Disorders of thinking and intellect

Disorders of thinking and intellect

Disorders of emotions

Disorders of effector sphere

 

Disorders of thinking

 

 

 

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. An example may help to clarify this. 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!” 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.

Typically if the physician confesses to some difficulty in understanding what patients say and asks for an explanation, patients show little or no concern and generally make no effort to clarify what they meant.

 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.

Given the diagnostic import of a finding of loosening of associations, differentiating it from other symptoms, namely flight of ideas and aphasia, is critical.

Flight of ideas,

 as may be seen in mania, is characterized by abrupt jumps from one thought to another, with each thought being left behind before it can be fully developed. Although this is often a rapid process, exceptions do occur and at times the flight may be quite slow. The key to differentiating flight from loosening of associations lies in the presence or absence of coherence. In flight of ideas, although thoughts are not fully developed, they are nevertheless coherent, as far as they go, in contrast with loosening of associations, wherein coherence is lost. Expressive aphasia is distinguished from loosening of associations by virtue of the fact that the aphasic patient is still able to communicate in modalities other than speech. The aphasic patient may write, use sign language, or “body language.” The patient with loosened associations, however, makes no attempt to communicate ideas more clearly in other modalities. Receptive, or Wernicke’s, aphasia may be very difficult to differentiate from loosening of associations. Like patients with loosening of associations, these aphasics do not understand well what is said to them, and often their incoherent speech is impossible to understand. Furthermore, like patients with loosened associations, they may at times show no concern over their incoherence and the inability of others to understand them. Preserved facial and gestural displays of emotion may be a clue. Patients with Wernicke’s aphasia often still respond to emotional displays and may make appropriate emotional displays in return. By contrast, loosening of associations is almost always accompanied by an abnormal affect, whether it be flattened, manneristic, or blunted.

  Poverty of Thought and of Speech

In poverty of thought, as the name implies, patients simply have few if any thoughts. Consequently they may say little or nothing spontaneously. This is different from the psychomotor retardation seen in depression, as these patients are not depressed. It is also different from mutism, as these patients respond to questions, albeit laconically.

In poverty of speech the patient may talk a normal amount, even at length, and yet “say” little. With an abundance of words, but a dearth of content and meaning, sentences tend to be full of stock phrases, repetitions, and vague or even bizarre references. Poverty of thought and poverty of speech may be seen in schizophrenia and in some cases of dementia.

  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, discussed above under Schneiderian delusions. The thoughts were taken away, patients were “deprived” of them; “the voices took them.”

Thought blocking differs from the sparse, halting speech seen in the psychomotor retardation of depression. In depression all speech is slow, and when it stops its cessation appears a natural consequence of the slow grinding down that characterized what the patient was saying previously. By contrast, just before thought blocking occurs, a patient may talk at a quite normal, even lively, rate.

 

 

  DELUSIONS

A delusion is a false belief that cannot be accounted for on the basis of a patient’s culture, upbringing, or religion. For example, to a Confucian the belief in the resurrection of the dead would be considered a delusion, whereas to a Christian it would not. Some beliefs, of course, are never normal regardless of background and may be assumed to be delusions: an example might be the belief that one’s hairs have been transformed into myriad antennae designed to pick up electronic signals from alien beings.

 

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. Such systematization is common in delusional disorder, but somewhat less so in paranoid schizophrenia. By contrast unsystematized delusions are often fragmentary and may be mutually contradictory—a fact that often fails to trouble the patient holding them.

Perhaps the most important clinical distinction among delusions is whether they are mood-congruent or mood-incongruent. In the middle half of the twentieth century, at least in America, it was often erroneously thought that the presence of delusions almost certainly indicated a diagnosis of schizophrenia. We now know that delusions are fairly common in mania and in depression, and that in these cases they are usually congruent with the patient’s mood. For example, when depressed patients full of self-loathing and guilt develop the belief that they had committed unpardonable sins, this seems logical and understandable in light of their mood. Likewise, one would not be surprised to find manic patients believing that they had inherited millions of dollars. A not uncommon corollary to such a grandiose delusion is the belief that the patient is being persecuted by those who wish to steal the fortune.

Certain delusions, however, are almost never mood-congruent. For example, the belief that one’s thoughts are extracted or with­drawn and sucked into telephone wires bears no relationship to any conceivable mood. Although such non-mood-congruent delusions are more likely in schizophrenia, exceptions do occur, especially in delirious mania. What follows is a compilation of relatively common delusions.

 

 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.

Such somatic delusions, however, must be distinguished from hypochondriacal concerns, wherein patients merely suspect that they have a serious illness.

  Delusions of Poverty

Patients are convinced that their resources are depleted, that they have lost all. The situation is hopeless; creditors will take the house and all possessions; the family will starve. Displaying healthy bank statement to such patients is of no avail; they dismiss it; they claim the bank is in error or their recent withdrawals have not as yet been tabulated. Destitution awaits them, they will sleep in the gutter, die unknown, and be buried ш a pauper’s grave.

  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 Sin

As guilt-ridden patients survey their lives they may begin to see many sins, some of them appearing monstrous. They cheated in school, they stole from neighbors, and they treated younger siblings roughly. They have committed adultery in their hearts, embezzled funds, and squandered the rent money. In severe cases these delusions may become quite fantastic. Patients may believe they have threatened the President, poisoned the reservoir, or betrayed their country. Some may present themselves to the authorities, demanding arrest and the ultimate punishment.

  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 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.

Such delusions, though typical of mania, may also be seen in schizophrenia and in delusional disorder.

  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. Someone   across thej-oom laughs, and patients are convinced that their shameful deeds have become known and have made them a laughing stock.

For grandiose patients a stroll down the street may be an occasion for exaltation. Horns honk to signal their coming; passersby cross the street to ‘get a better view; the clouds part to bestow the radiance of angels upon them.

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.

   Schneiderian Delusions

Kurt Schneider, a German psychiatrist, described a number of delusions that he believed to be of the “first rank” and more common in schizophrenia than in other disorders, including delusions of influence, thought broadcasting, thought insertion and thought withdrawal.

Patients with a delusion of influence, or control, believe that their thoughts, feelings, or actions are no longer under their own control but are in fact influenced and directed by some outside force or agency. Patients may believe that their thoughts are orches­trated by radio waves directed at them from a distant computer. Others may experience themselves as automatons or marionettes. Though their legs move in walking and their lips in speech, these are not their movements but are rather under the direct control of aliens who beam radar onto them.

In the delusion of thought broadcasting, patients believe that their thoughts literally leave their heads whereupon they are picked up or read by others. Some patients speak of telepathy, others of thoughts radiating out like radio waves. One patient sensed that thoughts were drawn out by magnets, then transmitted across telephone wires to waiting machines.

The delusion of thought insertion involves the belief that thoughts, which are not the patients’ own, are placed or somehow inserted directly into their heads. One patient, a physician, compared the inserted thought to a “foreign body in the mind”; though clearly it was the physician thinking the thought, clearly also it was alien, and not the physician’s own.

The delusion of thought withdrawal is in a sense the opposite of thought insertion. In thought withdrawal patients experience one or more of their thoughts being sucked out or somehow withdrawn from them by an outside force. A train of thought may suddenly be cut off, with all the succeeding thoughts withdrawn. The patient has no idea how to carry on with the previous thought. When thought withdrawal occurs while the patient is speaking, the observed sign is called thought blocking, as described below.

  Bizarre Delusions

Especially from disorganized patients, one may hear at times any number of fantastic beliefs that resist any clear classification except that of being bizarre. Ants crawl out the pupils; hair is electrified; light shines forth from the fingernails; dwarfs come out at night and mess the sheets.

   Erotomanic Delusions

Here patients come to believe that someone else, often someone of much higher social stature, has fallen in love with them, but for one compelling reason or another is unable to openly profess that love. Such a delusion is not uncommon in delusional disorder or in paranoid schizophrenia.

Pseudomemories

More often than is appreciated, patients will report as memories events and experiences that either did not or could not have occurred. In some cases what the patient believes happened represents a twist or modification of actual events-, and at other times the belief has no basis in fact. Such pseudomemories can make the history of the present illness that is obtained from patients unreliable.

One patient with paranoid schizophrenia reported that the persecution had begun only after graduating with a doctorate several months earlier. Upon questioning relatives, it was discovered that the patient had dropped out of undergraduate school.

Another less organized patient related with simple honesty being born into a royal family, kidnapped by gypsies, and sent to live in an orphanage. Confronted with the certificate of an otherwise prosaic birth, the patient dismissed the paper as a “forgery.”

