Descriptive Psychopathology

The form of abnormal movements may be classified (after Hamilton, 1974) as follows:

1. Disorders of Adaptive Movements:

   1. Expressive Behaviour:

      • Tearfulness
      • Unhappy facial expression
      • Paucity of movements, downcast appearance in depression
      • Expansive gesturing and overactivity in hypomania

   2. Obstruction:

      • Consists of irregular hindrance and sudden arrest of fluent movement, like a spoke stuck in a wheel
      • Seen in catatonia

   3. Mannerisms:

      • Abnormal, repetitive, goal-directed movements (e.g., bizarre methods of walking or eating)
      • Commonly seen in chronic schizophrenia

2. Non-Adaptive Movements:

   1. Spontaneous Movements, i.e., Habitual, Non-goal Directed:

      • Tics - sudden involuntary twitching of groups of muscles, particularly facial
      • Static tremor - of hands, head, or upper trunk
      • Spasmodic torticollis - involves spasm of neck muscles with twisting of the head, which may become permanent
      • Chorea - abrupt, random jerky movements resembling fragments of goal-directed behaviour
      • Athetosis - slow, semi-rotary writhing movements
      • Orofacial dyskinesia - restless movements of the tongue, mouth, and facial muscles
      • Stereotypies - regular, repetitive, non-goal directed movements, e.g., repetitive foot tapping, body rocking - seen in chronic schizophrenia, mental handicap, and infantile autism

   2. Induced Movements

      1. Automatic Obedience: Subject does whatever is asked of him or her, despite being told not to

      2. Ambitendence: Alternating cooperation and opposition; the patient makes a movement, but before completing it, starts the opposite movement

      3. Echopraxia: Subject imitates the movements of the interviewer

      4. Echolalia: Words or phrases are imitated

      5. Perseveration: Senseless repetition of previously requested movement, i.e., the repetition of a response after withdrawal of stimulus

         • Palilalia - perseverated word is repeated with increasing frequency
         • Logoclonia - perseveration of the last syllable of the last word; seen in organic disorders and occasionally in catatonia

      6. Forced Grasping: The offered hand is repeatedly grasped and shaken, despite requests not to do so; seen in frontal lobe lesions

      7. Mitmachen: The body can be put into any posture, despite instructions to resist

      8. Mitgehen: An extreme form of mitmachen in which very slight pressure leads to movement in any direction; the 'anglepoise' effect, despite being told to resist the pressure; often associated with forced grasping

      9. Excitement: Non-goal-directed overactivity, sometimes repetitive or violent

      10. Parakinesis: Milder version of excitement, includes rapidly changing sequence of mannerisms

3. Disorders of Posture:

   Postural Mannerisms: Strange and abnormal postures adopted habitually

   Perseveration of Posture: If the subject’s body is placed in an awkward posture and left, the posture is held for a period before slowly relaxing, despite asking the patient to relax; a.k.a. Catalepsy

   • Waxy Flexibility: Smooth resistant muscle tone is felt to initial movement (a.k.a. flexibilitas cerea); e.g. ‘psychological pillow’

Catatonia (Karl Kahlbaum, 1874)

• A predominantly motor disorder thought to be related to affective disorder
• May be found as part of chronic schizophrenia and occasionally in organic cerebral disorders – e.g., the sequelae of encephalitis lethargica
• The core features are:
  • Posturing
  • Stereotypies
  • Waxy Flexibility
• Other symptoms include:
  • Obstruction
  • Ambitendence
  • Automatic Obedience
  • Echolalia, Echopraxia
  • Mitgehen, Mitmachen
  • Mannerism
  • Excitement
  • Parakinesis
  • Negativism

Treatment:

• Avoid neuroleptics
• Possibly prescribe benzodiazepines
• ECT is of value

Motor and Behavioral Aspects of Affective Disorders

• Agitation is repetitive and usually purposeless movement; difference with mania is that in mania, several different activities are begun and none completed
• Retardation may be motor, verbal, or both
• Stupor

Motor and Behavioral Aspects of Schizophrenia

• Impulsivity
• Mannerisms and stereotypies may persist
• Also, complex maladaptive behaviors such as hoarding

