projection
tb decrease the anxiety Rationalization Regression

+ Reaction Formation
Repression
Schizoid Fantasy
Sornatization
A character trait or psychiatric symptom is formed
Sexualization
Undoing

314 315
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How is judgment determinetl?
Judgment is a process that leads to a decision oran action.
In interview situations, this is an assessment of what the
person did or didn't do with respect to his or her illness.
Judgment can be determined using the following criteria:
~ The ability to enumerate the pros & cons for a course of
action
., The degree to which actions are in the person's "best
ihterest"
o The extent to which insight is present
e The degree of contemplation prior to taking action
1 • How bad did things get before help wat .;ought?
, oor judgment can be evidenced by the following factors:
• lmpulsivity
• Engaging in actions with a high probability of damaging
consequences (regardless of how impulsively they were
carried out):
• shoplifting
• sexual promiscuity
• buying sprees many of these behaviors
• reckless driving are seen during manic or
• switching brands of cola hypomanic episodes
• physical assault
• vandalism
Although the most important factor leading to sound
judgment is adequate insight, the terms are not synonymous.
For example, there are many patients with personality
disorders who have an awareness that they have
interpersonal problems causing considerable distress to
themselves and others, yet they do not change their
behavior, despite this degree of insight. Similarly, sorne
patients display good judgment despite having poor insight.
For example, sorne patients take medication because others
want them to, not because they are convinced of its merits.
Other patients visit emergency departments for social
reasons when ill. Despite needing help, their visit is
coincidental to their need far treatment.
316
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How tlo I ask about judgment?
Again, judgment can usually be gleaned from historical
details obtained in other parts of the interview. The prime
feature of judgment is how a patient carne to therapeutic
attention. lf it is not clear, ask about the entry into the mental
health care system using the following parameters:
• Did the person seek assistance of his or her own
volition?
• To what extent were others needed to motívate or push
the patient into getting assistance?
• How long did the person wait befare seeking help?
• Were there associated medica! problems?
• How much did others suffer because of what the patient
was doing prior to seeking help?
• Were the police involved in bringing the patient to the
hospital?
• What was the "final straw" befare taking action?
In situations where judgment ¡leeds to be directly assessed,
questions about the present or future may be of sorne use:
• What are your plans far the future?
• What would you do if you became acutely suicida!?
• What are the first signs you are aware of when things are
starting to go downhill? What do you do about them?
• How does a seed know which way is up?
Traditionally, judgment has been assessed by asking what
the patient would do if he or she found a sealed, stamped,
addressed envelope on the street. Another standard
question is to ask what the person would do upon smelling
smoke or seeing a fire in a theater. While these questions do
assess "judgment," it is far more useful to look at actions in
reality rather than in hypothetical situations. Questions of a
similar nature assess abstract thinking (covered in
CoGNITIVE fuNcr10N1NG & SENSORIUM).
317
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JuDGMENT
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I;)

lnsight & Judgment Tidbits Referentes

• lntellectual insight refers to an awareness that a
THE CLJNICAL INTERVIEW USING DSM-IV
problem exists but there is no substantial effort going into
VoLUME 1: THE FuNDAMENTALS
chonging the situation; this is commonly referred to as
E. Othmer, MD, Ph.D & S. Othmer, Ph.D
"lip service" and is found most frequently in patients
American Psychiatric Press lnc., Washington D.C .. 1994
suffering from personality disorders and substance use
disorders; they agree there is a problem, but the situation
PsvcHIATRIC D1cr10NARY, 7TH EomoN
isn't serious enough motívate real change
R. Campbell. MD
• Emotional insight is a motivating influence that
Oxford University Press, New York, 1996
provides the fuel for patients to make real changes in
their relationships, jobs and even personality
DIAGNOSTIC ANO STATISTICAL MANUAL OF MENTAL 01SOROERS,
characteristics
4TH EomoN
• Mania and hypomania are classic conditions in which
American Psychiatric Association. Washington, D.C., 1994
patients have impaired judgment; they can appear
superficially reasonable in interviews but demonstrate an
COMPREHENSIVE TEXTBOOK OF PSYCHIATRY, 6TH EDITION
impaired ability to foresee consequences
H. Kaplan. MD & B. Sadock, MD, Editors
• Patients riay be more capable of identifying emotional or
Williams & Wilkins, Baltimore, 1995
behavioral problems than recognizing that their thinking
(cognition) is disordered
SYMPTOMS IN THE MINO, 2ND EDITION
• The frontal lobes are essential for higher reasoning and
A. Sims, MD
judgment; damage to this area causes disinhibition.
W.B. Saunders Co., Philadelphia, 1995
impulsivity, loss of reasoning ability, and indifference
• · lnsight-oriented psychotherapy (also called expressive)
EGO MECHANISMS OF DEFENSE
seeks to help patients develop an awareness of their
G. Vaillant, MD
psychological functioning and personality; this type of
American Psychiatric Press; Washington, D.C., 1992
therapy examines the dynamics of thoughts, feelings and
behavior with !he aim of improving relationships through
SvN0Ps1s OF PsvcHIATRY, 7TH EomoN
emotional insight
H. Kaplan, MD. B. Sadock, MD & J. Grebb MD, Editors
Summary Williams & Wilkins, Baltimore, 1994

lnsight and judgment are complex processes that occur as a

result of the integration of other aspects of functioning
(emotional. cognitive, perceptual, etc.). Diminished insight
and impaired judgment combine to cause the disruptions in
social and occupational functioning that add to the severity of
psychiatric conditions. Disturbed insight and judgment can
occur in any psychiatric disorder.

318 319
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The Transmutation ol Ego Delenses famous Moments in Bad Judgment

Old: Primitive ldealization New: American Expressization
Explanation: The ultimate expression of "plasticity;" allows the ego to Benjamin Franklin [a founding father]
function autonomously from the superego until the end of the month. + Emil Kraepelin [a phenomenal phenomenologist]

Old: Denial New: Alibido

= Benjemil Kranklin [a floundering father]
Explanation: An amalgamation of two other defenses, alibi and libido,
since the first is usually used to cover up the actions of the second.

Old: ·Passive Aggression New: Passé Aggression

Explanation: Here, the ego becomes embroiled in the social milieu
and struggles of a prior decade in order to avoid facing the demands
of the curren! one. Sorne decades (e.g. the 1960's) seem heavily
favored for use by this defense.

Old: Controlling Nl)w: Remole Controlling

. Explanation: The ego is now a ble to achieve remarkable control over
the externa! environment with this new defense. Not only is it effective
with electrical devices, it can cause pronounced changes in humans
as well.

Old: Humor New: Humor

Explanation: No comment.

Old: Altruism New: Trumanism

Explanation: Plainly stated, this enables the ego to have hard cash, as
well as responsibility seek a final resting place on one's desk.

Old: Suppression New: Supper-ession

Explanation: The (usually unilateral) decision to postpone attention to
a conscious impulse, at least until after dinner.

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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BRAIN C"Ái.IPERS
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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

These tests are given to be able to quickly screen for the

presence of more serious impairments. There is also
considerable diversity in the way different clinicians
administer this part of the MSE. Sorne give more tests,
including their own "rules" and observations that form an
important but unfortunately unstandardized contribution to
the assessment of cognitive functioning. What is more
important is that sorne measure of these functions be made
during the MSE, and that the same tests bt ddministered in
a consistent manner in interviews to be able to monitor a
patient's clinical course.

