ICD-11 clinical glossary

A

addiction

Other names: habit, substance dependence

Addiction is a disorder consisting of a loss of control over the use of a psychoactive substance or - in the case of behavioural addictions - over a particular behaviour, despite mounting harms. In the ICD-11 classification, substance dependence is diagnosed on the basis of three principal features: impaired control over use (over its initiation, amount, circumstances and termination), giving the substance an increasing priority at the expense of other activities and obligations, and physiological features such as tolerance and withdrawal symptoms.

Addiction is recurrent and entrenched in nature - it usually does not result from a lack of willpower, but is associated with lasting changes in the functioning of the brain, especially in the systems responsible for the experience of reward, motivation and the control of behaviour. It is often accompanied by an intense craving for the substance and by continued use despite clear harms to health, family, occupation or legal standing. Addiction can concern alcohol, nicotine, opioids, sedative medications and many other substances.

Addiction must be distinguished from harmful substance use, in which a loss of control and an entrenched pattern have not yet developed, although harms are already appearing. The contemporary approach treats addiction as a health disorder requiring treatment, rather than a question of weakness of character. Effective help usually combines medical and psychological interventions with support from the person's environment.

affect

Affect is the observable, outward expression of experienced emotions, visible above all in facial expression, the tone and modulation of the voice, gestures and body posture. In psychiatry and clinical psychology affect is distinguished from mood. Mood is a longer-lasting, relatively stable emotional state reported by the person themselves, whereas affect is the expression of emotion, variable over time, assessed by the examiner during the conversation. Figuratively speaking, mood resembles the climate, and affect the current weather.

During a psychiatric examination the clinician describes affect according to several features. The range and variability are assessed, from normal affect, that is, appropriately varied, through constricted or blunted affect, to flat affect, which scarcely changes at all. Its appropriateness to the content of the utterance and the situation is also assessed, as is its quality, for example a depressed, anxious, irritable or euphoric affect. Inappropriate affect is affect that does not fit the topic being discussed, for example laughter while recounting a difficult, painful experience.

The assessment of affect is one of the basic elements of the mental state examination and assists in recognising mood disorders, psychotic disorders and many other states. The ICD-11 classification and the CDDR criteria refer to abnormalities of affect in the descriptions of numerous disorders. Affect itself, however, is not a diagnosis but a symptom and an element of the clinical description that always requires interpretation in a broader context. The significance of observed changes in affect is determined by a specialist, taking into account the whole picture of the person's functioning.

agoraphobia

Agoraphobia is an anxiety disorder consisting of intense fear of situations or places from which it would be difficult to escape, or in which it would be difficult to obtain help, should symptoms of anxiety or panic arise. Typical triggering situations are using public transport, being in a crowd, in a queue, in open spaces, in enclosed places, or moving away from home on one's own. Contrary to the colloquial understanding of the name, it is not solely about fear of open spaces.

A person with agoraphobia is afraid that in such a situation distressing bodily symptoms or a panic attack will appear, and that escape or help will be impossible or embarrassing. These situations are actively avoided, endured with great discomfort, or require the presence of an accompanying person. The fear is disproportionate to the actual danger and persists despite awareness of its excessiveness.

In the ICD-11 classification, agoraphobia is a separate entity, independent of whether the person experiences full panic attacks. It often co-occurs with panic disorder. In more severe forms the limitations can be serious enough to make it impossible to leave the house unaccompanied, which significantly narrows occupational, social and family life.

alogia

Other names: impoverishment of speech

Alogia is an impoverishment of speech consisting in a marked reduction of both its quantity and its content. A person with alogia speaks little, gives short and terse answers, rarely initiates conversation themselves, and their utterances may be poor in information despite a correct grammatical form. In more severe forms there are long pauses before answering or an almost complete absence of spontaneous speech, and verbal contact becomes greatly impeded.

Alogia belongs to the negative symptoms and is one of the symptoms characteristic of schizophrenia and other primary psychotic disorders. The ICD-11 classification and the CDDR criteria list impoverishment of speech among the features of the negative dimension of psychosis. Alogia must be distinguished from speech disturbances of a different character, for example from disorganisation of speech, in which utterances are abundant but incoherent and difficult to understand. In alogia the problem is a scarcity of speech, not its chaos.

Alogia may also be a consequence of a marked slowing of thinking in the course of severe depression, of the action of certain medications, and also of neurological disorders affecting speech or the initiation of utterances. It must also be distinguished from a natural taciturnity, which in some people is simply an individual trait. Because alogia limits communication, impedes contact with other people, the maintenance of relationships and the use of forms of therapy based on conversation, its recognition has practical significance for planning help. Establishing whether the paucity of speech results from a negative symptom or from another cause is the responsibility of a specialist assessing the overall clinical picture and the course of the difficulties over time.

anhedonia

Anhedonia is the inability, or a markedly reduced ability, to feel pleasure and satisfaction from activities and situations that previously brought joy. A person with anhedonia loses interest in favourite pursuits, social contacts, food, sexual activity or hobbies, and the activities performed seem empty and devoid of reward. Anhedonia may concern both the anticipation of pleasure, that is, the expectation that something will bring joy, and the very experiencing of it in the moment.

Anhedonia is one of the core symptoms of a depressive episode. The ICD-11 classification and the CDDR criteria list the loss of interest and of the ability to feel pleasure as one of the main symptoms of depressive disorders, alongside depressed mood. Anhedonia also occurs as a negative symptom in schizophrenia and other psychotic disorders, and may also be present in anxiety disorders, in post-traumatic stress disorder and in addictions.

The presence of anhedonia is significant for diagnosis and for treatment planning, because it is associated with a greater risk of a chronic course of the illness and a weaker response to some forms of therapy. It must be distinguished from transient weariness, fatigue or a momentary decline in interests, which are part of normal life and resolve spontaneously after rest or a change in circumstances. A clinical diagnosis is determined by a specialist, assessing the duration of the symptom, its severity and its impact on everyday functioning, study, work and relationships. Anhedonia is also sometimes an important warning sign, because it may co-occur with a sense of hopelessness and with a diminished will to live, and so it should not be disregarded.

anticipatory anxiety

Other names: anticipatory fear, fear of fear

Anticipatory anxiety is anxiety felt in advance, before a situation perceived as difficult or threatening occurs. It is not a reaction to a real, present danger, but to its imagined version - the person responds with tension to the very thought of an event awaiting them, for example public speaking, a medical examination, travel or a meeting. It is often accompanied by bodily symptoms familiar from other forms of anxiety: a racing heartbeat, muscle tension, motor restlessness, sleep problems and persistent rumination about what might go wrong.

In clinical practice, anticipatory anxiety is an important mechanism that maintains many anxiety disorders. In panic disorder it takes the form of fear of another attack (so-called fear of fear), in phobias it is fear of contact with the feared object, and in social anxiety it is fear of being judged by others. It is not, in itself, a separate diagnostic entity, but a symptom described within the presentation of these disorders.

Anticipatory anxiety often leads to avoidance: giving up on plans or postponing them, which brings momentary relief but in the long term intensifies the anxiety and narrows functioning. Mild, short-lived tension before an important event is a normal reaction. We speak of clinical significance when the anxiety is severe, prolonged, disproportionate to the situation and impairs everyday life.

avoidance

Other names: avoidance behaviour

Avoidance is a pattern of behaviour consisting of keeping away from situations, places, people, thoughts or memories that provoke anxiety, discomfort or distressing emotions. It can take an overt form - giving up going out, travelling or making contact - or a subtle one, for example diverting one's attention, putting things off until later, or steering clear of particular topics in conversation. Avoidance is an understandable reaction: it brings immediate relief because it removes the source of tension.

