Psychoneuroimmunology

THE INTERPRETATION OF DREAMS
Significance of Dreams
Freud became aware of the significance of dreams when he noted that patients frequently reported their dreams in the process of free association. Through their further associations to the dream content, he learned that the dreams were definitely meaningful, even though that meaning was often hidden or disguised. Most of all, Freud was struck by the intimate connection between dream content and unconscious memories or fantasies that were long repressed. That observation led Freud to declare that the interpretation of dreams was the royal road to the understanding of the unconscious.
Freud's self-analysis also contributed to his appreciation of the significance of dreams. One of his principal methods in conducting his own analysis was to rely on dreams and his associative exploration of those dreams. Indeed, Freud used many of his own dreams as illustrative examples in The Interpretation of Dreams, which appeared in 1900. Considered by many to be Freud's greatest work, the book still informs clinical psychoanalytic work with dreams today. In his magnum opus Freud put forth the notion that a dream is the disguised fulfillment of an unconscious childhood wish that is otherwise not readily accessible to conscious awareness in waking life.
In attempting to characterize the psychology of dreaming, Freud laid the foundations for ego psychology. He suggested that unconscious childhood wishes can be transformed into disguised conscious manifestations only if a censor exists in the mind. The censor, acting in the service of the ego, functions to preserve sleep. By disguising disturbing thoughts and feelings, the censor makes sure that the dreamer's sleep will not be disturbed. Moreover, early forms of defense mechanisms in the ego were delineated by Freud's investigation of the different methods of disguise used by the ego—for example, displacement, condensation, and symbolic representation. Freud also drew beginning parallels between the dream mechanisms and the pathological thoughts of psychotic patients in the waking state.
Analysis of Dream Content
The dream, as it is recalled by the dreamer, is the result of the unconscious mental activity that occurs during sleep. Freud believed that dreaming is simply the conscious experience of thoughts during sleep. Contemporary research has revealed that the cognitive activity of sleep actually varies considerably. The dreaming activity described by Freud is probably more or less restricted to the stage 1 rapid eye movement (REM) periods of the sleep-dream cycle; those periods occur approximately every 90 minutes during the night. The thoughts that occur in non-REM sleep periods tend to be more logically organized, briefer, and more realistic.
Freud distinguished between two layers of dream content. The manifest dream refers to the content as it is recalled by the dreamer, including the mood and sensory experiences accompanying the dream and any commentaries on the dream that occur within the dream. The unconscious thoughts and wishes that threaten to awaken the dreamer constitute the latent content. Freud referred to the unconscious mental operations by which the latent dream content is transformed into the manifest dream as the dream work. Freud's technique of dream interpretation was based on free association, in which the patient would say whatever came to mind in response to aspects of the dream. Through this approach the manifest content of the dream would gradually give way to the underlying latent content in which the unconscious meaning of the dream is contained.
Freud initially believed that internal or external stimuli initiate dreaming. Modern dream research has demonstrated that endogenous patterns of activation in the central nervous system associated with particular phases of sleep are responsible for the onset of dreaming activity. A more contemporary understanding of what Freud viewed as initiating stimuli are that such phenomena are simply incorporated into dream content and influence the material in the dream to that extent.
Nocturnal Sensory Stimuli A variety of sensory impressions—including hunger, pain, thirst, and urinary urgency—may influence dream content. For example, a man whose thirst is beginning to interfere with his sleep may dream that he has risen from bed, gone to the bathroom, drunk a glass of water, and returned to bed as a way of safeguarding the continuity of sleep. Freud's view of dreaming as the guardian of sleep is still considered a valid function of dreaming, but recent research suggests that the function of dreams is considerably more complex in that the preservation of sleep is only one of many functions.
Day Residues Freud discerned that an important influence on the dream thoughts is the residues of feelings, ideas, and thoughts associated with experiences of the preceding day. The final form of the manifest content of the dream is shaped by those day residues, as well as by sensory stimuli. Seemingly innocuous or unimportant elements from the day residues may be used as the vehicle for the disguised expression of unconscious drives and wishes of an erotic or aggressive nature. Hence, events of the preceding day may effectively conceal the infantile impulse at the core of the dream.
Repressed Infantile Drives Following the dictum that a dream represents the disguised fulfillment of an unconscious childhood wish, Freud understood the driving forces behind dream activity as impulses or wishes from the earliest years of life. Those repressed wishes, usually sexual or aggressive and stemming from oedipal and preoedipal levels of development, are melded with day residues and nocturnal stimuli to produce the end result. Despite some challenges from discoveries of recent sleep research, Freud's observations continue to have clinical utility.
Dreams by young children are particularly unique because they show little distinction between infantile and current conflicts. In general, the dreams of young children are less disguised than the dreams of older persons and show much less distinction between manifest and latent dream content because of the relative immaturity of the defensive operations of the child's ego.
Dream Work
As just noted, the dream work comprises several processes that transform latent dream content into manifest dream content. The theory of the nature of dream work, which Freud first put forth in The Interpretation of Dreams, became the fundamental description of the operation of unconscious processes. The mechanisms that Freud elaborated from his study of dreams proved to have broad applications to neurotic symptom formation and to a general psychology of the mind.
Dream Formation The basic problem of dream formation is to determine how the latent dream content represents itself through the manifest dream. In Freud's view the state of sleep leads to a relaxation of repression. With the repressive forces weakened, unconscious impulses and wishes are allowed to press for gratification and discharge. Since an outlet in motor expression is blocked by the sleep state, those repressed wishes and impulses have to find means of representation through mechanisms of thought and fantasy. Both elements of day residues and nocturnal stimuli are appropriated to express those latent wishes or impulses in the manifest dream.
The unconscious wishes and impulses that emanate from childhood are repressed because they are painful or unacceptable. Although repression is relaxed during sleep, Freud postulated that a dream censor is still actively involved in resisting the discharge of those impulses and disguising their true nature. The dream censor serves to attach impulses and wishes to neutral or innocent images from the residues of the dreamer's current psychological experience. Trivial or insignificant images from the dreamer's day residues are presumably linked on the basis of some resemblance that allows connections to be established. To enable those neutral images to surface in the dream, the dream work uses a set of disguised mechanisms that include condensation, displacement, symbolic representation, and secondary revision.
Condensation In condensation several unconscious impulses, wishes, or feelings can be combined and attached to one manifest dream image. For example, a composite character may appear in the dream that has the name of one person in the dreamer's life, a beard like another person, and a musical instrument that reflects a third person. The feelings associated with those three persons may be disguised in the resulting amalgam and may become apparent only through analysis of the various dream elements. The converse of condensation, diffusion, can also occur in a dream when a single latent wish or impulse is distributed through multiple representations in the manifest content.
Displacement In displacement the energy or intensity associated with one object is diverted to a substitute object that is associatively related but more acceptable to the dreamer's ego. Murderous wishes toward one's mother, for example, may be redirected toward a neutral or insignificant figure in one's life. In that manner the dream censor has displaced affective energy in such a way that the dreamer's sleep can continue undisturbed.
A special instance of displacement, projection, involves the attribution of the dreamer's own unacceptable impulses or wishes to another character in the dream. For example, a dreamer who finds homosexual impulses unacceptable may attribute them to his analyst in the dream. In some cases different aspects of the dreamer are represented in several characters in the dream.
Symbolic Representation Freud noted that the dreamer would often represent ideas or objects that were highly charged by using innocent images that were in some way connected with the idea or object being represented. In that manner an abstract concept or a complex set of feelings toward a person could be symbolized by a simple, concrete, or sensory image. Freud noted that symbols have unconscious meanings that can be discerned through the patient's associations to the symbol. However, he also believed that certain symbols have universal meanings—for example, a flower as a symbol for female genitalia, a snake as a symbol for the penis.
Secondary Revision The mechanisms of condensation, displacement, and symbolic representation are characteristic of a type of thinking that Freud referred to as primary process. That primitive mode of cognitive activity is characterized by illogical, bizarre, and absurd images that seem incoherent. Freud believed that a more mature and reasonable aspect of the ego is at work during the dream to organize some of those primitive aspects of the dream into a more coherent form. He called that process secondary revision; in it intellectual processes of a more mature nature make the dream somewhat more rational. The process is related to more mature activity characteristic of waking life, which Freud termed secondary process.
Typical Dreams
For the most part Freud believed that the underlying meaning of a dream reveals itself only through a proper analysis of the dreamer's associations. However, just as he made exceptions to certain universal symbols, he also thought that certain dreams are universal in their meaning, and he referred to them as typical dreams.
Anxiety Dreams
Freud's dream theory preceded his development of a comprehensive theory of the ego. Hence, his understanding of dreams stressed the importance of discharging drives or wishes through the hallucinatory contents of the dream. He viewed such mechanisms as condensation, displacement, symbolic representation, projection, and secondary revision primarily as facilitating the discharge of latent impulses, rather than protecting the dreamer from anxiety and pain. Freud understood anxiety dreams as reflecting a failure in the protective function of the dream work mechanisms. In other words, the repressed impulses succeed in working their way into the manifest content in a more or less recognizable manner. The ego reacts to the emergence of the threatening content with intense anxiety; the dreamer often experiences severe distress or may even partially awaken.
Punishment Dreams
Dreams in which the dreamer experiences punishment represented a special challenge for Freud because they appear to represent an exception to his wish-fulfillment theory of dreams. He came to understand such dreams as reflective of a compromise between the repressed wish and the repressing agency or conscience. In the punishment dream the ego anticipates condemnation by the dreamer's conscience if the latent unacceptable impulses are allowed direct expression in the manifest dream content. Hence, the wish for punishment by the patient's conscience is satisfied by giving expression to punishment fantasies. In that formulation Freud anticipated the concept of the superego and the interplay between the ego and the superego, which he did not elaborate into the structural model for some 20 years.

http://www.geocities.com/aishya_m123/

web

A

abreaction An emotional release or discharge after recalling a painful experience that has been repressed because it was not consciously tolerable. Often the release is surprising to the individual experiencing it because of it's intensity and the circumstances surrounding its onset.  A therapeutic effect sometimes occurs through partial or repeated discharge of the painful affect.

abstract attitude (categorical attitude) This is a type of thinking that includes voluntarily shifting one's mind set from a specific aspect of a situation to the general aspect; It involves keeping in mind different simultaneous aspects of a situation while grasping the essentials of the situation.  It can involve breaking a situation down into its parts and isolating them voluntarily; planning ahead ideationally; and/or thinking or performing symbolically. A characteristic of many psychiatric disorders is the person's inability to assume the abstract attitude or to shift readily from the concrete to the abstract and back again as demanded by circumstances.

abulia  A lack of will or motivation which is often expressed as inability to make decisions or set goals. Often, the reduction in impulse to action and thought is coupled with an indifference or lack of concern about the consequences of action.

acalculia The loss of a previously possessed ability to engage in arithmetic calculation.

acculturation difficulty A problem stemming from an inability to appropriately adapt to a different culture or environment. The problem is not based on any coexisting mental disorder.

acetylcholine A neurotransmitter in the brain, which helps to regulate memory, and in the peripheral nervous system, where it affects the actions of skeletal and smooth muscle.

acting out This is the process of expressing unconscious emotional conflicts or feelings via actions rather than words. The person is not consciously aware of the meaning or etiology of such acts. Acting out may be harmful or, in controlled situations, therapeutic (e.g., children's play therapy).

actualization The realization of one's full potential - intellectual, psychological, physical, etc.

adiadochokinesia  The inability to perform rapid alternating movements of one or more of the extremities.  This task is sometimes requested by physicians of patients during physical examinations to determine if there exists neurological problems.

adrenergic This refers to neuronal or neurologic activity caused by neurotransmitters such as epinephrine, norepinephrine, and dopamine.

affect This word is used to described observable behavior that represents the expression of a subjectively experienced feeling state (emotion). Common examples of affect are sadness, fear, joy, and anger. The normal range of expressed affect varies considerably between different cultures and even within the same culture. Types of affect include: euthymic, irritable, constricted; blunted; flat; inappropriate, and labile.

affective disorders Refers to disorders of mood.  Examples would include Major Depressive Disorder, Dysthymia, Depressive Disorder, N.O.S., Adjustment Disorder with Depressed Mood, Bipolar Disorder...

age-associated memory impairment (AAMI) The mild disturbance in memory function that occurs normally with aging; benign senescent forgetfulness.  Such lapses in memory are lately humorously referred to as representing "a senior moment".

agitation (psychomotor agitation) Excessive motor activity that accompanies and is associated with a feeling of inner tension. The activity is usually nonproductive and repetitious and consists of such behavior as pacing, fidgeting, wringing of the hands, pulling of clothes, and inability to sit still.

agnosia Failure to recognize or identify objects despite intact sensory function; This may be seen in dementia of various types.  An example would be the failure of someone to recognize a paper clip placed in their hand while keeping their eyes closed.

agonist medication A chemical entity that is not naturally occuring within the body which acts upon a receptor and is capable of producing the maximal effect that can be produced by stimulating that receptor. A partial agonist is capable only of producing less than the maximal effect even when given in a concentration sufficient to bind with all available receptors.

agonist/antagonist medication A chemical entity that is not naturally occuring within the body which acts on a family of receptors (such as mu, delta, and kappa opiate receptors) in such a fashion that it is an agonist or partial agonist on one type of receptor while at the same time it is also an antagonist on another different receptor.

agoraphobia Anxiety about being in places or situations in which escape might be difficut or embarrassing or in which help may not be available should a panic attack occur. The fears typically relate to venturing into the open, of leaving the familiar setting of one's home, or of being in a crowd, standing in line, or traveling in a car or train. Although agoraphobia usually occurs as a part of panic disorder, agoraphobia without a history of panic disorder has been described as also occuring without other disorders.

agraphia The loss of a pre-existing ability to express one's self through the act of writing.

akathisia Complaints of restlessness accompanied by movements such as fidgeting of the legs, rocking from foot to foot, pacing, or inability to sit or stand. Symptoms can develop within a few weeks of starting or raising the dose of traditional neuroleptic medications or of reducing the dose of medication used to treat extrapyramidal symptoms. akathisia is a state of motor restlessness ranging from a feeling of inner disquiet to inability to sit still or lie quietly.

akinesia A state of motor inhibition or reduced voluntary movement.

akinetic mutism A state of apparent alertness with following eye movements but no speech or voluntary motor responses.

alexia Loss of a previously intact ability to grasp the meaning of written or printed words and sentences.

alexithymia A disturbance in affective and cognitive function that can be present in an assortment of diagnostic entities.  Is common in psychosomatic disorders, addictive disorders, and posttraumatic stress disorder. The chief manifestations are difficulty in describing or recognizing one's own emotions, a limited fantasy life, and general constriction in affective life.

algophobia Fear of pain.

alienation The estrangement felt in a setting one views as foreign, unpredictable, or unacceptable. For example, in depersonalization phenomena, feelings of unreality or strangeness produce a sense of alienation from one's self or environment.

alloplastic Referring to adaptation by means of altering the external environment. This can be contrasted to autoplastic, which refers to the alteration of one's own behavior and responses.

alogia An impoverishment in thinking that is inferred from observing speech and language behavior. There may be brief and concrete replies to questions and restriction in the amount of spontaneous speech (poverty of speech). Sometimes the speech is adequate in amount but conveys little information because it is overconcrete, overabstract, repetitive, or stereotyped (poverty of content).

ambivalence The coexistence of contradictory emotions, attitudes, ideas, or desires with respect to a particular person, object, or situation. Ordinarily, the ambivalence is not fully conscious and suggests psychopathology only when present in an extreme form.

amentia Subnormal development of the mind, with particular reference to intellectual capacities; a type of severe mental retardation.

amimia A disorder of language characterized by an inability to make gestures or to understand the significance of gestures.

amines Organic compounds containing the amino group. Amines such as epinephrine and norepinephrine are significant because they function as neurotransmitters.

amnesia Loss of memory. Types of amnesia include: anterograde Loss of memory of events that occur after the onset of the etiological condition or agent. retrograde Loss of memory of events that occurred before the onset of the etiological condition or agent.

amok A culture specific syndrome from Malay involving acute indiscriminate homicidal mania .

amygdala This is a structure of the brain which is part of the basal ganglia located on the roof of the temporal horn of the lateral ventricle at the inferior end of the caudate nucleus. It is a structure in the forebrain that is an important component of the limbic system.

amyloid Any one of various complex proteins that are deposited in tissues in different disease processes. These proteins have an affinity for Congo red dye. In neuropsychiatry, of particular interest are the beta-amyloid (A4) protein, which is the major component of the characteristic senile plaques of Alzheimer's disease, and the amyloid precursor protein (APP).

