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PSYCHOPATHOLOGY I
Chee Kuan Tsee

Introduction In clinical practice, the patient complains of physical and / or mental symptoms and the doctor examines for signs. Diagnosis is made according to aetiology based on positive laboratory findings. However, in psychiatric disorders, apart from some with known organic causes, diagnosis depends on symptomatology. In fact, the diagnosis could be a syndrome made up of a cluster of symptoms. It is therefore important to establish accurate or reliable descriptions of subjective experiences and observed behaviour in the patient a checklist approach is best avoided. Just as the body is divided into systems, e.g. central nervous system, cardiovascular system, endocrine system, etc., the mind is divided into mental functions, i.e. cognitive function, emotions and volition or drive. These functions are normally interrelated, interactional, integrated and manifested as the individuals psychic experience and behaviour. It should be emphasized that the division of body and mind is artificial and undesirable.

DISORDERS OF PERCEPTIONS Illusions An illusion can be experienced by normal people under certain circumstances. It consists of an object/stimulus that is falsely perceived either because of the lack of clarity of the object/stimulus or due to the psychological state of the person. Thus an innocuous silhouette or sound may be perceived as something threatening by someone in a suggestible condition. When the psychological state is morbid, then what is perceived may be misinterpreted. The misperception is understandable and secondary to an underlying morbid state. The perception of the object/stimulus may undergo distortion in reality, dimension or intensity as a result of physical disease or psychiatric disorder. The object/stimulus may appear amplified, diminished or strange e.g. hyper-aesthesia (in emotional or physical state), micropsia (in temporal lobe epilepsy), or deja vu respectively.

Hallucinations Hallucinations are "perceptions" in whatever modalities (visual, auditory, olfactory, gustatory and tactile) where stimuli/objects are absent or non-existent. The contents are of importance and should be noted. There are many varieties of hallucinations indicative of different organic and mental disorders. Temporal lobe hallucinations are multi-sensory but not including somatic sensations. The primary auditory field lies in this lobe as do parts of the cortical fields for smell and taste. Certain auditory hallucinations (discussing the patient in the third person, hearing of one's own thought or a running commentary on one's actions) are diagnostic of schizophrenia. Visual hallucinations are more common in acute organic states with clouding of consciousness or delirious states than in so called functional psychoses. Depressed patients may hear critical or condemning voices.

Not all hallucinations are morbid in nature e.g. hypnogogic when falling to sleep, hypnopompic on waking up, and during sensory deprivation. Pseudo-hallucinations are thought to be more mental images in internal subjective space and lacking substance. A simpler view is that the patient is aware of its non- reality. Delusional perception starts with a normal perception but with concomitant formation of a new abnormal idea of delusional nature. For instance, a patient sees someone washing a car and instantaneously believes that gangsters are after him. It is sometimes preceded by a delusional mood (feeling of something going on that concerns him). Together with the sudden development or intrusion of a delusional idea (out of the blue) they form the primary delusional experience characteristic of schizophrenia.

DISORDERS OF MEMORY The formation of normal memory begins with attention to and normal perception of stimulus or subject material. Then there has to be proper registration, consolidation and retention of the perception and material for future recall when required. Any stage of the memory formation process may be affected by various reasons e.g. poor attention and concentration, mood state, brain diseases, drugs, emotional conflict and normal forgetting. In addition, the left brain is more concerned with verbal memory and the right brain with visual-spatial memory. Impairment of memory in general indicates organic disorders e.g. delirium, dementia, brain disease, head injury and effect of drug/alcohol. However memory function could be disturbed when the normal processes of registration, retention and retrieval are affected by various mental states. In situations of distraction, deficits of attention and concentration and emotional conflicts such as anxiety, depression and dissociative disorders, memory disturbance is frequently complained of with fear of brain damage. Depending on the cause, amnesia may thus be subjective, reversible or permanent. Memory could also be falsified in that what is remembered had in fact never happened or not exactly as it was. Deja vu, in which sense of familiarity in a new place would be an example. In confabulation, fabricated or false answers of the past are given to questions asked because of amnesia. Delusional memory is the development of a delusion, side by side with a normal memory. It is similar in concept to delusional perception of the primary delusional experience.

DISORDERS OF THINKING Thinking is an association of ideas and is expressed in speech or writing for communication. However, in order to respond and communicate, the capacity to understand what is heard or read must be intact. In a psychiatric setting, disorders of thinking cause breakdown in communication that is not due to organic lesion, intellectual functioning, language ability or barrier, or cultural difference. Frank Fish classifies disorders of thinking according to: 1. Stream/Flow - whether rapid or slow, and its direction/goal e.g. flight of ideas with chance association in mania; retardation of speech in depression

2.

Possession/Ownership - involuntary or alien in nature e.g. obsessional ruminations or thought insertion / withdrawal / broadcast as in schizophrenia respectively Content - what is expressed i.e. delusional ideas which may be persecutory, grandiose, nihilistic, erotic or jealousy Form - how words and ideas are associated or linked.

3.

