Key DSM-IV Mental Status Exam Phrases

This material draws strongly on David Robinson's excellent book: Brain Calipers, 2nd Edition. Rapid Psychler Press. www.psychler.com. Residents are encouraged to buy David's excellent, and entertaining, book.

Attitude

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

Hostility - Actual or threatened aggressive contact, destructive in intent.

Malingering - Intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives such as avoiding onerous duties, obtaining financial compensation, evading criminal prosecution, or obtaining drugs. There is often marked discrepancy between the person's claimed disability and objective findings. The person may be uncooperative during the diagnostic evaluation or fail to comply with the prescribed treatment.

Manipulation - A behavior pattern characterized by attempts to exploit interpersonal contact.

Kinesics - The study of  body posture, movement, and facial expressions.

• Agitation - Excessive motor activity, usually non-purposeful and associated with internal tension. Examples include inability to sit still, fidgeting, pacing, wringing of hands, and pulling of clothes. A particular form of agitation that is very important to recognize is:

• Akathisia - Complaints of restlessness accompanied by movements such as fidgeting of the legs, rocking from foot to foot, pacing, or inability to sit or stand. Symptoms develop within a few weeks of starting or raising the dose of a neuroleptic medication or of reducing the dose of medication used to treat extrapyramidal symptoms.

• Psychomotor Agitation - Excessive motor activity associated with a feeling of inner tension. When severe, agitation may involve shouting and loud complaining. The activity is usually nonproductive and repetitious, and consists of such behavior as pacing, wringing of hands, and inability to sit still.
• Psychomotor Retardation - A generalized slowing of physical and emotional reactions. Specifically, the slowing of movements such as eye blinking; frequently seen in depression.
• Bradykinesia - Neurologic condition characterized by a generalized slowness of motor activity.
• Catalepsy - A generalized condition of diminished responsiveness shown by trancelike  states, posturing, or maintenance of physical attitudes for a prolonged period of time. May occur in organic or psychological disorders, or under hypnosis.
  
  Cataplexy - Sudden loss of postural tone without loss of consciousness, typically triggered by some emotional stimulus such as laughter, anger, or excitement. It is a characteristic of narcolepsy.
  
  Catatonia - Immobility with muscular rigidity or inflexibility and at times excitability. See also schizophrenia.
• Catatonic Behavior - Marked motor abnormalities, generally limited to those occurring as part of a non-organic psychotic disorder. This term includes catatonic excitement (apparently purposeless agitation not influenced by external stimuli), stupor (decreased reactivity and fewer spontaneous movements, often with apparent unawareness of the surroundings), negativism (apparent motiveless resistance to instructions or attempts to be moved), posturing (the person's assuming and maintaining an inappropriate or bizarre stance), rigidity (the person's maintaining a stance or posture against all efforts to be moved), and waxy flexibility, or cerea flexibilitas (the person's limbs can be put into positions that are maintained).
• Compulsion - Repetitive ritualistic behavior such as hand washing or ordering or a mental act such as praying or repeating words silently that aims to prevent or reduce distress or prevent some dreaded event or situation. The person feels driven to perform such actions in response to an obsession or according to rules that must be applied rigidly, even though the behaviors are recognized to be excessive or unreasonable.
• Disinhibition - Freedom to act according to one's inner drives or feelings, with less regard for restraints imposed by cultural norms or one's superego; removal of an inhibitory, constraining, or limiting influence, as in the escape from higher cortical control in neurologic injury, or in uncontrolled firing of impulses, as when a drug interferes with the usual limiting or inhibiting action of GABA within the central nervous system.
• Dyskinesia - Any disturbance of movement. It may also be induced by medication.
• Dystonia - Abnormal positioning or spasm of the muscles of the head, neck, limbs, or trunk; the dystonia develops within a few days of starting or raising the dose of a neuroleptic medication, because of dysfunction of the extrapyramidal system.
• Echopraxia - Imitative repetition of the movements, gestures, or posture of another. It may be part of a neurologic disorder or of schizophrenia.
• Explosive Disorder, Intermittent - An impulse control disorder consisting of aggressive outbursts (e.g., assaultiveness or destruction of property) that are out of proportion to any evident stressors. Often the behavior is completely uncharacteristic of the person, who does not exhibit this behavior between episodes. In many cases, however, this aggressiveness comes out in less explosive ways between episodes.
• Hyperactivity - Excessive motor activity that may be purposeful or aimless; movements and utterances are usually more rapid than normal. Hyperactivity is a prominent feature of attention-deficit disorder, so much so that in DSM-IV the latter is called attention- deficit/hyperactivity disorder (ADHD).
• Tic - An involuntary, sudden, rapid, recurrent, non-rhythmic stereotyped motor movement or vocalization. A tic may be an expression of an emotional conflict, the result of neurologic disease, or an effect of a drug (especially a stimulant or other dopamine agonist)

Speech Disturbance - Any disorder of verbal communication that is not due to faulty innervation of speech muscles or organs of articulation. The term includes many language and learning disabilities. Contrast with agraphia, aphasia, and apraxia.

