Psychopathology Department of Psychiatry University of Zambia
Dec 01, 2015
Psychopathology
Department of Psychiatry
University of Zambia
Psychopathology
The study of abnormal states of mind is
know as psychopathology a term which
denotes two distinct approaches
Phenomenological
Psychopathology(phenomenology)
Psychodynamic psychopathology
Experimental Psychopathology
PHENOMENOLOGICAL
PSYCHOPATHOLOGY
It is an attempt to understand the signs and
symptoms observed in the patient. It is
concerned with objective description of
abnormal states of mind.
The doctor must try to understand how the
patient fulfils social roles such as worker,
spouse, parent, friend, or sibling.
He should consider what effect the disorders
of function have had upon the remaining
healthy parts of the person.
The doctor will gain such understanding
only if he is prepared to spend time listening
to patients and their families and to interest
himself in every aspect of their lives
Once the clinician has elicited a patient’s
symptoms and signs he needs to:
Decide how far these phenomena
resemble or differ from those of other
psychiatric patients.
Determine whether the clinical features
form a syndrome,which is a group of
symptoms and signs that specify a
particular diagnosis
The purpose of identifying a syndrome is
to be able to plan management and
predict the likely outcome by reference to
accumulated knowledge about the cause
treatment, and outcome of the same
syndrome
PSYCHOSIS
The traditional meaning of the term psychotic
emphasized loss of reality testing and impairment
of mental functioning manifested by delusions,
hallucinations, confusion, and impaired memory.
In the most common psychiatric use of the term,
psychotic became synonymous with severe
impairment of social and personal functioning
characterized by social withdrawal and an inability
to perform the usual household and occupational
roles.
According to the American Psychiatric Glossary
of the American Psychiatric Association, the term
psychotic means grossly impaired reality testing.
The term can be used to describe the behavior of a
person at a given time or a mental disorder in which
at some time during its course all persons with the
disorder have grossly impaired reality testing.
With gross impairment in reality testing, persons
incorrectly evaluate the accuracy of their
perceptions and thoughts and make incorrect
inferences about external reality, even in the face of
contrary evidence.
The term psychotic does not apply to minor
distortions of reality that involve matters of relative
judgment. For example, depressed persons who
underestimate their achievements are not described
as psychotic; those who believe that they have
caused natural catastrophes are so described.
NEUROSIS
A mental disorder in which the predominant
disturbance is a symptom or group of symptoms
that is distressing to the individual and is
recognized by him or her as unacceptable and
alien (ego-dystonic);
Reality testing is grossly intact.
A neurosis is a chronic or recurrent non-psychotic
disorder characterized:
mainly by anxiety,
experienced or expressed directly or is altered
through defense mechanisms;
Appears as a symptom, such as an obsession, a
compulsion, a phobia, or a sexual dysfunction.
Behavior does not actively violate gross social
norms (though it may be quite disabling). The
disturbance is relatively enduring or recurrent
without treatment, and is not limited to a transitory
reaction to stressors.
There is no demonstrable organic etiology or
factor.
The term neuroses encompasses a broad range of
disorders of various signs and symptoms. As such,
it has lost precision, except to signify that the
person's gross reality testing and personality
organization are intact. However, a neurosis can
be, and usually is, sufficient to impair the person's
functioning in a number of areas.
Disorder of perception
Perception is the process of becoming
aware of what is presented through the
sense organs
Disorder of perception
Illusions
Illusions are misperception or misinterpretation of
external stimuli. They are most likely to occur when the
general level of sensory stimulation is reduced.
Thus at dusk a common illusion is to misperceive the
outline of a bush as that of a man.
Illusions are also more likely to occur when the level of
consciousness is reduced, as for example in an acute
brain syndrome.
Illusions occur more often when attention is not
focused on the sensory modality, or when there is a
strong affective state
Hallucination A hallucination is a percept experienced in the
absence of a external stimulus to the sense organs,and with a similar quality to a true percept. Ahallucination is experienced as originating in theoutside world (or within one's own body) like apercept and not within the mind like imagery
Hallucinations are not restricted to the mentally ill.A few normal people experience them, especiallywhen tired. Hallucinations also occur in healthypeople during the transition between sleep andwaking
Hallucinations
Type of hallucinations
Hallucinations may be auditory, visual, tactile,gustatory, olfactory, or of deep sensation
l) Auditory hallucinations may be experienced as noises,music, or voices.
Voices may be heard clearly or indistinctly; they mayappear to speak words, phrases, or sentences; and theymay address the patient (Second Person) or sound as iftalking to one another, referring to the patient as 'he'or 'she' (third person hallucinations).
Sometimes voices seem to anticipate what the patientthinks a few moments later, or speak his own thoughtsas he thinks them, or repeat them immediately after hehas thought them; the auditory hallucinations oftenseen in schizophrenic patients
2) Visual hallucinations may also be elementaryor complex. They may appear normal orabnormal in size; if the latter, they are moreoften smaller than the corresponding realpercept; the visual hallucinations will be seen inthe patients suffering from derangedconsciousness, epilepsy, substance misuse andschizophrenia
3) Olfactory and gustatory hallucinations arefrequently experienced together, often asunpleasant smell or tastes
4) Tactile hallucinations may be experienced as
sensations of being touched, pricked, or
strangled. They may also be felt as movements
just below the skin which the patient may
attribute to insects, worms or other small
creatures burrowing through the tissues
(Cocaine bugs);
tactile hallucination often occur in the patients
with drug dependence, schizophrenia, and
hysteria
Hallucinations may occur in all kinds of
psychosis, in hysterical neuroses and at times,
among healthy people. Therefore the finding of
hallucinations does not itself help in diagnosis.
