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Psychopathology

 Psychiatry studies the causes of mental disorders, gives their description, predicts their future course and outcome, looks for prevention of their appearance and presents the best ways of their treatment

 Psychopathology describes symptoms of mental disorders

 Special psychiatry is devoted to individual mental diseases

 General psychiatry studies psychopathological phenomena, symptoms of abnormal states of mind:

1. Disorders of perception

2. Disorders of thought and speech

3. Disorders of memory

4. Disorders of emotions

5. Disorders of experience of self

6. Disorders of consciousness

7. Motor disorders

Disorders of perception

1. Sensory distortion

Changes in intensity ( hyper- hypo - aesthesia) Hyperaesthesia, is the increased intensity of sensations , may be due to the result of intense emotions or lowering of the physiological threshold . E.g seeing roof tiles as a flaming red fire or hearing door closing like a clap of thunder. Seeing colours brighter and more intense than usual is seen in hypomania, epileptic aura, and seen in intense normal emotion such as the unsurpassed happiness of being in love

Hyperacusis; ; is the increased sensitivity to noise , seen in depression , anxiety , alcohol hangover and migraine . Hypoacusis; where the sensation thresholds are all raised, seen on Delirium when the defect of attention reduces sensory acuity. Hence, the need to speak to delirious patients on a slow and load manner. In depression visual and gustatory sensations are lowered so everything will become black and all the food tastes the same.

Changes on quality It is mainly visual perception that is affected in terms of quality. Drugs such as mescaline and digitalis can change the quality of the perceived colour. In derealisation everything is unreal and strange while in mania objects looks beautiful and perfect.

Changes in spatial form

Refers to the change on the perceived shape of an object. Micropsia , is a visual disorder in which the patients sees objects are smaller than they really are . The opposite form of visual experience is known as Macropsia or megalopsia Dysmegalopsia , some authors use this term to describe objects that are perceived to be larger ( smaller ) on one side than the other , seen in retinal disease , Disorders of Accommodation and convergence and most commonly on temporal and parietal lobe lesions. Rarely associated with Schizophrenia.

2. Distortion of the experience of time

Has two types, physical and personal, the latter is being determined by personal judgment and it's the one which is affected in psychiatric disorders. E. G when we are happy / manic time flies and when we are sad/depressed it passes slowly. Some schizophrenic patients can even develop delusional elaboration that the clock is being interfered with. Recent research evidence suggests that schizophrenic patient’s estimates time intervals to be less than they actually are.

3. Sensory deception

It can be divided into illusions, and hallucinations

Illusions: is the misinterpretation of stimuli arising from an external object. I.e an external stimuli is combined with a mental image to produce a false perception . Illusions on its own are not indicative of any psychopathology since they can occur in absence of psychiatric disorder. e.g seeing shadows on a dark night and misinterpreting it as threatening attacker . It's also seen in delirium. While Illusions are most commonly experienced in visual modalities , they can also occur in any modality e.g auditory illusions may occur when a person hears wits in s conversation that resemble their own name and they believe they are being talked about . Illusions are divided into 3 types

1. Completion illusion : these depends on inattention such as misreading words in newspaper .alternatively , if we see faded letters we may misread the word on the basis of our previous interest in reading ,the word '-ook' might be misread as 'book' even though the faded letter was an 'L' . 2. Affect illusion: these arise in context of a particular mood state .e.g a bereaved person may momentarily believe they 'see' the deceased person

3. Paredolia: in which vivid illusions occur without the patient making any effort. These illusions are a result of excessive thinking and vivid visual imagery. E.g seeing vivid pictures in a fire or in clouds, without any conscious effort.

Hallucinations

Is a perception without an object / stimuli. The subject reacts to them as if they were true perceptions.

True perception : are substantial , appear in objective space , are clearly delineated , constant and independent of the will and their sensory element are full and fresh

Mental images : are incomplete , and not clearly delineated ,are dependent on will , exist in subjective space , are inconstant and have to be recreated .

Peudo-hallucinations: Are a type of mental image that , although clear and vivid , lacks the substantially of the perception , they are seen in full consciousness , known to be not real perception and are located in the subjective space e.g hearing voices inside of the head . It can occur on auditory, tactile or visual modalities. They do not represent any form of psychopathology, unlike true hallucination which is indicative of serious mental illness.

Causes of Hallucination

1. Emotions : very depressed with delusion of guilt may hear voices reproaching them , the voices in this case tend to be disjointed or fragmentary , uttering single words or short phrases such as ' kill yourself' .

2. Suggestions ;several experiment have shown that patients could be persuaded to hallucinate e.g when asked to walk down a dimly lit corridor and stop when they see a faint light, most subjects stopped walking at some point during the study saying that they could see s light even though none was switched on .

3. Disorder of a peripheral sense organ Hallucinatory voices may occur in ear disease and visual hallucinations in eye diseases . E.g Charles Bonnet Syndrome, is a condition in which complex visual hallucinations occur in absence of any psychopathology and in clear consciousness . It's associated with either central or peripheral reduction in vision, common in elderly.

4. Sensory deprivation: normal subjects can hallucinate if all incoming stimuli are reduced to a minimum after few hours. E.g sensory derivation due to the use of protective patches following Cataract surgery may contribute to Delerium .

5. Disorder of CNS : brain lesions can Leed to visual hallucination . Auditory hallucinations can also occur.

DDX of hallucinations

1. Illusions 2. Pseudo-hallucinations 3.hypnagogic and hypnopompic images 4. Vivid imagery 5. Normal perception

Auditory Hallucination : A. Elementry , such as noises , bells, whispers B. Partly organised: as in music C. Completely organise : as well formed hallucinatory voices in schizophrenia .

In terms if quality in can vary from being quite clear to those that are vague which the patient can not describe clearly . The voices can be of a person of either sex , giving instructions to the patient which the patient may or may not act on them and sometimes it can be abusive , neutral or even helpful . The effect of hallucinations varies according to the patient , some are not troubled by them . For others the hallucination makes the person to stop all the activities to listen to them and sometime even replies to them.

- Thought Echo: hearing your thoughts spoken out loud. First rank symptoms of schizophrenia - Running commentary: voices speak about the person in 3rd person and may give running commentary on their actions. First rank symptoms of schizophrenia.

- 2nd person auditory hallucination : voices addressing the patient directly

- 3rd person auditory hallucination: Voices of people talking to one another addressing the patient directly.

