Examen Mental UMNG PDF

# EXAMEN MENTAL The present document is a compilation of the main definitions used in psychiatric semiology, presented in the order of the different areas of the mental examination. The objective is to specify each of the alterations, in such a way that specialists and pre and postgraduate students...

# EXAMEN MENTAL The present document is a compilation of the main definitions used in psychiatric semiology, presented in the order of the different areas of the mental examination. The objective is to specify each of the alterations, in such a way that specialists and pre and postgraduate students of the Psychiatry Service of the Central Military Hospital - New Military University of Granada achieve a common language that allows us to adequately use each of these definitions. Contrary to what is thought, semiology is not as precise as is believed, since the same term can have different meanings, according to different schools of thought. As these are definitions, an exact transcription of those consulted in the different books consulted has been carried out, which are listed at the end in the bibliography section. ## **EXAMEN MENTAL** The mental examination is the descriptive record of the signs and symptoms present in a patient at a given moment (cross-sectional cut), the product of observation and orderly exploration during the psychiatric interview. ### **It consists of the following areas** 1. **GENERAL APPEARANCE/ATTITUDE** - Refers to the general presentation and behavior of the patient during the examination. The "scene" where the interview takes place is described. The description should take into account the following aspects: - Whether he enters alone or accompanied. - Voluntarily or by obligation. - Gait (general description). Example: fast, slow, antalgic, staggering, etc. - If specific motor alterations are present, they will be described later in the section reserved for this purpose. - Race, height, build, apparent age in relation to chronological age, prominent physical characteristics - Visual contact with the interviewer. - Personal grooming: presentation, hygiene, use of makeup, adornments, clothing. - Posture during the interview (standing, sitting, lying down, constant changes in position) - Visual contact with the interviewer. - Volume of voice - Facial expression (facies) - Degree of cooperation for the examination - Attitude during the interview: seductive, shy, aggressive, mocking, distrustful, arrogant, submissive, friendly, respectful, interested, compliant, distant, complaining, infantile, demanding, hostile, inhibited, with strangeness, intrusive, infantile, etc. - Reaction that it evokes in the interviewer: sympathy, compassion, pity, desire to help, indifference, rejection, fear, disgust. It may be one or more alternatives. - **Example of description**: - Patient who enters the office accompanied voluntarily, with antalgic gait, tall, thin, mixed race, with a scar on the right cheek, apparent age coincides with the actual age, adequately dressed for age, sex, condition and situation, remains seated, with an adequate posture, maintains eye contact, low voice volume, sad facies, collaborative, he is complaining and very respectful, he inspires curiosity and desire to help. 2. **PSYCHOMOTOR STATE** - Refers to the movements and postures of the patient during the interview. Alterations in motor skills that are the product of disturbances in mental processes are called psychomotor disorders. - They can be quantitative and qualitative. - **Quantitative alterations:** - **By increase:** - **HYPERKINESIA** (Synonyms: hyperactivity, psychomotor restlessness): increase in the amount and speed of movements without a determined end. - **PSYCHOMOTOR AGITATION:** extreme degree of increased motor activity. It goes beyond the limits of habitual behavior and is accompanied by internal tension and impulsivity. Control over movements is lost, becoming a state of risk for oneself or for third parties. - **AKATHISIA:** Feeling of restlessness and internal tension, with the inability to remain still. It is caused by some psychotropic drugs. - **By decrease:** - **PSYCHOMOTOR RETARDATION**: Decrease in the amount and speed of movements. If the decrease occurs only in the amount of movements, it is called BRADYKINESIA. - **STUPOR**: Extreme degree of psychomotor retardation. It presents complete immobility with little or no response or absence of it in the face of environmental stimuli, even if they are painful. - **CATATONIA**: Type of stupor in which the patient can remain immobile for long periods of time. It often is accompanied by hypertonia, peculiarities in movements (mannerisms, stereotypies, etc.), negativism, and