sims' symptoms in the mind

Sims’ Symptoms in the Mind

For my father, Jonathan Akinyemi Oyebode (1918–1971)

Femi Oyebode

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SIMS’ SYMPTOMS IN THE MINDTextbook of Descriptive Psychopathology

FEMI OYEBODE MBBS, MD, PHD, FRCPSYCHProfessor of Psychiatry & Consultant PsychiatristUniversity of Birmingham, National Centre for Mental HealthBirmingham, UK

F I F T H E D I T I O N

Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2015

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NoticesKnowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

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v

C O N T E N T S

Preface to the Fifth Edition vii

Additional Materials within Accompanying Electronic Version viii

SECTION ONE Concepts and Method 1

1 Fundamental Concepts of Descriptive Psychopathology 3

2 Eliciting the Symptoms of Mental Illness 19

SECTION TWO Consciousness and Cognition 31

3 Consciousness and Disturbed Consciousness 33

4 Attention, Concentration, Orientation and Sleep 45

5 Disturbance of Memory 59

SECTION THREE Awareness of Reality: Time, Perception and Judgement 73

6 Disorder of Time 75

7 Pathology of Perception 87

8 Delusions and Other Erroneous Ideas 111

9 Disorder of the Thinking Process 139

10 Disorder of Speech and Language 159

11 Insight 175

SECTION FOUR Self and Body 185

12 The Disordered Self 187

13 Depersonalization 205

14 Disorder of the Awareness of the Body 217

15 The Psychopathology of Pain 245

SECTION FIVE Emotions and Action 255

16 Affect and Emotional Disorders 257

17 Anxiety, Panic, Irritability, Phobia and Obsession 279

18 Disorders of Volition and Execution 293

vi Contents

SECTION SIX Variations of Human Nature 315

19 The Expression of Disordered Personality 317

SECTION SEVEN Diagnosis 331

20 Psychopathology and Diagnosis 333

Self-Assessment 1 345

Self-Assessment 2 353

Self-Assessment 1: Answers 359

Self-Assessment 2: Answers 363

Index 367

vii

P R E F A C E T O T H E F I F T H E D I T I O N

Sims’ Symptoms in the Mind has, since its first publication in 1988, become established as theleadingtextbookonclinicalpsychopathology.Inthisnewfifthedition,asinthefourthedition,Ihave retained theoriginal structureof thebookbutmadesomechanges.Thereare shifts inemphasisandnewmaterialinanumberofchapters.Easilyrecognizablemodificationsareevidentinthechaptersondisturbanceofmemory,disorderoftime,pathologyofperception,disorderofspeechandlanguage,affectandemotionaldisorders,anddisordersofvolitionandexecution.Inthemainthesehavebeenpromptedbyadesiretoincorporateadvancesfromneuropsychologyandcognitiveneuroscience.InsomecasesIhaveprovidednovelclassificationsoftheabnormali-tiesunderconsideration.Additionalpathologicalphenomenaaredescribedinvariouschapters.Thesephenomenaincludesuchexperiencesaspalinopsia,palinaptia,teleopsia,pelopsia,akine-topsia,zëitrafferphenomenon,exosomesthesia,synaesthesia,bodyintegritydisorder,vulvodynia,penoscrotodyniaandmanyothers.

Inthisnewedition,Ihavebroughtuptodatemanyoftheconceptsanddescriptionsinvariouschapters.Ihavetriedtoreducetheoverlapinsubjectmatterbutitisimpossibletodoawaywithrepetitionsentirely.Someconcepts,suchaspassivityexperiencesforexample,arebetterunder-stood from different perspectives. However, the main innovation is in the accompanying filmclipsandpodcaststhatextendtherangeofwhatitispossibletoincludeinatextandthatallowmetoillustratecomplexideasbothvisuallyandaurally.OneofthedistinctivefeaturesofSims’ Symptoms in the Mindhasbeenitsuseoffigures,tablesandillustrativecaseexamples.Ihavekepttothisandaddedboxesandadditionalcaseexamplesfromtheclassicalliterature,autobiographi-calnarrativesandfiction.

IhavebeenconsciousofthecentenaryofKarlJaspers’General Psychopathologywhilstpreparingthisneweditionforpublication.Descriptivepsychopathology,asamethod,hasenduredthepast100years.Itisthepre-eminentfoundationforthepracticeofclinicalpsychiatry.Thismethodallowsustoobserveanddescribeabnormalsubjectivephenomenaandbehaviours,andtocatego-rize these inorder to communicatemoreprecisely about theworld thatpatients inhabit.Thecliniciantrainedinthephenomenologicalapproachisallthemoreawareoftheneedforempathicunderstanding, forassuminganatheoretical stance,andfinallyof theprovisional statusofourunderstandingandexplanationsregardingpsychopathology.

I am indebted to many more people than I can list.The Birmingham Philosophy Grouphas been meeting monthly since 1992. Its members continue to influence my thinking aboutpsychiatricphenomenaasdothemembersoftheEuropeanPsychiatricAssociationSectionofPsychopathology including John Cutting, Maria Luisa Figueira, Mircea Lazarescu, MichaelMusalek,GilbertodiPettaandPedroVarandas.Finally,withoutthepatientswhoexperienceandenduretheseabnormalphenomena,andthestudentsandpsychiatrictraineeswhoaskawkwardquestionsandoutofcuriosityenquireintothenatureofthesephenomena,thisbookwoulddefi-nitelybethepoorer.

Femi Oyebode

viii

The searchable full text for ‘Sims’ Symptoms in the Mind 5E’ is available at www.expertconsult.com, accessible via the enclosed pin code. Please follow the instructions on the inside front cover of this book. Additional materials integrated within this enhanced electronic version include:

■ Four patient scenarios (videos with transcripts), exploring:1. auditory verbal hallucinations2. persecutory delusion3. low mood4. obsessive compulsive phenomenon

Look out for alongside the related sections within this book.■ Six author podcasts on the following topics:

1. What is psychopathology?2. What are hallucinations?3. Critique of the nature of delusions4. The nature of obsessions5. The self in psychopathology6. Affect, mood and emotions

Look out for alongside the related sections within this book.■ Interactive question-and-answer sections for each chapter to test your understanding of key

topics.

ADDITIONAL MATERIALS WITHIN ACCOMPANYING ELECTRONIC VERSION

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S E C T I O N ONEConcepts and Method

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3

C H A P T E R 1

Fundamental Concepts of Descriptive Psychopathology

SummaryDescriptivepsychopathologyistheprecisedescription,categorizationanddefinitionofabnormalexperiencesasrecountedbythepatientandobservedinhisbehaviour.Itreliesonthemethodofphenomenologybyfocusingonexperiencedphenomenainordertoestablishtheiruniversalcharacter.Theaimistolistenattentively,toaccuratelyobserveandtounderstandthepsychologi-caleventorphenomenonbyempathysothatthecliniciancan,asfaraspossible,knowforhimselfwhatthepatient’sexperiencemustfeellike.

How the mind should be conceived for the purposes of psychopathology, what its faculties, functions or elements are (if there are any), how these can be

distinguished, and how mental disorders can be comprehended by an application of these concepts are philosophical questions.

Manfred Spitzer (1990)

Psychiatry is thatbranchofmedicinethatdealswithmorbidpsychologicalexperiences.Bydefinition,inthemedicalconditionsthatarecentraltopsychiatricpractice,psychologicalphe-nomenaareimportantascauses,symptomsandobservableclinicalsignsandalsoastherapeuticagents.The scopeof psychiatry canbe said to includeminor emotional disturbances that aremeaningfulreactionstoenvironmentalorpsychosocialstress;profoundpsychologicalchangethatisunheraldedbysignificantormeaningfulstress;disturbancesofpersonalitythathaveapervasiveinfluence on behaviour such that the person or others suffer; psychological changes that aredirectlytheconsequencesofdemonstrableorganicbrainchange;andpsychologicalandbehav-iouralconsequencesoftheuseofsubstancessuchasalcohol,cannabis,cocaineorheroin.Inordertodescribe,delineateanddifferentiate these conditions, themorbidpsychologicalphenomenathat constitute the subjective experienceofpatientsneed tobe carefully assessed, elicited andrecorded.This is the territoryofdescriptivepsychopathology. Inotherwords,descriptivepsy-chopathology is concerned with the selection, delimitation, differentiation and description ofparticularphenomenaofexperience,whichthroughtheuseofacceptedterminologybecomebothdefinedandcapableofrepeatedidentification.

Itcanbesaid thatdescriptivepsychopathology is the fundamentalprofessional skillof thepsychiatrist;itis,possibly,theonlydiagnosticskilluniquetothepsychiatrist.Itisconsiderablymore than just carrying out a clinical interview of a patient, or even listening to the patient,althoughitnecessarily involvesbothofthese.Itsaccurateapplicationinvolvesthedeploymentofempathyandunderstanding(weshallreturntotheselater).Ofcourse,fortherationalpracticeofpsychiatrythereisaneedforknowledgeofthebasicneurosciences;appropriatefactualknowl-edge of psychology, sociology and social anthropology is also required.With these, there is a

Keywords:Descriptivepsychopathology,Phenomenology,Norms,Subjectivity.

1—FuNDAMENTAl CONCEPTS OF DESCriPTivE PSyCHOPATHOlOgy 3.e1

4 ONE—CONCEPTS AND METHOD

need for a comprehensive working knowledge of general medicine, especially neurology andendocrinology.Thiscouldbeconsideredtobetheminimumknowledgebasethatisessentialforpractisingpsychiatry.However,itisdescriptivepsychopathologythatprovidesthefoundationofclinical psychiatric practice. The subjective phenomena that are revealed during the clinicalassessment, coupled with observable behaviours, ultimately determine the clinical judgementsthatinfluencetreatmentandmanagementdecisions.

What is Psychopathology?Psychopathology is the systematic studyof abnormalexperience, cognitionandbehaviour– thestudyoftheproductsofadisorderedmind.Itincludestheexplanatory psychopathologies,inwhichthereareassumedexplanationsaccordingtotheoreticalconstructs(forexampleonacognitive,behavioural,psychodynamicorexistentialbasisandsoon),anddescriptive psychopathology,whichistheprecisedescription,categorizationanddefinitionofabnormalexperiencesasrecountedbythepatientandobservedinhisbehaviour(Figure1.1).

Descriptive psychopathologyasdistinctfromotherformsofpsychopathologyeschewsexplana-tionofthephenomenathatitdescribes.Itsimplydescribes,therebyavoidingargumentsaboutcausation.Hence,descriptivepsychopathologyguardsagainstandavoidstheory,presuppositionorprejudice.Thisconstraintofdescriptivepsychopathologyactstosecuretheconceptualframe-workofphenomenology,restrictingittotheactualexperienceofthepatient.

Explanatorypsychopathologies,ontheotherhand,oftenassumethatmentalphenomenaaremeaningful.Inpsychoanalysis,forexample,atleastoneofseveralbasicmechanismsareassumedto be taking place and the mental state becomes understandable within this framework.Explanationsofwhatoccursinthoughtorbehaviourarebasedontheseunderlyingtheoreticalprocesses,suchastransferenceorego defence mechanisms.Forexamplewithadelusion,descriptivepsychopathologytriestodescribewhatitisthatthepersonbelieves,howhedescribeshisexperi-enceofbelieving,whatevidencehegivesforitsveracityandwhatisthesignificanceofthisbeliefornotion tohis life situation.Anattempt ismade to assesswhether thisbeliefhas the exactcharacteristicsofadelusionand,ifso,ofwhattypeofdelusion.Havingmadethisphenomeno-logicalevaluation, the informationgainedcanbeuseddiagnostically,prognosticallyandhencetherapeutically.SomeofthecontrastsbetweendescriptiveandpsychoanalyticpsychopathologyaresummarizedinTable1.1.

Analyticalordynamicpsychopathology,however,wouldbemorelikelytoattempttoexplainthe delusion in terms of early conflicts repressed into the unconscious and now able to gainexpressiononlyinpsychoticform,perhapsonabasisofprojection.Thecontentofthedelusion

Figure 1.1 The psychopathologies.

Explanatory

Descriptive

Psychopathology

Psychodynamic

Behavioural etc.

Observation

Phenomenology

1—FuNDAMENTAl CONCEPTS OF DESCriPTivE PSyCHOPATHOlOgy 5

wouldbe considered an importantkey to thenatureof theunderlying conflict,whichhas itsrootsinearlydevelopment.Descriptivepsychopathologymakesnoattempttosaywhyadelusionispresent;itsolelyobserves,describesandclassifies.Dynamicpsychopathologyaimstodescribehowthedelusionoccurredandwhyitshouldbethatparticulardelusion,ontheevidenceofthatperson’sexperienceinearlylife.

There are other radically different models of psychology that regard mental experience,includingthoughts,moodsanddrives,asepiphenomena,thatis,asnomorethanfrothontopofthebeer.Inthesemodels(radicalmaterialismoreliminativematerialism),mentallifeisillusory;it isonly thematerial,organicprocesses thatare real.Thesignificance the thinkerattaches tosubjectiveexperienceisregardedaspurelyillusory.Suchapositionposesdifficultiesforpsycho-logicalenquiryandtreatment.

Berrios (1996)hasdescribed two formulationsofdescriptivepsychopathology in thenine-teenthcentury.Psychologistsandbrainscientistspredominantlytendedtoregardmorbidphe-nomenaasquantitativevariationsonnormalmentalfunctions–thecontinuityview.Psychiatrists,workingdirectlywiththementallyill(alienists),consideredthatsomesymptomsweretoobizarreto have a counterpart in normal behaviour – the discontinuity view. Both formulations havecontributed to the current state of descriptive psychopathology. Undoubtedly, the quality ofempathyshownbythedoctorcontributestoanunderstandingofthepatient,butthereisalimit,for example with psychotic phenomena in which the patient’s notions and behaviour may nolongerbeunderstandablebyusingempathy,andpatientanddoctormaybemutuallyalienated.These two formulations, the continuity and discontinuity views, continue to influence howabnormalphenomenaareconceptualizedeventoday.

There are two distinct parts to descriptive psychopathology: the empathic assessment of the patient’s subjective experienceandtheobservation of the patient’s behaviour. Empathyisanimportantpsychiatrictermthatliterallymeans‘feelingoneselfinto’andinpsychiatricpracticeemphasizestheimaginativeexperiencingofanotherperson’sworld.Itcanbedistinguishedfromsympathy,whichis‘feelingwith’.Awaytoappreciatethedistinctionbetween‘empathy’and‘sympathy’istorecognizetheroleofanobjectivestancecoupledwithanactiveattempttounderstandhowcertainthoughtsrisefromparticularmoods,wishesorfearsandthenexusofconnectionsbetweendifferentaspectsofthepatient’sexperienceswhichisintegraltoempathy.

TABLE 1.1 ■ Psychopathology: descriptive versus psychoanalytic

Descriptive Psychoanalytic

Summary Empathic evaluation of patient’s subjective experience

Study of the roots of current behaviour and conscious experience through unconscious conflicts

Terminology Description of phenomena Theoretical processes demonstrated

Methods Understanding the patient’s subjective state through empathic interview

Free association, dreams, transference

Differences in practical application

Makes distinction between understanding and explanation: understanding through observation and empathy

Understanding in terms of notional theoretical processes

Form and content clearly separated: form of importance for diagnosis

No distinction made; concerned with content

Process and development distinguished: process interferes with development basis

No distinction made; symptoms seen as having unconscious psychological basis


Indescriptivepsychopathology,theconceptofempathyislikeaclinicalinstrumentthatneedstobeusedwith skill tomeasure anotherperson’s internal subjective stateusing theobserver’sown capacity for emotional and cognitive experience as a yardstick. Empathy is achieved byprecise,insightful,persistentandknowledgeablequestioninguntilthedoctorisabletogiveanaccountofthepatient’ssubjectiveexperiencethatthepatientrecognizesashisown.Ifthedoc-tor’saccountofthepatient’sinternalexperienceisnotrecognizedbythepatientashisown,thenthequestioningmustcontinueuntiltheinternalexperienceisrecognizablydescribed.Throughouttheprocess,successdependsonthecapacityofthedoctorasahumanbeingtoexperiencesome-thing likethe internalexperienceof theotherperson, thepatient; it isnotanassessmentthatcouldbecarriedoutbyamicrophoneandcomputer.Itdependsabsolutelyonthesharedcapacityofbothdoctorandpatientforhumanexperienceandfeeling.Itisempathythatallowsthedoctortocometounderstandthepatient’sexperiences.Inthissense,itisempathythatmakesitpossibleforustoknowwhatitislikeforanotherperson,anothersubjectofexperience,tobeinaparticularmentalstate.Whenempathyfailstorenderapatient’ssubjectiveexperienceunderstandable,wecan then talk about that experience as being un-understandable. In other words, the farthestreachesofourintuitivecomprehensionofaphenomenonhavebeenexceeded.

Accurate observation of behaviour is the other component of descriptive psychopathology.Subjectivehumanexperiencebecomesavailabletousforexaminationandexplorationthroughverbalcommunicationbutalsothroughmeaningfulgestures,bodilystance,behaviourandactions.Observationoftheobjectiveexpressionofsubjectiveexperience,thatis,ofbehaviour,isextremelyimportantandisamuchmoreusefulexercisethansimplycountingsymptoms;theslavishuseof a symptom checklist for their presence or absence is often an obstacle to genuine clinicalobservation,ifnottothequalityofdoctor-patientcommunication.Theobjectivitythatisfacili-tatedbychecklistsiscrucial,butthereisaneedalsofortheskilledobservationofbehaviourandforattentiveandfocusedlistening.

Phenomenology and PsychopathologyPsychopathology is concerned with abnormal experience, cognition and behaviour. Descriptive psychopathologyavoidstheoreticalexplanationsforpsychologicalevents.Itdescribesandcatego-rizestheabnormalexperienceasrecountedbythepatientandobservedinhisbehaviour.Initshistoricalcontext,Berrios(1984)definesitasacognitivesystemconstitutedbyterms,assump-tions and rules for its application, ‘the identification of classes of abnormal mental acts’.Phenomenologyisatermthatiscloselyalliedtodescriptivepsychopathology.Ithasalongtradi-tioninphilosophyandisassociatedwiththenameofEdmundHusserl(1859–1938).Itisusuallyusedtodenoteenquiryintoone’sconsciousandintellectualprocesses,eschewinganypreconcep-tionsaboutexternalcausesandpreconceptions.Themethodofphenomenologyaims to focusonexperiencedphenomenainordertoestablishtheiruniversalcharacter.Asusedinpsychiatry,phenomenology involves the elicitation and description of abnormal psychological events, theinternalexperiencesofthepatientandhisconsequentbehaviour.Anattemptismadetolistenattentively, accuratelyobserveandunderstand thepsychological eventorphenomenon so thattheobservercan,asfaraspossible,knowforhimselfwhatthepatient’sexperiencemustfeellike.

Howcanoneusethewordobserveraboutsomeoneelse’sinternalexperience?Thisiswheretheprocessofempathybecomesrelevant.Descriptivepsychopathologythereforeincludessubjec-tiveaspects (phenomenology)andobjectiveaspects (descriptionofbehaviour). It is concernedwiththerichvarietyofhumanexperience,but it isdeliberately limitedin itsscopetowhat isclinicallyrelevant;forexampleitcansaynothingaboutthereligiousvalidityofwhatJames(1902)hascalled‘saintliness’.

Howdoesthisworkinpractice?MrsJenkinscomplainsthatsheisunhappy.Itisthebusinessof descriptive psychopathology both to elicit her thoughts and actionswithout trying to explainthemandtoobserveanddescribeherbehaviour–thelistlesssaggingofhershoulders,thetense


grippingandwringingofherhands.Phenomenologydemandsaveryprecisedescriptionofexactlyhowshefeelsinsideherself:‘thathorriblefeelingofnotreallyexisting’and‘notbeingabletofeelanyemotion’.

Some psychiatrists have held the method of phenomenology in derision as archaic, hair-splittingorhare-chasingpedantry,butthediagnosticevaluationofsymptomsisataskthatthepsychiatristomitsathisown,andhispatient’s,peril.Studyingphenomenawhetsdiagnostictools,sharpens clinical acumen and improves communication with the patient.The patient and hiscomplaintsdeserveourscrupulousattention.If‘theproperstudyofmankindisman’,theproperstudyofhismentalillnessstartswiththedescriptionofhowhethinksandfeelsinside–‘chaosofthoughtandpassion,allconfused’(Pope,1688–1744).

A cavalier neglect of abnormal phenomena can have serious repercussions for care of thepatient. Eight mentally well researchers were sent separately to twelve admission units inAmericanmentalhospitalsonthepretenceofcomplainingofhearingthesewordssaidaloud:‘empty’,‘hollow’and‘thud’(Rosenhan,1973).Inallcasessaveone,theywerediagnosedassuf-feringfromschizophrenia.Theyproducednofurtherpsychiatricsymptomsafteradmissiontohospitalbut acted asnormally as they could, answeringquestions truthfully except to concealtheirnameandoccupation.Theethicsandgoodsenseoftheexperimentcancertainlybeques-tioned,butwhatcomesoutclearlyisnotthatpsychiatristsshouldrefrainfrommakingadiagnosisbutthattheirdiagnosisshouldbemadeonasoundpsychopathologicalbasis.NeitherRosenhan,norhis colleagues,nor theadmittingpsychiatristsgaveany informationas towhat symptomscould reasonably be required for making a diagnosis of schizophrenia; this requires a methodbasedonpsychopathology(Wing,1978).Withadequateuseofphenomenologicalpsychopathol-ogy,thisfailureofdiagnosiswouldnothaveoccurred.

Jaspers(1959)wrote,‘Phenomenology,thoughoneofthefoundationstonesofpsychopathol-ogy,isstillverycrude’.Oneofthegreatproblemsinusingthismethodisthemuddlednatureofterminology.Almostidenticalideasmaybeassigneddifferentnamesbypeoplefromdifferenttheoreticalbackgrounds,forexampletheplethoraofdescriptionsofhowapersonmayconcep-tualizehimself:self-image,cathexis,bodyawarenessandsoon.

Thereisconsiderableconfusionoverthemeaningofthetermphenomenology.Berrios(1992)hasdescribedfourmeaningsinpsychiatry.

P1 refers to its commonest clinical usage as a mere synonym for ‘signs and symptoms’ (as in ‘phenomenological psychopathology’); this is a bastardized usage, and hence conceptually uninteresting. P2 refers to a pseudo-technical

sense often used in dictionaries and which achieves spurious unity of meaning by simply cataloguing successive usages in chronological order; this approach is

misleading in that it suggests false evolutionary lines and begs important questions relating to history of phenomenology. P3 refers to the idiosyncratic usage started by Karl Jaspers who dedicated his early clinical writings to the

description of mental states in a manner which (according to him) was empathic and theoretically neutral. Finally, P4 refers to a complex

philosophical system started by Edmund Husserl and continued by writers collectively named the ‘Phenomenological Movement’.

(p. 304)

Of these meanings, this chapter, and indeed this book, will concentrate entirely on theJaspersianmeaningofphenomenology,P3ofBerrios. Jaspersdefinesphenomenologyperhaps30to40timesinhiswritingsinsubtlydifferentwaysbutalwaysimplyingthestudy of subjective experience.Walker (1988,1993a,b,1994)has argued, very elegantly, that even though JaspershimselfthoughtthathehadbeeninfluencedbyHusserlandhissystemofphenomenology,thiswasnotinfactso,andhispsychopathologyowedmoretoKantianconceptssuchasformand


content.Walker(1995a,b)considersthatJaspersradicallymisconstruedHusserl’sphenomenol-ogy.This view has been rebutted by others (Wiggins etal., 1992).The implication for whatfollowsinthischapter,andintherestofthebook,isthattheconceptofphenomenologyusedherecomesdirectlyfromJaspersandwasprobablyinfluencedbybothKantandHusserl.

Phenomenology,theempathicmethodfortheelicitingofsymptoms,cannotbelearnedfromabook.Patientsarethebestteachers,butitisnecessarytoknowwhatoneislookingfor–thepractical,clinicalaspectsinwhichthepatientdescribeshimself,hisfeelingsandhisworld.Thedoctortriestounravelthenatureofthesufferer’sexperience,tounderstanditwellenoughandtofeelitsopoignantlythattheaccountofhisfindingsevokesrecognitionfromthepatient.Themethodofphenomenologyinpsychiatryisentirelysubjugatedtoitssinglepurposeofrenderingthepatient’sexperienceunderstandable(thisisatechnicalwordinphenomenologyandisdescribedinmoredetailonp.10–12;however,itincorporatesthecapacityforputtingoneselfinthepatient’splace)sothatclassificationandrationaltherapymayproceed.

Itisnottheassimilationofabstrusefactsortheaccumulationofforeigneponymsthatismostdifficultinphenomenology,althougheitherofthesemaybehard:itisthecomprehensionofamethodofinvestigationandtheabilitytousenewconcepts.Inanattempttoavoidtheobscureandobvious,intherestofthischaptersomeoftheseconceptsarediscussed.

ConceptsDISEASE AND ILLNESS

Psychopathologyconcernsitselfwithdisease of the mind,butwhatisdisease?And,howdoesitdifferfromdisorderandillness?Thisisavastsubjectthathasreceiveddiscussionfromphiloso-phers, theologians, administrators and lawyers aswell as fromphysicians.Doctorswho spendmostoftheirworkingtimedealingwithdiseaserarelyaskthisquestionandevenlessfrequentlyattempt toanswer it.Talkofdiseasebydefinition raisesquestionsabout thenatureofhealth.But,anevenmorepressingissueiswhetheritispossibleforthemindtobediseasedinthesamewayormannerthattheliverorthekidneyscanbediseased.Thesequestionsareoutsideofthescopeofthisbookbutitisimportanttobeawareofthevariedapproachesthatdifferentauthori-tiestaketothismatter.Ioutlinethebasicargumentsbelow.

Themostcompellingmodelofadiseaseisthatwhichgroundsamedicalconditionsuchaspulmonarytuberculosisonthebasisofadistinctivemorbidanatomydemonstrableonexamina-tionofthelungsandwhichisindependentofanyparticularobserverandisassumedtobevaluefree.Itisevenbetterifthereisanunderstandingofthedetailedpathophysiology:howthecausa-tiveagent,intuberculosisforinstance,resultsintherecognized,typicalmorbidanatomyofthelungs.Itisobviousfromtheforegoingthatinmostpsychiatricdiseasesnosuchtypicalmorbidanatomyorpathophysiologyhasbeendescribed.

Onthebasisoftheabsenceofdemonstrablephysicallesions,Szasz(1960)arguedthatpsy-chiatricormentaldiseasesdidnotexistandthatonlybehaviouraldevianceandmoralorsocialjudgementswereatplay inpsychiatry.Healsoarguedthat‘mental’ isanabstractconceptandnotanobjective,physicalthingandhenceitcouldnotbediseased.Braindiseases, inhisvieware realbutmentaldiseases are a logical impossibility, and thusSzaszuses the term‘myth’ tocharacterizementaldiseases.

OtherwritersincludingScadding(1967),Kendell(1975),Boorse(1976)andSedgwick(1973)haveput forwardarguments that stand inopposition toSzasz.ScaddingandKendelluse thecombination of statistical deviance and biological disadvantage defined as reduced fertility todeterminewhatadiseaseis.Boorseaddsthatadiseaseisanyconditionthatinterfereswithanyfunction of an organism (and in this view mental functioning counts), which is necessary forits survival and reproduction. Additionally, a disease becomes an illness when it is deemed


undesirable, a title for special treatment and a valid excuse for particular behaviours. FinallySedgwickmakestheclaimthatalldiseasesstartoffasillnesses,becausethesymptomsarenega-tively valued and hence become a focus of social and moral interest and that in this way thesymptoms later attain disease status. In this account both the so-called physical illnesses andmentalillnessesstartoffasnegativelyvaluedstatesafflictinghumanbeingsandthereisnosharpdistinctiontobedrawnbetweenthem.SeeFulfordetal.(2006)forfurtherelaborationoftheseissues.

It isclear that there isnowidelyacceptedviewabout thestatusof theconditions that fallundertheinterestofpsychiatrists.Asimpledictumistoregarddiseaseaswhatdoctorstreatandillness as what persons suffer from. Although this distinction between normality and disease,healthandillness,isbynomeanstrivial:

A large part of medical ethics and much of the whole underpinning of current medical policy, private and public, are squarely based on the notion of disease

and normality. Left to himself the physician (whether he realizes it or not) can do very well without a formal definition of disease … Unfortunately, the

physician is not left alone to work his common sense. He is attacked from two angles: the predatory consumers and the pretentious advisers.

(Murphy, 1979)

NORMS, NORMAL AND ABNORMAL

Thesubjectofpsychiatryistheperson,notanorgansuchastheliver,kidneyoreventhebrain.Psychiatricdiseasesaredistinctfrommereneurologicaldiseases inthesensethat inneurologythediseaseprocessleavestheself,thepersonhoodofanindividual,intact.Thismeansthatwecanspeakofapersonwhosuffersfrommultiplesclerosisormotorneurondisease.Inpsychiatry,thediseasesafflicttheself;affectthepersoninadeepandnotsuperficialsense.Mooddisordersandschizophreniahaveapervasiveinfluenceonaspectsoftheselfinawaythatstrikesatwhatitmeanstobehuman.

The ability to experience and represent the world; the capacity to inhabit a social worldincludingrecognizingtherulesandconventionsthatoperatetherein;theabilitytoformrelation-shipsandtoimaginetheworldoftheOther;theabilitytocommunicate,touselanguageandtounderstandsymbols,thatistoinhabitaworldofmeanings;thewherewithaltobeanagent,theauthorofone’sownprojectsandthedriveandwilltoact;thecapacitytooperateinaworldofmoralandaestheticvalues;and,thepossibilityofhavinganattitudetotime,anorientationtothefuture;thesemanifoldaspectsofthepersonandmanymoreyettobefullydescribedareinfluenced if not impaired by psychiatric diseases. Our understanding of these higher humanfunctionsistrivial.Abnormalitiesandpathologyinthesedomainsaremanifestinsocialbehaviourandarewithoutindependentorobjectivemarkers.So,talkofnorms,normalityandabnormalityareintegraltoanydiscussionofpsychiatricphenomena,sinceinordertorecognizeimpairmentsintheseareasoffunctionweneedanunderstandingofwhatnormalfunctionentails,butmorefundamentallywhatitmeanstotalkaboutnorms,normalityandabnormality.

ThewordnormalisusedcorrectlyinatleastfoursensesintheEnglishlanguageaccordingtoMowbrayetal. (1979).Theseare thevaluenorm, the statisticalnorm, the individualnormandthetypologicalnorm.Thevaluenormtakestheidealas itsconceptofnormality.Thusthestatement‘Itisnormaltohaveperfectteeth’isusingnormalinavaluesense;inpractice,mostpeoplehavesomethingwrongwiththeirteeth.The statisticalnormis,ofcourse,thepreferreduse; the abnormal is considered to be that which falls outside the average range. If a normalEnglishmanis5feet8inchestall,tobeeither6feet2inchesor5feet2inchestallisequallyabnormalstatistically.


Theindividualnormistheconsistentleveloffunctioningthatanindividualmaintainsovertime.Followingbraindamage,apersonmayexperienceadeclineinintelligencethatiscertainlyadeteriorationfromhispreviousindividuallevelbutmaynotrepresentanystatisticalabnormalityfrom that of the general population (for example a decline in intelligence quotient from 125to105).

Typologicalabnormalityisanecessarytermtodescribethesituationinwhichaconditionisregardedasnormalinallthethreemeaningsaboveandyetrepresentsabnormality,perhapsevendisease.TheexamplegivenbyMowbrayetal.istheinfectiveconditionofpinta.ThemottlingoftheskinofthisconditionishighlyprizedbytheSouthAmericanIndianswho‘suffer’fromit, to theextent that‘non-sufferers’ areexcluded fromthe tribe.Thus,having thecondition isnormalinavalue,statisticalandindividualsense,andyetitispathologicalinthesensethatitistheresultofaspirochaetalskininfection.Thepursuitofthinnessbymodelsanddancersinoursocietywouldbeaneverydayexample.

Inaddition,onecantalkabout socialnormsbywhichwemeantherules,conventions,andpractices that determine in specific cultures what behaviours are acceptable and approved of.Theseincludetheetiquette,moresandethicsunderpinningbehaviour.Infactforsomepeople,psychiatricdiseasesarenomorethanbehavioursclassedasdeviantbysocialrulesandpsychiatristsarenomorethansocialpolicemen.

Thereareotherconceptsimplicitindiscussionsofnorms,normalityandabnormality.Thesearewhetherthediscretephenomenaofinteresttopsychopathologistsarecategoricallydifferentfromnormalexperienceorwhetherthedistinctionbetweennormalandabnormalphenomenaaredimensionalinnature.Thedistinctionbeingdrawnhereisoverandbeyondwhetherpsycho-pathologicalphenomenaarestatisticallydeviant.Thequestioniswhethertheanxietyexperiencedbyapsychiatricpatient, forexample, isonlyanexaggerationof thatexperiencedbya‘normal’personorwhetherthereissomethingcategorically/qualitativelydifferentaboutit.

UNDERSTANDING AND UN-UNDERSTANDABLE

Itseemsself-evidentthatunderstandingthepatient’sstory,graspingtheinnerlogicofthenar-rativeandrepresentingtooneselfthepatient’ssubjectiveexperiencesisfundamentaltoclinicalpractice.Understanding,inbothaneverydayandaphenomenologicalsense,cannotbecompleteunless the doctor has a detailed knowledge of the patient’s background culture and specificinformationabouthisfamilyandimmediateenvironment.Neithercanphenomenologyconcen-tratesolelyontheindividualisolatedinamomentoftime.Itmustbeconcernedwiththepersoninasocialsetting;afterall,aperson’sexperienceis largelydeterminedbyhisinteractionswithothers.Itmustalsobeconcernedwiththementalstateandenvironmentoftheindividualbeforetheeventofimmediateinterestandwithwhatoccursafterwards.

The method of phenomenology facilitates communication: its use makes it easier for thedoctor tounderstandhispatient.Thepatient is alsohelped tohave confidence in thedoctor,becauseherealizesthathissymptomsareunderstoodandthereforeacceptedas‘real’.Theprecisedescriptionandevaluationofsymptomsalsohelpscommunicationbetweendoctors.

WilhelmDilthey (1833–1911) argued that thenatural sciences treatnature as objects andforcesthatcanbeexplainedthroughcausallaws.Inotherwords,thegoalofsuchscienceistheformulationofgeneral,universallaws,whereasthehumanities,forexamplehistoryandpsychol-ogy,havethehumansubjectastheirfocusandcausallawsdonotapplyinthesecircumstances.ForDilthey,science‘explains’naturalphenomenabycausalexplanation.Thehumanities‘under-stand’humanpsychicphenomenathroughtheinterpretationofthemeaningstructuresrevealedin texts or through dialogue with another person.This distinction between ‘explanation’ and‘understanding’continuestobeinfluentialinourthinkingeventoday(Phillips,2004).Insciencewecometoknowtheobjectfromoutside,butinthehumanitiesweareableto‘know’thesubjectfrominside.Weareabletorepresenttoourselves,ifnotto‘know’,theinnerlifeofanotherperson


becausewetoohaveaninnerlife.Weareabletounderstandtheotherpersonthroughthenetworkofmeaningsassociatedwith theirbehaviour.Westartwith thepremise thatbehaviourmeanssomething; that is, it arises with internal consistency from psychological events.Wittgenstein(1953)hasstated,‘Weexplainhumanbehaviourbygivingreasonsnotcauses’.

JaspersdrewonDilthey’sformulationandcontrastedunderstanding(verstehen)withexplain-ing(erklären).Hehasshownhowthesetermsmaybeusedinbotha‘static’anda‘genetic’sense.Staticimpliesunderstandingorexplainingthepresentsituationfrominformationthatisavailablenow;whereasthegenetic[anunfortunatetermgivencontemporaryuse]senseconsidershowthesituationreacheditspresentstatebyexaminingantecedents,theevolvingprocessandemergingsituation.ThisisrepresentedinTable1.2.

Understanding and explanation are both necessary parts of the psychiatric investigation.Explanationisconcernedwithaccountingforeventsfromapointofobservationoutsidethem,understandingfrominsidethem.Oneunderstandsanotherperson’sangeranditsconsequences;oneexplains theoccurrenceof snow inwinter.Explanationsalsocanbedescribedas staticorgenetic.SeeBoxes1.1and1.2.