Visual Hallucinations V.H: Elementary: Flashes of light, partly organised: Patterns Completely organised: vision of people, objects or animals. Figures are formed on the background of normal perception or the whole scene (scenic hallucinations)

 All V.H are found in acute organic state

 Small animals and insects found in Delirium

 Scenic hallucinations are common in psychiatric disorders associated with epilepsy

 V.H could be accompanied by other forms of hallucinations e.g. TLE  V.H with Micropsia = Lilliputian hallucinations seen in DT

Olfactory Hallucinations :

 Seen in Schizophrenia, organic state, and uncommonly in depressive psychosis.

 Might be difficult to distinguish from delusion in psychotic patients.

 Associated with the Aura phase of TLE

Gustatory hallucination: This type of hallucination is the perception of taste without a stimulus. These hallucinations, which are typically strange or unpleasant, are relatively common among individuals who have certain types of focal epilepsy, especially temporal lobe epilepsy

Tactile hallucination:

- Fomication : small animals crawling over the body, seen in acute organic state

- Sensation of wind blowing, heat , electrical shocks and sexual sensations

- Secondary delusional elaboration is common

- Schizophrenia is the main DDX in the absence of organicity

Hallucinatory syndromes:

Also called ( Hallucinosis ) , refer to those disorders in which there are persistent hallucinations in any sensory modalities in the absence of other psychotic features , the main hallucinatory syndromes are :

1. Alcoholic Hallucinosis : these hallucinations are usually auditory and occur during period of relative abstinence . They may be threatening or reproachful. Hallucinations rarely persist longer than one week and are associated with long standing alcohol misuse.

2. Organic Hallucinosis: These are present in 20-30 % of patients with dementia, especially of Alzheimer type, and are most commonly auditory or visual. There is also disorientation and memory is impaired. The

Special Kinds of hallucinations

Functional hallucinations: functional hallucinations are defined as those that occur when a patient simultaneously receives a real stimulus in the perceptual field concerned. In another word the hallucinations requires the presence of another real sensation e.g a patient with schizophrenia first heard the voice of god as her clock ticked. Patient crucially can distinguish both sensations from each other and the hallucination does not occur without the stimulus. Some patients who discover that noises induce hallucinatory voices put plugs in their ears to reduce the intensity of the stimulus and hence the hallucinations. Seen in chronic schizophrenia

Reflex Hallucination (Synaesthesia): A stimulus in one sensory modality produces a hallucination in another e.g. a patient felt a pain in her head (somatic hallucination) when she heard other people sneeze (the stimulus). Synaesthesia is the experience of a stimulus in one sensory modality producing a sensory experience in another, e.g. the feeling of cold in one’s spine on hearing a figure nail scratch a blackboard. Is manifested when patients are under the influence of LSD mescaline when they describe feeling, tasting and hearing flowers simultaneously.

Extarcampain hallucinations: The patient has hallucinations that is outside the limit of the sensory field e.g a patient hear voices talking in Sulymania when they are in Erbil . Can occur in healthy people as Hypnagogic hallucinations but is also seen in schizophrenia or organic condition such as epilepsy.

Autoscopy or phanotom mirror-image: Is the experience of seeing oneself and knowing that is oneself. It is not just a visual hallucination because Kinaesthetic and somatic sensation must also be present to give the subject the impression that the hallucination is oneself. Can occur in healthy subjects when they are emotionally upset or exhausted. Occasionally autoscopy can be a hysterical phenomena . Also seen in schizophrenia but they are more common in acute and subacute deleium and other organic conditions.

Hypnagogic and hypnopompic hallucinations: these hallucinations occurs when the subject is falling into sleep or waking up respectively. Hypnagogic hallucinations are three times commoner that the Hypnopopmic one , although the latter are a better indicator for narcolepsy . the subject often believe that the hallucination has woken them up ( e.g hearing a telephone ring even though it has not ) and although the auditory modality is the most common it can also be visual, kinaesthetic or tactile and is sudden in occurrence. EEG recordings during the episode show a low of alph rhythm at the time of the hallucinations. hypnagogic visual hallucinations may be geometrical design , abstract shapes, faces figures and scenes from the nature . Auditory hallucinations may be animal noises, music or voices. It could also be a manifestation of sleep deprivation in which the patient dose not retains insight into the morbid phenomena; it usually resolves ones the patient has a good sleep. Both phenomena are not indicative of any psychopathology even though they are true hallucinatory experiences.

Organic Hallucinations: can occur in any sensory modality and they may occur in a variety of neurological and psychiatric disorder. Organic visual hallucinations occur in eye disorder as well as in CNS disorder and lesions of optic tract. Complex scenic visual hallucinations are seen in temporal lobe epilepsy. Charles Barnett syndrome consists of visual hallucinations in absence of any other psychopathology of. All the dementias as well as in delirium and substance abuse are associated with visual hallucinations.

The phantom limb is the most common organic somatic hallucination of psychiatric origin. In this case the patient feels that they have a limb from which in fact they are not receiving any sensation either because it has been amputated our because the sensory pathways for it had been destroyed. Phantom limbs or careers in about 95% of all the amputations after the age of six years. Occasionally it develops after a lesion of the peripheral nerve or the medulla or spinal cord. The phantom limb does not necessarily correspond to the previous image of the limb in that it may be shorter or and consists only of the distal portion so that the phantom hand arises from the shoulder. Equivalent perceptions of phantom organs may also occur after surgical procedures such as mastectomy, removal of the larynx or the construction of colostomy. The person is aware of the existence of the organ or the limb and describes pain or parasthesia in the space occupied by the phantom organ.

The patient attitudes to hallucinations

In organic hallucinations patient is usually terrified by the visual hallucinations and may try desperately to get away from them. Was delirious patients feel threatened and are generally suspicious. The combination of prosecuted attitude or visual hallucinations may lead to resistance to all nursing care and two it can also attempts to escape from the threatening situation, so that the image on top of the window and jeopardise their lives. The exception is Lilliputian hallucinations, which are usually regarded with amusement by the patient may be watched with delight.

Patients with depression often hear disjointed voices of using them or telling them to kill themselves. They are not terrified by the voices, as they believe they are wicked and deserve to hear what’s being said to them. With instructions to kill them selves are not frightening sense that they may have thought of this for some time anyway.

The unsettled voices in acute schizophrenia is often very frightening than the patient at times imitate the person he believes to be their source. Those with chronic schizophrenia on the other hand are often not troubled by the voices and may treat them as old friends. But a few patients complain bitterly about them. The stations for are knowledgeable about their illness or who have insight into it may deny hallucinations, since they know this is an abnormal feature. Some time it is obvious that the patient is hallucinating if they stopped talking and appear to be listening to something else or if they attempted to apply to the voices.

