Introduction to psychopathology

Year 4 psychiatry - 2013

Dr Oliver Schubert

psyche gr. psukhein to breathe psukh breath, soul The mind as the center of thought, emotion, and behavior, consciously or unconsciously adjusting or mediating the body's responses to the social and physical environment

Definitive classification of disease must be based on aetiology

Pragmatic approach to classification that will best enable us to care for our patients, communicate with other health professionals, carry out high-quality research

How should the mind be conceived? What are the minds faculties, functions, or elements (if there are any)? How can these be distinguished? How can mental disorders be comprehended by application of these principles?
Manfred Spitzer

Traditional distinctions:
Organic syndromes vs. functional syndromes psychosis vs .neurosis

Psychopathology:
Systematic study of abnormal experience, cognition and behaviour Study of the products of the disordered mind

The science and study of psychological and psychiatric symptoms

Description, delineation, differentiation of the morbid phenomena that constitute the subjective experience of patients

Karl Jaspers 1882-1969

General Psychopathology, 1913

psychodynamic explanatory behavioural etc. psychopathology observation (appearance, behaviour) descriptive phenomenology (empathic assessment of subjective experience)

Sims Symptoms of the mind, 2011

empathy: gr. feeling oneself into Clinical instrument: measuring another persons subjective state using the observers own capacity for emotional and cognitive experience as a yardstick giving an account of the patients inner experience that the patient recognizes as his/her own

NOT sympathy: gr. feeling with

Mrs Jenkins complains that she is unhappy

descriptive psychopathology: elicit thoughts and actions without trying to explain them;

Observation: listless sagging of shoulders; tense gripping and wringing of her hands -> use in MSE Phenomenology: that horrible feeling of not really existing; not being able to feel any emotion -> use in presenting complaint, HPC, or succinctly in MSE
labelling: assigning universally recognized symptoms: anergia; psychomotor agitation; anhedonia; loss of emotional resonance;nihilistic preocupa tions -> use in the Mental State Examination diagnosis: recognizing symptoms as part of a syndrome: depression (Using a classification system: DSM-IV, ICD-10

Descriptive psychopathology is the fundamental professional skill of the psychiatrist

Insanity defence DSM IV Descriptive psychopathology Mental Health Act 2009

ICD-10

Uses of descriptive psychopathology

Diagnostic: facilitates communication of the clinical features to other professionals Scientific: allows precise observations and deductions to be made Therapeutic: facilitates establishment of an empathic relationship Forensic: medico-legal evaluation is largely based on psychopathology

A appearance
Mental processes

motor acts
speech

Consciousness
Experience of self

B behaviour

thinking

C conversation

Emotion

A affect
Perception

P perception

Attention

Memory

C cognition (I insight, J judgement, R rapport)

A appearance
Mental processes

motor acts
speech

Consciousness
Experience of self

B behaviour

thinking

C conversation

Emotion

A affect
Perception

P perception

Orinetation, Atten-tion

Memory

C cognition (I insight, J judgement, R rapport)

Disorders of adaptive movements

Limited range Psychomotor retardation/agitatio n Expansive gestures Ecstasy/exaltation Obstruction mannerisms

Static tremor Tortocollis Abnormal induced movements: Disorders of non Echopraxia, adaptive echolalia movements Perseveration Gegenhalten Negativism

Disorders of posture

- Perseveration of posture/ Posturing -waxy flexibility - catalepsy

Abnormal complex patterns of behaviour Subjective motor disorders: Alinenation of motor acts

Stupor excitement

Made actions

consciousness

Dream-like change of consciousness

Rise of the threshold for incoming stimuli thinking shows excessive displacement, condensation, misuse of symbols Hallucinations frequent Misinterpretations (threats)

Lowering of consciousness

Apathy general slowing Perseveration No hallucinations or delusions Awareness narrowed down to a few ideas often slight bemusement Relatively well ordered behaviours twilight state

State of awareness of the self and the environment

Restricition of consciousness

A appearance
Mental processes

motor acts
speech

Consciousness
Experience of self

B behaviour

thinking

C conversation

Emotion

A affect
Perception

P perception

Attention

Memory

C cognition (I insight, J judgement, R rapport)

