02_Semple_Chap02.indd 74 12/7/2012 7:03:23 PM PHYSICAL EXAMINATION 75 Physical examination Examination of the patient \200\231s physical condition is an integral part of a com- prehensive psychiatric assessment. There are \201 ve main reasons why thi s is so: \200 Physical symptoms may be a direct result of psychiatric illness (e.g. alcohol dependency \200\224see b p. 574; eating disorders \200\224see b p. 402; physical neglect in severe dep ression, schizophrenia, etc.). Psychiatric drugs may have physical side-effects (e.g. extra -pyramidal side-effects [EPSEs] and antipsychotics, hypothyroidism and lithium, withdrawal syndromes). Physical illnesses can cause or exacerbate mental symptoms. Occult physical ill ness may be present. In the case of later development of illness (or more rarely, medico- l egal issues) it is helpful to have baseline physical \201 ndings documented. \200 \200 Physical examination is all too often deferred and then not done, or not done as thoroughly as is indicated. It may well be acceptable to defer full examination on occasions (e.g. a distressed and paranoid man seen in A&E), but a minimal investigation can be done and compl eted as the situation allows. A routine physical examination has the aim of documenting the patient \200\231s baseline ph ysical state, noting the presence or absence of abnormal signs which could be associated wi th mental or physical illness, and highlighting areas requiring further examination or inve stigation. General condition Note height and weight. Does the patient look well or unwell? Are they un derweight or are there signs of recent weight loss? Note bruising or other injuries and est imate their age. Cardiovascular Radial pulse \200\224rate, rhythm, and character. Blood pres- sure. Carotid bruits? Heart sounds. Pedal oedema. Respiratory Respiratory rate. Expansion. Percussion note. Breath sounds to auscultation. Abdominal Swelling or ascites. Masses. Bowel sounds. Hernias. Neurological Pupillary response and other cranial nerves. Wasting. Tone. Power. Sensation. Re \202 exes. Gait. Involuntary movements. 02_Semple_Chap02.indd 75 12/7/2012 7:03:23 PM CHAPTER 2 Psychiatric assessment 76 Some physical signs in psychiatric illness, and possible causes (Table 2.1) General examina tion Table 2.1 Some physical signs in psychiatric illness, and possible causes. Parkinsonian facies Antipsychotic drug treatment Psychomotor retardation (depression) Opiate use Neurosyphilis Bulimia nervosa (secondary to vomiting) Clozapine treatment Thyroid disease Borderline pers onality disorder Dissocial personality disorder IV drug use Antipsychotic drug treatment Al coholic liver disease Bulimia nervosa (secondary to inducing vomiting) Anorexia nervosa Opi ate withdrawal Anorexia nervosa Abnormal pupil size Argyll \200\223Robertson pupil Enlarged parotids ( \200\230hamster face \200\231) Hypersalivation Goiter Multiple forearm scars Multiple tattoos Needle tracks/phl ebitis Gynaecomastia Russell \200\231s sign (knuckle callus) Lanugo hair Piloerection ( \200\230goose \202 esh \200\231) Excessive thinness Cardiovascular Rapid/irregular pulse Anxiety disorder Drug/alcohol withdrawal Hyperthyroidism Hypothyroidism Slow pulse Abdominal Enlarged liver Alcoholic liver disease Hepatitis Somatization disorder Multiple surgical scars ( \200\230checkerboard \200\231 abdomen) Multiple self-in \202 ict ed scars Borderline personality disorder Neurological Resting tremor Increased sympathetic drive (anxiety, drug/ alcohol misuse) Antipsychotic drug treatment Li thium treatment Antipsychotic drug treatment Tic disorder Huntingtons \200\231s/Sydenham \200\231s chorea Antipsychotic-induced dystonia Catatonia Antipsychotic drug treatment Cere bellar disease (alcohol, lithium toxicity) Involuntary movements Abnormal posturing Festinant (shuf \202 ing) gait Broad-based gait 02_Semple_Chap02.indd 76 12/7/2012 7:03:23 PM This page intentionally left blank CHAPTER 2 Psychiatric assessment 78 Clinical investigation Clinical investigations, including blood testing, imaging techniques , and karyotyping, play a smaller role in psychiatry than in other medical special- ties. T hey are mainly carried out to exclude medical conditions which may be part of the different ial diagnosis (such as hypothyroidism as a cause of lethargy and low mood) or which may be comorbid. They should gener- ally be carried out as a result of positive \201 ndings in t he history or physical examination or in order to exclude serious and reversible occult dis orders (such as syphilis as a cause of dementia). Routine investigations may be carried out to assess general physical health, and to provide a baseline measure prior to commencing medica- tion known to have possible adverse effects , for example full blood count (FBC), liver function tests (LFTs) and antipsychotic medicat ion; urea and electrolytes (U&Es), creatinine clearance, thyroid function