clinical psychopathology
TRANSCRIPT
892019 Clinical Psychopathology
httpslidepdfcomreaderfullclinical-psychopathology 15
Learning objectives- Accurate gathering and collating of clinical data
- Understanding the significance of clinical data
- Applying data on actual clinical situations
Psychiatric skills knowledge and attitudes- Skills on what to ask how to ask and when to
ask tricky at times
- Knowledge of how each sign and symptom is
defined very crucial
- Attitudes on how to respond appropriately to
various patientssituations takes time
Diagnosis in Psychiatry
Primarily through 1 Psychiatric History (anamnesis)
Predisposing factors (family history)
Precipitating factors (stressors drugsalcohol)
2 Mental Status Examination
Signs and symptoms
Secondarily through 1 PE (with neuro exam) EEG
2 Imaging techniques (CATscan MRI PETscan)
3 Laboratory tests ( to rule out GMCs eg drugs of
abuse liver thyroid abnormalities)
Core Clinical Signs and SymptomsDisorders of Perception
983085 Hallucination
Disorders of Thought and Speech
983085 Delusions
983085 Thought alienation
983085 Obsessions and Compulsions
983085 Flight of ideas
983085 Looseness of Associations
Disorders of Emotion
983085 Manic Mood (different levels)
983085 Depression
983085 Disorders of Memory
983085 Amnesias
983085 Dysmnesias
Other Disorders
983085 experience of the self
983085 Consciousness
983085 motor functions
1 Disorders of PerceptionHallucination arguably the most important
symptom in clinical psychiatry
ldquoPerception without an objectrdquo ( Esquirol )
-hear something that is not there hears voices
ldquoPerceived in external objective spacerdquo ( Jaspers )
Differentiate from pseudohallucination
Hallucinationsndash false sensory perception not associated with
real external stimuli there may or may not be
delusional interpretation of the hallucinatory
experience
Pseudo-hallucination983085 -The main difference between someone with a
pseudo-hallucination and someone experiencing
schizophrenic hallucination is that the person with
schizophrenia will think that it is real and engage in
the hallucination whereas the person with a pseudo-
hallucination will often recognize that it is not real
Auditory Hallucination983085 - Most important symptom in psychotic disorders
-High in reliability frequency and specificity in
schizophrenia (WHO IPSS )
983085 - Some are not pathological like hypnagogic and
983085 hypnopompic types (dropping off to sleep
983085 awakening)
983085 Auditory ndash false perception of sound usually voices but
also other noises such as music
983085 Most common hallucination in psychiatric disorders
(schizophrenia)
983085 High in reliability frequency and specificity
983085
983085 - some auditory hallucinations are not pathological like
983085 Hypnagogic ndash false sensory perception occurring while
falling asleep non-pathological
983085 Hypnopompic ndash false perception occurring while
awakening from sleep non-pathological
983085
Schizophrenic Depressive
Multiple Voices Single Voice
Running commentary Staccato
Third person AbusiveDerogatory
Clinical Psychopathology
Dr Cabuquit 080910
892019 Clinical Psychopathology
httpslidepdfcomreaderfullclinical-psychopathology 25
In both schizophrenic and depressive types be aware
of the commanding quality of the voice(s)
Command HallucinationsAlso known as ldquoimperative hallucinationsrdquo
- Patients who hear voices should be asked ifthe voices have commanding quality
- About 23 of Filipino patients obey voicesrsquo
commands (Cabuquit )
- Obeyed commands usually prolonged
intense and frequent (Cabuquit )
Significance of Mumbling Episodes - Patients who mumble actually hear voices
(even when they deny it)
- Mumbling is the patientsrsquo way of responding
to the voices
- Usually verified by observant relatives
Organic Hallucinations
Visual- More common in organic states like
delirium tremens and dementias (
lsquoLilliputianrsquo type)
Lilliputian Type ndash false perception in
which objects are seen as reduced in size
also termed micropsia
- All varieties from elementary forms likeflashes of light to fully formed people or
animals
- Can be with simultaneous auditory
hallucination
ndash false perception involving sight
consisting of both formed and unformed
images
- Most common in medically determined
disorders
Olfactory (Smell) false perception of smell
- Temporal Lobe Epilepsy (TLE) attacks areusually ushered in by an unpleasant odour like
burning rubber or rotten food
Gustatory (Taste) false perception of taste
- Usually caused by uncinate seizures could
also be due to TLE when associated with
salivation chewing and sniffing movements
Tactile (Haptic) false perception of taste
lsquoCocaine bugrsquo or formication ndash feeling of
small animals crawling all over the body or
under the skin associated with delusion ofpersecution
Sexual sensations (eg being masturbated
to orgasm) seen in some schizophrenics
lsquoPhantom limbrsquo phenomenon- most
common organic somatic hallucination occurs
in about 95 of all amputations could be very
painful
2 Disorders of Thought
- Delusional Triad a belief that is
