Paper A Psychopathology - Notes

Paper A: PSYCHOPATHOLOGY
Paper&A:&PSYCHOPATHOLOGY&
Contents'
I.& GENERAL&PSYCHOPATHOLOGY.& 2&
II.& PERCEPTUAL&DISORDER:& 2&
III.& THOUGHT&DISORDERS:& 9&
IV.& DISORDERS&OF&SPEECH.& 20&
V.& DISORDERS&OF&MEMORY.& 23&
VI.& DISORDERS&OF&MOOD.& 25&
VII.& DEPERSONALISATION&/&DEREALISATION& 27&
VIII.& &MOTOR/VOLITION&DISORDERS:& 28&
IX.& PSYCHODYNAMIC&PSYCHOPATHOLOGY:& 31&
1
I.' GENERAL'PSYCHOPATHOLOGY.'
&
Psychopathology& is& the& systematic& study& of& abnormal& experience,& cognition,& and&
behaviour.&It&consists&of&two&major&divisions&–&&
1. Explanatory& psychopathologies& assume& causative& factors& according& to&
theoretical& construct& (e.g.& psychoanalysis).& This& can& be& further& divided& into&
experimental&(behaviourism)&and&theoretical&(psychoanalysis)&
2. Descriptive& psychopathology& precisely& describes& and& categorises& abnormal&
experiences&as&reported&by&the&patient&and&observed&from&his&behaviour.&&
The&two&essential&components&of&practising&descriptive&psychopathology&are:&&
1.&The&observation&of&behaviour&and&&
2.&The&empathic&assessment&of&subjective&experience.&&
The&latter&is&referred&to&by&Jaspers&as&phenomenology&and&implies&that&the&patient&
is& able& to& introspect& and& describe& his& internal& experiences,& in& turn& enabling& the&
doctor& to& recognise& and& understand& the& description.& Empathic& understanding,& an&
essential&component&of&the&psychiatric&examination,&is&a&key&tool&in&order&to&explore&
and&clarify&the&patient’s&subjective&experiences.1.&&
The& patient& usually& presents& with& loss& or& impairment& of& functions,& the& reasons& for&
which& will& reveal& the& contents& of& the& patient's& thoughts& and& feelings.& Form& is& the&
technical&term&used&to&identify&a&recurring&pattern&of&experience&or&behaviour&(e.g.&
phobia,&obsession&or&delusion)&and&so,&helps&in&diagnosing&the&psychiatric&disorder.&
Content&is&essential&for&decisions&about&the&management&of&both&the&patient&and&
their&family&(suicidal&ideation&may&lead&to–admission&being&considered&etc.),&and&is&
an& important& indicator& of& the& severity& of& the& disorder2.& Therefore,& both& the& form&
and& content& of& symptoms& are& equally& important& aspects& of& descriptive&
psychopathology.&The&same&content&e.g.&‘I’m&too&fat’&can&occur&in&different&forms&–&
obsessions,&delusions,&overvalued&ideas&or&even&hallucinations.&
&
II.' PERCEPTUAL'DISORDER:'
&
Perception& consists& of& two& parts& –& sensation& (any& modality)& and& interpretation&
(cognitive&element&–&but&automatic,&largely&instantaneous).&&
! A&stimulus&is&perceived&as&the&object.&Perception&occurs&in&visual,&auditory,&
tactile,&gustatory,&olfactory,&kinaesthetic&or&proprioceptive&modalities&–&any&
distortions&in&perception&could&also&occur&in&any&of&these&domains.&&
! The&errors&in&perception&can&occur&at&different&levels:&&
1
"Sims"Symptoms"in"the"mind:"An"introduction"to"descriptive"psychopathology,"Oyebode"F,"
Fourth"edition,"2008."Saunders"Elsevier."P5.
2 !
!New!Oxford!Textbook!of!Psychiatry,!Ed:!Gelder,!Lopez?Ibor!Jr!&!Andreasen,!2000!edition!P71!
2
!New!Oxford!Textbook!of!Psychiatry,!Ed:!Gelder,!Lopez?Ibor!Jr!&!Andreasen,!2000!edition!P71!
2
1.&& Stimulus&is&perceived&as&the&corresponding&object&but&not'accurately&–&
changes&in&physical&properties,&e.g.,&size,&shape,&intensity&and&colour.&In&
depression&and&hypoactive&delirium,&patients&may&experience&dulled&
perception;&intense&perceptions&can&occur&in&mania,&hyperactive&delirium&
and&drug&induced&states&(hallucinogens).&Hyperacusis&is&associated&with&
migraines&and&alcohol&hangovers.&&
• Perceived&changes&in&shape&of&objects,&especially&with&loss&of&
symmetry,&are&known&as&dysmegalopsia.&&
• The&objects&can&shrink&in&size&–&micropsia&or&enlarge&d&macropsia.&&
• Such&perceptual&alterations&are&&are&usually&organic&–&could&be&ictal&
(parietal)&or&ocular&(accommodation&errors&such&as&paralysed&
accommodation&can&result&in&micropsia).&&These&symptoms&are&rare&
in&acute&schizophrenia.&Hallucinogens&(Mescalin)&can&also&change&
the&colour&of&perceived&objects&or&make&components&of&an&object,&
e.g.,&body&parts,&appearto&be&detached&in&space.&
2.& Illusion:&The&stimulus&is&perceived&as&an&object&but&not&corresponding&to&
the&source&–&both'stimulus'and'perceived'object'are'present,&but&
different&from&each&other.&&
3.&& Hallucination:&There&is&no'stimulus&but&the&perception&occurs.&
4.&& Negative'Hallucination:&There&is&a&stimulus&but&no&perception&occurs.'
'
IIa.' Imagery'&'Illusions.'
Imagery:&&
! Imagery& is& not& a& perception& because& there& is& no& stimulus& involved& and& no&
object&is&perceived;&it&is&essentially&a&fantasy.&&
! Imagery& refers& to& images& produced& voluntarily& with& complete& insight& that&
they& are& mental& and& not& external& phenomena.& They& also& lack& the& objective&
quality&of&hallucinations&and&normal&sense&perceptions.&&
! A& form& of& imagery,& called& eidetic' imagery& is& considered& to& be& a& special&
ability&of&memory&where&visual&images&are&drawn&from&memory&accurately&at&
will& and& described& as& if& being& perceived& currently.& This& is& noted& in& children&
(2d15%& school& goers,& Haber& && Haber& 1964)& and& may& be& a& part& of& religious&
experiences;&no&pathological&association&is&consistently&noted.&
Illusions:'
! Illusions&may&be&difficult&to&differentiate&from&hallucinations&if&the&source&of&
stimulus&is&difficult&to&trace&–&e.g.&‘Did&I&see&the&face&on&the&wall&or&from&the&
wall& paper& pattern?’& Fortunately& these& are& qualitatively& different& and& so&
eliciting&the&description&patiently&can&help.&&
! There&are&three&major&types&of&illusions&:&
3
! Affect'illusion:&The&prevailing&emotional&state&leads&to&misperceptions,&e.g.,&
a& depressed& patient& reading& ‘deed’& as& ‘dead’,& a& fear& of& dark& resulting& in&
perceiving& the& drapes& are& monsters& etc.& It& disappears& on& paying& extra&
concentration.&
! Completion' illusion:& Due& to& inattention,& a& stimulus& that& does& not& form& a&
complete& object& might& be& perceived& to& be& complete,& e.g.,& CCOK& is& read& as&
COOK.&Again,&disappearance&on&concentration&is&the&rule.&
! Pareidolia:& Perceiving& formed& objects& from& ambiguous& stimuli.& A& classic&
example&that&is&often&quoted&is&seeing&shapes&such&as&animals&or&cars&in&the&
clouds.&It&is&again&coloured&by&the&prevailing&emotion&and&not&entirely&due&to&
inattention& or& affective& change;& fantasy& and& imagery& play& a& part& apart& from&
actual&sense&perception&in&producing&them.&On#paying#extra#effort#the#object#
intensifies& –& does& not& disappear.& It& is& common& in& delirium,& especially& in&
children& when& febrile,& and& in& hallucinogen& use.& They& are& under& voluntary&
control&and&often&playful&–&not&characteristic&of&any&psychotic&illness.&&
'
IIb.' Hallucinations'&'Pseudohallucinations.'
Hallucinations& have& several& important& qualities,& which& are& essential& in&
differentiating&them&from&other&mental&phenomena:&
1. They&take&place&at#the#same#time&as&other&sensory&perceptions,&e.g.,&the&voice&
is&heard&even&when&music&is&playing&or&someone&is&talking&to&me.&So&they&are&
different& from& dreams& where& no& real& component& exists& alongside& the& false&
perception.&
2. They&take&place&in#the#same#space&as&other&perceptions,&e.g.,&anangel&is&seen&
standing&at&the&corner&of&my&room.&This&is&different&from&fantasy&or&imagery&
which&takes&place&in&a&subjective&space.&
3. They&are&experienced&as#sensations&–&not&as&thoughts&–&this&is&in&contrast&to&
obsessional&images.&
4. The& percept& has& all& qualities# of# an# object,& i.e.,& it& is& believed& that& it& can& be&
experienced&in&other&modalities&too,&like&a&real&object&which&can&be&seen,&felt,&
smelt& and& heard.& This& is& why& hallucinators& search& for& the& man& behind& the&
voice,&or&try&and&reach&out&and&touch&visual&percepts.&
5. They& are& involuntary& –& appearance& cannot& be& controlled;& independent& –& will&
exist& even& when& not& perceived& by& the& hallucinators;& may& lack& quality& of&
publicness&–&not&every&one&could&hear&and&see&them.&
Auditory'Hallucinations:''
! Elementary,&unstructured&hallucinations&are&seen&in&acute&organic&states.&&
! Musical' hallucinations,& such& as& those& that& occur& in& Musical& Ear&
Syndrome,& are& similar& to& Charles& Bonnet& syndrome& in& the& visual& domain,&
i.e.,& they& can& occur& in& those& with& deafness& and& also& in& organic& conditions.&&
Formed&auditiondlike&voices&–&as&in&thought&echo&–&cannot&be&elementary.&
4
! Phonemes& are& any& auditory& hallucinations& that& occur& as& human& voices.&
Schizophrenic& phonemes& are& usually& multiple,& may& or& may& not& be&
recognisable,&usually&male&with&a&different&accent,&speaking&in&one’s&mother&
tongue& and& usually& episodic& –& they& are& almost& never& continuous.& When& a&
same& word& is& repeated& continuously,& normal& subjects& hear& phonetically&
linked& but& different& words.& Hallucinating& schizophrenia& subjects& hear&
different&words&that&have&no&phonetic&connection&to&the&original&repeated&
word& –& this& is& called& verbal# transformation# effect.& Patients& could& be&
distracted&from&their&voices;&but&it&is&the&attention&paid&to&external&stimulus&
which& is& more& important& than& the& degree& of& external& stimulus& used& to&
distract.&
! Alcoholic& hallucinosis& initially& starts& as& fragmented& voices,& and& later&
becomes&organised&into&clear&voices.&
