Psych-CLEAR: Basic Psychopathology Made Clear & Easy

Psych-CLEAR

â„¢

Psychopathology Made Clear and Easy Published by

Department of Psychiatry, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia

Edited by Dr. Phang Cheng Kar (M.D.)

Psych-CLEAR

â„¢

Psychopathology Made Clear and Easy Published by

Department of Psychiatry, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia

Edited by Dr. Phang Cheng Kar (M.D.)

Copyright Š & Published

by Department of Psychiatry, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia (UPM) All Rights Reserved.

1st edition - 2010

Project Coordinator: Associate Professor Dr. Khin Ohnmar Naing @ Noor Jan

Contributing Authors: Professor Dr. Azhar Md Zain Associate Professor Dr. Brian Ho Kong Wai Associate Professor Dr. Khin Ohnmar Naing @ Noor Jan Dr. Bharathi Vengadalasam Dr. Nik Shaliza Hussin Dr. Hamidin Awang Dr. Normala Ibrahim Dr. Phang Cheng Kar Dr. Ang Jin Kiat Dr. Zubaidah Jamil Othman Dr. Firdaus Mukhtar Cik Siti Irma Fadhilah Ismail Cik Nor Sheereen Zulkefly ISBN: 978-983-43735-2-8

This book is dedicated to all our patients who have provided us experiential knowledge of psychopathology and meaningful livelihood in treatment of mental illness

A great teacher is one who was once confused and knows what can be confusing for the students -Zhen-Phang-

Psych-CLEAR – Psychopathology Made Clear and Easy ď Š

What is Psych-CLEAR?

P

sychopathology is the study of abnormal experience in psychiatric illness. Understanding of psychopathology is very important, as up to this point of time, there is no biological diagnostic test in psychiatry.

Therefore, psychiatric diagnosis is made mainly through the understanding and eliciting of psychopathology. Undergraduate medical students who are new to psychiatry often have difficulty in this area. Psych-CLEAR is written to guide medical students through aspects of common psychopathology that is discussed in undergraduate psychiatric postings. With Psych-CLEAR, psychopathology can also be taught in a standardized way to minimize confusion to students. The conclusions made in Psych-CLEAR are based on major psychiatric textbooks and consensus from UPM lecturers teaching psychiatry.

Psych-CLEAR is presented in a Q & A format for easy reading. While Psych-CLEAR is not a comprehensive textbook on psychopathology, it is definitely a good companion to other references for medical students.

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Glossary of FAP (Frequently Asked Psychopathologies) Hallucination - a sensory perception in the absence of stimulus.

Delusion - a false and fixed belief that is not shared by someone of similar socio-cultural background.

Obsession - a repetitive thought, impulse or image that is recognized by patient as a product of one’s own mind. It is intrusive, inappropriate and distressing.

Compulsion - a repetitive physical or mental behavior that is in response to an obsession.

Anhedonia - diminished or loss of interest in pleasurable activities.

Phobia - an excessive and persistent fear.

Pressure of speech - speech is increased in speed and is difficult to interrupt.

Looseness of association - a formal thought disorder whereby there is lack of meaningful connection between ideas.

Flight of ideas - a thought disorder whereby thoughts move quickly from one topic to another, but there is still some logical connection between ideas.

Depersonalization - an unpleasant subjective experience whereby the patients feel that ‘they’ have become unreal.

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Derealization - an unpleasant subjective experience whereby the patients feel that ‘the world’ has become unreal.

Mannerism - a voluntary and repetitive movement that appears to be goal directed e.g. saluting.

Stereotypy - a voluntary and repetitive movement that is not goal directed e.g. rocking to and fro.

Tremor - a repetitive and rhythmic movement.

Defense mechanism - an unconscious psychological strategy to exclude unacceptable impulse or urge, from awareness e.g. denial.

Cognitive error - a distorted pattern of thinking that affects a person’s view of himself, others and the future e.g. black and white thinking.