Body image of distortions

Hyperschwmazia, is the perceived magnification of body parts seen in a variety of organic & for the conditions

Aschemazia and hyposchemazia, is the perception of body parts as absent or diminished respectively, seen in parietal lobe lesions

Koro, is the belief that the penis this shrinking and will retract into the abdomen any cause the death the condition is found in South East Asia and thought to be due to faulty understanding of the anatomy. The diagnostic equipment is already anxiety disorder

Paraschemazia, all of the distortion of the body image is described as feeling that part of the body are distorted or twisted or separated from the rest of the body and can occur in associations with hallucinogenic use, with epileptic aura or migraine. Hemisomatognosia,is the unilateral lack of body image in which the person behaves as if one side of the body existing, it’s seen in migraine and during epileptic aura.

Anosognosia, is the denial of illness for example patients with hemiplegia after stroke are seen to deny the existence of any form of paralysis..

Disorders of thought and speech

Disorders of thought includes the disorder of intelligence, stream of thought and possession of thought, obsessions and compulsions and disorders of the content and form or thinking. Disorder of intelligence

Intelligence is the ability to think and act rationally and logically. In practice, intelligence is measured with tests of the ability of the individual to solve problems and performed concepts through the use of words, numbers, symbols, patterns and non verbal materials. Intelligence tests showed that intelligence begins to decline in middle age and receives significantly less rapidly than previously believed.

The most common way of measuring intelligence is in terms of distribution of scores in the population. The person who has an intelligence corps of the 75 percentile has a score that such that 75 per cent of the appropriate population scor Less than 25 % score more. Most intelligence test are designed to give a mean IQ of 100 with standard deviation of 15. Learning disability tend to be categorised as a borderline if they have an IQ of 70 – 90, mild 50 – 69, moderate 35 – 49, severe 20- 35, profound less than 20.

Dementia is a loss of intelligence resulting form of brain disease, characterized by disturbances of multiple cortical functions, including thinking, memory, comprehension and orientation.

Disorder of thinking

1. Disorder of stream of thinking

2. Obsession, compulsions and disorder of thought possession

3. Disorder of thought content

4. Disorder of the form of thinking

1. Disorder of stream of thinking: this can be further subdivided into disorder of tempo and disorder of continuity Disorder of thought tempo

a. Flights of idea: in this case thoughts follows each other rapidly, there is no general direction of thinking, and the connections between successive thoughts appears to be due to chance factor which, however can usually be understood. The patient speech is easily diverted to external stimuli and by internal superficial associations. The associations of the train of thought are determined by Chance relationship, verbal associations of all kinds, clang associations, proverbs. The Chance linkage of thoughts seen flights of idea is demonstrated by the fact that one could completely reverse the sequence of the record and the progression of thought would be understood just as well. An example of light of idea in manic patient when she asked where she lives, she stated Birmingham, Kensington, king standing, King, Sing, bed on the wing, wing, wing on the bird.

Patients generally lose the thread for a few moments and finally reaches their goal. Unlike the detailed elaborations in “Circumstamtiality”. In acute mania flights of idea can become so severe leading to incoherence, as before one thought is formulated in two words another forces its way forward. Flights of ideal occasionally seen in individuals with schizophrenia, organic states such as lesions of hypothalamus.

b. Inhibition or slowing of thinking: in this case the train of thought is slowdown and the number of ideas and mental images that presents themselves is decreased leading to difficulties in making decisions, lack of concentration, and the loss of clarity of thinking. This is usually accompanied by diminished active attention, so that events are poorly registered leading to patients complaining of memory loss. The appearance of cognitive deficits in individuals with thought slowing may lead to a mistaken diagnosis of dementia. Also seen in depression and the rare conditions such as of manic stupor.

c. Circumstamtiality: it’s seen when thinking proceeds slowly with many irrelevant and trivial details, but finally the point is reached. The golf thinking is never completely lost and thinking proceeds towards it by an intricate and convoluted path. Circumstamtiality can occur in context of epilepsy and learning disability and individuals with obsessional personality traits

Disorder of the continuity of thinking

a. Perseveration: it’s manifested when the mental operation continues beyond the point at which they are relevant and thus prevent progress of thinking. There are verbal and ideational perseverations. For example a patient may be asked the name of the previous prime minister and reply John major. On being asked by the name of the present prime minister he may reply John major. Perseveration is common in generalised and local organic disorder of brain and when present they provide strong support for such diagnosis. The patient may be aware the initial stages of such a difficulties and they may even try to overcome it. This should be differentiated from verbal Stereotypy in which the same phrase or word is repeated which is not related to the current situation. Whereas in Perseveration a word, phrase or ideas persists beyond the point at which it is relevant.

b. Thought blocking: describes the sudden arrest of the train of thought, after which an entirely new thought may then begin. In patients who retain some insight, this may be a terrifying experience this phenomenon is different from the common experience of sudden loss of train of thought due to anxiety or exhaustion. It’s a highly suggestive of schizophrenia.

2. Obsessions, compulsions and disorders of the possession of thought

Obsessions and compulsions:

An obsession, also termed rumination, is a thought that persists and dominates an individual thinking despite the individual’s awareness that the thought is either entirely without a purpose or continued and dominated their thinking beyond the point of relevance or usefulness. One of the most important features of obsessions is the great deal of anxiety and guilt which caused the patient. The patient retains insight into the difficulties and resisting the obsession leads to great deal of anxiety and frustrations.

Compulsions are in fact obsessional motor acts. There results from an obsessional impulse which may lead directly into action, for example the obsessional fear of contamination may lead to compulsive washing.

The essential feature of obsession is that it appears against a patient will and it could be in form of images, ideas, fears and impulses. Obsessional images are a vivid image that occupies the patient mind. At times they may be so vivid that they can be mistaken for pseudo-hallucinations. For example a patient is obsessed by an image of his on gravestone to an extent he can clearly see his name engraved on it. Obsessional ideas could cover a variety of subjects ranging from Why the sky is blue to the possibility of committing a murder. Obsessional impulses may be in form of impulses to touch,count, or arrange objects or an impulses to comment antisocial acts. Obsessional fears or phobias consist of groundless fear without a cause.

Obsessions are seen in depression, schizophrenia and occasionally and organic states. Up to 14 per cent of patients with OCD may report psychotic phenomena such as delusions and hallucinations and thought disorder.

Thought alienation While patients with OCD recognizes that there were obsessional thoughts belongs to them selves and does not regard them as being foreign or outside of their control. in thought alienation the patient has the experience that they are thoughts are under the control of an outside agency or that others are participating in their thinking.