In anxiety disorders and in post-traumatic stress disorder, however, avoidance is a key mechanism that maintains the problem. Short-lived relief reinforces the tendency to avoid in the future, while at the same time making it impossible to discover that the feared situation is less dangerous than it seems. The anxiety does not decrease but becomes entrenched, and the range of situations the person avoids gradually widens, narrowing everyday functioning.

Avoidance is one of the principal symptoms taken into account in diagnosing phobias, agoraphobia, social anxiety and post-traumatic stress disorder. Because it is a mechanism that maintains anxiety, gradually overcoming it - usually through controlled, gentle approach towards difficult situations - is an important element of the treatment of anxiety disorders.

avolition

Other names: abulia

Avolition is a marked weakening of, or lack of, motivation, drive and the ability to undertake and complete goal-directed actions. A person with avolition has difficulty initiating even simple everyday activities, such as getting out of bed, attending to hygiene, preparing a meal or dealing with administrative matters. Activities that have been started often remain unfinished, and the person may spend long periods in inactivity, without feeling a clear desire to change this state.

Avolition belongs to the negative symptoms and is one of the significant symptoms of schizophrenia and other primary psychotic disorders. The ICD-11 classification and the CDDR criteria list it among the features of the negative dimension of psychosis. A reduction of drive and activity also occurs in depressive episodes, where it is often combined with anhedonia, that is, the inability to feel pleasure, and with fatigability and a lack of energy.

Avolition is sometimes wrongly perceived by those around the person as laziness, weakness of character or an unwillingness to cooperate, which may lead to misunderstandings, family conflicts and a sense of guilt in the ill person. In reality it is a symptom of illness that significantly impedes study, work and independent functioning, as well as the maintenance of relationships with those close to the person. It must be distinguished from the side effects of medication, from a reduced drive in the course of depression and from a transient lack of desire to act, which happens to everyone and does not require treatment. The assessment of the cause and severity of avolition is the responsibility of a specialist, who takes into account the whole clinical picture and the course of the difficulties over a longer time.

B

blunted affect

Other names: flattened affect, constricted affect

Blunted affect, also called flattened affect, is a marked weakening of the outward expression of emotion. The person speaks in a monotonous voice, has little varied facial expression, limited gesturing and poor eye contact, so that it is difficult to read from their behaviour what they are experiencing. Blunted affect concerns the expression of emotions, that is, their outward display, and does not necessarily mean that the person feels nothing inwardly. Many people with this symptom still experience emotions but are unable to express them outwardly.

Blunted affect belongs to the negative symptoms and is one of the main symptoms of schizophrenia and other primary psychotic disorders. The ICD-11 classification and the CDDR criteria list it among the features characteristic of the negative dimension of psychosis. This symptom may persist even during periods in which there are no delusions or hallucinations, and often influences the chronic course of the difficulties and the prognosis concerning social functioning.

Blunted affect must be distinguished from other states with a similar picture. A similar weakening of expression may be a side effect of some antipsychotic medications, may accompany severe depression, Parkinson's disease and other neurological diseases, and may also be a reaction to chronic stress or trauma. It must also be distinguished from a natural reserve in showing emotions, which in some people is simply an individual trait and does not indicate illness. Because blunted affect significantly impedes contact and social relationships, and is sometimes perceived by those close to the person as coldness or indifference, its recognition and the establishing of its cause are the responsibility of the specialist, who assesses the overall clinical picture and the course of the symptoms over time.

C

catatonia

Other names: catatonic syndrome

Catatonia is a syndrome of symptoms involving marked disturbances in movement, drive, speech and responsiveness to the surroundings. It can take the form of inhibition, in which the person remains immobile, does not answer questions, holds unnatural body postures or remains motionless despite preserved consciousness. It can also take the form of excitement, with excessive, purposeless motor activity. Typical symptoms include, among others, stupor, posturing, waxy flexibility, mutism (the absence of speech), negativism, repetition of movements, and echolalia and echopraxia, that is the repetition of other people's words and movements.

In the ICD-11 classification, catatonia is treated as a separate diagnostic category, and not solely as a subtype of schizophrenia. The CDDR criteria indicate that catatonia may accompany schizophrenia and other psychotic disorders, mood disorders and autism spectrum disorders, and may also be induced by substances, medications or a physical (somatic) illness. For this reason, a diagnosis of catatonia always requires identifying the underlying condition.

Catatonia can be a serious condition, since in more severe forms it carries the risk of complications such as dehydration, malnutrition, thrombosis or life-threatening malignant catatonia, in which fever and instability of vital functions appear. For this reason it requires urgent assessment and treatment, sometimes in a hospital setting. Catatonia must also be distinguished from other movement disorders of neurological origin. Diagnosing catatonia and establishing its cause is the task of a specialist who assesses the overall clinical picture.

categorical approach

Other names: categorical model, categorical framework

The categorical approach is a way of classifying mental disorders in which each diagnosis is a distinct category with fixed boundaries. The patient either meets its criteria or does not. Disorders are treated here as qualitatively delineated entities, in much the same way that somatic medicine distinguishes individual diseases. This is historically the most widespread model for organising diagnoses, present in successive editions of the ICD classification and in the American DSM system (Diagnostic and Statistical Manual of Mental Disorders).

The main advantage of the categorical approach is the clarity and convenience of communication. A diagnosis in the form of a single label simplifies the exchange of information among specialists, facilitates treatment decisions, the keeping of medical records, scientific research and the billing of health services. The clinician and the patient receive a clear point of reference that organises the discussion of the problem and of further management.

The categorical approach does, however, have significant limitations. Setting rigid thresholds dividing health from disorder is sometimes arbitrary, and borderline states are difficult to assign unambiguously to a single category. The model poorly reflects differences in symptom severity and the frequent overlap of disorders in one person. For this reason the ICD-11 classification combines the categorical approach with dimensional elements, that is, with a gradable assessment of severity, seeking to retain the advantages of both solutions and limit their drawbacks. In clinical practice a diagnostic label is therefore a point of departure, not a complete and final description of a particular person's difficulties, which should always be assessed individually and in that person's own context.

co-occurrence of disorders

Other names: comorbidity, co-morbidity

Co-occurrence of disorders, also referred to by the term comorbidity, denotes a situation in which two or more distinct mental disorders, or a mental disorder and a somatic (bodily) illness, are diagnosed in one person at the same time. This is not uncommon. Many patients seeking help meet the criteria for more than one diagnosis, for example an anxiety disorder and a depressive disorder at once, or a mood disorder and a substance use disorder.

Co-occurrence has several possible sources. Sometimes one disorder increases the risk of another, for example chronic anxiety predisposes to the development of depression. Sometimes both share a common basis, biological, familial or environmental. It also happens that the overlap of symptoms results from the limitations of the classifications themselves, which divide a continuous spectrum of difficulties into separate categories. The ICD-11 classification permits and recommends making several diagnoses at once, provided each of them is clinically justified and is not merely a symptom of the other.