Jaspersmakesanimportantdistinctionbetweenthatwhichismeaningfulandallowsempathyandthat,whichisultimatelyun-understandable,theessenceofthepsychoticexperience.There

TABLE 1.2 ■ Diagram of understanding and explanation

Understanding Explanation

Static Phenomenological description Observation through external sense perception

Genetic Empathy established from what emerges Cause and effect of scientific method

BOX 1.1 ■ Static and genetic understanding

Understandingistheperceptionofpersonalmeaningofthepatient’ssubjectiveexperience.■ If we want to find meaning at a particular moment in time, the method of phenomenology is

appropriate.The patient’s subjective experience is dissected out, and a static picture is formed ofwhatthatthoughtoreventmeanttohimatthatparticulartime.Nocommentismadeonhowtheeventarose,andnopredictionismadeastowhatwillhappennext.Themeaningissimplyextractedasadescriptionofwhatthepatientisexperiencingandwhatthissignifiestohimnow.Amanfeelsangry:staticunderstandingusesempathytodescribeindetailexactlywhatitislikeforhimtofeelangry.HaveI,theexaminer,experiencedphenomenalikethese?AretheyknowntomethroughtheexperiencesIhavehadinmylifetime?

■ Geneticunderstanding,asopposedtostaticunderstanding,isconcernedwithaprocess.Itisunderstoodthatwhenthismanisinsulted,hereactswithviolence;whenthatwomanhearsvoicescommentingonheractions,shedrawsthecurtains.Forunderstandingthewaythatpsychiceventsemergeonefromanotherinthepatient’sexperience,thetherapistusesempathyasamethodoratool.Hefeels himself intothepatient’ssituation.Ifthatfirsteventweretohaveoccurredtohimpersonallyinthepatient’stotalcircumstances,thesecondevent,whichwasthepatient’sreactiontoit,mightreasonablybeexpectedtohavefollowed.Heunderstandsthefeelingsheascribedtothepatientbytheactionthatresultsfromthesefeelings.SoifIwerethepatientwiththesamehistory,doIfeelthatIwouldhavethesameexperiencesandbehaveinthesameway?Anexamplewouldhelptodemonstratethehumanityof this approachand theuniversalityofhumanexperience: Imustputmyself into theshoesofanotheryoungwoman,aged19,alsoraisedinanisolatedfishingcommunity,theeldestofeightsiblings,whobecomesstuporoseduringhersecondpregnancy.Sheismarriedtoanalcoholicmanaged35, andher father is also alcoholic. Imustunderstandhowshedealtwithher father’salcoholic behaviour as a child,whatherpregnancymeant toher,how she regardedhermother’sbehaviourduringherownpregnanciesandsoon.


is,thus,alimittounderstandingpsychopathologicalphenomena.Althoughonecanempathizewith the contentofapatient’sdelusionand therebyunderstandhowthatcontentof thebelieforiginated,theoccurrenceofthedelusionitself,isinthismodel,morerecalcitranttoourempathyandunderstanding.Itcanbesaidthatourunderstandingreachesitslimitwhenitconfrontsthefactofthedelusionitself.Forthat,weneedtoappealtocognitivemechanismsorothernaturalscienceprocesses.Weareinneedofscientificexplanation,notpsychologicalunderstanding.

We can understand from a knowledge of the patient’s background why, if her thinking isgoingtobedisorderedinform,thetopicorcontentofthatthinkingshouldbeconcernedwithpersecutionbytheNazis–perhapsbecauseherparentsescapedfromGermanyin1937.Butwecanhavenounderstandingofwhysheshouldbelievesomethingthatisdemonstrablyfalse:thatherpersecutorsareputtingatastelessfluidintoherdrinkingwaterthatmakesherfeelill.Thedelusionitself,aspsychopathologicalform,isun-understandable.Meaningfulconnections,then,show the linkage between different psychological events by understanding how these eventsemergeonefromanotherbyaprocessofempathy.

This is a controversial concept in that it implies that there are aspects of another person’smentallifethatarebeyondourgraspandempathicunderstanding.Itcontradictsanotheraxiomin psychiatric practice, namely that our purpose is to understand another person, and whenunderstanding fails, it calls into question how conscientious and rigorous the psychiatrist hasbeeninthepursuitofgraspingtheinnerlifeofthepatient.

EMPATHY

The classic method in medicine of gaining information about the patient is from the historyand by physical examination.The use of phenomenology in psychiatry is an extension of thehistory,inthatitamplifiesthedescriptionofthepresentcomplainttogivemoredetailedinfor-mation. It is also examination in that it reveals themental state. It isnotpossible forme, thedoctor,toobservemypatient’shallucinationorinanydirectwaytomeasureit.However,whatIcandotocomprehendhimistousethosehumancharacteristicsIholdincommonwithhim:thefactthatweinhabitthesameworldofmeanings,thatwecommunicateinlanguageandthatlikehimIhavearichinner life.It isalsoimportanttobeintellectuallycuriousandgenuinelyinterested in the inner lifeofanotherperson.The inquiries thatarise fromthis stance shouldaimtorecreateforoneselforrepresenttooneself thesubjectiveexperiencesofanotherpersonwiththeaimofunderstandingandmakingsenseofthem.Theaimisthustoexploreandtest,throughdialogue,thepatient’ssubjectiveexperience.Iendeavourtocreateinmyownmindwhathisexperiencemustbelike.IthentesttoseeifIamcorrectinmyreconstructionofhisexperi-encebyaskinghimtoaffirmordenymydescription.Ialsousemyobservationofhisbehaviour– the sad expression of his face or him thumping the desk with his fist – to reconstruct hisexperiences.

Listeningandobservingarecrucialforunderstanding.Greatcaremustbetakenwithaskingquestions.Doctorsnotinfrequentlyidentifysymptomsincorrectlyandcometothewrongdiag-

BOX 1.2 ■ Static and genetic explanation

■ Static explanation is concerned with external sense perception, observing an event, for example‘Iwitnessedthe1999eclipseinPlymouth’.

■ Geneticexplanationconsistsofunravellingcausalconnections;itdescribesachainofeventsandwhytheyfollowthatsequence(‘visualperceptionoftheeclipseistheresultofphysiologicalchangesinmyretina,whichinturnproducechangesinmyoccipitalcortexthatultimatelycausemetoseetheeclipse’).


nosisbecausetheyhaveaskedleadingquestionswithwhichthepatient,throughhissubmissive-nesstothedoctor’sstatusandhisanxietytocooperate,isonlytoowillingtoconcur.

The method of empathyimpliesusingtheabilitytofeeloneselfintothesituationoftheotherpersonbyproceedingthroughanorganizedseriesofquestions,rephrasingandreiteratingwhennecessaryuntiloneisquitesureofwhatisbeingdescribedbythepatient.Thesequencemightgoasfollows.

Question:‘Youdescribeyourthoughtschanging;whathappenstothem?’Answer:adescriptionofhowhehasarecurringthoughttokillpeopleandthisresultsfrom

apaininhisstomach.Question:(tryingtoisolatetheelementsofhisexperience)‘Whatisyourthoughtofkilling

peoplelike?’(obsession,delusion,fantasy,islikelytobeactedon,etc.).‘Doyoubelievethatyourstomachaffects your thinking?’, ‘Is thisdifferent fromapersonwhoknows that theybecomeirritablewhenhungry?’, ‘Inwhatway is itdifferent fromthat?’,Whatcausesyourpain in thestomach?’

Answer: he describes the details, which will include among irrelevant material the sort ofinformationrequiredfordeterminingwhatsymptomsarepresent.

Question: (the invitation for empathy) ‘Am I right in thinking that you are describing anexperienceinwhichraysarecausingpaininyourstomach,andthatyourstomachinsomewayquiteindependentofyourselfcausesthisthought,whichfrightensyou,thatyoumustkillsome-bodywithaknife?’Thisisanaccountoftherelevantsymptomsthathehasdescribedinlanguageheshouldbeabletorecognizeashisown.

Answer:‘Yes’(wehavethenachievedourgoal);‘No’(thereforeImusttryagaintoelicitthesymptoms,experiencethemformyselfanddescribethembacktohimagain).

Togiveexamplesofwhatthis implies inpractice:howdoI,aclinician,decidewhetheranindividualpatientisdepressedornot?Thisisnotdonebyimitatingamachinethatmightrecordunitsofvocaltoneoroffacialexpression,addinguptoadiagnosisofdepression.Fortheclinicalassessment,Igothroughthefollowingprocess.

■ Iamcapableof feelingunhappy,miserableanddepressedandknowwhat this feeling islikeinsidemyself.

■ IfIwerefeelingasIobservethepatienttobelooking,speaking,actingandsoon,Iwouldbefeelingmiserable,depressedandunhappy.

■ ThereforeIassessthemoodofthepatienttobethatofdepression.Ofcourse,thismentalprocessofdiagnosisisnotusuallyverbalized.Inanotherexample,apatientsays,‘theMartiansaremakingmesayswearwords;itisnotme

doingit’.Empathicquestioningrevealsthefalsebeliefheldbythepatientthatwhenswearwordscome fromhismouthhebelieves that the cause is actually outsidehimself, ‘Martians’, ratherthanfrominsidehimself.Questioningwouldinclude‘DoyouactuallyheartheMartians?HowdoyouknowthatitisMartiansandnooneelse?’andsoon.

Afurther,non-psychoticexamplewouldbea20-year-oldgirlwhohasfaintingattackswhenshe iscriticizedatwork.Theclinicianhas toplacehimorherself,even ifhe isa55-year-oldmanfromadifferentculturalbackground, intoherpositionwithaknowledgenotonlyofhersocialhistorybutalsoofthewaythatshe,inthepresent,perceivesthathistory;onlythenmaythedevelopmentofhersymptomsbecomeunderstandable.Forinstance,whenitisknownaboutheralcohol-abusingfather,therowshehadwithhermotherwhosufferedfromepilepsy,theveryrestrictedculturalbackgroundthattheyexperiencedinanisolatedfishingvillageandhowhermother would have a fit when rows became intolerable, then one may begin to understandsomething of the development of the patient’s own symptom.This is not achieved solely byexplanationasanoutsideobserverbutbyempathicunderstandingandthecapacityforsubjectiveexperiencebythedoctor,whoputshimselfinto,andthereforebecomes,the20-year-oldgirlfortheprocessofthepsychiatricinterview.


Itisthepurposeofthephenomenologicalmethodthereforeto(a)describeinnerexperiences,(b) order and classify them and (c) create a reliable terminology. Empathy is also invaluabletherapeuticallyinestablishingarelationshipwiththepatient.Knowingthatthedoctorunder-stands,andiseventosomeextentabletosharehisfeelings,givesthepatientconfidenceandasenseof relief.Thismethodof empathy is alsouseful as awayof extendingknowledgemoregenerallyinthefieldofpsychiatry,asitallowsadiagnosticterminologytobedeveloped.

FORM AND CONTENT

Formandcontentaredistinctinphenomenology.ForJaspers:

form must be kept distinct from content which may change from time to time, e.g., the fact of a hallucination is to be distinguished from its content, whether this is a man or a tree, threatening figures or peaceful landscapes. Perceptions,

ideas, judgements, feelings, drives, self-awareness, are all forms of psychic phenomenon; they denote the particular mode of existence in which content is

presented to us.(Jaspers, 1959)

Thus,likewarpandwoof,formandcontentareessentiallydifferentbutinextricablywoventogether.Onewaytothinkofformistoregarditasthesensemodalityinwhichaperceptionispresentedtousorthecognitivedomaininwhichaparticularaspectofpsychiclifeisexperiencedorenacted.Theformofapsychicexperienceisthedescriptionofitsstructureinphenomenologi-cal terms, for example adelusion,or, asBerrios (1996) says, ‘Form refers to those impersonalaspectsofthementalsymptomsthatguaranteeitsstability intimeandspace;that is, its‘con-stancy’elements’.Viewedinthisway,contentisthesubjectivecolouringoftheexperience.Thepatientisconcernedbecausehebelievesthatpeoplearestealinghismoney.Hisconcernisthat‘peoplearetakingmymoney’,notthat‘Iholdonunacceptablegroundsafalsebeliefthatpeoplearetakingmymoney’.Heisconcernedaboutthecontent.Clearly, formandcontentarebothimportantbutindifferentcontexts.Thepatientisconcernedonlywiththecontent:‘thatIampursuedbytenthousandhockeysticks’.Thedoctor isconcernedwithbothformandcontent,butasaphenomenologistonlywithform,inthiscaseafalsebeliefofbeingpursued.Asfarasformisconcerned,thehockeysticksareirrelevant.Thepatientfindsthedoctor’sinterestinformunintelligibleandadistractionfromwhatheregardsas important,andheoftendemonstrateshisirritation.

InChapter7,apatientisdescribedwhosaid,‘WhenIturnthetapon,Ihearavoicewhis-peringinthewaterpipe,“She’sonherwaytothemoon.Let’shopeshehasasoftlanding”’.Theform of this experience is what demands the attention of the phenomenologist and is usefuldiagnostically.Sheisdescribingaperception;itisanauditoryperceptionandafalseordisorderedauditoryperception.Ithasthecharacteristicsofahallucination,andspecificallyofafunctionalhallucination.This is the form.While thepsychiatrist isbusy clarifying the form, thepatientmightbegettingveryirritatedbecause‘heisnottakinganynoticeofwhatIamsaying’.Sheisworriedthatsheisbeingsenttothemoon.Whatwillhappenwhenshegetsthere?Howwillshe get back?So the content is all-important toher, and thedoctor’s absorptionwith form isincomprehensibleandfrustratingintheextreme.

Theformisdependenton,andisthereforeadiagnostickeyto,theparticularmentalillnessfromwhichthepatientsuffers.Forexample,delusional perceptsoccurinschizophrenia,andwhendemonstratedastheformoftheexperiencetheyindicatethiscondition.Thefindingofavisualhallucinationsuggeststhelikelihoodofanorganicbraindisease(Chapter7).Thenatureofthecontentofthesetwoexamplesisirrelevantincomingtoadiagnosis.Thecontentcanbeunder-stoodbythepatient’slifesituationwithregardtoculture,peergroup,status,sophistication,age,


sex, life events and geographical location. For example, another patient described himself ashavingbeensenttothemoonandbackduringthenightwithinafortnightofthefirstlandingbymanonthemoon.Describingone’sthoughtsasbeingcontrolledbytelevisionisnecessarilyconfinedtothosepeoplewhohaveseenthatinvention.

Hypochondriacal content can occur in more than one form. It could take the form of anauditoryhallucinationinwhichthepatienthearsavoicesaying‘youhavecancer’.Itcouldbeadelusion, in that he holds with conviction the false belief that he has cancer. It could be anovervaluedidea,inthatthepatienthasaconvictionarisingfrompriorexperienceofamistakendiagnosisofcancer,andthisresultsinhimspendingamajorpartofeverydaycheckingonhishealth. It could be an abnormality of affect that manifests itself in extreme hypochondriacalanxietyorindepressivehypochondriacaldespondency.

The significance of culture and individual variation in ascertaining the detailed complaintofthepatientshouldbestressed.Becausethepsychiatristneedstoassesswhetherthisnotionofthepatientdemonstratesthespecificpsychopathologicalformofdelusion,itdoesnotdiminishtheparallelneedtounderstandthepatient’sphilosophical,religious,politicalandsocialbeliefs,andknowhowtheyfit,orfailtofit,intothepatient’slarger,nationalandmoreintimate,sub-culturalsocialcontexts(Fabrega,2000).

Alongsidetheneedofthepsychiatristtoacquireskillsinpsychopathologyandtheelucidatingofmentalsymptomsistheparallelrequirementforculturaleducationandsensitivity.Bothaspectsarenecessaryforeverypatient-doctorinteraction.Ifanything,thepainstakinganddetailedstudyofphenomenologyincreasestheawarenessoftheculturalcontextandhowitinfluencescognitionandbehaviour.

PRIMARY AND SECONDARY PHENOMENA

Jaspersdiscussesthedifferentmeaningthatcanbegiventothetermsprimaryandsecondarywhenapplied to symptoms.The distinction may be in terms of understanding; what is primary isimmediateandultimateandthereforecannotbefurtherreducedbyunderstanding,forexamplehallucinations.Whatissecondaryiswhatemergesfromtheprimaryinawaythatcanbeunder-stood,forexampledelusionalelaborationarisingfromthehealthypartofthepsycheinresponsetohallucinationsfromtheunhealthypartofthepsyche.Again,theconceptualdistinctionofwhatisprimaryorsecondarymaybedeterminedbythecausalchain, inthatwhatisprimaryistheproximatecausewhilewhatissecondaryisthediscernibledistaleffect:acerebrovascularaccidentcauses sensoryaphasiaandis thereforeprimary; theaphasia is thedistaleffectandis thereforesecondarytothecerebrovascularaccident.

These two distinct meanings of the term primary overlie the crucial distinction betweenmeaningful connections and causal connections. For the avoidance of doubt in physics andchemistry,wemakeobservationsbyexperimentandthenformulatecausalconnectionsandcausallaws, whereas in psychopathology we experience another sort of connection, wherein psychicevents emerge out of one another in a way that can be understood – so-called meaningful connections.

SUBJECTIVITY AND OBJECTIVITY IN PSYCHOPATHOLOGY

Objectivity insciencehascometobereveredastheideal,sothatonlywhat isexternaltothemind is considered to be real, measurable and valuable. This is a mistake, because objectiveassessmentsarenecessarilysubjectivelyvalue-ladeninwhattheobserverchoosestomeasure,andthissubjectiveaspectcanbemademorepreciseandreliable.Therearealwaysvaluejudgementsassociated with both subjective and objective assessments.The process of making a scientificevaluationconsistsofvariousstages:receivingasensorystimulus,perceiving,observing(makingthe percepts meaningful), noting, coding and formulating hypotheses. This is a progressive


processofdiscardinginformation,anditisthesubjectivejudgementofwhatinformationisvalu-ablethatdeterminesthesmallamountfromeachstagethatisretainedfortransmissiontothenextpartoftheprocess.‘Thereisnosuchthingasanunprejudicedobservation’(Popper,1974).

Objectiveassessmentsinpsychiatryhavecoveredmanyaspectsoflife.Afewexamplesare,inadditiontomanyphysiologicalmeasures,themeasurementofbodymovements,facialexpression,patients’writings,learningcapacity,responsestoanoperantconditioningprogramme,memoryspan,workefficiencyandevaluationoflogicalcontentofthepatients’statements.Allthesecanbequantifiedandanalyzedobjectively.Subjectiveanalysiscanbemade,forexample,fromfacialexpressionorfromthepatient’sdescriptionofhimself,ofhisownwritingorofhisinnerevents.Whenadoctorsaysaboutapatient‘shelookssad’,heisnotmeasuringthepatient’sfacialexpres-sionin‘unitsofsadness’bysomeobjectiveyardstick.Heisgoingthroughthisprocess:‘IassociateherfacialexpressionwiththeaffectthatIrecognizeinmyselfasfeelingsad;seeingherexpressionmakesmefeelsad’.Rapportisthisqualitythatthepatientestablisheswiththedoctorduringtheclinicalinterview.Inorderforittohappen,thedoctorhastobereceptivetothiscommunication.Hehastobeabletoestablishrapporthimself,tohaveacapacityforhumanunderstanding.Thisisnecessarilyasubjectiveexperienceforthedoctor,butthatisnottosaythatitisunrealoreventhatitcannotbemeasured.Themethodofphenomenologytriestoincreaseourknowledgeofsubjectiveeventssothattheycanbeclassifiedandultimatelyquantified.

Aggernaes (1972) has defined subjectivity and objectivity for immediate everydayexperiences.

When an experienced something has a quality of ‘sensation’, it is also said to have a quality of ‘objectivity’ if the experiencer feels that under favourable

circumstances, he would be able to experience the same something with another modality of sensation than the one giving the quality of sensation. When an

experienced something has a quality of ‘ideation’, i.e., is not being directly sensed at the moment, it is also said to have a quality of ‘objectivity’ if the

experiencer feels that under favourable circumstances, he would nevertheless be able to experience the same something with at least two modalities of sensation.An experienced something has a quality of ‘subjectivity’ if the experiencer feels

that under no circumstances would he be able to experience this something with two or more modalities of sensation.

ThusIcanlookatthetableinfrontofmeasavisualperceptionorIcanturnmyheadandstill fantasize it as avisual image.As I ‘see’ it, ineitherway, the fact that I can imaginebothhearingasoundifIweretohititwithaspoonandbruisingmyknucklesifIweretopunchitconfirmsitsqualityofobjectivity.IfIusemyimaginationtocreateinmymindavisualimageofaChippendalechairthatIhaveneveractuallyseenbutisacompositeofobjectsandpicturesIhaveseen,IknowthatIwillneverbeable to feelorhear thisactualchair; it isasubjectiveimagewithoutexternal,objectivereality.

UNCONSCIOUS EXPERIENCE AND PHENOMENOLOGY

Phenomenologycannotbeconcernedwiththeunconsciousbecausethepatientcannotdescribeit,andsothedoctorcannotempathize.Descriptivepsychopathologyhasnotheoryoftheuncon-scious,nordoesitdenyitsexistence.Strictlyspeakingtheunconsciousissimplyoutsideitstermsof reference, and psychic events are described without recourse to explanations involving theunconscious. Dreams, the contents of hypnotic trance and slips of the tongue are describedaccording to how the patient experienced them, that is, according to how they manifest inconsciousness.


ORGANIC AND NEURAL SUBSTRATES AND PSYCHOPATHOLOGY

Psychopathologyisthestudyofabnormalmentalprocesses,sothat,evenwhentheorganiccausesofaconditionareknown,psychopathologyremainsinvolvedindescribing,definingandorderingthe symptomaticphenomenaand theexperienceof thepatient rather thanbeingpreoccupiedwithitsneuraloriginorpathophysiology.Thisisnottoimplythatunderlyingneuralmechanismsareunimportant.Tothecontrary,theyareundeniablyimportant.However,theactualsubjectiveexperienceofthepatientisalsoimportantandpsychopathologyconcentratesonthis.

Thereareestablishedlinksbetweendifferentabnormalphenomenaandidentifiableorganicpathologies.However,itisnotwiththeselinksthatpsychopathologyisconcerned,anditsuseful-ness isnotdependentonultimatelyfinding the localization in thebrainof adelusionor anyotherpsychicevent.Early,organicallyorientedpsychiatrists,suchasGriesingerandWernicke,werenotconcernedwiththepsychopathologicalinpsychiatrybutmuchmorewithchartingthediseasedbrain.Thispaidarichdividend,forexampleinelucidatingthenatureandtreatmentofcerebralsyphilis.Similarly,somemodernbehaviouristshavebeenuninterestedinphenomenol-ogy.Phenomenologyisnotultimatelyconcernedwithorganicpathologyorwithbehaviourpersebutwiththepatient’ssubjectiveexperienceofhisworld.

Foralongtime,symptomaticpsychiatryanddescriptivepsychopathologyseemedtohavelostcontactwithorganicpsychiatry,inwhichevidenceofmentalillnessissoughtindiseaseofthebrain.TherehasnowdevelopedwhatMundt(2000)describesasa‘freshwindfromtheexperi-mentalfieldofpsychopathology,neuropsychologyandbiologicalneurosciences’.Thislinkageisstillatanearlystage,butithaspotentialforthefuturestudyofsymptomsandofbrainpathology.Butfortheseinvestigationstosucceedandtocometofruition,athoroughappreciationofpsy-chopathologyisessential.

MIND-BRAIN DUALITY AND PSYCHOPATHOLOGY

Cartesiandualismistheviewthatmindandbodyareseparatesubstances;themindhappenstobeassociatedwithaparticularbody,butisultimatelyself-sufficient,andcapableofindependentexistence.Thisview,expoundedbyRenéDescartes(1596–1650)inwhichhemadeadistinctionbetween the material and physical world and the thinking human mind continues to exertextraordinaryinfluence.Husserl’sphilosophy,phenomenology,aroseoutofHusserl’srejectionofmany of Descartes’ conclusions. There are a number of significant problems with Cartesiandualism,notleasthowanimmaterialsubstancelikethemindcaninfluenceamaterialsubstancelikethebody.

Therearevariedphilosophicalattemptstodealwiththeproblemofdualismandanaccountoftheseisbeyondthescopeofthisbook.Whatisimportantisthatpsychiatryisbedevilledbythisproblem:howtoreconcilethephenomenathatpatientsreportwiththematerialityofthebrain. Is itpossibleorplausible to reducementalevents tophysicalevents in thebrain?And,howfarcanthechangesobservableduringfunctionalMRIscanningbeinterpretedasproductsofcertainmentalphenomena?Phenomenology,asanapproach,avoidsthisdebatebyleavingittooneside(bracketingitasHusserlwouldhavesaid)whilecontinuingtoexplore,investigate,describe,defineandcataloguethementalevents,thephenomena,reportedbypatients.Descriptivepsychopathologyisnotconcernedwithcausesbutwithdescriptionsofexperience.

The philosophy of mind is a thriving area of research, in particular the elucidation of thenatureofmind.Thespecific theoriesareoutside thescopeof thisbook(seeC.McGinn,The Character of Mind: an Introduction to the Philosophy of Mind ).Thatisnottosaythatthosetheoriessuch as Spinoza’s token identity theory, or the type identity theory (also known as reductivematerialism) or eliminative materialism or functionalism are not relevant to psychiatry or toexperimentalpsychopathology,butmerelytoemphasizethatpsychopathologycandevelopintheabsenceofafullandfinaltheoryofthenatureofmind.


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303–13.BerriosGE(1992)Phenomenology,psychopathologyandJaspers:aconceptualhistory.History of Psychiatry

iii,303–27.BerriosGE(1996)The History of Mental Symptoms: Descriptive Psychopathology Since the Nineteenth Century.

Cambridge:CambridgeUniversityPress.BoorseC (1976)What a theory ofmental health shouldbe. Journal of the Theory of Social Behavior 6, 1,

61–84.FabregaH(2000)Culture,spiritualityandpsychiatry.Current Opinion in Psychiatry13,525–30.Fulford KWM, Thornton T and Graham G (2006) Oxford Textbook of Philosophy of Psychiatry. Oxford:

OxfordUniversityPress.JamesW(1902)The Varieties of Religious Experience.London:Penguin.JaspersK(1959)General Psychopathology,7thedn.(transl.HoenigJandHamiltonMW,1963).Manchester:

ManchesterUniversityPress.KendellRE(1975)Theconceptofdiseaseand its implications forpsychiatry.British Journal of Psychiatry

127,305–15.McGinnC(1997)The character of mind: an introduction to the philosophy of mind,2ndedn.Oxford:Oxford

UniversityPress.Mowbray RM, Ferguson Rodger T and Mellor CS (1979) Psychology in Relation to Medicine, 5th edn.

Edinburgh:ChurchillLivingstone.MundtC(2000)Editorial.Psychopathology33,2–4.MurphyEA(1979)Theepistemologyofnormality.Psychological Medicine9,409–15.Phillips J (2004)Understanding/explanation. InRadden J (ed.)The Philosophy of Psychiatry: a Companion.

Oxford:OxfordUniversityPress.PopperK(1974)Unended Quest.Harmondsworth:Penguin.RosenhanDL(1973)Onbeingsaneininsaneplaces.Science179,250–8.ScaddingJG(1967)Diagnosis:theclinicianandthecomputer.Lancetii,877–82.SedgwickP(1973)Illness–mentalandotherwise.Hastings Center Studies1,3,19–40SpitzerM(1990)Whyphilosophy?InSpitzerMandMaherBA(eds.)Philosophy and Psychopathology.New

York:Springer-Verlag.SzaszTS(1960)Themythofmentalillness.American Psychologist15,113–8.WalkerC(1988)Philosophicalconceptsandpractice:thelegacyofKarlJasper’spsychopathology.Current

Opinion in Psychiatry1,624–9.WalkerC(1993a)KarlJaspersasaKantianpsychopathologist.I.Thephilosophicaloriginsoftheconcept

offormandcontext.History of Psychiatry4,209–38.WalkerC(1993b)KarlJaspersasaKantianpsychopathologist.II.TheconceptofformandcontextinJaspers’

psychopathology.History of Psychiatry4,321–48.WalkerC(1994)KarlJaspersandEdmundHusserl:I:theperceivedconvergence.Philosophy, Psychiatry and

Psychology1,117–34.WalkerC(1995a)KarlJaspersandEdmundHusserl:II:thedivergence.Philosophy, Psychiatry and Psychology

2,245–65.WalkerC(1995b)KarlJaspersandEdmundHusserl:III:JaspersasaKantianphenomenologist.Philosophy,

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Edmund Husserl and Karl Jaspers. In Spitzer M, Uehlein F, Schawartz MA and Mundt C (eds.)Phenomenology, Language and Schizophrenia.NewYork:Springer-Verlag.

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19

C H A P T E R 2

Eliciting the Symptoms of Mental Illness

SummaryThe clinical assessment of patients, which includes history taking, mental state examination,physicalexaminationandthesynthesisofthefindingsintoadiagnosisthattakesaccountofthepatient’s biological, psychological and social environment, is the basis of psychiatric practice.Withoutit,noadequatetreatmentandfurtherclinicalmanagementispossible.Attheheartofthistaskistheimportanceoffocusingonthepatientasthecentreofclinicalattention,recogniz-ingthevalueofrespectforthedignityofthepatient,andregardingthepatient’snarrativeaccountasvaluable,richandprivileged.Theascendancyofatickboxapproachtoclinicalassessmentistobedeplored.Itfailstograspthatdespitethefactthatassessmentshaveastructuretothem,andthattheyaresystematicinquiries,assessmentsmustbeconductedinaconversationalstyleandinahumanemanner.

Human beings are like parts of a body,Created from the same essence.

When one part is hurt and in pain,The others cannot remain in peace and be quiet.

If the misery of others leaves you indifferentAnd with no feelings of sorrow,

You cannot be called a human being.Sa’adi (thirteenth century), Persian

Elicitingthesymptomsandsignsofemotionaldistressinvolvesactivelylisteningtoanarrativeaccountoftheperson’scomplaintsandhisinternalstateandobservingthewholerepertoireofbehaviourandthenreducingthesetoafewsummarizingphrases.Itisadifficulttask,requiringanabilitytolistenandcommunicate,asensitivitytotheneedsandfeelingsofapersonwhoisbewilderedanddistressedandaknowledgeofthepossibleconditionsgivingrisetothecomplaint.Agenuine interest inthehumanconditionanditsmanifoldexpressions,aswellasacuriosityabout intrapsychic experiences, is essential.This cannot be learned from a book alone, but astructureforcasetakingthatsuggestslikelyareasforexplorationisinvaluable.Therearemanycomprehensiveschemes,andtheycanoftenbetracedtoearliertextbookswithonlyslightmodi-fication.AsummaryoftheschemeonwhichthischapterisbasedisshowninBox2.1.Apracticalguidetohistorytakingandevaluationofthementalstate,diagnosis,formulationandmanage-mentisfoundintheHandbook for Trainee Psychiatrists(Rix,1987)andinThe Psychiatric Interview(Carlat,2005).Ausefulapproachtomakingthepatientinformationavailablefordiagnosisandplanning treatment is Making Sense of Psychiatric Cases (Greenberg etal., 1986) and there aremore in-depth texts on the psychiatric interview such as The Psychiatric Interview in Clinical Practice(MacKinnonetal.,2006)andThe First Interview(Morrison,2008).Afurtheraccount

Keywords:Diagnosis,History,MentalStateExamination.

2—ElICITINg THE SyMPTOMS Of MENTAl IllNESS 19.e1


BOX 2.1 ■ Outline for psychiatric examination

Patient’sname:__________________Age:___________________Occupation:__________________Maritalstatus:__________________Address:________________________Sourceofreferral:________________________

■ Reasonforreferral■ Presentillness:symptomsandtheirchronology■ Previousmedicalhistory

i Physicalii Psychiatric

■ Familyhistory:father,mother,siblings,otherrelations,atmosphereathome■ Personalhistory

i Pregnancyii Infancyiii Childhoodandadolescenceiv Educationatschoolv Furthereducationvi Occupation(andmilitaryservice)vii Sexualhistory:puberty,menstruationviii Maritalhistoryix Children

■ Socialdatai Lifesituation:currentlyworking,housingsituation,financialproblems,relationshipsii Crime,delinquencyiii Alcohol,drugs,tobaccoiv Socialandreligiousaffiliationsandbeliefs

■ Premorbidpersonality■ Mentalstate

i Appearanceandbehaviourii Talkandthoughtiii Mood:subjective,objective,rapportiv Thoughts and beliefs: phobias, obsessions, compulsions, suicidal thoughts, delusions,

misinterpretationsv Experienceandperception:

a oftheenvironment(hallucinations,illusions,derealization)b ofthebody(hypochondriasis,somatichallucinations)c oftheself(depersonalization,thoughtpassivity)

vi Cognitivestate:orientation,attention,concentrationandmemoryvii Insight

■ Diagnosisandassessmenti Diagnosisanddifferentialdiagnosisii Evidencefordiagnosisiii Aetiologicalfactorsiv Managementv Prognosis

oftheareastobeconsideredandthemodificationsofthehistoryandexaminationrequiredinparticularcircumstancesistobefoundinSimsandCurran(2001).

Thereisasignificantconflictofinterestbetweenthepatientandtheinterviewer.Thepatientdescribesuntowardanddistressingexperiences.Hewants tobe ridof these experiences.Onepatientmay,forexample,saythatheisdepressedandmiserable,oranothermaycomplainthathis thoughtsarebeing suckedoutofhisheadby theMartians. Inboth instances, thepatientwantsthesymptomtoberelievedandhefeelsthatdescribingittothedoctorinthewaythatit

2—ElICITINg THE SyMPTOMS Of MENTAl IllNESS 21

isaffectinghimisthefirststageinachievingthis.Thedoctorneedstolearnalotofthingsfromthepatientthatthelattermayconsiderirrelevant.Sheneedstohaveaprecisedescriptionofthesymptomsandofthepatient’sstateofmind.Sheneedstoknowaboutthecontextofthepatient’ssymptoms,includingthepatient’sdevelopmentalhistory,andabouthisadjustmenttohissocialenvironmentingeneralandtohissymptomsinparticular.Toreturntoourexamples,thedoctorneedstoknownotonlythatthepatientfeelsdepressed;shemustenquireabouttheprecisenatureofthe‘depression’,whatthewordimpliestothepatient,howtheaffectdisturbstheroutineofhislifeandwhetherthereareanyotherassociatedsymptoms.

The person suffering at the hands of the Martians will be only too ready to talk aboutMartians. However, they are largely irrelevant to the interviewer, who is interested in exactlywhattheexperienceof‘thoughtsbeingextracted’entails.Whatisthepatient’sevidencethatthishappens? What other abnormal mental phenomena are experienced?The reader can perhapsunderstandthepatient’s irritationifhecanimaginethat,afterhehadpaidhisgasbill,afinaldemandnoticewithanintimationthathisgassupplywastobecutoffcamethroughthelet-terbox.Onexplainingtotheauthoritiesthathisbillwasalreadypaid,theydidnotapologizeorsaythattheywouldcorrecttheircomputer,buttheystartedinterrogatingtheharassedconsumerastowhyheshouldbesoupsetaboutit,andwhatwashisevidencethathehadbeenespeciallypickedonbytheauthorities.Understandably,thereisapotentialconflictofinterestbetweenthepatient’s wish for relief of symptoms and the doctor’s need to start by making a diagnosis.Acompromiseisnecessary.

Thepatientwillquitequicklytireoftheeffortrequiredtoanswerquestionsthatareaimedat establishing thephenomenological statusof subjective experiences.Several short interviewsarepreferabletoamarathonsession:‘neverasktodaywhatyoucanasktomorrow’.Thismethodshouldencouragetheexaminerto‘bracketout’allpreconceptions,andthepatienttoreflectonhisexperiencesunderguidancefromtheexaminer,whoshouldnotbediggingforphenomenalikeadogatarabbithole.Itisimportantfortheexaminertodistinguishquiteclearlybetweenobservationsandinferences.

Diagnosis and LabellingWhymakeadiagnosis?Themedicalclassificationofdiseasesallowsaclusterofsymptomstobebroughtunderasingletermthatembodiestheessenceofagivencondition.Thediagnostictermcarriesinformationinanefficientmanner.Buttherearedisadvantages,includingtheunreliabilityofdiagnostictermsaswellastheriskofunduelabellingandtheassociatedstigmaofpsychiatricdiagnosis. It is central to the work of a professional that her first task is to carefully collectinformationsothatsheknowsexactlywhatclinicalproblemconfrontsherwithinherprofessionalcompetence,andthereforewhatactionwouldbeappropriate;thisiswhatdiagnosisimplies.Itis true that formanycommonmedicaldiseases suchasdiabetes, thediagnostic termrefers tounderlyingdemonstrablepathophysiology forwhich independentmarkersexist, suchasbloodsugarlevels,etc.Inpsychiatry,practicallyallthemajordisordersarestillrecognizedatasyndromallevel, that isby theclusterof signsandsymptoms thatare thought tobe typicalof thegivendisease.The diagnostic term does not, as yet, refer to any well-described pathophysiology orindeed to any independent or reliable marker.This is a significant problem for the status ofpsychiatricdiseasesasbona fidemedicaldiseases.

