MENTAL PHENOMENA
1.Disordered form
Deviation from rational, logical, goal directed thinking.
Autistic thinking
Here
thought is directed by inner fantasies and is associated with social
withdrawal.
Thinking
here is less subject to correction by reality than is normal thinking.
Blocking
Cessation
in the flow of thought or speech; occurs in schizophrenia.
Schizophrenic thought disorder
Disturbance
in association leading to subtle discontinuities in the flow of speech
(knight's
move, derailment). It may lead to neologisms which is newly invented words or
incoherence when severe.
Pressure of speech
Speech
is voluble and difficult to interrupt. Often related to anxiety.
Flight of ideas
High
speed speech with leaps from one subject to another which are connected
tenuously together.
Speech
is distractible in response to environmental stimuli.
Speech
is voluble and often includes punning. This is common in hypomanic illness.
Clang associations
Connections
between thoughts are dictated by chance sounds of words rather than their
meanings.
This
is often associated with flight of ideas.
Retardation
Slowing
of speech as in depression when it may be part of a general picture of
psychomotor retardation.
Mutism
The
patient refuses to speak whether for conscious or unconscious reasons.
2. Disordered content
Obsessianal ruminations
Rumination
is the pathological presence of a persistent and repetitive thought, feeling or
impulse that cannot be eliminated from consciousness by deliberate effort. On
quiet reflection the patient recognises that it has no rational basis and that
it is due to his own psychological processes rather than some outside
influence. Resistance to it is accompanied by anxiety. In obsessive compulsive
neurosis it may lead to severe disturbance in behaviour.
DELUSIONS
A delusion is a belief that
is firmly held against all evidence to the contrary and which is out of context
with the person's educational and cultural background. It is incorrigible,
often centred on the self (egocentric) and usually, but not necessarily, false.
Types
Paranoid: ideas of persecution and
injustice.
Depressive: morbid guilt, sell blame, futility.
Hypochondrial: concern with bodily and personal
attributes and may be bizarre.
Grandiose: over-estimation of personal
qualities, abilities, and finances (as in hypomanic illness).
Passivity: abnormal influences on bodily
processes by outside agencies (as in schizophrenic illness).
Reference: excessive focus of attention from
others, often associated with undue sensitivity or paranoid ideation.
Autochthonous
(apophanous): sudden
onset, fully elaborated apparently not related to situations or current
preoccupation (in schizophrenia).
Secondary: follows some other morbid
experience. For example, severe depression with morbid guilt may lead to belief
that others will share that view of him and behave towards him accordingly. Sysmatised:
usually in chronic schizophrenic psychosis, when a rational internal
consistency between various delusions is developed.
Level
of consciousness
Organic
states may lead to confusion in which there is disorientation in time, place
and person, with feelings of bewilderment. In clouding of consciousness there
is similar disturbance of perception and
attention with subsequent amnesia.
When there is also marked anxiety a state of delirium exists when there
may also be hallucinations, paranoid ideation and consequently
overactive or aggressive behaviour.
Coma
Profound loss of
consciousness due to organic cause is the deepest level of loss of
responsiveness and may be associated with loss of all responses and even
reflexes.
Stupor
A state of relative
non-responsiveness to the environment which may be part of precoma in organic disturbance,
electrolyte disorders, mid brain tumours or hypoglycaemia. The psychogenic type
(depressive or catatonic or hysterical) is associated with full awareness of
environment.
Patient is immobile, mute,
while his eyes may follow external object. EEG may be useful in diagnosis.
Attention
In the normal state this
involves a central focus of high intensity with extension to include a variable
amount of peripheral material in a less clear way. Both intensity and extent of
attention may be impaired by psychological and organic factors, often in a
fluctuant way.
Variability is a marked
feature of early organic impairment. DistractiiIity is common in hypomanic
euphoria. Intense preoccupation with a single theme may occur in depression
(guilt) or obsessional states (phobic objects or rituals).
Selective inattention is
similar to the defence of denial with avoidance of matters that generate
anxiety.
In Hypnosis, there is
restricted awareness with intense focus on one area o consciousness and
heightened suggestibility.
Orientation
The ability to recognise
one's surroundings and their temporal and spatial relationship to oneself, or
to appreciate one's relatonship to the environment requires adequacy of
exteroceptive data, effective recent correct inteIIectal adjustment to outer
reality (level of consciousness, freedom from delusional thinking).
Concerns
Time: (hour, day, week and year).
Place: (present location, its nature, home
address, reasons for being in present situation).
Person: (Identity of self and others).
May be related to organic
disorder but psychogenic factors may also lead to disorientation as in
hysterical dissociation.
