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218 Cards in this Set

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Thought disorders usually associated w/? Also associated w/?
Usually associated with schizophrenia. Also with mania, severe depression, delirium/advanced dementia, personality disorder, drug intoxication
MSE 82
Thought disorder - mania
Severe mania often associated with hallucinations, delusions (typically grandiose or persecutory), and flight of ideas
MSE 82
Thought disorder - severe depression
Can be of a psychotic depth, accompanied by delusions (often persecutory, nihilistic, or somatic in nature) and hallucinations.
MSE 82
Thought d/o - delirium, advanced dementia
Usually include delusions (often persecutory), hallucinations, and incoherence.
MSE 82
Thought d/o - personality disorder
Personality disordered pts, particularly those of borderline type, often use immature defense mechanisms that are associated with psychosis, such as splitting, denial, and projection. May at times slip into overtly psychotic Sx, e.g. hallucinations or delusions.
MSE 82
Thought d/o - Drugs
Some drug intoxication and w/d states include thought d/o and psychosis; phencyclidine or meperidine intoxication and EtOH w/d delirium are examples.
MSE 82
Primary process
thinking of the dream state or of early childhood. Cannot differentiate, e.g., b/w fantasy and reality; engage in a great deal of magical thinking.
MSE 82
Secondary process - definition. What does it require person to be able to distinguish between (two pairs of things)?
This thought is the normal thinking process of healthy, awake, alert human; requires ability to distinguish reality from fantasy, and self from others, as well as capacity for logical thought process.
MSE 82
Relation between thoughts/thought d/o and language
Deaf/mute pts who are thought disordered, e.g. schizophrenic, reveal abnormal thinking in their sign language. Thinking involves more than just language, and disruptions of thought and disruptions of language occur independently of one another.
MSE 83
Psychosis - broadest definition
Dysjunction of thinking from reality
MSE 83
Psychosis - most classic and undisputed symptoms
delusions and hallucinations (abnormal thought content) and loosening of associations (abnormal thought process)
MSE 83
Broader symptoms of psychosis
include abnormalities of appearance, affect, socialization, and volition. Positive and negative symptoms are discussed in this context.
MSE 83
Positive symptoms
No reason to just use this term with schizophrenia. This is the addition of some attribute or behavior not normally present. Inc. delusions, hallucinations, ideas of reference, agitated and bizarre behavior, loose associations, nelogisms, blocking, hostility, and affective lability.
MSE 83
Negative symptoms
Can be applicable to all psychosis, not just schizophrenia. This is the lack of attributes or abilities that are normal present. Inc. blunted or inappropriate affect, apathy, lack of motivation, social isolation, withdrawal, neglect of personal appearance, paucity of thought, and incapacity for abstraction.
MSE 83-4
Why is attention to thought content important? Where is it particularly vital?
Thought content is important in understanding the patient's personality, situation and chief complaint. Its assessment is particularly vital in detecting dangerousness to self and others.
MSE 84
Questions to ask self when assesssing thought process
Was conversation direct/informative or confusing/vague? Easy to gather info. or did I have to work hard at asking questions to elicit information? Pt answer questions directly, or did they ened to be repeated/rephrased? Re: open ended questions and opportunities to initiate/engage in conversation - did pt speak spontaneously? About what? How smoothly did ideas flow? E.g. of thought blocking, loose assoc., neologisms? Return to same theme, perseveration? Did pt. lapse into silence when not questioned?
MSE 85
Disordered connectedness and organization of thought - 5 examples
Circumstantiality
Flight of ideas
Loose associations
Tangentiality
Word salad
MSE 85
Other peculiarities of thought process - 5 examples
Clang associations
Echolalia
Neologisms
Perseveration
Thought blocking
MSE 85
Forms of thought disorder, e.g. loose associations, incoherence, in order of severity
Circumstantiality and tangentiality are relatively mild forms of thought d/o. Worse disruptions are, in increasing order of severity, flight of ideas, loose associations, word salad, incoherence.
MSE 86
Flow of words - how is this affected in thought disorders?
Syntax is usually intact in thought disorders, though in loose dissociations, the logical flow of ideas in paragraphs is disrupted. In word salad, even the integrity of phrases is lost. This is the form of thought d/o most difficult to distinguish from fluent aphasia.
MSE 86
Tangentiality - definition, severity
Straying down other paths of conversation w/o returning back to topic. Must be considered excessive to describe patient as tangential. Is not in itself conclusive evidence of psychosis.
MSE 86
Circumstantiality - definition, how to handle, seen in?
"talking around" topic. Digressive and overly detailed, but returns to original topic/point. Increase structure/productivity through directive questions and interruption of digressions. Most commonly seen in obsessive patients, but also seen in psychosis and n eurologic conditions, including mild delirium and temporal lobe epilepsy.
MSE 86-7
Flight of ideas
Tangentiality that occurs quickly - every one to two sentences - before thoughts can be elaborated upon. Seen in manic patients, often concurrently w/ pressured speech.
MSE 87
Loose associations vs. flight of ideas
Loose associations have no obvious connectedness, or apparent connection is not logical one.
MSE 87
Loose associations - clinical correlation
Occurs ato some degree in the majority of acutely psychotic patients, may be the only evidence of psychosis in patients who are adequately self-controlled and insightful enough to conceal their hallucinations and delusions. Seen in schizophrenia, advanced dementia, severe mania, psychotic depression, drug intox or w/d, brief reactive psychosis, and delirium. Must differentiate from Wernicke's.
MSE 87-9
Looseness of associations - as affected by interviewing
The more structured the interview, the more directive and closed-ended the questioning, the less looseness. The interviewer may choose to leave it unstructured to enhance detection of a thought d/o.