324 325
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What is the diagnostic signilicance ol • Schizophrenia 295.X

delicils in cognitive lundion?
While cognitive impairments can occur in any psychiatric
e' ,sorder, they are most prominent in the following disorders:
• Delirium (of any etiology) 293.0
A. D_isturbance of consciousness with reduced ability to
focus, sustain, or shift attention
B. A change in cognition (such as memory deficit,
disorientation, language disturbance) ...
• Dementia (of any etiology) 290.X
A. The development of multiple cognitive deficits manifested
by both:
(1) Memory impairment (impaired ability to learn new
information or recall previously learned information)
(2) One of more or the following cognitive disturbances:
• aphasia
• apraxia
• agnosia
• disturbance in executive functioning
• Mental Retardation 317/318.X
A. Significantly subaverage iritellectual functioning: an IQ of
approximately 70 or below on an individually
administered IQ test
B. Concurren! deficits or impairments in present adaptive
functioning in meeting the standards expected for his or
her age in ... communication, self-direction, functional
academic skills, work, etc.
• Substance lntoxication
B. Clinically significant maladaptive behavioral or
psychological changes that are due to the effect of a
substance on the central nervous system (e.g. cognitive
impairment, impaired judgment, etc.)
A. (5) Negative Symptoms - includes attentional deficits;
social inattentiveness, inattention during testing on the
MSE; and afogia - poverty of speech, poverty of
speech content, increased latency of res(v:>nse
• Major Depressive Episode 296.X
A. (8) Diminished ability to think or concentrate, or
indecisiveness, nearly every day (either by subjective
account oras observed by others)
• Manic/Hypomanic Episode 296.X
B. Distractibility (i.e. attention too easily drawn to
unimportant or irrelevant bXternal stimuli)
• Dysthymic Disorder 300.4
B. (5) Poor concentration or difficulty making decisions
• Posttraumatic Stress Disorder 309.81
D. (3) Difficulty concentrating
• Acute Stress Disorder 308.3
B. (2) A reduction in awareness of the surroundings (e.g.
"being in a daze")
• Generalized Anxiety Disorder 300.02
C. (3) Difficulty concentrating or mind going blank
• Dementia Syndrome of Depression, also called
Depression-Related Cognitive Dysfunction or
Pseudodementia
This is not a DSM-IV diagnosis, although it is often reported
in patients with depression, particularly in severe cases or in
geriatric populations (up to 15% ). Deficits in attention are
variable and memory is most impaired on free recall tests.
Diagnostic Criteria are from the DSM-IV.
©American Psychiatric Association, Washington, D.C. 1994
Reprinted with permission.

326 327
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Why are cognitive lunctions assessetl?
Cognition, in a general sense, refers to information
processing. Cognitive functioning draws on both thinking and
memory. The storage, retrieval and ability to manipulate
information are assessed in this part of the MSE.
Testing specific cognitive components reveals information
about the functioning of cortical and subcortical structures.
1
mpairment .. , cognitive functioning is common in patients
with psychiatric disorders, with estimates as high as 60% in
sorne studies. lmpairments in cognitive function impact on
the quality and reliability of information given by patients. In
the mind/brain dimension, higher cortical functions ("mind")
such as mo0d and perception cannot be adequately
assessed if there is an organic ("brain") dysfunction.
Cognitive assessments also have three important functions:
• Rapidly determining if the patient is delirious or otherwise
in need of urgent medical attention
• Gauging the severity of psychiatric illnesses; for
example, schizophrenia, was formerly called dementia
praecox because of the deteriorating course and early
decline in mental abilities
• Monitoring the effects of psychiatric medications; in
particular, antipsychotics and mood stabilizers can cause
a significant decrease in cognitive performance, though
ali psychotropic medications can have such effects
Cognitive impairment can lead to inadvertent self-injury and
decreased compliance. lt also calls into question the
patient's ability to operate motor vehicles or aircraft, and to
give informed consent for treatment, financia! matters
(including the ability to make a will, called testamentary
capacity), discretion over the release of medica! information,
etc.
328
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Patients can appear cognitively intact for the balance of the
interview and still have deficits when given more specific
tasks. Delirious patients have lucid moments, and if an
interview is brief enough, significant impairment can be
missed. Repeated experiences of this phenomenon can be
summarized as follows: "The MSE always changes when the
patient is reviewed by the consultant psychiatrist."
Other points to keep in mind are:
• Focal impairments and mild dementia are unlikely to be
picked up by the "conversational manner" i" the
interview and other parts of the MSE
• Patients who are hypomanic may seem charming and
gregarious, and their deficits aren't highlighted until they
are asked to perform structured tasks
• Psychotic patients often remain oriented and can appear
intact as long as relatively straightfoiward questions are
asked of them an~ brief answers are accepted
lt is not essential to test completely the cognitive functions of
every patient in every interview. While each section can be
administered at the discretion of the interviewer, the
following guidelines should be kept in mind:
• In exams, ask these questions as thoroughly as possible
(or have good reasons to justify why you didn't)
• Assess all of these areas in initial interviews
• Where cognitive decline is suspected, administer these
tests early and often
The tests listed in this chapter are by no means a complete
evaluation of a patient's cognitive abilities. As demonstrated
on p. 11, the interview and MSE delineate symptoms,
generate a provisional (or working) diagnosis with a list of
differential diagnoses, and form the basis for further testing.
Following certain sections in this chapter, a listof
standardized tests is provided as a guide to ordering
appropriate neurodiagnostic investigations.
329
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Leve/ al Consciousness/Alerlness
Degree of alertness is the first cognitive function that is
assessed, and is essential for higher mental abilities to be
intact. There is a hierarchy of processes that are evaluated,
and unless patients are awake and capable of language, the
remainder of the functions can't be accurately examined.
.. Alertness can be impaired in the following ways:
• Decreased leve! of consciousness
• lnability to screen out extraneous stimuli
• Disinterest in the interview (which can also be a matter of
cooperation)
Many factor:·' can dirninish leve! of consciousness, which
almost always has a medica! cause:
• Delirium
• Substance intoxication (especially sedative-hypnotics,
alcohol, opioids, etc.) or toxic levels of prescription
medication (iatrogenic, deliberate and unintentional)
• Drug-drug interactions, especially in the elderly
• Anticholinergic agents (used to treat parkinsonian side- .
effects ), which can be additive to the anticholinergic side-
effects of most neuroleptic medications
• Strokes, infections, intracranial bleeding, etc.
• Residents who are post-cal!
• Post-ictal states
Brain areas involved: leve! of consciousness/degree of
alertness and orientation are global brain functions involving
many components: various brainstem pathways, reticular
activating system, cingulate gyrus, thalamic nuclei, the
nondominant parietal lobe and frontal lobes.
Standardized Tests: this area doesn't generally require a
formalized assessment; test~ for more subtle impairment
have been developed and are covered in the section on
Attention & Concentration
330
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COGNITIVE FUNCTION/NG & SENSORIUM
I went through an orientation in .high school
and now you're going to test me?
Orientation is tested according to the following parameters:
• Time (time of day, day of week, date, month, year,
season)
• Place (hospital/clinic/office address & floor leve!, town or
city, state, county, country)
• Person (identity of the person and recognition of family
members, friends, health-care providers, etc.)
Orientation is usually lost in the sequen ce of:
time (most common) > place> person (least common;1
Disorientation to Time
Orientation to time can be asked about as follows:
• Mr. K.Y., 1 know you've been very affected by this illness .
Sometimes when people aren't feeling well, they lose
track of sorne of the things happening around them. l'd
like to ask yoq sorne questions to see if you've been
keeping track of time ...
Demented patients usually become disoriented to year first,
so even if they get other parts right, ask about ali of the
parameters of time. Sorne patients are clever enough to look
at their watches, newspapers or the calendaron the wall
befare answering questions about time. You can circumvent
this by asking them not to look at anything first (and block
their view of the wall calendar). lnpatients frequently lose
track of the day of the week and date, which doesn't in itself
indicate a pathological process. To be considered intact,
patients should still know within a day or two what day of the
week it is, and if it is closer to the beginning, middle or end of
the month. Proximity to major holidays can also be inquired
about if appropriate. Reorienting patients to time is not only
helpful, it gives you the chance to test their short-term
memory by repeating these questions a few minutes later.
331
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Disorientation to Place
Ouestions about orientation to place can be asked in an
indirect manner, such as:
• Did you have any trouble finding the clinic today?
• Where did you ... (park your car, get off the bus, etc.)?
• l've never heard of ... (oatient's address), how would 1
get there from the hospital?
• Mr. B.O., if you were at the intersection of Cedar and
Elm, how would (or wood) you get to Oak Street?
·· ·• .What is the nearest main intersection to the hospital?
Delirium is the most common reason for patients to lose
track of where they are and why they are in hospital.
Frequent misinterpretations of location are that they are in a
hotel, jail, laboratory or army barracks (which, at times,
seems to be the majar extended functions of hospitals).
lf patients are unable to give adequate answers to questions
like those above, ascertain where they think they are and
what happens in the building:
.. What tyr. J of building are you in now?
lf they know it is a hospital/clinic/office, ask if they know the
name. lf they don't know this, try asking about:
• What goes on in this building?
• Do you think this is a school, library, bank ... ?
Disorientation to Person
Disoriented patients are rarely so impaired that they lose
track of their own identity. This occurs in severe delirium,
head injuries (especially involving the frontal lobes ),
profound dementia and dissociative disorders. Orientation to
person can be tested at the beginning of the interview by
asking patients to state their full name (as if you needed to
check that yoú were speaking to the right person or had a
profound interest in the person's middle na me). Another
approach is to have patients write their name and the date at
the top of a piece of paper at the start of the interview.
332
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COGNITIVE FUNCTIONING & SENSORIUM
Attention & Concentration
Attention is the ability to direct mental energy when fully
alert. lt is a conscious, willful focusing of cognitive processes
while excluding competing stimuli (such as mood state,
thoughts, perceptions, ecc.). Concentration is the sustained
focus of attention for a period of time. While these terms are
interrelated, they are still evaluated separately. For example,
patients with mild to moderate dementia can attend to tasks
but have deficits in their ability to concentrate. ·
Ouestions about attention and concentration are fairly easy
to introduce into the MSE as patients frequently complain of
difficulties in these areas. When this arises, you have the
option of either performing tests of concentration at that time,
or using the patient's complaints as a segue later in the
interview. For patients who don't specifically complain about
diminished concentration, the topic can be introduced as:
• Ms. Nebular, it is common for people who have the kinds
of problems with ... (repeat presenting d;"~culties) to
have difficulties with their concentration.
lf the patient agrees that she's had trouble, say that you
would like to test this more formally. For patients who do not
endorse such difficulties, you can say something like:
• Ms. Nebular, 1would like to do as thorough an
assessment as possible, and this involves sorne
screening tests to check yo 1 ir level of concentration.
Would you be agreeable to proceeding with this?
Attention is assessed by checking the person's digit span.
This isn't the size of their hands, but the number of numbers
they can recall both forwards and backwards. Introduce this
by saying that you want them to repeat a list of numbers.
Once you've read the list, you can signal this by lowering the
tone of your voice with the last digit. Another method is to
keep your head down and only make contact with the patient
333
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tiRAIN CALIPERS
at the end of the sequence. This gives you the advantage of
being able to write the numbers down as you recite them
(the patient is NOT allowed to write the numbers down).
Read off the numbers so that there are pauses of about one
second between them. Avoid adding emphasis (prosody) to
the numbers as you read them. Numbers that are grouped
too closely or with sorne rhythm can give a spuriously good
result. For example, many companies have developed a
jingle so that their phone numbers are more memorable.
Another consideration is to avoid using numbers in a
sequence (5-6-7-8) or exclusively odd or even numbers.
This test is given for numbers both in a forward and
backward direction. lt may help to start with an example to
illustrate what you're expecting. You can usually start by
testing 4 numbers recited in a forward fashion. Most adults
have digit recall spans of between 5 to 7 numbers forward
and 4 to 6 numbers backward, without errors, and completed
within 30 seconds.
Digit span is impaired in patients with: dementia, delirium,
frontal lobe lesions, head injuries, marked medication side-
effects, anxiety disorders and mania/hypomania. lt is also
unusual to r-we a greater span backwards than forwards,
and this should prompt an investigation for an organic cause.
Concentration is most frequently tested with serial seven
subtractions. Again, patients are not allowed to use any aid
in this test, including counting with their fingers. You can
introduce this as follows:
• l'd like you to start with the number 100 and subtract 7;
then, from this number, subtract 7 and keep going as far
as you can.
lt may be necessary to give the patient an example of what
you want by doing the first subtraction, so that the first effort
he or she makes is attempting 93 - 7.
334
'CoGNITIVE FuNCTIONtNG & SENSORIUM
Alternative numerical tests are:
• Subtracting serial 3's starting at 20
• Serial additions
• Starting at another number using a different inteNal of
subtraction (e.g. 103 - 8)
lt is both a strength and weakness of the serial sevens test
that both concentration and arithmetic ability are tested. For
this reason, other tasks involving concentration over 30 to 60
seconds are sometimes used. For patients who have had
repeated admis.sions to.hospital, the serial sevens test
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
such patients, a different interval of subtraction is warranted.
A more advanceo testinvolves alternating between serial
seven subtractions and reciting the months backwards.
While the serial sevens test is commonly employed, it
suffers from a lack of standardization. There are no uniform
guidelines regarding:
• Time between individual subtractions
• Time for the total test
• How many subtractions should be recorded
• The number of errors allowed
The CoMPREHENs1ve TexrsooK oF PsvcHIATRY, $ecoNo EomoN
(1975) suggests that 30 seconds be allowed between
successive subtractions. A study* done using'subjects with
above-average levels of education had the following findings:
• Only 42% made errorless subtractions
• 19% made one error, 14% made two errors
This test is frequently abandonad by patients lacking at least
high school education and by those with "math phobia" (or, in
the DSM-IV, Mathematics Disorder 315.1.)
* The Serial Sevens Subtraction Test
A Smith, Ph.D.
ArchivesofNeurology, Vol. 17., p. 78, July 1967
335
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BRAIN CAl.IPERS COGNITIVE fUNCTIONING & SENSORIUM

