Disorders of consciousness. Main syndromes in psychiatry Disorders of consciousness. Main syndromes in psychiatry Lyudmyla.T.Snovyda

Disorders of consciousness. Disorders of consciousness. Main syndromes in psychiatry Main syndromes in psychiatry

Lyudmyla.T.Snovyda

Any disorder of psyche – is a disorder of consciousness. Term “ consciousness ” has different determinations. Theme and term “ consciousness ” is studied from different

clinical traditions – from view of biologists, psychologists and, of course, from our

psychiatrists, view.

• There are a lot of determinations of consciousness:

• Lenin: “Consciousness is property of the high-organized matter”.

• Marks“ Consciousness is my attitude toward surrounding reality”.

• Pavlov “Consciousness is a dynamic hearth of optimum excitation in cerebrum with negative induction around”.

• From the medic-psychological point of view:

• Consciousness is a higher form of psychic activity of man and consists in the reflection of objective reality and purposeful adjusting of co-operation of man with outward world.

• Psychologists – “consciousness’ - awareness by individual of objective reality”;

• “Consciousness” – awareness of “me” in surrounding, connections with past, future and knowledge about myself;

• “Consciousness” – knowledge quantity;• “Consciousness” – higher psychic function which is only

characterized for human beings.• In Dal’s vocabulary: “Consciousness” – is awareness of

myself, full memory, human condition in health meaning, which can give report to his actions.

• A philosophy says: “Consciousness” – higher, peculiar only to human being form of psyche, represent objective reality, which is mediated by inherited in life process.

Brain and consciousnessBrain and consciousness

A brain in itself as component part of organism does not have consciousness. It is financial substratom of consciousness, but only then, when a man in the process of active activity gains experience and knowledges, masters the culture of people.

Concept of consciousness Concept of consciousness

Consciousness consist of self-consciousness (self-concept) is an awareness a man itself in the attitudes toward the outer world and other people. It is a psychic function of itself reflection - autopsychic orientation or autoorientation.

Self-consciousness has a lot Self-consciousness has a lot of forms of the display: of forms of the display: In the sphere of cognitive processes: feel,

introspection, self-examination, self-appraisal, self-criticism, selfintercourse and other

Emotional sphere: proudness, self-praise, self-confidence, selfhumility, modesty, pomposity, call of duty, own dignity, conscience and other

• Volitional side of psyche: restraint, self-possession, self-control, initiative, independence, selfdiscipline and others like that.

Symptoms of violations of consciousness Symptoms of violations of consciousness

(K.Yaspers 1948) (K.Yaspers 1948)

Complete absence of ability to perceive the surrounding world, or perception is fragmentary, unclear.

Violation of thought (it is torn, disorderliness, an analysis, synthesis, is here violated).

Complete or partial violation of orientation in a place, time, own person.

amnestic violations which engulf the period of the broken consciousness.

Symptoms of violations of consciousness Symptoms of violations of consciousness

(K.Yaspers 1948) (K.Yaspers 1948)

• Paroxysmal of origin of psychopathologic signs, which disappear so quickly, as well as appear, in accordance with the change of etiologic factor (an example is an epileptic attack).

Violation of consciousnessViolation of consciousness

• Quantitative (switching off of consciousness):• Stunning: • Obnubilation• Somnolence• Spoor • Coma • Absans • Fainting fit

• Qualitive (eclipse) • Delіrіum state• Amentive state • Oneyroid state• Twilight state

• state of consciousness, including ambulatory automatism, fuges, transes, sleepwalking.

