In general medicine, symptom refers to an abnormality reported by the patient, while sign refers to an abnormality detected by the doctor by observation or clinical examination. In psychiatry, the terms symptom and sign tend to be used synonymously because abnormalities of mental state can only be elicited by exploring, with the patient, their internal experiences.

Psychopathology is the study of abnormalities in mental state and is one of the core sciences in clinical psychiatry. Descriptive psychopathology is one method for describing the subjective experience and behaviour of patients and is the basis for our current clinical descriptions of mental disorder. It is atheoretical, and does not rest on any particular explana- tion for the cause of the abnormal mental state. In this it contrasts with dynamic (Freudian) psychopathology which attempts to describe and then to explain these states.

Descriptive psychopathology includes close observation of the patient’s behaviour and empathic exploration of their subjective experience. The latter is called phenomenology. The following general terms are used as qualifiers for symptoms described in the following pages:

• Subjective vs. objective Objective signs are those noted by an external observer; subjective signs are those reported by the patient.
• Form vs. content A distinction is drawn between the form and content of abnormal internal experiences. For example, a patient may believe that he is continually under surveillance by agents of MI5 who are plotting to frame him for another’s crimes. Here, the content of the symptom is the belief about the name and methods of the persecutor; the form is that of a persecutory delusion. Content is culture- and experience-related, whereas form is attributable to the type of underlying mental illness.
• Primary vs. secondary Primary symptoms are considered as arising directly from the pathology of the mental illness; secondary symptoms arise as an understandable response to some aspect of the disordered mental state (e.g. a patient with severe depression developing a secondary delusion of being wicked and deserving punishment). Secondary symptoms can be understood in the light of knowledge of the patient’s symptoms; primary symptoms can be empathized with but not fully understood.
• Endogenous vs. reactive These terms have been largely made redundant by developments in understanding of mental disorders, but are still seen occasionally. It was formerly thought that some conditions arose in response to external events (e.g. depression arising after job loss) (reactive), while others arose spontaneously from within (endogenous).
• Psychotic vs. neurotic In present classifications these terms are used purely descriptively to describe two common types of symptoms that may occur in a variety of mental disorders. Previously, they were used to distinguish those disorders characterized by impairment of insight, abnormal beliefs, and abnormal perceptual experiences from those where there was preserved insight but abnormal affect.
• Congruent vs. incongruent This is an observation made regarding the apparent appropriateness of a patient’s affect towards their symptoms or their symptoms to their mood. A patient with apparent cheerfulness despite persecutory beliefs is described as having incongruent affect; a patient with profoundly depressed mood developing a delusion that they were mortally ill is described as possessing a mood-congruent delusion.
• Structural vs. functional A distinction formerly made between those brain disorders with observable structural abnormalities on post-mortem (e.g. Alzheimer’s disease) and those without (e.g. schizophrenia). This usage has diminished since the discovery of definite observable brain changes in those disorders formerly called functional psychoses. Nowadays, the term is more often used in neurology/neuropsychiatry to distinguish syndromes which generally

have abnormal investigation findings (e.g. multiple sclerosis) from those without (e.g. conversion paralysis).

Abnormal beliefs A category of disturbance which includes delusions

and overvalued ideas.

Abnormal perceptions A category of disturbance which includes sen- sory distortions and false perceptions.

Acute confusional state See Delirium.

Affect The emotional state prevailing in a patient at a particular moment and in response to a particular event or situation. Contrasted with mood which is the prevailing emotional state over a longer period of time.

Affect illusion See Illusion.

Agitated depression A combination of depressed mood and psycho- motor agitation, contrasting with the more usual association of depressed mood with psychomotor retardation. A common presentation of depres- sive illness in the elderly.

Agitation See Psychomotor agitation

Agoraphobia A generalized phobia in which there is fear of open spaces, social situations, crowds, etc. Associated with avoidance of these stimuli.

Akathisia A subjective sense of uncomfortable desire to move, relieved by repeated movement of the affected part (usually the legs). A side-effect of treatment with neuroleptic drugs.

Alexithymia The inability to describe one’s subjective emotional experi- ences verbally. May be a personality characteristic but is also associated with somatization.

Alogia Poverty of thoughts as observed by absence of spontaneous speech. A negative symptom of schizophrenia and a symptom of depres- sive illness.

Ambitendency A motor symptom of schizophrenia in which there is an alternating mixture of automatic obedience and negativism.

Amnesia Loss of the ability to recall memories for a period of time. May be global (complete memory loss for the time period), or partial (patchy memory loss with ‘islands’ of preserved memory).

Anergia The subjective feeling of lack of energy and sense of increased effort required to carry out tasks. Associated with depressive illness.

Anhedonia The feeling of absent or significantly diminished enjoyment of previously pleasurable activities. A core symptom of depressive illness, also a negative symptom of schizophrenia.

Anorexia Loss of appetite for food. Seen in depressive illness and many general medical conditions. Interestingly, patients with anorexia nervosa often do not have anorexia as so defined. They commonly describe them- selves as very hungry—controlling their desire for food by supreme effort in order to control their weight.

‌Anterograde amnesia The period of amnesia between an event (e.g. head injury) and the resumption of continuous memory. The length of anterograde amnesia is correlated with the extent of brain injury.

Anxiety A normal and adaptive response to stress and danger which is pathological if prolonged, severe, or out of keeping with the real threat of the external situation. Anxiety has two components: psychic anxiety, which is an affect characterized by increased arousal, apprehension, sense of vulnerability, and dysphoria; and somatic anxiety, in which there are bodily sensations of palpitations, sweating, dyspnoea, pallor, and abdomi- nal discomfort.

Aphonia Loss of the ability to vocalize. May occur with structural disease affecting the vocal cords directly, the 9th cranial nerve, or higher centres. May also occur in functional illness where the underlying vocal cord function is normal. This can be demonstrated by asking the patient to cough—a nor- mal cough demonstrates the ability of the vocal cords to oppose normally.

Asyndesis Synonym for loosening of associations.

Ataxia Loss of coordination of voluntary movement. Seen in drug and alcohol intoxication and organic disorders, particularly cerebellar.