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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CoGN1r1vE FuNcr10NtNG & SENSORIUM

• Registration is the instantaneous recall of new

information; this is also called immediate memory, and
is dependent on alertness and adequate concentration
• Short-term memory is thought to have a capacity of
about 7 items over 20 seconds, though this can be
increased with training; recent memory is sometimes
used synonymously, but is also used to denote events
that occurred i:1 the past few hours. Depending on intact
attentiveness, concentration and registration, this
· information is either discarded or committed to long-term
memory.
• Long-term memory has no demonstrable limits of
storage and provides the fund of knowledge for
patients; this is also called remate memory or delayed
recall; this type of memory remains quite stable over
time and is the type most affected by forms of amnesia.
Long-term memory has two subtypes:
Other terms associated with these types of memory are:
Declarative Procedural
explicit implicit
working reference
elaboration integration
conscious recollection automatic skills or habits
Declarative memory is further subdivided into:
• Episodic memory, which involves the recall of events
and the context in which they occurred (where, when,
etc.); this type of memory is personalized and also called
autobiographical; an example of episodic memory would
be a first beer, first kiss or first driving lesson
• Semantic memory, which refers to general knowledge
that is not remembered in a specific context; e.g. many
people know the colors that make up the spectrum of
light but wouldn't. know where and when this was learned

Amnesia is the inability to recall learned material or past

experiences in a person who has no impairment of attention.
This is further divided into two types:
• Retrograde amnesia is the loss ofmemories that were
declarative procedural made prior toan event (e.g. accident, ECT); this is also
called circumscribed or backward amnesia
~ ~ ~ ~ • Anterograde amnesia is the inability to make memories

