The first encounter between psychiatrist or therapist and patient (or client) is multi-phased. The mental health practitioner notes the patient’s history and administers or prescribes a physical examination to rule out certain medical conditions. Armed with the results, the diagnostician now observes the patient carefully and compiles lists of signs and symptoms, grouped into syndromes.
Symptoms are the patient’s complaints. They are highly subjective and amenable to suggestion and to alterations in the patient’s mood and other mental processes. Symptoms are no more than mere indications. Signs, on the other hand, are objective and measurable. Signs are evidence of the existence, stage, and extent of a pathological state. Headache is a symptom – short-sightedness (which may well be the cause of the headache) is a sign.
Here is a partial list of the most important signs and symptoms in alphabetical order:
We all experience emotions, but each and every one of us expresses them differently. Affect is HOW we express our innermost feelings and how other people observe and interpret our expressions. Affect is characterized by the type of emotion involved (sadness, happiness, anger, etc.) and by the intensity of its expression. Some people have flat affect: they maintain “poker faces”, monotonous, immobile, apparently unmoved. This is typical of the Schizoid Personality Disorder Others have blunted, constricted, or broad (healthy) affect. Patients with the dramatic (Cluster B) personality disorders – especially the Histrionic and the Borderline – have exaggerate and labile (changeable) affect. They are “drama queens”.
In certain mental health disorders, the affect is inappropriate. For instance: such people laugh when they recount a sad or horrifying event or when they find themselves is morbid settings (e.g., in a funeral). Also see: Mood.
Read about inappropriate affect in narcissists
We have all come across situations and dilemmas which evoked equipotent – but opposing and conflicting – emotions or ideas. Now, imagine someone with a permanent state of inner turmoil: her emotions come in mutually exclusive pairs, her thoughts and conclusions arrayed in contradictory dyads. The result is, of course, extreme indecision, to the point of utter paralysis and inaction. Sufferers of Obsessive-Compulsive Disorders and the Obsessive-Compulsive Personality Disorder are highly ambivalent.
When we lose the urge to seek pleasure and to prefer it to nothingness or even pain, we become anhedonic. Depression inevitably involves anhedonia. The depressed are unable to conjure sufficient mental energy to get off the couch and do something because they find everything equally boring and unattractive.
Diminished appetite to the point of refraining from eating. Whether it is part of a depressive illness or a body dysmorphic disorder (erroneous perception of one’s body as too fat) is still debated. Anorexia is one of a family of eating disorders which also includes bulimia (compulsive gorging on food and then its forced purging, usually by vomiting).
Learn more about comorbidity of eating disorders and personality disorders
A kind of unpleasant (dysphoric), mild fear, with no apparent external reason. Anxiety is akin to dread, or apprehension, or fearful anticipation of some imminent but diffuse and unspecified danger. The mental state of anxiety (and the concomitant hypervigilance) has physiological complements: tensed muscle tone, elevated blood pressure, tachycardia, and sweating (arousal).
Generalized Anxiety Disorder is sometimes misdiagnosed as a personality disorder
More precisely: autistic thinking and inter-relating (relating to other people). Fantasy-infused thoughts. The patient’s cognitions derive from an overarching and all-pervasive fantasy life. Moreover, the patient infuses people and events around him or her with fantastic and completely subjective meanings. The patient regards the external world as an extension or projection of the internal one. He, thus, often withdraws completely and retreats into his inner, private realm, unavailable to communicate and interact with others.
Asperger’s Disorder, one of the spectrum of autistic disorders, is sometimes misdiagnosed as Narcissistic Personality Disorder (NPD)
Automatic obeisance or obedience
Automatic, unquestioning, and immediate obeisance of all commands, even the most manifestly absurd and dangerous ones. This suspension of critical judgment is sometimes an indication of incipient catatonia.
Halted, frequently interrupted speech to the point of incoherence indicates a parallel disruption of thought processes. The patient appears to try hard to remember what it was that he or she were saying or thinking (as if they “lost the thread” of conversation).
“Human sculptures” are patients who freeze in any posture and position that they are placed, no matter how painful and unusual. Typical of catatonics.
A syndrome comprised of various signs, amongst which are: catalepsy, mutism, stereotypy, negativism, stupor, automatic obedience, echolalia, and echopraxia. Until recently it was thought to be related to schizophrenia, but this view has been discredited when the biochemical basis for schizophrenia had been discovered. The current thinking is that catatonia is an exaggerated form of mania (in other words: an affective disorder). It is a feature of catatonic schizophrenia, though, and also appears in certain psychotic states and mental disorders that have organic (medical) roots.