Athetosis Sinuous, writhing involuntary movements.

Aura Episode of disturbed sensation occurring before an epileptic event. Wide range of manifestations although usually stereotyped for each individual.

Autistic thinking An abnormal absorption with the self, distinguished by interpersonal communication difficulties, a short attention span, and inability to relate to others as people.

Autochthonous delusion A primary delusion which appears to arise fully formed in the patient’s mind without explanation (e.g. a patient sud- denly becomes aware that he has inherited a large estate in the Scottish Highlands and will thus have the funds to settle scores with all those who have ever wronged him).

Automatic obedience A motor symptom of schizophrenia in which the patient obeys the examiner’s instructions unquestioningly. This coop- eration may be ‘excessive’, with the patient going beyond what is asked (e.g. raising both arms and both legs when asked to raise an arm).

Automatism Behaviour which is apparently conscious in nature which occurs in the absence of full consciousness (e.g. during a temporal lobe seizure).

Autoscopy The experience of seeing a visual hallucination or pseudo- hallucination of oneself. Also known as ‘phantom mirror image’. Uncommon symptom reported in schizophrenia and in temporal lobe epilepsy.

Autotopagnosia Condition where one cannot identify or describe their own body parts. Individuals can dress and move appropriately, but cannot talk about their bodies.

Avoidance The action of not exposing oneself to situations which gener- ate anxiety, for example a patient with agoraphobia remaining at home or a patient with post-traumatic stress disorder (PTSD) following a road traffic accident (RTA) refusing to drive. Can be understood in terms of an operant conditioning model where actions with reward—in this case reduction of anxiety—are repeated.

Belle indifference A surprising lack of concern for, or denial of, appar- ently severe functional disability. It is part of classical descriptions of hysteria and continues to be associated with operational descriptions of conversion disorder. It is also seen in medical illnesses (e.g. cerebrovascular accident [CVA]) and is a rare and non-specific symptom of no diagnostic value.

Biological features of depression Symptoms of moderate to severe depressive illness which reflect disturbance of core vegetative function. They are depressive sleep disturbance, anorexia, loss of libido, anergia, and subjective impression of deterioration in memory and concentration.

Blunting of affect Loss of the normal degree of emotional sensitivity and sense of the appropriate emotional response to events. A negative symptom of schizophrenia.

Broca’s dysphasia A type of expressive dysphasia due to damage to the posterior part of the inferior frontal gyrus of the dominant hemisphere (Broca’s language area).

Bulimia Increased appetite and desire for food and/or excessive, impul- sive eating of large quantities of usually high-calorie food. Core symptom of bulimia nervosa and may also be seen in mania and in some types of learning disability.

Capgras syndrome A type of delusional misidentification in which the patient believes that a person known to them has been replaced by a ‘double’ who is to all external appearances identical, but is not the ‘real person’.

Catalepsy A rare motor symptom of schizophrenia. Describes a situa- tion in which the patient’s limbs can be passively moved to any posture which will then be held for a prolonged period of time. Also known as waxy flexibility or flexibilitas cerea. See also Psychological pillow.

Cataplexy Symptom of narcolepsy in which there is sudden loss of mus- cle tone leading to collapse. Usually occurs following emotional stress.

Catastrophic reaction Response occasionally seen in patients with dementia who are asked to perform tasks beyond their, now impaired, performance level. There is sudden agitation, anger, and occasionally violence.

Catatonia Increased resting muscle tone which is not present on active or passive movement (in contrast to the rigidity associated with Parkinson’s disease and extra-pyramidal side-effects). A motor symptom of schizophrenia.

Chorea Sudden and involuntary movement of several muscle groups with the resultant action appearing like part of a voluntary movement.

‌Circumstantial thinking A disorder of the form of thought where irrelevant details and digressions overwhelm the direction of the thought process. This abnormality may be reflected in the resultant speech. It is seen in mania and in anankastic personality disorder.

Clang association An abnormality of speech where the connection between words is their sound rather than their meaning. May occur dur- ing manic flight of ideas.

Clouding of consciousness Conscious level between full consciousness and coma. Covers a range of increasingly severe loss of function with drowsiness and impairment of concentration and perception.

Command hallucination An auditory hallucination of a commanding voice, instructing the patient towards a particular action. Also known as teleological hallucination.

Completion illusion See Illusion.

Compulsion A behaviour or action which is recognized by the patient as unnecessary and purposeless but which he cannot resist performing repeatedly (e.g. hand washing). The drive to perform the action is recog- nized by the patient as his own (i.e. there is no sense of ‘possession’ or passivity) but it is associated with a subjective sense of need to perform the act, often in order to avoid the occurrence of an adverse event. The patient may resist carrying out the action for a time at the expense of mounting anxiety.

Concrete thinking The loss of the ability to understand abstract con- cepts and metaphorical ideas leading to a strictly literal form of speech and inability to comprehend allusive language. Seen in schizophrenia and in dementing illnesses.

Confabulation The process of describing plausibly false memories for a period for which the patient has amnesia. Occurs in Korsakoff psychosis, dementia, and following alcoholic palimpsest.

Confusion The core symptom of delirium or acute confusional state. There is disorientation, clouding of consciousness and deterioration in the ability to think rationally, lay down new memories, and to understand sensory input.

Conversion The development of features suggestive of physical illness but which are attributed to psychiatric illness or emotional disturbance rather than organic pathology. Originally described in terms of psycho- analytic theory where the presumed mechanism was the ‘conversion’ of unconscious distress to physical symptoms rather than allowing its expres- sion in conscious thought.

Coprolalia A ‘forced’ vocalization of obscene words or phrases. The symptom is largely involuntary but can be resisted for a time, at the expense of mounting anxiety. Seen in Gilles de la Tourette’s syndrome.

Cotard syndrome A presentation of psychotic depressive illness seen particularly in elderly people. There is a combination of severely depressed mood with nihilistic delusions and/or hypochondriacal delusions. The patient may state that he is already dead and should be buried, that his insides have stopped working and are rotting away, or that he has stopped existing altogether.