However, certain kinds of hallucinations do
have important implications for diagnosis
Delusions
A delusion is a belief that is firmly held despite
evidence to the contrary and is not a
conventional belief that the person might be
expected to hold given his educational and
cultural background
This definition is intended to separate
delusions, which are indicators of mental
disorder, from other strongly held beliefs found
among healthy people.
Delusions have to be distinguished from the
shared beliefs of people with a common
religious or ethnic background; For example a
person who has been brought up to believe in
spiritualism is unlikely to change his
convictions when presented with contrary
evidence that convinces a non-believer
Although delusions are as a rule false beliefs,
in exceptional circumstances they can be true
or subsequently become true. Thus a man may
develop a jealous delusion about his wife, in
the absence of any reasonable evidence of
infidelity.
Even if the wife is being unfaithful at the time,
the belief is still delusional if there is no
rational grounds for holding it.
Exceptions of this kind remind us that it is not
the falsity of the belief that determines whether
it is delusional but the nature of the mental
processes that led up to it
Conversely, it is a well-known pitfall of clinical
practice to assume that an idea is false because
it is odd, instead of checking the facts or
finding out how the idea was arrived at.
For example, improbable stories of persecution
by neighbors or of attempts at poisoning by a
spouse may turn out to be correct and to be
arrived at through normal processes of logical
thinking
Types of delusion
For the purposes of clinical work delusions are
grouped according to their main themes.
This is useful because there is some
correspondence between these themes and the
major forms of mental illness.
However it is important to remember that
there are many exceptions to the broad
associations mentioned below
Persecutory delusions are most commonly
concerned with persons or organizations that are
thought to be trying to inflict harm on the patient,
damage his reputation, make him insane, or poison
him. Such delusions are common but of little help
in diagnosis, for they can occur in organic states,
schizophrenia, and affective psychosis.
However, the patient’s attitude to the delusion may
point to the diagnosis: in a severe depressive
disorder he characteristically accepts the supposed
activities of the persecutors as justified by his own
guilt and wickedness, but in schizophrenia he
resents them often angrily.
In assessing such ideas, it is essential to
remember that apparently improbable
accounts of persecution are sometimes true and
that it is normal in certain cultures to believe in
witchcraft and to ascribe misfortune to the
malign activities of other people
Delusions of reference are concerned with the
idea that objects, events, or people have a
personal significance for the patient: for
example, an article read in a newspaper or a
remark heard on television is believed to be
directed specifically to himself.
Delusions of reference may also relate to
actions or gestures made by other people which
are thought to convey something about the
patient
Grandiose to expansive delusions are beliefs ofexaggerated self-importance. The patient maythink himself wealthy, endowed with unusualabilities, or a special person. Such ideas occurin mania and schizophrenia
Delusions of guilt and worthlessness are foundmost often in depressive illness, and aretherefore sometimes called depressive delusions.Typical themes are that a minor infringementof the law in the past will be discovered andbring shame upon the patient, or that hissinfulness will lead to divine retribution on hisfamily
Nihilistic delusions are strictly speaking beliefs
about be non-existence of some person or thing,
but they are extended to include pessimistic
ideas that the patient's career is finished, that
he is about to die, that he has no money, or
that the world is doomed, They are associated
with extreme degrees of depressive mood
changed
HypochondriacaI delusions are concerned with
illness The patient may believe wrongly, and in
the face of all medical evidence to the contrary,
that he is ill. Such delusions are more common
in time elderly, Reflecting the increasing
concern with health among mentally normal
people at this time of life
Delusions of jealousy; Othello’s Syndrome:these are more common among men. Not alljealous ideas are delusions; less intense jealouspreoccupations are common, and someobsessional thoughts are concerned with doubtsabout the spouse's fidelity However, when thebeliefs are delusional they have particularimportance because they may lead todangerously aggressive behavior towards theperson thought to be unfaithfu1
Special care is needed if the patient follows thespouse to spy on her, examines her clothes formarks of semen, or searches her handbag forletters
Sexual or amorous delusions; Erotomania:Both sexual and amorous delusions are rare
but when they accrue they are more frequent
among women. A woman with amorous
delusions believes that she is loved by a man
who is usually inaccessible, often of higher
social status, and someone to whom she has
never even spoken
Delusion of control :The patient who has adelusion of control believes that his actions,impulses, or thoughts are controlled by anoutside agency
Because the symptom strongly suggestsschizophrenia, it is important not to record itunless definitely present. Sometimes thesedelusions are confused with the experience ofhearing hallucinatory voices giving commandsthat the patient obeys voluntarily
At other times it is misdiagnosed because thepatient has mistaken the question for one aboutreligious belief concerning the divine control ofhuman actions
Delusions concerning the possession of thoughts:
Healthy people take for granted the experience
that their thoughts are their own. They also
assume that thoughts are private experiences
which other people can only know if they are
spoken aloud, or if facial expression, gesture or
action gives them away. Patients with delusions
about the possession of thoughts may lose these
convictions in several ways
Those who have delusions about thoughtinsertion believe that some of their thoughts arenot their own but have been implanted by anoutside agency. This differs from theexperience of obsessional patient who may bedistressed by unpleasant thoughts but neverdoubts that they originate within his own mind.The patient with a delusion of thought insertionwill not accept that the thoughts haveoriginated in his own mind
Patients who have delusions of thought
withdraw believe that thoughts have been
taken out of the mind. This delusion usually
accompanies thought blocking, so that the
patient experiences a break in the flow of
thoughts through his mind and believes that
the ‘missing' thoughts have been taken away
by some outside agency, often his supposed
persecutors
In delusions of thought broadcasting the
patient believes that his unspoken thoughts
are known to other people, through radio,
television, or in some other way. All three of
these symptoms occur much more commonly
in schizophrenia than in any other disorder
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