5.2.2 Descriptive psychopathology
Descriptive Psychopathology
Psychopathology is ‘the systematic study of abnormal experience, cognition and behaviour; the study of the products of a disordered mind’. Descriptive psychopathology is a method of assessing and comprehending the signs and symptoms of mental disorders that serves as the foundation for clinical psychiatry. In this application, the term descriptive refers to a value-free and theory-free interpretation of the mental and behavioural experiences that a patient can present with. It is critical for students of psychiatry to comprehend the relevance of this and the reasoning behind it.
Disorders of Self
The notion of self is an awareness that all experiences articulate in the first person perspective as ‘my’ experience. “In other words, all conscious acts are intrinsically self-conscious, a feature sometimes designated as “self-affection” (Nelson, Parnas & Sass, 2014, pg. 479). People believe that the core sense of existing stems from personal experience and are responsible for their actions. Ipseity is based on inner time consciousness and is perceived as the origin of thoughts, experiences, and actions. Minimal self is the direct experience of selfhood and does not have specific properties. Instead, it refers to the ‘mine-ness’ and is implied; the person does not need reflection to know what they are experiencing. According to Sass et al. (2018), it is a source of activity, awareness medium, and the directedness toward life. Persons with disorders of self have self-awareness abnormalities. The minimal self is challenged to become unstable, ultimately resulting in self-disorders.
The disorder of self has three aspects: hyper-reflexivity, disturbed grip or hold, and diminished self-presence. Hyper-reflexivity is an exaggerated self-consciousness that makes a person disengage from ordinary processes of nature and society. People with this disorder have a tendency for focal attention, behaviour that would otherwise be experienced as part of oneself. On the other hand, a disturbed grip or hold is a distortion influencing the sense of ownership of experience and actions. The alterations commonly affect the tacit-focal structure of reality and the affordance quality of the real world. Diminished self-presence, also referred to as diminished self-affection, is a reduced or weakened sense of awareness of self.
Disorders of Emotion
Understanding disorders of emotion starts with differentiating between feelings, emotions, and mood. Feelings refer to positive or negative reactions to specific events and are experienced consciously. On the other hand, emotions are stirred-up states caused by specific stimuli and tend to eliminate or maintain the causative stimuli (Casey & Brendan, 2019). Mood refers to sustained emotions that reflect a person’s perception of the world. According to Casey and Brendan (2019), the mood is measured through intensity, fluctuations, and duration. Emotional disorders affect the psychological well-being of a person and, ultimately, their ability to function. For example, an individual may be depressed and extremely sad, affecting their quality of life.
Emotions may be classified based on the fact that some are normal and have no negative consequences, while others are severe and warrant medical interventions. Normal emotions are the expected reactions to certain events. For instance, a person has grief reactions upon the death of their loved one, such as a friend or family member. Abnormal emotions are expected when a person is subjected to stressful events (Casey & Brendan, 2019). However, they lead to prolonged impairment or lasting effects on a person’s functioning. People expressing abnormal emotional reactions are aware of the abnormality and may be influenced by cultural norms (Casey & Brendan, 2019). Expressing emotions is also morbid, in which a patient is unaware of the abnormality. In such cases, a patient may have schizophrenia, a mental health issue characterized by abnormal interpretation of realities (Casey & Brendan, 2019). Disorders of emotion are disabling, so patients should seek medical treatment to improve the quality of their life.
Disorders of Speech
Disorders of speech refer to conditions in which people have difficulties producing sounds to create words. Such disorders cause a person to strain during communication, and even when they speak, their speech is difficult to understand. Common speech disorders include phonological, articulation, resonance, and dis-fluency disorders (Kaneshiro, 2022). Dis-fluency is a state in which a person repeats sounds and may be caused by emotional distress, trauma, or genetic abnormalities (Kaneshiro, 2022). In articulation and phonological disorders, an individual does not produce sounds correctly and uses them in the wrong place. Resonance, also known as voice disorders, is characterized by symptoms such as voice break, odd speech sounds, and voice hoarseness (Kaneshiro, 2022). Practitioners provide interventions depending on the causes and severity of the speech disorder.