Couvade syndrome A conversion symptom seen in partners of expect- ant mothers during their pregnancy. The symptoms vary but mimic preg- nancy symptoms and so include nausea, vomiting, abdominal pain, and food cravings. It is not delusional in nature; the affected individual does not believe they are pregnant (cf. pseudocyesis). This behaviour is a cultural norm in some societies.

Craving A subjective sense of need to consume a particular substance (e.g. drugs or alcohol) for which there may be dependence.

Cyclothymia A personality characteristic in which there is cyclical mood variation to a lesser degree than in bipolar disorder.

De Clérambault syndrome A form of delusion of love. The patient, usually female, believes that another, higher-status individual is in love with them. There may be an additional persecutory delusional compo- nent where the affected individual comes to believe that individuals are conspiring to keep them apart. The object may be an employer or doctor, or in some cases a prominent public figure or celebrity.

Déjà vu A sense that events being experienced for the first time have been experienced before. An everyday experience but also a non- specific symptom of a number of disorders including temporal lobe epi- lepsy, schizophrenia, and anxiety disorders.

Delirium A clinical syndrome of confusion, variable degree of clouding of consciousness, visual illusions, and/or visual hallucinations, lability of affect, and disorientation. The clinical features can vary markedly in severity hour by hour. Delirium is a stereotyped response by the brain to a variety of insults and is similar in presentation whatever the primary cause.

Delirium tremens The clinical picture of acute confusional state sec- ondary to alcohol withdrawal. Comprises confusion, withdrawals, visual hallucinations, and, occasionally, persecutory delusions and Lilliputian hallucinations.

Delusion An abnormal belief which is held with absolute subjective certainty, which requires no external proof, which may be held in the face of contradic- tory evidence, and which has personal significance and importance to the individual concerned. Excluded are those beliefs which can be understood as part of the subject’s cultural or religious background. While the content is usually demonstrably false and bizarre in nature, this is not invariably so.

Primary delusions are the direct result of psychopathology, while secondary delusions can be understood as having arisen in response to other primary psychiatric conditions (e.g. a patient with severely depressed mood developing delusions of poverty, or a patient with progressive memory impairment developing a delusion that people are entering his house and stealing or moving items). Primary delusions can be subdivided by the method by which they are perceived as having arisen or into broad classes based on their content.

‌If the patient is asked to recall the point when they became aware of the delusion and its significance to them, they may report that the belief arose: ‘out of the blue’ (autochthonous delusion); on seeing a normal percept delusional perception); on recalling a memory (delusional memory); or on a background of anticipation, odd experiences, and increased aware- ness (delusional mood).

Based on their content, 12 types of primary delusion are commonly recognized: persecutory, grandiose, delusions of control, of thought interference, of reference, of guilt, of love, delusional misidentification, jealousy, hypochondriacal delusions, nihilistic delusions, and delusions of infestation.

Delusional atmosphere Synonym for delusional mood.

Delusional elaboration Secondary delusions which arise in a manner which is understandable as the patient attempting to find explanations for primary psychopathological processes (e.g. a patient with persistent audi- tory hallucinations developing a belief that a transmitter has been placed in his ear).

Delusional jealousy A delusional belief that one’s partner is being unfaithful. This can occur as part of a wider psychotic illness, secondary to organic brain damage (e.g. following the ‘punch drunk syndrome’ in boxers), associated with alcohol dependence, or as a monosymptomatic delusional disorder (‘Othello syndrome’). Whatever the primary cause, there is a strong association with violence, usually towards the supposedly unfaithful partner. For this type of delusion the content is not bizarre or inconceivable and the central belief may even be true.

Delusional memory A primary delusion which is recalled as arising as a result of a memory (e.g. a patient who remembers his parents taking him to hospital for an operation as a child becoming convinced that he had been implanted with control and monitoring devices which have become active in his adult life).

Delusional misidentification A delusional belief that certain individu- als are not who they externally appear to be. The delusion may be that familiar people have been replaced with outwardly identical strangers (Capgras syndrome) or that strangers are ‘really’ familiar people (Frégoli syndrome). A rare symptom of schizophrenia or of other psychotic illnesses.

Delusional mood A primary delusion which is recalled as arising follow- ing a period when there is an abnormal mood state characterized by antici- patory anxiety, a sense of ‘something about to happen’, and an increased sense of the significance of minor events. The development of the formed delusion may come as a relief to the patient in this situation.

Delusional perception A primary delusion which is recalled as having arisen as a result of a perception (e.g. a patient who, on seeing two white cars pull up in front of his house became convinced that he was therefore about to be wrongly accused of being a paedophile). The percept is a real external object, not a hallucinatory experience.

Delusions of control A group of delusions which are also known as passivity phenomena or delusions of bodily passivity. They are considered first-rank symptoms of schizophrenia. The core feature is the delusional belief that one is no longer in sole control of one’s own body. The indi- vidual delusions are that one is being forced by some external agent to feel emotions, to desire to do things, to perform actions, or to experience bod- ily sensations. Respectively these delusions are called: passivity of affect, passivity of impulse, passivity of volition, and somatic passivity.

Delusions of guilt A delusional belief that one has committed a crime or other reprehensible act. A feature of psychotic depressive illness (e.g. an elderly woman with severe depressive illness who becomes convinced that her child, who died by cot death many years before, was in fact mur- dered by her).

Delusions of infestation A delusional belief that one’s skin is infested with multiple, tiny mite-like animals. As a monosymptomatic delusional disorder this is called Ekbom syndrome. It is also seen in acute confu- sional states (particularly secondary to drug or alcohol withdrawal), in schizophrenia, in dementing illnesses, and as delusional elaboration of tactile hallucinatory experiences.

Delusions of love A delusion where the patient believes another individ- ual is in love with them and that they are destined to be together. A rare symptom of schizophrenia and other psychotic illnesses, one particular subtype of this delusion is de Clérambault syndrome.

Delusions of reference A delusional belief that external events or situ- ations have been arranged in such a way as to have particular significance for, or to convey a message to, the affected individual. The patient may believe that television news items are referring to him or that parts of the Bible are about him directly.

Delusions of thought interference A group of delusions which are considered first-rank symptoms of schizophrenia. They are thought insertion, thought withdrawal, and thought broadcasting.

