Psychosis: descriptive psychopathology

Descriptive Psychopathology of • Language/speech Psychosis • Thought • Perception Adrian Lloyd • Movement • Disorders of self

Language & Speech

Relationship of thought & Language & Speech language • Revise Thought/Language from psychopathology covered in affective Thought disorders • Relationship of thought & language • Disorders of language & speech • Psychotic language & speech disorders Language

1 Speech disturbance Thought & language disturbance • Mutism (all major  s, organic disorders) e.g. Flight of ideas • Prosody & volume changes Thought Derailment Loose associations • Unintelligible speech Clang associations – Paragrammatism / incoherent syntax Retardation (>>> ‘word salad’) Circumstantiality Overinclusiveness – Neoligisms Fusion – Stock words/phrases private symbolism Thought block Language Rhymes – Cryptolalia/graphia Perseveration Concrete thinking

? Speech areas

Organic speech disorders further reading:

Strub RL & Black WF, AF The mental status Examination in B neurology; BA 44 FA Davis

WBA 22 Lishman WA, Organic psychiatry; Blackwell

Speech/language disorders of Speech/language disorders of localising value localising value • Sensory dysphasias • Motor dysphasias – Pure word deafness – Pure word dumbness – Pure word blindness – Pure agraphia – 1º sensory dysphasia – 1º motor dysphasia – (Nominal dysphasia) – Alexia with agraphia – Jargon aphasia – Isolated speech area

2 Generation of language/speech

• Language development (phonemes - categorisation) Assessment of speech • Memory stores (verbs: frontal; nouns: temporal) • Phonation • Prososdy • Word generation (syllable production & connection: • Articulation • Volume posterior parietal) • Quantity • Vocabulary • Grammar / syntax (revolves around verbs; ?frontal) • Rate • Syntax • Prosody (largely R hemisphere) • Fluency • Cohesive ties • Short term memory (for understanding of discourse) • Spontaneity • Proposition • Semantic processing (largely R hemisphere) • Phonation (motor) • Articulation (motor)

Language in affective psychoses Language in affective psychoses

Mania – Pressured ( quantity, rate & spontaneity), loud,  cohesive links, clang associations (terminal syllable) Depression –  quantity, rate, volume, spontaneity, prosody, retardation

Language in schizophrenia Language in schizophrenia •Thought disorder as expressed in language •Altered / misused words, phrases & grammar

– Akataphasia – Neologism – Stock words/phrases – Alogia – Loss of continuity of – Block – Semantic halo – Paralogia

associations – Derailment – neoligism – Paraphasia (destruction of words)

– Asyndesis – Loss of goal – intrusion of dominant – Literal paraphasia (misused words)

– Metonyms – Tangentiality meanings – Verbal paraphasia (loss of words)

– Over-inclusive thinking – Illogicality – Clang associations (initial – Agrammatism (loss of parts of speech) syllable) – Concrete thinking – defect of deductive – Telegramese (loss of adverbs) – Repetitive speech (intrusion – Poverty of speech (thought) reasoning – Paragrammatism (loss of complex • empty speech of associations) grammar / overall sense, but each phrase make sense) • alogia • verbigeration • Syntax preserved long after word use disturbance occurs • Sz speech is less predictable than normal speech

3 Thought

Assessment of thought Form: Normal thought • Form • Content – Quantity/rate – Specific ideas of the – Fluency/associations subject Constellation of associations for each thought – Judgement/reasoning • eg • Delusion – Terrorists are after me • Overvalued – I am God • Obsessional – I receive radio waves • Normal – The world is in ruin Initial thought – Possession – Trees speak to me Goal • Passivity* (* = 1st rank) – Mood congruence? – Themes • Self-referent – Ideas of harm to • Depressive/nihilistic self/others? Determining tendency • Grandiose • Persecutory • Religious After Sims

Form: Retardation Form: Flight of ideas

•Rate  •Loss of determining tendency Goal •Individual associations can be recognised (but may be unusual) •Rate slowed •Determining T. intact •Fewer associations

After Sims After Sims

4 Form: Form: Circumstantiality Derailment / knight’s move / entgleisen

Goal

•Loss of understandable associations •Rate normal •Determining T. intact •lots of unnecessary detail After Sims After Sims

Form: Derailment / knight’s move / entgleisen Fusion / verschmelzung

Bringing together of various themes – conversation •Loss of understandable associations difficult to follow

After Sims After Sims

Form: Thought block / entgleiten Form: Thought block / entgleiten

Unexpected breaking off of chain of thought* (= 1st rank)

Unexpected breaking off of chain of thought After Sims After Sims

5 Judgement / reasoning

Delusion or • Delusion Obsessional thinking? – Unshakeable false belief out of keeping with social/cultural background • Primary*: un-understandable (1st rank, delusional percept) • Secondary: evolve to explain other experiences (voices, thought block etc)

