Introduction to psychopathology

Year 4 psychiatry - 2013

Dr Oliver Schubert

psychegr. psukhein to breathe

psukhē breath, soul

The mind as the center of thought, emotion, and behavior, consciously or unconsciously adjusting or mediating the body's responses to the social

and physical environment

Definitive classification of disease must be based on aetiology

Pragmatic approach to classification that will best enable us to care for our patients,

communicate with other health professionals,carry out high-quality research

How should the mind be conceived?

What are the mind’s faculties, functions, or elements (if there are any)?

How can these be distinguished?

How can mental disorders be comprehended by application of these principles?

Manfred Spitzer

Traditional distinctions:

Organic syndromes vs. functional syndromes

psychosis vs .neurosis

Psychopathology:Systematic study of abnormal experience, cognition and

behaviour

Study of the products of the disordered mind

The science and study of psychological and psychiatric symptoms

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

patients

Karl Jaspers 1882-1969 “General Psychopathology”, 1913

Sims’ Symptoms of the mind, 2011

empathy: gr. feeling oneself intoClinical instrument:

measuring another person’s subjective state

using the observer’s own capacity for emotional and cognitive experience as a yardstick

giving an account of the patient’s inner experience that the patient recognizes as his/her own

NOT sympathy: gr. feeling with

Mrs Jenkins complains that she is unhappy

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

Observation: listless sagging of shoulders; tense gripping and wringing of her hands-> use in MSE

Phenomenology: ‘that horrible feeling of not really existing’; ‘not being able to feel any emotion’

-> use in ‘presenting complaint’, ‘HPC’, or succinctly in MSE

labelling: assigning universally recognized symptoms:anergia; psychomotor agitation; anhedonia; loss of emotional resonance;nihilistic preocupa tions -> use in the Mental State Examination

diagnosis: recognizing symptoms as part of a syndrome: depression (Using a classification system: DSM-IV, ICD-10

Descriptive psychopathology is the fundamental professional skill of the psychiatrist

Uses of descriptive psychopathology

• Diagnostic: facilitates communication of the clinical features to other professionals

• Scientific: allows precise observations and deductions to be made

• Therapeutic: facilitates establishment of an empathic relationship

• Forensic: medico-legal evaluation is largely based on psychopathology

A appearance

B behaviour

C conversation

A affect

P perception

C cognition

(I insight, J judgement,R rapport)

A appearance

B behaviour

C conversation

A affect

P perception

C cognition

(I insight, J judgement,R rapport)

“Made” actions

consciousness

State of awareness ofthe self and the environment

A appearance

B behaviour

C conversation

A affect

P perception

C cognition

(I insight, J judgement,R rapport)

Thought/Speech

Refraining from speechin full consciousness

Receptive dysphasias Expressive dysphasias

-Approximate answers (Ganser syndrome)

Stream of thought

Formal thinking

Possession of thought

Content of thinking

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

A appearance

B behaviour

C conversation

A affect

P perception

C cognition

(I insight, J judgement,R rapport)

A appearance

B behaviour

C conversation

A affect

P perception

C cognition

(I insight, J judgement,R rapport)

Disorders of perception

A appearance

B behaviour

C conversation

A affect

P perception

C cognition

(I insight, J judgement,R rapport)

Psychopathology of personality

Mental illness is a myth, whose function it is to disguise and render more palatable the bitter pill of

moral conflict in human relationsThomas Szaz, 1970

We call people physically ill when their body functioning violates certain physiological and

anatomical norms; similarly we call people mentally ill when their personal conduct violates certain

ethical, political, and social normsThomas Szaz, 1970

The Rosenhan experiment (1973)

Stigma

Answers (?) -1

Operational classification systems:

Diagnostic and Statistical Manual of Mental Disorders (DSM)

International Statistical Classification of Diseases and Related Health Problems (ICD)

=> formalistic reductionism?

Answers (?)-2• Psychiatric endophenotypes (Gottesman,2003)=neurobiological

correlates of disorders– Genetically influenced– stable over time– Neurobiological component that contributes to the disorder– Genes influencing the endophenotype are also susceptibility genes for

the disorder– determined by fewer genes than the disorder– Not/marginally influenced by environment

Example: higher beta-activity in the EEG of alcoholics found in familiy members also. Linked with GABAa receptor

genes (Porjecz et al, 2002)

=> Naturalistic reductionism?

Answers (?)-3

• User movement• Person-centered care• Recovery approach

=> heuristic reductionism?

Psychopathology quiz

• Example question:– A man in his mid-30s with an established diagnosis

of chronic schizophrenia shows no emotional reactivity during the interview (doesn’t smile when a joke is made; doesn’t get animated when talking about his puppy dog; doesn’t look sad when talking about the death of his beloved mother last year). His affect can be described as…

Practising descriptive psychopathology

• written accounts of inner experience– literature (Sylvia Plath; Sarah Kane; Sebastian

Faulks; Elyn Saks– Patient’s notes/letters– TED talk Eilyn Saks

www.ted.com/talks/elyn_saks_seeing_mental_illness.html

– Patient encounters– Clinical meetings (handovers etc.)