Current Medical Diagnosis & Treatment in Psychiatry

Abnormalities of the Sense of Self

Techniques & Settings • • Psychiatric InterviewSep 18, 05

The normal person has a sense of selfhood composed of the following elements: a sense of existing and being involved in one’s own body and activity; a sense of personal continuity in time between past, present, and future; a sense of personal integrity; and a sense of distinction between self and outside world. In psychiatric disorders, any or several of these phenomena may be disturbed. For example, the individual may feel uninvolved in his or her own body or actions, like a spectator looking at another person (as in depersonalization); the individual’s sense of temporal continuity may be dislocated, with the past and future seeming remote and the present but a series of disconnected scenes; the individual’s ego may feel as though it is falling apart, shedding, fragmented, or split in two; or the difference between the self and other persons or objects may have become blurred.

The sense of depersonalization, often associated with derealization, occurs in adolescence, epilepsy, dissociative disorders, schizophrenia, and depression. Adolescents in severe emotional turmoil sometimes develop a sense of discontinuity, disintegration, and dedifferentiation. These symptoms are very common after ingestion of hallucinogens (and may be reexperienced as flashbacks) and in reactive psychosis, schizophreniform disorder, or schizophrenic disorders.

Physiologic Function
Sleep disturbances are often encountered in psychiatric practice. Sleep deprivation may precipitate or accentuate psychiatric disorder. Sleep disturbance may be a prodrome, a symptom, or a sequel of psychiatric disorder. Many psychopharmacologic agents also affect sleep.

Appetite may be increased in depression (especially dysthymic personality) and after psychotropic drug medication. Eating binges (not necessarily determined by increased appetite) may occur in bulimia nervosa as a condition separate from, in alternation with, or following, anorexia nervosa.

Anorexia and weight loss can occur in almost any stress condition but are particularly likely in major depression, paranoid schizophrenia, somatoform disorders, alcoholism or drug addiction, and, of course, anorexia nervosa. A comprehensive physical screening investigation is always required when anorexia and weight loss are present.

Sexual desire may be increased in mania, in some forms of acute schizophrenia, and in narcissistic or borderline personality under stress. Sexual behavior may be disinhibited after alcohol or drug ingestion, in delirium, or in organic dementia. Sexual desire is decreased by any debilitating disorder, by anxiety, worry, tiredness, age, poor nutrition, and lack of affection for the partner. It is usually reduced by depression, schizophrenia, alcoholism, substance abuse, and by neuroleptic, antihypertensive, and antidepressant medication.

Absent, irregular, infrequent and scanty menstrual periods may occur in psychiatric disorder, particularly in depression, anorexia nervosa, anxiety disorders, schizophrenia, and substance abuse. Any condition that reduces total body fat to below 14%, in the female, produces anovulation and amenorrhea. Dysmenorrhea, dyspareunia, vaginismus, and other pelvic complaints are common in somatoform disorders, and in abnormal illness behavior generally, but a discretionary physical screen is required before a stress-related condition is diagnosed.

Any or all body systems may be accelerated in the hyperdynamic states of anxiety, delirium, mania, and catatonic excitement or slowed in the general hypomotility of depression, organic dementia, and hypothyroidism. The patient’s level of energy, or fatigue, may also be affected by disorders with accelerated or sluggish mental processes. Anergia, weakness, or obscure bodily discomfort are encountered frequently in somatoform disorders.

Insight & Judgment

The patient’s attitude or insight into the illness has several aspects. For example, does the patient recognize that he or she has a problem? Does he or she identify the problem as personal and psychological in nature? Does he or she understand the nature and cause of the illness? Does he or she want help and, if so, what kind of help?

The hypomanic patient has no problem. He or she feels very well (eg, high-spirited, amusing, energetic, expansive, and optimistic). The manic or schizophrenic patient may view the problem as external (ie, other people or agencies are stupidly obstructive or malevolent). Many patients with externalizing personality disorders (eg, borderline, antisocial, narcissistic) blame others for their predicament.

Sophisticated patients, particularly those who have undergone previous treatment, may have considerable knowledge of the formal diagnosis and the theoretical or actual causes of their disorder. Indeed, sometimes this causes problems in treatment: Other mental health professionals who develop psychiatric illness are notoriously difficult to manage for this reason.

The patient may be aware of having a problem but want no help, or he or she may want help of a particular sort or from a particular kind of clinician. Whenever this is reasonable and feasible, it should be arranged. The patient’s desires should be respected as much as possible in the negotiation phase of the clinical process.

The interviewer can ask the patient one of the following questions to test judgment: What would you do if you found a stamped, addressed envelope in the street? Why are there laws? Why should promises be kept? Good judgment requires intact orientation, concentration, and memory. There is no evidence that a finding of poor judgment adds anything to diagnosis beyond that provided by the detection of deficits in the lower-order functions, such as accomplishing household chores, maintaining personal hygiene, or selecting appropriate attire.

A psychiatric interview may last 15 minutes or go on for much longer. The usual time is about 50 minutes: long enough for a rapid survey but not so long as to exhaust the patient. The interviewer can signal the approach of the conclusion by saying, for example,"Our time is almost finished, and there are a few things we need to discuss . . .”

A concluding summary of the material points of the interview can be very helpful. It allows the patient to correct or modify misinterpretations and leads naturally into the interviewer’s plan for what happens next—another interview, for example, or special investigations.

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