Disorders of consciousness.

Basic psychopathological

syndromes.

Olena SmashnaOlena Smashna

DeliriumDeliriumis from Latin and literally means the is from Latin and literally means the individual is not at the top of his/her individual is not at the top of his/her

form and travelling at a lower level than form and travelling at a lower level than normal [de – (off, away from) + lira (a normal [de – (off, away from) + lira (a

ridge between ploughed furrows)]. ridge between ploughed furrows)].

DeliriumDelirium

is an outcome of a general medical is an outcome of a general medical condition and drug intoxication or condition and drug intoxication or withdrawal. It may accompany withdrawal. It may accompany dysfunction of various bodily organs dysfunction of various bodily organs such as the kidneys and liver, but it such as the kidneys and liver, but it may also accompany primary may also accompany primary pathological processes in the brain. pathological processes in the brain.

Predisposing factorsPredisposing factors

Advanced age Advanced age • • Dementia Dementia • • Functional impairment in Functional impairment in

activities of daily living activities of daily living • • Medical comorbidity Medical comorbidity • • History of alcohol abuse History of alcohol abuse • • Male gender Male gender • • Sensory impairment (blindness, Sensory impairment (blindness,

deafness) deafness)

Precipitating factorsPrecipitating factors Acute myocardial events Acute myocardial events

• • Acute pulmonary events Acute pulmonary events • • Bed rest Bed rest

• • Fluid and electrolyte disturbance Fluid and electrolyte disturbance (including dehydration) (including dehydration)

• • Drug withdrawal (sedatives, alcohol) Drug withdrawal (sedatives, alcohol) • • Infection (especially respiratory, Infection (especially respiratory,

urinary) urinary) • • Medications Medications

• • Uncontrolled pain Uncontrolled pain • • Urinary retentionUrinary retention

• • Indwelling catheters Indwelling catheters • • Severe anaemia Severe anaemia • • Use of restraints Use of restraints

• • Intracranial events Intracranial events

The diagnostic criteria have The diagnostic criteria have changed over time. changed over time.

5 sets of diagnostic criteria:5 sets of diagnostic criteria:

1) due to a general medical 1) due to a general medical condition,condition,

2) due to substance intoxication,2) due to substance intoxication, 3) due to substance withdrawal, 3) due to substance withdrawal, 4) due to multiple aetiologies,4) due to multiple aetiologies, 5) not otherwise specified. 5) not otherwise specified.

C. The disturbance develops over C. The disturbance develops over a short period of time (usually a short period of time (usually hours to days) and tends to hours to days) and tends to fluctuate during the course of fluctuate during the course of the day.the day.

D. There is evidence from the D. There is evidence from the history, physical examination, or history, physical examination, or laboratory findings that suggest laboratory findings that suggest the disturbance is caused by the the disturbance is caused by the direct physiological direct physiological consequences of a general consequences of a general medical condition.medical condition.

Three clinical subtypes of deliriumThree clinical subtypes of delirium::

1. Hyperactive (hyperaroused, 1. Hyperactive (hyperaroused, hyperalert, or agitated) hyperalert, or agitated)

2. Hypoactive (hypoaroused, 2. Hypoactive (hypoaroused, hypoalert, or lethargic) hypoalert, or lethargic)

3. Mixed (alternating features of 3. Mixed (alternating features of hyperactive and hypoactive types) hyperactive and hypoactive types)

Hyperactive symptomsHyperactive symptoms Restlessness Restlessness Fast or loud speech Fast or loud speech Irritability Irritability Combativeness Combativeness Impatience Impatience Swearing Swearing Singing Singing Laughing Laughing Uncooperativeness Uncooperativeness Euphoria Euphoria Anger Anger Wandering Wandering Easy startling Easy startling Fast motor responses Fast motor responses Distractibility Distractibility Tangentiality Tangentiality Nightmares Nightmares Persistent thoughtsPersistent thoughts

Hyperactive deliriumHyperactive delirium

is rarely taken to be agitated depression, is rarely taken to be agitated depression, however, it may be more difficult to however, it may be more difficult to exclude a severe anxiety disorder. exclude a severe anxiety disorder. Hallucinations and delusions associated Hallucinations and delusions associated with delirium may suggest a “functional” with delirium may suggest a “functional” psychosis, but the picture is clarified by psychosis, but the picture is clarified by looking for clouding of consciousness looking for clouding of consciousness (concentration), cognitive difficulties (concentration), cognitive difficulties (memory and orientation difficulties) and a (memory and orientation difficulties) and a fluctuating course. fluctuating course.