Literally: wax-like flexibility. In the common form of catalepsy, the patient offers no resistance to the re-arrangement of his limbs or to the re-alignment of her posture. In Cerea Flexibilitas, there is some resistance, though it is very mild, much like the resistance a sculpture made of soft wax would offer.
When the train of thought and speech is often derailed by unrelated digressions, based on chaotic associations. The patient finally succeeds to express his or her main idea but only after much effort and wandering. In extreme cases considered to be a communication disorder.
Rhyming or punning associations of words with no logical connection or any discernible relationship between them. Typical of manic episodes, psychotic states, and schizophrenia.
(Also: Clouding of Consciousness)
The patient is wide awake but his or her awareness of the environment is partial, distorted, or impaired. Clouding also occurs when one gradually loses consciousness (for instance, as a result of intense pain or lack of oxygen).
Involuntary repetition of a stereotyped and ritualistic action or movement, usually in connection with a wish or a fear. The patient is aware of the irrationality of the compulsive act (in other words: she knows that there is no real connection between her fears and wishes and what she is repeatedly compelled to do). Most compulsive patients find their compulsions tedious, bothersome, distressing, and unpleasant – but resisting the urge results in mounting anxiety from which only the compulsive act provides much needed relief. Compulsions are common in obsessive-compulsive disorders, the Obsessive-Compulsive Personality Disorder (OCPD), and in certain types of schizophrenia.
Obsessive-Compulsive Personality Disorder (OCPD)
Read about the compulsive acts of the narcissist
Inability or diminished capacity to form abstractions or to think using abstract categories. The patient is unable to consider and formulate hypotheses or to grasp and apply metaphors. Only one layer of meaning is attributed to each word or phrase and figures of speech are taken literally. Consequently, nuances are not detected or appreciated. A common feature of schizophrenia, autism spectrum disorders, and certain organic disorders.
Read about narcissism and Asperger’s Disorder
The constant and unnecessary fabrication of information or events to fill in gaps in the patient’s memory, biography or knowledge, or to substitute for unacceptable reality. Common in the Cluster B personality disorders (narcissistic, histrionic, borderline, and antisocial) and in organic memory impairment or the amnestic syndrome (amnesia).
Read about the Narcissist’s Confabulated Life
Complete (though often momentary) loss of orientation in relation to one’s location, time, and to other people. Usually the result of impaired memory (often occurs in dementia) or attention deficit (for instance, in delirium). Also see: Disorientation.
Delirium is a syndrome which involves clouding, confusion, restlessness, psychomotor disorders (retardation or, on the opposite pole, agitation), and mood and affective disturbances (lability). Delirium is not a constant state. It waxes and wanes and its onset is sudden, usually the result of some organic affliction of the brain.
A belief, idea, or conviction firmly held despite abundant information to the contrary. The partial or complete loss of reality test is the first indication of a psychotic state or episode. Beliefs, ideas, or convictions shared by other people, members of the same collective, are not, strictly speaking, delusions, although they may be hallmarks of shared psychosis. There are many types of delusions:
The belief that one is being controlled or persecuted by stealth powers and conspiracies.
The conviction that one is important, omnipotent, possessed of occult powers, or a historic figure.
3. Referential (ideas of reference)
The belief that external, objective events carry hidden or coded messages or that one is the subject of discussion, derision, or opprobrium, even by total strangers.
The Delusional Way Out
Psychosis and Delusions
Ideas of Reference
Simultaneous impairment of various mental faculties, especially the intellect, memory, judgment, abstract thinking, and impulse control due to brain damage, usually as an outcome of organic illness. Dementia ultimately leads to the transformation of the patient’s whole personality. Dementia does not involve clouding and can have acute or slow (insidious) onset. Some dementia states are reversible.
Feeling that one’s body has changed shape or that specific organs have become elastic and are not under one’s control. Usually coupled with “out of body” experiences. Common in a variety of mental health and physiological disorders: depression, anxiety, epilepsy, schizophrenia, and hypnagogic states. Often observed in adolescents. See: Derealization.
A loosening of associations. A pattern of speech in which unrelated or loosely-related ideas are expressed hurriedly and forcefully, with frequent topical shifts and with no apparent internal logic or reason. See: Incoherence.
Feeling that one’s immediate environment is unreal, dream-like, or somehow altered. See: Depersonalization.
Inability to incorporate reality-based facts and logical inference into one’s thinking. Fantasy-based thoughts.