• Dysarthria - Difficulty in speech production due to lack of coordination of the speech apparatus.
• Dysphonia - Disorder of speech due to dysfunction of vocal cords.
• Flight of Ideas - A nearly continuous flow of accelerated speech with abrupt changes from one topic to another, usually based on understandable associations, distracting stimuli, or playing on words. When severe, however, this may lead to disorganized and incoherent speech. Flight of ideas is characteristic of manic episodes, but it may occur also in organic mental disorders, schizophrenia, other psychoses, and, rarely, acute reactions to stress. Pressured speech + Loosening of Associations = Flight of Ideas.
  •  Pressured Speech - Rapid, accelerated, frenzied speech. Sometimes it exceeds the ability of the vocal musculature to articulate, leading to jumbled and cluttered speech; at other times it exceeds the ability of the listener to comprehend as the speech expresses a flight of ideas (as in mania) or unintelligible jargon. See also logorrhea.
• Poverty of Speech - Restriction in the amount of speech; spontaneous speech and replies to questions range from brief and unelaborated to monosyllabic or no response at all. When the amount of speech is adequate, there may be a poverty of content if the answer is vague or if there is a substitution of stereotyped or obscure phrases for meaningful responses.
• Mutism - Refusal to speak; may be for conscious or unconscious reasons.

Mood and Affect - Behavior that expresses a subjectively experienced feeling state (emotion); affect is responsive to changing emotional states, whereas mood refers to a pervasive and sustained emotion. Common affects are euphoria, anger, and sadness. Some types of affect disturbance are:

• Restricted or Constricted Affect - Reduction in the expressive range and intensity of affects. (See also intellectualization and isolation under Defense Mechanisms). For instance..
  • Blunted Affect - Severe reduction in the intensity of affective expression.
  • Flat Affect - Absence or near absence of any signs of affective expression such as a  monotonous voice and an immobile face.
• Inappropriate Affect - Discordance of voice and movements with the content of the person's speech or ideation.
• Labile Affect - Abnormal variability, with repeated, rapid, and abrupt shifts in affective expression.
• Apathy - Lack of feeling, emotion, interest, or concern.
• Avolition - Lack of initiative or goals; one of the negative symptoms of schizophrenia. The person may wish to do something, but the desire is without power or energy.
• Anhedonia - Inability to experience pleasure from activities that usually produce pleasurable feelings. Contrast with hedonism.
• Anxiety - Apprehension, tension, or uneasiness from anticipation of danger, the source of which is largely unknown or unrecognized. Primarily of intra-psychic origin, in distinction to fear, which is the emotional response to a consciously recognized and usually external threat or danger. May be regarded as pathologic when it interferes with effectiveness in living, achievement of desired goals or satisfaction, or reasonable emotional comfort.
  • Panic - Sudden, overwhelming anxiety of such intensity that it produces terror and
    physiological changes.
  • Panic Attack - A period of intense fear or discomfort, with the abrupt development of a variety of symptoms and fears of dying, going crazy, or losing control that reach a crescendo within 10 minutes. The symptoms may include shortness of breath or smothering sensations; dizziness, faintness, or feelings of unsteadiness; trembling or shaking; sweating; choking; nausea or abdominal distress; flushes or chills; and chest pain or discomfort.
  • Fear - Unpleasant emotional and physiological response to recognized sources of danger, to be distinguished from anxiety. See also phobia.
  • Free-Floating Anxiety - Severe, generalized, persistent anxiety not specifically ascribed to a particular object or event and often a precursor of panic. See generalized anxiety disorder.
  • Obsession - Recurrent and persistent thought, impulse, or image experienced as intrusive and distressing. Recognized as being excessive and unreasonable even though it is the product of one's mind. This thought, impulse, or image cannot be expunged by logic or reasoning.
  • Phobia - Fear cued by the presence or anticipation of a specific object or situation,
    exposure to which almost invariably provokes an immediate anxiety response or panic attack even though the subject recognizes that the fear is excessive or unreasonable. The phobic stimulus is avoided or endured with marked distress. In earlier psychoanalytic literature, phobia was called anxiety hysteria. Two types of phobia have been differentiated: specific phobia (simple phobia) and social
    phobia. Specific phobia is subtyped on the basis of the object feared. The natural
    environment (animals, insects, storms, water, etc.); blood, injection, or injury; situations (cars, airplanes, heights, tunnels, etc.); and other situations that may lead to choking, vomiting, or contracting an illness are all specific phobias. In social phobia (social anxiety disorder), the persistent fear is of social situations that might
    expose one to scrutiny by others and induce one to act in a way or show anxiety symptoms that will be humiliating or embarrassing. Avoidance may be limited to one or only a few situations, or it may occur in most social situations. Performing in front of others or social interactions may be the focus of concern. It is sometimes difficult to distinguish between social phobia and agoraphobia when social avoidance accompanies panic attacks. Avoidant disorder has been used to refer to social phobia occurring in childhood and adolescence. Some of the common phobias are (add “abnormal fear of” to each entry):
     