- false ndash no logic no proof
- fixed
- incongruent with the personrsquos socio-
cultural and religious background
- Overvalued Idea an idea that is
false fixed and congruent with the
personrsquos background
Main Types of Delusions
Persecutory- most common in schizophrenia
- personrsquos false belief that he or she is being
harassed cheated or persecuted often found in
litigious patients who have a pathologic
tendency to take legal action because of
imagined mistreatment
Grandiose ndash most common in mania
- personrsquos exaggerated conception of his orher importance power or identity
Guilt- most common in depression
983085 - False feeling of remorsegrief
Jealousy (Othellorsquos syndrome)- most common
in delusional disorders drugs and alcohol
abuse aggravating factors violence frequent
983085 - False belief derived from pathological
983085 jealousy about a personrsquos lover being
983085 unfaithful
- Delusions have a tendency to be acted upon
Schizophrenic vs Depressive Delusions
Schizophrenic Delusions-Delusion of control- most reliable
symptom false feeling that a personrsquos
will thoughts or feelings are being
controlled by external forces
- Primary delusional perception
(Both are parts of First Rank Symptoms)
892019 Clinical Psychopathology
httpslidepdfcomreaderfullclinical-psychopathology 35
Depressive DelusionsDelusion of guilt- could lead to suicide
Nihilistic delusion - false feeling that self
others or the world is nonexistent or coming
to an end
Thought AlienationThought Echo983085 - A form of auditory hallucination in which the
patient hears his thoughts spoken aloud either
simultaneous with him thinking it or moment or
two afterwards
Thought Insertion983085 Delusion that thoughts are being implanted in a
personrsquos mind by other persons or forces
Thought Withdrawal983085 Delusion that thoughts are being removed from a
personrsquos mind by other persons or forces
Thought Broadcasting983085 Delusion that a personrsquos thoughts can be heard by
others as though they were being broadcast
through the air
Thought Blocking983085 An objective phenomenon in which the patient
abruptly breaks off his conversation and is silentfor a few seconds and then resumes on a different
topic Subjectively they experience a complete
cessation of all thought
All of the above are commonly seen in
schizophrenia the first four are parts of Schneiderrsquos
First Rank Symptoms
OBSESSIONS AND COMPULSIONSObsessions ndash internal resistance subjective
compulsion983085 Pathological persistence of an irresistible thought
or feelings that cannot be eliminated from
consciousness by logical effort
983085 Associated with anxiety
Compulsions ndash simply the motor components of
obsessions
983085 pathological need to act on an impulse that if
resisted produces anxiety
983085 Repetitive behavior in response to an obsession or
performed according to certain rules with no true
end in itself other than to prevent something from
occurring in the future
Contrast Ideas ndash similar to obsessions
983085 With internal resistance but without subjective
compulsion
Most Common Types of OCs-Handwashing eg Lady Macbethrsquos
-Re-checkingrepeatingrearranging
-Examining things in great detail
3 Disorders of Speech
Looseness of Association - flow of thought in which
ideas shift from one subject to another in a completely
unrelated way
983085 Common in schizophrenia
983085 A schizophrenic talking (desultory manner)
lsquo Itrsquos your cross to stand down considering
itrsquos Saturday The Episcopal twitter neon sign in
occupational street is eating jackass moon in the
nearby tropic of cancer of Jupiter and Pluto So
will you tie me up and down in the percolating
stairs Or shall we eat nincompoop pizzaiersquo
-Notice how difficult it is to understand what
the patient is talking about what about
lsquopizzaiersquo
Flight of Ideas ndash rapid continuous verbalizations orplays on words produce constant shifting from one
idea to another ideas tend to be connected association
of words similar in sound but not in meaning words
have no logical connection may include rhyming and
punning
983085 Common in mania
lsquo The king is standing see HEY The king king is
standing ding ding a ling sing sing HEY HEY
(Laughs) Bird on the wing wing pilot is a harlot
on the trot and he is always hot Irsquom so hotrsquo
- Observe the rhyming punning and clanging
Neologism ndash forming new words
983085 Most specific symptom of schizophrenia
MutismDifferential diagnoses
bull Catatonic schizophrenia ndash markedly
slowed motor activity often to the point of
immobility amp seeming unawareness of
surroundings
bull Hysterical mutism ndash a diagnostic label applied to
state of mind one of unmanageable fear or
emotional excess The fear is often centered on abody part most often on an imagined problem
892019 Clinical Psychopathology
httpslidepdfcomreaderfullclinical-psychopathology 45
with that body part People who are hysterical
often lose self-control due to the overwhelming
fear
bull Organic stupor ndash eg demyelinating disease
bull Depressive stupor
Talking to Mute Patients