From the standpoint of treatment, co-occurrence carries considerable significance. It is usually associated with greater symptom severity, poorer functioning, a more difficult course and a less favourable prognosis than a single disorder. The treatment plan must take into account all the diagnosed problems and their mutual interaction, rather than focusing solely on the single, most visible symptom. Overlooking a co-occurring disorder is a frequent cause of treatment failure. For this reason the diagnostic assessment should be comprehensive, and once improvement has been achieved in one area it is worth checking whether other difficulties require separate, further attention.

compulsion

Other names: compulsive act, ritual

A compulsion, also called a compulsive act, is a repetitive behaviour or mental act that a person feels compelled to perform, usually in response to an intrusive thought (an obsession) or according to rigid, self-imposed rules. Examples include repeated checking, washing and decontaminating, arranging and ordering, counting, and repeating words or actions. Mental compulsions, such as silently repeating formulas or prayers, are not visible from the outside, but serve the same function.

The aim of a compulsion is to reduce the anxiety or unease provoked by an obsession, or to prevent a feared misfortune. It brings, however, only momentary relief, and in the longer term it maintains and reinforces the obsessive-compulsive cycle: the more often the ritual is performed, the stronger the need to repeat it becomes. A compulsion is usually experienced as excessive or irrational, yet refraining from it is associated with tension that is hard to endure.

Compulsions are - alongside obsessions - a core symptom of obsessive-compulsive disorder and can also occur in related disorders. We speak of clinical significance when these acts take up a great deal of time, cause distress or clearly impair everyday functioning.

course of a disorder

Other names: clinical course, course of illness

The course of a disorder is the way in which symptoms develop and change over time, from their first appearance, through phases of worsening and improvement, to the state in the more distant perspective. Describing the course answers the questions: when did the disorder begin, how rapidly did it build up, is it of a one-off, recurrent or continuous character, and how long has it persisted to date. It is a view of the disorder as a process, rather than as a static picture.

Several typical patterns of course are distinguished. An episodic course means alternating periods of illness and health. A recurrent course is the repeated return of symptoms after periods of remission. A chronic course, also called continuous, means the persistence of symptoms over a long time without clear remissions. There is also reference to a progressive course, when the state gradually worsens. The ICD-11 classification often incorporates this information in the diagnosis itself, for example by distinguishing a single episode from a recurrent disorder.

Knowledge of the course is of practical importance, because it influences therapeutic decisions and the prognosis. Management is planned differently for a one-off, self-limiting reaction than for a chronic or recurrent disorder that requires long-term treatment and consistent prevention of relapse. The course is assessed retrospectively, on the basis of a history covering the whole history of the difficulties, and prospectively, by observing the patient over successive periods and verifying earlier assumptions. For this reason the full picture of the course often emerges only over time, rather than at the first visit.

craving

Other names: craving, drug craving, alcohol craving

Craving, also referred to in the literature by the English term craving, is an intense, intrusive desire to take a psychoactive substance. It is sometimes experienced as a hard-to-resist need, a self-imposing thought about the substance, or a tension that will subside only once it has been taken. Craving can appear suddenly and reach great intensity, and then weaken - even without resorting to the substance.

Craving is one of the important symptoms of addiction and an expression of impaired control over use. It is often triggered by cues associated with previous use: particular places, people, situations, times of day or emotional states such as stress, sadness or boredom. For this reason, craving can return long after use has ceased and is one of the principal causes of relapse.

In therapeutic practice, recognizing the situations that trigger craving and learning ways to get through it without resorting to the substance are important elements of the treatment of addictions. It can be helpful to be aware that craving, although unpleasant and intense, is a transient state that rises and falls in waves. Craving must be distinguished from an ordinary wish or habit - its hallmark is its intrusive, compulsive nature and the strength of the desire experienced.

D

delusions

Delusions are false beliefs of which the person is unshakeably certain, even though they are clearly at odds with reality and with the knowledge and experience shared by the person's cultural environment. A characteristic feature of a delusion is that the belief cannot be corrected by logical arguments or by evidence against it. A delusion does not arise from religious or worldview differences typical of a given group, but constitutes an individual, pathological way of thinking about oneself and the world.

Various types of delusions are distinguished according to content, for example persecutory delusions, that is, the belief of being followed or harmed, delusions of reference, that is, the conviction that indifferent events relate directly to the given person, grandiose delusions, delusions of guilt and somatic delusions concerning one's own body. Delusions are one of the main positive symptoms of psychosis. The ICD-11 classification and the CDDR criteria describe them as key to the diagnosis of schizophrenia, delusional disorder and other primary psychotic disorders.

Delusions may also occur in episodes of mood disorders with psychotic symptoms, in psychoses induced by a somatic illness or by substances, and also in some dementia diseases. They are often associated with great distress and with a risk of behaviours dangerous to the ill person or to those around them. They must be distinguished from strongly entrenched but non-delusional beliefs and from views typical of a given culture. The recognition of delusions and the establishing of their cause are always the responsibility of a specialist, who assesses the duration of the symptoms and the clinical context.

diagnostic criteria

Other names: diagnostic requirements, criteria for diagnosis

Diagnostic criteria are an established set of clinical features whose presence or absence must be ascertained before a diagnosis of a specific disorder is justified. They serve as a point of reference: they organise the clinical picture, standardise the language used among clinicians and limit arbitrariness in assessment. In the ICD-11 classification, developed by the World Health Organization, the counterpart of the classic criteria lists is the diagnostic requirements set out in the CDDR document (Clinical Descriptions and Diagnostic Requirements). These indicate which symptoms, persisting for how long and at what severity, are necessary to establish a diagnosis.

Typical criteria comprise several elements: characteristic symptoms, such as depressed mood or anxiety, the required duration of symptoms, the degree of impairment in everyday functioning, and what are known as exclusion criteria. The latter are conditions that point toward a different diagnosis, for example the effects of a psychoactive substance or a somatic (bodily) illness that accounts for the symptoms. Meeting all the required conditions distinguishes a disorder requiring treatment from transient, understandable reactions to difficult life events.

Diagnostic criteria are a tool, not an oracle. They do not replace the clinical interview, history-taking or assessment of the patient's life context. ICD-11 explicitly encourages assessment based on the judgement of an experienced clinician rather than on mechanically ticking symptoms off a list. A diagnosis should be made by a qualified specialist, and the published criteria descriptions serve mainly to clarify what underlies that decision and to ensure that similar cases are assessed in a comparable way.

diagnostic qualifiers

Other names: diagnostic specifiers, qualifiers of diagnosis

Diagnostic qualifiers are additional designations attached to a diagnosis that make its picture more precise without changing the disorder category itself. They serve a supplementary role. After it has been indicated which disorder is present, a qualifier specifies how it is running its course or how it currently presents. As a result, a single, general diagnosis can yield a description considerably better matched to the situation of the particular patient.

Qualifiers can specify, among other things, the severity of the disorder, defined as mild, moderate or severe, the current state of the course, for example an active episode, partial remission or full remission, and also the presence of distinguishing features. Examples of such features are psychotic symptoms in a depressive episode or anxiety accompanying a mood disorder. Qualifiers can also indicate the timing of onset or the pattern of course. In the ICD-11 classification they are an extensive and important tool supporting a detailed clinical description.

The practical value of qualifiers lies in the fact that they combine the convenience of a categorical diagnosis with the flexibility of a dimensional description. Two people with the same primary diagnosis may require different treatment, and qualifiers help to capture this difference and convey it clearly to other specialists. They therefore influence treatment planning, the assessment of prognosis, the keeping of medical records and the comparability of data used in scientific research and in health statistics. Thanks to them a diagnosis becomes a more accurate, better-matched description of the patient's real situation, rather than merely a general name for a disorder category. They are also helpful in assessing progress during treatment.

differential diagnosis

Other names: differential diagnostics, diagnostic differentiation

Differential diagnosis is the process of systematically considering and comparing several possible diagnoses that could account for a patient's symptoms, in order to identify the most probable one. The starting point is the observation that the same symptom, for example anxiety, insomnia or difficulty concentrating, can occur in many different disorders, as well as in somatic (bodily) conditions or as a consequence of substances being used. Without such a comparison it is easy to settle on the first diagnosis that comes to mind, which is not necessarily the correct one.

