Clinical Psychopathology

Dr. Cabuquit

08/09/10

Learning objectives:
- Accurate gathering and collating of clinical data
- Understanding the significance of clinical data
- Applying data on actual clinical situations

1. Disorders of Perception
Hallucination: arguably, the most important
symptom in clinical psychiatry
Perception without an object (Esquirol )
-hear something that is not there, hears voices
Perceived in external objective space (Jaspers )
Differentiate from pseudohallucination

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 patients/situations; takes time

Hallucinations
false sensory perception not associated with
real external stimuli; there may or may not be
delusional interpretation of the hallucinatory
experience

Diagnosis in Psychiatry
Primarily through:
1. Psychiatric History (anamnesis)
Predisposing factors (family history)
Precipitating factors (stressors, drugs/alcohol)
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, e.g. drugs of
abuse, liver, thyroid abnormalities)
Core Clinical Signs and Symptoms
Disorders of Perception
- Hallucination
Disorders of Thought and Speech
- Delusions
- Thought alienation
- Obsessions and Compulsions
- Flight of ideas
- Looseness of Associations
Disorders of Emotion
- Manic Mood (different levels)
- Depression
- Disorders of Memory
- Amnesias
- Dysmnesias
Other Disorders
experience of the self
- Consciousness
- motor functions

Pseudo-hallucination
-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 pseudohallucination will often recognize that it is not real.
Auditory Hallucination
- Most important symptom in psychotic disorders
-High in reliability, frequency, and specificity in
schizophrenia (WHO IPSS)
- Some are not pathological like hypnagogic and
hypnopompic types (dropping off to sleep,
awakening)
Auditory false perception of sound, usually voices but
also other noises such as music
Most common hallucination in psychiatric disorders
(schizophrenia)
High in reliability, frequency, and specificity
- some auditory hallucinations are not pathological like:
Hypnagogic false sensory perception occurring while
falling asleep, non-pathological
Hypnopompic false perception occurring while
awakening from sleep, non-pathological

Schizophrenic
Multiple Voices
Running commentary
Third person
Derogatory

Depressive
Single Voice
Staccato
Abusive

In both schizophrenic and depressive types, be aware

of the commanding quality of the voice(s)

Sexual sensations (e.g. being masturbated

to orgasm); seen in some schizophrenics
Phantom limb phenomenon- most
common organic somatic hallucination; occurs
in about 95% of all amputations; could be very
painful

Command Hallucinations
Also known as imperative hallucinations
- Patients who hear voices should be asked if
the voices have commanding quality
- About 2/3 of Filipino patients obey voices
commands (Cabuquit)
- Obeyed commands usually prolonged,
intense, and frequent (Cabuquit)

2. Disorders of Thought
- Delusional Triad: a belief that is
- false no logic, no proof
- fixed
- incongruent with the persons sociocultural and religious background
- Overvalued Idea: an idea that is
false, fixed, and congruent with the
persons background

Significance of Mumbling Episodes

- Patients who mumble actually hear voices
(even when they deny it)
- Mumbling is the patients way of responding
to the voices
- Usually verified by observant relatives

Main Types of Delusions

Organic Hallucinations
Visual
- More common in organic states like
delirium tremens and dementias (
Lilliputian type)
Lilliputian Type false perception in
which objects are seen as reduced in size;
also termed micropsia
- All varieties, from elementary forms like
flashes of light to fully formed people or
animals
- Can be with simultaneous auditory
hallucination
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 are
usually 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
Cocaine bug or formication feeling of
small animals crawling all over the body or
under the skin; associated with delusion of
persecution

Persecutory- most common in schizophrenia

- persons 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 most common in mania
- persons exaggerated conception of his or
her importance, power or identity

Guilt- most common in depression

- False feeling of remorse/grief

Jealousy (Othellos syndrome)- most common

in delusional disorders; drugs and alcohol
abuse aggravating factors; violence frequent
- False belief derived from pathological
jealousy about a persons lover being
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 persons
will, thoughts or feelings are being
controlled by external forces
- Primary delusional perception
(Both are parts of First Rank Symptoms)

Depressive Delusions
Delusion of guilt- could lead to suicide
Nihilistic delusion - false feeling that self,
others or the world is nonexistent or coming
to an end.
Thought Alienation
Thought Echo
- - 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 Insertion
Delusion that thoughts are being implanted in a
persons mind by other persons or forces
Thought Withdrawal
- Delusion that thoughts are being removed from a
persons mind by other persons or forces
Thought Broadcasting
- Delusion that a persons thoughts can be heard by
others, as though they were being broadcast
through the air.
Thought Blocking
- An objective phenomenon in which the patient
abruptly breaks off his conversation and is silent
for 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 Schneiders
First Rank Symptoms.

