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