SIGNS AND SYMPTOMS and in organic mental disorders e.g.

drug addiction
and temporal lobe epilepsy.
• Symptoms are the complaints with which a patient presents iv. Difference between manic and catatonic
to the clinician. schizophrenic excitement
• Signs are the ones which the clinician obtains on
examination of the patient. Manic excitement Catatonic excitement

Occurs mainly’ in Occurs without

• In psychiatry, the boundary between symptoms and signs is
response to environmental provocation. Mostly in response to
not that distinct because when explored further, a symptom stimuli delusion or hallucination
can become a sign.
Accompanied with
The mood is apathetic
cheerful or irritable mood

Usually unexpected and

Usually expected and organized
disorganized

Accompanied with other Accompanied with other

manifestations of mania manifestations of schizophrenia

b. Diminished Motor activity

i. Partial retardation of motor activity e.g. in cases of
retarded depression or simple schizophrenia.
Aspects of Psychopathology ii. Complete suppression of motor activity (Stupor):
1. No profound disturbance of consciousness
Psychopathology: 2. There is complete suppression of motor
Descriptive (phenomenological) and Experimental activity (speech and movement). The patient
does not respond to any stimulus, neither
Signs and symptoms categories: external (question or painful stimulus), nor
1. Behavior internal (hunger, thirst or distended bladder).
2. Mood and Affect 3. In stupor the patient is arousable but not
3. Talk responsive. It occurs in psychiatric disorders
4. Thinking like depression, schizophrenia, and hysteria,
5. Perception or in acute organic mental disorders.
6. Memory
7. Orientation QUANTITATIVE DISTURBANCE
8. Attention and Concentration 1. Stereotypy: means monotonous repetition, which may be:
9. Abstraction i. In movement (e.g. touching the nose, or pacing up
10. Intelligence and down the room)
11. Insight ii. In speech (e.g. some words are repeated).
2. Mannerism: repeated movements, which may continue for
DISTURBANCE OF BEHAVIOR hours or days without cessation, and are keeping with the
1. Quantitative disturbance thought (e.g. a patient with paranoia salutes repeatedly in a
a. Excess motor activity grandiose manner).
i. Agitation: the patient is moving around, moving his 3. Perseveration: denotes the repetition of the same act (a
limbs and head, wrinkling his fingers and cannot stay movement, a word, or a phrase in spite of the patient’s effort
for some time in one place. This sign is found in or desire to do a new one i.e. inability to move from one act to
many psychiatric disorders e.g. mania, agitated the next one (e.g. during a meal the patient continues to put
depression, some cases of schizophrenia. the spoon in the plate and up to his mouth, even after the plate
ii. Restlessness: the patient feels inner tension with gets empty).
some agitation and cannot standstill. On sitting he sits 4. Lack of initiation and reduction of spontaneous
on the edge of the chair and moves his body parts like movement, lack of volition: the patient has no desire or will
arms, head and neck. This condition found mainly in to perform acts.
anxiety, and akathisia, also in some psychotic state. 5. Negativism: means automatic resistance to all stimuli.
The differentiation between restlessness and agitation i. In muscular field it may show itself as a resistance
may be difficult but in restlessness the condition to passive movements (e.g. keeping the arm extended
usually not desired by the patient i.e. out of his on trying to flex it or as opposite performances to that
control but agitation is usually are action to the asked for (e.g. looking down when asked to look up).
thoughts of the patient. ii. In speech it consists of total loss of it i.e. mutism.
iii. Excitement: Excitement occurs in primary iii. Negativism is seen also in the retention of saliva,
psychiatric disorders e.g. mania and schizophrenia urine and feces.
6. Resistiveness: in which the patient simply oppose or resists 7. Anxiety: is an emotional state characterized by anticipation
anything he is asked to do e.g. when he is setting and is asked of danger.
to stand up, he will remain setting down. If the source of anticipation is unknown it is called generalized
7. Automatic obedience: in contrast with negativism there is anxiety,
abnormal suggestibility; it shows itself as: If the anticipation is from potentially non dangerous object or
i. Echopraxia which is repetition of actions seen (e.g. situation it is called phobia,
when the doctor walks the patient walks too). If the anticipation is from consequences of act or situation it is
ii. Echolalia which is repetition of words heard (e.g. regarded as obsessive fear.
when the doctor says to the patient: how are you? the The anxious mood is that of fear accompanied with
patient answers: how are you?). restlessness.
8. Apathy: is absence of affect, or loss of emotion, or lack of
2. Qualitative disturbance feel ing (there is loss of both emotional expression and
iii. Waxy flexibility (Flexibilitas cerea) which is the experience). Occurs in some schizophrenics.
maintenance of imposed postures however abnormal 9. Indifference: is lack of objective emotional response.
they may be (e.g. rising-the head of the patient from (There is loss of emotional expression, but emotional
the pillow, or the arm up). The absence of fatigue in experience is preserved). Occurs in schizophrenia. a type of