~~ ~~
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
The most common test of verbal rnernory involves word
recall. Thi~ ;s used to test immediate memory (registration)
and short-term memory (recent rnemory). The patient is
given a list of three to five words and asked to repeat them
approximately five minutes later.
The words chosen should have the following characteristics:
8 · They should be unrelated to each other (e.g. don't use
red, white & blue; sax, drums & rock 'n rol!)
e They should not be something in the room or shown to
the patient (e.g. a set of keys, coins, chairs, light bulbs)
• They should be unrelated to the person's vocation or
interests (e.g. don't ask a mechanic to remember a lug
nut, cam shaft and exhaust manifold)
Sorne popular combinations involve a color, quality and item
not in the room (green, honesty, postcard). This test is
presented to the patient as follows:
"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
you've learned thern, and then l'm going to ask you to repeat them in
a few minutes. The words are bench press, dumbbe/I f/y and arm-curl.
Can you please repeat thern far me now? · intact registration anda variable short-term memory. Testing
Of course, if Arnold was a body-builder, these wouldn't be
good choices of items for him to rernember. lf patients are
notable to register these items, repeat them once. lf they
have trouble a second time, this may indicate a cognitive
deficit, and further testing of concentration is warranted.
Registration tests the same cognitive abilities as digit span.
There is no clear rationale for why numbers are used in one
area and words in another.
Sorne clinicians use four or five words for this test. Again,
there is no standard of what is considered average. Missing
one itern out of four or five is less significant than missing
340
* u • ti' ~· ~· tIJ. 11r m, 11t m •r IJ' 1/1 "-' · ~
COGNITIVE FUNCTIONING & SENSORIUM
one out of three. You can vary the number of words used to
suit the educational status, degree of alertness and level of
cooperation of the patient being interviewed.
lf a patient cannot rernember all of the items, it is a cornrnon
practice to prompt thern. This can be done initially by stating
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
words which include the missing item(s). This provides
patients with more help than listing the category, failing this
prompt may indicate a more serious impairment. Make sure
you don't mention the missing '.tem too close to the
beginning of the list, and don't add any inflection to your
voice far the correct word. Again, there is no established
standard with which to assess performance of short-term
memory. lf the patient requires prompting ora word list,
record this as such.
Keepirig an eye on the time is important. Report the duration
as accurately as possible between registration and testing.
Typically, this is recorded as, "Mr. T. was able to register ali
three items and recall two of three at about four minutes'
time. He was able to recall the third with prompting. Patients
with Korsakoff Syndrome have anterograde amnesia, but
such patients too quickly will miss this important deficit.
This test is often included at the beginning of the cognitive
evaluation. In many interviews (such as the Psychiatry &
Neurology Board exams) there are only thirty minutes
allotted for the whole exam, and five minutes for the entire
MSE may be all that is available. Frequently, interviewers
forget to ask patients to recall these items. lt is prudent to get
in the habit of writing them down, because:
• This ensures you won't forget what they were
• You get a visual cue to ask the patient to repeat them
lt is embarrassing when patients ask (invariably at the end of
an exam) if you still want them to repeat the thme items.
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:
• A name, address and zip code of a fictitious person
• A short "story" of three to four sentences having about 25
points of information; an intact response involves
remembering in the vicinity of 15 details
e Word lists of about 15 items which can be related or
unrelated; intact recall is considered to be somewhere in
the vicir ·ty of 50% of the words, which declines as age
increases; a standardized test assessing this is the Rey
·Auditory-Verbal Learning Test (RAVLT)
Short-term memory can also be assessed by using visual
design reproduction tests. One such test involves copying
a design from memory that was placed in front of the patient
for O - 30 seconds. These designs are usually an
amalgamation of severa! geometric shapes.
A variation on this is to give patients the chance to study a
certain number of shapes, and then select them from a
larger group presented for a fíxed period of time (e.g. 30
seconds) later. A standardized
Long-term memory can be assessed in terms of recent
events (hours to days) or remate (years to decades). This
can be tested in a practicar manner in interviews by giving
patients questions to which you can verify the answer. For
example, the following information is usually readily
available:
• Date of birth
• Address, zip code and phone number
o Previous appointments or hospitalizations
• Medication type and dosage
• Recollection of your name (as long as you gave it)
Remate memory can be distingui·shed from fund of
knowledge by testing for personal details. Various other
forms of personal information can be elicited, but need to be
corroborated to exclude the po&sibility of confabulation (the
falsifícation of memory in response to questions ).
Brain areas involved in memory:
• Verbal memory dominant temporal lobe
• 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
lnte//igence is a mu/ti-faceted group of mental abi/ities
invo/ving:
• The assimi/ation and reca// of factual information
• logical reasoning
• Problem-solving skil/s
• The use of abstraction, genera/ization and symbolization
• lntegration of parts into a who/e
Three distinct types of inte//igence have been described:
mechanical, abstract and socia/. lnte//igence is usual/y
reported asan intelligence quotient (l.Q.)
Knowledge Base/fund of lnlormation
Another component of assessing cognitive function is to test
a patient's knowledge base. This can be estimated by
incidental factors during the interview or may need to be
more fully explored if cognitive deficits are discovered in
other areas of testing. Head injuries and dernentia are the
most cornmon causes of permanent knowledge deficits. The
pseudodementia of depression can give the appearanca of
impaired cognitive functioning because patients tend to
answer with "I don't know" responses. When pressed to
respond, they often can, if sufficient time is allowed.

l.Q. = mental age Common questions involve:

X 100
chronologica/ age
Mental age is a rneasure of inte//ectua/ leve/. The most
widely used and best standardized intelligence test is the
Wechsler Adult lntelligence Sea/e (WAIS). The current
version is the WAIS-R (R far revised). Because
chronologica/ age has such a bearing on IQ, there are
separa te versior1s for schoo/children (a ges 5 to 15) and
preschoolers (ages 4 to 6). By definition, a normal IQ is 100,
and mental retardation is defined as an IQ less than 70.
Superior intel/igence is above 120.
The WAIS-R consists of six verbal subtests and five
nonverba/ subtests. The Kent Test consists of four probJem-
solving and six knowledge questions that can be given in
interviews and yield an approximate leve/ of intel/igence.
lnte//igence is one dimension of cognitive functioning. lt can
be gauged in interviews by:
• Degree of insight, judgment and abstract thinking
• Fund of knowledge
• Vocabu/ary (considered the best single indicator)
• Level of education, vocation, interests & hobbies
• Naming political figures
• Significant dates (e.g. W.W. 1, W.W. 11, Civil War, etc.)
• Capital cities, neighboring states, etc.
This information is "common knowledge" and doesn't have to
involve the personal significance of the questions used to
test remo te memory.
Capacity to Reatl and Write
Assessment of these basic functions is often omitted in initial
interviews. llliteracy is present atan unfortunately high rate
and can be masked by people with good verbal skills. lt is
common for illiterate patients to be able to sign their narnes,
which is often ali that is required in clinical settings. As
described in the orientation section, having patients write
down their names and the date and {later) follow a simple
written command at least screens for deficits in these areas.
lt is also useful to have patients write a sentence on the
page. This is part of the Folstein Mini-Mental Status Exam
{covered in the next chapter) and can provide important
information about patients as they often succinctly express
their presenting problems when writing these sentences.