Special states of Special states of consciousness: consciousness:

• à) Pathological affect• b) Pathological intoxication;• c) Reaction of “short circuit”• d) Syndromes “already seen” and “never • not seen; (“deja vu”, “jamais vu”)

• “already heard” and “never heard”-(“deja vecu” ,”jamais vecu”)

Quantitative violations.Quantitative violations. Stunning Stunning

• Obnubilation (nubes - cloud) - the most light stunning degree. Refers to a state of drowsiness with incomplete reaction to stimuli, impared attention, concentration, and memory, and slow muddled thinking. In this state a patient still can move, walk, answer simple questions, although doesn’t have initiative, reactions are slow, answers are short and often incoherent. Reflexes are normal or little decreased

Quantitative violations.Quantitative violations. Stunning Stunning

• Somnolence - unnatural sleepiness, drowsiness.The threshold of perception of external irritants rises. On quiet voice irresponsive, on a vowel language answer slowly, easy tasks execute slowly, difficult tasks can not comprehend; face mimics is stupid, dull, a reaction on pain is reduced. Can give short answers to simple questions.

• Sopor - (torpor, deep sleep) can arise up as isolated or right after obnubilation. A contact with a patient is broken, as though sleeps deeply. Irresponsive on surrounding. All types of orientation are loose. On strong irritants (pain, sound) - elementary, to uncomprehended reaction. Unconditioned reflexes are present, including pain, corneal, swallowing.

• Stupor - refers to a state in which the person is mute, immobile and unresponsive, but appears to be conscious because the eyes are open and follow external objects.

• A coma (fast sleep, without memory) is the deepest degree of stunning. Complete absence of reaction on external irritants and unconditioned reflexes. Violation of breathing, cardiac activity, functions of second vital systems. Psychomotor excitation is possible, epileptic attacks. Complete amnesia.

• Types of comas: hyperglycemic, kidney, hepatic, thyreotoxic, alcoholic, posttraumatic etc.

• Reasons of switching off of consciousness: heavy intoxications, brain traumas, organic defeats of CNS, nasty somatic illnesses, epileptic attack.

• Absans (eng. - absent) is a brief (2-5 sec) loss of consciousness - as display of epilepsy

Quality violationsQuality violations (eclipse) (eclipse)

• Delіrіum (lat. - crazy).

• Alloorientation is changed, but an autoorientation is kept. There are bright (more frequent visual) hallucinations, delusions (more frequent persecutory).

• Hallucinations of horrific maintenance, single or panoramіc, affect of fear. A patient behaves in accordance with seeing (the defensive, attacks).

• The state gets worse in the evening and at night, “light windows are possible “in the day-time”.

• Vegetative disorders are expressed (turning red, pallor, takhycardia).


• Symptoms of delirium:• Impared consciousness:• disorientation

• poor concentration

• Behaviour• overactive

• underactive

• Mood• anxious, irritable

• depressed

• Thinking• muddled(confused)

• ideas of reference


• Perception• Illusions

• hallucinations

• Memory• impared


• At alcoholism ÷black and white hallucinations, microzoohallucinations (devils, rats, insects)


• At alcoholism ÷black and white hallucinations, microzoohallucinations (devils, rats, insects)

• Epilepsy (epileptic delіrіum) is the bright, colored (blood, flame) hallucinations, quite often religious maintenance. Ends with amnesia, remembers the most bright seeing only. Lasts 2-5-7 days

• There are atypical forms of delіrіum at alcoholism:

• musitative delіrіum ;• professional delіrіum.

•

• Amentive state (lat - “without sense”) is characterized by confusion, affect of bewilderment and incoherence of thinking. The patient cannot percept the events that happen around them in general, catch the connection between objects and phenomena. They percept only fragments of the situation, but are unable to connect them in their mind into joint, coherent picture. Deep disorientation to time, place, people and self is observed. The speech is incoherent, they say senseless, disconnected

consequences of words. Mood is changeable). After amentive state patients have absolutely no recollections about their experience or the real events that happened during that time - there is total amnesia for the period of amentive state.

• Fragmentary hallucinations and raving ideas, especially in the evening and at night.

• Excitation is within the limits of bed. Observed at heavy somatic and infectious diseases, sepsis, post- births psychoses.

Oneiroid state(lat. - is dream) - appearance of dreamlike fantastic hallucinations, thus pseudohallucinations (events take place as though in mind space, instead of in reality).

