Descriptive Psychopathology

Descriptive psychopathology attempts to portray in words, as subtly and accurately as
possible, the nature of experiences, perceptions and behaviour. It defines, differentiates
and inter-relates such experiences.
It owes a great deal to the philosophical discipline called ‘phenomenology’ – a
method (developed by Husserl) of scrupulously inspecting one’s own conscious
processes, without assuming anything about external causes or consequences of those
‘phenomena’ and without altering the phenomena by observational methods.
This school of thought has influenced psychiatry through the philosopher/
psychiatrist Karl Jaspers. The development of sympathy and intuitive understanding
allows for the objective observation of phenomena in others, by relating them to
phenomena in ourselves.
Descriptive psychopathology may be seen, with epidemiology, as a scientific basis for
the practice of psychiatry. It should not be confused with ‘dynamic psychopathology’ – the
attempt to explain the phenomena of mental disorder in terms of psychodynamic
theories of aetiology.

DISORDERS OF APPEARANCE AND BEHAVIOUR
Appearance (state of health, posture, cleanliness, clothing, self-care) is an important
indication of other mental functions. Mood may be expressed in the form of:
• Appearance (facial expression, posture)
• Manner (response to others)
• Motility (degree and form of movements)


MOTOR DISORDERS (OF GENERAL BEHAVIOUR)
The degree and quality of activity are important. There may be increased restless
motor activity in agitation or in hypomania, but the quality will differ. The form of abnormal movements may be classified (after Hamilton, 1974) as follows.

DISORDERS OF ADAPTIVE MOVEMENTS
• Expressive behaviour – e.g. tearfulness, unhappy facial expression, paucity of movements or downcast appearance in depression; laughing, expansive gesturing and
overactivity in hypomania.
• Obstruction – seen in catatonia and consisting of irregular hindrance and blocking
of movements.
• Mannerisms – abnormal, repetitive goal-directed movements (e.g. bizarre methods
of walking or eating) commonly seen in chronic schizophrenia.

NON-ADAPTIVE MOVEMENTS
Spontaneous movements – habitual, not goal-directed
• Tics are sudden involuntary twitchings of groups of muscles, particularly facial
(seen in extreme form in Gilles de la Tourette syndrome).
• Static tremor of hands, head or upper trunk indicates anxiety, hyperthyroidism,
hysteria or ‘essential’ tremor, lithium toxicity, parkinsonism.
• Spasmodic torticollis involves spasm of neck muscles with twisting of head, which
may become permanent.
• Chorea is abrupt, random jerky movements resembling fragments of goal-directed
behaviour.
• Athetosis is slow, semi-rotary writhing movements.
• Orofacial dyskinesia is restless movements of tongue, mouth and facial muscles
(seen in the elderly and following chronic neuroleptic ingestion).
• Stereotypies are regular, repetitive non-goal-directed movements; e.g. repetitive
foot tapping, body rocking. Stereotyped utterances can occur. Stereotypies are seen
in chronic schizophrenia, mental handicap and infantile autism.
Induced movements
• Automatic obedience – the subject does whatever is asked of him or her.
• Echopraxia – the subject imitates the movements of the interviewer.
• Echolalia – words or phrases are imitated.
• Perseveration – the senseless repetition of a previously requested movement; i.e.
the repetition of a response after withdrawal of the stimulus. Special variants of
this are palilalia (the perseverated word is repeated with increasing frequency) and
logoclonia (perseveration of the last syllable of the last word). These are seen in
organic disorders and occasionally in catatonia.
• Forced grasping – the offered hand is repeatedly grasped and shaken, despite
requests not to do so. Seen in frontal lobe lesions.
• Mitmachen – the body can be put into any posture, despite instructions to resist.
• Mitgehen – an extreme form of mitmachen in which very slight pressure leads to
movement in any direction.
• Negativism – apparently motiveless resistance to suggestion or attempts at
movement.

Disorders of posture
• Postural mannerisms – strange and abnormal postures adopted habitually.
• Perseveration of posture – may be seen in schizophrenia and lesions of the midbrain. If the subject’s body is placed in an awkward posture and left, the posture is
held for a period before slowly relaxing, despite asking the patient to relax. If a
plastic resistance is felt to initial movement, this is termed ‘waxy flexibility’ (or
flexibilitas cerea).

DISORDERS OF PERCEPTION

SENSORY DISTORTIONS
Sensory distortions are changes in the quality, intensity or spatial form of a perception. Examples are:
• Hyperacusis – in mania, hyperthyroidism.
• Hypoacusis – in some acute organic states.
• Xanthopsia, micropsia – produced by psychedelics and temporal lobe lesions.

SENSORY DECEPTIONS
Hallucinations
Hallucinations are perceptions which arise in the absence of any external stimulus
(Esquirol, 1833). They are actual sense deceptions, not distortions of real perceptions.
Hallucinations are perceived as being located in the external world. They are perceived as having the same qualities as normal perceptions – i.e. vivid, solid.
Hallucinations are not subject to conscious manipulation, in the same sense that
normal perceptions cannot be produced or dismissed at will.
Illusions
Illusions are distortions of perceptions of real objects; e.g. flowery wallpaper is perceived as swarming snakes. Illusions are perceived as having the same qualities as
normal perceptions, but often are more fleeting than hallucinations.
Pseudohallucinations
Pseudohallucinations are not perceived by the actual sense organs, but experienced as
emanating from within the mind. They are a form of imagery. Although vivid they
lack the substantiality of normal perceptions.
Pseudohallucinations are located in subjective rather than objective space. They are
not subject to conscious control or manipulations.
Other mental images
• Eidetic images – previous perceptions are reproduced as a mental image of vivid
intensity and uncanny detail. May be regarded as a form of pseudohallucination.
• Pareidolia – vivid mental images occurring withthout conscious effort when perceiving an ill-defined stimulus; e.g. glowing fire.

DISORDERS OF THOUGHT

DISORDERED CONTENT

DELUSIONS
A delusion is a fixed false idea held in the face of evidence to the contrary, and out of
keeping with the patient’s social milieu.
• Held unshakeably.
• Not modified by experience or reason.
• Content often bizarre.
• Not dependent on disintegration of general intellectual functioning or reasoning
abilities.
• Often infused with a sense of great personal significance.
Types
• Autochthonous or primary delusions have no discernible connection with any previous interactions or experiences. They arise fully formed as sudden intuitions, like
sudden ‘brainwaves’. They are often preceded by a period of ‘delusional mood’ (or
‘delusional atmosphere’) in which the subject is aware of something strange happening; he/she then suddenly realizes the personal significance of this feeling with
a complete delusional understanding. This period of delusional perception is seen
as having two stages: first, the real perception of some object or event and, second,
the delusional misinterpretation of that event.
• Secondary delusions emerge understandably from other psychic experiences or current
preoccupations; e.g. prevailing affect, fears, personal stress, habitual attitudes of mind.
• Overvalued ideas are intense preoccupations with marked associated emotional
investment. The patient holds tenaciously to the idea, demonstrably false, with virtual certainty but not unshakeable conviction.

OBSESSIONS AND COMPULSIVE PHENOMENA
• ‘Obsession’ refers to impulses and thoughts.
• ‘Compulsion’ is confined to motor acts.
Obsessional phenomena describes persistent intrusion into consciousness of unwanted
thoughts, feelings or impulses, despite the individual’s recognition of their senseless
nature and resistance to them.
Although rejected by the individual, phenomena are owned as being ‘his’ or ‘hers’ (cf.
passivity phenomena experienced as being something imposed from outside). Thoughts
are often of a repugnant or bizarre nature, e.g. violent, sexual and blasphemous themes.
These thoughts are resisted initially, at the cost of mounting anxiety. Resistance may
lessen after time.

PASSIVITY PHENOMENA
Passivity phenomena are a variety of phenomena which have in common the apparent
disintegration of boundaries between the self and the surrounding world. The individual experiences outside control of, or interference with, his/her thinking, feeling, perception
or behaviour.
• Thought insertion and withdrawal – the experience of thoughts being put into or
taken out of the mind by some external agency or force.
• Thought broadcast – the experience that others can read or hear the individual’s
thoughts as they are ‘broadcast’ from him or her.
• ‘Made actions’ – either simple motor actions or more complex patterns of behaviour are experienced as being caused by an outside agency.

DISORDERED FORM OF THINKING

ACCELERATED TEMPO
This produces increased rate of delivery of speech (‘pressure of speech’) and ‘flight of
ideas’. There is loss of coherent goal-directed thinking with increasingly obscure associations between ideas. Vague connections may be prompted by rhyme, sounds of words
(‘clang associations’) and associations only acceptable in other contexts. Punning is
a common feature.
It is characteristic of hypomania, mania and may occur in delirium, and in rare
organic states, e.g. hypothalamic lesions.

DECREASED TEMPO – PSYCHIC RETARDATION
Subjectively experienced as ‘muzziness in thinking’ or difficulty in concentration,
leading to difficulty in decision-making and pseudo-dementia. It is characteristic of
retarded depressive states; said to occur rarely in manic stupor.

SCHIZOPHRENIC THOUGHT DISORDER
Bleuler considered disturbance of association of ideas to be a fundamental feature of
schizophrenia. In contrast to the thought disorder of hypomania, the logical associations between ideas are not only loosened, but often incomprehensible to the listener.
See also Table 2.1.
• Omission – a sudden discontinuation of a chain of thought.
• Derailment – a disruption of the continuity of speech by the insertion of novel and
inappropriate material to the chain of thought.
• Fusion – a merging and ‘interweaving’ of separate ideas.
• Drivelling – refers to the muddling of elements within an idea to the extent that
the meaning is totally obscured to a listener.Desultory thinking – ideas are expressed correctly in terms of syntax and grammatical
construction, but juxtaposed inappropriately. The ideas would be comprehensible if
expressed in another context or in isolation.
Other features of schizophrenic thought disorder
• Thought blocking – a sudden cessation of speech mid-sentence with an accompanying sense of subjective distress. A patients may complain that his/her mind has
‘gone blank’ or that his/her thoughts have been interfered with.
• Clang associations
– Verbal stereotypy – repetition of a word or phrase which has no immediate relevance to the context.
– Condensations – common themes from two or more separate ideas are combined
to form an incomprehensible concept.

DISORDERS OF EMOTION
• Mood – the emotional ‘tone’ prevailing at any given time. A ‘mood state’ will last
over a longer period.
• Affect – synonymous with ‘emotion’ and also meaning a short-lived feeling state.
Related to cognitive attitudes and understandings, and to physiological sensations.
When examining for disorders of emotion, look for:
1 The quality of the emotion: anxiety, sadness, cheerfulness, suspiciousness, irritability, apathy
2 The appropriateness of the emotion to what is being said and to behaviour
3 The constancy of the emotion at interview and what factors appear to influence it.

ABNORMAL EMOTIONAL PREDISPOSITION
Abnormal emotional predisposition is found in disorders of personality and signifies
a consistent tendency to particular stereotyped emotional expressions. Thus a person
may be:
• Dysthymic – always tending to be sad and miserable.
• Hyperthymic – always tending to be overcheerful, unrealistically optimistic.
• Cyclothymic – tending to marked swings of mood from cheerful to unhappy.
• Affectless – emotionally cold and indifferent.

ABNORMAL EMOTIONAL REACTIONS
• Anxiety is a fear with no adequate cause. Fear and anxiety may be normal experiences, but are regarded as pathological if they are excessive or prolonged, or interfere markedly with normal life. Anxiety is usually accompanied by somatic and
autonomic changes.
• Depression is a feeling of misery, inner emptiness, hopelessness and helplessness,
accompanied by morbid preoccupations. Such emotions may be normal in the
bereaved, but are regarded as pathological if excessive, prolonged, and accompaniedby disturbance of appetite, sleep, concentration, etc., or by depressive delusions.
Depression is often associated with (or may present as) somatic complaints,
hypochondriasis or a feeling of bodily insecurity.
• Euphoria and ecstasy are excessive and unrealistic cheerfulness and a feeling of
extreme well-being.
• Apathy is the loss of all feeling. No emotional response can be elicited.

ABNORMAL EXPRESSION OF EMOTION
• Denial or dissociation of affect – as seen in hysteria (la belle indifférence) or occasionally in situations of extreme danger.
• Emotional indifference – as may be seen in ‘psychopathic’ disorder. Expected emotional response is not shown to others, or to his/her own antisocial behaviour.
• Perplexity – anxious and puzzled bewilderment. Seen in early schizophrenia and
confusional states.
• Emotional incongruity – the abnormal presence or absence of emotions; e.g. fatuous euphoria in a situation which would normally evoke a depressed mood. The
criterion of ‘understandability’ is therefore employed; i.e. the mood is not understandable to the ‘normal’ person. Emotional incongruity is characteristic of acute
schizophrenic disorder.
• Emotional blunting – insensitivity to the emotions of others and a dulling of the
normal emotional responses. It is characteristic of chronic schizophrenia.
• Emotional lability – rapid fluctuations of emotion. The emotions may be appropriate in a less intense form, but the rapid change is not. Emotional lability is seen in
organic disorders, brain stem lesions, mania, and some personality disorders.
• Emotional incontinence – an extreme form of emotional lability, with complete
loss of control over the emotions. It is seen in organic disorders, especially
pseudobulbar palsy.

DISORDERS OF SELF-AWARENESS
Self-experience has four aspects, according to Jaspers (1959):
• Awareness of the existence of activity of the self
• Awareness of the unity of the self at any one time
• Awareness of the continuity of self-identity through time
• Awareness of the self as distinct from the outside world.
The final three aspects may be abnormal in schizophrenia.

AWARENESS OF THE EXISTENCE OF ACTIVITY OF THE SELF
All psychic life involves the experience of a unique and fundamental activity of the
self. All emotions, behaviour, ideas, etc., are experienced as ‘being mine’. This experience is absent in depersonalization, in which the sense of awareness of existence as a
person is altered or lost. This is often accompanied by derealization, the loss of the
sense of reality of surroundings. These experiences may be seen in dissociative hysteria,
temporal lobe epilepsy, extreme fatigue or anxiety and psychotic illness of all sorts.

The alteration of awareness of one’s activities (moods, thoughts, acts) as belonging
to the self is seen in passivity experiences. In these the mental phenomena are often
seen as being under the passive influence of some outside force or person. This is the
elementary, primary experience of being actually and directly influenced. This is characteristic of schizophrenia.

DISORDERS OF INTELLECTUAL FUNCTIONS

CONSCIOUSNESS
Consciousness is the state of awareness of the self and its environment. Reduced levels
of consciousness are seen in:
• Clouding of consciousness – disorientation in time, place, person, disturbances of
perception and attention and subsequent amnesia.
• Drowsiness – further reduction in level of consciousness, with unconsciousness if
unstimulated, but can be stimulated to a wakeful state.
• Stupor – further loss of responsiveness, which can be only aroused by considerable
stimulation. Awareness of environment is often maintained in depressive or catatonic
stupor, but not in organic stupor (cf. neurological and psychiatric definitions).
• Coma – profound reduction of conscious level with very little or no response to
stimulation.

ATTENTION AND CONCENTRATION
The intensity and extent of attention may be abnormal, as may the ability to sustain
attention (i.e. to concentrate). Attention may be intensified in a restricted area in those
with preoccupations (depressive, hypochondriacal, etc.). Attention may be reduced or
absent in certain restricted areas in those with hysterical denial.
Attention may be easily distracted in hypomania or organic psychoses. In the latter,
the ability to concentrate may be very variable.
Tests of attention
1 Reverse order of months of year.
2 Subtraction of serial 7s from 100.
3 A series of digits repeated forwards and backwards.
Record time and accuracy for these tests.