Inpsychiatry, amultifactorial approach to theunderstandingof disorder is the rule ratherthan the exception.This is the basis of the biopsychosocial approach topsychiatric disorders.Thismeansthatanarrowdiagnosis,inpurelyorganicorpurelybehaviouralterms,isinadequate.Thediagnosisneedstobemadeinthecontextofanunderstandingofthebiological,psychologi-cal and social antecedents, which in turn determine the biological, psychological and socialmanagementofthecondition.


The Psychiatric HistoryThisaccountischieflyinterestedinthewaythattaking the historyshedslightonthemental state.Thenatureandtypeofreferralisnotedandrecorded,forexamplefromageneralpractitionerasanurgentproblem,fromasolicitorforacourtreportandsoon.Afterrecordingthereasonforreferral,thehistorywillusuallybeginwiththepatient’sverbatimdescriptionofhispresent symp-toms,includingthedurationofeachsymptomandanaccountofthedevelopmentoftheillness.Usingthepatient’sownwords isvaluable ingiving insight intohisstateofmindandhowhehimselfviewshissymptoms.Itishelpfulafterreceivingacatalogueofcomplaintstoask‘Whichistheveryworstofall thesesymptoms?Orwhat isyourmainconcern?’Thisrevealshowthepatientconceptualizeshisproblemandalsosuggestsapreliminarytargetfortreatment.

Often, the patient’s history of his present complaint is literally his story; there is nothingwronginrecordingthisinnarrativestyleprovidedthisisaccurate.Achronologicalaccountofthepresentillnessrevealshowthepatientregardsthedevelopmentofhissymptomsaswellasgivinginformationontheactualhistory.Inthehistory,onewantstoknowaboutthesequenceof symptoms and the effects these symptoms had on the patient’s lifestyle, about changes inbehaviourandaboutalterationsinphysicalfunction.Itisappropriateatthispointtonotepsy-chiatricsymptomsofwhichthepatienthasbeenawareinthepastbutforwhichhehasneverconsultedadoctororreceivedtreatment.Theymayhaverelevance inthetotalpictureofhowtheillnessdeveloped,anditisknownthatthemajorityofpeoplewithpsychiatricconditionsofclinicalseveritydonotseekmedicalconsultation,letalonecometotheattentionofapsychiatrist(Andrewsetal.,2001).

Thepatientfeelsittobeinnatelyreasonabletodescribechronologicallyandmeticulouslyhispreviousillnesses,operationsandaccidents.Healsowillappreciatethelogicofgivingdetailsofhospitalandgeneralpracticetreatmentformentalillnessandwillusuallygiveaccurateinforma-tionwithregardtodates,duration,natureoftreatment,inwhathospitalandwhetherhewasanin-patient or out-patient.Treatment received from the family doctor is recalled less well; thedatesarelessreliableandoftenthepatientdoesnotknowwhatwasthenatureoftreatmentorwhatitwasfor.

Thefamily historyisconcernedwithgeneticandenvironmental,pathoplasticfeatures.Historyofmentalillness,suicide,natureoftreatmentandsoonisrelevantforthefirst-degreerelatives(thosesharing50%ofthegeneticmaterialwiththepatient:parents,siblings,children)andmoredistantrelatives.Itisimportanttoknowaboutthequalityofrelationships,emotionalbondingandinterpersonalconflicts,bothforthefamilyinwhichthepatientwasachildandforthefamilyinwhichthepatientmaybeaparent.Relationshipsbetweenindividualmembersofthefamilyaredescribed,andalsothegeneralemotionalatmosphereandsocialandfinancialproblems.Theoccupationsofdifferentfamilymembersgiveinformationaboutthesocialcontext;arecordofhealthmayberelevant,asmayadescriptionoftheirpersonalities.Ofcourse,thefamilyisseenthroughthepatient’seyes;thismeansthatitisnotjustafactualdescriptionbutratheranaccountof theemotional impactthepatient feelshis familyhasmadeonhim.If thehistoryfromthepatientissupplementedbyanaccountfromanotherinformant,thisbiasofthepatient’swillitselfgiveinformationthatmaybeusefulinsubsequenttreatment.

Thepersonal history tracesthestagesofthepatient’sdevelopment,healthandformationofrelationshipsfromconception,birthandinfancythroughchildhood,schoolexperiences,adoles-cenceandfurthereducationtoanoccupational,maritalandsexualhistory.Thefactualdetailsofthese stages need to be recorded, and also the way they have influenced the personality andattitudesofthepatient,howhefeelsaboutthem,howhehasrelatedtootherpeople(forexampleteachersandworkmates)andhowallthesedetailsareconnectedwiththepsychiatriccondition.Thereareatleasttwoprocessesatplayintakingahistory.Thereisthesimplebusinessoftakingafactuallyaccurateaccountofapatient’shistoryofcomplaintsaswellasthefamily,personaland


socialhistory.Inadditiontothisapproach,thereistherequirementtograspthemeaningofthepatient’shistory,thatis,hisstory,inordertounderstandhowheseeshimselfinrelationtotheworldandhowhisdevelopmentandcircumstanceshavebeeninfluentialinprovoking,exacerbat-ing or ameliorating his present illness. The factual history is the foundation of the clinicaldiagnosis.Humanbeingsliveinaworldofmeanings,andthesymbolicandsocialdimensionofthehistoryarethebasisofanadequateandhumaneresponsetothepatient’sillnessanddistress.Accountsthatemphasize,forexample,thefactthatthepatientisanonlychild,apreciouschild,avictimofotherpeople’smaliciousintentions,afighterwhohasstruggledagainsttheodds,oranunluckyindividualforwhomonlyfailureandrejectioncharacterizetheirlifeallsaysomethingaboutthedominantthemes,theprismthroughwhichtheindividualanalyzesandperceivestheworld.So,whilstitisimportanttorecordthefacts,themeaningsandunderstandingthatpatientshaveofthetrajectoryoftheirlifeallcommunicatesomethingthatenrichestheclinicalencounter,andpotentiallymakepossibleadeeperdoctor-patientrelationshipthatshouldbesatisfyingforbothdoctorandpatient.

Premorbid, Previous or Usual PersonalityAssessmentofpersonalityisthemostcomplexandproblematictaskthatapsychiatristfaces.Inclinicalinterviews,thedoctorassessesthepatient’spersonalityusingthreeareasofinformation.First,theexaminerasksthepatienttodescribeindetailhisrelationshipswithotherpeople,hisinterestsandactivities.Second,theexaminerstudiesthewayinwhichthepatientreactstotheexaminerintheinterviewsituation.Third,theexaminertriestohelpthepatienttodescribeanddemonstratewhathe,thepatient,islikeasaperson;howhefeelsinsidehimselfindifferentsitu-ations;andhisinterests,goalsandstandards.

Personalityassessmentisnottheexclusivepreserveofpsychiatristsorpsychologists,butanimportantlearnedskillofmanyprofessionalswhodealwithpeople,forexampleschoolteachers,lawyersandevenbankmanagers,althoughtheirterminologyisdifferent.Personalityisthatpartofaperson,exceptinghisphysical characteristics, thatmakeshim individual, that is,differentfromotherpeople.Personalityisrevealedbyaperson’scharacteristicbehaviour;ifonecanpredicthowhewillreact,whathisbehaviourwillbeinparticularcircumstances,thenthebasisofthatpredictionistheevaluationofhispersonality.Subjectively,personalityisshowninthetotalityofaperson’saimsandgoals,formedofeverythingthathevaluesandtowhichheaspires.Personalityisnotathingbutanabstraction;onewayoflookingathumanbeings.Furthermore,itismulti-dimensionalandisbestdefinedinaction.Verbaldescriptionisunlikelytoexhausttheessenceofanyindividual.Indeed,nodescriptioncanexhausttheessenceofanyindividualperson.Itisatruismthathumanbeingsarefullofpotentialandcontinuetosurpriseandastonishwiththeircapacityforchange,fortransformationandformoralvirtues,whichmaynotbereadilyidentifi-ableonfirstcontact.

Categorizationintonormalandabnormalpersonalityrequiresafurtherlevelofabstraction.Normal,anordinarywordineverydayuse,needstobeusedmorerigorouslyinthiscontext(seeChapter1).Inmedicine,thetermnormalisoftenusedtodenoteastatisticalnorm,thatis,whatoccursinthemajorityofpeople.Equally,thetermisalsousedtomean‘ideal’,inthesenseofadescriptionthatconformstoan‘ideal’type.Inrelationtopersonality,classificationanddefinitionsofpersonalitydisordersdependondeviancefromthenorm,butthedefinitionsdependon‘ideal’descriptionsofpersonalitytypesorbetterstillatypology.Anormalpersonalityconformsthere-fore in its characteristics and the extent to which they are developed with the majority ofmankind.Abnormalpersonalityhassomecharacteristicsdevelopedorunderdevelopedtosuchanextentastobequantitativelydifferentfromthemassofpeople.Inotherwords,abnormalitiesofpersonalityaredifferencesofdegree;thedevianttraitsaresharedincommonwithothersbutexaggeratedinexpression.


Intheclinicalinterview,therearevariousareasofdialoguewiththepatientthatarelikelytoleadtousefulinformationfordepictingthedetailandcolouringofhispersonality–thepersonality type.Paintingthepictureanddefiningthetypearebothnecessaryclinicalexercises.Socialrela-tionsareinvestigated.Howdoesherelatetohisfamily?Ishedetachedoroverdependent?Whatsortoffriendshipsdoesheform,withwhatsortofpeople,andaretheycloseknitorsuperficial,withanexclusivefeworanunlimitedcrowd?Howdohisinterestsandleisureactivitiesinvolvehimwithothers?Socialorsolitary,structuredorinformal?Howdoesherelatetobosses,work-matesandemployeesatwork?Ishealeaderorafollower,anorganizeroraloner?Ishepliantor truculent, cooperative, sympathetic or clubbable? His sexual preferences and relationshipsshouldbenoted.

Thenatureofhisinterestsandactivitiesisinformative.Whatdoeshelikedoinginhissparetime?Ifheisinterestedinsport,itisusefultoknowifhecanfeelpartisanandinvolvedandalsowhetherhe is aparticipantor anobserver.Enquiry ismadeofhispreferenceand interests infilmsandliterature:howheobserves,criticizesandenjoysthematerial.Towhatsocialorganiza-tionsdoeshebelong?Religionrequiresmorethanasingleworddesignatingreligiousaffiliationinthecasenotes.Thephenomenologicalmethodisequallyrelevantforthisareaoflife.Whatistheindividual’sself-experienceofhisreligiousbeliefsandhowdotheseinteractwithpsychiatricsymptomatology(Sims,1994)?

Anaccountofhispredominantmood is requested, andwhetherhismood isfluctuatingorstable,responsivetoprecipitantsorendogenous.Charactertraitsimplyadetailedadjectivallist,forexample irritable,reserved, fussyandsoon.Itwill,ofcourse,behelpful tocorroboratehisdescriptionwithanaccountfromanotherperson.Enquiryismadeabouthisattitudesandvalues;hisviewsabouthimselfandhisbody;howheregardsothersclosetohim;hismoregeneralsocialvaluesinreligion,morality,politicsandeconomics;howhefeelseventsoccurandcanbemadetooccur.Driveandenergyandthewaytheseareexpressedinambition,lethargy,effectivenessandpersistenceareanimportantaspectofpersonality.

Studyofhisfantasylifeismade:thefrequencyanddurationofdaydreamsandtheircontent;whether thesearegoal-directedandrealisticordissociatedfromanyexpectationof fulfilment.Dreamsandothersupposedsignsofunconsciouspsychicactivityareuseful,especiallywhenthesubjectattemptstointerpretthem.Wemaycommentonhishabitsofingestion,inhalationandexcretion;whethertheyareregularandtowhatextenthedependsonthisregularity;ifthereisanindicationthatthereshouldbeamoredetailedhistoryandexplorationofcurrenthabitsofeating, smoking,drinkingalcoholandtakingotherdrugs.As thepatientunfolds the facetsofhispersonality,sotheoverallemphasesthatheputsinareasofdescriptionbecomeilluminatinginunderstandinghimasawholeperson.

Differentiation of Personality DisorderAllocatingthepatienttoapersonalitytypewithouttakingintoaccountthe infinitevariabilityofindividualsisquiteinadequate.However,certaincharacteristicstendtooccurtogetherandareof clinical significance. Allocation to a particular category of personality disorder is made onthe relative predominance of these different character traits. Having decided that a certaindefinitetraitortraitsarepresentinthisindividualtoanabnormalextent,doestheabnormalityofpersonalitycausethepersonhimselforotherpeopletosuffer?Thatis,ispersonalitydisorderpresent?

Morethanoneabnormaltypeofpersonalitymaybepresentinanyindividual;theyarenotmutuallyexclusive.Informulatingthepsychiatrichistoryandevaluationofmentalstate,commentonpremorbidpersonalityshouldalwaysbemade,evenifitisonlytostatethatduetotheravagesofthementalillnessitisimpossibletoassesspremorbidstate.Thepredominanttraitsshouldbedescribed,preferablywithverbatimcommentsofthepatienttoillustratethem.Theinterviewer


shoulddecidewhetherthesetraitsaretheretoastatisticallyabnormalextentand,ifso,whetherthisamountstopersonalitydisorder.Thetypeofdisordershouldbedifferentiated.

The Mental State ExaminationThementalstateexaminationisthespecialareaofexpertiseofpsychiatrists.Itisthepsychiatrist’sequivalentoftheneurologicalexamination.Thementalstateexaminationisguidedbythesameprinciplesandcommunicationskillsasanyotherclinicalinterview(Box2.2).Itisdependentonfacilitywithlanguage,becausethatisthetoolwithwhichpsychiatricpracticeisconducted.Theclinicianuses‘open’questionsatthebeginningofclinicalinquiriesandutilizes‘closed’questionsto clarify specific points. There are specific techniques for signalling active listening. Theseincludetheuseof‘summarystatements’tosummarizewhattheclinicianhasmadeofwhatthepatientissayingandtoprovidetheopportunityforthepatienttocorrectanymisapprehensiononthepartoftheclinician.Furthermore,‘normalizingstatements’canbeusedtointroducedif-ficultsubjects,forexamplethecliniciancouldintroducetheissueofsuicidalthoughtsbysaying,‘Itisnotuncommonforpeoplewhoaredepressedtofindthattheyfeelhopelessandthatlifeisnotworthliving;haveyoufeltlikethat?’Statementsthatcommentontheemotionalaspectsofthepatient’scommunicationorbehaviour,suchas‘Icanseethatitmustbeverydifficultforyoutotalkabouttheseexperiences’,mayhelptodeepentherapportbetweenclinicianandpatient.FurtherpracticaladviceonconductingthepsychiatricexaminationisfoundinLeffandIsaacs(1990).

As the interviewer asks each question, she should be thinking what the possible answersto that question could be from a reasonable person in this context. In everyday conversations,one is conditioned to avoid asking embarrassing questions and so, when someone makes anoddremark,thetendencyistofillinthemeaningoftheresponseinordertomakeitordinary,sensibleandavoidaskingfurtherquestionsinthisarea.Thisisexactlytheoppositetophenom-enological investigation, inwhichthe interviewer is lookingforways intothepatient’sprivatewayofthinking.Whenthepatientsayssomethingunreasonable,oddorunexpected,theinter-viewermustnoteitand,withoutembarrassingordisturbingthepatient’sequanimity,clarifythe

BOX 2.2 ■ Communication skills techniques

■ Introductorystatementsandsettingthecontext:‘MynameisDrSmith.IhavealetterfromyourGPinformingmethatyouhavebeenfeelinglowforthepastsixweeks.’etc.

■ Openquestions:‘CanIstartoffbyaskinghowyouhavebeenfeelinglately?’■ Closedquestions:‘Iunderstandthatyouhavebeenhearingvoicesforseveralweeksnow.Arethese

voicesthereallthetime?’■ Summary statements: ‘From what you have been saying, I understand that you have been

feeling low for the past six weeks, and that this has been steadily getting worse to the degreethat you are now tearful all the time and for no good reason, and that your sleep has also beenbadlyaffected.’

■ Normalizingstatements:‘Itisnotuncommonforpeopleinyourkindofsituationtofeelsolowthatlifenolongerseemsworthliving.Haveyoufeltlikethat?’

■ Reflective and empathic statements: ‘As I understand it, when your husband lost his job youhada lotofmoneyworries.Thatmusthavebeenquitedifficult for you, especiallywith thenewbabytoo.’

■ Concluding statements: ‘I now have a good grasp of how things have been for you in the pastyear. Are there things that you wanted to tell me that you have not yet had the opportunity tobringup?’


innerexperiencepartly revealed.Thiswillentail theuseof theempathicmethoddescribed inChapter1.Oneofthedifficultiesfortheaspiringphenomenologististoknowwhentopursuewhatthepatientrevealsinmoredetail–whentomaketheincisionforthepsychopathologicaloperation.

Wordslimitaswellasliberate.Theclinicalinterviewerneedstobeverycarefulnottorestrainherpatient’sanswersbyimposingtheshacklesofpsychiatrictechnicaljargon.Carefulattentionmust be paid to the patient’s use of language and, as far as possible, the clinician should uselanguagethatmirrorsthepatient’slanguage.Itisimportanttobecertainthatbothclinicianandpatientareusingwordsinthesamesense.Thequestion‘Doyouhearvoices?’isagoodexampleof this.The patient may truthfully answer ‘No’ and yet be suffering from almost continuousauditoryhallucinations.Thisparticularperceptualexperienceismostoftendescribedbypatientsandtheirdoctorsas‘voices’.However,phonemesmaybethoughtofbythepatientinquiteotherterms.Hemaymakenodistinctionatallbetweentheseauditoryperceptions,‘voices’hehearsforwhichanoutsideobserverrealizesthereisanappropriatestimulus,andauditoryhallucina-tions.Hemaybelargelyobliviousoftheformofthecommunicationasauditoryandhallucinatorybecause he is totally absorbed with its content (an order telling him to go to Strasbourg andpreach).Obviously,anotherpatientmayanswerthequestion‘Doyouhearvoices?’truthfullyintheaffirmativeandyethaveaquitedifferentformofphenomenologicalexperiencefromauditoryhallucination(seeChapter7).

Almosteverytechnical termingeneralmedicinehasdiagnosticimplications.Thisisalsotrueinpsychiatry.Asymptommaynotbepathognomonicofacertainconditionbutneverthelessispredominantlyfoundwiththatillness.Ifthedoctorusesthetermperseverationindescribingherpatient’s mental state to a colleague, she is by inference suggesting a diagnosis of an organicpsychiatricstate.If this isnotthediagnosis,shehassomehardexplainingtodoto justifytheuseofthatword.Isitreallyperseverationorjusttherepetitioususeofwordsandphrasesinapersonwhohasintellectualdisabilityandshowspovertyofexpression?Toavoidmisunderstand-ing, it isbesttouse longerdescriptionsuntil the interviewer issurethatthesymptomistrulypresent.

Observationoftheappearanceandbehaviourofthepatientisaninvaluablesupplementtohisself-description.Theobservationsofothers,andat timesother thanthe interview,needtobetakenintoaccount.Astheinterviewproceeds,theinterviewermoredefinitelypursuesherrealintention of finding out the meaning behind the words the patient uses.What is the patientfeeling and experiencing? His own account may be a blind to prevent other people, or evenhimself,seeinghowbadhereallyfeels.Theempathic method isinvaluableinworkingoutwhatheisimplying.Soalsoisacute,insightfulandtrainedobservation.Observationmayrevealwhitelinesacrosstheknucklesofananxiouspersontalkingaboutwhatupsetshimmostandwhichrenders him impotently angry. Empathy allows the observer to employ his own capacity foremotionasadiagnosticandtherapeutictool.Trainingandexperienceareessentialforknowinginwhichareasdelvingwillberewardedwithusefulinformation:howtoaskquestionsthatarecomprehensibletopatientsofdifferentverbalabilitiesandculturalbackgrounds,andwhichwillresultinappropriateanswers;howtoavoiddamagingthepatientstillfurtherwithwell-directedbut brutal questions. Observation and empathy must always be used together in eliciting themental state. Note also the double meaning of the word observant: not only noticing what isgoingonaroundbutalsoconformingwiththeculturalmoresoftheimmediatesociety.Agoodphenomenologistwillbeobservantinbothsensesoftheword.

Systematic EnquiryTheappearance andbehaviour of thepatient areobserved for the clinicalmedical informationtheycarry.Doesthepatientlookill?Ishealert,oriented,fullyconscious,fluctuatinginhismental


state? Are there any behavioural or neurological abnormalities? Observation is also useful forassessingnon-verbalcommunication(Argyle,1975).Fromhisposture,gestures,facialexpressionandsoonhebetrayshisstateofemotion,informationabouthispersonalityandhisattitudetotheobserverandtoothersdespitehissilenceorcontradictoryverbalcommunication.Obviously,observationofbehaviouralsoindicatespsychiatricsymptomatologysuchastics,catatonicmove-ments,possiblehallucinatoryperception,feedingandexcretingdisorders.Posturecanberevealingto theacuteobserver, for instance thepharaonic posture and the slowdeliberatemovementsofheadandneckofthepatientwithschizophrenia.Ifthepatient ismute,observedbehaviour istheonlysourceofclinical information,buttheimportanceofobservationneedstobestressedalsoforthosepatientswhodospeak.Observationmaybevaluabletocorroboratethepatient’scomplaints, to make clear the degree of emotional involvement he has in his symptoms, orsometimestocontradicthisstatement,forexamplethepersonwhomanifestsphysicallyextremeanxietyyetdeniesanyworriesonenquiry.

Talk reveals thought.Listening to and studying thepatient’s utterances is usually themostimportantpartofassessinghismentalstate.Thoughtdisorderandtheinterpretationofabnor-malitiesintheuseofwords,syntaxandassociationofideasarediscussedinmoredetailinChapter9.Theflowoftalkmeritsnotice.Doeshetalkvolublyandeasilyorintaciturnmonosyllables?Doeshe just answer questions or speak spontaneously? Is his conversation appropriate to thesocial context, and is it coherent? Is the train of thought readily distracted?Throughout theinterview,asmuchaspossibleofthepatient’sspeechshouldberecordedverbatim.Thisprovidesaclearerpictureofthisindividualperson’sinnermilieu,andalsothedataofself-experiencewillallowanotherpersontoevaluatethediagnosis.

Astheinterviewerenquiresaboutandformsherownassessmentofmood,shehasthreeareasforexploration:subjectiveandobjectivedescriptionofmoodandevaluationofrapport.Thereismuchmoretomoodthanjustdepressionorelation;thefinernuancesofthisperson’ssubjectiveemotionalexperiencemustbecarefullydugoutliketruffles,usingasensitivenoseanddelicateextraction.Apersonanticipatinganeventmaybeacutelyapprehensive,exquisitelyexcitedbutratheranxious,hopelesslyresignedandsoon;‘afraidofthefuture’isnotanadequatedescription.Moodcanbestudiedforitsdirection(depressionorelation),itsconsistency(stableorlabile),itsappropriateness,itsamplitudeandthedegreeofdiscrepancybetweensubjectivedescriptionandobjectiveobservation.

Ofcourse,thereisreallynosuchthingaswhollyobjectiveassessmentofmood.Thedoctorcommentsonthemoodstateofherpatientfromherobservationofthepatient’sdemeanourandthegeneraltoneofhisconversationduringtheinterview.Shemakesthecomment,‘Heappearsdepressed;heisagitatedandtense’.Infact,thiscommentonherpatient’semotionabbreviatestheempathicprocessthroughwhichshegoestomakethisjudgement.Thedoctorobservesthepatientandpicksupavailablecuesformood,relatingthesetoherexperiencewithotherpatientsandotherpeople throughher life,andultimately toherknowledgeofherownaffectivestate.Herassessment runs ‘If I felthowmypatient looks, speaksandacts, Iwould feelprofoundlydepressedandagitated;heis,onobservation,depressedandagitated.’

Rapport is ausefulmeasureof thepatient’s ability to communicatehis feelings to anotherperson.Theinterviewerneedstomakeherselfintoayardstick,aconstant rapport maker,againstwhich the patient’s ability to make rapport can be measured.To do this, the doctor requiresclinicalexperienceandanobjectivityinwhichsheknowshowshereactsto,andcommunicateswith,manydifferentsortsofpeople.Sheknowsherselfandherowncompetencewellenoughtoexclude this from the assessment of rapport so that, as far as possible, it is only the patient’scapacityforemotionalcommunicationthatisbeingtested.

Theideasandbeliefsthepatientholdsandabnormalities of perceptionheexperiencesareascer-tainedandexploredduringtheinterview.Inordinaryconversation,thereisagreatdealoffillinginoreditingtoeliminatethedeficienciesofcommunication.Apersontalksandcomestoahalt


halfway through a sentence for loss of a word.The other person provides the word and thuscontinuestheconversationtobothparties’satisfaction.Thereisatendencyforthosecomingnewtodialoguewith thementally ill tobring into their conversation these socialniceties that areusedtosaveembarrassment.Thedoctortendstonotewhatshethinksthepatientmeanttosay,asifthelatter’sthinkingprocessesweresimilartoherown,ratherthanconcentratingonwhatheactuallysaid.Alotofsignificantpsychopathologyisthusmissed.Delusionsandhallucinationsarenotvolunteeredbythepatientassymptomsfortheobviousreasonthattheyarenotexperi-encedasdifferentfromtherestoftheperson’sthinkingorperceiving.Tothepatient,subjectively,adelusionisindistinguishablefromanyotheridea,ahallucinationisindistinguishablefromanyothernormalperception.Skillininterviewingthereforecomesverymuchinknowingwhentolookforadelusionandhowtomakeacleardistinctionbetweenwhatthepersondescribesasexperienceandwhatitrevealsphenomenologically.

Passivityordelusionsofcontrol,obsessions, compulsionsanddepersonalizationmaybeobviousoronlymadeplainwithsomedifficulty.Itisimportanttotrytocategorizethetypeofexperienceasearlyinthecourseofexposuretoprofessionalenquiryaspossible,becausepatients’explana-tions tend to become contaminated on repeated questioning. When passivity, for example, issuspected,itisgenerallybesttofollowupthecluesrightawayanddecideonceandforallwhetherthesymptomispresent.

Assessmentof the cognitive state includes, at leastbriefly, testing fororientation, attention,concentration and memory. The Mini-Mental State Examination (Folstein etal., 1975) is awidelyused standardizedbedside testof cognitive function that isuseful toadminister in theclinicalsetting.

Thedoctor,fromspecificquestionsandfromtheinterviewingeneral,needstoformanideaof her patient’s attitude to his illness, difficulties and prospects.To what extent does he haveinsightintohiscondition?Anyillnessofsomeseveritywillalterthepatient’sworldandviewoftheworld.Insightassessestheawarenessofthischangebythepatientandtheaccuratelabellingofthischangeasoriginatingfromamental illnessthatrequirestreatment.Insightisthereforehighlycomplexasafunction.Itistheabilityoftheindividualtobeself-awareandtobesensitivetoinnersubjectivechange.Thecapacitytocorrectlyattributethesubjectivepsychologicalchangetopathologicalcausesisevidenceofintactself-awarenessdespiteevidenceofmentalillness.Itispotentiallyanextremelyvaluablepartofthementalstateexamination,asitisassociatedwithcompliance with treatment and also with the likelihood of treatment under compulsion. Insummary,insighthasthreecomponents:recognitionofsubjectivepsychologicalchange,labellingofthischangeaspathologicalinnatureandrecognitionofneedfortreatmentaswellascompli-ancewithtreatment(David,1990;seeChapter11).

Manytextbooksandnumerouspsychiatricinstitutionshavetheirownschemeforpsychiatricinterviewing.This account is a general commentary rather than yet another scheme. Box 2.1containsamemorandumofkeyareastobecoveredinthehistoryandexaminationofapsychiatricpatient.

ReferencesAndrewsG,IssakidisCandCarterG(2001)Theshortfallinmentalhealthserviceutilisation.British Journal

of Psychiatry179,417–25.ArgyleM(1975)Bodily Communication.London:Methuen.CarlatDJ(2005)The Psychiatric Interview,2ndedn.Philadelphia,LippincottWilliams&Wilkins.DavidAS(1990)Insightandpsychosis.British Journal of Psychiatry156,789–808.FolsteinMF,FolsteinSEandMcHughPR(1975)‘Mini-mentalstate’.Apracticalmethodofgradingthe

cognitivestateofpatientsfortheclinician.Journal of Psychiatric Research12,189–98.Greenberg M, Szmuckler G and Tantam D (1986) Making Sense of Psychiatric Cases. Oxford: Oxford

UniversityPress.


Leff JP and Isaacs AD (1990) Psychiatric Examination in Clinical Practice, 3rd edn. Oxford: BlackwellScientific.

MacKinnonRA,MichelsRandBuckleyPJ(2006)The Psychiatric Interview in Clinical Practice.Arlington:AmericanPsychiatricPublishing.

MorrisonJ(2008)The First Interview,3rdedn.London:TheGuildfordPress.RixKJB(1987)Handbook for Trainee Psychiatrists.London:BaillièreTindall.SimsA(1994)‘Psyche’–spiritaswellasmind?British Journal of Psychiatry165,441–6.SimsAandCurranS(2001)Examinationofthepsychiatricpatient.InHennF,SartoriusN,HelmchenH

andLauterH(eds.)Contemporary Psychiatry.Berlin:Springer.

S E C T I O N TWOConsciousness and Cognition

33

C H A P T E R 3

Consciousness and Disturbed Consciousness

SummaryConsciousnessisadefiningcharacteristicofanimals,althoughconsciousself-awarenessmaybeparticulartohumanbeings.Abnormalitiesofconsciousnessareproblematicfromaphenomenol-ogypointofviewbecause,bydefinition,self-reportsofpathologicalstatesunlikeself-reportsofconsciousexperiencearenot immunefromerror.Theunconsciousstate isnotprivilegedsincethesubjectisunabletoreportonthenatureandqualityoftheexperienceandeveninsituationswherethereisonlyminimalimpairmentofconsciousness,self-reportsarestillopentoqualifica-tionandquery.Hencetheterminologyisdeterminedbytheobservationofeitherthequantitativedegreeofabnormalityortheapparentqualitativechangesinconsciousstate.Theterminologyisimprecise and often several different terms are used for identical or frankly indistinguishablestates.Inthischaptertermssuchasvigilance,lucidity,cloudingofconsciousness,delirium,stupor,comaandsomeothershavebeenintroducedanddefined.

Psychiatry and neuropathology are not merely two closely related fields, they are but one field in which only one language is spoken and the same laws rule.

Wilhelm Griesinger (1868)

I have always been intrigued by the specific moment when, as we sit awaiting in the auditorium, the door to the stage opens and a performer steps into the light, or, to take the other perspective, the moment when a performer

who waits in semidarkness sees the same door open, revealing the lights, the stage, and the audience … as I reflect on what I have written, I sense that stepping into the light is also a powerful metaphor for consciousness, for the

birth of the knowing mind, for the simple and momentous coming of the self into the world of the mental.

Antonio Damasio (1999)

Onemustbeconscious inorder tobeable toexperience theworld.Sothe logical startingplaceforthestudyofsymptoms,fromasubjectivestandpoint,isthatwhichallowssubjectivitytoexist(consciousness).Untilquiterecently,studiesofconsciousnesswerelookedonwithsus-picionbyneuroscientists,therebyleavingclinicians,bothneurologistsandpsychiatrists,inintel-lectualdarkness.Thishasbeenrectifiedinthepastdecadethroughcombiningandsharingtheperspectivesofdifferentdisciplines:philosophy,psychology,medicineandneurosciences(BockandMarsh,1993).

Althoughit isessential forourclinicalworkconcerningdisturbances inconsciousnessthatweusetheprinciplesofdescriptivepsychopathologyandappliedphenomenology,weneedtobeawareofthelimitations(Dennett,1991).DennetthaspointedoutthatfromDescartesviaLocke,

Keywords: Consciousness,Delirium,Stupor,TwilightState,Automatism.

3—CONSCIOUSNESS AND DISTUrbED CONSCIOUSNESS 33.e1

34 TWO—CONSCIOUSNESS AND COGNITION

BerkeleyandHume,phenomenologyhastendedtodescribeconsciousnessfromthefirstpersonplural: ‘according to longstanding philosophical tradition we all agree on what we find whenwe“lookinside”atourownphenomenology’.Wemaynotallbethesameinside,andevenifweare, we may get it wrong when we try to describe our inner experiences. He also questionsthe purely third person perspective of behavioural psychology and advocates the ‘Method ofHeterophenomenology’.This depends, for its authenticity, on the meticulous precision of thequestionsasked,theobjectivityofrecordingthetranscript(threestenographerspreparingseparatedocumentsfromanaudiotapedinterview),adoptingthe‘intentionalstance’(assumingthatthesubjectofinvestigationwasintendingtomakeastatementaboutsomething)andscopeforclari-fication.Whenthisprocesshasbeenfollowed,thetext‘istakentobethesincere,reliableexpres-sionandtobeasingle,unified subjectofthatverysubject’sbeliefsandopinions’.Itbecomesclearthatthisprocessissimilar,althoughmorehighlystructuredforresearchpurposes,totheseparatestepsinthemethod of empathy,asdescribedinChapter1.

The terminology in this area is appallingly confused. This and subsequent chapters haveattemptedtoclarifythewordsused,sometimesattheexpenseofsacrificingaltogethertermswithalonghistory,andsometimeslumpingasasingleconceptwordsbetweenwhichthereareonlyminutedifferencesofmeaning.Onemajorproblemisthatdifferentdisciplinesusedifferenttermstocoverpartlyoverlappingmeanings.

Conscious and Unconscious ExperiencesCONSCIOUSNESS

Thewordsconsciousness, conscious mindandawarenessareusedveryfreelyinpsychiatrybutoftenwithoutaprecisemeaning.Consciousness‘isastateofawarenessoftheselfandtheenvironment’(Fish, 1967); also, consciousness ‘is to be conscious, to know about oneself and the world’(Scharfetter,1980);and,‘byconsciousness,Isimplymeanthosesubjectivestatesofsentienceorawareness thatendwhenonegoes tosleepatnightor falls intoacoma,ordies,orotherwisebecomes as one would say, unconscious’ (Searle, 1994). Consciousness is characterized by itssubjective nature and privacy. Furthermore, consciousness appears to have a unique quality,termed qualia, that is recalcitrant to any external physical description. This is the particularcharacterofanyobjectofourconsciousexperience,forexampletherednessofthecolourredasweperceiveit.Consciousnessisalsointentional,bywhichwemeanthatit isdirectedtowardsobjects;thatistosaythatconsciousnesshascontent–itisalwaysaboutsomething.Finally,ourconsciousexperience isunified intoawholeandnotgiventous in fragmentsorunintegratedparts.

Theterm,asusedbyclinicians,refersfirsttotheinnerawarenessofexperienceasopposedtothecategorizingofeventsastheyoccur.Second,itreferstothesubjectreactingtoobjectsdelib-erately.Third,itdenotesaknowledgeofaconsciousself.

UNCONSCIOUSNESS

Unconscious, according to Jaspers (1959), ‘means something that is not an inner existence anddoesnotoccurasanexperience;secondly,somethingthatisnotthoughtofasanobjectandhasgoneunregarded;thirdly,itissomethingwhichhasnotreachedanyknowledgeofitself ’.

In clinical practice, the term unconscious is used in three quite different ways that have incommononlythephenomenologicalelementinthatthereisnosubjectiveexperience(Figure3.1).

■ Aperson suffering fromseriousbraindiseasemaybeunconscious; consciousness in thisinstanceisseenasbeingonacontinuum,withanormalstateofconsciousnessatoneendanddeathattheother.

3—CONSCIOUSNESS AND DISTUrbED CONSCIOUSNESS 35

■ Someonewhoisasleepisunconscious;again,thereisacontinuumfromfullwakefulnesstodeepsleep.

■ Analertandhealthypersonisawareofonlycertainpartsofhisenvironmentbothexternallyandinternally;oftherest,heisunconscious.Thereisalsoacontinuumherefromfullvigi-lancedirectedtowardstheimmediateobjectofawarenesstototalunawareness.

Theorganicstateofthebrainas,forinstance,demonstratedbytheelectroencephalogramisutterlydifferentinthesethreesituations.