• Illusive - hallucinate phenomenon extraordinarily bright and unusual. fantastic maintenance (trip on Rome, flight in Space).

• An orientation is the fully broken or double orientation (reality + fantastic events).

• The direct participating of patient is in fantastic events. Time flies too quickly (a few millenniums passed, a few civilizations changed or too slowly).

• When? - Sch, oneiroid catatony,• epilepsy, organic injuries of • brain.

Twilight state of consciousnessTwilight state of consciousness

• Consciousness is pathologically narrowed, arises up suddenly.

• Various hallucinations, delusions - excitation, aggression in accordance with the fabule of delusion. Complete amnesia. Complete disorientation.

• Meets: epilepsy, organic defeats of brain, hysterical psychoses.

•

Twilight (gloomy) state of consciousnessTwilight (gloomy) state of consciousness

• The subspecies of the twilight state of consciousness is ambulatory automatism, when hallucinations, delusions are absent, that is why the behavior of patients from outside is well-organized.(they look as their behavior is normal)

Types of ambulatory automatysm

Transes - patients carry out the protracted trips, from outside as though confused. Appearing in a new place, do not understand, as found oneself there. Amnesia of what happened.

Fugue (lat. - to run) is a stormy, unrestrained gust to run on a background of the gloomy state of consciousness. Lasts minutes, stops suddenly. Amnesia.

When ? Epilepsy, organic injuries of brain.

• .

Types of ambulatory automatysm

Somnambulism (dreamwalking) - (lat. dream-walk)

It is the gloomy state which arises up in sleep. A child (rarer adult) rises among sleep, walks on a room, can go out on a street, overcomes dangerous obstacles (walking is on a roof of house) and does not feel at this fear. Complete amnesia. It is impossible to wake (fright).

• When ? Neuroses, epilepsy, organic injury of brain

The special states of consciousness are The special states of consciousness are

a variety of the gloomy statea variety of the gloomy state

• A pathological affect is a brief, strong emotional reaction on an insignificant irritant with the eclipse of consciousness with fury, aggression, exhaustion of CNS - deep sleep and next complete amnesia.

• When ? Organic injury of brain,character pathology (psychopathies of explosive type)

The special states of consciousness are The special states of consciousness are

a variety of the gloomy statea variety of the gloomy state

Pathological intoxication: insignificant dose of the accepted alcohol, there are not signs of intoxication, sharp eclipse of consciousness with aggression, dangerous effects. Dream. Complete amnesia.

• When? Organic injury of brain, psychopathy, asthenic condition.

• Symptoms “already seen”, “never seen; “already heard” - are at neuroses, epilepsy.

Main psychopathological Main psychopathological syndromessyndromes

Symptom – syndrome: simple , complex

All syndromes in psychiatry could be divided to:

Asthenic ;

Affective:

• depressive

• manic

Main psychopathological syndromsMain psychopathological syndroms

Neurotic syndromes:• Hysteric (conversive)• obsessive• Hypochondric - senestopathic• depersonalisative• dysmorphophobicParanoyal syndromeHallucinosisHallucinative - paranoid, s-me Candinskyy-Clerambot• ideatoric (associative),• senestopathic• motor (kinaesthetic)


Neurotic syndromes:• Hysteric (conversive)• obsessive• Hypochondric - senestopathic• depersonalisative• dysmorphophobicParanoyal syndromeHallucinosisHallucinative - paranoid, s-me Candinskyy-Clerambot• ideatoric (associative),• senestopathic• motor (kinaesthetic)


Paraphrenic syndromeCatatonic syndromeDisorders of consciousnessSeizeuresPsychoorganic syndrome (amnestic).

Main symptomsMain symptoms

Lyudmyla T. SnovydaLyudmyla T. Snovyda

APPEARANCE

• The overall appearance of the patient may offer valuable diagnostic clues. Dress, grooming, and demeanor may be an integral part of the symptomatology of an illness.