Stupor

• Is the absence of relational functions, i.e., action and speech
• Usually involves clouding of consciousness
• Occurs in:
• Schizophrenia (30%)
• Depression (25%)
• Psychological trauma
• Mania
• Organic brain lesions (20%):
• Diencephalon and upper brain stem
• Frontal lobe
• Basal ganglia
• The 'locked in' syndrome is due to lesions in the ventral pons
• Severe stupor seems to have a better prognosis
• Spontaneous resolution occurs in 30% of cases
• Stupor has a mortality of 20% (perhaps due to encephalitis)

Apraxia

• Is the inability to perform purposeful volitional acts
• Does not result from sensory loss, paresis, incoordination, or involuntary movements

1. Ideational Apraxia

   • Inability to imitate or put together complex gestures and actions, despite understanding the request
   • Is always bilateral

2. Dressing Apraxia

   • A form of ideational apraxia
   • Due to lesions of the non-dominant parietal lobe

3. Constructional Apraxia

   • Inability to copy designs and structures
   • Twice as frequent in right- as in left-sided lesions
   • Closely associated with visuospatial agnosia

Changes in the quality, intensity, or spatial form of a perception; may be distorted in terms of:

1. Intensity:

   • Hyperacusis
   • Mania
   • Hyperthyroidism
   • Depression
   • Migraine
   • Toxic states (e.g., alcohol 'hangover')
   • Hypoacusis - in some organic states

2. Colour:

   • Xanthopsia - produced by psychedelics and temporal lobe lesions

3. Proportions:

   • Dysmegalopsia (a.k.a. Dysmetropsia) – a disorder of visual processing causing subjective distortions in the size of the object. It can be described as Macropsia or Micropsia.
   • Macropsia – objects appear larger than their normal size; can result from normal accommodation and weak convergence
   • Micropsia – objects appear smaller than their normal size; can result from weak ocular accommodation and normal convergence
   • Metamorphopsia – a disorder of visual processing causing subjective distortions in the shape of the object
   • Oscillopsia – visual disturbance, in which objects appear to be jumping or bouncing

4. Affective Components (Derealisation)

Visual Hyperaesthesia

Conditions associated with visual hyperaesthesia include:

• Ecstasy experiences
• LSD
• Mania
• Epileptic aura

Hallucinations are:

‘Perceptions which arise in the absence of any external stimulus’ (Esquirol, 1833)

‘A false perception which is not in any way a distortion of a real perception but which springs up alongside it’ (Jaspers)

Characteristics:

• Unwilled - not subject to conscious manipulation
• Has the same qualities of a real perception, i.e., vivid, solid
• Perceived as being located in the external world

Types of Hallucination

• Auditory

  • Simple (sounds)
  • Complex (voices)
  • Musical - brain/ear disease

• Visual

  • Simple (flashes of light) - organic disease
  • Complex (objects, animals, people)
  • Panoramic/Experiential/Peduncular - organic disease
  • Lilliputian - abnormal perception of objects shrunken in size but normal in detail

• Hypnogogic (going to sleep) & Hypnapompic (on waking) Hallucinations

  • Occur at either end of the sleep period
  • Can be visual or auditory
  • Associated with:
    • Healthy people
    • Toxic states (e.g., fever, glue-sniffing)
    • Post-infective depressive states
    • Phobic anxiety neuroses

• Extracampine (Concrete Awareness)

  • Hallucinations experienced outside of the normal sensory field, e.g., “he’s right behind me walking everywhere I go”
  • Not of diagnostic importance
  • Occur in:
    • Schizophrenia
    • Epilepsy
    • Organic states
    • Hypnagogic hallucinations in healthy people

• Functional

  • Hallucinations that are generated in the presence of an unrelated external stimulus of the same modality (usually auditory)
  • Can occur in schizophrenia

• Reflex Hallucinations

  • Denotes a veridical perception in one modality producing an hallucination in another, e.g., seeing a doctor writing and then feeling him writing across one’s stomach
  • Is a hallucinatory form of synaesthesia

• Palinopsia

  • Is the reappearance (often repeatedly) of material just veridically perceived
  • Seen in organic diseases such as Parkinson’s

