Psychiatry 2

Clinical Manifestations of Psychiatric Disorders

HYACINTH C. MANOOD, MD, FPPA |September 2018 | Topic IV
I. Negative and Positive signs  describes the stringing together of words that seem to have no
II. Disturbance in Flow and form of thinking logical association
III. Disturbance in thought Content
IV. Disturbance in Perception  Verbigeration
V.
VI.
Disturbance in the level of consciousness
Drug-induced movement disorder
 describes the disappearance of understandable speech, replaced
by strings of incoherent utterances
 Clang association
I. NEGATIVE AND POSITIVE SIGNS  refers to a sequence of thoughts stimulated by the sound of a
– Negative signs preceding word.(ex. “I'll kill with a drill or a pill—God, I'm ill—what
 Abulia - reduced impulse to act and to think, associated with swill.”)
indifference about consequences of action  Echolalia
 Alogia - inability to speak because of a mental deficiency or an  the patient repeats a sentence just uttered by the examiner.
episode of dementia.  Palilalia
 Apathy - dulled emotional tone associated with detachment or  Involuntary repetition of words. Patients repeat their own phrase
indifference or words
 Flat affect  Perseveration
– Positive signs  a sentence or phrase is repeated, sometimes several
 Hallucination times over, after it is no longer relevant.
 Delusion  commonly seen in delirium and other organic mental
 Thought Disorder disorders
 Stereotypy
Disturbance in Flow and Form of Thinking  refers to the constant repetition of a phrase or a behavior in many
different settings, irrespective of context.
– Slowed (retarded) thought
 Concrete thinking
 Typically, goal directed but characterized by little initiative
or planning  is a disturbance in the ability to form abstract concepts, generally
illustrated by literal mindedness and the inability to abstract the
 Expressed as slowness in decision making, long latency of
commonality of members of a group,
response, increase pause time when initiating and during
speech.
– Thought withdrawal Disturbance in Thought Content
 a disturbance in the control of thought in which the patient  Overvalued ideas
feels as if some alien force has intentionally withdrawn the  are unreasonable and sustained abnormal beliefs that are held
thoughts from consciousness
beyond the bounds of reason
 Thought blocking
 Ideas of reference
 the snapping off or as a sudden break in a train of thought, as
if a wall suddenly comes down, interrupting thinking (and  are false personalized interpretations of actual events in which
speaking) in midsentence. individuals believe that occurrences or remarks refer specifically
 Pressure of speech to them when in fact they do not.
 speech that is rapid, excessive, and typically loud—is  Delusions
characteristic of mania (or hypomania), stimulant intoxication,  are fixed, false beliefs, strongly held and immutable in the face of
and, occasionally, anxiety
refuting evidence, that are not consonant with the person's
 Flight of Ideas
educational, social, and cultural background.
 occurs when the flow of thought increases to the point at
which the train of thought switches direction frequently and  Systematized delusions are usually restricted or
rapidly circumscribed to well-delineated areas and are ordinarily
 Circumstantiality associated with a clear sensorium and absence of
 the flow of thought includes many digressive turns and hallucinations
associations, often including a great deal of unnecessary  Autochthonous delusion is one that takes form in an instant,
detail; eventually returns to the point that was initially without identifiable preceding events, as if full awareness
intended without having to be prompted by the listener.
suddenly bursts forth in an unexpected flash of insight like a
 Tangentiality
bolt from the blue
 the person's thought wanders further and further away from
the intended point, without ever returning, so that the person
may not even remember what the original point was Disturbance in Perception
supposed to be; milder form of derailment!
 Illusions - are misinterpretations of real sensory stimuli.
 Loose associations
 Pareidolia - playful and whimsical voluntary illusions that can
 exemplify more severe derailment, in which the flows of ideas
are no longer comprehensible to the listener because the be seen when one looks at ambiguously defined or
individual thoughts seem to have no logical relation to one evanescent images such as clouds or flames in a fireplace
another.  Trailing - is the perception that an object moving steadily in
 Word salad space is followed by temporally distinct, after-images of
itself; fatigue, marijuana and mescaline intoxication during

