Symptoms of violations of consciousness

Disorders of Consciousness.

Main psychopathological syndromes.

 

BRAIN,  MIND  AND  SOUL.  A  continuing  debate  in  psychology   and philosophy has centered on the relationship between mind and  body,  or between the physical brain and the ephemeral  mind.  Dualism  considers them separate. Monism postulates they are one. The emergentinteraction approach offers a reconciliation of the two postures by proposing  that the brain activities give rise  to  mental  states  that  are  emergent properties of the brain’s hierarchical organization ,  that  brain  and mind interact and that the mind can exert causal  influences  over  the brain in controlling behaviour. Different cultures have various beliefs about what the mind is.

 THE  NATURE  OF  CONSCIOUSNESS.  Consciousness is an extremely complicated mental function, it is considered by modern psychology to be characteristic only of human beings. It can be determined as a state of awareness of the mind functioning and its contents,  and  also  of the external environment. Consciousness aids our survival  and  enables us to construct both personal and culturally shared  realities. Three levels of consciousness are: 1) a basic  awareness  of  the world, 2) a reflection of what we are aware of,  and  3)  self-awareness.  The structure of consciousness involves nonconscious processes, preconscious memories  subconscious  awareness,  the  unconscious,  and conscious awareness. Many different research techniques are employed to study different aspects of  consciousness.  These  include  think-aloud protocols, experience sampling and dichotic listening tasks.

 

SELF-AWARENESS – is a process of becoming aware of the autobiographical character of personally experienced events.

 

SELF-CONCEPT (self-consciousness)  is  an  individual’s  awareness  of  his  or   her continuing identity as a person.

EVERYDAY  CHANGES  IN  CONSCIOUSNESS.  Ordinary alterations of consciousness  include  daydreaming, fantasy, sleep, and dreams. Daydreaming is a common experience when attention is shifted  from  the immediate  situation  to   other thoughts that are elicited semiautomatically. Both genetical and volitional factors determine  the length of sleep for humans. Sleep  patterns  change  with  age.  Babies sleep about 16 hours each day, and by old age sleep may last fewer than 6 hours. Freud proposed  that  the  content  of  dream  is  unconscious material stimulated by the day events. The activation-synthesis dream theory  challenges  Freud’s  psychodynamic  approach  with  a    purely biological explanation.

Psychologists says that “consciousness’ – awareness by individual of objective reality”.

 

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

“Consciousness” – knowledge quantity and  higher psychic function.

How it sounds in Dals vocabulary: “Consciousness” – is awareness of myself, full memory, human condition in health meaning, which can give report to his actions.

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

 Properties of Consciousness

Content: Content of associations which arise up under act of  different irritants and are in consciousness, ò. content of ideas and experiencing.

Continuity: unity of experiencing of the past, modern and future.

 

 

 

Symptoms of violations of consciousness

 

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

 

States of consciousness  

 

Violation of consciousness

 •         Quantitative (switching off of consciousness):

 •         Stunning:

 •         Obnubilation

 •         Somnolence

 •         Spoor

 •        Comma

 •         Absans

 •         Fainting fit

 • Qualitive (eclipse)

 • Delіrіy

 • Amentsіya

 • Oneyroid

 • Twilight (gloomy)

 • State of consciousness, including ambulatory automatism, fugues, trances, sleepwalking.

Special states of consciousness:

 à) Pathological affect

 b) Pathological intoxication;

 c) Reaction of “short circuit”

 d) Syndromes “already seen” and “never   not seen;(“deja vu”, “jamais vu”) “already heard” and “never heard”.(“deja vecu”,”jamais vecu”)

Quantitative violations.

 Stunning

Obnubilation (nubes – cloud) – the most light stunning degree. Oscillation of degree of clarity of consciousness with the incomplete understanding of that which takes place around, patients answer question slowly, caot quickly comprehend a situation, languid, slow.

Somnolence – the threshold of perception of external irritants rises. On quiet voice irresponsive, on a vowel  language answer slowly, easy tasks execute slowly, difficult tasks can not comprehend; face mimics is stupid, dull, a reaction on pain is reduced.

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

Comma  (from the Greek κῶμα koma, meaning “deep sleep”) is a state of unconsciousness lasting more than six hours, in which a person: cannot be awakened; fails to respond normally to painful stimuli, light, or sound; lacks a normal sleep-wake cycle; and, does not initiate voluntary actions. A person in a state of coma is described as being comatose.

A comatose person exhibits a complete absence of wakefulness and is unable to consciously feel, speak, hear, or move. For a patient to maintain consciousness, two important neurological components must function. The first is the cerebral cortex—the gray matter that covers the outer layer of the brain. The other is a structure located in the brainstem, called reticular activating system (RAS). Injury to either or both of these components is sufficient to cause a patient to experience a coma.^] The cerebral cortex is a group of tight, dense, “gray matter” composed of the nucleus of the neurons whose axons then form the “white matter”, and is responsible for perception, relay of the sensory input (sensation) via the thalamic pathway, and many other neurological functions, including complex thinking.

RAS, on the other hand, is a more primitive structure in the brainstem that is tightly in connection with reticular formation (RF). The RAS area of the brain has two tracts, the ascending and descending tract. Made up of a system of acetylcholine-producing neurons, the ascending track, or ascending reticular activating system (ARAS), works to arouse and wake up the brain, from the RF, through the thalamus, and then finally to the cerebral cortex. A failure in ARAS functioning may then lead to a coma.^] It is therefore necessary to investigate the integrity of cerebral cortex as well of the reticular activating system (RAS) in a comatose patient

 

 

 

Coma may result from a variety of conditions, including intoxication (such as drug abuse, overdose or misuse of over the counter medications, prescribed medication, or controlled substances), metabolic abnormalities, central nervous system diseases, acute neurologic injuries such as strokes or herniations, hypoxia, hypothermia, hypoglycemia or traumatic injuries such as head trauma caused by falls or vehicle collisions. It may also be deliberately induced by pharmaceutical agents during major neurosurgery, to preserve higher brain functions following brain trauma, or to save the patient from extreme pain during healing of injuries or diseases.

Forty percent of comatose states result from drug poisoning. Drugs damage or weaken the synaptic functioning in the ARAS and keep the system from properly functioning to arouse the brain. Secondary effects of drugs, which include abnormal heart rate and blood pressure, as well as abnormal breathing and sweating, may also indirectly harm the functioning of the ARAS and lead to a coma. Seizures and hallucinations have shown to also play a major role in ARAS malfunction. Given that drug poisoning causes a large portion of patients in a coma, hospitals first test all comatose patients by observing pupil size and eye movement, through the vestibular-ocular reflex.

The second most common cause of coma, which makes up about 25% of comatose patients, occurs from lack of oxygen, generally resulting from cardiac arrest. The Central Nervous System (CNS) requires a great deal of oxygen for its neurons. Oxygen deprivation in the brain, also known as hypoxia, causes neuronal extracellular sodium and calcium to decrease and intracellular calcium to increase, which harms neuron communication. Lack of oxygen in the brain also causes ATP exhaustion and cellular breakdown from cytoskeleton damage and nitric oxide production.

Twenty percent of comatose states result from the side effects of a stroke. During a stroke, blood flow to part of the brain is restricted or blocked. An ischemic stroke, brain hemorrhage, or tumor may cause such cessation of blood flow. Lack of blood to cells in the brain prevents nutrients and oxygen from getting to the neurons, and consequently causes cells to become disrupted and eventually die. As brain cells die, brain tissue continues to deteriorate, which may affect functioning of the ARAS.

The remaining 15% of comatose cases result from trauma, excessive blood loss, malnutrition, hypothermia, hyperthermia, abnormal glucose levels, and many other biological disorders.

 

Absans are brief (usually less than 20 seconds), generalized epileptic seizures of sudden onset and termination. When someone experiences an absence seizure they are often unaware of their episode. Those most susceptible to this are children and the first episode usually occurs between 4–12 years old. It is very rare that someone older will experience their first absence seizure.^] Episodes of absence seizures can often be mistaken for inattentiveness when misdiagnosed and can occur 50-100 times a day. They can be so difficult to detect that some people may go months or years before given a proper diagnosis. There are no known before or after effects of absence seizures They have two essential components:

• clinically, the impairment of consciousness (absence)
• Electroencephalography (EEG) shows generalized spike-and-slow wave discharges.

Absence seizures are broadly divided into typical and atypical types. Typical absence seizures usually occur in the context of idiopathic generalised epilepsies and EEG shows fast >2.5 Hz generalised spike-wave discharges. The prefix “typical” is to differentiate them from atypical absences rather than to characterise them as “classical” or characteristic of any particular syndrome.