In thought insertion the patient knows there that thoughts are being inserted into their mind and they recognise them as being foreign and coming from without, this symptoms is commonly associated with schizophrenia

In Thought deprivation and the patient suddenly finds that there thought has disappeared and are withdrawn from their mind by a foreign influence.

In thought broadcasting the patient knows as they are thinking, everyone else is thinking Unison with them. In another word thoughts are being escaping from one’s mind and that other people might be able to access them. Thought alienations form an important component in the diagnostic criteria for schizophrenia.

Disorders of the content of thinking

Delusion is defined as false, unshakable belief that is out of keeping with the patient’s social and cultural background. Delusions are the results of primary delusion of experience that cannot be deduced from any other morbid phenomena while delusion –like a ideas is a secondary and can be understandably drive from some other morbid psychological phenomena.

Overvalued ideas these ideas which are neither obsessional nor delusional, the thought process takes precedence over all other ideas and maintain this precedence permanently or for a long period of time. Even though overvalued ideas tend to be less fixed them delusions and tend to have some degree of basis in reality, it may at times be difficult to distinguish between overvalued ideas and delusions.

Primary delusions

The essence of the primary delusional experience is that a new meaning of a rises in connection with some other psychological event. It has three forms delusional mood, delusional perception, and the sudden delusional ideas

In the delusional mood, the patient has the knowledge that there is something going on around him which concerns him, but it does not know what is it. It’s usually followed by the development of a sudden delusional ideas this is also known as Autochthonous Delusion.

The delusional perception is the attribution of new meaning, usually in the sense of self reference, to a normally perceived object. The new meaning that cannot be understood as arising from the patient’s affective state or previous attitudes.

Primary delusional experiences tends to be reported in acute schizophrenia but are less common in chronic schizophrenia where they may be buried under a mass of secondary delusions are rising from the primary delusional experiences, hallucinations, formal thought disorder and mood disorder.

Secondary Delusions and the systematisation

Secondary delusions can be understood as arising from other morbid experiences.

In schizophrenia once the primary Delusional experience is established they are commonly integrated into some sort of delusional system which is also called “Delusional work”. It is common among some practitioners to divide delusions into systematised and non –systematised.

The content of Delusions

a. Delusion of persecution – seen in context of primary delusional experience, auditory hallucinations, bodily hallucinations, or experiences of passivity seen in patients with schizophrenia and severe depression or mania. The supposed prosecutors of the deluded patient may be people from the environment such as family members, neighbours or maybe political or religious groups. Patients believes that there are people trying to harm him or harm their loved ones, believe that people are trying to poison or infected him/her.

b. Delusion of infidelity – the commonly used term “Delusion of jealousy”. A belief that one’s partner is being unfaithful. It seen in both organic and functional disorders the patient is often sensitive, suspicious and mildly jealous before the onset of illness. It’s not uncommon in patients with schizophrenia and alcohol dependency Syndrome. There is a strong association with violence, usually toward the partner.

c. Delusion of love- also called “ de Clerambault syndrome” or “Erotomania” or “ The fantasy lover syndrome” the patient is convinced that some person is in love with them although the alleged lover may never have spoken to them . A rare symptom of schizophrenia and other psychotic illnesses.

d. Grandiose Delusions- an exaggerated believe of one’s own importance or abilities. Some patients may believe there are God, queen of England or a famous pop singer. Others are less explosive and believe that they are a skilled sportsmen or an inventor. The delusion may be supported by auditory hallucinations which tell the patients that they are important or even hearing the voice of god.

e. Delusions of ill health – a characteristic feature of depressive illness, but also seen in other disorders such as schizophrenia. Patients with this delusion may believe that they are suffering from a serious illness such as cancer, tuberculosis, or HIV. Hypochondriacal delusions in schizophrenia can be as a result of depressed mood, somatic hallucinations or a subjective sense of change such as in case of somatic hallucinations.

f. Delusion of guilt – in which the patient believe that they are bad or evil person and have ruined their family and in severe cases it may have a grandiose content for example where the patient belief that they are the most evil person in the world. Delusions of guilt sometime give rise to delusion of persecution.

g. Nihilistic delusions-in which the patient denies the experience of their body, mind, their loved ones, and the world around them. Some time the even believe that they are dead, the world has stopped, and everyone else is dead. These delusions occur in context of severe, agitated depression as well as in schizophrenia and delirium.

h. Delusions of poverty – in which the patient is convinced that they are impoverished. This delusion is typical of depression.

The reality of delusions is that not all the individuals with delusions act on their belief. Usually, when the delusional illness becomes chronic there is a discrepancy between the delusions and the patient’s behaviour for example, the grandiose patient who believes they are god may be happy to remain in a psychiatric ward as a volunteer patient. Or the persecuted patient believes that they are being poisoned maybe happy to eat hospital food.

Delusions of infidelity are particularly dangerous and may be associated with violence or homicide.

Disorder of the form of thinking

The other term is” formal thought disorder “which is a disorder of conceptual or abstract thinking which are most commonly seen in patients with schizophrenia and organic brain disorder.

Types of Disorders of Thought

Overinclusion: refers to a widening of the boundaries of concepts such that things are grouped together that are NOT often closely connected. Loosening of Associations: refers to a loss of the normal structure of thinking. The person with loosening of associations demonstrates discourse that is muddled and illogical and does NOT become clearer with further questioning. In loosening of associations there is a lack of general clarity and the interviewer has the experience that the more the person tries to clarify the persons thinking the less it is understood. Loosening of associations is a type of thought disorder that occurs mostly in schizophrenia. Three Kinds of Loosening of Association: 1. Knight’s Move Thinking or Derailment: is characterized by speech where there are odd tangential associations between ideas. 2. Talking Past the Point (Vorbeireden): describes a situation where the person seems to get close to the point of discussion, but skirts around it and never actually reaches it. 3. Verbigeration, Word Salad, Schizophasia, or Paraphrasia: is a situation where speech is reduced to a senseless repetition of sounds and phrases.

Circumstantiality: where thinking proceeds slowly with many unnecessary details and digressions, before returning to the point. This is seen in epilepsy, learning difficulties and obsessional personalities Neologisms: are words and phrases invented by the patient or a new meaning to a known word.

Metonyms: are word approximations e.g. paperskate for pen. Hollywood for us cinema industry

Drivelling: is where there is a disordered intermixture of the constituent parts of one complex thought. Fusion: is where various thoughts are fused together, leading to a loss of goal direction. Omission: where a thought or part of a thought it is senselessly omitted.