Such pseudomemories should be distinguished from simple lies on the basis of the fact that the patient has believed them since they first came to mind; they were not suggested by someone else, nor did they begin as a lie, only to become gradually accepted as the truth.

 Intrusive thoughts are unwelcome involuntary thoughts, images, or unpleasant ideas that may become obsessions, are upsetting or distressing, and can be difficult to manage or eliminate. When they are associated with obsessive-compulsive disorder (OCD), depression, body dysmorphic disorder (BDD), and sometimes attention-deficit hyperactivity disorder (ADHD), the thoughts may become paralyzing, anxiety-provoking, or persistent. Intrusive thoughts may also be associated with episodic memory, unwanted worries or memories from OCD, posttraumatic stress disorder, other anxiety disorders, eating disorders, or psychosis. Intrusive thoughts, urges, and images are of inappropriate things at inappropriate times, and they can be divided into three categories: “inappropriate aggressive thoughts, inappropriate sexual thoughts, or blasphemous religious thoughts”.

Many people experience the type of bad or unwanted thoughts that people with more troubling intrusive thoughts have, but most people are able to dismiss these thoughts. For most people, intrusive thoughts are a “fleeting annoyance.” London psychologist Stanley Rachman presented a questionnaire to healthy college students and found that virtually all said they had these thoughts from time to time, including thoughts of sexual violence, sexual punishment, “unnatural” sex acts, painful sexual practices, blasphemous or obscene images, thoughts of harming elderly people or someone close to them, violence against animals or towards children, and impulsive or abusive outbursts or utterances. Such bad thoughts are universal among humans, and have “almost certainly always been a part of the human condition”.

When intrusive thoughts occur with obsessive-compulsive disorder (OCD), patients are less able to ignore the unpleasant thoughts and may pay undue attention to them, causing the thoughts to become more frequent and distressing. The thoughts may become obsessions which are paralyzing, severe, and constantly present, and can range from thoughts of violence or sex to religious blasphemy. Distinguishing them from normal intrusive thoughts experienced by many people, the intrusive thoughts associated with OCD may be anxiety provoking, irrepressible, and persistent.

How people react to intrusive thoughts may determine whether these thoughts will become severe, turn into obsessions, or require treatment. Intrusive thoughts can occur with or without compulsions. Carrying out the compulsion reduces the anxiety, but makes the urge to perform the compulsion stronger each time it recurs, reinforcing the intrusive thoughts. According to Baer, suppressing the thoughts only makes them stronger, and recognizing that bad thoughts do not signify that one is truly evil is one of the steps to overcoming them. There is evidence of the benefit of acceptance as an alternative to suppression of intrusive thoughts. A study showed that those instructed to suppress intrusive thoughts experienced more distress after suppression, while patients instructed to accept the bad thoughts experienced decreased discomfort. These results may be related to underlying cognitive processes involved in OCD. But, accepting the thoughts can be more difficult for persons with OCD. In the 19th century, OCD was known as “the doubting sickness”; the “pathological doubt” that accompanies OCD can make it harder for a person with OCD to distinguish “normal” intrusive thoughts as experienced by most people, causing them to “suffer in silence, feeling too embarrassed or worried that they will be thought crazy”.

The possibility that most patients suffering from intrusive thoughts will ever act on those thoughts is low. Patients who are experiencing intense guilt, anxiety, shame, and upset over these thoughts are different from those who actually act on them. The history of violent crime is dominated by those who feel no guilt or remorse; the very fact that someone is tormented by intrusive thoughts and has never acted on them before is an excellent predictor that they will not act upon the thoughts. Patients who are not troubled or shamed by their thoughts, do not find them distasteful, or who have actually taken action, might need to have more serious conditions such as psychosis or potentially criminal behaviors ruled out.^[14] According to Baer, a patient should be concerned that intrusive thoughts are dangerous if the person does not feel upset by the thoughts, or rather finds them pleasurable; has ever acted on violent or sexual thoughts or urges; hears voices or sees things that others do not see; or feels uncontrollable irresistible anger.

Inappropriate aggressive thoughts

Intrusive thoughts may involve violent obsessions about hurting others or themselves. They can include such thoughts as harming an innocent child, jumping from a bridge, mountain or the top of a tall building, urges to jump in front of a train or automobile, and urges to push another in front of a train or automobile Rachman’s survey of healthy college students found that virtually all of them had intrusive thoughts from time to time, including:

·                    Causing harm to elderly people

·                    Imagining or wishing harm upon someone close to oneself

·                    Impulses to violently attack, hit, harm or kill a person, small child, or animal

·                    Impulses to shout at or abuse someone, or attack and violently punish someone, or say something rude, inappropriate, nasty or violent to someone.

These thoughts are part of being human, and need not ruin the quality of life. Treatment is available when the thoughts are associated with OCD and become persistent, severe, or distressing.

Inappropriate sexual thoughts

Sexual obsessions involve intrusive thoughts or images of “kissing, touching, fondling, oral sex, anal sex, intercourse, and rape” with “strangers, acquaintances, parents, children, family members, friends, coworkers, animals and religious figures”, involving “heterosexual or homosexual content” with persons of any age.

Like other unwanted intrusive thoughts or images, everyone has some inappropriate sexual thoughts at times, but people with OCD may attach significance to the unwanted sexual thoughts, generating anxiety and distress. The doubt that accompanies OCD leads to uncertainty regarding whether one might act on the intrusive thoughts, resulting in self-criticism or loathing.

One of the more common sexual intrusive thoughts occurs when an obsessive person doubts his or her sexual identity. As in the case of most sexual obsessions, sufferers may feel shame and live in isolation, finding it hard to discuss their fears, doubts, and concerns about their sexual identity.

A person experiencing sexual intrusive thoughts may feel shame, “embarrassment, guilt, distress, torment, fear that you may act on the thought or perceived impulse, and doubt about whether you have already acted in such a way.” Depression may be a result of the self-loathing that can occur, depending on how much the OCD interferes with daily functioning or causes distress. Their concern over these thoughts may cause them to scrutinize their bodies to determine if the thoughts result in feelings of arousal. But, focusing attention of any part of the body can result in feelings in that part of the body, hence doing so may decrease confidence and increase fear about acting on the urges. Part of treatment of sexual intrusive thoughts involves therapy to help sufferers accept intrusive thoughts and stop trying to reassure themselves by checking their bodies.

Blasphemous religious thoughts

Blasphemous thoughts are a common component of OCD, documented throughout history; notable religious figures such as Martin Luther and St. Ignatius were known to be tormented by intrusive, blasphemous or religious thoughts and urges. Martin Luther had urges to curse God and Jesus, and was obsessed with images of “the Devil’s behind”. St. Ignatius had numerous obsessions, including the fear of stepping on pieces of straw forming a cross, fearing that it showed disrespect to Christ. A study of 50 patients with a primary diagnosis of obsessive-compulsive disorder found that 40% had religious and blasphemous thoughts and doubts—a higher, but not statistically significantly different number than the 38% who had the obsessional thoughts related to dirt and contamination more commonly associated with OCD. One study suggests that content of intrusive thoughts may vary depending on culture, and that blasphemous thoughts may be more common in men than in women.

According to Fred Penzel, a New York psychologist, some common religious obsessions and intrusive thoughts are:

·                    sexual thoughts about God, saints, and religious figures

·                    bad thoughts or images during prayer or meditation

·                    thoughts of being possessed

·                    fears of sinning or breaking a religious law or performing a ritual incorrectly

·                    fears of omitting prayers or reciting them incorrectly

·                    repetitive and intrusive blasphemous thoughts

·                    urges or impulses to say blasphemous words or commit blasphemous acts during religious services.

Suffering can be greater and treatment complicated when intrusive thoughts involve religious implications; patients may believe the thoughts are inspired by Satan, and may fear punishment from God or have magnified shame because they perceive themselves as sinful. Symptoms can be more distressful for sufferers with strong religious convictions or beliefs.

Baer believes that blasphemous thoughts are more common in Catholics and evangelical Protestants than in other religions, whereas Jews or Muslims tend to have obsessions related more to complying with the laws and rituals of their faith, and performing the rituals perfectly. He hypothesizes that this is because what is considered inappropriate varies among cultures and religions, and intrusive thoughts torment their sufferers with whatever is considered most inappropriate in the surrounding culture.

Associated conditions

Intrusive thoughts are associated with OCD or obsessive-compulsive personality disorder, but may also occur with other conditions such as post-traumatic stress disorder, clinical depression, postpartum depression, and anxiety. One of these conditions is almost always present in people whose intrusive thoughts reach a clinical level of severity. A large study published in 2005 found that aggressive, sexual, and religious obsessions were broadly associated with comorbid anxiety disorders and depression. The intrusive thoughts that occur in a schizophrenic episode differ from the obsessional thoughts that occur with OCD or depression in that the intrusive thoughts of schizophrenics are false or delusional beliefs (i.e. held by the schizophrenic individual to be real and not doubted, as is typically the case with intrusive thoughts) .