Atypical absence seizures:

• occur only in the context of mainly severe symptomatic or cryptogenic epilepsies of children with learning difficulties who also suffer from frequent seizures of other types, such as atonic, tonic and myoclonic.
• onset and termination is not so abrupt and changes in tone are more pronounced.
• ictal EEG is of slow (less than 2.5 Hz) spike and slow wave. The discharge is heterogeneous, often asymmetrical and may include irregular spike and slow wave complexes, fast and other paroxysmal activity. Background interictal EEG is usually abnormal.

The clinical manifestations of absence seizures vary significantly between patients. Impairment of consciousness is the essential ictal element and may be the only clinical symptom, but this is often combined with other manifestations. The hallmark of the absence seizures is abrupt and sudden-onset impairment of consciousness, interruption of ongoing activities, a blank stare, possibly a brief upward rotation of the eyes. If the patient is speaking, speech is slowed or interrupted, if walking, he or she stands transfixed; if eating, the food will stop on its way to the mouth. Usually, the patient will be unresponsive when addressed. In some cases, attacks are aborted when the patient is called. The attack lasts from a few seconds to half a minute, and evaporates as rapidly as it commenced.

1.     Absence with impairment of consciousness only as per the above description

2.     Absence with mild clonic components. Here the onset of the attack is indistinguishable from the above, but clonic components may occur in the eyelids, at the corner of the mouth, or in other muscle groups which may vary in severity from almost imperceptible movements to generalised myoclonic jerks. Objects held in the hand may be dropped.

3.     Absence with atonic components. Here there may be a diminution in tone of muscles subserving posture as well as in the limbs leading to drooping of the head, occasionally slumping of the trunk, dropping of the arms, and relaxation of the grip. Rarely tone is sufficiently diminished to cause this person to fall.

4.     Absence with tonic components. Here during the attack tonic muscular contraction may occur, leading to increase in muscle tone which may affect the extensor muscles or the flexor muscles symmetrically or asymmetrically. If the patient is standing the head may be drawn backward and the trunk may arch. This may lead to retropulsion. The head may tonically draw to one or another side.

5.     Absence with automatisms. Purposeful or quasipurposeful movements occurring in the absence of awareness during an absence attack are frequent and may range from lip licking and swallowing to clothes fumbling or aimless walking. If spoken to the patient may grunt or to the spoken voice and when touched or tickled may rub the site. Automatisms are quite elaborate and may consist of combinations of the above described movements or may be so simple as to be missed by casual observation.

6.     Absence with autonomic components. These may be pallor and less frequently flushing, sweating, dilatation of pupils and incontinence of urine.

Mixed forms of absence frequently occur. These seizures can happen a few times a day or in some cases hundreds of times a day, to the point that the person cannot concentrate in school or other situations requiring sustained, concentrated attention.

 

Delirium, or acute confusional state, is a syndrome that presents as severe confusion and disorientation, developing with relatively rapid onset and fluctuating in intensity. It is a syndrome which occurs more frequently in people in their later years. Delirium represents an organically caused decline from a previously-attained baseline level of cognitive function. It is typified by fluctuating course, attentional deficits and generalized severe disorganization of behavior. It typically involves other cognitive deficits, changes in arousal (hyperactive, hypoactive, or mixed), perceptual deficits, altered sleep-wake cycle, and psychotic features such as hallucinations and delusions. Delirium itself is not a disease, but rather a clinical syndrome (a set of symptoms), which result from an underlying disease, from medications administered during treatment of that disease in a critical phase or from a new problem with mentation.

It is a corollary of the criteria that a diagnosis of delirium cannot be made without a previous assessment, or knowledge, of the affected person’s baseline level of cognitive function. In other words, a mentally disabled or demented person who is operating at their own baseline level of mental ability would be expected to appear delirious without a baseline mental functional status against which to compare.

Delirium may be caused by a disease process outside the brain that nonetheless affects the brain, such as infection (urinary tract infection, pneumonia) or drug effects, particularly anticholinergics or other CNS depressants (benzodiazepines and opioids).^[1] Although hallucinations and delusions are sometimes present in delirium, these are not required for the diagnosis, and the symptoms of delirium are clinically distinct from those induced by psychosis or hallucinogens (with the exception of deliriants.) Delirium must by definition be caused by an organic process, i.e., a physically identifiable structural, functional, or chemical problem in the brain (see organic brain syndrome), and thus, fluctuations of mentation due to changes in purely psychiatric processes or diseases, such as sudden psychosis from schizophrenia or bipolar disorder, are (by definition) not termed delirium.

 

Like its components (inability to focus attention, mental confusion and various impairments in awareness and temporal and spatial orientation), delirium is the common symptomatic manifestation of new organic brain dysfunction (for any reason). Delirium requires both a sudden change in mentation, and an organic cause for this. Thus, without careful assessment and history, delirium can easily be confused with a number of psychiatric disorders or long term organic brain syndromes, because many of the signs and symptoms of delirium are conditions also present in dementia, depression, and psychosis.^[2] Delirium may newly appear on a background of mental illness, baseline intellectual disability, or dementia, without being due to any of these problems.

Treatment of delirium requires treatment of the underlying organic cause(s). In some cases, temporary or palliative or symptomatic treatments are used to comfort patients or to allow better patient management (for example, a patient who, without understanding, is trying to pull out a ventilation tube that is required for survival). Delirium is probably the single most common acute disorder affecting adults in general hospitals. It affects 10-20% of all hospitalized adults, and 30-40% of elderly hospitalized patients and up to 80% of ICU patients. In ICU patients or in other patients requiring critical care, delirium is not simply an acute brain disorder but in fact is a harbinger of much greater likelihood of death within the 12 months which follow the ICU patient’s hospital discharge.^[3]

Definition

In common usage, delirium is often used to refer to drowsiness, disorientation, and hallucination. In broader medical terminology, however, a number of other symptoms, including a sudden inability to focus attention, and even (occasionally) sleeplessness and severe agitation and irritability, also define “delirium,” and hallucination, drowsiness, and disorientation are not required.

There are several medical definitions of delirium (including those in the DSM-IV and ICD-10). However, all include some core features.

The core features are:

Disturbance of consciousness (that is, reduced clarity of awareness of the environment, with reduced ability to focus, sustain, or shift attention)

Change in cognition (e.g., problem-solving impairment or memory impairment) or a perceptual disturbance

Onset of hours to days, and tendency to fluctuate.

Behaviour may be either overactive or underactive, sleep is often disturbed.

Thinking is slow and muddled but the content is often complex.

Common features also tend to include:

Intrusive abnormalities of awareness and affect, such as hallucinations or inappropriate emotional states.

Delirium is a syndrome encompassing an array of neuropsychiatric symptoms, including a disturbance in consciousness/attention and cognition that develops acutely and tends to fluctuate.^[5] The change in cognition (memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance, must be one that is not better accounted for by a pre-existing, established, or evolving dementia. .^[6] Other symptoms can include disorientation, thought disorder, memory problems, language disorder, sleep disturbance, delusions, mood lability, psychomotor changes (changes in rate of activity/movement), and hallucinations.^[5]

Delirium occurs as a stage of consciousness in the continuum betweeormal awakeness/alertness and coma. During the 20th century, delirium was described as a ‘clouding of consciousness’ but this rather nebulous concept has been replaced by a better understanding of the components of phenomenology that culminate in severely impaired higher order brain functions. Lipowski described delirium as a disorder of attention, wakefulness, cognition, and motor behaviour, while a disturbance in attention is often considered the cardinal symptom.^[5] Disrupted sleep-wake cycles can result from a loss of normal circadian rhythm.^[5]

Accumulating evidence indicates three core domains of delirium phenomenology: “Cognition”, composed of inattention and other cognitive deficits; “Higher Level Thinking Processes” including impaired executive function, semantic expression and comprehension; and “Circadian Rhythm” including altered motor activity and fragmented sleep-wake cycle.^[7] Phenomenology studies suggest that “core” symptoms occur with greater frequency while other less consistent “associated” symptoms may reflect the biochemical influence of particular aetiologies or genetic, neuronal or physiological vulnerabilities.^[7]

Inattention and associated cognitive deficits

Inattention is the cardinal and required symptom to diagnose delirium and is noticeable on interview by distractibility and inability to shift and / or sustain attention. More formal testing can include the months of the year backwards, serial sevens or digit span tests. Disorientation (another symptom of confusion, and usually a more severe one) describes the loss of awareness of the surroundings, environment and context in which the person exists. It may also appear with delirium, but it is not required, as noted. Disorientation may occur in time (not knowing what time of day, day of week, month, season or year it is), place (not knowing where one is) or person (not knowing who one is).