Dementia Chronic brain failure—in contrast with delirium (which is acute brain failure). In dementia, there is progressive and global loss of brain function. It is usually irreversible. Different dementing illnesses will show different patterns and rate of functional loss but, in general, there is impairment of memory, loss of higher cognitive function, perceptual abnormalities, dyspraxia, and disintegration of the personality.

Dependence The inability to control intake of a substance to which one is addicted. The dependence syndrome (b p. 542) is characterized by pri- macy of drug-seeking behaviour, inability to control intake of the substance once consumption has started, use of the substance to avoid withdrawals, increased tolerance to the intoxicating effects of the substance, and re- instigation of the pattern of use after a period of abstinence. Dependence has two components: psychological dependence, which is the subjective feeling of loss of control, cravings, and preoccupation with obtaining the substance; and physiological dependence, which is the physical conse- quences of withdrawal and is specific to each drug. For some drugs (e.g. alcohol) both psychological and physiological dependence occur; for others (e.g. LSD) there are no marked features of physiological dependence.

Depersonalization An unpleasant subjective experience where the patient feels as if they have become ‘unreal’. A non-specific symptom occurring in many psychiatric disorders as well as in normal people.

Depressed mood The core feature of depressive illness. Milder forms of depressed mood are part of the human experience, but in its pathological form it is a subjective experience. Patients describe variously: an unremit- ting and pervasive unhappiness; a loss of the ability to experience the normal range of positive emotions (‘feeling of a lack of feeling’); a sense of hopelessness and negative thoughts about themselves, their situation, and the future; somatic sensations of ‘a weight’ pressing down on head and body; and a sort of ‘psychic pain’ or wound.

Depressive sleep disturbance Characteristic pattern of sleep disturbance seen in depressive illness. It includes initial insomnia and early morning waking. In addition, sleep is described as more shallow, broken, and less refreshing. There is increased rapid eye movement (REM) latency, where the patient enters REM sleep more rapidly than normal and REM sleep is concentrated in the beginning rather than the end of the sleep period.

Derailment A symptom of schizophrenic thought disorder in which there is a total break in the chain of association between the meaning of thoughts. The connection between the two sequential ideas is apparent neither to the patient nor to the examiner.

Derealization An unpleasant subjective experience where the patient feels as if the world has become unreal. Like depersonalization it is a non- specific symptom of a number of disorders.

Diogenes syndrome Hoarding of objects, usually of no practical use, and the neglect of one’s home or environment. May be a behavioural manifestation of an organic disorder, schizophrenia, depressive disorder, or obsessive–compulsive disorder; or reflect a reaction late in life to stress in a certain type of personality.

Disinhibition Loss of the normal sense of which behaviours are appropri- ate in the current social setting. Symptom of manic illnesses and occurs in the later stages of dementing illnesses and during intoxication with drugs or alcohol.

Disorientation Loss of the ability to recall and accurately update infor- mation as to current time, place, and personal identity. Occurs in delirium and dementia. With increasing severity of illness, orientation for time is lost first, then orientation for place, with orientation for person usually preserved until dysfunction becomes very severe.

Dissociation The separation of unpleasant emotions and memories from consciousness awareness with subsequent disruption to the normal inte- grated function of consciousness and memory. Conversion and dissociation are related concepts. In conversion the emotional abnormality produces physical symptoms; while in dissociation there is impairment of mental func- tioning (e.g. in dissociative fugue and dissociative amnesia).

Distractibility Inability to maintain attention or the loss of vigilance on minimal distracting stimulation.

Diurnal variation A variation in the severity of a symptom depending on the time of day (e.g. depressed mood experienced as most severe in the morning and improving later in the day).

Double depression A combination of dysthymia and depressive illness.

Dysarthria Impairment in the ability to properly articulate speech. Caused by lesions in brainstem, cranial nerves, or pharynx. Distinguished from dysphasia in that there is no impairment of comprehension, writing, or higher language function.

Dyskinesia The impairment of voluntary motor activity by superimposed involuntary motor activity.

Dyslexia Inability to read at the level normal for one’s age or intelligence level.

Dysmorphophobia A type of over-valued idea where the patient believes one aspect of his body is abnormal or conspicuously deformed.

Dysphasia Impairment in producing or understanding speech (expres- sive dysphasia and receptive dysphasia respectively) related to cortical abnormality, in contrast with dysarthria where the abnormality is in the organs of speech production.

Dysphoria An emotional state experienced as unpleasant. Secondary to a number of symptoms (e.g. depressed mood, withdrawals).

Dyspraxia Inability to carry out complex motor tasks (e.g. dressing, eat- ing) although the component motor movements are preserved.

Dysthymia Chronic, mildly depressed mood and diminished enjoyment, not severe enough to be considered depressive illness.

Early morning waking (EMW) Feature of depressive sleep disturbance. The patient wakes in the very early morning and is unable to return to sleep.

Echo de la pensée Synonym for thought echo.

Echolalia The repetition of phrases or sentences spoken by the exam- iner. Occurs in schizophrenia and mental retardation.

Echopraxia Motor symptom of schizophrenia in which the patient mirrors the doctor’s body movements. This continues after being told to stop.

Eidetic imagery Particular type of exceptionally vivid visual memory. Not a hallucination. More common in children than adults, cf. flashbacks.

Ekbom syndrome A monosymptomatic delusional disorder where the core delusion is a delusion of infestation.

Elation Severe and prolonged elevation of mood. A feature of manic illnesses.

Elemental hallucination A type of hallucination where the false per- ceptions are of very simple form (e.g. flashes of light or clicks and bangs). Associated with organic illness.

‌Elevation of mood The core feature of manic illnesses. The mood is preternaturally cheerful, the patient may describe feeling ‘high’, and there is subjectively increased speed and ease of thinking.

Entgleisen Synonym for derailment.

Entgleiten Synonym for thought blocking or snapping off.

Erotomania Synonym for delusions of love.

Euphoria Sustained and unwarranted cheerfulness. Associated with manic states and organic impairment.

Euthymia A ‘normal’ mood state, neither depressed nor manic.