! Auditory& hallucinations& of& sufficient& complexity& can& be& classified& as& first&
(patient’s&thoughts),&second&(“you&are…”)&and&third&person&(“he&is…”).&Third&
person&auditory&hallucinations&are&suggestive&of&schizophrenia.&
&
Visual'hallucinations:'
! Occipital& lobe& tumours,& post& concussional& states,& epileptic& twilight& state,&
hepatic& failure& (any& toxic& delirium),& dementia& are& some& of& causes& for& visual&
hallucinations.&&
! 30%&of&old&age&psychiatric&referrals&have&visual&hallucinations.&&
! Solvent&sniffing&and&hallucinogens&can&cause&elementary&visual&hallucinations&
like&lightdflashes.&&
! Temporal& Lobe& Epilepsy& is& classically& associated& with& simultaneous& visual&
verbal&hallucinations,&e.g.,&agreen&man&speaking&to&me.&&
! Visual& hallucinations& are& very& uncommon& in& schizophrenia& (But& Andreasen&
quotes&30%&in&a&series&observed&with&acute&schizophrenia).&
! Reports& of& “black& patch”& psychosis& were& frequent& following& simultaneous&
bilateral& cataract& surgery& in& the& early& era& of& the& procedure,& attributed& to&
sensory& deprivation,& leading& to& the& recommendation& that& only& one& eye& be&
operated& on& at& a& time.& It& was& subsequently& recognised& that& “black& patch”&
psychosis& was& a& relatively& uncommon& postoperative& delirium& partly&
attributed&to&anticholinergic&eye&drops3.&
&
Charles'Bonnet'Syndrome:&&
! Elderly&patients,&with&normal&consciousness&and&no&brain&pathology,&with&
reduced& visual& acuity& due& to& ocular& problems,& experience& vivid,& distinct,&
3
! Psychiatric! Issues! in! Surgery! —! Part! 2:! Specific! Topics.! Levenson,! Primary! Psychiatry.! 2007;!
14(7):40?4.!
5
usually&well=coloured#(in&contrast&to&real&sensation&that&is&blurred&due&to&
eye&disease)&formed&hallucinations&–&mostly&humans,&at&times&animals&and&
cartoons.&&
! These&objects&usually&show&movement,&and&can&be&voluntarily&controlled&–&
disappear&on&closing&the&eyes;&insight&about&unreality&is&usually&preserved&
–&though&the&objects&seen&may&evoke&emotions&including&fear&and&joy.&&
! About& 1/3rd& are& elementary;& usually& the& hallucinations& are& located& in&
external&space.&&&
! Podoll's& criteria& for& diagnosis& include:& Elderly& person& with& normal&
consciousness&with&visual&hallucinations;&not&in&the&presence&of&delirium,&
dementia,&psychosis,&intoxication&or&neurological&disorder&with&lesions&of&
central& visual& cortex;& Reduced& vision& resulting& from& eye& disease& (most&
commonly& macular& degeneration).& The& syndrome& can& occur& in& people&
with&normal&vision4,&5&
Lilliputian' hallucinations' can& occur& in& visual& (seeing& tiny& people& or& animals)& or&
haptic&modalities&(feeling&ofdiminutive&insects&crawling)..&&This&phenomena&can&be&
seen& in& delirium& tremens.& & Unlike& other& organic& visual& hallucinations,& Lilliputian&
hallucinations& can& be& accompanied& by& pleasure& though& often& intermingled& with&
terror.& These& are& not& the& same& as& micropsia.& Patients& with& DT& often& have& a&
prodromal&affect&or&experience&pareidolic&illusions&before&these&hallucinations&form.&
Autoscopic'hallucinations&(Fere&1891),&also&known&as&phantom&mirror&images,&are&
the&visual&experience&of&seeing&oneself.&This&occurs&predominantly&in&males&(M:F&2:1)&
and& may& take& the& form& of& psedohallucinations..# Impaired& consciousness& is& a&
common& accompaniment& and& depression& is& the& commonest& psychiatric& cause.&
Schizophrenia,& TLE,& parietal& lesions& (organic& states& more& likely& to& have& true&
hallucinations)& are& also& implicated.& In# negative# autoscopy,& one& looks& into& a& mirror&
and&sees&no&image&at&all.&The&‘mirror'sign’&in&dementia&is&when&the&person&does&not&
recognise&the&man&in&the&mirror&and&may&start&a&conversation&with&him&or&may&get&
delusional&about&a&phantom&boarder&in&the&house.&
Palinopsia:' palin& for& "again"& and& opsia& for& "seeing".& It& is& a& visual& disturbance& that&
causes&images&to&persist&even&after&their&corresponding&stimulus&has&left.&It&is&seen&in&
LSD& use,& migraine,& occipital& epilepsy,& and& head& trauma.& It& is& similar& to& afterimage&
but&colour&inversion&(usually&shadows&or&distorted&colours&noted&in&afterimages)&is&
conspicuously&absent.&&
Somatic'hallucinations:&
These&can&be&divided&into&superficial,&visceral&and&kinaesthetic.&&
The& superficial& somatic& hallucinations& are& tactile& (haptic& d& touch),& hygric& (fluid& –&
wetness&etc)&and&thermic&(heat&or&cold).&&
4
!Sims!Symptoms!in!the!mind:!An!introduction!to!descriptive!psychopathology,!Oyebode!F,!Fourth!
edition,!2008.!Saunders!Elsevier.!P105,!109?110.!
5
!BMJ!!2004;328:1552?1554"
6
Visceral&hallucinations&are&usually&pain&like&sensations&arising&from&deep&viscera&like&
the&liver.&&
Kinaesthetic& or& proprioceptive& hallucinations& refer& to& joint& or& muscle& sense,& often&
linked&to&bizarre&somatic&delusions.&They&are&also&seen&in&benzodiazepine#withdrawal&
and&alcohol&intoxication.&&
Formication&(formic&acid&–&from&ant)&is&a&special&type&of&haptic&hallucination&–&an&
unpleasant&sensation&of&little&animals&or&insects&crawling&on&or&under&skin,&seen&in&
DT&and&cocaine&intoxication.&
Tactile& hallucinations& can& be& seen& in& parietal& seizures.& Superficial& somatic&
hallucinations& are& almost& never& noted& in& TLE,& though& a& visceral& sense& of& a& ‘raising&
epigastrium’&is&seen.&&
Phantom'limb:&A&common&body&image&disturbance&with&neurological&basis&and&not&
a& hallucination.& Although& it& is& in& external& space,& it& does& not& satisfy& the& other&
qualities&of&a&hallucination&and&patients&are&usually&aware&of&unreality.&&
Somatic& hallucinations& may& or& may& not& be& accompanied& by& passivity& delusions.&
Without&the&passivity&element,&they&cannot&be&classed&as&a&First&rank&symptom.&
Olfactory'hallucinations&can&occur&in&aura&of&TLE&–&usually&a&burning&smell&or&the&
smell&of&urine.&In&depression&this&can&be&an&adjunct&to&nihilism.&&
Gustatory&hallucinations,&e.g.,&the&bitter&taste&of&poison&can&give&rise&to&delusions&
of&persecution&in&schizophrenia.&They&are&also&seen&in&TLE.&
Extracampine'hallucinations:&Hallucinations&that&occur&beyond&the&normal&field&
of& perception,& e.g.,& images& seen& behind& your& back,& under& your& sternum& or& hearing&
voices&from&Inverness&when&you&are&in&Birmingham&etc.&They&occur&in&schizophrenia&
and&epilepsy.&&However,&this&phenomena&also&occursin&hypnogogic&hallucinations&of&
healthy&people&and&so&is&not&diagnostically&important.&
Hypnogogic' hallucinations& occur& when& going& to& sleep& (‘go& for& gogic‘)& and& are&
usually&auditory.&They&are&also&seen&in&narcolepsydcataplexy.&They&can&be&visual&or&
tactile&too&and&were&first&noted&by&Aristotle.&Hypnopompic'hallucinations&occur&
when&one&is&waking&up.&
Functional& hallucinations:& An& external& stimulus& provokes& a& hallucination,& and&
both& hallucination& and& stimulus& are& in& same& modality& but& individually& perceived.&
E.g.,&voices&are&heard&whenever&the&noise&of&water&running&from&a&tap&is&heard.&&They&
are&not&illusions&–&as&the&stimulus&is&perceived&appropriately&(noise&of&water),&but&in&
addition&there&is&another&perception&(voices)&without&any&appropriate&object.&&
Synaesthesia:&&
The& phenomenon& of& perceiving& a& stimulus& of& one& modality& in& a& different& modality&
(may& be& single& or& multiple& modalities)& is& called& synaesthesia.& E.g.,& tasting& music,&
hearing&colours&and&smelling&voices.&&
It& is& not& a& hallucination& as& the& perceived& object& has& an& appropriate& stimulus.& The&
original& stimulus& is& usually& perceived& in& appropriate& modality& too& when& the& cross&
modality&perception&occurs&(syn&–&joint,&simultaneous).&&
7
It& is& more& common& in& females& (F:M& 4:1),& runs& in& families& and& colourdnumber&
synaesthesia&is&the&most&common&form.&&
It& is& thought& to& be& due& to& extensive& crossdwiring& between& multimodal& association&
regions&in&some&people,&probably&due&to&failed&selective&pruning.&
Reflex'hallucinations:&&
These& are& hallucinations& in& one& modality& of& sensation& experienced& after&
experiencing& a& normal& stimulus& in& another& modality& of& sensation,e.g.,& seeing& an&
angel&whenever&listening&to&music.&&
They& are& similar& to& functional& hallucinations& in& that& there& is& a& stimulus,& which& is&
perceived& normally,& followed& by& a& hallucinatory& perception& –& the& only& difference&
being& the& modality& of& & stimulus& and& perception& being& same& in& a& functional&
hallucination&while&different&in&reflex&hallucinations.&
It&is&important&to&differentiate&synaesthesia&from&reflex&hallucinations&in&EMIs.&&
In& synaesthesia& it& is& the& music& that& is& seen& –& the& stimulus# and# object# of# perception#
remain#the#same&albeit&in&different&modalities&d&the&patient&does&not&claim&that&she&
could&see&Jesus&or&an&angel.&&
Also& the& perceptions& are& simple,# unformed& and& nondbizarre& in& synaesthesia& e.g.&
colours;&in&reflex&hallucination&these&are&formed&voices,&vivid&images&like&angels&etc.&&
The& stimulus–perception& sequence& is& usually& completed& before& the& hallucination&
occurs& in& reflex& hallucination& –& ‘I& heard& the& music& and& then& came& the& angel’;& in&
synaesthesia&itself&music&itself&is&seen&as&colour&simultaneously.&
Pseudohallucinations:'
There& are& two& different& definitions:& Involuntary& hallucinationdlike& experiences&
occurring& in& inner& subjective& space,& with& vivid& outline& that& are& absolutely& different&