In practice, the clinician draws up a list of disorders that fit the clinical picture and then verifies them one by one on the basis of the history, the duration of symptoms, their severity, the context in which they appeared and additional investigations. Some diagnoses are ruled out because the required features are lacking, others because a different explanation accounts for the symptoms more fully. Differential diagnosis also makes it possible to identify situations in which the cause of psychiatric symptoms is bodily in nature, for example hormonal disorders, deficiencies or neurological diseases.

Careful differential diagnosis has direct significance for the patient, because the accuracy of the diagnosis translates into the choice of treatment and into the prognosis. An error, for example diagnosing depression instead of bipolar affective disorder, may lead to treatment that is ineffective or even harmful. For this reason the process is sometimes spread out over time, and an initial diagnosis is treated as a working hypothesis that is corrected as new information accumulates and the course of the disorder is observed.

dimensional approach

Other names: dimensional model, dimensional framework

The dimensional approach is a way of describing psychological difficulties in which symptoms and traits are treated as a gradable intensity on a continuous scale, rather than as a state that is simply either present or absent. Instead of asking only whether a disorder is present, it also asks how severe it is. Anxiety, low mood or impulsivity do not appear suddenly in a complete, full-blown form. They occur to varying degrees, from slight to very severe, and the dimensional approach seeks to reproduce this gradation faithfully.

In the ICD-11 classification, the dimensional approach is most clearly visible in the way personality disorders are described. Instead of separate, rigid types, the overall severity of the disorder is assessed, defined as mild, moderate or severe, along with prominent trait domains, such as negative affectivity, detachment, dissociality, disinhibition or anankastia. Similarly, schizophrenia and related disorders can be described by assessing the severity of individual symptom groups. As a result, the description of the patient becomes more individualised.

An advantage of the dimensional approach is that it better reflects clinical reality and is sensitive to change, because it makes it possible to track whether symptom severity is increasing or decreasing. It is, however, less convenient in everyday communication than an unambiguous diagnostic label and harder to capture in simple statistics. Contemporary classifications therefore combine both approaches: they establish a categorical diagnosis and then supplement it with a dimensional assessment of severity. For the patient this means a description that conveys not only the name of the problem but also its scale and how it changes during treatment.

disorganization

Other names: disorganized thinking, disorganized thought

Disorganization is a psychotic symptom consisting of a disturbance in the coherence of thinking, speech and behaviour. Disorganized speech is manifested by utterances becoming difficult to understand. The person jumps between topics without any clear connection, loses the thread, combines words in an illogical way, and in severe forms their speech may resemble a jumble of unconnected words. This reflects a disturbance of the thought process itself, since speech is its outward expression.

Disorganized behaviour means actions that are undirected, inappropriate to the situation or incomprehensible to those around the person, for example difficulty carrying out ordinary purposeful activities or behaviour ill-suited to the circumstances. Disorganization is one of the principal symptom dimensions of psychosis, alongside positive and negative symptoms. The ICD-11 classification and the CDDR criteria list disorganized thinking and behaviour among the features characteristic of schizophrenia and other primary psychotic disorders.

Marked disorganization considerably impairs communication, independent functioning and the ability to make use of help, since the person may have difficulty conveying their needs and experiences, as well as carrying out ordinary everyday activities. Mild disturbances of the thought process must be distinguished from a digressive but understandable way of speaking, which falls within the bounds of the norm. This symptom can also occur in severe episodes of mood disorders and in delirious states, which is why its appearance alone does not yet point to one specific illness. Assessing the type and cause of disorganization is the task of a specialist who evaluates the overall clinical picture and the course of the symptoms over time.

dissociation

Other names: dissociative symptoms

Dissociation is a partial or total disruption of the integrated experience of oneself and one's surroundings. In normal functioning, memory, identity, emotions, the perception of the body and consciousness operate as a coherent whole; in dissociation this integration is broken. This can take various forms: a sense of detachment from one's own body or emotions (depersonalization), a sense of unreality of the surroundings (derealization), gaps in memory, a narrowing of consciousness, or the experiencing of distinct states of identity.

Mild, transient dissociative phenomena - such as becoming lost in thought or a momentary sense of unreality in a situation of intense stress or fatigue - are common and do not indicate a disorder. Dissociation takes on clinical significance when it is severe, recurrent or chronic and disrupts functioning. The ICD-11 classification distinguishes a group of dissociative disorders, including depersonalization-derealization disorder, dissociative identity disorder and dissociative neurological symptom disorder.

Dissociation is often understood as a defence mechanism of the psyche in the face of overwhelming experiences - it allows a person to separate emotionally from what is unbearable. For this reason it is strongly linked to a history of trauma, especially chronic trauma from childhood, and often accompanies post-traumatic stress disorder.

dysthymia

Other names: dysthymic disorder, chronic depression

Dysthymia, that is dysthymic disorder, is a chronic lowering of mood that persists for most of the day, for most days, over a long period. The ICD-11 classification and the CDDR criteria indicate that the symptoms last at least two years. The severity of the symptoms is usually lower than in a depressive episode, yet their long duration means that low mood becomes an almost constant backdrop to the person's life, with periods of better well-being being short and infrequent.

Typical symptoms of dysthymia include low mood, low self-esteem, a sense of inadequacy, fatigue and lack of energy, difficulty concentrating, disturbances of sleep and appetite, and a sense of hopelessness. These symptoms persist chronically, although they may at times diminish somewhat. Dysthymia must be distinguished from a single depressive episode, which is shorter but usually more severe, and also from transient drops in mood that are part of normal life.

Because of its long course, dysthymia is sometimes mistakenly regarded, including by the person themselves, as a character trait or a natural disposition rather than as a disorder requiring treatment. In fact, chronically low mood significantly worsens quality of life as well as social and occupational functioning, and the difficulties may build up over many years. It is also possible for a depressive episode to be superimposed on dysthymia, which is sometimes called double depression and usually requires more intensive treatment. Diagnosing dysthymia and choosing the appropriate course of action are always the task of a specialist who assesses the overall clinical picture and the duration of the symptoms.

E

episode

Other names: illness episode

An episode is a period of time, set apart from the rest, in which the symptoms of a disorder are present and meet the criteria for the diagnosis, with a relatively distinct beginning and end. The concept organises the course of a disorder, dividing it into active phases, with symptoms, and the periods between them, without symptoms or with residual symptoms only. The term is most often used with reference to mood disorders, where one speaks of a depressive, manic, hypomanic or mixed episode.

The definition of an episode usually includes a requirement of a minimum duration of symptoms. For example, in a depressive episode the symptoms must persist for a defined period, usually counted in weeks. This makes it possible to distinguish a disorder requiring clinical attention from short-lived, transient changes in mood that are a natural reaction to life events. An episode is also described by severity, defined as mild, moderate or severe, and sometimes also by additional features, for example the presence of psychotic symptoms.

The number and character of episodes are significant for the diagnosis and for the prognosis. A single depressive episode differs from recurrent depressive disorder, in which episodes appear repeatedly after periods of improvement. The occurrence of even a single manic episode shifts the diagnosis toward bipolar affective disorder. Tracking episodes over time helps to plan treatment, select maintenance therapy and assess the risk of further relapses. For this reason a thorough history concerning earlier episodes is one of the more important elements of the diagnostic assessment.

