Lecture no.

2
Psychiatric semiology
 Content
Psychiatric semiology
1. Behavior
1.1 General aspects
1.2 Ontogenesis
1.3 Pathology
2. Psychiatric examination
3. Cognitive functions
3.1 Sensation
3.2 Perception
3.3 Attention
3.4 Memory
3.5 Thinking
3.6 Imagination
 1. Behavior
• Behavior = outward or avert actions and
reactions; talking, facial expressions and
movement
1.1 General aspects:
• Human behavior is studied by the specialized
academic disciplines of psychiatry, psychology,
social work, sociology, economics, and
anthropology.
• It includes the way one acts based on different
factors such as genetics, social norms, core faith,
and attitude.
 1.2 Ontogenesis
• Genetics:
– Recent trends in behaviour genetics have indicated an
additional focus toward researching the inheritance
of human characteristics typically studied in
developmental psychology.
– Behaviour genetics research is currently undertaking
to distinguish the effects of the family environment
from the effects of genes.
• Social norms:
– Social norms, the often-unspoken rules of a group,
shape not just our behaviors but also our attitudes.
– The institutionalization of norms is, however, inherent
in human society perhaps as a direct result of the
desire to be accepted by others, which leads humans
to manipulate their own behaviour in order to “fit in”
with others.
 1.2 Ontogenesis
• Core faith and culture:
– These can be manifested in the forms of religion,
philosophy, culture, and/or personal belief and
often affects the way a person can behave.
– The beliefs of certain cultures are taught to
children from such a young age that they are
greatly affected as they grow up.
– These beliefs are taken into consideration
throughout daily life, which leads to people from
different cultures acting differently.
– These differences are able to alter the way
different cultures and areas of the world interact
and act.
 1.3 Pathology
• The four Ds:
• Deviance: this term describes the idea that a specific
behavior is considered deviant when it is unacceptable or
not common in society. An individual's actions are deviant
or abnormal when his or her behaviour is deemed
unacceptable by the culture he or she belongs to.
• Distress: this term accounts for negative feelings by the
individual with the disorder. He or she may feel deeply
troubled and affected by their illness.
• Dysfunction: this term involves maladaptive behaviour
that impairs the individual's ability to perform normal daily
functions.
• Danger: this term implies dangerous or violent behaviour
directed at the individual, or others in the environment. An
example of dangerous behaviour that may suggest a
psychological disorder is engaging in suicidal activity.
 2. Psychiatric examination
General aims:
● begin to form a therapeutic relationship with the
patient;
● understand the problem, the symptoms, and their
functional impact, from the patient’s perspective,
including their concerns; understand these issues from
the perspective of the relatives/ other carrers, if
appropriate;
● compare the present condition of the patient with their
former state, including any previous illnesses;
● enquire about current and past medication, and other
treatments;
● learn about the patient’s family and other
circumstances, including sources of support.
 2. Psychiatric examination
• The clinical skills required to elicit symptoms and signs
and to make a diagnosis are similar to those used in
other branches of medicine
– careful history taking
– systematic clinical examination
– sound clinical reasoning.
• The only substantial difference is that the clinical
examination includes the mental as well as the
physical state of the patient.

Recommended book: “Psychiatry”, Forth Edition, Oxford

Medical Publications
How to conduct a Mental Health
Assessment and Intake (10 min)
https://www.youtube.com/watch?v=IfdApaOIt4E
Mental status examination (36 min)
https://www.youtube.com/watch?v=VjWVYgf2UcU
 2. Psychiatric examination
• Psychiatric diagnosis of general appearance
and behavior - objective observation:
– Attitude (cooperative/uncooperative)
– Clothing and hygiene (adequate/extravagant)
– Gestures (amplitude/pace/general connectivity
with speech content)
– Mimicry (amplitude/pace/general connectivity with
speech content)
– Look (eye contact with doctor –
initiation/maintenance, mobility)
– Voice (pace/intensity/tone)
 2. Psychiatric examination
• Functional groups in psychiatry
• Cognitive group:
– Sensation
– Perception
– Attention
– Memory
– Thinking
– Imagination
• Affective (motivational) group:
– Mood
– Emotion
– Sentiment (feeling)
– Passion
– Instincts
– Motivation
 2. Psychiatric examination
• Effective group:
– Volition (will)
– Motor behavior
– Activity
– Sleep
• Synthetic group:
– Temperament
– Character
– Personality
– Consciousness
– Personality
– Intellect
 3. Cognitive functions
3.1 Sensation = elementary psychological act –
projection (in consciousness) of the subjective
images of the objects and phenomena from
the environment
3.2 Perception
3.3 Attention
3.4 Memory
3.5 Thinking
3.6 Imagination
 3.2 Perception
Perception = psychological process of sensation
processing through analyzing, comparing and synthesis
=> unique, unitary and synthetic image (in
consciousness)
• Quantitative disturbances:
– Hyperesthesia/hypoesthesia – depending on the
receptor modality (extero/intero/proprioception);
↑- irritability, irascibility – OCD, depression;
↓-lethargy – dementia;
– Anesthesia – chemical/hypnotic/hysterical.