from& normal& sense& perceptions& and& hallucinations& (Kandinsky,& Jaspers& && Sims).&
Often& quoted& by& European& psychopathologists,& according& to& Hare,&
pseudohallucinations& are& hallucinations& that& are& recognised& to& be& unreal& and& selfd
originatingPseudohallucinations& are& not& pathognomonic& of& any& diagnosis;& they& are&
not&necessarily&psychopathological&too&–&and&therefore&must&be&differentiated&from&
hallucinations.&&
They&are&intermediate&between&fantasy&(imagery)&and&hallucinations;&&
Like&fantasy,&pseudohallucinations&lack&the&quality&of&concrete&reality,&are&perceived&
in& subjective& space,& possess& quality& of& idea& (and& hence& are& not& sought& in& other&
modalities/& the& individual& does& not& make& attempts& to& reach& out& etc.),& are&
appreciated&to&be&observer&dependant&and&self&originating.&&
Like&a&hallucination,&they&have&clear&vivid&outline&and&are&retained&for&a&good&length&
of&time.&&Pseudohallucinations&cannot&be&dismissed&at&will&and&are&behaviourally&and&
emotionally&relevant,&i.e.,&they&can&be&acted&upon&or&felt&for.&&
The& hallucinatory& experiences& of& bereavement& and& in& Ganser’s& state& are&
pseudohallucinations.&
8
Both& illusions& and& hallucinations& are& not& necessarily& pathological& though& they& are&
both& false& perceptions,& along& with& pseudohallucinations.& For& example& hypnogogic&
hallucinations& and& hypnopompic& hallucinations& can& occur& in& normal& individuals.&
They&also&occur&in&glue&sniffing,&post&infective&depression,&children&with&fevers&and&
in& phobic& anxiety.& Sensory& deprivation& can& result& in& hallucinations& in& normal&
healthy&peopleThey&are&not&more&frequent&in&schizophrenia&than&other&conditions.&
&
&
III.' THOUGHT'DISORDERS:''''''' ' '
&
Normal&human&thinking&has&three&characters&–&&
1. Content:&what&is&being&‘thought&about’?&&
2. Form:&In&what&manner&(or&shape)&is&the&thought&present?&&
3. Stream&or&flow:&How&is&it&being&thought&about?&
&
Disordered'thought'content&refers&to&the&theme&of&delusions&(–&e.g.&persecutory)&
and&the&subject&obsessions&and&preoccupations.&Overvalued&ideas&are&also&disorders&
of&thought&content.&
Disordered'stream'of'thought&includes&poverty&of&thought,&pressure&of&speech&
and&crowding&of&thoughts.&
Disordered'form'of'thought&as&seen&in&schizophrenia&and&other&psychotic&
disorders&refers&to&a&set&of&various&alterations&in&thinking&process/&the&way&thoughts&
are&put&together&(e.g.&loosening&of&associations,&metonyms,&tangentiality,&
circumstantiality&to&name&a&few).&
Thought&content&could&be&deciphered&from&ones&behaviour,&but&thought&form&and&
stream,&unless&extremely&deranged,&cannot&be&studied&without&being&expressed&as&
speech&–&so&linguists&are&increasingly&interested&in&thought&disturbances.&&
The&term&Formal&Thought&Disorder&(FTD)&increasingly&includes&both&form&and&
stream&errors.&Scales&that&measure&thought&disorder&do&not&differentiate&stream&
from&form&anymore&(e.g.&TLC&d&Andreasen,&TDI&d&Liddle).&&
Of&all&thought&disorders&classified&by&Andreasen,&clang&associations&and&flight&of&
ideas&are&more&common&in&mania,&while&derailment&(loosening)&and&thought&
blocking&(and&to&some&extent&tangentiality&and&poverty&of&content&of&speech)&are&
seen&often&in&schizophrenia&d&other&items&were&largely&nondspecific.&FTD&is&also&seen&
in&organic&syndromes&6.&&
Patients&themselves&can&describe&subjective&experiences&of&FTD&in&contrast&to&
delusions&where&insight&is&absent&by&definition.&
6
Andreasen,"N."C."(1979)"Thought,"language,"and"communication"disorders:"I."Clinical"assessment,"definition"
of"terms,"and"evaluation"of"their"reliability."Archives"of"General"Psychiatry,"36,"1315O1321."
9
&
IIIa.' Thought'content''
&
Delusions.'
Kendler& (AJP,& 1983)& has& listed& the& dimensions' of' delusional' experiences& (also&
incorporated&in&Maudsley&Assessment&of&Delusions&scale)&–&&
! conviction,&&
! extension&(to&various&spheres&of&life),&&
! disorganisation&(or&organisation&–&internal&consistency&and&systematisation),&&
! bizarreness&(especially&in&schizophrenia),&&
! pressure&(includes&preoccupation&and&distress).&&
! acting&on&the&delusion&&
Seeking& evidence& and& lack& of& insight& can& be& added& as& other& qualities.& These&
various&dimensions&exist&in&a&continuum&with&normal&beliefs.&
Primary'delusions:'
&These&are&defined&in&two&different&ways&&
1.&Jasper’s&concept:&undunderstandable&and&cannot&be&reduced&further&to&any&
other& mental& experiences.& This& has& been& challenged& recently.& See& below& for&
various&psychological&models&of&understanding&delusions.&&&
2.&Primary&in&the&sense&that&it&is&the&first&to&occur&(temporal&sequence).&&
Often&both&are&true&–&they&are&irreducible&and&precede&other&mental&phenomena.&&
There&are&4&types:&
1. Autochthonous&delusions&or&delusional&intuitions&or&simply,&primary/true&
delusions:&These&are&ideas&that&occur&de&novo,&or&'out&of&the&blue'&d&takes&form&
in& an& instant,& without& identifiable& preceding& events,& as& if& full& awareness&
suddenly& burst& forth& in& an& unexpected& flash& of& insight,& like& a& bolt& from& the&
blue.& This& can& be& an& elaborate& delusional& system& on& formation.& Wernicke&
formulated&the&concept&of&autochthonousdness&i.e.&‘out&of&soil’,&‘aboriginal’.&
2. In& delusional' perception,& a& normally& perceived& object& is& given& a& new&
meaning,&usually&in&the&sense&of&selfdreference&–&the&conclusion&being&entirely&
unwarranted,& the& perception& is& normal.& Hence& it& is& a& two& staged& process& –&
normal# perception& preceds& the& attachment& of& delusional# significance;& these&
two& steps& need& not& be& simultaneous& and& might& even& be& separated& by& years!&
The& only& type& of& delusion& included& in& Schneider's& first& rank& symptoms& is&
delusional&perception.&
3. Delusional' atmosphere/mood& refers& to& the& sense& of& perplexity& and&
uncertainty&that&exists&during&a&prodrome&of&psychosis,&usually&ending&in&an&
autochthonous& delusion& which& will& make& sense& of& the& perplexity& on& arrival.&
Delusional&mood/atmosphere&can&precede&other&primary&delusions.&It&is&the&
only&psychiatric&phenomenon&that&can&directly&precede&and&causally&relate&to&
10
primary& autochthonous& delusions.& Note& that& delusional& mood& itself& is& a&
specific&affective&experience&–&not&thought&content.&
4. Delusional'memory'can&be&of&two&types.&It&can&be&a&retrospective&delusion&
about& something& that& never& happened& and& therefore& is& false,& irrational& or&
bizarre.&The&episode&is&reported&as&if&it&occurred&in&the&past&and&recollected&
now,& e.g.,& a& male& schizophrenia& patient& said& “I& had& a& hysterectomy& at& age& 3&
and& since# then& I& became& a& man”.& & Alternatively& a& normal& memory& might& be&
delusionally& elaborated& –& “My& dad& bought& me& a& camera& when& I& was& seven,&
now&I&understand&it&is&because&he&was&homosexual”.&It&is&difficult&sometimes&
to&say&what&is&fact&and&what&is&not,&though&the&distinction&between&the&above&
two& variants& is& more& of& an& academic& exercise.& More& importantly& delusional&
perception& can& mimic& delusional& memory& when& the& first& stage& of& normal&
perception&is&actually&a&‘recollected’&normal&perception&from&memory.&But&in&
spite& of& this,& delusional& perceptions& are& a& two& stage& process& –& e.g.& “I& saw& an&
envelope& yesterday& (normal& perception& but& recollected& from& memory),& I&
realised&my&stomach&is&upturned”.&
Primary&delusions&do&not&carry&any&prognostic#significance&in&schizophrenia,&though&
they&have&diagnostic&relevance.&&
While& primary& delusions& can& occur& in& epileptic& psychoses,& they& are& not& generally&
associated&with&epilepsy&when&they&occur&in&psychotic&disorders.&&
Primary&delusional&experiences&occur&more&in&acute#stages#of#schizophrenia,&and&are&
not& seen& in& chronic& schizophrenia,& due& to& being& mixed& with& secondary& delusions,&
hallucinations,&FTD&etc.&&
Other& delusions& that& follow& a& primary& delusion& or& other& mental& phenomena& like&
hallucinations,&affective&disturbances&etc.&are&termed&secondary#delusions.&
Specific'disorders'of'thought:'
Persecutory'delusions:&Primary&delusions&vary&considerably&in&content&and&are&not&
characteristically& persecutory& in& nature.& In& contrast& most& secondary& delusions& are&
often&persecutory,&making&persecutory&themes&the&commonest&contents&of&delusions&
as&a&whole.&
Morbid' jealousy& can& occur& in& various& forms& –& either& as& a& delusion& or& overvalued&
idea,& in& both& depression& and& in& anxiety& states& and& it& is& not& a& misidentification&
syndrome.& It& was& first& described& by& Ey.& It& is& common& in& alcoholics& and& has& the&
potential& for& violence& directed& towards& the& perceived& rival& than& the& individual’s&
partner.&&This&phenomenon&can&occur&among&cohabiters,&married&and&homosexual&
couples.&
De' Clerambault’s' syndrome& is& a& type& of& delusion& of& love,& in& which& a& woman&
believes&that&an&older&man,&who&is&usually&of&higher&social&status,&is&in&love&with&her.&&
It&is&not&related&to&delusional&misidentification.&It&is&also&called&‘Old&Maid's&insanity’&
where& persecutory& beliefs& coexist& where& the& affected& individual& comes& to& believe&
that& individuals& are& conspiring& to& keep& them& apart.& The& object& may& be& a& doctor,&
employer,&prominent&public&figure&or&celebrity.&
11
Cotards& syndrome& is& severe& depression& with& nihilistic& and& hypochondriacal&