Confabulation - an unconscious filling of gaps in memory with imagined or untrue experience.

Perseveration - a repetitive verbal or motor response to different situations.

Negative symptoms of schizophrenia: 1. Alogia or poverty of speech 2. Avolition or the lack of physical activities 3. Asocial or social withdrawal or autism 4. Apathy or amotivation or the lack of drive 5. Anhedonia or the lack of interest 6. Affective blunting

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Psych-CLEAR - Q & A 1. What is the difference between ‘mood’ and ‘affect’?

Mood is a pervasive emotional state.

and

sustained

Affect is the outward manifestation of a current emotional state.

In another words, in mental state examination (MSE), mood is a patient’s emotional state that is subjectively described by the patient himself or herself e.g. feeling depressed over the past few weeks.

Affect is a patient’s current emotional state objectively inferred from the patient’s facial expression and body language e.g. patient who is tearful and sitting in a stooped posture.

2. Can I describe a patient’s mood as ‘happy’ or ‘sad’ in MSE? No. Though it has been mentioned that mood is a patient’s sustained emotional state that is subjectively described by the patient e.g. ‘happy’ or ‘sad’, you have to decide on what does patient really mean by ‘happy’. Is it normal or elated? Then you should report the finding in MSE using standard psychiatric terminologies e.g. depressed, anxious, irritable, elated etc. If the mood is normal, you should report it as ‘euthymic,’ instead of ‘normal.’ The same thing applies when you are describing patient’s affect. However, if you are presenting the ‘history of present illness’ (HOPI), you should use the exact terminologies used by patient to describe their mood e.g. sad, happy, frustrated, empty.

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3. What is labile affect?

It is sudden, abrupt and inappropriate shift of affect e.g. emotional state shifts from cheerfulness to tears to irritability and back again over a brief period. A depressed lady who burst into tears while talking about her deceased husband is not considered to have labile affect as it is appropriate.

4. Is it necessary to quantify patient’s mood? e.g. “he’s depressed and it is 3/10” This can be a useful way to assess and describe the severity of patient’s depression in HOPI. It is more helpful to standardize the method of assessing mood. For example, 0 = minimally depressed and 10 = very depressed and suicidal. When you are reporting the mood in MSE, it is not necessary to quantify the mood.

5. What is the difference between, ‘elated mood,’ ‘elevated mood,’ ‘expansive mood,’ and ‘euphoric mood’?

While they are minor difference in meaning, it is acceptable to use these terminologies interchangeably, and without any implication on severity. In another words, ‘expansive mood’ is not more ‘high’ than ‘elated mood.’

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6. What is the difference between ‘blunted,’ ‘restricted,’ ‘constricted’ and ‘flatten’ affect?

As there are different opinions on this in the psychiatric textbooks reviewed, it is acceptable to use these terminologies interchangeably, and without any implication on severity. In another words, ‘blunted affect’ is not more severe than ‘restricted affect,’ or ‘flattened affect’ is not more severe than ‘blunted affect.’ However, in daily clinical practice, there is a tendency to imply that ‘restricted/constricted’ is less severe than ‘blunted,’ and ‘flattened’ is the worst of all.

7. What is the difference between ‘clang association,’ ‘rhyming’ and ‘punning’?

There are different opinions on this. Here, we conclude that there are 3 types of clang associations; assonance, rhyming and punning.

“I like your brain, train, gain…that’s the main thing…,” is an example of assonance. There is use of words with similar sound (brain, train, gain, main), but you cannot understand the meaning of the sentence. It is something like a ‘looseness of association’ with words using similar sound.

“I’m Mr. Ting. I stay near Genting, and I like to eat Artane,” is an example of rhyming. There is use of words with similar sound (Ting, Genting, Artane), and you can have some understanding of the sentence. Nursery rhyme, “Twinkle twinkle little star, how I wonder what you are,” is also a form of rhyming.

