She must have a precise description of the symptoms and of the patient's state of mind. Rapport is a useful measure of the patient's ability to communicate his feelings to another person.
Since sleepwalking occurs in deep sleep (stages 3 and 4), usually during the first third of the night, it is unlikely to be the acting out of dreams. Sense of time is also lost: there is no sense of progression of events, but only immediate awareness of the present. As well as the loss of temporal and spatial connections, there is a loss of the psychological associations between events.
There is now new evidence for the underlying neural correlates of hypnotizability and the hypnotic state itself. These terms allow for an understanding of the anomalies exhibited in organic impairments of memory.
This is the so-called “remember-know” paradigm, and it proposes a dual-process memory system, one based on conscious memory and the other based on familiarity. Recognition can occur when the stimulus evokes a specific experience in which the stimulus was previously involved, or alternatively the stimulus only gives rise to a feeling of familiarity without any memory experience. A 'remember' response indicates that recognizing the stimulus evokes a conscious memory of its previous occurrence, while a 'know' response indicates that recognizing the stimulus is not accompanied by any conscious memory of its previous occurrence (Dalla Barba, 1997; Tulving, 2000).
DÉJÀ VU AND RELATED PHENOMENA (IDENTIFICATION OF PARAMNESIA) Déjà vu is not primarily a memory disorder, but a disorder in which the associated sense of familiarity that normally occurs with previously experienced events occurs with a new event, that is, when the event is experienced for the first time. In jamais vu, an experience that the patient knows he has experienced before is not associated with the appropriate sense of familiarity.
Cognitive impairment has been described in Alzheimer's disease (Dalla Barba, 1997) and in schizophrenia (Drakeford et al., 2006). The patient may also have the feeling that an important memory is ready to be recalled, when in fact it is not. Déjà vu and jamais vu are common, normal experiences, but can also be important symptoms of temporal lobe epilepsy or cerebrovascular disorder (Lishman, 1998).
The term is used to describe mild distortions of an actual memory, such as intrusions, embellishments, elaborations, paraphrases, or high false alarm rates on tests of anterograde amnesia. However, it is also true that the term 'confabulation' has been extended, unhelpfully in my view, to include:.
In other words, the phenomenal experience accompanying the recognition of a previously presented stimulus appears to take at least two forms. However, these experiences alone, or associated with only vague feelings of depersonalization, should not be taken as evidence of temporal lobe epilepsy, as these symptoms often occur in patients with anxiety-related disorders as well as in normal individuals. It is a falsification of memory that occurs in clear consciousness in association with organically derived amnesia (Berlyne, 1972).
It is probably best to think of confabulation as a loose term that covers a wide range of qualitatively different memory phenomena. It can also refer to highly improbable bizarre descriptions of false realities, such as claims to be a space traveler temporarily residing on earth (Gilboa and Moscovitch, 2002; Box 5.1).
It thus reveals a social consciousness and some awareness of the demands of the situation in terms of social behavior. In other cases, the confabulation exceeded the needs of the memory impairment; the patient spontaneously describes adventurous experiences of a fantastic nature. Suggestibility is a prominent feature of the confabulating patient and was regarded by Pick (1921) as dependent on clouding of consciousness, impaired judgment, and the interplay of fantasy; in fact, it can be very similar to daydreaming.
To the question "What did you do yesterday?" the confabulating patient might say, "I pushed my baby in the stroller to the office to see my old colleagues there." The patient is unaware that he or she is confabulating and is often unaware of the existence of a memory impairment.
Central to the idea of confabulation is therefore a notion of false reports in the context of memory disorders. A citizen of Birmingham, United Kingdom, described a state where he 'came to' in a city he did not recognize and where people spoke French. Vorbeigehen ('passing over') or approximate answers, described by Ganser thus: 'In the choice of answers the patient seems to deliberately pass over the given correct answer and choose a false answer which any child could recognize as such'.
Në Baddeley AD, Kopelman MD dhe Wilson BA (eds.) The Handbook of Memory Disorders, fq.