MSE 88
Looseness of associations - writing, language
Pt will demonstrate the same looseness in writing, but will be able to copy from written material and may be able to sing verses in connected way. This demonstrates separateness of thought and language d/o
MSE 88
Looseness of association - apparent looseness in healthy individuals vs. actual looseness
Healthy individuals may appear to have this when they skip verbalizing logical steps in their thought process, or they abruptly change subjects, but they are able to retrace their steps if asked to.
MSE 88
Loose associations - diagnostic significance
most often associated with schizophrenia, was a cornerstone to Bleulerian approach to diagnosing this illness, before DSM-III-R
MSE 88
Loose associations - documentation
Among most difficult to describe or quantify of schizophrenia symptoms, so preferable to record verbatim examples.
MSE 88
Word salad - definition, differential
More severe than loose associations. Intact words strung together with no apparent logical/meaningful connection. Fluent and prosodic vs. Broca's, but difficult to distinguish from Wernicke's or severe Alzheimer's
MSE 89
Incoherence - definition, causes
less specific term than word salad. Occurs in various d/o inc. delirium, dementia, aphasia, severe manic psychosis. Prefer to use for speech that is truly unintelligible b/c of severe loosening of associations, poor articulation (dysarthria), or both. Preferable to elaborate other signs/Sx in an incoherent pt to be more specific and aid in DDx
MSE 89
Incoherence in schizophrenia vs. in delirium/aphasia - abilities in examination
An incoherent, actively psychotic schizophrenic patient is usually capable of comprehending commands, naming, repeating, reading, and writing, whereas delirius or fluently aphasic patients usually are not.
MSE 89
Thought blocking - definition
Thought is lost in midsentence, usually leading to a pause of a few seconds in speech. Pt may desribe as "idea disappeared from my head." This should be distinguished from failure to answer due to preoccupation w/ hallucinations.
MSE 89, 111
Though blocking - prevalence, clinical correlation
relatively rare, associated w/ psychosis, observed most frequently in schizophrenia and delirium
MSE 89
Thought blocking vs. looseness of associations
Thought blocking might seem like looseness of associations b/c of change in topic, but it is distinguished by clear and unexpected pause b/w otherwise fluent statements.
MSE 89
Thought blocking vs. telegraphic speech of nonfluent aphasics
In thought blocking, pauses occur less frequently, conjuctives are not omitted, grammar is intact.
MSE 89
Thought blocking vs. losing train of thought in normal individual
After blocking, pt generally unable to recollect previous topic of conversation, is unaware that blocking occurred. Normal individuals are aware that train of thought has been disrupted, can recollect preceding topic, and don't have loose associations.
MSE 89
Thought blocking in histrionic pts
They may unconsciously block an affectively laden thought that is being repressed.
MSE 89
Perseveration - seen in?
psychosis, obsessive pts, brain-disordered pts, delirium, dementia, catatonia
MSE 90
Clang associations
words or phrases connected by sound rather than meaning, usually within the matrix of sentences, e.g. I drive an old car. I wish upon a star. Do you drink in a bar? etc. etc. May be seen in mania and other forms of psychosis
MSE 90, 112
Echolalia - definition, seen in?
repeat statements and questions made by examiner, sometimes more than once. Independently produced statements scant or non-existent. Rare condition, seen MC in schizophrenia and mania, usually in assoc. with catatonia. also seen in transcortical pts and in some pts with frontal dementias.
MSE 90
neologisms - seen in?
made up words. Evidence of psychosis. Seen in minority of schizophrenic pts, occasionally in other psychotic conditions, dementias, aphasias. Often associated with delusions, e.g. manic pt creating terms to describe machines he's invented. Differentiate from paraphasias
MSE 90
Patient recognition of abnormalities of thought process
In general, pts don't recognize these. Some with flight of ideas will admit to racing thoughts. After recovering from psychotic episode or delirium, may describe how confused or mixed up they felt previously. Schizophrenic patients may describe antipsychotics of gluing their thoughts together.
MSE 90-1
Thought content - initial questions
Open-ended, unless pt is not responding/opening up/comfortable. Do MH ROS to elicit more symptoms/info
MSE 92
Abnormalities of thought content (12)
Delusion, homicidal ideation, magical thinking, obsession, overvalued idea, paranoia, phobia, poverty of speech, preoccupation, rumination, suicidal ideation, suspiciousness
MSE 92
Abnormalities of precepts (7)
Autoscopy, Deja vu, Depersonalization, Derealization, Hallucination, Illusion, Jamais vu
MSE 92
Degree of insight of thought content is related to the degree of what?
The degree of recognition of reality, including both external world and pt's internal reality, as well as capacity to be aware of both. Psychotic pts usually have impaired insight. By definition, delusions are not recognized by pt as being false ideas or incongruent with reality.
MSE 93
Delusions in pts with insight
insightful pts may recognize incongruity of beliefs - e.g. saying, "I know it sounds strange, but..." May hide delusions from examiner to avoid some perceived consequence. E.g. pt makes association b/w bringing up his neighbor's murderous plot against him and being committed, so he no longer brings it up.
MSE 93
Which delusional patients come in for treatment?
Those who are distressed will come in. Less likely if reaction to delusions is bland (e.g. blunted affect, more common in chronic psychosis) or pleasurable (e.g. grandiose, etc. delusions). Contact can be due to other related symptom (e.g. trouble sleeping, mood disturbance); can be brought in by family. can be involuntary (epitomizing lack of insight)
MSE 93
Delusions - definition
objectively incorrect beliefs that are not culturally determined or shared with a large group of people and that cannot be shaken by contrary evidence
MSE 93
Delusions - documentation
Be humble and confident. Humble in calling delusions "possible" ones if you're not sure they are incorrect beliefs (considering them in the context of the patient's history and hospitalization may help), confident that mental illness exists.