• Some patients may appear bizarre, unkempt or disheveled. The hair may be uncut, dirty, and uncombed; the fingernails long and likewise dirty. The clothing may be torn, mismatched for color and pattern, and is often layered with redundant shirts, sweaters, and socks. Ornaments and bits of jewelry may be oddly placed; some patients may wear tin foil to keep off noxious influences, or have their ears plugged with cotton to keep away the voices. Such an overall appearance may be seen in schizophrenia.

APPEARANCE

• Depression, when severe, may render certain aspects of dress and grooming such an effort that they are left undone. The hair, though perhaps clean, may only be halfheartedly combed; women may omit their makeup. When less severe, patients may be able to keep up appearances, but their overall demeanor may indicate their illness. The shoulders sag, the posture is slumped, the head may be hung, and the over-all impression is of a body drained of life. In some cases this drained appearance can be truly remarkable. During depression the skin may become deeply lined and lack turgor, the hair appear lifeless and dull, and the eyes lack any vibrancy. Upon recovery the change may be startling. Patients may appear to have become 10 years younger; the eyes may sparkle, the hair appear almost lustrous, and the skin appear smooth and vital.

APPEARANCE

• In contrast with depressed patients, manic patients may appear overvitalized. Dress is often overly colorful, at times clashing. Jewelry may be in abundance and overly gaudy; at times patients may be absolutely festooned with jewelry. Veritable headdresses may be worn, and women may plait their hair, often intertwining it with flowers or colorful ribbons. Colorful appearance may also be seen in patients with a histrionic personality disorder. The dress of histrionic patients, however, though perhaps tastefully colorful, rarely becomes as garish as that sported by the manic.

• Some patients with anorexia nervosa attempt to hide their emaciation with long hair, bulky sweaters, and long heavy skirts. The drawn, sunken face, however, belies the robust impression offered by the dress.

DISTURBANCES OF ACTIVITY

• Inactivity may stem from a variety of causes including psycho-motor retardation and lack of interest (or anhedonia), as seen in depression, a general slowing of all processes as may be seen in hypothyroidism, ambivalence and "annihilation of the will" as in schizophrenia, abulia of the frontal lobe syndrome, and the peculiar combination of paralyzing ambivalence and tension seen in catatonic stupor.

• In depression patients lose their hedonic capacity: they take no pleasure in things; nothing excites or motivates them; and they lose interest in former pleasures. For them, all the color seems drained away from life, leaving it stale and tasteless, a wearisome burden. Coupled with this lack of interest, there is typically a more or less profound anergia, or lack of energy. Patients complain of feeling fatigued, drained, and exhausted.


• The ambivalence seen in schizophrenia may paralyze the patient into inaction. Here it is not so much a case of an inability to exert the will, but rather the simultaneous appearance of two opposite but equally strong inclinations. When faced with a choice, the patient may thus be unable to commit to one or another course of action. In one case, a patient, though hungry, sat through a meal without eating, being unable to decide whether to use a fork or a spoon.

• Abulia, as seen in the frontal lobe syndrome, shares certain characteristics with annihilation of the will seen in schizophrenia. The abulic patient, though neither depressed, slowed down, nor fatigued, appears apathetic and lacking in motivation. With their mental horizons undisturbed by any impulses or strivings, such patients may sit quietly for long periods.


• In stuporous catatonia patients may lie motionless for hours, days, weeks, or even longer. Saliva may drool from their mouths, and the contents of bowel and bladder may be loosed into their clothing. Yet no matter how profound the stupor, such patients never appear quite dead inside, and at times, as proof of this, they may suddenly erupt into a frenzy of catatonic excitement.

Agitation and Hyperactivity

• Depressed patients may at times exhibit an extraordinary degree of psychomotor agitation. They may wail loudly, plead for relief, or even for death. They may pace agitatedly about their room or up and down the hall, and classically one sees prominent and unceasing hand-wringing.

• Excited catatonia presents a different picture. Here patients are neither despairing nor pleading for help; rather their hyperactivity seems senseless and bizarre. One patient may stand in a corner, bellowing in a declamatory voice; another may pace about the ward from one door to another always touching the doorknobs twice; another may simply march frantically in place, first in one spot, then another. In extreme catatonic excitation patients may jump up, scooch across the floor, turn somersaults, tear up the bed linen, and eventually require restraint.