-lsquoWhispering Techniquersquo ( Cabuquit ) Literally a whispering conversation between
doctor and patient
Good technique to differentiate one mute
patient from another
Best results with hysterical mutism
depressive schizophrenic organic patients
1 Organic stupor Speak slowly and loudly
and hold the patientrsquos hand
2 Depressive stupor Go near the patient
speak with a firm calm and reassuring voice
may hold patientrsquos hand
3 Schizophrenic mutism Speak confidently
normal tone holding hands not advised
4 Hysterical mutism Stay close hold hands
and use your best voice do this with a
companion
4 Disorders of Emotion-Depressed Mood (LAPEL by Cabuquit )
Low mood (depressed sad) Anhedonia ( loss of pleasure or interest)
Poor appetite (with weight loss)
Early morning awakening (3-4 hrs earlier)
Low self-esteem ( guilt feelings suicidal
ideasattempts hopelessness)
Eliciting LAPEL
Low mood lsquoHow do you feel these last few weeks Have you
felt depressed How do you feel upon waking
Anhedonia (loss of interest)
lsquoWhat have you been doing lately Any change in
your usual activities Poor appetite
Any change in your appetite Any weight loss
Early morning awakening lsquoWhatrsquos your usual waking time Any change lately
(3-4 hours earlier than usual)
Low self-esteem lsquoHave you felt helpless hopeless lately Any guilt
feelings Suicidal ideas Attempts
Caution Patients who admit to harboring suicidal
ideas require extra attention look out for lsquosmiling
depressivesrsquo
Rating LAPEL
Positive responses to three out five questions
indicate that the patient is clinically depressed
(two of the three responses should be low
mood and anhedonia)
Specificity of 94Sensitivity of 96
(Brody and Spitzer 2002)
Depression Guilt and Suicide-Depressed patients should always be asked
about suicidal ideas or attempts
-Guilty feelings need for punishment if
no one would mete punishment would
punish himself best way is by suicide
(presence of command hallucination the
risk)
-About 10 of depressed patients die from it
more women than men attempt it more men
than women are successful
Mania The other end of the spectrumManic Mood Gradations (LEXUS byCabuquit)E LEvated m (cheerfulnessconfidence)rarr
E X pansive m (disinhibition)rarr
EU phoric m (unrestrained grandiose feelings)
rarr EcStatic mrarr (intense feelings of
rapture)- Manic stupor - rare
- Hypomania- milder form
- Bipolar- with depression and mania
Mania and its lsquooffspringsrsquo-The manic mood gives birth to
-hyperactivity
- pressure of speech
-grandiosity
-disinhibition eg sexual
-lack of sleep
-irritability ( when frustrated )
5 Disorders of Memory-Amnesias (loss of memory)
Hysterical or Dissociative
Organic ( acute sub-acute chronic)
-Dysmnesias (distortion of memory)Confabulation
Deacutejagrave vu jamais vu
892019 Clinical Psychopathology
httpslidepdfcomreaderfullclinical-psychopathology 55
AmnesiasHysterical or dissociative
complete loss of memory and loss of
identity temporary intact personality
Organic
acute- (eg head injury) retrogradeanterogradeamnesia
sub-acute- (eg Korsakoff ) no new memories
chronic - (eg dementias) loss of recent memory
rarr remoterarr global irreversible personality
Dysmnesias
-Confabulationdetailed false description of an event which never
happened patient tries to lsquofill in the gapsrsquo seen in
alcoholics and hysterics and chronic schizophrenics
-Deacutejagrave vusomething new is remembered as something old
-Jamais vusomething old is remembered as something
new
Both observed in complex partial seizures
6 Other DisordersDisorders of Experience of the Self
depersonalization
derealization
Disorders of Consciousness
lsquotwilightrsquo statefugue state
Disorders of Motor Function
waxy flexibility
lsquooccupational deliriumrsquo
7 SUMMARY
The most important symptom in clinical
psychiatry is hallucination
Think of schizophrenia when Schneiderrsquos First
Rank Symptoms are prominent
Depressed patients should always be asked
about suicidal ideas or attempts
Command hallucinations increase the risk of
untoward behaviours
In depression think of LAPEL
In mania think of LEXUS
In mutism think of CHODE
Looseness of association is commonly seen in
schizophrenia
Flight of ideas is commonly seen in mania
NOTE the latter parts of this trans was not
entirely lectured They were included because
they were in the given power point
REFERENCES
Dr Cabuquitrsquos lectureDr Cabuquitrsquos ppt
Trans medicine 2011 A
892019 Clinical Psychopathology
httpslidepdfcomreaderfullclinical-psychopathology 25
In both schizophrenic and depressive types be aware
of the commanding quality of the voice(s)
Command HallucinationsAlso known as ldquoimperative hallucinationsrdquo
- Patients who hear voices should be asked ifthe voices have commanding quality
- About 23 of Filipino patients obey voicesrsquo
commands (Cabuquit )
- Obeyed commands usually prolonged
intense and frequent (Cabuquit )
Significance of Mumbling Episodes - Patients who mumble actually hear voices
(even when they deny it)
- Mumbling is the patientsrsquo way of responding
to the voices
- Usually verified by observant relatives