• Cenestopathy – complex, often migratory, hard to
describe discomfort (pain/tingling/sting) with no organic
basis
• Synaesthesia – feeling a perception (typical for a
receptor) with another receptor (e.g. tasting/hearing
colors)
 3.2 Perception
• Qualitative disturbances:
– Illusion = false perception of a real object
• Physiological – checking, critique (e.g. long distance,
low luminosity, exhaustion)
• Pathological – no checking, critique
• Sensorial modalities: interoceptive (visceral)/
exteroceptive (visual, auditory, olfactory, gustatory,
tactile)/proprioceptive
• Most common: visual
– metamorphopsia (deformation of space and objects –
substance intoxication):
» micropsia (objects are perceived smaller than they
actually are)
» macropsia (objects are perceived bigger than they
actually are)
– Capgras Syndrome – a close family member has been
replaced by an identical-looking impostor (illusion +
delusion)
Optical illusions show how we see (19 min)
https://www.youtube.com/watch?v=mf5otGNbkuc
 3.2 Perception
– Agnosia = loss of the ability to recognize objects
after their sensorial features (CNS lesions)
• Visual – prosopagnosia (face blindness – the inability
to recognize faces)/ graphic symbols (e.g. alexia –
inability to understand what one is reading; agraphia
– inability to write)
• Asomatognosia – loss of recognition or awareness
of the body.
• Anosognosia – loss of awareness of one’s illness
• Anosodiaphoria – a person who suffers disability
due to brain injury seems indifferent to the
existence of their handicap
– Hallucination = false perception without a real
object
• Perceived reproductions of objects that are not
present (psychosis)
 3.2 Perception
• Hallucination:
– Functional – having a hallucination simultaneously with
another “trigger”; starts and stops with the other stimulus;
e.g. “Whenever my neighbor takes a shower, I hear lots of
dogs barking.”
– Eidetic images – physiological (images seen before/after
sleep – hypnagogic/hypnopomping hallucinations); also
caused by hallucinogenes/alcohol withdrawal;
– Hallucinosis – critical attitude remains intact; organic
lesions/ or drug/alcohol users;
– Psycho-sensorial – critical attitude disappears, the patient
starts to believe the hallucinations to be real;
– Pseudohallucinations – perceiving a hallucination via
another sensor modality than the usual one; e.g. “I hear a
voice with my knee.”, “I don’t listen to that voice with my
ears, I hear it in my head, I am sure it is telepathy.” –
endophasia;
Oliver Sacks: What hallucination reveals about our
minds (19 min)
https://www.youtube.com/watch?v=SgOTaXhbqPQ
 3.3 Attention
• Attention = psychological process of prospective
orientation; focalization of the psychological
functions on the object of interest
• Types: spontaneous (reflex)/ voluntary
• Tests:
– tachystoscopy (successive, rapid images shown to the
patient which must then be recalled);
– counting down from 100 by 7’s; naming all the
months of the year backwards.
• Quantitative:
– Hyperprosexia (reflex) – ADHD, mania, anxiety;
– Hypoprosexia – dementia;
– Aprosexia – dementia, oligophrenia.
Attention, distraction and the war in our brain
(18 min)
https://www.youtube.com/watch?v=PNbR_nbfK9c
 3.4 Memory
• Memory = psychological process of retrospective
orientation; fixing, stocking, recalling information
• Types:
– very short term (10-15 sec)/ short term (few min)/
long-term (can be lifelong)
– sensorial/social
• Quantitative:
• hyper/hypo/amnesia – lacunar (period of time)/ post-critical/
selective (theme)/ anterograde/ retrograde/ antero-retrograde
• Qualitative:
– sudden synthesis memory disorders (memory
illusions)
– past recall disorders (memory hallucinations)
 3.4 Memory
• Sudden synthesis memory disorders (memory
illusions):
• Cryptomnesia – one claims that a scenario based on
someone else’s story (e.g. an article in a magazine)
happened to him/her (schizophrenia);
• Projecting – one tells his own story but replaces
him/herself in the memory with another person;
• Pick paramnesia – one identifies present situations
as being similar to situations he/she has been
through before; e.g. Pick’s patient claimed he has
been treated by the same doctor, in the same
hospital.