• Delusions of control*: Passivity experiences (1st rank)

• Overvalued idea (“as if” quality) – Challengeable; open to reasoning but cannot be ignored • Obsessional thought – Own, recognised as illogical, resisted, intrusive

Other aspects of thought form

• Passivity: Thoughts are not my own / are controlled by something other than me • Can also apply to interpretation of actions/behaviour

• Self referent ideas (= ‘paranoid’) • Grandiosity Can be • Nihilism delusional or overvalued • etc

Perception

6 Perception Perception

• Revise Perception from psychopathology Normal Abnormal covered in affective disorders •Sensory perception •Imagery •Eidetic Imagery • Perception in psychosis False Perceptions Sensory Distortions •Intensity •Size •Colour

Illusions Pseudohallucinations Hallucinations

False Perceptions in Psychosis Sensory Distortions in Psychosis

•  intensity • mania, drug-induced, epilepsy • Hallucinations •  intensity •  normal perception, can percieve > 1 at once • depression • may not have corroborative evidence, may be • micropsia/macropsia/dysmaegalopsia explained delusionally (as may the fact that others do not have access to the experience) /metamporphopsia(paraprosipia: faces) • Organic states, epilepsy, Sz (rare), drug-induced • Split perception • organic states, Sz

Hallucinations Hallucinations • Visual • Auditory • Can be difficult to differentiate from other visual abnormalities – elementary • Organic rather than ‘functional’ psychoses • noises: usually in organic states » TLE, delerium, dementias, encephalopthies etc. – complex • Drug-induced • Voices » mescaline, LSD, solvents, mushrooms. – organic states (including alcohol-inuced): simple words • may have affective associations - e.g. DTs – Affective psychoses & Sz - simple words, complex speech (2nd &/or 3rd person/arguing*, Gedenkenlautwerden – audible • Association with other visual abnormalities thoughts*, running commentary*) » e.g. cortical blindness, hemianopias, dyslexia etc. – behaviour observed 2º to hallucination • Sz: rare » distraction, verbal responses, actions ?vocalisation » cf vis. pseudohallucinations related to auditory hallns. st (* = 1 rank) » Scenic vis. hallns. in oneroid states. • Charles Bonnet syndrome • Autoscopic visual hallucination.

7 Hallucinations Hallucinations

• Bodily sensation • Olfactory / gustatory May self-referentially – Strong link with memory – Superficial Frequently delusionally interpreted • Thermic interpreted • Persecutory • Haptic • Often as passivity • Mood congruent • Common in Sz – Epilpsy (esp TLE) • Hygric – With both hallucinatory – Sz Distinguish from other – Kinaesthetic & delusional components factors relating to •Affective psychoses – Other organic pathology smell/tatse • Joint / muscle sensation •Drug-induced / withdrawal • Medication states – Affective psychoses • Overvalued normal odours – Visceral • (mood congruence) • Inner organs • Delusion without hallucination

False Perceptions in Psychosis Hallucinations v Pseudo- v Fantasy Hallucin’ns • Pseudohallucinations – Nature External space Internal space Internal space • Visual, auditory, tactile Unwilled Unwilled Willed • Involuntary • Figurative Vivid/well defined Vivid/well defd. indef/incomplete • Not as real as normal perception Concrete/real Not completely Pictorial quality • Internal subjective space (Kandinsky/Jaspers) real; “inner eye”

– Occur in many psychiatric (psychotic & non- Could exist in other ? Could not do so psychotic) disorders and in non-pathological states sens. Modality • No diagnostic significance Independent of Dependent Dependent observer

Other specific sensory experiences

• Autoscopy – Visual halln or pseudohalln • Extracampine hallucination – a perception outside normal sensory field • Hypnagogic/Hypnopompic hallucinations – falling asleep / waking respectively – in narcolepsy, cataplexy & sleep paralysis • Functional hallucination – halln provoked by an external stimulus • Reflex hallucination – hallucinatory synaesthesia • Abnormal imagery – reduced or abnormally vivid

• Abnormal perception in sensory deprivation

8 Movement disorders

• Classification » none is all-encompassing Movement Disorders » none are mutually exclusive – MSE – Disorder-based – Aetiological – Form of movement • Checklists

Classification - MSE Classification - disorder-based • Motor symptoms characteristic of • Appearance – depression – facial expression – mania – posture – schizophrenia • Behaviour – Huntington’s Huge overlap, – OCD – reflective of mood state v non-specific as – Hysteria regards description – independent of mood – Dementias of movement – ‘bizarre’ – etc etc etc

Classification - aetiological Classification - form

agitation • Adaptive movements organic EPS 2 º to Sx of disorder • Non-adaptive movements cerebellar myoclonus Response – spontaneous fear & distress chorea to hall’ns – induced /dell’ns • Speech • Posture 1º Sx of disorder Drugs • Complex behavioural patterns