Memory impairment occurs and is linked to inattention. Reduction in formation of new long-term memory (which by definition survives withdrawal of attention), is common in delirium, because initial formation of (new) long-term memories generally requires an even higher degree of attention than do short-term memory tasks. Since older memories are retained without need of concentration, previously formed long-term memories (i.e., those formed before the period of delirium) are usually preserved in all but the most severe cases of delirium.

Higher level thinking processes

Delirious patients have diminished comprehension as evidenced by reduced ‘grasp’ of their surroundings and difficulties in connecting with their immediate environment, executive dysfunction affecting abstraction, initiation/perseveration, switching mental sets, working memory, temporal sequencing and organization, insight and judgment. Though none of these cognitive deficits is specific to delirium, the array and pattern is highly suggestive.

Language disturbances in delirium include dysnomia, paraphasias, impaired comprehension, dysgraphia, and word-finding difficulties. Incoherent or illogical / rambling conversation is reported commonly. Disorganised thinking includes tangentiality, circumstantiality and a proneness to loose associations between elements of thought which results in speech that often makes limited sense with multiple apparent irrelevancies. This aspect of delirium is common but often difficult for non-experts to assess reliably.

Circadian disruption

Disruption of sleep-wake cycle is almost invariably present in delirium and often predates the appearance of a full-blown episode. Minor disturbances with insomnia or excessive daytime somnolence may be hard to distinguish from other medically ill patients without delirium, but delirium typically involves more substantial alterations with sleep fragmentation or even complete sleep-wake cycle reversal that reflect disturbed circadian rhythm regulation. The relationship of circadian disturbances to the characteristic fluctuating severity of delirium symptoms over a 24 hour period or to motor disturbance is unknown.

Motor activity alterations are very common in delirium. They have been used to define clinical subtypes (hypoactive, hyperactive, mixed) though studies are inconsistent as to the prevalence of these subtypes. Cognitive impairments and EEG slowing are comparable in hyperactive and hypoactive patients though other symptoms may vary. Psychotic symptoms occur in both although the prevailing stereotype suggests that they only occur in hyperactive cases. Hypoactive cases are prone to non detection or misdiagnosis as depression. A range of studies suggest that motor subtypes differ regarding underlying pathophysiology, treatment needs, and prognosis for function and mortality though inconsistent subtype definitions and poorer detection of hypoactives impacts interpretation of these findings.

Psychotic symptoms occur in up to 50% of patients with delirium. While the commoon-medical view of a delirious patient is one who is hallucinating, most people who are medically delirious do not have either hallucinations or delusions. Thought content abnormalities include suspiciousness, overvalued ideation and frank delusions. Delusions are typically poorly-formed and less stereotyped than in schizophrenia or Alzheimer’s disease. They usually relate to persecutory themes of impending danger or threat in the immediate environment (e.g. being poisoned by nurses). Misperceptions include depersonalisation, delusional misidentifications, illusions and hallucinations. Hallucinations and illusions are frequently visual though can be tactile and auditory. Abnormalities of affect which may attend the state of delirium may include many distortions to perceived or communicated emotional states. Emotional states may also fluctuate, so that a delirious person may rapidly change between, for example, terror, sadness and jocularity.

Persistent delirium

It was thought for many years that all delirium was a transient state of brain dysfunction that fluctuated on an hourly basis. Interestingly, Barrough noted in 1583 that if delirium resolves, it may be followed by a “loss of memory and reasoning power.” Recent long-term studies bear this out, showing that many patients end up meeting criteria for delirium for an alarmingly long time.^[12] For example, in ICU cohorts, it is common to find that 10% of patients still have delirium at the time of hospital discharge.^[13]

 Acquired dementia in ICU survivors

Dementia is supposed to be an entity that continues to decline, such as Alzheimer’s disease. Another way of looking at dementia, however, is not strictly based on the decline component but on the degree of memory and executive function problems. It is now known, for example, that between 50% and 70% of ICU patients have tremendous problems with ongoing brain dysfunction that looks a lot like the degree of problems experienced by Alzheimer’s or TBI (traumatic brain injury) patients and which leaves too many ICU survivors disabled and unable to go back to work and unable to serve effectively as the matriarchs and patriarchs of their families.^[14] This is a distressing personal and public health problem that is getting an increasing amount of scrutiny in ongoing investigations. The implications of such an “acquired dementia-like illness” (note: the term here is being used in a circumstance in which not all patients continue to decline as some have persistent yet stable brain dysfunction and others with newly acquired brain problems can recover fully) are profound at the private level, dismantling the person’s life in very practical ways such as inability to find a car in a parking lot or even complete shopping lists or job-related tasks done previously for years. The societal relevance is also huge when one considers work-force issues related to the inability of a young wage earner being unable to work because of either being a newly disabled ICU survivor him/herself or because he/she now has to care for their family member who is now suffering this “dementia-like” illness following ICU care.

Amentsіya (lat – “without sense”) is sharp entangled of consciousness, violation of synthetic activity at the partial saving of analysis, that is why language unconnected, comprehension surrounding it is absent, ò. there is a primary disorderliness of thought (incoherence). Fragmentary hallucinations and raving ideas, especially in the evening and at night. All types of orientation are broken. Excitation is within the limits of bed. Observed at heavy somatic and infectious diseases, sepsis, post- births psychoses.

Oneiroid (lat. – is dream) – or dream-like fantastic delusional derangement of consciousness, is characterized by a kaleidoscopic quality of psychopathological experiences, wherein reality, illusions and hallucinations are merged into one. It is typically accompanied by motor and, in particular, catatonic disturbances. This syndrome is an uncommon psychiatric state, which is hardly mentioned in standard psychiatric textbooks. OS is a neglected entity among DSM-oriented psychiatrists because it deals with a phenomenological approach in contrast to the European attitude, which deals with detailed clinical descriptions. Here, we propose detailed clinical descriptions with a number of consecutive stages of the OS development, illustrated by two vignettes with typical variants of oneiroid syndrome, in order to raise the awareness of psychiatrists who are not familiar with this state, and to try to open a window to the inner life of those patients suffering from this syndrome. These cases may also serve as illustration of certain principles which, when understood, may be found to lead in turn to a deeper knowledge of the psychopathology of other more commonplace conditions.

Oneiroid syndrome, from the Ancient Greek “ὄνειρος” (oneiros, meaning “dream”), and “εἶδος” (eidos, meaning “form, likeness”) is an element of the catatonic form of schizophrenia and presents with a dream-like or nightmare-like state as a background of intensive psychopathological experiences.

Oneiroid states were first described by the German physician Meyer-Gross in 1928, mainly statistically.

Later in 1961 the Bulgarian psychiatrist S.T. Stoyanov studied the dynamics and the course of the oneiroid syndrome in “periodic”, or remittant schizophrenia (ICD-10).

According to this research the syndrome has six stages in its course:

1.     initial general-somatic and vegetative disorder

2.     delusional mood

3.     affective-delusional depersonalisation and derealisation

4.     fantastic-delusional and affective depersonalisation and derealisation

5.     illusional depersonalisation and derealisation, and

6.     catatonic-oneiroid state in the culmination.

The prognosis of oneiroid catatonia is optimal, in comparison with lucid catatonia.

Illusive – hallucinate phenomenon extraordinarily bright and unusual. Delirium of fantastic maintenance (trip on Rome, flight in Space).

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

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

When occures? – Sch, oneiroid catatony, epilepsy, organic injuries of brain.

Twilight (gloomy) state of consciousness

Consciousness is pathologically narrowed, arises up suddenly.

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

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

 

Types of ambulatory automatysm

 • Trances – denotes any state of awareness or consciousness other thaormal waking consciousness. Trance states may occur involuntarily and unbidden.

The term trance may be associated with hypnosis, meditation, magic, flow, and prayer. It may also be related to the earlier generic term, altered states of consciousness, which is no longer used in “consciousness studies” discourse.

 

 • Fugue (lat. – to run) formally dissociative fugue or psychogenic fugue (DSM-IV Dissociative Disorders 300.1), is a rare psychiatric disorder characterized by reversible amnesia for personal identity, including the memories, personality, and other identifying characteristics of individuality. The state is usually short-lived (ranging from hours to days), but can last months or longer. Dissociative fugue usually involves unplanned travel or wandering, and is sometimes accompanied by the establishment of a new identity.