such cases is remarkable. this called “a belle indifference “ occurs in hysteria when the
iv. Catalepsy (posturing) is sometimes used for any patient`s feelings are not in tune with the problem, happy in
form of sustained immobility. spite of his disability.
v. Automatic movements or automatism occur in a 10. Emotional deterioration: is a progressive failure to show
pathological sense, without the subject being aware the normal emotional responses (characterized by a childish,
of their meaning and even without his being aware of easily suggestible, facile state). Occurs in disorganized
their happening at all. Automatism may be (i) local schizophrenias.
e.g. automatic writing (ii) general e.g. fugue and 11. Emotional instability or lability: is inability to control
somnambulism the emotions and their expression. The emotional change from
8. Impulsive action or impulses: consist of sudden outbursts one extreme to the other with no obvious cause (e.g. Laughing
of activity with little or no provocation, such as attacking and weeping. it occurs in gross organic disorders, such as
another person (bystander), or breaking a window. dementia).
9. Aggression: means intention to inflect harm to the others 11. Morbid anger: is an unprovoked transient angry outburst
without their permission or even their trial to avoid this harm, with violence. (In children and mentally defectives, it is called
the aggression could be physical, verbal, or moral. physical 'tantrums'). Occurs in schizophrenia and personality disorders.
aggression like body injuring, verbal aggression like obscene
words, moral aggression like violation of social or religious B) Qualitative disturbance:
norms that cause harm or embarrassment to others. The i. Incongruity or disharmony of affect: inappropriateness of
nonphysical aggression is called hostility. affect to thought content (e.g. the patient feels happy while he
believes that he is going to be killed by his enemies).
AFFECT VS MOOD ii. Ambivalence denotes the simultaneous existence of
• Mood: Sustained and pervasive emotion that colors the contradic tory emotions (e.g. Love and hate), or ideas (e.g.
person’s perception of the world. being present and absent at the same time, or present in two
The patient may report his feelings or the psychiatrist ask how places simultaneously. It occurs in schizophrenia.
he or she feels.
• Affect: The patient present emotional responsiveness that is DISORDERS OF TALK
inferred from his facial expression. A. Disorders of Stream
1- Slow stream: Slowing of the stream of talk occurs in
DISTURBANCE OF AFFECT different psychiatric disorders particularly in psychosis and the
A) Quantitative disturbance: disturbance shows different degrees:
1. Cheerfulness is used for happiness or gladness. It is a. Lack of spontaneous talk.
pathological when out of the patient's actual circumstances. b. Delayed response to questions.
2. Euphoria is a generalized feeling of well being (not c. Short response to questions.
amounting to a definite affect of gladness). d. No response to questions Mutism.
3. Exaltation means something in addition to elation, an 2- Blocking is a sudden stoppage of the stream of talk, for a
element of grandeur. while and then it is resumed without the patient being able to
4. Ecstasy is a feeling of happiness, usually with a mystical account for such stoppage. This could occur in some normal
coloring. individuals when surprised and in some schizophrenics.
5. Depression is an emotional state characterized by pervasive 3- Rapid stream occurs mainly in mania and some
lack of interest, difficulty to be in pleasure (anhedonia) and schizophrenics.
sadness not in accord with the patient's actual circumstances.
6. Sadness: it is and emotional state occurs as a reaction to
loss of loved object, the object could be a person; money or
status. Sadness could be a part of depressed mood when B. Disorders of Expression
occurs without cause. a. Irrelevant answers to questions. When the patient is asked
a question he responded by answer not related to that question.
b. Over inclusions: the patient talk is much abbreviated and Nihilistic delusion in which the patient declare that he does
not giving the necessary details. not exist (dead) and that there is no world.
c. Derailment: the patient deviates in his talks to subjects Hypochondriacal delusion in, which the patient is convinced
away from the main topic. that he has a physical disease (e.g. cancer stomach) in, the
d. Circumstantiality: there are much unnecessary details, but absence of any evidence thereof.
the subject in view at the beginning is ultimately reached.
Depersonalization: the patient feels that he is no longer
C. Disorders of Association himself; he can no longer believe in his own existence. When
i. Vagueness (the paragraphs of the story are not harmonious) he looks in the mirror he feels himself changed throughout in
ii. Flights of ideas ( the sentences of the paragraph are not comparison with his former state. He feels unreal, strange,
harmonious) lifeless, detached and automatic.
iii. Incoherence (the words of the sentence are not Derealization: the patient feels that the outer world has
harmonious) changed the people, streets and houses look different and
iv. Neologism (the letters of the word in the word are not unusual. He wonders whether his friends are the same people
harmonious) as they were, or whether indeed they exist at all.