delusions& tinged& with& grandiosity& and& a& negative& attitude.& & It& is& not& related& to&
delusional& misidentification.& Cotards& syndrome& can& be& seen& in& schizophrenia&
though&more&commonly&in&depressive&psychosis.&It&is&generally&seen&in&the&elderly,&
with& hypochondriacal& and& nihilistic& delusions& with& a& tinge& of& grandiosity& amidst&
nihilism& (not& grandiose& delusions!).& It& is& also& reported& in& organic& lesions& and&
migraine.&
Hypochondriacal' delusions:& These& are& seen& typically& in& psychotic& depression,&
especially&in&the&elderly,&and&a&part&of&Cotard’s&syndrome.&A&specific&type&described&
by&Munro&called&monosymptomatic'hypochondriacal'psychosis&consists&of&&
1. Delusions&of&body&odour&and&halitosis&(olfactory&delusions).&Some&may&have&
olfactory1 reference1 syndrome& –& no& olfactory& experiences& but& only& fixed&
beliefs& about& body& odour& with& an& associated& anxiety& reaction.& Paranoid&
personality&disorder&is&often&associated&with&this&syndrome.&
2. Delusional& infestation& (Ekbom’s1 syndrome)& a& delusion& of& parasitic& –&
macroscopic& d& infestation& with& classical& matchbox& sign:& An& old& lady& comes&
to& clinic& with& a& match& box,& of& skin& scrapings& usually,& as& evidence& for& the&
parasite&that&infests&her&causing&itching.&This&can&predate&onset&of&dementia.&
It&may&or&may&not&be&associated&with&somatic&hallucinations.&
3. Dysmorphic1delusions&(misshaped&nose&etc.)&
If&the&presentation&is&not&an&isolated&delusional&disorder,&dysmorphic&delusions&may&
present&as&part&of&a&depression.&
Koro& is& a& culture& bound& anxiety& state& where& the& patient& believes& that& his& penis& is&
shrinking& into& his& abdomen& and& he& will& die& as& a& result.& This& is& considered& to& be& a&
desomatisation& (organ& specific& depersonalisation)& experience& associated& with& folk&
beliefs&(hence&not&a&delusion&d&as&it&is&culturally&relevant).&It&is&seen&in&Malaysia&and&
Singapore.&
The&various&misidentification#syndromes7&are&&
1. In& Capgras& syndrome,& a& person& believes& that& a& person& usually& close& to& him&
has& been& replaced& by& an& exact& double.& Capgras& syndrome& is& sometimes&
referred& to& as& the& illusion& of& doubles& though& it& is& a& delusion.& It& is& now&
predominantly&thought&to&be&due&to&organic&brain&damage&(>50%,&Lishman)&
apart& from& being& seen& as& a& part& of& schizophrenia& or& isolated& delusional&
disorder.&
2. In& Fregoli& syndrome,& there& is& false& identification& in& which& the& patient&
believes& that& strangers& have& been& replaced& with& familiar& people& A& familiar&
person&is&thought&to&be&taking&various&disguises.&(Fregoli&was&a&French&drama&
actor)&
7
Sadock,"B.J.,"&"Sadock,"V.A."(1999)."Comprehensive"textbook"of"psychiatry."Lippincott"
Williams"&"Wilkins,"London."
12
3. In& syndrome' of' subjective' doubles,& the& patient& believes& that& another&
person& has& been& physically& transformed& into& his& own& self& and& the& patient& is&
convinced&that&exact&doubles&of&him&or&herself&exist.&
4. Intermetamorphosis& d& A& becomes& B,& B& becomes& B& etc.& People& keep&
transforming&their&physical&and&psychological&identities.&
&The& concept& of& misidentification& is& now& being& extended& beyond& person& to&
misidentification&of&time&and&place&(reduplication&phenomenon).&&
Folie' a' deux& is& a& shared& delusion,& in& which& a& psychotic& person& transfers& his&
delusions& to& one& or& more& people& close& to& him.& & The& non& psychotic& victim& usually&
exhibits&dependent&traits&on&the&primary&patient.&Separation&of&the&pair&can&result&in&
remission.&
Couvade& syndrome& describes& a& sympathetic& pregnancy& that& affects& the& husband&
(rarely& other& family& members)& during& their& wife’s& pregnancy.& The& most& frequent&
time& of& onset& of& symptoms& is& between& 3& and9& months& of& pregnancy& d& it& is& a&
conversion& symptom& and& not& delusional& as& the& husband& does& not& think& he& is&
pregnant!&&
Pseudocyesis&is&a&condition&where&a&woman&experiences&clinical&signs&of&pregnancy&
without&being&pregnant,&and&the&patient&is&convinced&of&pregnancy.&&&
Neuropsychology1of1delusions8,19:1
1. Attentional'biases:&People&with&persecutory&delusions&preferentially&attend&
to& threatdrelated& stimuli& and& preferentially& recall& threatening& episodes.&
(Blackwood,&AJP&2001)&
2. Attributional' biases:& An& exaggeration& of& selfdserving& attributional& bias& is&
seen& in& psychosis.& Patients& excessively& attribute& hypothetical& positive& events&
to& internal& causes& (grandiose)& and& hypothetical& negative& events& to& external&
causes& (persecutory).& The& attributional& bias& in& paranoid& subjects& shapes&
delusional& content& rather& than& form,& as& patients& with& nondpersecutory&
delusions& do& not& show& this& bias& significantly.& Paranoid& patients& specifically&
attribute&negative&selfdreferent&events&as&malevolence&on&the&part&of&the&other&
person& (external& personal& attribution)& rather& than& circumstances& or& chance&
(external&situational&attribution).&(Blackwood,&AJP&2001).&This&might&serve&to&
preserve&selfdesteem&of&paranoid&patients,&acting&as&a&selfddefence.&
3. Probabilistic' reasoning' bias:& When& deluded& patients& were& shown&
sequences&of&black&and&white&beads&and&were&asked&to&decide&which&jar&the&
sequence&was&probably&drawn&from&[jar&A&had&a&majority&of&black&beads&and&
B&had&a&majority&white]&they&came&to&a&conclusion&with&far&fewer&beads&in&a&
sequence& than& controls.& They& were& also& relatively& overconfident& about& the&
accuracy& of& their& judgement.& This& was& hypothesised& to& be& due& to& impaired&
8
!Manschreck,"T."C."(1995)."Pathogenesis"of"delusions."Psychiatric"clinics"of"North"America,"18,"213"!
9
!Blackwood,"N"et"al."Cognitive"Neuropsychiatric"Models"of"Persecutory"Delusions.!!!!Am"J"Psychiatry"2001"
158:"527O539!
13
probabilistic& reasoning& (the& ability& to& generate& a& hypothesis& and& test&
statistical&probability).&But&later&studies&showed&that&when&allowed&to&see&as&
many& number& of& beads& as& controls& generally& do,& patients& reached& similar&
correct& conclusions& –& they& were& able& to& generate& hypothesis& and& test& the&
probability;&the&defect&being&deficient&datadgathering&(less&information&before&
decision).&This&is&called&Jumpingdtodconclusion&style&of&reasoning&(JTC).&
4. Mentalising' deficits/bias:& Persecutory& delusions& reflect& false& beliefs& about&
the&intentions&and&behaviour&of&others& that&could&arise&from&theory&of&mind&
deficits.&&
'
Doppelganger:&This&is&also&known&as&‘double&phenomenon’&–&it&is&the&awareness&of&
oneself& being& both& outside& and& inside& oneself.& It& is& cognitive& and& ideational& as&
opposed&to&autoscopy&which&is&perceptual.&It&can&also&occur&in&the&absence&of&mental&
illness&And&is&not&related&to&delusional&misidentification&syndromes&where&there&is&
pathology#of#familiarity.&
Ideas' of' reference& are& seen& in& paranoid& PD& where& the& individual& is& unduly& selfd
conscious&and&feels&that&people&take&notice&of&him&or&observe&things&about&him&that&
he& would& rather& not& be& seen.& It& can& also& precede& development& of& full& blown&
schizophrenia& where& it& is& called& sensitive& ideas& of& reference& or& "sensitiver&
Beziehungswahn”!!&It&is&not&characteristic&of&mania.&
Overvalued'ideas:&Overvalued&ideas&(Wernicke)&are&solitary&abnormal&beliefs&that&
are& neither# delusional# nor# obsessional& in& nature.& & They& are& both& reasonable& and&
understandable& in& themselves& but& which& come& to& unreasonably& dominate&
theperson’s& life& and& his& actions.& They& have& a& poor& prognosis.& Common& conditions&
presenting& with& overvalued& ideas& are& paranoid& or& anankastic& personality& disorder,&
body&dysmorphophobia,&anorexia&nervosa,&morbid&jealousy&&&transsexualism.&
Obsessions& usually& evoke& distress& and& anxiety& and& are& not& pleasurable& by&
definition.&&
They&are&unwanted,&intrusive,&repetitive,&senseless&thoughts&experienced&by&patients&
as&troublesome&and&attempts&to&resis&are&made.&
Though& the& appearance& of& the& thoughts& themselves& is& appreciated& to& be& beyond&
their&control,&they&are&not&claimed&to&be&due&to&an&external&agency&and&regarded&to&
be&one’s&own&mind's&product&but&egodalien&d&against&their&values&and&needs.&&
Intrusive& thoughts& occur& before& motor& (compulsive)& acts.& It& is& not,& however,&
necessary&that&every&compulsion&is&preceded&by&an&obsession&or&vice&versa.&&
Often& during& the& course& of& OCD,& primary& obsessions& fade& while& compulsions&
dominate& the& clinical& picture;& some& compulsions& can& be& mental& behaviours& like&
praying,&counting&etc.&&
Obsessional&slowness&can&occur&either&when&obsessional&thoughts&occur&as&part&of&a&
depressive& illness& or& in& cases& of& severe& OCD& where& primary& obsessional& slowness&
ensues.&Still&another&pattern&is&the&obsession&for&symmetry&or&precision,&which&leads&
to& a& compulsion& of& slowness.& Patients& take& hours& to& eat& a& meal& or& shave,& in& an&
14
attempt&to&do&things&‘just&right’.&Unlike&other&patients&with&OCD,&these&patients&do&
not&resist&their&symptoms!&&
In& thought' alienation,& a& person& has& the& experience& that& his& thoughts& are& under&
control&of&outside&influences&or&that&others&participate&in&his&thinking.&&
The& subjective& disturbance& in& thinking& in& schizophrenia& can& be& described& as&
passivity,& which& can& occur& in& the& form& of& thought& insertion,& thought& withdrawal,&
and& thought& broadcasting.& These& are& first& rank& symptoms& of& schizophrenia,& which&
will&be&elaborated&below&as&it&forms&the&subject&of&many&MCQs.&
First1rank1symptoms1of1Schizophrenia#
Kurt#Schneider&proposed&an&empirical&cluster&of&symptoms,&one&or&more&of&which&in&
the&absence&of&evidence&of&organic&processes,&can&be&used&as&a&positive&evidence&for&
schizophrenia.&&
These& symptoms& are& not# comprehensive& features& of& schizophrenia;& they& are& clearly&
identifiable,& frequently& occurring& and& occur& more& often& in& schizophrenia& than& any&
other&disorder.&&&
It&emphasizes&on&form#rather#than#content,&i.e.,&echoing&thoughts&as&voices&is&more&
important&that&what&actually&the&voice&said;&this&increases&cross&cultural&reliability,&
although&variations&exist.&&
Schneider&classed&all&non&first&rank&schizophrenic&symptoms&as&second'rank'(other&
delusions,&hallucinations,&affective&changes)&–&and&FRS&are&not#essential&to&diagnose&
schizophrenia.& The& ICD10& description& of& schizophrenia& however,& largely& borrows&
Schneider’s&ideas.&&
FRS&are&not&of&any&prognostic&importance&at&all.&They&do&not&specify&any&subgroups&
with&differential&treatment&response&or&heritability.&&
Disturbance&of&selfdimage&(egodboundary)&is&the&predominant&underlying&feature&of&
all&FRS.&
The&First&Rank&Symptoms&are&3+3+3+2.&
3'hallucinations:'
Audible&thoughts&(Thought#echo)&
Voices&heard&arguing#(3rd#person)&
Voices&heard&commenting&on&one's&actions&(running#commentary)&
3'‘Made’'phenomena:'
Made#affect#(someone&controlling&the&mood/affect)&
Made#volition&(someone&controlling&the&action&–&usually&a&completed&act)&
Made#impulse&(someone&controlling&the&desire&to&act&–not&the&completed&act&
but&the&drive.&If&the&action&has&been&carried&out,&the&patient&admits&to&
ownership&of&act,&not&the&impulse&behind&it)&&
3'Thought'phenomena/passivity'of'thinking:&&
Thought#withdrawal##
Thought#insertion&(external&agency&inserting&thoughts&upon&the&patient&)&
Thought#broadcast&(also&called&thought&diffusion&–&as&if&in&television&
broadcast,&everyone&comes&to&know&about&the&patient’s&thinking&as#and#when#
15
the#patient#thinks&–&refers&to&loss&of&privacy&of&thoughts.&Cf.&referential&
delusion&–&‘people&act&as&if&they&know&what&I&am&thinking’)&&
The&experiences&themselves&are&more&important&than&later&explanations&of&
how&the&patient&interprets&them.&
2'isolated'symptoms:'
Delusional#perception#(delusional&interpretation&of&an&actual&perception)&
Experience&of&sensations&on&the&body&caused&by&external&agency&(somatic#
passivity)#
#
Command# hallucinations& (aka& imperative)& are& not& first& rank& symptoms.& Somatic#
hallucinations& are& also& NOT& first& rank& symptoms& unless& there& is& a& delusional&
elaboration& and& attribution& of& the& origin& of& sensations& to& an& external& agency&
(passivity).& Note& that& somatic& passivity& can& follow& a& normal& sensation& like& an&
osteoarthritic& knee& pain,& ascribed& to& be& caused& by& ‘Meekee,& the& leader& of& Martian&
extermination&gang’&(for&example)!&
&
'
Double' orientation& refers& to& a& state& in& which& a& patient& manages& to& reconcile& a&
delusional&orientation,&with&the&real&world&d&although&seemingly&contradictory&(e.g.&
the& patient& performs& his& duties& as& a& janitor,& despite& adamantly& believing& he& is& the&
president).&&&
Age' disorientation& is& most& commonly& seen& in& older& schizophrenic& patients& who&
have& had& a& long& duration& of& illness.& & Patients& with& early& onset& schizophrenia& are&
more&likely&to&develop&this&as&they&age.&It&has&been&suggested&by&some&authors&that&
this&is&a&marker&of&progressive&cognitive&decline.&
&
IIIb.' Stream'of'Thought.'
&
Thought&flow&can&be&speeded&up,&slowed&down,&interrupted,&and&changed&(note&how&
this&begins&to&overlap&with&formal&thought&disorders).&
&
" Acceleration/Flight'of'ideas:&Is&characteristic&of&mania,&wherein&&
! Thoughts&follow&each&other&rapidly,&&
! No&general&direction&for&thinking&
! Chance& associations& between& succeeding& thoughts.& This& may& be&
understandable& due& to& distractions& in& the& environment& or& verbal&
associations& (due& to& words& spoken)& such& as& clang& associations&
(thoughts& being& associated& by& sounds& of& words& rather& than& their&
meaning.),&puns&&&rhymes.&These&are&disorders&of&thought&form.&
" Retardation' of' thinking:' Seen& in& depression.& Train& of& thought& is& slowed&
down,&though&remains&goal&directed&&This&is&characterised&by&little&initiative&
or&planning,&long&latency&of&response,&increased&pause&times&when&speech&is&
16
initiated&and&during&speech.&In&both&the&above&the&mood&state&of&the&patient&
dictates& the& flow& of& thoughts.& Also& note& agitation& with& restlessness& and&
anxious&thoughts&can&codexist&in&depression.&&
" Circumstantiality:' ' A& slowing& of& the& rate& of& thought& (but& not& necessarily&
speech),&with&many&unnecessary&details&and&digressions&that&may&overwhelm&
the&direction&of&the&thought&process,&before&returning&to&the&point.&This&may&
be& seen& in& epilepsy,& learning& difficulty,& mania& and& in& obsessional&
personalities.&
" Thought' Blocking:& a& ‘snapping& off’,& unexpectedly& and& unintentionally& of& a&
train& of& thought.& Not& caused& by& distraction,& another& thought& or&
introspection.& It& can& be& described& by& patients& as& the& experience& of& thought&
withdrawal.&
" Crowding:& seen& in& schizophrenia& as& a& passive& packing& of& excessive,& fast,&
inexplicable& thoughts.& This& is& a& phenomenon& perceived& by& the& individual& as&
outside&their&control.&
" Perseveration:' The& thought& process& tends& to& persist& beyond& a& point& at&
which& they& are& relevant.& Perseveration& generally& occurs& with& clouded&
consciousness& and& is& considered& pathognomonic# of# organic# brain# disease.&
Perseveration& can& be& demonstrated& verbally& or& through& repetitive& motor&
activity10.&
IIIc.'Formal'thought'disorders'(FTD).&
Normal&thinking&is&of&three&types&(or&functions):&
1.&& Fantasy/dereistic' thinking' or' autistic' thinking:& There& is& no& goal&
direction,& thoughts& are& unrealistic& and& likened& to& day& dreaming.& This&
presents& predominantly& in& cluster& A& personality,& and& is& associated& with&
dissociation&and&pseudologia&fantastica.&
2.&& Imaginative' thinking:& Again& fantasy& elements& but& admixed& with& memory,&
involving&abstract&concepts.&&Imaginative&thinking,&however,&is&goal&directed&
and& does& not& cross& boundaries& of& possibility& and& realism.& Determining&
tendency&of&thoughts&preserved&e.g.&lateral&thinking&&
3.&& Rational'or'conceptual'thinking:&based&on&material&reality&and&uses&logic.&
&
Disordered'thinking:'Important'concepts.'
Cameron&proposed&5&characteristic&formal&thought&disorders&–&MAO]ID:&&
• Metonymy&(imprecise&but&approximate&expressions)&
• Asyndesis&(lack&of&genuine&causal&links&in&speech)&&
• Overinclusion&(see&below)&&
10
Companion"to"Psychiatric"Studies,"Ed:"Johnstone,"Lawrie"et"al,"Seventh"edition""7"e"P232"box"13.6"
17
• Interpenetration& (irrelevant& thought& penetrating& ondgoing& stream& of&