The third meaning of unconsciousness implies that certain mental processes cannot beobservedbyintrospectionalone,evenwhenthebrainisnormalandhealthy.Amongsuchproc-esses, forwhich there is goodevidenceof their existence, frequency andcomplexity, there aresomethathavebeen,ormayyetbecome,conscious.This iswhatFreudcalledthepreconscious(Frith,1979).Whereasthereisastrict limittothenumberofitemsavailableintheconsciousstate and that are therefore capable of being memorized (approximately seven, for example anumberwithsevendigits),thereisverymuchmoreinformationstoredatthepreconsciouslevel.Ifastimulusisambiguous,onlyoneinterpretationispossibleinconsciousnessatanyonetime;however,multiplemeaningsareavailablepreconsciously.Itisverydifficulttocarryoutmorethanone task at a time consciously, but undertaking parallel tasks is usual at a preconscious level.Preconscious processes are automatic, whereas conscious ones are flexible and strategic. ThisfunctionofthepreconsciouswaswellknownlongbeforeFreud,forexampleBrodie(1854):

But it seems to me that on some occasions a still more remarkable process takes place in the mind, which is even more independent of volition than that of

which we are speaking; as if there were in the mind a principle of order which operates without our being at the time conscious of it. It has often

happened to me to have been occupied by a particular subject of inquiry; to

Figure 3.1 Three dimensions of unconsciousness.

Stages of sleep

Reduced wakefulnessPreconscious – not readily available

Normalconsciousness

3.Unconscious

mind

2.Deepsleep

1.Coma

(stages)

Death

Normalsleeping

Organicimpairment

Braindisease

Clouding

Drowsiness

Sopor

Attentionawareness


have accumulated a store of facts connected with it; but to have been able to proceed no further. Then, after an interval of time, without any addition to

my stock of knowledge, I have found the obscurity and confusion, in which the subject was originally enveloped, to have cleared away; the facts have all seemed to have settled themselves in their right places, and their mutual relations to have become apparent, although I have not been sensible of

having made any distinct effort for that purpose.

Unconsciousinthesenseaboveisatheorythatpsychiatristsandpsychopathologistshavetoexplain some aspects of observable behaviour. Whereas in the other two senses of the term‘unconscious’,itisthefactthattheindividualisunconscioustotheworld,thatisheisunrousableandunabletoparticipatewiththisawarenessofthesensoryworldintact,thatisatstake.

DIMENSIONS OF CONSCIOUSNESS

Consciousness,then,istheawarenessofexperience.Theremaybeawarenessofobjectsorself-reflection. Awareness of objects includes the capacity to be aware of oneself as an object (seeChapter14); self-reflection refers to the subjective experiencingof self.The threedimensionsofconsciousness(contrastedwithunconsciousness,as inFigure3.1)arevigilance, lucidityandself-consciousness.

Vigilance (Wakefulness)–Drowsiness (Sleep)

Vigilanceistakentomeanthefacultyofdeliberatelyremainingalertwhenotherwiseonemightbedrowsyor asleep.This isnot auniformorunvarying state,but itfluctuates.Factors insidethe individual thatpromotevigilanceare interest, anxiety, extreme fearor enjoyment,whereasboredomencouragesdrowsiness.Thesituation in theenvironmentandtheway the individualperceivesthatsituationalsoaffecttheirpositiononthevigilance–drowsinessaxis.Someabnormalstatesofhealthincreasevigilance,whilemanydiminishit.

Aswellasthecontrastbetweenvigilanceanddrowsiness,therearequalitativedifferencesinthenatureofwakefulness.Thevigilantstateofmindofapersonscanningaradarscreenforapossibleenemyinterceptorisverydifferentfromtheraptattentionofamusicloverlisteningtoasymphony.TheseaspectsofattentionandtheirabnormalitiesarediscussedinChapter4.

Lucidity–Clouding

Consciousnessisinseparablefromtheobjectofconsciousattention:luciditycanbedemonstratedonlyinclarityofthoughtonaparticulartopic.Thesensorium,thetotalawarenessofallinternalandexternalsensationspresentingthemselvestotheorganismatanyparticularmoment,maybeclearorclouded.Obviously,lucidityisnotunrelatedtovigilance:unlessthepersonisfullyawake,hecannotbeclearinconsciousness.

Clouding of consciousness denotes the lesser stages of impairment of consciousness on acontinuum from full alertness and awareness to coma (Lishman, 1997).The patient may bedrowsyor agitated and is likely to showmemorydisturbance anddisorientation. In clouding,mostintellectualfunctionsareimpaired,includingattentionandconcentration,comprehensionand recognition, understanding, forming associations, logical judgement, communication byspeechandpurposefulaction.

Consciousness of Self

Alongsidefullwakefulnessandclearawarenessisanabilitytoexperienceself,andanawarenessofself,thatisbothimmediateandcomplex.ThisisconsideredinmoredetailinChapter12.


Pathology of ConsciousnessIthasprovedcomplicatedtodescribeexactlywhatisdisorderedinpathologicalstates,hencethisratherconvoluteddefinitionofadisturbedstateofconsciousness(DSC)byAggernaes(1975):

A state in a person in which he has no experiences at all, or in which all of his experiences are deviant, concerning other or more qualities than tempo

and mood colouring, from those he would have under similar stimulus conditions in his habitual waking state. The state is a DSC only if the

individual cannot return to, and remain in, his habitual state by deciding to do so himself, and if others bring about a lasting return to his habitual state

by the application of a simple social procedure.

Most abnormal states of consciousness show a lowering or diminution of consciousness.However,heightenedconsciousnessoccursinwhichthereisasubjectivesenseofricherperception:coloursseembrighterandsoon;therearechangesinmood,usuallyexhilaration,perhapsamount-ing to ecstasy; there is subjective experience of increased alertness and a greater capacity forintellectualactivity,memoryandunderstanding.Theremayalsobesynaesthesiae(asensorystimu-lusinonemodalityresultinginsensoryexperienceinanother,forexamplehearingafingernaildrawndownablackboardresultsinacoldfeelingdownthespine).Suchstates,bothheighteningofconsciousnessandsynaesthesiae,mayoccurinnormal,healthypeople,especiallyinadolescenceorattimesofemotional,socialorreligiouscrisis:whenfallinginlove,onwinningalargesumofmoney,atsuddenreligiousconversionandsoon.

Heightenedawarenessisnotuncommonwithcertaindrugs,notablywiththehallucinogens,for example lysergic acid diethylamide, and central nervous system stimulants, for exampleamphetamine. A similar state of awareness may occur occasionally in early psychotic illness,especiallymania,orlessofteninschizophrenia.

Consciousness isclearlyassociatedwiththearousalsystemsoftheorganism.AconjecturalrepresentationofthisrelationshipisshowninFigure3.2.

QUANTITATIVE LOWERING OF CONSCIOUSNESS

Asmentionedabove,consciousnessmaybeconsideredasacontinuumfromfullalertnessandawareness to coma. In that sense, consciousnessmaybe regarded asquantitative (Figure3.3).Impairmentofconsciousnessistheprimarychangeinacuteorganicreactionsandholdsafun-damentallyimportantplaceinthedetectionofacutedisturbanceofbrainfunctionandinassess-mentofseverity(Lishman,1997).

Figure 3.2 Arousal systems of consciousness.

Orienting

Motivated

Conscious

Unconscious

Asleep

AwakePreconscious

Reticular-activatingsystem

Limbicsystem


Figure 3.3 Levels or stages of diminished consciousness.

CloudingDrowsiness

SoporComa

Normal consciousness:alert, vigilant, lucid

Death

Someconditionsmayproduceavariablelevelofdiminutionofconsciousness;thatoccurringwithmigraine,forexample,mayrangefrombluntedawarenessthroughlethargyanddrowsinesstolossofconsciousness(Lishman,1997).

Clouding of Consciousness

Thisrepresentsthelesserstagesofimpairmentofconsciousness,withdeteriorationinthinking,attention,perceptionandmemoryand,usually,drowsinessandreducedawarenessoftheenviron-ment.Thereareimportantdifferencesbetweenthereducedwakefulnessbeforefallingasleepandclouding inanorganic state (Lipowski,1967).Although thepatient’s awareness is clouded,hemaybe agitated and excitable rather thandrowsy.Cloudingmaybe seen in awide varietyofacuteorganicconditions,includingdrugandalcoholintoxication,headinjury,meningealirrita-tioncausedby infectionandsoon.Drowsinessasadescriptive termsimplymeansdiminishedalertnessandattentionthatisnotunderthepatient’scontrol.

Thetermcloudingshouldbeusedforthepsychopathologicalstate:impairmentofconscious-ness,slightdrowsinesswithorwithoutagitationanddifficultywithattentionandconcentration.Thiswillusuallyoccurwithorganicimpairmentoffunction,forinstancewithcerebraltumour,afterheadinjuryorwithraisedintracranialpressure.Ifitoccursinschizophrenia,itisasapartofthecognitivedeficitthathasbeenshownsometimestooccurinthisdisease(Frith,1979).Itis suggested that in this condition there is an awarenessof automaticprocesses thatnormallyoccur below the level of consciousness. These processes are concerned with the selection ofappropriateinterpretationofstimuliandofresponse.

Drowsiness

Asapersistentstate,thisisthenextlevelofprogressiveimpairment.Thepatientis‘awake’butwilldriftinto‘sleep’ifleftwithoutsensorystimulation.Heisslowinactions,slurredinspeech,sluggish in intentionandsleepyonsubjectivedescription.There isanattemptatavoidanceofpainful stimuli.Reflexes, including coughing and swallowing, arepresentbut reduced;muscletoneisalsodiminished.

Inpsychiatricpractice, this iscommonlyseen followingoverdosagewithdrugs thathaveacentralnervoussystemdepressanteffect (forexample tricyclicantidepressants).Fromthepsy-chiatrist’spointofview, itmeans,ofcourse, that interviewingthepatient is impossible.Theselevelsofdiminishedconsciousness arequitenonspecific andoccurwhatever thenatureof thecause: head injury, tumour, epilepsy, infection, cerebrovascular disorder, metabolic disorder ortoxicstate.

Coma

Whereasthedrowsypatientisconsciousbutlapsingattimesintounconsciousness,incomathepatient isunconscious. In lighter states,with strongstimuli,hemaybemomentarily rousable.


Therearenoverbalresponsesorresponsestopainfulstimuli.Therightingresponseofposturehasbeenlost;reflexesandmuscletonearepresentbutgreatlyreduced;breathingisslow,deepandrhythmic;thefaceandskinmaybeflushed.

Inlaterstages,thepatientisnolongerrousable;heisdeeplyunconscious.Distinctstagesofcomahave identifiablephysical signsultimately culminating inbraindeath, but these arenotdiscussedfurtherinthisbook–theyarebeyondpsychiatry(ConferenceofMedicalRoyalCollegesandtheirFaculties,1976).Practicalassessmentofthedepthanddurationofimpairedconscious-nessandcomahasbeenquantifiedonthescaledevisedbyTeasdaleandJennett(1974).

Thesestagesareall thosethatoccurprogressivelyandquantitativelywithloweringofcon-sciousness.Qualitativevariationsarenowdiscussedfurther.

QUALITATIVE CHANGES OF CONSCIOUSNESS

Variousotherorganicdisturbances inbrainfunctionarerecognized.Thesearevirtuallyalwaysassociatedwithsomedegreeofquantitativeimpairment.Theuseofterminologyinthiswholeareaofdiscourseis,unfortunately,verymuddled,withthesametermsometimeshavingdifferentmeaningsandsimilarphenomenabeingdescribedbydifferentwords.

Delirium

Lipowski(1990)definesdeliriumas‘atransientorganicmentalsyndromeofacuteonset,char-acterizedbyglobal impairmentofcognitive functions,a reduced levelofconsciousness,atten-tionalabnormalities, increasedordecreasedpsychomotoractivityandadisordered sleep–wakecycle’.Therecognitionthatthetermdeliriumshouldrefertoasyndromeinvolvingglobaldis-turbancewas incorporated in the Diagnostic and Statistical Manual of Mental Disorders, fourthedition(DSM-IV;AmericanPsychiatricAssociation,1994).InDSM-IV,thetermdescribesadisturbanceofconsciousnessthatisaccompaniedbyachangeincognitionthatcannotbebetteraccountedforbyapre-existingorevolvingdementia.Thereisareductionintheclarityofaware-nessoftheenvironment.Similarly,theICD-10 Classification of Mental and Behavioural Disorders(WorldHealthOrganization,1992)usesthetermdeliriuminagenericandglobalsense:

An etiologically nonspecific syndrome characterized by concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor

behaviour, emotion and the sleep-wake cycle.(p. 57)

Subjectiveaccountsofdeliriumarerareandthefewpublisheddescriptionsareopentocriti-cismgiventheestablishedfactthatconsciousness is impairedindeliriumandthedescriptionshavehadtobeconstructedwithhindsight.Nonetheless,Crammer’s(2002)accountconfirmedpartialstatesofarousalduringwhichsomememoryfunctionsandbeliefformationcanbepresent,despite apparent unconsciousness. Inhis comments onCrammer’s account,Fleminger (2002)drewattentiontothefactthattheexperienceofdeliriumisakintodreaming,butthatdeliriumisrememberedwithgreatervividnessthandreams.Also,thatwhereasitistraditionaltoconceiveofdeliriumasbeingadisturbanceofconsciousness,itmightbemoreprofitabletothinkofitasadisturbanceofthesleep-wakecycle.Thisiswhytheexperienceofdeliriumisakintodreamingandwhythereisevidencethatdeliriumismorelikelyinindividualswithsleepdeprivation.

Fluctuation of Consciousness

Fluctuations in consciousness levels are seen in various conditions. It occurs in health, insleepandinfatigue.Inpatientswithepilepsy,thereisfluctuationinrelationtofitsanditmayoccurbefore,duringoraftertheseizures.Alterationsofconsciousness levelaredescribedwiththird-ventricle tumours associated with variations in intracranial pressure (Sim, 1974). In


deliriousstates,theremaybeconsiderablediurnalfluctuationofconsciousness.Characteristically,the patient becomes more disorientated, disturbed in mood and distracted perceptually withillusionsandhallucinationsinthelateeveningandshowsgreatestluciditymid-morning.Suchvariationofconsciousnesslevelisalsodescribedandobservedwithdrugs,forinstancemescaline,inwhichtheremayalsobefluctuationsoftimesense.

Confusion

The concept of confusion was originally developed in France (confusion mentale) and later inGermany (Verwirrtheit) in the nineteenth century (Berrios, 1981). It is a term, impreciselydefined,referringtosubjectivesymptomsandobjectivesignsindicatinglossofcapacityforclearand coherent thought. It is purely a descriptiveword anddoesnot only apply to cloudingofconsciousness. When physicians, psychiatrists and nurses were asked what confusion meant,markeddiscordancewasfound.Thetermshouldbeusedonlyifclearlydefined(Simpson,1984).Itoccurswithimpairmentofconsciousnessinacuteorganicstatesandwithdisruptionofthoughtprocessesduetobraindamageinchronicorganicstates,butitisalsoseeninnon-organicdis-turbance.Thus,confusionofthinkingmayoccuraspartofthepictureinfunctionalpsychosesandalsoinassociationwithpowerfulemotioninneuroticdisorders.Itshouldthereforebeusedsimplytodescribethesedisturbancesofthoughtandnotasatermpathognomonicoforganicpsychosyndromes.

To simplify, therefore, confusion of thinking canbedescribed as occurring eitherwhen theindividualdescribeshisownthinkingasbeingconfusedorwhentheexternalobserverconsidersthatthethoughtprocessesaredisturbedandconfused.Phenomenologically,therefore,itissimplyadescriptionofthepatient’sself-experienceorthedoctor’sobservation.

OTHER TERMS

Twilight State

A twilight state is a well-defined interruption of the continuity of consciousness (Sims etal.,2000).Itisusuallyanorganicconditionandoccursinthecontextofepilepsy,alcoholism(mania à potu),braintraumaandgeneralparesis;itmayalsooccurwithdissociativestates.Itischaracter-izedby(a)abruptonsetandend;(b)variableduration,fromafewhourstoseveralweeks;and(c) theoccurrenceofunexpectedviolentactsoremotionaloutburstsduringotherwisenormal,quietbehaviour(Lishman,1997).Ifthetermisreservedforthesethreefeaturesincombination,asapsychopathologicalentity,thenitshouldbeusedwhenevertheyconcur,irrespectiveofcause.

Theforensicimplicationsofthisconditionarethereforeimportant,andithasbeenusedasalegaldefenceforviolentbehaviourforwhichthepersonhadsubsequentamnesia.

Consciousnessmaybemarkedlyimpairedorrelativelynormalbetweenepisodes.Theremaybeassociateddream-likestates,delusionsorhallucinations.Itissometimesassociatedwiththetemporallobeseizuresofepilepsy;itmayoccurwithotherorganicstateswithoutepilepsy;similarbehaviourmayoccurinapparenthystericaldissociation;anditisalsodescribedasanacutereac-tiontomassivecatastrophe.Intheforensiccontext,itisimportanttodemonstrate(a)theoccur-renceof similar episodeswith inexplicablebehaviourbefore thekeyhappening and (b)other,objectiveevidenceofphysicalormentalillness.TheGanser state(describedwithmemorydisordersinChapter5)is,inpractice,asortoftwilightstateinwhichtheorganicelementisoftendubious.

Mania à Potu (Pathological Intoxication)

Thisisonetypeoftwilightstatespecificallyassociatedwithalcoholism.Itisimportanttodis-tinguish this syndromeofacutepathological intoxicationwithalcohol fromdeliriumtremens,whichisasymptomofwithdrawal.Keller(1977)hasdefinedmania à potuas:


an extraordinarily severe response to alcohol, especially to small amounts, marked by apparently senseless violent behaviour, usually followed by

exhaustion, sleep and amnesia for the episode. Intoxication is apparently not always involved and for this reason pathological reaction to alcohol is the

preferred term. The reaction is thought to be associated with exhaustion, great strain or hypoglycaemia, and to occur especially in people poorly defended

against their own violent impulses.

Coid(1979)describesfourcomponents:■ theconditionfollowstheconsumptionofavariablequantityofalcohol■ senseless,violentbehaviourthenensues■ thereisthenprolongedsleep■ totalorpartialamnesiaforthedisturbedbehaviouroccurs.Becausethereisoftendoubtastowhetherintoxicationreallyfollowedtheconsumptionof

aninappropriatelysmallamountofalcohol,andbecauseseveraloftheothercausal factorsarediagnosticcategoriesintheirownright(hypoglycaemia,epilepsy),Coidwoulddoawaywiththediagnosticcategoryofpathologicalintoxicationinthedefinitionabove,leavingonlyeitheracutedrunkennessoranotherconditionassociatedwithalcoholintake.

Automatism

Automatismimpliesactiontakingplaceintheabsenceofconsciousness.IthasbeendefinedbyFenwick(1990)asfollows:

An automatism is an involuntary piece of behaviour over which an individual has no control. The behaviour itself is usually inappropriate to the

circumstances, and may be out of character for the individual. It can be complex, co-ordinated, and apparently purposeful and directed, though lacking

in judgement. Afterwards, the individual may have no recollection, or only partial and confused memory, of his actions.

Epilepticautomatismmaybedefinedasastateofcloudingofconsciousnessthatoccursduring,or immediatelyafter, a seizureandduringwhich the individual retainscontrolofpostureandmuscletoneandperformssimpleorcomplexmovementsandactionswithoutbeingawareofwhatishappening(Fenton,1975).Itoccursaspartoftheclinicalpresentationofpsychomotorepilepsy,mostoftenarising fromdischarge in the temporal lobes. Itwasparticularlycommon in thosepatientswithchronicepilepsywhowereresidentinanepilepsycolonyoramentalhospital.

Anauramaybethefirstsignofanepilepticattackwithtemporallobeautomatismandmaybemanifestedasabdominalsensations;feelingsofconfusionwiththinking;sensationselsewhereinthebody,especiallythehead;hallucinationsorillusions(especiallyolfactoryorgustatory);andmotorabnormalitiessuchastoniccontracture,masticatorymovement,salivationorswallowing.

Behaviourduringautomatismisusuallypurposefulandoftenappropriate,forinstancecon-tinuingtodrythedishes.Awarenessoftheenvironmentisimpaired;thepatientappearstobeonlypartlyawareofbeingspokentoanddoesnotreplyappropriately.Initially,activityisdimin-ished,withstaringeyesandslumpedposture;itthenbecomesstereotyped,withrepetitivemove-ments, lip smacking, fumbling andother actions.Finally,more complexpurposeful behaviouroccurs, such as walking about, making irrelevant utterances, removing clothing and so on.Sometimes,thepatientmaycontinue,duringautomatism,withwhateverhewasdoingbefore,forexampledrivinghiscar,althoughthereissubsequentamnesiaandthebehaviourorspeechatthetimeneverappearsentirelynormal.


Violence is rare during automatism, and when it occurs it usually amounts to resistingrestraint.However,automatismis,rarely,citedasanexplanationforaperson’sviolentandcriminalactionofwhichheisunawareafterwards.Thelegaldefinitionthenbecomes‘Thestateofapersonwho though capable of action, is not conscious of what he is doing… it means unconscious,involuntaryactionand it isadefencebecause theminddoesnotgowithwhat isbeingdone’(Kilmuir,1963).Clearly,whensuchviolentbehaviouroccursautomatismfulfilsthecriteriaforthedefinitionoftwilight stateasdefinedabove.

Speech automatism occurs when there is utterance of identifiable words or phrases at somestageduringtheepilepticattack,ofwhichthepatienthasnomemorylater.Phenomenologically,then,automatismisactionwithoutanyknowledgeofacting,anditisthelatterclaimthatrequirescarefulinvestigation.

Dream-Like (Oneiroid) State

This is an unsatisfactory term not clearly differentiated from twilight state or delirium.Thepatientisdisorientated,confusedandexperienceselaboratehallucinations,usuallyvisual.Thereisimpairmentofconsciousnessandmarkedemotionalchange,whichmaybeterrororenjoymentofthehallucinatoryexperiences;theremayalsobeauditoryortactilehallucinations.Thepatientmayappeartobelivinginadreamworld,andso-calledoccupational deliriumcouldbementionedinthiscontext,forinstancetheship’spettyofficer,admittedtohospitalafteraheadinjuryatsea(associatedwithexcessalcoholintake),whokeptshouting‘Mantheboats’.

Itisimportanttolookforothersymptomsororganicstatestomaketheimportantdistinctionbetweenphysicalillnessandadissociativenon-organiccondition.

Stupor

‘Stupornamesasymptomcomplexwhosecentralfeatureisareductionin,orabsenceof,relationalfunctions:thatis,actionandspeech’(Berrios,1996).Itisdistinctfromcomaanddoesnotlieonacontinuumfromwakefulnesstocoma.Thistermshouldbereservedforthesyndromeinwhichmutism and akinesis occur; that is, the inability to initiate speech or action in a patient whoappearsawakeandevenalert.Itusuallyoccurswithsomedegreeofcloudingofconsciousnessbut does not refer solely to a diminished level.The patient may look ahead or his eyes maywander,butheappearstotakenothingin.

Thissyndromeischaracteristicoflesionsintheareaofthediencephalonandupperbrainstem,andalso the frontal lobe andbasal ganglia, and the termakinetic mutism has sometimesbeenreservedbyneurologiststodescribeamuchmorenarrowlydefinedorganicsyndrome.Ararebutspecificconditioninvolvingthemotorpathwaysintheventralponsiscalledthe locked-in syn-drome,inwhichthereisquadriplegiaandanarthriawithpreservedconsciousnessandverticaleyemovement(PlumandPosner,1972;SmithandDelargy,2005).Itisimportanttorealize,however,thatthesymptomsofakinesisandmutisminaconsciouspatientalsooccurwithschizophrenia,withaffectivepsychoses(bothdepressiveandmanic)andindissociativestates.

Thedifferencebetweenpsychogenic(so-calledfunctional)andneurological(organic)causesofstuporcanbeclinicallyextremelyperplexing.Psychiatricdefinitionshavedemandedthatthecondition occurs when there is ‘a complete absence, in clear consciousness, of any voluntarymovements’(Wingetal.,1974).Ofcourse,itisnotpossibleatthetimeofobservationtoknowwhetherconsciousnessisquiteclearornot;andevenforfunctionalstupors,subsequentamnesiaiscommon.Aphenomenologicaldefinitionofstupormust,therefore,excludethestateofcon-sciousnessofamutepatient,anddiagnosisofstupormustthenbefollowedbyinvestigationofthedifferentialdiagnosiswhichincludesbothorganicandnon-organicconditions.

Sleep Disorders

ThesearediscussedinChapter4.


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Scandinavica51,119–33.American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders, 4th edn.

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Psychiatry139,439–49.BerriosGE(1996)The History of Mental Symptoms: Descriptive Psychopathology Since the Nineteenth Century.

Cambridge:CambridgeUniversityPress.BockGRandMarshJ(1993)Experimental and Theoretical Studies of Consciousness.Chichester:JohnWiley.BrodieBC(1854)Psychological Inquiries: in a Series of Essays.London:Longman,Brown,Green&Longman.CoidJ(1979)Maniaàpotu:acriticalreviewofpathologicalintoxication.Psychological Medicine9,709–19.ConferenceofMedicalRoyalCollegesandtheirFaculties(1976)Diagnosisofbraindeath.British Medical

Journalii,1187–8.CrammerJL(2002)Subjectiveexperienceofaconfusionalstate.British Journal of Psychiatry180,71–5.DamasioA(1999)The Feeling of What Happens: Body and Emotion in the Making of Consciousness.London:

WilliamHeinemann.DennettD(1991)Consciousness Explained.London:AllenLane.Fenton GW (1975) Epilepsy and automatism. In Silverstone T and Barraclough B (eds.) Contemporary

Psychiatry,pp.429–39.Ashford:HeadleyBrothers.Fenwick P (1990) Automatism. In Bluglass R and Bowden P (eds.) Principles and Practice of Forensic

Psychiatry.Edinburgh:ChurchillLivingstone.FishF(1967)Clinical Psychopathology.Bristol:JohnWright.FlemingerS(2002)Rememberingdelirium.British Journal of Psychiatry180,4–5.FrithCD(1979)Consciousness,informationprocessingandschizophrenia.British Journal of Psychiatry134,

225–35.GriesingerW(1868)QuotedinZilboorgGandHenryGW(eds.)(1941)A History of Medical Psychology.

NewYork:WWNorton.JaspersK(1959)General Psychopathology(transl.HoenigJandHamiltonMW,1963).Manchester:Manchester

UniversityPress.KellerM(1977)A lexiconofdisablements related toalcohol consumption. InAlcohol Related Disabilities.

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3AllER523.LipowskiZJ(1990)Delirium: Acute Confusional States.Oxford:OxfordUniversityPress.LipowskiZS(1967)Delirium,cloudingofconsciousnessandconfusion.Journal of Nervous Mental Diseases

145,227–55.LishmanWA(1997)Organic Psychiatry: the Psychological Consequences of Cerebral Disorder,3rdedn.Oxford:

BlackwellScientific.PlumFandPosnerJB(1972)Diagnosis of Stupor and Coma,2ndedn.Philadelphia:Davis.ScharfetterC(1980)General Psychopathology: an Introduction.Cambridge:CambridgeUniversityPress.SearleJR(1994)Theproblemofconsciousness.InRevonsuoAandKamppinenM(eds.)Consciousness in

Philosophy and Cognitive Neuroscience.Hillsdale:LawrenceErlbaumAssociates.SimM(1974)Guide to Psychiatry.Edinburgh:ChurchillLivingstone.SimpsonCJ(1984)Doctorsandnursesuseoftheword‘confused’.British Journal of Psychiatry145,441–3.SimsA,MundtC,BernerPandBarockaA(2000)Descriptivephenomenology.InGelderMG,López-Ibor

JJandAndreasenN(eds.)New Oxford Textbook of Psychiatry.Oxford:OxfordUniversityPress.SmithEandDelargyM(2005)Locked-insyndrome.British Medical Journal330,406–9.TeasdaleGandJennettB(1974)Assessmentofcomaandimpairedconsciousness:apracticalscale.Lancet

ii,81–4.Wing JK, Cooper JE and Sartorius N (1974) The Measurement and Classification of Psychiatric Symptoms.

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Description and Diagnostic Guidelines.Geneva:WorldHealthOrganization.

45

C H A P T E R 4

Attention, Concentration, Orientation and Sleep

SummaryConsciousness,attention,concentrationandsleepareallinterrelatedphenomena.Inthepreviouschapter,consciousnessanditsabnormalitiesweredescribed.Attentionisoftenlikenedtoabeamoflightthatfocusesonalimitedareaofinterestwithinageneralfield,butitisbesttoconceiveofitasalimitedcapacitychannelthatisdynamicintheselectionandinhibitionofinformationforfurtherprocessing(Broadbent,1958;SmithandKosslyn,2007).Itisimportantforanorgan-ism’sabilitytoengagewithaspectsofitsenvironment.Itisrequiredfororientatingtheorganismwithin its environment. Abnormalities of impairment, therefore, underlie such disparate phe-nomenaasdisorientationandimpairmentofnewlearning.Thesleep-wakecycleisaphysiologicalmechanismthatdeterminesthealterationfromwakefulness,thatis,consciousnessandthespecialtemporarystateofunconsciousnessthatismanifestassleep.Abnormalitiesofthiscycleincludingdisturbancesofamount,quality,etc.aredescribedinthischapter.

Come, Sleep! O Sleep, the certain knot of peaceThe baiting–place of wit, the balm of woe,

The poor man’s wealth, the prisoner’s release,Th’ indifferent judge between the high and low.

Sir Philip Sidney (1554–1586), Astrophel and Stella, sonnet 39

Thetermsattention,concentrationandorientationhaveoftenbeenusedvery loosely. It issuggestedthattheiruseisrestrictedtothefollowing.Attentionistheactiveorpassivefocusingof consciousness on an experience such as sensory inputs, motor programmes, memories orinternal representations. It canbedefinedas theprocess that enhances some informationandinhibits others, thereby allowing us to select some information for further processing (SmithandKosslyn,2007).Theconceptoverlapswiththetermsalertness, awarenessandresponsiveness. Voluntaryattentionoccurswhenthesubjectfocuseshisattentiononaninternalorexternalevent;involuntary when the event attracts the subject’s attention without his conscious effort.Concentration is only one aspect of attention. It involves focused or selective attention. Otheraspects of attention include sustained attention or vigilance, divided attention and alternatingattention.Orientation isanawarenessofone’s setting in timeandplaceandof the realitiesofone’spersonandsituation.Itisnotadiscretefunctionbutiscloselyboundupwithmemoryandtheclarityorcoherenceofthought.

Thischapterisconcernedwithcognitivefunction,butitisnotlimitedtothefunctionsthatare disturbed by organic lesions and covers a wider field than just consciousness and itsdisorders.

Keywords:Attention,Concentration,Sleep,Hypersomnia,Parasomnia,Hypnosis.

4—ATTENTION, CONCENTrATION, OrIENTATION AND SlEEp 45.e1


Attention, Awareness and ConcentrationAttention is adifferent function fromconsciousness, but it is dependenton it.Thus, variabledegreesofattentionarepossiblewithfullconsciousness,butcompleteattentionandconcentra-tionareimpossiblewithdiminishedconsciousness.WilliamJames’(1842–1910)(1890)accountisstillagoodstartingpoint:

Attention is … the taking into possession of the mind, in clear and vivid form, of one out of what seem several simultaneously possible objects or trains

of thought. Focalization, concentration, of consciousness are of its essence.

Therearepassiveandactivemodesofattention.Inpassiveattention,thesubjectrespondsto,forexample,aloudnoise,whereasinactiveattention,anindividual’spriorexpectationsandgoalsdetermineinatop-downfashionwhatisattendedto(seeEysenckandKeane,2010forafullerdescription).Acentralfeatureofattentionisitslimitedcapacity.Thisreferstothefactthatonlysomuchcognitiveprocessingactivitycanbecarriedoutatanyonetime.Attentionalcapacityisusually testedby thedigit span, and although it is a relatively stable feature of attention it ispronetoinfluenceby,forexample,fatigue,depressionandbraininjury.Componentsofattentionincludeorientatingtosensoryevents,detectingsignalsforfocusedprocessing,andmaintaininga vigilant andalert state. It is important to recognize thatknowledge,priorbeliefs, goals andexpectationscanalterthespeedandaccuracyoftheprocessesthatselectmeaningfulordesirableinformationfromtheenvironment.

Therearefourotheraspectsofattention.Focusedor selective attention referstothecapacitytohighlighttheoneortwoimportantstimuliorideasbeingdealtwithwhilesuppressingaware-ness of competing distractions.This aspect of attention is usually referred to as concentration.Serialsevensisusuallyemployedtoassessthisaspectofattention,anditrequiresfocusedatten-tionaswell asothercognitiveprocesses.Sustained attentionorvigilance involves theability tomaintain attentional activity over a period of time. It is usually measured by vigilance tests.Divided attentioninvolvestheabilitytorespondtomorethanonetaskatatimeortomultipleelementswithinatask.Alternating attentionallowsforshiftsinfocusofattentionandtasks(Lezaketal.,2004;Table4.1).

Automaticcognitiveprocesses,thatis,thosethatoccurwithoutintention,thatareinvoluntaryandthatdonotinterferewithotherongoingactivities,existinparallelwiththosethatrequireattentiveprocesses(KolbandWhishaw,1996).Theseautomaticprocessesallowfortheeffortlessextractionoffeaturesofaperceptioninbottom-upfashion,whereasattentiveprocessesallowforthetop-downprocessingofinformation(Figure4.1).

ALTERATION OF THE DEGREE OF ATTENTION

Attentionisdecreasedinnormalpeopleinsleep,dreams,hypnoticstates,fatigueandboredom.Itmaybepathologicallydecreasedinorganicstates,usuallywithloweringofconsciousness,forinstancewithheadinjury,acutetoxicconfusionalstatessuchasdrug-andalcohol-inducedcondi-tions,epilepsy,raisedintracranialpressureandbrainstemlesions.Inpsychogenicstates,attentionmaybealtered,forexamplediminishedinhystericaldissociation.Narrowingofattentionisalsoprominentindepressiveillness,inwhichthemorbidmoodstateresultsinattentionbeinglimitedtoarestrictednumberofthemes–mostlyunhappy.

Aseveredeficitofattentionisaprominentfeatureinthehyperkineticdisordersinchildhood(WorldHealthOrganization,1992)butwhichalsooccurinadultlife(seeChapter3).Observationofthechild’sbehaviourbyadultssuchasparentsorteachersconcentratesonthreeaspects:inat-tention,impulsivenessandhyperactivity.Inattentionisshowninthatthechild,mostoftenaboy

4—ATTENTION, CONCENTrATION, OrIENTATION AND SlEEp 47

TABLE 4.1 ■ Aspects of attention

Aspect of attention Definition

Focused attention The capacity to highlight important stimuli while suppressing awareness of competing distractions

Sustained attention or vigilance

The capacity to maintain attentional activity over a prolonged period

Divided attention The ability to respond to more than one task at a time, including taking account of the multiple elements within a complex task

Alternating attention The ability to shift attentional focus from task to task

Attentional capacity The extent of the processing ability inherent in the attentional system; it is often considered to be a form of working memory

Figure 4.1 Variations in level of awareness.

Clear consciousnesswith voluntary attention

directed towards anobject of awareness –

e.g. watching a radar screen

Clear consciousnesswith involuntary attention

drawn to a field of attention –e.g. thinking in a deck chair

Narrowing of consciousnesswith constriction of the field ofattention – e.g. epileptic aura

Lowering of consciousnesswith patchy areas of attention

Object of awareness

Normal

Pathological

Conscious awareness

Unconscious Unconscious

Field of attentionConsciousawareness

andusuallyagedbetweenthreeandtenyears, fails tofinishactivitieshestarts,appearsnottolisten,iseasilydistracted,hasdifficultyinconcentratingonanytaskrequiringsustainedattentionandhasdifficultystickingtoaplayactivity.

Impairmentoffocusedattentionandconcentrationdenotesaninabilitytoexerciseattentiononanobjectinapurposefulway,implyingweakeningofthedetermining tendency.Thisisafeatureofmaniaandhypomaniaandalsooccursinorganicstates.Thesefeaturescombinetoshowthesymptomsofdistractibility,whichisprominentinmaniaandsomeorganicstates.


Narrowingofattentionentailstheabilityofthesubjecttofocusonasmallpartofthefieldofawarenessandoccursinconditionsinwhichinvoluntaryattentionisdirectedelsewhere–byhallucinations, by delusions or by strong emotion. After an unprofitable conversation with apatientwithschizophreniainwhichsherepeatedlyignoredquestions,shesaid,‘IwishyouwouldnotinterruptwhenIambeinggivenmyinstructions’.