Not knowing what year, month, or day it is or not knowing one’s location (country, state, city, street, or building one is in). Also: not knowing who one is, one’s identity. One of the signs of delirium.
Imitation by way of exactly repeating another person’s speech. Involuntary, semiautomatic, uncontrollable, and repeated imitation of the speech of others. Observed in organic mental disorders, pervasive developmental disorders, psychosis, and catatonia. See: Echopraxia.
Imitation by way or exactly repeating another person’s movements. Involuntary, semiautomatic, uncontrollable, and repeated imitation of the movements of others. Observed in organic mental disorders, pervasive developmental disorders, psychosis, and catatonia. See: Echolalia.
Flight of Ideas
Rapidly verbalized train of unrelated thoughts or of thoughts related only via relatively-coherent associations. Still, in its extreme forms, flight of ideas involves cognitive incoherence and disorganization. Appears as a sign of mania, certain organic mental health disorders, schizophrenia, and psychotic states. Also see: Pressure of Speech and Loosening of Associations.
More about the manic phase of the Bipolar disorder
Folie a Deux (Madness in Twosome, Shared Psychosis)
The sharing of delusional (often persecutory) ideas and beliefs by two or more (folie a plusieurs) persons who cohabitate or form a social unit (e.g., a family, a cult, or an organization). One of the members in each of these groups is dominant and is the source of the delusional content and the instigator of the idiosyncratic behaviors that accompany the delusions.
Read more about Shared Psychosis and cults – click on these links:
Vanishing act. A sudden flight or wandering away and disappearance from home or work, followed by the assumption of a new identity and the commencement of a new life in a new place. The previous life is completely erased from memory (amnesia). When the fugue is over, it is also forgotten as is the new life adopted by the patient.
False perceptions based on false sensa (sensory input) not triggered by any external event or entity. The patient is usually not psychotic – he is aware that he what he sees, smells, feels, or hears is not there. Still, some psychotic states are accompanied by hallucinations (e.g., formication – the feeling that bugs are crawling over or under one’s skin).
There are a few classes of hallucinations:
Auditory – The false perception of voices and sounds (such as buzzing, humming, radio transmissions, whispering, motor noises, and so on).
Gustatory – The false perception of tastes
Olfactory – The false perception of smells and scents (e.g., burning flesh, candles)
Somatic – The false perception of processes and events that are happening inside the body or to the body (e.g., piercing objects, electricity running through one’s extremities). Usually supported by an appropriate and relevant delusional content.
Tactile – The false sensation of being touched, or crawled upon or that events and processes are taking place under one’s skin. Usually supported by an appropriate and relevant delusional content.
Visual – The false perception of objects, people, or events in broad daylight or in an illuminated environment with eyes wide open.
Hypnagogic and Hypnopompic – Images and trains of events experienced while falling asleep or when waking up. Not hallucinations in the strict sense of the word.
Hallucinations are common in schizophrenia, affective disorders, and mental health disorders with organic origins. Hallucinations are also common in drug and alcohol withdrawal and among substance abusers.
Ideas of Reference
Weak delusions of reference, devoid of inner conviction and with a stronger reality test. See: Delusion.
The Delusional Way Out
Psychosis and Delusions
Ideas of Reference
The misperception or misinterpretation of real external – visual or auditory – stimuli, attributing them to non-existent events and actions. Incorrect perception of a material object. See: Hallucination.
Incomprehensible speech, rife with severely loose associations, distorted grammar, tortured syntax, and idiosyncratic definitions of the words used by the patient (“private language”). A loosening of associations. A pattern of speech in which unrelated or loosely-related ideas are expressed hurriedly and forcefully, using broken, ungrammatical, non-syntactical sentences, an idiosyncratic vocabulary (“private language”), topical shifts, and inane juxtapositions (“word salad”). See: Loosening of Associations; Flight of Ideas; Tangentiality.
Sleep disorder or disturbance involving difficulties to either fall asleep (“initial insomnia”) or to remain asleep (“middle insomnia”). Waking up early and being unable to resume sleep is also a form of insomnia (“terminal insomnia”).
Loosening of Associations
Thought and speech disorder which involves the translocation of the focus of attention from one subject to another for no apparent reason. The patient is usually unaware of the fact that his train of thoughts and his speech are incongruous and incoherent. A sign of schizophrenia and some psychotic states. See: Incoherence; Flight of Ideas; Tangentiality.
