Clinical Psychopathology

892019 Clinical Psychopathology

httpslidepdfcomreaderfullclinical-psychopathology 15

Learning objectives- Accurate gathering and collating of clinical data

- Understanding the significance of clinical data

- Applying data on actual clinical situations

Psychiatric skills knowledge and attitudes- Skills on what to ask how to ask and when to

ask tricky at times

- Knowledge of how each sign and symptom is

defined very crucial

- Attitudes on how to respond appropriately to

various patientssituations takes time

Diagnosis in Psychiatry

Primarily through 1 Psychiatric History (anamnesis)

Predisposing factors (family history)

Precipitating factors (stressors drugsalcohol)

2 Mental Status Examination

Signs and symptoms

Secondarily through 1 PE (with neuro exam) EEG

2 Imaging techniques (CATscan MRI PETscan)

3 Laboratory tests ( to rule out GMCs eg drugs of

abuse liver thyroid abnormalities)

Core Clinical Signs and SymptomsDisorders of Perception

983085 Hallucination

Disorders of Thought and Speech

983085 Delusions

983085 Thought alienation

983085 Obsessions and Compulsions

983085 Flight of ideas

983085 Looseness of Associations

Disorders of Emotion

983085 Manic Mood (different levels)

983085 Depression

983085 Disorders of Memory

983085 Amnesias

983085 Dysmnesias

Other Disorders

983085 experience of the self

983085 Consciousness

983085 motor functions

1 Disorders of PerceptionHallucination arguably the most important

symptom in clinical psychiatry

ldquoPerception without an objectrdquo ( Esquirol )

-hear something that is not there hears voices

ldquoPerceived in external objective spacerdquo ( Jaspers )

Differentiate from pseudohallucination

Hallucinationsndash false sensory perception not associated with

real external stimuli there may or may not be

delusional interpretation of the hallucinatory

experience

Pseudo-hallucination983085 -The main difference between someone with a

pseudo-hallucination and someone experiencing

schizophrenic hallucination is that the person with

schizophrenia will think that it is real and engage in

the hallucination whereas the person with a pseudo-

hallucination will often recognize that it is not real

Auditory Hallucination983085 - Most important symptom in psychotic disorders

-High in reliability frequency and specificity in

schizophrenia (WHO IPSS )

983085 - Some are not pathological like hypnagogic and

983085 hypnopompic types (dropping off to sleep

983085 awakening)

983085 Auditory ndash false perception of sound usually voices but

also other noises such as music

983085 Most common hallucination in psychiatric disorders

(schizophrenia)

983085 High in reliability frequency and specificity

983085

983085 - some auditory hallucinations are not pathological like

983085 Hypnagogic ndash false sensory perception occurring while

falling asleep non-pathological

983085 Hypnopompic ndash false perception occurring while

awakening from sleep non-pathological

983085

Schizophrenic Depressive

Multiple Voices Single Voice

Running commentary Staccato

Third person AbusiveDerogatory

Clinical Psychopathology

Dr Cabuquit 080910



In both schizophrenic and depressive types be aware

of the commanding quality of the voice(s)

Command HallucinationsAlso known as ldquoimperative hallucinationsrdquo

- Patients who hear voices should be asked ifthe voices have commanding quality

- About 23 of Filipino patients obey voicesrsquo

commands (Cabuquit )

- Obeyed commands usually prolonged

intense and frequent (Cabuquit )

Significance of Mumbling Episodes - Patients who mumble actually hear voices

(even when they deny it)

- Mumbling is the patientsrsquo way of responding

to the voices

- Usually verified by observant relatives

Organic Hallucinations

Visual- More common in organic states like

delirium tremens and dementias (

lsquoLilliputianrsquo type)

Lilliputian Type ndash false perception in

which objects are seen as reduced in size

also termed micropsia

- All varieties from elementary forms likeflashes of light to fully formed people or

animals

- Can be with simultaneous auditory

hallucination

ndash false perception involving sight

consisting of both formed and unformed

images

- Most common in medically determined

disorders

Olfactory (Smell) false perception of smell

- Temporal Lobe Epilepsy (TLE) attacks areusually ushered in by an unpleasant odour like