PSYCHOSIS AND ATTENTION

Schizophreniaisrecognizedasinvolvingdeficitsofattention(Posneretal.,1988).However,thereisconsiderabledifficultyinestablishingwhataspectsofattentionareimpairedinschizophreniabecausethetasksthatareusedtoassessattentionmayinvolveothercognitivefunctions,particu-larlysinceattentioniscloselytiedtoconceptsofworkingmemoryandalsotoexecutivefunction.Current evidence suggests that schizophrenia is associatedwith significant impairment in thecontrolofselection,theabilitytoidentifyandattendtotask-relevantinputs,whereastheremaynotbeimpairmentoftheimplementationofselection–theprocessesthatdeterminetheprocess-ingofrelevantinformationalinputs(LuckandGold,2008).

Ataphenomenological level,Cutting(2011)hasemphasizedthedegree towhichpatientswithschizophreniahaveheightenedattention.Whatremainstobedeterminediswhethertheexperiencesthatarereportedspeaktoactiveorpassiveattention.SeequotationsfromMcGhieandChapman(1961):

‘Things are coming in too fast. I lose my grip of it and get lost. I am attending to everything at once and as a result I do not really

attend to anything.’‘Everything seems to grip my attention although I am not particularly

interested in anything … often the silliest little things that are going on seem to interest me. That’s not even true, they don’t interest me but I find myself

attending to them.’

Itseemslikelythatinschizophrenia,onthebasisofthesereports,thereisagreatersuscep-tibilitytolureswithintheenvironmentthatcapturethepassiveattentionofthepatient.Agoodwaytounderstandthisistoimaginehowasudden,unexpectednoisecapturesourpassiveatten-tion. Itdoes seemas ifpatientswith schizophrenia are in thrall to irrelevant featuresof theirenvironment.

Thereiswell-establishedevidencethatinmooddisorders,includingbipolarmooddisorders,during the acute phase as well as in the euthymic state there are demonstrable impairmentsin sustained attention and working memory (Clark etal., 2002; Marvel and Paradiso, 2004;Thompsonetal.,2005).

Depressedmoodisoftenassociatedwithapreoccupationwithgloomythoughtstosuchanextentthatconcentrationandattentionareimpaired.Thissuggeststhatattention,whetheractiveorpassive, is luredbynegativelyvalued featuresof the individual’s innerorexternalworld. Insuchasituation,misinterpretationsofperceptioninfluencedbythemoodstatefrequentlyarise.Everyhearseisbelievedtobetheretocarrythepatienttothegraveyard,andapassingblackcarisnoticedjustsufficientlytobeconsideredasstrengtheningthisbelief.Similarly,acuteanxietyoftenresults indiminishedattention.Cutting(2011)arguesthat inmooddisorder,what lurestheindividualarepeopleandnotthings,incontrasttoschizophreniawherethereverseistrue.HisexampleisdrawnfromMinkowski:

‘I feel as if when you insist on something I must submit to your will and do what you demand of me … I am caught up in your affairs’.


There is aneed todraw thepsychopathologyandcognitivepsychology literature together.In the current state of knowledge it is impossible to see clearly how the patient’s subjectiveexperiencerelatestothefindingsoncognitivetesting.Eventhough,strictlyspeaking,phenom-enology is atheoretical in stance, this does not mean that a severe disjunction ought to existbetweenthedifferentmodesofknowledgeasthereisatpresent.

OrientationOrientationisthecapacityofanindividualtoaccuratelygaugetime,spaceandpersoninhiscurrentsetting.Thisenableshimtomakesenseof,andbeathomein,hisenvironment.Thisisvirtuallythesamefacultyasintellectualgrasp,inthatvariousperceptualcuesareused,andwithcorrectsenseoftimeandplacethepersonisabletocometoappropriateconclusionsfromhiscontext.Amansufferingfromanadvanceddementiawasbeinginterviewedbyadoctorinthepresenceofadozenstudentnurses,whoweretakingnoteswithpenandnotebook.Whenaskedwherehewas,helookedaroundtheratherdingyhospitalclassroomandsaid,‘Well,we’rewaitingtoseethedoctor’.Hehadpickedupcertaincluesthatremindedhimofageneralpractitioner’swaitingroom;hehadtotallymissedthefactthatallthenurseswereinuniform,thattheyweretakingnotesandthathewasbeingaskedformalquestions.Hewasdisorientatedinplaceandinperson.

Orientationintimeislabileandquitereadilydisturbedbyraptconcentration,strongemotionororganicbrainfactors(forexamplealcoholicintoxication).Milderdegreesofdisorientationareshownbyinaccuracyofmorethanhalfanhourforthetimeofdayordurationofinterview.Moreadvancedstatesaredemonstratedwithincorrectdayoftheweek,yearorperiodofday.Yetfurtherdisturbanceisshownwhentheseasonoftheyearisnotknowncorrectly.

Orientation in space is disturbed later in the disease process than time. A patient may beunable tofindhisway,especially inanarea that is relativelynew tohim. Itmay takehimaninordinate length of time to learn his way to the dining table in the ward after admission.Disorientation in time andplace are,when clearly established, evidenceof anorganicmentalstate;theymaybetheearliestsignsinadementingprocess.

Indisorientationforperson,thepatientfailstorememberhisownname.Lossofknowledgeofthepatient’sownnameandidentityoccursataverylatestageoforganicdeterioration.Lossofintellectualgrasp(apprehension)occursinorganicstatesasaformofdisorientation,usuallycombinedwithotherevidenceofdeterioration.Suchapersoncannotunderstandthecontextofhispresentsituationandconnectsoutsideobjectsandeventswithhimself.Disorientationmayoccurwithadisturbanceofconsciousness,attention,perceptionorintelligence.Insevereintel-lectualdefectandseveredisturbancesofmemory,orientationisimpairedevenwhenconscious-nessisclear(Scharfetter,1980).

DISORIENTATION

Orientationmayfluctuateinsomeorganicconditions,forexampleapatientwithanacutetoxicstateassociatedwithcongestivecardiacfailurewasdisorientatedintimeeveryeveningbutquiteclearmentallyinthemorning.

Disorientationintimeandlossofintellectualgrasp(situationaldisorientation)usuallyoccurfirstinaprogressiveillness;disorientationinplaceusuallyoccurslaterand,inperson,lastofall.Disorientation forone’sown identityoccursat a later stage than for thatofotherpeople.Anelderly woman who knew who she was and her previous status as a professor’s wife kept onreferringtoherdaughteras‘thatminxwhocomesineverytimethedoctorvisits’.

Delusions that Mimic Disorientation

Itis,ofcourse,importanttounderstandthephenomenologicaldistinctionbetweendisorientationandadelusionthatresultsinmisinterpretationofplace,ofsituationorofperson.Disorientationisusuallyassociatedwithotherorganicfeatures,suchasloweringofconsciousnessordisturbance


ofmemory.Delusionsofmisorientationhavethefeaturesofadelusion(Chapter8):apersononthewardmaybelievehimselftobeinprison,andavisitingrelativemaybeconsideredtobeaninterrogatorfromtheGestapo.

Dissociation and Disorientation

Definite, undisputed disorientation is indicative of either an acute organic brain syndrome, ifcoupledwithloweringofconsciousness,orchronicorganicdeterioration.Hystericaldissociationmaymimicthis,however,withapparentdisorientation.Carefulexaminationofthementalstateis likely torevealsuggestivediscrepancies, forexampledisorientationforpersonmaybemuchmoremarkedthanfortime,ormaybebizarretoanexcessiveextent.Apatientisdescribedinthe next chapter who lived in Birmingham, United Kingdom, but who found himself after ahystericalfugueinMontreal.Althoughapparentlydisorientated,heactuallyshowedanabnor-malityofmemoryaspartofadissociativestate.

Sleep DisordersSleep,deep, satisfyingandundisturbed, is conventionallyassociatedwithwell-beingandgoodhealth,asexemplifiedbythequotationwithwhichthischapterbegins;itsabsenceorpoorquality,equally, is held to account for disorder of mood and misery.There is a relationship betweendisturbedsleepandpsychiatricdisorder;mentalillnessmaycauseandmanifestassleepdistur-bance,disturbedsleepmayprecipitatepsychiatricsymptomsorthetwomayoccurtogetherbutindependently.TheInternationalClassificationofSleepDisorderssubsumes85sleepdisordersintosevencategoriesincluding:

1. insomnias;2. sleep-relatedbreathingdisorders;3. thehypersomniasnotduetoabreathingdisorder;4. theparasomnias;5. thesleep-relatedmovementsdisorders;6. othersleepdisorders;and7. isolatedsymptoms,apparentlynormalvariantsandunresolvedissues.ForafulleraccountseeAmericanAcademyofSleepMedicine(2005).Theobjectiveassessmentofsleepisusuallycarriedoutelectrophysiologically.Fivestagesof

sleep can be identified (Rechtschaffen and Kales, 1968). Using an electroencephalogram andelectromyogramoftheexternalocularmuscles,thedurationsofthedifferentstagesarerecorded.It has been shown that rapid eye movement (REM) sleep is associated with dreaming.Withcurrentneuroimagingtechniques, it ispossible,byshowingchanges inregionalcerebralbloodflow,tolocalizeandrepresentvisuallyalteredactivity,especiallyinthemedialthalamus,thatisassociatedwithdifferentstagesofsleepfromrelaxedwakefulnesstotheslow-wavesleepofstage4.Therearealsochanges in thevisualandauditorycortex,possiblyassociatedwithdreaming(Hofle etal., 1997). When considering the quality and duration of sleep and its stages, andwhetherthisamountstoasymptom,itisimportanttotakeintoaccounttheageofthepatient,anymedicationhemaybetakingandwhetherhehassleptduringtheday.Thesubjectiveexperi-ence,asdescribedbythepatient,maybeverydifferentfromtheobjectivefindingsofobservationandmeasurement.Thepsychiatristshouldinvestigatethemeaningofthisdiscrepancyphenom-enologicallyandconsidertheconsequencesfordiagnosisandtreatment.

INSOMNIA

Insomniaimpliessubjectivedissatisfactionwiththedurationorqualityofsleep(Oswald,1981);however, in many psychiatric conditions there is also objective disturbance of sleep. Formally,


insomniasaredefinedbydifficultywithsleepinitiationand/ormaintenance,andfinalawakeningsthatoccurearlierthantheestablishedwake-uptime(AhmedandThorpy,2010).Theindividualmaycomplainthatthedurationofsleepistooshort;orthatsleepfeelsbroken,lessrefreshingorinsufficientlydeep;orthatthepatternofsleephaschangedfortheworse.Insomniaismorecommoninwomenandinolderpeopleandismoreoftenassociatedwithafeelingofexcessivemental arousal than bodily disorder. Causes of dissatisfaction include unrealistic expectationsfromtheelderlythattheywillsleepforaslongastheydidwhentheywereyounger,andfromthesedentarythattheywillsleepasdeeplyasafterexhaustingphysicalactivity.

Adiscussionofprimaryinsomniaisoutsidethescopeofthisbook.Itiswellrecognizedthatcomplaintsofsleepingpoorlyarecommon,andoccur inmanypsychiatricdisorders, includingdepression,generalizedanxiety,panicandphobia,hypochondriasisandwithpersonalitydisorders.Theyareamongthemostfrequentsymptomsinanxiety-relateddisordersandaffectivedisorders.Comparingthosepeoplewithneuroseswithanormalpopulation,Jovanovic(1978)foundthatneuroticpatientscomplainedofmorewakefulnessinthefirstthirdofthenight;theyspentmoretime lyingawake inbed, theyawokeduring thenightmore frequently, they spenta relativelyshortperiodindeepsleepandtheirsleepwasmorelikelytobeimpairedbyunfamiliarsurround-ings.Thosewithmajordepressivedisordersufferfromdisturbedsleep,inwhichtheytakelongertofallasleepandspendlesstimeasleepbecauseofperiodsofwakefulnessduringthenightandearlymorningwakening.

Early insomnia,ordifficultyingettingofftosleep,occursinnormalpeoplewhoarearousedthroughanxietyorexcitement.Theirthoughtstendtodwellontheaffect-ladenexperiencesoftheimmediatepastandalsotorehearsewaysofdealingwithproblems.Fatigueisexperienced,but there is also ahigh level of arousal thatprevents thenecessary relaxation andwithdrawalfromperceptionthatisrequiredforsleeping.Late insomniaorearly morning wakeningisparticu-larlycharacteristicofthedepressivephaseofaffectivedisorders.Thepatientmaywakefrequentlyin the night after getting off to sleep satisfactorily and thenceforward sleep only fitfully andlightly.Alternatively,hemaywakeearlyinthemorningandbeunabletogettosleepagain.Theimportantcharacteristicofdepressionisthatthereisamarkedchangeinsleeprhythmfromthenormalpattern for thatperson. Indepression, theearlymorningwakening isoftenassociatedwithmarkeddiurnalityofmood,withthemostseverefeelingsofdespondencyandretardationoccurringintheearlymorning.Thereisalsooftenamarkedreductionofsleeprequirementinmania.

Themeansleeprequirementdiminisheswithincreasingage.Itisusuallyaboutseventoeighthoursthroughthemiddleadultyearsbutismarkedlyreducedfromabout50yearsofageonwards.Withinsomnia,intermediatestagesoflight,restlesssleepoccur.Theseareoftenassociatedwithabnormal experience in the sleepy state, such as hypnagogic and hypnopompic hallucinations(Chapter7).Pseudohallucinationsalsooccur,asdoesvividimagerythatisdifficulttodistinguishfromhallucination.Normally,passage intosleepisrapidandoccurspassivelyratherthanwithactiveintentiontosleep.Wakingisalsonormallyrapid,andtheslowingofthisprocessofbecom-ingawakemaybedescribedasasymptom:acomplaintoffeelingdrowsyandbeingincompetentanduncoordinatedforanexcessivetimeonwakening–inotherwords,sleep drunkennessormoreaccurately confusional arousals from non-REM sleep in which confusion and disorientation,slowedspeechandmentationoccur(Lishman,1997;AhmedandThorpy,2010).Suchpatientsmay sleep for 17 hours or more and always require vigorous stimulation to wake them.Theconditionmaypersistthroughoutlife.

HYPERSOMNIA

Inhypersomniathedefiningcharacteristicisdaytimesleepiness.Thesecasesaremoreoftenseenbyaneurologistthanapsychiatristandarereportedonlybrieflyhere.


IntheKleine–Levin syndrome,attacksofsomnolenceoccur,usuallyinadolescents.Thecondi-tionisrare.Inearlieraccounts,thepatientsleepsexcessivelybydayandnightbutisrousableasfromnormalsleep.Whenawake,thepatienteatsvoraciously(megaphagia)andmayshowmarkedirritability(Critchley,1962).Morerecentlyithasbecomeclearerthattheconditionischaracter-izedbyrelapsing-remittingepisodesofseverehypersomnia,cognitiveimpairment,apathy,dere-alizationandpsychiatricandbehaviouraldisturbances.Boysaremore frequentlyaffected thangirls.Justoverhalfofpatientshavehyperphagia,arehypersexual(mainlyboys),orhavedepressedmood(mainlygirls),andaboutathirdhaveotherpsychiatricsymptomssuchasanxiety,delusionsorhallucinations.Althoughsomesymptomsaresimilartothoseinpatientswithencephalopathy,imaging and laboratory findings are unremarkable.The first episode of hypersomnia is oftentriggeredbyaninfection,withrelapsesoccurringevery1–12monthsforamedianof14years.Between episodes, patients generally have normal sleep patterns, cognition, mood and eatinghabits. During episodes, electroencephalography might show diffuse or local slow activity.Functional imaging studies have revealed hypoactivity in thalamic and hypothalamic regions,andinthefrontalandtemporallobes(Arnulfetal.,2012).

Narcolepsyisaformofhypersomniaandcanoccureitherwithorwithoutcataplexy.Narcolepticattacksareshortepisodesofsleep(10to15minutes)thatoccurirresistiblyduringtheday;theyusuallybeginduringadolescenceandpersistthroughoutlife.Narcolepsyisoftenassociatedwithcataplexy,duringwhichthesubjectfallsdownbecauseofsuddenlossofmuscletoneprovokedbystrongemotion.Hypnagogic hallucinationsandsleep paralysismayalsooccur,butlesscommonlyso. Narcolepsy is associated with short sleep latency and sleep-onset REM periods.There isusuallyno structuralbraindiseasepresent.Hypnagogichallucinationsareusuallyauditorybutmaybevisualortactile.Theyoccurbetweenwakefulnessandsleep,lesscommonlybetweensleepandwakening (hypopompichallucination).Sleepparalysis is the inability tomoveduring theperiodbetweenwakefulnessandsleep(ineitherdirection).

InthePickwickian syndrome,namedafterthefatboyofThe Pickwick Papers(Dickens,1837),ormorespecificallyobstructive sleep apnoea,profounddaytimesomnolenceisassociatedwithgrossobesityandcyanosisduetohypoventilation.Breathingisperiodicduringsleepandsomnolence,withapnoeicphasesthatmaylastforuptoaminute.

Sustaineddrowsinessmayoccurwithorganiclesionsofthemidbrainorhypothalamusfromvarious causes. Hunger, weight gain, excessive thirst and polyuria may also occur. The mostimportantconditionsgivingrisetosecondaryhypersomniaarebraintumours,neurosarcoidosisandNiemann-PicktypeCdisease.

Hypersomniamayalsooccurasapsychogenicsymptom.Theremaybeastateamountingtohystericalstupor,andotherconversionsymptomsmaybepresent.Otherpatientswithneuroticdisorderscomplainpersistentlyofdaytimesomnolenceandaninabilitytoconcentrate.

PARASOMNIAS

The parasomnias are disorders of arousal and sleep-stage transition that consist of abnormalsleep-relatedmovements,behaviours, emotions,perceptions,dreamingandautonomicnervoussystemfunctioningthataccompanysleep(AhmedandThorpy,2010).Sleepwalkingisanexampleandconsistsofa seriesofcomplexbehavioursarisingduringslow-wavesleepandresulting inwalkingduringaperiodofalteredconsciousness.Itismorecharacteristicofchildrenthanadults,andofmalesmorethanfemales.Activityisusuallyconfinedtoaimlesswanderingandpurposelessrepetitivebehaviourforafewminutes.Thesleepwalkermayreplymono-syllabicallytoquestions,andthereislittleawarenessoftheenvironment,butinjuryisunusual.Frequentlythereisafamilyhistory,andenuresisisoftenassociated.Assleepwalkingoccursindeepsleep(stages3and4),usuallyduringthefirstthirdofthenight,itisunlikelytobetheactingoutofdreams.Itisnotthe same phenomenon as epileptic automatism, which may also result in a person, who is


apparentlyasleep,gettingupandwalkingaround.It is important toestablish thediagnosis ineachcase.

Night terrorsalsooccurindeepsleepearlyinthenightandofteninthesameindividualwhosleepwalks. Intense anxiety is manifested, the subject may shout and there is rapid pulse andrespiration.Usually,thereiscompleteamnesiafortheexperienceonwaking.Itisnotthesameexperience as anightmare,because the latter is a typeofdream,occurring in lighter statesofsleep, and is rememberedvividly if thepersonawakes immediatelyafter theexperience.Mostchildrengrowoutofnightterrorsandsleepwalking.

Claimshavebeenmadethatautomatic,violentbehaviourhastakenplaceduringanightterror.Apersonwhocommitsacriminalactwhileasleepisnotconsciousofhisactionsandcannotbeheld legally responsible for them; the lawcalls this sane automatism (Fenwick,1986;EbrahimandFenwick,2010).Iftheact,for instancehomicide, isrememberedbyitsperpetratorasfol-lowingachainofpsychicevents(‘beingchasedbyJapanesesoldiers’),theseimagesaremostlikelytohaveoccurredinthecontextofanightmareandtheactthereforetookplaceonwakingfromthedreamandwouldberegardedasmotivated.Duringthenightmareitself,sleepparalysiswillpreventviolentemotionsbeingactedon.Fortheacttobeconvincinglyascribedtonightterror,neithertheactnoritsantecedentstorylineshouldberememberedandall theevidenceshouldpointtotheindividualbeingasleepatthetime.Previousevidenceofnightterrorandsleepactivityisimportantforcorroboration.

Less known are the reports of sexsomnia in which sexual behaviour occurs during sleep.These cases seem to occur in the setting of disorders of arousal, the so-called non-REMparasomniasthatincludeconfusionalarousal,sleepterror,andsleepwalking;REMsleepbehav-iour disorder; nocturnal partial complex seizures; and obstructive sleep apnoea (Ebrahim andFenwick,2010).

DreamsHowdoesphenomenologyviewdreams,theirsignificanceandtheirinterpretation?First,phe-nomenologycanbeconcernedonlywithwhatisconscious;itcannotcommentonthatwhichisunconscious, although it may infer the existence of unconscious insofar as it explains someobservedbehavioursandphenomena.Second,themeaningbelongstothedreamerandnottoan interpreter or theorist.This has implications for the way in which the phenomenologicalapproachwillbeusedintherapy.

Phenomenologycanmakeacontributiontotheunderstandingofdreaming.Bothbyintro-spectingandbytakingaccountsfrompatientswhileactuallydreaming,weknowthatmemoryisaccurateanddetailed,sometimesverydetailed.Also,theprocessofreasoningisfaultless,bothforwhenbizarreelementsintrudeandalsoforwhentheydonot.Thesebizarreelements,there-fore,demonstrateneitherdeficientmemorynorincapacityforrationalthinking.Theyappeartobepremises –theEuclidean‘let’.Indreaming,fantasyispermittedsothatwhenwesay,ordream,‘letBillSnooks (who lives inHeckmondwike andhasnevermet thePresidentof theUnitedStatesofAmerica)travelonabargedowntheAmazon’;what,then,wouldhappennext?Thisphenomenologicaltheoryofdreamscouldbeexploredexperimentally;ifattitudescanbechangedinconsciousnessbycognitivereprocessing, thentheconstructs thatareused indreamsshouldalsobecapableofchange.

Orthodox sleep (stages 1 to 4) and paradoxical sleep (REM sleep) have been distinguishedfrom each other through the use of sleep electroencephalographic tracings in human subjects(Oswald,1980).Normalreflexactivityoccursinthestagesoforthodoxsleep,butlocalizedactivityis seen in paradoxical sleep while other muscle actions are paralyzed. REMs in paradoxicalsleep are to some extent associated with dreaming. Nightmares are unpleasant dreams; often,the particular horror of a nightmare is that there is nothing the sufferer can do about the


terrifying experience. Dreaming occurs in REM (paradoxical) sleep, and the transfixedsensation of the nightmare is an accurate representation of the sleep paralysis that occurs inthatphase.

Dreamshavebeenusedtoestablishelaboratepsychiatrictheoriesconcerningtheoriginsofconflict; it is outside the scopeof this book to enter into anydiscussionof this area. It is, ofcourse,atopicthatwasextensivelywrittenaboutbySigmundFreud(1976).Morerecently,themeaningofdreamshasbeenexploredempiricallybyKrameretal.(1976).Dreamsareremem-beredanddescribedasapsychicevent:nightmares(unpleasantdreams)areoftencomplainedofandmaybeaprominentsymptom,forinstanceindepression.Dreamsarehighlycomplexexperi-encesand,sofar,havedefiedadequateanalysisandexplanation.However,certaincharacteristicscanbedescribed.

Thereisalossofsomeofthestructuresofwakingconsciousness,thusthereisalossofself-awarenessandawarenessoftheconfinesofone’sownbody.Themarginbetweenselfandnot-selfbecomesindefinite.Thedreamermaydreamofhimselfmergingortransformingintosomeoneelsewithoutcontradiction.Timesenseisalsolost:thereisnosenseofprogressionofeventsbutonlyimmediateawarenessofthepresent.Eventsoccurringinthedreamincludethoseinwhichthedreamerhimselfisinstrumental.Thereisoftenalossofthesenseofhishavingcircumstanceswithinhiscontrol,andthereisalsoalossofthephysicalandmentalassociationsbetweenthedifferentpartsofawholeexperience.Thereare,therefore,gapsunaccountedforinspaceaswellasintimeandcausation.

Aswellas the lossof temporalandspatialconnections, there isa lossof thepsychologicalassociations between events.There is no progressive sequence of serial ideas or pictures.Thedreamisoftenlikeagroupofshortexcerptsfromverydifferentfilms.

Inadditiontothelossofstructurethatistypicalinthedreamingstate,therearealsoelementsthatdonotoccur inthenormalwakingstate.Thesearebestcalleddreamimages,as theyarenotaccuratelydelusions,hallucinations,falsememoriesorotherabnormalitiesofperceptionorideation characteristic of being awake.These images are more vivid than fantasy and have acharacteristicofimmediacyandimportance,soitisnotsurprisingthatfromthebeginningsoftimepeoplehaveactedontheirdreamsasiftheywereinstructions.

To regard dreaming as a symptom rather than merely a remembered experience, it hastobecomeinvestedwithunpleasantaffect.Apatientmaydescribepleasantdreamsifrequested,buthedoesnot usually complainof these as symptomsor ask for their removal.However, ifthedreamisassociatedwithanxiety,terror,gloomorforeboding,andespeciallyifthecontentorthethemeisrecurrent,itwillbecomplainedofandwillindicateaprevailingaffect;possibly,theareasofconflictthathaveprecipitatedthedistresswillberevealedinthecontentofthedream.Unpleasant dreams in which a part of the traumatic event is re-experienced are a diagnosticfeatureofpost-traumaticstressdisorderfollowingmajordisasterorcatastrophe.

HypnosisIthasbeensuggestedbyMarcuse(1959)thatwe‘definehypnosisbywhatitdoesratherthanbywhatitis’.Atoneextreme,hypnosisisconsideredtobeaverydifferentstateofawarenessfromnormalwakingconsciousness.Attheotherextreme,Merskey(1979)considersthat‘thephenom-enaofhypnosisareidenticalwiththoseofhysteria:theyinvolveself-deceptionandtheproductionofalternativesymptomsorbehaviourtosolveaproblem,evenifnotaconflict’.Merskeyfurthergoesontoproposeasdefinition:

Hypnosis is a manoeuvre in which the subject and hypnotist have an implicit agreement that certain events (e.g. paralysis, hallucinations, amnesias) will

occur, either during a special procedure or later, in accordance with the


hypnotist’s instructions. Both try hard to put this agreement into effect and adopt appropriate behavioural rules, and the subject uses mechanisms of

denial to report on the events in accordance with the implicit agreement. This situation is used to implement various motives whether therapeutic or otherwise, on the part of both participants. There is no trance state, no

detectable cerebral physiological change, and only such peripheral physiological responses as may be produced equally by non-hypnotic suggestions or other

emotional changes.

Superficially, hypnosis appears to resemble sleep, but there are no electroencephalographicfindingstodistinguishhypnosisfromotherstatesofrelaxedwakefulness.Thetranceinhypnosisisproduced,therefore,inawakingstatebyonepersononanotherusingsuggestionwithcompli-ance(Marcuse,1959).Ithasbeenclaimedtooccurinnon-humanspecies,butthisstatecannotnecessarilybeconsideredidenticalwithhypnosis.Hypnosishasbeenusedforthecontrolofpain,inthetreatmentofhyperemesisgravidarum,forvarioussexualdifficultiesandespeciallyinthecontrolofanxiety(Waxman,1984).

TheinductionofhypnosisrequirestheimplicitcontractMerskeyimplies.Thesubjectmustbewillingandcooperative;heorsherelaxesandexercisesimagination.Thefieldofconsciousnessisnarrowedtoincludeonlytheinstructionsofthehypnotist.Thesubjectrelinquishessomedegreeofcontroltothehypnotistandacceptsrealitydistortion.Followingthesuccessfulinductionofhypnosis,autohypnosiscanbecomeestablished.Marcuseconsidersthefollowingtobethechar-acteristicsofahypnoticstate:

■ thesubjectceasestomakehisownplans■ attentionisselectivelydirected,forexampletowardsthevoiceofthehypnotist■ realitytestingisdiminishedanddistortionsareaccepted■ suggestibilityisincreased■ thehypnotizedsubjectreadilyenactsunusualroles■ post-hypnoticamnesiaisoftenpresent.Suggestion,forthehypnoticsubject,isstraightforwardandobvious;itdoesnotimplygullibil-

ityorlossofwill-power.Itdescribestheemotionoftrustoccurringwithintheimplicitrelation-shipinwhichthesubjectacceptsthehypnotist’sstatements,actsonhiscommandsanddeniesevidencefromhisownsensesthatwouldcontradictthosestatements.

Acapacityforfantasyisnecessaryforhypnosistotakeplace.Therelaxationthataccompanieshypnosis may progress to normal sleeping, even during a hypnotic session.The alteration inconsciousawarenessoccurring inhypnosis is similar to that indissociative statesbutdifferentfromthefluctuationsofconsciousnessleveloccurringinorganicpsychosyndromes.

Suggestionhasbeenusedtoproducemanyphysicalsequelae,forexampleblisters,alterationsinpulseandbloodpressure,levitationofanarm,opisthotonos,absenceofpainsensationandsoon.Thepsychologicaleffectsareequallyvariableandincludealterationstoperception,cognition,ideation,memoryandaffect.Thesubjectentersadramaticallyalteredstateinwhichhetempo-rarilysurrendersresponsibilityforhisactionstothehypnotist.Inhisturn,thehypnotistretainstheconfidenceof the subjectonlyas longashekeepswithin the limitsofbehaviour that thesubjectfindsacceptable;beyondthis,thesubjectwillrelinquishhisdependentrelationshipandcomeoutofthehypnoticstate.

Hypnosisremainsanenigma.Thereisnowemergingevidenceoftheunderlyingneuralcor-relatesofhypnotizabilityandofthehypnoticstateitself.Thesepointtogreaterfunctionalcon-nectivitybetweentheleftdorsolateralprefrontalcortex,anexecutive-controlregionofthebrain,andthesaliencenetworkcomposedofthedorsalanteriorcingulatecortex,anteriorinsula,amyg-dala and ventral striatum, involved in detecting, integrating, and filtering relevant somatic,


autonomicandemotionalinformationinhighlyhypnotizablesubjectscomparedtolesshypnotiz-able subjects (Hoeft etal., 2012). As for the hypnotic state itself, during mental imagery forrehabilitationofneurodisability,fMRI-signalincreasesexclusivelyrelatedtohypnosishavebeenobserved inthe leftsuperior frontalcortex, the leftanteriorcingulategyrusand left thalamus.Whilethesuperiorfrontalcortexandtheanteriorcingulatewereactivatedrelatedmoretomove-mentperformancethantoimagery,thethalamuswasactivatedonlyduringmotorimagery.Theseareas represent centralnodesof the saliencenetwork linkingprimaryandhighermotorareas.Thissuggestshypnosisenhancesmotorimagery(Mülleretal.,2012).Muchworkstillneedstobedonetounravelthephysiologyofhypnosis.

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59

C H A P T E R 5

Disturbance of Memory

SummaryMemoryhasawell-describedanddelineatedarchitecture,namelysensorymemory,short-termmemoryandlong-termmemory.Short-termmemoryisitselfsubdividedintoacentralexecutiveandtheslavesystems,termedvisuospatialscratchpadandthephonologicalloop.Thisarchitec-tureallowsforasystematicunderstandingoftheunderlyingprocessesatplayinmemory.Itishelpfultoconceptualizethememoryprocessesasincludingregistration,retention,retrieval,recallandrecognition.Thesetermsallowforanunderstandingoftheanomaliesthatareexhibitedinorganicimpairmentsofmemory.

Cans’t thou not minister to a mind diseas’d;Pluck from the memory a rooted sorrow;

Raze out the written troubles of the brain;And with some sweet oblivious antidote

Cleanse the stuff ’d bosom of that perilous stuffWhich weighs upon the heart?

William Shakespeare (1606)

Disturbanceofmemoryisalwaysofsignificanceforthesufferer;sometimes,however,forget-tingisequallyimportantandisanactiveprocess,asinthequotationabove.Thatmemorydis-turbance was a specific feature following head injury and other conditions was recognized inneuropsychiatricwritingsinthemid-nineteenthcentury;HughlingsJackson(1887)consideredittobeanintegralpartofdeteriorationinorganicmentalfunctioning.Theearliestdetailedstudyofdisorderedmemory fromapsychological standpointwasbyRibot (1882).Korsakov (1890)subsequentlydescribedhis eponymous condition, pointingout that grossdisorder ofmemorymayoccurinpatientsinwhomotherintellectualfunctionsandjudgementarepreserved.

Mechanisms of MemoryOneofthemajorjustificationsforusingpsychopathologyinthedescriptionofmemorydistur-banceisthatthereexistsnogoodanalogueofmemoryinanimals.Conventionally,disturbanceofmemoryisdescribedbythe lengthoftimeforwhichinformationhasbeenretained.Ifoneconcentratesonthephenomenologicalaspects,theanalysisofexperience,itisinfactquitearbi-trarytomakeadistinctionbetweenmemoryandperceptionastheyarebothstagesininformationprocessing(Weinman,1981).Memorystorageisorganizedinthreeways.

SENSORY MEMORY

Sensorymemoryistheinitialandearlyphaseofmemory.Itholdslargeamountsof incominginformationbriefly.Itisaselectingandrecordingsystemviawhichperceptionsenterthememorysystem(Lezaketal.,2004).Fleetingvisual image,iconicmemory, lastsupto200milliseconds,

Keywords: Memory,Confabulation,GanserState.

5—DISTUrbANCE Of MEMOry 59.e1


whereas auditory, echoicmemory, lastsup to2,000milliseconds.The information selectedandrecordedatthis levelneedstobefurtherprocessedasshort-termmemoryoritquicklydecaysandislost.

SHORT-TERM MEMORY

Short-termmemoryisconceptualizedasalimitedcapacitysystemthatoperatesasasetofsub-systems.Whileitistheoreticallydistinguishablefromattention,inpracticeitisprofitablyequatedwithasimplespanofattentionlimitedtosixorsevenitemsandlasting15to30secondsunlesstheitemsarerehearsed.BaddeleyandHitch(1974)hypothesizedamodelofworkingmemorycomprisingacentral executive, a visuospatial scratch padandaphonological loop.Inthissystem,thecentral executiveistheattentionalcontrollerassistedbythevisuospatial scratch padthatallowsforthetemporarystorageandmanipulationofvisualandspatialinformation.Thephonological loopholds memory traces of verbal information for a couple of seconds combined with subvocalrehearsal(Baddeley,1986;Baddeley,2002).

LONG-TERM MEMORY

Long-term memory can be conceptualized into two retrieval systems: a declarative system, orexplicitmemory,thatdealswithfactsandeventsandisavailabletoconsciousnessfordeclaration,and a non-declarative or implicit system (Lezak etal., 2004).The declarative system can befurtherdividedinto semantic (factmemory)andepisodic (memoryforspecificautobiographicalincidents)memory.Inotherwords,semantic memoryisthestorageofinformationinpureformwithout specification of time or place (‘General Psychopathology was written by Karl Jaspers’),whereas episodic memory refers to personally experienced events (‘I had a kipper for breakfasttoday’)(Baddeley,1990).Long-termmemorycanholdinformationforperiodsoftimefromafewminutestomanydecades,andthecapacityisverylarge.Forgettingmaybebylossofinfor-mationorfailureofretrieval.Normalforgettingratesaredeterminedbysuchvariablesaspersonalmeaningfulnessofthematerial,conceptualstyleandage.Storagein,andalsoretrievalfrom,thelong-termmemoryisimpairedinthedysmnestic syndromes.Informationisstoredinreorganizedandsometimesdistortedform.

Descriptionof the requirements formemory is chiefly referable to long-termmemoryandcanbesubdividedphenomenologicallyintothefollowingfivefunctions.

■ Registrationorencodingisthecapacitytoaddnewinformationtothememorystore.■ Retentionorstorageistheabilitytomaintainknowledgethatcansubsequentlybereturned

toconsciousness.■ Retrieval isthecapacitytoaccessstoredinformationfrommemorybyrecognition,recall

orimplicitlybydemonstratingthatarelevanttaskisperformedmoreefficientlyasaresultofpriorexperience.

■ Recallistheeffortfulretrievalofstoredinformationintoconsciousnessatachosenmoment.It requires anactive, complex searchprocess. It is influencedbyprimacy (first item)andrecency(lastitem)effects.Thequestion‘WhatisthecapitalofFrance?’requirestherecallfunction.

■ Recognitionistheretrievalofstoredinformationthatdependsontheidentificationofitemspreviously learnedand isbasedoneither remembering (effortful recollection)orknowing(familiarity-basedrecollection).Inthisprocess,astimulustriggersawareness;rememberingorknowingthentakesplace.Thequestion‘WhichofthefollowingisthecapitalofFrance:Paris,LilleorLyon?’teststherecognitionfunction.

Abnormalityofmemorymayoccurinanyoftheseareas.Inotherwords,therecanbeimpair-mentofencoding,impairmentofstorageorimpairmentofretrieval.