344
345
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BRAIN CALIPERS
Ahstraction/Concrete Thinking
Abstrae! thinking is a complex mental ability. lt requires the
ability to think in a multidimensional manner by keeping ali
the characteristics of a "mental set" in mind and integrating
th2 nuances into a new understanding. In interviews,
patients demonstrate abstract thinking when they can
appreciate all the meanings of an item, list similarities and
differences, use logical reasoning, and grasp the "whole
picture."
.A.bstract thinking is made possible by the integration of many
brain structures. The main areas involved are:
• Frontal lobes - attention, executive functioning,
organizing, integration of other brain areas
• Temporal & parietal lobes - association areas,
language
• Lirnbic s·,stem - memory and emotional tone
The dominant hemisphere regulates the language aspect,
while the nondominant hemisphere provides an integration of
other elements (e.g. spatial, emotional, graphic) into a global
understanding.
The opposite of abstraction is concrete thinking. This is a
literal, unimaginative, narrow understanding of a concept. lt
is also called one-dimensional thinking and is often a
feature of lower intelligence. Examples are as follows:
• Why is property downtown so expensive?
abstract thinking - high demand, limited amount available
concrete thinking - beca use they charge a lot for it
• Whiskey kills more people than bullets.
abstract - alcohol is deadlier to more people than gunfire
concrete - bullets don't drink
• She's got a head on her shoulders
abstract - she has common sense and thinks befare acting
concrete - she has no neck
346
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CoGNITIVE FuNCTIONING & SENSORWM
AbstracUConcrete Thinking can be tested in the following
ways:
• Similarities & differences • Proverbs
The similarities test involves asking patients to compare
two objects and list as many common qualities as they can. •
For example:
• What are the similarities between a chair and a desk
abstract - both furniture, things can be put on them, etc.
concrete - tour legs, made of wood, touch the floor, etc.
Abstraction involves function instead of form and an ability to
generalization from particulars. The differences test
requires patients to consider similar objects and list their
distinguishing features (e.g. apple vs. orange; wine goblet
vs. coffee mug, etc.)
Proverb interpretation is another commonly used method
to test abstraction. Proverbs are "common t .hs" or
generalizations born of experience. A concrete interpretation
misses the "spirit" or message contained in the saying:
• The golden hammer opens an iron door.
abstract - the right touch is all that is needed
concrete - you'd have to hit it awfully hard !
Sorne clinicians do not consider proverbs a good test of
abstraction because they are ~~o culturally specific.
Abstraction is dependent on:
• lntelligence
• Degree of insight and judgment
• Education
Abstracting ability is reported to be particularly diminished in
schizophrenia. However, low intelligence, irrespective of any
disease process, has been suggested as the central cause
of concrete thinking. Uncooperative patients can pick words
out of context to obscure pertinent issues or resist the
assessment process.
347
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M1N \.ALIPn's
Visuospatial Ability
The ability to perform visuospatial functions is an essential
part of performing daily activities. The ability to navigate, use
machinery and perceive the environment all depend on intact
visuospatial functions.
This is tested in the MSE by assessing constructional
ability. Patients are asked to draw a figure (usually
geometric) on a piece of paper, which demonstrates the
integration of several functions:
• Motor coordination
• Praxis (performing and action)
• Dominant hemisphere function (mainly parietal) for the
details of the design; lesions in this area cause drawings
to be correct spatially but lacking detail
• Nondominant hemisphere function (mainly parietal) for
the overall integration of the design; lesions in this area
affect the spatial orientation of the components, which
become scattered, duplicated or fragmented
The Mini-Mental Status Examination (MMSE)
uses interlocking pentagons for this test.
Trie aspects ' · volved in scoring the
drawing are preserving: (i) the sides,
(ii) the angles & (iii) interlocking corners.
A simpler test can comprise interlocking circles or squares.
Another common test is to have patients draw a cube
showing the correct three-dimensional orientation.
The Rey-Osterreith Complex Figure Test is appropriately
named. This test has a Form A and B that involve the
reproduction of a detailed geometric figure. This is done
initially by copying the figure, and then reproducing it from
memory. Scoring keys are available and normative data
have been established.
348
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CoGN1r1vE FuNcnoNING & SENSORIUM
Clock Drawing
The clock drawing test has been used extensively as a
means of assessing visuospatial ability and screening for
cognitive impairment (primarily forms of dementia).
The patient is usually given a blank sheet of paper, though
sorne clinicians advocate drawing the circle or using forms
with preprinted circles on them. lf the circle is supplied for
patients, it should be relatively large (4 in./10 cm) because
patients may be able to spuriously fit numbers correctly into
a smaller area. The patient is asked to draw a complete
clock face and indicate a certain time. Various "times" can be
used, but the hands on the face should not overlap. Far
example, common times are 10 to 2, 20 to 4 and 10 after 10;
ones that are not suitable are 6:30, 12:00, 3:15 or 9:45.
There are many scoring schemes in existence (see
reference list below). Gene rally, dock drawings are scored
for: completeness (all the numbers), correctness (numbers in
the proper place and sequence) and orientation (numbers on
both sides and evenly spaced).
References for Scoring Clock Drawings
O. Spreen & E. Strauss
A Compendlum of Neúropsychological Tests
Oxford University Press, New York, p. 280, 1991
Development of Scoring Criteria for the Clock Drawing Task in
Alzheimer's Disease
M. Mendez, T. Ala & K Underwood
Journal of the American Geriatric Society, Vol. 40, p. 1095-1099, 1992
The Ten Point Clock Test: A Quick Screen and Grading Method of
Cognitiva lmpairment in Medical ar.d Surglcal Patients
P. Manos & R. Wu
lnt'I Joumal of Psychiatry in Medicine, Vol. 24(3), p. 229-244, 1994
Comparlson of clock drawlng with Mini Mental State Examlnatlon as a
screenlng test In elderly acute hospital admlssion
J. Dealh, A. Douglas & R. Kennedy
Postgraduate Medica/ Journal, Vol. (69), p. 696-700, 1993
349
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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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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

What is the Mini-Mental Status ixam?

The Mini-Mental Status Exam (MMSE} is a structured clinical
assessment of cognitive functioning. lt was published by Dr.
M. Folstein* in 1975 and has been referred to as "The
Folstein Test" or the "Folstein MMSE." The MMSE provides
a quantified assessment of various dimensions of cognitive
functioning. The original article does not describe time limits
far giving this test. The usual testing time is between three to
five minutes.

The test is scored out of a maximum of thirty points. An

average score for patients without cognitive impairment is
twenty-eight. Seores of twenty-four or less indicate than an
abnormality is present, which is usually dementia or delirium.

The MMSE is one of severa! screening tests far cognitive

impairment. Others are listed after the section on the MMSE.

The MMSE is reprinted on the next two pages. Following this

are the guidelines suggested by the authors for
·~ administering the test.

* M. Folstein, S. Folstein & P. McHugh

Mini-Mental State: A Practica! Method for Grading the Cognitive
State of Patients for the Clinician
Joumal of Psychiatric Research 12, p.189-198, 1975
Reprinted with permission.

356 357
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MMSE & ScREENING TEsrs

The Folstein Mini-Mental Status Exam Se ore

• Write a sentence:
Orientation Score
• What is !he - (day) (date) (month) (season) (year)? 15
• Where you are now? (building) (floor) (town)
(state) (country) /5

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

kttention & Calculation

Copy the following diagram:
• Serial ?'s Test up to 5 subtractions; alternatively
spell WORLD backwards (D - L - R - O - W) 15

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

• Ask the patient to follow these commands:

Take this piece of paper in your right hand (1 pt.)
Fold it in half (1 pt.)
Place it on the floor ( 1 pt.) Total Score
13

• Read and follow this command /30

CLOSE YOUR EYES /1

358
359
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lnstructions lar Administering the MMSE
Orientation
• Ask for the date, then ask specifically for parts omitted (e.g. season,
ye ar)
• Ask patients to tell you exactly where they are now, then ask for the
parts omitted (state, country, etc.)
Registration
• Ask if you may test memory, then list 3 unrelated objects in a clear
voice with about 1 second between each item. After giving the list
once, ask the patient to repeat this lis! and score 1 point for each item
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
are unable to repeat these items after 6 trials, they cannot be
rr.eaningfully tested.
Attention & Concentration
• 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
answers. lf patients can't or won't perform this task, ask them to spell
the word "world" backwards.
The score is the number of letters in corree! order, e.g., dlrow = 5,
dlorw = 3, dolrn·-= 2, dolwr = 1, world =O
F.ecall
• Ask patients to recall the 3 words you previously asked them to
remember. Score 0-3.
Language
• Naming: Show patients a wrist watch and ask what it is. Repeat for a
pen or pencil. Score 0-2.
• Repetition: Ask the patient to repeat the sentence after you. Allow
only one tria!. Score O or 1.
• 3-Stage command: Use blank paper and repeat the command. Score
1 point for each part correctly executed.
• Reading: On a blank piece of paper print the sentence "Clase your
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.
• Writing: Give patients a blank piece of paper and ask them to write a
sentence for you. Do not dictate a sentence, it is to be written
spontaneously. lt must contain a subject and verb and be sensible.
Corree! grammar and punctuation aren't necessary.
Copying
On a clean piece of paper, draw intersecting pentagons, each side
about 1 in., and the patient to copy it exactly as it is. All 10 angles
must be present and the pentagons must intersect to score 1 point
Tremar and rotation are ignored.
360
"°'
Critique of the MMSE
The fallowing scenario plays itself out over and over:
lt is the first day of a rotation in psychiatry for a group of
clinical clerks. One of thf'.: keener students grabs a chart to
review the presenting history befare seeing the patient After
having sorne idea what to ask about, she tries to recall the
format of a psychiatric interview. "Not much different than a
standard interview," she muses, "except for this weird thíng
called the mental status exam." Somewhere, somehow she
comes across a copy of the MMSE, and her confusion
disappears. She presents the case thoroughly, and when it
comes time to present the mental status. she smiles and
says, "On the mental status exam. the patient scored 26."
The majar pitfall of the MMSE is that it is NOT the same as a
complete mental status exam. The similarity in names is
certainly part of the confusion. The MMSE was designed to
be a r?pid screening instrument far cognitive i111pairment,
and has three main clinical applications:
• lt tests features that are often omitted in traditional
mental status exams, such as reading, writing, copying,
repetition, following commands, and detailed orientation
• The test score can serve as a screening tool far
dementia and delirium (i.e. a score less than 24 indicates
impaírment)
• lt provides a quantitative score to follow the day-to-day
progress of a patient in hospital
The MMSE does not include most of the features assessed
by a thorough MSE. While it can certainly be a useful
addition to the MSE, it is by no means a replacement. The
MMSE is the most popular cognitive screening instrument
and has a large body of literature supporting its use. The
validity of MMSE seores has been demonstrated through
positive correlations with performance on intelligence tests
and with deficits found on brain imaging.
361
¡ll¡r_~ ... ..... ~·
111...l ll.i
BRAIN CALIPERS
llJ ....... .u. ll.I la:,¡: ... .. ... .... .., Lt L.í L. L. ¡,.. ~ LI ~ ~ ~
MMSE &
~ ~ ~ ~
ScREENING TEsrs
~· ~