Expressive dysphasia Dysphasia affecting the production of speech. There is impairment of word-finding, sentence construction, and articulation.

Speech is slow and ‘telegraphic’, with substitutions, null words, and per- severation. The patient characteristically exhibits considerable frustration at his deficits. Writing is similarly affected. Basic comprehension is largely intact and emotional utterances and rote learned material may also be surprisingly preserved.

Extracampine hallucination A hallucination where the percept appears to come from beyond the area usually covered by the senses (e.g. a patient in Edinburgh ‘hearing’ voices seeming to come from a house in Glasgow).

Extra-pyramidal side-effects (EPSEs) Side-effects of rigidity, tremor, and dyskinesia caused by the anti-dopaminergic effects of psychotropic drugs, particularly neuroleptics. Unlike in idiopathic Parkinson’s disease, bradykinesia is not prominent.

Ey syndrome Synonym for Othello syndrome.

False perceptions Internal perceptions which do not have a corre- sponding object in the external or ‘real’ world. Includes hallucinations and pseudo-hallucinations.

Faseln Synonym for muddling.

First-rank symptoms (of schizophrenia) A group of symptoms origi- nally described by Schneider which are useful in the diagnosis of schizo- phrenia. They are neither pathognomic for, nor specific to, schizophrenia and are also seen in organic and affective psychoses. There are 11 symp- toms in 4 categories:

Auditory hallucinations

• ‘Voices heard arguing’.
• Thought echo.
• ‘Running commentary’.

Delusions of thought interference

• Thought insertion.
• Thought withdrawal.
• Thought broadcasting.

Delusions of control

• Passivity of affect.
• Passivity of impulse.
• Passivity of volitions.
• Somatic passivity.

Delusional perception

• A primary delusion of any content that is reported by the patient as having arisen following the experience of a normal perception.

Flashbacks Exceptionally vivid and affect-laden re-experiencing of remembered experiences. Flashbacks of the initial traumatic event occur in PTSD and flashbacks to abnormal perceptual experiences initially expe- rienced during lysergic acid diethylamide (LSD) intoxication can occur many years after the event.

Flattening of affect Diminution of the normal range of emotional expe- rience. A negative symptom of schizophrenia.

Flexibilitas cerea Synonym for catalepsy.

Flight of ideas Subjective experience of one’s thoughts being more rapid than normal, with each thought having a greater range of conse- quent thoughts than normal. Meaningful connections between thoughts are maintained.

Folie à deux Describes a situation where two people with a close rela- tionship share a delusional belief. This arises as a result of a psychotic illness in one individual with development of a delusional belief, which comes to be shared by the second. The delusion resolves in the second person on separation, the first should be assessed and treated in the usual way.

Formal thought disorder A term which is confusingly used for three different groups of psychiatric symptoms:

• To refer to all pathological disturbances in the form of thought.
• As a synonym for schizophrenic thought disorder.
• To mean the group of first-rank symptoms which are delusions regarding thought interference (i.e. thought insertion, thought withdrawal, and thought broadcasting).

The first of these uses is to be preferred.

Formication A form of tactile hallucination in which there is the sensa- tion of numerous insects crawling over the surface of the body. Occurs in alcohol or drug withdrawal, particularly from cocaine.

Free-floating anxiety Anxiety occurring without any identifiable exter- nal stimulus or threat (cf. Phobia).

Frégoli syndrome A type of delusional misidentification in which the patient believes that strangers have been replaced with familiar people.

Fugue A dissociative reaction to unbearable stress. Following a severe external stressor (e.g. marital break-up) the affected individual develops global amnesia and may wander to a distant location. Consciousness isunimpaired. Following resolution there is amnesia for the events which occurred during the fugue.

Functional hallucination A hallucination experienced only when expe- riencing a normal percept in that modality (e.g. hearing voices when the noise of an air conditioner is heard).

Fusion A symptom of schizophrenic thought disorder in which two or more unrelated concepts are brought together to form one compound idea.

Ganser symptom The production of ‘approximate answers’. Here the patient gives repeated wrong answers to questions which are nonethe- less ‘in the right ballpark’ (e.g. ‘what is the capital of Scotland?’—‘Paris’). Occasionally associated with organic brain illness it is much more com- monly seen as a form of malingering in those attempting to feign mental illness (e.g. in prisoners awaiting trial).

Gedankenlautwerden Synonym for thought echo.

Globus hystericus The sensation of a ‘lump in the throat’ occurring without oesophageal structural abnormality or motility problems. A symp- tom of anxiety and somatization disorders.

Glossolalia ‘Speaking in tongues’. Production of non-speech sounds as a substitute for speech. Seen in dissociative and neurotic disorders and accepted as a subcultural phenomenon in some religious groups.

Grandiose delusion A delusional belief that one has special powers, is unusually rich or powerful, or that one has an exceptional destiny (e.g. a man who requested admission to hospital because he had become con- vinced that God had granted him ‘the greatest possible sort of mind’ and that coming into contact with him would cure others of mental illnesses). Occurs in all psychotic illnesses but particularly in manic illnesses.

Grandiosity An exaggerated sense of one’s own importance or abilities. Seen in manic illnesses.

Hallucination An internal percept without a corresponding external object. The subjective experience of hallucination is that of experiencing a normal percept in that modality of sensation. A true hallucination will be perceived as in external space, distinct from imagined images, outside conscious control, and as possessing relative permanence. A pseudo- hallucination will lack one or all of these characteristics.

Hallucinations are subdivided according to their modality of sensation and may be auditory, visual, gustatory, tactile, olfactory, or kinaesthetic. Auditory hallucinations, particularly of voices, are characteristic of schizophrenic ill- ness, while visual hallucinations are characteristic of organic states.

Hemiballismus Involuntary, large-scale, ‘throwing’ movements of one limb or one body side.

Hypersomnia Excessive sleepiness with increased length of nocturnal sleep and daytime napping. Occurs as core feature of narcolepsy and in atypical depressive states.

Hypnagogic hallucination A transient false perception experienced while on the verge of falling asleep (e.g. hearing a voice calling one’s name which then startles you back to wakefulness to find no-one there). The same phenomenon experienced while waking up is called hypnopompic hallucination. Frequently experienced by healthy people and so not a symptom of mental illness.