MSE 94
Religious beliefs vs. delusions
Most religious beliefs are culturally determined, shared, accepted, and not the product of individual mental illness.
MSE 94
Rooting
E.g. of nonreligious belief that is unshakeable and objectively impossible, though not delusional. Common in southern US. Involves conviction that an evil spell can be cast.
MSE 94
Folie-a-deux
delusion shared by two individuals. usually points to pathology of both the affected individuals and their relationship
MSE 94
How to handle nonbizarre beliefs that may/may not be delusional
ask more questions. E.g. if pt. says "My neighbors are always bothering me," ask about in what way, to what degree they are, how certain the patient is, on what evidence it is based, and what the pt sees as the motivation (to uncover persecutory feelings), and how the pt. might revise his/her conclusion if contradictory evidence came to light. Involve family members to clarify, give corroborative Hx.
MSE 94-5
Common delusions that should always be asked about
e.g. being in danger, being watched, being plotted against, being discussed by the media, having thoughts read. Ask about these to exclude their presence in each pt.
MSE 95
Responding to delusions in initial evaluations
Generally, be neutral. Can assess how fixed or unshakable they are by asking if other explanations are possible. Resist answering queries about our opinions/beliefs, replying, "I need more information to comment," or "That's not something that I can be completely certain about" as pts can become angry or less communicative when confronted.
MSE 95
Delusions - types
paranoid (MC encountered), paranoid, Schneiderian symptoms, somatic, erotomanic, referential, nihilistic, delusional denial.
MSE 95
Paranoid delusions - two types
persecutory and grandiose (may also have delusions of reference)
MSE 95, 113
Persecutory delusions
of harm or threats. pt may also be guarded and vigilant or describe pervasive mistrust in the absence of clear delusion. Pts. described as suspicious.
MSE 95-6
Persecutory delusions - seen in?
Persecutory most frequently encountered type of delusion in general psych practice, inc. in demented/delirious pts. Also seen following R hemispheric brain damage, and in association w/ temporal epilepsy
MSE 96
Grandiose delusions - definition, seen in?
false beliefs about extraordinary talents, prowess, or importance. MC in mania, can also occur in other psychiatric conditions, and in chronic meningoencephalitis, particularly tertiary neurosyphilis.
MSE 96
Grandiose delusions - opposite?
Delusions of poverty are converse of some grandiose delusions - pts. insist they are destitute and deny ownership of their assets
MSE 96
Schneiderian symptoms
named for psychiatrist who grouped them. First-rank Schneiderian symptoms were previously considered pathgnomonic of schizophrenia. Include feeling that one is being externally controlled, thought broadcasting, thought insertion/withdrawal, certain hallucinatory experiences including commands or an ongoing commentary on one's behavior.
MSE 96
Thought broadcasting
belief that one's thoughts are no longer private. MC Schneiderian symptom. Pts may repetitively apologize or say "I didn't mean that" about thoughts they feel examiner could hear
MSE 96
Thought insertion
conviction that a thought is alien and placed in one's mind by some external power
MSe 96
Thought withdrawal
delusional sense that thoughts are being lost or stolen through the efforts of some external force
MSE 96
Erotomania
ungrounded conviction that another person is deeply in love with oneself. often a famous person. Sometimes referred to as Clerambault's syndrome
MSE 97
Delusional jealousy
Virtually inverse of erotomania. Unfounded and preoccupying conviction that one's spouse or lover is being unfaithful. Pts may violently act on their delusions. Delusional jealousy is sometimes considered to be a type of persecutory delusion.
MSE 97
Reduplicative paramnesia/delusional misidentification
can involve place, other persons, or self (including body parts).
MSE 97
Reduplicative paramnesia for place
fixed delusion that one is located elsewhere. can occur in functional psychotic d/o, but is perhaps more common in amnestic states
MSE 97
Capgras' syndrome
reduplicative paramnesia for person. fixed belief that an imposter, often malevolent, has been substituted for one or more persons with whom the patient interacts. Substituted person is usually someone important to pt, typically spouse, and is selective - most people in environment are correctly identified.
MSE 97
Capgras' syndrome vs. prosopagnosia
Prosopagnosia - inability to recognize faces. Pts. with Capgras' unimpaired in objective testing of facial recognition. Fixed delusion, belief in the existence of alleged double, as opposed to an illusion, hallucination, or misperception. Also not due to diffuse cognitive deficits or amnesia
MSE 97
Capgras' vs. schizophrenia
Capgras' involves delusion that intimates have been replaced by strangers. Schizophrenic patients often describe that strangers, e.g. other pts in ward, are actually friends, relatives, or familiar persons from their past.
MSE 97
Reduplicative phenomena involving body parts
e.g. extra limbs or heads. possibly delusions, but more likely hallucinations or illusions. Typically transient (i.e. not fixed), likely to occur in confused pts and/or in response to acute neurologic injury, such as to nondominant parietal lobe
MSE 97
Somatic delusions
usually of being ill, but may be of some unusual bodily attribute. Range from plausible "I have a broken arm" to absurd/bizarre "there are snakes in my heart"
MSE 97
Somatic delusions in narcissistically preoccupied pts
may report that some feature of their appearance is particularly ugly (e.g. facial moles that are not objectively visible). Such delusions should be carefully evaluated, as they may contain grain of reality or be based on a distorted report of a real pain or discomfort
MSE 97
Somatic delusions in MR pts
May be real somatic symptoms explained in fantastical ways
MSE 97
Somatic delusions - differentiate from?