F

functioning

Other names: psychosocial functioning, level of functioning

Functioning is a person's ability to cope with everyday tasks and to fulfil important life roles, in work or study, in family and social relationships, in independent self-care and in leisure time. In psychiatry and clinical psychology the assessment of functioning is as important as the description of the symptoms themselves, because it shows the real, practical impact of the disorder on the patient's life and on those around them.

The degree of impairment of functioning is one of the conditions for many diagnoses. In the ICD-11 classification, for difficulties to be recognised as a disorder it is often necessary to ascertain that the symptoms cause marked distress or significantly limit functioning in important areas of life. The mere presence of isolated symptoms, if it does not disrupt everyday life, is usually not sufficient to establish a diagnosis. Functioning is also assessed on a separate, gradable scale, ranging from full capacity to significant limitations in many spheres.

Functioning is also the main measure of the effectiveness of treatment. The goal of therapy is not merely the reduction of symptoms but a return to a satisfying life, that is, to work, relationships and independence. Two people with the same diagnosis may function very differently, depending on their personal resources, life situation and the support available. For this reason the assessment of functioning makes it possible to individualise the care plan, set therapeutic goals realistically and track the patient's real progress, rather than only the change in the number of symptoms in the records. Improvement in functioning is often what the patient and those close to them experience as the most important effect of treatment.

H

hallucinations

Other names: hallucinatory experiences

Hallucinations are perceptions that arise without any real external stimulus, which the person experiences as genuine and as coming from their surroundings. Hallucinations can involve any of the senses. The most common are auditory hallucinations, for example hearing voices that comment on one's behaviour or converse with one another. Visual, olfactory, gustatory and somatic hallucinations also occur, the last of these involving sensations originating in the body. The person usually does not have the sense that these experiences are a product of their own mind.

Hallucinations must be distinguished from illusions, which are a distorted perception of a stimulus that genuinely exists, for example mistaking a shadow for a figure. Hallucinations are one of the principal positive symptoms of psychosis. The ICD-11 classification and the CDDR criteria list them among the key symptoms of schizophrenia and other primary psychotic disorders. Persistent auditory hallucinations, which continue over an extended period, are of particular diagnostic significance.

Hallucinations can also occur in episodes of mood disorders with psychotic symptoms, in psychoses induced by substances or by a physical (somatic) illness, in delirious states and in dementias, and sometimes also in the course of neurological diseases. Single, brief experiences while falling asleep or waking up are a physiological phenomenon and usually do not indicate illness. It should also be borne in mind that in some cultures certain hallucination-like experiences are appraised differently, which is why assessment always takes cultural context into account. Identifying hallucinations and establishing their cause is always the task of a specialist, who assesses their type, severity and duration as well as the entire clinical context in which they appear.

hypervigilance (hyperarousal)

Other names: hyperexcitability, heightened vigilance, hypervigilance

Hypervigilance, also referred to as hyperarousal or heightened vigilance, is a state of persistently increased arousal of the nervous system, in which the person remains constantly alert to possible danger. It is manifested by continuous monitoring of the surroundings, difficulty relaxing, being easily startled (an exaggerated startle response to a sudden stimulus), irritability, problems with sleep and concentration, and muscle tension. The body behaves as if danger were present, even though the situation is objectively safe.

Hyperarousal is one of the core symptom clusters of post-traumatic stress disorder and complex post-traumatic stress disorder, where it results from the body remaining persistently in a state of alert after experiencing trauma. Increased arousal and tension also accompany generalized anxiety disorder and other anxiety disorders.

Hypervigilance can be exhausting: it impairs rest, sleep and recovery, and prolonged tension places a strain on the body and intensifies irritability. It must be distinguished from ordinary caution or attentiveness, which is a reaction appropriate to a real danger. We speak of hyperarousal in the clinical sense when the state of heightened arousal is constant, disproportionate to the situation and impairs functioning.

hypomania

Other names: hypomanic episode

Hypomania is a period of elevated, expansive or irritable mood combined with an increase in activity and energy, which has a milder course than a full manic episode. The symptoms are similar, namely a decreased need for sleep, increased talkativeness, greater self-confidence, accelerated thinking, garrulousness or easy distractibility, but they are less severe and usually shorter. Unlike mania, hypomania does not cause significant impairment of social or occupational functioning and does not require hospital treatment.

Psychotic symptoms such as delusions or hallucinations do not occur in hypomania. If they do appear, the state is then treated as a manic episode. The ICD-11 classification and the CDDR criteria indicate that hypomania is characteristic of bipolar type II disorder, in which depressive and hypomanic episodes occur but a full manic episode has never developed. Hypomanic states of lesser severity also appear in cyclothymic disorder.

Hypomania can be difficult to recognize, because a person in this state often feels well, is active and productive, and so does not regard their state of mind as a symptom of illness and rarely seeks help themselves. Changes in functioning are usually easier for those around the person to notice, for example family members or co-workers. A reliable assessment of hypomania is of great importance, since it influences the diagnosis and the choice of treatment, and overlooking hypomanic episodes can lead to a mistaken diagnosis of depression alone and to an inappropriate choice of medication. Establishing the diagnosis is the task of a specialist who assesses the overall course of the disorder and previous episodes of mood change.

I

impulsivity

Other names: impulsive action

Impulsivity is a tendency to act on the spur of the moment - quickly, abruptly and without sufficient consideration of the consequences. It is manifested by making hasty decisions, difficulty delaying a response and refraining from action, abrupt emotional reactions, and a striving for immediate satisfaction of a need. The person acts before they manage to weigh up the consequences, which can be a source of risky or harmful behaviour.

Impulsivity is not a separate disorder, but a trait or symptom that can occur in a very wide range of conditions. It can be an element of the presentation of conduct disorders, attention deficit hyperactivity disorder, borderline personality disorder, episodes of mania and hypomania, and also impulse control disorders and disorders due to substance use. Difficulty inhibiting behaviour can also be heightened in situations of intense stress or emotional overload.

A certain level of spontaneity and quick reacting is natural and at times beneficial. We speak of clinical significance when impulsivity is severe, entrenched, leads to actions harmful to the person or those around them, and clearly impairs functioning. In diagnosis it is important to situate impulsivity within the broader symptom picture, since its significance depends on the context in which it occurs.

insight

Other names: illness insight, illness awareness

Insight is a person's ability to recognise and understand that they are experiencing a mental disorder, and to assess accurately that their experiences, thoughts or behaviours are altered by illness. Insight usually comprises several related elements: awareness of the very fact of illness, an understanding of the nature of individual symptoms, and acceptance of the need for treatment and support. It is one of the standardly assessed elements of the mental state examination.

Insight is not an all-or-nothing trait but a gradable one. One speaks of full, partial or markedly limited insight. It is also variable over time and dependent on the current clinical state. In acute psychotic disorders insight is often seriously impaired, because the patient may be convinced that their delusions are true and their hallucinations real. Limited insight is also described in mania, in some neurocognitive (that is, dementia) disorders and in eating disorders. A lack of insight is not deliberate denial but is a symptom of the disorder.