Substitution : is where one thought fills the gap for another appropriate more ‘fitting-in’ thought.

Concrete Thinking: is seen as a literalness of expression and understanding, with failed abstraction. Can be tested by the use of proverbs.

Thought blocking refers to the sudden arrest in the flow of thoughts. The previous idea may then be taken up again or replaced by another thought.

Disorders of speech

1. Stammering and stuttering: in stammering the normal flow of the speech is interrupted by pauses or by the repetition of fragments of the words. Grimacing and tic-like movement of the body are often associated with stammer. Stuttering usually begins about the age 4 years and is more common in boys than girls. It often improves with time, and may only become noticeable when the person is anxious. Sometimes it persists into adult life when it may become a significant social disability. Occasionally it occur during sever adolescent crisis or at the onset of schizophrenia.

2. Mutism: there is complete loss of speech and may occur in children with a range of emotional or psychiatric disorders and in adults with hysteria, depression, schizophrenia or organic brain disorder. Elective Mutisim may occur in children who refuse to speak to certain people for example; the child may be mute at school but speaks at home. In certain families, refusal to speak may become a recognized technique for dealing with family quarrels. Occasionally, there are families in which some members have not spoken for years though they live under the same roof. Hysterical Mutisim is relatively rare and the most common form of it is called Aphonia. Severe depression with psychomotor retardation may be associated with mutisim, but more often there is poverty of speech and the patient replies to questions in a slow fashion. Mutisim is almost always present in catatonic stupor but it may also occur in non-stuperose catatonic individual as Mannerisim. In sever motor aphasia, complete mutisim does not happen. In pure Word- dumbness the patient is mute that can and will read and write.in Akinetic mutisim, which is associated with lesions of upper mid-brain , there is mutisim despite lowering of the level of consciousness and anterograde amnesia.

3. Talking past the point ( Vorbeireden) : in which the patient replies to the question asked and they appear to have understood it but they respond by talking about an associated topic. For example, if asked ( what is the colour of the grass ) ? the patient replies “White” or are enough of the dog by neck on . this condition is seen in Conversion disorder when psychiatric symptoms are unconciosly being presented for some advantage. Its also found in acute schizophrenia, especially among adolescents( Hebephrenic schizophrenia)

4. Neologisms: it is a new words that are constructed by the patient or an ordinary words that are used to in a different way. It seen in schizophrenia. Patients with motor aphasia sometimes use the wrong word, or even invent new words or distord the phenotic structure of the word and for the and from off from the of the thyroid

5. Speech confustion or schizophasia ( word salad): commonly in schizophrenia in which the speech is profoundly confustion and mixed.

6. Aphasia (Dysphasia): is the disorder of speech resulting from interference with the functioning of certain areas of the brain. It’s more likely to have an organic aetiology rather than a major psychiatric disorder. It’s classified into three types

A. Receptive aphasia: This is sub classifies in to Three types:

- Pure word deafness: in which the patient can hears the words but cannot understand them, this is usually attributed to the lesions in the dominant temporal lobe.

- Agnostic alexia: the patient can see the word but cannot read them; this is usually attributed to lesions in left visual cortex and corpus callosum.

- Visual Asymbolia: (Cortical visual aphasia): in this condition the patient finds difficult to read and write, they often able to understand and words or sentences but they cannot read out aloud or they can read out aloud but incorrectly; this is attributed to lesions involving the angular and supramarginal gyri. B. intermediate Aphasia: This is subclassifies in to Two types

- Nominal aphasia: the patient can not name objects, although they have plenty of word at their disposal . usually they find it difficult to carry out verbal written commands and they cannot write spontaneously although they can copy written written material. Found in diffuse brain damage or with focal lesions in dominant termporoparietal region.

- Central (conductive aphasia) : the patient experiences substantial disturbances in language function with impairments of speech and writing. Speech is faulty in grammar and syntax. Both receptive and expressive aspects of speech is affected.

C. Expressive aphasia:

- Cortical motor aphasia (Brocas aphasia): caused by lesions in the Broca’s area in the posterior two-thirds of the third frontal convolution. In this type of patient has difficulties in putting their thoughts into words and in severe cases speech may be restricted to a few words. The patient is typically aware about the deficit and this in turn leads to intends frustration and anxiety. The sentence organisation is not as severely affected as the use of words. The use of short words leeds to a “telegram style” of speech.

- Pure word-dumbness: in which the patient is unable to speak spontaneously, to repeat words and to read aloud, but they can write spontaneously, copy and write to dictation. The disorder probably results from a lesion beneath the region of the insula.

Disorders of memory

Divided into three types

Sensory memory –which is the registered memory for each of the senses and its purpose is facilitate the rapid processing of incoming stimuli so that comparisons can be made with materials already stored in short – and long term . Selective attention allows for the shifting of relevant material from sensory memory for further processing and storage in short term memory. As a consequence most sensory memory fades with a few seconds.

Short term memory which is also called working memory, allows for the storage of memories for much longer than few seconds. It aids the constant updating of one’s surroundings. For example if the person sees a walking dog and a few seconds later heard a dog bark he would not be surprised since you would identify the likely source of the sound from sensory (visual) memory which had been processed and encoded in short term memory. When memories have been rehearsed in short term memory they are encoded in to long term memory.

Long term memory allows for recall of events from the past and the utilisation of information learned through the educational system. Encoding is the process of passing information from short to long term memory which has a limitless memory reservoir.LTM unlike STM, is resilient to attack by disorders of brain such as Alzheimer disease.

Auto biographical memory refers to the memories for events and issues that relates to oneself. These may be for specific facts, for example whether you are married, and specific experiences for example your wedding day. It’s characterized by general recall of the event with few specific details. It’s not necessarily like a video playback of the event.

Flashbulb memories are specific type of autobiographical memories in which the person becomes aware of an emotional arousing events, e.g 9/11 attacks

On clinical grounds memory can be divided into

Explicit or declarative or relational memory, which is subdivided into episodic memory for example, going to the shops this morning,: and Semantic memory for abstract facts such as” what is the capital of Iraq”. Autobiographical memory is one type of episodic memory.

Procedural memory ( implicit memory) in which there is no active awareness that the memory been searched for for example skills such as typing, swimming, and driving.

The process of remembering has four parts : registration, retention, retrieval, and recall . Memory impairments

Amnesia: is defined as partial or total inability to recall past experiences and events its due to organic oral psychgenic causes.