Agitation and Hyperactivity

• Manic excitation differs from the psychomotor agitation seen in depression by virtue of the abundance of energy seen in mania, and differs from catatonic excitement by the presence of purpose in the manic behavior. Exalted and energized, patients may rush from one person to another to loudly proclaim their news. They may bang on the doors, jump to the tabletop to give a speech, pour everyone water and insist it be drunk "now," and in general, in their overbusyness, inflict themselves on any who come into view. Distractibility becomes so severe that patients no sooner embark on one purposed activity before another commands their attention and resources. Eventually their behavior becomes characterized by competing and ever-changing fragments of purpose. Hundreds of things may be started, some simultaneously, yet none are completed.

Bizarre Behavior

• Bizarre or grossly disorganized behavior should always raise the question of schizophrenia. Under the influence of delusions patients may heap rotting fruits in a corner, paper their room with tinfoil to ward off noxious rays, paint windows black to thwart those spying on them, or take an ad in the paper announcing their plans for world peace through strict vegetarianism. At times, however, the bizarre behavior is apparently without motivation: bits of paper may be zealously stuffed into pockets; patients may march in place, walk backward, declaim to a wall, or turn their furniture upside down.

• Some patients with autism may be particularly bizarre. During an interview such patients may exhibit gaze avoidance, looking anywhere but at the person interviewing them. They may demonstrate a peculiar flapping tremor when stressed, skitter into a corner, squat, defecate, and crawl under

a chair, all the while chattering away.

ABNORMAL MOVEMENTS

• Stereotypy represents a kind of perseveration, which may be found in schizophrenia. In schizophrenia, stereotypies are often bizarre. One patient read a page, turned it, read the other side, then turned back to the original side, and repeated this over and over again in a stilted, ritualized way until the page disintegrated. Another sang the same fragment of a song recurrently through the morning, in a screeching, halting voice. Still another, shuffling along the hallway, all the while facing the wall, would lay one curiously bent finger on the wall every few feet, going thus up and down the hall for hours. Some patients exhibit stereotyped speech, repeating the same, often nonsensical, phrase again and again. Such verbal stereotypy, when fairly rapid and enduring, is known as verbigeration.

ABNORMAL MOVEMENTS

• Catatonic Symptoms• Traditionally the following symptoms have been considered

catatonic: catalepsy and waxy flexibility, posturing, negativism, and automatic obedience (including echopraxia and echolalia).

• In catalepsy, patients maintain whatever position they are placed into by the examiner, no matter how awkward. Indeed the limbs and torso may be molded into the most unnatural position, and patients stay that way perhaps for hours with no sign of fatigue until, over a brief period of time, a normal position is again assumed. Often, catalepsy is accompanied by waxy flexibility (also known as flexibilitas cerea).

ABNORMAL MOVEMENTS

• Catatonic Symptoms• In catatonic posturing, patients spontaneously, without any recognizable

motivation, assume bizarre postures and then maintain them for varying periods of time. One patient stood with one leg raised, like a stork; another sat with head hung and arms outstretched in front, as if attempting to catch something.

• Negativism, or the tendency to do or say the opposite of what is asked or what is appropriate to the situation.

• Automatic obedience is almost the exact opposite of negativism. Here patients do or say whatever is asked of them, regardless of

consequences. • In some cases of automatic obedience one may see echolalia or

echopraxia. Here, without being asked, the patient's behavior mirrors whatever is said or done by the interviewer. If the examiner speaks, the patient repeats the words, often in a monotonous voice. If the examiner raises an arm the patient does likewise.

DISTURBANCES OF MOOD AND AFFECT

• Pathologically depressed mood is often accompanied by a characteristic depressive "cognitive set" and by symptoms such as decreased energy, decreased interest, and difficulty with concentration and memory.