The degree of insight is of significant practical importance. It influences the patient's readiness to undertake and continue treatment, therapeutic cooperation and the prognosis. Insight may also improve in the course of therapy, as symptoms resolve and a relationship with the specialist is built. For this reason its absence at the outset does not preclude the possibility of effective treatment, but calls for a patient, individualised and non-judgemental approach on the part of the clinician and those close to the person. Confronting the patient directly with their symptoms usually does not build insight, and may erode the trust needed for further cooperation.

M

manic episode

Other names: mania

A manic episode is a clearly demarcated period of persistently elevated, expansive or irritable mood, accompanied by a marked increase in activity and energy. This state persists for most of the day for at least several days, is clearly different from the person's usual functioning and causes significant disruption to their life. Typical symptoms include a decreased need for sleep, increased talkativeness, racing thoughts, excessive self-confidence or a sense of grandiosity, easy distractibility, and engagement in risky behaviour, for example impulsive spending or decisions.

In more severe cases, psychotic symptoms such as delusions, often grandiose, or hallucinations may appear during a manic episode. A manic episode is the core symptom of bipolar type I disorder. The ICD-11 classification and the CDDR criteria indicate that even a single manic episode over the course of a lifetime is sufficient to diagnose this disorder, even if a depressive episode has never previously occurred.

A manic episode must be distinguished from hypomania, which has a milder and usually shorter course and does not impair functioning to such a marked degree. Mania often carries a risk of serious consequences for one's life, finances and health, partly because a person in this state usually does not recognize that they are ill. For this reason a manic episode usually requires prompt specialist assessment, and sometimes treatment in a hospital setting. The diagnosis is the task of a specialist who assesses the severity and duration of the symptoms and the entire course of the disorder.

mixed episode

Other names: episode with mixed features, mixed state

A mixed episode is a state in which manic and depressive symptoms co-occur or alternate rapidly within the same period. A person may, for example, feel dejection, a sense of hopelessness and depressive thoughts, while at the same time having heightened drive, racing thoughts, agitation, irritability and a decreased need for sleep. The combination of low mood with high energy, restlessness and agitation makes this state especially burdensome, exhausting and difficult to endure for the affected person.

A mixed episode is one of the possible types of episode in bipolar type I disorder. The ICD-11 classification and the CDDR criteria describe it as an episode in which prominent symptoms of both mood poles, namely manic and depressive, are present together for most of the time for at least two weeks. In more severe cases, a mixed episode may be accompanied by psychotic symptoms such as delusions or hallucinations.

A mixed episode is regarded as a state of increased risk, since the coexistence of depressive distress with agitation and heightened drive is associated with a greater danger of behaviour dangerous to the affected person. For this reason it requires careful specialist assessment and particular caution in the choice of treatment. A mixed episode can also be more difficult to recognize than pure mania or pure depression, because its presentation is heterogeneous and changeable, and the symptoms of both mood poles may mask one another. Diagnosing a mixed episode and choosing how to proceed are always the task of a specialist who assesses the entire course of the disorder and previous episodes of mood change.

N

negative symptoms

Negative symptoms are a group of psychotic symptoms consisting in the loss or weakening of mental functions present in a healthy person. The term negative does not mean worse, but subtracted, that is, signifying the absence of something that normally occurs. Negative symptoms include above all blunted affect, that is, an impoverished expression of emotion, anhedonia, that is, an inability to feel pleasure, avolition, that is, a lack of motivation and drive to act, alogia, that is, an impoverishment of speech, and social withdrawal consisting in a reduction of contacts with other people.

Negative symptoms are one of the main dimensions of schizophrenia and other primary psychotic disorders. In contrast to positive symptoms, such as delusions or hallucinations, they are less visible to those around the person and are sometimes mistakenly perceived as laziness, an unwillingness to cooperate or a symptom of depression. The ICD-11 classification and the CDDR criteria emphasise that negative symptoms may persist even when productive symptoms have already resolved, and that it is often they that determine the chronic character of the difficulties.

Negative symptoms can be difficult to treat and often respond more weakly to antipsychotic medication than positive symptoms. They greatly influence social, occupational and family functioning, as well as quality of life, and so they constitute an important target of rehabilitative and psychosocial interventions. They must be distinguished from secondary symptoms, for example the side effects of medication, untreated depression or the consequences of prolonged hospitalisation, because the latter have different causes and may require entirely different management. This distinction is the responsibility of the specialist assessing the overall clinical picture.

neurodevelopmental disorder

Other names: neurodevelopmental disorders, developmental disorder

A neurodevelopmental disorder is one of a group of disorders whose shared feature is developmental difficulties related to the functioning of the central nervous system, becoming apparent in the early stages of life, usually in childhood and sometimes already in infancy. These difficulties concern areas such as learning, speech and communication, motor skills, social contacts and the control of one's own behaviour and attention. They affect everyday functioning at home, at school and in relationships with peers.

In the ICD-11 classification, neurodevelopmental disorders include, among others, disorders of intellectual development, autism spectrum disorder, attention deficit hyperactivity disorder, abbreviated as ADHD, developmental speech and language disorders, developmental learning disorders and developmental motor coordination disorder. What they share is that they are not transient delays but persistent differences in development, although their picture changes with age.

Neurodevelopmental disorders are diagnosed on the basis of observation of the child's development in relation to expected developmental milestones and in comparison with peers. Early recognition is important, because appropriate educational, therapeutic and family support can significantly improve functioning and quality of life. These disorders often co-occur with one another and with other psychological difficulties, and so the assessment should be comprehensive, and the support provided tailored to the individual needs of the child. Many people with these disorders, given appropriate support, lead independent and satisfying lives.

O

obsession

Other names: intrusive thought, obsessive thought

An obsession, also called an intrusive thought in clinical terminology, is a recurrent, persistent thought, image or impulse that appears in the mind against the person's will and provokes marked unease, anxiety or discomfort. The content of an obsession is experienced as intrusive (imposing itself) and unwanted, often inconsistent with the person's values and self-image - which further intensifies the distress. Typical themes include fear of contamination or infection, fear of causing harm, a need for symmetry and order, or persistent doubts.

An obsession is one of the two core symptoms of obsessive-compulsive disorder; the other is compulsions, that is repetitive behaviours or mental acts performed in order to reduce the tension provoked by an obsession. In practice, obsessions and compulsions usually form a closed cycle. Thoughts of an intrusive nature can also occur in other disorders belonging to the group of obsessive-compulsive and related disorders.

Single, fleeting intrusive thoughts are familiar to almost everyone and are not a symptom of illness. We speak of an obsession in the clinical sense when the thoughts are frequent, persistent, difficult to dismiss, provoke considerable unease and take up a great deal of time or disrupt functioning. It is worth distinguishing this meaning from the colloquial use of the word obsession to denote a strong interest in something.

obsessive-compulsive phenomena

Other names: obsessional neurosis, obsessive-compulsive disorder

The term obsessive-compulsive phenomena is both a colloquial expression and one used in the literature to denote obsessive-compulsive phenomena: intrusive thoughts and compulsive acts. In this sense it encompasses both obsessions - recurrent, self-imposing thoughts, images or impulses that provoke unease - and compulsions, that is repetitive behaviours or mental rituals performed in order to alleviate that unease. The term aptly captures the essence of the phenomenon: something that imposes itself against one's will and is difficult to push away.

The term is often used as a name for obsessive-compulsive disorder, formerly also described as obsessional neurosis. In the contemporary ICD-11 classification, this disorder belongs to the group of obsessive-compulsive and related disorders. It is characterized by the presence of obsessions, compulsions, or both at once, which take up a great deal of time, provoke distress or impair everyday functioning.