Disorders of Thought
Thought disorders are a disturbance in how a person processes and expresses thoughts. Their causes are not clearly defined; however, medical experts believe that factors like brain abnormalities and genetics lead to thought disorders. Thinking requires a person to reason about a subject and organize those thoughts appropriately to express them clearly. A thought disorder disrupts this process, resulting in disorganized thinking and abnormal speaking or writing (Kubal & Moore, 2022). It is one of the symptoms denoting the presence of schizophrenia. Thought disorders may lead to positive or negative symptoms. Positive symptoms include signs of added behaviours such as poor judgment, whereas negative symptoms include the absence of specific aspects like a lack of emotions (Kubala & Moore, 2022). To identify thought disorders, practitioners ask patients open-ended questions to assess responses.
Thought insertion is a type of thought disorder characterized by the belief that one’s thoughts are being inserted or imposed upon by an external force. This can include the feeling that thoughts are being planted in one’s mind or that someone is controlling one’s thoughts.
Thought withdrawal is a type of thought disorder characterized by the belief that one’s thoughts are being taken away or removed by an external force. This can include the feeling that thoughts are being removed from one’s mind or that someone is controlling one’s thoughts.
Thought broadcast is a type of thought disorder characterized by the belief that one’s thoughts are being broadcast or transmitted to others. This can include the feeling that others can hear one’s thoughts or that one’s thoughts are being broadcasted to others against one’s will.
Disorders of Perception
Perception refers to using sensory organs to integrate what is being presented into meaningful information. In other words, it is the ability to select a stimulus that requires action, attention, and interpretation. Perception disorders are grouped into two categories: sensory distortions and deceptions. Sensory distortion includes shifts in perceptions due to changes in stimulus quality and intensity (Casey & Brendan, 2019). An alteration in quality mainly affects visual perception. Casey and Brendan (2019) explain that intensity changes, hyper or hypo-aesthesia, result from intense emotions or a low psychological threshold. Resultantly, a patient may hear the sound of a closing door as thunder. A change in the spatial form, commonly known as dysmegalopsia, is the shift in the perceived shape of an object. For example, a patient may see an object as bigger than its actual size.
Sensory deceptions are classified into illusions and hallucinations, in which the former refers to stimuli misrepresentation, while the latter is false perceptions. A hallucination is a perception in the absence of a stimulus. An illusion is an altered perception of a stimulus and differs from a hallucination in that in hallucinations there is no stimulus. Casey and Brendan (2019) mention that illusions combine mental images with a perceived object to produce a false perception. They may occur without a psychiatric disorder; for instance, a person walking through a dark place may interpret shadows as an attacker. Although illusions mainly occur visually, they can present in different forms, like a person hearing their name being called out when a word that resembles their name is pronounced (Casey & Brendan, 2019). With hallucinations, an individual believes that their perceptions are accurate.
Kurt Schneider proposed first-rank symptoms in 1938. He introduced them as a practical way to help general practitioners (non-psychiatrists) identify schizophrenia.
| First-rank Symptoms: | Summary: |
| Running commentary | A type of auditory hallucination where the individual hears a voice or voices providing a continuous commentary on their thoughts, feelings or actions. |
| Thought echo | A type of auditory hallucination is where an individual hears their own thoughts repeated back to them as if they were spoken aloud. |
| Voices heard arguing | A type of auditory hallucination where the individual hears two or more distinct voices engaging in an argument or conversation. |
| Thought insertion | Delusional belief that someone or something is putting thoughts into the individual’s mind without their consent. |
| Thought withdrawal | Delusional belief that someone or something is taking thoughts out of the individual’s mind without their consent. |
| Thought broadcast | The belief that one’s thoughts are leaving the mind and being perceived by others. |
| Delusional perception | The belief that a normal perception has been altered or manipulated by an external force. |
| Somatic passivity | The belief that one’s body is being controlled by an external force. |
| Made affect | The belief that feelings are controlled by an outside/external force |
| Made volition | The belief that impulses and/or behaviour are controlled by an outside/external force |
(Norgaard, 2008)
| Type of hallucination: | Summary: |
|---|---|
| Auditory | These can be first person, in which the patient hears their own thoughts, second person, in which the patient hears a voice speaking directly to them, or third person, in which the patient hears a voice conversing. The term “thought echo” refers to hearing one’s own thoughts aloud shortly after thinking them. Gedankenlautwerden is an experience similar to thought echo in which patients hear their own thoughts aloud as they think them. |