• Hallucinations of Bodily Sensation

  • Superficial:
  • Thermic (temperature)
  • Haptic (touch)
  • Hygric (perception of fluid)
  • Kinaesthetic:
  • Organic states
  • BZD withdrawal
  • Alcohol intoxication
  • Visceral

• Olfactory Hallucinations

  • Often associated with powerful emotions
  • Usually has a special or personal significance

• Gustatory Hallucinations

  • Occur in:
  • Schizophrenia
  • Temporal lobe epilepsy
  • Lithium carbonate
  • Disulfiram

• Tactile Hallucinations

  • Perceptions related to the sense of touch
  • Can be present in various conditions, including:
  • Schizophrenia
  • Alcohol withdrawal
  • Drug-induced psychosis

Auditory Hallucinations

1. Hearing Thought Spoken Aloud

   1. A.k.a. Gedankenlautwerden (thoughts are spoken as they are thought) or Echo de la pensees (thoughts are spoken just afterward)
   2. The experience of hearing one’s thoughts aloud

2. Voices Heard Arguing

   1. The patient usually features in the third person in the content

3. Voices Giving a Commentary

   1. May occur just before, during, or after the patient’s actions
4. Must be experienced as coming from outside the self

Visual Hallucinations

Associations with:

• Occipital lobe tumors
• Loss of color vision
• Homonymous hemianopia
• Dyslexia
• Alexia (in a dominant hemisphere lesion)
• Cortical blindness

Can occur in:

• Post-concussional state
• Epileptic twilight states
• Hepatic failure
• Alzheimer’s disease
• Senile dementia
• Multi-infarct dementia
• Pick’s disease
• Huntington’s chorea

Additional points:

• Strong correlation between the presence of visual hallucinations and eye pathology
• Can occur simultaneously with auditory hallucinations in temporal lobe epilepsy
• Very uncommon in schizophrenia – common for the patient to describe auditory hallucinations with visual pseudohallucinations
• Vivid elaborate scenic hallucinations have been described in oneiroid states in schizophrenia

Charles Bonnet Syndrome

• Described in relation to Bonnet’s grandfather, Charles Lullin
• Complex visual hallucinations which are formed, complex, persisting, or repetitive
• No demonstrable psychopathology or disturbance of normal consciousness
• More common in the elderly but can occur at any age
• Insight is fully or partially retained
• Usually associated with central or peripheral reduction in vision
• No delusions
• No hallucinations in other modalities
• May last from days to years

Autoscopic (Heautoscopic) Hallucinations

• First described by Féré in 1891
• A.k.a. phantom mirror image – the experience of seeing a double of oneself projected into external space
• M:F = 2:1
• Mean age of 40
• Neurological and psychiatric disorder occur in 60%
• Occur in:
• Depressive illness
• Schizophrenia
• Temporal lobe epilepsy (in 30%)
• Parietal lobe lesions
• Associated with:
• Decreased consciousness
• Delirium
• Visual imagery
• Narcissism
• Depersonalization
• Negative autoscopy is the experience of looking into a mirror and seeing nothing at all

The Double Phenomenon: Doppelgänger

• Is an awareness of oneself as being both outside alongside and inside oneself
• Is the subjective phenomenon of doubling
• It is cognitive and ideational, rather than perceptual
• Often a variety of depersonalization
• Can occur in normal people
• May be due to:
1. Fantasy
2. Depersonalization
3. Conflict
4. Compulsive ideas (repetitive, self-produced and self-ascribed, resisted)
5. Double personality (alternating states of consciousness)
6. Being in two, being doubled

• An illusion is an involuntary false perception consequent on a real object in which a transformation of the object takes place
• Distortions of real objects, e.g., flowery wallpaper is perceived as swarming snakes
• May often occur at extremes of tiredness and emotion

Completion Illusions

• Occur during inattention
• Banished by attention

Affective Illusions

• Based in mood, especially fear

Pareidolic Illusions

• Vivid mental images occurring without conscious effort when perceiving ill-defined stimuli, e.g., shapes in clouds
• Occurs more in children than adults
• Increased by attention