Organic Hallucinations
Visual- More common in organic states like
delirium tremens and dementias (
lsquoLilliputianrsquo type)
Lilliputian Type ndash false perception in
which objects are seen as reduced in size
also termed micropsia
- All varieties from elementary forms likeflashes of light to fully formed people or
animals
- Can be with simultaneous auditory
hallucination
ndash false perception involving sight
consisting of both formed and unformed
images
- Most common in medically determined
disorders
Olfactory (Smell) false perception of smell
- Temporal Lobe Epilepsy (TLE) attacks areusually ushered in by an unpleasant odour like
burning rubber or rotten food
Gustatory (Taste) false perception of taste
- Usually caused by uncinate seizures could
also be due to TLE when associated with
salivation chewing and sniffing movements
Tactile (Haptic) false perception of taste
lsquoCocaine bugrsquo or formication ndash feeling of
small animals crawling all over the body or
under the skin associated with delusion ofpersecution
Sexual sensations (eg being masturbated
to orgasm) seen in some schizophrenics
lsquoPhantom limbrsquo phenomenon- most
common organic somatic hallucination occurs
in about 95 of all amputations could be very
painful
2 Disorders of Thought
- Delusional Triad a belief that is
- false ndash no logic no proof
- fixed
- incongruent with the personrsquos socio-
cultural and religious background
- Overvalued Idea an idea that is
false fixed and congruent with the
personrsquos background
Main Types of Delusions
Persecutory- most common in schizophrenia
- personrsquos false belief that he or she is being
harassed cheated or persecuted often found in
litigious patients who have a pathologic
tendency to take legal action because of
imagined mistreatment
Grandiose ndash most common in mania
- personrsquos exaggerated conception of his orher importance power or identity
Guilt- most common in depression
983085 - False feeling of remorsegrief
Jealousy (Othellorsquos syndrome)- most common
in delusional disorders drugs and alcohol
abuse aggravating factors violence frequent
983085 - False belief derived from pathological
983085 jealousy about a personrsquos lover being
983085 unfaithful
- Delusions have a tendency to be acted upon
Schizophrenic vs Depressive Delusions
Schizophrenic Delusions-Delusion of control- most reliable
symptom false feeling that a personrsquos
will thoughts or feelings are being
controlled by external forces
- Primary delusional perception
(Both are parts of First Rank Symptoms)
892019 Clinical Psychopathology
httpslidepdfcomreaderfullclinical-psychopathology 35
Depressive DelusionsDelusion of guilt- could lead to suicide
Nihilistic delusion - false feeling that self
others or the world is nonexistent or coming
to an end
Thought AlienationThought Echo983085 - A form of auditory hallucination in which the
patient hears his thoughts spoken aloud either
simultaneous with him thinking it or moment or
two afterwards
Thought Insertion983085 Delusion that thoughts are being implanted in a
personrsquos mind by other persons or forces
Thought Withdrawal983085 Delusion that thoughts are being removed from a
personrsquos mind by other persons or forces
Thought Broadcasting983085 Delusion that a personrsquos thoughts can be heard by
others as though they were being broadcast
through the air
Thought Blocking983085 An objective phenomenon in which the patient
abruptly breaks off his conversation and is silentfor a few seconds and then resumes on a different
topic Subjectively they experience a complete
cessation of all thought
All of the above are commonly seen in
schizophrenia the first four are parts of Schneiderrsquos
First Rank Symptoms
OBSESSIONS AND COMPULSIONSObsessions ndash internal resistance subjective
compulsion983085 Pathological persistence of an irresistible thought
or feelings that cannot be eliminated from
consciousness by logical effort
983085 Associated with anxiety
Compulsions ndash simply the motor components of
obsessions
983085 pathological need to act on an impulse that if
resisted produces anxiety
983085 Repetitive behavior in response to an obsession or
performed according to certain rules with no true
end in itself other than to prevent something from
occurring in the future
Contrast Ideas ndash similar to obsessions
983085 With internal resistance but without subjective
compulsion
Most Common Types of OCs-Handwashing eg Lady Macbethrsquos
-Re-checkingrepeatingrearranging
-Examining things in great detail
3 Disorders of Speech
Looseness of Association - flow of thought in which
ideas shift from one subject to another in a completely
unrelated way
983085 Common in schizophrenia
983085 A schizophrenic talking (desultory manner)
lsquo Itrsquos your cross to stand down considering
itrsquos Saturday The Episcopal twitter neon sign in
occupational street is eating jackass moon in the
nearby tropic of cancer of Jupiter and Pluto So
will you tie me up and down in the percolating
stairs Or shall we eat nincompoop pizzaiersquo
-Notice how difficult it is to understand what
