Psychopathology

د. وليد عزيز العميدي Psychopathology
Psychopathology is the science and study of psychological and psychiatric symptoms
Clinical psychopathology locates this study in the clinical context in which psychiatrists make diagnostic assessment and deliver mental health services.
Disorders of thinking : thinking mean the use of thoughts and concepts in solving problems , thought means the sum of ideas connected in logical organized way.
Classification of disorders of thinking :
1- Disorders of the stream of thought.
2- Disorders of possession of thought.
3- Disorders of content of thought.
4- Disorders of form of thought.
- Disorders of the stream of thought : can be further divided into the following :
A- Flight of ideas : the thoughts follow each other rapidly , there is no general direction of thinking ; and the connections between successive thoughts appear to be due to chance factors which , however can usually be understood. Flight of ideas is typical of mania , and occasionally occurs in individuals with schizophrenia when they are excited and individuals with organic states including for example lesions of the hypothalamus.
B- Inhibition or slowing of thinking : the train of thought is slowed down and the number of ideas and mental images which present themselves is decreased. This is experienced by the patient as difficulty in making decisions , lack of concentration and loss of clarity of thinking , diminution in active attention so that events are poorly registered. This leads the patient to complain of loss of memory. Slowing of thinking is seen in both depression and the rare condition of manic stupor.
C- Circumstantiality : occurs when thinking proceeds slowly with many unnecessary and trivial details , but finally the point is reached . the goal of thinking is never completely lost and thinking proceeds toward it by an intricate and convoluted path. It can be seen in epileptic personality , learning disability and obsessional personality traits.
D- Perseveration : occurs when mental operations persist beyond the point at which they are relevant and thus prevent progress of thinking , this symptom is related to the severity of the task facing the patient , so that the more difficult the problem , the more likely it is that perseveration will occur. Perseveration is common in generalized and local organic disorders of the brain .
E- Thought blocking : there is a sudden arrest of the train of thought , leaving a blank. An entirely new thought may then begin . it is highly suggestive of schizophrenia . however , patients who are exhausted and anxious may also lose the thread of the conversation and may appear to have thought blocking.
- Disorders of possession of thought :
A- Obsessions and compulsions.
Obsessions : are recurrent persistent thoughts , impulses , or images that enter the mind despite efforts to exclude them .one characteristic feature is the subjective sense of a struggle-the patient resist the obsession . another characteristic feature is a conviction that to think something is to make it more likely to happen. Obsession are recognized by the person as her own and not implanted from elsewhere (in contrast to delusion or thought insertion ) . another important distinction from delusions is that obsessions are regarded as untrue or senseless , obsession can take various forms :
Obsessional thoughts , obsessional ruminations , obsessional doubts , obsessional impulses , obsessional phobias.
Compulsions : are repeatitive and seemingly purposeful behaviors , performed in a stereotyped way in response to obsession.
Compulsive acts are of many kinds :
- Checking rituals are often concerned with safety ,e.g. checking over and over again that the doors locked.
- Cleaning rituals often take the form of repeated hand washing.
- Counting rituals involve counting in some special way.
B- Thought alienation : the patient has the experience that their thoughts are under the control of outside agency or that others are participating in their thinking , there are several varieties :
- Thought insertion : the patient knows that thoughts are being inserted into their mind and they recognize them as being foreign and coming from without , this symptom commonly associated with schizophrenia.
- Thought deprivation : the patient finds that as they thinking , their thoughts suddenly disappear and are withdrawn from their mind by a foreign influence .
- Thought broadcasting : the patient knows that as they are thinking , everyone else is thinking in unison with them.

- Disorders of the content of thinking : a delusion is defined as a false , unshakable belief that is out of keeping with the patient`s social and cultural background. Another important variety of false belief , which can occur in individuals both with and without mental illness, is the overvalued ideas . this is a thought that , because of the associated feeling tone , takes precedence over all other ideas and maintains this precedence permanently or for a long period of time . overvalued ideas tend to be less fixed than delusions and tend to have some degree of basis in reality.
Primary delusions are the first psychopathology to occur in the course of symptoms
(temporal sequence).
Types of primary delusion :
1- Delusional mood : the patient has the knowledge that there is something going on around him that concerns him , but he does not know what it is.
2- Sudden delusional idea : a delusion appears fully formed in the patient`s mind . this is sometimes known as an autochthonous delusion .
3- Delusional perception : is the attribution of new meaning , usually in the sense of self-reference , to a normally perceived object .