    • Achluophobia - Darkness
    • Acrophobia - Heights
    • Agoraphobia - Open spaces or leaving the familiar setting of the home.
    • Aailurophobia  -Cats
    • Algophobia - Pain
    • Androphobia  -Men
    • Autophobia  -Being alone or solitude
    • Bathophobia  -Depths
    • Claustrophobia  -Closed spaces
    • Cynophobia - Dogs
    • Demophobia  -Crowds
    • Erythrophobia  -Blushing; sometimes used to refer to the blushing itself
    • Gynophobia - Women
    • Hypnophobia - Sleep
    • Mysophobia - Dirt and germs
    • Panphobia - Everything
    • Pedophobia - Children
    • Xenophobia - Strangers
• Depression - When used to describe a mood, depression refers to feelings of sadness, despair, and discouragement. As such, depression may be a normal feeling state. The overt manifestations are highly variable and may be culture specific. Depression may be a symptom seen in a variety of mental or physical disorders, a syndrome of associated symptoms secondary to an underlying disorder, or a specific mental disorder. Slowed thinking, decreased pleasure, decreased purposeful physical activity, guilt and hopelessness, and disorders of eating and sleeping may be seen in the depressive syndrome.
• Dysphoria - Unpleasant mood.
• Euphoria - An exaggerated feeling of physical and emotional well-being, usually of
  psychological origin. Also seen in organic mental disorders and in toxic and drug-induced
  states. See also bipolar disorders.
• Guilt - Emotion resulting from doing what one conceives of as wrong, thereby violating
  superego precepts; results in feelings of worthlessness and at times the need for
  punishment.
• Shame - An emotion resulting from the failure to live up to self-expectations.
• Humiliation - Sense of disgrace and shame often experienced in depression.
• Hypomania - A psychopathological state and abnormality of mood falling somewhere
  between normal euphoria and mania. It is characterized by unrealistic optimism, pressure of speech and activity, and a decreased need for sleep. Some people show increased creativity during hypomanic states, whereas others show poor judgment, irritability, and irascibility. See bipolar disorders.
• Negative Symptoms - Most commonly refers to a group of symptoms characteristic of schizophrenia that include loss of fluency and spontaneity of verbal expression, impaired ability to focus or sustain attention on a particular task, difficulty in initiating or following through on tasks, impaired ability to experience pleasure to form emotional attachment to others, and blunted affect.

Thought Disorder - A disturbance of speech, communication, or content of thought, such as delusions, ideas of reference, poverty of thought, flight of ideas, perseveration, loosening of associations, and so forth. A thought disorder can be caused by a functional emotional disorder or an organic condition. A formal thought disorder is a disturbance in the form of thought rather than in the content of thought (e.g., loosening of associations).

• Delusion - A false belief based on an incorrect inference about external reality and firmly sustained despite clear evidence to the contrary. The belief is not part of a cultural tradition such as an article of religious faith.
• Dimensions of Delusions:
• Conviction. How convinced patient is of belief.
• Extent. Do delusions involve many areas of patient’s life.
• Bizarreness. Do delusions depart from culturally determined reality. Bizarre delusions suggest schizophrenia.
• Disorganization. Are beliefs internally consistent, logical, and systematized.
• Pressure. How preoccupied is patient with belief.
   