Disorders of Thinking Content (Obsessions)

Stream Obsessions
Expression Feeling of compulsion to repeat physical or mental act, the
Content patient realizing that it is silly and meaningless, resisting it and
Form the resistance is accompanied by increasing inner tension
Possession which is relieved by repeating again.
The first and second is the same as those discussed under talk.

Content (Delusions)
Delusions: false, fixed beliefs which is not accepted by
individuals of the same social, cultural or educational Content (overvalued ideas)
background and not corrected by logic reasoning. The overvalued idea refers to a solitary, abnormal belief that is
If the belief is false but is widely accepted by individuals of neither delusional nor obsessional in nature, but which is
the same culture and education it is called culture bound preoccupying to the extent of dominating the sufferer's life.
belief, if it could be corrected by logic reasoning it is called
idea and not delusion. DISORDERS OF PERCEPTION
Hallucinations
Perception of non-existed stimulus
Delusions may be: Types:
I. Systematized (well knit) when they form a coherent system – Visual
and appear to be logical, or – Auditory
II. Non-Systematized when they are fleeting and appear to – Olfactory
have no logical connection – Tactile
– Gustatory
Types of delusions: • Normal (physiological)
Delusion of grandeur: in which the patient imagines that he – Hypna-gogic
is great individual, very rich, strong, intelligent, etc. – Hypna-bombic
Delusion of persecution in which the patient thinks that he is • Pathological
chased (run after) by certain people, or his food is poisoned by – Primary psychiatric disorders
them. • Schizophrenia
Delusion of reference in which the patient believes that • Rarely in depression, mania, paranoid disorder.
everything in the environment is referring to him (e.g. people - Organic mental disorders
talking in the street. newspapers, radio, television, etc. are • Delirium
referring to him). • Drug dependence
Delusion of influences (Passivity feeling) in which the patient • TL epilepsy
says that he is under the influence of electricity, wireless, • Brain tumors
hypnotism or telepathy, utilized by some other person. Such • Encephalitis
delusions include such diverse ideas as a) that the patient's
thoughts are being read b) his limbs are moved without his Illusions
control or consent by some invisible agency. False perception of external stimulus
Delusion of self-reproach (self blame) or sin-: in which the Types:
patient feels that he is wicked, full of sins and unfit to live or – Visual
mix with other people (feeling of unworthiness). – Auditory
Delusion of poverty in which the patient believes that he lost – Olfactory
all his money, property and everything in life. – Tactile
– Gustatory
• Physiological:  the patient mentions even small unnecessary details.
– Intense emotions, change of set, lack of perceptual  It is present in (ii) some normal people (geniuses) (ii) some
clarity mental disorders (hypomania and paranoia).
• Pathological:
– Primary mental disorders CLINICAL EXAM OF MEMORY
• Schizophrenia • Immediate recall:
– Organic mental disorders – (5-7 digits or home address immediately)
• Delirium • Short-term recall:
• Epilepsy – (5-7 digits or home address at 5 min)
• Brain tumors • Recent:
• Encephalitis – what patient did past several days
• Recent past:
DISORDERS OF MEMORY – what patient did past few months, present President,
• Registration recent news events
• Retention • Remote:
• Recall & Recognition – Childhood events, past Presidents, historical events
Any failure of one of these functions is regarded as memory (years)
disorders.
Clinical significance:
• Anxious patient may complain of poor memory because of
defective registration
• In Korsakoff’s syndrome there is failure of retention so the
patient has disturbed immediate recall
• In dementia the recall of recent events is disturbed.

