psychopathology 6th year revised

Psychopathology

Department of Psychiatry

University of Zambia

Psychopathology

The study of abnormal states of mind is

know as psychopathology a term which

denotes two distinct approaches

Phenomenological

Psychopathology(phenomenology)

Psychodynamic psychopathology

Experimental Psychopathology

PHENOMENOLOGICAL

PSYCHOPATHOLOGY

It is an attempt to understand the signs and

symptoms observed in the patient. It is

concerned with objective description of

abnormal states of mind.

The doctor must try to understand how the

patient fulfils social roles such as worker,

spouse, parent, friend, or sibling.

He should consider what effect the disorders

of function have had upon the remaining

healthy parts of the person.

The doctor will gain such understanding

only if he is prepared to spend time listening

to patients and their families and to interest

himself in every aspect of their lives

Once the clinician has elicited a patient’s

symptoms and signs he needs to:

Decide how far these phenomena

resemble or differ from those of other

psychiatric patients.

Determine whether the clinical features

form a syndrome，which is a group of

symptoms and signs that specify a

particular diagnosis

The purpose of identifying a syndrome is

to be able to plan management and

predict the likely outcome by reference to

accumulated knowledge about the cause

treatment, and outcome of the same

syndrome

PSYCHOSIS

The traditional meaning of the term psychotic

emphasized loss of reality testing and impairment

of mental functioning manifested by delusions,

hallucinations, confusion, and impaired memory.

In the most common psychiatric use of the term,

psychotic became synonymous with severe

impairment of social and personal functioning

characterized by social withdrawal and an inability

to perform the usual household and occupational

roles.

According to the American Psychiatric Glossary

of the American Psychiatric Association, the term

psychotic means grossly impaired reality testing.

The term can be used to describe the behavior of a

person at a given time or a mental disorder in which

at some time during its course all persons with the

disorder have grossly impaired reality testing.

With gross impairment in reality testing, persons

incorrectly evaluate the accuracy of their

perceptions and thoughts and make incorrect

inferences about external reality, even in the face of

contrary evidence.

The term psychotic does not apply to minor

distortions of reality that involve matters of relative

judgment. For example, depressed persons who

underestimate their achievements are not described

as psychotic; those who believe that they have

caused natural catastrophes are so described.

NEUROSIS

A mental disorder in which the predominant

disturbance is a symptom or group of symptoms

that is distressing to the individual and is

recognized by him or her as unacceptable and

alien (ego-dystonic);

Reality testing is grossly intact.

A neurosis is a chronic or recurrent non-psychotic

disorder characterized:

mainly by anxiety,

experienced or expressed directly or is altered

through defense mechanisms;

Appears as a symptom, such as an obsession, a

compulsion, a phobia, or a sexual dysfunction.

Behavior does not actively violate gross social

norms (though it may be quite disabling). The

disturbance is relatively enduring or recurrent

without treatment, and is not limited to a transitory

reaction to stressors.

There is no demonstrable organic etiology or

factor.

The term neuroses encompasses a broad range of

disorders of various signs and symptoms. As such,

it has lost precision, except to signify that the

person's gross reality testing and personality

organization are intact. However, a neurosis can

be, and usually is, sufficient to impair the person's

functioning in a number of areas.

Disorder of perception

Perception is the process of becoming

aware of what is presented through the

sense organs

Disorder of perception

Illusions

Illusions are misperception or misinterpretation of

external stimuli. They are most likely to occur when the

general level of sensory stimulation is reduced.

Thus at dusk a common illusion is to misperceive the

outline of a bush as that of a man.

Illusions are also more likely to occur when the level of

consciousness is reduced, as for example in an acute

brain syndrome.

Illusions occur more often when attention is not

focused on the sensory modality, or when there is a

strong affective state

Hallucination A hallucination is a percept experienced in the

absence of a external stimulus to the sense organs,and with a similar quality to a true percept. Ahallucination is experienced as originating in theoutside world (or within one's own body) like apercept and not within the mind like imagery

Hallucinations are not restricted to the mentally ill.A few normal people experience them, especiallywhen tired. Hallucinations also occur in healthypeople during the transition between sleep andwaking

Hallucinations

Type of hallucinations

Hallucinations may be auditory, visual, tactile,gustatory, olfactory, or of deep sensation

l) Auditory hallucinations may be experienced as noises,music, or voices.

Voices may be heard clearly or indistinctly; they mayappear to speak words, phrases, or sentences; and theymay address the patient (Second Person) or sound as iftalking to one another, referring to the patient as 'he'or 'she' (third person hallucinations).

Sometimes voices seem to anticipate what the patientthinks a few moments later, or speak his own thoughtsas he thinks them, or repeat them immediately after hehas thought them; the auditory hallucinations oftenseen in schizophrenic patients

2) Visual hallucinations may also be elementaryor complex. They may appear normal orabnormal in size; if the latter, they are moreoften smaller than the corresponding realpercept; the visual hallucinations will be seen inthe patients suffering from derangedconsciousness, epilepsy, substance misuse andschizophrenia

3) Olfactory and gustatory hallucinations arefrequently experienced together, often asunpleasant smell or tastes

4) Tactile hallucinations may be experienced as

sensations of being touched, pricked, or

strangled. They may also be felt as movements

just below the skin which the patient may

attribute to insects, worms or other small

creatures burrowing through the tissues

(Cocaine bugs);

tactile hallucination often occur in the patients

with drug dependence, schizophrenia, and

hysteria

Hallucinations may occur in all kinds of

psychosis, in hysterical neuroses and at times,

among healthy people. Therefore the finding of

hallucinations does not itself help in diagnosis.