Memory
Registration may be Impaired by any reduction in
consciousness and awareness, alcohol, drug induced or other organic disorders
of the central nervous system or psychogenic factors including severe anxiety
and panic states.
Retention
Extremely rapid decay in
'curve of forgetting' may occur in certain organic brain diseases, e.g.
Korsakoft's Psychosis. In Alzheimer's disease there is a profoubd impairment of
new learning ,but in the early stages the rate of forgetting, once information
is acquired, may be normal.
Recall
Amnesia is the partial or
total inability to recall past experiences. Psychogenic impairment usually
related to emotional difficulties, selective for painful events, either recent
or distant, and memories may return. In gross hysterical state there may be
global amnesia involving all past events and identity. May be associated with
physical flight to new and strange surroundings (fugue). Organic amnesia may be
irreversible, usually concerns recent events and may leave remote memory intact
and not specifically selective for emotionally traumatic events. Important to
note that typical hysterical amnesia may occur in addition to underlying
organic brain disorder, and may even be precipitated by it.
Recognition
A sense of familiarity with
regards to recalled material. In mild nominal dysphasia words may be correctly
recognised and identified even though their spontaneous recall is not possible.
Deja vu
This
is an illusion of recognition in which a new situation is incorrectly regarded
as a repetition of a previous memory.
It
is Common in normal anxiety states or epileptic aura.
Jamais vu
It
is an illusion of failure to recognise familiar situations.
Confabulation
It
is the filling of gaps in memory by false imagined experiences which the
patient believes to be true.
Dysphasia and aphasia
These
are specific memory disorder for words and language related to organic brain
disturbance in the dominant temporal lobe (speech centre), and contiguous
areas.
Intelligence
Intellinence
is the ability to solve problems, which require logical thought processes.
There
is considerable normal individual differences in accuracy, speed, level of
problem complexity and flexibility as well as originality of solution.
Routine
clinical assessment of intelligence permits only approximate estimation. Poor
educational experience, sociocultural factors or mental illness must always be
allowed for before a judgement is made. Standardised intelligence tests are
highly reliable and should always be used when routine clinical assessment
suggests that further investigation of intelligence levelis needed.
Intelligence
quotient (I.Q.) = mental age (BineSimon scale) x 100 chronological age
Perception is the awareness of objects, qualities and
relations that follow stimulation of peripheral sensory organs as distinct from
awareness that results from memory.
Illusions
An
illusion is a perceptual misinterpretation of a real external sensory
experience.
It
is often dictated by dominant affective state, e.g. anxiety which may lead to
threatening distortion of visual experiences.
Hallucinations
This
is an apparent perception of an external object in the absence of an adequate
sensory stimulus. An internal psychological event is mistakenly attributed to
an external source.
Any
sensory modality may be involved: it may refer to external surroundings or to
bodily function.
When
caused by organic factors there may be impaired consciousness. Organic causes
include hallucinogenic drugs, epilepsy, delirium due to toxic agents or
alcohol/barbiturate withdrawal states. Psychogenic causes include schizophrenic
psychosis, which typically occurs in the setting of clear consciousness.
Hallucinations may be hypnagogic (preceding sleep) or hypnopompic (on waking).
This is the feeling tone that accompanies ideation. It is synonymous with emotion. Mood refers to a sustained affective state. Affect may be shallow, inappropriate (does not relate to stimuli or situation), labile, or qualitatively changed as in depression, euphoria, anxiety or anger. Consequent behaviour changes such as aggression may be closely associated with disorders of affect.
Anxiety
An
unpleasant emotional state characterised by feelings of apprehension, impending
threat or danger that is associated with characteristic pattern of somatic and
autonomic changes such as increased sweating, tremor, dry mouth, tachycardia
and subjective feelings of tension. It may be either free floating, or phobic
when it is focussed on specific objects or situations.
Depression
This
varies from mild dejection to deep melancholia and despair. It is often closely
associated with anxiety. When severe there may be secondary disorders of
ideation (self blame and futility, hypochondriasis, or suicidal thoughts) and
of behaviour (retardation, self neglect or agitation when anxiety is also
marked).
Euphoria and elation
Euphoria
is elevation of mood with feelings of emotional and physical well being
combined with optimism concerning the life situation. When pathological it is
usually quite clearly excessive and inappropriate, and may then be accompanied
by over-confidence, increased motor activity and impaired judgement (Elation).
Ambivalence
The
coexistence of opposite emotions and attitudes towards a given object or
situation is a common cause of mood swings or oscillation between mild euphoria
and depression/anxiety (cyclothymia).
Depersonalisition
It
is a feeling of unreality and strangeness concerning one's own person. The
person may feel outside the self, observing it objectively and feeling separate
from it. The condition may occur in normal people especially with fatigue, or
in epilepsy, psychosis (depressive or schizophrenic) or as a hysterical
phenomenon.