the patient is talking about what about
lsquopizzaiersquo
Flight of Ideas ndash rapid continuous verbalizations orplays on words produce constant shifting from one
idea to another ideas tend to be connected association
of words similar in sound but not in meaning words
have no logical connection may include rhyming and
punning
983085 Common in mania
lsquo The king is standing see HEY The king king is
standing ding ding a ling sing sing HEY HEY
(Laughs) Bird on the wing wing pilot is a harlot
on the trot and he is always hot Irsquom so hotrsquo
- Observe the rhyming punning and clanging
Neologism ndash forming new words
983085 Most specific symptom of schizophrenia
MutismDifferential diagnoses
bull Catatonic schizophrenia ndash markedly
slowed motor activity often to the point of
immobility amp seeming unawareness of
surroundings
bull Hysterical mutism ndash a diagnostic label applied to
state of mind one of unmanageable fear or
emotional excess The fear is often centered on abody part most often on an imagined problem
892019 Clinical Psychopathology
httpslidepdfcomreaderfullclinical-psychopathology 45
with that body part People who are hysterical
often lose self-control due to the overwhelming
fear
bull Organic stupor ndash eg demyelinating disease
bull Depressive stupor
Talking to Mute Patients
-lsquoWhispering Techniquersquo ( Cabuquit ) Literally a whispering conversation between
doctor and patient
Good technique to differentiate one mute
patient from another
Best results with hysterical mutism
depressive schizophrenic organic patients
1 Organic stupor Speak slowly and loudly
and hold the patientrsquos hand
2 Depressive stupor Go near the patient
speak with a firm calm and reassuring voice
may hold patientrsquos hand
3 Schizophrenic mutism Speak confidently
normal tone holding hands not advised
4 Hysterical mutism Stay close hold hands
and use your best voice do this with a
companion
4 Disorders of Emotion-Depressed Mood (LAPEL by Cabuquit )
Low mood (depressed sad) Anhedonia ( loss of pleasure or interest)
Poor appetite (with weight loss)
Early morning awakening (3-4 hrs earlier)
Low self-esteem ( guilt feelings suicidal
ideasattempts hopelessness)
Eliciting LAPEL
Low mood lsquoHow do you feel these last few weeks Have you
felt depressed How do you feel upon waking
Anhedonia (loss of interest)
lsquoWhat have you been doing lately Any change in
your usual activities Poor appetite
Any change in your appetite Any weight loss
Early morning awakening lsquoWhatrsquos your usual waking time Any change lately
(3-4 hours earlier than usual)
Low self-esteem lsquoHave you felt helpless hopeless lately Any guilt
feelings Suicidal ideas Attempts
Caution Patients who admit to harboring suicidal
ideas require extra attention look out for lsquosmiling
depressivesrsquo
Rating LAPEL
Positive responses to three out five questions
indicate that the patient is clinically depressed
(two of the three responses should be low
mood and anhedonia)
Specificity of 94Sensitivity of 96
(Brody and Spitzer 2002)
Depression Guilt and Suicide-Depressed patients should always be asked
about suicidal ideas or attempts
-Guilty feelings need for punishment if
no one would mete punishment would
punish himself best way is by suicide
(presence of command hallucination the
risk)
-About 10 of depressed patients die from it
more women than men attempt it more men
than women are successful
Mania The other end of the spectrumManic Mood Gradations (LEXUS byCabuquit)E LEvated m (cheerfulnessconfidence)rarr
E X pansive m (disinhibition)rarr
EU phoric m (unrestrained grandiose feelings)
rarr EcStatic mrarr (intense feelings of
rapture)- Manic stupor - rare
- Hypomania- milder form
- Bipolar- with depression and mania
Mania and its lsquooffspringsrsquo-The manic mood gives birth to
-hyperactivity
- pressure of speech
-grandiosity
-disinhibition eg sexual
-lack of sleep
-irritability ( when frustrated )
5 Disorders of Memory-Amnesias (loss of memory)
Hysterical or Dissociative
Organic ( acute sub-acute chronic)
-Dysmnesias (distortion of memory)Confabulation
Deacutejagrave vu jamais vu
892019 Clinical Psychopathology
httpslidepdfcomreaderfullclinical-psychopathology 55
AmnesiasHysterical or dissociative
complete loss of memory and loss of
identity temporary intact personality
Organic
acute- (eg head injury) retrogradeanterogradeamnesia
sub-acute- (eg Korsakoff ) no new memories
chronic - (eg dementias) loss of recent memory
rarr remoterarr global irreversible personality
Dysmnesias
-Confabulationdetailed false description of an event which never
happened patient tries to lsquofill in the gapsrsquo seen in
alcoholics and hysterics and chronic schizophrenics
-Deacutejagrave vusomething new is remembered as something old
-Jamais vusomething old is remembered as something
new
Both observed in complex partial seizures
6 Other DisordersDisorders of Experience of the Self
depersonalization
derealization
Disorders of Consciousness
lsquotwilightrsquo statefugue state
Disorders of Motor Function
waxy flexibility
lsquooccupational deliriumrsquo
7 SUMMARY