• A depressed mood may be described in a variety of ways. Patients may speak of being "down," "blue," unhappy, or simply sad. In some cases patients may speak more of being drained and empty, whereas in others there may be a sense of heaviness and oppression. In severe cases patients may deny having any feelings at all: some say they are simply "dead inside.” In depression, thinking may become distorted by a pervasive pessimism: thoughts and perceptions that fail to resonate with the depression either simply fail to register or are discarded. In reviewing the past, patients think only of

misfortune and misdeeds:


• In looking to the future the patient sees only futility and failure. Hopelessness may be so profound as to inhibit the patient from venturing anything. In looking at themselves patients see only that they do not measure up and are burdened with guilt, shame, and a sense of utter helplessness. In severe cases patients may come to "ruminate." Here the same damning and depressive thoughts come again and yet again, as a burdensome chain that the patient cannot throw off.

• Anergia may manifest as either a sense of being drained and lifeless, or a sensation of heaviness and leaden fatigue. Everything becomes an effort, and when anergia is severe even the smallest obstacles may become insurmountable. One patient simply* could not summon the energy to get dressed for work and sat motionless in a bedroom chair for hours.


• The loss of interest in formerly pleasurable activities is perhaps more properly construed as anhedonia, or an inability to experience pleasure. For anhedonic patients the world seems to have lost its color and appeal. Food may taste like cardboard, and things may actually come to appear in shades of gray, as if all the color had drained out from them. Libido is lost, and sexually provocative situations, which in the past would leave patients excited, now leave them cold and unmoved.

• Memory and the ability to concentrate may be lost. Patients cannot remember names or where they put things; they may lose their train of thought in the middle of a sentence. Thinking becomes slow and effortful, and patients have great difficulty in attending to what others say or to what they are reading. They may ask others to repeat themselves, or they may read a paragraph again and again and still not comprehend it. Some describe a sense of being "wooden headed," as if nothing can get in, nothing can be grasped. Some may lose track of the date.


• Heightened mood (either euphoric or irritable), increased energy, flight of ideas and pressured speech, and hyperactivity constitute the cardinal

manic symptoms and are a mirror image of the depressive symptoms. • Euphoric patients may burst with amusement and good cheer. Everything

appears to them wonderful, satisfying, and beyond contentment. They may positively beam with confidence and good will, and no task seems insurmountable to them. Their enthusiasm and good humor, are often "infectious”.

• The energy level, like mood, is heightened in mania, at times to an almost boundless degree. These patients seem inexhaustible, attack each new project with unflagging enthusiasm, and often find that they need little or no sleep. Fatigue has become a stranger to them. Some may work for days on end, without a break, leaving their exhausted coworkers far behind. In severe mania the energy level may surpass that which the patient is able to channel, and like a locomotive at full throttle the patient may find himself out of any possible control.


• In flight of ideas, patients find their thoughts passing in a rapid, uncontrollable, and at times disorganized progression. Some complain that they have "too many thoughts," that their thoughts "race"; others speak of "jumbled" thoughts that cannot be grasped.

• Anxiety may be either chronic or come in attacks, often referred to as "panic attacks," that may or may not have precipitants. It is generally accompanied by autonomic symptoms such as tremulousness, palpitations, and diaphoresis.

• The most common causes of chronic anxiety are dysthymia, a depressive episode, generalized anxiety disorder, substance use (e.g., caffeine), and importantly, alcohol or sedative-hypnotic withdrawal.


• Labile Affect• In normal adults affects tend to be slowly aroused, endure for

some time, and clear slowly. By contrast, in lability of affect the affects may come and go like brief summer storms. Such lability is normal in children, and a good example of lability may be found in almost any 3- or 4-year-old child.

• Among adults lability may be found in mania, histrionic personality disorder,delirium, and dementia. Among those in acute or delirious mania affect may be extremely mercurial, with changes occurring for no apparent reason every few seconds. By contrast, in histrionic personality disorder, usually a precipitant for the affective change is seen, but in most cases the precipitant is relatively minor, and the resultant affect tends to be dramatic and disproportionately extreme. Likewise, demented patients may weep or laugh whereas others might feel only slight sorrow or mirth.