burning rubber or rotten food

Gustatory (Taste) false perception of taste

- Usually caused by uncinate seizures could

also be due to TLE when associated with

salivation chewing and sniffing movements

Tactile (Haptic) false perception of taste

lsquoCocaine bugrsquo or formication ndash feeling of

small animals crawling all over the body or

under the skin associated with delusion ofpersecution

Sexual sensations (eg being masturbated

to orgasm) seen in some schizophrenics

lsquoPhantom limbrsquo phenomenon- most

common organic somatic hallucination occurs

in about 95 of all amputations could be very

painful

2 Disorders of Thought

- Delusional Triad a belief that is

- false ndash no logic no proof

- fixed

- incongruent with the personrsquos socio-

cultural and religious background

- Overvalued Idea an idea that is

false fixed and congruent with the

personrsquos background

Main Types of Delusions

Persecutory- most common in schizophrenia

- personrsquos false belief that he or she is being

harassed cheated or persecuted often found in

litigious patients who have a pathologic

tendency to take legal action because of

imagined mistreatment

Grandiose ndash most common in mania

- personrsquos exaggerated conception of his orher importance power or identity

Guilt- most common in depression

983085 - False feeling of remorsegrief

Jealousy (Othellorsquos syndrome)- most common

in delusional disorders drugs and alcohol

abuse aggravating factors violence frequent

983085 - False belief derived from pathological

983085 jealousy about a personrsquos lover being

983085 unfaithful

- Delusions have a tendency to be acted upon

Schizophrenic vs Depressive Delusions

Schizophrenic Delusions-Delusion of control- most reliable

symptom false feeling that a personrsquos

will thoughts or feelings are being

controlled by external forces

- Primary delusional perception

(Both are parts of First Rank Symptoms)



Depressive DelusionsDelusion of guilt- could lead to suicide

Nihilistic delusion - false feeling that self

others or the world is nonexistent or coming

to an end

Thought AlienationThought Echo983085 - A form of auditory hallucination in which the

patient hears his thoughts spoken aloud either

simultaneous with him thinking it or moment or

two afterwards

Thought Insertion983085 Delusion that thoughts are being implanted in a

personrsquos mind by other persons or forces

Thought Withdrawal983085 Delusion that thoughts are being removed from a


Thought Broadcasting983085 Delusion that a personrsquos thoughts can be heard by

others as though they were being broadcast

through the air

Thought Blocking983085 An objective phenomenon in which the patient

abruptly breaks off his conversation and is silentfor a few seconds and then resumes on a different

topic Subjectively they experience a complete

cessation of all thought

All of the above are commonly seen in

schizophrenia the first four are parts of Schneiderrsquos

First Rank Symptoms

OBSESSIONS AND COMPULSIONSObsessions ndash internal resistance subjective

compulsion983085 Pathological persistence of an irresistible thought

or feelings that cannot be eliminated from

consciousness by logical effort

983085 Associated with anxiety

Compulsions ndash simply the motor components of

obsessions

983085 pathological need to act on an impulse that if

resisted produces anxiety

983085 Repetitive behavior in response to an obsession or

performed according to certain rules with no true

end in itself other than to prevent something from

occurring in the future

Contrast Ideas ndash similar to obsessions

983085 With internal resistance but without subjective

compulsion

Most Common Types of OCs-Handwashing eg Lady Macbethrsquos

-Re-checkingrepeatingrearranging

-Examining things in great detail

3 Disorders of Speech

Looseness of Association - flow of thought in which

ideas shift from one subject to another in a completely

unrelated way

983085 Common in schizophrenia

983085 A schizophrenic talking (desultory manner)

lsquo Itrsquos your cross to stand down considering

itrsquos Saturday The Episcopal twitter neon sign in

occupational street is eating jackass moon in the

nearby tropic of cancer of Jupiter and Pluto So

will you tie me up and down in the percolating

stairs Or shall we eat nincompoop pizzaiersquo

-Notice how difficult it is to understand what

the patient is talking about what about

lsquopizzaiersquo

Flight of Ideas ndash rapid continuous verbalizations orplays on words produce constant shifting from one

idea to another ideas tend to be connected association

of words similar in sound but not in meaning words

have no logical connection may include rhyming and

punning

983085 Common in mania

lsquo The king is standing see HEY The king king is

standing ding ding a ling sing sing HEY HEY

(Laughs) Bird on the wing wing pilot is a harlot

on the trot and he is always hot Irsquom so hotrsquo

- Observe the rhyming punning and clanging

Neologism ndash forming new words

983085 Most specific symptom of schizophrenia

MutismDifferential diagnoses

bull Catatonic schizophrenia ndash markedly

slowed motor activity often to the point of

immobility amp seeming unawareness of

surroundings

bull Hysterical mutism ndash a diagnostic label applied to

state of mind one of unmanageable fear or

emotional excess The fear is often centered on abody part most often on an imagined problem



