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Mental Status And Behavior


1.  General Appearance and Behavior

a.  General Appearance
b.  Attitude towards Examiner
c.  Comprehension
d.  Gait and Posture
e.  Motor Activity
f.   Social Manner
g.  Rapport



Reflex hallucination is a type of (AIIMS May 09)
a.  Paraesthesia
b.  Synesthesia
c.  Hyperesthesia
d.  Kinesthesia


Ans. B. Synesthesi



Which is not true about Hallucination? (AIIMS May 09)
A. It is as vivid as normal stimulus
B. It occur in inner subjective space
C.  It is independent of will of observer
D. It occurs in absence of perceptual stimuli


Ans. B.


2.  Speech

a.  Rate and Quantity        

b.  Volume and Tone         

c.   Flow and Rhythm

3.  Mood and Affect


4.  Thought

a.  Stream and Form        

b.  Content


5.  Perception


6.  Cognition (Higher Mental Functions)

a.  Consciousness


b.  Orientation


c.   Attention


d.  Concentration


e.  Memory


f.    Intelligence


g.  Abstract thinking


7.   Judgment


8.   Insight

General Appearance

1.  Rapport (doctor-patient relationship): absent in Psychosis

    Built: Schizophrenia: asthenic (thin), athletic

             Bipolar disorder: pyknic (fat)


2.    Psychmotor Activity:              

  • Retardation in depression
  • Agitation in mania

Mannerism : Ingrained, habitual involuntary movement.

: Automatic performance of an art or acts generally representative of unconscious symbolic activity.

Akathisia :
Subjective feeling of muscular tension secondary to antipsychotic or other medication, which can cause restlessness, pacing, repeated sitting and standing: can be mistaken for psychotic agitation

Floccillation :
aimless picking usually at clothing or bed, clothes, commonly seen in delirium.

Twirling :
a sign present in autistic children who continually rotate in the direction in which their head is turned.

Automatism (automatic behaviour):
temporal lobe epilepsy


3.  Speech:


Reaction time:

Increased in depression, decreased in mania


Irrelevant in schizophrenia, normal in children

Coherence (meaning):

incoherence in psychosis

Coprolalia (abusive words):

Tourette’s disorder


  1. 3 Features of healthy thinning:
  • Constancy: the characteristic persistence of a completed thought whether or not it is simple or complicated in its content.
  • Organization: the contents of the thoughts are related to each other in consciousness and do not blend with each other, but are separated in an organized way.
  • Continuity: even the most heterogeneous thoughts, sudden ideas or observations which emerge are arranged in order in the hole content of the consciousness.
  1. There are 3 corresponding varieties of objective thoughts disorder:
    1. Transitory thinking: derailments, substitutions and omissions occur. Both grammatical and syntactical structures are disturbed.
    2. Drivelling thinking: the patient has a preliminary outline of a complicate thought with all its necessary particulars, but he loses his preliminary organization of the thought, so that all the constituent parts get muddled together. The patient has a critical attitude towards the thoughts.
    3. Desultory thinking: speech is grammatically and syntactically correct, but sudden ideas force their way in from time to time.
    • Desultoriness: the continuity is loosened.
    • Omission: The intention itself is interrupted and there is a gap.
  2. Stream:  the rate of flow of ideas
    • Flight of ideas: rapid, pressure, increased amount, shifting from one topic to another, chance associations, not goal-directed; seen in mania
    • Prolixity: goal-directed rapid thought; seen in hypomania
    • Thought block: sudden stoppage of thought; characteristically in schizophrenia
    • Circumstantiality: boring details; Normal, Classically described for epileptic personality.
    • Perseveration: repeated responses beyond point of relevance in response to stimuli; dementia (frontal lobe Lesions)

5.  Content:

  1. Overvalued idea: unreasonable, sustained false belief maintained less firmly than a delusion

Delusion: Fixed, firm, unshakable belief in something that is not a fact, not shared by other people in community and also not matching with socio-cultural background of the person.

  1. Types of delusion:
Persecutory: harming

: Things is surrounding have special meaning to self

: special power, money, status (mania)

(Also called as Cotard’s deity): nothing exists (depression)

Physically impossible & logical impassible:-  found in schizophrenia:
Capgras Delusion of doubles: familiar person replaced by someone

: delusion of love (de Clerambault’s syndrome)

- Del of infidelity: alcoholism (Othello syndrome)

Noesis :
a revelation in which immense illumination occurs in association with a sense that a person has been chose to lead and command.

Unio mystica :
an oceanic feeling of mystic unity with an infinite power, not considered a disturbance in thought content if congruent with person’s religious or cultural milieu.
  1. Mood-congruent delusion: delusion and mood are congruence with each other (mood disorders)
  2. Mood-incongruent delusion: no match between delusion and mood (schizophrenia)
  1. Possesion: control of thought
  • Obsession: repeated intrusive thoughts, OCD.
  • Thought alienation: thoughts controlled by someone( schizophrenia)
  1. Form: the way thoughts are put: abnormalities characteristic of Schizophrenia
  • Loosening of association: no connections between thoughts à one of 4A’s of schizophrenia as by Bleulea’s
  • Word salad: no connections between words
  • Neologism: coins new word - most chr. of schizophrenia
  • Tangentiality: connection between thoughts loses in between and (Goal is not achieved).
Circumstantiality à Unnecessary, tedious, boring details are conveyed before conveying the actual thought (Here the Goal is achieved).