| Visual | Seeing things that aren’t actually present. |
| Gustatory | Tasting things that aren’t actually present. |
| Olfactory | Smelling things that aren’t actually present. |
| Tactile (haptic) | These refer to false perceptions of touch. |
| Functional hallucinations | A patient experiences a hallucination at the same time as receiving a real stimulus in the same sensory modality. Hallucinations that are related to a specific function such as sexual or religious experiences often. |
| Extracampine hallucination | These are hallucinations beyond the possible sensory field. Hallucinations occur outside of the visual field, such as hearing voices that are coming from outside. |
| Reflex hallucinations | These occur in one sensory modality in response to a real stimulus in another sensory modality |
| Hypnopompic hallucinations | They occur during the transition from sleep to wakefulness. |
| Hypnagogic hallucinations | They occur during the transition from wakefulness to sleep. |
| Lilliputian hallucinations | Hallucinations of small, miniature people or objects. |
| Kinaesthetic hallucinations | These relate to hallucinations of muscle or joint sense. Hallucinations of movement or touch. |
| Autoscopic hallucinations | This refers to a person’s experience of seeing a double of themselves in their extrapersonal space without the experience of leaving one’s body. |
| Third person hallucinations | A type of auditory hallucination in which the individual hears voices or other sounds that are perceived as coming from outside of themselves and are directed towards a specific person or group of people. |
| Secondary hallucinations | Type of auditory hallucination in which the individual perceives voices or other sounds as coming from an external source, as opposed to originating within their own mind. |
| Illusion type: | Summary: |
|---|---|
| Completion illusions | The proclivity to fill in blanks in order to make sense of a stimulus |
| Affect illusions | Arise as a result of specific mood (affective) states, such as when a woman is walking home in the dark and is terrified, mistaking a tree for a tall man in a long coat. Another example is when an agitated person interprets harmless gestures as threatening. |
| Pareidolic illusions | Arise when detailed images of shapes are seen. For example, seeing the man in the moon or Michael Jordan on a burnt piece of toast. Pareidolic illusions occur when a person is concentrating, whereas affect and completion illusions occur when a person is distracted. |
| Persecutory delusions | Persecutory delusions are a type of delusional belief in which the individual believes that they are being singled out for harm, mistreatment, or harassment by one or more individuals or organizations. |
Pseudohallucinations versus hallucinations:
Pseudohallucinations and hallucinations are both types of perceptual experiences, but they have some important differences. Hallucinations are defined as perceptions in the absence of an external stimulus. They can be experienced in any of the five senses, such as seeing something that isn’t there or hearing voices. On the other hand, pseudohallucinations are also perceptions in the absence of an external stimulus, but they are experienced as being less vivid and less real than hallucinations. They are often described as “internal” or “mental” rather than “perceptual” experiences, and they may be more like vivid thoughts or memories than actual perceptions. They are often associated with conditions such as schizophrenia, dissociative disorders and conversion disorder.
Movement Disorders
Movement disorders are nervous system conditions that cause voluntary or involuntary body movements and increased or slow movements. One of the common movement disorders is ataxia, which affects the spinal cord or the brain. The effects result in problems such as clumsy balance, inaccuracy, or reduced coordination when a person moves voluntarily. Another movement disorder is dystonia, a condition characterized by involuntary muscle contractions. Dystonia affects any body part, such as the mouth, face, and limbs. It is caused by abnormal functioning of the basal ganglia, which is a part of the brain that controls movement. Essential tremor is another disorder that results in rhythmic shaking of body parts like hands. It results from abnormalities in the basal ganglia and worsens when a person tries making basic movements. Interventions such as surgery, medication, lifestyle changes, and physical therapies can improve symptoms caused by essential tremors.
Myoclonus is another movement disorder characterized by quick and uncontrollable muscle jerks. The movements have regular or regular contractions and may occur in one muscle or a group of muscles. Progressive Supranuclear Palsy (PSP) is a brain condition that leads to brain cell loss and movement issues. The problems may include decreased balance, walking, speech, and eye control. PSP commonly affects people aged 40 to 60 years, leading to severe symptoms after 6 to 10 years of infection (American Association of Neurological Surgeons, 2019). Other movement disorders include Rett Syndrome, Secondary Parkinsonism, Tourette Syndrome, Spasticity, Tardive Dyskinesia, Multiple System Atrophy (MSA), Huntington’s Disease, and Wilson’s disease.