Hypoactive symptomsHypoactive symptoms

Decreased Decreased alertness alertness

Lethargy Lethargy Slowed Slowed

movements movements Staring Staring Apathy Apathy

Hypoactive deliriumHypoactive delirium

may look like severe depression, with may look like severe depression, with lack of movement and interest in the lack of movement and interest in the surroundings. Such depression is surroundings. Such depression is usually preceded by a history of usually preceded by a history of mood disorder, and the thought mood disorder, and the thought content is usually helpful. content is usually helpful.

PreventionPrevention In efforts to prevent delirium, the following points are In efforts to prevent delirium, the following points are

recommended: recommended: – • • Routine cognitive testing on admission and during Routine cognitive testing on admission and during

hospitalization hospitalization – • • Cease or minimize use of potentially problematic Cease or minimize use of potentially problematic

medications medications – • • Ensure the continued use of glasses and hearing Ensure the continued use of glasses and hearing

aids as appropriate aids as appropriate – • • Ensure adequate intake of fluids and nutrition by Ensure adequate intake of fluids and nutrition by

providing assistance as necessary providing assistance as necessary – • • Early identification and treatment of dehydration Early identification and treatment of dehydration – • • Early mobilization Early mobilization – • • Avoid restraints (chemical and physical) Avoid restraints (chemical and physical) – • • Involving family members or one-to-one nursing to Involving family members or one-to-one nursing to

calm and reorientate. calm and reorientate. – • • Adequate pain relief, while avoiding anticholinergic Adequate pain relief, while avoiding anticholinergic

complic complic

The Confusion Assessment The Confusion Assessment Method (CAM)Method (CAM)

The CAM is a brief structured The CAM is a brief structured assessmentassessment. . It can achieve better It can achieve better than 95% sensitivity and specificity than 95% sensitivity and specificity and is quick and easy to administer. and is quick and easy to administer. The presence or absence of the four The presence or absence of the four following elements is determined by following elements is determined by the clinician. The diagnosis of the clinician. The diagnosis of delirium is made when both 1 and 2 delirium is made when both 1 and 2 and either or both 3 and 4 are and either or both 3 and 4 are present: present:

Testing attentionTesting attention

A commonly used method of testing A commonly used method of testing attention is to ask the patient to perform attention is to ask the patient to perform the serial 7’s test. the serial 7’s test. TThis test requires more his test requires more calculation skill than attention. calculation skill than attention. Accordingly, they recommend the Accordingly, they recommend the following: following: – • • Days of the week backwards Days of the week backwards – • • Months of the year backwards Months of the year backwards – • • Digit span (forwards and backwards) Digit span (forwards and backwards) – • • Spell “world” backwards Spell “world” backwards

Delirium tremens.Delirium tremens. Delirium tremens, also known as alcohol withdrawal Delirium tremens, also known as alcohol withdrawal

delirium and more commonly as "DTs," develops in delirium and more commonly as "DTs," develops in the setting of the alcohol withdrawal syndrome, and the setting of the alcohol withdrawal syndrome, and is seen in about is seen in about 5% 5% of hospitalized alcoholics. It is of hospitalized alcoholics. It is characterized by gross accentuation of the tremor characterized by gross accentuation of the tremor and autonomic signs and by the development of and autonomic signs and by the development of confusion, disorientation, and hallucinations.confusion, disorientation, and hallucinations.

the patient is generally agitated, markedly the patient is generally agitated, markedly tremulous, and very easily startled; mydriasis and tremulous, and very easily startled; mydriasis and generalized hyperreflexia are prominent,as are such generalized hyperreflexia are prominent,as are such autonomic signs as diaphoresis, tachycardia, autonomic signs as diaphoresis, tachycardia,

elevated blood pressure, and increased respirations.elevated blood pressure, and increased respirations.