thoughts)&&
• Derailment& (aka& entgleisen;& change& in& track& of& thoughts& –& preserved& but&
misdirected&determing&tendency/goal&of&thought).&&
Carl&(not&Kurt)&Schneider&also&proposed&his&own&5&elements&of&FTD&–&SOFDD:&&&
• Substitution& (one& thought,& & often& inappropriate& fills& the& gap& for& another&
appropriate,&more&fittingdin&thought)&&
• Omission&(A&chunk&of&thought&goes&missing&from&the&stream&of&conversation,&
patient&being&unaware&–&this&is&best&analysed&when&written)&&
• Fusion&(various&thoughts&fusing&together,&leading&to&loss&of&goal&direction)&&
• Drivelling&&
• Desultory&thinking'
Clang&associations:&thoughts&are&associated&by&the&sound&of&words&rather&than&their&
meaning,& e.g.& through& rhymes& (e.g.,& rail/tail/sail)& or& puns# (e.g.,# one& word& with& two&
meanings& rose=flower/past& tense& of& rise).& & This& may& occur& during& manicflight' of'
ideas&(through&a&succession&of&multiple&associations&and&thought&moves&from&idea&
to&idea&abruptly).&Flight&can&also&occur&secondary&to&chance&perceptions&or&external&
distractions& d& when& talking& about& a& holiday,& one& sees& a& car& passing& by& and& starts&
talking& about& a& Volkswagen!& In& schizophrenic& FTD,& clang& occurs& more& often& with&
first&syllables&as&opposed&to&clangs&in&poetry,&humour&and&manic&speech&where&they&
occur&more&at&the&end&of&syllables.&
Neologism&refers&to&making&up&a&totally&new&word&that&is&not&in&the&dictionary&or&
using&a&known&word&with&a&completely&different&meaning&e.g.&‘Inkur’&for&pen&(new)&
or& ‘roast’& for& pen& (different).& Metonyms& are& word& approximations& e.g.& paperskate&
for&pen.&Stock'words&are&either&newly&synthesised&or&already&known&words&but&used&
in& an& idiosyncratic& way& repeatedly,& often& with& many& meanings& and& in& different&
contexts,&sometimes&dominating&any&discourse,&e.g.,&&“The&fallacy&(?goal)&of&my&life,&
is&to&live&happily&–&not&to&do&any&fallacy&(?wrongs)&but,&often&not&easy,&full&of&fallacy&
(?difficulty),&as&everyone&does&them,&when&fallacy&(?the&world)&stops&all&that&let&me&
see&where&I&stand.”&&
Semantic&problems&in&speech&can&result&in&various&presentations:&&
1.'Verbal'paraphasia&–&where&meaningful&sentences&are&produced&in&spite&of&loss&of&
appropriate&words&e.g.&‘food&filling&muscular&carton’&for&stomach&(a&metonym).&&
2.&Literal'paraphasia']&no&one&can&make&out&the&meaning&of&the&sentence&spoken&
except&the&patient.&
In&overinclusive'thinking&–&
! &ideas& that& are& only& remotely& related& to& the& concept& under& consideration&
become&&&&&&incorporated&in&the&patient's&thinking;&&
18
! conceptual& boundaries& are& lost.& This& is& used& to& explain& the& thought&
disorders&in&schizophrenia&and&is&different&from&the&mechanism&in&flight&of&
ideas.&&
! sorting& tests& can& be& used& to& test& overinclusion.& It& occurs& in& nearly& 50%& of&
schizophrenia&patients,&especially&when&acutely&ill.&
Vorbeireden:'
Vorbeireden,& a& synonym& of& Ganser& symptom,& is& the& production& of& ‘approximate&
answers&and&can&be&described&as&‘talking&past&the&point’.&&The&patient&gives&repeated&
wrong&answers&to&questions,&which&are&‘in&the&right&ballpark’,&e.g.,&what&is&the&capital&
of&Wales?&–&Paris.&It&is&described&as&a&formal&thought&disorder,&different&from&flight&
of&ideas,&which&is&a&disorder&of&thought&stream.&&
Vorbeireden,& or& talking& past& the& point,& is& not& exclusively& associated& with& Ganser's&
syndrome.&&It&is&also&seen&in&acute&schizophrenia&and&hebephrenic&schizophrenia.&&
Vorbeireden& (‘talking& past& the& point’)& is& often& used& interchangeably& with&
vorbeigehen& (‘going& past& the& point’),& although& the& latter& was& originally& defined& as&
part& of& the& ‘Ganser& syndrome’,& whereby& some& criminals& would& give& incorrect&
answers& (‘approximate& answers’)& to& simple& questions& that& none& the& less& suggested&
that&the&correct&answer&was&known&(e.g.&saying&dogs&have&five&legs).&
Circumstantiality:'
In&circumstantiality,&thinking&proceeds&slowly,&with&many&unnecessary&details&and&
digressions,&before&returning&to&the&point&(see&disorders&of&thought&flow&above)&
It&is&seen&in&some&patients&with&temporal&lobe&epilepsy&or&alcoholdinduced&persisting&
dementia,&learning&difficulty&and&in&obsessional&personalities.&&
It& is& a& formal& thought& disorder& affecting& rate& of& flow& where& figure/ground&
differentiation&apparently&fails,&but&is&not&driven&by&affective&changes&like&mania&or&
depression.& Circumstantiality& may& be& related& to& loosened& associations& and& usually&
develops&within&the&setting&of&a&delusional&mood&in&schizophrenia;&it&may&be&due&to&
an& impairment& of& a& central& filtering& process& that& normally& inhibits& external&
sensations&and&internal&thoughts&that&are&irrelevant&to&a&given&focus&of&attention.&&
Circumstantiality&is&not&the&same&as&tangentiality&where&the&patient&never&reaches&
the&point,&whereas&they&do&reach&the&point&in&circumstantiality.&Imagine&a&spiral&that&
eventually& touches& its& centre,& while& a& tangent& scrapes& through& the& edge& and& never&
reaches&the&centre.&&
Concrete'thinking:&It&is&seen&as&literalness&of&expression&and&understanding,&with&
failed& abstraction.& It& is& recognisable& clinically& but& difficult& to& measure& using&
psychometry.& Goldstein& studied& this& loss& of& abstract& thinking& which& can& be& tested&
using&proverbs&and&similarities&tests&(e.g.&‘how&is&a&car&and&a&truck&alike?’).&It&seems&
concrete&thinking&is&evident&in&speech&and&formal#thought&disordered&schizophrenia&
patients,&but&not&the&nondFTD&group&(Allen&1984).&It&is&also&seen&in&frontodtemporal&
dementia.&
&
19
Formal& thought& disorder& can& produce& abnormalities& of& commission& as& well& as&
omission.&
Positive#FTD#can&produce&what&is&broadly&described&as&paralogia&–&intrusions,&the&
presence/appearance&of&an&abnormal&element&(e.g.&tangentiality)&and&alogia&refers&
to& negative# FTD# –& symptoms& considered& due& to& their& absence/disappearance& of& a&
normal&element&(e.g.&poverty&of&speech).&&
Thought& block& is& a& negative& FTD& –& involves& sudden& arrest& in& the& flow& of& thoughts;&
sometimes& resembles& an& absence& seizure& though& there& is& no& amnesia& for& the& idea&
that&was&discussed&and&no&motor&accompaniments&typical&of&absences.&Patients&can&
elaborate&on&thought&blocking&with&a&delusional&content&of&thought&withdrawal.&
In& schizophrenia,& semantic& disturbance& of& language& is& more& common& than&
grammatical&or&syntactical&errors.&Agrammatism&refers&to&loss&of&parts&of&speech&–&
e.g.&propositions.&In&paragrammatism,&individual&phrases&are&well&constructed&and&
meaningful&but&they&do&not&fit&in&with&the&goal&of&thought.&&
In& pure' word' deafness& the& patient& can& speak,& read& and& write& fluently,& but&
comprehension&of&speech&is&impaired.&In&pure'word]dumbness&the&disturbance&is&
limited&to&an&inability&to&produce&and&repeat&words&at&will.&In&pure'word]blindness&
(alexia),& understanding& of& spoken& words,& speech& and& writing& are& normal,&
howeverthe&patient&cannot&understand&text&that&they&read.&
Organic&psychosyndromes&affect&performance&scores&more&than&verbal&scores&in&
psychometry.&
&
IV.' DISORDERS'OF'SPEECH.'
&
Speech& disorders& can& be& grouped& into& functional& and& organic.& Functional& speech&
disorders&include:&
! Stuttering&&&stammering&
! Dissociative& aphonia:& ‘stage& whisper’& –& impaired& phonation& without& organic&
disease&(c.f.&aphonia&secondary&to&CN9&paralysis)&
! Mutism,&selective&mutism&(in&childhood)&
! Vorbeireden:& Can& occur& in& Ganser’s& syndrome,& acute& schizophrenia;&
hebephrenic&schizophrenia&(pseudodpseudoddementia).&
! Neologisms,&use&of&stock&words&or&phrases,&and&use&of&private&language.&
! Logoclonia:&spastic&repetition&of&syllables&(e.g.&in&Parkinson’s).&
! Echolalia:& Repetition& of& words& or& parts& of& a& sentence,& without& an&
understanding& of& the& meaning& of& the& words.& Seen& in& mental& retardation,&
schizophrenia&&&dementia.&
Organic& speech& disorders& are& due& to& the& dysphasias,& a& brief& discussion& of& which& is&
described&below.&
&
20
Type' Spontaneou Comprehend Repeats' Names'

