Oman Medical College

Psychiatry Department
Course Coordinator
Dr. Mohamed Mitwally
Associate Professor of Psychiatry
mohmits@yahoo.com

Behavior
Intellect

Affect

Disturbance of behavior
A. Quantitative disturbance:
a. Excess motor activity

i. Agitation: the patient is moving around, moving his limbs and head,
wrinkling his fingers and cannot stay for some time in one place. This
sign is found in many psychiatric disorders e.g. mania, agitated
depression, some cases of schizophrenia ,
ii.Restlessness: the patient feels inner tension with some agitation and
cannot standstill. On sitting he sits on the edge of the chair and moves
his body parts like arms, head and neck. This condition found mainly in
anxiety, and akathisia, also in some psychotic state. The differentiation
between restlessness and agitation may be difficult but in restlessness
the condition usually not desired by the patient i.e. out of his control but
agitation is usually are action to the thoughts of the patient.

Disturbance of behavior
A. Quantitative disturbance:

iii. Excitement: Excitement occurs in primary psychiatric

disorders e.g. mania and schizophrenia and in organic
mental disorders e.g. drug addiction and temporal lobe
epilepsy.
iv. Difference between manic and catatonic schizophrenic
excitement

Disturbance of behavior
A. Quantitative disturbance:
Manic excitement

Catatonic excitement

Occurs mainly in
response to
environmental stimuli

Occurs without
provocation. Mostly in response to
delusion or hallucination

Accompanied with
cheerful or irritable
mood

The mood is apathetic

Usually expected and organized

Usually unexpected and

disorganized

Accompanied with other

manifestations of mania

Accompanied with other

manifestations of
schizophrenia

Disturbance of behavior
A. Quantitative disturbance:
b. Diminished Motor activity
i.

Partial retardation of motor activity e.g. in cases

of retarded depression or simple schizophrenia.
ii. Complete suppression of motor activity (Stupor):
1. No profound disturbance of consciousness
2. There is complete suppression of motor activity
(speech and movement). The patient does not respond
to any stimulus, neither external (question or painful
stimulus), nor internal (hunger, thirst or distended
bladder).
3. In stupor the patient is arousable but not responsive. It
occurs in psychiatric disorders like depression,
schizophrenia, and hysteria, or in acute organic mental
disorders.

Disturbance of behavior
A. Quantitative disturbance:

1. Stereotypy: means monotonous repetition, which

may be :
i. In movement (e.g. touching the nose, or pacing
up and down the room)
ii. In speech (e.g. some words are repeated).

2. Mannerism: repeated movements, which may

continue for hours or days without cessation, and are
keeping with the thought (e.g. a patient with paranoia
salutes repeatedly in a grandiose manner).

Disturbance of behavior
A. Quantitative disturbance:

3. Perseveration: denotes the repetition of the same act

(a movement, a word, or a phrase in spite of the
patients effort or desire to do a new one i.e. inability
to move from one act to the next one (e.g. during a
meal the patient continues to put the spoon in the
plate and up to his mouth, even after the plate gets
empty).
4. Lack of initiation and reduction of spontaneous
movement, lack of volition: the patient has no desire
or will to perform acts.

Disturbance of behavior
A. Quantitative disturbance:

5. Negativism: means automatic resistance to

all stimuli.
i.

In muscular field it may show itself as a

resistance to passive movements (e.g. keeping
the arm extended on trying to flex it or as
opposite performances to that asked for (e.g.
looking down when asked to look up).
ii. In speech it consists of total loss of it i.e.
mutism.
iii. Negativism is seen also in the retention of
saliva, urine and feces.

Disturbance of behavior
A. Quantitative disturbance:

6. Resistiveness: in which the patient simply oppose or

resists anything he is asked to do e.g. when he is setting
and is asked to stand up, he will remain setting down.
7. Automatic obedience: in contrast with negativism there is
abnormal suggestibility; it shows itself as:
i.
ii.

Echopraxia which is repetition of actions seen (e.g.

when the doctor walks the patient walks too).
Echolalia which is repetition of words heard (e.g.
when the doctor says to the patient: how are you? the
patient answers: how are you?).