anaclitic In psychoanalytic terminology, dependence of the infant on the mother or mother substitute for a sense of well-being. This is considered normal behavior in childhood, but pathologic in later years.

anal stage The period of pregenital psychosexual development, usually from 1 to 3 years, in which the child has particular interest and concern with the process of defecation and the sensations connected with the anus. The pleasurable part of the experience is termed anal eroticism. 

anamnesis The developmental history of a patient and of his or her illness, especially recollections.

anankastic personality Synonym for obsessive-compulsive personality.

androgyny A combination of male and female characteristics in one person.

anhedonia Inability to experience pleasure from activities that usually produce pleasurable feelings. Contrast with hedonism.

anima In Jungian psychology, a person's inner being as opposed to the character or persona presented to the world. Further, the anima may be the more feminine "soul" or inner self of a man, and the animus the more masculine soul of a woman.

anomie Apathy, alienation, and personal distress resulting from the loss of goals previously valued. Emile Durkheim popularized this term when he listed it as a principal reason for suicide.

anosognosia The apparent unawareness of or failure to recognize one's own functional defect (e.g., hemiplegia, hemianopsia).

antagonist medication A chemical entity that is not naturally occuring within the body which occupies a receptor, produces no physiologic effects, and prevents endogenous and exogenous chemicals from producing an effect on that receptor.

anxiety The apprehensive anticipation of future danger or misfortune accompanied by a feeling of dysphoria or somatic symptoms of tension. The focus of anticipated danger may be internal or external.  Anxiety is often distinguished from fear in that fear is a more appropriate word to use when there exists threat or danger in the real world.  Anxiety is reflective more of a threat that is not apparent or imminent in the real world, at least not to the experienced degree.

apathy Lack of feeling, emotion, interest, or concern.

aphasia An impairment in the understanding or transmission of ideas by language in any of its forms--reading, writing, or speaking--that is due to injury or disease of the brain centers involved in language.

anomic or amnestic aphasia Loss of the ability to name objects.

aphonia An inability to produce speech sounds that require the use of the larynx that is not due to a lesion in the central nervous system.

apperception Perception as modified and enhanced by one's own emotions, memories, and biases.

apraxia Inability to carry out previously learned skilled motor activities despite intact comprehension and motor function; this may be seen in dementia.

assimilation A Piagetian term describing a person's ability to comprehend and integrate new experiences.

astereognosis Inability to recognize familiar objects by touch that cannot be explained by a defect of elementary tactile sensation.

ataxia Partial or complete loss of coordination of voluntary muscular movement.

attention The ability to focus in a sustained manner on a particular stimulus or activity. A disturbance in attention may be manifested by easy distractibility or difficulty in finishing tasks or in concentrating on work

auditory hallucination A hallucination involving the perception of sound, most commonly of voices. Some clinicians and investigators would not include those experiences perceived as coming from inside the head and would instead limit the concept of true auditory hallucinations to those sounds whose source is perceived as being external.

aura A premonitory, subjective brief sensation (e.g., a flash of light) that warns of an impending headache or convulsion. The nature of the sensation depends on the brain area in which the attack begins. Seen in migraine and epilepsy.

autoeroticism Sensual self-gratification. Characteristic of, but not limited to, an early stage of emotional development. Includes satisfactions derived from genital play, masturbation, fantasy, and oral, anal, and visual sources.

automatism Automatic and apparently undirected nonpurposeful behavior that is not consciously controlled. Seen in psychomotor epilepsy.

autoplastic Referring to adaptation by changing the self.

autotopagnosia Inability to localize and name the parts of one's own body. finger agnosia would be autotopagnosia restricted to the fingers.

avolition An inability to initiate and persist in goal-directed activities. When severe enough to be considered pathological, avolition is pervasive and prevents the person from completing many different types of activities (e.g., work, intellectual pursuits, self-care).

B

basal gangliaClusters of neurons located deep in the brain; they include the caudate nucleus and the putamen (corpus striatum), the globus pallidus, the subthalamic nucleus, and the substantia nigra. The basal ganglia appear to be involved in higher-order aspects of motor control, such as planning and execution of complex motor activity and the speed of movements. Lesions of the basal ganglia produce various types of involuntary movements such as athetosis, chorea, dystonia, and tremor. The basal ganglia are involved also in the pathophysiology of Parkinson's disease, Huntington's disease, and tardive dyskinesia. The internal capsule, containing all the fibers that ascend to or descend from the cortex, runs through the basal ganglia and separates them from the thalamus.

bestiality Zoophilia; sexual relations between a human being and an animal. See also paraphilia.

beta-blocker An agent that inhibits the action of beta-adrenergic receptors, which modulate cardiac functions, respiratory functions, and the dilation of blood vessels. Beta-blockers are of value in the treatment of hypertension, cardiac arrhythmias, and migraine. In psychiatry, they have been used in the treatment of aggression and violence, anxiety-related tremors and lithium-induced tremors, neuroleptic-induced akathisia, social phobias, panic states, and alcohol withdrawal.

bizarre delusion A delusion that involves a phenomenon that the person's culture would regard as totally implausible.

blind spot Visual scotoma, a circumscribed area of blindness or impaired vision in the visual field; by extension, an area of the personality of which the subject is unaware, typically because recognition of this area would cause painful emotions.

blocking A sudden obstruction or interruption in spontaneous flow of thinking or speaking, perceived as an absence or deprivation of thought.

blunted affect An affect type that represents significant reduction in the intensity of emotional expression

body image One's sense of the self and one's body.

bradykinesia Neurologic condition characterized by a generalized slowness of motor activity.

Broca's aphasia Loss of the ability to comprehend language coupled with production of inappropriate language.

bruxism Grinding of the teeth, occurs unconsciously while awake or during stage 2 sleep. May be secondary to anxiety, tension, or dental problems.

C 

Capgras' syndrome The delusion that others, or the self, have been replaced by imposters. It typically follows the development of negative feelings toward the other person that the subject cannot accept and attributes, instead, to the imposter. The syndrome has been reported in paranoid schizophrenia and, even more frequently, in organic brain disease.

catalepsy Waxy flexibility--rigid maintenance of a body position over an extended period of time.

cataplexy Episodes of sudden bilateral loss of muscle tone resulting in the individual collapsing, often in association with intense emotions such as laughter, anger, fear, or surprise.

catatonic behavior Marked motor abnormalities including motoric immobility (i.e., catalepsy or stupor), certain types of excessive motor activity (apparently purposeless agitation not influenced by external stimuli), extreme negativism (apparent motiveless resistance to instructions or attempts to be moved) or mutism, posturing or stereotyped movements, and echolalia or echopraxia

catharsis The healthful (therapeutic) release of ideas through "talking out" conscious material accompanied by an appropriate emotional reaction. Also, the release into awareness of repressed ("forgotten") material from the unconscious. See also repression.

cathexis Attachment, conscious or unconscious, of emotional feeling and significance to an idea, an object, or, most commonly, a person.

causalgia A sensation of intense pain of either organic or psychological origin.

cerea flexibilitas The "waxy flexibility" often present in catatonic schizophrenia in which the patient's arm or leg remains in the position in which it is placed.

circumstantiality Pattern of speech that is indirect and delayed in reaching its goal because of excessive or irrelevant detail or parenthetical remarks. The speaker does not lose the point, as is characteristic of loosening of associations, and clauses remain logically connected, but to the listener it seems that the end will never be reached.

clanging A type of thinking in which the sound of a word, rather than its meaning, gives the direction to subsequent associations.

climacteric Menopausal period in women. Sometimes used to refer to the corresponding age period in men. Also called involutional period.

cognitive Pertaining to thoughts or thinking. Cognitive disorders are disorders of thinking, for example, schizophrenia.

comorbidity The simultaneous appearance of two or more illnesses, such as the co-occurrence of schizophrenia and substance abuse or of alcohol dependence and depression. The association may reflect a causal relationship between one disorder and another or an underlying vulnerability to both disorders. Also, the appearance of the illnesses may be unrelated to any common etiology or vulnerability.

compensation A defense mechanism, operating unconsciously, by which one attempts to make up for real or fancied deficiencies. Also a conscious process in which one strives to make up for real or imagined defects of physique, performance skills, or psychological attributes. The two types frequently merge. See also overcompensation.

compulsion Repetitive ritualistic behavior such as hand washing or ordering or a mental act such as praying or repeating words silently that aims to prevent or reduce distress or prevent some dreaded event or situation. The person feels driven to perform such actions in response to an obsession or according to rules that must be applied rigidly, even though the behaviors are recognized to be excessive or unreasonable.

conative Pertains to one's basic strivings as expressed in behavior and actions

concrete thinking Thinking characterized by immediate experience, rather than abstractions. It may occur as a primary, developmental defect, or it may develop secondary to organic brain disease or schizophrenia.

condensation A psychological process, often present in dreams, in which two or more concepts are fused so that a single symbol represents the multiple components.

confabulation Fabrication of stories in response to questions about situations or events that are not recalled.

confrontation A communication that deliberately pressures or invites another to self-examine some aspect of behavior in which there is a discrepancy between self-reported and observed behavior.

constricted affect Affect type that represents mild reduction in the range and intensity of emotional expression.

constructional apraxia An acquired difficulty in drawing two-dimensional objects or forms, or in producing or copying three-dimensional arrangements of forms or shapes.

contingency reinforcement In operant or instrumental conditioning, ensuring that desired behavior is followed by positive consequences and that undesired behavior is not rewarded.

conversion A defense mechanism, operating unconsciously, by which intrapsychic conflicts that would otherwise give rise to anxiety are instead given symbolic external expression. The repressed ideas or impulses, and the psychological defenses against them, are converted into a variety of somatic symptoms. These may include such symptoms as paralysis, pain, or loss of sensory function.

coping mechanisms Ways of adjusting to environmental stress without altering one's goals or purposes; includes both conscious and unconscious mechanisms.

coprophagia Eating of filth or feces.

counterphobia Deliberately seeking out and exposing onself to, rather than avoiding, the object or situation that is consciously or unconsciously feared.

countertransference The therapist's emotional reactions to the patient that are based on the therapist's unconscious needs and conflicts, as distinguished from his or her conscious responses to the patient's behavior. Countertransference may interfere with the therapist's ability to understand the patient and may adversely affect the therapeutic technique. Currently, there is emphasis on the positive aspects of countertransference and its use as a guide to a more empathic understanding of the patient.

cretinism A type of mental retardation and bodily malformation caused by severe, uncorrected thyroid deficiency in infancy and early childhood.

cri du chat A type of mental retardation. The name is derived from a catlike cry emitted by children with this disorder, which is caused by partial deletion of chromosome 5.

conversion symptom A loss of, or alteration in, voluntary motor or sensory functioning suggesting a neurological or general medical condition. Psychological factors are judged to be associated with the development of the symptom, and the symptom is not fully explained by a neurological or general medical condition or the direct effects of a substance. The symptom is not intentionally produced or feigned and is not culturally sanctioned.

culture-specific syndromes Forms of disturbed behavior specific to certain cultural systems that do not conform to western nosologic entities. Some commonly cited syndromes are the following: amok; koro; latah; piblokto, and windigo.

D

Da Costa's syndrome Neurocirculatory asthenia; "soldier's heart"; a functional disorder of the circulatory system that is usually a part of an anxiety state or secondary to hyperventilation.

decompensation The deterioration of existing defenses, leading to an exacerbation of pathological behavior.

defense mechanism Automatic psychological process that protects the individual against anxiety and from awareness of internal or external stressors or dangers. Defense mechanisms mediate the individual's reaction to emotional conflicts and to external stressors. Some defense mechanisms (e.g., projection, splitting, and acting out) are almost invariably maladaptive. Others, such as suppression and denial, may be either maladaptive or adaptive, depending on their severity, their inflexibility, and the context in which they occur.

déjà vu A paramnesia consisting of the sensation or illusion that one is seeing what one has seen before

delusion A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person's culture or subculture (e.g., it is not an article of religious faith). When a false belief involves a value judgment, it is regarded as a delusion only when the judgment is so extreme as to defy credibility. Delusional conviction occurs on a continuum and can sometimes be inferred from an individual's behavior. It is often difficult to distinguish between a delusion and an overvalued idea (in which case the individual has an unreasonable belief or idea but does not hold it as firmly as is the case with a delusion). Delusions are subdivided according to their content. Some of the more common types are: bizarre; delusional jealousy; grandiose; delusion of reference; persecutory; somatic; thought broadcasting; thought insertion.

delusional jealousy The delusion that one's sexual partner is unfaithful. erotomanic A delusion that another person, usually of higher status, is in love with the individual.

delusion of reference A delusion whose theme is that events, objects, or other persons in one's immediate environment have a particular and unusual significance. These delusions are usually of a negative or pejorative nature, but also may be grandiose in content. This differs from an idea of reference, in which the false belief is not as firmly held nor as fully organized into a true belief.

denial A defense mechanism where certain information is not accessed by the conscious mind. Denial is related to repression, a similar defense mechanism, but denial is more pronounced or intense. Denial involves some impairment of reality. Denial would be operating (as an example) if a cardiac patient who has been warned about the potential fatal outcome of engaging in heavy work, decides to start building a wall of heavy stones.

depersonalization An alteration in the perception or experience of the self so that one feels detached from, and as if one is an outside observer of, one's mental processes or body (e.g., feeling like one is in a dream).

derailment ("loosening of associations") A pattern of speech in which a person's ideas slip off one track onto another that is completely unrelated or only obliquely related. In moving from one sentence or clause to another, the person shifts the topic idiosyncratically from one frame of reference to another and things may be said in juxtaposition that lack a meaningful relationship. This disturbance occurs between clauses, in contrast to incoherence, in which the disturbance is within clauses. An occasional change of topic without warning or obvious connection does not constitute derailment.

derealization An alteration in the perception or experience of the external world so that it seems strange or unreal (e.g., people may seem unfamiliar or mechanical).

dereistic Mental activity that is not in accordance with reality, logic, or experience.

detachment A behavior pattern characterized by general aloofness in interpersonal contact; may include intellectualization, denial, and superficiality.

diplopia Double vision due to paralysis of the ocular muscles; seen in inhalant intoxication and other conditions affecting the oculomotor nerve.

disconnection syndrome Term coined by Norman Geschwind (1926¾1984) to describe the interruption of information transferred from one brain region to another.

disinhibition Freedom to act according to one's inner drives or feelings, with less regard for restraints imposed by cultural norms or one's superego; removal of an inhibitory, constraining, or limiting influence, as in the escape from higher cortical control in neurologic injury, or in uncontrolled firing of impulses, as when a drug interferes with the usual limiting or inhibiting action of GABA within the central nervous system.

disorientation Confusion about the time of day, date, or season (time), where one is (place), or who one is (person).

dysphoric mood An unpleasant mood, such as sadness, anxiety, or irritability.

displacement A defense mechanism, operating unconsciously, in which emotions, ideas, or wishes are transferred from their original object to a more acceptable substitute; often used to allay anxiety.

dissociation A disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. The disturbance may be sudden or gradual, transient or chronic.

distractibility The inability to maintain attention, that is, the shifting from one area or topic to another with minimal provocation, or attention being drawn too frequently to unimportant or irrelevant external stimuli.

double bind Interaction in which one person demands a response to a message containing mutually contradictory signals, while the other person is unable either to comment on the incongruity or to escape from the situation.

drive Basic urge, instinct, motivation; a term used to avoid confusion with the more purely biological concept of instinct.

dyad A two-person relationship, such as the therapeutic relationship between doctor and patient in individual psychotherapy.

dysarthria Imperfect articulation of speech due to disturbances of muscular control or incoordination.

dysgeusia Perversion of the sense of taste.

dyskinesia Distortion of voluntary movements with involuntary muscular activity.

dyslexia Inability or difficulty in reading, including word-blindness and a tendency to reverse letters and words in reading and writing.

dyssomnia Primary disorders of sleep or wakefulness characterized by insomnia or hypersomnia as the major presenting symptom. Dyssomnias are disorders of the amount, quality, or timing of sleep.

dystonia Disordered tonicity of muscles.