Pervasive and sustained feelings and emotions as subjectively described by the patient. The same phenomena observed by the clinician are called affect. Mood can be either dysphoric (unpleasant) or euphoric (elevated, expansive, “good mood”). Dysphoric moods are characterized by a reduced sense of well-being, depleted energy, and negative self-regard or sense of self-worth. Euphoric moods typically involve an increased sense of well-being, ample energy, and a stable sense of self-worth and self-esteem. Also see: Affect.
Mood Congruence and Incongruence
The contents of mood-congruent hallucinations and delusions are consistent and compatible with the patient’s mood. During the manic phase of the Bipolar Disorder, for instance, such hallucinations and delusions involve grandiosity, omnipotence, personal identification with great personalities in history or with deities, and magical thinking. In depression, mood-congruent hallucinations and delusions revolve around themes like the patient’s self-misperceived faults, shortcomings, failures, worthlessness, guilt – or the patient’s impending doom, death, and “well-deserved” sadistic punishment.
The contents of mood-incongruent hallucinations and delusions are inconsistent and incompatible with the patient’s mood. Most persecutory delusions and delusions and ideas of reference, as well as phenomena such as control “freakery” and Schneiderian First-rank Symptoms are mood-incongruent. Mood incongruence is especially prevalent in schizophrenia, psychosis, mania, and depression.
Misdiagnosing the Bipolar Disorder as Narcissistic Personality Disorder
Depression and Cluster B Personality Disorders – click on these links:
Abstention from speech or refusal to speak. Common in catatonia.
In catatonia, complete opposition and resistance to suggestion.
In schizophrenia and other psychotic disorders, the invention of new “words” which are meaningful to the patient but meaningless to everyone else. To form the neologisms, the patient fuses together and combines syllables or other elements from existing words.
Recurring and intrusive images, thoughts, ideas, or wishes that dominate and exclude other cognitions. The patient often finds the contents of his obsessions unacceptable or even repulsive and actively resists them, but to no avail. Common in schizophrenia and obsessive-compulsive disorder.
Obsessions in the Narcissistic Personality Disorder
A form of severe anxiety attack accompanied by a sense of losing control and of an impending and imminent life-threatening danger (where there is none). Physiological markers of panic attacks include palpitation, sweating, tachycardia (rapid heart beats), dyspnea or apnoea (chest tightening and difficulties breathing), hyperventilation, light-headedness or dizziness, nausea, and peripheral paresthesias (an abnormal sensation of burning, prickling, tingling, or tickling). In normal people it is a reaction to sustained and extreme stress. Common in many mental health disorders.
Sudden, overpowering feelings of imminent threat and apprehension, bordering on fear and terror. There usually is no external cause for alarm (the attacks are uncued or unexpected, with no situational trigger) – though some panic attacks are situationally-bound (reactive) and follow exposure to “cues” (potentially or actually dangerous events or circumstances). Most patients display a mixture of both types of attacks (they are situationally predisposed).
Bodily manifestations include shortness of breath, sweating, pounding heart and increased pulse as well as palpitations, chest pain, overall discomfort, and choking. Sufferers often describe their experience as being smothered or suffocated. They are afraid that they may be going crazy or about to lose control.
Misdiagnosing General Anxiety Disorder (GAD) as Narcissistic Personality Disorder
Psychotic grandiose and persecutory delusions. Paranoids are characterized by a paranoid style: they are rigid, sullen, suspicious, hypervigilant, hypersensitive, envious, guarded, resentful, humorless, and litigious. Paranoids often suffer from paranoid ideation – they believe (though not firmly) that they are being stalked or followed, plotted against, or maliciously slandered. They constantly gather information to prove their “case” that they are the objects of conspiracies against them. Paranoia is not the same as Paranoid Schizophrenia, which is a subtype of schizophrenia.
Paranoid Personality Disorder
Repeating the same gesture, behavior, concept, idea, phrase, or word in speech. Common in schizophrenia, organic mental disorders, and psychotic disorders.
Dread of a particular object or situation, acknowledged by the patient to be irrational or excessive. Leads to all-pervasive avoidance behavior (attempts to avoid the feared object or situation). A persistent, unfounded, and irrational fear or dread of one or more classes of objects, activities, situations, or locations (the phobic stimuli) and the resulting overwhelming and compulsive desire to avoid them. See: Anxiety.
Assuming and remaining in abnormal and contorted bodily positions for prolonged periods of time. Typical of catatonic states.
Poverty of Content (of Speech)
Persistently vague, overly abstract or concrete, repetitive, or stereotyped speech.
Poverty of Speech
Reactive, non-spontaneous, extremely brief, intermittent, and halting speech. Such patients often remain silent for days on end unless and until spoken to.