“When you are young, you can have sex thrice weekly. When you are old, you have to try sex weakly,” is an example of punning. Besides the 6

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use of words with similar sound (week and weak), there is also the use of word with double meaning i.e. weakly. ‘Weakly’ here could mean ‘every 7 days’ or ‘sexually weak’.

In MSE, it can be difficult to differentiate the different types of clang associations. It is much more important to differentiate between ‘clang association’ and ‘looseness of association’ than the different types of clang associations.

8. What is the difference between ‘looseness of association,’ ‘derailment,’ ‘knight’s move’ and ‘tangentiality’ of speech?

All these are different types of formal thought disorders. While there may be minor difference in meaning, it is acceptable to use these terminologies interchangeably, and without any implication on severity or diagnosis.

9. What is ‘circumstantiality’?

It is thinking that proceeds slowly with many unnecessary details but finally the point is reached.

10. Does ‘neologism’ refer to the use of words that do not exist or known words that are used in a new way?

It can be both although the former is more common. You should clarify with patient before deciding that it is a neologism. Make sure that you understand the language that the patient is using.

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11. Is ‘flight of ideas’ a formal thought disorder or disorder of the stream/flow of thought?

It is acceptable to be under both, and should be reported under ‘speech’ and ‘thought’ in MSE.

12. When there are more than one ‘voices’ talking to patient, does that mean it is always a 3rd person auditory hallucination?

No. Whether an auditory hallucination is 2nd or 3rd person in nature depends on whether the voices are ‘talking to’ or ‘talking about’ patient. If the voices talked to patient, “You are stupid…you should not take medications…you have no problem,” this is a 2 nd person auditory hallucination. If the voices talk about patient, “He’s really stupid…he should not take the medications…he has no problem,” this is a 3 rd person auditory hallucination with a 3rd person pronoun like ‘he’ or ‘she’. Sometimes the voices can alternate between 2nd and 3rd person style of talking i.e. one voice may say to patient, “You are stupid,” and another voice supports the first voice, “Yes, he’s really stupid.”

13. If there is only once ‘voice’ talking to patient, is it possible that it is a 3rd person auditory hallucination?

Yes, but it is less likely. If there is only one voice, most likely the voice will be talking directly to patient, “You are stupid.” This is a 2nd person auditory hallucination. But if the voice is talking alone or to itself, “Let me tell you, he’s (patient) really stupid,” this is technically a 3rd person auditory hallucination although there is only one voice.

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14. What is the difference between ‘commanding’ and ‘commenting’ auditory hallucinations?

In commanding auditory hallucination, the voice is ordering patient to do something, “I want you to kill her!” In commenting auditory hallucination (a.k.a. voices commenting on one’s action or running commentary auditory hallucinations), the voice(s) is making a report on patient’s behavior, “He’s talking to the shrink…he’s calling his friends…he’s taking his stupid medications.” It is like a football commentator making comments on a football match. However, not all auditory hallucinations with comments are commentary auditory hallucinations. “Her dress is pink in color,” or “He’s not wearing his glasses,” are not commenting auditory hallucinations. They are just descriptions related to patient. In commenting auditory hallucination, the voice(s) has to be commenting on patient’s action. Although commanding auditory hallucination is clinically important (e.g. I want you to kill her), it is not a Schneider’s First Rank symptoms.

Commenting auditory hallucination is one of the Schneider’s First Rank symptoms.

15. What is the difference between ‘illusion,’ ‘hallucination,’ and ‘delusional perception’?

Illusion is a distorted sensory perception. For example, a crack on the wall is perceived as a snake on the wall. The stimulus (crack) is there but it is not perceived correctly i.e. the crack is mistaken to be a snake.

Hallucination is a sensory perception in the absence of stimulus i.e. seeing a crack on the wall when there is actually no such thing.

Delusional perception is a normal perception but with delusional belief.

For example, a crack on the wall is perceived as a crack (without distortion), but with the delusional belief that God is angry. Illusion and 9

Psych-CLEAR – Psychopathology Made Clear and Easy 

hallucination are perceptual disorder, and delusional perception is a delusion (thought disorder).