Derealisation
It
is loss of sense of reality concerning one's surroundings. This is closely
associated with depersonalisation and they may occur together with severe
anxiety in certain phobic states.
Closely
related to affective, cognitive and perceptual mental function.
Over-activity
Agitation
is a state of restless motor activity that is a manifestation of emotional
tension.
Hyperkinesis
in children may be related to organic or emotional disturbance.
General increase in activity may be related to euphoric mood states.
Focussed on compulsions and
rituals in obsessive compulsive states.
Under-activity
Depressive retardation may lead to slowing of response and
ultimate stupor.
Psychaethenic states due to anxiety may limit activities because of feelings of fatigue and exhaustion.
Catatonic stupor in schizophrenic patients may lead to prolonged periods of inactivity.
Self-neglect
May be related to:
- retardation and ideas of
futility in depressive psychosis.
- preoccupation with
fantasies and delusions in schizophrenia.
- excitement and lack of
judgement in hypomania.
- intellectual impairment
in dementia.
Abnormal movements
Stereotypies:
the frequent repetition of any speech or action. Common in chronic
schizophrenia.
Mannerisms:
idiosyncratic elaboration of normal movements,
common
in chronic schizophrenia.
Compulsions
Occur
as part of an obsessional state. Repetitive, stereotyped motor acts, usually
secondary to obsessional ideas: e.g. hand washing follows idea of
contamination. Only transient reduction of anxiety achieved.
Echolalia
Pathological
repetition by imitation of speech of another person.
Called
echopraxia when this involves imilation of movement
Flexibilitas cerea
Maintenance
of imposed posture as in hypnosis or catatonic schizophrenia.
Negativism
Resistance to suggestion, tending to do the opposite, as seen in catatonic schizophrenia.
Full insight requires a correct understanding of the severity, implications and causes of one's illness.
A psychotic patient may not recognise the presence of illness and may fail to accept any such proposition. He may later recover only
partial insight, accepting that he had previously been ill but remaining unwilling to agree to its psychiatric nature.
Neurotic illness is characterised by insight into the fact of disability, through true awareness of the nature of the underlying psychological factors is often absent.
The chronic brain syndrome
(dementia} may lead to severe loss of insight because of impaired judgement
secondary to loss of memory and other intellectual abilities. Acute clouding of
consciousness also impairs insight.
G) MENTAL MECHANISMS
Psychoanalytic theory proposes
that during development defence strategies are used to mediate between
unconscious instinctual drives and the structures of outside reality.
The repertoire of defences which an individual possesses dictates his character traits.
Defences occur as part of normal development and everyday life:
They are not in themselves
pathological unless they become excessive or fail to maintain adequate
functioning of the individual. Defences may be classified according to the
libidinal phase at which they arise, or according to the psychopathology with
which they are associated, or whether they are basic or composite.
Repression
Given a central position by
Freud. Leads to inabilityto remember unpleasant wishes or impulses. Common in
hysterical, dissociative behaviour but may occur as part of other defences,
e.g. sublimation.
Displacement
Shifting of emotion from
one idea or object to another in a way that causes less anxiety and guilt.
Reaction formation
An unacceptable impulse is
transformed into its opposite. Common in obsessive compulsive neurosis.
Isolation
Separation of an idea from
the affect which accompanies it.
Undoing
Attempts to cancel out a previously committed act by counter actions. Characteristic of obsessive compulsive states with
expiatory rituals which
attempt to undo some forbidden act or cancel the effects of a wish to which has
been attributed imaginary power of action.
Rationalisation
This provides alternative
explanation for instinctual motives and drives.
Intellectualisation
Excessive use of
intellectual processes to avoid affective experience.
Denial
May refer to the affect
associated with an idea or event or may include the whole episode. Exclusion
from conscious memory.
Projection
One's own feelings and wishes are attributed to another person.
Common in normals and
fundamental in paranoid psychosis.
Regression
A return to an earlier
state of psychological development in order to avoid tension and conflict of
the present. Common in normals under stress as well as in pathological states.
Counterphobic mechanisms
Attempt to alleviate phobic
anxieties by excessive activity in specific relation to the area of concern.
Withdrawal and avoidance
Removal of the self from
conflict situ. This may lead to a failure to resolve them.
Introjection
Qualities of a loved oblect
are iand the distinction between it and the self tends to be mini mised or
obliterated. This attempts to reduce painful awareness of separateness and
loss.
Identification
Usually with a loved oblect:
may also be dictated by guilt
Acting out
The living out (in action)
of warded-off memories when the links between the action and the memory are
obscure to the patient.
Sublimation
Psychic energy is deflected to another goal which is more acceptable to the individual concerned.