phenomena of pathological suggestibility (echopraxia, automatic obedience, cerea flexibilitas). - **Qualitative alterations:** - **Alterations of muscle tone:** - **By increase in muscle tone (hypertonia)** - **MUSCLE RIGIDITY OR SPASTICITY**: Involuntary muscle tension accompanied by exaggerated deep tendon reflexes that interfere with normal activity (walking, talking, swallowing, handling, etc.). - ** By decrease in muscle tone (hypotonia)** - **FLACCIDITY:** Decrease or loss of normal muscle tone. - **Posture alteration:** - **STEREOTYPICAL POSTURE:** Positions of the trunk, head, limbs or all of them, which persist for a longer period of time than usual, tend to be repeated and are not usual in - **Normal people. Postures that these patients maintain would be very uncomfortable or unsustainable for a person without illness. (Example, the "pillow of psychic").** - **FIXED POSTURE:** Position that is maintained for a long period of time, it is not uncomfortable or unusual. - **CEREA FLEXIBILITY:** It is the maintenance of forced postures, uncomfortable and even gravitational postures imposed by the examiner. 3. **MOVEMENT DISORDERS** - **NON-ADAPTIVE MOVEMENTS**: These are those that do not have a purpose or defined utility. They are motor habits without a purpose that tend to become more frequent when they are tense or anxious. They are called non-adaptive because they do not meet a demand for adaptation to the environment. - **TICs:** Sudden, repeated, involuntary contractions of small muscle groups that usually follow a pattern similar to expressive movements. (Ex. Blinking, winking, wrinkling your nose, twisting your mouth, stretching your neck or hunching your shoulders). They are considered motor habits of psychogenic origin. They can also be vocal. - **TREMORS:** Involuntary, relatively rhythmic, oscillatory movements resulting from the alternating contraction of opposing muscle groups. They can be psychogenic in which case they are usually of medium amplitude, fine or coarse, and although they can be found at rest, they are usually more pronounced when making voluntary movements. They are considered slow (from 3 to 6 per second) or fast (from 10 to 20 per second). - **STEREOTYPIES OF MOTION:** It is the persistent and uniform repetition of an act, without any purpose. It may consist of twisting or rhythmic flexion of the head, swinging of the arms, hitting the floor when passing through a door, opening and closing your eyes after each bite of food, etc. - **MANNERISMS:** Exaggeration of gestures, mannerisms and voluntary movements that make them look strange, unusual, strange or out of place compared to the usual ones of the social group of the subject. They appear as lacking in spontaneity, theatrical and artificial, inauthentic. - **CONVULSIONS:** Sudden, violent, involuntary contractions of the muscles of the entire body or of part of it. They can be tonic when the contraction is sustained for some time or clonic if they are more or less rhythmic movements, caused by the contraction and relaxation of the muscles. - **CHOREIFORM MOVEMENTS:** Involuntary movements, without purpose, asymmetric, arrhythmic, fast, abrupt and short. They resemble "fragments of involuntary movements." Sometimes, the patient modifies them to make them appear voluntary. (Ex. A sudden jerk of the upper limb can be continued to smooth out the hair). - **DYSTONIA:** Movement disorder characterized by involuntary muscle contractions, which result in a maintained abnormal posture, abnormal torsional movements or jerky movements. The contractions of dystonia usually follow a specific pattern, - **and are sustained and slow. Dystonia can affect only one part of the body (focal), or it may generalize (generalized).** - **DISMIMIAS:** alterations in gesticulation. **HYPERMIMIA** if it is exaggerated, **HYPOMIMIA** if it is diminished, **PARAMIMIA** if it is not congruent with the reported emotional state and **ECOMIMIA** if it is the imitation of gestures performed by other people. 4. **MOTOR ATTITUDES/INDUCED MOVEMENTS** - **MOTOR ATTITUDE:** Tendency to act in a specific way or to adopt a pattern of behavior. - **INDUCED MOVEMENT:** Movements that occur in response to orders, suggestions or actions of the examiner. - **AUTOMATIC OBEDIENCE:** The patient carries out any order without taking into account the consequences. (Ex. Stick out your tongue every time you are told to do so, even if every time you stick out your tongue, you are pricked with it with a pin.) - **NEGATIVISM:** The patient ignores or opposes orders and directions that are given to him. It is considered **PASSIVE** if he simply does not act, and **ACTIVE** when it implies an open opposition to orders, including actions opposite to the indicated ones. - **ECOPRAXIA** Imitation of the actions of other people It is to copy the movements of the other automatically. 