CLINICAL PSYCHOPATHOLOGY

1. CLINICAL PSYCHOPATHOLOGY
Lecture

2. INTRODUCTION
• Psychopathology is the study of abnormal
states of mind.
• This is a basic and fundamental professional
skill of a psychiatrist hence it is highly
important to have a good grasp of it.

3. Definition of major symptoms and
signs
1. Disorders of perception
a. Sensory distortions
• Hyper-aesthesia- increased intensity of
sensations.
• Hypo-aesthesia- decreased intensity of
sensations.
• Xanthopsia /chloropsia/erythropia – changes
in colour (yellow, green , red respectively)

4. • Dysmegalopsia – change in the shape of an
object. Micropsia is when the object is seen as
smaller than it is. Macropsia is when the
object is seen as bigger than it really is.
• Distortions in the experience of time – time
flies when the mood is happy and slows down
when the mood is sad. Age disorientation and
abnormalities of time judgement seen in
chronic schizophrenia.

5. b. Sensory deceptions
• Illusions – misinterpretation of stimuli arising
from an external object. Usually occurs in
states of a raised perceptual threshold
(anxious state), reduced attention.
• Hallucination – perception without an object.
Can be classified based on complexity –
simple/elementary, complex.

6. • Simple / Elementary – no distinct voices /
form is heard or seen e.g whistles, flashes of
light, birds chirping etc.
• Complex – refers to experiences such as
hearing voices, seeing faces or scenes etc.

7. Can also be classified according to sense organs
– auditory, visual, olfactory, gustatory,
tactile/somatic.
• Auditory hallucination – hearing of sounds or
voices unheard by people around. The voice
may talk directly to patient referring to him as
‘you’ (2nd person) or refers to the patient as
‘he or she’ (3rd person),

8. • it may comment about the action (voice
commenting)or command (voice commanding)
or discuss about the patient (voices discussing)
• Another type of auditory hallucination is when
patient hears his own thought spoken in his ears
– Thought Echo. Which can occur at the same
time the thought is spoken
(Gedankenlautwerden) or immediately after the
thought has occurred (Echo de la pensee)

9. • Visual hallucination – may be elementary in
form of flashes of light or completely
organised in form of objects, people etc. They
are more common in acute organic states.
• Olfactory hallucination – individuals
perceiving strange smells others around cant
perceive eg. Smell of insects, dead bodies etc.

10. • Gustatory hallucination – experiencing
unpleasant tastes.
• Tactile hallucination – experience of
sensations on the body, being touched,
pricked, strangulated, visceral been dragged
etc.

11. • Can be classified based on special features –
hypnagorgic, hypnopompic, extracampine,
autoscopic, functional, reflex
• Hypnagorgic hallucination – hallucination
occurring when a person is falling asleep.
• Hypnopompic hallucination –hallucination
occurring when a person is waking up.
• Extracampine hallucination – hallucinations
outside the field of vision of an individual.

12. • Autoscopic hallucination – experience of
seeing one’s own body projected in space in
front of oneself.
• Functional hallucination – stimulus in one
sensory modality producing hallucinations in
the same sensory modality.
• Reflex hallucination – stimulus in one sensory
modality producing hallucination in another
sensory modality.

13. 2. Disorders of thought form
• Tangentiality – replying to a question in an
oblique, irrelevant manner. The reply may be
related to the event in some distant way or
unrelated totally.
• Derailment – a pattern a speech in which the
idea slips off the track onto one that is clearly
but obliquely related or to a completely
unrelated one.

14. • Incoherence – a pattern of speech that is
incomprehensible.
• Circumstantiality – a pattern of speech that is
very indirect and delayed in reaching its goal
idea.
• Perseveration – occurs when mental
operations persist beyond the point at which
they are relevant.

15. • Echolalia – a pattern of speech in which the
patient echoes words or phrases of the
interviewer.
• Loosening of association – a loss of the normal
structure of thinking it may be muddled,
illogical etc.
• Poverty of content of speech – although
replies are long enough so that speech is
adequate in amount, it conveys little meaning.

16. • Flight of ideas – thought follows each other
rapidly and the connection between
successive thought can be by chance
associations, clang associations, alliterations,
proverbs, maxims and cliches.

17. 3. Disorder of thought stream
• Poverty of speech – restriction in the amount
of speech, so that response to speech tend to
be brief, concrete and rarely provided.
• Pressure of speech – increase in the amount
of speech as compared with what is
considered socially customary.

18. 4. Disorders of thought content
Delusions – beliefs held on inadequate
grounds, held on to firmly despite evidence to
the contrary and not in keeping with the
individuals educational, cultural or religious
background.
Can be classified based on onset
• Primary delusion – appears suddenly without
a mental event leading up to it.