• Among the more frequently reported delusions are the following:
• Capgras´ syndrome - The delusion that others, or the self, have been replaced by imposters. It typically follows the development of negative feelings toward the other person that the subject cannot accept and attributes, instead, to the imposter. The syndrome hasbeen reported in paranoid schizophrenia (see schizophrenia) and, even more frequently, in organic brain disease.
• Delusion of Control - The belief that one's feelings, impulses, thoughts, or actions are not one's own but have been imposed by some external force.
• Delusion of Poverty - The conviction that one is, or will be, bereft of all material
  possessions.
• Delusion of Reference - The conviction that events, objects, or other people in the
  immediate environment have a particular and unusual significance (usually negative)
• Delusional Jealousy - The false belief that one's sexual partner is unfaithful; also called the Othello delusion.
• Erotomania - The delusion that one is loved by a particular person.
• Grandiose Delusion - An exaggerated belief of one's importance, power, knowledge, or identity.
  • Grandiosity - Exaggerated belief or claims of one´s importance or identity, often manifested by delusions of great wealth, power, or fame. See bipolar disorders; mania.
• Ideas of Reference - Incorrect interpretations of casual incidents and external events as having direct reference to oneself. May reach sufficient intensity to constitute delusions.
• Idée Fixe - Fixed idea. Used in psychiatry to describe a compulsive drive, an obsessive idea, or a delusion.
• Magical Thinking - A conviction that thinking equates with doing. Occurs in dreams in children, in primitive peoples, and in patients under a variety of conditions. Characterized by lack of realistic relationship between cause and effect.
• Megalomania - Grandiose delusions of power, wealth, or fame.
• Nihilistic Delusion - A conviction of nonexistence of the self, part of the self, or others, or of the world. “I no longer have a brain” is an example.
  • Cotard's Syndrome - A nihilistic delusion in which one believes that one's body, or parts of it, is disintegrating, or that one is bereft of all resources, or one's family has been exterminated, and so forth. It has been reported in depressive disorders, schizophrenia, and lesions of the non-dominant lobe. Named after the French neurologist Jules Cotard (1840–1887).
• Paranoia - A condition characterized by the gradual development of an intricate, complex, and elaborate system of thinking based on (and often proceeding logically from) misinterpretation of an actual event; a delusional disorder. Despite its chronic course, this condition does not seem to interfere with thinking and personality. To be distinguished from schizophrenia, paranoid type.
• Paranoid - A lay term commonly used to describe an overly suspicious person. The
  technical use of the term refers to persons with paranoid ideation or to a type of
  schizophrenia or a class of disorders. See also delusional disorder
  • Paranoid Ideation - Suspiciousness or non-delusional belief that one is being harassed, persecuted, or unfairly treated.
• Persecutory Delusion - The conviction that one (or a group or institution close to one) is being harassed, attacked, persecuted, or conspired against.
• Somatic Delusion - A false belief involving the functioning of one's body, such as the conviction of a postmenopausal woman that she is pregnant, or a person's conviction that his nose is misshapen and ugly when there is nothing wrong with it.
• Systematized Delusion - A single false belief with multiple elaborations or a group of false beliefs that the person relates to a single event or theme. This event is believed to have caused every problem in life that the person experiences.
• Delusions of thought.
  • Delusions of thought interference
    • Delusions of thought broadcast
    • Delusions of thought withdrawal
    • Experience of thoughts spoken aloud
    • Experience of thought echo
  • Delusions of control. Patient experiences outside force/power replacing his control over intentions, desires, or bodily movements
     
• Alexithymia - A disturbance in affective and cognitive function that overlaps diagnostic
  entities but is common in psychosomatic disorders, addictive disorders, and  posttraumatic stress disorder. The chief manifestations are difficulty in describing or recognizing one's own emotions, a limited fantasy life, and general constriction in the affective life.
• Preoccupations -
• Egomania - Pathological preoccupation with self.
• Erotomania - The delusion that one is loved by a particular person.
• Hypochondriasis - One of the somatoform disorders, characterized by persisting worry about health or fear of having some disease despite appropriate medical reassurance and lack of findings on physical or laboratory examination. Fear of contracting a disease is considered to be a phobia rather than hypochondriasis.
• Kleptomania - Compulsion to steal.
• Megalomania - Grandiose delusions of power, wealth, or fame.
• Monomania - Pathological preoccupation with one subject.
• Obsession - Recurrent and persistent thought, impulse, or image experienced as intrusive and distressing. Recognized as being excessive and unreasonable even though it is the product of one's mind. This thought, impulse, or image cannot be expunged by logic or reasoning.
• Necromania - Pathological preoccupation with dead bodies.
• Nymphomania - Abnormal and excessive need or desire in the woman for sexual
  intercourse; see satyriasis.
• Pyromania - Compulsion to set fires; an impulse control disorder.
• Trichotillomania - Compulsion to pull one's own hair out; an impulse disorder.
• Formal Thought Disorder - An inexact term referring to a disturbance in the form of thinking rather than to abnormality of content. See blocking; incoherence; loosening of associations; poverty of speech.
• Positive thought disorder. Fluent speech that communicates poorly, a wealth of detail is usually provided, flow of speech tends to be energetic.