Delirium tremens.Delirium tremens.Visual hallucinations are very common; they Visual hallucinations are very common; they

tend to be extremely vivid and complex. tend to be extremely vivid and complex. Often the patient sees insects or animals: Often the patient sees insects or animals: dogs circle the bed; rats eat at the toes; dogs circle the bed; rats eat at the toes; bugs crawl on the arms and face. They may bugs crawl on the arms and face. They may cringe in fear or try to swat them away. At cringe in fear or try to swat them away. At times the patient may see simply a benign times the patient may see simply a benign procession of animals, which he may watch procession of animals, which he may watch from the bed as if it were an amusing from the bed as if it were an amusing procession. Curiously one also often sees a procession. Curiously one also often sees a predilection for hallucinating strings or predilection for hallucinating strings or threads; the patient may pick them out of threads; the patient may pick them out of the air or warn the physician to avoid the air or warn the physician to avoid running into one stretched across the running into one stretched across the hospital room. hospital room.

Often the visual hallucinations Often the visual hallucinations may be provoked by suggestion. may be provoked by suggestion. In the classic "string test" the In the classic "string test" the examiner holds her hands about examiner holds her hands about a foot and a half apart, the a foot and a half apart, the thumbs and index fingers thumbs and index fingers apposed, several feet in front of apposed, several feet in front of the patient and asks if the the patient and asks if the patient sees anything. After the patient sees anything. After the patient reports seeing nothing, patient reports seeing nothing, the examiner asks "Don't you the examiner asks "Don't you see the string?," whereupon the see the string?," whereupon the patient does indeed see a string patient does indeed see a string stretched between the stretched between the examiner's hands.examiner's hands.

Delirium tremens.Delirium tremens. Tactile hallucinations may accompany the Tactile hallucinations may accompany the

visual ones: the skin is ripped by teeth; visual ones: the skin is ripped by teeth; spiders bite; bugs are felt crawling all over. spiders bite; bugs are felt crawling all over. The patient may complain of electric The patient may complain of electric shocks or of pins being stuck into the toes.shocks or of pins being stuck into the toes.

Auditory hallucinations are common. Auditory hallucinations are common. Patients may hear bells, whistles, or Patients may hear bells, whistles, or alarms. If voices are heard, they tend to be alarms. If voices are heard, they tend to be critical, persecutory, or warning of dire critical, persecutory, or warning of dire events. Patients hear accusations of events. Patients hear accusations of neglecting their children; the children are neglecting their children; the children are starving because the patients spent their starving because the patients spent their paychecks on drink. The death sentence is paychecks on drink. The death sentence is pronounced; the physician is revealed as pronounced; the physician is revealed as the executioner.the executioner.

Delirium tremens.Delirium tremens. Delusions are common and tend to be Delusions are common and tend to be

persecutory. Murderers are outside the persecutory. Murderers are outside the door; the nurse is bringing poison to the door; the nurse is bringing poison to the patient; other patients talk about and patient; other patients talk about and conspire against the patient.conspire against the patient.

Disorientation always occurs, often to both Disorientation always occurs, often to both time and place. At times this disorientation time and place. At times this disorientation is intensified by hallucinations. The patient is intensified by hallucinations. The patient refuses the bedtime medicine offered by refuses the bedtime medicine offered by the nurse and announces that it must be the nurse and announces that it must be morning as the birds are chirping; if morning as the birds are chirping; if questioned as to orientation to place, the questioned as to orientation to place, the patient, seeing the clouds out the window, patient, seeing the clouds out the window, may report being in an airplane or perhaps may report being in an airplane or perhaps an air ambulance.an air ambulance.

Delirium tremens.Delirium tremens.

Memory tends to be severely disturbed. The patient is Memory tends to be severely disturbed. The patient is unable to recall the name of the physician or of the unable to recall the name of the physician or of the hospital. Recall of events before admission is also often hospital. Recall of events before admission is also often quite spotty.quite spotty.

The behavior of these patients is commensurate with their The behavior of these patients is commensurate with their symptoms. Some may sit tremulously on the bed, picking symptoms. Some may sit tremulously on the bed, picking at the bed sheets or brushing away insects. They may at the bed sheets or brushing away insects. They may grasp at strings in the air and mumble agitatedly about grasp at strings in the air and mumble agitatedly about events occurring outside the window. Others may strike events occurring outside the window. Others may strike out at their "persecutors"; they may attempt to escape out at their "persecutors"; they may attempt to escape through the door or jump out the window.through the door or jump out the window.