The MMSE is more specific than it is sensitive. An abnormal

score is highly suggestive of cognitive impairment, though
patients with mild dementia or delirium often score higher
than twenty-five. Patients with little formal education may
have spuriously low seores. Another pitfall concerns patients
who develop dementia but had a superior leve! of
intelligence. Such patients continue to have normal seores
on the MMSE despite their developing deficits.
Studies have shown the MMSE to have a high reliability,
both between interviewers and on successive days with the
same interviewer.
Molloy* has pointed out factors that can affect the reliability
ofthe MMSE:
• Brief guidelines allow the scoring to vary between raters
o Questions may have to be worded ditferently for
outpatients, which can affect responses and scoring
.,. Scoring of the interlocking pentagons is subjective
• Patients' leve! of education affects the results
• The lack of a time limit may have a bearing on scoring
• Spelling "world" backwards has been repeatedly found to
be easier to perform than serial 7 subtractions, despite
the equivalence in scoring
., There ar'. no guidelines far scoring "near misses," e.g.
being wrong by one day, especially at the beginning of a
new month
Molloy has developed a Standardized Mini-Mental Status
Exam with more detailed guidelines far execution and
scoring (he refers to the original as the Traditional MMSE).
The standardized version has shown greater inter-rater and
intra-rater reliability. lt has also been found to be faster to
administer.
*D. Molloy, E. Alemayehu & R. Roberts
Reliability of a Standard Mini-Mental State Examination
Compared With the Traditional Mini-Mental State Examination
American Journa/ of Psychiatry, Vol. 148 (1 ). p. 102-105, 1991
Referentes lar Other Screening Tests
G. Blessed, B. Tomlinson & M. Roth
The association between quantitative measures of dementia and of senile
changes in the cerebral gray matter of elderly subjects
British Joumal of Psychiatry, Vol. 114, p. 797, 1968
G. McDougall
A Review of Screening lnstruments for Assessing Cognition and Mental
Status in Older Adults
Nurse Practitioner, Vol. 15(11 ). p. í 8, Nov. 1990
J. Morris, A. Heyman & R. Mohs
The Consortium to Establish a Registry for Alzheimer's Dlsease (CERAD):
Part 1, Clinical and neuropsychological assessment of Alzheimer's
disease.
Neuro/ogy, Vol. 39a, 1989
D. Kaufman & L. Zun
A Quantifiable, Brief Mental Status Examination for Emergency Patients
The Joumal of Emergency Medicine, Vol. 13(4), p. 449, 1995
B. Reisberg, S. Ferris & M. De Leon
The Global Deterioration Scale (GDS) for assessment of primary
degenerative dementia
American Joumal of Psychiatry, Vol. 139, p.1136, 1982
Rosen, et al
A new rating scale for Alzheimer's disease
American Joumal of Psychiatry, Vol. 141, p.1356, 1984
R. Shader, J. Harmatz & C. Salzman
A New Scale for Clinical Assessment in Geriatric Populations: Sandoz
Clinical Assessment - Geriatric (SCAG)
Joumal of the American Geriatric Society, Vol. 22, p. 107, 1974
D. Towle, G. Wilcox & D. Surmon
The Kew Test - A Study of Reliabllity and Validity
Joumal of Experimental Gerontology, Vol 9(4), p. 245-256, 1987
M. Zaudig, J .. Mittelhammer, W. Hiller, et al
SIDAM -A Structured lnterview for the Diagnosis of Dementia of the
Alzheimer Type, Multi-lnfarct Dementia, and Dementias of Other Aetiology
according to ICD-10 and DSM-111-R
Psychologica/ Medicine, Vol. 21, p. 225, 1991

362 363
 /
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1
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No TES fuNNY SruFF

Classilication by Pentagon Drawing

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
11'.l w .a
1 .. 1
11&.i
1
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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

The MSE is reported at the same point in the presentation

as would the physical exam in other areas of medicine.
Depending on the number of findings, the MSE usually takes
between one and three minutes to present.

Many clinicians make a demarcation from the history by

using an introductory statement such as:
• "The mental status exam revealed ... "
• "Evaluation of the person's mental status showed ... "
• "I will now describe this patient's mental status exam ... "

The presentation can be structured by introducing each

section of the MSE before stating the findings. This may be
especially important in examination settings a~ a means of
demonstrating familiarity with the MSE. Anc ;1er common
practice is to provide a synopsis of the patient's problems at
the beginning of the MSE. The following five pages contain
sample MSE reports presented in various formats.