Post-traumatic stress disorder

The key difference between OCD and post-traumatic stress disorder (PTSD) is that the intrusive thoughts of PTSD sufferers are of traumatic events that actually happened to them, whereas OCD sufferers have thoughts of imagined catastrophes. PTSD patients with intrusive thoughts have to sort out violent, sexual, or blasphemous thoughts from memories of traumatic experiences. When patients with intrusive thoughts do not respond to treatment, physicians may suspect past physical, emotional, or sexual abuse.

Depression

People who are clinically depressed may experience intrusive thoughts more intensely, and view them as evidence that they are worthless or sinful people. The suicidal thoughts that are common in depression must be distinguished from intrusive thoughts, because suicidal thoughts—unlike harmless sexual, aggressive, or religious thoughts—can be dangerous.

Postpartum depression

Unwanted thoughts by mothers about harming their newborn infants are common in postpartum depression. A 1999 study of 65 women with postpartum major depression by Katherine Wisner et al. found the most frequent aggressive thought for women with postpartum depression was causing harm to their newborn infants. A study of 85 new parents found that 89% experienced intrusive images, for example, of the baby suffocating, having an accident, being harmed, or being kidnapped.

Some women may develop symptoms of OCD during pregnancy or the postpartum period. Postpartum OCD occurs mainly in women who may already have OCD, perhaps in a mild or undiagnosed form. Postpartum depression and OCD may be comorbid (often occurring together). And though physicians may focus more on the depressive symptoms, one study found that obsessive thoughts did accompany postpartum depression in 57% of new mothers.

Wisner found common obsessions about harming babies in mothers experiencing postpartum depression include images of the baby lying dead in a casket or being eaten by sharks; stabbing the baby; throwing the baby down the stairs; or drowning or burning the baby (as by submerging it in the bathtub in the former case or throwing it in the fire or putting it in the microwave in the latter). Baer estimates that up to 200,000 new mothers with postpartum depression each year may develop these obsessional thoughts about their babies; and because they may be reluctant to share these thoughts with a physician or family member, or suffer in silence and fear they are “crazy”, their depression can worsen.

Intrusive fears of harming immediate children can last longer than the postpartum period. A study of 100 clinically depressed women found that 41% had obsessive fears that they might harm their child, and some were afraid to care for their children. Among non-depressed mothers, the study found 7% had thoughts of harming their child—a rate that yields an additional 280,000 non-depressed mothers in the United States with intrusive thoughts about harming their children.

Unconscious complexes

In the field of analytical psychology intrusive thoughts can be understood as unconscious parts of one’s personality that affect them directly (due to the contents of the intrusive thoughts being associated with unconscious complexes). The self-sabotaging nature of intrusive thoughts is also seen in a more teleological approach, as a way for the shadow to reach consciousness and be dealt with and integrated by the ego.

 

An intellect (mind) is an aggregate of knowledges and vital experience of man, possibility of their subsequent accumulation and use in practice.

 

Intellectuality is a breadth of range of interests, general erudition.

 

Intelligence is a culture of display of intellect and conduct.

Intelligence –  the ability to understand, recall, mobilize and constructively integrate previous learning in meeting new situations.

 

Mental Retardation

A diagnosis of mental retardation carries with it certain unique treatment needs that must be understood and addressed. Unfortunately, most psychiatrists are ill-equipped to handle this situation, having received little or no formal training in this area. This article is written with the specific goal of giving psychiatrists a better understanding of the special needs of patients with mental retardation and strategies for improving their quality of life.

Mental retardation is a state of developmental deficit, beginning in childhood, that results in significant limitation of intellect or cognition and poor adaptation to the demands of everyday life. As noted by Esquirol, intellectual disability is not a disease in and of itself, but is the developmental consequence of some pathogenic process.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) defines mental retardation as follows:

Significantly subaverage intellectual functioning – An intelligence quotient (IQ) of approximately 70 or below

Concurrent deficits or impairments in adaptive functioning in at least 2 of the following areas: communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health, and safety

Onset before age 18 years

Although mental retardation is classified as an axis II disorder in DSM-IV-TR, it is not considered a mental illness as such, with its own unique signs and symptoms. It is a system of identifying groups of people who need social support and special educational services to carry out tasks of everyday living.

The causes of mental retardation can be grouped from most to least common as follows:

Alterations in embryonic development, such as those caused by chromosomal abnormalities or fetal exposure to drugs or toxins

Environmental deprivation and other mental disorders, such as autism

Problems of pregnancy and the perinatal period, such as fetal malnutrition, hypoxia, infection, trauma, or prematurity

Hereditary abnormalities, such as inborn errors of metabolism or chromosomal aberrations

Medical conditions of infancy or childhood, such as central nervous system (CNS) infection or trauma, or lead poisoning

Physical causes are evident in the majority of cases of moderate-to-profound retardation. A disadvantaged environment is more likely in mild retardation.

Many of the classification systems for mental retardation have been based on the timing of the insult to the CNS. The successive classification systems developed by the American Association on Mental Retardation also followed the timing approach.

Prenatal Causes – Genetic Disorders

Prenatal genetic disorders are characterized by changes in the genetic material, which may or may not have been inherited from the parents.

 

Dementia

The effects of the different dementia types are similar, but not identical, as each one tends to affect different parts of the brain.

Symptoms

The fourth edition, text revised version of the DSMwas published in 2000, and is known as DSM-IV-TR. DSM-IV-TRidentifies certain symptoms as criteria that must be met for a patient to be diagnosed with dementia. One criterion is significant weakening of the patient’s memory with regard to learning new information as well as recalling previously learned information.

In addition, the patient must be found to have one or more of the following disturbances:

Aphasia. 

Aphasia refers to loss of language function. A person with dementia may use vague words like “it” or “thing” often because he or she can’t recall the exact name of an object; the affected person may echo what other people say, or repeat a word or phrase over and over. People in the later stages of dementia may stop speaking at all.

Apraxia.

Apraxia refers to loss of the ability to perform intentional movements even though the person is not paralyzed, has not lost the sense of touch, and knows what he or she is trying to do. For example, a patient with apraxia may stop brushing their teeth, or have trouble tying their shoelaces.

 

Agnosia. 

 

Agnosia refers to loss of the ability to recognize objects even though the person’s sight and sense of touch are normal. People with severe agnosia may fail to recognize family members or even their own face reflected in a mirror.

Problems with abstract thinking and complex behavior. This criterion refers to the loss of the ability to make plans, carry out the steps of a task in the proper order, make appropriate decisions, evaluate situations, show good judgment, etc. For example, a patient might light a stove burner under a saucepan before putting food or water in the pan, or be unable to record checks and balance their checkbook.

DSM-IV-TR also specifies that these disturbances must be severe enough to cause problems in the person’s daily life, and that they must represent a decline from a previously higher level of functioning.

In addition to the changes in cognitive functioning, the symptoms of dementia may also include personality changes and emotional instability. Patients with dementia sometimes become mildly paranoid because their loss of short-term memory leads them to think that mislaid items have been stolen. About 25% of patients with dementia develop a significant degree of paranoia, that is, generalized suspiciousness or specific delusions of persecution. Mood swings, anxiety, and irritability or anger are also frequent occurrences, particularly when patients with dementia are in situations that force them to recognize the extent of their impairment.

The following sections describe the signs and symptoms that are used to differentiate among the various types of dementia during a diagnostic evaluation.

ALZHEIMER’S DISEASE.

Dementia related to AD often progresses slowly; it may be accompanied by irritability, wide mood swings, and personality changes in the early stage. Many patients, however, retain their normal degree of sociability in the early stages of Alzheimer’s. In second-stage AD, the patient typically gets lost easily, is completely disoriented with regard to time and space, and may become angry, uncooperative, or aggressive. Patients in second-stage AD are at high risk for falls and other accidents. In final-stage AD, the patient is completely bedridden, has lost control over bowel and bladder functions, and may be unable to swallow or eat. The risk of seizures increases as the patient progresses from early to end-stage Alzheimer’s. Death usually results from an infection or from malnutrition.

Pick’s Disease.