5—DISTUrbANCE Of MEMOry 61

Organic Impairment of MemoryMemory disturbances can be separated into those that are psychogenic, sometimes occurringin healthy people, and those that are organic, associated with disease of the brain.The latterare referred to as organic or true amnesias and can be described by the different functions ofmemory.

IMPAIRMENT OF REGISTRATION

In anterograde amnesia, the impairment is usually demonstrated in the failure of retrieval ofinformationencounteredaftertheonsetofaclinicaldisorder.Thisimpairmentofretrievalmay,ofcourse,beduetoproblemsattheregistration(encoding)stage,particularlyinpatientswithKorsakov’ssyndrome.Thereisevidencethatthesepatientsmayhavedifficultyinspontaneouslyencodingthesemanticfeaturesofinformationtoasufficientlevelatinput,andthisfailureresultsinpoormemory(Mayes,2002).Itisthereforeproblemsintheinitialanalysisandrepresentationofinformationandtheinabilitytoselectthesalientsemanticfeaturesofinformationthatunderlieimpairmentofregistration.Inalist-learningtestsituation,forexample,thesemanticfeaturesofthewords,suchasthefactthatthewordsarederivedfromalistofthenamesofflowers,failstoassistthesubjecttoencodethenewinformation.

IMPAIRMENT OF RETENTION

Retrograde amnesiaisthelossofmemoryforeventsprecedingtheonsetofbraininjury.Aswithanterogradeamnesia,thedeficitisdemonstratedintheimpairmentofretrieval,butitisthoughttobeduetoimpairmentofretention(storage),particularlyincasesofcerebraltrauma.Usually,itisofshortdurationoflessthan30minutes.Typically,itfollowsatemporalgradientinwhichnewermemories aremore vulnerable to loss thanolder ones.There is a dissociationbetweenanterogradeandretrogradeamnesiathatsuggeststhattheanatomicalstructuresinvolvedinnewlearningandretrievalofoldmemoriesaredistinct.

IMPAIRMENT OF RETRIEVAL OR RECALL

Retrievalisthecapacitytoaccessinformationfrommemorystores.Impairmentofretrievalcanbe due to a deficit in either direct retrieval, in which a cue elicits a memory automatically, orstrategic (indirect) retrieval, inwhich a cueprovokes a strategic searchprocess that produces aresult.Indirect retrieval,thequestion‘HaveyoueverbeentoLagos?’actsasacuethatelicitsamemoryautomatically.Instrategic retrieval,thequestion‘WhowontheWorldCupbeforethecurrentchampions?’instigatesastrategicprocessthatframesthememoryproblem,initiatesthesearch and constrains it, guiding it towards local, proximal cues that then activate associativememoryprocesses.Thememoryoutputisthenmonitoredforaccuracyandplacedinapropertemporal-spatial context in relation toothermemories (GilboaandMoscovitch,2002).Direct retrieval is thought tobedependentonmedial temporal lobes and related structures,whereasstrategic retrieval is dependenton the ventromedial prefrontal cortex.Confabulation is a goodexampleofaconditionthatisaresultofimpairmentofretrieval.Itresultsfromafaultymemorysystemcreatingfaultycue-memoryassociations,faultysearchstrategiesanddefectivemonitoringoffaultymemories(GilboaandMoscovitch,2002;DeLuca,2009).

IMPAIRMENT OF RECOGNITION

Recognition is the retrieval of stored information that depends on the identification of itemspreviously learned. In episodic memory, that is, memory for events that includes the context,


time, place and emotions associated with the event, recognition can take the form of eitherconsciousrecollection(remembering)orknowingbasedsimplyonasenseoffamiliarity.This isthe so-called remember-know paradigm, and it proposes a dual process memory system, onerelyingonconsciousrecollectionandtheotherbasedonfamiliarity.Inotherwords,thephenom-enal experience that accompanies the recognition of a previously presented stimulus seems totakeatleasttwoforms.Recognitioncanoccurwhenthestimulusevokessomespecificexperienceinwhichthestimuluswaspreviouslyinvolved,oralternativelythestimulusgivesriseonlytoafeelingof familiaritywithoutanyrecollectiveexperience.A‘remember’ response indicates thatrecognizingthestimulusbringsbacktomindsomeconsciousrecollectionofitsprioroccurrence,whereas a ‘know’ response indicates that recognizing the stimulus is not accompanied by anyconsciousrecollectionofitsprioroccurrence(DallaBarba,1997;Tulving,2000).ImpairmentofrecognitionhasbeendescribedinAlzheimer’sdisease(DallaBarba,1997)andinschizophrenia(Drakefordetal.,2006).

Various Disturbances of MemoryDÉJÀ VU AND RELATED PHENOMENA (IDENTIFYING PARAMNESIA)

Déjà vuisnotprimarilyamemorydisorderbutadisturbanceinwhichtheassociatedfeelingoffamiliarity thatnormallyoccurswithpreviously experiencedeventsoccurswith anovel event,that is, when the event is experienced for the first time. In jamais vu, an experience that thepatientknowshehasexperiencedbeforeisnotassociatedwiththeappropriatefeelingoffamiliar-ity.Thepatientmayalsohavethefeelingthatsomeimportantmemoryisabouttoberecalled,althoughitdoesnotactuallyarrive.

Déjà vuandjamais vuarecommon,normalexperiencesbutmayalsobesignificantsymptomsoftemporallobeepilepsyorcerebrovasculardisorder(Lishman,1998).Anepilepticpatientsaid,‘I feel that I’ve done something terribly wrong’. However, these experiences on their own, orassociatedonlywithvaguefeelingsofdepersonalization,shouldnotbeacceptedasevidenceoftemporallobeepilepsy,asthesesymptomsarealsofrequentlyexperiencedbothinpatientswithanxiety-relateddisordersandinnormalindividuals.

CONFABULATION

Thisisafalsificationofmemoryoccurringinclearconsciousnessinassociationwithanorgani-callyderivedamnesia(Berlyne,1972).Itisprobablybesttoconceiveofconfabulationasaloosetermthatcoversawiderangeofqualitativelydifferentmemoryphenomena.Thetermisusedtodescribemilddistortionsofanactualmemory,suchasintrusions,embellishments,elaborations,paraphrasingorhighfalsealarmratesontestsofanterogradeamnesia.Itcanalsorefertohighlyimplausiblebizarredescriptionsoffalserealitiessuchasclaimingtobeaspacetravellertemporar-ilyresidentonearth(GilboaandMoscovitch,2002;Box5.1).However,itisalsotruethattheterm‘confabulation’hasbeenextended,unhelpfullyinmyview,toinclude:

1. memoryconfabulations;2. confabulations about intentions and actions as can occur in split-brain subjects or in

hemiplegiaoftheleftarmwherethesubjectdeniestheirdisability;3. perceptualconfabulationswhichoccursinAnton’ssyndromecharacterizedbyunawareness

ofblindness;and4. confabulationaboutemotions(seeHirstein,2009forafullerreview).Bonhoeffer(1901)observedthatconfabulationinKorsakov’ssyndromecouldtaketwoforms.■ Confabulationofembarrassmentwasadirectresultofthememorylossanddependedfor

itspresenceonacertainattentivenessandactivity.Thisformofconfabulationismomentary


innature.Thepatient tries to cover an exposedmemory gapby an ad hoc confabulatedexcuserelatingtohisrecentbehaviour.Itdoes,therefore,revealsocialawarenessandsomerealizationoftherequirementsofthesituationintermsofsocialbehaviour.

■ Inothercases,confabulationexceededtheneedsofthememoryimpairment;thepatientdescribesspontaneouslyadventurousexperiencesofafantasticnature.Thespontaneityisakeycharacteristicofthisformofconfabulation.Suchmemorydisturbancemayoccurwithorganicdeteriorationfollowingalcoholabuseandalsointhe‘organicamnesicsyndrome,not induced by alcohol and other psychoactive substances’ (ICD-10; World HealthOrganization, 1992), in which there is severe memory impairment, especially for recentmemory;evidencefordisorderofthebrain;andabsenceofadefectinimmediaterecall,adisturbanceofattentionandconsciousness,andglobalintellectualimpairment.

SuggestibilityisaprominentfeatureoftheconfabulatingpatientandwasconsideredbyPick(1921)tobedependentoncloudingofconsciousness,weakenedjudgementandtheinterplayoffantasy; it may, in fact, closely resemble daydreams. The confabulating patient may producemutuallycontradictorystatementsconsecutivelyandnotmakeanyattempttocorrectthem.Thematerialofconfabulationshasbeenlikenedtodreams(Scheid,1934).Ithasalsobeenexplained,in termsofmemorydisturbance, that confabulations are actual experiences takenoutof theirchronologicalorder(VanderHorst,1932)andthattheindividual’swishesandinterestsguideconfabulationinthesamewayasindreamsandfantasy.

Itseemsprobablethatconfabulationisrelatedtothenormalmechanismsofrecollection.Forexample,saythatalltheownersofacertainmodelofcarwereaskedbythepolice,aspartofalarge-scalemurderhunt,whattheyweredoingonaparticularMondayaboutninemonthsprevi-ously. To answer this question, an individual would have no recollection for that particularMonday,sohewouldrecreateatypicalprogrammewithregularmovementsandtimesofappoint-mentsforaMondayfromaboutthatperiod.Itwouldseemthatthemechanismofsocial confabu-lation isofthatorder.Tothequestion‘Whatdidyoudoyesterday?’,theconfabulatingpatientmightsay,‘Ipushedmybaby in thepramdowntotheofficetoseemyoldworkmates there’.Thiscouldindeedhavehappened12yearspreviouslyaftershehadresignedherjobinthatofficeduringherpregnancy.Thefantastictypeofconfabulationisalsodirectlyassociatedwithmemory.Normally,onehasaclearmemoryofwhichsensationsandeventswereexperiencedandwhichwerefantasized,yetwithconfabulationitisprobablethatdistantfantasiesareremembered,butit is not remembered that they were fantasy rather than reality. Such confabulations, like themomentary type,areautobiographical.Themomentaryorembarrassmentconfabulationisverymuchmorecommonthanthefantastictypeandisatruememorydisplacedinitstimecontext(Berlyne,1972).

Fantastic confabulation with persecutory content has been described by Roth and Myers(1969).Thisisafalsificationofmemoryoccurringinclearconsciousness.Typically,thepatientbelievesothersarestealinghismoneyortryingtodefraudhim.Memoryfalsificationsofvarioustypes occur in schizophrenia, depressive illness, dissocial personality disorder and obsessional

BOX 5.1 ■ Characteristics of confabulation

■ Itisafalselyretrievedmemory,oftencontainingfalsedetailswithinitsowncontext.■ Thepatientisunawarethatheorsheisconfabulatingandoftenunawareoftheexistenceofmemory

deficit.Inotherwords,confabulationsarenotintentionallyproduced.■ Patientsmayactontheirconfabulation,confirmingtheirbeliefinthefalsememory.■ Confabulationismostapparentinautobiographicalmemory.

(FromGilboaandMoscovitch,2002,withpermissionofJohnWiley.)


states.Themoredefinite,fantasticandgap-fillingfeaturesoforganicconfabulationsarealwaysassociatedwithmemorydefect.

Central to the ideaofconfabulation is thereforeanotionof false reports in thecontextofmemory disorder. At a minimum, it involves both distortions of content as well as temporalcontext. The confabulatory recollection often includes additions, distortions or elaborationswhicheitheractuallyorplausiblyoccurred(DeLuca,2009).

‘Doctor: What did you do today?PatientVR: Today I got up this morning and visited the rehabilitation unit … then I went home and was expecting some material and we received it. Then I came to the rehabilitation institute, no I actually went to Jimsburg

store and we had a small meeting there. Then I came to the hospital and we had lunch and, then met with you …’

(DeLuca, 2009)

Theexamplefirstly illustratescontentdistortion,sincethepatienthadbeeninhospital forseveralmonthswithoutgoinghome,andsecondlyimpairedtemporalcontext,sincethepatienthadownedJimsburgstoremanyyearsbeforeandhadsoldit.

Thecurrentview is thatmemoryconfabulationusuallyderives fromdual lesions taking inbasal forebrain areas and frontal executive systems.These lesions appear to result in impairedstrategic retrieval of memory and disturbed verification/monitoring of the abnormal memoryoutput(DeLuca,2009).

PERSEVERATION

Perseverationusuallyoccursinassociationwithdisturbanceofmemoryandisasignoforganicbrain disease, perhaps the only pathognomonic sign in psychiatry. It occurs with clouding ofconsciousness and is particularly useful in distinguishing this from dissociative abnormalities(Allison,1962).Perseveration isdefinedas a response thatwas appropriate to afirst stimulusbeinggiveninappropriatelytoasecond,differentstimulus.Thismaybedemonstratedverballyorinmotoractivity.Theinterviewer,whileconductingthementalstateexamination,asks‘WhatisthecapitalofItaly?’–‘Rome’,andthensubsequently‘Whatistheobjectthatyouwearthattellsyouthetime?’–‘Rome’.Alternatively,theexaminerasksthepatienttoputhisrighthandonhisleftshoulder,whichhedoescorrectly,andthen,onaskinghimtoputhislefthandonhisleftknee,heagainputshisrighthandonhisleftshoulder.

MEMORY DISTURBANCE AND ELECTROCONVULSIVE THERAPY

Thereisalwayssomememorydisturbanceimmediatelyafterelectroconvulsivetherapy(ECT).This includes impaired learningability,defectiveretrievalandapparent lossofmemorystores.Memoriesofeventsimmediatelyprecedingthetreatments(retrogradeamnesia)aremostlikelytobepermanentlylost,andmorerecentpersonal(autobiographical)memoriesaremorevulnerabletolossthanolderones(CahillandFrith,1995;SternandSackeim,2002).Thereisalsosomeantero-gradeamnesia,withdifficultyinretentionforsomehoursaftertreatment.Defectofmemoryforcurrenteventsataboutthetimeofthetreatmentmaypersistforafewweeksaftercompletingacourseoftreatment.Thismemorydisturbanceissimilartootherorganicamnesicstates.

Theretentiondefect isrelatedtothestrengthanddurationofelectricalstimulationandtothedurationof the seizure.Confusion andmemorydisturbancehavebeen claimed tobe lessafterunilateral,non-dominantECT.Thereisnoevidenceforlossoftheabilitytoacquirenewpatternsofbehaviourorexecuteestablishedones,evenafteralongcourseofECT.


Usingaverywide-rangingbatteryofteststoexamineallareasofcognitivefunction,Weeksetal.(1981)statethatECTdoesnotproducelastingimpairmentwhenusedineverydayclinicalcircumstances. Memory functions tested included recall, releasing rate and recognition in theauditory-verbalandvisuospatialmodalities.Similarly,Fraser(1982)considersthatthememoryloss that follows ECT is minimal and can be detected for only a few hours after treatment.Unilateral placement of electrodes accelerates postictal recovery and shortens the duration ofamnesia(Fraser,1982).Insummary,itseemsnowthatECTdoesnotcausemorethanatem-porarydisturbanceinmemory(Williamsetal.,1990).

MEMORY IMPAIRMENT IN SCHIZOPHRENIA

Earlierwriterstendedtoplaydownthesignificanceofintellectualimpairmentinschizophrenia(Bleuler,1911;Kraepelin,1913).However,decline in intellectualperformance (Rogers,1986),impairment in neuropsychological test batteries (Taylor and Abrams, 1984), sometimes adementia-likesyndrome(LiddleandCrow,1984)andsubstantialmemorydeficit(Cutting,1985;McKenna etal., 1990) have been demonstrated. Memory deficit has been shown not to berestrictedtopatientswithchronicschizophrenia.

Therearedeficitsinlong-termmemory,includingevidenceofimpairedretrievalinbothrecallandrecognition.Thereisalsoevidenceofimpairedshort-termmemory,demonstratedbydeficitof forwarddigit span.Furthermore, there is evidenceof impairmentofworkingmemory andsemantic memory, but procedural or implicit memory is intact.The memory deficit has beenshowntobeassociatedwithseverityandchronicityofillness,andwithnegativesymptomsandformalthoughtdisorder(Tamlynetal.,1992;McKennaetal.,2002).

TEMPORAL LOBE DISORDER

Itisusefultosummarizeatthisstagethepsychopathologicalphenomenaoftemporallobedys-function:disturbanceofmemory,perceptionandaffect.Disorderofmemoryincludesthehip-pocampaldefectsofdiminished storageandaccelerated forgetting;déjà vu and jamais vu alsooccur, as described above.There may be altered states of consciousness such as a fugue, withimpairedregistration.Panoramic recall,inwhichthepatientmayfeelthatheisrapidlyre-enactinglongperiodsofhislife,isalsodescribed.

Affective Disorder of MemoryMemoryisnotonlydisturbedbyorganicdamagetothebrainitself;itisalsoaffectedbyemotion.Thisiscertainlytrueofnormal,healthypeople,inwhomtheaffectivestatestronglyinfluencestheprocessesofrememberingandforgetting.Itisalsotrueofthosewithaffectiveandschizo-phrenicpsychoses,andofneurosesandpersonalitydisorders.Depressionislinkedtoself-reportedmemoryproblems.Thereisalsosubstantialevidenceofanassociationbetweendepressionandgenericmemoryimpairment.Itisthoughtthatmooddisorder,suchasdepression,reducestheamountofcognitiveprocessingresourcesavailableforagiventask,andinthememorydomainthisismanifestasdeficitsintheelaboration,organization,encodingandretrievalofmaterialintoandoutofmemory(DalgleishandCox,2002).Thereisalsoevidenceofmemorybiasforaffec-tivelytonedmaterial,suchthatinformationthathasanemotionalvalenceismorelikelytoberetrieved if it is congruent with the individual’s mood during retrieval. This mood-congruent memory effect is similarbutdistinct from state-dependent memory,whichrefers to thememorybiasformaterialthatislearnedinaparticularmoodandismoreeasilyretrievediftheindividualisinthatsamemoodduringretrieval.


SELECTIVE FORGETTING

Innormalforgetting,thereislossofordiminishedaccesstorecentlyacquiredandstoredinfor-mation.Ratesof forgettingare influencedby thepersonalmeaningfulnessof the information,theconceptualstyleoftheindividual,thedegreeofprocessingandelaborationoftheinformationandage.Itislikelythatnormalforgettingisdeterminedbydisuseorinterferencebymorerecentlylearnedormorevividmaterialandunderpinnedbyphysiologicalormetabolicprocesses(Lezaketal.,2004).Additionally,therearetwoformsofinterference;proactiveandretroactive.Inproac-tiveinterference,newlylearnedmaterialinterfereswiththerecallofpreviouslylearnedmaterial.Inretroactiveinterference,previouslylearnedmaterialinterfereswiththerecallofnewlylearnedmaterial(seeEysenckandKeane,2010forafullerdiscussion).

Theprocessofrepressionorselective forgetting,however,suggeststhatforgettingisnotsimplydown toerrors in thefilingand retrievalmechanism.Forgetting is subject to the influenceofaffect:whichsensationsareregistered,whatisretainedandforhowlongandwhatinformationis available for recall. InFreud’s (1856–1939) account, traumaticor threateningmemories arekeptoutofconsciousawarenessbythemechanismofrepression.Otherformsofactiveforgettingexist, including motivated forgetting which subsumes repression as an example, and also thedeliberateforgettingofwhereweputourglassesyesterdaywhenwearelookingforthemtoday!Directedforgettingisthetermfortheprocessbywhichweactivelyuseexecutivecontrolproc-esseswithintheprefrontalcortextoforgetitemsthatwedonotwishtorecall.Itisobviousfromtheforegoingthatforgettingisanimportantandnormativeprocess.

FALSIFICATION OF MEMORY

Falsificationofmemoryoccurs tosomeextentbecauseof the interplayofmemorywithaffect.ThiswascommentedonbyNietzsche(1889):‘MemorydeclaresthatIdidthis;Icouldnothavedonethis,saysmypride;andmemorylosestheday’.

Inpseudologia fantastica –fluentplausiblelying–theuntruthfulstatementsareoftengrandioseandextreme.Questionsareansweredwithfluency,andthestoryappearstobebelievedimplicitlybythepseudologichimself.Thisusuallyoccurswithanassociatedpersonalitydisorderofhistri-onicordissocialtype,andoftenwhentheindividual isexperiencingamajor lifecrisissuchasfacingcriminalproceedings.Thepictureisofaveryisolatedperson,withoutfamilyorfriends,driftingintotheaccidentandemergencydepartmentofalargehospitalinastrangecitylateatnight,withstoriesofhisownexploitsandimportanceandtheunfortunatevicissitudeshehasexperienced.Thereisoverlapwiththeso-calledFactitiousDisorder.

Withpersonalitydisordersandalsowithaffectivedisorders,especiallyattimesofheightenedemotion, memory is falsified and distorted, and events and circumstances are misrepresented.Theadviceofdoctorsmaybegrosslymisconstrued.Anophthalmicsurgeonexaminedadepressedpatient’s eyes and informed her that her visual acuity was satisfactory and no treatment wasrequired.Shereportedthistoherpsychiatrist;her‘eyesightwouldbebadforevermoreandthesurgeonhastoldmethatnothingcanbedoneaboutit’.

Memoryimpairmentisaregularfeatureoforganicstates.Whenthereisadefectofreasoningand judgement, falsificationcanoccur.Sothegrandiosedelusionsandmemorydisturbanceofgeneral paresismayresultinfalsificationanddistortionofeventsremembered.Similarly,confabu-lationasintheKorsakovstateisassociatedwithfalsification.

Inschizophrenia,rememberedcircumstancesoftentakeonanewmeaning:‘IrememberlastweekthreeredcarsfollowingmeatthetrafficlightsinStafford…IrealizedthatIhavebecomeinvolvedinpolitics’.Thiswasstatedbyapatientwhohadquitesuddenlycometobelievethatall her actions were being observed and, subsequently, her behaviour controlled. Memory isaccurate, but its significance is distorted. A distinction should be made between delusional


memories, in which the primary delusional experience is a true memory, with delusionalinterpretation, and delusional retrospective falsification. This is a backdating of delusion toa timebeforethepatientwas ill,basedonanadmixtureofrememberedtrueeventsanddelu-sionalelaborationofthemeaningofthoseevents.Thishasbeendescribedbysomeauthoritiesas a form of confabulation (Nathaniel-James and Frith, 1996; McKenna etal., 2009). Intheoriginalstudy,whensubjectswerepresentedwithnarrativesandaskedtorecallthem,con-fabulationwasdefinedasrecallofinformationnotpresentintheoriginalnarrative.Thedegreeof confabulation was related to problems in suppressing inappropriate responses and formalthoughtdisorder.McKennaetal.(2009)concludethat,‘Thereisnodoubtthatthephenomenonofconfabulationcanbeseeninschizophrenia.Itisclearthatitisveryuncommoninaspontane-ousform,andwhenitdoesoccuritalwaysseemstotaketheformofso-calledfantasticconfabu-lation … Simple, momentary, or provoked confabulations, on the other hand, appear to becommonplace.’

Inaccuracyofrecallissometimescalledparamnesia.Aswellasoccurringinthenormalstateandinpersonalitydisorders, it isaprominentfeatureofaffectivedisturbances.Awomanwithdepressiveillnessfalsifiedtheeventsofherlife:‘Iamnotmarried.Mychildrenareillegitimate.Wedonotownthishouse.Wearebankrupt.’Allthesestatementswereuntrue,andthefalsifica-tion of her memory occurred in response to her severe depressive mood. Memory itself wasaccurate,butonremonstratingonanyparticularpointoffact,furtherdepressiveexplanationsofeventswouldbegiven.Forinstance,themarriagelicencewasdescribedasaforgery,andcom-plicatedlegalexplanationsweregivenastowhythehousedidnotbelongtoherandherhusband.In mania, unacceptable events or opinions may be brushed aside as not having occurred andunrealisticgoalspursuedasthoughtherewerenothingtopreventtheirattainment.

PSYCHOGENIC DISTURBANCE OF MEMORY

Cryptamnesiaistheexperienceofnotrememberingthatoneisremembering!Apersonmakesawitty remark, or writes a haunting melody, without realizing that he is quoting (plagiarizing)ratherthanproducingsomethingoriginal.Theprocessisseenwhenwordsorphrasescomeintopopularusageforafewmonthsoryearsbysomeprocessofmassspread,inwhichpeopleusingtheexpressionbelievetheyareintroducinganewidea.

Generally,unpleasantanduncomfortableexperiencesarenotrememberedaccuratelyorcom-pletely–‘forgettingofthedisagreeable’.Thisisadefectofrecallthatcanbeseenasasuccessfuldefence mechanism;ithelpstomaintaintheintegrityoftheperson.However,intheaffect of hope-lessness,reactivationofmemoriesofpreviousfailuresisafrequentreasonforperpetuatingneuroticthinking and behaviour (Engel, 1968). Psychogenic amnesia may appear without any organicdiseasebeingpresent,but thepresentationoforganicbraindisease isalwaysmodifiedbypsy-chogenicfactors(Pratt,1977).

Misnamingobjectsandmomentarylossofmemoryforwordsinhealthysubjectsmayresultfromfaultyretrievalfromshort-andlong-termmemorystoresratherthanfromthepsychoana-lyticexplanationof repression.Sucherrorsmaybecategorizedasacousticor semantic; acousticerrorstendingtooccurinshort-termstoresofupto30secondsandsemanticonesinlong-termstoresaftermorethanfiveminutes(ShalliceandMcGill,1977).

Dissociative (Hysterical) Fugue

The symptoms pertaining to dissociative (conversion) disorders (hysteria) in the International Classification of Diseases (World Health Organization, 1992) are of two types: conversion anddissociation.Indissociation,thereisanarrowingofthefieldofconsciousness,withsubsequentamnesiafortheepisode.Inmanyways,dissociativesymptomsrepresenta layman’s impressionof ‘madness’. In dissociative (hysterical) fugue states, there is narrowing of consciousness,


wanderingawayfromnormalsurroundingsandsubsequentamnesia.Thepersonappearstobein good contact with his environment and usually behaves appropriately, maintaining basicself-care,althoughhesometimesdisplaysdisinhibition.There isquiteoftenlossof identityorassumptionofanother, false identity.Thedurationof theepisodecanbeveryvariable, fromafew hours to several weeks, and the subject may travel considerable distances. A citizen ofBirmingham,UnitedKingdom,describedastateinwhichhe‘cameto’inacityhedidnotrec-ognizeandwherepeoplewerespeakingFrench.Ashewalkedaboutthestreets,hefoundhewasnearanairportterminaland,tohissurprise,hediscoveredthathewasinMontreal.Germanetohisadventurewasthehistoryofacatastrophicrowandthebreakdownofhismarriage justbeforehe tookoff.Thus the featuresofdissociative fuguearedissociativeamnesia,purposefultravel beyond the usual everyday range and maintenance of basic self-care (World HealthOrganization,1992).

Ganser State

The original paper by Ganser (1898) has been much misunderstood. In it, he described fourcriminalswhoshowedthefollowingsymptoms.

■ Vorbeigehen(‘topassby’)orapproximate answers,describedbyGanserthus:‘Inthechoiceofanswersthepatientappearstodeliberatelypassovertheindicatedcorrectanswerandtoselectafalseone,whichanychildcouldrecognizeassuch’.

■ Cloudingofconsciousnesswithdisorientation.■ ‘Hysterical’stigmata.■ Recenthistoryofheadinjury,typhusorsevereemotionalstress.■ ‘Hallucinations’, auditory and visual (from his description, they are more like

pseudohallucinations).■ Amnesiafortheperiodduringwhichtheabovesymptomsweremanifest.TheGanser state isvery rarely seen inEnglishprisonsbut,when itdoesoccur, it ismore

likelyinthoseawaitingtrialthanthosealreadysentenced(Enoch,1990).Therehasbeenconsiderableargumentastowhetherthisconditionisprimarilyhystericalor

anorganicpsychosis,withdifferentauthorssupportingeachcontention(Latchametal.,1978).Acasethatillustratedboththehysterical(dissociative)andorganicelementswasthatofafemaleuniversity student,aged20years,whoexperiencedhead injurywithconcussionwhen inItaly.Herpremorbidpersonalitywasmarkedlyhistrionicandtheatricaland,attheageof13years,shehad developed a hysterical inability to walk for a few weeks. After transfer from the ItalianhospitaltoBritain,shedemonstratedapproximateanswersthus:

Question:‘WhatisthecapitalofItaly?’Answer:‘Naples.’Question:‘Howmanylegshasacentipede?’Answer:‘Seven.’Thiswasaccompaniedbyinterferenceinthetreatmentofotherpatients,flirtatiousbehaviour

towards male staff, lability of mood and a facetious manner. On serial testing of intellectualfunctionontheWechslerAdultIntelligenceScale,initialtesting12daysafterheadinjuryhadtobeabandoned;afteronemonth,therewasmarkedimpairment,worseforperformancethanforverbal items. Intellectual functionhad eventually returned toherpremorbid, superior level byninemonths.Whitlock(1967)considersthedistinctionbetweentheGanserstateandpseudo-dementia to lie indisturbedconsciousness,present in the formerandnot the latter.However,sometimescloudingofconsciousnessinanorganicstatecannotbedistinguishedfromthealteredmentalstateofdissociativedisorderintheabsenceofotherorganicsigns.

EnochandTrethowan(1979)haveregardedthefourmainfeaturesofGanser’ssyndromeas:■ approximateanswers■ cloudingofconsciousness


■ somaticconversionfeatures■ pseudohallucinations(notalwayspresent).It shouldbenoted thatapproximateanswersarenot the randominaccuraciesof thequick

guessbutresponsesthatappeardeliberatelyjusttohavemissedthecorrectanswer.Theseauthorsregardthesyndromeasahystericaldissociativereactionandhavepointedoutthesimilarityoffeatureswiththoseexhibitedbynormalpeopleaskedtosimulatementaldisorder,thedifferencebeingthattheGansersubjectsweresubsequentlyamnesicfortheirabnormalbehaviour.UngvariandMullen (1997)have classifiedGanser’s syndromewith the controversial groupof reactivepsychosessothatastressfullifeeventistheusualpredisposingfactor.Cutting(2011)hasanovelandoriginalapproachtoGansersyndrome.OnthebasisofexaminationofanumberofcasesincludingtwoofhisownheconcludesthattheGansersyndromeiseitherpartofadepressiveillnessoratransientdisturbanceinthelefthemisphere’slexicalorsemanticknowledge.Cuttingargues that the knowledge deficit demonstrable in Ganser syndrome is not hysterical on anyaccountbutamanifestationofaparticularkindofcognitiveimpairment.

Recovered Memory and False Memory Syndrome

Thisiscurrentlyoneofthemosthotlydebatedissuesinpsychiatryandclinicalpsychology.Thoseworkingwithsurvivorsoftraumaticexperiencesnotedintheirpatientstherecoveryofadditionalmemoriesduringclinicalsessionsafterapparentpsychogenicamnesiaforalongtime;sometimesdecades. Recovered memory has been particularly associated with the return of memory forchildhoodsexualabuse.Brewin(1996)reviewstheevidenceforsucheventsbeing‘forgotten’andthenrecalledaftermanyyearsandthemechanismsthatmayaccountforthisamnesia.Hecon-cludesthatmemoriesmayberecoveredfromtotalamnesiaandtheymaysometimesbeessentiallyaccurate.Equally,such‘memories’maysometimesbeinaccurateinwholeorinpart.

Thetermfalse memory syndromecameintousein1992,whentheFalseMemorySyndromeFoundationwas setup to represent the interestsofparentswhohadbeenaccusedof abusingtheirchildrensexually.IntheopinionofMerskey(1998),sufferersfromfalsememorysyndromeare typically female and are usually participating in some type of psychotherapy.They reportsexualabuse inchildhood,which it is claimedhasbeen forgottenandrecoveredonly inadultlife,havingbeen repressed fromeight to40 years. It is considered that these ‘memories’havebeen implantedduring therapyby aprocessof suggestion similar to that thought tooccur inmultiplepersonalitydisorder.Anothersituationinwhichfalsememorieshavebeenthoughttodevelophasbeeninnurserydaycare,whencaregivershavebeensubjectedtograveandbizarreaccusations.

There is empirical evidence demonstrating that there are differences between individualswhoserecoveredmemorieshavebeenrecalledinsidetherapy,thosewhosememorieswererecalledoutside therapyanda thirdgroupwhosememoriesof abusewere continuous fromchildhoodintoadulthood.Inthefirstgrouptherewas0%corroborativeevidence,whereasfortheothertwogroupsitwas45%and37%.Furthermore,thosewhohadrecoveredmemoriesoutsidetherapywereabletosuppressanxiety-provokingthoughtsrelatingtothoseeventscomparedtothegroupswithrecoveredmemoryfromwithintherapyandthegroupwithcontinuousmemoriessuggestingthatwomenwithrecoveredmemoriesfromoutsidetherapyareespeciallyadeptatsuppressingemotional memories when under laboratory conditions, confirming their liability to remainunaware of traumatic memories for long periods prior to their recovery (Geraerts etal,2007;2008).

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S E C T I O N THREEAwareness of Reality: Time, Perception and Judgement

75

C H A P T E R 6

Disorder of Time

SummaryTimeis integraltohowhumanbeingsexperiencetheworld.Althoughit isdifficulttodefine,therearesomeovertaspectssuchasduration,sequence,synchrony,rhythm,past,present,futureorientation and an arrow of time that are easily recognizable and understood by most peoplewithouttheneedforfurtherelaboration.Thereisalsoanimportantrelationshipwithspaceandwithnotionsoftheself.Abnormalitiesoftimeexperiencecanbroadlyspeakingbedividedintothosethataffectobjectivetimeandthosethataffect thesubjectiveaspectsof timeexperience.Therearealsoinfluencesofcircadianrhythms,seasons,monthlycycles,andlifeepochsthatareworthyofnoting.

Space and time are always present in sensory processes. They are not primary objects themselves but they invest all objectivity. Kant calls them ‘forms of

intuition’. They are universal. No sensation, no sensible object, no image is exempt from them. Everything in the world that is presented to us comes to

us in space and time and we experience it only in these terms.Jaspers (1959)

Inthequotationabove,Jaspersdrawsattentiontothewayinwhichhumanbeingsliveinspaceandtimeandhowallsubjectiveexperienceinmediatedbyspaceandtime.Jasperscontinues:

‘If we want to bring these primary things home to ourselves in some neat phraseology we may say that they both represent the sundered existence of

Being, separated from itself. Space is extended being (the side-by-side) and time is sequential being (the one-after-the-other)’.

A sense of time is clearly very central to the concept of self and its relationship with theoutsideworld.Butwhatexactlyistimeandhowisitexperienced?BarbaraAdam(1995)inherbookTime Watchinterviewedanumberofpeopleabouthowtheyexperiencetimeandsometheirresponsesarebothinstructiveandhelpful:

‘How time enters my life? I was born and now I am fifteen years old. We use the word when we ask what time it is. We talk about closing time, lunch-

time, getting up time, and that time is up. What time is, that is more difficult to say. It is not a person, not a thing, not a vegetable. It’s a period and units,

the day chopped up into hours, minutes and seconds. But it also divides the past from the future … The time is now, this very second. But I do not know

what it is we are chopping up into units. I think it’s an illusion since there isn’t anything to be chopped.’

Keywords: Time,CircadianRhythm,Disorientation.

6—DISORDER OF TIME 75.e1

76 THREE—AWARENESS OF REALITY: TIME, PERCEPTION AND JUDGEMENT

‘For me time is a dimension within which everything moves and happens. In conjunction with space it is a universal framework. We can’t move through

space without time and vice versa which means that we can’t pass, spend, or allocate time without occupying space. Nothing exists and happens without

time and space.’

Adamherselfemphasizesvariousaspectsoftimeasfollows:

‘Thinking about time, therefore, involves rhythm with variation, a dynamic structure of framing, timing, synchronization, duration, sequence, tempo and

intensity. This cluster of time characteristics is implicated at all levels of being, from the most physical of planetary movements via physiological rhythms to

patterns of social organization, from the taken for granted via the invisible to the obvious, from the imposed via the lived to the culturally constructed.’‘Entailed within those processes is an irreversible unidirectionality, an

arrow of time. There can be no rejuvenation, no unknowing, no reconstitution of pollution back into aeroplane.’

Theseaccountsindicatethattimeisdifficulttodefinebutthattherearesomeovertaspectssuchasduration,sequence,synchrony,rhythm,past,present,futureorientationandanarrowoftime.Thereisalsoanimportantrelationshipwithspaceandwithnotionsoftheself,particularlywithenduringself-identity,thathasbeenremarkeduponbymanythinkersincludingKant(seeCritique of Pure Reason).