After recovery from fugue, previous memories usually return intact, but there is typically amnesia for the fugue episode. Additionally, an episode of fugue is not characterized as attributable to a psychiatric disorder if it can be related to the ingestion of psychotropic substances, to physical trauma, to a general medical condition, or to psychiatric conditions such as delirium, dementia, bipolar disorder or depression. Fugues are usually precipitated by a stressful episode, and upon recovery there may be amnesia for the original stressor (dissociative amnesia) Agatha Christie disappeared on 3 December 1926 only to reappear eleven days later in a hotel in Harrogate, apparently with no memory of the events which happened during that time span.

Examples:

• Shirley Ardell Mason also known as “Sybil” would disappear and then reappear with no recollection of what happened during the time span. She recalls “being here and theot here” and having no identity of herself; it should be noted that it is claimed she also suffered from what was formerly called “Multiple Personality Disorder.” However, Mason’s diagnosis has been challenged as a hoax

• Jody Roberts, a reporter for the Tacoma News Tribune, went missing in 1985, only to be found 12 years later in Sitka, Alaska, living under the name of “Jane Dee Williams.” While there were some initial suspicions that she had been faking amnesia, some experts have come to believe that she genuinely suffered a protracted fugue state.

• David Fitzpatrick, a sufferer of dissociative fugue disorder, from the United Kingdom, was profiled on Five‘s television series Extraordinary People. He entered a fugue state on December 4, 2005, and is still working on regaining his entire life’s memories.

• Hannah Upp, a teacher originally from Salem, Oregon, who was living in New York at the time of her disappearance, went missing on August 28, 2008. She was rescued after she jumped into the New York Harbor on September 16. She underwent a psychiatric evaluation and refused to speak to detectives. Upp was seen checking her email four times at Apple Stores while she was “missing.” She later claimed to have no recollection of the time in between. Upp claimed that the episode was diagnosed as dissociative fugue. On September 3, 2013, she went missing from her new job as a teacher’s assistant at Crossway Community Montessori in Kensington, Maryland. She was found unharmed September 5, 2013 in Wheaton, Maryland.

• Jeff Ingram, appeared in Denver in 2006 with no memory of his name or where he was from. After appearing oational television to appeal for help identifying himself, his fiancée Penny called Denver police identifying him. The episode was diagnosed as dissociative fugue. Jeff has experienced three incidents of amnesia: in 1994, 2006, and 2007.

.

 

 When ? Epilepsy, organic injuries of brain.

 Types of ambulatory automatysm

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

When ? Neuroses, epilepsy, organic injury of brain

The special states of consciousness are a variety of the gloomy state

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

Thus Poeck emphasized three primary features: 1) sudden loss of voluntary emotional control; 2) occurrence in response to onspecific often inconsequential stimuli; and 3) lack of clear association with prevailing mood state. Although pa-

tients may vary in the extent to which each of these aspects is found, these criteria have received wide accept ance

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

 

 The special states of consciousness are a variety of the gloomy state

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

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

Reaction of “short circuit”: On a background the protracted action  of offense, psychical trauma an insignificant occasion can cause a stormy inadequate reaction with aggression, dangerous effects.  All unjudged.

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

 ALTERED STATES OF AWARENESS

 After his capture, Victor engaged in an unusual habit. When the light of the moon penetrated his room, he rarely failed to awaken, and then he stood before the window much of the night. Motionless, with his head forward and his gaze fixed upon the moonlit scene, he gave himself up to some sort of contemplative experience, remaining silent, seemingly immersed in another world. This apparent ecstasy was interrupted only at long intervals by deep breathing and perhaps a plaintive little sound (Itard, 1894).

Victor in these instances seemed to be undergoing an experience apart from his normal, daily consciousness, and in most societies there is interest in perceptual experiences of this sort. These instances, collectively referred to as altered states of awareness, include sleep and dreams, meditation, drug-induced states, and the hypnotic condition.

We should emphasize that the three components of perception discussed earlier are all involved in these altered states. The range of attention is considerably narrower and critical. A stable perception requires organization, which sometimes is decidedly disrupted in drug-induced states. And the interpretation of incoming information is a defining characteristic of perception in all instances.

Practice of Meditation

The aim of most meditation is to transcend the hustle and bustle of everyday life, achieving a state of deep relaxation and inner peace. This detachment, sometimes accompanied by heightened self-awareness, is brought about chiefly by a restriction of incoming stimuli.

Techniques in Meditation In the general approach, the individual seeks some quiet setting and assumes a comfortable posture, usually a sitting or lying position. The person then attempts to shut out the external world insofar as possible, which is usually accomplished by thinking about some simple event, such as a candle, breathing, or a soft sound. Overall, the intent is to exclude the external world and to observe one’s own shifting thoughts, chiefly by intense concentration and complete relaxation in the rest of the body. Altered consciousness is attained by being as relaxed as possible, yet fully awake.

Each of the various types of meditation involves some special techniques as well. In transcendental meditation, the individual induces the altered awareness by silently repeating a special syllable or sound, called a mantra, over and over again. This sound is usually kept secret, for otherwise it presumably loses its personal significance. Any one of a wide variety of simple, pleasant sounds might serve this purpose, if it provides an adequate focus for the individual’s attention (Benson, 1975).

In Zen Buddhism people become especially aware of their breathing. Sometimes they even count their breaths. In traditional yoga, meditators concentrate upon breathing and engage in special stretching exercises at the same time. Sometimes they also gaze intently upon a fixed visual stimulus.

All of these techniques involve the features of perception that were emphasized at the outset of this chapter. First, there is the process of attending, significantly narrowed in these cases by focusing upon a specific stimulus. Second, there is the phenomenon of set, in which the individual has the expectation of an altered consciousness as he or she undertakes this activity.

Victor had his own wondrous method of achieving detachment from his newly imposed civilization, and it suggested both these characteristics of perception. The moon was the focus of his attention—perhaps evoking some mantra—leaving him transfixed. And perhaps there was significance in the silent scene before him. Maybe it gave him some sort of expectation, or set, for achieving tranquility. In any case, Victor’s watchful physician concluded that it would have been both useless and inhuman to oppose this regular contemplative habit in the boy (Itard, 1894).

Outcomes of Meditation Meditation is largely an Eastern phenomenon, with roots in Eastern religions, and shortly after it was introduced to the Western world on a wide scale, about 20 years ago, claims of every imaginable sort were made. Meditation would reduce all sorts of mental and physical ailments: anxiety, heart attack, phobia, drug and alcohol abuse, psychiatric symptoms, insomnia, and high blood pressure. It would augment desirable qualities: self-esteem, personal awareness, self-control, creativity, empathy, intelligence, and self-actualization (Walsh, 1979). It was also suggested that it would result in paranormal abilities, by which practitioners could know the thoughts of others, predict the future, and accomplish extraordinary physical feats.

Successful research demonstrating these outcomes is not an easy task. In the first place, it is very difficult to establish adequate control groups, for the motivation to undertake meditation may be a significant factor in achieving positive results. It is also difficult to measure gains in creativity, self-actualization, confidence, and other abstract qualities. In fact, when negative results have been obtained, investigators have pointed out that the most commonly used psychological measures may not be sufficiently sensitive to detect the very subtle shifts in perception and awareness claimed for meditation (Walsh, 1979).

Certain physiological changes can be readily assessed, however, such as heart rate, respiration, blood chemistry, and brain waves. In one instance, subjects who had been meditating for approximately two years were examined in these ways, and marked reductions in oxygen consumption, carbon dioxide production, and blood lactate concentrations were observed. There was also evidence of slower EEG patterns, with alpha waves predominating (Wallace & Benson, 1972). Th&latter finding is one of the most commonly reported accompaniments of meditation, influenced partly by the amount

Altogether, it is not yet clear that meditation provides a unique therapeutic outcome, distinct from those in other self-regulation procedures, such as relaxation and self-hypnosis. The above-mentioned psychological benefits, if reliable, might be obtained from the expectation of improvement. Also, the major physiological changes, which are better substantiated, have not yet been demonstrated to be significantly different from those that might accrue through regular resting, running, or some other activities (Smith, 1975).

 

Drug-Induced States

 The situation with regard to drug states is somewhat similar. Developing in Eastern cultures as early as 2737 B.C., under the Chinese Emperor Shen Hung, it has a long history and remains a puzzling phenomenon today.