Disturbance of behavior
B.
Qualitative
iii. Waxy
flexibility disturbance:
(Flexibilitas cerea) which is the
maintenance of imposed postures however abnormal
they may be (e.g. rising-the head of the patient from the
pillow, or the arm up). The absence of fatigue in such
cases is remarkable.
iv. Catalepsy (posturing) is sometimes used for any form
of sustained immobility.
v. Automatic movements or automatism occur in a
pathological sense, without the subject being aware of
their meaning and even without his being aware of their
happening at all. Automatism may be i) local e.g.
automatic writing or ii) general e.g. in fugue and

Disturbance of behavior
B. Qualitative disturbance:

8. Impulsive action or impulses: consist of sudden

outbursts of activity with little or no provocation, such as
attacking another person (bystander), or breaking a
window.
9. Aggression: means intention to inflect harm to the others
without their permission or even their trial to avoid this
harm, the aggression could be physical, verbal, or moral.
physical aggression like body injuring, verbal aggression
like obscene words, moral aggression like violation of
social or religious norms that cause harm or
embarrassment to others. The non physical aggression is
called hostility.

 Mood: Sustained and pervasive emotion that

colors the persons perception of the world.
The patient may report his feelings or the
psychiatrist ask how he or she feels.

Affect: The patient present emotional

responsiveness that is inferred from his facial
expression.

Disturbance of Affect
A) Quantitative disturbance:

1. Cheerfulness is used for happiness or

gladness. It is pathological when out of the
patient's actual circumstances.
2. Euphoria is a generalized feeling of well being
(not amounting to a definite affect of
gladness).
3. Exaltation means something in addition to
elation, an element of grandeur.
4. Ecstasy is a feeling of happiness, usually
with a mystical coloring.

Disturbance of Affect
A) Quantitative disturbance:

5. Depression is an emotional state characterized by

pervasive lack of interest, difficulty to be in
pleasure (anhedonia) and sadness not in accord
with the patient's actual circumstances.
6. Sadness: it is and emotional state occurs as a
reaction to loss of loved object, the object could
be a person; money or status. Sadness could be
a part of depressed mood when occurs without
cause.

Disturbance of Affect
A) Quantitative disturbance:

7. Anxiety: is an emotional state characterized by

anticipation of danger.
If the source of anticipation of unknown it is called
generalized anxiety,
if the anticipation is from potentially non dangerous
object or situation it is called phobia,
if the anticipation is from consequences of act or
situation it regarded as. Obsessive fear.
The anxious mood is that of fear accompanied with
restlessness.

Disturbance of Affect
A) Quantitative disturbance:

8. Apathy: is absence of affect, or loss of emotion,

or lack of feeling (there is loss of both emotional
expression and experience). Occurs in some
schizophrenics.
9. Indifference: is lack of objective emotional
response. (There is loss of emotional
expression, but emotional experience is
preserved). Occurs in schizophrenia. a type of
this called a belle indifference occurs in
hysteria when the patient feelings are not in
tune with the problem.happy in spite of his
disability

Disturbance of Affect
A)
Quantitative
disturbance:
10.Emotional
deterioration:
is a progressive failure
to show the normal emotional responses
(characterized by a childish, easily suggestible,
facile
state).
Occurs
in
disorganized
schizophrenias
11. Emotional instability or lability: is inability to
control the emotions and their expression. The
emotional change from one extreme to the
other with no obvious cause (e.g. Laughing and
weeping. it occurs in gross organic lesions of
the brain e.g. the pseudo bulbar syndrome.

Disturbance of Affect
A) Quantitative disturbance:

11. Morbid anger: is an unprovoked transient angry

outburst with violence. (In children and mentally
defectives, it is called 'tantrums'). Occurs in
schizophrenia and personality disorders

Disturbance of Affect
B) Qualitative disturbance:
i.

Incongruity
or
disharmony
of
affect:
inappropriateness of affect to thought content
(e.g. the patient feels happy while he believes
that he is going to be killed by his enemies).

ii. Ambivalence denotes the simultaneous

existence of contradictory emotions (e.g. Love
and hate), or ideas (e.g. being present and
absent at the same time, or present in two
places simultaneously e.g. in Sohar and
Salalah). It occurs in schizophrenia.

Disorders of Talk
A. Disorders of Stream
1- Slow stream: Slowing of the stream of talk
occurs in different psychiatric disorders
particularly in psychosis and the disturbance
shows different degrees:
a.
b.
c.
d.

Lack of spontaneous talk.

Delayed response to questions.
Short response to questions.
No response to questions Mutism.