Thereisasenseinwhichtimeleavesasignatureonthemostdiverseaspectsofhumanlife,yetinsuchawaythattheinfluenceoftimeisoftenunrecognized.Asidefromtheobvioussuchasovertwaysofmeasuringtime,thereisatimedimensioninmemory, inlanguage(giventherelianceonwordsequenceandorderformanifestmeaning),throughrhythmandnoteorderonmusic, and in all actions including symbolic movements, dance, sports, etc. Covertly, time isinvolvedinsuchconceptsasexpectation,desire,hope,prayerandevendeath.Theselatterideashave evolved from the writings of Eugene Minkowski (1885–1972), a phenomenologicalpsychiatrist.

Disturbanceofsenseoftimeortime-relateddisorderisasensitiveindicatorthatsomethingisgoingwrongeitherintheselforitsmechanisms.Senseoftimeandtime-relateddisordersofbiologicalrhythmwillbeconsideredseparatelyinthischapter.Thereisnowidelyagreedclas-sificationofdisordersof time.However, it ispossible todivide thedisordersof time intotwobroadcategories:disorderofobjectivetimeanddisorderofsubjectivetime(Box6.1).

BOX 6.1 ■ Classification of disorders of time

Disorder of objective time■ Disorderofknowledgeoftime:disorientationintime;agedisorientation■ Disorderofdurationoftime■ Disorderofchronology(temporalorder)

Disorder of subjective time■ Disorderofflowoftime■ Disorderofdirectionoftime■ Disorderofuniquenessoftime■ Disorderofqualityoftime

6—DISORDER OF TIME 77

OBJECTIVE (CLOCK) TIME AND SUBJECTIVE (PERSONAL) TIME

An important distinction is that between objective (clock) time and subjective (personal) time.Objectivetime–chronological,physicalorhistoricaltime–isquantitativeandindependentoftheself.Itdependsonaccuratemeasurementandisobjectivetothedegreethatitissharedwithothersandverifiable.Subjectivetimeistheinner,subjectiveexperienceoftime.Aspectsofbothkindsoftimemaybeaffectedbypsychiatricillnesses.Objectivetimemaybealteredsothattheknowledgeoftime,thatis,theorientationtotimeincludingagedisorientationandappreciationoftimedurationandofchronologymaybeadverselyaffected.Subjectivetimemaybealteredsothat the experience of time duration, flow of time, meaning of time, uniqueness of time andsuccessionoftimemaybeaffected.

BIOLOGICAL RHYTHMS AND TIME

Although our units of time are to some extent arbitrary, natural and biological time operateswithindefiniteperiods.Thefourperiodsthathavethemostrelevancetomentalillnessarecir-cadian rhythms (about24hours–nightandday),monthlycycles, seasonalvariationsand lifeepochs(frombirthtodeath).Alltheserhythmsareimportantforthementalstateintimesofhealthandformthebasisforsuchconditionsasearlymorningwakeningindepression,premen-strualtension,seasonalaffectivedisorderandinvolutionalmelancholia.Manyofthesebiologicalrhythmswithvariationofmoodarebiochemicallymediatedthroughtheendocrinesystem.

Personaltime(andalso,toalesserextent,clocktime)isoftendescribedinrelationtothesebiologicalrhythms.Ourwholenotionoftheprogressionoftimeiscloselyrelatedtoprocessesofphysicalfunction:birth,growthanddecay.

Disorder of Objective TimeAnabilitytoseparateeventsintopast,presentandfuture,eveniflimited;thecapacitytoestimateduration;andtheabilitytoputeventsinthecorrectsequencearenecessaryforintellectualproc-esses to be carried out satisfactorily. Disorder of knowledge of time is closely associated withdisturbanceofconsciousness,attentionandmemory.

DISORIENTATION IN TIME

Disorientationfortimeisdemonstratedbytheinabilitytocorrectlytellthetimewithoutrecoursetoaclock,toindicatethedate,dayandseason.Thisimpairmentiscloselyassociatedwithimpair-ment of attention, concentration, consciousness and memory. It is a feature of delirium anddementia.It isalsoagoodclinicalcriterionfordistinguishingbetweenorganicandfunctionaldisorders (Cutting, 1997).The second abnormality is impairment of the ability to assess theduration of time,andthisisalsodisturbedinorganicstates.

AGE DISORIENTATION

Thetermage disorientationwasfirstusedbyZangwill(1953)inrelationtoKorsakov’ssyndrometodescribea‘fixed,stabledisorientationforage,whichwasimpervioustologicalcorrection’.Age disorientation,nowdefinedasafiveyeardiscrepancybetweenthepatient’sactualageandwhatthepatientstatestobehisownage,hasbeenconsideredtocorrelateclinicallywithintellectualimpairmentinchronicschizophrenia(CrowandStevens,1978).Suchpatientsweremuchlessable thanchronicschizophrenicpatientswithoutagedisorientationtoanswerquestionsaboutdateandthedurationoftime.Theysystematicallyunderestimatedthepresentyearandthedura-tionoftheirstayinhospital,andsometimestheirownage.


Thisgivesquantitativesupporttotheobservationthatforsomechronicpatients‘timestandsstill’;theyremainintheculturalsetofthetimewhentheydevelopedtheirillness.Suchpatientstendtousetheidiomaticlanguage,singthepopularsongs,wearthemodishclothesandtellthecharacteristicjokesofthetimebeforetheirillnessbecameestablished.Itisamistaketobelievethattheyareindulginginnostalgia;theircultural lifeisstillfirmlyfixedwithinthatparticularperiod.Notonlyinthebackwardofanold-fashionedmentalhospital,butalsoinahostelinthecommunity,thesepatientsliveintheirowntimecapsulewithinvisible,butimpregnable,walls.

DISORDER OF TIME DURATION

Estimationoftimedurationhasbeenstudiedusingvariousmethods,buttheresultshavebeeninconsistent.Objectivemeasuresof estimationof thepassageof time, for example, show thatpatientswithdepressiveillnesstendtounderestimatethepassageof30seconds,onaverage,bysixseconds.Thisiscomparedwithoverestimationofthepassageoftimebynormalcontrolsbyon average 10 seconds (Kuhs etal., 1991).That is to say that depressed patients on averageestimated 30 seconds’ duration as 24 seconds and the normal controls estimated 30 seconds’duration as 40 seconds. In other words, time appeared to flow more slowly for patients withdepressionthanitdidfornormalcontrols.Itisimportanttoemphasizethatthisreferstoestima-tionofthepassageofmomentarytime.Otherinvestigationshavedemonstratedanoverestima-tionoftimedurationindepression(KitamuraandKumar,1984;Munzeletal.,1988).Thereismoreconsensusonthesubjectiveexperienceoftimeindepression(seebelow).

DISORDER OF CHRONOLOGY (TEMPORAL ORDER)

Memoryofthetemporalorderofeventsisanaspectoftimesensethatisoftenignored.Thereis evidence thatpatientswithdiencephalic lesionscomparedwith thosewithmedial temporallobelesionshavedistinctdeficitsintemporalordermemorytasks.Thesepatientsareunabletocorrectlyindicatethetemporalorderoflearnedwordsonalistorthesequenceofpresentationofparticularstimuli.Thishasledtothesuggestionthatdiencephalicstructuresmayhaveafunc-tion in the encoding of temporal information (O’Connor and Verfaellie, 2002). Frontal lobelesionsarealsoassociatedwithimpairmentoffunctionontemporalordertasks.Inadditiontothis,anaspectoftemporalordercoding,namelyfrequencyestimation,whichinvolvesestimatinghowoftenaneventhashappened,isknowntobeimpairedbyleftfrontalbutnottemporallesions(BaldoaandShimamura,2002).

Clinically significant disorders of temporal order for past and current events have beenreported.Thesetaketheformofintactmemoryforautobiographicaleventsbutimpairedappre-ciationofthedurationandtimingoftheseevents.Theseimpairmentsareassociatedwithorganiclesionsinthecingulategyrus,theparietallobesandtheleftanteriorfrontalareas(Cutting,1997).

Disorder of Subjective (Personal) TimeDisorderofsubjectivetime ischaracterizedbyabnormalities inhowtimeisexperienced.Thiscaninvolvetheexperienceof(a)flowoftime,(b)directionoftime,(c)uniquenessoftimeand(d)qualityoftime.Thesedisordersgototheheartofhowtheworldisexperienced.Anyaltera-tioninthewaythattimeisexperiencedwillbydefinitioninfluencetheexperienceoftheobjectiveworldandmaycometoimbueperceptionsoftheobjectiveworldwithanalienhue.

DISORDER OF FLOW OF TIME

Theflow(passage)oftimemayslowdownorspeedup.Insomeinstances,itmaybecomearrestedandstandstill.Tolstoy’s (1895) short storyMaster and Man is true to life–ordeath.LostatnightinaRussiansnowdrift,hischaracter,VasiliiAndreich,


got up and lay down a couple of dozen times. The night seemed it would never end. It must be getting on for morning now, he thought once as he raised

himself and looked around. Let’s have a look at my watch … He could not believe his eyes … It was only ten past twelve. The whole night still lay ahead.

Time, as a modality of personal experience, is disturbed in mood disorders. It has beenobservedbothclinicallyandexperimentallythatthosewithdepressiveillnessfeelthattimepassesslowly(WyrickandWyrick,1977).Lewis(1967)quotesapatientwhowasdepressedwithaffec-tive functional psychosis:

Everything seems very much longer. I should have said it was afternoon, though they say it is midday. They always tell me it is earlier than I think … and it looks as if I’m wrong and I can’t help feeling I’m right … I cannot see

any end to anything, only end to the world.

Theflowoftimecanalsobearrestedsuchthattimeappearstostandstill.Thepatientfeelsthat time is standing still, that in somewayeverything temporalhas come toanend.This isdescribednotuncommonlywithpsychoticdepression.Apatientsays,‘Ihavestoppedbeing,Ihave just stopped,everythingelsehas just stoppedaswell’.The incessant sequentialmarchofeventsnolongerimpressesthepersonwithitsinevitability.

This feeling of time standing still may also be experienced in ecstasy states, in which thepersonmayfeelthatheisexistinginthepast,thepresentandthefutureallatthesametime.Suchstatesmayoccurwithmania,withsomeneuroticconditionsorinnormalpeopleundergoinganexceptionalpsychologicalexperience.

Whenthedisturbanceinthesenseofthepassageoftimeoccursinthesettingofdepression,thedepressedmoodisalsoapparent.AnotherofLewis’(1967)patientssaid,

‘I never know any moment what is going to happen. It’s the most terrible outlook I’ve ever had to look to. It’s all perpetual. I’ve got to suffer perpetually.’

AndoneofMinkowski’s(1970)patientssaid:

‘I continue to live now in eternity; there are no more hours or days or nights. Outside things still go on, the fruits on trees move this way and that. The

others walk to and fro in the room, but time does not flow for me. My watch runs just as before … Sometimes when people run quickly to and fro in the

garden or if the wind stirs up the leaves, I would like to live again as before and be able to run interiorly with them in order that time would pass again.’

Intheseexamples,thepatientsaretryinghardtodescribetheindescribable,theexperienceof timestandingstill. Inaddition to thisexperience there isalso the relatedbutdistinctphe-nomenonof living inthe instantandthis feeling isalliedtothenotionoffinalityand lackofcontinuity:

‘I live in instantaneousness. I don’t have the feeling of continuity anymore … When I finish something, I have the feeling of not being able to do anything

else afterwards and of doing this thing, going to dinner for example, for the last time.’(Minkowski, 1970).


This last sentence isperhaps thekey to theabnormalpsychopathology. It is theabnormalmoodassociatedwithtimesensethatissignificant,sodepressivein-patientsweresignificantlymorelikelytofeelthattimewaspassingmoreslowlythanhealthy‘control’subjects(KitamuraandKumar,1982).

Inmania,timepassesrapidly,butthepictureisuncertaininschizophrenia(Orme,1966).Theflowoftimeisalsoknowntobeaffectedinorganicbrainconditions.PatientswithKorsakov’ssyndromeunderestimatethepassageoftime,andsubjectswhohavehadthalamotomyexperiencetheflowoftimeasspeededup(Cutting,1997).

AdistinctbutrelateddisturbanceoftheflowoftimeistheZeitrafferphenomenon.Thisisliterallyatime-lapsephenomenon.ItwasfirstdescribedintheGermanliteratureinthe1930s,and Cutting (1997) has now brought it to the attention of the English-speaking world.Thecharacteristicfeaturesare:

1. thespeedinguporslowingdownofevents;2. itsassociationwithincreasedspeed,pitchandvolumeofauditoryperceptions;and3. alterationsinthefluencyofobservedmovements.Theremayalsobevisualhallucinations,anomalousexperienceofspacesuchasdistortionsof

horizontalandverticallines.Thisphenomenoninvariablyoccursinthesettingofacuteorganicbraindiseasesuchascerebrovascularaccident.

TheoriginalcasewasdescribedbyHoffandPotzl(1934,quotedinCutting,1997):

Doctors and nurses were first of all moving with a measured step, conspicuously, as if on a film. Then the tempo of things became very erratic,

sometimes coming at a furious pace, ‘like moving pictures speeded up’ as if the people involved were ‘running a race’ … Music, whose source was to his left,

sounded very loud and very fast, as if ‘several radios were all blaring away together … as if all the instruments wanted to show how much noise they

could make’. Sometimes, other people’s speech seemed excessively fast and incomprehensible ‘as if the doctors and nurses were practising for a world

record’. However, if he were addressed directly, the rate appeared quite normal and he could understand it quite well. It was when someone was speaking away to the left that it sounded most peculiar – shriller, louder and faster

than when to away to the right.

DISORDER OF DIRECTION OF TIME

Itseemssuchafundamentalaspectofourexperienceoftimethatthearrowoftimetravelsfromthepastthroughthepresenttothefuture.Itisincomprehensiblethatanyonecouldexperiencetimeasifeventswerebeingplayedin‘rewindmode’backwards.ThisphenomenonwasreportedbyoneofLewis’patients(1967):

‘Whenever anyone said anything to me, it referred back to some part of my life … One mind was living back and my mind forward.’

AnotherofMinkowski’s(1970)patientssaid:

‘There is no present anymore, only a sense of the past. Is there a future? There used to be, but now it is shrinking. The past is so obtrusive … I’ll give you

an example of what it’s like. I’m like a machine that runs but does not move


from its place. It goes at full speed, but it remains in place. I am like a burning arrow that you hurl before you; then it stops, falls back, and is finally

extinguished as if in a space empty of air. It is hurled backwards.’

DISORDER OF UNIQUENESS OF TIME

Partofourexperienceoftimeisthesenseofuniquenessofthetime,momentaryorotherwise,thatwelivethrough.Thisuniquenessoftimeexperienceisinstantiatedintheuniqueeventsthatpopulatetime.Thismeansthateverymomentisgivenitssingularidentitybythecontext,bytheevents played out in a given place, by particular personalities and by association with specificemotions.Thesecoordinatesoftimestampeachmomentwithitsspecificuniquefeeling.

Thedéjà vu experiencecanbeconceptualizedasanalterationof the feelingofuniquenessthattimeandeventsareinvestedwith.Whenthisisdisrupted,noveleventsandthetimeandplaceinwhichtheyoccurseemfamiliar.Inthisconceptualization,déjà vu istheexperienceofthisfeelingoffamiliarityforeventsandtimesthathavenotbeenpreviouslyencountered.Jamais vuistheabsenceofthisfeelingoffamiliarityforeventsthathavebeenpreviouslyencountered.Inotherwords,evenpreviouslyencounteredsituationsareexperiencedasnovel,thatis,asunique.Althoughitispossibletoconceptualizetheseexperiencesasdisordersoftime,itisprobablymoreappropriatetoregardthemasaspectsofmemorydisturbance(Chapter5).

Déjà vu occurs in the normal state and in pathological conditions. The composer RalphVaughanWilliams,indescribinghisfirsthearingofthetuneusedinDives and Lazarus,explained,‘Ihadthatsenseofrecognition–here’ssomethingwhichIhaveknownallmylife,onlyIdidn’tknowit’(Kennedy,1964).Mostpeoplecanrecallsimilardéjà vuexperiences.Itisalsocommonlyassociatedwithtemporallobeepilepsy.Apatientdescribedhisaurabeforeafitexperiencedinhospital:‘Iwentintothekitchen.ThewindowlookedasifI’dseenitbefore.Ifeltverypeculiar’.Déjà vuandjamais vuarequiteoftendescribedinschizophrenia.

Déjà vuhasbeenproducedwithbrainstimulation.PenfieldandKristiensen(1951)wereabletoreproduceasensationoffamiliaritywithstimulationofabrainelectrodeinepilepticpatients.Thisstimulationclearlyproducedanabnormalityofthefeelingoffamiliarity,notanabnormalityof memory. It was a disturbance of the feeling of recognition that accompanies recall in theprocessofmemory. Janetconsidereddéjà vu tobea formof lossof realityornegationof thepresent (Taylor, 1947), while Freud (1901) regarded it as being associated with the recall ofunconsciousfantasies.

Inamoreextremeform, thedisorderof theuniquenessof timepresentsasreduplication of time.ThetermwasfirstusedbyWeinsteinetal.(1952).Petho(1985)describedacaseinwhichthepatient’scentralsymptomwasthebeliefthatshehadlivedthroughthislifeoncebefore.Thepatientexperiencedareduplicationofeveryevent,andinrelationtoattendingthe1976OlympicGamessaid,‘ItcouldhappenthatIwillgo;Ihaveamemoryof it.ButIalsohaveamemorythatIwon’tgotothoseGamessothatthatmemorywon’tcomebacktome.’

DISORDER OF THE QUALITY OF TIME

Intheseconditions,thenormalexperienceofthequalityoftimeiseitherlostordistortedinsomeway.Whatiscentraltotheseexperiencesisthatthe‘takenforgranted’aspectoftimeisreplacedbyadegreeofalienationfromitsuchthattimebecomessalient,obtrusiveandevenunreal.

Indepersonalizationandderealization, therecanbea lossof thefeelingofreality for timeexperience; theremayalsobealteration in the senseofdurationor in theperspectiveof time(FreemanandMelges,1977).Thepersoncanassessatimespanquiteaccurately,andthereisnolossofmemory.However,hehasno feeling that thingsarehappeningor time ispassing; the


abnormalityisalwaysoneofexperience.Timeitselftakesonafeelingofunreality,andhefeelsunabletoinitiateaction.

Thisphenomenoncanalsooccurinschizophrenia.OneofCutting’s(1997)patientssaid:

‘Time is somewhat changed. Time isn’t supposed to be the way it is. I don’t know in what way.’

Fischerdescribedanumberofcases(quotedinCutting,1997),ofwhichonesaid:

‘Time stood still. Then it became different. Then it disappeared entirely … Then a new time emerged. This new time was endless, more manifold than

the previous one, hardly deserving the name “time” as we know it. Suddenly it came to me that this time did not only lie in front of and behind me, but

spread out in all directions.’

Biological Rhythms and Their Relation to PsychiatryDaily,thereareprofoundchangesinthebodyandbrainassociatedwiththeexternalrhythmoftheworld.Duringthewakingdayweareactive,andatnightwesleep,recuperateandrepairourbodyparts.Thisbiologicalrhythmisdrivenbyaninternalclock.Theprimaryinternalbodyclockislocatedinthesuprachiasmaticnuclei,aclusterofapproximately100,000neuronslocatedoneither side of the midline above the optic chiasma, about three centimetres above the eyes(Hastings, 1998). There is strong evidence that the clock is an autonomous property of thesuprachiasmatic nuclei, and individual cells, in vitro, continue to fire rhythmically for severalweekswithonlytheslightestdeviationfrom24hours.Itisknownthatthisclockcanbedesyn-chronizedbyjetlag,shiftworkanddepression(Arendt,1995).However,thereisstillagreatdealofignoranceabouttheconnectionswithdifferentmentalillnesses.Inthissection,briefreferenceismadetodaily,monthlyandannualrhythms,andalsototheassociationwiththestageoflife.Amongpsychiatricdisorders,mostinformationisavailableonaffectivedisorderanditsassocia-tionswithdailyandannualrhythms(Thompson,1988).

CIRCADIAN RHYTHMS

Comparinginternaltimewithclocktime,repeatedestimatesoffixedtimespansshowagradualincreaseintimeoftheestimate,suggestingthatthereisaslowingoftheinternalclock.Subjectswereaskedrepeatedlytoguessafixeddurationoftime;theirestimatestartedbybeingslightlylongerthanactualtimeandbecameprogressivelylongerstill.Theintrinsicperiodofthecircadianrhythminhumansisapproximately25hours,butthisisusuallymodifiedbyexternalcuessuchasdaylight(WherandGoodwin,1983).Thishasbeenlikenedtothefindinginvigilanceexperi-ments, inwhichthere isagradualdecreaseofefficiency.Therewasalso foundtobeagreateroverestimationoffixedintervalsinthemorning,ascomparedwithintheafternoon,andthiswasfound to be correlated with body temperature.The internal clock accelerates when the bodytemperatureisraised.

There is considerable circumstantial, but little direct, evidence that circadian rhythms arecausally associated with affective disorders (Thompson, 1984). Early morning wakening anddiurnalvariationinmood,withthemoodmostdepressedintheearlymorning,areconsideredasbiologicalsymptomsofdepressionandhavebeenpostulatedasphase advanceofthesleep–wakecycle;thatis,eachpointoftherhythmoccursearlierthanusualrelativetothelight–darkcycle.Thereisachangeindepressioninthatrapideyemovementsleepoccursearlier,ratherthanlater,


inthenight,andthisalsomaypointtophaseadvanceofthecircadianrhythm.Sleepdeprivationhasbeenusedwithvariablesuccessinthetreatmentofdepression;therehasbeenresearchintothegeneticandfamilialaspectsofsleepdisturbance,intosleepdisordersindepressionandotherneuropsychiatricconditionsandintotherelationshipofsleepdisturbanceindepressionandotherneuroendocrinechanges(LinkowskiandMendlewicz,1993;Vogeletal.,1980).

Althoughdiurnalityofmoodusuallymanifestsitselfbythesubjectfeelingworseintheearlymorning,sometimesthisisreversed.Styron(1991)describesthisforhisownseveredepressiveillness:

‘there was now something that resembled bifurcation of mood: lucidity of sorts in the early hours of the day, gathering murk in the afternoon and evening’.

Indepression,changesofbody temperatureandcortisol levelsover the24hourshavealsobeen interpreted as phase advanceof the circadian rhythm,but the results are equivocal.Theactionofantidepressantdrugsontherhythmhasbeeninvestigatedbylengtheningtheintrinsiccyclesofrest,temperatureandsleep,butagaintheevidenceisnotclear.Corroborationstudiesofairtravellerscrossingtimezoneshavesuggestedthattravelfromeasttowestismorelikelytobeassociatedwithdepression,andfromwesttoeastwithhypomania( JauharandWeller,1982).However, physiological studies of jet lag would not support such an association (Arendt andMarks,1982).

Thinking in relation to circadian rhythms in mood disorders was given further impetusbecauseofthediscoveryofclockgenesandcellularclocks,eventhoughthere isnoconsistentfindingthatdisruptionoftheseclocksexistinmooddisorders(McCarthyandWelsh,2012).Itmaybethatclockgeneexpressionoutsideofthesuprachisamaticnucleus is involvedinmoodregulation(McClung,2007).Thisisamatterforfutureresearch.

Ithasbeensuggestedthattheremaybeashortenedrhythm,oflessthan24hours,inpatientswithlong-termschizophrenia.Abnormalitiesofcircadianrhythmhavealsobeendescribed,butnotfullysubstantiated,inanorexianervosaandinpeoplewithabnormalpersonalities.

MONTHLY CYCLES

Clearly,themostobvioushumanbiologicalrhythmtorecurmonthlyisthemenstrualcycle,andthishasbeenlinkedwithchangesinthementalstate,butpremenstrualsyndromeremainscon-troversialinitsdefinition,managementandpoliticosocialimplications(Bancroft,1993).Similarpsychologicalmoodswingswithamonthlycyclehavebeensoughtinthemalebutnotconvinc-ingly found. Estimates for the frequency of premenstrual syndrome have varied in the generalpopulationbetween30percentand80percentofwomenof reproductiveage (Clare,1982).Psychologicalsymptomsincludelethargy,anxiety,irritabilityanddepression,butmanysymptomsarebothpsychologicalandphysical(headache,feelingbloated,lossofenergy).Itisthetimingratherthanthenatureofthesymptomsthatindicatesthediagnosis,andthereareclearlydifferingconstellationsofcomplaintwithinthesyndrome(Sampson,1989).

MuchnumericaldatahavebeenprovidedbyDalton(1984)tosupportthecontentionthatthereisincreasedpsychopathologyofvarioustypesduringtheeightdaysofthepremenstruumandthemenstrualperiod itself relative to the restof thecycle.Shestated that46percentofemergencypsychiatricadmissions,53percentofattemptedsuicides,47percentofadmissionsfordepressionand47percentofadmissions for schizophreniaofwomenof reproductive ageoccurduring these stages,but thesefigureshavenot yetbeen substantiated.However, reportsofunusualmanifestationsofpremenstrualsyndromeincludedescriptionsofauditoryhallucina-tionsanddelusionsofreferencepresentonlyinthepremenstrualperiod,andhypomanicormanicstatespresentinthe2–3dayperiodbeforetheonsetofmenstruation(HsiaoandLiu,2007).


SEASONAL VARIATION

Season of the year has been invoked for the onset of episodes of many psychiatric illnesses.Understandably,thisismorepronouncedatincreasinglyhigherlatitudesinthenorthernhemi-sphere.Similarassociationsofillnesswithsummerorwinterhavebeenobservedinthesouthernhemisphere.

Inbothnorthernandsouthernhemispheres,patientswithadiagnosisofschizophreniaaremorelikelytohavebeenborninthewintermonths(Hare,1988);thisismoststrikinglyfoundforthosewithoutafamilyhistoryoftheillness(O’Callaghanetal.,1991).Thereisahigherrateforadmissiontopsychiatrichospitalduringthesummermonths.

Foreverydecadesince1921, suicide rates inEnglandandWaleshavebeenhighest in thequarter comprising April, May and June (Morgan, 1979).There appears to be no associationbetween season of birth and affective illness; however, the onset of depressive illness and theadministrationofelectroconvulsivetherapybothbecomemorecommoninspringandautumn(Rawnsley,1982).SymondsandWilliams(1976)foundapeakfortheadmissionoffemalemanicpatientsinAugustandSeptember.

Seasonal affective disorder (recurrent depressive disorder, F33 in ICD-10; World HealthOrganization, 1992) is characterized by repeated episodes of depression, which may vary inseverityfrommildtosevereandrecurwithanonsetat thesametimeofyear,mostoften latewinterorspring.Itismorecommoninwomenthaninmenandtendstostartlaterinlife,oftenabout the fifth decade.There are often a large number of episodes of depression in seasonalaffectivedisorder(10to17perpatient),eachepisodelastingfrom17to23weeks;anxiety,irri-tability, hypersomnia and gain in appetite and weight were prominent symptoms (Thompson

Figure 6.1 Psychiatric disturbance and life epoch.

Intellectualfunction

Psychoticphenomena

Mood

Copingbehaviour

806040200

Age (years)

Mentalhandicapmanifests

Paraphrenia

Seniledementia

Korsakov’s syndrome Multi-infarct dementia

Presenile dementias

Alzheimer'ssyndrome

Huntington'schorea

Infantileautism

Hebephrenicschizophrenia

Paranoidschizophrenia

Depression– rare Manic–depressive psychosis

Puerperal disorders

Involutional melancholia

Depressionremains

common andtreatable

Enuresis

Encopresis

Schoolrefusal

Truancy

Drug abuse

Anorexia nervosa

Sexual disorders

Alcohol dependence

Neurotic reaction withadverse life events

Chronic neurosis

Late-onset neurosis

Traumatic


and Isaacs, 1988).The distinctive symptoms of this condition have been measured using theSeasonalPatternAssessmentQuestionnaire(Thompsonetal.,1988).Itoccursmorefrequentlyinhigherlatitudesinthenorthernhemisphere.InastudyconductedinFinland(Saarijärvietal.,1999),inwhichtheprominentsymptomsincludedlackofenergy,hypersomnia,excessiveeating,weightgainandacravingforcarbohydratesinadditiontootherdepressivesymptoms,therewaslowerprevalenceamongLapps,whoareethnicallyandgeneticallydifferentfromFinnslivingatthesamelatitude.

LIFE EPOCHS

Virtuallythewholeofpsychopathologyismediatedthrough,andinfluencedby,changesinsitu-ationandlifeepoch.Itisimportanttotakeintoaccounttherelativepreponderanceofdifferentfactors:biologicalchange,pressureofsocialcontextandindividualperceptionoflifesituation.Itisoutsidethescopeofthisbooktocharttheseassociationsindetail,butanimpressionisticsketchisofferedinFigure6.1.Thepsychologicaleffectsofimportantlifechangeshavebeenstudiedinprimarycaresituations:birthofthefirstchild( Jewell,1984),startingschool(PittandBrowne,1984),puberty(HoweandPage,1984)andleavingschool(Brown,1984).

Some of the abnormal mental states associated with life changes of female gender couldequallywellbediscussedwithlifeepoch.

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87

C H A P T E R 7

Pathology of Perception

SummaryAbnormalities of perception remain some of the most compelling experiences that patientspresentwith.Theseexperiencesspeaktotheunderlyingstructuresoftheperceptualworldandtheneuralcorrelatesthatmakeperceptionitselfpossible.Sensorydistortionsandfalseperceptionsbetweenthempointtotherelativeimportanceandthedistinctionstobedrawnbetweensensa-tionandperception.Illusion,whichisthemisinterpretationofanormalperception,andhallu-cinations,theperceptionofanobjectintheabsenceofastimulusarethetwomostfrequentlyencounteredfalseperceptionsinclinicalpractice.

For almost seven years – except during sleep – I have never had a single moment in which I did not hear voices. They accompany me to every place

and at all times; they continue to sound even when I am in conversation with other people, they persist undeterred even when I concentrate on other things.

Daniel Schreber (1842–1911)

Disordersofperception,particularlyauditoryhallucinationsor‘hearingvoices’,haveacentralplaceinpsychopathology.Alongwithdelusions(Chapter8),theyarethoughtofassynonymouswithmentalillness.Thisapparentassociationwithmentalillnesshascometoimplythat‘hearingvoices’isasignofseriousmentalillnessandthathallucinationsportendmadness.Inthischapter,thenatureofsensation,perceptionandimageryisdiscussedasapreludetoexaminingthenatureofdisordersofperception.

Sensation and PerceptionSensationisonlythefirststageinreceivinginformationfromoutsidetheself.Thesensorysystemincludesthevisual,auditory,tactile,olfactory,gustatory,kinaestheticandproprioceptivepathways.These pathways deal with the receipt, transformation and transmission of raw and disparatesensorydatafromperipheralreceptorstothecentralnervoussystem.Thetransformationofrawsensorystimuliintosensoryinformationthatisthendecodedintomeaningfulperceptionatthecortical level involvesactiveprocessesthatare influencedbyattention,affect,culturalexpecta-tions,context,priorexperiences,memoryand,most importantly,priorconcepts.It isthereforethecasethatperceptionisnotapassiveprocessbutanactiveonethatinvolvestheconstructionofanexternalworldthatdependsoninternaltemplates.

Muchofwhatweknowaboutsensationandperceptionderivesfromourunderstandingofthevisualsystem.Inthevisualsystem,lightsensationisreceivedbytheretinaandtransformedintoaneuralcodethatistransmittedfromtheretinalganglioncellstotheprimaryvisualcortexviathelateralgeniculatenucleusofthethalamus.Perceptionoccurswhenastimulushasunder-goneprocessingaccordingtoitsform,colour,motionandmeaning.

The distinction between sensation and perception is well illustrated by the dissociationbetweenintactsensationandimpairedperceptionintheagnosias.Invisualobjectagnosia,the

Keywords: Imagery,FormConstants,Synaesthesia,Illusions,Hallucination,Pseudohallucination,Autoscopy.

7—PAThOLOGY OF PERCEPTION 87.e1


subjectisabletorecognizethatanobjectisinhisfieldofvision(thatis,sensationisintact),buthe is unable to recognizewhat theobject or its function is (impairedperception).This visualmodelofperceptionislikelytohavecounterpartswithintheothersensorysystems.

OliverSachs(1995)recountsthestoryofVirgil,a51-year-oldmanwhohadbeenblindsinceinfancy.Hehadacataractextraction,butthereturnofvisualsensationwasunaccompaniedbyuncomplicatedperception.Virgilwasableto‘pickupdetailsincessantly–butwouldnotbeabletosynthesizethem,toformacomplexperceptionataglance.Thiswasonereasonthecat,visuallywas sopuzzling;hewould see apaw, thenose, the tail, an ear, but couldnot see all of themtogether,seethecatasawhole’.ThiscaseisreminiscentofGregory’spatient(2004),S.B.,whowhenhewasfirstshownalatheafterrecoveringhissight,‘wasquiteunabletosayanythingaboutit,excepthethoughtthenearestpartwasahandle…Hecomplainedthathecouldnotseethecuttingedge,orthemetalbeingworked,oranythingelseaboutit,andappearedratheragitated…S.B.wasallowedtotouchthelathe.Theresultwasstartling…Heranhishandseagerlyoverthe lathe,withhiseyes shut.Thenhestoodbacka littleandopenedhiseyesandsaid:“Nowthat I’ve felt it I can see.”’These two cases underline the distinction between sensation andperceptionandconfirmthat‘wearenotgiventheworld:wemakeourworldthroughincessantexperience,categorization,memory,reconnection’(Sachs,1995).

There are various competing models of the way that recognition is achieved by the visualsystem.Adetaileddescriptionof thesemodels isoutside thescopeof thischapter (seeSmithandKosslyn,2007).Bottom-upprocessingconsistsoftheprimaryprocessesthattransformsensa-tionintotheperceptionofobjectsthathaveform,colour,motionandlocationinspace.Ontheother hand, top-down processes involve the influence of our learned experience of perceivingobjectstonarrowthecompetitionbetweenthepossibleinterpretationsofthesensoryinforma-tion.Thealternativemodelsofthetop-downprocessesthatattempttoexplainobjectrecognition,thatis,perception,arethetemplate-matchingmodel,thefeature-matchingmodel,therecognition-by-componentsmodelandtheconfiguralmodels.

Thetemplate-matchingmodelrequiresaninternaltemplateinmemorytowhichanobjectcanbematched.Theweaknessofthismodelisthatthetemplatemustaccommodateobjectsizeandorientation,forexample,andmuststillberapidandreliable.Thefeature-matchingmodelrequiresonly that adistinct anddiscriminating featureof anobjecton itsownshould specifywhattheobjectis.Treesneedonlybespecifiedbythefactthattheyhaveatrunkandbranches.The exact location of the branches and size of the trunk do not matter.The recognition-by-componentsmodelrequiresaknowledgeofthecorrectarrangementofpartsinthree-dimensionalspace.Thus,irrespectiveoftheperspective,abicycleisstillrecognizedasabicycle.Finally,theconfigural model is a refinement of the recognition-by-components model. It deals with themechanismwherebyindividualexamplesofaclassarerecognized.Thisisthedistinctionbetweendifferentmakesof cars, the variation thatdetermines thatone car is aMercedes andanotherisaVolvo.

IMAGERY

Imageryistheinternalmentalrepresentationoftheworldandisactivelydrawnfrommemory.Imageryunderliesourcapacityformanycrucialcognitiveactivities,suchasmentalarithmetic,mapreading,visualizingandimaginingplacespreviouslyvisitedandrecollectingspokenspeech.Inday-to-daylife,itiscommontoreferto‘seeinginthemind’seyes’or‘hearinginthemind’sears’.Thesetermsrefertoimagery.Jaspers(1962)describedtheformalcharacteristicsofimagesasfollows:

1. imagesarefigurativeandhaveacharacterofsubjectivity;2. theyappearininnersubjectivespace;3. theyarenotclearlydelineatedandcomebeforeusincomplete;

7—PAThOLOGY OF PERCEPTION 89

4. althoughsensoryelementsareindividuallytheequalofthoseinperception,mostlytheyareinsufficient;

5. imagesdissipateandalwayshavetoberecreated;and6. imagesareactivelycreatedandaredependentonourwill(Table7.1).Functionalimagingstudieshavedemonstratedthatthesamecorticalareasareimplicatedin

visual imageryandvisualperception (KosslynandThompson,2003),and transmagnetic reso-nance studieshavealso shown that transmagnetic resonanceapplied repeatedly tovisual areasreducesthecapacityforvisualimagery(Kosslynetal.,1999).Furthermore,behaviouralexperi-ments have shown that participants are able to construct mental images that have perceptualqualitiessuchascolour,size,shapeandorientation.Theseimagesareuneven,withthelevelofdetaildependingonthedegreeofvisualattention(SmithandKosslyn,2007).