tests (TFTs) prio r to lithium therapy). Speci \201 c screening and monitoring tests are detailed in speci \201 c sections. It is good practice to screen new patients with some standard tests, and t he usual test battery will include: FBC (and differential), U&Es, LFTs, TFTs, glucose. Wher e there is suspicion of drug or alcohol misuse/dependency, mean cell volume (MCV), B12/fola te, and toxicology screening may be added. Other physical investigations are rarely requested (with perhaps the exception of ECG for p atients on speci \201 c or high-dose antipsychot- ics) unless clinical examination indicat es the possibility of an underlying ( undiagnosed) physical disorder. Performance of a lumb ar puncture, for example, is reserved for situations where there is clear evidence to sug- gest a neurological disorder presenting with psychiatric symptoms (e.g. sus- pected meningi tis or encephalitis; multiple sclerosis) and, more often than not, in these circumstances a referral will be made for a medical review. Use of other tools, such as EEG, CT, or MRI (and SPECT or PET where available) requires jus ti \201 cation on the grounds of diagnostic need. EEG is frequently overused by psychiatri sts, and may be dif \201 cult to interpret as psychotropic medications may \200\230muddy the waters \200\231. EEG may be useful where epilepsy is suspected (on clinical grounds), t o monitor some acute (toxic) confusional states, to assess atypical patterns of cognitive i mpair- ment, to aid diagnosis in certain dementias (e.g. HIV, variant Creutzfeldt \200\223 Jakob disease [vCJD]), to evaluate particular sleep disorders, or as the gold standard for seizure monitoring during ECT. EEG should not be used as a general screening tool. Similarly, brain imaging adds little to the diagnosis of primary psychiatric disorders, and should only be used where there is good evidence for pos- sible neurological problems (e.g . history of signi \201 cant head injury, epilepsy, multiple sclerosis, previous neurosurg ery) or where history and clinical examination indicate the possibility of a space-occupyin g lesion (e.g. local- izing neurological signs, unexplained \202 uctuating level of consc iousness, severe headache, marked and unexplained acute behavioral change). With the except ion of organic disorders (e.g. the dementias \200\224where diag- nostic imaging techniques may add useful information to inform diagnosis, 02_Semple_Chap02.indd 78 12/7/2012 7:03:24 PM CLINICAL INVESTIGATION 79 management, and prognosis), the sensitivity and speci \201 city of imaging \201 nd- ings for most psychiatric conditions have yet to be established. As a general rule comorbid or causative disorders will be suspected due to other symptoms a nd signs or by the atypical nature of the psychiatric picture, and the likelihood of reveal ing a totally unexpected diagnosis is small. 02_Semple_Chap02.indd 79 12/7/2012 7:03:24 PM CHAPTER 2 Psychiatric assessment 80 Common assessment instruments 1 The diagnosis of psychiatric disorders is largely clinical, although assess- ment tools are increasingly used for both clinical and research purposes. A huge variety of assessment tools is available for the diagnosis and assess- ment of seve rity of individual disorders, and for the monitoring of progress and treatment response in established cases. Their primary use is as an aid in diagnosis and to provide an objective measurement of trea tment response. They should not be considered as a primary means of diagnosis. A secondary use is in research, in order to ensure heterogeneous patient groupings and reliably standar dized diagnosis. Scales are often available in several versions, are either clinician- or patient-administer ed and vary in required skill and experience of the administrator. Some are available for f ree by searching on the Internet, while others are copyrighted and are available from purch ase from the manufacturer. Examples of the more commonly found general and speci \201 c te sts are given here. General General Health Questionnaire (GHQ) Self-rated questionnaire used as screening instr ument for presence of psychiatric illness. Patient is asked to report the presence of a lis t of symptoms in the preceding weeks. Four versions are available using 12, 28, 30, and 60 items. Diagnostic Interview Schedule (DIS) Can be used by non-clinicians to administer a fully str uctured interview to diagnose the major psychiatric illnesses for research purposes. Global Assessment of Functioning Scale (GAF) 100-item, self-report rating scale measuring o verall psychosocial functioning. Minnesota Multiphasic Personality Inventory (MMPI) Self-report ques- tionnaire consisting o f 567 questions covering 8 areas of psychopathology, 2 additional areas of personality type , and 3 scales assessing truthfulness. Results are compared with normative data from non-cl inical popula- tions. Results generate