16. What is ‘thought echo’? Does ‘thought echo’ auditory hallucination consist of patient’s voice or other people’s voice?

‘Thought echo’ is a form of auditory hallucination whereby one hears one’s own thoughts spoken aloud. Thought echo is also known as ‘audible thought’ or ‘thoughts spoken aloud.’ It can be either patient’s voice or other people’s voice.

17. What is ‘pseudo-hallucination’?

Pseudo-hallucination is a hallucination that does not fulfill the full characteristics of a true hallucination. Characteristics of a true hallucination are: 1. It is perceived by sensory organs 2. It is perceived without stimulus 3. It cannot be voluntarily controlled 4. It occurs at clear consciousness 5. It originates from an objective space* 6. It happens in the absence of insight** It is very important to differentiate pseudo-hallucinations from true hallucinations so that we do not wrongly conclude that a person is psychotic. * This is also described as having the quality of representing external quality ** The perception is believed to be real

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Common examples of pseudo-hallucinations are ‘hypnogogic’ and ‘hypnopompic’ hallucinations. Hypnogogic hallucinations occur on the verge of falling asleep, while hypnopompic hallucinations occur while waking up. As the mental state between sleep and awake is not a clear conscious state, these are not considered as true hallucinations. In another words, criteria number 4 of a true hallucination, “It occurs at clear consciousness,” is not fulfilled.

There are 2 other types of less common pseudo-hallucinations: Imagined Pseudo-hallucination. This type of ‘hallucination’ is like an imagination in the sense that it lacks the quality of representing external reality (i.e. criteria number 5 of a true hallucination, “It originates from an objective space,” is not fulfilled). It is like when you close your eyes and try to imagine yourself lying on a beach (mental image). However, unlike in imagination, it cannot be changed or stopped with mental effort (i.e. it fulfills criteria number 3 of a true hallucination, ‘it cannot be voluntarily controlled). Using the same example, it means that you cannot change or stop the image of you lying on a beach, which normal people can easily do.

Perceived Pseudo-hallucination. This type of ‘hallucination’ has the quality of representing external reality. It is not imaginative as in the earlier type. The patient can really see or hear the non-existing stimulus. The only difference is that patient does not perceive it to be real (i.e. criteria number 6 of a true hallucination, “It happens in the absence of insight,” is not fulfilled), and therefore not really affected by it.

Neither imagined nor perceived pseudo-hallucinations are of diagnostic significance. In clinical practice, patients often have difficulty in differentiating them. Although pseudo-hallucinations are not true 11

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hallucinations and can occur in normal individuals, it is important to be aware that some patients with true auditory hallucinations may not describe it in a typical way i.e. fulfilling all the criteria of a true hallucination. Therefore, clinical experience and overall clinical impression in MSE is important to decide whether patient is really hallucinating.

18. What is the difference between ‘tactile’ and ‘somatic’ hallucination?

There are different opinions on this. To avoid confusion, it is acceptable to classify somatic hallucination into 2 main types; tactile (superficial bodily sensation) and deep (visceral bodily sensation). Examples of tactile sensations are temperature, vibration, pain and touch on the skin. Example of deep sensation is animals crawling in the brain.

19. How does ‘overvalued idea’ differ from ‘delusion’?

Overvalued idea is a false belief that is neither delusional (i.e. belief is not as fixed as in delusion) nor obsessional (i.e. belief is not considered to be irrational by the individual). But it does preoccupy a person’s life and cause sufferings. It is often understandable and not completely false when a person’s background is known. Common examples include body weight and shape preoccupation in anorexia nervosa, morbid jealousy and hypochondriasis.

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20. What is delusion of control?

Delusion of control is a delusion whereby one believes that there is no control over his or her own body. The control is believed to be under the influence of an external force or agent.

