Psychiatry Seminar: Psychopathology Flashcards
Psychopathology
Terminology:
- Symptoms vs Syndromes (Cluster of symptoms specific to particular disorder ~heart failure i.e. A disorder defined by symptoms instead of etiology (since etiology cannot be found))
- Disease / Disorder / Diagnosis
Psychopathology:
- Study of abnormal states of mind
- Systematic study of abnormal experience, cognition + behaviour / Study of the products of a disordered mind
Classification:
1. Explanatory (on top of describing the symptoms, also explain underlying mechanism of symptoms e.g. Freud)
- Psychodynamic
- Experimental (doing experiment to delineate cognitive mechanisms that lead to symptoms)
- Descriptive (simply describing the symptoms)
- Observation
- Subjective experiences
Descriptive psychopathology
- Precise **description + **categorization of abnormal experiences as recounted by patients & and observed in his behaviour
- Objective description of abnormal states of mind, avoiding as far as possible preconceived ideas or theories (***atheoretical) i.e. avoid theoretical explanations for psychological events
- Concerned solely with the descriptions of ***conscious experiences + observable behaviours
- 2 basic components: **observation (e.g. **behaviour) + **empathic assessment of subjective experience (e.g. **mood)
*this approach is also called “phenomenology” (internal / subjective experience)
Object of inquiry:
- Scientific investigation of internal (subjective) experiences of an individual…
- Mind vs. Brain
- Objective vs. Subjective
- A theoretical network meshing “observers”, “patients” & “symptoms together
- Clinicians as “observers” (recognizing patients’ subjective experience)
- Patients as “observers” (own subjective experience)
- Observation + empathic inquiry as a bridge between subjective experience & “object” under examination
- Subjective experience (mood, beliefs etc.) is in fact a reflection or manifestation of underlying neurobiological signal originated in an affected brain site
- Need to tease out layers of psychosocial noises partaking in the process of symptom formation (e.g. manipulation vs disorientation, hallucination)
Why is studying psychopathology important?
- This is the “language” coding for the abnormalities of the mind manifesting via subjective experience or behaviours (The history of mental symptoms)
- This is the units of analysis elicited in clinical interview and mental state examinations
- DP is the necessary professional skill for psychiatrists
- From symptoms to syndromes to diagnoses and disorders, then to disease entities
- Without understanding what the psychopathologies are, how can you make an accurate diagnosis? (pattern recognition as tradition in medicine)
Dimensions of Psychopathology
- Form vs Content
- Primary vs Secondary
- Significance of individual symptoms
- Cultural variations in psychopathology
- Normal vs Abnormal
Form vs Content
Form:
- Description of symptom’s structure in phenomenological terms (e.g. delusion, hallucination: auditory / visual / others)
- Assist in diagnosis
Content:
- Colouring of the experience e.g. being pinpointed by classmates (persecutory delusion)
- Concerned by patient
Primary vs Secondary
- Temporal
- Causal (e.g. delusion of persecution secondary to auditory hallucinations of derogatory content, grandiose delusion secondary to manic episode)
- Primary: Directly from pathological process
- Secondary: Reaction to a primary symptom
Significance of individual symptoms
- Key symptoms defining specific syndrome
- E.g. depressed mood defining depressive disorder, first rank symptom are specific features for schizophrenia
Cultural variations in psychopathology
- Depressed mood vs Somatisation presentation (e.g. Chinese people can present with body ache in depression)
- Content of delusions derived from cultural + ethnic background e.g. possessed by evil spirits
Normal vs Abnormal
- Statistical? Normal distribution?
- Cultural / Social standard?