from conversion disorder or hypochondriasis. Plausible somatic delusions are sometimes termed hypochondriacal delusions, so misdiagnosis could potentially result. Somatic delusions may accompany schizophrenia, brief reactive psychosis, major depression, dementia, delirium, mania. Do careful PE and labs
MSE 98
Nihilistic delusions
theme of some dire event impending or having taken place, such as that one is dead, has lost all possessions, has lost internal organs, is in need of burial, or is damned. The outside world does not exist or does not matter. AKA delusions of negation or Cotard's syndrome
MSE 98
Ideas of reference
incorrect ascription of special individual meaning to neutral stimuli. e.g. books, television, movies, radio, newspapers, so ask about pt getting any special messages from these sources
MSE 98
Delusional denial
Denial at delusional proportions, e.g. "That's not my chart. I don't have cancer." Denial of body part or dysfunction of body part might indicate anosognosia. This is form of psychotic denial, but typically occurs as a consequence of a well-defined neurologic lesion.
MSE 98, 113
Bizarre
Used to describe delusions, etc. that are totally implausible, e.g. pt being born on Mars, chopped into pieces, transported to Earth a millennium ago, then reassembled. Though being followed by the KGB, etc. might be unlikely, it is not implausible and therefore not bizarre
MSE 98
Monosymptomatic delusion
restricted to one delimited topic, occuring in absence of other gross psychopathology. Most commonly somatic, but can also be, e.g., isolated erotomanic or jealous delusions
MSE 99
Delusions - diagnostic significance
No longer considered pathognomonic of anything (e.g. Schneiderian of schizophrenia, though it is less commonly seen in affective d/o)
MSE 99
mood-congruency
content of delusion, etc. matches pt's affective state
MSE 99
mood-incongruency
content of delusion, etc. does not match affective state. For delusions, this is a poor prognostic sign, and might mean that there is a need to reevaluate the diagnosis - i.e. does the pt truly have an affective d/o or is a schizophreniform d/o more likely?
MSE 99
Delusions - mood congruent in depression
persecutory, somatic, nihilistic
MSE 99
Delusions - mood congruent in mania
Grandiose or persecutory
MSE 99
Delusions - as manifestation of neurologic dz
Reduplicative paramnesias are reported in schizophrenia and other psychotic d/o, but also seen commonly in chronic or resolving amnestic syndromes (perhaps induced by closed head injury, dementia, or a confusional state). Sometimes occurs in context of identifiable brain lesions - frontal, limbic, and R hemispheric areas all implicated
MSE 99
Delusions - stable/systematized
Chronically psychotic pts tend to have stable set of delusions in which various psychotic features tend to interrelate, new Sx are added to the matrix of old ones, and pt is able to discuss most things in terms of his or her system.
MSE 99
Delusions - unstable/nonsystematized
more common in transient organic states (esp. delirium) and at onset of psychotic condition, these pts. have rapidly changing content of delusions, organization that is difficult to elucidate, and psychotic elements that aren't particularly interrelated. Thought disorganization also leads to disorganization of delusions.
MSE 100
Overvalued ideas
near-delusional belief. Odd, not mainstream, firmly held, but not sufficiently absurd, illogical, or unshakable to warrant delusional label. Document with qualifiers such as liekly, possible, questionable
MSE 100
Magical thinking
illogical, often attributing more connectedness to events than is actually the case. Many superstutions are examples of culturally validated magical thinking. e.g. belief that an extramarital affair was responsible for a traffic accident. Common thinking amongst children, obsessive-compuslive, schizophrenic, schizotypal. Not necessarily sign of psychopathology
MSE 101
Obsessions
Undesired, unpleasant, intrusive thoughts that cannot be suppressed through pt's own volition. Typically, but not necessarily, persistent and frequent. Pt. realizes these obsessions are unreasonable, they cannot be suppressed or ignored.
MSE 101
Obsessions - content/themes
single word or phrase that keeps recurring, or a recurrent theme. Common themes are of engaging in some violent, silly, or socially inappropriate behavior.
MSe 101
Obsessions - dangeousness
Homicidal themes in obsessions are not true homicidal thoughts. Obsessive pts generally not dangerous to others. They recognize their thoughts as absurd, and have no intent/plan of acting on them. Desperately want not to do these things.
MSE 101
Obsessions - vs. delusions
People with obsessions have insight
MSE 101
Obsessions - Subtypes (3)
Ruminative, Doubting, Inhibiting
MSE 101
Obsessions - Ruminative
aka intellectual. Involves metaphysical or philosophical thoughts, such as purpose of life or fate of mankind. Thoughts mulled over continually without resolution.
MSE 101
Obsessions - Doubting
patients cannot stop thinking about some decision that has to be made or that has been made. All alternatives (and especially negative aspects of each) are weighed ad nauseum w/o reaching conclusion. May be about weighty or trivial decisions. When severe, these are incapacitating.
MSE 101
Obsessions - Inhibiting
Often involve violent ideation - pts don't desire to do them and instead repeatedly experience fear or premonition of committing these acts. Pt. recognizes the obsessive thoughts are unrealistic. Still, pt. may become so incapacitated (inhibited) and isolated as he or she does nothing at all for fear of losing control and acting violently
MSE 101-2
Obsessions - vs. preoccupations
Preoccupations - undue visitations to a topic, usually communicated by a persistent return to that topic during conversation. E.g. health, appearance, finances, etc. Not pathologic. Normal people have these, but are not obsessions unless unwanted and unsuppressible. Some pts are preoccupied about their psychiatric symptoms.