Secondary delusions : can be understood as arising from some other morbid experience .
The content of delusions in schizophrenia is dependent , to a greater or lesser extent , on the social and cultural background of the patient . common general themes include persecution , jealousy , love , grandiosity , ill health , guilt , nihilism and poverty .
Delusion of persecution : can take many forms. In delusion of reference the patient knows that people are talking about him , slandering him or spying on him . occurs in schizophrenia , depressive illness and other psychotic illnesses.
Delusions of guilt can be so marked that the patient believes that he is about to be put to death or imprisoned for life.
Delusion of infidelity : may develop gradually as a suspicious or insecure person becomes more and more convinced of their spouse`s infidelity and finally the idea reaches delusional intensity. May occur in both organic and functional disorders (schizophrenia , affective psychosis and alcohol dependency).
Delusion of love (fantasy lover syndrome) (erotomania) : the patient is convinced that some person is in love with them although the alleged lover may never have spoken to them.
Grandiose delusions : the patient believe that they are an important person who is able to help others , or may report hearing the voice of God and the saints , confirming their elevated status. Most commonly associated with manic psychosis in the context of bipolar affective disorder.
Delusions of ill health : are a characteristic feature of depressive illnesses , but are also seen in schizophrenia , it may develop on a background of concerns about health.
Nihilistic delusions : or delusions of negation occur when the patient denies the existence of their body , their mind , their loved ones and the world around them. These delusions tend to occur in the context of severe , agitated depression and also in schizophrenia and states of delirium .
Delusion of poverty : the patient is convinced that they are impoverished and believe that destitution is facing them and their family.
Overvalued ideas : is an isolated , acceptable , comprehensible idea pursued by the patient beyond the bounds of reason. It may preoccupy and dominate a person`s life for many years and affect their actions . overvalued ideas differ from delusions in three main way :
- The content of and basis for , the overvalued idea is usually understandable when the person`s background is known , whereas delusions and the person explanation of them tend to be bizarre.
- The theme also tends to be culturally common and acceptable.
- With an overvalued idea , there is some degree of insight .

Disorders of the form of thinking : formal thought disorder is usually recognized from speech and writing but is sometimes evident from the patient`s behavior. Disorders of the form of thought can be divided into several kinds :
1- Perseveration : usually occurs in dementia and frontal lobe injury.
2- Flight of ideas .
3- Loosening of association : it denotes a loss of the normal structure of thinking . the patient`s discourse seems muddled , illogical or tangential to the matter in hand , three characteristic kinds of loosening of association have been described , all of which are seen most often in schizophrenia :
a- Talking past the point(vorbeireden) : the patient seems always about to get to the end point of the topic in question , but skirts around it and never in fact reaches it.
b- Knight`s move thinking or derailment : refers to a transition from one topic to another , either between sentences or in mid-sentence , with no logical relationship between the two topics .
c- Verbigeration : is said to be present when speech is reduced to the senseless repetition of sounds , words , or phrases . this abnormality can occur with severe expressive aphasia and occasionally in schizophrenia . when this abnormality is extreme the disorder is called word salad.
Other disorders of thinking :
Neologisms : are words or phrases , invented by the patient , often to describe a morbid experience . it occurs most often in chronic schizophrenia.

Perception and imagery : perception is the process of becoming aware of what is presented through the sense organs. perception can be attended to or ignored , but it cannot be terminated by an effort of will .
Imagery : is the awareness of a percept that has been generated within the mind . imagery can be called up and terminated by an effort of will .
Disorders of perception can be divided into sensory distortions and sensory deceptions.
1- Sensory distortions: includes :
a- Changes in intensity : increased intensity of sensations(hyperaesthesia) may be a result of intense emotions or a lowering of the physiological threshold. Anxiety , depressive disorders and hangover from alcohol and migraine are all associated with increased sensitivity to noise. While hypoaesthesia is seen in delirium where the threshold for all sensations is raised.
b- Changes in quality : these are mainly visual perceptions that are affected , brought about by toxic substances ( e.g. poisoning with mescaline or digitalis).
c- Changes in spatial form (dysmegalopsia) : this refer to a change in the perceived shape of an object. Micropsia is a visual disorder in which the patient sees objects as smaller than they really are. The opposite kind of visual experience is known as macropsia or megalopsia. Dysmegalopsia can result from retinal disease , disorders of accommodation and convergence but most commonly from temporal and parietal lobe lesions.
2- Sensory deceptions : can be divided into illusions and hallucinations.