OBSESSIONS AND COMPULSIONS

Obsessions internal resistance, subjective
compulsion.
Pathological persistence of an irresistible thought
or feelings that cannot be eliminated from
consciousness by logical effort.
Associated with anxiety.
Compulsions simply the motor components of
obsessions
- pathological need to act on an impulse that, if
resisted, produces anxiety
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 similar to obsessions

With internal resistance but without subjective
compulsion
Most Common Types of OCs
-Handwashing, e.g. Lady Macbeths
-Re-checking/repeating/rearranging
-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.
- Common in schizophrenia
- A schizophrenic talking (desultory manner):
Its your cross to stand down considering
its 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 pizzaie?
-Notice how difficult it is to understand what
the patient is talking about; what about
pizzaie?

Flight of Ideas rapid continuous verbalizations or

plays 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.
- Common in mania
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. Im so hot!!!
- Observe the rhyming, punning, and clanging
Neologism forming new words
- Most specific symptom of schizophrenia
Mutism
Differential diagnoses
Catatonic schizophrenia markedly
slowed motor activity, often to the point of
immobility & seeming unawareness of
surroundings
Hysterical mutism a diagnostic label applied to
state of mind, one of unmanageable fear or
emotional excess. The fear is often centered on a
body part, most often on an imagined problem

with that body part. People who are hysterical

often lose self-control due to the overwhelming
fear.
Organic stupor e.g. demyelinating disease
Depressive stupor
Talking to Mute Patients
-Whispering Technique (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 patients hand
2. Depressive stupor: Go near the patient,
speak with a firm, calm, and reassuring voice;
may hold patients 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
ideas/attempts, hopelessness)
Eliciting LAPEL
Low mood
How do you feel these last few weeks? Have you
felt depressed? How do you feel upon waking?
Anhedonia (loss of interest)
What have you been doing lately? Any change in
your usual activities?
Poor appetite
Any change in your appetite? Any weight loss?
Early morning awakening
Whats your usual waking time? Any change lately?
(3-4 hours earlier than usual?)
Low self-esteem
Have 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 smiling
depressives

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 94%
Sensitivity 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 spectrum
Manic Mood Gradations (LEXUS by
Cabuquit)
ELEvated m. (cheerfulness/confidence)
EXpansive m. (disinhibition)
EUphoric m. (unrestrained grandiose feelings)
EcStatic m. (intense feelings of
rapture)
- Manic stupor - rare
- Hypomania- milder form
- Bipolar- with depression and mania
Mania and its offsprings
-The manic mood gives birth to:
-hyperactivity
- pressure of speech
-grandiosity
-disinhibition, e.g. 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
Dj vu / jamais vu

Amnesias
Hysterical or dissociative
complete loss of memory and loss of
identity; temporary; intact personality
Organic
acute- (e.g. head injury) retrograde/anterograde
amnesia
sub-acute- (e.g. Korsakoff ) no new memories
chronic - (e.g. dementias) loss of recent memory
remote global; irreversible;  personality
Dysmnesias
-Confabulation
detailed false description of an event which never
happened; patient tries to fill in the gaps; seen in
alcoholics and hysterics and chronic schizophrenics
-Dj vu
something new is remembered as something old
-Jamais vu
something old is remembered as something
new
Both observed in complex partial seizures
6. Other Disorders
Disorders of Experience of the Self
depersonalization
derealization
Disorders of Consciousness
twilight state
fugue state
Disorders of Motor Function
waxy flexibility
occupational delirium
7. SUMMARY
 The most important symptom in clinical
psychiatry is hallucination
 Think of schizophrenia when Schneiders First
Rank Symptoms are prominent
 Depressed patients should always be asked
about suicidal ideas or attempts
 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. Cabuquits lecture
Dr. Cabuquits ppt
Trans medicine 2011 A