One reason for the widely differing reports of drug-induced states is that the same drug affects different people differently. Another reason is that drugs today are used for widely different purposes, therapeutic and experiential. Prescriptions in therapy aim to alleviate aversive states, such as anxiety, depression, and hallucinations. The purpose in experiential use is to gain heightened awareness of oneself and the environment, as well as a feeling of well-being. Here we consider the experiential outcomes, for drugs in therapy are a topic for a later chapter.

Origins of Terms Lysergic acid diethylamide, or LSD, some years ago was referred to as a psychotomimetic drug, meaning that it produces psychotic-like symptoms. These reactions include hearing unspoken voices and seeing nonexistent events, which are sometimes observed in psychosis. The idea of psychotic induction came partly from this use of LSD in clinical work, especially for controlling severely depressed and hyperactive patients.

Later, when LSD was used in experiential settings, it was referred to as hallucinogenic, but this term is not completely accurate either. The visual reactions are not solely hallucinations, and they are not necessarily idiosyncratic. Often they have a substantial basis in reality.

Eventually, the term psychedelic was promoted as a neutral word, referring to many different states of consciousness. It simply means “mind-manifesting,” but this term also has fallen from use. In short, the normal or usual effects of LSD and comparable drugs are not known with any certainty. Results vary markedly according to the context and psychological pressures to whidr the consumer is exposed (Tart, 1969).

Factors Influencing Experiential Outcomes Users of marijuana commonly report that they must learew ways of perceiving under the influence of this drug. An altered state of awareness is not automatic, as emphasized by first-time users who indicate that they experienced nothing different. With practice and a drug of a certain potency, which is very difficult to assess, a person using marijuana might experience time expansion, in which a momentary scene seems quite prolonged, and sensory intensification, in which colors seem more saturated, shapes more distinct, and variations more noticeable. When these two features are combined, one can understand why a person in a drug-induced state may find fascination seemingly for hours in some leaf or in the face of a clock.

One reliably reported result of LSD and mescaline usage is the distortion of shape and size constancy. A hand held close to the face, for example, is perceived as being larger thaormal rather than closer thaormal. Such perceptual changes have obvious repercussions for the individual’s functioning.

Moreover, the unpleasant states, or “bad trips,” are difficult to predict. The user may experience frightening images and feelings of helplessness. There are also “flashbacks,” in which severely disturbing false perceptions reappear several days, weeks, or even months later. This result is related to the characteristics of the individual and the ingested drug rather than to any particular expectancy on the part of the user.* Long-term psychological damage from drug abuse seems to be associated primarily with the stability of the personality, as well as the chemical properties of the drug. The less stable the individual, the greater is the likelihood of a severe disturbance (McWilliams & Tuttle, 1973).

Parenthetically, it should be pointed out that in our society caffeine, nicotine, and alcohol are the most widely used of all drugs. The first serves as a stimulant; the second has only minor experiential effects, inducing relaxation or acting as a stimulant; and the third is also unpredictable, depending partly upon the user’s initial state. The dangers in these drugs, or any others taken in sufficient quantity, are three. They may result in damage to the lungs, liver, brain, or other organs. They can induce a psychological dependency, in which the individual feels irritated or tense without the drug. And in some instances there may be chemical changes in the body that result in physiological addiction, producing withdrawal symptoms when the drug is no longer available.

Ironically, the more a drug is used, the greater is the individual’s bodily tolerance for it, and therefore its experiential effects become less. To maintain the same altered state of awareness over a long period, larger and larger doses must be used.

We can sum up these observations on experiential outcomes by focusing upon the following influential factors: the general psychological adjustment of the individual; this person’s set or expectation as a user, especially with the less powerful jdrugs; and the chemical makeup of the drug. Some drugs produce temporary feelings of euphoria and sensory intensification; others can prompt violent, psychoticlike reactions. All of these factors combine to influence the outcome of drug usage and therefore to make it unpredictable.

 

Hypnotic Condition

Compared with drug abuse and the practice of meditation, vigorous interest in hypnosis has a relatively short history. It first came to public attention in the Western world just before the Wild Boy was running free in the forests of Aveyron. The city of Paris received Anton Mesmer’s brand of hypnosis with some curiosity, much as it awaited the Wild Boy’s arrival a generation later. Mesmer’s success in curing patients with all kinds of illnesses had earned a popular reputation for “mesmerism,” and subsequently an investigation was conducted. Ambassador Benjamin Franklin and other members of the investigating committee decided that the cures were brought about by the subjects’ imaginations, which prompted Mesmer to leave town, although the interest in hypnosis remained.

Phenomena Associated with Hypnosis Franklin’s commission did not dispute the cures, but neither did it explain how the patient’s imagination served in this way. It left us the question of what is meant by hypnosis, a problem with which we are still struggling today. The term includes a wide variety of theoretical assumptions and diverse clinical techniques.

Two myths can be readily dispelled, however. First, hypnosis cannot be used to coerce people into criminal, outrageous, sadistic, or other forms of deviant behavior. It will not compel individuals to commit acts they would otherwise resist (Conn, 1981). Second, the hypnotist does not play a magical role, exercising some inevitable power over the individual. The hypnotist is more like a teacher, facilitator, or coach, helping the subject to obtain his or her own best result. Hypnosis, in many respects, is guided self-hypnosis (Ruch, 1975).

The condition of hypnosis is best defined in terms of the traditional induction procedure, to which the subject willingly submits, and in terms of its outcomes. In the induction procedure, the subject is first told what to expect, and then there is the sug­gestion of drowsiness, relaxation, and an altered state of awareness. At this point any number of additional techniques can be employed, such as asking the person to concentrate on something in a methodical way—an object, a thought, or the hypnotist’s words. As the person yields control, certain characteristic reactions occur. These include analgesia, which is insensitivity to painful stimuli; amnesia, which is loss of memory; and age regression, in which the subject behaves as he or she did at an earlier stage in life.

In several respects, a comparison with meditation is useful. Both altered states are brought about by a narrowing of attention, and the object of attention can be much the same. Furthermore, set or expectation is involved in both cases. Persons who do not wish to meditate, or to be hypnotized, cannot be made to do so. Those who are most receptive experience the most positive outcomes. Both processes, although far from being fully understood, can be said to be significantly under the individual’s control.

Views of the Hypnotic Process How does the individual achieve the hypnotic state? Here there are two dominant views, one of which emphasizes suggestibility and the other a dissociative reaction.

From the suggestibility viewpoint, hypnosis is almost exclusively the result of expectation and motivation. These factors, collectively called set, can produce many of the behaviors attributed to the hypnotic trance, including analgesia, amnesia, and even age regression (Barber, 1969; Barber, Wilson, & Scott, 1980). The implication is that set is the significant factor in attaining the so-called hypnotic condition.

Those who stress the role of set argue that the idea of a special hypnotic state involves circular reasoning. A person is said to be under hypnosis when insensitive to pain or acting as a child, yet when these acts are explained, they are invariably attributed to the hypnotic trance. From the suggestibility viewpoint, reference to an unusual state of consciousness is not explanatory (Barber, 1969).

According to the dissociation viewpoint, hypnosis is brought  about through a shift in the locus of brain control. The lower brain centers apparently become more influential in what is experienced, remembered, and reported. As the normal brain controls are reduced, there is a change in overt responsiveness. There is, in effect, a dissociation or split in the hypnotized person’s internal experience and external reaction.

A hypnotized woman places one hand in a pail of cold water and experiences no significant pain, but physiological measures of heartbeat show little difference from the state in which pain is fully experienced. At some level the subject is responsive to the cold and when asked to write with the other hand about her experience, she indicates that she is aware of the pain. She also presses response keys in an enclosed box, where she cannot see what she is communicating, and she describes the experience as painful. But in conversation with the experimenter, the woman reports no pain (Hil-gard, 1973).

These and other demonstrations suggest that part of the individual’s consciousness has been separated from normal awareness. This consciousness has access to information otherwise unavailable, and it is also highly rational, in contrast to the irrational unconsciousness in psychoanalytic theory.

Interpretations from Clinical Hypnosis Some light is shed on these different views by the clinical use of hypnosis directed against a conglomerate of illnesses. One of the most popular clinical uses of hypnosis, for example, occurs in weight control, in which the therapy encourages nauseous reactions to habitual overeating. A review of this research suggests, however, that the positive outcomes may be largely attributable to nonhypnotic factors, such as the subject’s expectancy of success, dietary efforts, and support for weight loss. In contrast, the analgesic properties of hypnosis have been especially useful for treating migraine headaches and asthma, as well as warts. In these instances the subject is informed that a tingling sensation is occurring in the affected area, to be followed by regression of the wart (Wadden & Anderton, 1982).