  1. Affect: emotional state as seen by examiner at a point of time (Mood is persistent subjective emotional state of the person)
    1. Quality: low in depression
    2. Mood : A pervasive and sustained emotion subjectively experienced and reported by a patient and observed by others:examples include depression, elation, and anger.
  1. Dysphoric mood : an unpleasant mood.
  2. Euthymic mood : Normal range of mood, implying absence of depressed or elevated mood.
  3. Expansive mood : a person;s expression of feeling without restraint, frequently with an overestimation of their significance or importance.
  4. Irritable mood : A state in which a person is easily annoyed and provoked to anger.
  5. Mood swings (labile mood) : Oscillations between euphoria and depression or anxiety.
  6. Elevated mood : Air of confidence and enjoyment a mood more cheerful than usual.
  7. Euphoria : Intense elation with feelings of grandeur.
  8. Ecstasy : Feeling of intense rapture.
  9. Depression : Psychopathological feeling of sadness.
  10. Anhedonia : Loss of interest in and withdrawal from all regular and pleasurable activities, often associated with depression.
  11. Alexithymia : A person’s inability to describe of difficulty in describing or being aware of emotions or mood.
  12. Abreaction : Emotional release or discharge after recalling a painful experience.
  1. Range: (spectrum of emotions): blunted or flat affect in schizophrenia; no emotional expressions
  2. Appropriateness: inappropriate affect in schizophrenia.​
Emotions are controlled by Frontal Lobe
  1. Perception: is what we all perceive from our sensory organs, of the environmental stimuli
    1. Illusion: misinterpretation of stimulus; seen in delirium, may be normal
    2. Hallucination:
      1. False perception without stimulus             
      2. Clear, 3 dimensional, vivid
      3. Occurs in objective space                 
      4. Insight is absent
      5. Sensory organs are not involved.                     
      6. No voluntary control
    3. Visual: organic disorders
    4. Auditory: Functional disorders, Not in under voluntary control.
    5. Tactile: cocaine
    6. Olfactory: Temporal lobe epilepsy
    7. Imagery: Incomplete, not clear, subjective, can be controlled
Special kinds of hallucinations:
  1. Functional hallucinations: a stimulus causes the hallucination, but it is experienced as well as the hallucination.
i. Chronic schizophrenia
  1. Reflex hallucinations: a stimulus in one sensory field produces a hallucination in another. This is a morbid variety of synaesthesia, in which an image based on one sensory modality is associated with an image based on another.
  2. Extracampine hallucinations: a hallucination which is outside the limits of the sensory field. Have no diagnostic significance; can be hypnagogic, organic or schizophrenic.
  3. Autoscopy (phantom mirror image): the pt. sees himself and knows that it is he. It is not just a visual hallucination, because kinaesthetic and somatic sensation must also be present to give the subject the impression that the hallucination is he.
    1. Acute and subacute delirious states:
      1. Hypnagogic hallucinations
      2. Internal autoscopy: the subject sees his own internal organs.
      3. 'Negative autoscopy': the pt. looks in the mirror and sees no image; in organic states.
    2. Schizophrenia
    3. Hysteria
    4. Normal subjects when they are depressed or emotionally disturbed and also tired and exhausted.
    5. Occur when the subject is falling asleep, during drowsiness.
    6. Are discontinuous.
    7. Commonest hallucinations are auditory. One of the commonest is the subject hearing his own name being called. May also be animal noises, music or voices which may say a sentence or phrase which has no discoverable meaning.
    8. May be geometrical designs, abstract shapes, faces, figures or scenes from nature.
    9. EEG shows a loss of alpha rhythm at the time of the hallucination. In a sleep deprived subject a hypnagogic state may occur, in which there are auditory and visual hallucinations, ideas of persecution and no insight into the morbid phenomena. This condition usually disappears after a good sleep.
    10. Hypnopompic hallucinations:
    11. Occur when the subject is waking up.
    12. The term should be retained for hallucinations persisting from sleep when the eyes are open.
    13. Imperative hallucination (Command): voices giving instructions to patients, who mayor may not feel obliged to carry them out.
  1. Orientation: in time, place and person; loss occurs in this sequence, recovery in reverse order Disorientation in delirium: Orientation is the normal state of (oneself and one’s surrounding in terms of time, place and person.


Twilight state

Oneiroid state / Onirism

An imprecise term for

1. State of decreased reactivity to stimuli.

2.Unresponsiveness with immobility

3. Mutism but retention of consciousness

   & often with open eyes that follows external objects.

It is disturbed consciousness with hallucinations.

It appears as waking dreams that portray desires, wishes or fears in a direct or symbolic way as being already fulfilled.

A transitory disturbance of consciousness during which many acts, sometimes very complicated may be performed without the subjects conscious volition and without retaining any remembrance of them.

Responsiveness as a rule only to some given complex, the rest of the personality being subordinated to, or as a rule, more or less completely submerged during the period of twilight state for example an epileptic patient, entirely unmindful of his natural surroundings, believed that he was walking around in Heaven; during the phase he was utterly unable to recall any part of his life.

It is dream state, while one is awake, a waking dream.


Acute reversible cognitive disorder with relatively global impairment, consisting of deficits of attention, arousal, consciousness, memory, orientation, perception, and speech or language.

Akinetic mutism

It may be of two types-

- The patient lay inertly in bed mute and almost totally unresponsive, although he followed the movements of people around him with his eyes. H. Cairn described this state due to tumor of 3rd ventricle, hence known as Cairn stupor. The syndrome is probably a result of interference with RAS, so that response to environment stimuli is defective. The term has also been used to describe subjects with bilateral frontal lobe lesions who lack all drive and impulse to action, despite intact motor and sensory tracts.

- Coma vigil. Psedocoma / locked in syndrome / Deafferented state.

It is a state in which patient appears to be asleep but can be aroused. The subject is conscious and aware but is unable to respond. The lesion is in ventral pons with preservation of dorsal tegmental area, the activating system is intact but interruption of corticobulbar and spinal pathways make it impossible for the subject to move or speak.

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