• Not perceived by the actual sense organs, but experienced as emanating from within the mind
• They are a form of imagery
• Characteristics:
• Although vivid, they lack the substantiality of normal perception
• Located in subjective, rather than objective space
• Unwilled and not subject to conscious control or manipulation
• Retention of insight
• Not pathognomonic of any mental illness
• Occur in:
• Depression
• Obsessional states
• Hysteria
• Personality disorder
• Times of life crisis, e.g., bereavement - hallucinations of widowhood; tend to be reassuring rather than frightening

1. Hysterical Mutism

   • Often as a reaction to stress

2. Approximate Answers

   • Seen in:
   1. Hebephrenic schizophrenia
   2. Hysterical pseudodementia
   3. Ganser syndrome
   4. Organic brain disease

3. Pseudologia Fantastica

   • Seen in histrionic/asocial personality disorder
   • Overlap with Munchausen syndrome

1. Aphonia

   • Loss of ability to vocalize

2. Dysphonia

   • Impairment with hoarseness
   • Occurs in disease of the vocal cords and IXth cranial nerve lesions

3. Dysarthria

   • Lesions of the brain stem e.g. bulbar/pseudobulbar palsy
   • Schizophrenia
   • Personality disorders (perhaps consciously produced)

4. Logorrhoea

   • Excessive production of the volume of speech, without pressure of speech

5. Logoclonia

   • Spastic repetition of syllables
   • Occurs in Parkinsonism

6. Echolalia

   • Repetition of words or phrases that are spoken to him
   • Seen in:
     1. Learning disability
     2. Dementia
     3. Head injury
     4. Tourette’s syndrome

7. Unintelligible Speech

   • Dysphasia
   • Paragrammatism – disorder of grammatical construction
   • Private symbolism:
     1. Neologisms
     2. Stock words and phrases
     3. Cryptolalia
     4. Cryptographia

8. Verbigeration

   • Refers to the repetition of words or syllables that expressive aphasic patients may use while searching for the correct word

9. Paragrammatism

   • Any error in grammatical construction

• Clang Associations

  • Associations with the initial syllable in schizophrenia
  • Associations with the last syllable in mania

• Verbal Stereotypy

  • Repetition of a word or phrase (Stock word) which has no immediate relevance to the context

• Pressure of Thought
• Poverty of Thought
• Changes in the Flow of Thinking
• Crowding of Thought
• Subjective experience of thoughts being excessive in amount, too fast, inexplicable, and outside the person’s control
• Thought Blocking
• A sudden cessation of speech mid-sentence with an accompanying sense of subjective distress; patients may complain that their minds have ‘gone blank’ or that their thoughts have been interfered with
• Thought Withdrawal
• More usually classified as a form of delusion

• Normal Thinking (Fish, 1967):

  • Dereistic Thinking (Daydreams)
  • Imaginative thinking
  • Rational thinking

• Perseveration:

  • The patient retains a constellation of ideas long after they have ceased to be appropriate
  • Example: “Where do you live?”, “London”, “How old are you”, “London”...

• Explanatory Concepts for Formal Thought Disorder:

  • Loss of association (asyndesis)
  • Concrete Thinking – inability to think in an abstract way; unable to differentiate between primary and secondary meanings of words
  • Loss of redundancy (Cloze technique)
  • Loss of internal monitoring with consequent inability to ‘repair’ thought processes (Frith)
  • Impaired semantic memory or impaired access to this

• Accelerated Tempo:

  • Characteristic of hypomania, mania, and may also occur in delirium
  • Can occur in hypothalamic lesions
  • Pressure of Speech: Increased rate of delivery of speech
  • Flight of Ideas: Loss of coherent goal-directed thinking with increasingly obscure associations between ideas. Connections between thoughts may be based on:
  • Chance relationships
  • Clang associations
  • Distracting stimuli
  • Verbal associations, e.g., alliteration and assonance
  • Clang Associations: Vague connections prompted by rhyme and sounds of words.