E 

echolalia The pathological, parrotlike, and apparently senseless repetition (echoing) of a word or phrase just spoken by another person. echolalia Parrot-like repetition of overheard words or fragments of speech.

echopraxia Repetition by imitation of the movements of another. The action is not a willed or voluntary one and has a semiautomatic and uncontrollable quality.

ego In psychoanalytic theory, one of the three major divisions in the model of the psychic apparatus, the others being the id and the superego. The ego represents the sum of certain mental mechanisms, such as perception and memory, and specific defense mechanisms. It serves to mediate between the demands of primitive instinctual drives (the id), of internalized parental and social prohibitions (the superego), and of reality. The compromises between these forces achieved by the ego tend to resolve intrapsychic conflict and serve an adaptive and executive function. Psychiatric usage of the term should not be confused with common usage, which connotes self-love or selfishness.

ego ideal The part of the personality that comprises the aims and goals for the self; usually refers to the conscious or unconscious emulation of significant figures with whom one has identified. The ego ideal emphasizes what one should be or do in contrast to what one should not be or not do.

ego-dystonic Referring to aspects of a person's behavior, thoughts, and attitudes that are viewed by the self as repugnant or inconsistent with the total personality.

eidetic image Unusually vivid and apparently exact mental image; may be a memory, fantasy, or dream.

elaboration An unconscious process consisting of expansion and embellishment of detail, especially with reference to a symbol or representation in a dream.

elevated mood An exaggerated feeling of well-being, or euphoria or elation. A person with elevated mood may describe feeling "high," "ecstatic," "on top of the world," or "up in the clouds."

engram A memory trace; a neurophysiological process that accounts for persistence of memory

epigenesis Originally from the Greek "epi" (on, upon, on top of) and "genesis" (origin); the theory that the embryo is not preformed in the ovum or the sperm, but that it develops gradually by the successive formation of new parts. The concept has been extended to other areas of medicine, with different shades of meaning. Some of the other meanings are as follows: 1. Any change in an organism that is due to outside influences rather than to genetically determined ones. 2. The occurrence of secondary symptoms as a result of disease. 3. Developmental factors, and specifically the gene-environment interactions, that contribute to development. 4. The appearance of new functions that are not predictable on the basis of knowledge of the part-processes that have been combined. 5. The appearance of specific features at each stage of development, such as the different goals and risks that Erikson described for the eight stages of human life (trust vs. mistrust, autonomy vs. doubt, etc.). The life cycle theory adheres to the epigenetic principle in that each stage of development is characterized by crises or challenges that must be satisfactorily resolved if development is to proceed normally.

ethnology A science that concerns itself with the division of human beings into races and their origin, distribution, relations, and characteristics.

euthymic Mood in the "normal" range, which implies the absence of depressed or elevated mood.

expansive mood Lack of restraint in expressing one's feelings, frequently with an overvaluation of one's significance or importance. irritable Easily annoyed and provoked to anger.

extinction The weakening of a reinforced operant response as a result of ceasing reinforcement. See also operant conditioning. Also, the elimination of a conditioned response by repeated presentations of a conditioned stimulus without the unconditioned stimulus. See also respondent conditioning.

extraversion A state in which attention and energies are largely directed outward from the self as opposed to inward toward the self, as in introversion.

F 

fantasy An imagined sequence of events or mental images (e.g., daydreams) that serves to express unconscious conflicts, to gratify unconscious wishes, or to prepare for anticipated future events.

flashback A recurrence of a memory, feeling, or perceptual experience from the past.

flat affect An affect type that indicates the absence of signs of affective expression.

flight of ideas A nearly continuous flow of accelerated speech with abrupt changes from topic to topic that are usually based on understandable associations, distracting stimuli, or plays on words. When severe, speech may be disorganized and incoherent.

flooding (implosion) A behavior therapy procedure for phobias and other problems involving maladaptive anxiety, in which anxiety producers are presented in intense forms, either in imagination or in real life. The presentations, which act as desensitizers, are continued until the stimuli no longer produce disabling anxiety.

folie à deux A shared psychotic disorder between 2 people, usually people who are mutually dependent upon each other.

formal thought disorder An inexact term referring to a disturbance in the form of thinking rather than to abnormality of content. See blocking; loosening of associations; poverty of speech.

formication The tactile hallucination or illusion that insects are crawling on the body or under the skin.

fragmentation Separation into different parts, or preventing their integration, or detaching one or more parts from the rest. A fear of fragmentation of the personality, also known as disintegration anxiety, is often observed in patients whenever they are exposed to repetitions of earlier experiences that interfered with development of the self. This fear may be expressed as feelings of falling apart, as a loss of identity, or as a fear of impending loss of one's vitality and of psychological depletion.

free association In psychoanalytic therapy, spontaneous, uncensored verbalization by the patient of whatever comes to mind.

frotteurism One of the paraphilias, consisting of recurrent, intense sexual urges involving touching and rubbing against a nonconsenting person; common sites in which such activities take place are crowded trains, buses, and elevators. Fondling the victim may be part of the condition and is called toucherism.

fusion The union and integration of the instincts and drives so that they complement each other and help the organism to deal effectively with both internal needs and external demands.

G 

Gegenhalten "Active" resistance to passive movement of the extremities that does not appear to be under voluntary control.

globus hystericus The disturbing sensation of a lump in the throat.

glossolalia Gibberish-like speech or "speaking in tongues."

gender dysphoria A persistent aversion toward some or all of those physical characteristics or social roles that connote one's own biological sex.

gender identity A person's inner conviction of being male or female.

gender role Attitudes, patterns of behavior, and personality attributes defined by the culture in which the person lives as stereotypically "masculine" or "feminine" social roles.

grandiosity An inflated appraisal of one's worth, power, knowledge, importance, or identity. When extreme, grandiosity may be of delusional proportions.

grandiose delusion A delusion of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person.

gustatory hallucination A hallucination involving the perception of taste (usually unpleasant).

H 

hallucination A sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ. Hallucinations should be distinguished from illusions, in which an actual external stimulus is misperceived or misinterpreted. The person may or may not have insight into the fact that he or she is having a hallucination. One person with auditory hallucinations may recognize that he or she is having a false sensory experience, whereas another may be convinced that the source of the sensory experience has an independent physical reality. The term hallucination is not ordinarily applied to the false perceptions that occur during dreaming, while falling asleep (hypnagogic), or when awakening (hypnopompic). Transient hallucinatory experiences may occur in people without a mental disorder.

hedonism Pleasure-seeking behavior. Contrast with anhedonia.

5-HIAA (5-hydroxyindoleacetic acid) A major metabolite of serotonin, a biogenic amine found in the brain and other organs. Functional deficits of serotonin in the central nervous system have been implicated in certain types of major mood disorders, and particularly in suicide and impulsivity.

hippocampus Olfactory brain; a sea-horse¾shaped structure located within the brain that is an important part of the limbic system. The hippocampus is involved in some aspects of memory, in the control of the autonomic functions, and in emotional expression.

hyperacusis Inordinate sensitivity to sounds; it may be on an emotional or an organic basis.

hypersomnia Excessive sleepiness, as evidenced by prolonged nocturnal sleep, difficulty maintaining an alert awake state during the day, or undesired daytime sleep episodes. ideas of reference The feeling that casual incidents and external events have a particular and unusual meaning that is specific to the person. This is to be distinguished from a delusion of reference, in which there is a belief that is held with delusional conviction

hypnagogic Referring to the semiconscious state immediately preceding sleep; may include hallucinations that are of no pathological significance.

hypnopompic Referring to the state immediately preceding awakening; may include hallucinations that are of no pathological significance.

I 

id In Freudian theory, the part of the personality that is the unconscious source of unstructured desires and drives. See also ego; superego.

idealization A mental mechanism in which the person attributes exaggeratedly positive qualities to the self or others.

ideas of reference Incorrect interpretations of casual incidents and external events as having direct reference to oneself. May reach sufficient intensity to constitute delusions.

identification A defense mechanism, operating unconsciously, by which one patterns oneself after some other person. Identification plays a major role in the development of one's personality and specifically of the superego. To be differentiated from imitation or role modeling, which is a conscious process.

idiot savant A person with gross mental retardation who nonetheless is capable of performing certain remarkable feats in sharply circumscribed intellectual areas, such as calendar calculation or puzzle solving.

illusion A misperception or misinterpretation of a real external stimulus, such as hearing the rustling of leaves as the sound of voices. See also hallucination.

imprinting A term in ethology referring to a process similar to rapid learning or behavioral patterning that occurs at critical points in very early stages of animal development. The extent to which imprinting occurs in human development has not been established.

inappropriate affect An affect type that represents an unusual affective expression that does not match with the content of what is being said or thought.

incoherence Speech or thinking that is essentially incomprehensible to others because words or phrases are joined together without a logical or meaningful connection. This disturbance occurs within clauses, in contrast to derailment, in which the disturbance is between clauses. This has sometimes been referred to as "word salad" to convey the degree of linguistic disorganization. Mildly ungrammatical constructions or idiomatic usages characteristic of particular regional or cultural backgrounds, lack of education, or low intelligence should not be considered incoherence. The term is generally not applied when there is evidence that the disturbance in speech is due to an aphasia.

incorporation A primitive defense mechanism, operating unconsciously, in which the psychic representation of a person, or parts of the person, is figuratively ingested.

individuation A process of differentiation, the end result of which is development of the individual personality that is separate and distinct from all others.

indoleamine One of a group of biogenic amines (e.g., serotonin) that contains a five-membered, nitrogen-containing indole ring and an amine group within its chemical structure. inhibition Behavioral evidence of an unconscious defense against forbidden instinctual drives; may interfere with or restrict specific activities.

insomnia A subjective complaint of difficulty falling or staying asleep or poor sleep quality. Types of insomnia include:

initial insomnia Difficulty in falling asleep.

instinct An inborn drive. The primary human instincts include self-preservation, sexuality, and according to some proponents the death instinct, of which aggression is one manifestation.

integration The useful organization and incorporation of both new and old data, experience, and emotional capacities into the personality. Also refers to the organization and amalgamation of functions at various levels of psychosexual development.

intellectualization A mental mechanism in which the person engages in excessive abstract thinking to avoid confrontation with conflicts or disturbing feelings.

intersex condition A condition in which an individual shows intermingling, in various degrees, of the characteristics of each sex, including physical form, reproductive organs, and sexual behavior.

introspection Self-observation; examination of one's feelings, often as a result of psychotherapy.

introversion Preoccupation with oneself and accompanying reduction of interest in the outside world. Contrast to extraversion.

isolation A defense mechanism operating unconsciously central to obsessive-compulsive phenomena in which the affect is detached from an idea and rendered unconscious, leaving the conscious idea colorless and emotionally neutral.

K

Klinefelter's syndrome Chromosomal defect in males in which there is an extra X chromosome; manifestations may include underdeveloped testes, physical feminization, sterility, and mental retardation.

koro  A culture specific syndrome of China involving fear of retraction of penis into abdomen with the belief that this will lead to death.

L

la belle indifférence Literally, "beautiful indifference." Seen in certain patients with conversion disorders who show an inappropriate lack of concern about their disabilities. labile Rapidly shifting (as applied to emotions); unstable.

labile affect An affect type that indicates abnormal sudden rapid shifts in affect.

latah A culture specific syndrome of Southeast Asia involving startle-induced disorganization, hypersuggestibility, automatic obedience, and echopraxia.

latent content The hidden (i.e., unconscious) meaning of thoughts or actions, especially in dreams or fantasies. In dreams, it is expressed in distorted, disguised, condensed, and symbolic form.

learned helplessness A condition in which a person attempts to establish and maintain contact with another by adopting a helpless, powerless stance.

lethologica Temporary inability to remember a proper noun or name.

libido The psychic drive or energy usually associated with the sexual instinct. (Sexual is used here in the broad sense to include pleasure and love-object seeking.)

locus coeruleus A small area in the brain stem containing norepinephrine neurons that is considered to be a key brain center for anxiety and fear.

long-term memory The final phase of memory in which information storage may last from hours to a lifetime.

loosening of associations A disturbance of thinking shown by speech in which ideas shift from one subject to another that is unrelated or minimally related to the first. Statements that lack a meaningful relationship may be juxtaposed, or speech may shift suddenly from one frame of reference to another. The speaker gives no indication of being aware of the disconnectedness, contradictions, or illogicality of speech.

M 

macropsia The visual perception that objects are larger than they actually are.

magical thinking A conviction that thinking equates with doing. Occurs in dreams in children, in primitive peoples, and in patients under a variety of conditions. Characterized by lack of realistic relationship between cause and effect.

manifest content The remembered content of a dream or fantasy, as contrasted with latent content, which is concealed and distorted.

masochism Pleasure derived from physical or psychological pain inflicted on oneself either by oneself or by others. It is called sexual masochism and classified as a paraphilia when it is consciously sought as a part of the sexual act or as a prerequisite to sexual gratification. It is the converse of sadism, although the two tend to coexist in the same person.

memory consolidation The physical and psychological changes that take place as the brain organizes and restructures information that may become a permanent part of memory.

mental retardation A major group of disorders of infancy, childhood, or adolescence characterized by intellectual functioning that is significantly below average (IQ of 70 or below), manifested before the age of 18 by impaired adaptive functioning (below expected performance for age in such areas as social or daily living skills, communication, and self-sufficiency). Different levels of severity are recognized: an IQ level of 50/55 to 70 is Mild; an IQ level of 35/40 to 50/55 is Moderate; an IQ level of 20/25 to 35/40 is Severe; an IQ level below 20/25 is Profound.

MHPG (3-methoxy-4-hydroxyphenylglycol) A major metabolite of brain norepinephrine excreted in urine.

magical thinking The erroneous belief that one's thoughts, words, or actions will cause or prevent a specific outcome in some way that defies commonly understood laws of cause and effect. Magical thinking may be a part of normal child development.

micropsia The visual perception that objects are smaller than they actually are.

middle insomnia Awakening in the middle of the night followed by eventually falling back to sleep, but with difficulty.

mirroring 1) The empathic responsiveness of the parent to the developing child's grandiose-exhibitionistic needs. Parental expressions of delight in the child's activities signal that the child's wishes and experiences are accepted as legitimate. This teaches the child which of his or her potential qualities are most highly esteemed and valued. Mirroring validates the child as to who he or she is and affirms his or her worth. The process transforms archaic aims to realizable aims, and it determines in part the content of the self-assessing, self-monitoring functions and their relationships to the rest of the personality. The content of the superego is the residue of the mirroring experience. 2) A technique in psychodrama in which another person in the group plays the role of the patient, who watches the enactment as if gazing into a mirror. The first person may exaggerate one or more aspects of the patient's behavior. Following the portrayal, the patient is usually encouraged to comment on what he or she has observed.

mood A pervasive and sustained emotion that colors the perception of the world. Common examples of mood include depression, elation, anger, and anxiety. In contrast to affect, which refers to more fluctuating changes in emotional "weather," mood refers to a more pervasive and sustained emotional "climate."  Types of mood include: dysphoric, elevated, euthymic, expansive, irritable.

mood-congruent psychotic features Delusions or hallucinations whose content is entirely consistent with the typical themes of a depressed or manic mood. If the mood is depressed, the content of the delusions or hallucinations would involve themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. The content of the delusion may include themes of persecution if these are based on self-derogatory~ concepts such as deserved punishment. If the mood is manic, the content of the delusions or hallucinations would involve themes of inflated worth, power, knowledge, or identity, or a special relationship to a deity or a famous person. The content of the delusion may include themes of persecution if these are based on concepts such as inflated worth or deserved punishment.

mood-incongruent psychotic features Delusions or hallucinations whose content is not consistent with the typical themes of a depressed or manic mood. In the case of depression, the delusions or hallucinations would not involve themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. In the case of mania, the delusions or hallucinations would not involve themes of inflated worth, power, knowledge, or identity, or a special relationship to a deity or a famous person. Examples of mood-incongruent psychotic features include persecutory delusions (without self-derogatory~ or grandiose content), thought insertion, thought broadcasting, and delusions of being controlled whose content has no apparent relationship to any of the themes listed above.

N

negative symptoms Most commonly refers to a group of symptoms characteristic of schizophrenia that include loss of fluency and spontaneity of verbal expression, impaired ability to focus or sustain attention on a particular task, difficulty in initiating or following through on tasks, impaired ability to experience pleasure to form emotional attachment to others, and blunted affect.

negativism Opposition or resistance, either covert or overt, to outside suggestions or advice. May be seen in schizophrenia.

neologism In psychiatry, a new word or condensed combination of several words coined by a person to express a highly complex idea not readily understood by others; seen in schizophrenia and organic mental disorders.

neurotic disorder A mental disorder in which the predominant disturbance is a distressing symptom or group of symptoms that one considers unacceptable and alien to one's personality. There is no marked loss of reality testing ; behavior does not actively violate gross social norms, although it may be quite disabling. The disturbance is relatively enduring or recurrent without treatment and is not limited to a mild transitory reaction to stress. There is no demonstrable organic etiology.

nihilistic delusion The delusion of nonexistence of the self or part of the self, or of some object in external reality.

nystagmus Involuntary rhythmic movements of the eyes that consist of small-amplitude~ rapid tremors in one direction and a larger, slower, recurrent sweep in the opposite direction. Nystagmus may be horizontal, vertical, or rotary.