s,' fluent' s'
speech'
Pure&word&deafness& +& d& d& +&
Pure&word&blindness& +& +& +& +&
Primary&sensory& +& d& d& +/d&
dysphasia&
Conduction&aphasia& +& +& d& +/d&
Nominal&aphasia& +& +& +& d&
Pure&word&dumbness& d& +& d& +/d&
Isolated&speech&area& d& d& +& d&
Transcortical&motor& d& +& +& d&
dysphasia&
Transcortical&sensory& +& d& +& d&
dysphasia&
&
Sensory#(receptive/fluent)#dysphasia:&
Pure&word&deafness:&Patients&can&speak,&read&&&write&fluently,&but&comprehension&of&
speech&is&impaired.&
Pure& word& blindness:& Can& speak& normally& && understand& spoken& word,& can& write&
spontaneously&and&to&dictation,&but&reading&comprehension&is&impaired.&
Primary& sensory& dysphasia:& Speech& is& fluent& with& inability& to& understand& spoken&
speech.&
Conduction& dysphasia:& The& ability& to& speak& and& write& is& preserved,& however,& the&
reception&of&speech&&&writing&are&impaired.&
Nominal&dysphasia:&This&is&an&inability&to&produce&names&&&sounds.&The&patient&is&
able&to&describe&an&object&&&its&functions,&but&naming&is&difficult.&Understanding&is&
preserved.&
Motor#(expressive#/#non=fluent)#dysphasia:#
Pure&word&dumbness:&Speech&is&indistinct&and&cannot&be&produced&at&will.&Spoken&&&
written&comprehension&&&writing&is&preserved.&
Pure&agraphia:&Isolated&inability&to&write.&
Primary& motor& dysphasia:& Inability& to& select& words,& construct& sentences& && express&
them.&Reception&of&speech&&&writing&are&unimpaired.&Telegraphic&speech.&
Verbigeration&is&repetition&of&words&or&syllables&that&patients&with&motor&dysphasia&
may&use&while&searching&for&a&new&word.&
&
21
What'causes'schizophrenic'speech'disturbance?'
There&are&various&theories&from&different&scientific&disciplines.&
1. Kraeplin&used&the&term&akataphasia&to&explain&speech&disorders&as&a&result&of&
thought&disorder.&&
2. Bleuler&theorised&loosening'of'associations&to&underlie&FTD.&&
3. Von& Domarus& proposed& that& FTD& is& a& result& of& loss& of& deductive& reasoning& –&
illogical&thinking.&(Von'Domarus'law'–&Cat&is&an&animal&(premise&1),&cat&has&a&
tail& (premise& 2)& d& therefore& all& animals& have& a& tail& (conclusion);& note& that& the&
inferences&are&based&on&insufficient&premises.)&
4. Schizophrenic& thought& disorder& could& be& measured& using& Kelly’s& personal&
construct& theorydbased& ‘repertory' grids’' (Bannister).& The& patient& is& asked& to&
rate& different& elements& (e.g.,& relatives& or& friends)& under& different& constructs&
(qualities).&Normally&one&would&expect&congruence&between&certain&constructs&
scored& for& a& given& element,& e.g.,& mum& is& helpful& and& she& is& also& kind& and&
supportive.& But& in& schizophrenia& the& predictability& of& an& element’s& quality&
using&prior&constructs&is&affected&(mum&is&helpful&but&scores&low&on&kindness&
and& support& offered).& This& is& called& serial' invalidation& and& is& more&
pronounced&for&people&than&objects,&showing&that&thought&disorder&affects&the&
interpersonal&realm&more&than&other&spheres.&The&scores&can&be&used&to&draw&a&
semantic& space,& demonstrating& graphical& connections& between& people& and&
qualities&in&the&patient’s&personal&world.&&
5. Mortimer&considered&FTD&to&be&a&result&of&impaired&semantic'memory&–&so&
associations&between&words&and&qualities&are&lost.&&
6. Words& carry& a& ‘semantic& halo’& –& e.g.& the& word& ‘London’& is& linked,& through&
symbolic&meaning&to&words&like&‘tube’&and&also&‘Britain’,&‘England’&etc.&Imagine&
that&these&words&are&‘cross&wired’&in&the&brain.&So&whenever&the&word&London&is&
stimulated,&the&closely&‘cross&wired’&words&also&become&available&readily&for&the&
thought& process& to& proceed& uninterrupted.& This& activation& is& called& direct'
semantic' priming.& In& indirect& semantic& priming,& London& activates& the& word&
tube,&tube&activates&light&(as&in&tubedlight)&or&pipe&etc.&This&indirect&priming&is&
usually& minimal,& preventing& inappropriate& deviation& in& determining& tendency&
of&thought&flow.&In&schizophrenia&it&is&proposed&that&direct&priming&is&impaired&
but&indirect&priming&is&enhanced&resulting&in&a&FTD.&&
7. Word'association'tests&are&abnormal&in&schizophrenia&–&despite&the&context&
of&usage,&patients&preferred&the&dominant&meaning&of&a&word&e.g.&court&means&
‘lawdroom’&not&tennis&court,&in&spite&of&discussion&about&sports.&&
8. In& the& ‘cloze' procedure’& parts& of& recorded& speech& are& deleted& to& see& if& the&
meaning&could&still&be&predicted;&predictability&was&reduced&in&schizophrenia.&
In&reverse'cloze&procedure&patients&are&asked&to&predict&the&missing&elements&
of& someone& else’s& speech–& again& the& schizophrenia& group& performed& worse& in&
prediction.&&
9. Type–token' ratio& refers& to& the& ratio& between& the& number& of& different& words&
used&during&a&discourse&and&the&total&number&of&spoken&words.&Impoverished&
22
vocabulary& was& noted& with& a& low& type& token& ratio& among& schizophrenia&
patients.&
10. Cohesion' analysis& (analysing& the& links& between& sentences& and& words& in& a&
discourse)& shows& that& schizophrenia& patients& use& less& referential& ties& (using&
pronouns& without& mentioning& a& subject& in& first& place)& and& more& lexical& ties&
(connected&words).&Also&patients&make&more&errors&than&controls&when&asked&
to&construct&complex&sentences&from&simple&phrases&(Hunt'test).'&
11. Theory'of'mind'refers&to&the&ability&to&understand&that&other&individuals&have&
mental& processes& similar& to& one’s& self,& leading& to& appropriate& behaviour& and&
conversation,& e.g.,& taking& turns& while& conversing& (as& others& also& think& and& so&
want& to& speak).& This& is& deficient& in& development& of& autistic& children& and& can&
become& acutely& deficient& (but& develops& normally)& in& schizophrenia' during&
psychotic&episodes.&This&can&explain&some&pragmatic&errors&in&FTD.&
12. Dysexecutive'problems&are&increasingly&being&proposed&as&the&basis&of&FTD.&
The& frontal& lobe& plays& a& significant& role& in& the& development& of& human&
language.& As& a& result,& loss& of& executive& functions& can& result& in& poor& planning,&
error&monitoring,&and&correction&of&speech&production.&
&
V.' DISORDERS'OF'MEMORY.'
&
Memory& #& short' term' (recent,' immediate,' working)& or& long' term' (remote).'
Remote& memory& can& be& explicit& (declarative& –& episodic' or' semantic)& or& implicit&
(nonddeclarative& or& procedural).& Episodic& memory& is& the& memory& of& specific& facts&
(knowing&that).&Semantic&memory&is&the&memory&of&skills&(knowing&how).&
&
Long&term&memory&consists&of&five&components&(the&5&R’s):&
&
! Registration/'encoding&(adding&new&information&to&the&stores).&This&
component&is&impaired&in&anterograde&amnesia&of&Korsakov’s&syndrome.&
! Retention/storage&(accurately&maintain&information&for&retrieval).&This&
component&id&impaired&in&retrograde&amnesia,&e.g.,&secondary&to&brain&injury&
(where&it&is&usually&of&short&duration&–&30&minutes).&Newer&memories&are&
more&vulnerable&than&old.&
! Retrieval'(the&ability&to&access&stored&information,&implicitly&(strategic&
retrieval)&or&explicitly&(direct)).&Direct&retrieval&is&dependent&on&the&medial&
temporal&lobes;&strategic&retrieval&is&dependent&on&the&ventromedial&
prefrontal&cortex.&Confabulation&is&an&impairment&of&retrieval.&
! Recall&is&the&effortful,&conscious&retrieval&of&information&at&a&given&moment.&
! Recognition&is&a&stimulus&triggered&retrieval&of&stored&information&based&on&
items&previously&learned&–&either&effortful&or&familiaritydbased&(e.g.,&
answering&a&multiple&choice&question).&Impairments&of&recognition&are&
described&in&Alzheimer’s&disease&and&Schizophrenia.&
23
&
Déjà' vu& is& the& feeling& of& having& seen& or& experienced& an& event& that& is& being&
experienced&for&the&first&time.&&
Jamais' vu& is& is& the& sensation& that& events& are& unfamiliar& although& they& have& been&
experienced& before.& .& Both& déjà& vu& and& jamais& vu& can& occur& as& a& normal& everyday&
experience,& but& can& also& be& a& nondspecific& symptom& of& a& number& of& disorders&
including&Temporal&Lobe&Epilepsy,&schizophrenia&and&anxiety&disorders11.&
Confabulation& is& a& falsification& of& memory& occurring& in& clear& consciousness&
associated& with& organic& states.& Suggestibility& is& a& prominent& feature& of&
confabulation.& It& is& often& described& in& Korsakov& syndrome.& There& can& either& be&
confabulation&of&embarrassment&or&of&a&fantastic&nature.&
In&pseudologia'fantastica&there&is&fluent&plausible&lying&(falsification&of&memory),&
with& extreme& and& grandiose& statements& being& made..& It& is& usually& associated& with&
dissocial&or&histrionic&personality&disorders.&
In& dissociative' fugue,& there& is& narrowing& of& consciousness,& wandering& away& from&
surroundings&and&subsequent&amnesia&of&the&episode.&There&is&marked&memory&loss&
and&loss&of&identity,&but&the&patient&can&carry&out&complicated&patterns&of&behaviour&
and& is& able& to& look& after& himself.& There& is& gross& discrepancy& between& memory& loss&
and&intact&personality.&
For& some& reason,& there& always& seems& to& be& an& MCQ& on& Ganser’s' syndrome,&
considered&as&a&hysterical&dissociative&disorder.&Ganser’s&syndrome&includes:&
! Approximate&answers&(dog&has&5&legs)&
! Clouding&of&consciousness&with&disorientation&
! Psychogenic&physical&symptoms&–&analgesia&&&hyperaesthesia&
! Pseudohallucinations&–&not#always#present.&
! Patients&with&Ganser’s&syndrome&are&amnesic&for&their&abnormal&behaviour.&
In&pseudodementia,&&
! Cognitive&changes&are&of&acute&onset.&&
! Depressive&symptoms&start&earlier&than&cognitive&defects.&&
! Premorbid&personality&may&be&impaired.&&
! A& diurnal& variation& of& cognitive& symptoms& may& be& seen& with& early&
morning&worsening&of&the&deficits.&&
! Confabulation&is&usually&seen&in&AD.&&
! Patients&with&depression&present&with&"&I&don’t&know"&answers;&they&do&
not&minimise&or&deny&difficulties&with&memory12,&13&
11
Scott,"A."I."F."(1998)."Mental"State"Examination."In"Companion"to"psychiatric"studies"(eds."E."C"Johnstone,"
C.P.L"Freeman,"&"A.K.Zealley)"Chapter"9."Churchill"Livingstone,"Edinburgh,"UK).
12
College"Seminars"in"general"adult"psychiatry"P"521
13
Kaplan"&"Sadock"Synopsis"of"Psychiatry"10e"P556
24
Note& that& cognitive& impairment& is& associated& with& poor& prognosis& in& depression.&
50%&of&them&develop&dementia&in&5&years&time.&&
&
VI.' DISORDERS'OF'MOOD.'
Disorders&of&mood/emotions&can&be&conceptualised&in&the&following&way:&
a.'Abnormalities'of'basic'emotions'
&
! Changes&in&intensity&&
o E.g.,&reduced:&Anhedonia,&depersonalisation&and&deaffectualisation&
o E.g.,&Increased:&Euphoria,&ecstasy&
! Changes&in&timing,&lability&and&appropriateness&to&the&situation&
o E.g.,&Delayed&grieving,&pathological&crying&or&laughter&
o Parathymia,&paramimia&
! Expression&of&emotion&
o E.g.,&blunting&and&flattening&
! Appropriateness&to&the&object&
o E.g.,&phobias,&freedfloating&affect&
b.'Abnormalities'of'physiological'arousal'associated'with'emotions'
! Alexithymia&and&somatisation&
c.'Abnormalities'of'evaluation'of'social'context'
! Negative&cognitive&schema&
! Prosopoaffective&agnosia&
! Receptive&vocal&dysprosody&
&
VIa.'Abnormalities'of'basic'emotions'