Disorders of Talk
A. Disorders of Stream
2- Blocking is a sudden stoppage of the
stream of talk, for a while and then it is
resumed without the patient being able to
account for such stoppage. This could occur
in some normal individuals when surprised
and in some schizophrenics.
3- Rapid stream occurs mainly in mania and
some schizophrenics

Disorders of Talk
B. Disorders of Expression
a.Irrelevant answers to questions. When the patient is
asked a question he responded by answer not related
to that question.
b.Over inclusions: the patient talk is much abbreviated
and not giving the necessary details.
c. Derailment: the patient deviates in his talks to
subjects away from the main topic.
d.Circumstantiality: there are much unnecessary
details, but the subject in view at the beginning is
ultimately reached.

Disorders of Talk
C. Disorders of Association
i. Vagueness ( the paragraphs of the story
are not harmonious)
ii. Flights of ideas ( the sentences of the
paragraph are not harmonious)
iii. Incoherence ( the words of the sentence
are not harmonious)
iv. Neologism ( the letters of the word in the
word are not harmonious)

Disorders of Thinking
Stream
Expression
Content
Form
Possession.
The first and second is the same as those
.discussed under talk

Disorders of Thinking
Content (delusions)
Delusions: false, fixed beliefs which is not
accepted by individuals of the same social,
cultural or educational background and not
corrected by logic reasoning.
If the belief is false but is widely accepted by individuals of
the same culture and education it is called culture bound
belief, if it could be corrected by logic reasoning it is called
idea and not delusion.

Disorders of Thinking
Content (delusions)
Delusions may be
I.Systematized (well knit) when they form a
coherent system and appear to be logical, or
II.Non-Systematized when they are fleeting and
appear to have no logical connection

Disorders of Thinking
Content (delusions)

Types of delusions:
Delusion of grandeur: in which the patient imagines
that he is great individual, very rich, strong,
intelligent, etc.
Delusion of persecution in which the patient thinks
that he is chased (run after) by certain people, or his
food is poisoned by them.
Delusion of reference in which the patient believes
that everything in the environment is referring to him
(e.g. people talking in the street. newspapers, radio, television, etc. are
referring to him).

Disorders of Thinking
Content (delusions)
Delusion of influences (Passivity feeling) in which the
patient says that he is under the influence of electricity,
wireless, hypnotism or telepathy, utilized by some
other person. Such delusions include such diverse
ideas as a) that the patient's thoughts are being read
b) his limbs are moved without his control or consent
by some invisible agency.
Delusion of self reproach (self blame) or sin: in which
the patient feels that he is wicked, full of sins and unfit
to live or mix with other people (feeling of
unworthiness).

Disorders of Thinking
Content (delusions)
Delusion of poverty in which the patient believes that he
lost all his money, property and everything in life.
Nihilistic delusion in which the patient declare that he
does not exist (dead) and that there is no world.
Hypochondriacal delusion in, which the patient is
convinced that he has a physical disease (e.g. cancer
stomach) in, the absence of any evidence thereof.

Disorders of Thinking
Content (delusions)
Depersonalization: the patient feels that he is no longer
himself; he can no longer believe in his own existence.
When he looks in the mirror he feels himself changed
throughout in comparison with his former state. He feels
unreal, strange, lifeless, detached and automatic. (2)
Derealization: the patient feels that the outer world has
changed the people, streets and houses look different and
unusual. He wonders whether his friends are the same
people as they were, or whether indeed they exist at all.

Disorders of Thinking
Content (obsessions)
Obsessions
Feeling of compulsion to repeat physical or
mental act, the patient realizing that it is silly
and meaningless, resisting it and the
resistance is accompanied by increasing inner
tension which is relieved by repeating again.

The patient fights for his delusions and

resists his obsessions

Disorders of Perception
Hallucinations
Perception of non existed stimulus
Types
Visual
Auditory
Olfactory
Tactile
Gustatory

Disorders of Perception
Hallucinations
Normal (physiological)
Hypna-gogic
Hypna-bombic

Pathological
Primary psychiatric disorders
Schizophrenia
Rarely in depression, mania, paranoid disorder.