5. **INTERRUPTION OF MOVEMENTS AND MOTOR IMPAIRMENT** - **MOTOR BLOCK:** It consists in the sudden, apparently unmotivated interruption of a movement. The blockage sometimes prevents the initiation of movements. The patient 'may be unable to perform an action at a given time and perform it without difficulty a moment later. - **APRAXIA:** Inability or difficulty to carry out complex actions. - **PARALYSIS:** It is the inability to make movements. 6. **COMPULSION/IMPULSION/MOTOR AMBIVALENCE** - **COMPULSION:** An urgent need to perform a specific act that appears irrational to alleviate a growing anxiety. The return of anxiety forces the patient to repeat the compulsive act periodically. - **IMPULSION:** Sudden and urgent need, often irresistible, to perform an act without being mediated, as in the compulsion, by growing anxiety. This phenomenon can precede aggressive acts or unexpected suicide attempts. - **MOTOR AMBIVALENCE OR AMBITENDENCIA:** Opposing motor acts that are the product of two impulses in the patient, who simultaneously accepts and rejects the execution of an action. An example may be the patient who extends his hand to greet, but withdraws it when he is about to shake it. ___ ## **3. AFFECT** - **AFFECT:** It is defined as the external expression of mood or emotions through facial, bodily and verbal expression. - **EMOTIONS:** Variations in mood that are intense and fleeting, which vary in duration and intensity from person to person, they are accompanied by multiple somatic and behavioral manifestations, and they represent efficient ways of adapting to environmental demands. - **MOOD OR HUMOR STATE**: It refers to an emotional condition that is slow to establish, more sustained over time than emotions and without a clear physiological component. It is considered the underlying habitual affect, predominant over which emotions occur. Some authors also call it affective tone. - **EUTYHMIA:** The normal and desirable mood state. It is an emotional condition in which there is a serene experience of internal and external phenomena, adequate in intensity, onset and duration. An example would be the affective tone that is experienced without any worry or rush when listening to a pleasant piece of music. - The description of affect is the product of observing verbal, non-verbal communication and the behavior of the person. In the mental examination it should be carried out considering: - **A. MODULATION**: It refers to whether the gesturing used for affective expression is sufficient in quantity and intensity - **B. APPROPRIATION**: It refers to whether there is congruence between the affective expression and what is communicated verbally by the person. If there is no such congruence, it is considered an inappropriate affect. An example would be expressing joy while talking about a very sad topic. When there is an involuntary separation between the idea and the type of affect that accompanies it, in such a way that they are shown to be totally independent, it is called IDEO-AFFECTIVE DISSOCIATION. - **C. ADJUSTMENT**: It refers to whether there is congruence between environmental stimuli and what is expressed affectively. - **D. BACKGROUND/ELEMENTS**: It refers to the types of emotions and moods expressed by the person. - **Affects can be grouped into four major groups: joy, sadness, anxiety, irritability/anger.** - **GROUP OF JOY**: - **JOY:** It is an affective experience associated with the pleasurable and satisfying experience of current events and confidence in the immediate or future attainment of something good. - **EUPHORIA:** It is a joyful and optimistic affective tone, a feeling of well-being that permeates behavior. It is manifested by great talkativeness, optimism, and satisfaction. The person radiates happiness - **and laughs easily. It becomes pathological when judgment of reality is lost and actions are performed that involve difficulties for oneself and for others.