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and numbers for the objects for which they stand (symbolization) is a fundamental part of the process These symbols are formed into ideas or concepts, and the arrangement of new and remembered ideas into certain orders or relationships, according to the rules of logic, constitutes another intricate part of thought, presently beyond the scope of analysis On page 393, reference is made to Luria s analysis of the steps involved in problem solving in connection with frontal lobe function; but actually, as he himself points out, the whole cerebrum is implicated In a general way one may examine thinking in terms of speed and ef ciency, ideational content, coherence and logical relationships of ideas, quantity and quality of associations to a given idea, and the propriety of the feeling and behavior engendered by an idea Information concerning the thought processes and associative functions is best obtained by analyzing the patient s spontaneous verbal productions and by engaging him in conversation If the patient is taciturn or mute, one may have to depend on responses to direct questions or upon written material One notes the prevailing trends of the patient s thoughts: whether the ideas are reasonable, precise, and coherent or vague, circumstantial, tangential, and irrelevant, indicating that the thought processes are shallow and fragmented Disorders of thinking are prominent in delirium and other confusional states, in mania, dementia, and schizophrenia In confusional states of all types, the organization of thought processes is disrupted, with fragmentation, repetition, and perseveration; this is spoken of as an incoherence of thinking Or, the patient may be excessively critical, rationalizing, and hairsplitting; this disturbance of thinking is often seen in depressive psychoses Derangements of thinking may also take the form of a ight of ideas; patients move too facilely from one idea to another, and their associations are numerous and loosely linked This is a common feature of hypomanic and manic states The opposite condition, poverty of ideas, is characteristic both of depressive illnesses, in which it is combined with gloomy thoughts, and of dementing diseases, in which it is part of a reduction of all inner psychic intellectual activity This overall reduction in thought and action is often the most prominent feature of a dementia but is particularly prominent in diseases that damage the frontal lobes Thinking may be distorted in such a way that ideas are not checked against reality When a false belief is maintained in spite of convincing evidence to the contrary, the patient is said to have a delusion This abnormality is common to several illnesses, particularly manic-depressive, schizophrenic, and paranoid states as well as the early stages of dementia Often the story related by the patient has internal logic but is patently absurd Other patients believe that ideas have been implanted in their minds by some outside agency, such as the Internet, radio, television, or atomic energy; these passivity feelings are highly characteristic of schizophrenia and sometimes of manic disease Also diagnostic of schizophrenia are distortions of logical thought, such as gaps in sequential thinking, intrusion of irrelevant ideas, and condensation of associations.

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tionality lend themselves to observation and have clinical signi cance The usually volatile, cyclothymic person is said to be liable to manic-depressive disease, and the suspicious, withdrawn, introverted person to schizophrenia and paranoia, but there are frequent exceptions to this statement Strong, persistent emotional states, such as fear and anxiety, may occur as reactions to life situations and may be accompanied by derangements of visceral function If excessive and disproportionate to the stimulus, they are usually manifestations of an anxiety neurosis or depression In the latter state, all stimuli tend to enhance the somber mood of unhappiness Emotional responses that are excessively labile and poorly controlled or uninhibited are a common manifestation of many cerebral diseases, particularly those involving the corticopontine and corticobulbar pathways This disorder constitutes part of the syndrome of spastic bulbar (pseudobulbar) palsy (pages 426, 445 and 450), but they may occur at times independently of any problem with brainstem function Conversely, all emotional feeling and expression may be lacking, as in states of profound apathy or severe depression Or excessive cheerfulness may be maintained in the face of serious, potentially fatal disease or other adversity; a pathologic euphoria Finally, the emotional response may be inappropriate to the stimulus, eg, a depressing or morbid thought may seem amusing and be attended by a smile, as in schizophrenia Temperament, mood, and other emotional experiences are evaluated by observing the patient s behavior and appearance while questioning him about his feelings For these purposes it is convenient to divide emotionality into mood and affect By mood is meant the prevailing emotional state of an individual without reference to the stimuli immediately impinging upon him As reported by the patient when queried, it may be cheerful and optimistic or gloomy and melancholic The patient s language (eg, the adjectives used), facial expression, attitude, posture, and speed of movement most reliably re ect his prevailing mood By contrast, affect (or feeling) refers to the emotional reactions evoked by a thought or an environmental stimulus As such, it is the observable aspect of emotion According to some psychiatrists, feeling is the subjective component and affect is the overt manifestation of emotion These distinctions may seem rather tenuous, but they are clinically valuable For example, a dissociation of mood and affect is characteristic of the aforementioned pseudobulbar state in which the patient displays extremes of easily precipitated and unexpected crying or laughing while reporting only slight alterations in subjective emotion The emotional disturbances relating to neurological disease are discussed more fully in Chap 25 and depression is addressed in Chap 57.

Ascending fibers (Spinothalamic and other)

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rietal lobe is shown in Fig 9-4 (the sensory homunculus ) The cortical representation allows for accurate localization of the site of origin of a painful stimulus but the notion that thalamic projections terminate solely in this region is an oversimpli cation Thalamic and cerebral cortical localization of visceral sensation is not well known However, cerebral evoked potentials and increased cerebral blood ow (by positron emission tomography studies) have been demonstrated in the thalamus and pre- and postcentral gyri of patients undergoing rectal balloon distention (Silverman et al; and Rothstein et al)