| Movement disorder: | Summary: | Associated conditions: |
|---|---|---|
| Akinesia | Absence, poverty, or loss of control of voluntary muscle movements (eg. absence of facial expression, decreased blinking). Often understood as a severe form of bradykinesia. | Parkinson’s Progressive Supranuclear Palsy Multiple System Atrophy |
| Bradykinesia | The slowness of voluntary movement. It is a core symptom of Parkinson’s disease. | Parkinson’s Progressive Supranuclear Palsy Multiple System Atrophy |
| Akathisia | The subjective feeling of inner restlessness is often caused by side effects of neuroleptic medication. It often manifests as an inability to sit still. | Antipsychotic medication use (mainly) Also reported with calcium channel blockers, antiemetics, and vertigo drugs |
| Athetosis | A continuous stream of slow, flowing, writhing involuntary movements. | Cerebral palsy Stroke Huntington’s disease Wilson’s disease Medication / donepezil |
| Chorea | Brief, ‘quasi-purposeful’, irregular contractions that are not repetitive or rhythmic, but appear to flow from one muscle to the next. Described as ‘dance-like’. | Huntington’s disease Wilson’s disease Spinocerebellar ataxia type 2 Autoimmune / SLE Endocrine / hyperthyroidism Infection / Sydenham chorea – AIDS – TB Metabolic/hepatic and renal failure Medication/anticonvulsants – cocaine – lithium |
| Dystonia | Involuntary sustained or intermittent muscle contractions. Can lead to twisting and repetitive movements, abnormal postures, or both. | Medication/antipsychotics – certain antiemetics – lithium – stimulants – certain antidepressants (SSRIs and TCAs) Idiopathic Cerebral palsy Multiple sclerosis Encephalitis Stroke Wilson’s disease |
| Dyskinesia | A general term referring to problems with voluntary movements and the presence of involuntary movements. | |
| Myoclonus | A sequence of repeated, often non-rhythmic, brief shock-like jerks due to sudden involuntary contraction or relaxation of one or more muscles. | Sleep initiation (hypnic jerk)Epilepsy Stroke Renal and hepatic failure Poisoning Medication / tramadol – benzodiazepines – certain antiepileptics Multiple sclerosis Parkinson’s Alzheimer’s CJD |
| Parkinsonism | Syndrome characterized by tremors, rigidity, and bradykinesia. | |
| Tic | Sudden, repetitive, non-rhythmic, stereotyped motor movement or vocalization involving discrete muscle groups. These are different to myoclonus as they are suppressible. | Tourette’s Other causes (e.g. Huntington’s and stroke are rare). |
| Tremor | Involuntary, rhythmic, alternating movement of one or more body parts. | Anxiety Medication/caffeine – lithium – amphetamines Hereditary (essential tremor) Stroke Metabolic / hyperthyroidism Degenerative / Wilson’s – multiple sclerosis – Parkinson’s Alcohol abuse and withdrawal Medication / valproic acid |
| Hemiballismus | Hyperkinetic involuntary movement disorder, which is characterised by intermittent, sudden, violent, involuntary, flinging, or ballistic high-amplitude movements involving the ipsilateral arm and leg, caused dysfunction in the contralateral side’s central nervous system. | Stroke Traumatic brain injury Nonketotic hyperglycaemia Infection Amyotrophic lateral sclerosis |
| Stereotypies | Repetitive, simple movements that can be voluntarily suppressed. | Autism Sensory deprivation Intellectual disability |
Disorders of Cognition
Cognition disorders are mental health problems that affect memory, learning, problem-solving, and memory. The disorders affect a person to the extent that they cannot function normally without treatment. Cognitive disorders are grouped into three categories: dementia, delirium, and amnesia (Bonnice and Hoard, 2014). Dementia is a general term used to describe various mental health issues characterized by an impaired ability to make decisions, remember, or think. Abnormal brain changes cause disorders and affect other aspects of life, like behaviour, relationships, and feelings. Alzheimer’s disease is the primary cause of dementia, which leads to 60-80% of cases (Alzheimer’s Association, 2022). Although dementia affects older adults, it is not part of normal ageing.
Delirium is a sudden change in the brain that leads to reduced consciousness. It makes people appear distracted, confused, or unaware of their surrounding environment (Cleveland Clinic, 2020). Other delirium symptoms include difficulties remembering, thinking clearly, and maintaining focus. Cleveland Clinic (2020) reports that delirium differs from dementia since it occurs quickly. Delirium may be hyperactive or hypoactive: in the former case, a person becomes overactive and restless, whereas in the latter case, a person is inactive as they become sleepy. Amnesia is memory loss without other underlying cognitive deficits (Bonnice and Hoard, 2014). A person with amnesia forgets information, facts, and experiences. Unlike in movies and television shows, where they show people forgetting their identities, it is usually not the case in real-life situations (Cleveland Clinic, 2020). Damage, including infections or injuries, to the brain area responsible for memory processing, may cause amnesia.