The most important symptom in clinical
psychiatry is hallucination
Think of schizophrenia when Schneiderrsquos First
Rank Symptoms are prominent
Depressed patients should always be asked
about suicidal ideas or attempts
Command hallucinations increase the risk of
untoward behaviours
In depression think of LAPEL
In mania think of LEXUS
In mutism think of CHODE
Looseness of association is commonly seen in
schizophrenia
Flight of ideas is commonly seen in mania
NOTE the latter parts of this trans was not
entirely lectured They were included because
they were in the given power point
REFERENCES
Dr Cabuquitrsquos lectureDr Cabuquitrsquos ppt
Trans medicine 2011 A
892019 Clinical Psychopathology
httpslidepdfcomreaderfullclinical-psychopathology 35
Depressive DelusionsDelusion of guilt- could lead to suicide
Nihilistic delusion - false feeling that self
others or the world is nonexistent or coming
to an end
Thought AlienationThought Echo983085 - A form of auditory hallucination in which the
patient hears his thoughts spoken aloud either
simultaneous with him thinking it or moment or
two afterwards
Thought Insertion983085 Delusion that thoughts are being implanted in a
personrsquos mind by other persons or forces
Thought Withdrawal983085 Delusion that thoughts are being removed from a
personrsquos mind by other persons or forces
Thought Broadcasting983085 Delusion that a personrsquos thoughts can be heard by
others as though they were being broadcast
through the air
Thought Blocking983085 An objective phenomenon in which the patient
abruptly breaks off his conversation and is silentfor a few seconds and then resumes on a different
topic Subjectively they experience a complete
cessation of all thought
All of the above are commonly seen in
schizophrenia the first four are parts of Schneiderrsquos
First Rank Symptoms
OBSESSIONS AND COMPULSIONSObsessions ndash internal resistance subjective
compulsion983085 Pathological persistence of an irresistible thought
or feelings that cannot be eliminated from
consciousness by logical effort
983085 Associated with anxiety
Compulsions ndash simply the motor components of
obsessions
983085 pathological need to act on an impulse that if
resisted produces anxiety
983085 Repetitive behavior in response to an obsession or
performed according to certain rules with no true
end in itself other than to prevent something from
occurring in the future
Contrast Ideas ndash similar to obsessions
983085 With internal resistance but without subjective
compulsion
Most Common Types of OCs-Handwashing eg Lady Macbethrsquos
-Re-checkingrepeatingrearranging
-Examining things in great detail
3 Disorders of Speech
Looseness of Association - flow of thought in which
ideas shift from one subject to another in a completely
unrelated way
983085 Common in schizophrenia
983085 A schizophrenic talking (desultory manner)
lsquo Itrsquos your cross to stand down considering
itrsquos Saturday The Episcopal twitter neon sign in
occupational street is eating jackass moon in the
nearby tropic of cancer of Jupiter and Pluto So
will you tie me up and down in the percolating
stairs Or shall we eat nincompoop pizzaiersquo
-Notice how difficult it is to understand what
the patient is talking about what about
lsquopizzaiersquo
Flight of Ideas ndash rapid continuous verbalizations orplays on words produce constant shifting from one
idea to another ideas tend to be connected association
of words similar in sound but not in meaning words
have no logical connection may include rhyming and
punning
983085 Common in mania
lsquo The king is standing see HEY The king king is
standing ding ding a ling sing sing HEY HEY
(Laughs) Bird on the wing wing pilot is a harlot
on the trot and he is always hot Irsquom so hotrsquo
- Observe the rhyming punning and clanging
Neologism ndash forming new words
983085 Most specific symptom of schizophrenia
MutismDifferential diagnoses
bull Catatonic schizophrenia ndash markedly
slowed motor activity often to the point of
immobility amp seeming unawareness of
surroundings
bull Hysterical mutism ndash a diagnostic label applied to
state of mind one of unmanageable fear or
emotional excess The fear is often centered on abody part most often on an imagined problem
892019 Clinical Psychopathology
httpslidepdfcomreaderfullclinical-psychopathology 45
with that body part People who are hysterical
often lose self-control due to the overwhelming
fear
bull Organic stupor ndash eg demyelinating disease
bull Depressive stupor
Talking to Mute Patients
-lsquoWhispering Techniquersquo ( Cabuquit ) Literally a whispering conversation between
doctor and patient
Good technique to differentiate one mute
patient from another
Best results with hysterical mutism
depressive schizophrenic organic patients
1 Organic stupor Speak slowly and loudly
and hold the patientrsquos hand
2 Depressive stupor Go near the patient
speak with a firm calm and reassuring voice
may hold patientrsquos hand
3 Schizophrenic mutism Speak confidently
normal tone holding hands not advised
4 Hysterical mutism Stay close hold hands
and use your best voice do this with a