O

object relations The emotional bonds between one person and another, as contrasted with interest in and love for the self; usually described in terms of capacity for loving and reacting appropriately to others. Melanie Klein is generally credited with founding the British object-relations school.

obsession Recurrent and persistent thought, impulse, or image experienced as intrusive and distressing. Recognized as being excessive and unreasonable even though it is the product of one's mind. This thought, impulse, or image cannot be expunged by logic or reasoning.

oedipal stage Overlapping some with the phallic stage, this phase (ages 4 to 6) represents a time of inevitable conflict between the child and parents. The child must desexualize the relationship to both parents in order to retain affectionate kinship with both of them. The process is accomplished by the internalization of the images of both parents, thereby giving more definite shape to the child's personality. With this internalization largely completed, the regulation of self-esteem and moral behavior comes from within.

Oedipus complex Attachment of the child to the parent of the opposite sex, accompanied by envious and aggressive feelings toward the parent of the same sex. These feelings are largely repressed (i.e., made unconscious) because of the fear of displeasure or punishment by the parent of the same sex. In its original use, the term applied only to the boy or man.

olfactory hallucination A hallucination involving the perception of odor, such as of burning rubber or decaying fish.

ontogenetic Pertaining to the development of the individual.

operant conditioning (instrumental conditioning) A process by which the results of the person's behavior determine whether the behavior is more or less likely to occur in the future.

oral stage The earliest of the stages of infantile psychosexual development, lasting from birth to 12 months or longer. Usually subdivided into two stages: the oral erotic, relating to the pleasurable experience of sucking; and the oral sadistic, associated with aggressive biting. Both oral eroticism and sadism continue into adult life in disguised and sublimated forms, such as the character traits of demandingness or pessimism. Oral conflict, as a general and pervasive influence, might underlie the psychological determinants of addictive disorders, depression, and some functional psychotic disorders.

orientation Awareness of one's self in relation to time, place, and person.

overcompensation A conscious or unconscious process in which a real or imagined physical or psychological deficit generates exaggerated correction. Concept introduced by Adler.

overdetermination The concept of multiple unconscious causes of an emotional reaction or symptom.

overvalued idea An unreasonable and sustained belief that is maintained with less than delusional intensity (i.e., the person is able to acknowledge the possibility that the belief may not be true). The belief is not one that is ordinarily accepted by other members of the person's culture or subculture

P 

panic attacks Discrete periods of sudden onset of intense apprehension, fearfulness, or terror, often associated with feelings of impending doom. During these attacks there are symptoms such as shortness of breath or smothering sensations; palpitations, pounding heart, or accelerated heart rate; chest pain or discomfort; choking; and fear of going crazy or losing control. Panic attacks may be unexpected (uncued), in which the onset of the attack is not associated with a situational trigger and instead occurs "out of the blue"; situationally bound, in which the panic attack almost invariably occurs immediately on exposure to, or in anticipation of, a situational trigger ("cue"); and situationally predisposed, in which the panic attack is more likely to occur on exposure to a situational trigger but is not invariably associated with it.

paranoid ideation Ideation, of less than delusional proportions, involving suspiciousness or the belief that one is being harassed, persecuted, or unfairly treated.

parasomnia Abnormal behavior or physiological events occurring during sleep or sleep-wake transitions.

persecutory delusion  A delusion in which the central theme is that one (or someone to whom one is close) is being attacked, harassed, cheated, persecuted, or conspired against.

perseveration Tendency to emit the same verbal or motor response again and again to varied stimuli.

personality Enduring patterns of perceiving, relating to, and thinking about the environment and oneself. Personality traits are prominent aspects of personality that are exhibited in a wide range of important social and personal contexts. Only when personality traits are inflexible and maladaptive and cause either significant functional impairment or subjective distress do they constitute a Personality Disorder.

phallic stage The period, from about 21/2 to 6 years, during which sexual interest, curiosity, and pleasurable experience in boys center on the penis, and in girls, to a lesser extent, the clitoris.

phobia A persistent, irrational fear of a specific object, activity, or situation (the phobic stimulus) that results in a compelling desire to avoid it. This often leads either to avoidance of the phobic stimulus or to enduring it with dread.

piblokto  A culture specific syndrome of Eskimos involving attacks of screaming, crying, and running naked through the snow

preconscious Thoughts that are not in immediate awareness but that can be recalled by conscious effort.

pregenital In psychoanalysis, refers to the period of early childhood before the genitals have begun to exert the predominant influence in the organization or patterning of sexual behavior. Oral and anal influences predominate during this period.

pressured speech Speech that is increased in amount, accelerated, and difficult or impossible to interrupt. Usually it is also loud and emphatic. Frequently the person talks without any social stimulation and may continue to talk even though no one is listening.

prevalence Frequency of a disorder, used particularly in epidemiology to denote the total number of cases existing within a unit of population at a given time or over a specified period.

primary gain The relief from emotional conflict and the freedom from anxiety achieved by a defense mechanism. Contrast with secondary gain.

primary process In psychoanalytic theory, the generally unorganized mental activity characteristic of the unconscious. This activity is marked by the free discharge of energy and excitation without regard to the demands of environment, reality, or logic.

prodrome An early or premonitory sign or symptom of a disorder

projection A defense mechanism, operating unconsciously, in which what is emotionally unacceptable in the self is unconsciously rejected and attributed (projected) to others.

projective identification A term introduced by Melanie Klein to refer to the unconscious process of projection of one or more parts of the self or of the internal object into another person (such as the mother). What is projected may be an intolerable, painful, or dangerous part of the self or object (the bad object). It may also be a valued aspect of the self or object (the good object) that is projected into the other person for safekeeping. The other person is changed by the projection and is dealt with as though he or she is in fact characterized by the aspects of the self that have been projected.

projective tests Psychological diagnostic tests in which the test material is unstructured so that any response will reflect a projection of some aspect of the subject's underlying personality and psychopathology

prosopagnosia Inability to recognize familiar faces that is not explained by defective visual acuity or reduced consciousness or alertness.

pseudocyesis Included in DSM-IV as one of the somatoform disorders. It is characterized by a false belief of being pregnant and by the occurrence of signs of being pregnant, such as abdominal enlargement, breast engorgement, and labor pains.

pseudodementia A syndrome in which dementia is mimicked or caricatured by a functional psychiatric illness. Symptoms and response of mental status examination questions are similar to those found in verified cases of dementia. In pseudodementia, the chief diagnosis to be considered in the differential is depression in an older person vs. cognitive deterioration on the basis of organic brain disease.

psychomotor agitation Excessive motor activity associated with a feeling of inner tension. When severe, agitation may involve shouting and loud complaining. The activity is usually nonproductive and repetitious, and consists of such behavior as pacing, wringing of hands, and inability to sit still.

psychomotor retardation Visible generalized slowing of movements and speech.

psychosexual development A series of stages from infancy to adulthood, relatively fixed in time, determined by the interaction between a person's biological drives and the environment. With resolution of this interaction, a balanced, reality-oriented development takes place; with disturbance, fixation and conflict ensue. This disturbance may remain latent or give rise to characterological or behavioral disorders.

psychotic This term has historically received a number of different definitions, none of which has achieved universal acceptance. The narrowest definition of psychotic is restricted to delusions or prominent hallucinations, with the hallucinations occurring in the absence of insight into their pathological nature. A slightly less restrictive definition would also include prominent hallucinations that the individual realizes are hallucinatory experiences. Broader still is a definition that also includes other positive symptoms of Schizophrenia (i.e., disorganized speech, grossly disorganized or catatonic behavior). Unlike these definitions based on symptoms, the definition used in DSM-II and ICD-9 was probably far too inclusive and focused on the severity of functional impairment, so that a mental disorder was termed psychotic if it resulted in "impairment that grossly interferes with the capacity to meet ordinary demands of life." Finally, the term has been defined conceptually as a loss of ego boundaries or a gross impairment in reality testing. Based on their characteristic features, the different disorders in DSM-IV emphasize different aspects of the various definitions of psychotic.

psychotropic medication Medication that affects thought processes or feeling states.

AUTISM:

* associated with congenital rubella, PKU, tuberous sclerosis, Rett's disorder.

*show more evidence of perinatal complications

*have significantly more minor congenital physical anomalies than siblings & controls

*4-32% - Grand Mal seizures

*20-25% - ventricular enlargement on CT

*10-83% - various non-specific EEG abnormalities with some indication of failed cerebral lateralisation

*recently one MRI study showed hypoplasia of cerebellar vermal lobules 6 & 7

*another MRI study showed cortical abnormalities particularly polymicrogyria. May reflect abnormal cell migration in first 6 months of gestation

*Autopsy study showed decreased Purkinje cell counts, increased total brain volume, greates avg percentage increase in Occipital, parietal & temporal lobe. No difference in frontal lobes

*PET scan increased diffuse cortical metabolism

* 1/3 patients increased plasma serotonin.

*withdrawl & stereotypies showed increased CSF homovalinic acid. some evidences indicate that symptom severity decreases as ratio of CSF 5-HIAA to CSF HVA increases
ADHD:

*most children do not show evidence of gross structural damage in CNS

*some evidence suggestive that September is the peak month for births of ADHD children with or without co-morbid learning disorders

*Non-focal (soft) neurological signs are frequently seen

*PET scans show decreased cerebral blood flow & metabolic rates in frontal lobes of ADHD children
_________________

ANOREXIA NERVOSA:

*Anorexia nervosa has a negative impact on the immune system and the central nervous system (CNS).

*It is also thought to be linked to serotonin and dopamine abnormalities.

*Many anorectics are diagnosed with obsessive-compulsive behavior at some point in their lives.

*Some have an eating-disordered parent, demonstrating a possible genetic link with the disorder.

*In a long-term set of studies on fifty-one adolescents with anorexia nervosa, eighteen percent of subjects were consistently diagnosed with some type of autism-like disorder at onset and at five- and ten-year follow-ups.

*Researchers have noted that a "small but important minority" of young women with anorexia nervosa may be suffering from undetected and underlying autistic disorders.

*There is increasing speculation that the onset of anorexia has a genetic component. It has been shown that mutations in a certain gene linked to abnormalities with the neurotransmitter chemical serotonin is more common amongst sufferers of anorexia than in the general population.

*Victims of mercury, lead, beryllium and arsenic poisoning have been known to develop anorexia as a symptom thereof.

*Some psychological traits associated with anorexia are consistent with deficiencies in important vitamins and minerals, such as magnesium and the B vitamins.

*Zinc deficiency is common among anorexics, thereby resulting in heightened levels of copper which is associated with depression and nervousness.

*That these deficiencies (or untoward exposure to heavy metals) can produce powerful psychological effects, such as depression, anxiety, and loss of appetite, is not widely known.

*Anorexia is also associated with general anemia.

 

BULIMIA NERVOSA:

*Research done in 2003, shows a link to the development of bulimia nervosa with an area on the 10p chromosome.

*Familial links include a history of obesity, substance abuse, and depressive disorder.

*Twin studies also strongly support this genetic factor. While both genetics and unique environments contributed to the development of the disorder, twin studies indicate a slightly stronger effect from the genetic predisposition than from environmental circumstances.

*The protein leptin decreases hunger levels in a person, and is more often blocked in patients with bulimia causing abnormal hunger levels in comparison with the norm.

*Due to the binging and purging cycle the stomach is stretched to an enlarged state, and over the progression of time becomes more permanently enlarged, making it necessary for more food to be in the person’s stomach to reach a level of satiety. This is a primary cause of the need for a bulimic to gradually increase the caloric size of their binges, as the original quantities no longer satisfy their enlarged stomach.

 

Obsessive Compulsive Disorders

*Some research has discovered a type of size abnormality in different brain structures.

*The majority of researchers believe that there is some type of abnormality in the neurotransmitter serotonin

*Recent research has revealed a possible genetic mutation that could be the cause of OCD. Researchers have found a mutation in the human serotonin transporter gene, hSERT, in unrelated families with OCD.

*Using tools like positron emission tomography (PET scans), it has been shown that those with OCD tend to have brain activity that differs from those who do not have this disorder

*It has been theorized that a miscommunication between the orbital-frontal cortex, the caudate nucleus, and the thalamus may be a factor in the explanation of OCD.

*People with OCD may be diagnosed with other conditions, such as Tourette syndrome, compulsive skin picking, body dysmorphic disorder and trichotillomania.

*It is also interesting to note that there is some research demonstrating a link between drug addiction and obsessive compulsive disorder as well. There is a higher risk of drug addiction among those with any anxiety disorder (possibly as a way of coping with the heightened levels of anxiety), but drug addiction among obsessive compulsive patients may serve as a type of compulsive behavior and not just as a coping mechanism.

*Depression is also extremely prevalent among sufferers of OCD.

*Some cases are thought to be caused at least in part by childhood streptococcal infections and are termed P.A.N.D.A.S. (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections).

*OCD in men at least may be partially caused by low oestrogen levels

*OCD primarily involves the brain regions of the striatum and the cingulate cortex, especially the striatum.

*OCD involves several different receptors, mostly H2, M4, nk1, NMDA, and non-NMDA glutamate receptors. The receptors 5-HT1D, 5-HT2C, and the mu opioid receptor exert a secondary effect. The H2, M4, nk1, and non-NMDA glutamate receptors are active in the striatum, whereas the NMDA receptors are active in the cingulate cortex.

*The activity of certain receptors is positively correlated to the severity of OCD, whereas the activity of certain other receptors is negatively correlated to the severity of OCD. Those correlations are as follows:

*Activity positively correlated to severity:

H2
M4
nk1
non-NMDA glutamate receptors

*Activity negatively correlated to severity:

NMDA
mu opioid
5-HT1D
5-HT2C

*The central dysfunction of OCD involves the receptors nk1, non-NMDA glutamate receptors, and NMDA, whereas the other receptors exert secondary modulatory effects.

*Pharmaceuticals that act directly on those core mechanisms are aprepitant (nk1 antagonist), riluzole (glutamate release inhibitor), and tautomycin (NMDA receptor sensitizer). The drugs that are popularly used to fight OCD lack efficacy because they do not act upon the core mechanisms.

BIPOLAR DISORDER:

*Bipolar disorders research Bipolar disorder runs in families. More than two-thirds of people with bipolar disorder have at least one close relative with the disorder or with unipolar major depression, indicating that the disease has a genetic component.

*Studies seeking to identify the genetic basis of bipolar disorder indicate that susceptibility stems from multiple genes.
*The monozygotic concordance rate for the disorder is 70%. This means that if a person has the disorder, an identical twin has a 70% likelihood of having the disorder as well. Dizygotic twins have a 23% concordance rate. These concordance rates are not universally replicated in the literature, recent studies have shown rates of around 40% for monozygotic and <10% for dizygotic twins.

In 2003, a group of American and Canadian researchers published a paper that used gene linkage techniques to identify a mutation in the GRK3 gene as a possible cause of up to 10% of cases of bipolar disorder. This gene is associated with a kinase enzyme called G protein receptor kinase 3, which appears to be involved in dopamine metabolism, and may provide a possible target for new drugs for bipolar disorder

*PET & MRI studies have found anatomical differences in areas such as the prefrontal cortex and hippocampus
_________________

 

Evidence that a single nucleotide polymorphism in the promoter of the G protein receptor kinase 3 gene is associated with bipolar disorder.


In a genome-wide linkage survey, evidence suggesting that the chromosome 22q12 region contains a susceptibility locus for bipolar disorder (BPD).

Two independent family sets yielded lod scores suggestive of linkage at markers in this region near the gene G protein receptor kinase 3 (GRK3).

GRK3 is an excellent candidate risk gene for BPD since GRK3 is expressed widely in the brain, and since GRKs play key roles in the homologous desensitization of G protein-coupled receptor signaling.

It was also shown GRK3 expression to be induced by amphetamine in an animal model of mania using microarray-based expression profiling.

To identify possible functional mutations in GRK3, the putative promoter region, all 21 exons, and intronic sequence flanking each exon, in 14-22 individuals with BPD were sequenced.

Six sequence variants in the 5'-UTR/promoter region, but no coding or obvious splice variants were found.