 More severe symptoms will appear in later stages of the illness:

Behavioral changes

Impulsivity

Obsessive/compulsiveness (for example, overeating or only eating one type of food)

Drinking alcohol to excess (when this was not previously a problem)

Rudeness or impatience, leading to aggression

Poor judgment

Withdrawal or seclusion

Inability to function or interact in social situations

Inability to hold a job

Lack of attention to personal hygiene

Sexual exhibitionism or promiscuity

Emotional changes

Abrupt mood changes

Lack of warmth, concern, or empathy

Indifference to events or to one’s environment

Easily distracted; difficulty maintaining a line of thought

Unaware of the changes in behavior

Decreased interest in activities of daily living

Language changes

Reduced quality of speech: shrinking vocabulary, difficulty finding a word

Difficulty speaking or understanding speech (aphasia)

Repeating words others say (echolalia)

Weak, uncoordinated speech sounds

Decreased ability to read or write

Complete loss of speech (mute)

Neurological/physical problems

Increased muscle rigidity or stiffness

Difficulty moving about

Lack of coordination

General weakness

Memory loss

Urinary incontinence

As with Lewy Body Disease, Pick’s Disease can only be conclusively determined by a post-mortem examination of the brain. Careful symptomatic evaluation, together with brain scans and EEGs, are the best methods currently available for reaching a probable diagnosis. These techniques can help ascertain whether the presenting condition is likely to be Pick’s Disease or a related disorder, such as Alzheimer’s disease. If at least three of the following five distinguishing characteristics are present in the early stages, the diagnosis is likely to be Pick’s rather than Alzheimer’s:onset before age 65;

initial personality changes;

loss of normal controls, e.g., gluttony, hypersexuality;

lack of inhibition;

roaming behavior.

Also, as compared with Alzheimer’s disease, obvious mental impairment and memory loss occur later in Pick’s Disease patients than in Alzheimer’s patients.

How can someone with Pick’s Disease manage their condition?

Focusing on the positive aspects of dealing with a terminal disease might seem like an exercise in futility, and yet, there can be unexpected bright spots for patients with Pick’s Disease. For instance, at the University of California/San Francisco Medical Center’s Memory and Aging Center, doctors discovered a small group of frontotemporal dementia patients who developed new creative skills in music and art. The artistic talents emerged when the brain cell loss occurred predominantly in the left frontal lobe, which controls functions such as language.

As the ability to communicate through words declined, these patients’ brains somehow accessed other realms of self-expression. So exploring and encouraging the development of latent skills is one way in which Pick’s Disease patients can maintain their quality of life and possibly slow the progress of mental deterioration.

In addition, consider the following steps to help manage the symptoms of Pick’s Disease:

Sensory function aids, such as eyeglasses, hearing aids, etc.;

Behavior modification that rewards positive behaviors;

Speech therapy and/or occupational therapy;

Medication to control behaviors that can be dangerous to oneself or others. Antidepressants known as selective serotonin reuptake inhibitors (SSRIs) may offer some relief from apathy and depression and help reduce food cravings, loss of impulse control and compulsive activity.

MULTI-INFARCT DEMENTIA.

In MID, the symptoms are more likely to occur after age 70. In the early stages, the patient retains his or her personality more fully than a patient with AD. Another distinctive feature of this type of dementia is that it often progresses in a stepwise fashion; that is, the patient shows rapid changes in functioning, then remains at a plateau for a while rather than showing a continuous decline. The symptoms of MID may also have a “patchy” quality; that is, some of the patient’s mental functions may be severely affected while others are relatively undamaged. Other symptoms of MID include exaggerated reflexes, an abnormal gait (manner of walking), loss of bladder or bowel control, and inappropriate laughing or crying.

DEMENTIA WITH LEWY BODIES.

This type of dementia may combine some features of AD, such as severe memory loss and confusion, with certain symptoms associated with Parkinson’s disease, including stiff muscles, a shuffling gait, and trembling or shaking of the hands. Visual hallucinations may be one of the first symptoms of dementia with Lewy bodies.

 

FRONTAL LOBE DEMENTIAS.

The frontal lobe dementias are gradual in onset. Pick’s dementia is most likely to develop in persons between 40 and 60, while FLD typically begins before the age of 65. The first symptoms of the frontal lobe dementias often include socially inappropriate behavior (rude remarks, sexual acting-out, disregard of personal hygiene, etc.). Patients are also often obsessed with eating and may put non-food items in their mouths as well as making frequent sucking or smacking noises. In the later stages of frontal lobe dementia or Pick’s disease, the patient may develop muscle weakness, twitching, and delusions or hallucinations.

CREUTZFELDT-JAKOB DISEASE.

The dementia associated with Creutzfeldt-Jakob disease occurs most often in persons between 40 and 60. It is typically preceded by a period of several weeks in which the patient complains of unusual fatigue, anxiety, loss of appetite, or difficulty concentrating. This type of dementia also usually progresses much more rapidly than other dementias, frequently over a span of a few months.

Diagnosis

In some cases, a patient’s primary physician may be able to diagnose the dementia; in many instances, however, the patient will be referred to a neurologist or a gerontologist (specialist in medical care of the elderly). Distinguishing one disorder from other similar disorders is a process called differential diagnosis. The differential diagnosis of dementia is complicated because of the number of possible causes; because more than one cause may be present at the same time; and because dementia can coexist with such other conditions as depression and delirium. Delirium is a temporary disturbance of consciousness marked by confusion, restlessness, inability to focus one’s attention, hallucinations, or delusions. In elderly people, delirium is frequently a side effect of surgery, medications, infectious illnesses, or dehydration. Delirium can be distinguished from dementia by the fact that delirium usually comes on fairly suddenly (in a few hours or days) and may vary in severity it is often worse at night. Dementia develops much more slowly, over a period of months or years, and the patient’s symptoms are relatively stable. It is possible for a person to have delirium and dementia at the same time.

Mental status examination

A mental status examination (MSE) evaluates the patient’s ability to communicate, follow instructions, recall information, perform simple tasks involving movement and coordination, as well as his or her emotional state and general sense of space and time. The MSE includes the doctor’s informal evaluation of the patient’s appearance, vocal tone, facial expressions, posture, and gait as well as formal questions or instructions. A common form that has been used since 1975 is the so-called Folstein Mini-Mental Status Examination, or MMSE. Questions that are relevant to diagnosing dementia include asking the patient to count backward from 100 by 7s, to make change, to name the current President of the United States, to repeat a short phrase after the examiner (such as, “no ifs, ands, or buts”); to draw a clock face or geometric figure, and to follow a set of instructions involving movement (such as, “Show me how to throw a ball” or “Fold this piece of paper and place it under the lamp on the bookshelf.”) The examiner may test the patient’s abstract reasoning ability by asking him or her to explain a familiar proverb (“People who live in glass houses shouldn’t throw stones,” for example) or test the patient’s judgment by asking about a problem with a common-sense solution, such as what one does when a prescription runs out.

Neurological examination

A neurological examination includes an evaluation of the patient’s cranial nerves and reflexes. The cranial nerves govern the ability to speak as well as sight, hearing, taste, and smell. The patient will be asked to stick out the tongue, follow the examiner’s finger with the eyes, raise the eyebrows, etc. The patient is also asked to perform certain actions (such as touching the nose with the eyes closed) that test coordination and spatial orientation. The doctor will usually touch or tap certain areas of the body, such as the knee or the sole of the foot, to test the patient’s reflexes. Failure to respond to the touch or tap may indicate damage to certain parts of the brain.

Laboratory tests

Blood and urine samples may be collected in order to rule out such conditions as thyroid deficiency, niacin or vitamin B12deficiency, heavy metal poisoning, liver disease, HIV infection, syphilis, anemia, medication reactions, or kidney failure. A lumbar puncture (spinal tap) may be done to rule out neurosyphilis.

Diagnostic imaging

 The patient may be given a computed tomography (CT) scan or magnetic resonance imaging  (MRI) to detect evidence of strokes, disintegration of the brain tissue in certain areas, blood clots or tumors, a buildup of spinal fluid, or bleeding into the brain tissue. Positron-emission tomography (PET) or single-emission computed tomography (SPECT) imaging is not used routinely to diagnose dementia, but may be used to rule out Alzheimer’s disease or frontal lobe degeneration if a patient’s CT scan or MRI is unrevealing.

Reversible and responsive dementias

Some types of dementia are reversible, and a few types respond to specific treatments related to their causes. Dementia related to dietary deficiencies or metabolic disorders is treated with the appropriate vitamins or thyroid medication. Dementia related to HIV infection often responds well to zidovudine (Retrovir), a drug given to prevent the AIDS virus from replicating. Multi-infarct dementia is usually treated by controlling the patient’s blood pressure and/or diabetes; while treatments for these disorders cannot undo damage already caused to brain tissue, they can slow the progress of the dementia. Patients with alcohol-related dementia often improve over the long term if they are able to stop drinking. Dementias related to head injuries, hydrocephalus, and tumors are treated by surgery.