** - **JUBILATION:** Very intense euphoria that invades motor behavior in an exaggerated way - **EXALTATION:** Intense euphoria with hyperactivity (joy), accompanied by ideas of great personal importance and a slight increase in the speed of thought. Joy is contagious and the difficulty in tolerating frustration can trigger episodes of irritability - **ECSTASY:** Excessive joy with suspension of all voluntary activity. - **GROUP OF SADNESS:** - **SADNESS:** It is defined as a feeling of emotional pain, unpleasant, generally accompanied by self-perception of discomfort. It is considered part of the emotional repertoire of human beings and is associated with losses, but when it does not correspond to an objective experience of reality or when it persists abnormally over time, it is considered pathological. - **DISPHORIA:** Dysphoria is a psychological state of dissatisfaction, frustration, discomfort or restlessness halfway between sadness, anxiety, anger, irritability, fear and powerlessness. Some authors define it as the combination of sadness-irritability or sadness-anxiety. It is interesting to note that the Royal Spanish Academy does not accept the term, while Webster and Oxford do accept the English version and define it as "depression, feeling of discomfort and discontent." - **GROUP OF ANXIETY:** - **ANXIETY:** Unpleasant sensation of restlessness, despair, distress, which is usually accompanied by sympathetic activation. It is an experience associated with the expectation of an unidentified danger. - **FEAR OR DREAD:** It is an emotion triggered by the expectation of danger that represents a clearly identified object or situation. It is the central emotion of specific phobias. - **GROUP OF IRRITABILITY/ANGER:** - **IRRITABILITY:** Easy anger with provocation of anger and aggression. The person gets upset easily, reacts disproportionately to triggers and tends to address aggression towards people whose behavior has not contributed to triggering it. - **ANGER:** An unpleasant sensation that varies in intensity, ranging from irritation to intense fury. It is better understood in the context of frustration, when an experience is understood as unfair, arbitrary or illegitimate. It is often accompanied by aggressive behavior. - **OTHER DEFINITIONS:** - **RESTRICTED AFFECT:** It is characterized by a decrease in the range and intensity of emotional expression. Emotions such as joy or sadness are not clearly manifested. - **BLUNTED AFFECT:** Restricted affect, but this term is preferred when the direct cause is medication or psychoactive substances. - **AFFECT LABILITY:** Abrupt and generally intense fluctuation in emotional expression. - **AFFECTIVE AMBIVALENCE:** Simultaneous presence of two emotions related to the same person, object or circumstance. - **FLAT AFFECT (ATHYMIА):** Affect without modulation, usually accompanied by speech without prosody and disinterest in the environment. The person appears withdrawn and isolated. - **AFFECTIVE SUPPORT:** When affect is supported by the content of thinking, preverbal language and motor behavior; there is congruence between them . - **AFFECTIVE RESONANCE:** It occurs when the patient's affect manages to "infect" the interviewer. In other words, an affect is resonant when the interviewer feels what the person expressed through his affectivity. - **CHILDLIKE OR HEBOID:** It is characterized by an attitude, playfulness, clowning and lack of seriousness, not experienced by the interviewer with contagious joy, but rather felt as superficial banality and inappropriate. It causes annoyance or strangeness in others. - For the description of affect in terms of the elements that make it up, if there is a predominant emotion, it is considered that it constitutes the **BACKGROUND** of the affect; on the contrary, if there are several and none predominate, it is said that there are **ELEMENTS** of the affect. Example: if sadness predominates, it is said that there is a sad background; if there is no predominance, it is said that there are elements of sadness, anxiety, etc. - **Example of description:** - Modulated, appropriate, inadequate, labile, with elements of sadness, joy and anxiety. - Flat affect. - Hypodulated, appropriate, adequate, with a sad background affect. ## **4. THOUGHT** - It is defined as a flow of ideas, symbols and associations directed towards a goal and initiated by a problem, a task, and leading to a conclusion oriented towards reality. - For its description, the origin, course and content are taken into account. - **A. FORM OR ORIGIN OF THOUGHT**: It refers to the way in which thought occurs, that is, the way in which ideas are organized to represent reality. In other words, it refers to the rules with which associations are made in thinking. - **It can be:** - **1. LOGICAL:** It follows the principles/postulates of formal Aristotelian logic. That is, it complies with the precepts of identity, non-contradiction, causality. Some authors also include spatiality and temporality here. - **2. PARALOGICAL:** It is characterized by: - Accepting identity based on identical predicates. That is, it considers as identical those objects or events that have a common characteristic (Ex.: "Jesus Christ has a beard", "I have a beard", therefore "I am Jesus Christ". - Because associative links