companion
4 Disorders of Emotion-Depressed Mood (LAPEL by Cabuquit )
Low mood (depressed sad) Anhedonia ( loss of pleasure or interest)
Poor appetite (with weight loss)
Early morning awakening (3-4 hrs earlier)
Low self-esteem ( guilt feelings suicidal
ideasattempts hopelessness)
Eliciting LAPEL
Low mood lsquoHow do you feel these last few weeks Have you
felt depressed How do you feel upon waking
Anhedonia (loss of interest)
lsquoWhat have you been doing lately Any change in
your usual activities Poor appetite
Any change in your appetite Any weight loss
Early morning awakening lsquoWhatrsquos your usual waking time Any change lately
(3-4 hours earlier than usual)
Low self-esteem lsquoHave you felt helpless hopeless lately Any guilt
feelings Suicidal ideas Attempts
Caution Patients who admit to harboring suicidal
ideas require extra attention look out for lsquosmiling
depressivesrsquo
Rating LAPEL
Positive responses to three out five questions
indicate that the patient is clinically depressed
(two of the three responses should be low
mood and anhedonia)
Specificity of 94Sensitivity of 96
(Brody and Spitzer 2002)
Depression Guilt and Suicide-Depressed patients should always be asked
about suicidal ideas or attempts
-Guilty feelings need for punishment if
no one would mete punishment would
punish himself best way is by suicide
(presence of command hallucination the
risk)
-About 10 of depressed patients die from it
more women than men attempt it more men
than women are successful
Mania The other end of the spectrumManic Mood Gradations (LEXUS byCabuquit)E LEvated m (cheerfulnessconfidence)rarr
E X pansive m (disinhibition)rarr
EU phoric m (unrestrained grandiose feelings)
rarr EcStatic mrarr (intense feelings of
rapture)- Manic stupor - rare
- Hypomania- milder form
- Bipolar- with depression and mania
Mania and its lsquooffspringsrsquo-The manic mood gives birth to
-hyperactivity
- pressure of speech
-grandiosity
-disinhibition eg sexual
-lack of sleep
-irritability ( when frustrated )
5 Disorders of Memory-Amnesias (loss of memory)
Hysterical or Dissociative
Organic ( acute sub-acute chronic)
-Dysmnesias (distortion of memory)Confabulation
Deacutejagrave vu jamais vu
892019 Clinical Psychopathology
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AmnesiasHysterical or dissociative
complete loss of memory and loss of
identity temporary intact personality
Organic
acute- (eg head injury) retrogradeanterogradeamnesia
sub-acute- (eg Korsakoff ) no new memories
chronic - (eg dementias) loss of recent memory
rarr remoterarr global irreversible personality
Dysmnesias
-Confabulationdetailed false description of an event which never
happened patient tries to lsquofill in the gapsrsquo seen in
alcoholics and hysterics and chronic schizophrenics
-Deacutejagrave vusomething new is remembered as something old
-Jamais vusomething old is remembered as something
new
Both observed in complex partial seizures
6 Other DisordersDisorders of Experience of the Self
depersonalization
derealization
Disorders of Consciousness
lsquotwilightrsquo statefugue state
Disorders of Motor Function
waxy flexibility
lsquooccupational deliriumrsquo
7 SUMMARY
The most important symptom in clinical
psychiatry is hallucination
Think of schizophrenia when Schneiderrsquos First
Rank Symptoms are prominent
Depressed patients should always be asked
about suicidal ideas or attempts
Command hallucinations increase the risk of
untoward behaviours
In depression think of LAPEL
In mania think of LEXUS
In mutism think of CHODE
Looseness of association is commonly seen in
schizophrenia
Flight of ideas is commonly seen in mania
NOTE the latter parts of this trans was not
entirely lectured They were included because
they were in the given power point
REFERENCES
Dr Cabuquitrsquos lectureDr Cabuquitrsquos ppt
Trans medicine 2011 A
892019 Clinical Psychopathology
httpslidepdfcomreaderfullclinical-psychopathology 45
with that body part People who are hysterical
often lose self-control due to the overwhelming
fear
bull Organic stupor ndash eg demyelinating disease
bull Depressive stupor
Talking to Mute Patients
-lsquoWhispering Techniquersquo ( Cabuquit ) Literally a whispering conversation between
doctor and patient
Good technique to differentiate one mute
patient from another
Best results with hysterical mutism
depressive schizophrenic organic patients
1 Organic stupor Speak slowly and loudly
and hold the patientrsquos hand
2 Depressive stupor Go near the patient
speak with a firm calm and reassuring voice
may hold patientrsquos hand
3 Schizophrenic mutism Speak confidently
normal tone holding hands not advised
4 Hysterical mutism Stay close hold hands
and use your best voice do this with a
companion
4 Disorders of Emotion-Depressed Mood (LAPEL by Cabuquit )
Low mood (depressed sad) Anhedonia ( loss of pleasure or interest)
Poor appetite (with weight loss)
Early morning awakening (3-4 hrs earlier)
Low self-esteem ( guilt feelings suicidal
ideasattempts hopelessness)
Eliciting LAPEL
Low mood lsquoHow do you feel these last few weeks Have you
felt depressed How do you feel upon waking