information useful for a broad range of clinical app lications. Primary Care Evaluation of Mental Disorders (PRIME-MD) One-page patient-completed questionn aire focusing on psychiatric illness commonly encountered in primary care. Has a correspond ing Clinician Evaluation Guide. Quality of Life Interview (QOLI) Non-clinician-administered fully struc- tured interview av ailable in full and brief versions with 158 and 78 items respectively. Suitable for assessm ent of quality of life in those with endur- ing and severe mental illnesses. Structured Clinical Interview for DSM-IV (SCID-I/SCID-II) Clinician- administered semi-stru ctured clinical interview for use with patients in whom a psychiatric diagnosis is suspecte d. Primarily used in research with 02_Semple_Chap02.indd 80 12/7/2012 7:03:24 PM COMMON ASSESSMENT INSTRUMENTS 1 81 trained interviewers to inform the operationalized diagnosis of Axis I and II disorders. Mood disorders Beck Depression Inventory (BDI) Self-rated questionnaire containing 21 state ments with four possible responses for each. Total score is quoted with >17 indicating mode rate and >30 indicating severe depression. Hospital Anxiety and Depression Scale (HADS) 14-item, self-rated ques- tionnaire, producing an anxiety and a depression subscore. Hamilton Rating Scale for Depression (HAM-D) Interviewer-rated, 17-item rating scale for de pressive illness. Not a diagnostic instrument; used to measure changes (e.g. as a result of drug treatment), 17 items scored according to severity, producing total score. Montgomery-Asberg Depression Rating Scale (MADRaS) 10-item observ- er-rated scale. Each ite m rated 0 \200\2236 with total score obtained. Mood Disorders Questionnaire (MDQ) Self-rated screen for bipolar disor- der. 13 yes/no ques tions, and two others. Positive screen is \200\230yes \200\231 7/13, and \200\230yes \200 \231 to question 2, moderate/serious to question 3. Young Mania Rating Scale (YMRS) Assesses mania symptoms and weighted severity over the past 48 hr. Anxiety spectrum Hamilton Anxiety Rating scale (HAM-A) Clinician-administered rating scale for generalized anxiety disorder. 14 items rated on a 5-point scale. Yale \200\223Brown Obsessive \200\223Compulsive Scale (Y \200\223BOCS) Clinician-administer ed semi-structured interview allowing rating of severity in patients with a pre- existing d iagnosis of OCD. Schizophrenia Brief Psychiatric Rating Scale (BPRS) Measures major psychotic and non- psych otic symptoms, primarily used for schizophrenia patients. Clinician rated based on observat ion. Positive and Negative Symptom Scale (PANSS) Clinician-administered rat- ing scale for asses sment of severity and monitoring of change of symptoms in patients with a diagnosis of schi zophrenia. Items covering positive symp- toms, negative symptoms, and general psychopatholo gy. Scale for the Assessment of Positive/Negative Symptoms (SAPS/SANS) Administered together, a nd completed from history and clinician observa- tion. It breaks down into three divisions: psychoticism, negative symptoms and disorganization. Abnormal Involuntary Movement Scale ( AIMS) Clinician-administered scale for assessing the severity of anti-psychotic side-effect s. 12 items rated 0 \200\2234. 02_Semple_Chap02.indd 81 12/7/2012 7:03:24 PM CHAPTER 2 Psychiatric assessment 82 Common assessment instruments 2 Substance use Cut down? Annoyed? Guilty? Eye opener? (CAGE) Brief screening test for alcoho l problems consisting of 4 yes/no questions, a score of 2 or more indicating the need for f urther assessment. Alcohol Use Disorders Identi \201 cation Test (AUDIT) Completed by skilled clinician to re veal if there is a need for further evaluation. Questions cover quantity and frequency of a lcohol use, drinking behaviors, adverse psy- chological symptoms, and alcohol-related probl ems. Assessment instruments speci \201 c to children ADHD (SNAP, Vanderbilt, Conners \200\231 R ating Scale) Used to assess pres- ence and severity of ADHD symptoms in multiple settings. Completed by adults who know the child well (parents, teachers). Also have subscales to mea sure other symptoms, such as disruptive behavior. Anxiety Screen for Child Anxiety-Related Emotional Disorders (SCARED) A self-report instrum ent designed to measure anxiety symptoms in children. Autism Spectrum Childhood Autism Rating Scale (CARS) Ages 2 and up, scored by clinicians ba sed on observation. Gilliam Autism Rating Scale (GARS) Ages 3 to 22, scored by teachers and parents as well as clini- cians. Autism Diagnostic Observation Schedule (ADOS) A semi-stru ctured and lengthy diagnostic interview given by specially trained clinicians. It uses stan dardized data to aid in diagnosis of pervasive developmental disorders. Children \200\231s Depression Inventory (CDI) Self-report of depression symp- toms for ages 7 to 17 ( \201 rst-grade reading level). Structured interviews such as KSADS-PL