with that body part People who are hysterical

often lose self-control due to the overwhelming

fear

bull Organic stupor ndash eg demyelinating disease

bull Depressive stupor

Talking to Mute Patients

-lsquoWhispering Techniquersquo ( Cabuquit ) Literally a whispering conversation between

doctor and patient

Good technique to differentiate one mute

patient from another

Best results with hysterical mutism

depressive schizophrenic organic patients

1 Organic stupor Speak slowly and loudly

and hold the patientrsquos hand

2 Depressive stupor Go near the patient

speak with a firm calm and reassuring voice

may hold patientrsquos hand

3 Schizophrenic mutism Speak confidently

normal tone holding hands not advised

4 Hysterical mutism Stay close hold hands

and use your best voice do this with a

companion

4 Disorders of Emotion-Depressed Mood (LAPEL by Cabuquit )

Low mood (depressed sad) Anhedonia ( loss of pleasure or interest)

Poor appetite (with weight loss)

Early morning awakening (3-4 hrs earlier)

Low self-esteem ( guilt feelings suicidal

ideasattempts hopelessness)

Eliciting LAPEL

Low mood lsquoHow do you feel these last few weeks Have you

felt depressed How do you feel upon waking

Anhedonia (loss of interest)

lsquoWhat have you been doing lately Any change in

your usual activities Poor appetite

Any change in your appetite Any weight loss

Early morning awakening lsquoWhatrsquos your usual waking time Any change lately

(3-4 hours earlier than usual)

Low self-esteem lsquoHave you felt helpless hopeless lately Any guilt

feelings Suicidal ideas Attempts

Caution Patients who admit to harboring suicidal

ideas require extra attention look out for lsquosmiling

depressivesrsquo

Rating LAPEL

Positive responses to three out five questions

indicate that the patient is clinically depressed

(two of the three responses should be low

mood and anhedonia)

Specificity of 94Sensitivity of 96

(Brody and Spitzer 2002)

Depression Guilt and Suicide-Depressed patients should always be asked

about suicidal ideas or attempts

-Guilty feelings need for punishment if

no one would mete punishment would

punish himself best way is by suicide

(presence of command hallucination the

risk)

-About 10 of depressed patients die from it

more women than men attempt it more men

than women are successful

Mania The other end of the spectrumManic Mood Gradations (LEXUS byCabuquit)E LEvated m (cheerfulnessconfidence)rarr

E X pansive m (disinhibition)rarr

EU phoric m (unrestrained grandiose feelings)

rarr EcStatic mrarr (intense feelings of

rapture)- Manic stupor - rare

- Hypomania- milder form

- Bipolar- with depression and mania

Mania and its lsquooffspringsrsquo-The manic mood gives birth to

-hyperactivity

- pressure of speech

-grandiosity

-disinhibition eg sexual

-lack of sleep

-irritability ( when frustrated )

5 Disorders of Memory-Amnesias (loss of memory)

Hysterical or Dissociative

Organic ( acute sub-acute chronic)

-Dysmnesias (distortion of memory)Confabulation

Deacutejagrave vu jamais vu



AmnesiasHysterical or dissociative

complete loss of memory and loss of

identity temporary intact personality

Organic

acute- (eg head injury) retrogradeanterogradeamnesia

sub-acute- (eg Korsakoff ) no new memories

chronic - (eg dementias) loss of recent memory

rarr remoterarr global irreversible personality

Dysmnesias

-Confabulationdetailed false description of an event which never

happened patient tries to lsquofill in the gapsrsquo seen in

alcoholics and hysterics and chronic schizophrenics

-Deacutejagrave vusomething new is remembered as something old

-Jamais vusomething old is remembered as something

new

Both observed in complex partial seizures

6 Other DisordersDisorders of Experience of the Self

depersonalization

derealization

Disorders of Consciousness

lsquotwilightrsquo statefugue state

Disorders of Motor Function

waxy flexibility

lsquooccupational deliriumrsquo

7 SUMMARY

The most important symptom in clinical

psychiatry is hallucination

Think of schizophrenia when Schneiderrsquos First

Rank Symptoms are prominent

Depressed patients should always be asked


Command hallucinations increase the risk of

untoward behaviours

In depression think of LAPEL

In mania think of LEXUS

In mutism think of CHODE

Looseness of association is commonly seen in

schizophrenia

Flight of ideas is commonly seen in mania

NOTE the latter parts of this trans was not

entirely lectured They were included because

they were in the given power point

REFERENCES

Dr Cabuquitrsquos lectureDr Cabuquitrsquos ppt

Trans medicine 2011 A



In both schizophrenic and depressive types be aware

of the commanding quality of the voice(s)