In contrast one may occasionally encounter a "quiet" In contrast one may occasionally encounter a "quiet" delirium tremens. Here the tremor and autonomic signs delirium tremens. Here the tremor and autonomic signs and symptoms are minimal, and the patient, all the while and symptoms are minimal, and the patient, all the while experiencing sometimes fantastic visual hallucinations, experiencing sometimes fantastic visual hallucinations, may lie relatively quietly in bed.may lie relatively quietly in bed.

Oneiroid (lat. - is dream) - or dream-like fantastic delusional derangement of consciousness, is characterized by a kaleidoscopic quality of psychopathological experiences, wherein reality, illusions and hallucinations are merged into one. It is typically accompanied by motor and, in particular, catatonic disturbances.

Main psychopathological syndroms.Main psychopathological syndroms.

PsychoorganicPsychoorganic AmnesticAmnestic

ConvulsiveConvulsive Disorder of conciousnessDisorder of conciousness

CatatonicCatatonic GebefrenicGebefrenic

Gallucinatory-delusionalGallucinatory-delusional HypochondricHypochondric

AffectivAffectiv NeuroticNeurotic

Neurotic syndromsNeurotic syndroms

AnxiAnxiousous PHOBIPHOBICC ObsessiObsessiv-compulsivv-compulsiv AstenicAstenic

AnxiAnxious syndromous syndrom

Anxiety Anxiety is an unpleasant is an unpleasant emotional state with qualities emotional state with qualities of apprehension, dread, of apprehension, dread, distress and uneasiness and is distress and uneasiness and is often accompanied by often accompanied by physical sensations such as physical sensations such as palpitations, nausea, chest palpitations, nausea, chest pain and shortness of breath. pain and shortness of breath.

Normal anxietyNormal anxiety

is applied to states of arousal/anxiety which occur is applied to states of arousal/anxiety which occur in everyday life, in response to stimuli. It has an in everyday life, in response to stimuli. It has an adaptive role and is a signal to take action. In adaptive role and is a signal to take action. In normal anxiety the assessment of the danger is normal anxiety the assessment of the danger is appropriate and the action taken is effective. The appropriate and the action taken is effective. The healthy person who has lost her/his pay-packet healthy person who has lost her/his pay-packet will be anxious about paying outstanding bills. will be anxious about paying outstanding bills.

Fear Fear is generally regarded to be an extreme form is generally regarded to be an extreme form of normal anxiety. If an intruder comes into the of normal anxiety. If an intruder comes into the house most the healthy persons will be fearful. house most the healthy persons will be fearful.

Pathological anxietyPathological anxiety is diagnosed when there is is diagnosed when there is

inaccurate or excessive assessment inaccurate or excessive assessment of danger. The individual may be of danger. The individual may be unable to make any response, or unable to make any response, or make an excessive protective make an excessive protective response. The person with response. The person with pathological anxiety may be so pathological anxiety may be so disabled that he/she is unable to disabled that he/she is unable to conduct his/her usual duties such as conduct his/her usual duties such as prepare a meal, or overestimate a prepare a meal, or overestimate a danger such that he/she makes danger such that he/she makes maladaptive adjustments (the maladaptive adjustments (the person anxious about lifts will have person anxious about lifts will have to take the stairs). to take the stairs).

CriteriaCriteria– A. Excessive anxiety and worry (apprehensive A. Excessive anxiety and worry (apprehensive

expectation), occurring more days than not for at expectation), occurring more days than not for at least 6 months, about a number of events or least 6 months, about a number of events or activities (such as work or school activities). activities (such as work or school activities).

– B. The person finds it difficult to control the worry. B. The person finds it difficult to control the worry. – C. The anxiety and worry are associated with three C. The anxiety and worry are associated with three

(or more) of the following (or more) of the following 1. restlessness or feeling keyed up or on edge 1. restlessness or feeling keyed up or on edge 2. being easily fatigued 2. being easily fatigued 3. difficulty concentrating or mind going blank 3. difficulty concentrating or mind going blank 4. irritability 4. irritability 5. muscle tension 5. muscle tension 6. sleep disturbance (difficulty falling or staying 6. sleep disturbance (difficulty falling or staying

asleep, or restless unsatisfying sleep). asleep, or restless unsatisfying sleep). – D. The anxiety, worry or physical symptoms cause D. The anxiety, worry or physical symptoms cause

clinically significant distress or impairment in social, clinically significant distress or impairment in social, occupational, or other important areas of occupational, or other important areas of functioning. functioning.