Transmission disequilibrium analyses of one set of 153 families indicated that two of the 5'-UTR/promoter variants are associated with BPD in families of northern European Caucasian ancestry.

A supportive trend towards association to one of these two variants (P-5) was then subsequently obtained in an independent sample of 237 families.

In the combined sample, the P-5 variant had an estimated allele frequency of 3% in bipolar subjects, and displayed a transmission to non-transmission ratio of 26 : 7.7 (2=9.6, one-sided P value=0.0019).

Altogether, these data support the hypothesis that a dysregulation in GRK3 expression alters signaling desensitization, and thereby predisposes to the development of BPD.

 

 

Asperger described his patients as "little professors".Asperger's disorder or Asperger's syndrome (AS) is a pervasive developmental disorder most closely related to autism, and commonly referred to as a form of "high-functioning" autism. The term "Asperger's Syndrome" was coined by Lorna Wing in a 1981 medical paper; she named it after Hans Asperger, an Austrian psychiatrist and pediatrician whose work was not internationally recognized until the 1990s. "Aspie" is an affectionate term used by some with Asperger's syndrome to describe themselves; others prefer "Aspergian", or no name at all. Asperger's also has an especially significant part in the controversies surrounding the autism spectrum.

Non-autistics (neurotypicals) possess a comparatively sophisticated sense of other people's mental states. Most people are able to gather a whole host of information about other people's cognitive and emotional states based on clues gleaned from the environment and the other person's body language. Autists (or autistic persons) do not have this ability, and the individual with Asperger's can be every bit as "mind-blind" as the person with profound classical autism. For those who are severely affected by "mind-blindness", they may, at best, see a smile but not know what it means (is it an understanding, a condescending, or a malicious smile?) and at worst they will not even see the smile, frown, smirk, or any other nuance of interpersonal communication. They generally find it difficult or impossible to "read between the lines," that is, figure out those things a person is implying but is not saying directly. It is worth noting, however, that since it is a spectrum disorder, a few with Asperger's are nearly normal in their ability to read facial expressions and intentions of others. Those with Asperger's often have difficulty with eye contact. Many make very little eye contact, finding it overwhelming, while others have unmodulated, staring eye contact that can be "off-putting" to everyday people.

Asperger's Syndrome involves an intense level of focus on things of interest and is often characterized by special (and possibly peculiar) gifts; one person might be obsessed with 1950s professional wrestling, another with national anthems of African dictatorships, another with building models out of matchsticks. Particularly common interests are means of transportation (for example trains) and computers. In general, things with order have appeal. When these special interests coincide with a materially or socially useful task, the individual with Asperger's can often lead a profitable life — the child obsessed with naval architecture may grow up to be an accomplished shipwright, for instance. In pursuit of these interests, the individual with Asperger's often manifests extremely sophisticated reasoning, an almost obsessive focus, and eidetic memory. Hans Asperger called his young patients "little professors", based on the fact that his thirteen-year-old patients had as comprehensive and nuanced an understanding, within their area of expertise, as university professors. It is because of this that individuals with Asperger's are considered to have a higher intellectual capacity while suffering from a lower social capacity.

Autists have emotional responses as strong as, or perhaps stronger than, most "neurotypicals", though what generates an emotional response might not always be the same. What they lack is the inborn ability to express their emotional state via body language, facial expression, and nuance in the way that most neurotypicals do. Many people with Asperger's report a feeling of being unwillingly divorced from the world around them; they lack the natural ability to see the subtexts of social interaction, and equally lack the ability to broadcast their own emotional state to the world accurately.

This leads to no end of troubles both in childhood and adulthood. When a teacher asks a child with Asperger's, "And did the dog eat your homework?", the child with Asperger's will remain silent if they don't understand the expression, trying to figure out if they need to explain to the teacher that they don't have a dog and besides dogs don't generally like paper. The child doesn't understand what the teacher is asking, cannot infer the teacher's meaning or the fact that there is a non-literal meaning from the tone of voice, posture or facial expression, and is faced with a question which made as much sense to him as "did the glacier in the library bounce today?" The teacher walks away from the experience frustrated and thinking the child is arrogant, spiteful and insubordinate. The child sits there mutely, feeling frustrated and wronged.


Social interaction and cognitive patterns

Asperger's can also lead to problems with normal social interaction between peers. In childhood and teenage years, this can cause severe problems as a child or teen with Asperger's can have difficulty interpreting subtle social cues and as such be ostracized by his/her peers, leading to social cruelty. The child or teen with Asperger's is frequently puzzled as to the source of this cruelty, unaware of what he is doing "wrong". Recent efforts in the field of special education have worked to correct this problem, meeting with only minor to moderate success.

In adulthood, the person with Asperger's may find it difficult to differentiate between the smiles of a waitress waiting on his table and the woman at the next table who's interested in him. He may well wind up asking the waitress out for a cup of coffee and ignoring the woman at the next table.

The social alienation of people with asperger's syndrome is so intense from childhood that many of them have imaginary friends as companionship.

Asperger's Syndrome is hardly a guarantee of a miserable life, however — far from it. Often their intense focus and tendency to work things out logically will grant them a high level of ability in their fields of interest. Despite their difficulty with social interaction, many possess a rare gift for humor (especially puns, wordplay, doggerel, and satire) and written expression. In fact, sometimes their fluency with language is such that a number of them also qualify as hyperlexic. While their lives will probably not be considered a social success by the common standards, and there are a large number who will remain alone their entire lives, it is possible for them to find understanding people (sometimes also on the autistic spectrum, sometimes not) with whom they can have close relationships. While they face enormous obstacles, some overcome them and prosper in society. Many autists are married and have children; their children may be neurotypical or have an autism spectrum disorder. Many autists don't know they have autism and neither do their friends and family members, because milder forms of autism are widely undiagnosed and misdiagnosed by professionals and widely misunderstood.


DSM definition

Asperger's is defined in section 299.80 of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as:

Qualitative impairment in social interaction, as manifested by at least two of the following:
Marked impairments in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body posture, and gestures to regulate social interaction
Failure to develop peer relationships appropriate to developmental level
A lack of spontaneous seeking to share enjoyment, interest or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)
A lack of social or emotional reciprocity
Restricted repetitive and stereotyped patterns of behavior, interests and activities, as manifested by at least one of the following:
Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
Apparently inflexible adherence to specific, nonfunctional routines or rituals
Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
Persistent preoccupation with parts of objects.
The disturbance causes clinically significant impairments in social, occupational, or other important areas of functioning.
There is no clinically significant general delay in language (e.g., single words used by age two years, communicative phrases used by age three years)
There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills or adaptive behavior (other than in social interaction) and curiosity about the environment in childhood
Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.
The Diagnostic and Statistical Manual's diagnostic criteria have been roundly criticized for being far too vague and subjective: what one psychologist calls a "significant impairment" another psychologist may call insignificant.

A series of studies have supported the thesis that there are in fact no or only very few cases that strictly meet the above DSM-IV definition of Asperger's: patients typically show communication impairment, which then qualifies them for a diagnosis of autistic disorder and not Asperger's. See [1].


Relationship to autism

Asperger's syndrome is named after Hans Asperger.Experts today generally agree that there is no single mental condition called autism. Rather, there is a spectrum of autistic disorders, with different forms of autism taking different positions on this spectrum. But within certain circles of the autism/AS community, this concept of a "spectrum" is being severely questioned. If differences in development are purely a function of differential acquisition of skills, then attempting to distinguish between "degrees of severity" may be dangerously misleading. A person may be subjected to unrealistic expectations, or even denied life-saving services, solely on the basis of very superficial observations made by others in the community.

In the 1940s, Leo Kanner and Hans Asperger, working independently in the United States and Europe, identified essentially the same population, Asperger's group being perhaps more "socially functional" than Kanners as a whole. Some of Kanner's originally identified autistic children, might today get an Asperger's syndrome diagnosis, and vice versa. It is a mistake to say that a "Kanner autistic" is a child who sits and rocks and does not communicate. Kanner's study subjects were all along the spectrum.

Researchers are grappling with the problem of how to divide up the spectrum. There is no easy way to do this. It would appear that one can divide the population of autistics in any particular way and define the group accordingly. Autistics who speak, those who don't. Autistics with seizures, those without. Autistics with more "stereotypical behaviors", those with less, and so forth. Some are trying to identify genes associated with these traits as a way to make logical groupings. Eventually, one may hear about autistics with or without the HOXA 1 gene, with or without changes to chromosome 15, etc.

Kanner's syndrome is described in the article autism.

According to Dr. Peter Szatmari, and others in the field of autism research, if one strictly applies the DSM-IV guidelines, then, in fact, there are almost NO people with "Asperger's syndrome" pointing to the flawed nature of the DSM-IV description.


Leo Kanner discovered another form of autism around the same time as Hans Asperger.Dr. Sally Ozonoff, of the University of California at Davis's MIND institute, argues that there should be no dividing line between "high-functioning" autism and Asperger's, and that the fact that some don't start to produce speech until a later age is no reason to divide the two groups, as they are identical in the way they need to be treated.

Asperger's Syndrome and other forms of autism are often grouped together in a Pervasive Developmental Disorder family.


Probable causes and origins

The causes and origins of autism and Asperger's syndrome is a source of continuing conjecture and debate. Amongst several competing theories are the underconnectivity theory developed by cognitive scientists at Carnegie Mellon University and the University of Pittsburgh, the Neanderthal theory, the extreme male brain theory by simon baron cohen, the lack of theory of mind, and the Preoperational-autism theory, which states that autistic people are those who get neurologically stuck at the pre-operational stage of cognitive development, where much of information processing is at a wholistic-visual level and largely non verbal and musical. This also addresses the issue of the theory of mind where children at the pre-operational stage of cognitive development have not attained decentralisation from egocentrism.

The underconnectivity theory holds that autism is a system-wide brain disorder that limits the coordination and integration among brain areas. Since the brain is known to be modular, researchers examined white matter (which connects various areas of the brain like cables) with the aid of fMRI and found abnormalities in people with autism. Observation thus supports the idea that Asperger's syndrome is a deficiency in coordination among brain areas. This theory is parsimonious, in that it explains why autistic people are matured on certain dimensions eg: visual information processing and logical analysis, and yet are socially and sometimes neuro-physiologically, significantly younger to their chronological age.

Other probable theories, addresses the rise of autism in recent times. They suggests the rise of visual media and thereby the increasing central role of visual information processing in the breakdown of language and the rise of autism.


Effect on relationships

The significant others of people with Asperger's are more prone to major depression than the general population because Asperger's people often have trouble showing affection or understanding the need to show affection, and are very literal and hard to communicate with in an emotional way. It is very helpful for the spouses to read as much as they can about Asperger's syndrome, OCD, hyperlexia and other "comorbid disorders". It also helps to visit the support groups' websites online and talk with other spouses of people with Asperger's Syndrome. A spouse will often be much less angry or depressed if they understand that the Asperger's symptoms are not intentionally directed at them, but that they are part of a neurological condition. That someone does not spontaneously show affection does not necessarily mean that they do not feel it. Thus the spouse will feel a lot less rejected and be a lot more understanding. Light will be shed on the nature of the misunderstandings. They may figure out ways to work around the problems, for example being more explicit about their needs.


A gift and a curse

Recently, some researchers have speculated that many well-known people including Glenn Gould, Nikola Tesla, Albert Einstein and Isaac Newton had AS, as they showed some Asperger's related tendencies (such as intense interest in one subject and social problems); such diagnoses remain controversial, however (cf. BBC News, Einstein and Newton "had autism" (http://news.bbc.co.uk/1/hi/health/2988647.stm), 30 April 2003). The obvious social contributions of such individuals has led to a shift in the perception of Asperger's and autism away from the simple view of a disease just needing to be cured towards a more complex view of a syndrome with both advantages and disadvantages. There is a semi-jocular theory within science fiction fandom, for example, which argues that many of the distinctive traits of that subculture may be explained by the speculation that a significant portion thereof is composed of people with Asperger's. A Wired Magazine article called The Geek Syndrome (http://www.wired.com/wired/archive/9.12/aspergers_pr.html) suggested that Asperger's syndrome is more common in the Silicon Valley, a haven for computer scientists and mathematicians. It created an enduring myth popularized in the media and self-help books that "Geek Syndrome" equals Asperger's syndrome, and precipitated a rash of self-diagnoses. Though these conditions do share overlap, there is a consensus that most geeks are arguably "variant normal" and do not exhibit autistic spectrum behaviors.


Asperger's in the media

Detective Robert Goren from the television series Law & Order: Criminal Intent, has a touch of Asperger's Syndrome. The series has also dealt with a suspect who has a much more pronounced form. Detective Adrian Monk of the television series Monk may very well also have the syndrome.

Detective Vic Mackey from the television series The Shield has a son, Matthew, diagnosed with Asperger's Syndrome.

Georgia Lass from Dead Like Me, with her dead-pan facial expressions, blunt communication style and (earlier in the series) her awkward social skills, may have Asperger's Syndrome.

In production in 2004, the film Mozart and the Whale is a love story between two people with Asperger's Syndrome.

In The Curious Incident of the Dog in the Night-Time, a novel by Mark Haddon, the narrator is a 15 year old boy with Asperger's Syndrome.

Luke Jackson and his family starred in the British TV program, My Family and Autism (http://www.bbc.co.uk/ouch/tvradio/autism/). Luke is about 14 and has Asperger's Syndrome. He has a brother with dyslexia, a brother with ADHD and a brother with profound autism. He also has three neurotypical sisters. He has written a book called "Freaks, Geeks and Asperger Syndrome" (ISBN 1843100983) which focuses on Asperger's and how it affects teenagers.


Criticisms

Some people, including people diagnosed with Asperger Syndrome argue that asperger's syndrome is a social construct. Professor Simon Baron-Cohen of the Autism Research Centre has written a book arguing that Asperger Syndrome is an extreme version of the way in which men's brains differ to women's. He says that in general men are better at systemizing than women, and that women are better at empathizing than men. Hans Asperger himself is quoted as saying that his patients have 'an extreme version of the male form of intelligence'.


References

[1] Mayes SD, Calhoun SL, Crites DL: Does DSM-IV Asperger's disorder exist?, Journal of Abnormal Child Psychology 2001 June; 29(3), pages 263–271, online version (http://www.findarticles.com/cf_0/m0902/3_29/76558499/p1/article.jhtml)

The ADHD-Autism Connection: A Step toward more accurate diagnosis and effective treatment, by Diane M. Kennedy, ISBN 1578564980 (The aim of this book is to explore the similarities that attention deficit hyperactivity disorder (ADHD) shares with a spectrum of disorders currently known as pervasive developmental disorders.)

Asperger's Syndrome — A Guide for Parents and Professionals by Tony Atwood. This book is considered to be the Bible as far as general AS books go.

Martian in the Playground by Claire Sainsbury. This book is all about the schoolchild with Asperger's Syndrome.

Freaks, Geeks and Asperger's Syndrome by Luke Jackson. This book won the National Association of Special Educational Needs Children's book award. It is written by someone who has gone though all the experiences he is writing about.

Men, Women and the Extreme Male Brain by Simon Baron-Cohen. The author proposes the theory that autism and Asperger Syndrome can be explained as extreme examples of the male type of mind.

Level 1 Defense Mechanisms - Almost always pathological; for the user these three defenses permit someone to rearrange external reality (and therefore not have to cope with reality); for the beholder, the users of these mechanisms frequently appear crazy or insane. These are the "psychotic" defenses, common in overt psychosis, in dreams, and throughout childhood.

Denial - a refusal to accept external reality because it is too threatening. There are examples of denial being adaptive (for example, it might be adaptive for a person who is dying to have some denial)

Distortion - a gross reshaping of external reality to meet internal needs

Delusional Projection - frank delusions about external reality, usually of a persecutory nature

Level 2 Defense Mechanisms are seen frequently in adults and are common in adolescents. For the user these mechanism alter distress and anxiety caused by reality or other people; while for the beholder, people who use such defenses are seen as socially undesirable, immature, difficult and out of touch. They are considered "immature" defenses and almost always lead to serious problems in a person's ability to cope with the world. These defenses are seen in severe depression, personality disorders, and adolescence. They include:

Fantasy - tendency to retreat into fantasy in order to resolve inner and outer conflicts

Projection - attributing one's own unacknowledged feelings to others; includes severe prejudice, severe jealousy, hypervigilance to external danger, and "injustice collecting". (remember that projection is a primitive form of paranoia, so it is common in today's world)

Hypochondriasis - the transformation of negative feelings towards others into negative feelings toward self, pain, illness and anxiety

Passive Agressive Behavior - aggression towards others expressed indirectly or passively

Acting Out Behavior - direct expression of an unconscious wish or impulse to avoid being conscious of the emotion that accompanies it


Level 3 Defense Mechanisms are often considered "neurotic" but are fairly common in adults. They can have short-term advantages in coping, but they often cause long-term problems in relationships, work, and enjoyment of life for people who primarily use them as their basic style of coping with the world. They include:

Intellectualization - separation of emotion from ideas; thinking about wishes in formal, affectively bland terms and not acting on them

Repression - seemingly inexplicable naivete, memory lapse, or lack of awareness of physical status; the emotion is conscious, but the idea behind it is absent

Reaction Formation - behavior that is completely the opposite of what one really wants or feels (e.g, taking care of someone when what one really wants is to be taken care of; studying to be a pilot to cover-up being afraid to fly). Note - this can work in the short term as an effective strategy to cope, but will eventually break down.