are semi- structured diagnostic interviews covering the spectrum of psychiatric illness in children, admin- istered by trained clinicians only. Older adults Geriatric Depression Scale (GDS) Self-reported screen for depression using a s eries of yes/no questions. Instrumental Activities of Daily Living (IADL) Used to evaluate the day-to- day living skil ls in an older population. It can be used to evaluate treatment effectiveness or help ident ify placement needs of the individual. Recommended further reading Sajatovic M, Ramirez L, Ramirez LF (2003) Rating scales in ment al health, 2nd edn. Hudson: Lexi Comp. 02_Semple_Chap02.indd 82 12/7/2012 7:03:24 PM 83 Chapter 3 Symptoms of psychiatric illness Symptoms of psychiatric illness 84 Dictionary of psychiatric symptoms 86 03_Semple_Chap03.indd 83 12/7/2012 6:56:48 PM CHAPTER 3 Symptoms of psychiatric illness 84 Symptoms of psychiatric illness In general medicine, symptom refers to an abnormality repor ted by the patient, while sign refers to an abnormality detected by the doctor by observati on or clinical examination. In psychiatry, the terms symptom and sign tend to be used synon ymously because abnormalities of mental state can only be elicited by exploring, with the p atient, their internal experiences. Psychopathology is the study of abnormalities in mental state and is one of the core scienc es in clinical psychiatry. Descriptive psychopathology is one method for describing the sub jective experience and behavior of patients and is the basis for our current clinical descr iptions of mental disorder. It is atheoretical, and does not rest on any particular explana - tion for the cause of the abnormal mental state. In this it contrasts with dynamic (Freud ian) psychopathology which attempts to describe and then to explain these states. Descriptive psychopathology includes close observation of the patient \200\231s behavior an d empathic exploration of their subjective experience. The latter is called phenomenology. The following general terms are used as quali \201 ers for symptoms described in the follo wing pages: \200 Subjective vs. objective external observer; subjective signs are those reported by the pati ent. Form vs. content of abnormal internal experiences. For example, a patient may believe that he is continually under surveillance by agents of MI5 who are plotting to frame him fo r another \200\231s crimes. Here, the content of the symptom is the belief about the name a nd methods of the persecutor; the form is that of a persecutory delusion. Content is cultur e- and experience-related, whereas form is attributable to the type of underlying mental il lness. Primary vs. secondary directly from the pathology of the mental illness; secondary s ymptoms arise as an understandable response to some aspect of the disordered mental state ( e.g. a patient with severe depression developing a secondary delusion of being wicked and d eserving punishment). Secondary symptoms can be understood in the light of knowledge of the patient \200\231s symptoms; primary symptoms can be empathized with but not fully understo od. Endogenous vs. reactive redundant by developments in understanding of mental disorders, but are still seen occasionally. It was formerly thought that some conditions arose in res ponse to external events (e.g. depression arising after job loss) (reactive), while others arose spontaneously from within (endogenous). Psychotic vs. neurotic In present classi \201 cations these terms are used purely descriptively to describe two common types of symp toms that may occur in a variety of mental disorders. Previously, they were used to disting uish those disorders characterized by impairment of insight, abnormal beliefs, and abnormal perceptual experiences from those where there was preserved insight but abnormal affect. Objective signs are those noted by an A distinction is drawn between the form and content Primary symptoms are considered as arising These terms have been largely made 03_Semple_Chap03.indd 84 12/7/2012 6:56:49 PM SYMPTOMS OF PSYCHIATRIC ILLNESS 85 Congruent vs. incongruent the apparent appropriateness of a patient \200\231s affect toward s their symptoms or their symptoms to their mood. A patient with apparent cheerfulness desp ite persecutory beliefs is described as having incongruent affect; a patient with profoundl y depressed mood developing a delusion that they were mortally ill is described as possessi ng a mood-congruent delusion. Structural vs. functional those brain disorders with observab le structural abnormalities on post-mortem (e.g. Alzheimer \200\231s disease) and those wit hout (e.g. schizophrenia). This usage has diminished since the discovery of de \201 nite o bservable brain changes in those disorders formerly called functional psychoses. Nowadays, the term is more often used in neurology/neuropsychiatry to distinguish syndromes which gen erally