- the speeding up or slowing down of events;
- images are figurative and have a character of subjectivity;
- they appear in inner subjective space;
- they are not clearly delineated and come before us incomplete;
- although sensory elements are individually the equal of those in perception, mostly they are insufficient;
- images dissipate and always have to be recreated; and
- images are actively created and are dependent on our will (Table 7.1)
Remembering the temporal order of events is an aspect of time sense that is often ignored. When the disturbance in the sense of passage of time occurs in the environment of depression, the depressed mood is also evident. Part of our experience of time is the sense of uniqueness of the time, ephemeral or otherwise, through which we live.
It was a disturbance of the sense of recognition that accompanies recall in the process of memorization. Under these conditions, the normal experience of the quality of time is lost or distorted in some way.
Belief: the extent to which the patient is convinced of the reality of the delusions. Delusions occur in similar situations based on perception, memory, atmosphere or de novo – 'out of the blue'. While secondary delusions arise from some other abnormal phenomenon, overvalued ideas are understandable in light of the patient's personal history or an identifiable historical event whose value has been increased for some reason.
Primary symptoms are those that occur without an understandable cause in the context of a psychotic illness. They are therefore necessary manifestations of underlying psychopathology, just as swelling and redness are necessary consequences of physical trauma.
The mood of the atmosphere is very important and this experience is often referred to as delusion. Fish (1967) has made a useful clarification of the earlier German theories of the origin of delusion. Matussek believed that with delusions there is a change either in the meaning of the words used or in the perception itself.
It is easier to bear the certainty of an error than the uncertain premonition of the atmosphere. Jaspers held that there is a subtle personality change as a result of the disease itself, and this creates the condition for the development of the delusional atmosphere in which the delusional intuition arises.
According to an external commentator – the doctor – both of these latter conditions exist initially. She invited the Queen and the Prime Minister to a party in her student flat, thinking they would be honored to be invited: "It's only fair they get an invitation." The extensive influence of mania is very clearly visible to make this delusion understandable. Delusions of poverty are common with depression; an elderly patient believed that “the nurses” had systematically plundered her bag and that she was destitute.
According to Griesinger (1845), 'the patient confuses subjective change in his attitude towards external things. They have a headache or pain in the stomach, or in any other part of the body.
A safer approach is to consider the overestimation as understandable in the context of the patient's history and life. Mental imagery refers to the ability to create image-based mental representations of the world. Some clinicians may consider a particular belief held by the patient to be a primary delusion, while others do not.
Aphonia is the loss of the ability to vocalize; the patient only speaks in whispers. Speech is fluent, without appreciation of many errors in word usage, syntax and grammar. For example, the patient above might have said in this context, “the lamentations of syntax are.
One of his patients expressed this: 'and when I communicate normally, I can get lost in the chaos of language'.
Understandable attitudes to the sudden onset of acute psychosis (perplexity, awareness of change)
Even for the most personal and internal insights, social sense, the ability to relate, empathy, and knowing how our behavior will affect other people's emotions and experiences are important. Often our work with patients involves gaining insight into their thinking and behavior because of our capacity for empathy as fellow human beings and also helping them understand themselves and the roots of their problems. The relationship between this insight in a general sense and the practical aspects of the treatment is very close.
A delusional doctor advertised and sold magnets for the medical treatment of gout and hay fever. Because of his lack of insight into his own condition and the nature of his beliefs, it was impossible to begin treatment.
Working through the effects of acute psychoses
It is a quality highly valued by most mental health clinicians as it is believed that there is a strong link between having insight and a better quality of life (McGorry and McConville, 1999). Although we in psychiatry focus primarily on the narrow meaning of insight in relation to mental illness, we must retain this broader concept. He was convinced that this form of treatment was of unparalleled value for virtually all medical conditions, and he had physically attacked a pharmacist who had tried to convince him otherwise.
He condemned the validity of all psychiatry, 'because I am a scientist and everything must be proved by evidence'.
Working through the illness in chronic states
The patient’s judgement of his illness
The determination to fall ill
The attitude to one’s own illness: its meaning and possible implications
Insight assessment measures the patient's awareness of this change and their ability to adapt to the change. These quotes from Daniel Schreber demonstrate one of the most complex aspects of the nature of insight. Contributions to the development of the concept of insight come from psychopathology, gestalt psychology and psychoanalysis.
The fact that insight in gestalt psychology refers to a problem in the outside world distinguishes it from the concept of insight in clinical practice. However, there is a difference between the lack of understanding in psychiatry and the lack of awareness in neurological disorders.