Failure to recall may also occur due to memory decay or due to proactive interference in which old memories interferes with new learning and hence with recall for example learning Spanish this year make it difficult to learn German next year, while in retroactive interference new materials interferes with the retrieval of old material, for example learning Spanish this year makes it difficult to recall the German learned last year.

1. Psychogenic amnesias:

a. Dissociative or hysterical amnesia is the sudden amnesia that occurs during periods of extreme trauma and the last for hours or even days. Then amnesia will be for personal identity such as name, address and history as well as for personal event, well at the same time the ability to perform complex behaviour is maintained. There is a discrepancy between the marked memory impairment and the preservation of personality and social skills. Dissociation may be associated with a “Fugue” in which the subject travels to another town or country and is often found wandering and lost. Dissociative amnesia is believed to be more common in those with prior history of head injury.

b. Katathymic Amnesia : it is an amnesia which is limited for specific traumatic events such as painful memories. It is more persistent and circumscribed than dissociation in that there is no loss of personal identity. Psychotherapeutic intervention can help those memories to surface up from the unconscious to the consciousness.

2. Organic amnesias:

a. Acute brain disease : in these conditions memory is poor due to disorders of perception and attention. Hence there is a failure to encode materials into the long term memory. In acute brain injury there is a retrograde amnesia which includes memory loss for the events prior to the head injury, while anterograde amnesia is the amnesia for the events occurring after the head injury indicating a failure in the encoding process to LTM. Blackouts, are circumscribed periods of anterograde amnesia experienced particularly by those who are alcohol dependent during and following bouts of drinking, delusion, or epilepsy.

b. Subacute coarse brain disease : characterized by inability to learn new information (anterograde) and the inability to recall previously learned material ( retrograde), however, memories from the remote past remains intact . As improvement occurs , the amnestic period may shrink and recovery may sometime be total , e.g korsakoff’s syndrome .

c. Chronic coarse brain disease: it starts by memory loss for recent events followed by amnesi a for reward events extending over many years. E.g Alzeheimer Dementia.

3. Other amnesias: Anxiety amnesia : occurs where there is an anxious preoccupation or poor concentration in disorders such as depression and generalised anxiety disorder. They are generally caused by impaired concentration and can resolve ones the underlying disorder is treated.

Paramnesia ( distortion of memory)

This is the falsification of memory by distortion and can be divided into distortions of recall and distortions of recognition . This can also occur in normal subjects due to the process of normal forgetting or due to proactive and retroactive interference . It can also occur in adults with emotional problems as well as organic states.

Distortion of recall:

1. Retrospective falsification: refers to unintentional distortion of memory when it filters through the person’s emotional and cognitive state. For example, a patient with depression can describe all past experiences in negative terms due to the impact of their current mood. I.e. The highlight the negatives rather than the positives. Indeed any psychiatric illness can lead to retrospective falsification and it may even continue following recovery. 2. False memory: is the recollection of an event (or events) that did not occur by the individual subsequently strongly believes that it did take place . the syndrome does not refer to the distortion of true memories, in fact it refers to actual construction of memories for events that never took place . Seen in events of childhood abuse recalled by adults and on rare situations such as false confession to serious crime. It sometime even called memory distrust syndrome. It is common in people who are suggestable for example in the person who says they were in hospital following CVA when in fact they had no recollection of this and had been told by their family that it had happened.

3. Screen memory: it is a recollection that is partially true and partially false. It is thought that the individual only recalled part of the tree memory because the entirety of the true memory is too painful to recall. For example, a the childhood sexual abuse which was carried out by a brother was too painful to recall so that recalls the events as a sexual abuse by the neighbour.

4. Confabulation: is the falsification of memory occurring in clear consciousness in association with organic pathology. It manifests itself as the filling-in of gaps in memory by imagined or untrue experiences that have no basis in fact. It has two types, the embarrassed type in which the patient tries to fill in gaps in memory as a result of awareness of the deficit and secondly the fantastic type in which the patient fills the gaps with details exceeding the need of the memory impairment such as descriptions of wild adventure the former is more common. Some people has labelled Convfabulation as memory hallucinations or retrospective delusions.

5. Pseudologia fantastica : (fluant plausible lying) , (pathological lying) : is the term which is used to describe the Confabulation that occurs in those without organic brain pathology such as personality disorders of antisocial and hysterical type. Typically the subject described various major events and traumas or makes grandiose claims and these are often present a time of crisis, such as facing legal proceedings. Although they can usually seems to believe their own story, when confronted with contrary evidence these individuals will admit their lying.

6. Munchausen’s syndrome: is a variant of pathological lying in which the individual presents to hospital with bogus illnesses, complex medical stories and often multiple surgical scars and. A proxy form of this condition has been described in which the individual, usually the parent, produces a factitious illness in somebody else’s, usually their child. This when the to repeated presentations to the hospital over a long period of time.

7. Ganser syndrome ( approximate answeres)( Vorbeireden) : in which the patient gives approximate suggesting that they understood the question but appears to be deliberately well avoiding the correct answer , for example, when asked how many eyes a dog has , the answer given it three. Ganser believed it to be a hysterical condition with the unconscious production of symptoms to avoid court appearances in criminals. Many now believes that Ganser syndrome is indicative of either an organic or a psychotic state rather than hysteria as originally believed. The condition is found in Hebephrenic schizophrenia. 8. Cryptomnesia: is the experience of mot remembering that one is remembering for example, a person writes an original passage and does not realise he is quatting from some passage they have seen elsewhere rather than writing something original. There is no indication as to whether this condition reflects an abnormal pathology.

9. Retrospective delusion: are found in patients with psychses who back date their delusions in spite of clear evidence that their illness is of recent origin.

Distortion of recognition

1. Deja vu: is not strictly a disturbance of memory, but a problem with the familiarity of places and events. It is the feeling of having experienced a current event in the past, although it has no basis in fact.

2. The converse is called Jamais vu is the knowledge that an event has been experienced before but is not presently associated with the feelings of familiarity.

3. Deja entendu: the feeling of auditory recognition

4. Deja pense: a new thought recognised as having previously occurred. similar to déjà vu but in a different modality of experience. All the above can be experienced by normal subjects and patients with temporal lobe epilepsy.

5. False identification is the misidentification seen in organic psychosis or acute and chronic schizophrenia. Sometimes they recognise strangers as friends and relatives. In negative misidentification the patient believes that friends and relatives are in fact strangers. in Capgras syndrome the patient assert that some or all people are doubles of the real people whom they claim to be. Seen in schizophrenia and in dementia. Hyperamensia

Is the opposite of amnesia and paramensia . It is the exaggerated registration, retention and recall the. Flashbulb memories are those memories that are associated with intense emotions. They are unusually so vivid, detailed and longstanding; for example, many people can recall where and what they when doing when they heared the news of the death of Diana, princess of Wales. Disorders of emotion

A feeling can be defined as a positive or negative reaction to some experienced or event and it is this objective experience of emotion. By contrast, emotion is a stirred-up state caused by physiological changes occurring as a response to some an event and which tends to maintain or abolish the causative event.