have abnormal investigation \201 ndings (e.g. multiple sclerosis) from those witho ut (e.g. conversion paralysis). This is an observation made regarding A distinction formerly made between 03_Semple_Chap03.indd 85 12/7/2012 6:56:49 PM CHAPTER 3 Symptoms of psychiatric illness 86 Dictionary of psychiatric symptoms Abnormal beliefs A category of disturbance which includes delusions and overvalued ideas. Abnormal perceptions A category of disturbance which includes sen- sory distortions and fal se perceptions. Acute confusional state See Delirium. Affect The emotional state prevailing in a patient at a particular moment and in response t o a particular event or situation. Contrasted with mood which is the prevailing emotional s tate over a longer period of time. Affect illusion See Illusion. Agitated depression A combination of depressed mood and psycho- motor agitation, contrastin g with the more usual association of depressed mood with psychomotor retardation. A common presentation of depres- sive illness in the elderly. Agitation See Psychomotor agitation Agoraphobia A generalized phobia in which there is fear of open spaces, social situations, crowds, etc. Associated with avoidance of these stimuli. Akathisia A subjective sense of uncomfortable desire to move, relieved by repeated movement of the affected part (usually the legs). A side-effect of treatment with neuroleptic drugs . Alexithymia The inability to describe one \200\231s subjective emotional experi- ences verb ally. May be a personality characteristic but is also associated with somatization. Alogia Poverty of thoughts as observed by absence of spontaneous speech. A negative symptom of schizophrenia and a symptom of depres- sive illness. Ambitendency A motor symptom of schizophrenia in which there is an alternating mixture of a utomatic obedience and negativism. Amnesia Loss of the ability to recall memories for a period of time. May be global (complet e memory loss for the time period), or partial (patchy memory loss with \200\230islands \200\231 of preserved memory). Anergia The subjective feeling of lack of energy and sense of increased effort required to carry out tasks. Associated with depressive illness. Anhedonia The feeling of absent or signi \201 cantly diminished enjoyment of previously pl easurable activities. A core symptom of depressive illness, also a negative symptom of schi zophrenia. Anorexia Loss of appetite for food. Seen in depressive illness and many general medical con ditions. Interestingly, patients with anorexia nervosa often do not have anorexia as so de \201 ned. They commonly describe them- selves as very hungry \200\224controlling their des ire for food by supreme effort in order to control their weight. 03_Semple_Chap03.indd 86 12/7/2012 6:56:49 PM DICTIONARY OF PSYCHIATRIC SYMPTOMS 87 Anterograde amnesia The period of amnesia between an event (e.g. head injury) and the resum ption of continuous memory. The length of anterograde amnesia is correlated with the extent of brain injury. Anxiety A normal and adaptive response to stress and danger which is pathological if prolon ged, severe, or out of keeping with the real threat of the external situation. Anxiety has two components: psychic anxiety, which is an affect characterized by increased arousal, app rehension, sense of vulnerability, and dysphoria; and somatic anxiety, in which there are b odily sensations of palpitations, sweating, dyspnoea, pallor, and abdomi- nal discomfort. Aphonia Loss of the ability to vocalize. May occur with structural disease affecting the vo cal cords directly, the 9th cranial nerve, or higher centers. May also occur in functional illness where the underlying vocal cord function is normal. This can be demonstrated by ask ing the patient to cough \200\224a nor- mal cough demonstrates the ability of the vocal cor ds to oppose normally. Asyndesis Synonym for loosening of associations. Ataxia Loss of coordination of voluntary movement. Seen in drug and alcohol intoxication an d organic disorders, particularly cerebellar. Athetosis Sinuous, writhing involuntary movements. Aura Episode of disturbed sensation occurring before an epileptic event. Wide range of mani festations although usually stereotyped for each individual. Autistic thinking An abnormal absorption with the self, distinguished by interpersonal comm unication dif \201 culties, a short attention span, and inability to relate to others as p eople. Autochthonous delusion A primary delusion which appears to arise fully formed in the patien t \200\231s mind without explanation (e.g. a patient sud- denly becomes aware that he has i nherited a large estate in the Scottish Highlands and will thus have the funds to settle sc ores with all those who have ever wronged him). Automatic obedience A motor symptom of schizophrenia in which the patient obeys the examine r \200\231s instructions unquestioningly. This coop- eration may be \200\230excessive \200 \231, with the patient going beyond what is asked (e.g. raising both arms and both legs whe n asked to raise an arm). Automatism Behavior which is apparently conscious in nature which occurs in the absence of full consciousness (e.g. during a temporal lobe seizure). Autoscopy The experience of seeing a visual hallucination or pseudo- hallucination of onese lf. Also known as \200\230phantom mirror image \200\231. Uncommon symptom reported in schi zophrenia and in temporal lobe epilepsy. Autotopagnosia Condition where one cannot identify or describe their own body parts. Indivi duals can dress and move appropriately, but cannot talk about their bodies. 