These different findings are attributable partly to different methods and to different auxiliary techniques, but a most critical feature concerns the presenting problem, falling generally into either of two broad classes. It can be considered as essentially voluntary or involuntary. The former involves a learned activity, initiated by the individual, such as overeating, smoking, and alcoholism. The latter is unlearned, prompted by neural or hormonal conditions, as in pain, asthma, and warts. The aim of hypnotic treatment in the first instance is to alter the problematic behavior. In the second instance the goal is to change personal experience relating to some physiological condition.

It now appears that the hypnotic state is most useful in the second instance, for modifying the experience of migraine headaches, asthma, and so forth. In controlling pain, for example, the individual may imagine a warm liquid bathing the painful area and therefore alleviating the problem. But with more voluntary behavior, the subject must imagine that a formerly pleasurable experience, such as eating, smoking, or drinking, is now aversive. Addictive individuals must endure frustrating circumstances while awaiting long-term gain, whereas the short-term and long-term goals are the same when the problem is the experience of pain. In addition, changing subjective experience does not necessarily alter addictive behavior, which can be prompted by external cues. For these reasons, therapeutic success with addiction, even though it can occur through hypnosis, probably has less to do with hypnotic effects per se and more to do with the subject’s expectancy, readiness for change, social support, and use of adjunct treatments (Wadden & Anderton, 1982).

A most important consideration is the lack of any significant correlation between hypnotic suggestibility—that is, the tendency to be hypnotizable—and the reduction of addictive behavior. If the hypnotic state per se is an integral part of the treatment, one would expect a relationship between hypnotic susceptibility and treatment outcomes. But in hypnotherapy for smoking and for obesity there is no significant association.

Such findings may appear to support the dissociation view of hypnosis, but further data are needed. For instance, we need to know more about the correlation between hypnotic suggestibility and the reduction of experiential problems, which may constitute evidence for the suggestibility viewpoint. Ultimately these two views may not be incompatible. There are large individual differences in susceptibility to hypnosis, and we may understand the source of these differences through some combinations of studies on information processing under hypnosis (Sheehan & Tilden, 1984).

 

 

Mental Status Examination

Background: The history and Mental Status Examination (MSE) are the most important diagnostic tools a psychiatrist has to obtain information to make an accurate diagnosis. Although these important tools have been standardized in their own right, they remain primarily subjective measures that begin the moment the patient enters the office. The clinician must pay close attention to the patient’s presentation, including personal appearance, social interaction with office staff and others in the waiting area, and whether the patient is accompanied by someone (ie, to help determine if the patient has social support). These first few observations can provide important information about the patient that may not otherwise be revealed through interviewing or one-on-one conversation.

When patients enter the office, pay close attention to their personal grooming. One should always note things as obvious as hygiene, but, on a deeper level, also note things such as whether the patient is dressed appropriately according to the season. For example, note whether the patient has come to the clinic in the summer, with 3 layers of clothing and a jacket. These types of observations are important and may offer insight into the patient’s illness. Other behaviors to note may include patients talking to themselves in the waiting area or perhaps pacing outside the office door. Record all observations.

The next step for the interviewer is to establish adequate rapport with the patient by introducing himself or herself. Speak directly to the patient during this introduction, and pay attention to whether the patient is maintaining eye contact. Mental notes such as these may aid in guiding the interview later. If patients appear uneasy as they enter the office, attempt to ease the situation by offering small talk or even a cup of water. Many people feel more at ease if they can have something in their hands. This reflects an image of genuine concern to patients and may make the interview process much more relaxing for them.

Legally, a mental status if conducted against the patient’s will is considered assault with battery. Therefore, it is important to secure the patient’s permission or to document that a mental status is being done without the patient’s approval if in an emergency situation.

The time it takes to complete the initial interview may vary; however, with experience, interviewers develop their own comfortable pace and should not feel rushed to complete the interview in any time that is less than comfortable for either the interviewer or the patient. All patients require their own time during this initial interview and should never be made to feel they are being timed.

Beginning with open-ended questions is desirable in order to put the patient further at ease and to observe the patient’s stream of thought (content) and thought process. Begin with questions such as “What brings you here today?” or “Tell me about yourself.” These types of questions elicit responses that provide the basis of the interview. Keep in mind throughout the interview to look for nonverbal cues from patients. As they speak, for example, note if they are avoiding eye contact, acting nervous, playing with their hair, or tapping their foot repeatedly. In addition to the patient’s responses to questions, all of these observations should be noted during the interview process.

As the interview progresses, more specific or close-ended questions can be asked in order to obtain specific informatioeeded to complete the interview. For example, if the patient is reporting feelings of depression, but only states “I’m just depressed,” determining both the duration and frequency of these depressive episodes is important. Ask leading questions such as “How long have you had these feelings?” or “When did these feelings begin?” and “How often do you feel this way?” or “How many days in the past week have you felt this way?” These types of questions help patients understand what information is needed from them. For safety reasons, both the patient and the interviewer should have access to the door in case of an emergency during the interview process.

At some point during the initial interview, a detailed patient history should be taken. Every component of the patient history is crucial to the treatment and care of the patient it identifies. The patient history should begin with identifying patient data and the patient’s chief complaint or reason for coming to the clinic. The patient’s chief complaint should be a quote recorded just as it was spoken, in quotation marks, in the patient’s record. This also is where all history of illness is recorded, including psychiatric history, medical history, surgical history, and medications and allergies. Of interest, it is important to make direct inquiry to items such a family history of members being murdered—patients often do not volunteer this information.

Additionally, listing any family history of illness is important. This information can be very useful later, when determining treatment options. If a family member has a history of the same illness and had a successful drug regimen, that regimen may prove to be a viable option for the current patient. If possible, record the medications and dosages family members took for their illnesses. If these medications and dosages worked for family members, the chance is good that they may work for the current patient.

Obtain a complete social history. This addition to the patient history can be most crucial when discharge planning begins. Inquire if the patient has a home. Also ask if the patient has a family, and, if so, if the patient maintains contact with them. This also is the area in which any history of drug and alcohol abuse, legal problems, and history of abuse should be recorded.

Imperative to the recording of a patient’s social history is any information that may aid the physician or other clinicians in making special accommodations for the patient wheecessary. This would include an accurate record of the last grade completed in school, whether the patient was in special education classes, or if the patient required special assistance at work or school (ie, special listening devices for the hard of hearing).

Following completion of the patient’s history, perform the MSE in order to test specific areas of the patient’s spheres of consciousness. To begin the MSE, once again evaluate the patient’s appearance. Document if eye contact has been maintained throughout the interview and how the patient’s attitude has been toward the interviewer. Next, in order to describe the mood aspect of the examination, ask patients how they feel. Normally, this is a one-word response, such as “good,” “sad,” or another.

Next, the interviewer’s task is to define the patient’s affect, which will range from expansive (fully animated) to flat (no variation). The patient’s speech then is evaluated. Note if the patient is speaking at a fast pace or is talking very quietly, almost in a whisper. Thought process and content are evaluated next, including any hallucinations or delusions, obsessions or compulsions, phobias, and suicidal or homicidal ideation or intent.

Then, the patient’s sensorium and cognition are examined, most commonly using the Mini-Mental State Examination. The interviewer should ask patients if they know the current date and their current location to determine their level of orientation. Patients’ concentration is tested by spelling the word “world” forward and backward. Reading and writing are evaluated, as is visuospatial ability. To examine patients’ abstract thought process, have them identify similarities between 2 objects and give the meaning of proverbs, such as “Don’t cry over spilled milk.” Once this is completed, perform the physical examination and needed laboratory tests to help exclude medical causes of presenting symptoms.

A compilation of all information gathered throughout the interview and MSE leads to the differential diagnosis of the patient. Once this diagnosis is established, a treatment plan is formulated. At this point, involving the treatment team (eg, social workers, nurses, others) is important to help carefully explain to patients what their treatment will entail. Be sure to ask patients if they have any questions regarding their treatment plans. Discuss the details of the medications chosen, including adverse effects. Give details of the hospital stay if patients are to receive inpatient treatment, such as estimated length of stay, visiting hours, and other aspects. Inform patients that even though the interviewer is the treating physician, their input and concerns are valuable and necessary in order to fulfill treatment goals.

Every patient interview affords the health care professional an invaluable opportunity to provide patient education. While different illnesses may require specialized attention, this time can be used to discuss such patient issues as medication compliance, nutrition, the importance of follow-up appointments with primary care physicians and other specialists (eg, obstetricians, gynecologists), the urgency of seeking emergency medical help at the emergency department wheecessary, the prevalence of psychiatric disorders, and general education concerning the patient’s illness. Never overlook providing needed education to patients.