Anhedonia (loss of interest)
lsquoWhat have you been doing lately Any change in
your usual activities Poor appetite
Any change in your appetite Any weight loss
Early morning awakening lsquoWhatrsquos your usual waking time Any change lately
(3-4 hours earlier than usual)
Low self-esteem lsquoHave you felt helpless hopeless lately Any guilt
feelings Suicidal ideas Attempts
Caution Patients who admit to harboring suicidal
ideas require extra attention look out for lsquosmiling
depressivesrsquo
Rating LAPEL
Positive responses to three out five questions
indicate that the patient is clinically depressed
(two of the three responses should be low
mood and anhedonia)
Specificity of 94Sensitivity of 96
(Brody and Spitzer 2002)
Depression Guilt and Suicide-Depressed patients should always be asked
about suicidal ideas or attempts
-Guilty feelings need for punishment if
no one would mete punishment would
punish himself best way is by suicide
(presence of command hallucination the
risk)
-About 10 of depressed patients die from it
more women than men attempt it more men
than women are successful
Mania The other end of the spectrumManic Mood Gradations (LEXUS byCabuquit)E LEvated m (cheerfulnessconfidence)rarr
E X pansive m (disinhibition)rarr
EU phoric m (unrestrained grandiose feelings)
rarr EcStatic mrarr (intense feelings of
rapture)- Manic stupor - rare
- Hypomania- milder form
- Bipolar- with depression and mania
Mania and its lsquooffspringsrsquo-The manic mood gives birth to
-hyperactivity
- pressure of speech
-grandiosity
-disinhibition eg sexual
-lack of sleep
-irritability ( when frustrated )
5 Disorders of Memory-Amnesias (loss of memory)
Hysterical or Dissociative
Organic ( acute sub-acute chronic)
-Dysmnesias (distortion of memory)Confabulation
Deacutejagrave vu jamais vu
892019 Clinical Psychopathology
httpslidepdfcomreaderfullclinical-psychopathology 55
AmnesiasHysterical or dissociative
complete loss of memory and loss of
identity temporary intact personality
Organic
acute- (eg head injury) retrogradeanterogradeamnesia
sub-acute- (eg Korsakoff ) no new memories
chronic - (eg dementias) loss of recent memory
rarr remoterarr global irreversible personality
Dysmnesias
-Confabulationdetailed false description of an event which never
happened patient tries to lsquofill in the gapsrsquo seen in
alcoholics and hysterics and chronic schizophrenics
-Deacutejagrave vusomething new is remembered as something old
-Jamais vusomething old is remembered as something
new
Both observed in complex partial seizures
6 Other DisordersDisorders of Experience of the Self
depersonalization
derealization
Disorders of Consciousness
lsquotwilightrsquo statefugue state
Disorders of Motor Function
waxy flexibility
lsquooccupational deliriumrsquo
7 SUMMARY
The most important symptom in clinical
psychiatry is hallucination
Think of schizophrenia when Schneiderrsquos First
Rank Symptoms are prominent
Depressed patients should always be asked
about suicidal ideas or attempts
Command hallucinations increase the risk of
untoward behaviours
In depression think of LAPEL
In mania think of LEXUS
In mutism think of CHODE
Looseness of association is commonly seen in
schizophrenia
Flight of ideas is commonly seen in mania
NOTE the latter parts of this trans was not
entirely lectured They were included because
they were in the given power point
REFERENCES
Dr Cabuquitrsquos lectureDr Cabuquitrsquos ppt
Trans medicine 2011 A
892019 Clinical Psychopathology
httpslidepdfcomreaderfullclinical-psychopathology 55
AmnesiasHysterical or dissociative
complete loss of memory and loss of
identity temporary intact personality
Organic
acute- (eg head injury) retrogradeanterogradeamnesia
sub-acute- (eg Korsakoff ) no new memories
chronic - (eg dementias) loss of recent memory
rarr remoterarr global irreversible personality
Dysmnesias
-Confabulationdetailed false description of an event which never
happened patient tries to lsquofill in the gapsrsquo seen in
alcoholics and hysterics and chronic schizophrenics
-Deacutejagrave vusomething new is remembered as something old
-Jamais vusomething old is remembered as something
new
Both observed in complex partial seizures
6 Other DisordersDisorders of Experience of the Self
depersonalization
derealization
Disorders of Consciousness
lsquotwilightrsquo statefugue state
Disorders of Motor Function
waxy flexibility
lsquooccupational deliriumrsquo
7 SUMMARY
The most important symptom in clinical
psychiatry is hallucination
Think of schizophrenia when Schneiderrsquos First
Rank Symptoms are prominent
Depressed patients should always be asked
about suicidal ideas or attempts
Command hallucinations increase the risk of
untoward behaviours
In depression think of LAPEL
In mania think of LEXUS
In mutism think of CHODE
Looseness of association is commonly seen in
schizophrenia
Flight of ideas is commonly seen in mania
NOTE the latter parts of this trans was not
entirely lectured They were included because
they were in the given power point
REFERENCES
Dr Cabuquitrsquos lectureDr Cabuquitrsquos ppt
Trans medicine 2011 A