366 367

)
~trt ~ *' k,N*. gr alr' t
UP
afri k 11~ ~d ~ u~/ º"' olw r1~, &'.1-· ~~ Lr, ir i.'--' ü · a~/ */ 11~ ~ ~,J v "j 1r· Ir
P. S. is a 33-year-old, single. unemployed male brought to the
emergency department after accosting patrons for cigarettes in a
shopping center.
• Appearance: tattered jeans. soiled sneakers and a sweater which
seemed '· o heavy for the warm weather; unshaven with
unwashed hair and had tobacco-stains on his hands
• Behavior: restless during the interview, stood up twice to look in
the ashtray, but was able to be directed back to his seat; fidgeted
constantly with his lighter and appeared distracted
• "Cooperation: moderately interested in !he interview; information
limited but considered reliable; eye contact was intermittent
• Speech: spontaneous and fluent, spoke in a low voice and had
occasional difficulty naming people, places, and events
• Thought Content: answered questions grudgingly with little
elaboration; spontaneously spoke about the injustices he'd
suffered by "!he system" and specified how today's events were
part of a scheme to persecute him; this belief was strongly held
throughout !he interview and unwavering in intensity
• Thought Process: his thoughts were logically connected with a
restricted flow of ideas and one episode of thought derailment
• Affect & Mood: his emotional expression ranged from mildly
sullen to moderately irritable; he became hostile when he was told
he would have to remain in !he hospital; he described his mood
as pissed off and reported it as a one out of ten
• Perception: experienced continua!, clearly formed auditory
hallucinations throughout the interview which told him he was
stupid to get detained at the hospital and he should find a way to
· get released immediately; he did not report perceptual
disturbances in other sensory modalities
• Suicide/Homicide: no thoughts or plans for self-harm; he wishes
to assault one of the officers who brought him in
• lnsight & Judgment: impaired, denies he was bothering anyone or
that has any need for hospitalization or treatment
• Cognition:
alert and fully conscious throughout the interview
oriented to person, day, date, month, year, season and place
able to register three objects on the second attempt and recall
two of them four minutes later (despite prompting, he couldn't
recall the third); remate memory was impaired for historical details
obtained from hospital record (dates and events)
digit span five forward, four backward; attempted two serial seven
subtractions, both were incorrect (97, 87), then stopped this task
declined to answer questions testing general knowledge,
abstraction ability, proverb interpretation or hypothetical situations
368
REPORTING THE MSE
N. P. is a 50-year-old male real-estate agent who presented to the
clinic seeking counseling to deal with the loss of his dog, business,
and mistress.
Mr. P. is an immaculately groomed man who appears younger than
his stated age. Of particular note were his gold ring'-- .ailored suit and
manicured nails. He initially sat in the chair behind me desk
(designated far the interviewer) but was unruffled when asked to
move. He sat comtortably throughout the interview and spontaneously
preened his hair and adjusted his tie on severa! occasions. He
emphasized his speech with dramatic gestures of his hands.
He spoke spontaneously and made a special effort ·to enunciate his
words clearly. As he talked about his losses, there were pauses of up
to twenty seconds befare answerinq questions. There was a good
deal ot prosodic variation to his speech and he had an engaging
manner of speaking. He included a considerable amount ot detail to
emphasize a limited number ot points. He seemed appreciative of the
chance to speak and át times needed redirection to matters relevan!
to the interview. He focused principally on his los ses and how he felt
betrayed by everyone and everything in his life. In particular, he
thought he had been too trusting and too generous with those around
him. He denied thinking there was a conspiracy against him. His
emotions were intense, encompassed a range from tears to laughter,
and were appropriate to the tapie being discussed. His mood was
predominantly described as "hopeless" and he thoughl this was one of
the lowest times ot his lite. He had briet episodes ot hearing his
mistress whisper his name when she wasn't in the room, but denied
other experiences consistent with hallucinations or illusions. There
were no thoughts ot harm to others, but he had fleeting suicida!
wishes. He understood he wouldn't always teel this upset and had
hope for his tuture. He was willing to attend weekly appointments and
did not teel he would act on this thoughts ot lite not being worth living.
Orientation was not tormally tested as Mr. P. found the clinic, had his
watch set properly, and carried a newspaper. He related historical
information in considerable detail. Despite his complaints ot being
unable to concentrate, he was able to register five items and recall
them at about tour minutes' time. He could recall seven digits forward
and five backward. Serial sevens were correct to five subtractions. He
was able toread, write, and copy a diagram without difficulty. He had
an overly personal interpretation ot proverbs, and related them back to
wisdom that he should have possessed. He had an in-depth
knowledge ot current events and historical information.
369
 "
:.\!51! J lllJ kJ "--1=1Ll~~-1==1lt.'1~~ ...........1---·1
. 1 ' ! ' 1
··-
1
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a.1
Ms. B. A. is an 88-year-old woman referred to the psychiatric
""' aJ
consolation-liaison service due to recent behavioral problerns after
suffering a stroke and suspected alcohol withdrawal.
Appearance, Behavior & Cooperation - unkempt, slightly obese
woman dressed in a hospital gown with food stains on the front, hair
was dyed brown severa! weeks ago, prominent right facial droop and
right hemiparesis; she looked at areas in the room where there was
nothing occurring and was talking out loud prior to the introduction of
the interviewers; picked in the air al unseen objects and then knocked
over the items on her bedside table, struggled continuously against
her waist rest 'int; had a wide-arnplitude resting tremaron her left
side; she was unable to focus on the interview and did not appear to
comprehend the reason for the consult or that there was anything
amiss; her leve! of consciousness varied from alert at the beginning of
the interview to somnolent (but still rousable) at the end.
Speech, Thought & Perception - nonfluent speech, did not appear
to comprehend many of the statements made to her and could not
repeat them when asked; expressed speech was dysarthric, halting
and had an irregular rhythm; she spoke at times in stock phrases,
examples of which wer<J:
"Check's in the mail."
"No thanks."
"1'11 see"
Al other times, longer phrases were out of grammatical sequence and
contained mainly verbs and nouns; she seemed impervious to the
questions put to her and made replies that were not relevan! to what
was asked; she appeared to be experiencing perceptual disturbances
that contained at leas! visual and auditory hallucinations (based on her
reaction to nonexistent stimuli); unable to ascertain information about
other experiences.
Affect & Mood - labile with considerable intensity; she was startled
by the appearance of the interviewers and began to cry; later was
terrified by the hallucinatory experiences, bu! after knocking her
bedside items on the floor, she was calm enough to drift off to sleep.
lnsight & Judgment - not testable at the time of the interview.
Cognitive Functions - notable to answer any questions regarding
orientation despite wall calendar in clear view; responses to other
questions were either nonsensical or too garbled to understand.
370
kJ
a.J LJ ~ Lj La a1 ..J ..; ...1 ra; a). 91'
'EPORTING THE
M. E. is a 29-year-old college student brought to the hospital by her
ffsf "
roornrnate. Despite having final exams, M.E. had been busying herself
with a wide nurnber of activilies unrelated to her studies.
Ms. M. E. 's appearance was that of a woman who looked her stated
age and was dressed in mismatched clothes, consisting of a suit
jacket, leotards and hiking boots. In the interview, her behavior
involved refusing to be seated, and speaking only if she was allowed
to walk around the room. She rummaged through her purse at the
beginning of the interview and then wrote out severa! lisis for the
remainder of lhe time. She was superficially cooperative with the
assessment and said she'd talk as long as she co;, "write her lists
and if the interview didn't last more than ten minutes. She was
considered reliable, but biased towards minimizing her activities.
Her speech was loud, rapid and pressured, but remained
understandable and had proper syntax. Prosody was exaggerated,
regardless of the content. Thought process involved connections
that were generally logical. On two occasions she was unable to
repeat the questions posed to her, orto relate the connection between
them and what she was just sayin:;: The content of her thoughts had
to do with her plans to start at a senior management level in the
Fortune 500 company of her choice after graduation. She had
developed powerful insights inlo the business world and offered the
interviewer an autographed copy of her term paper.
Her affect was forceful and exuberant, and remained consistently high
for the interview. She described her mood as energetic and that she'd
never felt better, and gave herself a nine out of ten (she says she'd be
a ten after graduation). She denied any perceptual problems. She
stated she felt well and couldn't see why others were concerned. On
this basis, her insight and judgment were both deemed irnpaired.
Testing of her cognitive functions revealed that she was completely
oriented. She was able to register tour items and recalled them at
around five minutes. However, she could nol recite the interviewer's
name or her exam schedule, so her long-term memory was
considered impaired. Her attention and concentration were intact for
six numbers forward and four backward. She performed three serial
subtractions correctly and then told a story about the number
seventy-nine. She was able to enumerate a considerable list of
similarities and differences, many of which demonstrated a high
level of abstraction. Her knowledge base was consisten! with her
leve! of education and her intelligence seemed above average.
371
~, ¿,, &1¡j ~/ ~, ~: ~( ~/ 11:( ~( ~, 11( t./ Q / 1:1' ll" O. ir er·· ~ ir' ti"' fr lft E> 11Y~' lif' F' mY'" Ir) •r) ·~·/
BRA/N CALIPERS REPORT/NG THE MSE

Mrs. O.E. is a 47-year-old separated woman who is employed as a

professional cello player. After missing her third rehearsal, she was Mental "Status Symbols"
brought to the clinic after being found in the basement of her home.

.. 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
~
lli;j s
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
&-." J la.A llu iliaJ ..a..:/
BRAIN CAilPERS
lill:JI .._; lllJ 111.J flJ aJ &4 IJ ... IU
" .:.. u LI ~ ~ ~ ü -.J-·m_f!i_Ji_'1_~- J-"-r
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

,1.;,:J.
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, 1· / •-/ ra,. ·1a:· · i · d d · ~· d' lt oj ij·Y u· ,r. 1t1 · ·
~~