Orientation
• Realization of:
– Time
– Place
– Persons
– Situation
• Disturbed in acute organic brain disorders.

Attention and Concentration

• These terms are used for describing the experience that
certain objects are in the center of consciousness, whilst others
lie more towards the periphery.
• Attention may be disturbed in various ways
• difficult to arouse the attention of the patient.
Types of Amnesia – a) states of disturbed consciousness (e.g.
1. Anterograde amnesia when there is loss of memory for confusion) b) self absorption due to depression or
recent events. schizophrenia.
2. Retrograde amnesia when there is loss of memory for • Difficult to maintain or keep the attention of the patient due
remote events. to distractibility.
3. Total amnesia when there is loss of memory for all events, • Distractibility is a disorder of attention in which the patient
recent and Remote. gives attention to every passing stimulus.
4. Circumscribed amnesia when there is loss of memory for
a limited time (amnesic gap). Types of Attention:
• Active (voluntary) • Passive (involuntary).
Paramnesia (False Recall) • In organic disease: active attention is often good, while
1. Confabulation: when the patient fills the gaps in his passive attention is poor i.e. object in the center of
memory by fabrication i.e. by giving imaginary accounts of consciousness is observed, while those towards the periphery
his activities (Thus a bed ridden patient will describe a walk are not.
which he asserts he has just taken). It usually occurs in organic • In Psychogenic diseases (e.g. schizophrenia) the patient
diseases Korsakov’s syndrome which is typically seen in does not pay attention to what the doctor says to him and at
alcoholism). the same time he pays attention to what the nurses talk about.
2. Falsification (illusion of memory): when the patient adds
false details and meanings to a true memory. It occurs in
organic and psychiatric diseases (e.g. paranoid states). ABSTRACTION
• Abstraction: is the patient's ability to derive a general
Hypermnesia principle from a specific example.
 excessive memory,
• Abstract thinking is affected in psychosis particularly
schizophrenia and mental retardation.

Factors affecting abstraction:

– level of education.
– Culture
– cerebral dysfunction, abstraction deficits are
particularly common with frontal lobe disorders.

Clinical Assessment of Abstraction:

1- Similarities
– Similarities require the patient to identify the class
or category of which two items are members (e.g.,
rose and tulip, bicycle and train, watch and ruler).
2- Differences
– Differences require the patient to identify the
salient distinguishing feature between two similar
items (e.g., child and midget, canal and river, lie and
mistake).
3- Idioms
– Idioms are metaphorical statements or aphorisms that
require the patient to generalize to a larger meaning
(e.g., "seeing eye to eye," "level headed," and "eyes
peeled")
4- Proverbs
– Proverbs are usually double metaphors that require
the patient to ignore the immediate meaning and
derive a lesson or maxim (e.g., "don't cry over spilled
milk," "people who live in glass houses shouldn't
throw stones," "the tongue is the enemy of the neck").

INTELLIGENCE
• The ability to benefit from previous experiences and to get
maximum benefit from available data
• Intelligence is affected in mental retardation

Assessment of Intelligence:
• Clinical assessment
– During interview
– Mathematical problem solving
– Proverb test
– General information

• Psychometry
– WAIS
– WISC
– SB

INSIGHT & JUDGEMENT

• Insight: is the degree of realization the patient has of his
own condition.
• Judgment: is the ability to grasp the meaning of a situation
and hence react to it appropriately.