It is important to evaluate and treat elderly patients for depression, because the symptoms of depression in older people often mimic dementia. This condition is sometimes called pseudodementia. In addition, patients who suffer from both depression and dementia often show some improvement in intellectual functioning when the depression is treated. The medications most often used for depression related to dementia are the selective serotonin reuptake inhibitors (SSRIs) paroxetine and sertraline. The mental status examination should be repeated after six12 weeks of antidepressant medication.

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Prognosis

The prognosis for reversible dementia related to nutritional or thyroid problems is usually good once the cause has been identified and treated. The prognoses for dementias related to alcoholism or HIV infection depend on the patient’s age and the severity of the underlying disorder.

The prognosis for the irreversible dementias is gradual deterioration of the patient’s functioning ending in death. The length of time varies somewhat. Patients with Alzheimer’s disease may live from two20 years with the disease, with an average of seven years. Patients with frontal lobe dementia or Pick’s disease live on average between five and 10 years after diagnosis. The course of Creutzfeldt-Jakob disease is much more rapid, with patients living between five and 12 months after diagnosis.

Prevention

The reversible dementias related to thyroid and nutritional disorders can be prevented in many cases by regular physical checkups and proper attention to diet. Dementias related to toxic substances in the workplace may be prevented by careful monitoring of the work environment and by substituting less hazardous materials or substances in manufacturing processes. Dementias caused by infectious diseases are theoretically preventable by avoiding exposure to the prion, spirochete, or other disease agent. Multi-infarct dementia may be preventable in some patients by attention to diet and monitoring of blood pressure. Dementias caused by abnormalities in the structure of the brain are not preventable as of 2002.

With regard to genetic factors, tests are now available for the APOE gene implicated in late-onset Alzheimer’s, but these tests are used primarily in research instead of clinical practice. One reason is that the test results are not conclusive; about 20% of people who eventually develop AD do not carry this gene. Another important reason is the ethical implications of testing for a disease that presently has no cure. These considerations may change, however, if researchers discover better treatments for primary dementia, more effective preventive methods, or more reliable genetic markers.

 Intelligence testing in a research context is relatively more straightforward than in a clinical context. In research, intelligence is tested and results are generally as obtained, however in a clinical setting intelligence may be impaired so estimates are required for comparison with obtained results. Premorbid estimates can be determined through a number of methods, the most common include: comparison of test results to expected achievement levels based on prior education and occupation and the use of hold tests which are based on cognitive faculties which are generally good indicators of intelligence and thought to be more resistant to cognitive damage, e.g. language.

·                    Ammons Quick Test

·                    National Adult Reading Test (NART)

·                    Wechsler Adult Intelligence Scale (WAIS)

·                    Wechsler Intelligence Scale for Children (WISC)

·                    Wechsler Preschool and Primary Scale of Intelligence (WPPSI)

·                    Wechsler Test of Adult Reading (WTAR)

Executive functions are an umbrella term for a various cognitive processes and sub-processes. The executive functions include: problem solving, planning, organisational skills, selective attention, inhibitory control and some aspects of short term memory.

·                    Behavioural Assessment of Dysexecutive Syndrome (BADS)

·                    CogScreen: Aeromedical Edition

·                    Continuous Performance Task (CPT)

·                    Controlled Oral Word Association Test (COWAT)

·                    d2 Test of Attention

·                    Delis-Kaplan Executive Function System (D-KEFS)

·                    Digit Vigilance Test

·                    Figural Fluency Test

·                    Halstead Category Test

·                    Hayling and Brixton tests

·                    Iowa gambling task

·                    Kaplan Baycrest Neurocognitive Assessment (KBNA)

·                    Kaufman Short Neuropsychological Assessment

·                    Paced Auditory Serial Addition Test (PASAT)

·                    Pediatric Attention Disorders Diagnostic Screener (PADDS)

·                    Rey-Osterrieth Complex Figure

·                    Ruff Figural Fluency Test

·                    Stroop task

·                    Test of Variables of Attention (T.O.V.A.)

·                    Tower of London Test

·                    Trail-Making Test (TMT) or Trails A & B

·                    Wisconsin Card Sorting Test (WCST)

·                    Symbol Digit Modalities Test

Visuospatial

Neuropsychological tests of visuospatial function should cover the areas of visual perception, visual construction and visual integration. Though not their only functions, these tasks are to a large degree carried out by areas of the parietal lobe.

·                    Clock Test

·                    Hooper Visual Organisation Task (VOT)

·                    Rey-Osterrieth Complex Figure

Dementia specific

Dementia testing is often done by way of testing the cognitive functions that are most often impaired by the disease e.g. memory, orientation, language and problem solving. Tests such as these are by no means conclusive of deficits, but may give a good indication as to the presence or severity of dementia.

·                    Clinical Dementia Rating

·                    Dementia Rating Scale

·                    MCI Screen

Batteries assessing multiple neuropsychological functions

There are some test batteries which combine a range of tests to provide an overview of cognitive skills. These are usually good early tests to rule out problems in certain functions and provide an indication of functions which may need to be tested more specifically.

·                    Cambridge Neuropsychological Test Automated Battery (CANTAB)

·                    Cognistat (The Neurobehavioral Cognitive Status Examination)

·                    Cognitive Assessment Screening Instrument (CASI)

·                    CogScreen

·                    CNS Vital Signs (CNSVS)

·                    Cognitive Function Scanner (CFS)

·                    Dean-Woodcock Neuropsychology Assessment System (DWNAS)

·                    General Practitioner Assessment Of Cognition (GPCOG)

·                    Hooper Visual Organization Test

·                    Luria-Nebraska Neuropsychological battery

·                    MicroCog

·                    Mini mental state examination (MMSE)

·                    NEPSY

·                    Repeatable Battery for the Assessment of Neuropsychological Status

·                    CDR Computerized Assessment System

·         Thought process

Record the patient’s thought process information. The process of thoughts can be described with the following terms: looseness of association (irrelevance), flight of ideas (change topics), racing (rapid thoughts), tangential (departure from topic with no return), circumstantial (being vague, ie, “beating around the bush”), word salad (nonsensical responses), derailment (extreme irrelevance), neologism (creating new words), clanging (rhyming words), punning (talking in riddles), thought blocking (speech is halted), and poverty (limited content).

Throughout the interview, very specific questions will be asked regarding the patient’s history. Note whether the patient responds directly to the questions. For example, when asking for a date, note whether the response given is about the patient’s favorite color. Document whether the patient deviates from the subject at hand and has to be guided back to the topic more than once. Take all of these things in to account when documenting the patient’s thought process.

·         Thought content

To determine whether or not a patient is experiencing hallucinations, ask some of the following questions. “Do you hear voices wheo one else is around?” “Can you see things that no one else can see?” “Do you have other unexplained sensations such as smells, sounds, or feelings?”

Importantly, always ask about command-type hallucinations and inquire what the patient will do in response to these commanding hallucinations. For example, ask “When the voices tell you do something, do you obey their instructions or ignore them?” Types of hallucinations include auditory (hearing things), visual (seeing things), gustatory (tasting things), tactile (feeling sensations), and olfactory (smelling things).

To determine if a patient is having delusions, ask some of the following questions. “Do you have any thoughts that other people think are strange?” ”Do you have any special powers or abilities?” ”Does the television or radio give you special messages?” Types of delusions include grandiose (delusions of grandeur), religious (delusions of special status with God), persecution (belief that someone wants to cause them harm), erotomanic (belief that someone famous is in love with them), jealousy (belief that everyone wants what they have), thought insertion (belief that someone is putting ideas or thoughts into their mind), and ideas of reference (belief that everything refers to them).

 

·         Aspects of thought content are as follows:

·         Obsession and compulsions: Ask the following questions to determine if a patient has any obsessions or compulsions. “Are you afraid of dirt?” “Do you wash your hands often or count things over and over?” “Do you perform specific acts to reduce certain thoughts?” Signs of ritualistic type behaviors should be explored further to determine the severity of the obsession or compulsion.

·         Phobias: Determine if patients have any fears that cause them to avoid certain situations. The following are some possible questions to ask. “Do you have any fears, including fear of animals, needles, heights, snakes, public speaking, or crowds?”

·         Suicidal ideation or intent: Inquiring about suicidal ideation at each visit always is very important. In addition, the interviewer should inquire about past acts of self-harm or violence. Ask the following types of questions when determining suicidal ideation or intent. “Do you have any thoughts of wanting to harm or kill yourself?” “Do you have any thoughts that you would be better off dead?” If the reply is positive for these thoughts, inquire about specific plans, suicide notes, family history (anniversary reaction), and impulse control. Also, ask how the patient views suicide to determine if a suicidal gesture or act is ego-syntonic or ego-dystonic. Next, determine if the patient will contract for safety. For homicidal ideation, make similar inquiries.

