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Descriptive Psychopathology of Psychosis and Schizophrenia Dr. Emilio Fernandez-Egea Consultant Psychiatrist What is this talk NOT about • Full Description of Schizophrenia Psychopathology. – By content: Positive (=psychosis), AND negative, cognitive, emotional disturbances… – By course: premorbid, prodromal, acute, etc… – By Diagnostic Categories: DSM-IV-TR / ICD-10. • Psychopathology of Mental Disorders. – Psychosis as an epiphenomena in many other psychiatric and non psychiatric disorders. Learning objectives • Describing the main components of psychosis. • Describing the most common psychotic experiences in schizophrenia. • To increase the “psychiatric” vocabulary. • Useful references to increase your knowledge. Structure of the seminar • Definition of symptom. • Classification / characteristics. • Presence in Schizophrenia. • Differential diagnosis. Increasing the vocabulary… • Patient’s info details – House number – Street – Town – Post Code • Patient’s descriptive psychopathology of psychosis – “X presented paranoid delusions and hallucinations”. What is Psychosis? • Is the presence of positive symptoms (aka psychotic phenomena). – Delusions. – Hallucinations and other abnormal experiences. – Thought disorder. – Catatonia. Delusions Definition • Abnormal thought content. • DSM-IIIR – A false personal belief based on incorrect inference about external reality. – firmly sustained in spite of what almost everyone else believes and in spite of what constitutes incontrovertible and obvious proof or evidence to the contrary. – Is not one ordinarily accepted by other members of the person’s culture or sub-culture. • Jaspers’, Spitzer’s…. Delusions Definition Classification • According to four INDEPENDENT principles. – Degree of inexplicability. – Nature of subverted mental function. – Nosological significance. – Thematic content. Delusions Definition Classification • According to DEGREE of INEXPLICABILITY – Primary (AKA pure or true). – Secondary, delusion-like ideas. • According to the SUBVERTED MENTAL FUNCTION – – – – – Delusional perception. Delusional notion. Delusional memory. Delusional awareness. Delusional atmosphere/mood. Delusions Definition Classification • According to NOSOLOGICAL SIGNIFICANCE – – – – Paranoia. Delusional loving. Monosymptomatic hypochondriacal psychosis. Etc… Delusions Definition Classification • According to the THEMATIC CONTENT (1/2) – – – – – – – – Delusions of persecution (includes delusions of prejudice). Morbid jealousy and delusions of infidelity. Delusion of love / erotomania (includes Clerambault syndrome). Delusional misidentification. (e.g. Capgras, Fregoli, …). Grandiose delusions. Religious delusions. Delusions of guilt and unworthiness. Delusions of poverty and nihilistic delusions (Cottard’s Syndrome). – Hypochondriacal delusions. Delusions Definition Classification • According to the THEMATIC CONTENT (2/2) – Delusions of infestation (Ekbom’s syndrome). – Communicated insanity – Folie a deux. – Delusions of control of thinking (passivity of thought) • Thought withdrawal. • Thought broadcasting. • Thought insertion. – Delusions of control of experience (passivity of experiences) • • • • Passivity of affect (‘made’ feelings). Passivity of impulse (‘made’ drives). Passivity of volition (‘made’ volitional acts). Somatic passivity (influence playing on the body). Delusions Definition Classification Delusions in Schizophrenia • Very frequent (90%). • Paranoid ideas are not only persecutory. • Schneider’s First-Rank symptoms. – Delusions of perception. – Thought withdrawal / insertion / broadcasting. – Made feelings / impulses / volitional acts – Somatic passivity. Delusions Definition Classification Delusions in Schizophrenia Differential diagnosis • Other abnormal NON DELUSIONAL thought content: – Poverty of thought. – Erroneous Ideas (mistakes). – Overvalued ideas. – Obsessive Ideas. – …. Hallucinations Definition • Abnormal perception. • Is a perception of something when in fact nothing exists in the perceptual field. A perception without object. • It may be or NOT be followed by a delusional interpretation of the content. Hallucinations Definition Classification • According to four INDEPENDENT principles. – Modality. – Timing with respect to sleep. – Precipitation by a sensory stimulus. – Content. Hallucinations Definition Classification • According to MODALITY – Visual – Auditory – Olfactory – Gustatory – Tactile, somatic, kinaesthetic. • According to TIMING WITH RESPECT TO SLEEP – Hypnagogic: just before falling asleep. – Hypnopompic: on just waking up. Hallucinations Definition Classification • According to PRECIPITATION BY SENSORY STIMULUS – Synaesthetic: precipitation by sensation in a different modality from hallucination. – Functional (or reflex): precipitation by sensation in same modality. • According to CONTENT – Verbal / (simple, complex…) – Music. – Autostopic – Teichopsia, Lilliputian, etc…. Hallucinations Definition Classification Hallucinations in Schizophrenia • Very common (50%). – Auditory – Visual – Tactile 50% 15% 5% • Voice is the most common hallucination – It is usually heard in a grammatical form that is different from how we experience our own thoughts. – The sex of the voice is nearly always identified. – Voices diminish if there is a meaningful conversation. – Experienced in the head, poorly localized. Hallucinations Definition Classification Hallucinations in Schizophrenia • Schneider’s first-rank symptoms – Voices speaking thoughts aloud. – Voices arguing (two or more hallucinatory voices discussing the person in the third person), and – Voices commenting on the subject’s actions. Hallucinations Definition Classification Schizophrenia Differential diagnosis Not every abnormal perception is a psychotic hallucination Hallucinations Definition Classification Schizophrenia Differential diagnosis Not every abnormal perception is a psychotic hallucination Anomalous Experiences Illusions Pseudohallucinations Hallucination Does the object exists? YES YES NO No Is that completely misrecognized? NO YES N/A N/A YES NO Preserved Insight? Thought Disorder Definition • Disturbance of the form of thinking. • Covers a variety of positive and negative symptoms of schizophrenia. Thought Disorder Definition Classification • Two main categories: – Intrinsic disturbance of thinking (mechanics of thinking). – Disorder of language and speech. Thought Disorder Definition Classification • Two main categories: – Intrinsic disturbance of thinking (mechanics of thinking). – Disorder of language and speech. Thought Disorder Definition Classification • Intrinsic disturbance of thinking – Concrete thinking – Loosening of associations. – Overinclusion (circumstancial thinking). – Illogicality. – Thought blocking. Thought Disorder Definition Classification • Disorder of language and speech: – Derailment. – Neologism (paraphasia) – Poverty of speech (alogia). – Poverty of content of speech. – Incoherence: lack of grammatical structure. – Pressure of speech. – Retardation, including mutism. – Echolalia. – Tangentiality. Thought Disorder Definition Classification Thought disorder in Schizophrenia Schizophrenia Bipolar Affective Disorder – Manic episode Derailment 56% Similar Poverty of content of speech 40% 20% Pressure of speech 27% 70% Neologism 2% 0% Loosening associations 5% Overinclusion 25% Illogicality 10% Thought Disorder Definition Classification Schizophrenia Differential diagnosis • Other forms of Thinking processes…. – Fantasy Thinking. – Imaginative Thinking. – Rational or conceptual thinking. Catatonia Definition • It is not about the nosologic entity called Catatonia (Kahlbaum’s catatonia). • Set of abnormal involuntary movements associated to Mental Disorders. Catatonia Definition • • • • • • • • Classification Stupor Catalepsy (waxy flexibility). Automatism Mannerisms Stereotypies Posturing and Grimacing Negativism Echopraxia. Catatonia Definition Classification Catatonia in Schizophrenia • Rare: 5-10% • The most common: mannerism, then stereotypies, stupor, negativism, automatism, echopraxia,…. • None is specific. • Decreasing frequency (from 20% to 5%) in the last 100 years. • More common in schizophrenics from developing countries. Catatonia Definition Classification Schizophrenia • Other involuntary movement – Tics – Chorea – Dyskinesia – Athetosis – Balismus…. • Voluntary movement – Malingering. – Factitious disorder, etc…. Differential diagnosis Further reading Hirsch and Weinberger. Schizophrenia. 2nd Ed. (2003). Harrison and Weinberger. Schizophrenia. 3rd Ed (2011). Berrios. History of Mental Symptoms. (1998) Jaspers. General Psychopathology. (1965) Oyebode. Sims’ Symptoms in the Mind. 4th Ed. (2008) Cardinal and Bullmore. The Diagnosis of Psychosis. 1st Edition. (2011) Take home messages • Psychotic symptoms are more frequent in, but not specific to, psychotic disorders. • All psychotic disorders may also present nonpsychotic symptoms. • Psychotic phenomena should be thoroughly explored. Emilio Fernandez-Egea’s email: [email protected] or [email protected]