Formal Thought Disorders These refer particularly to that found in schizophrenia though they could also occur in coarse brain disease. If thought is words forming ideas then examples ranging from the worst to the subtle type of thought disorder are as follows: Neologism - letters of the alphabet put together but not forming words Word salad - words thrown together but not forming sentences Disjointed talk - no logical connection in sentences Dissociation of ideas -. paragraphs loosely linked

In circumstantiality, the person does not come to the point directly. There is much beating around the bush and giving of a lot of details before finally answering the question. When the answer goes off the point completely it becomes tangential.

DISORDERS OF MOODS What or how one feels and reacts depends on individual predisposition, which is part of personality trait, and external factors in the environment. There is a range of emotional experience and behaviour in sadness, joy, anger and fear that is considered appropriate and normal. However, when the mood of depression (low spirit), elation (high spirit) or irritability is out of proportion in intensity and duration to what is understandable or acceptable and it dominates or overwhelms the individual, affecting his normal functioning, then a mood disorder exists. Primary mood disorder has secondary effects on other mental functions e.g. thinking, memory and behaviour. Sometimes a mood disorder is not apparent unless the "emotional baseline" of the individual is known. It could also be an acute on chronic situation i.e. the so called "double depression". In psychotic conditions, mood may be incongruous. Patients may laugh or cry without appropriate reasons and feelings. Affective blunting which is characteristic if not diagnostic of schizophrenia shows a lack of sensitivity in feeling and has a quality of indifference or callousness to it. Flattening of affect is a loss of expressivity of feeling such as masked facies in Parkinsonism or induced by neuroleptics. "La belle indifference" is typically described in conversion disorders in which the patient shows an inappropriate lack of concern about his disability.

DISORDERS OF CONSCIOUSNESS Consciousness is the awareness of self and the environment. When the awareness is focused it is attention and when the attention is sustained it is concentration. Normally, when an individual is in control of his mind, he is able to shift his attention at will to concentrate on any immediate task at hand. Other objects or intrusions are kept out. In other words, at any point of time there would be a dominant consciousness and possibly an hierarchy of subsidiary consciousness in the background. It is like multi-tasking on the computer with windows being opened or minimized according to applications. However, when the mind is disturbed it loses control over what the dominant consciousness should be. Other covert mental processes become overt and manifest independently as various forms of psychopathology. Again it is like the computer with too many windows opened and fouls up. These independent mental processes may dominate, interfere or co-exist with the normal mind. Some patients are able to recognize these abnormal mental processes in their mind and learn to suppress or overcome them. Under physiological condition, lowering of consciousness leads to sleep. Pathological clouding of consciousness would result in a comatose state. Confusion is clouding of consciousness with disorientation. It is obvious that other mental functions i.e. perception, thinking and feeling are also affected. Hallucinations are present, thinking is disordered, the patient exhibits fear and restlessness as in delirium. Consciousness may also be restricted as in a dissociative or fugue state. This condition has a sudden onset usually in response to acute overbearing stress. It is associated with confusion about personal identity, inability to recall the past and disorientation. This could result in a person wandering away and sometimes even assuming a new identity.

OTHER DISTURBANCES OF SELF-AWARENESS Depersonalization This is a feeling or sense of change in oneself whether emotionally or physically with an unpleasant quality. It also includes derealization which refers to the same phenomenon but of the environment. This sense of dissonant change in oneself or the environment may be due to the dissociation between cognition and affect. For instance one patient says, "I know it is raining outside but I am unable to feel that it is so." Yet another who is panting away after exercise says "I am not able to feel breathless." On the other hand, although the patient is unable to subjectively feel emotions and yet his external emotional expressions or responses are observed to be quite normal. Thus he may laugh heartily at a joke but states that he could not feel the humour. In normal functioning we think, feel and behave in consonance.

Identity and Boundary These are more psychotic phenomena in which the patient thinks he is not himself but somebody else; his body is not his own; that he has no control over his thinking and feeling or there is mutual influence between himself and the environment.

Passivity Experience In schizophrenia there is complaint of being made to think, feel and act in certain manner by some external force outside voluntary control. For example, a schizophrenic patient may feel his thoughts are not his own but imposed on him by a computer.

MOTOR DISORDERS Generally, one's posture, movement, action or behaviour is intentional, purposeful and adaptive. But some postures, mannerisms and stereotyped movements are symptomatic of mental disorders and non-adaptive. In catatonia there may be stiff or frozen posture or restless over-activity. Motor Disorders have been classified according to adaptive and non-adaptive movements, motor speech, posture and abnormal patterns of behaviour. Thus there may be manneristic or stereotyped (rigid) speech and movements; echoing or repetitive imitating of what others say (echolalia) or do (echopraxia); perseveration of a response or activity and of posture (catalepsy). Catatonia may be exhibited at one extreme as excitement with marked agitation, impulsivity and aggressive behaviour and, at the other extreme, as rigidity with posturing and stereotyped behaviour or a stuporous state.

References 1. 2. Fish F. Clinical Psychopathology. Bristol: Wright, 1974. Sims A. Symptoms of the mind. London: Bailliere Tindall, 1988.