Uncommon Psychiatric Syndromes
Although people understand how the brain works and its different disorders, there are mechanisms that even experts may not explain concerning the human psyche. There are fascinating psychological disorders that are rare, ignored in diagnostic systems, or rarely taught in medical training. Some uncommon psychiatric syndrome: firstly Alice in Wonderland Syndrome (AIWS), in which victims have distorted perceptions of their surroundings, time, or body appearance (Sharpless, 2017). The second is Paris Syndrome, which refers to extreme disappointment by a person who visits Paris and finds that the city is the opposite of their expectations (Sharpless, 2017). The third syndrome is Capgras Syndrome, in which sufferers strongly believe that an identical imposter has replaced a person they know.
Another uncommon syndrome is Cotard’s Delusion which makes people believe that parts of their bodies are missing. It also makes sufferers think that they are dead, dying, or do not exist. Or Stendhal Syndrome, people experience panic attacks, anxiety, and hallucinations when exposed to art (Sharpless, 2017). The Alien hand syndrome causes sufferers to feel that one of their hands has a mind and operates independently. Clinical lycanthropy is another uncommon syndrome that makes an individual think they have turned into an animal (Wong, 2021). The factitious disorder causes people to exaggerate or fabricate symptoms to get attention. They feel consolation and pleasure for being patients (Sharpless, 2017). Uncommon psychiatric syndromes include disorders that appear fictional in real-world situations and include other varieties like Folie a Deux, the Fregoli delusion, Ekbom Syndrome, and Apotemnophilia.
References:
(1) Femi Oyebode (2022). SIMS’ Symptoms in the Mind: Textbook of Descriptive Psychopathology. S.L.: Elsevier Health Sciences.
(2) Summerfield, J. and Yousif, M. (2014). Descriptive Psychopathology. Oxford Assess and Progress: Psychiatry. [online] doi:10.1093/oso/9780199665662.003.0010.
(3) Alzheimer’s Association 2022, What Is Dementia?, Alzheimer’s Disease and Dementia, Alzheimer’s Association.
(4) American Association of Neurological Surgeons 2019, Movement Disorders – Classifications, Symptoms and Treatments, Aans.org.
(5) Bonnice, S & Hoard, C 2014, Cognitive disorders, Mason Crest, Broomall, Pennsylvania.
(6) Casey, PR & Brendan, K 2019, Fish’s clinical psychopathology: signs and symptoms in psychiatry, 4th edn, Royal College Of Psychiatrists, London.
(7) Cleveland Clinic 2020, Delirium and Mental Confusion: Symptoms, Causes, Treatment & Prevention, Cleveland Clinic.
(8) Kaneshiro, NK 2022, Speech and Language Disorders – Symptoms and Causes, www.pennmedicine.org.
(9) Kubala, K & Moore, M 2022, Thought Disorder: Signs, Causes, Treatment, and Related Conditions, Psych Central.
(10) Nelson, B, Parnas, J & Sass, LA 2014, ‘Disturbance of Minimal Self (Ipseity) in Schizophrenia: Clarification and Current Status’, Schizophrenia Bulletin, vol. 40, no. 3, pp. 479–482.
(11) Norgaard (2008) The Diagnostic Status of First-Rank Symptoms. Schizophrenia Bulletin 2008 34(1):137-154.
(12) Sass, L, Borda, JP, Madeira, L, Pienkos, E & Nelson, B 2018, ‘Varieties of Self Disorder: A Bio-Pheno-Social Model of Schizophrenia’, Schizophrenia Bulletin, vol. 44, no. 4, pp. 720–727, viewed 16 May 2021, <https://academic.oup.com/schizophreniabulletin/article/44/4/720/4839361?login=true>.
(13) Sharpless, BA 2017, Unusual and rare psychological disorders: a handbook for clinical practice and research, Oxford University Press, Oxford ; New York.
(14) Wong, DJ 2021, 11 rare and freaky mental illnesses that take bizarre to a whole new level, Mashable SEA.