Saturday, August 25, 2007

Fish's psychopathology

Fish's psychopathology is a book read by every psychiatrist in the world I think, it is about descriptive psychopathology, and have been read by many generations of psychiatrists and it is still valid..... In my first year of residency in psychiatry I have read the book, but now in the 3rd year I found myself sometimes forgetfull about it.... this is a summary of the all book I made for myself... hope it may help some:


Fish say that there are three types of thinking:
1. Undirected fantastic autistic thinking,
2. Imaginative thinking,
3. Rational or conceptual thinking which attempt to solve problems.
Autistic thinking is quit common in shy normal people who compensate for their disappointment by it. Bleuler suggests that the schizoid individual become schizophrenic when his autistic thinking become uncontrollable.

Classification of disorders of thinking is divided into disorders of: content, form, stream, and of control.

DISORDERS OF STREAM of thought are divided into disorders of tempo and of continuity. Disorders of tempo are of three types: flight of ideas, inhibition or retardation, and circumstantiality. While disorders of continuity are of 2 types: perseveration, and blocking.
In flight of ideas the thought are linked but by chance factor or by clang association and st. described as (like domino). In hypomania a milder degree of flight of ideas occur where the patient can return back to the task in hand and this type called prolixity.
In inhibition or retardation of thinking the train of thinking is slowed. Occur in depression and st. in manic stupor.
Circumstantiality is explained to occur as a result of weakness in judgment & egocentricity. It occur in epileptic personality.
Perseveration is common in localized and generalized brain disorders. Perseveration is different from verbal stereotypy in which the same word or phrase is used regardless of the situation, whereas in perseveration a word, phrase or idea persists beyond the point at which it is relevant.
Blocking is the arrest of train of thoughts and is diagnostic of schizophrenia.

DISORDERS OF THE POSSESSION of thought or control of thinking are obsession, and thought alienation. Schneider defines obsession as when someone can not get rid of a content of consciousness, although he realizes that it is senseless or at least it is dominating & persisting without cause. Essentially it is against the patient's will. Obsessional images are vivid images which occupy the patient's mind. Obsessional impulses may be impulses to touch, count or arrange. Obsessions occur in OCD, depression, schizophrenia, and occationally in organic states, esp. postencephalitic states.
Thought alienation means the patient feels that his thoughts are under control of an outside agency. Examples are thought insertion, thought deprivation (withdrawal), and thought broadcasting. Schneider claims that these are diagnostic for schizophrenia.


Delusions are false unshakable beliefs of morbid origin & are divided into: true delusions (primary), and delusion like ideas (secondary).
Overvalued ideas occur in healthy individuals which is a thought that take precedence overall other ideas for a long time because of the associated affect tone.
PRIMARY DELUSIONS are considered diagnostic of schizophrenia, although similar experience occurs in organic states like epilepsy. Delusion like ideas occur in all psychosis. In primary delusions a new meaning arises in connection with some psychological events. Schnieder suggested three experiences: delusional mood, delusional perception, and sudden delusional idea. While Conrad has put the term apophany as a better term to describe the primary delusional experience. Conrad has proposed 5 stages in the development of delusional psychosis: Trema (delusional mood), Apophany (searching to find a meaning), Anastrophy (heightening of psychosis), consolidation (formation of new world), and Residuum (eventual autistic state).
In the delusional mood the patient knows that there is something going on around him but do not know what it is. The meaning of this mood become obvious when a sudden delusional idea (autochthonous) or a delusional perception occur.
The delusional perception (also called apophanous perception) is the attribution of new meaning to a normally perceived object. The new meaning is not arising from the patient's affect. If it did arise from the patient's affect it will be called delusional misinterpretation (e.g. paranoid who hear stairs creak and knows that a detective is spying on him).
Primary delusional experiences occur in acute schizophrenia and are not seen in chronic schizophrenia.
SECONDARY DELUSTIONS occur as a result of other morbid phenomenon. Many have stressed the role of projection in the formation of delusions. Freud tried to explain delusions of persecution as a result of latent homosexuality. Gaupp and his student Kretschmer tried to explain paranoid psychosis as a result of sensitive personalities. This sensitivity comes from a physical defect, excessive masturbation, sexual perversion, membership of a minor group and so on. After years of struggle some experience will expose the patient's weakness and he develops paranoid psychosis. This is also called kretschmer's paranoia = sensitiver beziehungswahn = delirium of self trance.
Paranoid delusions can occur in schizophrenia, endogenous depression, and psychogenic reactions.
In schizophrenia once the primary delusional experience have occurred they are integrated into some sort of system. This elaboration on delusions has been called DELUSIONAL WORK.
Delusions are said to be systemized when there is one basic delusion and the remainder of the system is logically built on this error. Systematizations appear to be linked to the retention of integrity of the personality. Completely systematized delusions are extremely rare.