  • Derailment, loose associations, tangentiality, incoherence, illogicality, circumstantiality, pressured, clanging, neologisms, perseveration, echolalia, distractibility, word approximation are common features.
  • Derailment or loose associations. A pattern of spontaneous speech where ideas slip off one track onto another. Schizophrenic derailment tends to lead to unrelated thoughts S, manic derailment leads to related thoughts. M
  • Tangentiality. Replying to a question in an oblique or irrelevant way
  • Incoherence. A pattern of speech that is incomprehensible S
  • Illogicality. A pattern of speech in which conclusions reached do not follow from the facts
  • Circumstantiality: speech that is very indirect and delayed in reaching its goal (“long-winded”) S
  • Pressured speech: rapid and difficult to interrupt M
  • Clanging: sounds govern word choice M
  • Neologisms: New words, not approximations S
  • Perseveration: Repetition of ideas, subjects, words in speech
  • Echolalia: using same words or phrases as interviewer; mocking; mumbling; staccato
  • Distractible speech M
  • Word approximations: Paraphrasia; metonyms; old words used in unusual way or new words combined, as gloves called “hand-shoes”

• Negative thought disorder
  • Poverty of speech; minimal replies, information not volunteered, monosyllabic.
  • Poverty of speech content; minimal information, vague, abstract, over concrete, repetitive, stereotyped.
  • Blocking
  • Increased latency of response
     