Hypochondriacal delusion A delusional belief that one has a serious physical illness (e.g. cancer, AIDS). Most common in psychotic depressive illnesses.

Hypochondriasis The belief that one has a particular illness despite evidence to the contrary. Its form may be that of a primary delusion, an over-valued idea, a rumination, or a mood-congruent feature of depressive illness.

Hypomania Describes a mild degree of mania where there is elevated mood but no significant impairment of the patient’s day-to-day functioning.

Illusion A type of false perception in which the perception of a real world object is combined with internal imagery to produce a false internal percept. Three types are recognized: affect, completion, and pareidolic illusions. In affect illusion there is a combination of heightened emotion and mis- perception (e.g. whilst walking across a lonely park at night, briefly seeing a tree moving in the wind as an attacker). Completion illusions rely on our brain’s tendency to ‘fill in’ presumed missing parts of an object to produce a meaningful percept and are the basis for many types of optical illusion. Both these types of ilusions resolve on closer attention. Pareidolic illusions are meaningful percepts produced when experiencing a poorly defined stimulus (e.g. seeing faces in a fire or clouds).

Imperative hallucination A form of command hallucination in which the hallucinatory instruction is experienced as irresistible, a combination of command hallucination and passivity of action.

Impotence Loss of the ability to consummate sexual relationships. Refers to inability to achieve penile erection in men and lack of genital prepared- ness in women. It may have a primary medical cause, be related to psycho- logical factors, or can be a side-effect of many psychotropic medications.

Incongruity of affect Refers to the objective impression that the displayed affect is not consistent with the current thoughts or actions (e.g. laughing while discussing traumatic experiences). Occurs in schizophrenia.

Initial insomnia Difficulty getting off to sleep. Seen as a symptom of primary insomnia as well as in depressive sleep disturbance.

Insightlessness See Lack of insight.

Irritability Diminution in the stressor required to provoke anger or ver- bal or physical violence. Seen in manic illnesses, organic cognitive impair- ment, psychotic illnesses, and drug and alcohol intoxication. Can also be a feature of normal personality types and of personality disorder.

Jamais vu The sensation that events or situations are unfamiliar, although they have been experienced before. An everyday experience but also a non-specific symptom of a number of disorders including temporal lobe epilepsy, schizophrenia, and anxiety disorders.

Knight’s move thinking Synonym for derailment.

Lability of mood Marked variability in the prevailing affect.

Lack of insight Loss of the ability to recognize that one’s abnormal experiences are symptoms of psychiatric illness and that they require treatment.

Lilliputian hallucination A type of visual hallucination in which the subject sees miniature people or animals. Associated with organic states, particularly delirium tremens.

Logoclonia Symptom of Parkinson’s disease where the patient gets ‘stuck’ on a particular word of a sentence and repeats it.

Logorrhoea Excess speech or ‘verbal diarrhoea’. Symptom of mania.

Loosening of associations A symptom of formal thought disorder in which there is a lack of meaningful connection between sequential ideas.

Loss of libido Loss of the desire for sexual activity. Common in depres- sive illness and should be inquired about directly as it is usually not men- tioned spontaneously. Should be distinguished from impotence.

Magical thinking A belief that certain actions and outcomes are con- nected although there is no rational basis for establishing a connection (e.g. ‘if you step on a crack, your mother will break her back’). Magical thinking is common in normal children and is the basis for most supersti- tions. A similar type of thinking is seen in psychotic patients.

Malingering Deliberately falsifying the symptoms of illness for a second- ary gain (e.g. for compensation, to avoid military service, or to obtain an opiate prescription).

Mania A form of mood disorder initially characterized by elevated mood, insomnia, loss of appetite, increased libido, and grandiosity. More severe forms develop elation and grandiose delusions.

Mannerism Abnormal and occasionally bizarre performance of a volun- tary, goal-directed activity (e.g. a conspicuously dramatic manner of walk- ing. Imagine John Cleese’s ‘the minister of funny walks’).

Mental retardation Diminished intelligence below the second standard deviation (IQ <70). Increasing severity of retardation is associated with decreased ability to learn, to solve problems, and to understand abstract concepts. Subdivided as: mild: 50–69; moderate 35–49; severe 20–34; pro- found 0–19.

Micrographia Small ‘spidery’ handwriting seen in patients with Parkinson’s disease; a consequence of being unable to control fine movements. This is most easily recognized by comparing their current signature with one from a number of years previously.

Middle insomnia Wakefulness and inability to return to sleep occurring in the middle part of the night.

Mirror sign Lack of recognition of one’s own mirror reflection with the perception that the reflection is another individual who is mimicking your actions. Seen in dementia.

Mitgehen An extreme form of mitmachen where the patient’s limbs can be moved to any position by very slight or fingertip pressure (‘angle-poise lamp sign’).

Mitmachen A motor symptom of schizophrenia where the patient’s limbs can be moved without resistance to any position (cf. mitgehen). The limbs return to their resting state once the examiner lets go, in con- trast with catalepsy, where the limbs remain in their set positions for prolonged periods.

Mood The subjective emotional state over a period of time, in contrast to affect which describes the emotional response to a particular situation or event.

Mood congruent A secondary symptom which is understandable in the light of an abnormal mood state (e.g. a severely depressed patient devel- oping a delusion that they are in severe debt, or a manic patient develop- ing a delusion that they are exceptionally wealthy).

Morbid jealousy Synonym for delusional jealousy.

Motor symptoms of schizophrenia. Schizophrenic illness is associ- ated with a variety of soft neurological signs and motor abnormalities. In the modern era many motor abnormalities will be attributed to the side-effects of neuroleptic drugs, but all were described in schizophrenic patients prior to the introduction of these drugs in 1952.

Recognized motor symptoms in schizophrenia include: catatonia, cata- lepsy, automatic obedience, negativism, ambitendency, mitgehen, mit- machen, mannerism, stereotypy, echopraxia, and psychological pillow.

Muddling A feature of schizophrenic thought disorder caused by simul- taneous derailment and fusion. The speech so produced may be very bizarre.