• False recognition or non-recognition
(misidentification of a person – mania, dementia,
Korsakoff Syndrome)
• Déjà/jamais vu/connu/vécu
 3.4 Memory
• Past recall disorders (memory hallucinations):
• Confabulation – one can’t remember parts of the
story he/she is telling, so invents , in order to fill
up the gaps in memory (Korsakov).
• Ecmesia – one experiences an entirely different
time period of his/her life; e.g.
• Pseudoreminiscence – one mixes moments from
the past with present;
• Anecphoria – episodic inability to recall
information until one receives a hint;
The fiction of memory (18 min)
https://www.youtube.com/watch?v=PB2OegI6wvI
The Neuroscience of Memory (1 h)
https://www.youtube.com/watch?v=gdzmNwTLakg
 3.5 Thinking
• Thinking = processing information
– Operations:
• Specific:
– Associations between ideas/concepts – can be logical (cause-
effect) and mechanical (rime, assonance, contiguity)
• Non-specific:
– Analyzing, comparing, synthesizing, generalizing, anticipating,
concretizing
– Quantitative:
• ↑ tachypsychia – bavardage/ flight of ideas/mentism.
• ↓bradypsychia – brabylalia/ mental fading/ mental
blocking/ amentia
 3.5 Thinking
• Qualitative:
– Dominant idea – one thinks about something voluntarily
and can get rid of the thought at will; a dominant thought
can affect mood and may become pathological if it causes
a persistent mood disorder;
– Obsessive idea – one can’t focus on daily living because
the field of thought is occupied by this idea; one knows he
produces the idea but the content/frequency of it is
disturbing; can resort to rituals/compulsions;
– Prevalent idea – paralogical; one sees coincidence
everywhere (e.g. “That squirrel is from CIA and out to get
me. Look, it’s fixing me!”); the idea can progress to
delusion but one is still not so convinced by it.
– Delusional idea
• Paralogical;
• Consciousness is normal;
• One is convinced the idea is truth;
• Conviction despite evidence to the contrary.
 3.5 Thinking
• Dominant and obsessive ideas – one uses the
reality to fight against them – neurosis;
• Prevalent and delusional ideas – one uses reality
to sustain them – psychosis;
• Types of delusions:
– Macromanic/micromanic – euphoric, grandiose – “I
am rich and powerfull.”/ “God punishes me, I have
sinned and I will endure this forever, no one can stand
such a hideous creature like me.”
– Mixed – the content and the mood don’t match (“Oh,
I’m in such a good mood, today! My family is dead!”);
– Contents: persecutory/ jealousy/ prejudice/ richness
 3.5 Thinking
• Organization of delusional ideas:
– Systematized (organized – long duration;
one sustains the delusion by augmenting it
and adapting it to make sense)
• E.g. “I am the king of Brussels because I
graduated the 1000 years School in
Andromeda.”
– Unsystematized (one can’t sustain the
delusion, doesn’t have enough arguments)
• E.g. “Brussels doesn’t have a king.”
“I am the prime minister…”/ “I
don’t know what to say…”
 3.6 Imagination
• Imagination = creates new relationships
between objects/phenomena/ideas –
minimization/ amplification/ agglutination
• Types:
– Reproductive (rebuilt an image that one has seen
before)
– Creative (starts from something already perceived
and modifies it)
– Perspective dream - daydreamung (anticipation)
 3.6 Imagination
• Quantitative:
– ↑ mania, OCD, anxiety
– ↓ dementia, depression
• Qualitative: deformation of reality
– Mitomania – there are no benefits/goals; one lies just
to make him/herself look good through the eyes of
others; e.g. “I have 3 Porches and 8 Mercedes!”
– Simulation – one pretends having an illness
– Metasimulation – one doesn’t have symptoms
anymore but still pretends to have them for the
benefits;
– Oversimulation – one does have an illness but he/she
pretends the symptoms of it are more severe than
they actually are
– Dissimulation – one denies having an illness