• Decreased Tempo:

  • Subjectively experienced as ‘muzziness in thinking’ or difficulty in concentration
  • Leads to difficulty in decision making and pseudodementia
  • Characteristic of retarded depressive states
  • Said to occur rarely in depressive stupor

Circumstantial Thinking

• The slow stream of thought is affected by a defect of intellectual grasp, a failure of differentiation of the figure ground – there is a great deal of unnecessary detail which obscures the meaning
• Occurs in:
  • Epilepsy
  • Mental retardation
  • Obsessional personality

Concrete Thinking

• Abstractions and symbols are interpreted superficially without tact or awareness of nuance – the patient is unable to free himself from what the words actually mean

Theories of Schizophrenic Thinking

• Over-inclusive thinking
• Broadening of category boundary
• Personal construct theory – investigated using the Repertory Grid
• There is a process of serial invalidation
• People and things are construed in a loose and unpredictable way

Schizophrenic Thought Disorder

• Bleuler (1951) – Loosening of associations, condensation
• Cameron (1944) – Over-inclusive thinking
• Goldstein (1944) – Concrete thinking
• Schneider (1959) – Derailment, drivelling, desultory thinking, fusion, omission, substitutions

Thought Disorders in Schizophrenia

• Omission – A sudden discontinuation of a chain of thought
• Knight’s Move Thinking – Similar to flight of ideas but the omitted connection bears a more tangential relation to the whole
• Derailment – A disruption of the continuity of speech by the insertion of novel and inappropriate material to the chain of thought
• Fusion – A merging and ‘interweaving’ of separate ideas
• Drivelling – Refers to the muddling of elements within an idea to the extent that the meaning is totally obscured to the listener
• Desultory Thinking – Ideas are expressed correctly in terms of syntax and grammatical construction, but juxtaposed inappropriately – the ideas would be comprehensible if expressed in another context or in isolation
• Thought Blocking – A sudden cessation of speech mid-sentence with an accompanying sense of subjective distress; patients may complain that their minds have ‘gone blank’ or that their thoughts have been interfered with
• Condensations – Common themes from two or more separate ideas are combined to form an incomprehensible concept
• Schizophasia / Word Salad – Incomprehensible speech
• Schneiderian Terms:
  • verschmelzung – Fusion
  • faseln – Muddling
  • entgleiten – Snapping off
  • entgleisen – Derailment

Passivity Phenomena

• Common feature is the apparent disintegration of boundaries between the self and the surrounding world
• The individual experiences outside control of, or interference with, his or her thinking, feeling, perception, or behaviour
• Generally experienced as a delusion

Passivity Phenomena Types:

1. Thought insertion or withdrawal – the experience of thoughts being put into or taken out of the mind by some external agency or force without the patient’s volition
2. Thought broadcasting – the thoughts are withdrawn from his mind, and then made public and broadcast over a wide area out of his control
3. ‘Made actions’ – either simple motor actions or more complex patterns of behaviour are experienced as being caused by an outside agency
4. Passivity of emotion – occurs when the affect that the patient experiences does not seem to be his own; he has been made to feel it
5. Passivity of Impulse – the patient experiences a drive to carry out some motor activity which feels alien; the action is admitted to be the patient’s own, but the impulse is not

Definition of a Delusion

Jaspers (1959)

‘A belief held with unusual conviction that is unamenable to logic whose erroneousness is manifestly obvious to others’

Hamilton (1978)

A false, unshakeable belief which arises from internal morbid processes. It is clearly recognizable when it is out of keeping with the patient’s background’

‘A fixed, (usually) false or fantastic idea, held in the face of evidence to the contrary, and out of keeping with the patient’s social milieu’

Characteristics of Delusions:

• It is always self-involved/self-referential
• Held unshakably
• Not modified by experience or reason
• Content often bizarre
• Not dependent on disintegration of general intellectual functioning or reasoning abilities
• Some delusions where the content is not axiomatically impossible may be distinguished from overvalued ideas because of the evidence advanced on their behalf

Primary Delusions

Also known as: Autochthonous idea (Wernicke)

Un-understandable in terms of other psychopathology (Jaspers)

Has no discernible connection with any previous interactions or experiences

Not dependent on temporal relationships

May arise from memory, atmosphere, or perception

Type of Primary Delusions:

1. Delusional Intuition (Autochthonous)
   • 'Out of the blue', 'brain wave'
   • Arise fully formed as sudden intuitions
   • Occur in a single stage
   • Also known as Wahneinfall (Ger.)
   • Consistent with 'double orientation'
2. Delusional Perception
   • Occurs in two stages:
     1. Real perception
     2. Delusional interpretation
   • Is a 1st rank symptom of schizophrenia
   • Does not have to be simultaneous
   • Usually occurs in the setting of a delusional mood
3. Delusional Atmosphere
   • Also known as delusional mood
4. Delusional Memory
   • Also known as retrospective delusions
   • Is remembered in the past – both the perception and the interpretation are retrospective

Stages in the Development of a Delusion (Fish, Conrad)

1. Trema – Delusional mood
2. Apophany – Search for a new meaning
3. Anastrophy – Heightening of the psychosis
4. Consolidation – Formation of a new cognitive set based on the new meanings
5. Residuum – Eventual autistic state

Secondary Delusions

• May be grandiose (thinking you are Napoleon) or depressive (delusions of guilt or filth)
• A secondary delusion emerges understandably from other psychic experiences or current preoccupations, e.g. prevailing affect, fears, personal stress, habitual attitudes of mind, hallucinosis, cognitive impairment, thought disorder, or other delusions
• A Delusional misinterpretation is the formation of a delusional explanation for a veridical perception, usually based on a strong prevailing mood

Ideas of Reference, Overvalued Ideas, and Delusions with Partial Insight

• Ideas of Reference: Denote ambiguous events in the outside world whose interpretation, though feasible, is wholly or mainly self-centered.
  • Experienced by normal people under stress, sensitive individuals, and those suffering social phobia.
  • Usually accompanied by delusions of reference (which differ in that their explanation is unfeasible).
  • A.K.A. Sensitiver Beziehungswahn.
  • Often arise as a consequence of a key experience.
• Overvalued Idea: An idea that is comprehensible or socially acceptable but dominates the patient’s life, pursued beyond the bounds of reason.
  • Does not have a stereotypic quality (unlike obsessional rumination).
  • Never considered senseless by the patient.
  • Tends not to have a bizarre quality, e.g., preoccupation with water being over-fluoridated.
  • Associated with:
    • Personality disorder (especially paranoid).
    • Morbid jealousy.
    • Hypochondriasis.
    • Dysmorphophobia.
    • Parasitophobia (Ekbom’s syndrome).
    • Anorexia nervosa.
    • Transsexualism.
• Partial Delusion: Held with a certain degree of doubt, especially during the remission stage of a psychosis.
  • Differ from overvalued ideas in the degree of personal investment.
  • Differ from ideas of reference in that they may still retain all the other qualities of a delusion.

Type of Delusions and Overvalued Ideas

• Persecution
• Reference
• The delusion that others believe one smells is a monosymptomatic reference delusion and is also an example of dysmorphophobia.
• Dysmorphophobia
• Jealousy
• Love
• C.F. De Clerambault’s Syndrome (2 phases - one elated, the other frustrated, irritable, aggressive, feels others are interfering)
• Guilt, Unworthiness
• Poverty, Nihilism
• Grandiosity
• Infestation:
• Ekbom’s Syndrome - seen in organic states and drug (cocaine) misuse.
• Misidentification:
• Capgras’ Syndrome
• Fregoli Syndrome - the belief that one familiar individual has replaced various strangers.
• Reduplicative Paramnesia - in which the patient’s surroundings are believed to exist in more than one physical location.
• Communicated Delusion - Folie à Deux:
• Principle (already psychotic) transmits ideas to the associate, who then becomes psychotic.
• Principle is often in a relationship of dominance with the associate.
• Hypochondriasis
• Passivity and Thought Alienation
• Bizarre and Fantastic Delusions
• Usually schizophrenic and are a means by which the patient can explain the unexplainable.

Delusions and Religious Beliefs

• Delusions are held in a concrete rather than a conceptual way.
• Delusions are held in a way more resembling knowledge.
• Religious beliefs are usually invigorating and purpose-giving and are held with the possibility of doubts.