Command HallucinationsAlso known as ldquoimperative hallucinationsrdquo

- Patients who hear voices should be asked ifthe voices have commanding quality

- About 23 of Filipino patients obey voicesrsquo

commands (Cabuquit )

- Obeyed commands usually prolonged

intense and frequent (Cabuquit )

Significance of Mumbling Episodes - Patients who mumble actually hear voices

(even when they deny it)

- Mumbling is the patientsrsquo way of responding

to the voices

- Usually verified by observant relatives

Organic Hallucinations

Visual- More common in organic states like

delirium tremens and dementias (

lsquoLilliputianrsquo type)

Lilliputian Type ndash false perception in

which objects are seen as reduced in size

also termed micropsia

- All varieties from elementary forms likeflashes of light to fully formed people or

animals

- Can be with simultaneous auditory

hallucination

ndash false perception involving sight

consisting of both formed and unformed

images

- Most common in medically determined

disorders

Olfactory (Smell) false perception of smell

- Temporal Lobe Epilepsy (TLE) attacks areusually ushered in by an unpleasant odour like

burning rubber or rotten food

Gustatory (Taste) false perception of taste

- Usually caused by uncinate seizures could

also be due to TLE when associated with

salivation chewing and sniffing movements

Tactile (Haptic) false perception of taste

lsquoCocaine bugrsquo or formication ndash feeling of

small animals crawling all over the body or

under the skin associated with delusion ofpersecution

Sexual sensations (eg being masturbated

to orgasm) seen in some schizophrenics

lsquoPhantom limbrsquo phenomenon- most

common organic somatic hallucination occurs

in about 95 of all amputations could be very

painful

2 Disorders of Thought

- Delusional Triad a belief that is

- false ndash no logic no proof

- fixed

- incongruent with the personrsquos socio-

cultural and religious background

- Overvalued Idea an idea that is

false fixed and congruent with the

personrsquos background

Main Types of Delusions

Persecutory- most common in schizophrenia

- personrsquos false belief that he or she is being

harassed cheated or persecuted often found in

litigious patients who have a pathologic

tendency to take legal action because of

imagined mistreatment

Grandiose ndash most common in mania

- personrsquos exaggerated conception of his orher importance power or identity

Guilt- most common in depression

983085 - False feeling of remorsegrief

Jealousy (Othellorsquos syndrome)- most common

in delusional disorders drugs and alcohol

abuse aggravating factors violence frequent

983085 - False belief derived from pathological

983085 jealousy about a personrsquos lover being

983085 unfaithful

- Delusions have a tendency to be acted upon

Schizophrenic vs Depressive Delusions

Schizophrenic Delusions-Delusion of control- most reliable

symptom false feeling that a personrsquos

will thoughts or feelings are being

controlled by external forces

- Primary delusional perception

(Both are parts of First Rank Symptoms)






to an end




two afterwards







through the air







First Rank Symptoms







obsessions









compulsion







unrelated way











lsquopizzaiersquo





punning













surroundings








fear





doctor and patient














companion







Eliciting LAPEL













depressivesrsquo

Rating LAPEL




mood and anhedonia)









risk)












-hyperactivity


-grandiosity


-lack of sleep












Organic





Dysmnesias






new



depersonalization

derealization




waxy flexibility


7 SUMMARY








untoward behaviours





schizophrenia





REFERENCES








to an end




two afterwards







through the air







First Rank Symptoms







obsessions









compulsion







unrelated way











lsquopizzaiersquo





punning













surroundings








fear





doctor and patient














companion







Eliciting LAPEL













depressivesrsquo

Rating LAPEL




mood and anhedonia)









risk)












-hyperactivity


-grandiosity


-lack of sleep












Organic





Dysmnesias






new



depersonalization

derealization




waxy flexibility


7 SUMMARY








untoward behaviours





schizophrenia





REFERENCES







fear





doctor and patient














companion







Eliciting LAPEL













depressivesrsquo

Rating LAPEL




mood and anhedonia)









risk)












-hyperactivity


-grandiosity


-lack of sleep












Organic





Dysmnesias






new



depersonalization

derealization




waxy flexibility


7 SUMMARY








untoward behaviours





schizophrenia





REFERENCES








Organic





Dysmnesias






new



depersonalization

derealization




waxy flexibility


7 SUMMARY








untoward behaviours





schizophrenia





REFERENCES



Clinical Psychopathology

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Transcript of Clinical Psychopathology