21. What is the difference between ‘delusion of control,’ ‘passivity phenomena’ and ‘passivity experience’?

To avoid unnecessary confusion, they can be used interchangeably to refer to the experience of being controlled or a passive recipient of something associated with an external force. Patient may describe the experience as being spiritually possessed. The symptoms include thought insertion, thought withdrawal, thought broadcasting, ‘made’ affect/feeling, ‘made’ action/volitional act, ‘made’ impulse/drive and somatic passivity.

Thought insertion, thought withdrawal and thought broadcasting are also known as ‘thought alienation’ or ‘passivity of thoughts’ or ‘delusion of possession of thoughts.’ ‘Made’ affect/feeling,’ ‘made’ action/volitional act’ and ‘made impulse’ are also known as ‘passivity of experience’ or ‘delusion of control*.’ * In this context, delusion of control is a type of passivity phenomena.

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22. What is the difference between ‘made action’ and ‘made impulse’?

Both are different types of delusion of control. In ‘made action,’ patient believes that his or her action is under the control of an external force.

For example, a 29-year-old shorthand typist described her actions as follows, “When I reach my hand for the comb, it is my hands and arms which move, and my fingers pick up the pen, but I do not control them.”

In ‘made impulse’, the patient believes that his or her urge is under the control of an external force. The urge may be experienced with or without carrying out the action. If the action is carried out, it is admitted to be the patient’s own action. If the action is admitted not to be the patient’s own, it becomes ‘made action.’ For example, a 26year-old engineer emptied the contents of a urine bottle over the ward dinner trolley and said, “The sudden impulse came over me and I must do it. It was not my feeling. It came into me from the X-Ray department. It was nothing to do with me, they wanted it done. So, I picked up the bottle and poured it in.”

23. What is the difference between ‘somatic hallucination,’ ‘somatic delusion’ and ‘somatic passivity’?

Somatic hallucination is as described earlier e.g. sensing the presence of insects crawling under the skin where there is no insects. Somatic passivity is like a somatic hallucination e.g. sensing the presence of insects crawling under the skin, but with the added delusional belief that it is under the control of some external force. It is a form of delusion of control or passivity phenomena. For example, a patient

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with Schizophrenia believes that someone is using an electronic device to control the felt movement of insects crawling under the skin.

Somatic Hallucination + Delusion of Control = Somatic Passivity

Somatic delusion is a delusion that involves false belief with regards to bodily functions e.g. false belief that the gut is rotten or the body is producing an offensive smell. It does not have a ‘control’ or ‘hallucination’ component. But of course if the delusion is very strong, it can lead to hallucination e.g. perceiving the offensive smell which is actually not there.

24. What is the difference between ‘obsession’ and ‘rumination’?

Rumination is thinking that is repetitive, pseudophilosophical, irritatingly unnecessary and it achieves no conclusion. It is like an intellectual obsession. Example includes ruminative thoughts on the origin of the world.

In ‘Sim’s Symptoms In The Mind,’ ‘rumination’ is a subtype of obsession, “Obsession may occur as thoughts, images, impulse, ruminations or fear.”

However, in ‘Fish’s Clinical Psychopathology,’ ‘rumination’ is used to describe the characteristics of ‘obsession’. Thus, ‘rumination’ is the same as ‘obsession’.

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25. In cognitive assessment for MSE, should I use 3 or 5 objects for ‘registration’?

3 objects are good enough. Use 3 objects for ‘3-object recall’ and 5 objects for ‘5-object recall.’ Do not use 5 objects for ‘3-object recall’ or 3 objects for ‘5-minute recall.’

26. In MSE, What is the difference between, ‘5-minute recall’ and ‘short- term/recent memory’ test?

Strictly speaking, ‘short-term/recent memory’ is used to denote events that occurred in the past few hours. As it may be difficult to verify patient’s short-term/recent memory e.g. what patient ate in the last meal, ‘5-minute recall’ test is acceptable for assessment of shortterm/recent memory.