Multiple personality The finding of two or more distinct ‘personali- ties’ in one individual. These personalities may answer to different names, exhibit markedly different behaviours, and describe amnesia for periods when other personalities were active. This symptom is most probably an iatrogenic condition produced during exploratory psychotherapy in sug- gestible individuals.

Mutism Absence of speech without impairment of consciousness.

Negative symptoms (of schizophrenia) The symptoms of schizo- phrenia which reflect impairment of normal function. They are: lack of volition, lack of drive, apathy, anhedonia, flattening of affect, blunting of affect, and alogia. Believed to be related to cortical cell loss.

Negativism A motor symptom of schizophrenia where the patient resists carrying out the examiner’s instructions and his attempts to move or direct the limbs.

‌Neologism A made-up word or normal word used in an idiosyncratic way. Neologisms are found in schizophrenic speech.

Nihilistic delusions A delusional belief that the patient has died or no longer exists or that the world has ended or is no longer real. Nothing matters any longer and continued effort is pointless. A feature of psychotic depressive illness.

Nystagmus Involuntary oscillating eye movements.

Obsession An idea, image, or impulse which is recognized by the patient as their own, but which is experienced as repetitive, intrusive, and distress- ing. The return of the obsession can be resisted for a time at the expense of mounting anxiety. In some situations the anxiety accompanying the obses- sional thoughts can be relieved by associated compulsions (e.g. a patient with an obsession that his wife may have come to harm feeling compelled to phone her constantly during the day to check she is still alive).

Othello syndrome A monosymptomatic delusional disorder where the core delusion has the content of delusional jealousy.

Over-valued ideas A form of abnormal belief. These are ideas which are reasonable and understandable in themselves but which come to unrea- sonably dominate the patient’s life.

Palimpsest Episode of discrete amnesia related to alcohol or drug intoxi- cation. The individual has no recall for a period when, although intoxicated, he appeared to be functioning normally. This is also commonly known as ‘blackout’, but the term palimpsest is preferable as it avoids confusion with episodes of loss of consciousness.

Panic attack Paroxysmal, severe anxiety. May occur in response to a particular stimulus or occur without apparent stimulus.

Paranoid delusion Strictly speaking this describes self-referential delu- sions (i.e. grandiose delusions and persecutory delusions). It is however more commonly used as a synonym for persecutory delusion.

Paraphasia The substitution of a non-verbal sound in place of a word. Occurs in organic lesions affecting speech.

Passivity phenomena Synonym for delusions of control.

Persecutory delusion A delusional belief that one’s life is being inter- fered with in a harmful way.

Perseveration Continuing with a verbal response or action which was initially appropriate after it ceases to be apposite (e.g. ‘Do you know where you are?’—‘in the hospital’; ‘do you know what day it is?’—‘in the hospital’. Associated with organic brain disease and is occasionally seen in schizophrenia).

Phantom mirror image Synonym for autoscopy.

Phobia A particular stimulus, event, or situation which arouses anxiety in an individual and is therefore associated with avoidance. The concept of ‘biological preparedness’ is that some fears (e.g. of snakes, fire, heights) had evolutionary advantage and so it is easier to develop phobias for these stimuli than other, more evolutionarily recent threats (e.g. of guns or electric shock).

Physiological dependence See Dependence.

Pica The eating of things which are not food or of food items in abnormal quantities.

Positive symptoms (of schizophrenia) The symptoms of schizophre- nia which are qualitatively different from normal experience (i.e. delu- sions, hallucinations, schizophrenic thought disorder). Believed to be related to neuro-chemical abnormalities.

Posturing The maintenance of bizarre and uncomfortable limb and body positions. Associated with psychotic illnesses and may have delusional sig- nificance to the patient.

Pressure of speech The speech pattern consequent upon pressure of thought. The speech is rapid, difficult to interrupt, and, with increasing severity of illness, the connection between sequential ideas may become increasingly hard to follow. Occurs in manic illness.

Pressure of thought The subjective experience of one’s thoughts occur- ring rapidly, each thought being associated with a wider range of conse- quent ideas than normal and with inability to remain on one idea for any length of time. Occurs in manic illness.

Priapism A sustained and painful penile erection, not associated with sexual arousal. A rare side-effect of antidepressant medication. If not relieved can cause permanent penile damage.

Pseudocyesis A false pregnancy. May be hysterical or delusional in nature and can occur in both sexes although more commonly in women. The belief in the false pregnancy may be accompanied by abdominal distension, lumbar lordosis, and amenorrhoea.

Pseudodementia A presentation of severe depression in the elderly where the combination of psychomotor retardation, apparent cognitive deficits, and functional decline causes diagnostic confusion with dementia.

Pseudo-hallucination A false perception which is perceived as occur- ring as part of one’s internal experience, not as part of the external world. It may be described as having an ‘as if’ quality or as being seen with the mind’s eye. Additionally, hallucinations experienced as true hallucinations during the active phase of a patient’s illness may become perceived as pseudo-hallucinations as they recover. They can occur in all modalities of sensation and are described in psychotic, organic, and drug-induced conditions as well as occasionally in normal individuals. (The hallucinations of deceased spouses commonly described by widows and widowers may have the form of a pseudo-hallucination.)

Pseudologica fantastica The production of convincing false accounts, often with apparent sincere conviction. There may be a grandiose or over- exaggerated flavour to the accounts produced. A feature of Munchausen’s disease.

‌Psychic anxiety See anxiety.

Psychogenic polydipsia Excessive fluid intake without organic cause.

Psychological dependence See Dependence.

Psychological pillow A motor symptom of schizophrenia. The patient holds their head several inches above the bed while lying and can maintain this uncomfortable position for prolonged periods of time.

Psychomotor agitation A combination of psychic anxiety and excess and purposeless motor activity. A symptom common to many mental ill- nesses and found in normal individuals in response to stress.

Psychomotor retardation Decreased spontaneous movement and slowness in instigating and completing voluntary movement. Usually asso- ciated with subjective sense of actions being more of an effort and with subjective retardation of thought. Occurs in moderate to severe depres- sive illness.