Illusions : are misperceptions of external stimuli . they occur when the general level of sensory stimulation is reduced and when attention is not focused on the relevant sensory modality . illusions occur also when the level of consciousness is reduced , as in delirium . illusions are more likely when the person is anxious. Thus in a dark lane a frightened person is more likely than a calm person to misperceieve the outline of a bush as that of a man.
Hallucinations : is a percept experienced in the absence of an external stimulus to the corresponding sense organ . hallucination can not terminated at will . hallucinations are generally indications of significant psychiatric disorder. However , hallucinations occur occasionally in healthy people , usually when falling asleep (hypnagogic hallucination ) or on waking ( hypnopompic hallucinations ) . these two types of hallucination may be either visual or auditory . such hallucinations are common in narcolepsy . some recently bereaved people experience hallucinations of the dead person . hallucinations can occur after sensory deprivation, in people with blindness or deafness of peripheral origin.
Types of hallucination : hallucinations can be described in terms of their complexity and their sensory modality . the term elementary hallucination refers to experiences such as bangs , whistles and flashes of light ; complex hallucination refers to experiences such as hearing voices or music or seeing faces and scenes.
Auditory hallucinations : may be experienced as noises , music or voices.voices may be heard clearly or indistinctly . they may seem to address the patient directly(second person hallucinations) or talk to one another referring to the patient as "he" or "she" (third person hallucinations) . sometimes, the voices seem to repeat patient`s thought immediately after he has thought them (echo de la pensee).
Visual hallucinations : may also be elementary or complex . hallucinations of dwarf figures are sometimes called Lilliputian .
Olfactory and gustatory hallucinations .
Tactile hallucinations : sometimes called haptic hallucinations, may be experienced as sensations of being touched , pricked , or strangled .sometimes they are felt as movements just below the skin , which the patient may attribute to insects or worms.

Depersonalization and derealisation :
Depersonalization : is a change of self-awareness such that the person feels unreal
, detached from his own experience and unable to feel emotion.
Derealisation : is a similar change in relation to environment , such that objects appear unreal and people appear as lifeless , both depersonalization and derealisation are described as highly unpleasant experiences , they are experienced quite commonly by healthy people especially when tired as transient phenomena of abrupt onset , they are also reported after sleep deprivation and sensory deprivation , as effect of hallucinogenic drugs , generalized anxiety disorder , depressive disorders , schizophrenia and temporal lobe epilepsy .

Motor symptoms and signs :
Tics : are irregular repeated movements involving a group of muscles , e.g. sideways movement of the head or the raising of one shoulder.
Mannerism : are repeated movements that appear to have some functional significance , e.g. saluting.
Stereotypies : are repeated movements that are regular and without obvious significance (unlike mannerism ) .
Catatonia : is a state of increased muscle tone affecting extension and flexion and abolished by voluntary movement .
Catalepsy (waxy flexibility ) : is a term to describe the tonus in catatonia .it is detected when a patient`s limbs can be placed in a position in which they then remain for long periods whilst at the same time muscle tone is uniformly increased.
Patients with this abnormality sometimes maintain the head a little way above the pillow in a position that a healthy person could not maintain without extreme discomfort( psychological pillow ) .
Posturing : is the adoption of unusual bodily postures continuously for a long time.

Negativism : patients are said to show negativism when they do the opposite of what is asked and actively resist efforts to persuade them to comply.
Echopraxia : is the imitation of interviewer`s movement automatically even when asked not to do so.
Mitgehen : excessive compliance in which the patient`s limb can be moved into any position with the slightest pressure.
Ambitendence : patients are said to exhibit ambitendence when they alternate between opposite movements ,e.g. putting out the arm to shake hands, then withdrawing it , extending it again , and so on repeatedly.

Disturbance of recognitions : several disorders of recognition occur occasionally in neurological and psychiatric disorders :
Jamais vu : is the failure to recognize events that have been encountered before.
Déjà vu : is the conviction that an event repeats one that has been experienced in the past when in fact it is novel.
Confabulation : is the reporting as memories of events at one time , of events that took place at another time , or never involved the person. It is characteristic of amnestic syndrome.

Disturbances of consciousness :
Consciousness : is awareness of the self and the environment .
Coma : is the most extreme form of impaired consciousness . the patient shows no external evidence of mental activity and little motor activity other than breathing . he does not respond even to strong stimuli .
Stupor : refers to a condition in which the patient is immobile , mute and unresponsive but appears to be fully conscious in that the eyes are usually open and follow external objects. If the eyes are closed , the patient resists attempts to open them . reflexes are normal . it may occur in catatonia .
Oneiroid states : in which there is dream like imagery although the person is not asleep , if prolonged this may be called a twilight state .
Torpor : in which the patient appears drowsy , readily falls asleep and shows evidence of slow thinking and narrowed range of perception .

Insight : in psychopathology , the term insight refers to awareness of morbid change in oneself and a correct attitude to this change in appropriate cases a realization that it signifies a mental disorder , insight has several facets , each being a matter of degree :
- Is the patient aware of phenomena that others have observed (e.g. that he is unusually active and elated).
- If so , does he recognize the phenomena as abnormal.
- If so , does he consider that they are caused by mental illness.
- If so , does he think that he needs treatments.