However, certain kinds of hallucinations do

have important implications for diagnosis

Delusions

A delusion is a belief that is firmly held despite

evidence to the contrary and is not a

conventional belief that the person might be

expected to hold given his educational and

cultural background

This definition is intended to separate

delusions, which are indicators of mental

disorder, from other strongly held beliefs found

among healthy people.

Delusions have to be distinguished from the

shared beliefs of people with a common

religious or ethnic background; For example a

person who has been brought up to believe in

spiritualism is unlikely to change his

convictions when presented with contrary

evidence that convinces a non-believer

Although delusions are as a rule false beliefs,

in exceptional circumstances they can be true

or subsequently become true. Thus a man may

develop a jealous delusion about his wife, in

the absence of any reasonable evidence of

infidelity.

Even if the wife is being unfaithful at the time,

the belief is still delusional if there is no

rational grounds for holding it.

Exceptions of this kind remind us that it is not

the falsity of the belief that determines whether

it is delusional but the nature of the mental

processes that led up to it

Conversely, it is a well-known pitfall of clinical

practice to assume that an idea is false because

it is odd, instead of checking the facts or

finding out how the idea was arrived at.

For example, improbable stories of persecution

by neighbors or of attempts at poisoning by a

spouse may turn out to be correct and to be

arrived at through normal processes of logical

thinking

Types of delusion

For the purposes of clinical work delusions are

grouped according to their main themes.

This is useful because there is some

correspondence between these themes and the

major forms of mental illness.

However it is important to remember that

there are many exceptions to the broad

associations mentioned below

Persecutory delusions are most commonly

concerned with persons or organizations that are

thought to be trying to inflict harm on the patient,

damage his reputation, make him insane, or poison

him. Such delusions are common but of little help

in diagnosis, for they can occur in organic states,

schizophrenia, and affective psychosis.

However, the patient’s attitude to the delusion may

point to the diagnosis: in a severe depressive

disorder he characteristically accepts the supposed

activities of the persecutors as justified by his own

guilt and wickedness, but in schizophrenia he

resents them often angrily.

In assessing such ideas, it is essential to

remember that apparently improbable

accounts of persecution are sometimes true and

that it is normal in certain cultures to believe in

witchcraft and to ascribe misfortune to the

malign activities of other people

Delusions of reference are concerned with the

idea that objects, events, or people have a

personal significance for the patient: for

example, an article read in a newspaper or a

remark heard on television is believed to be

directed specifically to himself.

Delusions of reference may also relate to

actions or gestures made by other people which

are thought to convey something about the

patient

Grandiose to expansive delusions are beliefs ofexaggerated self-importance. The patient maythink himself wealthy, endowed with unusualabilities, or a special person. Such ideas occurin mania and schizophrenia

Delusions of guilt and worthlessness are foundmost often in depressive illness, and aretherefore sometimes called depressive delusions.Typical themes are that a minor infringementof the law in the past will be discovered andbring shame upon the patient, or that hissinfulness will lead to divine retribution on hisfamily

Nihilistic delusions are strictly speaking beliefs

about be non-existence of some person or thing,

but they are extended to include pessimistic

ideas that the patient's career is finished, that

he is about to die, that he has no money, or

that the world is doomed, They are associated

with extreme degrees of depressive mood

changed

HypochondriacaI delusions are concerned with

illness The patient may believe wrongly, and in

the face of all medical evidence to the contrary,

that he is ill. Such delusions are more common

in time elderly, Reflecting the increasing

concern with health among mentally normal

people at this time of life

Delusions of jealousy; Othello’s Syndrome:these are more common among men. Not alljealous ideas are delusions; less intense jealouspreoccupations are common, and someobsessional thoughts are concerned with doubtsabout the spouse's fidelity However, when thebeliefs are delusional they have particularimportance because they may lead todangerously aggressive behavior towards theperson thought to be unfaithfu1

Special care is needed if the patient follows thespouse to spy on her, examines her clothes formarks of semen, or searches her handbag forletters

Sexual or amorous delusions; Erotomania：Both sexual and amorous delusions are rare

but when they accrue they are more frequent

among women. A woman with amorous

delusions believes that she is loved by a man

who is usually inaccessible, often of higher

social status, and someone to whom she has

never even spoken

Delusion of control ：The patient who has adelusion of control believes that his actions,impulses, or thoughts are controlled by anoutside agency

Because the symptom strongly suggestsschizophrenia, it is important not to record itunless definitely present. Sometimes thesedelusions are confused with the experience ofhearing hallucinatory voices giving commandsthat the patient obeys voluntarily

At other times it is misdiagnosed because thepatient has mistaken the question for one aboutreligious belief concerning the divine control ofhuman actions

Delusions concerning the possession of thoughts:

Healthy people take for granted the experience

that their thoughts are their own. They also

assume that thoughts are private experiences

which other people can only know if they are

spoken aloud, or if facial expression, gesture or

action gives them away. Patients with delusions

about the possession of thoughts may lose these

convictions in several ways

Those who have delusions about thoughtinsertion believe that some of their thoughts arenot their own but have been implanted by anoutside agency. This differs from theexperience of obsessional patient who may bedistressed by unpleasant thoughts but neverdoubts that they originate within his own mind.The patient with a delusion of thought insertionwill not accept that the thoughts haveoriginated in his own mind

Patients who have delusions of thought

withdraw believe that thoughts have been

taken out of the mind. This delusion usually

accompanies thought blocking, so that the

patient experiences a break in the flow of

thoughts through his mind and believes that

the ‘missing' thoughts have been taken away

by some outside agency, often his supposed

persecutors

In delusions of thought broadcasting the

patient believes that his unspoken thoughts

are known to other people, through radio,

television, or in some other way. All three of

these symptoms occur much more commonly

in schizophrenia than in any other disorder

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