&
Anhedonia&was&coined&by&Ribot;&it&refers&to&the&inability&to&derive&pleasure&in&life,&
often&leading&to&diminished&interests&in&activities.&There&are&two&types&of&anhedonia;&
physical&anhedonia&and&social&anhedonia.&Physical&anhedonia&which,&usually,&
precedes&the&onset&of&the&disease,&represents&a&defect&in&the&ability&to&experience&
physical&pleasures,&such&as&pleasures&of&eating,&touching&etc.,&while&social&anhedonia&
represents&a&defect&in&the&ability&to&experience&interpersonal&pleasure,&such&as&
pleasure&of&being&with&people,&talking&etc.&Anhedonic&patients&are&usually&aware&of&
their&state,&but&apathetic&patients&are&often&not&aware&of&their&state.&&Physical&
anhedonia&is&more&commonly&linked&to&both&positive&and&negative&symptoms&of&
schizophrenia,&whereas&social&anhedonia&is&more&commonly&linked&to&depression.&In&
depression,&anhedonia&is&a&core&symptom,&especially&in&melancholic,&somatic&
syndrome.&In&schizophrenia,&&anhedonia&forms&a&part&of&the&negative&syndrome&of&
25
schizophrenia&within&the&&social&or&interpersonal&context,&as&opposed&to&the&
individual&personal/physical&context.&
Euphoria&is&a&state&of&excessive&cheerfulness,&illustrated&typically&in&mania&and&can&
appear&bizarre.&It&is&commonly&seen&secondary&to&organic&causes&such&as&frontal&lobe&
impairment.&
Hyperrekplexia&is&a&heightened&startle&reflex,&secondary&to&an&inherited&
abnormality&in&the&glycine&receptor&which&can&provoke&frontal&lobe&seizures.&
Parathymia,&described&by&Bleuler&in&schizophrenia,&is&an&unexpected,&inappropriate&
emotional&response.&It&is&exemplified&by&a&patient&reacting&to&sad&news&with&
cheerfulness&or&laughter,&or&perhaps&sadness&when&pleasure&might&be&the&expected&
response.&&Paramimia&refers&to&the&lack&of&integration&of&the&various&modes&of&
emotional&expression,&e.g.,&verbal&expression&being&incongruent&with&facial&
expression&of&emotion.&
Blunting&and&flattening&refer&to&the&lack&of&facial&expression,&decreased&
spontaneous&movements,&poverty&of&gesture,&poor&eye&contact,&affective&
unresponsiveness&and&lack&of&vocal&inflection.&&Blunting&has&the&added&implication&
of&a&lack&of&emotional&sensitivity&and&flattening&implies&a&limitation&of&the&usual&
range&of&emotion&expressed.&&Both&can&occur&in&schizophrenia.&
A&specific'phobia&is&a&fear&out&of&proportion&of&the&stimulus,&which&cannot&by&
reasoned&with,&it&is&not&under&voluntary&control&and&there&is&avoidant&behaviour&
(Mark’s&criteria).&&Anticipatory&anxiety&is&more&consistent&with&agoraphobia.&
VI'b.'Abnormality'of'physiological'arousal.'
&
Alexithymia&was&described&by&Sifneos.&Ad&Absence&or&defective&+&LEXI&–words&+&
THYMIA'']&emotion,&i.e.,&difficulties&in&using&words&to&express&emotions.&It&is&often&
accompanied&by&
1. Diminution&of&fantasy.&
2. reduced&symbolic&thinking&
3. Literal&thinking&concerned&with&details&&
4. Difficulties&in&recognising&one’s&own&feelings&
5. Difficulties&in&differentiating&body&sensations&and&emotional&states.&
6. Complaints&of&robotdlike&existence.&
It&is&especially&seen&in&psychosomatic&illnesses,&somatoform&disorders,&depression,&
PTSD,&personality&disorders&and&paraphilias.&Note&that&in&some&cultures,&especially&
south&Asian,&somatic&metaphors&are&often&used&to&describe&emotions.&
Somatisation&can&be&viewed&as&a&perception,&the&focus&being&on&the&somatic&
manifestations&of&a&mental&disorder&with&the&denial&or&minimisation&of&the&affective&
and&cognitive&changes.&
Melancholic&depression&is&a&subtype&of&major&depression&characterized&by&its&
‘endogenous’&nature;&anhedonia,&with&lack&of&mood&reactivity&(c.f.&atypical&subtype),&
26
combined&with&psychomotor&changes,&diurnal&variation&insomnia&or&appetite&
decrease.&
VI'c.'Abnormalities'of'evaluation'of'social'context'
&
Beck&highlighted&the&twodway&interaction&between&emotions&and&thoughts,&thus&
negative&cognitions&could&trigger&and&perpetuate&low&mood.&Negative&cognitive&
schemas,&Beck’s'cognitive'errors&include:&arbitrary&inferences,&selective&
abstractions,&overgeneralisations,&magnification&and&minimisation.&
Prosopoaffective'agnosia&refers&to&a&selective&deficiency&in&recognising&the&
emotional&expression&in&others’&faces.&It&has&been&seen&in&frontotemporal&dementia,&
right&thalamic&infarct&and&in&right&limbic&lesions.&It&is&distinct&from&prosopagnosia,&
the&inability&to&recognise&familiar&faces.&
Receptive'emotional'dysprosody'refers&to&a&selective&deficit&in&recognising&the&
emotional&content&of&speech.&This&can&often&be&associated&with&expressive'
emotional'dysprosody,&for&example,&in&Parkinson’s&disease.&
&Depression&is&often&difficult&to&diagnose&in&the&learning&disabled&group.&Irritability,&
psychomotor&agitation,&behavioural&problems&and&loss&of&adaptive&functions&may&be&
the&only&clues.&
VII.' DEPERSONALISATION'/'DEREALISATION14'
Depersonalisation&is&the&third&most&common&symptom&in&psychiatric&clinics.&It&is&
defined& as& a& change& in& selfdawareness& where& the& individual& feels& as' if& he& is& unreal.&
The& ‘as& if’& quality& differentiates& it& from& psychotic& states.& When& a& similar& feeling&
occurs& for& objects& and& environment& around& an& individual,& it& is& termed&
derealisation'(Mapother).&&
The& experience& is& always& subjective,& unpleasant,& and& invariably& associated& with&
affective& change.& Emotional& numbing,& loss& of& feelings& of& agency& and& selfdesteem,&
disturbed&body&image,&altered&perception&of&time,&memory&and&sensory&experiences&
of&all&modalities&are&reported.&&
Temporal& lobe& epilepsy& (lasting& for& minutes),& hysterical& dissociation,& depression,&
any& anxiety& state& (lasting& for& seconds),& anankastic& personality,& using& tricyclics,&
hallucinogens&and&cannabis&can&cause&depersonalisation.&A&similar&syndrome&can&be&
seen&in&fatigue&or&meditation/yoga&in&normal&people&in&the&absence&of&illness.&&
In&depersonalisation'disorder&(classified&as&a&dissociative&disorder&in&DSM&4)&the&
experience&is&recurrent&and&lasts&for&hours.&&Whilst&complicating&other&conditions,&it&
is&frequently&situational&and&almost&always&episodic.&
In& psychiatric& populations,& the& affect& associated& with& the& depersonalisation& is&
extremely&unpleasant&as&opposed&to&the&experience&in&normal&populations.&The&most&
common& psychiatric& cause& of& depersonalisation& is& depression& followed& by& anxiety&
disorders& (dissociation& is& actually& only& infrequently& associated).& The& patients& often&
do&not&report&the&symptom&as&it&is&difficult&to&express.&&
14
Noyes," R." and" Kletti," R." 'Depersonalisation" in" the" Face" of" LifeOthreatening" Danger:" A" Description'"
(Psychiatry,"1976,"39,"pp."19O27).
27
Depersonalisation&is&often&difficult&to&distinguish&from&derealisation&and&they&often&
occur&together&though&the&former&being&commoner.&&
Depersonalisation&may&be&related&to&pathology1of1familiarity&where&familiarity&of&
the&self&is&lost.&Depersonalisation&is&also&associated&with&déjà&vu&/&jamais&vu.&&
Desomatisation& refers& to& depersonalisation& that& is& localised& to& a& body& part.&
Deaffectualisation&is&an&extreme&form&of&anhedonia&where&the&capacity&to&feel&any&
emotion,& not& only& pleasure,& is& consistently& lost.& It& is& not& specific& to& any& organic&
syndrome.& It& is& never& reported& in& mania.& Patients& score& high& on& neuroticism& with&
introversion&being&predominant.&
Roth& described& Phobic' Anxiety' Depersonalisation' syndrome' typically& as& a&
married& female& in& her& thirties& with& agoraphobia& and& anxiety& which& worsens& with&
ECT&treatment.&This&is&now&only&of&historical&relevance.&
Other&states&in&which&a&patient&may&be&come&disconnected&from&the&self&include:&
Multiple'personality'disorder:&dissociative.&In&multiple&personality&disorder,&oned
way&amnesia&is&common.&(A&knows&B’s&existence,&B&is&not&aware).&&
Possession' states& (being& possessed& by& an& outside& force)& can& occur& as& a& part& of&
dissociation,& in& normal& religious& experiences,& or& under& hypnosis.& Possession& states&
where& consciousness& is& preserved& can& occur& in& schizophrenia,& whereas&
consciousness&is&altered&in&dissociative&states.&&
Lycanthropy'is&a&form&of&possession&where&the&patient&loses&awareness&and&identity&
and&believes&he&has&been&transformed&to&an&animal,&usually&a&wolf.&
Out& of& body& experiences,& autoscopy& (hallucinations),& depersonalisation& and&
transcendental& experiences& are& often& clustered& together& as& Near' Death'
Experiences.& A& & sensation& of& impending& ego& dissolution& is& noted& in& LSD&
intoxication.&
&
VIII.'' MOTOR/VOLITION'DISORDERS:'
Volitional'disorders:'
Scarfetter&(1980)&classified&the&components&of&volition&as&follows&(with&examples&of&
abnormalities):&
Need:&striving&towards&an&object,&state&or&action&that&is&experienced&as&a&desire.&
Appetite&
" Loss&in&anorexia&
" Increased&in&KleinedLevin&syndrome&
" Altered&in&Pica&
Thirst&
" Increased&in&diabetes&insipidus&(seen&secondary&to&Lithium)&
Prodaction&
28
" Reduced&in&Schizophrenia&and&depression&
" Increased&in&mania&
Sleep&
" Decreased&in&anxiety&&
" Increased&in&Pickwickian&syndrome&
&
Drive:&an&inclination&to&satisfy&an&innate&need&or,&as&an&action,&the&individual’s&basic&
mode&of&expression&&
" Reduced&in&schizophrenia&and&depression&
" Altered&in&fetishism&
Instinct:&an&innate&pattern&of&behaviour&that&leads&to&satisfaction&of&the&drive&
Motivation:&experienced&mood&or&affect&that&is&governed&by&needs&and&moves&us&to&
satisfy&them.&
" Reduced&in&anhedonia&
Will:&a&goalddirected&striving/intention&base&on&planned&motivation&
" Loss&in&apathy&of&schizophrenia&and&depression/abulia&
" Oscillating&in&ambitendancy&
" Abnormal&in&passivity&experiences&
Motor'disorders:'
The&motor&disorders&are&difficult&to&classify,&but&the&questions&seem&to&be&centred&on&
the&catatonic&signs,.&&Therefore&a&brief&description&of&each&of&the&catatonic&signs&will&
be& discussed.& Catatonia& is& a& state& of& increased& muscle& tone& at& rest,& abolished& by&
voluntary& activity,& distinguishing& it& from& dystonia/rigidity.& It& is& a& constellation& of&
symptoms& associated& with& a& number& of& disorders& (most& notably& nondconvulsive&
status& epilepticus).& Its& pathophysiology& is& thought& to& be& similar& to& NMS& and& its&
treatment& is& with& benzodiazepines,& antipsychotics& can& potentially& worsen& it.& An&
excited,& impulsive,& combative& subtype& of& catatonia& (with& autonomic& instability)& is&
more& associated& with& bipolar& disorder.& After& the& description& of& catatonia& by&
Kahlbaum&in&1874,&there&have&been&many&reports&on&this&subject,&with&up&to&40&signs&
of&catatonia&described.&Some&of&the&common&signs&are&detailed&below15.&
! Ambitendency:&Patient&appears&stuck&in&indecisive,&hesitant&movement.&
! Catalepsy:& The& state& of& persisting& in& unusual& postures& or& facial& expressions,&
regardless& of& outside& stimuli,& as& is& seen& in& schizophrenia& and& some& other&
diseases&of&the&nervous&system&
15
Bush%Francis%Catatonia%rating%scale.!In!Bush!G,!Fink!M,!Petrides,!Dowling!F,!Francis!A:!Catatonia,!I:!rating!
scale!and!standardized!examination.!Acta!Psychiatr!Scand!1996;!93:129–136
29
! Automatic# obedience:& Exaggerated& cooperation& with& examiner’s& request& or&