• Association - Relationship between ideas and emotions by contiguity, continuity, or similarity.
• Blocking - A sudden obstruction or interruption in spontaneous flow of thinking or speaking, perceived as an absence or deprivation of thought.
• Circumstantiality - Pattern of speech that is indirect and delayed in reaching its goal because of excessive or irrelevant detail or parenthetical remarks. The speaker does not lose the point, as is characteristic of loosening of associations, and clauses remain  logically connected, but to the listener it seems that the end will never be reached. Compare with tangentiality.
• Clanging - A type of thinking in which the sound of a word, rather than its meaning, gives the direction to subsequent associations. Punning and rhyming may substitute for logic, and language may become increasingly a senseless compulsion to associate and decreasingly a vehicle for communication. For example, in response to the statement “That will probably remain a mystery,” a patient said, “History is one of my strong points.
• Echolalia - Parrot-like repetition of overheard words or fragments of speech. It may be part of a developmental disorder, a neurologic disorder, or schizophrenia. Echolalia tends to be repetitive and persistent and is often uttered with a mocking, mumbling, or staccato intonation.
• Glossolalia - Gibberish-like speech or “speaking in tongues.”
• Incoherence - Lacking in unity or consistency; often applied to speech or thinking that is not understandable owing to any of the following: lack of logical connection between words or phrases; excessive use of incomplete sentences; many irrelevancies or abrupt changes in subject matter; idiosyncratic word usage; or distorted grammar. See also loosening of associations.
• Loosening of Associations - A disturbance of thinking shown by speech in which ideas shift from one subject to another that is unrelated or minimally related to the first. Statements that lack a meaningful relationship may be juxtaposed, or speech may shift suddenly from one frame of reference to another. The speaker gives no indication of being aware of the disconnectedness, contradictions, or illogicality of speech. See also incoherence.
• Neologism - In psychiatry, a new word or condensed combination of several words coined by a person to express a highly complex idea not readily understood by others; seen in schizophrenia and organic mental disorders.
• Poverty of Content - When the amount of speech is adequate, there may be a poverty of content if the answer is vague or if there is a substitution of stereotyped or obscure phrases for meaningful responses.
• Tangentiality - Replying to a question in an oblique or irrelevant way. Compare with
  circumstantiality.
• Word Salad - A mixture of words and phrases that lack comprehensive meaning or logical coherence; commonly seen in schizophrenic states (see schizophrenia).
• Déja Vu - A paramnesia consisting of the sensation or illusion that one is seeing what one has seen before.
• Defense Mechanism - Unconscious intra-psychic processes serving to provide relief from emotional conflict and anxiety. Conscious efforts are frequently made for the same reasons, but true defense mechanisms are unconscious. Some of the common defense mechanisms defined in this glossary are compensation, conversion, denial, displacement, dissociation, idealization, identification, incorporation, introjection, projection, rationalization, reaction formation, regression, sublimation, substitution, symbolization, and undoing.
• Compensation - A defense mechanism, operating unconsciously (see unconscious), by which one attempts to make up for real or fancied deficiencies. Also a conscious process in which one strives to make up for real or imagined defects of physique, performance skills, or psychological attributes. The two types frequently merge. See also Adler; individual psychology; overcompensation.
• Conversion - A defense mechanism, operating unconsciously (see unconscious), by which intra-psychic conflicts that would otherwise give rise to anxiety are instead given symbolic external expression. The repressed ideas or impulses, and the psychological defenses against them, are converted into a variety of somatic symptoms. These may include such symptoms as paralysis, pain, or loss of sensory function.
• Denial  - A defense mechanism, operating unconsciously, used to resolve emotional conflict and allay anxiety by disavowing thoughts, feelings, wishes, needs, or external reality factors that are consciously intolerable.
• Displacement - A defense mechanism, operating unconsciously (see unconscious), in which emotions, ideas, or wishes are transferred from their original object to a more acceptable substitute; often used to allay anxiety.
• Dissociation - The splitting off of clusters of mental contents from conscious awareness, a mechanism central to hysterical conversion and dissociative disorders; the separation of an idea from its emotional significance and affect as seen in the inappropriate affect of schizophrenic patients.
  • Conversion Disorder - One of the somatoform disorders (but in some classifications called a dissociative disorder), characterized by a symptom suggestive of a neurologic disorder that affects sensation or voluntary motor function. The symptom is not consciously or intentionally produced, it cannot be explained fully by any known general medical condition, and it is severe enough to impair functioning or require medical attention. Commonly seen symptoms are blindness, double vision, deafness, impaired coordination, paralysis, and seizures.
    • La Belle Indifférence - Literally, “beautiful indifference.” Seen in certain patients with conversion disorders who show an inappropriate lack of concern about their disabilities.
  • Derealization - A feeling of estrangement or detachment from one's environment. May be accompanied by depersonalization.
  • Depersonalization - Feelings of unreality or strangeness concerning either the environment, the self, or both. This is characteristic of depersonalization disorder and may also occur in schizotypal personality disorder, schizophrenia, and in those persons experiencing overwhelming anxiety, stress, or fatigue.
  • Fragmentation - Separation into different parts, or preventing their integration, or detaching one or more parts from the rest. A fear of fragmentation of the personality, also known as disintegration anxiety, is often observed in patients whenever they are exposed to repetitions of earlier experiences that interfered with development of the self. This fear may be expressed as feelings of falling apart, as a loss of identity, or as a fear of impending loss of one's vitality and of psychological depletion.
  • Fugue - A dissociative disorder marked by sudden, unexpected travel away from one's customary environment, with inability to recall one's past and assumption of a new identity, which may be partial or complete.
• Devaluation - In psychiatry, a mental mechanism in which one attributes exaggeratedly negative qualities to oneself or others.
• Entitlement - In psychodynamic psychiatry, entitlement usually refers to an unreasonable expectation or unfounded claim. An example is a person with narcissistic personality disorder who feels deserving of preferred status and special treatment even though there is no apparent justification for such treatment.
• Fantasy - An imagined sequence of events or mental images (e.g., daydreams) that serves to express unconscious conflicts, to gratify unconscious wishes, or to prepare for anticipated future events.
• Idealization - A mental mechanism in which the person attributes exaggeratedly positive qualities to the self or others.
• Identification - A defense mechanism, operating unconsciously, by which one patterns oneself after some other person. Identification plays a major role in the development of one's personality and specifically of the superego. To be differentiated from imitation or role modeling, which is a conscious process.
• Inhibition - Behavioral evidence of an unconscious defense against forbidden instinctual drives (see instinct); may interfere with or restrict specific activities.
• Intellectualization - A mental mechanism in which the person engages in excessive abstract thinking to avoid confrontation with conflicts or disturbing feelings.
• Introjection - A defense mechanism, operating unconsciously (see unconscious), whereby loved or hated external objects are symbolically absorbed within oneself. The converse of projection. May serve as a defense against conscious recognition of intolerable hostile impulses. For example, in severe depression, the individual may unconsciously direct unacceptable hatred or aggression toward herself or himself. Related to the more primitive fantasy of oral incorporation.
• Isolation - A defense mechanism operating unconsciously (see unconscious) central to obsessive-compulsive phenomena in which the affect is detached from an idea and rendered unconscious, leaving the conscious idea colorless and emotionally neutral.
• Overcompensation - A conscious or unconscious process in which a real or imagined physical or psychological deficit generates exaggerated correction. Concept introduced by Adler.
• Parataxic Distortion - Sullivan's term for inaccuracies in judgment and perception,
  particularly in interpersonal relations, based on the observer's need to perceive subjects and relationships in accordance with a pattern set by earlier experience. Parataxic distortions develop as a defense against anxiety.
• Projection - A defense mechanism, operating unconsciously (see unconscious), in which what is emotionally unacceptable in the self is unconsciously rejected and attributed (projected) to others.
• Projective Identification - A term introduced by Melanie Klein to refer to the unconscious process of projection of one or more parts of the self or of the internal object into another person (such as the mother). What is projected may be an intolerable, painful, or dangerous part of the self or object (the bad object). It may also be a valued aspect of the self or object (the good object) that is projected into the other person for safekeeping. The other person is changed by the projection and is dealt with as though he or she is in fact characterized by the aspects of the self that have been projected. Counter Projective Identification - This refers to the experience on the part of the therapist of acting as if the patient's projection is accurate. Once the therapist is "hooked", the therapist becomes the projection. The patient can