Punding A form of stereotyped motor behaviour in which there is appar- ent fascination with repetitive, mechanical tasks such as arranging items or dismantling and reassembling mechanical objects. It is seen as a side-effect of anti-Parkinsonian medication and in some individuals taking metham- fetamine. It bears some similarity to behaviours seen in individuals with autism.

Receptive dysphasia Dysphasia affecting the understanding of speech. There is impairment in understanding spoken commands and repeating back speech. There are also significant abnormalities in spontaneous speech with word substitutions, defects in grammar, and syntax and neologisms. The abnormal speech so produced is however fluent (cf. expressive dysphasia) and the patient may be unconcerned by his deficits.

Reflex hallucination The experience of a real stimulus in one sensory modality triggering a hallucination in another.

Retrograde amnesia The period of amnesia between an event (e.g. head injury) and the last continuous memory before the event.

Rumination A compulsion to engage in repetitive and pointless consid- eration of phrases or ideas, usually of a pseudo-philosophical nature. May be resisted for a period with consequent mounting anxiety.

‘Running commentary’ A type of third-person auditory hallucination which is a first-rank symptom of schizophrenia. The patient hears one or more voices providing a narrative of their current actions, ‘he’s getting up…now he’s going towards the window’.

Russell sign Skin abrasions, small lacerations, and calluses on the dorsum of the hand overlying the metacarpophalangeal and interphalangeal joints found in patients with symptoms of bulimia. Caused by repeated contact between the incisors and the skin of the hand which occurs during self- induced vomiting.

Schizophasia Synonym for word salad.

Schizophrenic speech disorder This includes the abnormalities in the form of speech consequent upon schizophrenic thought disorder, and those abnormalities in the use of language characteristic of schizophrenia such as use of neologisms and stock words/phrases.

Schizophrenic thought disorder A group of abnormalities in the sub- jective description of the form of thought which occurs in schizophrenia. The abnormalities include: loosening of associations, derailment, thought blocking, fusion, and muddling.

Sensory distortions Changes in the perceived intensity or quality of a real external stimulus. Associated with organic conditions and with drug ingestion or withdrawals. Examples include: hyperacusis (hearing sounds as abnormally loud), micropsia (‘wrong end of the telescope effect’, per- ceiving objects which are close as small and far away).

Snapping off Synonym for thought blocking.

Somatic anxiety See Anxiety.

Somatization The experience of bodily symptoms with no, or no suf- ficient, physical cause for them, with presumed psychological causation.

Splitting of perception Loss of the ability to simultaneously process complementary information in two modalities of sensation (e.g. sound and pictures on television). Rare symptom of schizophrenia.

Stereotypy A repetitive and bizarre movement which is not goal-directed (in contrast to mannerism). The action may have delusional significance to the patient. Seen in schizophrenia.

Stock phrases/stock words Feature of schizophrenic speech disorder. The use of particular words and phrases more frequently than in normal speech and with a wider variety of meanings than normal.

Stupor Absence of movement and mutism where there is no impairment of consciousness. Functional stupor occurs in a variety of psychiatric ill- nesses. Organic stupor is caused by lesions in the midbrain (the ‘locked-in’ syndrome).

Synaesthesia A stimulus in one sensory modality is perceived in a fashion characteristic of an experience in another sensory modality (e.g. ‘tasting’ sounds or ‘hearing’ colours). Occurs in hallucinogenic drug intoxication and in epileptic states.

Tangentiality Producing answers which are only very indirectly related to the question asked by the examiner.

Tardive dyskinesia A movement disorder associated with long-term treatment with neuroleptic drugs (although it was described in psychotic patients before the use of these drugs in clinical practice). There is con- tinuous involuntary movement of the tongue and lower face. More severe cases involve the upper face and have choreoathetoid movements of the limbs.

Teleological hallucination Synonym for command hallucination.

Terminal insomnia Synonym for early morning waking.

‌Third-person auditory hallucinations Auditory hallucinations charac- teristic of schizophrenia where voices are heard referring to the patient as ‘he’ or ‘she’, rather than ‘you’. The first-rank symptoms of ‘voices heard arguing’ and ‘running commentary’ are of this type.

Thought blocking A symptom of schizophrenic thought disorder. The patient experiences a sudden break in the chain of thought. It may be explained as due to thought withdrawal. In the absence of such delu- sional elaboration it is not a first-rank symptom.

Thought broadcasting The delusional belief that one’s thoughts are accessible directly to others. A first-rank symptom of schizophrenia.

Thought disorder See Formal thought disorder.

Thought echo The experience of an auditory hallucination in which the content is the individual’s current thoughts. A first-rank symptom of schizo- phrenia. Also known as gedankenlautwerden or echo de la pensée.

Thought insertion The delusional belief that thoughts are being placed in the patient’s head from outside. A first-rank symptom of schizophrenia.

Tic Sudden twitches of a single muscle or muscle group.

Trichotillomania The compulsion to pull one’s hair out.

Verbigeration Repetition of words or phrase while unable to articulate the ‘next’ word in the sentence. Seen in expressive dysphasia.

Verschmelzung Synonym for fusion.

‘Voices heard arguing’ A type of auditory hallucination which is a first-rank symptom of schizophrenia. The patient hears two or more voices debating with one another, sometimes about a matter over which the patient is agonizing (e.g. ‘he should take the medication, it’s worked before’, ‘no, not again, he’ll not take it this time’).

Vorbeigehen Synonym for Ganser symptom. Vorbeireden Synonym for Ganser symptom. Waxy flexibility Synonym for catalepsy.

Wernicke’s dysphasia A type of receptive dysphasia due to cortical lesions in or near the posterior portion of the left first temporal convolu- tion (superior temporal gyrus)—known as the Wernicke area.

Withdrawals The physical sequelae of abstinence from a drug to which one is dependent. These are individual to the drug concerned (e.g. sweat- ing, tachycardia, and tremor for alcohol; dilated pupils, piloerection, abdominal pain, and diarrhoea for opiates).

Word salad The most severe degree of schizophrenic thought disorder in which no connection of any kind is understandable between sequential words and phrases the patient uses. Also called schizophasia.