The process of conducting an accurate history and MSE takes practice and patience, but it is very important in order to evaluate and treat patients effectively. This part of psychiatry is so important that it comprises part II of the Board Certification Test. The history and MSE are crucial first steps in the assessment and are the only diagnostic tools psychiatrists have to select treatment for each patient and, therefore, ultimately are the deciding factor for initial treatments. This fact alone should make the interviewer cognizant of the essential role the history and MSE play each time a patient is evaluated.

Once the history and MSE are complete, documenting this event accurately and efficiently is important.

Patient History

Identifying data

Ask patients their name or what name they prefer to be called. If the patient is a child or adolescent, asking what grade the patient is in also may be appropriate. Also, ask patients their marital status, occupation, religious belief, and living circumstance. Also document their sex and race in this section.

Chief complaint

This is the patient’s problem or reason for the visit. Most often, this is recorded as the patient’s own words, in quotation marks. This statement allows identification of the problem by identifying symptoms that lead to a diagnosis and, eventually, a specific treatment plan. To elicit this response, the interviewer should ask leading questions such as “What brings you here today?”

History of present illness

This is the main part of the interview because there are no specific elements that will lead to the diagnosis and ultimately treatment besides the interview. An exact history allows one to gather basic information along with specific symptoms including timing in the patient’s life to allow the healthcare provider to take care of the whole patient.

The important part of taking a history of present illness is listening. One should have an organized format but not too rigid in administering the examination. For example, if asking about medication allergies and the patient brings up problems with alcohol, follow the patients lead and obtain information regarding the new data but then guide the patient back to the interview to allow all information to be gathered. Without a specific format, important information may be missed.

Remember to include both pertinent positives and negatives because these could be important aspects in determining diagnosis and treatment in complicated cases. Record important life events to complete this part of the evaluation, and this may help in establishing rapport with a patient.

This is the patient’s story of the presenting problem and any additional details that led the patient to visit the psychiatrist. This includes information regarding why the patient is seeking help at a particular time (the “why now” aspect of the patient’s life). This usually involves a triggering event or something that caused the patient to choose this point in life to seek help.

Realize there is no one particular way to take the history of present illness. Each person may differ in obtaining this important part of the examination. Remember different approaches may be needed depending on the circumstances (eg, emergency department consult versus a forensic evaluation).

Past medical history

List medical problems, both past and present, and all medical illnesses. At least ask a few screening questions regarding medical illnesses such as do you see a doctor regularly. If possible, try to obtain the patient’s entire medical records rather than depending solely on the patient’s self-report. Even the most minute detail of a patient’s medical history, from as far back as childhood, could play a significant role in the presenting problem. Be certain to inquire about specific events that may have occurred in childhood, such as falls, head trauma, seizures, and injuries with loss of consciousness. All of these could be relevant to their current problems.

Past surgical history

List all surgical procedures the patient has undergone, including dates. Be as specific as possible when recording dates, and obtain medical records for review when possible. Patients may not volunteer this information unless asked specifically about operations.

Medication

List the patient’s current medications, including dosages, route, regimen, and whether or not the patient has been compliant. If possible, have the patient bring his or her medications to the visit. Also, inquire about past medications. Additionally, with all past medications, look for signs or patterns of noncompliance. If noncompliance issues or even drug-seeking behaviors appear evident, ask the patient who prescribed the medications and when or why the patient discontinued taking them.

Allergies

List all drug and food allergies the patient currently has or has had in the past, and list what type of reactions the patient had to the medications.

Past psychiatric history

List all of the patient’s treatment, including outpatient, inpatient, and therapy-based (ie, individual, couples, family, group), including dates. Inquire about past psychotropic medications and response, compliance, and dosages. Ask patients if they feel that they received any benefits from the treatments. If so, inquire about the specific type of benefit. Additionally, ask patients which medications they feel helped them most in the past and ask which ones helped them least. From an insightful patient, this information may offer clues as to which class of medication the patient responds to best. If possible, try to obtain old psychiatric records.

Family history

List any psychiatric or medical illnesses, including method of treatment such as hospitalization (medical and psychiatric) of family members and response. Once again, the emphasis here is strong. Record any information obtained because it may help in treatment planning. If a patient’s family member has been diagnosed with the same psychiatric illness and has been treated successfully, treating the current patient with that same medication may be appropriate. This may be a reasonable place to begin.

Social history

Obtain a complete social history of the patient. Ask patients their marital status. Also, inquire about employment status. If the patient is employed, inquire about the frequency of absences from work. If the patient is not employed, inquire about whether the patient currently is looking for work. Also inquire if a previously held job was lost as a result of the illness. Obtain as much detailed information as possible.

Recording an accurate educational history is imperative. Inquire how far the patient went in school. Ask if he or she was in special education classes. Ask if the patient has a learning disability and if the patient has any other problem such as a hearing impairment or speech problem. These issues are very important in the evaluation of patients undergoing psychiatric assessment, and patient care could be jeopardized if they are not addressed. A patient’s communication problems, for example, could be due to a language disorder rather than a thought disorder, and the initiation of psychiatric medications could further affect communication, not to mention cause legal concerns for the prescribing physician. All of these things must be kept in mind at all times when completing the social history.

Record the number, sex, and age of the patient’s children. Ask if any of the children have any medical or psychiatric problems. List the patient’s toxic habits, including past and current use of tobacco, alcohol, and street drugs. This is important because many patients can become dependent on prescribed medications. Try to determine whether the patient has a history of drug abuse.

Include any military history, including length of service and rank. This could help determine if a patient is eligible for US Veterans Administration benefits or other assistance.

Another important issue in obtaining a very thorough patient history is the patient’s housing status. This becomes a vital part of the discharge plans. Ask if the patient has a home. Inquire if they have a family and if they have contact with that family. Ask where the patient will go at the completion of his or her hospital stay. Also ask who will ensure that the patient remains compliant with medication therapy. These become crucial points when finding placement for patients at discharge and planning long-term follow-up care. Therefore, careful recording of housing and support is very important.

Inquire about the existence (and number) of siblings, their names and phone numbers, and any church affiliations, just in case the information is needed later.

Also in the history section, record any legal problems the patient may have had in the past. This should include jail time, probation, arrests (eg, for driving while intoxicated or driving under the influence of drugs), and any other relevant information that can provide insight into the patient’s problems with the law.

Patient history also should include hobbies, social activities, and friends. If the patient has any history of abuse, mental or physical, it should be recorded here. Any other relevant information that may be useful in treating the patient or helpful in aiding in aftercare should be recorded in the patient history.

Inquire about the patient’s and the patient’s parents’ religious beliefs. Did the patient grow up in a strict religious environment? Does the patient have a particular religious belief and has that changed since childhood, adolescence, or adulthood? Investigate what effect the patient’s beliefs have on treatment of psychiatric illnesses or suicide.

Perinatal and developmental history

Record any relevant perinatal and developmental history. Ask if the patient was born prematurely. Ask about any complications associated with their birth. Ask if they were told how old they were when they spoke their first word or took their first step.

Assets

List attributes of the patient. Examples may include that the patient agreed to voluntary acceptance of treatment, has strong verbal skills, or exhibits above average intelligence, just to name a few.

Mental Status Examination

 

 Appearance

Record the patient’s sex, age, race, and ethnic background. Document the patient’s nutritional status by observing the patient’s current body weight and appearance. Remember recording the exact time and date of this interview is important, especially since the mental status can change over time such as in delirium.

Recall how the patient first appeared upon entering the office for the interview. Note whether this posture has changed. Note whether the patient appears more relaxed. Record the patient’s posture and motor activity. If nervousness was evident earlier, note whether the patient still seems nervous. Record notes on grooming and hygiene. Most of these documentations on appearance should be a mere transfer from mind to paper because mental notes of the actual observations were made when the patient was first encountered. Record whether the patient has maintained eye contact throughout the interview or if he or she has avoided eye contact as much as possible, scanning the room or staring at the floor or the ceiling.

Attitude toward the examiner

Next, record the patient’s facial expressions and attitude toward the examiner. Note whether the patient appeared interested during the interview or, perhaps, if the patient appeared bored. Record whether the patient is hostile and defensive or friendly and cooperative. Note whether the patient seems guarded and whether the patient seems relaxed with the interview process or seems uncomfortable. This part of the examination is based solely on observations made by the health care professional.