become causal links. The temporal or spatial coexistence of two events implies a causal relationship between them. (Ex.: a patient feels bad after talking to a friend and thinks that it was he, through witchcraft, who caused him the discomfort). - Because there is an identity between the image or symbol of an object and the object itself that it represents. Therefore, what happens to the image or symbol happens to the object (Ex.: voodoo dolls). - Because it accepts that thought has direct power over matter and over the minds of others and is not subject to the limitations of time and distance. It includes the ability to perform, through thought: move objects or produce changes in them, transmit thoughts to other people, know future events in advance, perform actions that are not possible by natural means. It accepts the existence of beings with characteristics superior to humans such as spirits, demons, etc. - Paralogical thinking can break one or more Aristotelian postulates, but this break is shared by a social or cultural group. - **3. ILLOGICAL:** It does not comply with one or more Aristotelian postulates. On it, delirious ideas are built. - **B. COURSE OF THOUGHT:** It refers to the dynamics of the associations that are used when thinking. - **Disorders:** - **1. Alteration of ASSOCIATIVE SPEED:** - **TAQUIPSIQUIA:** It consists of a stream of thoughts that are faster than usual. It is associated with **TAQUILALIA** in which the patient speaks at a faster pace. - **LOGORREA:** there is an increase in associative speed and word production. It is a rapid and abundant speech. Generally, the train of thought is not lost. - **BRADIPSIQUIA:** Decrease in the speed of association of ideas, not necessarily associated with a decrease in the production of these. It is associated with **BRADILALIA**, in which the patient speaks more slowly than usual. - **BLOCKING OR INTERRUPTION:** interruption of the flow of thoughts without reaching an objective or being able to communicate what is being thought adequately. - **RETARDATION:** Decrease in associative speed with slowness in the production of words. - **2. Alteration of ASSOCIATIONS:** - **By decrease:** - **LACONICISM:** It is the reduction of verbal communication to the minimum number of words needed to answer questions and to express ideas. - **POOR IDEA CONTENT:** Decrease in the number of ideas and words available for communication. - **CONCRETE THINKING:** Inability to generate and associate general concepts about particular phenomena and to categorize them. There is a significant reduction in deductive, inductive and analogical reasoning. There is no abstraction. - **PERSEVERATION:** It is the repetitive and persistent expression of an idea with changes, although slight, in the words used to express oneself. It is the repetition of the same topic throughout different moments of the conversation. - **VERBAL STEREOTYPY:** It is the persistent and always uniform repetition of a word or phrase. They are sounds, syllables, words that the person emits when trying to articulate language, involuntarily and disconnected from the speech. - **VERBIGERATION:** It is the stereotyped repetition without meaning of the same words or phrases that are interspersed in the speech. - **LOGOCLONIA:** It is the spasmodic repetition of syllables in the middle or at the end when pronouncing each word. - **ECHOLALIA:** It is the repetition of the last words spoken by another person. It is done unintentionally, with the same intonation. When the repetition is of the words of another person present, different from the interviewer, it is called **METALLALIA**. If the repetition is of the last word of the interviewer, it is called **PALILALIA**. - **By increase:** - **CIRCUMSTANTIALITY:** Use of unnecessary details, finishing by saying what was intended, after many detours. - **FLIGHT OF IDEAS:** Acceleration of thinking that surpasses the capacity for verbal expression. The patient cannot keep up with his thoughts as fast as he thinks, so there is a fragmented (incomplete) expression of ideas. - **3. ALTERATION OF ASSOCIATIVE LINKS:** - **ASINDESIS OR PARASYNTAXIS:** It occurs when associative links are loose. It is also called disaggregation. - **INCOHERENCE:** Absence of associative links between ideas. - **DISAGGREGATION OR WORD SALAD:** The association between words is lost. Sentences are not constructed. - **4. INTRUSION OF STRANGE IDEAS:** - **INTERPENETRATION:** Two or more simultaneous topics appear in the stream of thought, compromising the clarity of expression and syntax. - **OVERINCLUSION:** Associations are made with environmental stimuli, interfering with the course of thinking. - **5. ALTERATION IN THE MEANING