Transcribed by: Argee Asturiano Page 1 of 3

PSY202 Clinical Manifestations of Psychiatric Disorders T4
withdrawal from SSRIs, or, less commonly, in association which usually presents as a resting rhythmic oscillation (3 to 6
with nefazodone (Serzone). Hz) affecting the head, tongue, jaw, legs, and extremities in a
– Hallucinations- are perceptions that occur in the absence of unilateral or symmetrical fashion.
corresponding sensory stimuli  Patients who are elderly and female are at the highest risk for
1. Hypnagogic- occur during the moments neuroleptic-induced parkinsonism, although the disorder can
immediately preceding falling asleep occur at all ages.
2. Hypnopompic - during the transition from sleep to  Neuroleptic-induced parkinsonism is caused by the blockade
wakefulness of dopamine type 2 (D2) receptors in the caudate at the
 Phantom limb hallucinations -are common after termination of the nigrostriatal dopamine neurons.
Amputation, feeling pain in a body part that was no longer  All antipsychotics can cause the symptoms, especially
there. highpotency drugs with low levels of anticholinergic activity
 Charles Bonnet syndrome - complex hallucinations (i.e., visual (e.g.,trifluoperazine [Stelazine]). Chlorpromazine (Thorazine)
hallucinations with preserved insight) with preserved and thioridazine (Mellaril) are not likely to be involved
cognitive status; common is visually impaired – Treatment:
– Auditory hallucinations – most commonly seen in Schizophrenia  Parkinsonism can be treated with anticholinergic agents,
Three types: benztropine (Cogentin), amantadine (Symmetrel), or
1. audible thoughts described as hallucinated voices diphenhydramine (Benadryl)
that speak aloud what the patient is thinking  Anticholinergics should be withdrawn after 4 to 6 weeks to
2. voices that give a running commentary on the assess whether tolerance to the parkinsonian effects has
patient's actions developed; about half of patients with neuroleptic-induced
3. hearing two or more voices arguing with each parkinsonism require continued treatment.
other, often about the patient, who is referred to in  Even after the antipsychotics are withdrawn, parkinsonian
the third person symptoms can last up to 2 weeks and even up to 3 months
– Ictal hallucinations - simple images, such as flashes of light, or in elderly patients. With such patients, the clinician may
elaborate ones, such as visual recollections of past experiences continue the anticholinergic drug after the antipsychotic has
– Flashback - is an intense visual re-experience of highly charged been stopped until the parkinsonian symptoms resolve
past events, which are often replays of hallucinations. completely
– Formication - tactile hallucination involving the sensation that tiny – Acute Dystonia
insects are crawling over the skin. Seen in cocaine addiction and  abnormal positioning of the head and neck (e.g.,torticollis);
delirium tremens. spasm of jaw muscles (e.g., trismus); impaired swallowing,
– Agnosia -, lack of awareness of some parts of the body, may speaking, or breathing; thickened or slurred speech; tongue
accompany brain damage, most often of the non-dominant protrusion or dysfunction; deviated eyes in any direction
parietal lobe (e.g., oculogyric crisis); and abnormal positioning of limbs or
– Dysmorphophobia refers to conditions in which patients trunk (e.g.,opisthotonos).
distortedly perceive and intensely dislike the shape of a particular  early onset during the course of treatment with
body part neuroleptics
 high incidence in men, in patients younger than age 30
Disturbance in the Level of Consciousness years, and in patients given high dosages of high-potency
– Hypervigilance - Excessive attention to, and focus on, all internal medications.
and external stimuli; usually seen in delusional or paranoid states.  dystonia can occur with any antipsychotic; common in IM
– Clouding of consciousness - is marked by diminished meds.
awareness of sensory cues and diminished attentiveness to  mechanism of action - dopaminergic hyperactivity in the
the environment and to the self basal ganglia that occurs when central nervous system
– Torpor - condition in which the patient is drowsy, falls asleep (CNS) levels of the antipsychotic drug begin to fall between
easily, and shows a narrowed range of perception and slowed doses.
thinking  can fluctuate spontaneously and respond to reassurance, so
– Stupor - state of diminished consciousness in which the that the clinician acquires the false impression that the
patient remains mute and still, although the eyes are open and movement is hysterical or completely under conscious
may follow external objects control
 Prophylaxis with anticholinergics or related drugs usually
Drug-Induced Movement Disorder prevents dystonia, although the risks of prophylactic
– Neuroleptic-Induced Parkinsonism treatment weigh against that benefit.
 rigidity, which can be continuous (“lead pipe”) or  Treatment with intramuscular anticholinergics or
cogwheeling (a discontinuous, ratchet-like muscle motion); intravenous or intramuscular diphenhydramine (50 mg)
bradykinesia, which is characterized by a minimization of almost always relieves the symptoms.
spontaneous motor activity, slowed speech, decreased arm  Diazepam (Valium) (10 mg intravenously), amobarbital
movements during walking, and masked facies; and tremor, (Amytal), caffeine sodium benzoate, and hypnosis have also
been reported to be effective.