  

   now attempt to control the therapist by manipulating the projection. The thing to do first is to become aware of an unusual set of feelings. A resident who was usually extremely compassionate, found that while treating a contemptuous, defensive borderline patient he was becoming extremely frustrated with her slanderous remarks. One day he was pushed over the line when she said, "I hope you don’t quite your day job if you go into practice. I mean, look at the way you dress! You will never be able to attract clients!" Withdrawing from this interaction he reflected on this event and noticed that he was becoming just like the abusive patient.

• Rationalization - A defense mechanism, operating unconsciously, in which an individual attempts to justify or make consciously tolerable by plausible means, feelings or behavior that otherwise would be intolerable. Not to be confused with conscious evasion or dissimulation. See also projection.
• Reaction Formation - A defense mechanism, operating unconsciously, in which a person adopts affects, ideas, and behaviors that are the opposites of impulses harbored either consciously or unconsciously (see conscious; unconscious). For example, excessive moral zeal may be a reaction to strong but repressed asocial impulses.
• Regression - Partial or symbolic return to earlier patterns of reacting or thinking. Manifested in a wide variety of circumstances such as normal sleep, play, physical illness, and in many mental disorders.
• Repression - A defense mechanism, operating unconsciously, that banishes unacceptable ideas, fantasies, affects, or impulses from consciousness or that keeps out of consciousness what has never been conscious. Although not subject to voluntary recall, the repressed material may emerge in disguised form. Often confused with the conscious mechanism of suppression.
• Splitting - A mental mechanism in which the self or others are reviewed as all good or all bad, with failure to integrate the positive and negative qualities of self and others into cohesive images. Often the person alternately idealizes and devalues the same person.
• Sublimation - A defense mechanism, operating unconsciously, by which instinctual drives, consciously unacceptable, are diverted into personally and socially acceptable channels.
• Substitution - A defense mechanism, operating unconsciously, by which an unattainable or unacceptable goal, emotion, or object is replaced by one that is more attainable or acceptable.
• Undoing - A mental mechanism consisting of behavior that symbolically atones for, makes amends for, or reverses previous thoughts, feelings, or actions.
• Trance - A state of focused attention and diminished sensory and motor activity seen in hypnosis; hysterical neurosis, dissociative type (see under neurosis ); and ecstatic religious states.

Perception - Mental processes by which intellectual, sensory, and emotional data are organized logically or meaningfully.

• Eidetic Image - Unusually vivid and apparently exact mental image; may be a memory, fantasy, or dream.
• Hallucination - A sensory perception in the absence of an actual external stimulus; to be distinguished from an illusion, which is a misperception or misinterpretation of an external stimulus. Hallucinations may involve any of the senses.

• • Auditory Hallucination - Perception of sound, most frequently of voices but sometimes of clicks or other noises.
    • May be accompanied by subvocalizations. Neural correlates observed during PET scan-- > activity in bilateral thalamus, left/right hippocampus, parahippocampal gyrus. Also right anterior cingulate and left orbitofrontal cortex. May be verbal or nonverbal. Verbal may be:
      • Third person (e.g. running commentary on actions of patient)
      • Second person (Talking to patient) [Also common in affective psychoses]. In manic psychoses, do not have the distinct and intrusive perceptual quality that they have in schizophrenia
        Command hallucinations
         
  • Gustatory and Olfactory Hallucinations - Perception of odor such as of burning rubber or decaying fish.
    • Gustatory. Detection of particular and unusual taste in foods.
    • Olfactory. Experience of particular and unusual smell. Can occur in schizophrenia, temporal lobe epilepsy. Psychosis (20-30%), Affective illness (20-30%), Anxiety disorders (10-50%).
       