CONTENT OF DELUSIONS depend on social and cultural background. Delusions have changed with time. Yet Kranz found that as depressive delusions had not changed as much as schizophrenia. Delusions of persecution occur in schizophrenia, depression and psychogenic reactions.
Delusions of influence are a logical result of experience of passivity which is diagnostic to schizophrenia.
Delusions of marital infidelity occur in schizophrenia and coarse brain disease esp. alcohol abuse.
Erotomania is also called the fantasy lover.
Grandiose delusions occur in schizophrenia, drug dependency and organic brain syndromes esp. general paresis (was 50% before the advance in treatment).
Grandiose and expansive delusions may be part of fantastic hallucinosis in which all forms of hallucination occur.
Delusions of grandeur occur in happiness psychosis when the patient believes that he is an important person and able to help others.
Delusions of ill health are characteristic to depression but occur in schizophrenia and personality disorders.
Hypochondriacal delusions e.g. belief he got lung cancer.
Nihilistic delusions are also called delusions of negation occur in depression but sometimes in delirium and schizophrenia. St. nihilistic delusions are associated with delusions of enormity when the patient believes that he can produce a catastrophe by some action, e.g. refuse to pass water because he will flood the world.
Delusions of guilt & of poverty occur in depression.

When the illness become chronic there is discrepancy between delusion and behavior, e.g. the grandiose patient may scrub the floor.
Delusions of jealousy seem to be the most dangerous kind and lead to hurting people more than other type of delusions.


Occur in schizophrenia and coarse brain disease. In schizophrenia it can be divided into positive and negative. Bleuler believed that the main feature of formal thought disorder is the lack of connection between thoughts which is caused by condensation, displacement, and the misuse of symbols.

Cameron put the list of formal thought disorder as: inco-ordination, interpenetration, fragmentation, and overinclusion which means the inability to maintain the bloundaries of a problem. Cameron also used the term asyndesis to describe the inadequate connection between thoughts. And used the term metonyms to describe the imprecise approximation in which some substitute term or phrase is used instead of the more exact one.

Glodstein sees formal thought disorder as the loss of abstract attitude leading to concrete thinking in which the patient is unable to free himself from the superficial concrete aspect of thinking.
Schneider put his list as: derailment (the thought slides on to a subsidiary thought), substitution (a major thought is substituted by a subsidiary thought), omission (sensless omission of a part of thought), fusion and driveling (intermixture of parts of one complex thought).
Schneider suggest that there are 3 features of healthy thinking: constancy, organization, and continuity. In schizophrenia these normal features change into: transitory thinking (derailment, substitution, and omission), driveling thinking (lack of organization), and desultory thinking (sudden ideas forced).


1. Stuttering and Stammering: flow of speech interrupted by a pause or by repetition of fragments of the word.

2. Mutism: comlete loss of speech. Hysterical mutism is rare. It also occur in depression, schizophrenia asp. Catatonic, disturbed children, and brain lesions.

3. Vorbeireden: deliberate talking about an associated topic. Occur in hysterical pseudodementia, and also in Ganser syndrome which is also called ganserism in which the patient got lack of insight, and st. disorientation, fluctuation of consciousness, and hysterical anaelgesia and hyperaesthesia. st. vorbeirden is found in acute schizophrenia and in chronic catatonics.
Conrad called this symptom pseudopseudodementia.

4. Neologisms: new words constructed by the patient or ordinary words which are used in special way. Neologism in catatonics may be mannerism or sterotypies. Neologisms may be the obvious result of a derailment, e.g. a patient used the word "relativity" instead of the word "relationship". Technical neologism is an attempt to find a word for an experience which is completely outside the realm of normal. Hallucinatory voices may use neologisms. Paraphasia occurs in motor aphasia as distortion of the phonetic structure of words. Malapropisms are misused words, are not of psychiatric significance except that st. used by dullards & mistaken for neologism. Speech confusion, which is also called word salad, and called by bleuler schizoaphasia, occur in few chronic schizophrenics, and the disorder of speech is much greater than the defect in intelligence.