The features of panic attack The features of panic attack include: include:

1. palpitations 1. palpitations 2. sweating 2. sweating 3. trembling or shaking 3. trembling or shaking 4. shortness of breath or sensation 4. shortness of breath or sensation

of smothering of smothering 5. feeling of choking 5. feeling of choking 6. chest pain or discomfort 6. chest pain or discomfort 7. nausea or abdominal distress 7. nausea or abdominal distress 8. feeling dizzy, unsteady, light-8. feeling dizzy, unsteady, light-

headed, or faint headed, or faint 9. derealization (feelings of 9. derealization (feelings of

unreality) or depersonalization unreality) or depersonalization (being detached from oneself) (being detached from oneself)

10. fear of losing control or going 10. fear of losing control or going crazy crazy

1111. paresthesia (numbness or . paresthesia (numbness or tingling sensations) tingling sensations)

1122. chills or hot flushes . chills or hot flushes

The features of agoraphobia The features of agoraphobia include:include:

– A. Anxiety about being in places or situations A. Anxiety about being in places or situations from which escape might be difficult (or from which escape might be difficult (or embarrassing) or in which help may not be embarrassing) or in which help may not be available. Agoraphobic fears typically involve available. Agoraphobic fears typically involve characteristic clusters of situations that characteristic clusters of situations that include being outside the home alone; being include being outside the home alone; being in a crowd or standing in a line; being on a in a crowd or standing in a line; being on a bridge; and travelling in a bus, train, or bridge; and travelling in a bus, train, or automobile. automobile.

– B. The situations are avoided (e.g., travel is B. The situations are avoided (e.g., travel is restricted) or else are endured with marked restricted) or else are endured with marked distress or with anxiety about having a Panic distress or with anxiety about having a Panic Attack or require the presence of a Attack or require the presence of a companion. companion.

PHOBIPHOBIC SYNDROMC SYNDROM The specific phobias feature marked and persistent fears which The specific phobias feature marked and persistent fears which

are excessive to any risks. Commonly feared objects include are excessive to any risks. Commonly feared objects include animals, insects, aspects of the natural environment, heights, animals, insects, aspects of the natural environment, heights, injections/blood, and dental procedures. injections/blood, and dental procedures.

The diagnostic criteria for specific phobia are as follows: The diagnostic criteria for specific phobia are as follows: – A. Marked and persistent fear that is excessive or A. Marked and persistent fear that is excessive or

unreasonable, cued by the presence or anticipated presence unreasonable, cued by the presence or anticipated presence of a specific object or situation (e.g., flying, heights, of a specific object or situation (e.g., flying, heights, animals, injections, blood) animals, injections, blood)

– B. Exposure to the phobic stimulus almost always provokes B. Exposure to the phobic stimulus almost always provokes an immediate anxiety response, which may take the form of an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic a situationally bound or situationally predisposed Panic Attack. Attack.

– C. The person recognizes that the fear is excessive or C. The person recognizes that the fear is excessive or unreasonable. unreasonable.

– D. The phobic situation is avoided or else endured with D. The phobic situation is avoided or else endured with intense anxiety or distress intense anxiety or distress

– E. The avoidance, anxious anticipation, or distress in the E. The avoidance, anxious anticipation, or distress in the feared situation interferes significantly with the person’s feared situation interferes significantly with the person’s normal routine, occupational (or academic) functioning, or normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress social activities or relationships, or there is marked distress about having the phobia. about having the phobia.

Sub-classificationSub-classification

– 1. animal type 1. animal type – 2. natural environment type 2. natural environment type – 3. situational type 3. situational type – 4. blood/injection type (see next entry) 4. blood/injection type (see next entry) – 5. other type 5. other type

ObsessionsObsessions

are persistent, intrusive ideas, thoughts, are persistent, intrusive ideas, thoughts, impulses, or images that areimpulses, or images that are experienced as inappropriate and that experienced as inappropriate and that cause marked anxiety or distress. The cause marked anxiety or distress. The individualindividual is able to recognise that the is able to recognise that the obsessions are the product of his or her obsessions are the product of his or her own mind and notown mind and not imposed from outside imposed from outside (that is, they are not related the (that is, they are not related the psychotic experience of thoughtpsychotic experience of thought insertion).insertion).