MSE 102
Obsessions - Examination
Ask pts if they have any repetitive thoughts/actions they want to but can't stop. If uncovered, ask about content and frequency. Determine if unwanted, if pt has tried to stop them, how they affect pt's life, and whether they cause any actions/compulsions
MSE 102
Obsessions - Which types of people tend to have them
More likely in pts whose overall thinking is rigid stereotyped, and repetitive, in those who are fastidious, perfectionistic, and very concerned about time, and in those who rearrange the environment (even if not their office).
MSE 102
Obsessions - Diagnostic Significance
Normal individuals have thoughts and behaviors that appear obsessive/compulsive that can be exaggerated under stress. Can be adaptive, socially acceptable, e.g. punctuality or arranging drawers in particular way. Only obsession/compulsion if pt acknowledges they are unwanted. Note that pt has obsessive/compulsive traits/characteristics - description of personality/style. Not necessarily psychopathology.
MSe 102
Obsessions - Examination (DDx)
O/C may be associated w/ OCD, anxiety, mood d/o, psychoses, organic mental d/o. B/c obsessions usually considered anxiety Sx, should elicit other signs/Sx of anxiety. B/c of link b/w OCD and depression, should also check for affective d/o signs/symptoms.
MSE 103
Obsessions - Schizophrenia
Obsessions may be prodrome of impending psychosis. Schizophrenic sometimes exhibit strange/ritualistic behaviors
MSE 103
Obsessions - Depression
Pts. w/ depression commonly have obsessive, though rarely compulsive, features, esp. ruminative obsessions. OCD pts seem predisposed to depression; So in pts with obsessions, look for affective d/o s/s.
MSE 103
Obsessions - Neurologic d/o
Rarely manifest in this way; seen in Tourette's, Huntington's, postencephalitic parkinsonism, basal ganglia damage from anoxia or CO poisoning; in strokes, tumors or seizures affecting basal ganglia or limbic areas.
MSE 103
Phobia - definition
Dread of object/situation that in reality does not pose any threat
MSE 103
Phobia - vs. delusion
Phobic pts not delusional. They intellectually recognize there is no danger, however this does not prevent emotional response of fear.
MSE 103
Phobia - three groups
agoraphobia, social phobia, simple phobia
MSE 103
Agoraphobia
Fear of open spaces; most pts fear all public places, or particular public places, regardless of whether these places are open. Consequently, may become homebound.
MSe 103
Agoraphobia - Sx
Panic attacks are frequent/severe complication. Sx of panic include sense of impending doom, evidence of autonomic hyperactivity, such as sweating, palpitations, hyperventilation. Complicated by social+simple phobias, dysphoria, anxiety, obsessions, depersonalization.
MSE 103
Phobias - most common?
Probably agoraphobia, which is also most debilitating
MSE 103
Social phobia
fear of public humiliation. Most often focuses on public speaking. Variety of other potentially embarrassing circumstances, e.g. fear of blushing, fainting, financial discussions.
MSe 104
Social phobia vs. normal concern of what others think
Remember that some level of concern over what others think is considered normal, and its absence is prceived as rude, possibly pathologic (e.g. narcissistic or schizoid personality d/o). Record if pt is complaining of these Sx, if they significantly interfere w/ social/occupational functioning, if fears more powerful or stimuli more benign than in most people
MSE 104
Simple phobia
All phobias other than agora/social. Circumscribed but inordinate fear of a particular situation or object. Those that focus on social interaction, e.g. speaking to opposite sex, should be classified as social.
MSe 104
Simple phobias - severity, Px
Simple phobias not usually indicative of severe psychopathology, but may have specific behavioral impact, such as needing to travel by trains rather than airplanes.
MSe 104
Simple phobias - who's prone?
Children are especially prone to phobias.
MSE 104
Simple phobias - multiple stimuli possible?
Pt may have more than type of object or situation that may induce this fear
MSE 104
Simple phobias - DDx/Exam
Pts. should be closely questioned to determine they recognize their fears are idiosyncratic, rather than provoked by realistic danger to differentiate from persecutory delusions or magical thinking
MSe 104
Anticipatory anxiety
Phobic patients can become quite anxious simply by thinking of encountering phobic stimulus. This may come up in interview. Can help pt deal with anxiety by pointing out that the stimulus is not around now, by having pt. describe concrete objects in environment, by having patient rate anxiety level 1-10 every minute, and by having pt focus on others. Each of these things turns pt's attention onto present and away from the future, and reinforces the fact that the danger/stimulus is not present right now.
MSE 104, Psychology Today
Suicidal ideation - motivations
Desire to escape situation/problems; desperate attempt to exercise control in troubled lives; expression of anger toward others whom they want to make feel guilty, manipulate, or gain revenge against.
MSE 104
Suicidal ideation - Methods of killing self
general hospital - more likely to jump from window. psychiatric hospital - more likely to hang self.
MSE 104-5
Suicidal ideation - risk related to mental health
Chronic schizophrenia or recurrent mood d/o > general population. Anxiety d/o, organic states, drug/EtOH abuse - also associated risk of suicide.
MSE 105
Suicide - alcoholics
more commonly attempt suicide while intoxicated
MSE 105
Suicide - delirious pts
Even these pts can kill selves, though usually accidentally
MSE 105
Suicide - mania
Sometimes kill seves as result of recklessness, abrupt swings into depression, or psychosis.
MSE 105
Suicide - Schizophrenia
as response to overwhelmingly terrifying delusions, delusions of invulnerability, command hallucinations, concurrent depression.
MSE 105
Suicide/Homicide - pts. with mental health issues
Homicide less common than in general population, much less common than suicide, but should be assessed, particularly in angry or paranoid patients.
MSE 105
Suicide - Risk factors (associated with successful attempts)
Past Hx of attempts, depresion, severe psychosis, alcohol abuse, male gender, white race, advanced age, chronic/terminal physical illness.