Thought/Speech

Receptive dysphasias Expressive dysphasias

Stammering stuttering

Refraining from speech in full consciousness

Aphasia/ Dysphasia Agnosia mutism

speech
Speech confusions

Schizophasia/word salad

Pressured speech

neologisms

Talking past the point

(Vorbeireden)

-Approximate answers (Ganser syndrome)

Stream of thought

Form of thinking

thinking

Possession of thought

Content of thinking

Stream of thought

Thought tempo

Flight of ideas Inhibition or slowing circumstantiality

Continuity of thought

perseveration Thouht blocking

Transitory thinking
Formal thinking

derailments fusion Substitutions Omissions Grammar and syntax disturbed

Drivelling thinking

mixing Muddling Grammar and syntax disturbed Similar to speech disorder :schizophasia/word salad

Desultory thinking

Loosening of associations Sudden ideas Grammar and syntax intact

Possession of thought

Obsessions/ compulsions

unwanted, persistent thought that dominates the persons thinking

Recognized as purposeless Recognized as coming from own mind actively resisted (without success) May present as vivid images Compulsions are acted-upon obsessions (obsessional motor acts)

Thought alienation

Thoughts are under the control of an outside agency Others can participate in ones thinking
Thought insertion Thought deprivation/withdrawal Thought broadcasting

 A subject or matter that engrosses someone

preoccupations
With gloomy thoughts (depression) With the deepest questions (hebephrenia) With illness (hypochondriasis) With food (anorexia/bulemia) With rules, details, procedures, protocol (anankastic personality) Etc etc

Acceptable, comprehensible idea pursued beyond the bounds of reason Content of thinking
Overvalued ideas
takes precedence over all other ideas Maintains precedence over long period of time Less fixed than delusions Tends to be based in reality (to a degree)

Delusions

Fixed false idea - Primary vs secondary delusions - Delusional system - Common themes: persecution, jealousy, love, grandiosity, ill health, guilt, nihilism, poverty, reference

Disturbance of awareness of selfactivity

Depersonalization/derealization Loss of emotional resonance

Disturbance in the immediate awareness of self-unity

Talking/acting in an automatic way feelingas if they are 2 people

Disturbance of the continuity of self

being born again Dissociative identity disrder/multiple personalities

Disturbances of the boundaries of the self

Alienation of personal action and feelings=passivity phenomena Alienation of thought

A appearance
Mental processes

motor acts
speech

Consciousness
Experience of self

B behaviour

thinking

C conversation

Emotion

A affect
Perception

P perception

Attention

Memory

C cognition (I insight, J judgement, R rapport)

Pervasive and sustained emotion Coloring the persons perception of the world Descriptions:

mood

intensity duration (pervasiveness) Fluctuations/reactivity Descriptive adjectives (gloomy etc.)

affect

present emotional responsiveness inferred from body language, facial expression, behaviour Congruent or incongruent with mood Descriptions: Normal range constricted/restricted blunt flat

Normal emotional reactions

Resulting from events Lie within cultural and social norms Grief reactions Stress reactions No functional incapacity

Abnormal emotional reactions

Adjustment disorders with disturbance of mood (ICD 10) Resulting from events Understandable but excessive (in relation to norms) Prolonged functional impairment anxiety=fear for no adequate reason Anxious foreboding Depressed mood

Morbid expressions of emotion

sufferer is usually unaware of abnormal expression incongruity of affect Inadequacy/blunting of affect Emotional constriction/flattening Labiility of affect Affective incontinence

Morbid expressions of emotion

Very different from average normal reaction Sufferer aware of abnormalitty Culturally colourend Dissociation of affect The Smiling depressive belle indifference Perplexity=tentative, bewildered, puzzled

Morbid disorders of emotion

Can be triggered by stessful events, but do not resolve with removal of the stressor Morbid depression Anhedonia Somatization Loss of emotional resonance Diurnal mood variation Morbid anxiety/agitation Apathy Irritability Mania/hypomania Irritability Extreme cheerfulness Elation Euphoria overactivity