The most common obsessions are The most common obsessions are repeated thoughts about contamination repeated thoughts about contamination (e.g.,(e.g., becoming contaminated by becoming contaminated by shaking hands) repeated doubts ( e.g., shaking hands) repeated doubts ( e.g., wondering wetherwondering wether one has left a door one has left a door unlocked), a need to have things in a unlocked), a need to have things in a particular order (e.g., intenseparticular order (e.g., intense distress distress when objects are disordered), when objects are disordered), aggressive or horrific impulses (e.g., to aggressive or horrific impulses (e.g., to hurthurt one’s child or shout an obscenity in one’s child or shout an obscenity in church), and sexual imagery .church), and sexual imagery .

Compulsions Compulsions are repetitive behaviours (e.g., are repetitive behaviours (e.g., hand washing, ordering, checking) orhand washing, ordering, checking) or mental mental acts (e.g., praying, counting, repeating words acts (e.g., praying, counting, repeating words silently), the goal of which is tosilently), the goal of which is to prevent or prevent or reduce anxiety or distress which accompanies reduce anxiety or distress which accompanies an obsession. The individualan obsession. The individual feels driven to feels driven to perform the compulsion. The individual with perform the compulsion. The individual with obsessions aboutobsessions about contamination may wash contamination may wash hands until the skin is damaged.hands until the skin is damaged. Individuals Individuals may perform stereotyped acts according to may perform stereotyped acts according to idiosyncratically elaboratedidiosyncratically elaborated rules without being rules without being able to indicate why they are doing them. able to indicate why they are doing them. Compulsive behaviourCompulsive behaviour may not be connected in may not be connected in a realistic way with what it are designed to a realistic way with what it are designed to neutralize.neutralize.

The The positive symptoms positive symptoms (phenomena which are in(phenomena which are in addition addition

to normal experience), to normal experience), are the most remarkable features of theare the most remarkable features of the acute/psychotic phase, and include acute/psychotic phase, and include

hallucinations, delusions and disorders of hallucinations, delusions and disorders of the formthe form

of thought such as derailment, of thought such as derailment, incoherence and neologisms. These may incoherence and neologisms. These may also bealso be

present during the chronic phase, but with present during the chronic phase, but with the passage of time they usually decreasethe passage of time they usually decrease

or at least have less impact on the or at least have less impact on the patient’s life.patient’s life.

The The negative symptoms negative symptoms (loss (loss of personality features and of personality features and

abilities) are the mostabilities) are the most troublesome symptoms of the chronic phase of schizophren troublesome symptoms of the chronic phase of schizophren

ia and include diminishedia and include diminished emotional expression (flattening or blunting of affect), emotional expression (flattening or blunting of affect),

reduced ability to experiencereduced ability to experience pleasure (anhedonia), reduced interpersonal skills, social pleasure (anhedonia), reduced interpersonal skills, social

isolation, reducedisolation, reduced motivation and drive (avolition/apathy) and thought motivation and drive (avolition/apathy) and thought

disorder of t he poverty of thoughtdisorder of t he poverty of thought type (alogia). While the negative symptoms are the type (alogia). While the negative symptoms are the

predominant feature of the chronicpredominant feature of the chronic phase, they may also be present at the first psychotic phase, they may also be present at the first psychotic

episode, and may even precedeepisode, and may even precede the first psychotic episode during a prodromal period.the first psychotic episode during a prodromal period.

Delusional syndromDelusions are false beliefs that

continue to be believed in spite of evidence to the contrary(these are beliefs which are not held by the general public, or a any sub-group of thecommunity).

Delusions may occur

in schizophrenia, bipolar disorder

(manic or depressed phases),

major depressive disorder,

substance abuse organic mental

disorders

Paranoyal syndromParanoyal syndrom

Systematized delusions are united by a single theme. They are often highly detailed and may remain unchanged for years

Paranoid syndromParanoid syndrom

Persecutory (or paranoid) delusional syndrom

are usually beliefs that the individual is being harassed, watched or bugged. They often involve spies, bikies, God, Satan or neighbours

Ex.: Patient belief that Ex.: Patient belief that the secret service has the secret service has a plan to kill him. He a plan to kill him. He began to think that began to think that food is poisoning by food is poisoning by pursuers.pursuers.