• Inappropriate Affect

• Inappropriate affect, as seen in schizophrenia, often has a bizarre tinge to it, as the patients' affective expressions, in part or in whole, become inappropriate to what they claim to be feeling. For example, one patient spoke of grief over a parent's death; yet even while speaking of the grief, a grin appeared on

the left side of the face.

• Flat Affect• In flattened affect patients become devoid of all feeling and of all

emotional expression. This symptom is almost specific for schizophrenia and is often accompanied by a remarkable degree of indifference. Though not depressed, these patients are unmoved by events around them and display no emotion. Lighter degrees of this symptom are often termed "blunting" of affect.

DELUSIONS

• A delusion is a false belief that cannot be accounted for on the basis of a patient's culture, upbringing, or religion.

• In some cases delusions develop gradually and mature slowly into unshakable beliefs. In others they appear suddenly, as if by revelation. Once established, delusions may be either systematized or unsystematized. When they are systematized, delusions often form an elaborate, more or less internally logical view of the world.

• Somatic Delusions• Patients may come to believe themselves to be afflicted in all manner of

ways. Rumblings in the belly indicate a tumor, headache a stroke, and cough a cancer. They are convinced they are ill, no matter what the physicians say. The bones are becoming brittle, the skin dry and about to fall off. The intestines have turned to concrete, the brain to dust, and all the internal organs are shriveled and dry. In the most extreme cases patients may come to believe і that they are already dead.

DELUSIONS

• Delusions of Grandeur

• Delusions of grandeur may occur alone; however, often they are accompanied by delusions of persecution. In their milder form certain grandiose delusions may be hard to identify as such. For example, paupers may insist that their parents were in fact millionaires and that they had fallen on hard times. Typically, however, grandiose delusions fly in the face of reality. Patients declare that they have billions, that they have invented a perpetual motion machine, or that the President has sought their opinion. They may reveal themselves as heirs to the throne, the elect of God, or the bearer of peace and salvation. Superhuman powers may be asserted: the patient could break down the walls, break the restraints, or lift cars high in the air.

DELUSIONS

• Delusions of Persecution• Persecutory beliefs may leave patients feeling hemmed in,

hounded, and attacked from all sides. They are followed, tailed, and the phone is tapped. Large organizations may be involved, such as the CIA, the FBI, or the mafia. Carloads of agents cruise the street in front of the house; patients find evidence that someone has broken in. At times these delusions may become bizarre. Patients report that they are attacked at night, cut with knives, subjected to electric shocks, or burned with scalding water. Others are convinced that torture, even execution, is imminent. They hear the chains, smell the burning flesh, see lumber hauled away to make the gallows.

DELUSIONS

• Nihilistic Delusions• Here the patient believes that everything has become dead,

lifeless, and inanimate. Figures may walk around, but they are not people; rather they are automatons. Trees and animals slowly turn to ashes. Some patients believe that a part of them has died: though an arm may yet still move, the patient knows that it is dead, useless, and fit only for amputation.

• Delusions of Reference• Here patients come to believe that chance events and

encounters in some way or other refer or pertain to them. Typically these delusions of reference serve to bolster other delusions, such as delusions of sin, grandeur, or persecution.

• Patients convinced they have sinned may note the peculiar way a police officer stands: a sign that apprehension is near. The pealing of church bells stops as patients pass by: an indication that their souls are lost, that no prayers will be offered for them.

DELUSIONS

• Delusions of reference are perhaps most common in those patients who believe themselves persecuted. Conversation stops when they enter the room, and patients are convinced that others were talking about them. The lights blink when they enter a building, a sign to their pursuers that their quarry has entered. Patients find indirect allusions to themselves in the newspaper, hear them on the radio, or see them on television. Attempts to convince patients that these are mere coincidences are doomed to failure. To the patients simply too many coincidences have occurred. Everything has meaning, and they are skilled at reading the signs. They are perhaps cleverer than those who torment them.