·         Homicidal ideation or intent: Inquiring about homicidal ideation or intent during each patient interview also is important. Ask the following types of questions to help determine homicidal ideation or intent. “Do you have any thoughts of wanting to hurt anyone?” “Do you have any feelings or thoughts that you wish someone were dead?” If the reply to one of these questions is positive, ask the patient if he or she has any specific plans to injure someone and how he or she plans to control these feelings if they occur again.

·         Sensorium and cognition: Perform the Folstein Mini-Mental State Examination.

·         Consciousness: Levels of consciousness are determined by the interviewer and are rated as (1) coma, characterized by unresponsiveness; (2) stuporous, characterized by response to pain; (3) lethargic, characterized by drowsiness; and (4) alert, characterized by full awareness.

·         Orientation: To elicit responses concerning orientation, ask the patient questions, as follows. “What is your full name?” (ie, person). “Do you know where you are?” (ie, place). “What is the month, the date, the year, the day of the week, and the time?” (ie, time). “Do you know why you are here?” (ie, situation).

·         Concentration and attention: Ask the patient to subtract 7 from 100, then to repeat the task from that response. This is known as “serial 7s.” Next, ask the patient to spell the word world forward and backward.

·         Reading and writing: Ask the patient to write a simple sentence (noun/verb). Then, ask patient to read a sentence (eg, “Close your eyes.”). This part of the MSE evaluates the patient’s ability to sequence.

·         Visuospatial ability: Have the patient draw interlocking pentagons in order to determine constructional apraxia.

·         Memory: To evaluate a patient’s memory, have them respond to the following prompts. “What was the name of your first grade teacher?” (ie, for remote memory). “What did you eat for dinner last night?” (ie, for recent memory). “Repeat these 3 words: ‘pen,’ ‘chair,’ ‘flag.’ ” (ie, for immediate memory). Tell the patient to remember these words. Then, after 5 minutes, have the patient repeat the words.

·         Abstract thought: Assess the patient’s ability to determine similarities. Ask the patient how 2 items are alike. For example, an apple and an orange (good response is “fruit”; poor response is “round”), a fly and a tree (good response is “alive”; poor response is “nothing”), or a train and a car (good response is “modes of transportation”). Assess the patient’s ability to understand proverbs. Ask the patient the meaning of certain proverbial phrases. Examples include the following. “A bird in the hand is worth two in the bush” (good response is “be grateful for what you already have”; poor response is “one bird in the hand”). “Don’t cry over spilled milk” (good response is “don’t get upset over the little things”; poor response is “spilling milk is bad”).

·         General fund of knowledge: Test the patient’s knowledge by asking some of the following questions. “How many nickels are in $1.15?” “List the last 5 presidents of the United States.” “List 5 major US cities.” Obviously, a higher number of correct answers is better; however, the interviewer always should take into consideration the patient’s educational background and other training in evaluating answers and assigning scores.

·         Intelligence: Based on the information provided by the patient throughout the interview, estimate the patient’s intelligence quotient (ie, below average, average, above average).

 

DISTURBANCES OF MOOD AND AFFECT

In speaking of mood one is referring to a patient’s sustained, relatively long-lasting emotional tone. Thus moods may be depressed, manic (either euphoric or irritable), or anxious. In contrast, affect refers to the emotional “look” of the patient: facial    j expression, gestures, and postures, all of which convey a certain     j emotion. Whereas mood is fairly constant, affect may change from    j one minute to the next in the context of a patient’s ongoing     І reaction to events and other people. Indeed, in certain cases, affect    j may change so rapidly as to merit the term “labile.” To use an analogy, mood is to affect as climate is to weather.

Distinguishing an abnormal mood from a normal one may at times be difficult, as all persons at times experience depression, irritability, elation, and anxiety. The key differential point is the presence or absence of autonomy, or independence, of the patients’ moods, not only from their own attempts at control, but also from the events of their lives. Iormal life, moods gradually come and go, are understandable in light of the events of the patients’ lives, and, to a considerable extent, are subject to some degree of control: most persons are able to “shake off” a bad mood and get on with life. Pathologic moods, however, are autonomous and have a life of their own. They are out of proportion to the patients’ lives; they are simply too profound or too long-lasting in light of any supposed precipitating event. Furthermore, in cases where the presumed precipitating stress is resolved, the mood in question persists, rather than gradually clearing, again for no apparent reason. The autonomy of a pathologic mood is also evident in its persistence despite all reasonable attempts by patients to “shake it off” or “pull themselves out of it.”

 

 

 Depressive Symptoms

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. Other depressive symptoms are described in the chapter on major depression.

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: someone else reminds the patient of past successes or accomplish- , ments, they are either belittled and undercut, or simply dismissed as not important. 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. One patient was absolutely unable to comprehend how it was possible to get through morning chores and, thus perplexed, remained in bed. In such cases patients may complain that it is as if a fog lay over everything. Indeed one of the first signs of recovery may be the sense that the “fog” is lifting.

Diagnostic of severity of depressive symptoms can be performed with Hamilton depression rating scale and Montgomery Asberg depression rating scale.

 

Manic Symptoms

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. They may be seen in bipolar disorder, cyclothymia, hyperthymia, and secondary mania.

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, as noted earlier, are often “infectious,” and indeed only the dour physician can avoid being swept up in their mirth.

Irritability may be extreme and can eventuate in violence. Some manic patients are predominately irritable, whereas others may tend toward euphoria and only flash into irritability when one of their many designs are thwarted. Irritable patients tend to be overbearing, insistent, quick to take offense, and are constantly pressing their own opinions and plans. As they seek to control all around them they inevitably come into conflict with others, whereupon they often become threatening and may flash into violence.

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 almost all cases hyperactivity, as might be expected, accompanies this increased level of energy. These patients seem always on the go, restless, and unable to sit down and be still. In mild forms of mania the activity is often channeled and clearly purposeful, however misguided. One patient began three new businesses, bought a house, married, and visited every single relative throughout the state, all in a few days time. When hyperactivity becomes more severe, however, the patient’s behavior begins to disintegrate into multiple and at times conflicting fragments of purpose. Too many projects are begun and few, if any, are brought even close to completion.

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.

Pressured speech is almost unmistakable. Patients pour forth a veritable torrent of words, inundating anyone close enough to hear. Speech is rapid, often loud, and typically laced with rhymes, puns, and clang associations. Others can “barely get a word in edgewise.”

Pressured speech is almost unmistakable. Patients pour forth a veritable torrent of words, inundating anyone close enough to hear. Speech is rapid, often loud, and typically laced with rhymes, puns, and clang associations. Others can “barely get a word in edgewise.”

 Diagnostic of severity of Manic symptoms can be performed with Young mania rating scale (YMRS).

Irritability

The quality of irritability is strongly influenced by the disorder in which it appears. Patients with paranoia tend to be querulous; those with mania tend to be more actively and constantly argumentative and threatening. In patients with paranoid schizophrenia the irritability, though ever-present, is held in check, almost like a constant veiled threat.

Anxiety

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 tremu-lousness, 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.

Precipitated anxiety attacks (also known as “situationally bound or predisposed attacks”) may occur in the phobias (simple, social, and agoraphobia), panic disorder, post-traumatic stress disorder, separation anxiety disorder, and in patients with obsessive-compulsive disorder when they are unable to follow through on their compulsions.

Unprecipitated anxiety attacks are seen in panic disorder, during depressive episodes, and in various other conditions, as for example hypoglycemia.

Labile Affect

Iormal 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.

Pathological laughing and crying, as described in the chapter on pseudobulbar palsy, represents a peculiar form ofjability. Here patients may laugh or cry for no apparent reason; in addition they may honestly deny feeling happy or sad. A divorce occurs between felt emotion and the facial expression of emotion.

 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. Another example is a patient who, though recounting horrible tortures endured every day, had a beatific facial expression.

The term “inappropriate affect” has also been used in situations where emotion and affect correspond, but those listening to the patient find the emotional display offensive or inappropriate to the occasion. For example, though it is inappropriate for someone to laugh at a parent’s funeral, and certainly shocking to other mourners, such an emotional display might not indicate pathology. If the parent had been abusive and the person was seething with triumphant hatred, then the laughter in this light would be “appropriate” to the emotion that the person had. To avoid confusion one may best reserve the term “inappropriate affect” only to those situations where a discordance exists between what the patient feels and what shows on 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.