03_Semple_Chap03.indd 87 12/7/2012 6:56:49 PM CHAPTER 3 Symptoms of psychiatric illness 88 Avoidance The action of not exposing oneself to situations which gener- ate anxiety, for ex ample a patient with agoraphobia remaining at home or a patient with post-traumatic stress disorder (PTSD) following a road traf \201 c accident (RTA) refusing to drive. Can be unde rstood in terms of an operant conditioning model where actions with reward \200\224in this case reduction of anxiety \200\224are repeated. Belle indifference A surprising lack of concern for, or denial of, appar- ently severe func tional disability. It is part of classical descriptions of hysteria and continues to be ass ociated with operational descriptions of conversion disorder. It is also seen in medical il lnesses (e.g. cerebrovascular accident [CVA]) and is a rare and non-speci \201 c symptom o f no diagnostic value. Biological features of depression Symptoms of moderate to severe depressive illness which r e \202 ect disturbance of core vegetative function. They are depressive sleep disturbance, anorexia, loss of libido, anergia, and subjective impression of deterioration in memory an d concentration. Blunting of affect Loss of the normal degree of emotional sensitivity and sense of the appr opriate emotional response to events. A negative symptom of schizophrenia. Broca \200\231s dysphasia A type of expressive dysphasia due to damage to the posterior par t of the inferior frontal gyrus of the dominant hemisphere (Broca \200\231s language area). Bulimia Increased appetite and desire for food and/or excessive, impul- sive eating of larg e quantities of usually high-calorie food. Core symptom of bulimia nervosa and may also be seen in mania and in some types of learning disability. Capgras syndrome A type of delusional misidenti \201 cation in which the patient believes that a person known to them has been replaced by a \200\230double \200\231 who is to all e xternal appearances identical, but is not the \200\230real person \200\231. Catalepsy A rare motor symptom of schizophrenia. Describes a situa- tion in which the patie nt \200\231s limbs can be passively moved to any posture which will then be held for a prol onged period of time. Also known as waxy \202 exibility or \202 exibilitas cerea. See a lso Psychological pillow. Cataplexy Symptom of narcolepsy in which there is sudden loss of mus- cle tone leading to c ollapse. Usually occurs following emotional stress. Catastrophic reaction Response occasionally seen in patients with dementia who are asked to perform tasks beyond their, now impaired, performance level. There is sudden agitation, an ger, and occasionally violence. Catatonia Increased resting muscle tone which is not present on active or passive movement (in contrast to the rigidity associated with Parkinson \200\231s disease and extra-pyramida l side-effects). A motor symptom of schizophrenia. Chorea Sudden and involuntary movement of several muscle groups with the resultant action a ppearing like part of a voluntary movement. 03_Semple_Chap03.indd 88 12/7/2012 6:56:49 PM DICTIONARY OF PSYCHIATRIC SYMPTOMS 89 Circumstantial thinking A disorder of the form of thought where irrelevant details and digr essions overwhelm the direction of the thought process. This abnormality may be re \202 ec ted in the resultant speech. It is seen in mania and in anankastic personality disorder. Clang association An abnormality of speech where the connection between words is their soun d rather than their meaning. May occur dur- ing manic \202 ight of ideas. Clouding of consciousness Conscious level between full consciousness and coma. Covers a ran ge of increasingly severe loss of function with drowsiness and impairment of concentration and perception. Command hallucination An auditory hallucination of a commanding voice, instructing the pati ent towards a particular action. Also known as teleological hallucination. Completion illus ion See Illusion. Compulsion A behavior or action which is recognized by the patient as unn ecessary and purposeless but which he cannot resist performing repeatedly (e.g. hand washin g). The drive to perform the action is recog- nized by the patient as his own (i.e. there