Can idiopathic hypersomnia ever be fatal

Common Psychiatric Syndromes and Disorders in Neurology

Psychopathological findings

Based on the basic concepts of psychopathology, the examiner should extract a short and concise report on the patient's current psychiatric condition from the exploration. In addition to the documentation requirement, an essential aim of this report is to serve as a basis for comparison for a possible later investigator. For this purpose, an accurate and vivid picture of the patient's condition should be conveyed. In addition to the current findings (cross-sectional image), findings at other times in the course of the disease (longitudinal section) are helpful, sometimes even indispensable, for the psychiatric diagnosis.

State of consciousness and orientation

Quantitative disturbances of consciousness are indicated on a one-dimensional scale (awake, somnolent, soporous, comatose). Qualitative disorders of consciousness can be classified into 3 categories. In the case of clouding of consciousness, the patient has the difficulty of understanding and connecting the various aspects of himself and the environment and acting accordingly. When narrowing the consciousness, the psychological functions are relatively well preserved within a limited range, but the responsiveness to stimuli outside this range is greatly reduced. With the shift in consciousness, an intensification of perception and wakefulness is registered subjectively.

The orientation is checked in terms of quality in terms of time, location, situation and with regard to the person.

Attention and memory

Attention is the ability to direct awareness towards experiences. Concentration means the ability to maintain this alignment over the long term. Clinically, disorders of these functions can be seen in conversation, but also in the non-verbal area. Perception describes the ability to understand experiences in their meaning and to be able to combine them in a meaningful way. You check them z. B. by allowing simple picture stories to be interpreted.

Memory ability means the ability to remember new information over a period of about 10 minutes. The function of memory beyond 10 minutes can be tested randomly for different periods of time. Here one can come across amnesias, disturbances of the time grid or confabulations (the patient fills memory gaps with free inventions that he himself considers to be memories). If one knows little about the patient, confabulations are easily overlooked. In case of doubt, it is advisable to ask questions several times, as different answers will be noticed. Tests of the memory can also be carried out with given terms. First of all, disturbances of comprehension should be ruled out by allowing people to speak.

Formal thinking

In this category the speed, coherence and stringency of the thought process are assessed. Usually one is dependent on the observation of the language as an expression of thought processes. Disturbances can be described with characteristics such as inhibited, slowed down, cumbersome, narrowed, persevering, incoherent or distracted. Typical formal thought disorders are also thought rushing, talking past, tearing off thoughts, volatility of ideas and the use of neologisms.

Fears and compulsions

Sometimes these symptoms, along with the delusion, are viewed as substantive thinking disorders. Fears can express themselves as suspicion about the behavior of others, about one's own health as hypochondria, and about certain objects or situations as phobias. It should be checked whether these fears are of a delusional character (uncorrectability of beliefs).

Compulsions come in the form of obsessive thoughts (involuntary thoughts that cannot be let go of), compulsive impulses (internal urges to perform dangerous, embarrassing, or superfluous actions), and compulsive acts (e.g., repeated checking of objects, excessive hand washing). The individual experiences these ideas and actions as meaningless, but as belonging to their own person. Deliberate restraint typically creates unbearable pressure.

Overvalued ideas are on the verge of madness. The delusional beliefs that occur often have a real core, but their influence on the patient's life and experience is overestimated in an incomprehensible way.

Delusion

Delusion can be understood as a "private reality" that opposes the reality of the environment and is stubbornly defended. This irreversibility of an erroneous belief is an essential characteristic of madness. The assessment of the severity is based on the extent of the impairment of the individual within his social framework, measured on his previous level of function.

Delusion can be linked to other psychological processes and then appear as delusional moods (something meaningful is in the air), delusional thoughts (cognitive preoccupation with the delusional), as well as delusional perception (misinterpreted real sensory perception) and delusion (sudden delusional belief). In the so-called delusional work, delusion and other parts of the psychological experience are transformed into a coherent structure (delusional system). In the context of a psychotic exacerbation, the delusion can experience a relevant affective tone (delusional dynamics). A synthymic delusion can be understood from an existing affective constitution (delusions of grandeur in mania, delusion of sin in depression), this is not the case with parathymal delusions. A delusion that is neutral with regard to affect is also referred to as parathyma.

Certain delusional themes are overly frequent. The following topics should be asked explicitly: delusions of relationships (radio broadcasts are related to the patient), delusions of impairment and persecution (strangers use radioactive rays to harm the patient or microphones to eavesdrop on them), delusions of jealousy, delusions of love, delusions of grandeur and hypochondriac, querulous and nihilistic madness.

Sensory perception

Deviations from normal sensory perception are divided into hallucinations (perceptions without an existing stimulus source), pseudo-hallucinations (such as hallucinations, but the deception is cognitively identified as such), illusionary misjudgments (an existing stimulus source is misinterpreted) and perceptual anomalies (an object becomes in certain aspects such as size, perceived changed). Illusions of the senses, especially in delirious patients, can often be generated or influenced by suggestions. Their complexity can reach very different dimensions and in the optical range can go from photopsies to simple pictures to scenes with a dream-like character. Examples of acoustic hallucinations are hearing noises (acoasms), linguistic sounds (phonemes), one's own thoughts (referred to as sounding thoughts) as well as commenting, dialogizing or imperative voices. The latter is particularly important to assess the risk of suicide. Illusions of the skin senses are called tactile hallucinations, those of the body sensation are called zoenesthesia. The latter can take on very bizarre forms and can only be sharply differentiated from delusions and disturbances in the experience of the self. Patients experience hallucinations of taste and smell that are often very painful.