The masked or flattened facies of parkinsonism may be distinguished from flattened affect by virtue of the fact that these patients still have feelings but simply cannot express them by facial movement.

Expressive aprosodia likewise differs from flattened affect in that these patients still experience feelings. A global aprosodia may be quite difficult to distinguish from flattened affect. The absence, however, of any other signs or symptoms typical for schizophrenia should prompt a thorough search for a lesion affecting the right parietotemporal cortex.

Dysthymia

There are no blood or other objective tests for the mental disorders. This makes psychiatry more difficult ( and more interesting). Objective tests would be  particularly useful in the area betweeormal sadness and major depressive disorder. The question has long been deb ated: is there a disorder in this space, and if so, what are its characteristics?

Personality is the constellation of behaviour/reactions which make us different from each other. Just as individuals differ in their capacity for honesty and generosity, so too, do they differ in their capacity for cheerfulness, optimism and energy. Those who by nature/make-up are at the low end of the scale on cheerfulness, optimism and energy may be described as possessing a depressive type of personality.

The DSM-IV and ICD-10 use the term dysthymia (bad mood). The diagnostic criteriainclude low-grade depressive symptoms, similar to those of major depressive disorder, but insufficient to satisfy that diagnosis, and persisting for at least 2 years.

This is a chronic condition. Onset may be during  to late childhood. A large proportion has experienced, or will go on to develop, a major depressive episode.

Finally, there are clear accounts of the treatment of some people with dysthymia with antidepressants leading to hypomanic episodes.

 

Disorders of will

Agitated behavior

Causes

There are many causes of agitation, some of which include:

• Alcohol intoxication or withdrawal
• Allergic reaction
• Caffeine intoxication
• Certain forms of heart, lung, liver, or kidney disease
• Intoxication or withdrawal from drugs of abuse (such as cocaine, marijuana, hallucinogens, PCP, or opiates)
• Hospitalization (older adults often have delirium while in the hospital)
• Hyperthyroidism (overactive thyroid gland)
• Infection (especially in elderly people)
• Nicotine withdrawal
• Poisoning (for example, carbon monoxide poisoning)
• Theophylline, amphetamines, steroids, and certain other medicines
• Trauma
• Vitamin B6 deficiency

Agitation can occur with brain and mental health disorders, such as:

• Anxiety
• Dementia (such as Alzheimer’s disease)
• Depression
• Mania
• Schizophrenia

Types of psychomotor excitement.

·                   Depressive

·                   Manic 

·                   Catatonic

·                   Psychogenic

·                   Hallucinative

·                   Depressive 

·                   Catatonic

·                   Psychogenic

 

 

 

Aboulia

  has been known to clinicians since 1838. However, in the time since its inception, the definition of aboulia has been subjected to many different forms, some even contradictory with previous ones. Aboulia has been described as a loss of drive, expression, loss of behavior and speech output, slowing and prolonged speech latency, and reduction of spontaneous thought content and initiative. The clinical features most commonly associated with aboulia are:

Difficulty in initiating and sustaining purposeful movements

Lack of spontaneous movement

Reduced spontaneous movement

Increased response-time to queries

Passivity

Reduced emotional responsiveness and spontaneity

Reduced social interactions

Reduced interest in usual pastimes

Especially in patients with progressive dementia, it may affect feeding. Patients may continue to chew or hold food in their mouths for hours without swallowing it. The behavior may be most evident after these patients have eaten part of their meals and no longer have strong appetites.

Illnesses where aboulia may be present

1.     Depression

2.     Schizophrenia

3.     Parkinson’s Disease

4.     Huntington’s Disease

5.     Progressive supranuclear palsy

6.     Traumatic Brain Injury

7.     Stroke

In psychology and psychiatry, anhedonia (pron.: /ˌænhiˈdoʊniə/ AN-hee-DOH-nee-ə; Greek: ἀν– an-, “without” + ἡδονή hēdonē, “pleasure”) is defined as the inability to experience pleasure from activities usually found enjoyable, e.g. exercise, hobbies, sexual activities or social interactions.

  

While earlier definitions of anhedonia emphasized pleasurable experience, more recent models have highlighted the need to consider different aspects of enjoyable behavior, such as motivation or desire to engage in an activity (“motivational anhedonia”), as compared to the level of enjoyment of the activity itself (“consummatory anhedonia”).

According to William James the term was coined by Théodule-Armand Ribot.

One can distinguish many kinds of pathological depression. Sometimes it is mere passive joylessness and dreariness, discouragement, dejection, lack of taste and zest and spring. Professor Ribot has proposed the name anhedonia to designate this condition. “The state of anhedonia, if I may coin a new word to pair off with analgesia,” he writes, “has been very little studied, but it exists.”

Anhedonia can be a characteristic of mental disorders including mood disorders, schizoaffective disorder, schizoid personality disorder and schizophrenia. For example, people affected with schizophrenia often describe themselves as feeling emotionally empty^.

Mood disturbances are commonly observed in many psychiatric disorders. Disturbing mood changes may occur resultant to stressful life events and they are not uncommon during times of physical illness^.While anhedonia can be a feature of such mood changes, they are not mutually inclusive.

Athymhormic syndrome, or psychic akinesia, is a rare neurological syndrome characterized by extreme passivity, apathy, blunted affect, and a profound generalized loss of self-motivation and conscious thought. For example, a patient with this syndrome might sustain severe burns on contact with a hot stove, due to lacking the will to move away despite experiencing severe pain. The existence of such symptoms in patients after damage to certain structures in the brain has been used to support a physical model of motivation in human beings, wherein the limbic loop of the basal ganglia is the initiator of directed action and thought.

The word Athymhormic is derived from the Greek (Greek: Thumos), which means mood or affect, and (Greek: Horme), which means impulse, drive, or appetite. First described by French neurologist Dominique Laplane in 1982 as “”PAP syndrome” (French: perte d’auto-activation psychique, or “loss of psychic autoactivation”), the syndrome is believed to be due to damage to areas of the basal ganglia or frontal cortex, specifically the striatum and globus pallidus, responsible for motivation and executive functions. It may occur without any preexisting psychiatric condition.

Symptoms

It is characterized by an absence of voluntary motion without any apparent motor deficit, and patients often describe a complete mental void or blank. This is accompanied by reduced affect or emotional concern (athymhormy) and often by compulsions, repetitive actions, or tics. After stimulation from the outside, such as a direct command, the patient is able to move normally and carry out complex physical and mental tasks for as long as they are prompted to continue.

The symptoms may be differentiated from depression because depression requires the existence of sadness or negative thoughts, while athymhormic patients claim to have complete lack of thoughts, positive or negative.

A stereotypy (pron.: /ˈstɛriː.ɵtaɪpi/) is a repetitive or ritualistic movement, posture, or utterance. Stereotypies may be simple movements such as body rocking, or complex, such as self-caressing, crossing and uncrossing of legs, and marching in place. They are found in people with mental retardation, autism spectrum disorders, tardive dyskinesia and stereotypic movement disorder; studies have shown stereotypies associated with some types of schizophrenia. Frontotemporal dementia is also a commoeurological cause of repetitive behaviors and stereotypies. Several causes have been hypothesized for stereotypy, and several treatment options are available.

Stereotypy is sometimes called stimming in autism, under the hypothesis that it self-stimulates one or more senses. Related terms include punding and tweaking to describe repetitive behavior that is a side effect of some drugs.

Among people with frontotemporal lobar degeneration, more than half (60%) had stereotypies. The time to onset of stereotypies in people with frontotemporal lobar degeneration may be years (average 2.1 years).

Distinction from tics

Like tics, stereotypies are patterned and periodic, and are made worse by fatigue, stress, and anxiety. Unlike tics, stereotypies usually begin before the age of three, involve more of the body, are more rhythmic and less random, and are associated more with engrossment in another activity rather than premonitory urges. Examples of early tics are things like blinking and throat clearing, while arm flapping is a more common stereotypy. Stereotypies do not have the ever-changing, waxing and waning nature of tics, and can remain constant for years. Tics are usually suppressible for brief periods; in contrast, children rarely consciously attempt to control a stereotypy, although they can be distracted from one.

Catatonia is a state of neurogenic motor immobility, and behavioral abnormality manifested by stupor. It was first described, in 1874, by Karl Ludwig Kahlbaum in Die Katatonie oder das Spannungsirresein.

In the current Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association (DSM-IV-TR) it is not recognized as a separate disorder, but is associated with psychiatric conditions such as schizophrenia (catatonic type), bipolar disorder, post-traumatic stress disorder, depression and other mental disorders, as well as drug abuse or overdose (or both). It may also be seen in many medical disorders including infections (such as encephalitis), autoimmune disorders, focal neurologic lesions (including strokes), metabolic disturbances and abrupt or overly rapid benzodiazepine withdrawal.