i s no sense of \200\230possession \200\231 or passivity) but it is associated with a subjec tive sense of need to perform the act, often in order to avoid the occurrence of an adverse event. The patient may resist carrying out the action for a time at the expense of mountin g anxiety. Concrete thinking The loss of the ability to understand abstract con- cepts and metaphorica l ideas leading to a strictly literal form of speech and inability to comprehend allusive l anguage. Seen in schizophrenia and in dementing illnesses. Confabulation The process of describing plausibly false memories for a period for which the patient has amnesia. Occurs in Korsakoff psychosis, dementia, and following alcoholic pali mpsest. Confusion The core symptom of delirium or acute confusional state. There is disorientation, clouding of consciousness and deterioration in the ability to think rationally, lay down n ew memories, and to understand sensory input. Conversion The development of features suggestive of physical illness but which are attribu ted to psychiatric illness or emotional disturbance rather than organic pathology. Original ly described in terms of psycho- analytic theory where the presumed mechanism was the \200 \230conversion \200\231 of unconscious distress to physical symptoms rather than allowing i ts expres- sion in conscious thought. Coprolalia A \200\230forced \200\231 vocalization of obscene words or phrases. The symptom is largely involuntary but can be resisted for a time, at the expense of mounting anxiety. Seen in Gilles de la Tourette \200\231s syndrome. Cotard syndrome A presentation of psychotic depressive illness seen particularly in elderly people. There is a combination of severely depressed mood with nihilistic delusions and/or hypochondriacal delusions. The 03_Semple_Chap03.indd 89 12/7/2012 6:56:49 PM CHAPTER 3 Symptoms of psychiatric illness 90 patient may state that he is already dead and should be buried, that his insides have stopp ed working and are rotting away, or that he has stopped existing altogether. Couvade syndrome A conversion symptom seen in partners of expect- ant mothers during their pregnancy. The symptoms vary but mimic preg- nancy symptoms and so include nausea, vomiting , abdominal pain, and food cravings. It is not delusional in nature; the affected individua l does not believe they are pregnant (cf. pseudocyesis). This behavior is a cultural norm i n some societies. Craving A subjective sense of need to consume a particular substance (e.g. drugs or alcohol ) for which there may be dependence. Cyclothymia A personality characteristic in which there is cyclical mood variation to a les ser degree than in bipolar disorder. De Cl rambault syndrome A form of delusion of love. The patient, usually female, believes that another, higher-status individual is in love with them. There may be an additional per secutory delusional compo- nent where the affected individual comes to believe that individ uals are conspiring to keep them apart. The object may be an employer or doctor, or in some cases a prominent public \201 gure or celebrity. D j vu A sense that events being experienced for the \201 rst time have been experienc ed before. An everyday experience but also a non- speci \201 c symptom of a number of diso rders including temporal lobe epi- lepsy, schizophrenia, and anxiety disorders. Delirium A clinical syndrome of confusion, variable degree of clouding of consciousness, vi sual illusions, and/or visual hallucinations, lability of affect, and disorientation. The c linical features can vary markedly in severity hour by hour. Delirium is a stereotyped resp onse by the brain to a variety of insults and is similar in presentation whatever the prima ry cause. Delirium tremens The clinical picture of acute confusional state sec- ondary to alcohol wit hdrawal. Comprises confusion, withdrawals, visual hallucinations, and, occasionally, persec utory delusions and Lilliputian hallucinations. Delusion An abnormal belief which is held with absolute subjective certainty, which require s no external proof, which may be held in the face of contradic- tory evidence, and which h as personal signi \201 cance and importance to the individual concerned. Excluded are thos e beliefs which can be understood as part of the subject \200\231s cultural or religious ba ckground. While the content is usually demonstrably false and bizarre in nature, this is no t invariably so. Primary delusions are the direct result of psychopathology, while secondary delusions can b e understood as having arisen in response to other primary psychiatric conditions (e.g. a p atient with severely depressed mood developing delusions of poverty, or a patient with prog ressive memory impairment developing a delusion that people are entering his house and stea ling or moving items). Primary delusions can be subdivided by the method by which they are perceived as having arisen or into broad classes based on their content. 