- Continuum vs Discrete (categorical) model (e.g. depressed mood vs delusion)
- Distress + Dysfunction (definition of disorder)
***Disorders of Mood
- Nature
- Depressed
- Anxiety
- Elated
- Irritable - Variation
- Labile mood (increased range of variation)
- Emotional incontinence (extreme variation)
- Blunted affect (lack of emotional sensitivity: negative symptom)
- Flattening of affect (reduced range of emotion: negative symptom)
- Anhedonia (loss of ability to experience pleasure) - Congruity
- Whether mood state is in keeping with person’s circumstances + thoughts
- Incongruous **affect (feature of Schizophrenia) e.g. laugh when talking about husband’s death
- Congruent / Incongruent **psychotic symptoms e.g. grandiose delusion in mania, delusion of guilt in depression
Major mood disorders:
1. Depressive disorder
2. Bipolar disorder
- Mania / Hypomania / Depressive episode
- Anxiety
- Psychological component: apprehension + worries (e.g. free-floating anxiety)
- Somatic component: muscle tension, increased respiratory rate
- Autonomic component: palpitation, increase sweating, dry mouth (panic attack)
- Avoidance of danger (Phobia): irrational fear + wish to avoid specific object / situation with anticipatory anxiety (e.g. social phobia, agoraphobia, specific phobia, PTSD with avoidance of reminders of event)
***Disorders of Perception
- Process of being aware of what is presented via sensory organ
- Can be attended to / ignored but ***cannot be terminated by will
- Perception vs Imagery (generated within the mind)
Abnormal perception:
1. Sensory distortion
- e.g. heightened intensity (hyperacusis), changed quality (micropsia: smaller than real size)
- Illusion (misperception of external stimuli)
- Hallucination
- Pseudo-hallucination (definition of hallucination not fully met, occurs in internal subjective space (vs external in hallucinations) e.g. heard something in one’s thoughts, not perceived as auditory i.e. not come from ears)
Hallucinations
- ***Perception without external stimuli to corresponding sensory organ
- 2 exceptions
—> Functional hallucinations (External stimuli triggering hallucinations e.g. water tap noise trigger 3rd person AH)
—> Reflex hallucinations (A particular stimuli trigger hallucinations of another sense e.g. water tap noise trigger visual hallucinations)
Types:
- Visual
- Auditory (Elementary vs Complex (e.g. Musical))
- Somatic (Tactile (e.g. Formication (Formite): Sensation of insects crawling under the skin) vs Deep)
- Olfactory
- Gustatory
Healthy people can experience hallucinations occasionally
- **Hypnagogic (from wake to sleep) + **Hypnopompic (from sleep to wake) (Visual / Auditory)
- **After sensory deprivation (blindness, deafness)
- **Bereavement (grief reaction)
- Neurological disease (e.g. Temporal lobe epilepsy (rubber burning smell), Charles Bonnet syndrome (VH associated with disease of visual pathway))
- VH: may indicate organic condition
Auditory hallucination (AH)
Auditory verbal hallucination (AVH):
1. 2nd / **3rd person
2. **Thought echo
3. **Running commentary
4. **Discussing among themselves / Conversing with each other
5. Commands (risk of self-harm / suicide)
6. Derogatory
***: First rank symptoms (proposed to be of first rank importance in making a diagnosis of schizophrenia)
***Disorders of Thinking
Particular kinds / Contents of thoughts:
1. Delusions
2. Obsessions
3. Over-valued ideas
4. Negative cognition
Stream and Form of thoughts:
- Speed / Pressure of thoughts
- Linking of thoughts together
Possession of thoughts (***Thought alienation: first rank symptom)
- Thought insertion
- Thought withdrawal
- Thought broadcasting
- Delusions
- Idea, Belief
- **Firmly held (Unshakeable / Fully convicted) on **inadequate ground
- Not affected by ***rational argument / evidence to the contrary
- Not a conventional belief that the person might be expected to hold given his educational + cultural background
- NOT defined by true / false (even though 99.9% is false)
- NOT all or none (a continuum (e.g. might not be true —> probably true —> definitely true))
Dimensions of delusion:
1. Degree of conviction (Partial delusion)
2. Emotional distress (e.g. from persecutory delusion)
3. Preoccupation
4. Acting-out (e.g. confronting by arguing with persecutory delusion)
5. Pervasiveness vs Encapsulation (pervasive across different settings e.g. at school, at work, at home vs encapsulated: at a particular setting only)
6. Bizarreness (e.g. delusional disorders tend to have delusion that is single-theme, non-bizarre, encapsulated, systematised)
7. Systematisation (e.g. delusional thoughts starting to expand to form a system e.g. persecutory delusion from neighbours only to security to teachers to public)
8. Functional level
Karl Jaspers (Concept of understandable):
1. Primary delusion: Not occurring in response to another psychopathological form
2. Secondary delusion: Understandable in present circumstances e.g. pervasive depressive mood state / AH-triggered off abnormal belief
Primary delusions:
1. Delusional intuition (autochthonous, out of the blue)
2. **Delusional perception (abnormal significance attached to a real percept without any cause that is understandable in rational / emotional terms, momentous, of overwhelming personal significance)
3. Delusional atmosphere (mood)
4. Delusional memory (retrospective delusion)
**: First rank symptom
Content of delusions:
- Persecutory (most common)
- Referential (most common)
- Grandiose (identity / ability)
- Delusion of infidelity / jealousy
- Delusion of love / erotomanic delusion (usually subject is of higher status than patient)
- Delusion of poverty and guilt
- Nihilistic delusion (Cotard’s syndrome) (associated with very severe depression)
- Hypochondriacal delusion (belief of suffering from a disease)
- Dysmorphophobic delusion (belief of disfigurement of face)
- Delusions of misidentification (Capgras (belief that a close person has been replaced by an identical imposter i.e. faked) / Fregoli delusions (an unfamiliar person as a familiar person))
- Shared delusions (Folie a deux) (delusions transmitted from one person to another)
- **Delusion of control (passivity)
- **Thought alienation (thought withdrawal, insertion, broadcasting)
***first rank symptoms