I experience

In addition to derealization and depersonalization (the environment or one's own person appears strange and unfamiliar), the disturbances of selfhood are included, in which one's own psychological or physical experience takes on the character of what is made from outside in a sometimes bizarre way. Examples of this are the spreading of thoughts (other people have a share in the patient's thoughts), withdrawal and inspiration of thoughts (thoughts are extracted, entered or changed from outside the patient), influencing the will (e.g. through a transmitter in the head) and bodily influencing experiences (organs are damaged by irradiation from the outside).

Affectivity

A short-term emotional reaction is called affect, a longer-term overall condition is called mood. Affective processes are closely related to physical well-being. It is not uncommon for this to go so far that, in affective disorders, the somatic experience is in the foreground over the psychological experience. One speaks of a disturbance of the vital feelings, which in depression can express itself as a feeling of heaviness, increased sensitivity to pain, weakness or a feeling of pressure, in mania as lightness, elasticity and insensitivity to pain. Conversely, physical sensations such as B. hunger, thirst or sexual arousal strongly modulate the emotional life.

Affectivity abnormalities can be described as depressed, subdepressive, hypomanic and euphoric, apathetic, inwardly driven, perplexed, desperate, hopeless, plaintive, anxious, irritable, ambivalent, suspicious, angry, dysphoric or ridiculous.

Other terms characterize formal abnormalities of affectivity. Poor affect (reduction of the affects spontaneously shown and the affective responsiveness) and affective rigidity (persistence in certain affects, also against external influences) together denote an affective flattening (limited ability to vibrate) of the patient. A further distinction can be made between: affect lability (spontaneous or induced rapid changes in mood), affect incontinence (spontaneous or induced excessive and insufficiently controllable emotions) and parathymia (incongruence of the content of the experience and the affect that occurs). The last phenomenon is also described as inadequate or paradoxical affect. The feeling of numbness (painfully experienced lack of emotions) and anhedonia (stimuli lose their attraction) remain more in the subjective.

Drive and psychomotor skills

Physical and psychological processes are modulated by the drive. This can be increased, decreased or inhibited and accordingly z. B. express in physical restlessness or stupor, logorrhea or mutism. Psychomotor abnormalities can be described as mannerisms (everyday movements or verbal utterances that stand out due to their emphasis, delicacy, or convulsions), parakinesia (qualitatively abnormal utterances or movements) or theatrical behavior.

Endangering yourself and others

The psychiatric findings should include a statement on the risk to oneself and, if available, also to the risk to others. Mental illness is a key risk factor for attempted suicide. These are among the most serious complications of psychiatric disorders. With more than 10,000 suicides per year in Germany, the number of suicide victims significantly exceeds that of road deaths. Considering that the number of parasuicidal acts is likely to be more than 10 times as high, the importance of this part of the psychiatric examination becomes clear. About three quarters of all suicide attempts are announced in advance. The inadequate reaction of the environment to statements in this regard is an essential element of suicidal development. It is not uncommon for the examiner to overcome his own shyness in order to specifically inquire about the various shades of potential suicidality. These range from the occasional wish not to want to live any longer, to persistent weariness with life, passive death wishes, to mental and active preparations. The examiner should not accept ambiguous answers from the patient. The term “latent suicidality” should be avoided at all costs. The argument that suicidal intentions are kept secret anyway and that questions about this are pointless is refuted by daily practice. In addition to the specific suicidal statements, an increasing narrowing of the psychological experience, self-reproaches and feelings of guilt, inner emptiness, changes in contact with the examiner and the "calm before the storm" can be signs of increased self-endangerment. The following common characteristics are indications of an increased risk of harm to yourself and others:
  • direct or indirect announcement or preparation

  • similar actions in one's own or family history

  • similar actions in the environment of the person concerned

  • psychiatric illnesses (depression / mania, schizophrenia, addiction, personality disorder)

  • psychopathological factors (imperative voices, delusion, disinhibition through intoxication)

  • social factors (lack of social contact or conflict situations)

  • noticeable dissimulation

As an additional indication of a threat to others, attention should be paid to relevant criminal offenses in the past.

intelligence

A few tests are sufficient for clinical purposes in order to be able to get an idea of ​​the extent of the deficits in congenital and acquired disorders of intellectual performance. To do this, you use simple arithmetic tasks, create generic terms, ask about the differences between related terms, test judgment and abstraction skills, or have proverbs interpreted. However, the diagnosis of inadequate talent should not be made without a psychological test.

Vegetative

In the case of sleep disorders, a distinction is made between insomnias (difficulty falling asleep, staying asleep and waking up early in the morning) and hypersomnias. Daytime sleepiness, appetite disorders and the daily cycle of symptoms (especially a morning low in mood) should be recorded. If there is no organic correlate, pain, abnormal sensations and unspecific complaints such as a feeling of lumpiness, dizziness, digestive problems and excessive sweating are also counted among the vegetative functional disorders.

Other findings

Notes about the external appearance, the appearance of the patient, existing or missing insight into the disease as well as the quality of the contact help a later examiner to get an idea of ​​the previous exploration. Impulse control disorders (self-harm, aggressive breakthroughs, pathological gambling, tendency to steal, eating behavior) should be asked about.