Emotion is defined as complex feeling state with psychic, somatic, and behavioral components that is related to affect and mood.
Affect is observed expression of emotion possibly inconsistent with patient's description of emotion.
Mood is sustained emotion subjectively experienced and reported by a patient and observed by others. When unpleasant called dysphoric; when easily annoyed called irritable mood; when more cheerful than usual called elevated; and when intense elation with feeling of grandeur called euphoria; when pathological feeling of sadness called depression; when loss of interest in all pleasurable activities called anhedonia; and finally when patient is unable of got difficulty in describing or being aware of mood or emotion called alexithymia.
Some psychiatrists have divided affects into sthenic (anger, rage, hate, or joy), and asthenic (anxiety, horror, shame, grief, and sadness).
Fish classify emotional disorders into:
1. Abnormal emotional predisposition.
2. Abnormal emotional reactions.
3. Abnormal emotional expression.
4. Morbid disorders of emotion.
5. Morbid disorders of the expression of emotion.

Abnormal emotional predispositions like the hyperthymic personality where the person is over cheerful and is not affected by minor irritations of life. The dysthymic personalities always look on the sad side of life. Those were inherited temperaments. Early childhood experiences may increase emotional responsiveness leading to disinhibited behavior easily, or may decrease emotional responsiveness leading to emotionally cold personalities who got general indifference.
Children and adolescents got lack of consistency in emotional feeling which is associated with a tendency to egotism, cruelty, outbursts of emotion and overvalued thinking. This disappears with maturity. It is normal to have some degree of ambivalence but the disturbed adolescent got marked ambivalence toward his parents leading to stormy relationship.

Abnormal emotional reactions are like anxiety which is fear for no adequate reason. Some got anxious disposition i.e. got low threshold for the development of anxiety. Morbid anxiety is always accompanied by disturbance of autonomic system. They commonly got panic attacks and phobias which are fears restricted to a specific object, situation, or idea.
The emotional reaction to chronic frustration is depression. Verstimmung is translated to English as "ill-humored mood state" and is an irritable, angry depressive state which makes other unhappy as a result of their unpleasant, aggressive behavior.
Free floating anxiety is fear not attached to any idea. Fear is anxiety caused by consciously recognized and real danger. Agitation is severe anxiety with motor restlessness similar to irritability. Tension is increased and unpleasant motor and psychological activity. Apathy is dulled emotional tone associated with detachment or indifference.

Learning affects the way we express emotion. Dissociation of affect is a lack of manifestation of anxiety or fear under conditions where this would be expected e.g. la belle indifference, denial of anxiety, and derealization.
Dissociation of affect should not be applied to apathy which the loss of all feelings and is associated with a sense of futility. Apathy is common is prisons and depressed areas. Dissociation of affect should not applied also to violent criminals who discuss their crimes with indifference because they simply got used to do crimes.

The most common is depressive mood state in which the emotional resonance is abolished leading to a sense of inner emptiness or deadness and may lead to desensitization or derealization. The absent emotional resonance is most marked when the depressed meet his loved ones.
Morbid anxiety occurs in depression, and paranoid schizophrenia.
Irritability is a liability to outburst and may be a trait or cause by organisity. Ill-humored states (verstimmung) may be seen in morbid depression, schizophrenia, and organic states like epilepsy where there is what is called as ictal mood.
Morbid euphoria occurs in mania, schizophrenia and organisity. Silly euphoria with lack of foresight and general indifference occur in frontal lobe lesions and called moria or witselsucht.
Ecstatic state (ecstasy) is a sense of extreme well-being associated with a feeling of rapture, bliss, and grace. Unlike elation it is not associated with overactivity and flight of ideas. Ecstasy may be accompanied by religious themes and hearing of voices of higher beings and occur in happiness psychosis, schizophrenia, and epilepsy.

Inadequacy and incongruity of affect are characteristic of schizophrenia. The inadequacy of affect, or blunting, was called by bleuler as parathymia and it means that the patient is indifferent (loss of emotion) to his own well being and that of others.
Depressives are anything but cheerful, but they can produce the communicating smile and this is not incongruity of affect. St. we see them smile only by there lips, not by their eyes.
Liability of affect in which rapid changes of emotion occur, is found in abnormal personalities. Such as the appreciation-needing, but also st. in normal people, and in organic state like organic neurasthenia. Patients with depression are easy to made cry and made worse by sympathy. Liability of affect is also found in manic patients who show short bursts of depression and weeping.
In affective incontinence there is complete loss of control. The expression of emotion in the absence of any adequate cause is called compulsive affect and also called forced weeping and forced laughing.
Affective incontinence occurs in organic states esp. in cerebral atherosclerosis and MS.