Culture-Bound Syndromes 37,51, 189 Repression 102, 233, 241

Dangerousness 242,243 Symbolization 202
Delirium 12,50,51,53, 94, 128, 130, Turning against the self 233
113, 127, 142, 147, 148, 150, Undoing 195
154, 157,257,280,326 Ego Syntonicity 190
Delusional Atmosphere/Mood 177 Electroconvulsive Therapy (ECT) 57
Delusional Disorder 12, 91, 172, 280 Endogenous Depression 268
Delusional lntuition 177 Exhibitionism 46
Delusional Mood 177 Expressed Emotion 301
Delusional Perception 177, 284 Expressive Language Disorder 112, 142
.Oelusions 79, 176 - 81, 188, 189, 191 Extrapyramidal Symptoms (EPS) 63-68
Types 182 - 7 Eye Contad 91 - 92
Dementia 29, 50, 53, 90, 113, 127, 128, Facial Expression 52, 70, 79
130, 142, 147, 148, 150, 154, Factitious Disorder 90, 99, 103, 281
155, 157 - 59, 257, 326, 327 Fight Response 217. 240
Dementia Syndrome of Depression - see Pseudodementia Flight of Ideas 144, 149, 150, 152, 154, 160-1
Derealization 293 First Rank Symptoms 187, 284, 285, 300
Depersonalization 281, 293 Flight Response 217, 240
Depression - See Major Depressive Episode Fragmentation of thought 144, 154, 157
Diagnostic Scales 14 Frotteurism 46
Differences Test 347 Ganser's Syndrome 102
Digit Span 333 Gender ldentity Disorder 26
üissociative States 54, 102, 332 Generalized Anxiety Disorder 46,267,327
Oisturbed Interpersonal Relationships (DIRs) Grimacing 56
215 - 17 Habits & Mannerisms 45, 76
Driveling 156, 163 Hallucinations 79, 91, 94, 282 - 91
Dysarthria 118, 119, 121, 144, 156 Head Injuries/Trauma 51,55,65
Dysgraphia - see Agraphia Hygiene & Grooming 30, 79
Dyslexia 118 Hyperactivity 51
Dysmegalopsia 294 Hypochondriasis 173, 186, 1°", 281
uyssomnia 51 Hypomania - See Mania
Dysthymic Disorder 130,254,264,327 Hypothesis Generation 14, 18,37
Dystonia 47,63,64,68, 72,81, 156 Hysterical Misapperception 302
Treatment 64 lllusions 204, 292
Echolalia 58, 74, 117, 122, 124, 158 lncoherence 144, 156
Echopraxia 57,58, 73 lnflection of speech 132
Ego Defenses 201,313-15 lnformed Consent 72,311,328
Oenial 102,233,241 lnsight 175, 180, 192, 198, 296, 309 -
Displacement 195,202,241 312
Oistortion 233 lntegration of History & MSE 10, 11
ldentification 227 lntelligence 344
lsolation of Affect 195 lntermittent Explosive Disorder 212,255
Projection 233, 241 lnternalized Objects 301
Projective ldentification 184 lnterviewing 15, 19
Reaction Formation 195,233 Jargon 120, 123, 144, 156-58, 163
Regression 241 Jewelry & Cosmetic Use 32

376 377
 & ~
- 19 -Ir

8. }). ,!'a ~
·~ .'.1
<lU .e'.!J smwrr-=t~z=-=~d·~~-==-!J~--~--·rl¡ •'~ -~ .&j _a:J .t1 ~ aüi h a'.'J aJ ..it ~ Al; ,J.!J. .!j ..llJ
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

Other Protlucts Brain Calipers

Presenfation Sr~
Ordering lnformation
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382 383
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BRAIN CALIPERS
OrHER RAPID PSYCHLER PRooucrs

"This is a unique new book on the basics of personality

disorders that is presented in a humorous style. This primer
DISORDERED is funny and well written and would be a useful teaching tool
for trainees ... The book is filled with amusing illustrations,
caricatures, and even media examples of the various
PERSONALITIES personality traits, which is a good way to remember these
disorders. Assessment: This is an excellent, humorous, and
useful teaching tool intended far trainees. This is definitely a
A PRIMER fun way to learn this material."
Doody's Review

"Disordered Personalities is both informative and fun to

read. lt demonstrates that humor is useful in diagnosis,
discussions with patients, and one's own awareness and
self-care."
Alan D. Schmetzer, MD
Director of Education & Assistant Chairman
Department of Psychiatry
Indiana University School of Medicine

Disordered Personalities: A Primer

provides a comprehensive and entertaining introduction
to the DSM-IV personality disorders. The information is
presented in an organized and readable formal, with humor
integrated to make an effective and entertaining
presentation. This book takes a unique approach by
illustrating "textbook" concepts with examples that ali
readers will enjoy.

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

288 pages, hard-cover, ISBN 0-9680324-0-0

384 385
~¡ l. ~ B. .1N 6ift1P.. .. ... .. .. .. .. .. .. .. .. . ~ ~ .... !i L

~ ~ ~ ~
OrHER
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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!
9. Obsessive-Compulsive 10. Avoidant
11. Passive-Aggressive 12. Asthenic
13. Cyclothymic 14. Explosive
15. Self-Defeating & Masochistic Personalities
16. Multiple Personality Disorder
17. lnadequate The Psycho-lllogical Bulletin is a collection of
humorous and satirical articles published twice per
*Part 11 - lllustrations from the sections on year (summer and winter)
Theoretical and Diagnostic Principies:
18. Personality or Personality Disorder? Submissions are accepted in both text and
19. Object Relations Therapy graphical formats and are always welcome.
20. Transference/Countertransference (together in one slide)
21. Theoretical Principies (Freud Family)
Subscriptions are $1 O per year which includes
22. Resistance 23. Behavior Therapy
24. Countertransference 25. Cognitive Therapy 2 issues. Past volumes have included these articles:
26. Parking Lo! of !he Personality Disordered • The Feral Child Syndrome
27. Conflict in Ego Psychology • The Wobegon lntelligence Test
28. Ego Defenses 29. Organic Personality Disorder • Kevorkian's Organs
30. Medica! vs. Psychiatric Perspectives
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containing Parts 1 & 11. • Caricatures of Famous Clinical Figures
• Auto-Neurotica
~ Please specify slides or overheads when ordering. • Bitcheril Attitude Suppressant

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

"For those who are teaching Abnormal Psychology (or

even Normal Psychology), this book is a great way to
PsvcH1ATR1c help students and interns deal with the Major Clinical and
Personality Disorders from the DSM-IV. Using funny and
appropriate mnemonics, Dr. Robinson helps us to
MNEMONICS remember the essential elements of various ailments.

& 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."
Michael F. Shaughnessy Ph.D.
Professor of Psycr -·JQY
Eastern New Mexico University.

Psychiatric Mnemonics provides a practica! and

comprehensiva introduction to clinical psychiatry.
Mnemonics, summaries & guides are included far:

• Clinical Disorders
• Personality Disorders
• Conducting lnterviews
• Mental Status Examination
• Cognitive Functioning
• Differential Diagnosis
• Medica! Disorders
• Medication Side-Effects
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

K{CKIN SCIENCE FRICTION

Grins and Groans

THE PJ\l\TTS Among the Titles of Scientific Studies

THERAPY
Lubertus Berrens

illus1ra1~d by
WaUher M. E1jkeleslam

~ & ~ ~~9ll~HfHS

The anthology of articles and caricatures from the
Psycholllogical Bulletin. This unique volume is an
excellent resource for teaching classes, speaking
engagements and !ivening up bulletin boards.
192 pages, soft-cover, ISBN 0-9680324-4-3
Available in August, 1997
Science Friction is a collection of (real !) articles from
the biomedical literature. This book contains witty
commentary and drawings satirizing many of the tilles.
This book was written by p,·of. Lubertus Berrens,
illustrated by Walther Eijkelestam, and published by
Hogrefe & Huber.
91 pages, soft-cover, ISBN 0-88937-146-6

390 391
(1

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11 111 tt fl D
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a· i6 11' 11 9' mm' .,, 1r mr fl lí' 1111' ii' li

About the Author

Dave Robinson is a psychiatrist practising in London,
Ontario, Canada. His particular interests are consultation-
liaison psychiatry and education. A graduate of the
University of Toronto Medica! School, he completed a
Residency in Family Practice befare entering the
Psychiatry Residency Program. During a fugue state, he
relocated to London in 1991.

His hobbies are playing the sax, computer simulation

games, Coca-Cola collectibles and, yes, cycling.

He is a Lecturer in Psychiatry at the University of

Western Ontario in London, Canada and was the
recipient of the 1996 Award far Excellence in Clinical
Clerk Teaching.

About the Arlist

Brian Chapman is a resident of Oakville, Ontario,
Canada. He was born in Sussex, England and moved to
Canada in 1957. His first commercial work took place
during W.W. 11 when he traded drawings for cigarettes
while serving in the British Navy. Now retired, Brian was
formerly a Creative Director at Mediacom. He continues
to freelance and is versatile in a wide range of media. He
is a master of the caricature, and his talents are
ce stantly in demand. He doesn't smoke anymore.

Brian is an avid swimmer and trumpeter. He performs

regularly (playing the trumpet) in the Toronto area as a
member of three bands. He is the author's godfather.
Br;an is married to Fanny, a cook, bridge player and
crossword puzzle solver extraordinaire.

392
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