03_Semple_Chap03.indd 90 12/7/2012 6:56:49 PM DICTIONARY OF PSYCHIATRIC SYMPTOMS 91 If the patient is asked to recall the point when they became aware of the delusion and its signi \201 cance to them, they may report that the belief arose: \200\230out of the blue \200\231 (autochthonous delusion); on seeing a normal percept (delusional perception); on r ecalling a memory (delusional memory); or on a background of anticipation, odd experiences, and increased aware- ness (delusional mood). Based on their content, 12 types of primary delusion are commonly recognized: persecutory, grandiose, delusions of control, of thought interference, of reference, of guilt, of love, delusional misidenti \201 cation, jealousy, hypochondriacal delusions, nihilistic delusion s, and delusions of infestation. Delusional atmosphere Synonym for delusional mood. Delusional elaboration Secondary delusions which arise in a manner which is understandable as the patient attempting to \201 nd explanations for primary psychopathological processe s (e.g. a patient with persistent audi- tory hallucinations developing a belief that a tran smitter has been placed in his ear). Delusional jealousy A delusional belief that one \200\231s partner is being unfaithful. Thi s can occur as part of a wider psychotic illness, secondary to organic brain damage (e.g. f ollowing the \200\230punch drunk syndrome \200\231 in boxers), associated with alcohol dep endence, or as a monosymptomatic delusional disorder ( \200\230Othello syndrome \200\231). Whatever the primary cause, there is a strong association with violence, usually towards th e supposedly unfaithful partner. For this type of delusion the content is not bizarre or in conceivable and the central belief may even be true. Delusional memory A primary delusion which is recalled as arising as a result of a memory ( e.g. a patient who remembers his parents taking him to hospital for an operation as a child becoming convinced that he had been implanted with control and monitoring devices which ha ve become active in his adult life). Delusional misidenti \201 cation A delusional belief that certain individu- als are not wh o they externally appear to be. The delusion may be that familiar people have been replaced with outwardly identical strangers (Capgras syndrome) or that strangers are \200\230reall y \200\231 familiar people (Fr goli syndrome). A rare symptom of schizophrenia or of other psychotic illnesses. Delusional mood A primary delusion which is recalled as arising follow- ing a period when t here is an abnormal mood state characterized by antici- patory anxiety, a sense of \200 \230something about to happen \200\231, and an increased sense of the signi \201 cance of minor events. The development of the formed delusion may come as a relief to the patient in this situation. Delusional perception A primary delusion which is recalled as having arisen as a result of a perception (e.g. a patient who, on seeing two white cars pull up in front of his house be came convinced that he was therefore about to be wrongly accused of being a pedophile). The percept is a real external object, not a hallucinatory experience. 03_Semple_Chap03.indd 91 12/7/2012 6:56:49 PM CHAPTER 3 Symptoms of psychiatric illness 92 Delusions of control A group of delusions which are also known as passivity phenomena or de lusions of bodily passivity. They are considered \201 rst-rank symptoms of schizophrenia. The core feature is the delusional belief that one is no longer in sole control of one \200\231s own body. The indi- vidual delusions are that one is being forced by some externa l agent to feel emotions, to desire to do things, to perform actions, or to experience bod- ily sensations. Respectively these delusions are called: passivity of affect, passivity of impulse, passivity of volition, and somatic passivity. Delusions of guilt A delusional belief that one has committed a crime or other reprehensibl e act. A feature of psychotic depressive illness (e.g. an elderly woman with severe depress ive illness who becomes convinced that her child, who died by cot death many years before, was in fact mur- dered by her). Delusions of infestation A delusional belief that one \200\231s skin is infested with multi ple, tiny mite-like animals. As a monosymptomatic delusional disorder this is called Ekbom syndrome. It is also seen in acute confu- sional states (particularly secondary to drug or alcohol withdrawal), in schizophrenia, in dementing illnesses, and as delusional elaboratio n of tactile hallucinatory experiences. Delusions of love A delusion where the patient believes another individ- ual is in love wit h them and that they are destined to be together. A rare symptom of schizophrenia and other psychotic illnesses, one particular subtype of this delusion is de Cl rambault syndrome.