Definitions from synopsis (kaplan and sadock's):
Shame: failure to live up to self expectation.
Guilt: emotion secondary to doing what is perceived as wrong.
Ineffability: ecstatic state in which person states it is indescribable, inexpressible, and impossible to convey to another person.
Acathexis: lack of feeling associated with an inordinarily emotionally charged subject; in cathexis the feeling is connected.
Decathexis: detaching emotions from thoughts, ideas or persons.


Jasper pointed out that there are 4 aspects of self-experience:
1. Awareness of existence & activity of the self.
2. Awareness of being a unity at any given time.
3. Awareness of continuity of identity over time.
4. Awareness of being separate from the environment (i.e. awareness of self boundaries).

Awareness of self activity means the awareness of the performance of one's actions. It is disturbed in depersonalization which is the feeling that he is no longer his normal natural self. It is often associated with a feeling of unreality so that the environment is experienced as flat, dull, and unreal, unrealisation. It is always an unpleasant experience. When first experience it is very frightening for the patient but with the course of time it is accustomed to. It is not a delusion and must be differentiated from nihilistic delusion. Depersonalization is common experience. Occur in emotional crisis or threat to life and found in anxiety states and phobias and st. in depression, schizophrenia, organisity like epilepsy.
Loss of emotional resonance is also discussed here and it makes the depressed feel more guilt.

In depression the patient may feel that he is talking and acting in an automatic way. This may lead him to say that he feels as if he is 2 persons. Naïve or appreciation needing personalities may leave this as if and say that they are 2 persons. The subject with demoniac possession feels he is 2 people, himself and the devil. Some schizophrenics also feels that they are 2 or more people.

Schizophrenic patients may feel that he is not the same person before the illness. Fantastic paraphrenics may claim that they died and born again. This also occurs in religious conversion. Multiple personalities occur in appreciation-needing personalities.

Disturbances of body image occur chiefly in organic conditions and also in hypnogogic state and in schizophrenia. Anosognosia is not only unawairness of body but also the denial of existence of disability. The depressed may say that his face become ugly. Most schizophrenic symptoms are aspects of a breakdown of the boundaries between self and environment. For example the passivity feeling where the patient knows that his actions are not his own, which is also called made and fabricated experiences. Another example is when the patient knows that his actions and thoughts have an excessive effect on the world around him (when pass urine he made bombs fall on London). Thought broadcasting is the result of loss of boundaries between self and environment.


Consciousness is the awareness of the self and the environment. Active attention is the focusing on an event. Passive attention is when the event attracts one's attention without conscious effort.
Disturbance of active attention shows itself as distractibility, so that the patient is diverted by almost all new stimuli and habituation to new stimuli takes longer than usual. This occurs in fatigue, severe depression, mania, schizophrenia, and organic states.
Consciousness can be changed in 3 ways: it may be dream like, depressed, or restricted.

Dream-like changes of consciousness (e.g. delirium tremens and occupational delirium).
There is a subjective experience of a rise in the threshold for all incoming stimuli. Disorientation for time and place occur but not to person. Visual hallucinations usually of small animals associated with fear. There is an inability between mental images and real perception. As in dreams there is displacement, condensation, and misuse of symbols. Occasionally Lilliputian hallucinations occur and are associated with feeling of pleasure. Elementary auditory hallucinations are common. The patient is fearful and st. got insomnia, and his condition is worst at night. Mild delirium is called subacute delirious state where the picture varies during the day.

Lowering of consciousness here there is no hallucinations, illusions, delusions, nor restlessness. Patient is apathetic, slow, unable to express himself clearly and may perseverate. Torpor is the best term for this. Caused by severe infection, and CVA.

Restriction of consciousness where the awareness narrowed down to few ideas with mild decrease in consciousness and might not be realized by others. Disorientation for time and place occurs but the patient is well ordered in there behavior. The term TWILIGHT STATE was introduced by WESTPHAL for conditions in which there is break in the continuity of consciousness with relatively well ordered behavior. Commonest cause is epilepsy. There is also the HYS. Twilight state in which there is temporarly solution of a psychological problem by amnesia and forgetting the identity. Wandering states with some loss of memory are called FUGUES. Not all the cases are HYS., because some depressives got it. HYS. Fugues are more common in subjects who have previously had a head injury with concussion.


The alienation of motor acts:
In obsessions and compulsions the sense of possession of the thought or act is not impaired, but described as against the will. In schizophrenia patient not only loss control over thoughts or actions but also experiences them as being foreign or manufactured against his will by some foreign influence. Known as ideas or delusions of passivity Schneider considered them as symptoms of first rank and diagnostic of schizophrenia.