In everyday speech the term is sometimes used loosely - to denote habits or persistent routines. In the clinical context, however, it denotes specific, burdensome symptoms experienced as self-imposing and beyond one's control. Single intrusive thoughts occur in many people; we speak of a problem when they are severe, persistent and disrupt life.

P

panic attack

Other names: panic attack

A panic attack is a sudden, short-lived episode of very intense anxiety or terror, which usually reaches its peak severity within a few minutes. It is accompanied by marked bodily symptoms: palpitations or a racing heartbeat, breathlessness or a feeling of choking, tightness in the chest, dizziness, trembling, sweating, tingling, and hot or cold flushes. Cognitive symptoms are also common, such as fear of losing control, fear of dying or a conviction that misfortune is approaching, as well as a sense of unreality (detachment from oneself or one's surroundings).

A panic attack on its own is not a separate diagnosis - it is a symptom that can occur in many disorders. Attacks may appear unexpectedly, without a clear trigger, or be linked to specific situations. When they occur recurrently and unexpectedly and lead to persistent fear of another attack, panic disorder is diagnosed. Attacks may also accompany phobias, agoraphobia, social anxiety or post-traumatic stress disorder.

Despite its very unpleasant course, a panic attack is not dangerous to health and resolves on its own. The bodily symptoms do, however, resemble physical (somatic) conditions (for example cardiac problems), which is why, with the first episodes, a medical assessment is recommended in order to rule out physical causes.

positive symptoms (productive symptoms)

Other names: productive symptoms

Positive symptoms, also called productive symptoms, are a group of psychotic symptoms consisting in the appearance of experiences and behaviours that a healthy person does not have. The term positive does not mean favourable, but added, that is, constituting an excess relative to normal experience. Positive symptoms include above all delusions, that is, false, unshakeable beliefs inconsistent with reality, hallucinations, that is, perceptions arising without a stimulus, for example hearing voices, and disorganisation of thinking, speech and behaviour, in which utterances and actions lose their coherence.

Positive symptoms are characteristic of schizophrenia and other primary psychotic disorders, but they may also occur in episodes of mood disorders with psychotic symptoms, for example in severe depression or in mania, as well as in psychoses induced by a somatic illness or by substances. The ICD-11 classification and the CDDR diagnostic criteria describe them as one of the main dimensions of the picture of psychosis and as symptoms key to the diagnosis of its acute phase.

In contrast to negative symptoms, positive symptoms often respond well to pharmacological treatment and may decrease considerably or resolve completely once appropriate therapy has been introduced. Their severity usually fluctuates over time, and periods of exacerbation alternate with periods of remission, that is, of the symptoms abating. The mere presence of productive symptoms does not determine a specific diagnosis, because the same symptom may have various causes. For this reason their assessment always requires examination by a specialist, who takes into account the duration of the symptoms, their context and co-occurring somatic and mental disorders.

prodromal phase

Other names: prodromal period, prodrome, warning period

The prodromal phase, also called the warning period, is an early stage of a disorder preceding its full, developed picture, in which the first, usually non-specific and mild signs of change appear. The word prodrome comes from Greek and means a harbinger. In this phase the symptoms do not yet meet the criteria for a diagnosis, but they constitute a noticeable departure from the person's previous, typical functioning.

The prodromal phase is most often discussed in the context of schizophrenia and other psychotic disorders. It may then comprise a gradual withdrawal from contacts, a decline in activity and in performance in study or work, unusual beliefs or experiences of an indistinct character, irritability, anxiety, sleep disturbances and deterioration in self-care. Similar warning periods are also described before some episodes of mood disorders. A characteristic feature of the prodrome is its non-specificity, since the same symptoms may not lead to any disorder.

Recognising the prodromal phase carries considerable importance, because early intervention can mitigate the further course and improve the prognosis. At the same time it calls for great caution. A prodrome is usually recognised only in retrospect, when the further development of symptoms is already visible, and over-interpreting transient difficulties in a young person carries a risk of needless anxiety and stigmatisation. For this reason this period is treated rather as a state of heightened risk requiring careful observation and support than as a ready-made, certain diagnosis that determines the future. In some people warning symptoms never progress to a full disorder.

prognosis

Other names: outlook

Prognosis is the prediction of the further course of a disorder and its likely outcome, that is, of how far the symptoms may decrease, whether there is a risk of relapse and to what extent a return to good functioning is possible. It is a forward-looking assessment, based on knowledge of the typical course of a given disorder in the population and on the individual characteristics of the particular patient and his or her life situation.

The prognosis is influenced by many factors. A more favourable prognosis is associated with, among other things, early diagnosis and the prompt initiation of treatment, milder symptom severity, good functioning before the onset of illness, support from those close to the person and the patient's active cooperation in therapy. Unfavourable factors include a long delay in treatment, the co-occurrence of other disorders, the use of psychoactive substances, social isolation and a chronic, severe course. The prognosis concerns not only the symptoms themselves but also social, family and occupational functioning.

A prognosis should be treated as an estimate of probability, not as a certain prediction. It is based on data concerning groups of patients and does not make it possible to predict the fate of one individual with complete certainty. The course is sometimes more favourable or more difficult than the initial assessment would suggest, and so the prognosis is verified and updated as observation continues. A prognosis conveyed carefully and honestly helps the patient and those close to them make decisions, without depriving them of realistic hope. For many mental disorders, especially with early and consistent treatment, the prognosis today is considerably more favourable than is commonly believed.

psychological trauma

Other names: psychological injury, trauma

Psychological trauma is an intense, overwhelming reaction of the psyche to an experience that threatens life, health or integrity - one's own or someone else's. A traumatic event may be, for example, an accident, violence, an assault, a disaster, a serious illness, as well as witnessing such an event or learning of it as it relates to a close person. The term refers both to the event itself and to its lasting consequences for a person's experience and functioning.

Most people, after a difficult event, experience intense reactions - anxiety, tension, intrusive memories, sleep problems - which gradually subside over the course of a few weeks. This is a natural process of recovery, not a disorder. We speak of lasting consequences when the symptoms persist longer and clearly disrupt everyday life. In that case post-traumatic stress disorder may be diagnosed, and after prolonged or repeated trauma, complex post-traumatic stress disorder.

Psychological trauma is not, in itself, a diagnostic entity, but a concept describing an experience and its effects. It can also contribute to other difficulties, including dissociative disorders, mood disorders and problems with sleep and the regulation of emotions. Reactions to trauma are individual and depend on the type of event, the support of those around the person and previous experiences.

psychosis

Other names: psychotic state

Psychosis is a state in which there is a significant disturbance of contact with reality. A person in a psychotic state may have difficulty distinguishing their own inner experiences from external facts. Typical symptoms of psychosis include delusions, that is false, unshakeable beliefs; hallucinations, that is perceptions arising without a stimulus, for example hearing voices; disorganization of thinking, speech and behaviour; and negative symptoms such as flattening of affect or withdrawal from social contact.

Psychosis is not a single illness but a syndrome of symptoms that can occur in many different disorders. It is a feature of schizophrenia and other primary psychotic disorders described in the ICD-11 classification and the CDDR criteria. Psychotic symptoms can, however, also appear in episodes of mood disorders, in psychoses induced by substances or medications, in delirious states, and in physical (somatic) and neurological diseases that affect the functioning of the brain. For this reason the term psychosis describes a state, not a specific diagnosis.