Transcribed by: Argee Asturiano Page 2 of 3

PSY202 Clinical Manifestations of Psychiatric Disorders T4

 Although tolerance for the adverse effects usually develops, reported. Dyskinesia is exacerbated by stress and
it is sometimes prudent to change the antipsychotic if the disappears during sleep.
patient is particularly concerned that the reaction may  Women are more likely to be affected than men. Children,
recur. patients who are more than 50 years of age, and patients
with brain damage or mood disorders are also at high risk.
 Clozapine is the only antipsychotic to have minimal risk of
tardive dyskinesia, and can even help improve preexisting
symptoms of tardive dyskinesia. This has been attributed to
its low affinity for D2 receptors and high affinity for 5-
hydroxytryptamine (5HT) receptors.
 reducing the dose of the antipsychotic or even stop the
medication altogether
 may switch the patient to clozapine or to one of the new
– Akathisia SDAs lithium, carbamazepine (Tegretol), or
 inner sense of restlessness and at least one of the following benzodiazepines may effectively reduce the symptoms of
objective, observable movements:Fidgeting or swinging of both the movement disorder and the psychosis.
the legs, rocking from foot to foot while standing, pacing,
lifting the feet as if marching in place, crossing and
uncrossing the legs when sitting, or the inability to sit or
stand in one place for several minutes.
 Middle-aged women are at increased risk of akathisia, and
the time course is similar to that for neuroleptic-induced
parkinsonism.
 Three basic steps in the treatment of akathisia:
1. Reducing medication dosage
2. Attempting treatment with appropriate drugs
3. Considering changing the neuroleptic.
 although anticholinergic drugs, benzodiazepines, and REFERENCES
cyproheptadine (Periactin) may benefit some patients. In
1. lecturers ppt.
some cases of akathisia, no treatment seems to be effective.
– Tardive Dyskinesia

 involuntary movements of the tongue (e.g., twisting,

protrusion), jaw (e.g., chewing), lips (e.g., smacking,
puckering), trunk, or extremities. Patterns of movements
may include rapid, jerky and nonrepetitive movements
(i.e.,choreiform); slow, continuous and sinuous movements
(i.e., athetoid); or rhythmic movements.
 a delayed effect of antipsychotic
 it rarely occurs until after 6 months of treatment
 Perioral movements are the most common and include
darting, twisting, and protruding movements of the tongue;
chewing and lateral jaw movements; lip puckering; and
facial grimacing.
 In the most serious cases, patients may have breathing and
swallowing irregularities that result in aerophagia, belching,
and grunting. Respiratory dyskinesia has also been

Transcribed by: Argee Asturiano Page 3 of 3