MEMORY
Memory involves the registration of data, the retention in the mind and recall at will –
both immediately and at a later time. Thus anything interfering with registration (e.g.
alcohol, organic psychosis, head injury), retention (e.g. Korsakoff’s psychosis) or
recall (organic or hysterical amnesia) will lead to defect of memory.

Tests of memory
1 Recall of past personal life events which can be corroborated.
2 Recall of recent personal life events. Note any specific periods of amnesia (e.g. retrograde or anterograde amnesia) or any particular topics which are forgotten (e.g.
hysterical amnesia).
3 Short-term memory can be tested using recall of a simple name and address after
5 minutes, repeating a sentence (e.g. Babcock sentence) and digit span.
4 General knowledge tests (e.g. names of royal family, prime minister, recent events
in the newspapers, dates of first and second world wars).
Note any confabulation to fill in the memory gaps with false information.

LANGUAGE FUNCTIONS (PARTICULARLY CENTERED IN THE TEMPORAL LOBE)
Language functioning is tested both by listening to spontaneous conversation and by
direct testing. Observe any errors in the form of:
• Dysarthria – disorder of articulation of speech.
• Neologizing – new words which do not exist.
• Paraphasia – words which are slightly incorrect.
• Dysphasias:
– Receptive – disorder of the comprehension of words due to dysfunction of
Wernicke’s area in the temporal lobe.
– Expressive – disorder of expressing thoughts in the correct form of words, due to
dysfunction of Broca’s area in the posterior frontal lobe.
– Intermediate, particularly nominal dysphasia – inability to name objects correctly. This should always be tested for in assessment of intellectual function.
Test by using a series of objects.
• Perseveration – inappropriate repetition of a previous name, word, theme or act.

VISUOSPATIAL FUNCTIONS (PARTICULARLY CENTRED IN THE PARIETAL LOBE)
Visuospatial functioning is tested by observation and by direct testing. Test the ability
to copy an asymmetrical object, to draw a clock face, to construct a star from matchsticks (constructional dyspraxia). Test right–left orientation and ability to name fingers (finger agnosia). Observe any difficulty in dressing and in finding his/her way
about (dressing apraxia, topographical disorientation).

INSIGHT
Insight according to Lewis (1934) is a ‘correct attitude to morbid change in oneself’.
The concept is multidimensional, incorporates both current and retrospective
components, and is usually not an ‘all-or-none’ phenomenon (Amador and David,
2004).

According to Amador et al. (1993), insight includes:
• Recognition of illness (signs, symptoms, etc.)
• Attribution of illness (attributes of illness phenomena to a mental disorder)
• Awareness of treatment – benefit–compliance
• Awareness of social consequences of illness – e.g. disability, involuntary commital to
hospital, response/concern of relatives.
Partial insight (i.e. retrospective insight) may not be the same as pseudo-insight.
Medication compliance and awareness of illness are separate but overlapping constructs which contribute to insight (Amador and David, 2004).
Issues: Is loss of insight consequent upon cognitive deficit, perhaps with a specific
pattern of localization (e.g. parietal), or is persistent symptomatology only partially
related to these factors?

Published by dewantoandoko

Dewanto Andoko Psychiatry Resident, Cipto Mangunkusumo Hospital - Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia 1. Educational Background: 1998 – 2000 : Petra Elementary School, Kediri 2000 – 2002 : BPK Penabur Elementary School, Bandar Lampung 2003 – 2004 : Brookfield State Primary School, Brisbane, Australia 2004 – 2007 : Immanuel Junior High School, Bandar Lampung 2007 – 2010 : St. Francis Senior High School, Bandar Lampung 2010 – 2017 : Maranatha Christian University Medical School, Bandung (GPA 3,35) 2. Work Experience: April 2019 - January 2020 : Assistant Researcher of dr. Profitasari Kusumaningrum, Sp.KJ, Psychogeriatric Division, Psychiatry Department, Faculty of Medicine University of Indonesia / Cipto Mangunkusumo Hospital February 2018 – February 2019 : Internship Medical Doctor at Bhayangkara Hospital Tulungagung & Puskesmas Kauman.

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