Mood

The mood of the patient is defined as “sustained emotion that the patient is experiencing.” Ask questions such as “How do you feel most days?” in order to trigger a response. Helpful answers include those that specifically describe the patient’s mood, such as “depressed,” “anxious,” “good,” and “tired.” Elicited responses that are less helpful in determining a patient’s mood adequately include “OK,” “rough,” and “don’t know.” These responses require further questioning for clarification.

Establishing accurate information pertaining to the length of a particular mood, if the mood has been reactive or not, and if the mood has been stable or unstable also is helpful.

Affect

A patient’s affect is defined in the following terms: expansive (contagious), euthymic (normal), constricted (limited variation), blunted (minimal variation), and flat (no variation). A patient whose mood could be defined as expansive may be so cheerful and full of laughter that it is difficult to refrain from smiling while conducting the interview. A patient’s affect is determined by the observations made by the interviewer during the course of the interview.

Speech

Document information on all aspects of the patient’s speech, including quality, quantity, rate, and volume of speech during the interview. Paying attention to patients’ responses to determine how to rate their speech is important. Some things to keep in mind during the interview are whether patients raise their voice when responding, whether the replies to questions are one-word answers or elaborative, and how fast or slow they are speaking.

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, ie, jabberwocky), 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).

Insight

Assess the patients’ understanding of the illness. To assess patients’ insight to their illness, the interviewer may ask patients if they need help or if they believe their feelings or conditions are normal.

Judgment

Estimate the patient’s judgment based on the history or on an imaginary scenario. To elicit responses that evaluate a patient’s judgment adequately, ask the following questions. “What would you do if you smelled smoke in a crowded theater?” (good response is “call 911” or “get help”; poor response is “do nothing” or “light a cigarette”).

Impulsivity

Estimate the degree of the patient’s impulse control. Ask the patient about doing things without thinking or planning. Ask about hobbies such as coin collecting, golf, skydiving, or rock climbing.

Reliability

Estimate the patient’s reliability. Determine if the patient “seems reliable,” if it is “difficult to determine,” or if the patient seems “unreliable.” This determination requires collateral information of an accurate assessment, diagnosis, and treatment.

Other Diagnostic Evaluations

Perform a complete physical examination, including a neurological examination. Obtaining collateral information from family members, friends, and colleagues is important. These individuals all can help in formulating an accurate account of the events that led to the patient’s visit to the psychiatrist.

Psychological evaluation: Some evaluations require a battery of psychological tests, including neuropsychological testing when deemed appropriate. This series of tests can help determine what types of deficits the patient might have, can help identify any Axis II diagnoses, and can help identify other factors, such as factitious disorders or malingering.

Laboratory testing

Diagnosis: Use the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) Axis I-V.

Differential diagnosis: Determine the patient’s differential diagnosis, for both medical and psychiatric illnesses, based on all information gathered from the patient interview, MSE, psychological testing, review of medical history, and current laboratory reports.

Formulation: Use the biopsychosocial model. The formulation is for the current situation and identifies the specific event, state of mind, topics of concern and defense mechanism(s) used, relationships, and the strengths that the patient brings to the treatment setting. The Cultural Formulation is appropriate for patients from various cultural backgrounds, and it can be found in Appendix I of the DSM-IV-TR.

Treatment: The treatment approach that is best suited as a starting point should be noted, including psychotherapeutic, psychopharmacologic, behavioral, and social interventions. This also is an excellent place to document further consultations that are deemed necessary. A statement regarding the patient’s agreement (or lack thereof) with participating in the various portions of the recommended treatment also is wise to add.

Prognosis: Patients’ prognoses are dependent on the specific illness with which they are diagnosed. However, patients should be encouraged to pursue treatment regardless of their prognosis and should be encouraged to be compliant with the treatment plans formulated for them. Make them understand that their prognosis is always better when they are compliant with medications and follow-up appointments and instructions.

 

Main psychopathological syndroms

 

 

Neurotic syndroms

·        Anxious

·        Phobic

·        Obsessiv-compulsiv

·        Astenic

Anxious syndrome

Anxiety is an unpleasant emotional state with qualities of apprehension, dread, distress and uneasiness and is often accompanied by physical sensations such as palpitations, nausea, chest pain and shortness of breath.

Normal anxiety is applied to states of arousal/anxiety which occur in everyday life, in response to stimuli. It has an adaptive role and is a signal to take action. In normal anxiety the assessment of the danger is appropriate and the action taken is effective. The healthy person who has lost her/his pay-packet will be anxious about paying outstanding bills.

Fear is generally regarded to be an extreme form of normal anxiety. If an intruder comes into the house most the healthy persons will be fearful.

Pathological anxietyis diagnosed when there is inaccurate or excessive assessment of danger. The individual may be unable to make any response, or make an excessive protective response. The person with pathological anxiety may be so disabled that he/she is unable to conduct his/her usual duties such as prepare a meal, or overestimate a danger such that he/she makes maladaptive adjustments (the person anxious about lifts will have to take the stairs).

The features of panic attack include:

1. palpitations

2. sweating

3. trembling or shaking

4. shortness of breath or sensation of smothering

5. feeling of choking

6. chest pain or discomfort

7. nausea or abdominal distress

8. feeling dizzy, unsteady, light-headed, or faint

9. derealization (feelings of unreality) or depersonalization (being detached from oneself)

10. fear of losing control or going crazy

11. paresthesia (numbness or tingling sensations)

12. chills or hot flushes

The features of agoraphobia include:

A. Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and travelling in a bus, train, or automobile.

B. The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a Panic Attack or require the presence of a companion.

PHOBIC SYNDROM

The specific phobias feature marked and persistent fears which are excessive to any risks. Commonly feared objects include animals, insects, aspects of the natural environment, heights, injections/blood, and dental procedures.

The diagnostic criteria for specific phobia are as follows:

A. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipated presence of a specific object or situation (e.g., flying, heights, animals, injections, blood)

B. Exposure to the phobic stimulus almost always provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack.

C. The person recognizes that the fear is excessive or unreasonable.

D. The phobic situation is avoided or else endured with intense anxiety or distress

E. The avoidance, anxious anticipation, or distress in the feared situation interferes significantly with the person’s normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

Sub-classification

1. animal type

2. natural environment type

3. situational type

4. blood/injection type (see next entry)

5. other type

 

 

Boderline syndroms

 

The negative symptoms (loss of personality features and abilities):

·                   troublesome symptoms of the chronic phase of schizophren ia and include diminished

·                   emotional expression (flattening or blunting of affect), reduced ability to experience

·                   pleasure (anhedonia), reduced interpersonal skills, social isolation, reduced

·                   motivation and drive (avolition/apathy) and thought disorder of t he poverty of thought

·                   type (alogia). While the negative symptoms are the predominant feature of the chronic

·                   phase, they may also be present at the first psychotic episode, and may even precede

·                   the first psychotic episode during a prodromal period.

 

Delusional syndrome

 

Delusions are false beliefs that continue to be believed in spite of evidence to the contrary (these are beliefs which are not held by the general public, or a any sub-group of the community).

Delusions may occur

Paranoyal syndrome

·                   Systematized delusions are united by a single theme. They are often highly detailed and may remain unchanged for years

 

Paranoid syndrome

·                   are usually beliefs that the individual is being harassed, watched or bugged. They often involve spies, bikies, God, Satan or neighbours

·                   Ex.: Patient belief that the secret service has a plan to kill him. He began to think that food is poisoning by pursuers.

Delusions of reference

·                   are the belief that the everyday actions of others are premeditated and make special reference to the patient. Commonly patients complain about being talked about on television or the radio. Patients may believe that music played or words spoken on television have been specifically chosen to identify or annoy them. People crossing the street or coughing may be interpreted as purposeful actions, performed to indicate something to or about the patient.

Delusions of control involve the belief that others are controlling the patient ’s thoughts, feelings or actions.

Thought broadcasting, the belief that one’s thoughts can be heard by others ( e.g., “My brain is connected to the world mind. I can control all heads of state thought my thoughts.”).

Thought insertion, the belief that thoughts have been removed from one’s mind by an outside agency (e.g., “They make me think bad thoughts and are rotting my brain”.).

Thoughts withdrawal, the belief that’s thoughts has been removed from ones mind by an outside agency (e.g., “The devil takes my thoughts away and leaves me empty.”).

Ideas of physical action – they are sure that some people make some harm to their inner organs;

Ideas of psychic actions – with the help of telepathy, biofields, noosphere act on their mind, behavior;

Types of psychomotor excitement.

·                   Depressive

·                   Manic 

·                   Catatonic

·                   Psychogenic

·                   Hallucinative

·                   Depressive 

·                   Catatonic

·                   Psychogenic