Classifications of motor disorders:

disorders of adaptive movements:
disorders of expressive movement.
Disorders of reactive movement.
Disorders of goal directed movements.

Non-adaptive movements:
spontaneous movement.
Abnormal induced mevements.

motor speech disturbances in mental disorders:
attitude to conversation.
The flow of speech.
Mannerisms and stereotypies.

Disorders of posture: disturbed normal posture, manneristic posture, abnormal postures, stereotyped postures.

abnormal complex pattern of behavior:
non goal directed patterns of behavior.
Goal directed.

Disorders of expressive movements:
Different cultures got different expressive movement. In depression there is a characteristic faces (omega sign), produced by the excessive action of the corrugator muscle. In depression weeping increases. In retarded depression all body movements decrease or absent. In agitated depression the patient is restless.
Catatonics got stiff expressless face and scanty body movements. Excessive grimacing also occurs in catatonia and is best regarded as stereotypies. In catatonia the rounded lips are st. protruded forward in a tubular manner so that they are called schnauzkrampf or snout spasm and is considered as stereotyped posture.
The expresless face of Parkinsonism is called ointment face.
In mania expressive movements are exaggerated. Ecstasy or exaltation means tha patient is not restless and overactive like the maniac. Ecstasy is found in happiness psychosis, schizophrenia, epilepsy, and abnormal personalities with the appropriate religious training.
Disorders of reactive movements
Reactive movements are immediate automatic adjustments to new stimuli. With marked anxiety there may be increase in the startle reflex. In catatonia & parkinsonism they are lost.
Disorders of goal directed movement
In depression there is psychomotor retardation st..
In catatonia there is what is called as SPERRUNG which is translated as blocking or obstruction, where irregular hindrance of psychic or motor activity occur. Here the patient is unable to begin an action at one time, and then a little later be able to carry it out without difficulty. KLEIST pointed out that a characteristic feature of obstruction is " the reaction at the last moment ". With more severe grades of obstruction akinesia occurs and when the symptom is very marked stupor occurs. There are different forms of stupor.
MANNERISM is unusual repeated performances of a goal directed motor action or the maintenance of an unusual modification of an adaptive posture. Specularities of dress, hair style and writing are also mannerisms. Some German authors had used the term BIZZARIES as a synonym for mannerism, but it is also st. applied to STEREOTYPY which has no goal. St. it is difficult to ddx. Between mannerisms and stereotypies. Mannerisms can be found in relatively normal subjects, abnormal personalities, schizophrenia, and in neurological disorders. It occur in normal subjects when the subject need to be noticed and also in adolescents it is frequent due to the immaturity and insecurity. Also it occur in art when the artist do not got the artistic ability. Schizophrenic mannerisms may result from delusional ideas, and can be expression of the catatonic motor disorder. Mannerisms are not diagnostic for anything.

a. spontaneous movements: most normal subjects have motor habits which are not goal-directed and which tend to become more frequent during anxiety, e.g. scratching the head and face or touching the nose or cleaning the throat. When an animal is prevented from doing a normal pattern of behavior it may perform another pattern of movement which is non adaptive and is called DISPLACEMENT ACTIVITY.
TICS are sudden involuntary twitching of small group of muscles and are usually reminiscent of expressive movements or defensive flexes. They can occur after encephalitis, or on torsion dystonia, or in Huntington's disease. In Gilles de la Tourette's syndrome it is accompanied by vocal tics and obscene ejaculations called COPROLALIA.
Static TREMOR occurs in anxiety but not in all because there seems to be an inborn predisposition to it. Tremor can be hysterical and in world war I solders who got tremor were dx. As shell shock cases. Static tremor is st. familial and worsen with age. Organic tremor vary in intensity from day to day and are made worse by emotional disturbance.
Some had thought that TORTICOLLIS is hysterical, but now it is considered as neurological.
Snoring and sniffing also occur in Huntington's chorea and respiratory irregulatory and also hypotonia and st. hyporeflexia and st. prolongation of the muscular contraction during tendon reflex " GORDON'S PHENOMENON".
Although CHOREA and ATHETOSIS are the result of diseases of the nervous system, similar movements st. encountered in catatonia.
PARAKINETIC CATATONICS are in almost constant motion. They grimace frequently and often produce a smile like a clown this is why they were called CLOWN-LIKE. The parakinetic catatonic is usually able to answer simple questions and may be capable of simple routine work. These patients tend to touch and handle everything within reach.
STEREOTYPE movements is a repetitive non-goal directed action which is carried out in a uniform way. It may be a simple movement or a recurrent utterance when the content may be considerable e.g. a catatonic female continuously mumble the words "Eesa Marider" which appeared to be a corruption of "he is a married man" and that sign began after she knew that her fiancé whom she was pregnant from was a married man. Verbal stereotypies are present in expressive aphasia.