Displacement - separation of emotion from its real object and redirection of the intense emotion toward someone or something that is less offensive or threatening in order to avoid dealing directly with what is frightening or threatening

Dissociation - temporary and drastic modification of one's personal identity or character to avoid emotional distress

Rationalization :is the process of constructing a logical justification for a decision that was originally arrived at through a different mental process.


Level 4 Defense Mechanisms are common among most "healthy" adults and are considered the most "mature". Many of them have their origins in the "immature" level, but have been honed by the individual to optimize his/her success in life and relationships. Use of these defenses gives the user pleasure and feelings of mastery. For the user, these defenses help them to integrate many conflicting emotions and thoughts and still be effective; and for the beholder their use by someone is viewed as a virtue. They include:

Sublimation - transformation of negative emotions or instincts into positive actions, behavior, or emotion

Altruism - constructive service to others that brings pleasure and personal satisfaction

Suppression - the conscious decision to delay paying attention to an emotion or need in order to cope with the present reality; able to later access the emotion and accept it.

Anticipation - realistic planning for future discomfort

Humor - overt expression of ideas and feelings (especially those that are unpleasant to focus on or too terrible to talk about) that gives pleasure to others; (humor lets you call a spade a spade, while "wit" is actually a form of displacement.

Wernicke’s encephalopathy
An acute reaction to severe thiamine deficiency mostly d/t chronic alcohol use.
C/b ocular signs (nystagmus & external ophthalmoplagia)
Higher mental function disturbance(disorientation, confusion, recent memory disturbances)
Apathy & ataxia.
Peripheral neuropathy & malnutrition may be co-existent.

Korsakoff’s psychosis
Also d/t severe thiamine deficiency d/t chronic alcohol use.
C/b amnestic syndrome with gross memory disturbances
Confabulation
Insight often impaired.

Marchiafava-Bignami syndrome
A rare disorder most probably d/t alcohol-related nutritional deficiency.
C/b disorientation, personality & intellectual deterioration, hallucinations, epilepsy, dysarthria, ataxia & spastic limb paralysis.

Holiday Heart
Atrial or ventricular arrhythmias, especially paroxysmal tachycardia, after drinking a binge of alcohol in individuals showing no other evidence of heart disease.

Hemp insanity (cannabis psychosis)
Asso with cannabis.
Acute schizophreniform disorder with disorientation & confusion
Good prognosis.

Amotivational syndrome
Lethargy, apathy, loss of interest, anergia, reduced drive & lack of ambition d/t chronic cannabis use.

Van Gogh syndrome
Dramatic self-mutilation occurring in schizophrenia.

Pfropf schizophrenia
A syndrome of schizophrenia occurring in presence of mental retardation.

Oneiroid schizophrenia
A subtype of schizophrenia with acute onset, clouding of consciousness, disorientation, dream-like states & perceptual disturbances with rapid shifting.

Alice in Wonderland syndrome
Perceptual distortion of shape, size, colour& reciprocal position of objects. seen with schizophrenia, migraine

PAD syndrome
Phobic-Anxiety-Depersonalization syndrome.
Commoner in women 20-40 years.
C/b diffuse anxiety, multiple phobias, panic attacks, depersonalization, derealization & depressive features.

Othello syndrome (conjugal paranoia)
A psychosis in which the content of delusions is predominantly jealousy (infidelity) involving spouse.

Clerambault’s syndrome (erotomania)
A psychosis in which the content of delusions is erotic.
Most often in women with erotic conviction that a person with higher status is in love with the patient.

Kadinsky-Clerambault’s syndrome
A syndrome of mental automatism

Folie a deux
Induced delusional disorder c/b sharing of delusions b/w 2 persons.
So is folie a trios, folie a quatre, folie a famille…

Capgras’ syndrome (delusion of doubles)
C/b delusional conviction that other persons in environment are not their real selves but are their own doubles.
There are 4 types
1. Typical Capgras’ syndrome(illusion des sosies)- pt sees a familiar person as a stranger who is imposing as the familiar person.
2. Illusion de Fregoli pt falsely identifies strangers as familiar persons.
3. Syndrome of subjective doubles pt’s own self is perceived as being replaced by a double.
4. Intermetamorphosis pt’s misidentification is complete including both external appearance & personality.

Fregoli’s phenomenon
Delusion that a persecutor is taking on a variety of faces like an actor.

Cotard’s syndrome
Delusion that one has lost everything- possessions, strength & even bodily organs such as heart.
Seen in severe depression where pt has extreme nihilistic delusion (e.g. may think that his bowels are rotting and he will never pass stools again)

Ganser’s syndrome (hysterical pseudodementia)
Commonly found in prison inmates.
C/b vorbeireden- approximate answers- person understands nature of questions but answers wrong.

La-Belle-Indifference
Lack of concern towards symptoms despite apparent severity of disability produces.
Seen in pts with conversion & dissociation disorder(hysteria).

Briquet’s syndrome (Somatisation disorder)
A chronic or recurrent illness with either a dramatic or complicated medical history.
A pt with at least 25 unexplained medical symptoms for a diagnosis or with 20-25 unexplained symptoms for a probable diagnosis.

Munchausen syndrome (Factitious disorder, Polysurgis, Professional patients, Hospital hoboes, Hospital addiction)
Pt repeatedly simulates or fakes diseases for sole purpose of obtaining medical attention.

Munchausen syndrome by proxy
Pt intentionally produces physical signs & symptoms in another person who is under pt’s care.

Ekbom syndrome (Restless Legs syndrome)
Pt experiences extremely uncomfortable feeling in leg muscles during walking.
Asso with insomnia.

Gelineu’s syndrome
Narcolepsy.
Asso with hypersomnia.

Pickwickian syndrome
Sleep apnea commoner in elderly & obese persons, asso with hypersomnia.

Kleine-Levin syndrome
C/b hypersomnia
Hyperphagia
Hypersexuality

Clumsy Child syndrome (Motor dyspraxia, Motor skills disorder, Developmental coordination disorder)
C/b poor coordination in daily activities of life.

Idiot Savant syndrome
Pervasive impairment of functions but certain islets of precocity or splinter functions may remain.

Heller’s syndrome (Disintegrative psychosis)
A type of childhood psychosis with age of onset 3-5 years.
C/b rapid downhill course leading to deterioration & development of neurological deficits.

Asperger’s syndrome
Predominantly in boys.
Less severe form of pervasive developmental disorder
Autism without significant delay in language & cognitive development.
schizoid personality
pedantic speech
preoccupation with obscure facts

Rett’s syndrome
Occurs in girls.
After an apparently normal early development & normal head circumference at birth, there is deceleration of head growth b/w age of 5-30 months.
Loss of purposive hand movements & acquired fine motor manipulative skills with subsequent development of stereotyped hand movements.

Strauss syndrome
Attention deficit hyperkinetic disorder, Minimal brain dysfunction, Organic drivenness.

Gilles de la Tourette’s syndrome
C/b multiple motor tics
Multiple vocal tics
Duration of >1 year

Kanner syndrome
Failure to develop attachment with a parenteral figure & pre-occupation with inanimate objects.

Syndromes associated with dementia
Alzheimer’s disease
Pick’s disease
Parkinson’s disease
Shy-Drager syndrome (Multisystem degeneration)
Huntington’s chorea
Steel-Richardson syndrome (progressive Supranuclear palsy)
Binswanger’s disease (subcortical arteriosclerotic encephalopathy)
Wilson’s disease
Leigh’s disease
Creutzfeldt-Jacob disease
Gerstmann-Straussler-Scheinker disease
ALS-Parkinson’s-Dementia complex of Gaum

Syndromes associated with mental retardation
Down’s syndrome
Turner’s syndrome
Kleinfelter’s syndrome
Cri du chat syndrome
Fragile X syndrome
Hartnup’s disease
Tay-Sachs disease
Gaucher’s disease
Niemann-Pick disease
Lesch Nyhan syndrome
Hurler’s disease
Hunter’s disease
Sanfillipo’s disease
Renpenning’s syndrome
Sturge-Weber syndrome
Crouzon’s syndrome
Apert’s syndrome
De Lange syndrome (Amsterdam dwarfism)

Some Culture-Bound Syndromes are as follows

Dhat syndrome
A culture-bound syndrome prevalent in Indian subcontinent.
C/b complaint of passage of ‘dhat’ in urine.
Multiple somatic symptoms.
Asthenia
May be anxiety, depression or sexual dysfunction associated.

Koro
Prevalent in Asia including India.
Affected male pt believes that his penis is shrinking & may disappear into his abdominal wall & he may die.
Females affected infrequently, believing that their breasts & vulva are shrinking.

Amok
Prevalent in South-East Asia.
C/b sudden, unprovoked episode of rage in which affected person runs about & indiscriminately injures or kills any person who in encountered on the way.

Latah (Startle reaction)
Prevalent in South-East Asia & Japan.
More in women, c/b automatic obedience, echolalia & echopraxia.

Windigo (Wihtigo)
Prevalent in native American Indians.
Pt believes that he has been transformed into a wihtigo, a cannibal monster, occurring especially during times of starvation.

Shinkeishitsu
A defense syndrome, mainly of anxiety but with obsessive features occurring in young Japanese thrown into a modern industrial society for which they are not equipped. They feel inadequate, lost & unloved.

Susto
Occurs in Latin America.
Pt believes that his body is entered by a magical substance & that he is altered. It takes on a delusional quality.

Piblokto (Arctic Hysteria)
Occurs in Askimos.
Often female, who screams & tears off her clothes, throw herself on ice in extremely cold conditions.
She may imitate the cry of a bird or an animal.
The episode lasting for 1-2 hours, f/b amnesia of events.

Other culture-bound syndromes in India are- Suchi-bai syndrome (purity mania), Ascetic syndrome, Nuptial psychosis & Jhin-jhinia.

Phototherapy (light therapy) was introduced in 1984 as a treatment for seasonal affective disorder (mood disorder with seasonal pattern). In this disorder, patients typically experience depression as the photo period of the day decreases with advancing winter. Women represent at least 75 percent of all patients with seasonal depression, and the mean age of presentation is 40. Patients rarely present over the age of 55 with seasonal affective disorder.


Phototherapy typically involves exposing the afflicted patient to bright light in the range of 1,500 to 10,000 lux or more, typically with a light box that sits on a table or desk. Patients sit in front of the box for approximately 1 to 2 hours before dawn each day, although some patients may also benefit from exposure after dusk. Alternatively, some manufacturers have developed light visors, with a light source built into the brim of the hat. These light visors allow mobility, but recent controlled studies have questioned the utility of this type of light exposure. Trials have typically lasted 1 week, but longer treatment durations may be associated with greater response.


Phototherapy tends to be well tolerated. Some patients have complained of irritability and headache. Ophthalmic damage was reported with earlier light boxes that emitted high-intensity light over long periods of exposure. Some investigators have implicated the concurrent use of tricyclic drugs or neuroleptic agents in ophthalmic damage associated with phototherapy. Newer light sources tend to use lower light intensities and come equipped with filters; patients are instructed not to look directly at the light source. As with any effective antidepressant, phototherapy has on rare occasions been implicated in switching some depressed patients into mania or hypomania.


Phototherapy is primarily indicated in the treatment of so-called seasonal depressions. Patients with more prominent hypersomnia as a feature of their seasonal depression may show more robust response to phototherapy. However, recent data suggest that phototherapy may benefit both other types of depression and other psychiatric disorders. For example, exposure to bright light has been suggested to reduce hospital stays in depressed patients, whether or not a seasonal component is evident. Also, case reports suggest that phototherapy may alleviate depression in immobile, terminally ill patients. Some preliminary data indicate phototherapy may benefit some patients with obsessive-compulsive disorder that has a seasonal variation.


In addition to seasonal depression, the other major indication for phototherapy may be in sleep disorders. Phototherapy has been used to decrease the irritability and diminished functioning associated with shift work. Sleep disorders in geriatric patients have reportedly improved with exposure to bright light during the day. Likewise, some evidence suggests that jet lag might be responsive to light therapy.


In mammals, the photo period of the day may significantly influence circadian cycles. For example, in some mammals a decreasing photo period stimulates hormonal events that precipitate hibernation.


Circadian rhythms are frequently disrupted in major depression, resulting in sleep disturbance and other symptoms. Exposure to light results in a phase advance that shifts the phase response curve earlier in the day. In addition, light suppresses the production of melatonin from the pineal gland at night. This hormone may affect both mood and sleep cycles. The interplay of melatonin and the phase response curve in phototherapy is the focus of current investigation.


A number of controlled studies suggest that phototherapy is effective as monotherapy and as an adjunctive agent in the treatment of winter depressions. Studies have generally compared low-intensity light (<100 lux) with high-intensity light (>1500 lux). In general, patients with milder seasonal depressions appear more likely to respond to phototherapy treatment alone than do patients with more serious depression. Bipolar depression with a seasonal component frequently appears responsive to phototherapy, and these patients also appear to be more susceptible to light-induced mania.

Seasonal depressions often are characterized by the reverse neurovegetative symptoms of atypical depressions. However, studies of phototherapy in atypical depression without a seasonal component have failed to show benefit.


Research into the efficacy of phototherapy has been hindered by the lack of a placebo for bright light. Patients can differentiate low-intensity from high-intensity exposures.
_________________
DR.M.RAJARAM

Psychogenic Excoriation

Psychogenic excoriations (also called neurotic excoriations) are lesions caused by scratching or picking in response to an itch or other skin sensation or because of an urge to remove an irregularity on the skin from preexisting dermatoses such as acne (acne acné excoriee excoriée). Lesions are typically found in areas that the patient can easily reach (e.g., the face, upper back, and the upper and lower extremities) and are a few millimeters in diameter and weeping, crusted, or scarred, with occasional postinflammatory hypopigmentation or hyperpigmentation The patients usually acknowledge the self-inflicted nature of the lesions. There is an incidence of 2 percent among Dermatology clinic patients and a predominance of women. Most studies report a mean age of onset between 30 and 45 years of age, although acne acné excoriee excoriée can begin in adolescence and persist into adulthood. The mean duration of symptoms is 5 years, with a better prognosis for patients who have had the symptoms for less than 1 year.

The behavior in psychogenic excoriation sometimes resembles obsessive-compulsive disorder in that it is repetitive, ritualistic, and tension reducing, and patients attempt (often unsuccessfully) to resist excoriating, a behavior they find ego-dystonic. Patients also sometimes describe obsessions about an irregularity on the skin or preoccupations with having smooth skin and may excoriate in response to the thoughts. The preoccupation with appearance can be severe enough to meet criteria for body dysmorphic disorder, a disorder also thought to be related to obsessive-compulsive disorder. The excoriative behavior can also have features characteristic of impulse-control disorders in that the patients often act automatically and sometimes experience increased tension before the behavior, with transient pleasure or relief immediately afterward. Thus, behaviors can span a compulsivity-impulsivity continuum from purely obsessive-compulsive to purely impulsive with mixed symptoms in between.


The repetitive and tension-reducing nature of the behavior and the resistance to performing the behavior are consistent with compulsions. Obsessive features include the preoccupation with a flawless complexion and cleanliness. The automatic enactment of the excoriation and the sense of tension before the behavior and pleasure upon acting are characteristic of impulsivity.


Studies examining the psychiatric comorbidity of patients with psychogenic excoriation found depressive and anxiety disorders to be common. A recent report noted that patients with impulsive excoriative behavior had a high rate of comorbid bipolar disorders, consistent with studies of other impulse-control disorders in which bipolar disorders are frequently comorbid.
Case reports and open trials demonstrate the responsiveness of compulsive skin picking or scratching to treatment with the serotonin reuptake inhibitors fluoxetine (Prozac), sertraline (Zoloft), clomipramine (Anafranil), and fluvoxamine (Luvox). One controlled trial of the treatment of psychogenic excoriation found that fluoxetine may be beneficial. There are also case reports of successful treatment of psychogenic excoriation and acne acné excoriee excoriée with behavioral therapy.