Pressure of Speech
Rapid, condensed, unstoppable and “driven” speech. The patient dominates the conversation, speaks loudly and emphatically, ignores attempted interruptions, and doesn’t care if anyone is listening or responding to him or her. Seen in manic states, psychotic or organic mental disorders, and conditions associated with stress. See: Flight of Ideas.
Mounting internal tension associated with excessive, non-productive (not goal orientated), and repeated motor activity (hand wringing, fidgeting, and similar gestures). Hyperactivity and motor restlessness which co-occur with anxiety and irritability.
Visible slowing of speech or movements or both. Usually affects the entire range of performance (entire repertory). Typically involves poverty of speech, delayed response time (subjects answer questions after an inordinately long silence), monotonous and flat voice tone, and constant feelings of overwhelming fatigue.
Chaotic thinking that is the result of a severely impaired reality test ( the patient cannot tell inner fantasy from outside reality). Some psychotic states are short-lived and transient (microepisodes). These last from a few hours to a few days and are sometimes reactions to stress. Persistent psychoses are a fixture of the patient’s mental life and manifest for months or years.
Psychotics are fully aware of events and people “out there”. They cannot, however separate data and experiences originating in the outside world from information generated by internal mental processes. They confuse the external universe with their inner emotions, cognitions, preconceptions, fears, expectations, and representations.
Consequently, psychotics have a distorted view of reality and are not rational. No amount of objective evidence can cause them to doubt or reject their hypotheses and convictions. Full-fledged psychosis involves complex and ever more bizarre delusions and the unwillingness to confront and consider contrary data and information (preoccupation with the subjective rather than the objective). Thought becomes utterly disorganized and fantastic.
There is a thin line separating nonpsychotic from psychotic perception and ideation. On this spectrum we also find the schizotypal personality disorder.
Narcissism, Psychosis, and Delusions
The way one thinks about, perceives, and feels reality.
Comparing one’s reality sense and one’s hypotheses about the way things are and how things operate to objective, external cues from the environment.
Schneiderian First-rank Symptoms
A list of symptoms compiled by Kurt Schneider, a German psychiatrist, in 1957 and indicative of the presence of schizophrenia. Includes:
Hearing conversations between a few imaginary “interlocutors”, or one’s thoughts spoken out loud, or a running background commentary on one’s actions and thoughts.
Experiencing imagined sexual acts couple with delusions attributed to forces, “energy”, or hypnotic suggestion.
The delusion that one’s thoughts are taken over and controlled by others and then “drained” from one’s brain.
The delusion that thoughts are being implanted or inserted into one’s mind involuntarily.
The delusion that everyone can read one’s mind, as though one’s thoughts were being broadcast.
Attaching unusual meanings and significance to genuine perceptions, usually with some kind of (paranoid or narcissistic) self-reference.
Delusion of control
The delusion that one’s acts, thoughts, feelings, perceptions, and impulses are directed or influenced by other people.
Stereotyping or Stereotyped movement (or motion)
Repetitive, urgent, compulsive, purposeless, and non-functional movements, such as head banging, waving, rocking, biting, or picking at one’s nose or skin. Common in catatonia, amphetamine poisoning, and schizophrenia.
Restricted and constricted consciousness akin in some respects to coma. Activity, both mental and physical, is limited. Some patients in stupor are unresponsive and seem to be unaware of the environment. Others sit motionless and frozen but are clearly cognizant of their surroundings. Often the result of an organic impairment. Common in catatonia, schizophrenia, and extreme depressive states.
Inability or unwillingness to focus on an idea, issue, question, or theme of conversation. The patient “takes off on a tangent” and hops from one topic to another in accordance with his own coherent inner agenda, frequently changing subjects, and ignoring any attempts to restore “discipline” to the communication. Often co-occurs with speech derailment. As distinct from loosening of associations, tangential thinking and speech are coherent and logical but they seek to evade the issue, problem, question, or theme raised by the other interlocutor.
Thought Broadcasting, Though Insertion, Thought Withdrawal
See: Schneiderian First-rank Symptoms
A consistent disturbance that affects the process or content of thinking, the use of language, and, consequently, the ability to communicate effectively. An all-pervasive failure to observe semantic, logical, or even syntactical rules and forms. A fundamental feature of schizophrenia.
A set of signs in depression which includes loss of appetite, sleep disorder, loss of sexual drive, loss of weight, and constipation. May also indicate an eating disorder.
Read more about eating disorders – click on these links: