Psychopathology

Definition : psychiatry

• It is a branch of medicine that deals with the diagnosis ,treatment and prevention of mental illness .

Definition : Psychiatric nursing

• It is a specialized area of nursing practice , employing theories of human behavior as it is a science , and the purposeful use of self as it is an art , in the diagnosis and treatment of human responses to actual or potential mental health problems .

( ANA1994 )

SIGNS & SYMPTOMS OF MENTAL ILLNESS

DISORDERS OF

PERCEPTION

• Perception is the meaningful organization of sensory data and their interpretation in the light of one’s past experience.

• Hyper aesthesia: Increased intensity of sensations, seen in intense emotions and hypochondriacal personalities.

In hyper aesthesia sounds appear louder, colors brighter ,and pain unbearable .

• Illusions: Misperceptions or misinterpretations of real external sensory stimuli:

e.g. Shadows may be misperceived as frightening figures., In a fading light rope is misperceived as a snake .

• Hallucinations:

Perception in the absence of real external stimuli; experienced as true perception coming from the external world (not within the mind).

e.g. Hearing a voice of someone when actually nobody is speaking within the hearing distance.

Types

Auditory hallucinations (voice, sound, noise).

is a form of hallucination that involves perceiving sounds without auditory stimulus.

Types of auditory hallucination:•Second-person hallucinations: voice speaking to the person addressing him as “you”.

•Third-person hallucinations: voice talking about the person as “he” or “she”:

•Thought echo: hearing one’s own thoughts spoken aloud.

• Visual hallucination is the seeing of things that are

not there .

Olfactory hallucinations is the phenomenon of smelling odors that are not really present. The most common odors are unpleasant smells such as rotting flesh ,vomit, urine, feces, smoke, or others

Gustatory hallucination is the perception of taste without a stimulus.

• Tactile hallucinations occurs when someone feels a sensation on the body that is, in fact, not present.

Tactile hallucination is the false perception of tactile

sensory input that creates a hallucinatory sensation of physical contact with an imaginary object.

One subtype of tactile hallucination, formication, is the sensation of insects crawling underneath the skin and is frequently associated with prolonged cocaine use.

• somatic hallucination

Somatic hallucinations refer to sensations or perceptions concerning body organs that have no known medical cause or reason, such as the notion that one's brain is radioactive.

• Imperative hallucination: voices giving instructions to patients, who may or may not feel obliged to carry them out.

• ‘Thought echo’ : hearing one’s own thoughts being spoken aloud; the voice may come from inside or outside the head.

• Running commentary hallucinations: are usually abusive and often talk about sexual topics.

• Scenic hallucinations: hallucinations in which whole scenes are hallucinated like a cinema film; more common in psychiatric disorders associated with epilepsy.

• Lilliputian hallucinations: A term used to denote a

hallucination featuring miniature individuals, animals, objects, or fantasy figures.

• Autoscopy (phantom mirror image): the patient sees himself and knows that it is he. Seen in normal subjects when they are depressed or emotionally disturbed.

• ‘Negative autoscopy’: the patient looks in the mirror and sees no image; in organic states.

• Internal autoscopy: the subject sees his own internal organs.

• Extracampine hallucinations: a hallucination which is outside the limits of the sensory field.

• Extracampine hallucinations are hallucinations beyond the possible sensory field.

• e.g., 'seeing' somebody standing behind you is a visual extracampine hallucination experience.

• Hypnagogic hallucinations: hallucinations when falling asleep.

• Hypnopompic hallucinations: hallucinations when waking from sleep.

ABNORMALITIES IN THINKING

• Autistic thinking is a form of thought disturbance and is a term used to refer to thinking not in accordance with consensus reality and emphasizes preoccupation with inner experience.

A. Abnormalities of Stream of Thought

• Flight of ideas: the thoughts follow each other rapidly and there is no general direction of thinking, seen in mania /excited schizophrenics.

• Flight of ideas Flight of ideas describes excessive

speech at a rapid rate that involves fragmented or unrelated ideas. It is common in mania. It has also been described in schizophrenia and ADHD

• Pressure of thoughts: Rapid abundant varying thoughts associated with pressure of speech and flight of ideas.

• Poverty of thoughts: Few, slow, unvaried thoughts associated with poverty of speech.

• Thought block: Sudden cessation of thought flow with complete emptying of the mind not caused by an external influence.

B. Abnormalities of Form of thought

• Formal thought disorder: a synonym for the disorders of

conceptual or abstract thinking which occur in schizophrenia and coarse brain disease.

Loosening of Association: (Loose Association) A thought disorder in which series of ideas are presented with loosely apparent or completely in apparent logical connections.

A manifestation of a thought disorder whereby the patient's responses do not relate to the interviewer's questions, or one paragraph, sentence, or phrase is not logically connected to those that occur before or after.

Example: I sang out for my mother …… for this to hell I went…how long is road …

Tangentiality: It is a form of derailment. Wandering from the topic

and never returning to it or providing the information requested.

e.g. In answer to the question "Where are you from?", a response "My dog is from England. They have good fish and chips there. Fish breathe through gills."

• Derailment: direction of thought is lost and the thought goes away from the intended theme .

Example:

• "The next day when I'd be going out you know, I took control, like uh, I put bleach on my hair in California.”

Neologism: completely new word or phrase whose deviation cannot be understood.

OR is the name for a newly coined term, word, or phrase that may be in the process of entering common use but that has not yet been accepted into mainstream language.

C. Abnormal Thought Content

• Overvalued Ideas: abnormal beliefs ,unique to the individual which dominates his life .

Example: *A woman falsely believes herself unusually unattractive.

* A person with no computer science training might, believe he is going to write the next great computer program and fixate on this idea rather than pursuing training in computer science or going to work.

* A person who works at a company may rigidly maintain the idea that he or she is the most valuable member of the company, that he/she will save the company from ruin, or that he/she will soon be made president of the company.

•Delusions: Fixed false beliefs which are not shared by others ,are out of keeping with one’s educational ,social and cultural background and are unshakable in the face of evidence to the contrary.

Delusional Contents:• Persecutory (paranoid) delusion: Delusion of

being persecuted (cheated, mistreated, etc.)• Grandiose delusion: Delusion of exaggerated

self-importance, power or identity.• Delusion of reference: Delusion that some

events and others behavior refer to oneself.• “Idea of Reference”: misattribution of events

as referring to oneself.

• Delusion of jealousy: Delusion that a loved person (wife/husband) is unfaithful (infidelity delusion)

• Delusions of love (‘fantasy lover’, ‘erotomania’): Delusion that someone, (usually inaccessible, high social class person) is deeply in love with the patient.

• Nihilistic delusion: Delusion of nonexistence of self, part of the body, belongings, others or the world.

• Delusion of self - accusation: Delusion that a patient has done something sinful, with excessive feeling of remorse and guilt.

• Delusion of influence: Delusion that person’s thoughts, actions, or feelings are controlled by outside forces.

• Passivity phenomena: person reports being made feel, made think or made act.

• Delusions of Replacement (Capgras Syndrome): a belief that important people in one's life have been replaced by impostors.

• Delusions can be either :• Mood-Congruent Delusion – Delusional

content has association to mood: - in depressed mood: delusion of

self - accusation. - in elevated mood: grandiose delusion.

• Mood-Incongruent Delusions – Delusional content has no association to mood, e.g. patient with elevated mood has delusion of thought insertion.

• Delusions can also be either:• Systematized Delusion - Delusion

united by a single event or theme e.g. delusion of jealousy/thematically well connected with each other.

• Bizarre Delusion - Totally odd and strange delusional belief, e.g. delusion that person’s acts are controlled by stars.

D. Abnormalities of Possession of thought

• Obsessions:–Repetitive ideas, images, feelings

or urges insistently entering person’s mind despite resistance. They are unwanted, distressful and recognized as senseless and irrational. Obsessions are frequently followed by compelling actions (compulsions).

• Common Obsessional Contents:–dirt/contamination/cleaning–orderliness–doubts/checking/counting–aggressive impulses/inappropriate acts–Ruminations: internal debates in which

arguments for and against even the simplest everyday actions are reviewed endlessly .

• Thought Alienation:– Thought Insertion: Delusion that some of

person’s thoughts being put into the mind by an external force (other people, certain agency).

– Thought Withdrawal: Delusion that some of person’s thoughts being taken out of the mind.

– Thought Broadcasting: Delusion that others can read or hear the person’s thoughts, as they are broadcast over the air, radio or some other unusual way.

• Dysmorphophobia:

a type of overvalued idea where the patient believes one aspect of his body is abnormal or conspicuously deformed.

ABNORMALITIES OF MOOD /EMOTION

• Feeling: a positive or negative reaction to some experience

• Emotion: a stirred up state due to physiological changes which occurs as a response to some event and which tends to maintain or abolish the causative event.

• Mood: the pervasive feeling tone which is sustained (lasts for a length of time) and colors the total experience of the person.

• Affect: is the outward objective expression of the immediate cross-sectional emotion at a given time.

• Euthymia: a normal mood state, neither depressed nor manic.

• Cheerfulness: being in good spirits.• Perplexity: a state of puzzled

bewilderment.

• Anxiety: feeling of apprehension accompanied by autonomic symptoms (such as muscles tension, perspiration and tachycardia), caused by anticipation of danger.

• Free-floating anxiety: diffuse, unfocused anxiety, not attached to a specific danger.

• Fear: anxiety caused by realistic consciously recognized danger.

• Panic: acute, self-limiting, episodic intense attack of anxiety associated with overwhelming dread and autonomic symptoms.

• Phobia: irrational exaggerated fear and avoidance of a specific object, situation or activity.

• Agoraphobia: patients rigidly avoids situations in which it would be difficult to obtain help.

• Social phobia - Intense and excessive fear of being observed by other people–Eg: eating or drinking in public or

talking to the other member of sex

• Specific phobia: irrational fear of a specific object or stimulus.Acrophobia : fear of heightsArachnophobia : fear of spidersClaustrophobia : fear of closed spacesGamophobia : fear of marriageHemophobia : fear of bloodZoophobia : fear of animals

• Agitation: severe feeling of inner tension associated with motor restlessness.

• Irritable mood: easily annoyed and provoked to anger.

• Dysphoria: mixture feelings of sadness and apprehension.

• Depressed mood: feeling of sadness, pessimism and a sense of loneliness.

• Anhedonia: lack of pleasure in acts which are normally pleasurable.

• Diurnal variation: a variation in the severity of symptoms (mood) depending on the time of the day

• Grief: sadness appropriate to a real loss (e.g. death of a relative)

• Guilt: unpleasant emotion secondary to doing what is perceived as wrong.

• Shame: unpleasant emotion secondary to failure to live up to self-expectations.

• Perplexity: anxious mood with bewilderment.

• Ambivalent Mood: coexistence of two opposing emotional tones towards the same object in the same person at the same time.

• Alexithymia: inability to, or difficulty in, expressing one’s own emotions.

• Elevated Mood: a mood more cheerful than usual .

• Elevated Mood:– Euphoria (Stage I): mild elevation of mood in which

feeling of elevated mood with optimism and self-satisfaction not keeping with ongoing events. Usually seen in hypomania.

– Elation (stage II): (Moderate elevation of mood) - a feeling of confidence and enjoyment, along with increased PMA. –a feature of manic illness

– Exaltation (stage III): (severe elevation of mod): intense elation with delusions of grandeur, seen in severe mania.

– Ecstasy (Stage IV): (very severe elevation of mod): a sense of extreme well-being associated with a feeling of rapture, bliss and grace. typically seen in delirious and stuporous mania .

• Expansive Mood: expression of euphoria with an overestimation of self-importance.

• Grandiosity: feeling and thinking of great importance (in identity or ability).

• Constricted Affect: significant reduction in the normal emotional responses.

• Flat affect: absence of emotional expression.• Apathy: lack of emotion, interest or concern,

associated with detachment.• Labile Affect: rapid, abrupt changes in emotions in

the same setting, unrelated to external stimuli.

• La Belle Indifference: inappropriate denial of expected affect and lack of concern about physical disability (seen in conversion disorders).

• Inappropriate Affect: disharmony between emotions and the idea, thought, or speech, accompanying it.

• Cyclothymia: There is cyclical mood variation to a lesser degree than in bipolar disorder.

ABNORMALITIES OF SPEECH• Echolalia: imitation of words or phrases

made by others.• Verbigeration : repetition of words of

phases while unable to articulate the next word in the sentence/senseless repetition of same words or phrases over and over again.

• Pressure of Speech: rapid, uninterrupted speech that is increased in amount.

–Mutism: inability to speak.

–Elective Mutism: refusal to speak in certain circumstances.

–Poverty of Speech: restricted amount of speech.

–Stuttering (Stammering): frequent repetition or prolongation of a sound or syllable, leading to markedly impaired speech fluency.

–Cluttering: dysrhythmic rapid and jerky speech.

–Clang Associations (Rhyming): association of word similar in sound but not in meaning (e.g. deep, keep, sleep)

–Punning: playing upon words, by using a word of more than one meaning (e.g. ant, aunt)

–Word Salad: incoherent mixture of words and phrases.

–Dysphasia: impairment in producing or understanding speech.

–Dysarthria: difficulty in articulation and speech production.

–Sensory Aphasia: nonsensical fluent speech due to lesion affecting Wernicke’s (receptive) area.

–Motor Aphasia: impairment in the ability to formulate fluent speech due to lesion affecting Broca’s (motor) area.

–Dysphonia: difficulty in voicing speech clearly, due to dysfunction of vocal cords or soft palate.

–Circumstanciality: over inclusion of details delaying reaching the desired goal.

–Coprolalia: forced vocalization of obscene words or phrases,

–Palilalia: is characterized by the repetition of a word or phrase; i.e., the subject continues to repeat a word or phrase after once having said. It is a perseveratory phenomenon.

–Alogia: lack of speech output.• Mutism: complete absence of speech.