Delusions of reference are the belief that the everyday

actions of others are premeditated and make special reference to the patient. Commonly patients complain about being talked about on television or the radio. Patients may believe that music played or words spoken on television have been specifically chosen to identify or annoy them. People crossing the street or coughing may be interpreted as purposeful actions, performed to indicate something to or about the patient.

Delusions of controlDelusions of control involve the belief that involve the belief that others are controlling the patient ’s thoughts,others are controlling the patient ’s thoughts,

feelings or actions.feelings or actions.

Thought broadcastingThought broadcasting, the belief that one’s , the belief that one’s thoughts can be heard by others ( e.g., “My thoughts can be heard by others ( e.g., “My brain is connected to the world mind. I can brain is connected to the world mind. I can control all heads of state thought my control all heads of state thought my thoughts.”).thoughts.”).

Thought insertionThought insertion, the belief that thoughts , the belief that thoughts have been removed from one’s mind by an have been removed from one’s mind by an outside agency (e.g., “They make me think outside agency (e.g., “They make me think bad thoughts and are rotting my brain”.).bad thoughts and are rotting my brain”.).

Thoughts withdrawalThoughts withdrawal, the belief that’s , the belief that’s thoughts has been removed from ones mind thoughts has been removed from ones mind by an outside agency (e.g., “The devil takes by an outside agency (e.g., “The devil takes my thoughts away and leaves me empty.”).my thoughts away and leaves me empty.”).

Ideas of physical action – Ideas of physical action – they are sure that some they are sure that some people make some harm people make some harm to their inner organs;to their inner organs;

Ideas of psychic actions – Ideas of psychic actions – with the help of telepathy, with the help of telepathy, biofields, noosphere act on biofields, noosphere act on their mind, behavior;their mind, behavior;

Criteria for Hypomanic EpisodeCriteria for Hypomanic Episode A. A. A distinct period of persistently A distinct period of persistently

elevated, expansive, or irritable mood, elevated, expansive, or irritable mood, lasting throughout lasting throughout

at least 4 days, that is clearly at least 4 days, that is clearly different from the usual nondepressed different from the usual nondepressed mood. mood.

B. B. During the period of mood During the period of mood disturbance, three (or more) of the disturbance, three (or more) of the following symptoms have following symptoms have

persisted (four if the mood is only persisted (four if the mood is only irritable) and have been present to a irritable) and have been present to a significant degree: significant degree:

(1.) (1.) inflated self-esteem or grandiosity inflated self-esteem or grandiosity (2.) (2.) decreased need for sleep (e.g., feels rested after decreased need for sleep (e.g., feels rested after

only 3 hours of sleep) only 3 hours of sleep) (3.) (3.) more talkative than usual or pressure to keep more talkative than usual or pressure to keep

talking talking (4.) (4.) flight of ideas or subjective experience that thoughts flight of ideas or subjective experience that thoughts

are racing are racing (5.) (5.) distractibility (i.e., attention too easily drawn to distractibility (i.e., attention too easily drawn to

unimportant or irrelevant unimportant or irrelevant external stimuli) external stimuli) (6.) (6.) increase in goal-directed activity (either socially, at increase in goal-directed activity (either socially, at

work or school, or sexually) work or school, or sexually) (7.) (7.) excessive involvement in pleasurable activities that excessive involvement in pleasurable activities that

have a high potential for have a high potential for painful consequences (e.g., engaging in painful consequences (e.g., engaging in

unrestrained buying sprees, sexual unrestrained buying sprees, sexual indiscretions, or foolish business investments)indiscretions, or foolish business investments)

C. C. The episode is associated with an unequivocal The episode is associated with an unequivocal change in functioning that is change in functioning that is

uncharacteristic of the person when not uncharacteristic of the person when not symptomatic. symptomatic.

D. D. The disturbance in mood and the change in The disturbance in mood and the change in functioning are observable by others. functioning are observable by others.

E. E. The episode is not severe enough to cause marked The episode is not severe enough to cause marked impairment in occupational impairment in occupational

functioning or in usual social activities or functioning or in usual social activities or relationships with others, or to necessitate relationships with others, or to necessitate

hospitalization to prevent harm to self or others, or hospitalization to prevent harm to self or others, or there are no psychotic features. there are no psychotic features.