spontaneous&continuation&of&movement&requested.&
! Echopraxia#/#echolalia:&mimicking&of&examiner’s&movements&/&speech&
! Excitement:& Extreme& hyperactivity,& constant& motor& unrest& which& is&
apparently&nondpurposeful.&
! Gegenhalten:& Resistance& to& passive& movement,& which& is& proportional& to& the&
strength&of&the&stimulus,&appears&automatic&rather&than&wilful.&
! Grimacing:&Maintenance&of&odd&facial&expressions.&
! Impulsivity:&Patient&suddenly&engages&in&inappropriate&behaviour.&
! Mannerisms:& Odd,& purposeful& movements& (hopping,& saluting& passersdby& or&
mundane&movements).&The&abnormality&is&inherent&in&the&act.&
! Mitgehen:& “Anglepoise& lamp”& arm& raising& in& response& to& light& pressure& of& a&
finger&despite&instructions&to&the&contrary.&
! Mutism:&Verbally&unresponsive&or&minimally&responsive.&
! Negativism:& Apparently& motiveless& resistance& to& instructions& or& attempts& to&
move& or& examine& patient.& Contrary& behaviour,& does& exact& opposite& of&
instruction.&
! Obstruction:#&Obstruction&is&similar&to&thought&block&in&the&flow&of&speech.&A&
sudden&interruption&of&an&action.&
! Perseveration:& Repeatedly& returns& to& same& topic& or& persists& with& the& same&
movement.&
! Posturing# /# catalepsy:& Spontaneous& maintenance& of& postures,& including&
mundane&ones.&
! Rigidity:&Maintenance&of&a&rigid&position&despite&efforts&to&be&moved.&
! Staring:& Fixed& gaze,& little& or& no& visual& scanning& of& the& environment& and&
decreased&blinking.&
! Stereotypy:& Repetitive,& nondgoal& directed& motor& activity& (e.g.,& finger& play,&
repeated& touching,& patting,& rubbing& self).& The& abnormality& lies& in& the&
frequency/repetitive&nature&of&the&act.&
! Stupor:&Extreme&hypoactivity,&immobile,&minimally&responsive&to&stimuli&(the&
psychiatric&definition&has&less&emphasis&on&clouding&of&consciousness).&
! Verbigeration:&Repetition&of&phrases&or&sentences.&
! Waxy#flexibility:&During&redposturing&of&the&patient,&the&patient&offers&initial&
resistance& before& allowing& himself& to& be& repositioned,& similar& to& that& of& a&
bending&candle.&
Motor&retardation&is&not&a&negative&symptom&of&schizophrenia,&it&implies&slowness&
of&the&initiation,&execution&and&completion&of&physical&activity.&It&is&characteristic&of&
severe&depression.&
30
Stupor& as& described& above& can& occur& in& catatonia,& depression,& mania,& neurotic&
disorders,&and&organic&conditions.&In&catatonic&stupor&the&common&features&include,&
deadpan& facial& expression,& changes& in& muscle& tone,& catalepsy,& stereotypies& and&
incontinence&of&urine.&This&is&in&contrast&to&depressive&stupor&with&depressive&facies,&
normal& muscle& tone,& the& response& to& emotional& stimuli,& and& the& absence# of#
incontinence&in&depressive&stupor.&
! Astasia=abasia:&is&the&inability&to&stand&or&to&walk&in&a&normal&manner,&even&
though& normal& leg& movements& can& be& performed& in& a& sitting& or& lying& down&
position.& La& belle& indifference& (the& inappropriate& attitude& of& calm& or& lack& of&
concern&about&one's&disability)&features.&This&is&seen&as&a&conversion&disorder.&
&
IX.' Psychodynamic'Psychopathology:'
Defense& is& the& general& term& used& by& Freud& to& describe& ‘all& the& techniques& the& ego&
makes&use&of&in&conflicts&which&may&lead&to&neurosis’&(Freud,&1923,&The#Ego#and#the#
Id,).&The&function&of&defense&is&to&protect&the&ego&(typically&against&anxiety&resulting&
from&loss&of&love&object,&loss&of&object’s&love,&castration&and&superego&disapproval).&
Human& ego,& so& the& theory& goes,& is& beset& by& threats& to& its& survival& emanating& from&
the& id,& superego& and& the& outside& world,& and& is& therefore,& perpetually& on& the&
defensive.& The& conflict& caused& by& the& competing& needs& of& the& id& and& ego& cause&
anxiety.&There&are&three&sources&of&anxiety:&&&
(1) &Reality#threats:'This&is&the&most&basic&form&rooted&in&reality;&for&example&fear&of&
fire.&The&most&common&method&of&dealing&with&this&is&removing&oneself&from&the&
harmful&situation.&#
(2) Id# threats:& Anxiety& due& to& increased& instinctual& tension,& drives& and& impulses.&
This&arises&from&an&unconscious&fear&that&the&impulses&of&the&id&will&take&control&
at& an& inopportune& time.& This& type& of& anxiety& is& driven& by& a& fear& of& punishment&
that&will&result&from&expressing&the&id’s&desires&in&an&inappropriate&manner.#
(3) Superego#threats:#This&results&from&fear&of&violating&moral&or&societal&codes.&Also&
called,&moral&anxiety,&it&manifests&as&guilt&or&shame.&#
The& ego& deals& with& these& type& of& anxiety& by& using& ‘defense# mechanisms’# (see&
later).They& begin& as& healthy& adaptations& to& deal& with& anxiety& but& can& become&
pathological.& Defense# mechanisms1 can# thus# be# psychologically# healthy# or#
maladaptive,#but#tension#reduction#is#always#the#main#aim.&Freud’s&initial&list&of&ego&
defence& mechanisms& included& a& list& of& 11:& denial,& displacement,& intellectualization,&
fantasy,& compensation,& projection,& rationalization,& reaction& formation,& regression,&
repression& and& sublimation.& Anna& Freud& (1936)& later& added& more& to& this& list& and&
categorised& & & them& as& ranging& from& primitive& defences& (meaning& that& the& defences&
originated& in& infancy& and&function& on& a& global,& undifferentiated& level& in& a& person's&
total& mental/behavioural/feeling& experience),& to& more& mature,& advanced& defences,&
which& make& specific& transformations& of& thought,& feeling,& behaviour,& or& some&
combination.&See&table&for&definitions.&&
Defence'& Description'''
Denial& A&primitive&defence&mechanism&by&which&an&individual&
31
unconsciously&repudiates&either&(a)&some&painful&experience&or&
(b)&some&impulse&or&aspects&of&self.&&E.g.&Denial&of&trauma,&
illness.&
Displacement& The&process&by&which&affects&and&impulses&associated&with&one&
person&or&object&is&transferred&to&another&E.g.&‘Blaming&the&
messenger,&‘kicking&the&cat’&
Intellectualisation& Avoiding&dealing&with&anxiety&producing&information&or&
unacceptable&emotions&by&focusing&on&their&intellectual&aspects.&
Typically&seen&in&adolescents&when&abstract&discussions&and&
speculations&about&philosophical&and&religious&topics&tend&to&
avoid&conflictual&ideas&or&feelings&
Projection& The&process&by&which&specific&unacceptable&impulses,&wishes&or&
parts&of&the&self&are&externalised&and&attributed&to&another&
person,&i.e.&‘put&into’&or&imagined&to&be&located&in&some&other&
person.&E.g.&Calling&another&person&miserly.&When,&in&fact&you&
are&stingy&with&money.&Projection&is&thought&to&be&the&
mechanism&involved&in&the&formation&of&persecutory&delusions.&
E.g.&In&erotomania&the&subject&projects&is&in&love&with&the&other&
person&but&believes&he#is&in&love&with&her.&
Rationalisation& Providing&a&logical&or&rational&reason&as&‘justifications’&for&
actions/thoughts&as&opposed&to&accepting&the&real&reason&
Reaction& Defensive&process&by&which&an&unacceptable&impulse&is&turned&
formation&& into&its&opposite.&E.g.&mother&who&did&not&want&the&child&
becomes&overprotective&of&the&child.&
Regression& A&return&to&an&earlier&mode&of&functioning,&i.e.&to&a&previous&
stage&in&the&psychodsexual&development.&May&be&precipitated&by&
trauma,&guilt,&depression&or&by&physical&illness&
Repression&& Impulses&or&memories&that&are&too&painful&or&frightening&are&
excluded&from&conscious&awareness.&E.g.&‘forgetting’&past&
trauma.&Different&from&suppression&which&is&a&conscious&
process&
Sublimation& Changing&the&form&of&the&unacceptable&drive&to&one&that&is&
acceptable.&Redirecting&libidinal&energy&from&the&original&
aim/objects&to&more&socially&acceptable&aims&such&as&artistic&
creation,&work&altruistic&activities&and&so&on.&E.g.&A&man&torn&by&
aggressive&sexual&impulses&takes&to&missionary&work.&
&
Some%other%defense%mechanisms%are:%
32
Undoing:% often% called% magical% undoing% % this% refers% to% ‘making% something%
unhappen’%E.g.%compulsive%hand%washing%to%prevent%something%‘bad’%happening%
to%loved%ones.%It%is%thought%to%be%the%one%of%the%mechanisms%involved%in%obsessions%
and%compulsions.%
Turning+against+the+self%described%by%Anna%Freud%refers%to%redirecting%aggressive%or%
sadistic%impulses%towards%oneself.%Thought%to%be%one%of%the%defense%mechanisms%
involved%in%depression%(‘aggression%turned%inwards)%
Isolation:+ The% action% is% isolated% from% its% affect% separating% a% painful% idea% or% event%
from% feelings% associated% with% it% thereby% altering% its% emotional% impact.% Feeling%
aggressive% thoughts% (‘I% will% plunge% a% knife% into% her’)% occur% without% the% emotion%
(anger)%appropriate%to%such%thoughts.%It%typically%occurs%in%obsessions%
Defense+ mechanisms+ in+ OCD:% Isolation,% reaction% formation% and% undoing;% in%
developmental%terms%regression%to%anal%stage.%
George+ Valliant% later% classified% defense% mechanisms% into% ‘levels’% ranging% 1% to% 4.%
These%are%‘psychotic’%(e.g.,%delusional%projection),%‘immature’%(e.g.,%fantasy,%acting%
out),% ‘neurotic’% (e.g.,% displacement,% reaction% formation),% and% ‘mature’% (e.g.,%
humour,%altruism)%defenses.%
Otto+Kernberg%proposed%projection,%denial,%dissociation%or%splitting,%to%be%involved%
in% people% with% Borderline% Personality% Disorders,% labelling% them% ‘borderline%
defence%mechanisms’.%
Common'Defence'Mechanisms'and'levels'of'maturity'
'
Primitive'' Neurotic' Mature'
Projective& Denial& Humour& &
identification& Displacement& Sublimation&& &
Introjective& Intellectualisation& Altruism&
identification&& Isolation& & &
Withdrawal&& Reaction& &
Autistic&Phantasy& formation&
&
Omnipotent& control&& Rationalisation&
Primitive& idealization&& Repression& &
Splitting&of&the&ego& Suppression& &
Defence& mechanisms& are& often& dichotomised& into& primitive& and& mature,& but& they&
can&also&be&viewed&as&4&levels&(with&examples,&below):&
1.&‘Psychotic&defences’,&severely&pathological.&
Denial:&claiming/believing&that&what&is&true&is&actually&false.&
Distortion:'gross&reshaping&of&reality&to&suit&needs&
2.& ‘Immature& defences’,& found& in& adults& and& more& commonly& adolescents.& Cause&
trouble&in&overuse.&
Projection:&attributing&uncomfortable&feelings&to&others.&&
33
Acting' Out:& performing& an& extreme& behaviour& in& order& to& express& thoughts& or&
feelings&one&feels&incapable&of&otherwise&expressing.&&
Somatisation:' transformation& of& negative& feelings& towards& others& into& physical&
experience&or&feeling&toward&self.&
Passive'aggression:&indirect&aggressive&behaviour&towards&others.&
Fantasy:' retreat& into& fantasy& in& order& to& resolve& inner& and& outer& conflicts.& (A& rich&
fantasy& life& is& associated& with& satisfaction& with& life& and& emotional& stability& rather&
than&with&neuroticism.&Depressed&people&find&it&difficult&to&fantasise&as&the&exercise&
of&fantasising&becomes&very&difficult.)&
3.&‘Neurotic&Defences’,&common&in&adults,&short&term&coping,&long&term&problems&
Dissociation:&Dissociation&is&when&a&person&loses&track&of&time&and/or&person,&and&
instead& finds& another& representation& of& their& self& in& order& to& continue& in& the&
moment.&
Intellectualisation:& the& overemphasis& on& thinking& when& confronted& with& an&
unacceptable& impulse,& situation& or& behaviour& without& employing& any& emotions&
whatsoever& to& help& mediate& and& place& the& thoughts& into& an& emotional,& human&
context.&
Reaction' Formation:& Reaction& Formation& is& the& conversion& of& unwanted& or&
dangerous& thoughts,& feelings& or& impulses& into& their& opposites.& For& instance,& a&
woman&who&is&very&angry&with&her&boss&and&would&like&to&quit&her&job&may&instead&
be&overly&kind&and&generous&toward&her&boss&and&express&a&desire&to&keep&working&
there&forever.&&
Repression:&pushing&uncomfortable&thoughts&into&the&subconscious&
Rationalization:&creating&false&but&credible&justifications.&
Regression:&‘going&back&to&acting&as&a&child’.&
Displacement:&redirecting&emotions&to&a&substitute&target.&
4.& ‘Mature& defences’,& have& origins& in& immature,& optimized& for& success& in&
life/relationships.&
Sublimation:& redirecting& 'wrong'& urges& into& socially& acceptable,& positive& actions,&
behaviours&or&emotions.&
Humour:&overt&expression&of&ideas/feelings&in&order&to&give&pleasure&to&others.&
Altruism:&constructive&service&to&others&to&bring&personal&satisfaction&
Suppression:'consciously&pushing&unacceptable&thoughts&into&the&preconscious&to&
postpone& dealing& with& it& in& order& to& cope& with& the& present& reality;& accepting& the&
thoughts&and&making&it&possible&to&access&them&later.'
'
'
34

Paper A Psychopathology - Notes

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Paper A Psychopathology - Notes

Uploaded by

Copyright:

Available Formats

Paper A: PSYCHOPATHOLOGY

I.& GENERAL&PSYCHOPATHOLOGY.& 2&

II.& PERCEPTUAL&DISORDER:& 2&

III.& THOUGHT&DISORDERS:& 9&

IV.& DISORDERS&OF&SPEECH.& 20&

V.& DISORDERS&OF&MEMORY.& 23&

VI.& DISORDERS&OF&MOOD.& 25&

VII.& DEPERSONALISATION&/&DEREALISATION& 27&

VIII.& &MOTOR/VOLITION&DISORDERS:& 28&

IX.& PSYCHODYNAMIC&PSYCHOPATHOLOGY:& 31&

Cotards& syndrome& is& severe& depression& with& nihilistic& and& hypochondriacal&

• Interpenetration& (irrelevant& thought& penetrating& ondgoing& stream& of&

Type' Spontaneou Comprehend Repeats' Names'

! Automatic# obedience:& Exaggerated& cooperation& with& examiner’s& request& or&

You might also like