b. abnormal induced movement: in AUTOMATIC OBEDIENCE the patient carries out every instruction regardless of the consequences. It occurs in catatonia, but also in dementia. ECHOPRACTIC patients imitate simple actions which they see. In ECHOLALIA, the patient echoes a part or the whole of what has been said to him, even st. if not understood the language. Echo reactions occur in transcortical aphasia, dementia, severe mental retardation, epileptic personality deterioration, clouded consciousness, catatonia, fatigue, and inattentiveness in normal subjects. Schizophrenics have difficulty in understanding speech and may got echoprexia from time to time when they try to communicate with another person and was difficult to communicate verbally.
While stereotypy is a spontaneous abnormal movement, PERSEVERATION is an induced movement, but it is a senseless repetition of a goal directed action which has already served its purpose (e.g. when ask a patient to put out his tongue then put it in he continue doing that).. perseveration affects speech and it got 2 forms: LOGOCLONIA & PALILALIA. In logoclonia the last syllable of the last word is repeated (e.g. I am well today ay ay ay). In palilalia the repeated word is perseverated with increasing frequency. Logoclonia and palilalia is present in coarse brain disease esp. in Alz.. Perseveration also occurs in catatonia and coarse brain disease.

Perseveration got 3 types:
Compulsive repetition: the act repeated until the patient receives another instruction and it is more common in schizophrenia.
Impairment of switching: the repetition continues after the patient has been given a new task which is more common in dementia.
Ideational perseveration: the patient repeats words and phrases during his replay to a question and is equally common in both schizophrenia and dementia.

FORCED GRASPING is very common in chronic catatonia, but also seen in dementias. Here the patient shakes the examiner's hand despite freq. instructions not to touch the examiner's hand.
GRASP REFLEX if unilateral indicates contralateral frontal lobe lesion.
MAGNET REACTION: if the examiner rapidly touches the palm and then withdraws his finger the patient's hand may follow the examiner finger. It occurs in catatonia and coarse brain disease.
In co-operation or MITMACHEN, the body can be put into any position without any resistance by the patient, even if told to resist the movement. Once the examiner lets go of the body, the part which has been moved returns to the resting position. Found in catatonia and neurological dis..
MITGEHEN is very extreme form of co-operation. The patient moves his body in the direction of the slightest pressure on the part of the examiner. Once the pressure stops the arm returns to its former position. Also it is a must to tell the patient to resist it.
Some catatonic patients oppose all passive movements with the same degree of the force as that which is being applied by the examiner. This is known as GEGENHALTEN or OPPOSITION.
NAGATIVISM is an apparently motiveless resistance to all interferences and may or may not be associated with an outspoken defensive attitude. Found in catatonia, severe MR, and dementia. Can be passive or active. The passive he simply do not obey while in the active he will do the opposite action in a reflex way. Negativistic behavior in catatonics is almost completely abolished by drugs.
AMBITENDENCY can be regarded as a mild variety of negativism in the will or as the result of obstruction. It is ambivalence in the will. Here there is series of tentative movements which do not reach the intended goal. It occur in some negativistic patients.


attitude to conversation: negativistic patients turn away from all attempts to speak to them. Some schizophrenic are unable to maintain a conversation because they are easily distracted. Other schizophrenics got continuous auditory hallucinations which make it difficult or impossible for them to attend to what is being said. Some catatonics and paraphrenics whisper continuously and appear to be speaking to voices. Some catatonics do not answer any question, other catatonics replay with a blank face to every question even if very silly.
Flow of speech: mutism and slowness of speech both were discussed above. Pressure of speech occurs in schizophrenia and mania. Many schizophrenics never stop talking when spoken to and give lectures to the examiner. The quality of speech in catatonia may be strange and stilted متكلف , so that the patient sounds like a foreigner. Some catatonics have odd intonations. A few schizophrenics never speak above a whisper or speak with a strange voice called WURGSTIMME. This may be a mannerism or a result of delusions.
Mannerisms and stereotypies: mannerism of pronunciation occurs. Verbal stereotypies are words or phrases which are repeated. In VERBIGERATION one or several sentences are repeated continuously. St. jargon is used. Usually the tone of voice in monotonous. In SCHIZOPHASIA (called also SPEECH CONFUSION or WORD SALAD) the patient speak in a normal way with change in intonation.
Perseveration: in some cases there is preservation of the theme rathere than the words and this is regarded as impairment of switching.
Echolalia: kliest pointed out that some catatonic patients replay to questions by echoing the content of the question in different words and he called this as ECHOLOGIA.