27. In MSE, should I do ‘digit span’ or ‘serial-seven’ test for assessing attention and concentration?

Both can be used.

Strictly speaking, ‘digit span’ is for assessment of attention, and ‘serial7’ test is for assessment of concentration (sustained attention). As it may be difficult to do proper ‘digit span’ in a bedside setting (it requires standardized numbers and longer time to assess), ‘serial-7’ test is acceptable for assessing both attention and concentration (sustained attention).

‘Digit span’ can also be used for testing immediate memory, besides doing immediate recall of 3 objects.

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28. In MSE, if patient failed ‘serial-7’ test, should I do ‘serial-3’ test?

Yes, ‘serial-3’ test can be used followed by other alternatives: days in a week forward and backward, name of months in a year forward and backward. You can also use ‘serial-7’ test using money as an example, “If you have 10 ringgit, and you have bought something that costs 70 cents, how much more balance do you have?” Bear in mind that ‘serial7’ and ‘serial-3’ are also associated with educational level. Do not use ‘serial-1’ or other serial number tests e.g. ‘serial-5’ as it is too simple to conclude anything.

29. In MSE, how do I assess ‘judgment’?

There are 3 aspects of judgment: 1. Personal judgment. This is about future plans on discharge e.g.

“What will you do if you are discharged today?” If a manic patient said, “I’ll go to the palace tonight and discuss my plans with the king,” the patient is obviously having poor personal judgment.

2. Social judgment. This is about behavior in social situation e.g. “What would you do if you saw a ‘silence’ sign in the library?” Expected response of good social judgment should be based on universal social values and not moral values that can be subjective.

3. Test judgment. This is about behavior in hypothetical situation (something that one has not experienced before) e.g. “What would you do if you found a stamped and addressed letter in the street?” or “What would you do if this place is on fire?”

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30. In MSE, how do I assess ‘insight’?

There are 3 aspects of insight: 1) Awareness of illness. This is the understanding that one has some form of mental, psychological, psychiatric, emotional or brain illness.

Patient may use different terminologies to describe his or her mental illness. As long as it is described as something mind-brain in nature and with some understanding of symptoms, it is considered as good awareness.

2) Attribution of illness. This is the understanding on the causes of mental illness that can be biological (genetics, brain structure, neurotransmitters etc) and/or psycho-social factors (various life stressors). Attribution to magico-mystical causes (e.g. spiritual possession), particularly for psychosis, and with the refusal to accept medications is considered as poor insight.

3. Need for treatment. This is the understanding that one needs medications and/or psycho-social support for the mental illness.

The overall insight can be described as ‘good,’ ‘poor,’ or ‘no insight.’

- END -

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Reference: 1. Casey P, Kelly B. Fish’s Clinical Psychopathology: Signs and Symptoms in Psychiatry (3rd edition). Gaskell, 2007.

2. Oyrbode F. Sims’ Symptoms in the Mind (4th edition). Saunders Elsevier, 2008.

3. Sadock, BJ, Sadock, VA. Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (10th edition). Lippincott Williams and Wilkins, 2007.

4. Gelder M, Mayou R, Cowen P. Shorter Oxford Textbook of Psychiatry (4th edition). Oxford Universiti Press, 2001.

5. Johnstone EC, Owens DGC, Lawrie SM, Sharpe M, Freeman CPL (eds).

Companion to Psychiatric Studies (7th edition). Churchill Livingstone, 2004.

6. Chandrasena R. Schneider's First Rank Symptoms: A Review.

Psychiatr J Univ Ott. 1983; 8(2): 86-95.

7. Mellor C.S. First Rank Symptoms of Schizophrenia. British Journal of Psychiatry. 1970; 117, 15-23.

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Notes

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Psych-CLEAR – Psychopathology Made Clear and Easy 

If you are not confused, You are not paying attention -Tom Peters-

Psych-CLEAR – Psychopathology Made Clear and Easy 

Psych-CLEAR – Psychopathology Made Clear and Easy 