ABNORMALITIES OF MOTOR BEHAVIOUR• Psychomotor Retardation: Slowed mental and

motor activities.• Stupor: A state in which a person does not

react to the surroundings: (mute, immobile and unresponsive).

• Catatonic Stupor: Stupor with rigid posturing.• Psychomotor Agitation: Restlessness with

psychological tension. (Patient is not fully aware of restlessness.)

• Catatonic Excitement: Marked agitation, impulsivity and aggression without external provocation.

• Chorea: sudden involuntary movement of several muscle groups with the resultant action appearing like part of voluntary movement.

• Aggression: Verbal or physical hostile behavior, with rage and anger.

• Akathisia: Inability to keep sitting still, due to a compelling subjective feeling of restlessness.

• Dyskinesia: Restless movement of group of muscles (face, neck, hands).

• Dystonia: Painful severe muscle spasm.• Torticollis: Contraction of neck muscles.• Tics: Sudden repeated involuntary muscle

twisting. e.g. repeated blinking, grimacing.

• Compulsions: Compelling repeated irrational actions associated with obsessions. e.g. repeated hand washing.

• Echopraxia: Imitative repetition of movement of somebody.

• Stereotypies: Purposeless repetitive involuntary movements. e.g. foot tapping, thigh rocking.

• Mannerism: Odd goal-directed movements. e.g. repeated hand movement resembling a military salute.

• Waxy Flexibility: Patient’s limbs may be moved like wax, holding position for long period of time before returning to previous position.

• Cerea flexibilitas, meaning "waxy flexibility", refers to people allowing themselves to be placed in postures by others, and then maintaining those postures for long periods even if they are obviously uncomfortable. It is characterized by a patient's movements having the feeling of a plastic resistance, as if the person were made of wax. This occurs in catatonic schizophrenia, and a person suffering from this condition can have his limbs placed in fixed positions as if the person were in fact made from wax.

• Automatic obedience: the pt. carries out every instruction regardless of the consequences.

• Perseveration: is a senseless repetition of a goal-directed action, a particular response, such as a word, phrase, or gesture which has already served its purpose (beyond their relevance).

• Dyspraxia; inability to carryout complex motor tasks, although the component motor movements are preserved.

• Omega sign (Athanassio): the occurrence of a fold like the Greek letter omega in the forehead above the root of the nose produced by the excessive action of the corrugator muscle; seen in depression.

• Ambitendency: a motor symptom of schizophrenia in which there is an alternating mixture of automatic obedience and negativism.

• Mitgehen: The pt. moves his body in the direction of the slightest pressure on the part of the examiner. seen in catatonia

• Mitmachen (Co-operation): The body can be put to any position without any resistance on the part of the patient seen in catatonia.

• Trichotillomania: a condition characterized by an overwhelming urge to pluck out specific hairs.

• Pyromania: is an impulse control disorder in which individuals repeatedly fail to resist impulses to deliberately start fires, in order to relieve tension or for instant gratification.

• Dipsomania: uncontrollable craving for alcohol or compulsive drinking of alcohol.

• Kleptomania: a disorder in which the individual impulsively steals things other than personal use or financial gain.

• Negativism: an apparently motiveless resistance to all commands and attempts to be moved or doing just the opposite.

Collective Symptoms

• Positive symptoms: refers to presence of delusions, disordered thoughts and speech, and tactile, auditory, visual, olfactory and gustatory hallucinations

• Negative symptoms : are deficits of normal emotional responses or of other thought processes, and respond poorly to medication which includes flat or blunted affect and emotion, poverty of speech (alogia), inability to experience pleasure (anhedonia), lack of desire to form relationships (asociality), and lack of motivation (avolition).

• Biological symptoms (somatic symptoms./melancholic symptoms.): refers to changes in sleep, appetite, libido, activity, diurnal changes in mood, anhedonia, early morning awakening, and psychomotor agitation or retardation.

• Psychotic symptoms: presence of hallucinations and delusions.

• First Rank Symptoms of Schizophrenia (Kurt Schneider)– Audible thoughts (thought echo)– Voices heard arguing– Voices heard commenting on one's actions– Somatic/thought passivity experiences (delusions of

control)– Thought withdrawal– Thought insertion - Thoughts are ascribed to other

people who intrude their thoughts upon the patient– Thought broadcasting (also called thought diffusion)– Delusional perception.

• Motor Symptoms of schizophrenia

• Catatonia• Catalepsy• Automatic obedience• Negativism• Ambitendency• Mitgehen . Psychological pillow• Mitmachen• Mannerism• Stereotypy• Echopraxia

• In Capgras syndrome, the patient feels that a person familiar to him, usually a family member has been replaced by an imposter.[1] This is a type of delusion that can be experienced as part of schizophrenia. Capgras Syndrome and several other related disorders are referred to as delusional misidentification syndrome.