Early recognition of psychosis and prompt initiation of treatment are of great importance, since they are associated with a better prognosis and a lower risk of complications. Psychosis often causes considerable distress, a deterioration of social and occupational functioning and, in some cases, a risk of behaviour dangerous to the affected person or those around them. The word psychosis should not be used as a moral judgement or as a derogatory label. Identifying the specific cause of psychotic symptoms is always the task of a specialist who assesses the full clinical picture.

R

relapse

Other names: recurrence of symptoms, recurrence

Relapse is the reappearance of the symptoms of a disorder after a period of improvement, that is, after remission. It denotes the return of the full or near-full clinical picture in a person whose symptoms had previously resolved or had substantially decreased. Relapse is a typical element of the course of many mental disorders, especially those of a recurrent nature, such as depressive disorders, bipolar affective disorder or schizophrenia. The very possibility of it is an important reason for providing long-term care.

In the clinical literature two related concepts are sometimes distinguished. A return of symptoms shortly after improvement has been achieved, when the current episode has not in fact yet ended on a lasting basis, is sometimes described as a worsening within the same episode. A reappearance of symptoms after a longer, stable period of health, on the other hand, is treated as a new episode of the illness. This distinction is significant for treatment planning, although in clinical practice the boundary between them is sometimes blurred.

The risk of relapse is increased by, among other things, premature discontinuation of treatment, chronic stress, lack of social support, sleep disturbances and the use of psychoactive substances. Preventing relapse is one of the main goals of long-term care. It comprises maintenance treatment, psychoeducation, recognition of early warning signs and a previously agreed plan of action in case of worsening. The occurrence of a relapse does not mean that the treatment has failed or that the patient is at fault, but indicates the need for a renewed assessment of the patient's state and an adjustment of management. The earlier a relapse is noticed, the easier it usually is to bring under control.

remission

Other names: symptom remission

Remission is a period in which the symptoms of a disorder resolve completely or persist only to a degree slight enough that they no longer meet the criteria for the diagnosis and do not significantly impair functioning. The term describes a favourable change in clinical state, that is, a marked improvement, rather than the mere ending of treatment. Remission is sometimes the result of effective therapy, but in some disorders it also occurs spontaneously, with the passage of time or a change in life circumstances.

Clinicians distinguish partial and full remission. In partial remission some symptoms still persist, but at a clearly lesser severity than in the active, acute phase of the disorder. In full remission symptoms are practically absent for a defined period of time. An important concept is also recovery, which denotes the persistence of remission over a longer, stable period and is sometimes regarded as a more durable, more firmly established state of getting well.

Remission does not always mean that the disorder will not return. In many disorders, especially recurrent ones such as mood disorders, a recurrence of symptoms may occur after remission. For this reason, achieving remission often does not bring care to an end. Maintenance treatment, monitoring of the patient's state and measures to prevent recurrence are continued, such as psychoeducation and recognition of early warning signs. For the patient, remission is a real and important therapeutic goal, but it requires continued vigilance and cooperation with a specialist. Discontinuing treatment too early after improvement has been achieved is one of the main causes of the return of symptoms.

S

safety behaviours

Other names: precautionary behaviours

Safety behaviours are actions undertaken in a feared situation in order to prevent an anticipated misfortune or to reduce anxiety. Unlike full avoidance, the person confronts the difficult situation, but while doing so carries out additional, precautionary actions. Examples include holding on to a wall out of fear of fainting, carrying medication in case of a panic attack, constantly preparing for a conversation, avoiding eye contact, or relying on the company of a trusted person.

Safety behaviours bring immediate relief, but in the long term they maintain anxiety. They cause the person to attribute the absence of catastrophe precisely to these actions (for example: I did not faint because I held on to the wall), instead of becoming convinced that the feared situation was not, in itself, dangerous. In this way the anxiety does not extinguish but becomes entrenched - the mechanism is similar to the one at work in avoidance.

Safety behaviours are described primarily in the context of anxiety disorders: social anxiety, agoraphobia, panic disorder and phobias. They are often subtle and not easy to notice, which is why recognizing them is an important element of assessment and treatment. In the treatment of anxiety disorders, gradually giving up these precautions - as with reducing avoidance - allows anxiety to weaken naturally.

spectrum in psychiatry

Other names: spectrum of disorders, spectrum model

A spectrum in psychiatry is a concept describing a group of interrelated states or symptoms that form a continuity, from mild and subtle forms to clearly severe ones, rather than being arranged into sharply separated, distinct categories. The term emphasises that the boundaries between what is termed normality and a disorder, and between individual clinical pictures, are sometimes fluid rather than abrupt, and that related states may merge into one another.

The most widespread is the concept of the autism spectrum. It captures within a single diagnostic category a broad range of difficulties in social communication and of repetitive patterns of behaviour and interests, which in different people have very different severity and presentation. The idea of a spectrum is also applied to psychotic disorders and to mood disorders, where one speaks of an affective spectrum encompassing states from depression to bipolar disorders. In all these applications the word spectrum points to kinship and gradation, not to a single, uniform state.

Thinking in terms of a spectrum has practical significance. It helps in seeing that people with the same diagnosis may function very differently, and that more important than the label itself is sometimes the individual profile of the severity of particular symptoms. This favours a dimensional approach in diagnosis and the tailoring of support to the particular person and their needs, rather than only to the name of the disorder appearing in the records. The concept of a spectrum also reminds us that the boundary between a trait and a disorder is not always sharp and requires a careful, individual clinical assessment.

T

tolerance in addiction

Other names: tolerance

Tolerance in addiction is a phenomenon whereby the body gradually becomes accustomed to the action of a psychoactive substance. As a result, the same dose produces a weaker effect than before, and increasingly larger doses are needed to achieve a similar effect. Tolerance is an expression of the body's adaptation, especially that of the nervous system, to the regular presence of a substance.

Tolerance is one of the physiological indicators of dependence taken into account in the ICD-11 classification, alongside withdrawal symptoms and the use of a substance in order to alleviate or prevent withdrawal symptoms. It is evidence of neuroadaptation - lasting adaptive changes in the body. It must be distinguished from dependence as a whole: the occurrence of tolerance alone does not determine a diagnosis, although it is an important element of it.

Increasing tolerance has serious practical significance. Raising doses increases the risk of health harms and overdose, especially since tolerance can decline rapidly after a period of abstinence - returning to a previously used dose can then be particularly dangerous. Tolerance can develop not only towards illegal substances, but also towards alcohol and certain medications, for example sedatives and hypnotics.

W

withdrawal syndrome

Other names: withdrawal state, withdrawal, withdrawal symptoms

Withdrawal syndrome, also called the withdrawal state, is a set of symptoms that appears after the cessation or significant reduction of the use of a substance on which the body has become dependent. It arises because the body has adapted to the constant presence of the substance, and its absence throws the body off balance. The symptoms are usually the opposite of the action of the substance itself - after stopping a sedative, agitation and anxiety may appear.

The presentation of a withdrawal syndrome depends on the type of substance. After stopping alcohol, trembling, sweating, restlessness, insomnia, nausea, a racing heartbeat may appear, and in more severe forms seizures and alcoholic delirium. After opioids, muscle pain, diarrhoea, tearing and a runny nose, chills and intense restlessness are typical. Withdrawal symptoms can also concern nicotine, sedative and hypnotic medications, and other substances.

The occurrence of a withdrawal syndrome is one of the core symptoms of dependence and a physiological indicator of neuroadaptation. A severe withdrawal syndrome - especially after alcohol or sedative medications - can be a life-threatening condition and requires medical assessment and supervision. For this reason, the withdrawal of such substances should not be carried out on one's own and abruptly.