Abnormal postures occur in abnormal personalities who are seeking attention these people are called poseurs. MANNERISTIC POSTURE is an odd one, which is an exaggeration of the normal posture and not rigidly preserved. Manneristic posture occur also in some schizophrenics when they may be related to delusional attitudes or may be without any understandable basis and therefore catatonic. STEREOTYPED POSTURE is an abnormal and non-adaptive posture which is rigidly maintained, e.g. the psychological pillow found in catatonia. In PERSEVERATION OF POSTURE the patient posture lasts one minute or slightly more, and st. there is feeling of plastic resistance as the examiner moves the body and when the passive movement stops, the final posture is preserved. Wernicke called this WAXY FLEXIBILITY or FLEXIBILITAS CEREA. In many cases of perseveration of posture there is no resistance to passive movement but as the examiner releases the patient's body, those muscles which fix the body in that posture can be felt to contract and this is not waxy flexibility, and should be called either perseveration of posture or CATALEPSY. The patient must be told always to resist the movement. In catalepsy the limb do not back to its position after released. Catalepsy occurs in mute stuporous catatonics and also in mild state of akinesia. St. it occur at the same time of obstruction so that the patient maintain a body posture in a mid-fight position. Catalepsy is usually lasting for more than one minute and ends with the body slowly sinking back into resting position. Catalepsy is very variable and may disappear for a day or so only to return again. Waxy flexibility and catalepsy also occur in encephalitis, vascular disorders, and neoplasms affecting the midbrain.

Non-goal directed pattern of behavior: e.g. stupor and excitement. Stupor is a state of complete loss of activity with no reaction to external stimuli. It is an extreme degree of hypokinesia. Stuporous patients are mute. It occurs in fright neurosis, HYS., depression, cycloid psychosis, catatonia, and organisity esp. lesions in 3rd ventricle, thalamus, and midbrain. Stupor can occur in epilepsy in petit mal status epilepticus. Urine incontinence is a rule and fecal incontinence can occur. In MOTILITY PSYCHOSIS, movements are affected more than speech. In depressive stupor, catalepsy, & obstruction stereotypies, changes in muscle tone and incontinence of urine and feces do not occur.
EXCITEMENT occurs in paranoid schizoph., appreciation needing personality, mania, catatonia and organisity. Chaotic restlessness may occur in stress, and MR. Excitement occurs in moderately agitated depressives. In maniac excitement the pat. is cheerful and may exhaust themselves and may become violent. In catatonic excitement the face is a dead pan and the movement of the body are often stiff and the violence is senseless and purposeless. In delirium there may be ill directed overactivity. Epileptic patient may become senselessly violent. In pathological drunkiness there is an excitement with sensless violence, often the patient drunk a small amount of alcohol, here the patient is not ataxic. Impulsive actions usually of an aggressive kind are common in catatonia.

goal-directed abnormal patterns of behavior
occur in nearly all psychiatric syndromes. Compulsive rituals are characteristic of OCD, but occurs in other conditions. Some schizoph. Behave in childish spiteful حاقد way to others. Maniacs and abnormal personalities play practical jokes. Surprisingly few schizoph. With persecutory delusions attack their alleged persecutors. Aggressiveness in chronic schizophrenics increase in cultures with more aggression. Delusions of marital infidelity are more ;likely to cause violence and murder. Some murderers suffer from epilepsy, paranoia, st. the depressive kill their beloved ones and this is called EXTENDED SUICIDE. Disinhibition in mania, organisity, and schizophrenia lead to promiscuity.


Disorders of memory are: amnesia, & dysmnesia.
Amnesia is either psychogenic or organic.
Much nonsense was said about psychogenic amnesia by psychiatrists who study books rather than patients.
Psychogenic amnesia:
a. anxiety amnesia: in psychogenic reactions & morbid anxiety particularly in depression.
b. Katathymic amnesia: a complex-determined partial amnesia occur in normal and hysterics.
c. Hysterical or dissociative amnesia: coplete loss of memory & identity with intact personality and the ability to carry out complicated procedures (e.g. Reverand كاهن Ansel Bourne).
N.B. The patient with organic amnesia when have total amnesia can not take care of himself in anyway.
N.B. Fish himself had seen many patients with hysterical amnesia and could not convince himself that there was any true in their stories.