Trichotillomania


Trichotillomania is a disorder of chronic hair pulling currently classified as an impulse-control disorder in DSM-IV, but like psychogenic excoriations, the hair pulling has characteristics of both impulsivity and compulsivity. It causes significant distress or impairment in functioning and leads to notable alopecia, most commonly of the scalp hair, but lashes, brows, pubic hair, and other body hair may be involved (Patients may also develop infections at the site of hair pulling, a change in texture or color of the hair or carpal tunnel syndrome from pulling. In a survey of college freshmen, the lifetime prevalence of trichotillomania (by strict criteria) was 0.6 percent for both men and women but rose to 3.4 percent for women and 1.5 percent for men if all hair pulling with noticeable hair loss was included. The condition typically persists for years, with a mean age of onset of 13 years. The prognosis appears to be better with hair pulling of 6 months' duration or less, but most do not seek treatment.


In the focused style, patients focus solely on the pulling without attention to other thoughts and activities. Symptoms resemble obsessive-compulsive disorder in that there is resistance to the pulling and relief with pulling. However, most patients engage in an automatic style of pulling that occurs during situations described as "sedentary or contemplative" such as reading or watching TV. Many patients have a combination of these two styles.

In clinical samples of trichotillomania, Axis I comorbidity included anxiety, mood, obsessive-compulsive, substance use, and eating disorders. The most frequent comorbid Axis II disorders included Cluster B (histrionic, borderline) personality disorders and Cluster C (obsessive-compulsive, passive-aggressive) personality disorders. However, whether one particular personality disorder is characteristic of patients with trichotillomania is unclear. Patients with trichotillomania frequently have first-degree relatives with obsessive-compulsive disorder and trichotillomania, and family histories of mood disorders, substance use disorders, anxiety disorders, and schizophrenia.


In a double-blind crossover study, trichotillomania responded preferentially to the antiobsessional agent clomipramine over desipramine, and in another report, response to clomipramine negatively correlated with anterior cingulate and orbital frontal metabolism on position emission tomography (PET) examination, a finding also characteristic of obsessive-compulsive disorder. Open studies of the antiobsessional SSRI fluoxetine reported positive short- and long-term results, but controlled studies have yielded mixed results. Two placebo-controlled studies found that fluoxetine was not superior to placebo in the treatment of trichotillomania, but in a double-blind crossover study of clomipramine and fluoxetine, both medications had positive treatment effects on trichotillomania. Case reports and open trials also relate successful treatment with other SSRIs including fluvoxamine, paroxetine (Paxil), and sertraline, and other antidepressants, lithium, and buspirone (Buspar). Pimozide augmentation of clomipramine or fluoxetine and olanzapine augmentation of fluoxetine have also proved useful in case studies. The behavioral treatment of habit reversal was reported effective in trichotillomania and involves increasing awareness of situations or stressors associated with hair pulling, relaxation training, and competing response training. Hypnosis and other behavioral treatments have also been useful in case reports.


Onychophagia


Onychophagia (repetitive nail biting) is a common behavior that can begin as early as age 4, with a peak between the ages of 10 and 18 years of age and appears to be familial. Severe onychophagia can lead to significant medical and dental problems such as hand infection and craniomandibular disorders. Onychotillomania, the picking or tearing of the nail, may be a variant of the behavior. Like trichotillomania and psychogenic excoriation, onychophagia possesses the phenomenological features of repetition, resistance, and relief and may therefore be one of the obsessive-compulsive spectrum disorders. Like trichotillomania, a double-blind crossover study demonstrated that onychophagia responded preferentially to clomipramine over desipramine. Many forms of behavioral therapy, including habit reversal, have been efficacious.
_________________
DR.M.RAJARAM

Commonly used defense mechanisms:

1. Repression
- Unconsciously expelling the anxiety provoking ideas or feeling from conscious awareness
Eg. Forgetting, Slips of tongues
Clinical Illustration : Psychogenic Amnesia

2. Regression
- Reversion to Childhood’s psychological functioning
Eg. Playful childlike activities
Clinical Illustration : Neuroses, Psychoses

3. Denial
- Involuntary exclusion of unpleasant & painful reality from conscious awareness
Eg. Grief 3 – 6 years olds
Clinical Illustration : Psychoses, Terminal Illness

4. Conversion
- Repressed forbidden urge is simultaneously kept out of awareness & also expressed in disguised or symbolic form of Somatic Disturbance (Mostly sensory & Motor)
E.g. During Catastrophic stress
it always implies a psychopathology
Clinical Illustration : Hysteria (Conversion Disorder)

5. Dissociation
- Involuntary splitting of mental function from rest of the personality & allowing the forbidden impulses to express out without having any sense of responsibility for actions
Eg. Near Death Experience
Clinical Illustration : Fugue, Amnesia, Mulitiple Personality, Possesion Syndrome, Somnabulism, Dissociative Disorder.

6. Displacement
- Unconcious shifting of emotions aroused out of threatening external object.
Eg. Deflection of anger on a substitute target.
Clinical Illustration : Phobia, Obsessive Compulsive Disorder

7. Rationalization
- Providing Logical explanations for irrational behaviour motivated by unacceptable unconscious wishes.
Eg. a universal phenomenon
Clinical Illustration : Usually used to explain behaviours resulting from other defense mechanisms.

8. Projection
- Unconscious attributions of one’s own attitudes and urges to other person.
Eg. A universal phenomenon
Clinical Illustration : Persecutory delusions and Hallucinations

9. Fixation
- Attaching oneself in an unreasonable or exaggerated way to some person or arresting emotional development.
Eg. A bacholor middle aged still depends on his mother to provide basic needs.

10. Hypochondriasis
- Unconscious transformation of unacceptable impulses into inappropriate somatic concern
Eg. Abnormal Illness Behaviour in Physically Disordered or Normal Individuals
Clinical Illustration : Hypochondriasis
_________________
©2005 DR.M.RAJARAM

Mental Retardation

 

Mental Retardation is below average general intellectual functioning originating during the development period and associated with Impairment in Adaptive Behaviour.

 

            Arrested or Incomplete Development of Mind

            Subnormal State of Intelligence

            It is not an illness, but a condition of poor development of Brain

 

 

Age à before 18 years

 

            1 to 2 % of General Population

            Growth & Development is Slow

            Associated Conditions like Fits, Hearing Problem, Visual Problem or Physically Handicap or Behavioural Problems.

 

            When the Mental age lesser than the Physical Age, Such child is considered Mentally Retarded.

 

Intelligence of a person is referred à Intelligence Quotient

 

                 Mental Age

IQ =    ----------------------   X 100

            Chronological Age

 

IQ = < 70 – Mental Retardation

 

 

Classification – On the Basis of IQ

 

1. Mild Mental Retardation                   50 – 69

2. Moderate Mental Retardation           35 – 49

3. Severe Mental Retardation                20 – 34

4. Profound Mental Retardation            Below 20

 

Based on Practical Classification

 

1. Educable Group

2. Trainable Group

3. Custodial Group

 

Recognition of Mental Retardation in Children

 

1. By talking to the parents, especially mother, in detail about the growth of the Child.
2. By observing the child’s physical appearance and behaviour.

 

Important Mile Stones

 

            3 Months                      - Holding Neck Erect

 

            6 Months                      - Sitting with Support

 

            9 Months - 1 Year        -  Walking

 

            1 – 1 ½  Years             - Speaking few words or phrases

 

 

1. Below 5 Years – History of Delayed Milestones

2. Above 5 Years – History of School Failures, Behaviour Problems & Behaviour against society’s expectations.

 

Physical Appearance

 

Small or Large Head

Slanting Eyes

Thick Protruding Tongue

Microcephaly, Hydrocephalus

Rough Skin

Stunted Growth

 

Causes of Mental Retardation

 

Genetic

 

Chromosome Abnormalities

 

Down’s Syndrome

Klinefelter’s Syndrome

Turner’s Syndrome

 

Metabolic Disorders Affecting

 

Amino Acids (Eg. Phenylketonuria, Homocystinuria)

The Urea Cycle (Eg. Citrullinuria, Aminosuccinic Aciduria)

Lipids (Tay-Sach, Gaucher)

Carbohydrate (Lesch-Nyhan Syndrome)

Mucopolysaccaharidoses (Hurler, Hunter)

 

Gross Disease of the Brain

 

Tuberous Sclerosis

Neurofibromatosis

 

Cranial Malformations

 

Hydrocephalus

Microcephalus

 

Antenatal Damage

 

Infections (Rubella, Cytomegalo Virus)

Intoxications (Lead, Alcohol)

Physical Damage (Injury, Radiation)

Placental Dysfunction (Toxaemia, Nutritional Growth Retardation)

Endocrine Disorders (Hypothyroidism, Hypoparathyroidism)

 

Perinatal

 

Birth Asphyxia

Complications of Prematurity

Kernicterus

Intraventricular Haemorrhage

 

 

Post-Natal Damage

 

Injury

Lead Intoxication

Infection

Malnutrition

 

Common Causes of Mental Retardation in Our Country

 

1. Infection during Infant – Encephalities Meningitis

2. Infection during pregnancy – Rubella, Syphilis, AIDS

3. Nutritional Deficiency during Pregnancy and Childhood

4. Primary & Genetically related Causes

5. Chromosomal Abnormality – Downs Syndrome

6. Endocrine – Cretinism

7. Phenylketonuria

 

Rehabilitation

 

            Depends upon their disability

 

            Assesses through IQ & Clinical Evaluation

Problem – Three Aspects

 

1. Impairment – Brain Injury

2. Disability – Reading Arithmetic

3. Social Handicap – Occupation or Personal Relationship

 

 

Assessment

 

Whether the condition is treatable and reversible

 

Education of Mentally Retarded Children

 

Mild and Moderate Mentally Retarded

Education Program in a Special School

Specially trained Teachers

 

Training the Mentally Retarded

 

Mild & Moderate Mental Retardation

Special Training

Sheltered Workshop – Gardening, Book Binding, Paper & Cover Making

Specially trained teachers with Occupational Therapists

 

Custodial Care

 

Severe or profound mentally retarded

 

Either at home or in the institutions like Special Center or Hospital.

 

Indication for Institutional Care

 

1. Severe Mentally Retarded without any Social Support

2. Severe Mentally Retarded with Behavioural Problems

3. Severe Mental Retarded with Complications like intractable epilepsy

4. Short Time stay for Family Members [like Function Time]

 

Prevention of Mental Retardation

 

Before Conceiving (for mothers)

 

Rubella Immunisation

Genetic Counselling

Health Education – Diet, Smoking & Alcohol abstinent.

Consanguinous Marriages

 

Prenatal

 

Identification of Risk /groups

Rubella Screening

Syphilis & Aids Screening

Ultrasound Scan

            Microcephalus

            Hydrocephalus

            Multiple Births

 

Natal

 

Improved obstetric & Natal Care

 

Postnatal

 

Neonatal Screening of treatment of Hypothyroidism

Immunisation – Encephalitis & Meningitis

Reduce Child abuse, Road Traffic Accident & Home Accident

 

Health Education

 

Mental Retardation cannot be cured, but can b improved through proper care

Mental Retardation improved with training but slowly

Require Good Food, Love & Affection, Special Education & Training, Good Social Support

Controlling systemic infections

 

 

Parent’s Counselling

 

 

 

 

 

 

DISSOCIATIVE AND CONVERSION DISORDERS

 

hysteria has various contexts are:

 

1. Impulsive, uncontrolled behavior (impulse dyscontrol).

2. Manipulative, dramatic, exhibitionistic, emotional and/or seductive behavior (histrionic personality traits).

 

3. Absence of objective signs of an organicillness.

4. Presence of multiple vague somatic symptoms, especially in a female patient (masked depression, somatization disorder Or Briquet’s  hysteria).

5> Hypochondnasis.

6. Any mental illness.

7. Presence of certain symptoms which are not explainable in the context of present organic illness (functional overlav, conversion symptoms).

 

8. Difficult patient; poor doctor-patient communication,

9. 'Sick' role or 'abnormal illness behavior'.

10. Psychosomatic disorders.

1L Malingering.

12. Psychosexual dysfunctions,

Conversion Disorder

 

1. Presence of symptoms or deficits affecting motor or sensory function, suggesting a  medical  or neurological disorder.

 

2. Sudden onset.

 

3. Development of symptoms usually in the presence of a significant psychosocial stressor(s).

 

4. A clear temporal relationship between stressor and development or exacerbation of symptoms,

 

5. Patient does not intentionally produce symptoms.

 

6. There is usually a 'secondary gain' (though not required by ICD-10 for diagnosis).

 

7. Detailed physical examination and investigations do not reveal any abnormality that can explain the symptoms adequately.

 

8. The symptom may have a ‘symbolic' relationship with the stressor/conflict.

 

1. Dissociative Motor Disorders

 

The motor disturbance usually involves

The 'paralysis' - monoplegia, paraplegia or quadriplegia. Examination shows normal or voluntarily increased tone and normal reflexes.

 

The 'abnormal movements’, gait, gait disturbance {aslasia abasia) is usually characterized by a wide-based, staggering, Jerky, dramatic and irregular gait with exaggerated body movements.

 

 

2. Dissociative Anesthesia and Sensory Loss (Sensory Disorders)

 

sensory disturbance 'glove and stocking anesthesia (absence of all sensations with an abrupt boundary, not confirming with the distribution of derma tomes, and usually limiting at wrists and ankles), hemianesthesias blindness or contracted visual fields (‘tubular vision’) and deafness.

 

 

3. Dissociative Convulsions (Hysterical Fits)

 

'hysterical fits' or pseudoseizures, convulsive movements and partial loss of consciousness

 

 

2. Dissociative Disorder

 

1. Disturbance in the normally integrated functions of consciousness, identity and/or

memory. .

2. Onset is usually sudden and the disturbance is usually temporary- Recovery is often abrupt,

3. Often, there is a precipitating stress before the onset. There is a clear temporal relationship between the stressor and the onset of the illness- A frequent stressful situation is an ongoing war.

4. A 'secondary gain' resulting from the development of symptoms may be found.

 

 

1. Dissociative Amnesia

 

adolescent and young adults (females more than males, except in war), it is characterized by a sudden inability to recall important personal information (amnesia), particularly concerning stressful or traumatic life events.

 

Types of Dissociative Amnesia

 

1. Circumscribed Amnesia (Commonest Type) :

 

There is an inability to recall all the personal events during a circumscribed period of time, usually corresponding with the presence of the stressor.

 

2- Selective Amnesia (less common) :

 

This is similar to circumscribed amnesia but there is an inability to recall only some selective personal events during that period while some other events during the same period rnay be recalled.                          .

 

3. Continuous Amnesia (eare)

 

In. this type, there is an inability to recall all personal events following the stressful event, till the present time

 

4. Generalized Amnesia (very rare)

 

In this type, there is an inability to recall the personal stressful events of the whole life.

 

 

2. Dissociative Fugue

 

is characterised  by episodes of wandering away (usually from home).

 

The onset is usually sudden often in the presence of severe stress.

 

The termination is abrupt followed by amnesia for the episode

 

 

3. Multiple Personality

 (Dissociative Identity) Disorder

 

In this dissociative disorder, the person is dominated by two or more personalities of which only one is being manifest at a time.

 

Both the onset and termination of control of the each personality is sudden.

 

4. Trance and Possession Disorders

 

Trance and possession disorders {possession hysteria} are characterized by the control of person's personality by a 'spirit', during the episodes.

 

Usually the person is aware of the existence of the other (i.e. possessor), unlike in multiple personality. Theis disorder is very commonly seen in India and certain African countries.

 

5. Other Dissociative Disorders

 

 

Etiology

 

Psychodynarnic Theory

 

Behavioral Theory

 

 

Diagnosis

 

Diagnosis is not merely based on the absence of objective signs of Physical Illness, although it is very important to exclude an underlying or associated physical Illness

 

Dissociative (conversion) symptoms appearing for the first time in an elderly male, especially

 

Treatment

 

1. Behavior Therapy

 

Hysterical patients are attention seeking and their symptoms increase with focus of attention, the symptoms should be ignored; the patients treated as normals, and not given sick-role; and any improvement should be encouraged,

 

This may be achieved by one of the following methods:

 

i. Srong suggestion to return to normalcy.