Mood is a pervasive and sustained emotion . Descriptions of mood should include intensity, duration and fluctuations.

Affect refers to short-lived emotion and it may not be congruent with the mood. It is described as reactive, constricted, blunt or flat.

Five levels to of emotional reaction an expression which have clinical relevance are

1. Normal emotional reactions : is used to describe emotional states that are the result of events and that lie within cultural and social norms an example would be “grief reaction” that follows the death of a loved one of the response of the previously healthy person to a life threatening diagnosis. It should be differentiated from the morbid psychiatric disorder in terms of its quantity and quality and functional capacity of the patients.

2. Abnormal emotional reactions: these are states that are understandable in the context of stressful events but are associated with more prolonged impairment in functioning. This is determined by individual attribute such as genetic and personality predisposition and by external factors such as social support and the duration and severity of the stressors. The above is classified into DSM as” adjustment disorder” . This category also includes phobia, depression and anxiety, which is unpleasant affective state in which there is fear for no adequate reason.

3. Abnormal expression of emotion: these refer to emotional expressions that of very different from the average normal reaction from staff individuals in this category are generally aware of the abnormality. Excessive emotional response may be the result of learning and often different cultural norms. So the distraught woman screaming at the death of a loved one may be reflecting a cultural variant of normal brief. The converse is noticed in depressed patients who fail to exhibit any emotion “ Dissociation of affect “or they may smile to you without showing emotions “Smiling depressive”.

4. Morbid expressions of emotion: in which the patient is unaware of the morbidity in emotional expression even though it is apparent to observers.

” Blunted affect “ which is the loss of normal degree of emotional sensitivity and sense of the appropriate response to events, it’s one of the negatives symptoms of schizophrenia. “incongruent affect “ refers to the objective impression that the displayed affect is not consistent with the current thoughts or actions, for example, laughing while discussing a traumatic experience. Also seen in schizophrenia.

” Flat affect “, which is evident by a limitation in the usual range of emotional response so that the patient displays little emotional response in any directions, although they expressed amount is in the appropriate direction, unlike incongruity of affect, which is not.

“ lability of affect “ , is defined as rapid and abrupt changes in emotion largely unrelated to external stimuli. These shifts occur without warning. It can be seen in absence of psychiatric disorder, for example, those who are very soft hearted may be easily moved to tears. Also seen in borderline personality disorder, mania, frontal lobe impairment, cerebral vascular accidents.

Morbid disorders of emotion

These can be regarded as pathological state that, although sometimes triggered by stressful events, do not spontaneously resolve with the removal of the stressor.

1. Depressive illness

2. Morbid anxiety

3. Irritability : diminution in the stressor required to provoke anger or physical violence

4. Apathy: i.e. Lack of motivation seen in severe depression and schizophrenia.

5. Morbid euphoria and elation: seen in mania and hypomania

Disorders of the experience of self

There are 4 aspects to self experience 1. existence and activity of the self

2. Being a unity at any given point in time

3. Continuity of identity over a period of time

4. Being separated from the environment

Disturbance of awareness of self activity

There are two aspects to the sense of self activity: the sense of existence and the awareness of the performance of ones actions

1. Depersonalisation : an unpleasant subjective experience where the patient feels as if they have become “unreal” its seen in many psychiatric disorders as well as in normal people

2. Derealisation: the subjective feeling of unreal environment

Disturbances in the immediate awareness of self unity

In Psychogenic and depressive Depersonalisation the patient may feel that they are talking and acting in an automatic way. also Seen in schizophrenia

Disturbances of the continuity of self

The individuals with schizophrenia may feel that they are not the same person that they were before the illness. This may be expressed as a sense of change, but some patients may claim that they died under their old name and have come to life as a new person. The sense of complete change of personality may be described in context of religious conversions and some individuals may refer to this as being born again. Seen in Dissociative and conversion disorder is as well as in schizophrenia.

Disturbances of the boundaries of the self

One of the most fundamental experiences is the difference between one’s body and the rest of the world. This distinction is largely attributed to the function of the proprioceptive system . This phenomenon could be normally experienced with a local anesthesia is applied to or part of the body. Individuals with schizophrenia can experience breakdown of the boundary between self and the environment Specially in acute phase of their illness when they can feel that their actions are under the control of some external power. “passivity phenomena” the patient is aware that direction is not under their control the mean attribute this control to hypnosis, radio waves Internet. Disorders of consciousness

Consciousness can be defined as a state of awareness of the self and the environment. Intensity of consciousness can vary considerably according to the perform tasks.

Attention, can be active when the subject focuses their attention on some internal or external event, or passive when the same event attracts the subject attention without any conscious effort. Disturbance of active attention shows itself as distractibility, so that the patient is diverted by almost all new stimuli and habituation to new stimuli takes longer than usual. It can occur in fatigue, anxiety, sever depression, mania and schizophrenia.

Orientation is normally described in terms of time, place and person . When consciousness is disturbed tends to affect these three aspects in that order.

Dream like changes of consciousness

Mainly seen in delirium, in which a dreamlike change of consciousness is the outstanding feature, but mild and degrees of delirium may also occur. The patient may have a general lowering of consciousness during the day and the incoherent and confused with further worsening at night. In addition patients may also experience visual hallucinations and restlessness which usually improves due the daytime. There is also restriction in the mind in which the patient has the ideas, attitude and hallucinations. The milder form of delirium is called toxic confusional state. In delirium is also characterised by rapid onset, fluctuating cause and the relatively short duration (six months) when compared to dementia. In addition to hallucinations patients also experience agitation, restlessness and delusions.

Lowering of the consciousness

Seen in patients with CVA in which there is a general lowering of the consciousness without hallucinations, delusions, illusions and restlessness . The patient is apathetic, and generally slowed down and unable to express themselves clearly and made perseverate. Unlike dementia there is usually a partial recovery and the patient is left with mild organic deficit.