/motor EPSE intoxication catatonia retardation tremor tics conversion akathisia

9 Form – adaptive movements Form – non-adaptive movements

• Expressive behaviour • Spontaneous – Facial expression, gesturing – e.g. tics, tremor, EPS, conversion, choreo-athetosis, • Reactive behaviour dyskinesias, dystonias, stereotypies – e.g. startle ( in PTSD/anx; in depn, Sz –ve Sx) (Can increase in anxiety) • Goal directed movements – Mannerisms • Induced – Abnormal, repetitive goal directed movements – e.g. in catatonia – Obstruction (in catatonia) – automatic obedience, mitgehen, echopraxia, echolalia, – Stopping in mid-goal directed movement negativism, perseveration, etc. » ? Motor equivalent of thought block

Form – motor speech disturbances • Attitude – negativism, responding to voices, etc. • Flow – Mutism, slowed, staccato, pressure Tic v stereotypy v mannerism • Mannerisms – Stress, inflection, rhythm, pronunciation etc • Stereotypies – Words & phrases used repeatedly • Perseveration – of words or themes • Echolalia – Speech equivalent of echopraxia

Form - patterns of complex behaviour

Form – posture Abnormal psychic events

• Catatonic posturing Subjective Consequent • including waxy flexibility behaviour experience • Postural mannerisms • ‘Sagging’ in depression = Phenomenology = Observation • ‘Upright/tense’ in anxiety Assumption

Goal directed Non-goal directed OCD – rituals Stupor  excitement hebephrenic ‘silliness’ catatonia catatonia mania hysteria anxiety response to psychotic Sx organic mania etc. etc.

10 Make sure you know these!! Make sure you know these!!

• Agitation • Athetosis • Catatonia – Excessive opposition • Retardation • Myoclonus – Psychological pillow • Gegenhalten • Negativism (psychomotor) • Ataxia – Posturing • Aversion • Hyperactivity • EPS / EPSE – Excessive compliance • mutism • Hyperkinesis • Tremors • Mitmachen – Ambitendency • Mitgehen • Mannerism – Schnauzkrampf • Conversion • Automatic obedience • Stereotypy • (Dissociation) • Echopraxia – Stupor/akinetic mutism • Dystonia • Tics • Echolalia – Waxy flexibility • Dyskinesia • Stupor • Forced grasping – Obstruction • Advertance • Chorea • Akinesis • Perseveration • Akathisia

Disorders of Self

‘Self’ Social setting Self awareness/experience Body Schema • Awareness of existence & activity of the self Perceived body Self-concept 2 • Mental • Physical • Awareness of being a unity at any given point of Self-concept 1 Body image time Body concept • Awareness of continuity of identity over time • Awareness of the boundaries of self

Jaspers.

11 Disorders of self Disorders of self • Unity/singleness • Existence & activity: (possession of activity, perception, • Autoscopy (=haeutoscopy, =phantom mirror image) movement, mental functions, cognition, emotions etc) » seeing oneself (haeutoscopic hallucination) • changed experience of activity: depersonalization » loss of feeling of familiarity (this is not psychotic) » Sz (rare), parietal lobe disorders – feel as if unreal • Doppelganger (? “haeutoscopic depersonalization”) – internal &/or external change – unpleasant » “being outside, alongside & inside oneself” – affect always involved » ideational (form of depersonalization), delusional, &/or – insight preserved perceptual – often assoc. with derealization • Haeutoscopic delusion (rare) – also desomatization/de-affectualization • Multiple personality • not existing: nihilistic delusions » Hysterical dissociative states • passivity phenomena • Lability in awareness of personality » In Sz: believing one has become someone/something else & simultaneously believing self to be separate from it (?)

Disorders of self Disorders of self • Identity • Belief of having not always been the same person • Boundaries » Exclusively psychotic • Losing differentiation between I & not I » Sz – Sz » Characteristically a passivity experience: “been changed” » common feature of 1st rank Sx • Non-psychotic feeling: as if no longer truly self » blurred boundaries less apparent to patient than to observers » passivity » ie thoughts/feelings differ from previously accepted self » hallucinosis (esp. 3rd person & hearing own thoughts out loud) » no loss of contact with reality that is in fact the same person » delusional percept • Loss of continuity of self over time » Sz: changed person – Ecstasy states » Depression: will not continue into future » Affectively mediated: ‘as if’ » Role in insight » Normal • Possession state » Personality disorders » Temporary, Cultural v Pathological, Conscious level » Psychotic states • Near death experiences » Depersonaliz’n, autoscopy, alert, trancendental exp’nces

Psychosis Environment

Movement/behaviour Self Perception Thought /language s s s i n e g l e n Time: flow / direction / uniqueness / quality Loss of distinction of ‘I’ v ‘not I’

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