 

ii. Aversion therapy

 

iii- Amplification of suggestion with hypnosis, free-association, intravenous amytal or

thiopentone (pentothal), or intravenous diazepam.

 

2. Psychotherapy with Abreaction

 

Abreaction is bringing to conscious awareness, thoughts, affects and memories for the first time.

 

This may be achieved by:

i. Hypnosis;

 

ii- Free association.

iii. Intravenous barbiturates (thiopentone) or diazepam.

 

3. Supportive Psychotherapy         /

4. Psychoanalysis

5. Drug Therapy

 

Definition: - Psychiatric Disturbances resulting from transient or permanent Central Nervous System dysfunction.

Mental Illness à Underlying Brain Pathology

1. Acute Organic Mental Disorder (Delirium)

2. Chronic Organic Mental Disorder (Dementia)

Acute Condition – Sudden Onset, Reversible Impairment with time and Treatment

Chronic condition – Insidious Onset, Progression of Deterioration is slow and often irreversible

Delirium Dementia
1. Acute Onset Insidious Onset
2. Disorientation, Anxiety & Poor Attention Disturbed Memory & Personality Deterioration
3. Perceptual Abnormalities (illusions, Hallucinations) Global Impairment & Cerebral Function
4. Clouding of Consciousness Clear Consciousness
5. Fluctuating Course Progressive Course
6. Reversible Mostly Irreversible


DELIRIUM (Acute Organic Mental Disorder)

Delirium - Transient Organic Mental Disorders

- Generalised Physiological dysfunction, Usually fluctuating in Degree.

Clinical Features

- Sudden Onset
- Prodromal Period – Insomnia and Nightmares
- Clouding of Consciousness, Drowsiness, Restlessness and Inattentiveness
- Disorientation
- Impaired Attention Span
- Confused, Incoherent and Unitelligible Talk
- Fearful Mood
- Restless & Agitation
- Illusion (Visual)
- Visual & Auditory Hallucinations
- Delusional Ideas

Symptoms Fluctuating – Quiet during day & disturbed at Night
Amnesia – Not able to remember the symptoms of Previous Night
Duration – Few days to two weeks
Mild Delirium – In elder & severly ill patient
Severe Delirium – Severe Infection, Alcohol Withdrawal, Metabolic Diseases à Liver Failure & Uremia

Important Causes

Infections – Typhoid, Pneumonia, Septicaemia
Intracranial - Encephalitis, Meningitis, Neurosyphilis
Acute Brain Disorders – Head Injury, Cerebral Haemorrhage, Hypertensive Encephalopathy
Vitamin Deficiency – Pellagra, Wernicke’s Encephalopathy
Drug Withdrawal – Opiates, Batbiturates, Alcohol (Delirium Tremens)
Drug Intoxication – Atropine, Cocaine, Bromides

Management

- Identify the Cause
- Investigate & treat the Cause
- Correct Symptoms
- Sedation for Disturbed Patients

Nursing Care

- Agitation – Physical Restraint

Patient Vital Signs

- Diet - Patients Exhausted & Die, Adequate Nourishment
- Rest
- Reassurance & Support

DEMENTIA (Chronic Organic Mental Disorder)

- Acquired Global Impairment of Intellect, Memory and Personality without Impairment of Consciousness
- Elder people – Dementia ********
- It is a Syndrome – due to disease of Brain – Chronic & Progressive in Nature
- Disturbance Higher function – Memory, thinking, Orientation, Compression, Learning Capacity, Language & Judgment
“Dementia is like a Dying Mind ina living Body”

- 5 % population aged over 65
- 10% over – 80

Classification of Dementia

1. Senile Dementia (Alzheimer’s Type)
2. Vascular Dementia
3. Dementia in Other Diseases
- Pick’s Diseases
- Creuzfeldt-Jakob Disease
- Huntington’s Disease
- Parkinson’s Disease
- HIV Disease
- Unspecified Dementia

Common Causes of Dementia

1. Degenerative (Cortical)
- Alzheimer’s Disease
- Pick’s Disease

2. Subcortical Degenerative
- Parkinson’s
- Huntington’s Disease
- Progressive Supranuclear Palsy
- Punch-drunk Syndrome

3. Infection and Inflammation
- Neurosyphilis (GPI)
- AIDS
- Creutzfeldt-Jakob Disease (Slow Virus)
- Multiple Sclerosis
- Post encephalitis

4. Toxic
- Alcohol
- Carbon Monoxide
- Heavy Metal Poisoning

5. Metabolic
- Hyupothyroidism
- Hypocalcaemi
- Hypoglycaemia
- Heptic encephalopathy
- Chronic uraemia and Dialysis
- Vit. B12 Deficiency
- Pellagra

6. Tumours
- Meningioma
- Benign Glioma
- Para-Pituitary Tumours
- Secondary Deposits
- Subdural Haematoma
- Normal Pressure Hydrocephalus

7. Trauma
- Head Injury

Clinical Features of Dementia

Impairment of Memory, Thinking & Judgement, Orientation, Comprehension & Learning Capacity, Calculation, Language

Diagnostic Criteria

1. Evidence of Organic Change
2. Evidence if Impairment in short and long-term memory
3. Impairment in Abstract Thinking, Judgment & Higher Cortical Function
4. Disturbance Interfering with work and Social Activities

Alzheimer’s Dementia

- Unknown Aetiology, Old Age (higher), Insidious Onset (Over period of Years), Presenile Period – May Occur, All Feutures Present, Brain Biopsy, Senile Plaques, Neuro Fibrillary Tangles, Granules & Ventricular Dilatation

Multi Infarct Dementia (Vascular Dementia) – Chronic Anoxia from Atherosclerosis, Cerebral and Systemic Vascular Disease, Associated with Hypertension, Course Stepwise & Fluctuating.

Pick’s Disease – Asymmetric Atrophy of the frontal and temporal lobes., Common in Females

Huntington’s Chorea - A Dementing disease with an autosomal dominant transmission, presenting with insidious onset of involuntary choreiform movement. The average age of onset is in the 30s.

Normal Pressure Hydrocephalus – Occurs mainly in the 7th and 8th decades and may be present with dementia. Unsteadiness of gait, urinary incontinence and nystagmus.
General Paralysis of Insane (GPI)

A condition of neurosyphilis leading on to dementia. Develops usually 10-20 years after initial infection (Syphilis) There is astrophy of the cerebral cortex, more severe in the frontal and temporal areas. Dementia is associated with depression, mania or schizophreniform psychosis. Other features include epilepsy, Argyll Robertson pupils, tremor, cerebellar or extra pyramidal symptoms, dysarthria, aphasia and hemiplegia

Management of Dementia

1. Drug Treatment – No Specific Drugs, Hygine, Papaverine, Piracetam, Sym**** treatment.
2. Psychosocial Management – Behavioural Methods, Milieu Therapy, Activity Engagement, Physical Exercise, Problem Oriented Approach, Reality Orientation, Organisation of Psychiatric Services

Nursing Care of Dementia

- Assess Patient’s Level of Functioning, Nurse the Patient in Familiar Surrounding, Due to Disorientation patient may be Wandering (Advice to tie ID-Card), Violent – May restrain, Simple Explanation & face to face Instruction, Stimuli – Noise – Visitors, Reassurance, Educating the Carer.

Psychiatric Aspects of Head Injury

Common Cause

- Road Accident, Fall from Height, Injury associated with alcoholism and Quarrels

Acute State

- Loss of Consciousness, Amnesia-retrograde,post traumatic, Delirium and Fits, Subdural Haematoma


Psychiatric Complication

- Dementia, Organic Personality Problem, Schizophrenia like Psychosis, Postconcussion Syndrome, Compensation Neurosis

Psychiatric Clinical Examination

Basic Information

Name, Age, Sex, Occupation, Address

Identification Marks – Medico legal purpose

Informant à to be reliable (who is staying with patient during the illness)

Chief Complaints (as patient and relative say)

General

- Sleep Disturbances, Appetite, Appearance, Sex, Personal Relationship, Day to Day Activity, Behaviour.

Schizophrenia

- Talking to Self, Laughing to Self, Hearing Voices, Suspicious about Others, Not doing any job, Lack of Personal Care, Violent behavior, Suicidal Attempt, Somebody trying to kill him, Somebody watching him.

Depression

Reduced Activity, Not talking with Others, Crying Spells, Death Wish, Guilty Feeling, Worried about Future Life.

Mania

- Excessive Talk, increased Activity, Frequently Changing the Dress, Dressed Neatly, Talk about Superior power, Talk of Wealthiness, Talking that she is the God.

Delusional disorders

- Suspicious about Wife or Husband
- Crawling sensation over the head or body

Psychotic Symptoms

- Hearing Voices, Suspicious about Others

Neurotic Symptoms

- Headache, vomiting, palpitation, Chest pain, Fear of Death, Fear of having some Illness, Fear to go to Crowded Place, Fear to Stay Alone, Fear to stay in Height Place, Repeated checking, Repeated washing, Repeated thought, multiple pain site.
Hysterical Symptoms

- Sudden fainting attack, H/O jerky movements for long time., Mute


History of Present Illness

- Onset - Sudden, gradual
- Precipitating Factors
- Course – Episodic, Progressive

H/O Previous Illness

- Past Psychiatric Consultation
- Past Medical History

Family History

- Pedigree Chart
-
- Male Female

à Mental Illness

Died

- Family Background
- Parents and Siblings
- Family History of Mental Illness

Personal Life History

A. Early Childhood

1. Developmental Mile Stones
2. Intrafamilial Relationship



B. Middle Childhood

1. Friends
2. School

C. Adolescence

1. Puberty
2. Psychosexual History
3. Dating & Peer Relationship
4. School Performance
5. Drug & Alcohol abuse

D. Early Adulthood

1. Marital and Other Adult Relationship
2. Work History
3. Recreational & Vocational pursuits
4. military History
5. Prison History

E. Middle and Old Adulthood

1. Changing Family constellation
2. Retirement
3. Loses
4. Aging

- Birth, Childhood, Education Occupation, Marriage, Sexual Practice, Mental History (Female), Habits liked Alcohol, Drugs & Smoking, Religious Practices, Hobbies, Interests, Daily Activity)

Pre morbid Personality

- Reserved (Introvert)
- Social (Extrovert)
- Suspicious (Paranoid)
- Perfectionist (Obsessive)
- Hysterical
- Antisocial
- Aggressive
- Frequent Mood Change (Cyclothymics)



Mental Status Examination

General Appearance & Behaviour

- dressing, Care of Hair, Care of Nail
- Personal Hygiene
- Psycho Motor Activity
- Touch of Surrounding or Not
- Rapport

Speech

- Tone & Quantum of Speech
- Relevant / Irrelevant
- Coherent /incoherent
- Neologism

Mood & Emotional State

- Affect – Reacting or Not
- Subjective Mood
- Objective Mood

- Depressed, Irritate, Elated, Agitated, labile Mood

Thought Form & Context

Thought form

- Circumstantialities
- Derailment
- Flight of Ideas
- Neologism
- Thought Block

Thought Context

- Delusions
- Ideas of Reference
- Obsessions
- Preoccupation with Suicidal Ideas

Perception

- Illusion
- Hallucinations

Higher Functions

1. Alertness
2. Orientation
a. Person
b. Time
c. Place

3. Attention and Concentration
4. Memory
a. Immediate
b. Recent
c. Remote

5. Abstract Thinking
6. Judgment

Insight

- Whether the person knows that he is mentally ill or not and to what extent.

Mood – Internal Emotional State of an Individual

Mood Disorder – Excessive swing of Mood

Normal – Mild Elation to Mild Depression depending on many factors.

--------------------
Classification
--------------------
1. Manic Depressive Psychosis - Bipolar Affective Disorders
2. Endogenus Depression - Major Depression
3. Neurotic Depression - Dysthymic Disorder Depression

It is the common cold of Psychiatric Illness, Commonly people says – Sad – Depressed – Down, Mood out, Dull, Lost of Interest & isolated.

========================================
Depression
========================================
– reaction to an event such as death of a loved one or Change in financial situation or it may come without any obvious external cause

--------------------
Epidemiology
--------------------
-Wide Spread Problem
-Young and Old
-Rich and Poor
-Men & Women

India – 1-6 % population
5 – 20 % Psychiatric Out Patient
Age  30 – 50 Yrs.
> 60 Yrs.  13 – 22 % Depression
Female > Male

--------------------
Major Depression
--------------------
Presence of
a. Depressed Mood
b. Loss of Interest and Pleasure
c. 4 or more of following symptoms
Feelings of worthlessness or guilt
Impaired Concentration
Loss of Energy and Fatigue
Thoughts Suicide
Loss or increase of Appetite & Weight
Insomnia or Excessive sleep
Retardation or Agitation

- Symptoms for atleast 2 weeks, Major Depression
- Major Depression may present with or without psychotic symptoms.
- Delusions, Hallucination & Bizaree Behaviour

--------------------
Dysthymic Disorder
--------------------

Depressed Mood – 2 Years
Other Symptoms
Or Sleep
Or Appetite, Energy
Self Esteem
Poor Concentration & Hopelessness

--------------------
Masked Depression
--------------------

--------------------
Seasonal Depression – Winter
--------------------

--------------------
Aetiology for Depression
--------------------

Biological Factors

Genetic Factors
- Higher among the relatives of Individual

Biochemical
- Reduced Norepinephrine, Serotonin & Dopamine
- Transposition of Sodium and Potassium

Psychological Factors
- Low Self-Esteem
- Guilt
- Lack of Support System
- Lack of Clear Goals
- Feelings of Failure
- Inability to fulfill expectations
- Separation or Object Loss

Cognitive
- Narrow negative attitude about self, environment & future, bad or inadequate judgement

Behavioural
- Hopelessness, Loss of positive reinforcement

Socio Cultural Factors
- Social Situations
- Minority Group
- Women in a male-dominant Occupation
- Role Loss (Empty nest syndrome)

Adverse Events
- Injustice
- Poverty
- Unemployment

Alcohol & Depression
- Alcohol, Drug Abuse

--------------------
Complications
--------------------

Recover spontaneously after sometime some patient may so far

His work & day to day activity suffer
Loss in productivity & financial status
Alcoholism or Drug Abuse
Suicide

--------------------
Management
--------------------
Hospitalisation Indiacation: Severe Depression, Suicidal Tendencies

Drug Therapy: Anti-Depressant

Electro-Convulsive Therapy

Psychotherapy - Problem Oriented, Positive Reinforcement, Family Therapy, Group Therapy & Cognitive Therapy

Nursing Care in Depression

Promote food intake & Sleep & Monitoring Food Intake & Drugs

Take safety measures – In suicidal tendency

Diminish feeling of loneliness

Interaction focus on present & not the past – Reassurance

Provide non-intellectual activities (Cleaning & Exercise)

Strict record of Sleeping – Discourse sleep during daytime

Health Education

Family Education

========================================
Bipolar Disorders
========================================
- Mood swings from profound depression to extreme euphoria (Mania) with intervening period of normalcy.

Mixed
Manic
Depressed

========================================
MANIA
========================================
It is mood disorder

Patient excessively Happy & Energetic

Usually occur as a part of Bipolar

Very rarely mania alone occur (recurrently)
Primary Mania  Affective or Mood Disorder
Secondary Mania  Due to Organic Disorder

--------------------
Aetiology
--------------------

Biological Factors
- Genetic Factors: Among the relative of Bipolar Disorders
- Biochemical: Excessive Serotonin & Norepinephrine

Psychological Factors
- Faulty dynamics in the family system and disturbed ego development gives way to a strong id.

--------------------
Clinical Features
--------------------
Persistently Elevated, Expansive or Irritable Mood
Inflated Self Esteem or Grandiosity
Hyperactivity or Psychomotor Agitation
Sleep Disturbance
Pressure of Speech, More Talkative
Flight of Ideas
Distracted – Poor attention Span
Pleasurable Activity – Spending, - Sexual Activity
Dress in Bright Colour, Excessive Make Up & Jewellery
Impaired Occupational Functioning
Psychotic Symptoms
Delusions, Hallucinations

--------------------
Hypomonia
--------------------
Euphoric, Elated, Dressing Colourfully, Cracking Jokes, Excessive Talk, Overactivity

Manic Excitement
Irritable, Excited, Violent

--------------------
Management
--------------------
Hospitalisation - Excited
Drug Treatment
- Anti-Psychotics
- Anti-Manic
- ECT

Nursing Care Manic Patient
Special attention to patient diet
Drugs for restlessness & overactivity
Emotional Needs
_________________
©2005 DR.M.RAJARAM