Organic mental disorders

Delirium, Drug dependence, TL epilepsy, Brain
tumors. Encephalitis

Disorders of Perception
Illusions
False perception of an external stimulus
Types:
Visual
Auditory
Olfactory
Tactile
Gustatory

Disorders of Perception
Illusions
Physiological:
Intense emotions, change of set, lack of perceptual
clarity

Pathological:
Primary mental disorders
Schizophrenia

Organic mental disorders

Delirium
Epilepsy
Brain tumors
Encephalitis

Disorders of Memory
Registration
Retention
Recall & Recognition
Any failure of one of these functions is
regarded as memory disorders

Disorders of Memory
Types of Amnesia
1. Anterograde amnesia when there is loss of
memory for recent events.
2. Retrograde amnesia when there is loss of
memory for remote events.
3. Total amnesia when there is loss of memory
for all events, recent and Remote.
4. Circumscribed amnesia when there is loss of
memory for a limited time (amnesic gap).

Disorders of Memory
Paramnesia (False Recall)
1. Confabulation: when the patient fills the gaps in his
memory by fabrication i.e. by giving imaginary accounts
of his activities (Thus a bed ridden patient will describe a
walk which he asserts he has just taken). It usually
occurs in organic diseases Korsakovs syndrome which is
typically seen in alcoholism).
2. Falsification (illusion of memory): when the patient adds
false details and meanings to a true memory. It occurs in
organic and psychiatric diseases (e.g. paranoid states).

Disorders of Memory
Hypermnesia
excessive memory,
the patient mentions even small unnecessary
details.
It is present in
1- some normal people (geniuses)
2- some mental disorders (hypomania
and paranoia).

Clinical exam of of Memory

Immediate recall:
(5-7 digits or home address immediately)

Short-term recall:
(5-7 digits or home address at 5 min)

Recent:
what patient did past several days

Recent past:
what patient did past few months, present President, recent
news events

Remote:
Childhood events, past Presidents, historical events (years)

Disorders of Memory
Clinical significance
Anxious patient may complain of poor
memory because of defective registration
In Korsakoffs syndrome there is failure of
retention so the patient has disturbed
immediate recall
In dementia the recall of recent events is
disturbed.

Orientation
Realization of:
Time
Place
Persons
Situation.

Disturbed in acute organic brain disorders.

Attention and Concentration

These terms are used for describing the
experience that certain objects are in the
center of consciousness, whilst others lie
more towards the periphery.

Attention may be disturbed in various

ways
difficult to arouse the attention of the patient.
a) states of disturbed consciousness (e.g. confusion)
b) selfabsorption due to depression or schizophrenia.

Difficult to maintain or keep the attention of the

patient due to distractibility.
Distractibility is a disorder of attention in which
the patient gives attention to every passing
stimulus

Types of Attention
Active (voluntary)
Passive (involuntary).
In organic disease: active attention is often
good, while passive attention is poor i.e. object
in the center of consciousness is observed,
while those towards the periphery are not.
In Psychogenic diseases (e.g. schizophrenia)
the patient does not pay attention to what the
doctor says to him and at the same time he pays
attention to what the nurses talk about.

Abstraction
Abstraction: is the patient's ability to
derive a general principle from a specific
example.
Abstract thinking is affected in psychosis
particularly schizophrenia and mental
retardation

Factors affecting Abstraction

level of education.
Culture
cerebral dysfunction. Abstraction
deficits are particularly common
with frontal lobe disorders.

Clinical Assessment of Abstraction

1- Similarities
Similarities require the patient to identify the class or category of
which two items are members (e.g., rose and tulip, bicycle and
train, watch and ruler).

2- Differences
Differences require the patient to identify the salient distinguishing
feature between two similar items (e.g., child and midget, canal and
river, lie and mistake)

3- Idioms
Idioms are metaphorical statements or aphorisms that require the
patient to generalize to a larger meaning (e.g., "seeing eye to eye,"
"level headed," and "eyes peeled")

4- Proverbs.
Proverbs are usually double metaphors that require the patient to
ignore the immediate meaning and derive a lesson or maxim (e.g.,
"don't cry over spilled milk," "people who live in glass houses
shouldn't throw stones," "the tongue is the enemy of the neck").

Intelligence
The ability to benefit from previous
experiences and to get maximum benefit
from available data
Intelligence is affected in mental retardation

Assessment of Intelligence
Clinical assessment
During interview
Mathematical problem
solving.
Proverb test
General information.

Psychometry
WAIS
WISC
SB

Insight & Judgment

Insight: is the degree of realization the
patient has of his own condition.
Judgment: is the ability to grasp the
meaning of a situation and hence react to
it appropriately.
Insight and judgment are disturbed in
psychotic conditions e.g. schizophrenia
and mania.