ORGANIC AMNESIA : acute, subacute and chronic.

Acute: poor perception and attention & failure to make durable traces in the cause of amnesia. Examples: acute head injury, alcoholic blackout, and transient global amnesia.

Subacute: the amnestic state which is due to damage to the floor and walls of 3rd ventricle lead to inability to form permanent traces, difficulty in recall & trame like thinking, all of these lead to disorientation for place & time, anterograde amnesia, euphoris, and confabulation.

Chronic:(talk about korsakoff: anterograde amnesia for a year or so), and talked about dementia that follow Ribot’s law.
Disorders of recall:
1. Retrospective falsification: we all falsify the past to some degree, and this is related inversely to the degree of insight, self-criticism, and general attitude. E.g. in depression the patient sees only his failure; & in the maniac who recovers he remember the restrains put on him and not the reason of these restrains.
2. Retrospective delusions: schizophrenics may back date their delusion, e.g. think that he was persecuted for many years.
3. Delusional memories: primary delusional experience may take the form of memories.
4. Confabulations: detailed false description of an event. Bleuler think that suggestibility is an important feature of confabulation and that confabulation is characteristic for organic states. Yet it occurs in hysterical psychopaths and in chronic schizophrenics. Mechanism of confabulation could be explained to be as a result of tram-line thinking.
Some schizophrenics produce a detailed descriptions of ridiculous fantastic events without turning a hair. Leonard called this pictorial مصوَر thinking and consider it as formal thought disorder, and Bleuler also object to the use of the term “ confabulations “ in these cases and preferred to call them “ memory hallucinations “.

Disorders of recognition:
1. déjà vu & deja vecu: occur in normal and excessively in temporal lobe lesions.
2. misidentifications: occur in confusion psychosis & in acute and chronic schizophrenia.
(+ve): patient recognize strangers as his friend or relatives.
(-ve): denies that his friend and relatives are the people whom they are and insists that they are strangers in disguise.
Capgras syndrome: commonest cause is schizophrenia, less often evolutionary depression, and in hysterical women who feel that their husbands do not like them.
It is often accompanied by depersonalization and occurs in a paranoid setting.
In the Greek mythology the god Zeus had taken the phape of Amphitryon to have a sexual intercourse with Alcmene Amphitrion’s wife, while his servant take the shape of Sosias, Amphitryon’s servant.
Amphitryon illusion: spouse is doubled.
Sosias illusion: other people as spouse is doubled.
Chistodoulou had found EEG changes and enlarged 3rd ventricle in almost all cases.

The rarer syndrome of Fregoli is identifying a familiar person, usually the persecutor , in strangers.


Kaliki said...

Thanks, Saminke,this is a very interesting post. Do psychiatrists actually bother to diagnose people with this kind of detail? Would it make a difference if they did--that is- would medication or therapy be available to help? Or is medication only for the huge categories, like depression or schizophrenia?

saminkie said...

dear Kaliki,

this book is about describing the signs and symptoms of mental illnes... but there are different books for diagnosis (ICD10 and DSM IV) the ICD stands for International Classification of Diseases and it contain detailed account on the criteria we depend to diagnose all mental illnesses (more than 300 till now) and the DSM IV is similar and stand for Diagnostic and statistical manual....hope i was clear kaliki ...

Anonymous said...

Dear Dr. Sami,

Hey look, I can diagnose myself...! Not that I haven't done that a bunch of times already, with the help of the DSM lV, etc :-) Nothing like a little knowledge being a dangerous thing, but I don't think I could be much more of that Thanks as always, for a very interesting read, best always, tracy

saminkie said...

dear Tracy,
It was said that the UNEXAMINED LIFE IS NOT WORTH LIVING, anyway, i think even the unexamined life is worth living with nice people like you...sami

Anonymous said...

Thanks, Dr. Sami, you are one of the dear ones. tracy

അഫ്ഗാര്‍ (afgaar) said...

thanks, myself a 3rd yr resident in psychiatry revising Fish, i find this very useful. thanks a lot

saminkie said...

dear afgar i suggest you copy it than past it on word document then put it on the smallest size of lettres and print it into will see how Fish can be so small and got the perceoption that it is easy and take fewer neorons to remember it...take care and hope all the success for you...

vani said...

well written sir...makes a good read indeed..

saminkie said...

Thanks Vani, glad that you liked it.