OF WORDS:** - **METONYMY:** It is the use of words that give the approximate meaning of what is intended but are not the usual words within the context of the sentence. (Ex.: "I am meditating on transporting myself by rail"). - **NEOLOGISMS:** Invented words that do not exist in the language. - **GLOSSOLALIA:** Systematic use of neologisms and abnormal syntactic forms that produce a pseudo-language. - **6. INADEQUATE VERBAL RESPONSES:** - **TANGENTIALITY:** When the answers given by a person are related to the questions, but they do not answer in an exact or adequate way. It can occur in spontaneous speech, not necessarily in answers. - **IRRELEVANCE:** It is the use of answers that have nothing to do with the question. - **PARARESPONDSES:** Inexact, absurd and incorrect answers, apparently deliberately given that give the feeling of mockery towards the interviewer. - **C. THOUGHT CONTENT:** Refer to ideas or concepts and content that are associated with thinking. They come from other mental functions such as memory or perception. - **TYPES OF IDEAS:** - **DELIRIOUS IDEAS:** False beliefs that are not systematized, produced by a distorted interpretation of reality that is not modified by logical reasoning and is not shared by other members of their socio-cultural group. - **DELIRIUM:** Systematized delusional idea, that is, formed by delusional ideas related to each other in a consistent way, to the point that they might make the interviewer doubt its truthfulness. - **According to the dominant basic idea, they are classified into:** - **HYPOCHONDRIACAL:** They refer to the patient's physical health or organs. - **REFERENTIAL:** The patient believes that many environmental events, especially actions of other people, refer to him, when in reality they have nothing to do with him. - **PERSECUTORY:** The patient mistakenly believes that someone is trying to harm him, to harm him in some way or to kill him. He believes that he is being attacked, persecuted, deceived, spied on, slandered, tormented. - **EROTOMANIC:** The patient believes he is loved or desired sexually by one or more people, usually of higher status. - **JEALOUS:** It is jealousy caused by a distortion of real events into a false belief. - **INFLUENCE:** These are those in which the patient believes that external forces intervene in his thoughts and actions. They are based on the so-called "passivity experiences" in which the subject feels at the mercy of foreign forces that are inexplicable. The patient attributes such power over his mind to people or natural and supernatural entities, that make him have ideas, experience emotions and perform actions, without his will being able to prevent it. It includes robbery, thought insertion and transmission. The patient believes to be controlled. Ideas of influence may also manifest through the belief that the subject can act directly on the thoughts or actions of others. - **GRANDIOSE:** Those in which the patient feels superior in some way, to what he actually is, being the self-perception of himself very far from the real facts. - **PHYSICAL TRANSFORMATION:** The patient believes that his body has changed in its shape or constitution or is in the process of doing so. - **MYSTICAL-RELIGIOUS:** Those in which the patient believes he is involved in some relationship with God or with a supernatural religious figure. Its central theme is religious. Mystical delirium has also been called messianic delirium because it is common for those who suffer from it to feel that they have been chosen to fulfill a specific mission, entrusted by God. - **MAGIC:** Those in which the patient has the belief that the behavior of people and events in the world are ruled or determined by beings, forces or powerful, ethereal objects, and generally unknown. - **GUILT OR SIN:** Those in which the patient believes he is guilty of unforgivable actions that do not correspond to transgressions of social or religious norms that he has actually been able to commit. - **DENIAL OR NIHILIST:** Those in which the patient believes that nothing exists, that the world is over and that they themselves are dead. In less intense cases, the patient only denies the existence of certain organs. - **SUBSTITUTION:** The patient believes that loved ones have been replaced by substitutes. - **MEGALOMANIACAL OR GRANDIOSITY:** Belief of possessing exaggerated value, power, wealth and abilities of all kinds. - **ILLNESS OR HYPOCHONDRIACAL:** Conviction of having an illness and acting accordingly. - **INDUCED:** The individual does not present his own alterations but the coexistence with delirious people, generally added to social isolation and high suggestibility, leads to the ideas being "contagious" and delirious with the same topic. - **OVERVALUE IDEAS:** Ideas firmly established in the content of the patient's thought, apparently valid, emotionally charged in a disproportionate way and that frequently intrude into the mind. They come from logical thinking and real events. They are defended in an abnormal way, although they allow introspection only partially. - **They can be of:** - **FEELING OF INFERIORITY:** Belief of having fewer skills and abilities than other people; one thinks oneself less valuable than others. - **DESPAIR:** Belief that everything will go wrong in the future and nothing that is done will change that outcome. It foreshadows an empty future, without opportunities, painful, full of failure, loneliness and without purpose. - **GUILT AND SELF-REPROACH:** The person believes he is responsible for the difficulties faced by other people or for the problems existing in the society in which he lives. - **HYPOCHONDRIARCAL:** The person believes he is suffering from a serious illness or that the normal manifestations of bodily functioning correspond t an illness. - **MYSTICAL:** Belief that the conduct of people and events in the world are governed or determined by gods or their representatives. It is necessary to distinguish between beliefs and religious conceptions accepted socially. Usually, the patient has difficulties with family, social or work life due to exaggerated religious behavior. - **GRANDIOSITY OR EGOTISM:** The person overestimates his true positive characteristics. He exaggerates them and convinces others that he has a high value. - **OBSESSIVE IDEAS:** Intrusive ideas. Repetitive, generating discomfort and anxiety, the person tries to suppress them and recognizes them as their own. The person usually rejects, criticizes and classifies them as absurd and irrational. They can be of contamination. Obsessive doubt (wondering again and again if an act has been performed), of aggression and the need to maintain a specific order. - **PREDOMINANT OR FIXED IDEA:** They are "parasitic" ideas that can last hours, days or weeks. They can be pleasant or unpleasant, they are related to the person's life experiences, they do not disturb the rest of thinking and they can be rectified by criticism and reason. They are also called obsessions. - **IDEAS OF DEATH:** Thoughts related to the desire to cease to exist, generally associated with extreme suffering. - **IDEAS OF SUICIDE:** They refer to all those thoughts related to taking one's life intentionally. They can occur without a specific method, with a specific method without planning (unstructured suicidal idea), or with a specific method with planning (structured suicidal idea). - **IDEAS OF SELF-AGGRESSION:** They are thoughts related to the desire to harm oneself, not necessarily to die. Example: cutting oneself, hitting oneself, etc. - **IDEAS OF HETEROAGGRESSION:** They are thoughts that reflect the desire to harm other people. ## **5. SENSORY PERCEPTION** - It is defined as the function by which sense organs are activated by different stimuli (sensation), producing nerve impulses that travel to the central nervous system where they are processed in the different cortical areas to generate an interpretation (perception). - Sensory perception processes two types of stimuli: external ones coming from the environment, and internal ones whose origin is the body itself. - **External:** Visual, auditory, gustatory, olfactory, tactile (painful, thermal, pressure) - **Internal:** Kinesthetic (related to the movement and position of the parts of the body), cenesthetic (coming from internal organs) and those that indicate the overall body position in space (vestibular sense). - **ALTERATIONS:** - **ILLUSIONS:** They are defined as the distorted perception of a stimulus or of one of its relevant characteristics. The stimulus exists, but the perception changes. It occurs in all modalities of external sensory perception. In the case of visual illusions, if objects are perceived as smaller than they actually are, they are called MICROPSIAS, on the contrary, if they are perceived as larger than they actually are, they are called MACROPSIAS, often with the feeling that they are moving away or getting closer. - **HALLUCINATIONS:** Perceptions without a stimulus. They have certainty of reality and are not modifiable or correctable by conceptual demonstration. There is no stimulus, but there is perception. - **Two classification criteria are used:** - **According to their complexity:** - **SIMPLE OR ELEMENTARY HALLUCINATIONS:** Simple, blurry or undifferentiated impressions such as noises, lights, hums, isolated sounds. Their sensory modality should be mentioned (auditory, visual, etc.) - **COMPLEX OR FORMED HALLUCINATIONS:** More concrete perceptions of voices, people, animals, music, complex scenes, conversations, etc. - **According to the perceptive modality:** - **AUDITORY:** They can be simple or complex. **DIRECT:** if they speak to the individual, **INDIRECT:** if they speak among themselves (also called third person, since the person usually hears them comment about him or about his activity), **IMPERATIVE** (also called commands or orders) if what the person hears are orders, **THREATENING** or, on the contrary, **FRIENDLY**. It should be described whether they are masculine, feminine, collective, neutral (if the sex is not identified). - **VISUAL:** They can be simple or complex. **ZOOMORPHIC:** if what is seen are animals, **ANTHROPOMORPHIC:** if they are human beings, **LILLIPUTIAN:** if they are small in size, **GULLIVERIAN** - **if they are gigantic in size, AUTOSCOPIC:** if what is perceived is to see oneself as a double. If what the person visualizes are scenes of past experiences, generally traumatic, they are called **FLASHBACKS** (usually accompanied by an auditory component). - **OLFACTORY:** Perception of generally unpleasant odors, with a specific meaning. - **GUSTATORY:** Perception of unpleasant tastes (rotten, feces, toxic substances) that the patient usually attributes to the outside or to his own body. - **TACTILE OR HAPTIC:** Perceptions of being touched, pinched, fondled. There may be an abnormal or extreme perception of heat or cold, in which case they are called **THERMAL**, or the perception of liquids through the body. If the perception is to have the sensation that small animals or insects are crawling under or over the skin, they are called **DERMATOZOIC** or of **FORMICATION.** - **CENESTHETIC:** Sensations originating in the body itself: skin, muscles, joints, viscera, etc. In addition, abnormal positions of different parts of the body can be perceived. They are also called somatic hallucinations. If sensations are produced due to damage to the peripheral nervous system, such as when the patient with an amputated limb claims to continue feeling it (phantom limb), it is called **PARALUCINATION**. - **KINESTHETIC** (of movement): They are perceptions of movement of specific parts of the body. Patients have a vivid sensation that their muscles contract, that their arms rise, that their legs turn, etc. - **INTRAPSYCHIC HALLUCINATIONS:** They are a hallucinatory phenomenon that does not follow any of the sensory pathways. They are perceived in the patient's psychic space, that is, they are not perceived with the sense organs but with the mind itself. The patient's sensation of hearing his thoughts as if someone were repeating them aloud inside his head is called **ECHO OF THOUGHT**. Another example of psychic or extrasensorial hallucination is when the patient says "it's a voice inside my head". - **HYPNAGOGIC HALLUCINATIONS:** They occur at the beginning of sleep, generally in an auditory and/or visual modality. - **HYPNOPOMPICAL HALLUCINATIONS:** They occur upon waking, generally in an auditory and/or visual modality. - **SENSATIONS OF PRESENCE:** It refers to the experience of having the sensation that someone or something is nearby, without that perception being attributable to any of the senses. - **PSEUDO HALLUCINATIONS:** Hallucinations that occur preferably in the visual and/or auditory modalities, and in which there is no clear conviction about the reality of the perceptual experience, so the person classifies them as images or experiences produced by their own mind (insight becomes the differentiating criterion from hallucinations). - **ALUCINOSIS:** Hallucinations of organic origin in which the person is able to discern that they are not real. - **DEPERSONALIZATION PHENOMENA:** The person experiences a sensation of strangeness of their own body, or parts of it. Occasionally, they may experience the feeling of being separated from or out of their own body. - **Derealization PHENOMENA:** The person experiences the world as if it were something strange or unreal, as if they were dreaming. ## **6. SENSORIUM** - **A. STATE OF CONSCIOUSNESS:** It is defined as the individual's capacity to respond to internal and external stimuli. - **States of consciousness:** - **ALERT:** The person is able to interact with their external environment and with themselves. It is the state in which an individual is when completely awake. It corresponds to wakefulness. - **SOMNOLENCE:** There is a tendency to fall asleep. Easily, with verbal or tactile stimuli that are common and frequent, they return to being alert. - **CONFUSION OR OBNUBILATION:** In this state, somnolence, although mild, is constant. The