MSE 105
Suicide - men vs. women
Women 3x more likely to attempt, but men successful 2x as often. Women use less lethal means, e.g. drug O/D, men more often choose guns.
MSE 105
Suicidal ideation - initial questioning
Explore if problems are at times too much to bear, if pt would be better off dead, life devoid of pleasure or worth living, pt wish he/she could die, thoughts about taking own life.
MSE 105
Suicidal ideation - Questioning in pt with passve SI
Ask about plans, details of plan, steps taken to further plan (e.g. writing will, purchasing firearm). If no plan endorsed, pt has not acted upon thoughts - focus on how pt handled thoughts, whether he/she sought help from loved ones, called hotline. Document answers.
MSE 105-6
Self-mutilation w/o interest to die - seen in?
most frequently in pts who have primitive personality d/o and schizophrenia. Self-abusive acts, typically superficial cuts and burns, are hallmark of borderline personality d/o - these pts make repeated self-destructive gestures related to manipulating interpersonal relationships (or to counter feelings of derealization) - not real intent to die.
MSE 106
Self-mutilation - psychotic vs. personality d/o
in psychotic patients, self-mutilation is generally not for manipulative purposes, is more often severe in nature, e.g. autocastration in response to delusion of being harmed by testosterone. Head shaving in psychotic patients is possible prologue to further self-injury
MSE 106
Violence - by pts with MH issues
bulk of serious violence in US not perpetrated by psychiuatric pts. But document ideation of violence toward others all the same.
MSE 106
Violence - antisocial personality d/o
may act in cruel/violent ways as theya re notoriously deficient in empathy for others and acceptance of societal or moral restrictions
MSe 106
Violence - Conduct d/o children
torture animals, set fires, beat up smaller children, etc.
MSE 106
Violence - paranoid individuals
sometimes act on their delusions with violent preemptorystrikes. Should ask these pts how they plan to deal with their fears and whether they've thought about harming others.
MSE 106
Violence - brain injury pts
Those with brain injury affecting prefrontal cortex are disinhibited and impulsive
MSE 106
Violence - depressed/despondent individuals
sometimes commit "murder suicides"
MSE 106
Homicidal/Violent ideation - questioning
Should inquire whether pt has ever harmed anyone, ever seriously injured another person such that treatment was necessary, feels like hurting anyone currently or in foreseeable future. Document presence/absence of aggressive urges or plans in MSE. May lead to commitment proceedings or police action.
MSe 106
Perceptual disturbances - types (7)
hallucinations, illusions, derealization, depersonalization, autoscopy, deja vu, jamais vu
MSe 106
Hallucination - definition
unprovoked perceptual experiences that occur in mind of patient - any sensory modality (sight, hearing, smell, taste, touch) in absence of any external physical stimulation. May be simple or complex. Pts. w/ chronic psychotic conditions may hallucinate continually. Others may have episodic or single episode hallucinations, e.g. those induced by psychoactive drugs or delirium
MSe 106-7
Illusion - definition
exaggeration, distortion, misinterpretation of actual physical stimulus. Also occur in absence of psychopathology, especially during fatigue or sleep-deprivation
MSE 107, 115
Metamorphosia
visual illusion in which images of actual objects or persons are distorted in size. Micropsia - everything in environment is unduly small. Macropsia - objects unduly large
MSE 107
Palinopsia
visual perseveration. Persistence or repeated recurrence of something previously seen but no longer in field of vision
MSe 107
Anton's syndrome
Pts. with cortical blindness due to bilateral occipital lesions confabulate descriptions of what they cannot see
MSE 107
Illusions - occurs in?
not infrequent in psychosis, delirium, dementia, neurologic d/o (e.g. temporal lobe epilepsy), normal individuals
MSe 107
Depersonalization
feeling that one's self or one's body is unreal or unfamiliar. Sense of being outside one's self (differentiate from autoscopy, in which pts actually see themselves as if from some external vantage point in the room), that one's goals or mores are wrongheaded or meaningless. Generally accompanied by anxiety or dysphoria
MSE 107, 113
Derealization
feeling that the world is unreal or has abruptly taken on unreal characteristics. Is to external environment what depersonalization is to internal one. Pts describe feeling as though they are in a play or in outer space.
MSE 107
Depersonalization/derealization - insight, reality testing
Except in most extreme cases, pts w/ these intellectually recognize what is or is not real. Usually not delusional.
MSE 107
Depersonality/derealization - occurs in?
most commonly encountered in borderline personality d/o, partial complex seizure d/o, conversion/hysterical d/o, early/mild psychotic states, normal adolescence. Usually transient experiences, lasting minutes to hours, but may recur. Some experience both.
MSE 107
Deja vu
Perception of having previously seen or lived the current (novel) setting or situation.
MSE 107
Jamais vu
More or less converse of deja vu - sense that something familiar is strange. Less common than deja vu
MSe 107, 115
Deja vu/Jamais vu - seen in?
Both associated w/ complex partial epilepsy, but can occur in variety of psychiatric and neurologic d/o, can be experienced by otherwise healthy individuals if of moderate or less degree. Classically associated w/ partial complex sz d/o
MSe 107, 112
Hallucinations - auditory
characteristic of schizophrenia and mood d/o. Other forms of hallucinations coexist with auditory in primary psychiatric d/o, but presence of them W/O auditory is strongly suggestive of organicity
MSE 107-8
Hallucinations - Hypnagogic/Hypnopompic
Hypnagogic - during transition b/w wakefulness and sleep. Hypnopompic - during transition b/w sleep and awakening. These are most commonly visual, occasionally auditory, may be complex. Appear to be dreamlike states, not necessarily psychopathologic, but commonly associated w/ narcolepsy
MSE 108
Auditory hallucinations
MC hallucinations, important in primary psych illness. range from elemental sounds --> well-formed/elaborate conversations.