Restriction of consciousness

In which awareness is narrowed down to a few ideas and attitudes that dominate the patients mind. There is some lowering of the level of consciousness, so that in some cases with a patient may only appear slightly bemused may not realise that they are confused. This irritation to time and place occur. Restriction of the consciousness with some the loss of memory is seen in”Fugues” which is seen in depression, head injury. Motor disorders

Subjective motor disorder

Normally humans experience the actions as being their own and as being under their own control. In schizophrenia the patient may not only lose the control although their thought, actions or feelings but may also experience them as being foreign or manufactured against their will by some foreign influences , the symptoms are known as delusions of passivity in which the patient may also develop secondary delusions that explains the foreign control as a result of radio waves, X ray, television, witchcraft, the Internet and so on.

Classification of motor disorders

1. Disorders of adaptive movements

A . Disorders of expressive movements: in severe depression were the manifestations is” generalised psychomotor retardation” in which all bodily movements, including gestures, may be diminished or absence. The patient may walked slowly and bowed down as if carrying the load on their shoulders. In agitated or anxious depression on the other hand, the nation by the restless, apprehensive . In catatonic schizophrenia ,expressive movements may also be disordered the individuals with have a stiff expressive phase and the expressive movement of the body are scanty. In mania, expressive movements are exaggerated the patient is unusually cheerful and uses wide expressive gestures.

B. Disorders of reactive movements: reactive movements are immediate autonomic adjustments to stimuli. Such as turning towards the source of noval sound. These movements give rise to the general impression of alertness and adaptation to the new environment. These disorders are found in catatonic schizophrenia when the patient is affected by” obstruction” as well as neurological disorders such as parkinsonism .

C. Disorders of goal-directed movements: seen in psychomotor retardation in which the patient feels that all actions have become much more difficult to initiate and carry out while patients with mania can carry out actions much more swiftly. In catatonia, blocking or obstruction give rise to irregular hindrance to motor activity. Patients with obstruction, is unable to begin an action at one time that may be able to carry out the same action later on. There is a reduction in habitual and the reactive movements” patients may allow a fly to remain on the face without brushing it off”. In Mannerism there is an abnormal and occasionally bizarre performance of a voluntary, goal-directed activity, for example, than usual hand movements was shaking hands when greeting others. Mannerism can be found in individuals with individuals without mental illness” reflecting lack of confidence” and in a wide range of psychiatric a neurological disorders such as schizophrenia. Mannerism does not have the diagnostic value in schizophrenia.

2. Disorders of non-adaptive movements

A. spontaneous movements: Tics, a sudden involuntary twitching of small group of muscles. If commonly affects the face in form of blinking, clearing the throat and twitching the shoulder. Seen in Huntington chorea and tourette syndrome. Static tremor of the hands, head and upper trunk is another example of spontaneous movement that tend to occur in anxious and frightened individuals. It’s also seen parkinsonism , alcohol dependence, and thyrotoxicosis. Then spasmodic torticollis, there is a spasm of the neck muscles which pulls the head towards the same side and twisted faces in the opposite direction. in chorea, abrupt jerking movements , in Huntington chorea the patient may attempt to disguise the choreic movement by turning them into voluntary or habitual ones. While in Sydenham’s Chorea, the movements are less jerky and slower than one in Huntington chorea. In athetosis, there are spontaneous movements which are slow, twisting and writhing especially in the hands. The occurrence of abnormal involuntary movements in schizophrenia and the use of anti psychotic medication has attracted an increasing recognition. Stereotyped movements are a repetitive, none goal-directed actions that is carried out in a uniform way. Seen in patients with catatonic schizophrenia

B.. Abnormally induced movements:

- Automatic obedience the patient Carries out every instruction regardless of its consequence. Echopractic patients imitate simple actions such as hand-clapping, snapping the fingers.

- Echolalia, the patients echo’s apart or the whole of what’s being said to them, Word are echoed the respectively of whether the patients understand them or not.

- Perseveration, is an induced movement because it is a senseless repetition of a goal-directed action that has already served its purpose.

- forced grasping, this most common in catatonia but also seen in dementia. It is demonstrated when the examiner offers his hand to the patients and the patients shakes it. The patient continues to shrink and despite frequent instructions not to touch the examiners hand.

-Cooperation or Mitmachen, the body can be put into any position without any resistance from the patient. The disorder is found in catatonic schizophrenia. Mitgehen, can be regarded as a very extreme form of corporation because the patient moves their body in any directions on slightest pressure by the examiner.

-Opposition or Gegnenhalten : the patient oppose all passage movements were some degree of force, seen in catatonic schizophrenia. -negativism, can be regarded as an accentuation of opposition. It may be passive when all interference is resisted and orders not carried-out, or may be active where the patient does the exact opposite of what they have been asked to do. Seen in depression and psychosis.

-Ambitendency, is a mild variety of negativism in which the patient makes a series of tentative movements that does not reach the intended goal. For example where the examiner puts his hand out to shake hands, the patient move their hand towards the examiners hand, Stops, start moving their hands,stops and so on, until finally comes to rest without touching the examiners hand. Seen in catatonic schizophrenia.

3. Disorder of posture

A . Manneristic posture is an odd stilted posture that is an exaggeration of normal posture. Seen in patients with schizophrenia where they may be related to delusional attitudes toward catatonia.

B.. Stereotyped posture : is an abnormal and non-adaptive posture which is rigidly maintained For example patients with catatonia lie with their head few inches of the panel” psychological pillow” and maintain this posture for hours.

C. Perseveration of posture: the patient tends to maintain for long periods postures that have arisen fortuitously, which have been imposed by the examiner. The patient allows the examiner to put their body into strange and comfortable positions and then maintain such positions at least for 1 minute for even longer. Seen in catatonic schizophrenia also called waxy flexibility or catalepsy.

Abnormal complex pattern of behaviour

1. Non-goal directed abnormal pattern of behaviour

A. Stupor: is a state of more or less complete loss of activity where there is no reaction to external stimuli. A completely stuporous patient are mute.. Stupor may occur in state of shock, conversion disorder, depression, psychosis, catatonia, and organic brain disease.

B. Excitement: although excitement appears to be opposite of stupor, it often occurs in the state mental illness. Seen in mania secondary to elated mood and can also be part of attention seeking behaviour in people with personality disorders. 2. Goal directed abnormal pattern of behaviour

Which is seen in most of the psychiatric illnesses including schizophrenia and depression. Aggression, siucidality, disinhibition are all examples of goal-directed abnormal pattern of behaviour.

Movement disorders associated with antipsychotic medication

1. Acute akathesia: restlessness or inability to keep still.

2. Chronic Akathesia

3. Acute dystonia: involuntary to sustained muscle contractions or spasm

4. Tardive dyskinesia: repetitive, purposeless movements, usually of the mouth, tongue and facial muscles.

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