HALLUCINATIONS

• Hallucinations may occur in each of the five sensory modalities: patients may hear, see, feel, smell, or taste things that are not in fact there.

• Patients react differently to these experiences. Occasionally patients have insight about these and recognize that although these experiences appear as vivid and clear as things that other people hear and see, they are not in fact real. More often, however, patients insist these experiences are real, and when the physician denies hearing or seeing the same things, the patients may assume that the physician is lying or is perhaps part of the plot against them. In such cases trying to convince patients that they are wrong is useless.

HALLUCINATIONS

• Auditory Hallucinations• At times only simple sounds are heard: bells, cracklings, "the voice of

chewing," or the roar of animals. Music may be heard. When voices occur they may be only in a whisper or mumbled indistinctly. At other times they may be distinct, even overpowering. Short phrases or just single words may be heard: "whore," "murderer," "guilty," "look-out." At other times patients hear long sentences, even conversations.

• At times patients hear "command hallucinations," or voices that direct them to do specific things. They may be innocuous: a voice commanding them to get dressed or to not eat certain foods. At other times, however, patients may be commanded to do dangerous things: the voices may even tell them to kill themselves or someone else. Most often patients are able to resist such command hallucinations, but not always.

HALLUCINATIONS

• Auditory Hallucinations• Most patients have a sense of where the voices come from. They may

be "in the air," in walls or furniture, or emanating from television, radios, or electrical appliances. Not uncommonly they are heard in the midst of music, in what is said on the radio, in rushing water, or from the wind as it rustles the leaves of trees. At times they are located in the body, perhaps the spleen, or some other organ.

• Kurt Schneider identified three types of auditory hallucinationsthat he believed were of the "first rank" and found more commonlyin schizophrenia than in other conditions. These three hallucinations consist of the following: voices talking to each other, voicescommenting on what the patient is doing, and voices that repeat orspeak out loud the patient's thoughts. This last hallucination, oftenknown as "audible thoughts," is perhaps the most suggestive ofschizophrenia.

DISTURBANCES OF THOUGHT

• Loosening of Associations.

• Loosening of associations, called "formal thought disorder," may be seen in schizophrenia, schizoaffective disorder, or delirious mania, and as such is a symptom of great diagnostic import. When loosening of associations occurs, the interviewer can often make little or no sense of what the patient is saying. Thoughts seem to lack goal-directedness; they appear to be joined together as if by accident, almost at random, as if fragments of disparate thoughts had all been haphazardly mixed. Upon being asked by the physician what had occasioned this admission to the hospital, a patient with schizophrenia replied: "Oh, but doctor, the trams, the cars and stars, I wrote my mother a letter, the dog, I see was blue, if only once, twice, nice day to you too!"


• Loosening of Associations.

• At its most severe, loosening of associations is characterized by a "word salad" wherein the various words spoken by the patient have no relation with each other at all, much as if they had been tossed together in a linguistic salad.

• Neologisms often accompany loosening of associations. Here the patient uses a totally private and invented word as readily as any word in common usage. For example, when asked to describe a favorite activity, one patient responded "birkenstun-ning." When asked what this meant, the patient simply repeated the word.


• Thought Blocking.• Thought blocking may be suspected when patients suddenly cease to

talk in the middle of a sentence or even of a word and look as if their minds just went blank. If the physician asks what happened, patients may respond that their minds did indeed go blank. If pressed as to how that happened patients often express the delusion of thought withdrawal.


• Mutism.• Mutism, or the absence of any verbal production, may

occur in a number of conditions. Depressive stupor is suggested by the depressive affect, slumped posture, and similar signs. In catatonic stupor one typically sees other catatonic symptoms, such as rigidity or waxy flexibility. In selective mutism patients are typically children or young teenagers who otherwise appear normal.

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Disorders of consciousness. Main syndromes in psychiatry Disorders of consciousness. Main syndromes in psychiatry Lyudmyla.T.Snovyda