  • Somatic Hallucination - Perception of a physical sensation within the body such as a feeling of electricity running through one's body.
  • Tactile Hallucination - Perception of being touched or of something being under one's skin such as the sensation of pins being stuck into one's finger. The sensation of something crawling under one's skin is called formication; it occurs most frequently in alcohol withdrawal syndrome and in cocaine withdrawal.
  • Visual Hallucination - Perception of an image such as people (formed) or a flash of light (unformed).
    • Previously thought to have been uncommon in schizophrenia, but now found to be prevalent in high numbers in subjects with chronic schizophrenia. Also occur in patients with visual system disease (eg, macular degeneration) unrelated to primary psychiatric disorder. Common with substance induced psychosis.
       
  • Hypnagogic - Referring to the semiconscious state immediately preceding sleep; may include hallucinations that are of no pathological significance.
  • Hypnopompic - Referring to the state immediately preceding awakening; may include
    hallucinations that are of no pathological significance.

• Hyperacusis - Inordinate sensitivity to sounds; it may be on an emotional or an organic
  basis.
• Hypesthesia - Diminished sensitivity to tactile stimuli.
• Illusion - A misperception of a real external stimulus. Example: the rustling of leaves is
  heard as the sound of voices. Contrast with hallucination.
• Paresthesia - Abnormal tactile sensation, often described as burning, pricking, tickling,
  tingling, or creeping.

Cognitive

Attention - Ability to sustain focus on one activity. A disturbance in attention may appear as having difficulty in finishing tasks that have been started, being easily distracted, or having difficulty in concentrating.

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

Disorientation - Loss of awareness of the position of the self in relation to space, time, or other persons; confusion. See also delirium; dementia.

Distractibility - Inability to maintain attention; shifting from one area or topic to another with minimal provocation. Distractibility may be a manifestation of organic impairment or it may be a part of a functional disorder such as an anxiety disorder, mania, or schizophrenia.

Executive Functioning - Cognitive abilities such as planning, organizing, sequencing, and abstracting; may be seen in dementia.

• Problem Solving - A specific form of intellectual activity used when a person faces a situation that cannot be handled in terms of past learning. Problem-solving strategies are considered crucial in any psychotherapeutic endeavor.

Memory - The ability, process, or act of remembering or recalling; especially the ability to reproduce what has been learned or explained.

• Memory Consolidation - The physical and psychological changes that take place as the brain organizes and restructures information that may become a permanent part of memory.
• Immediate Memory - The recall of perceived material within a period of 30 seconds to 25 minutes after presentation.
• Long-Term Memory - The final phase of memory in which information storage may last from hours to a lifetime. Contrast with immediate memory.
• Short-Term Memory - The recognition, recall, and reproduction of perceived material 10 seconds or longer after initial presentation.
• Recall - The process of bringing a memory into consciousness (see conscious). Recall is often used to refer to the recollection of facts, events, and feelings that occurred in the immediate past.

Parapraxis - A faulty act, blunder, or lapse of memory such as a slip of the tongue or
misplacement of an article. According to Freud, these acts are caused by unconscious
motives.

Sensorium - Synonymous with consciousness. Includes the special sensory perceptive powers and their central correlation and integration in the brain. A clear sensorium conveys the presence of a reasonably accurate memory together with orientation for time, place, and person. See also mental status.

Stupor - Marked decrease in reactivity to and awareness of the environment, with reduced spontaneous movements and activity. It can be seen as a type of catatonic behavior inschizophrenia, but it can also be observed in neurologic disorders.

Insight - Self-understanding; the extent of a person's understanding of the origin, nature,
and mechanisms of his or her maladaptive attitudes and behavior.

• Reality Testing - The ability to evaluate the external world objectively and to differentiate adequately between it and the internal world. Falsification of reality, as with massive denial or projection, indicates a severe disturbance of ego functioning and/or of the perceptual and memory processes upon which it is partly based. See also psychosis.

Judgment - Mental act of comparing choices between a given set of values in order to select a course of action.

Transference - The unconscious assignment to others of feelings and attitudes that were originally associated with important figures (parents, siblings, etc.) in one's early life. The transference relationship follows the pattern of its prototype. The psychiatrist utilizes this phenomenon as a therapeutic tool to help the patient understand emotional problems and their origins. In the patient-physician relationship, the transference may be negative (hostile) or positive (affectionate). See also countertransference; parataxic distortion.

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

REFERENCE

Brain Calipers, 2nd Edition, David J. Robinson, MD
Rapid Psychler Press  www.psychler.com