19. a. Delusional mood – a feeling of foreboding
that that some unidentified sinister event is
about to occur.
b. Delusional perception – attaching a new
significance to a familiar percept without any
reason to do so.
c. Delusional memory - a delusional
interpretation is attached to a past event
which may be true or false

20. • Secondary delusions – delusions derived from
a preceding morbid experiences.
Can be classified based on themes
a. Persecutory delusion – belief that
someone/an organisation is out to harm him
i.e damage his reputation, cause bodily harm
etc
b. Delusion of guilt – having guilt feelings due to
minor offences /acts committed in the past.

21. c. Grandiose delusion – beliefs of exaggerated
self-importance. If its in special powers,
unusual talents (ability). If its in fame, wealth,
prominent person (identity).
d. Nihilistic delusion – beliefs that some person
or things has ceased or is about to cease to
exist.

22. e. Delusions of reference- thing happening
around has a personal significance to the
person.
f. Delusion of love – the individual is convinced
that someone of a higher status is in love
with them.
g. Delusion of jealousy – the individual believes
their partner/spouse is unfaithful.
h. Hypochondriacal delusion – the individual
believes he/she has a serious disease.

23. i. Delusion of control – believes that his
thoughts, actions and impulses are
controlled by external forces or agencies. It is
also called passivity phenomenon
j. Delusion concerning possession of thought
• Thought insertion – thoughts which do not
belong to the individual has been placed in
his mind by external agents.

24. • Thought withdrawal – thoughts are taken out
of the mind by external agents.
• Thought broadcast – unspoken thoughts are
known to people around.
k. Obsessions – recurrent persistent thoughts,
impulses or images which enter the mind
despite efforts to exclude them.

25. l. Overvalued ideas – it is an isolated,
acceptable, comprehensible idea pursed
beyond the bounds of reason.

26. 5. Disorder of emotion and mood
• An emotion is a feeling state which may be
provoked by a stimulus(internal or external)
and is usually accompanied by certain bodily
phenomenon.
• Mood is a prolonged emotional feeling state,
more intense and lasts longer and colours the
whole psychic life of the individual while it
lasts.

27. • Affect is the tone of the emotion.
• Mood states can be anger, anxious, irritable,
depressed/sad, happy/elated etc.
• Labile mood – increase variation in the mood.
• Blunting – a reduction in emotional tone in
response to stimuli.
• Apathy – absence of feeling.

28. 6. Motor signs and symptoms
• Mannerisms – repeated movements with a
functional significance.
• Stereotypies – repeated movements without a
functional significance.
• Tics – repeated irregular involuntary
movements of a group of muscles.

29. • Posturing - voluntary assumption and
maintenance of inappropriate or bizarre
postures.
• Negativism - an apparently motiveless
resistance to all instructions or attempts to be
moved, or movement in the opposite
direction.
• Rigidity - maintenance of a rigid posture
against efforts to be moved

30. • Waxy flexibility - maintenance of limbs and
body in externally imposed positions.
• Stupor - marked decrease in reactivity to the
environment and reduction of spontaneous
movements and activity.
• Catatonia – a state of increased muscle tone
affecting extension and flexion abolished by
voluntary movement.

31. • Echopraxia – imitation of interviewers
movement automatically even when not
asked to do so.
• Ambitendence – alternating between
opposing movements.

32. How to elicit these symptoms
i. Observation
• Mood is assessed not only on the basis of
what the patient says but also on the basis of
facial expressions, bodily gestures, posture,
tone of the voice etc.

33. ii. Questioning
• This technique is acquired with practise – start
with open ended questions e.g have you been
experiencing some strange things over the
past few weeks? Would you like to talk about
these strange things?
• Has there been periods when even there is no
one present in the room, you seem to hear
unseen persons talking?

34. Blueler’s description
4 A’s of Blueler
• Autism
• Ambivalence
• Incongruity of affect
• Loosening of association

35. Schneiderian description
1st rank symptoms
• Delusional perception
• 3rd person auditory hallucination
• Voices commenting
• Passivity of action
• Passivity of impulse
• Passivity of emotion

36. • Thought echo
• Thought broadcast
• Thought withdrawal
• Thought insertion
• Somatic hallucination

37. Psychotic Vs Neurotic
• Hallucinations and delusions are the hallmark
of psychosis while patient with neurosis have
intact reality testing.
• Patient with neurosis is believed to have
preserved insight while those with psychosis
do not have preserved insight.

38. • Patient with psychoses are thought to have a
distorted personality by the illness and
constructed a false environment out of his
distorted subjective experience.
N.B - these differences are oversimplification, as
an individual with neurosis may have no
insight while patient with psychosis may
willingly seek treatment. Personality may also
be changed in neurosis.

39. THANK YOU