MSE 108
Auditory hallucinations - clearly articulated voices
Clearly articulated voices MC reported by psychotic schiz pts. Often derogatory, insulting, critical of pt. Less commonly, more than one voice carrying on conversation.
MSE 108
Auditory Hallucinations - vague sounds
May hear vague voices, indistinct sounds, buzzing/ringing in ears. This is less helpful in diagnosing schizophrenia.
MSE 108
Auditory hallucinations - buzzing, elemental sounds
more suggestive of neurologic problem (e.g. ear, acoustic nerve, central auditory system pathology). Ringing in ears (tinnitus) occurs w/ salicylate intoxication.
MSE 108
Auditory hallucinations - command
Voices that instruct/direct pt
MSE 108
Auditory hallucinations - musical
can occur in psychotic illnesses, but are also infrequent concomitant of acquired deafness, particularly in those w/ musical training and in pts with R temporal lobe epileptiform discharges.
MSE 108
Auditory hallucinations - perceived source
Some perceive voices as originating in their heads, while others perceive them as coming from outside, like normal conversation. Some consider the former to be relatively more healthy and/or insightful, though this is not established.
MSE 108
Auditory hallucinations - Schneiderian
One or more voices in a running commentary remarking on pt's thoughts/behavior or more than one voice conversing with another.
MSE 108-9
Visual hallucinations - clinical associations
occur in many mental d/o, often in conjunction w/ auditory hallucinations. Chronic visual hallucinations occur in Alzheimer's dementia, can be complex.
MSE 109
Visual hallucinations - poorly formed
Can happen in chronic visual hallucinations. Described as flashing lights or colors. Rarely distinct and frightening.
MSE 109
Autoscopic hallucinations - definition and clinical association
Hallucinations of seeing oneself, as though in a mirror, often secondary to temporal lobe seizures
MSE 109
Lilliputian hallucinations
visual hallucinations o fvery tiny objects
MSE 109
Visual hallucinations - significance
usually suggest "organicity", i.e. occur as a result of dementia, delirium, recently developed blindness, drug w/d states (classically, in DTs, pts report seeing insects or animals), drug intoxications (especially w/ hallucinogenic, anticholinergic or dopaminergic substances), temporal lobe epilepsy, migraine, and other organic mental disorders. Look for possible accompaniment of fluctuating LOC or cognitive performance, as in delirium, or signs of physical illness
MSE 109
Peduncular hallucinations - definition, localization
lesions of the thalamus and/or cerebral peduncles (i.e. areas not immediately involved in the geniculocalcarine or visual tract) can cause these, which are vivid, colorful, well-formed, but changeable images.
MSE 109
Visual hallucination DDx - Flashing lights?
due to retinal detachment
MSE 109
Visual hallucinations DDx - scintillating lights, series of undulating jagged lines, blurred areas, or dark spots
occur in migraines, called scotomas.
MSE 109
Visual hallucinations DDx - curtain of carkness lower over visual field
sign of TIA
MSE 109
Visual hallucinations DDx - small dark specks that drift across the visual field
"floaters" - common and benign result of senescent changes in the eye
MSE 109
Olfactory hallucinations - significance, quality
relatively rare. Like visual hallucinations, are quite suggestive of a neurologic problem. Olfactory hallucinations are rarely pleasant, and are typically of a foul, stinking smell, such as burning rubber, feces, or rotting garbage.
MSE 109
Olfactory hallucinations - epilepsy
Epileptiform discharges in the temporal lobe are a common cause of olfactory hallucinations. They occur in isolation or as an aura preceding a secondarily generalized convulsion
MSE 109
Gustatory hallucinations - significance, quality, prevalence
least frequently encountered hallucinations. Usually associated w/ temporal lobe epilepsy and tend to be unpleasant.
MSE 109
Somatic hallucinations - quality
bodily sensations, most commonly on surface of skin (aka tactile or haptic hallucinations)
MSE 110
formication
somatic hallucination of ants crawling over one's skin, and is particularly common in DTs, delirium 2/2 anticholinergic or other drug toxicity, and in delusions of parasitosis
MSE 110
Somatic hallucinations - internal bodily sensations
Autonomic/cenesthetic/visceral hallucinations. Hard to distinguish from somatic delusions. Peculiar and physiologically implausible, such as burning in the brain.
MSE 110, 114
Epigastric aura
somatic hallucination - rising feeling originating in abdomen, climbing to chest, throat and/or mouth; reflects partial seizure involving mesial temporal region.
MSE 110
Somatic hallucinations - clinical associations
occur in psychosis and in neurologic dysfunction. Be sure to r/o primary physical etiology in involved organ/body area.