F. F. Symptoms are not due to the direct physiological Symptoms are not due to the direct physiological effects of a substance (e.g., a drug of effects of a substance (e.g., a drug of

abuse, a medication) or a general medical condition abuse, a medication) or a general medical condition (e.g., hyperthyroidism). (e.g., hyperthyroidism).

DepressionDepression may cause a person may cause a person to:to:

Feel sad or anxious for a significant time. Feel sad or anxious for a significant time. Feel hopeless or pessimistic. Feel hopeless or pessimistic. Have slowed thoughts and speech because of low energy. Have slowed thoughts and speech because of low energy. Have difficulty concentrating, remembering, and making Have difficulty concentrating, remembering, and making

decisions. decisions. Have changes in eating and sleeping habits leading to too Have changes in eating and sleeping habits leading to too

much or too little eating or sleeping. much or too little eating or sleeping. Have decreased interest in usual activities, including sex. Have decreased interest in usual activities, including sex. Have suicidal thoughts. Have suicidal thoughts. Not enjoy things he or she normally would.Not enjoy things he or she normally would.

DepressionDepressionFeelingsFeelings

• depressed mood remorseful depressed mood remorseful by feeling sad, low, blue, by feeling sad, low, blue,

hopeless, helpless, useless, hopeless, helpless, useless, guilty, ashamed, remorseful guilty, ashamed, remorseful

• loss of interest in work loss of interest in work • loss of feelings for family or loss of feelings for family or

friends friends • anxiety, fears, worries anxiety, fears, worries

worthlessness, undeserving even of worthlessness, undeserving even of help help

pessimism pessimism loss of interest in sex loss of interest in sex

inability to experience pleasure, have inability to experience pleasure, have fun fun

ThoughtsThoughts slowed thinking, difficulty in slowed thinking, difficulty in

concentrating, in making decisions, concentrating, in making decisions, mixed-up thoughts mixed-up thoughts

preoccupation with failures, loss of self-preoccupation with failures, loss of self-esteem, obsession with certain thoughts esteem, obsession with certain thoughts

that one cannot seem to turn off that one cannot seem to turn off loss of touch with reality, hearing voices loss of touch with reality, hearing voices

(hallucinations) or having strange ideas (hallucinations) or having strange ideas (delusions) (delusions)

thoughts of suicide, of homicide thoughts of suicide, of homicide (Approximately 15% of untreated or (Approximately 15% of untreated or

inadequately treated patients with an inadequately treated patients with an affective illness commit suicide, often affective illness commit suicide, often

just as the depression is lifting and more just as the depression is lifting and more energy and activity is experienced.) energy and activity is experienced.)

Warning signs of suicide include:Warning signs of suicide include:

Use of illegal drugs or drinking alcohol Use of illegal drugs or drinking alcohol heavily. heavily.

Talking, writing, or drawing about death, Talking, writing, or drawing about death, including writing suicide notes and including writing suicide notes and speaking of items that can cause physical speaking of items that can cause physical harm, such as pills, guns, or knives. harm, such as pills, guns, or knives.

Spending long periods of time alone. Spending long periods of time alone. Giving away possessions. Giving away possessions. Acting aggressive or suddenly appearing Acting aggressive or suddenly appearing

calm.calm.

Types of psychomotor Types of psychomotor excitement.excitement.

.. Depressive Depressive Manic Manic Catatonic Catatonic PsychogenicPsychogenic

Types of stuporTypes of stupor

HallucinativeHallucinative Depressive Depressive Catatonic Catatonic PsychogenicPsychogenic

Catatonic syndromCatatonic syndrom

““wax flexibilitywax flexibility ” or “catalepsy” – which posture ” or “catalepsy” – which posture we put them – they will take it, doesn’t react on we put them – they will take it, doesn’t react on speech, doesn’t to contradict on putting him in speech, doesn’t to contradict on putting him in that posture, can stay for a long time. Can be that posture, can stay for a long time. Can be accompanied with negativism – that he make accompanied with negativism – that he make opposite things.opposite things.

Symptom of “air pillow”-patient lays in bed and Symptom of “air pillow”-patient lays in bed and his head is in the air, over a pillow, because of his head is in the air, over a pillow, because of muscle tonus.muscle tonus.

Automatic obedience – a catatonic patient may perform, without hesitation, all simple commands in a robot-like fashion.

Disorders of will sphereDisorders of will sphere::