It can be an adverse reaction to prescribed medication. It bears similarity to conditions such as encephalitis lethargica and neuroleptic malignant syndrome. There are a variety of treatments available; benzodiazepines are a first-line treatment strategy. Electro-convulsive therapy is also sometimes used. There is growing evidence for the effectiveness of NMDA antagonists for benzodiazepine resistant catatonia. Antipsychotics are sometimes employed but require caution as they can worsen symptoms and have serious adverse effects.

Clinical features

Patients with catatonia may experience an extreme loss of motor skills or even constant hyperactive motor activity. Catatonic patients will sometimes hold rigid poses for hours and will ignore any external stimuli. Patients with catatonic excitement can suffer from exhaustion if not treated. Patients may also show stereotyped, repetitive movements.

They may show specific types of movement such as waxy flexibility,  in which they maintain positions after being placed in them by someone else, or gegenhalten (lit. “counterhold”), in which they resist movement in proportion to the force applied by the examiner. They may repeat meaningless phrases or speak only to repeat what the examiner says.

While catatonia is only identified as a symptom of schizophrenia in present psychiatric classifications, it is increasingly recognized as a syndrome with many faces. It appears as the Kahlbaum syndrome (retarded catatonia), malignant catatonia (neuroleptic malignant syndrome, toxic serotonin syndrome), and excited forms (delirious mania, catatonic excitement, oneirophrenia). It has also been recognized as grafted on to autism spectrum disorders.

Diagnostic criteria

According to the DSM-IV, the “With catatonic features” specifier can be applied if the clinical picture is dominated by at least two of the following:

·                    motor immobility as evidenced by catalepsy (including waxy flexibility) or stupor

·                    excessive motor activity (purposeless, not influenced by external stimuli)

·                    extreme negativism (motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism

·                    peculiarities of voluntary movement as evidenced by posturing, stereotyped movements, prominent mannerisms, or prominent grimacing

·                    echolalia or echopraxia

Subtypes

·                    Stupor is a motionless, apathetic state in which one is oblivious or does not react to external stimuli. Motor activity is nearly non-existent. Individuals in this state make little or no eye contact with others and may be mute and rigid. One might remain in one position for a long period of time, and then go directly to another position immediately after the first position.  

·                    Catatonic excitement is a state of constant purposeless agitation and excitation. Individuals in this state are extremely hyperactive, although, as aforementioned, the activity seems to lack purpose. It is commonly cited as one of the most dangerous mental states in psychiatry.

·                    Malignant catatonia is an acute onset of excitement, fever, autonomic instability, delirium and may be fatal.

 

Catatonia rating scale

Fink and Taylor developed a catatonia rating scale to identify the syndrome. A diagnosis is verified by a benzodiazepine or barbiturate test. The diagnosis is validated by the quick response to either benzodiazepines or electroconvulsive therapy (ECT). While proven useful in the past, barbiturates are no longer commonly used in psychiatry; thus the option of either benzodiazepines or ECT.

 

Disordered eating is a classification (within DSM-IV-TR, used in the health-care field) to describe a wide range of irregular eating behaviors that do not warrant a diagnosis of a specific eating disorder such as anorexia nervosa or bulimia nervosa. Affected people may be diagnosed with an eating disorder not otherwise specified. A change in eating patterns can also be caused by other mental disorders (e.g. clinical depression), or by factors that are generally considered to be unrelated to mental disorders (e.g. extreme homesickness).

Some people consider disordered-eating patterns that are not the result of a specific eating disorder to be less serious than symptoms of disorders such as anorexia nervosa. Others note that individual cases may involve serious problems with food and body image. Additionally, certain types of disordered eating can include symptoms from both classic cases of anorexia and bulimia, making disordered eating just as dangerous.

Some counselors specialize in disordered-eating patterns. The recognition that some people have eating problems that do not fit into the scope of specific eating disorders makes it possible for a larger proportion of people who have eating problems to receive help.

Currently recognized in medical manuals

Specified as mental disorders in standard medical manuals, such as the ICD-10 or the DSM-IV.

·                     Anorexia nervosa (AN), characterized by refusal to maintain a healthy body weight, an obsessive fear of gaining weight, and an unrealistic perception of current body weight.

·                     However, some patients can suffer from anorexia nervosa unconsciously. These patients are classified under “atypical eating disorders”. Anorexia can cause menstruation to stop, and often leads to bone loss, loss of skin integrity, etc. It greatly stresses the heart, increasing the risk of heart attacks and related heart problems. The risk of death is greatly increased in individuals with this disease. The most underlining factor researchers are starting to take notice of is that it may not just be a vanity, social, or media issue, but it could also be related to biological and or genetic components.

• Bulimia nervosa (BN), characterized by recurrent binge eating followed by compensatory behaviors such as purging (self-induced vomiting, excessive use of laxatives/diuretics, or excessive exercise). Fasting and over-exercising may also be used as a method of purging following a binge.
• 
• Eating disorders not otherwise specified (EDNOS) is an eating disorder that does not meet the DSM-IV criteria for anorexia or bulimia. Examples can be a female who suffers from anorexia but still has her period or someone who may be at a “healthy weight” but who has anorexic thought patterns and behaviors; it can mean the sufferer equally participates in some anorexic as well as bulimic behaviors (sometimes referred to as purge-type anorexia) or to any combination of eating disorder behaviors that do not directly put them in a separate category.
• Binge eating disorder (BED) or ‘compulsive overeating’, characterized by binge eating, without compensatory behavior. This type of eating disorder is even more common than bulimia or anorexia. This disorder does not have a category of people in which it can develop. In fact, this disorder can develop in a range of ages and is unbiased to classes.
• Pica, characterized by a compulsive craving for eating, chewing or licking non-food items or foods containing no nutrition. These can include such things as chalk, paper, plaster, paint chips, baking soda, starch, glue, rust, ice, coffee grounds, and cigarette ashes. These individuals cannot distinguish a difference between food and non-food items.

Not currently recognized in standard medical manuals

• Compulsive overeating, (COE) characteristic of binge eating disorder, in which people tend to eat more thaecessary resulting in more stress. This is mainly caused by ‘binge eating disorder’.  
• Purging disorder, characterized by recurrent purging to control weight or shape in the absence of binge eating episodes.
• Rumination, characterized by involving the repeated painless regurgitation of food following a meal which is then either re-chewed and re-swallowed, or discarded.
• Diabulimia, characterized by the deliberate manipulation of insulin levels by diabetics in an effort to control their weight.
• Food maintenance, characterized by a set of aberrant eating behaviors of children in foster care.
• Night eating syndrome, characterized by morning anorexia, evening polyphagia (abnormally increased appetite for consumption of food (frequently associated with insomnia, and injury to the hypothalamus).
• Orthorexia nervosa, a term used by Steven Bratman to characterize an obsession with a “pure” diet, in which people develop an obsession with avoiding unhealthy foods to the point where it interferes with a person’s life.
• Drunkorexia, commonly characterized by purposely restricting food intake in order to reserve food calories for alcoholic calories, exercising excessively in order to burn calories consumed from drinking, and over-drinking alcohols in order to purge previously consumed food.
• Pregorexia, characterized by extreme dieting and over-exercising in order to control pregnancy weight gain. Under-nutrition during pregnancy is associated with low birth weight, coronary heart disease, type 2 diabetes, stroke, hypertension, cardiovascular disease risk, and depression.

 

Paraphilia

 

Paraphilia (from Greek para παρά = beside and -philia φιλία = friendship, meaning love) describes the experience of intense sexual arousal to atypical objects, situations, or individuals. Paraphilic behavior (such as pedophilia, zoophilia, sexual sadism, and exhibitionism) may be illegal in some jurisdictions, but may also be tolerated^{[citatioeeded]}. No consensus has been found for any precise border between unusual personal sexual tastes and paraphilic ones. There is debate over which, if any, of the paraphilias should be listed in diagnostic manuals, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases.

The number and taxonomy of paraphilias is under debate; one source lists as many as 549 paraphilias. Several sub-classifications of the paraphilias have been proposed, and some argue that a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.

Current definitions include:

(1) Sexual excitement to the point of erection and/or orgasm, when the object of that excitement is considered abnormal in the context of the practitioner’s learned societal norms.

(2) Recurrent intense sexual urges and fantasies in response to sexual objects or situations which are not part of normative arousal patterns, e.g., clothing fetishes.

 (3) A sexuoerotic embellishment of, or alternative to the official, ideological norm

 

Types: Exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, transvestic fetishism, voyeurism.