A appearance
Mental processes

motor acts
speech

Consciousness
Experience of self

B behaviour

thinking

C conversation

Emotion

A affect
Perception

P perception

Attention

Memory

C cognition (I insight, J judgement, R rapport)

Sensory distortions

intensity quality spatial form (dysmegalopsia) body parts (hyperhyposchemazia) Experience of time

Disorders of perception

Illusions
Real perceived stimulus + mental image = false perception Completion illusions Affect illusions pareidolia

Sensory deceptions

Hallucinations
Perception without an object

Hallucinatory syndromes

Hallucinosis Alcoholic Organic

Individual senses

Auditory Elementary voices Imperative/command hallucinations Running commentary Gedankenlautwerden echo de la pensee

Visual
Functional hallucinations Reflex hallucinations (synaesthesia) Extracampine hallucinations Autoscopy/mirror image Hypnagoggic.hypnopompnic hallucinations Organic hallucinations (Charles Bonnet syndrome, phantom limb) small animals (delirium) scenes (epilepsy)

Touch (tactile)
Formication (small animals crawling over the body/undet the skin

Special kinds of hallucinations

Gustatory, olfactory,visceral

A appearance
Mental processes

motor acts
speech

Consciousness
Experience of self

B behaviour

thinking

C conversation

Emotion

A affect
Perception

P perception

Orientat ion, Attention

Memory

C cognition (I insight, J judgement, R rapport)

Hyperamnesia

Flashbulb memories Flashbacks Intrusive recollections Eidetic images

Paramnesiasdistortions of memory

Dissociative amnesia Fugue/wandering stat Katathymic amnesia/motivated forgetting Amnesias Organic amnesias Acute brain disease Loss of Anterograde anmne memory Retrograde amnesia Subacute brain disease Amnestic state/amnestic syndrome (e.g.Korsakoffs) Distortions of recall Chronic coarse brain Retrospecitve falsification disease False memory Source amnesia Screen memory Confabulation Pseudologia fantastica (pathological lying) Munchhausens syndrome Vorbeireden or approximate answers (Ganser syndrome) Distortions of recognition Dj vu, jamais vu

Psychopathology of personality

Mental illness is a myth, whose function it is to disguise and render more palatable the bitter pill of moral conflict in human relations
Thomas Szaz, 1970

We call people physically ill when their body functioning violates certain physiological and anatomical norms; similarly we call people mentally ill when their personal conduct violates certain ethical, political, and social norms
Thomas Szaz, 1970

The Rosenhan experiment (1973)

Stigma

Answers (?) -1
Operational classification systems: Diagnostic and Statistical Manual of Mental Disorders (DSM) International Statistical Classification of Diseases and Related Health Problems (ICD) => formalistic reductionism?

Answers (?)-2
Psychiatric endophenotypes (Gottesman,2003)=neurobiological correlates of disorders
Genetically influenced stable over time Neurobiological component that contributes to the disorder Genes influencing the endophenotype are also susceptibility genes for the disorder determined by fewer genes than the disorder Not/marginally influenced by environment Example: higher beta-activity in the EEG of alcoholics found in familiy members also. Linked with GABAa receptor genes (Porjecz et al, 2002) => Naturalistic reductionism?

Answers (?)-3
User movement Person-centered care Recovery approach

=> heuristic reductionism?

Psychopathology quiz
Example question:
A man in his mid-30s with an established diagnosis of chronic schizophrenia shows no emotional reactivity during the interview (doesnt smile when a joke is made; doesnt get animated when talking about his puppy dog; doesnt look sad when talking about the death of his beloved mother last year). His affect can be described as

Practising descriptive psychopathology

written accounts of inner experience
literature (Sylvia Plath; Sarah Kane; Sebastian Faulks; Elyn Saks Patients notes/letters TED talk Eilyn Saks www.ted.com/talks/elyn_saks_seeing_mental_ill ness.html Patient encounters Clinical meetings (handovers etc.)