MSE 110
Hallucination - evaluation (inference)
auditory - pt may pause during conversation, appear preoccupied while they are attending to hallucinations. Less frequently, they look toward direction of perceived source, or respond to hallucination. If appropriate, reference what happened and ask about it
MSE 110
Hallucinations - questioning
asking about past hallucinations (good predictor of present Sx) may defuse anxiety about hospitalization. Can say, "it is common for people in your situation...has this ever happened to you?" Pts newly experiencing hallucinations are generally more distressed than those who experience them chronically
MSE 110
Hallucinations - when pt endorses auditory
Ask whether more than one voice is heard, if voice is known, if content is derogatory or critical, if command hallucinations, if urging violent/dangerous behavior, if pt has acted on them, if it is difficult to resist
MSE 111
Hallucinations - screening for nonauditory
Have you smelled/tasted/felt things that aren't there/real? Ask more detailed questions if you suspect such Sx, e.g. in temporal lobe epilepsy
MSE 111
Hallucinations - significance
may establish dx of psychotic illness. May signal a primary psychiatric illness, e.g. schizophrenia, schizoaffective d/o, brief reactive psychosis, or an illness w/ secondary or associated psychotic Sx, e.g. depression, mania, delirium, Alzheimer's dz, amphetamine intoxication, EtOH w/d
MSe 111
Hallucinations - significance of non-auditory
suggestive of neurologic or medical problem. If such hallucinations are present without auditory hallucinations, medical/neurologic evaluations should be done, even if pt previously diagnosed w/ schizophrenia. Visual hallucinations occur in drug intoxication/w/d states, sz, delirium, brain tumors, etc. Olfactory particularly suggestive of pathology in temporal/limbic area.
MSE 111
Delusional denial vs. denial
Must differentiate psychotic level denial from psychologic defense mechanisms of repression, suppression, rationalization. In these, certain aspects of reality are avoided and excluded from conscious awareness, but on direct confrontation, reality is not denied.
MSE 113
Derailment
Thoughts are disconnected or illogically connected. Speech is difficult to follow because it jumps from one topic to another in a matter analogous to a train derailing or jumping off the tracks. This term also implies severe loosening of associations.
MSE 113
Formal thought d/o
disturbance of structure or form of thought, as opposed to a disorder of thought content. This is not a particularly helpful term, and when used is usually synonymous w/ loosening of associations. However, tangentiality, perseveration, neogolisms, and derailment are also e.g. of formal thought d/o
MSE 114
Guardedness
Wariness and resistance to discussing personal matters, often accompanying suspiciousness and physical evidence of arousal and vigilance. Often seen in paranoid or delusional patients, but not necessarily implying psychosis.
MSE 114
Kinesthetic hallucination
sensation of movement in a body part that is not actually moving. May involve phantom limb
MSE 115
Phantom limb
Perceived sensation from an amputated extremity, including that it is still attached. This is not indicative of psychopathology, as it is a product of information/percepts stored in the brain from the limb that is no longer there.
MSE 115
Xenophobia
Fear of strangers
MSE 117
Hemophobia
Fear of blood
MSE 117
Acrophobia
Fear of heights
MSE 117
Poverty of speech
Little meaningful info contianed in pt's conversation. Manifested by absence or near absence of spontaneous comment, and response to questions w/ terse or one-word answers, even when elaboration is obviously in order. Alternatively, amount of speech normal/increased, but low in content. Such speech is vague, repetitious, circumstantial.
MSe 117
Poverty of thought/content
Poverty of thought is equivalent to poverty of speech. Poverty of content is sometimes used to describe situation where pt speaks much but with little content. It is considered a d/o of thought and not of language.
MSE 117
Projection
Attributing one's thoughts, intentions, feelings or actions to another. Regarded as the defense mechanism responsible for paranoia, in which patients attribute hostile intent to those around them.
MSE 117
Monomania
Having an overly focused interest in only one subject, to the exclusion of other thoughts and activities.
MSE 117
Psychosis
severe mental disturbance in which thinking is disconnected from external reality. Diminished ability to perceive and accept reality
MSE 118
Manifestations of disordered thought (positive)
unreal perceptions (e.g. hallucinations) and unreal beliefs (e.g. delusions). Encompasses bizarre behavior or gross disorganization of speech that occurs w/o recognition by the patient that anything is amiss.
MSE 118
Negative symptoms of psychosis
Largely studied in schizophrenia. Not proof of psychosis, but often accompany psychotic conditions. Include blunting of affect, impoverished, rigd or concrete thinking, and very poor social functioning and motivation (apathy)
MSE 118
Primary process thinking - what is it, in what psych d/o is it prominent
symbolic and illogical thinking that is thought to occur normally in early childhood, but related mostly to dreams and the unconscious as the mind develops and secondary process (more logical) thinking predominates
MSE 118
Racing thoughts. Definition, seen in?
subjective experience of thoughts moving very quickly from topic to topic. Reported most often by patients with mania, hypomania, anxiety, hyperthyroidism, drug intoxication (e.g. amphetamines)
MSE 118
Rumination
persistent mulling over of an unpleasant theme or thought. Unproductive, does not reach resolution, may be time-consuming, tends to be negative, unenjoyable, frequently contains metaphysical, philosophic, or self-criticizing themes.
MSE 118
Rumination vs. preoccupation vs. obsessions; clinical correlation
somewhat related to preoccupation, but may be less narrowly focused; if thoughts identified by pt as trivial or unwanted - may be termed ruminative obsessions. Occurs commonly in MDD and OCD.
MSE 118-9
Delusional perception
Schneiderian symptom that has extreme elements of referential or magical thinking. Novel, often self-referential delusions triggered by perceptual experiences, e.g. concluding that seeing a bird in a tree "means that I will be made king"
MSE 119
Thought echo
Schneiderian symptom. Hallucination of one's own thoughts spoken aloud
MSE 119
Suspiciousness - definition, clinical correlations
mild form of paranoia. Distrustfulness, vigilance for malfeasance, criticism, or aggression in others. May be manifest in interview as guardedness, wariness, litigiousness, and/or lack of cooperation. May perceive danger or a plot w/o substantial evidence. Common in paranoid personality d/o, delusional d/o, paranoid schizophrenia. Does not necessarily imply psychosis
MSE 119
Thought disorder
generic term that encompasses abnormalities of the content or form of thought and abnormal perceptions. Not in itself a dx and would be considered by many to be roughly equivalent to the term psychosis.
MSE 120