Thestudyofimageryremainsacontroversialareawithincognitiveneuroscience.Theoriesofvisualimageryhaveborrowedfromthelanguageandmodelofthecamera;thisisreferredtoasthepictorialordepictiontheoryofmentalimagery.TheforemostproponentofthisapproachisKosslyn.Adetailedaccountof the theoryand itsdifficulties isoutside thescopeof thisbook(seeKosslyn,2004;Pylyshyn,2004).Kosslynarguesthatamentalimageisfigurativelyaccurate,aseachpointoftheimagecorrespondstoeachpointontherepresentedobject.Thismeansthatthereisapoint-to-pointrepresentationsuchthatperformingparticularoperationsontheimagetakesasmuchtimeasitwouldtaketoperformthesameoperationontheobject.Inotherwords,the time to scanamental image is the sameas the time to scan theobject.Pylyshyn,on theother hand, argues that there are decisive differences between retinal or cortical images andmentalimages.

Imageryisimportantforpsychopathologybecauseanunderstandingoftheformalcharacter-isticsornatureofimageryisrequiredforexaminingthenatureofperceptions,hallucinationsandpseudohallucinations.Functionalimagingstudiesandcasereportshaveshownthatthemecha-nismsresponsibleforthevisualperceptionofobjectsandthoseresponsibleforimagerymaybesimilar.Inotherwords,theneuralsubstratesofperceptionandimageryattheveryleastoverlap(Martin, 2006). Ultimately, these investigations may shed light on the mechanisms unitingimageryandabnormalperceptions.

FORM CONSTANTS, EXTENSION AND SYNAESTHESIA

Synaesthesia isa rareconditionthat isnot regardedasanexampleofabnormalexperiencebutnonethelessprovidessomeunderstandingofelementaryperceptualneuralsystemsthatmayhelptoclarifyandilluminatetheproblemofabnormalperception.Synaesthesiacanbedefinedasthe

TABLE 7.1 ■ Formal characteristics of normal perception and imagery

Normal perception Imagery

Perceptions are of concrete reality Images are figurative and have a character of subjectivity

Perceptions occur in external objective space Images appear in inner subjective space

Perceptions are clearly delineated Images are incomplete and poorly delineated

The sensory elements are full and fresh The sensory elements are relatively insufficient

Perceptions are constant and remain unaltered Images dissipate and have to be recreated

Perceptions are independent of our will Images are dependent on our will

(After Jaspers, 1962)


perceptionof anobject,presented inone sensorymodality, at the same timeas in adifferentsensorymodality.Thisisbestillustratedbygivinganexampleofmusictocolour:

When I listen to music, I see the shapes on an externalized area about 12 inches in front of my face and about one foot high onto which the music is

visually projected. Sounds are most easily likened to oscilloscope configurations – lines moving in colour, often metallic, with height, width and, most

importantly, depth. My favourite music has lines that extend horizontally beyond the ‘screen’ area.

(Cytowic and Eagleman, 2009)

Various forms of synaesthesia have been reported including most commonly grapheme tocolour;timeunittocolour;musicalsoundstocolour;generalsoundstocolour;and,phonemetocolour.Otherformsaresoundstotaste;soundtotouch;visiontotaste;etc.Anotherexampleofsoundtocolour:

One of the things I love about my husband are the colours of his voice and his laugh. It’s a wonderful golden brown, like crisp, buttery toast, which sounds

very odd, I know, but it is very real.(Cytowic and Eagleman, 2009)

Theseexperiencesasdescribedaboveseemtobespatiallyextended,butdifferentfromseeingor imagining. They are experienced close to the body, within limb’s reach, and within ‘peri-personalspace’.Theseexperiencesraisethequestionofhowtheextendedspaceinsynaesthesiaisakintothespaceinwhichhallucinationsareexperienced.Furthermore,thesynaestheticexperi-encesareconsistentovertimeandareelementaryandspecificinnature.Thesensationsdonotevokeelaborateorcomplexperceptions,butratherelementarycolours,shapes,bright-darkcon-figurations,jagged-smoothsensations,etc.areprovoked.Indeed,thereisevidencethatthesensa-tionsareexamplesorelaborationsofForm Constants.Form Constants in thevisualdomainarevariations of tunnels and cones; central radiations; gratings and honeycombs; and spirals.Variations in colour, brightness, symmetry, replication, rotation and pulsation provide furthergradationsofthesubjectiveexperienceofthesepercepts.Whatissignificantisthattheseformconstantsseemtobeapropertyofthevisualcortexitselfandaremorecommonlyexperiencedintheauraphaseofmigraineorinperiodsofsensorydeprivation(seeCytowicandEagleman,2009foramoredetaileddiscussion).

Insummary,synaesthesiaintroducesthepossibilityofunderstandingsomeabnormalpercep-tions as occurring within peri-personal space which is neither like imagery nor like a normalpercept. Inotherwords,a thirdspacemightexist inwhichsomeexperiencessuchas those insynaesthesiatakeplace.Additionally,fundamentalandelementaryfeaturesoftheneuralunder-pinningofperceptionmightbeinvolvedindeterminingtheformofabnormalperception,thatis,thenatureofabnormalperceptionsisnotrandomlydetermined.

PRIVATE SPEECH AND INNER SPEECH

Inadditiontounderstandingthenatureofimagery,extendedspaceandformconstants,thereisaneedtocomprehendwhyauditoryhallucinationshavethesyntacticalstructurethattheyhave,namelycommandformatandsecondandthirdpersonsyntax.AnapproachisVygotsky’s(1896–1934)developmentalmodelof thoughtandspeech.Heproposedthat innerspeechdevelopedfirstfromtheinternalizationofexternaldialogueintoprivatespeechandfinallyintoinnerspeech(Vygotsky,1934/1987;Fernyhough,1996).Achildmight,forexample,beinstructedbyaparent;‘Dothisorthat’andthechildinternalizesthisinstructionintoprivatespeechandlaterintoinner


speech.Private speech is anovert, spoken language that isnot aimed at communicatingwithothersbut is linkedwith thinking.This transformationofdialogic, external speech into innerspeechprovidesabasisforunderstandingtheubiquityof‘command’auditoryhallucinations.Asimilarcasecanbemadeforsecondandthirdpersonauditoryhallucinations.WhatisimportanthereisthemannerinwhichVygotsky’sclaimlinksthinkingandspeechandalsohowhisbeliefthatinnerspeechandthinkingarebuiltonfragmentaryandcondensedimages,makethephe-nomenologyofverbalhallucinations,inparticular,morecomprehensible.

Abnormal PerceptionWewillnowdivideabnormalperceptionintosensory distortions,inwhicharealperceptualobjectisperceivedinadistortedway,andfalse perceptions,inwhichanewperceptionoccursthatmayormaynotbeinresponsetoanexternalstimulus.Illusions, hallucinationsandpseudohallucinationswillbeincludedunderfalseperceptions.Thepossibilityofaneurologicaldeficitaffectingpercep-tionalsoneedstobeconsidered.

Subjectively,hallucinationissimilartosenseperception:itisexperiencedasanormalpercep-tionanditcanbedistinguishedfromthefantasyelementsthat invest it.Invivid imagery, thewhole experience is imaginary. Pseudohallucination has a close affinity to imagerybut alsohassome aspects that are characteristic of sense perception or hallucination: vividness, definition,constancyandapparentindependencefromvolition.

SENSORY DISTORTIONS

Disturbance of the mental state, with or without organic brain pathology, may cause sensorydistortion.Thisdistortionmayinvolveanyofthecomponentsorelementaryaspectsofpercep-tion,suchasuniqueness,size,shape,colour,location,motionorgeneralquality.Whatissignifi-cant is that theperceivedobject is correctly recognized and identifiedyet there is adeviationfromitscustomaryappearancewithoutprejudicingtheknowledgeofthekindofthingthatitis(Cutting,1997).

Elementary Aspects of Visual Perception

Invisualperception,therecurrenceorprolongationofavisualphenomenonbeyondthecustom-arylimitsoftheappearanceoftherealeventintheworldistermedpalinopsia(Cutting,1997).Critchley(1951)gaveanumberofexamples:acatnoticedinthestreetonedaykeptappearingatvarioustimesandvarioussituationsoverthenextfewdays,andthewords‘PullmanSprings’noticedonthebackofavankeptappearingonothervehiclesoverthenextfewmonths.

Thesizeoftheperceptioncanbeeitherlarger(macropsia)orsmaller(micropsia)thanexpected.Insomecases,therecanbeapparentreductioninonehemifieldofvision(hemimicropsia).Theseanomaliesarecommonintemporallobeepilepsy.Alterationinthecustomaryshapeoftheper-ceivedobjectistermedmetamorphopsia.Usually,thismayinvolvetheappearanceofthingstakingonadifferentaspect:‘Onewomansawpeopleupsidedown,ontheirheads’(Bleuler,1950).Thisisanexampleofinversion.Whenmetamorphopsiaaffectsfaces,itisreferredtoasparaprosopia.Typically,theseperceptualdistortionsoffacesarerapidlyfluctuantanddynamic.Schreber(1955)describeshisexperienceasfollows:‘AtthesametimeIrepeatedlywitnessedthat[somepatients]changedheadsduringtheirstayinthecommonroom;thatistosaywithoutleavingtheroomandwhileIwasobservingthem,theysuddenlyranaboutwithadifferenthead.’Bleuler(1950)alsodescribes,‘Wardmateschangetheirfacestheverymomentthatonelooksatthem’.OneofCutting’spatients(1997)said,‘Manbehindalorrywaspullinghideousfaces’.

Different aspects of colour perception can be affected.The intensity of the colour (visual hyperaesthesia), theactualhueandthequalityofthecolourcanallbeaffected.Cutting(1997)givesseveralexamples:


1. ‘coloursarebrighter’,‘coloursmorevivid–red,yellow,orangestoodout’;2. ‘black lookedbrownsometimes’, ‘brown lookeddifferent; troublewithpinkas it comes

acrossasgreen’;and3. ‘thiscolourlookslikeanoldblue–somethinghorrible’.Bleuler(1950)describes‘onepatientseeseverythingascolouredred;anotherseeseverything

aswhite’,andJaspers‘Ionlyseeblack;evenwhenthesunisshining,itisstillallblack’.Theseperceptual distortions of colour occur in schizophrenia. In organic conditions, achromatopsia,which is the complete absence of colour, has been described following unilateral or bilateraloccipitallesions,usuallyofthelingualandfusiformgyri.Dyschromatopsiareferstotheperversionofcolourperceptionandoccursfollowingunilateralposteriorlesions.

The spatial location of a perceived object may be distorted. Teleopsia involves the objectappearing faraway,andpelopsia theobjectappearingnearer than it should.Alloaesthesia is thetermforwhentheperceivedobjectisinadifferentpositionfromwhatisexpected,sothatthepatient,forexample,experiencesthetranspositionofobjectsfromlefttoright.

Akinetopsiaistheimpairmentofvisualperceptionofmotioninwhichtheindividualisunabletoperceivethemotionofobjects.Itisveryrareandissaidtofollowbilateralposteriorcorticaldamage.Zeki(1993)quotesZihl’scase:

‘She had difficulty, for example, in pouring tea or coffee into a cup because the fluid appeared to be frozen, like a glacier. In addition, she could not stop

pouring at the right time since she was unable to perceive the movement in the cup (or a pot) when the fluid rose.’

Thegeneralqualityofperceptioncanbeaffected.Thisusuallyinvolvesanindefinablealtera-tioninthevisualappearanceoftheperceivedworldsothateverythingseemsdifferentfromwhatitusedtobe:‘People[look]liketoys–almostdeadandlifeless,carryingoutautomaticmove-mentswithspecialmeaning’(Cutting,1997);‘people lookdead,pale,cold’ (Cutting,1997);‘Afactory-worker seesagrasshopperandbecomesverydisturbedandexcitedat thesightof thisvery strange[myemphasis]andunknownanimal’(Bleuler,1950).Theseexperiencesareexamplesofderealization.Normally,perceptionisaccompaniedbyaffect,whichmaybeafeelingoffamili-arity,ofenjoyment,ofdislike,ofinvolvement,ofproximityandsoon.Thisisusuallyappropriateandsoignored.However,changesinthesefeelingsmaypresentassymptoms,forexample,‘eve-rythinglooksclearbutitalllooksmilesaway’,‘Ifeelinseclusion.Itislikelookingthroughthewrong end of a telescope’.These, and many other feelings, are described under derealization(Chapter13).Thereisafeelingofunrealityintheperceptualfield,analterationinthefeelingsassociatedwiththeobjectsofperception.

Apatientwhoexemplifiedboththelossofintensityofsensationandthechangeinfeelingsassociatedwithperception in thecontextofadepressive illnesswasa23-year-oldSriLankanBuddhistpriest.Followingasessionofmeditation,hebecameveryfrightenedonwakinguptodiscoverthathehadassaultedanotherpriestduringthenight.Inthenextfewdays,hefeltthathehadlostallsensation.Thingshesawandheardhecouldnotunderstandproperly.Hecouldseeonlythethingsthatwerenearby.Hecouldnotgetanysensationsfromhisskin.Hesaidthathecouldnotreadnorunderstand,norfeelsadnessorhappiness.Hesaidthathecouldnotfeelanything:‘all isnumbed,bodyandmind’.Headmittedto feeling low, that lifewasnotworthlivingandthathehadthoughtofendinghis life.Therewasnoneurologicalorotherphysicalabnormality.

Elementary Aspects of Auditory Perception

Theelementaryelementsofauditoryperceptionthatcanbedisturbedincludetheuniquenessofthe experience, the intensity and the spatial position (Cutting, 1997). In palinacousis, the


uniqueness of a perceptual experience is disturbed and there is persistence of sounds that areheard.Asubjectreturnedtoanswerthedoorseveraltimesduringa30minuteperiodafterthedoorbell had actually rung ( Jacobs etal., 1973).The intensity of auditory perception may bealteredsothat it iseitherheightenedordiminished.Forexample,heighteningintheauditorymodalityiscalledhyperacusis,asymptominwhichthepatientcomplainsofeverythingsoundingabnormally loud, saying, ‘I can’t bear thenoise’.Ordinary conversationmay sound intolerablynoisy, andevenwhisperingat adistancemaybe founduncomfortable.There is,of course,notrueimprovementofauditoryperceptionbutsimplyaloweringofthethresholdatwhichnoisebecomes unpleasant.The symptom occurs in depression, migraine and some toxic states, forexample the hangover following acute alcohol excess.The spatial position of a sound may bedisturbedsothatthesoundappearsasifitwasnearer,furtherordisplacedinposition.

Elementary Aspects of Tactile Perception

Palinaptiaistheexperienceoftactilesensationoutlastingthestimulus,sothatanobjectheldinthehandcontinuestobeperceivedwellafterithasbeendiscarded.Stacy(1987)reportsacaseofapatientwithbiparietallesionswhocouldfeelhertoothbrushinherhand15minutesafterputtingitaway.Thepalinapticexperienceoccurredinthesettingofastereognosisandpalpatoryapraxia.Thepalinaptiacanbeconceivedasacomplexhaptichallucination.Exosomesthesiaisthe‘displacementofcutaneoussensationintoextrapersonalspace’(ShapiroandFink,1952;Shapiroetal., 1952).This is a curious condition in which the individual experiences direct cutaneoustouchsensationasanobjectintheroomthatisdistalfromthembeingtouched.

If the palm of his hand was in contact with some object (bed, table, book) and the dorsum of that pricked with a pin, the patient insisted that the bed or

table had been touched and not his hand. This phenomenon could be elicited only from the hand and only when the palm was in contact with some object.

Thisunusualphenomenoncanbeexperimentallyinduced,andithasbeensuggestedthatthebody image,despite its appearanceofdurability andpermanence, is a transitory internal con-struct that canbe alteredby the stimulus contingencies and correlations that are encountered(RamachandranandHirstein,1998).

It is even possible to ‘project’ tactile sensations onto inanimate objects such as tables and shoes that do not resemble body parts. The subject is asked to place

his right hand below a table surface (or behind a vertical screen) so that he cannot see it. The experimenter then uses his right hand to randomly stroke and tap the subject’s right hand (under the table or behind the screen) and

uses his left hand to simultaneously stroke and tap the table in perfect synchrony … After 10–30 seconds, the subject starts developing the uncanny illusion that the sensations are now coming from the table and that the table

is now part of his body.

Alloaesthesiaisaneurologicalconditionfollowingright-sidedvascularlesionsoftheputamenthatischaracterizedbyasensorystimulusononesideofthebodybeingperceivedonthecon-tralateralside.Itcanalsooccurfollowingspinalcordlesionssuchascervicaltumours,cervicaldischerniationandmultiplesclerosis(Fukutakeetal.,1993;Kawamuraetal.,1987).

Splitting of Perception

Thisratherrarephenomenonisdescribedsometimeswithorganicstatesandalsowithschizo-phrenia:thepatientisunabletoformtheusual,assumedlinksbetweentwoormoreperceptions.


Apatientwatchingtelevisionexperiencedafeelingofcompetitionbetweenthevisualandaudi-toryperceptions.Shefeltthatthetwowerenotcomingfromthesamesourcebutwerecompetingforherattentionandconveyingoppositemessages.Splitting of perceptionoccurswhenthelinksbetweendifferentsensorymodalitiesfailtobemade,andsothesensationsthemselves,althoughinfactassociated,appeartobequiteseparateandeveninconflict.

FALSE PERCEPTION

Nowwe turn fromthealteredperceptionof realobjects toconsider theperceptionofobjectsthatarenotthere;thesearenew perceptions that includeillusion,hallucinationandpseudohal-lucination. Illusions were separated phenomenonologically from hallucinations by Esquirol(1817)andlateralsobyHagen,whointroducedthetermpseudohallucination(Berrios,1996).Hedescribedthemastransformationsofperceptions,comingaboutbyamixingofthereproducedperceptionsofthesubject’sfantasywithnaturalperceptions.

Illusion

Three types of illusion are normally described: completion illusion, affect illusion and pareidolic illusion.Completionillusionsdependoninattentionfortheiroccurrence.ThefadedletteringofanadvertisementoutsideagarageisrepresentedinFigure7.1.Beingmoreinterestedinmusicthancars,theauthorregularlymisreadthisas‘Vivaldi’.Wecommonlymissthemisprintsinanewspaperbecausewereadthewordsasiftheywerewrittencorrectly.Assoonasourattentionisdrawntothemistake,ourperceptionalters.Anincompleteperceptionthatismeaninglessinitselfisfilledinbyaprocessofextrapolationfrompreviousexperienceandpriorexpectationtoproducesignificance.

Completion illusion demonstrates the principle of closure in gestalt psychology: there is ahuman tendency tocompletea familiarbutnotquitefinishedpattern (Beveridge,1985). It isnecessaryforustomakesenseofourenvironment;sowhenthesensorycuesarenonsensical,wealterthemslightlywithrememberedorfantasymaterialsothatthewholeperceptualexperiencebecomesmeaningful.

Whenillusionarisesthroughaffect,theperceptionofeverydayobjectsischanged.Theillusioncanbeunderstoodonlyinthecontextoftheprevailingmoodstate.Achildwhoisfrightenedof thedarkwakesup in thehalf light andmistakes a towelhangingby thewall for apersonmoving.Theexperiencelastsonlyashorttimeanddisappearswhentheintensefeargoes:theillusionisbanishedbyattention.Ofcourse,thereisnoabsolutedistinctionbetweenthesedif-ferenttypesofillusion.Thedegreeofcompletion,orofaffectinvolved,isvariable.Forexample,

Figure 7.1 Illusion.


amanlookingthroughadvertisementsforapostfoundajobthathelikedandmisreadthewrittenword‘suitable’fortheillusionalword‘superior …applicantisrequired’.Clearly,thiswasbothanaffective and a completion illusion. Similarly, in the stage of searching that occurs followingbereavement, momentary recognition of the dead person may occur for someone in a crowd.Closeobservationoftheindividualimmediatelydispelsthefeelingoffamiliarity.

Pareidoliaoccursinaconsiderableproportionofnormalpeople.Itmayalsobeprovokedbypsychomimeticdrugs.Typically,imagesareseeninshapesinpareidolicillusion.Forexample,theauthorusedtoseetheheadofaspanielinachiponthefirstpavingstoneofthepathleadingtothehousewherehelivedasachild;theimagewasnotjustadogbutdefinitelyaspaniel.

Pareidolicillusionsarecreatedoutofsensoryperceptsbyanadmixturewithimagination.Thepercept takes on a full and detailed appearance: ‘AVictorian lady with a crinoline and frilledbloomers’.Thepersonexperiencing it, likesomeoneseeingaphotograph,knowsthat it isnottruly there as an object but that it is pictorial. However, he cannot dismiss what he sees.Completionandaffectillusionsoccurduringinattention;theyarebanishedbyattention,whichwill,ifanything,increasetheintensityofpareidolicillusionsastheybecomemoreintricateanddetailed.

Pareidolicillusionoccursinchildrenmorethaninadults.Itshouldbedistinguishedfromthefollowingconditions.

■ Perceptual misinterpretation,thatis,simplymakingamistakeastothenatureofperceptionwithoutthatperceptionbeingparticularlyinfluencedbyemotionmixedwithfantasy.

■ Functional hallucination,whichoccurswhenacertainperceptisnecessaryfortheproductionof a hallucination, but the hallucination is not a transformation of that perception. Forexample,thepatienthearsvoiceswhenthetapisturnedon;hehearsvoicesintherunningwater,butthevoicesandthenoiseofwaterarequitedistinctandcanbeheardseparatelyandsynchronouslylikeanyothervoicethatisheardagainstabackgroundnoise.Theper-ceptionofhearingrunningwaterisnecessarytoproducethehallucination,butthehallu-cinationisnotatransformationofthatperception.

■ Fantastic interpretationsorelaboratedaydreamingcanbeverysimilartopareidolicillusionsand,aswehavealreadydiscussed,thereisalargeadmixtureoffantasyinsuchillusions.

HallucinationHallucinationsare,phenomenologically,themostsignificanttypeoffalseperceptions.Herearefivedefinitionsofhallucination.

■ Aperceptionwithoutanobject(Esquirol,1817).■ Hallucinationsproperarefalseperceptionsthatarenotinanywaydistortionsofrealper-

ceptionsbutspringupontheirownassomethingquitenewandoccursimultaneouslywithandalongsiderealperception( Jaspers,1962).

■ Ahallucinationisanexteroceptiveorinteroceptiveperceptthatdoesnotcorrespondtoanactualobject(Smythies,1956).

■ According to Slade (1976a), three criteria are essential for an operational definition:(a)percept-likeexperienceintheabsenceofanexternalstimulus;(b)percept-likeexperi-encethathasthefullforceandimpactofarealperception;and(c)percept-likeexperiencethatisunwilled,occursspontaneouslyandcannotbereadilycontrolledbythepercipient.ThisdefinitionisderivedfromJasper’sformalcharacteristicsofanormalperception(seeTable7.1).

■ Ahallucinationisaperception without an object(withinarealisticphilosophicalframework)ortheappearance of an individual thing in the world without any corresponding material event(withinaKantianframework),accordingtoCutting(1997).

Oneofthesimplestfactsabouthallucinationsisoftenoneofthemostdifficulttocomprehend.Thatis,whatthedoctorcallsahallucinationisanormal sensory experiencetothepatient.Although


thestandarddefinitionsofhallucinationimplythat,subjectively,ahallucinationisindistinguish-ablefromanormalpercept,someauthorsarguethathallucinatoryperceptsmaybedistinctfromnormalpercepts (seebelow).Oneof the clues that the sufferer uses to grasp the fact thathemightbehallucinatingisthatthereisnocorroborativeevidencefortheperceptinothermodali-ties.Awomanhearsvoicesgivingacommentaryonheractivity:‘Sheisgoingtothesink.Sheis putting the coffee on’. She sees no one else in the room but recognizes the voices of herneighbours.Shecannotunderstandhowshecanbehearingthem,butsheissoconvincedbytherealityofthevoicesthatshedrawsthecurtainsandtakesthemirrorsoffthewalls.Thereissomeconflictinhermind:shehearsvoicesbutcanseenopersontoaccountforthem.However,sheresolvesthisconflictinwhatisarationalway,assumingthatshebelievesimplicitlyinthegenu-ineness of the perception: ‘someone must have fixed a device or altered my sense of hearing’.Whatisnotableisthatshedoesnotdoubttherealityofthepercept.

Horowitz(1975)hasinvestigatedhallucinationsusingacognitiveapproach,lookingateachofthefollowingfourconstructsintermsofcoding,appraisingandtransforminginformation.

Hallucinations are mental images that (1) occur in the form of images, (2) are derived from internal sources of information, (3) are appraised

incorrectly as if from external sources of information, and (4) usually occur intrusively. Each of these four constructs refers to a separate set of

psychological processes, although together they comprise a holistic experience.

Thisprovidesaconceptualframeworkforinvestigatingthephenomenaofhallucination.This ideahasbeendeveloped furtherbyBentall (1990),who considers thathallucinations

representfaultyjudgementsabouttheoriginoftheirperceptions,tendingtoattributethemtoanexternalsource.Thecontentofhallucinationwasthoughttobeexplained,atleastinpart,bytheneedtodefendtheindividual’sownself-esteem.Hallucinationsmayresultfromafailureofthemetacognitive skills involved indiscriminatingbetween self-generated and external sourcesofinformation.Thisexplanationwasgivenfurthersupportbythefindingthathallucinatorsmoreoftenmisattributedauditorilypresentedanswerstodifficultcluesfromanexperimenterthaneitheradeludedbutnothallucinatedgroupofpatientsornormalcontrolsubjects(Bentalletal.,1991).

Attemptstoexplainhallucinationsbyunderlyingneurochemistryandneuropathologyhavesofarnotmademuchprogress.Anattempthasbeenmadetoincorporateconceptsofbiologicalvulnerabilityandpsychologicalinfluencesintheaetiologyandclinicalpresentationofhallucina-tions,butresearchhasproducednosinglemechanismtoaccountforthem(AsaadandShapiro,1986).

Hallucinations takeplaceat thesametimeasnormalsensorystimuliareperceived.Inthisway, they are unlike dreams, which in fact have more of the characteristics of illusions.Hallucinationsarelikenormalpercepts,ofwhichseveralcanbeperceivedsimultaneouslyorinrapidsuccession.Thus,thepatientcanhearhallucinatoryvoicesatthesametimeasheisseeinghis interviewer and listening to him speak. Hallucination is like after-image, pareidolia or theobservationofanormalsensoryobject,inthatattentionwillnotremoveit.

The sense of reality experienced by patients when they hallucinate has been studied byAggernaes(1972),developingtheconceptsofRasmussen.Hepointedoutsixqualitiesofwhichnormalpeoplecanbeawarewhentheyexperienceasensation,whichalsooccurredinover90percentofaseriesofhallucinations.

■ Withnormalsensation,weareabletodistinguishperceivingwithoursenseorgansfromimaginingthesameobjects;hallucinationssimilarlyareexperiencedassensationandnotasthoughtorfantasy.

■ Whenasubjectexperiencessomething,herealizesitspossiblerelevanceforhisownemo-tions,needsoractions;hallucinationsalsohavethisqualityofbehaviouralrelevance.


■ Normalsensationhasaqualityofobjectivity,inthattheexperiencerfeelsthatunderfavour-able circumstances he would be able to experience the same something with anothermodalityofsensation;thisisalsotheexperienceofthehallucinator.

■ Anobjectisconsideredtoexistiftheobserverfeelscertainthatitstillexistseventhoughnobodyelseisexperiencingitatthattime;perceivedobjectsandhallucinationssharethisquality.

■ Experienceofobjectperceptionandhallucination is involuntary, in that the experiencerfeelsthatitisimpossibleorextremelydifficulttoalterordismisstheexperiencesimplybywishingtodoso.

■ Normally,theexperiencerisaware,orthroughsimplequestioningbecomesaware,thathisexperience is not simply the result of being in an unusual mental state; this quality ofindependenceispresentwithnormalperceptionandwithhallucination.

Onefurtherqualityofnormalobjectperceptionwasfoundtobeabsentmoreoftenthannotwithhallucination.Thisisthequalityofpublicness,inwhichtheexperiencerwouldbeawarethatanybodyelsewithnormalsensoryfacultieswouldbeabletoperceivethissomething.Often,thehallucinatordoesnotbelievethatotherscouldsharehisexperience(delusionalexplanationmaybegivenforthis).

Clearly,culturalfactorsinfluencethemannerinwhichsubjectsdescribetheirabnormalper-ceptions.IthasbeenclaimedbyAndrade(1988)thatbecausepatientsinIndiaweremorepre-paredtoacceptparanormalexplanationsforphenomena,falseperceptionsor‘truehallucinations’aremore likely tobeascribedwithobjectivityandveridicality.Even if this is so,and it isnotproven,thequalitiesdescribedbyAggernaeswouldstillbeusefulindistinguishinghallucinationfromotherabnormalitiesofperception.

Cutting(1997)hasarguedthathallucinatoryexperiencesarehardlyplausibleeverydayoccur-rences,andthatthereforeitisnotthathallucinatoryperceptsareindistinguishablefromnormalpercepts, but rather that they are taken for realitydespite the fact that they aredistinct fromeverydayreality.Hemakesthepointthat,forexample,Lilliputianhallucinationsindeliriumandcomplexhallucinationsinvolvingcomiccharactersareobviouslynotplausibleperceptionsintherealworldyettheyaretakenasreal!However,Cuttingignoresthefactthatitispreciselybecausehallucinatoryphenomenahavethequalityofanormalexperiencethattheyaretakenforrealitydespitebeing,ashepointsout, implausible.Otherauthors, suchasSpitzer (1994),argue thathallucinations are not like normal perceptions, in that patients can distinguish between realperceptualexperiencesandtheirhallucinatoryexperiences.Thisisonereasonwhypatientsareable to understand the reference to ‘hearing voices’ in interactionswith clinicians; bothpartiesknowwhatthiswayofspeakingstandsfor.Indeed,Wernicke(1906)hadalreadydrawnattentiontothisfactwhenhepointedoutthatthenotionof‘hearingvoices’wasnotinventedbypsychia-trists but rather was used by patients to indicate that somehow their experience was akin tohearingotherpeopletalkbutalsodifferentfromthisaswell.JungingerandFrame(1985)showedthatasubstantialproportionofpatients(40percent)ratedthevoicestheyheardasmoreakinto innerspeechthantoexternalspokenorheardspeech,thusemphasizingthathallucinationsmaynotalwayshavethehallmarkofnormalperception.

AUDITORY HALLUCINATION

An additional video for this topic is available online.

Hallucinationscanoccurinanyoftheareasofthefivespecialsensesandalsowithsomaticsensation.Wewillstartbydiscussingauditory hallucinations,astheyaremostoftenofsupremediagnosticsignificance.Inacuteorganicstates,theauditoryhallucinationsareusuallyunstruc-turedsounds–elementary hallucinations,forexamplethepatienthearswhirringnoisesorrattles,


whistling,machineryormusic.Often,thenoiseisexperiencedasveryunpleasantandfrightening.Ofinterestaremusicalhallucinations,whichtendtooccurinolderwomenwithdeafnessorbraindiseaseandnohistoryofpsychiatricillness(Berrios,1990).Thereare,therefore,similaritieswithCharlesBonnet’ssyndrome,describedbelowinthesectiononvisualhallucinations.

Hearingvoicesis,ofcourse,characteristicofschizophrenia,butitalsooccursoccasionallyinotherconditions, forexample chronic alcoholic hallucinosisoraffective psychoses.Thesevoicesaresometimescalledphonemes(confusionexists,unfortunately,becausethewordisusedwithatotallydifferentmeaninginlinguistics,inwhichphonemesaretheunitsofspeech-soundfromwhichwords are made). Usually in organic states the phonemes are simple words or short sentences,oftenspokentothepatientinthesecondpersonaseitherperemptoryordersorabusiveremarks.Theseabusiveorimperativephonemesalsooccurinschizophrenia,butothermorecomplicatedspeechisalsoheard;thevoicesmaybesingleormultiple,maleorfemaleorboth,peopleknownandrecognizedbythepatientornotknown.Theyareexperiencedascomingfromoutsidehisheadorhisself.Thevoiceisclear,objectiveanddefiniteandisassumedbythepatienttobeanormal percept that at the same time may be baffling and incomprehensible in its import.Particularlycharacteristicofschizophreniaarevoicesthatsaythepatient’sown thoughts out loud,whichgivearunning commentaryonthepatient’sactionsorvoices,whichargueordiscussvigor-ouslywith each other.Theyrefertothepatientinthethirdperson(Schneider,1959).

In a series of 100 current patients experiencing auditory hallucinations, all of which weredescribedas‘hearingvoices’,61sufferedfromschizophreniaand78fromschizophrenia-relatedconditions (NayaniandDavid,1996).Fifty-twopercentof thepatientshadanexperienceofsadness,and45percentexperiencedchurningorbutterflysensationsinthestomachatorbeforeonset.Mostvoicesspokeinconversationaltones,butafewwhisperedandafewshouted;halfofthesampleheardtheirvoicesthroughtheirearsasexternalstimuli.Mostvoicesweremale,oftenamiddle-agedman,usuallyspeaking inadifferentaccent fromthepatient, forexample‘anupper-classvoice’.Subjectsheardameanof3.2differentvoicesandusuallyknewtheidentityofat leastone; inhalfof thesubjects, thevoicessignifiedforcesofGoodorEvil.Halfof thesubjectswereabletoexertsomecontrolovertheirvoices,andtwo-thirdshaddevelopedcopingmechanismstodealwiththem;highlevelsofdistresswerefoundamongthosewithlittlecontrolandfewmeansofcoping.Themajorityofsubjectsascribedrealitycharacteristicstotheirvoices.Alonghistoryofauditoryhallucinationstendedtobeassociatedwithmorehallucinatedwords,morevoices,agreaterrangeofemotionalexpressionandgrammaticalstyleandgreaterlikelihoodofinterpretingthevoicesdelusionally.

Auditoryhallucinationsinschizophreniaaregenerallyprivateevents,butseveralearlywritersobservedvocalizationsthatcorrespondedwiththecontentofthevoicestakingplaceatthesametimeasthehallucinations.Normalpeopleoccasionallyvocalizetheirownthoughtssotto voce;inthepsychoticequivalentofthis,itseemsthatsometimesthosewithschizophreniaarevocalizingtheirhallucinationsatthesametimeastheyexperiencethem.GreenandPreston(1981)increasedtheaudibilityofthewhispersofsuchapatienttoanintelligiblelevelusingauditoryfeedback.

Sometimes,patientswithschizophreniadescribeabnormalperceptionsinboththevisualandtheauditorymodalities.Theexaminershouldbecarefulnottoassumethattherearebothaudi-toryandvisualhallucinationspresent; theremaybeadifferent form,particularly forthevisualexperience.Amanaged45describedhisexperienceasfollows:‘Ihearmynephewstalking[aboutme].“Heisapoofter[homosexual]andapervert”…Iseethemaswell.ThecurtainsmoveandIknowthatitisthemmovingthem’.Thisisadescriptionofapersecutoryauditoryhallucination,but the visual experience is a delusional interpretation of a normal perception, not a visualhallucination.

Patients’ descriptions of their phonemes vary greatly. Sometimes, patients talk openly andquiteblandlyabouttheir‘voices’.Notuncommonly,apatientmaydenyvoicesbutassertthathehears‘spokenmessages’or‘transmissions’orsomeotherspokensound,anditmaybedifficultto


decidewhetherthisisarealperceptionoranauditoryhallucination.Thephonemesmaybesoinsistent,compellingandinterestingthatordinaryconversationwiththedoctorisfoundboring,andevenunreal,incomparison.Thevoicesmayformaninsistentbackgroundtolife,soensuringthatalargepartofthepatient’sspeechandbehaviourisoccupiedinansweringandobeyingthevoices. Psychiatric nursing staff often observe that the auditory hallucinations described bypatientsareasrealtothemasanyotherrememberedconversations,andbothhallucinatoryandrealauditoryperceptionsformthememoriesonwhichpatientsbasetheirlifeandbehaviourinthepresent.

Auditoryhallucinationsoccurwhenthereisacombinationofvividmentalimageryandpoorrealitytestingintheauditorymodality(Slade,1976b).Thishasbeeninvestigatedusingabatteryoftestsincludingtheverbal transformation effect.Theword‘tress’wasrepeatedonataperecordertothesubjectsfortenminutes.Afteratime,subjectsbegantohearotherwordsandsyllables.Normal subjectsandpatientswith schizophreniawhowerenotauditorilyhallucinatedusuallyheardwordsthatwerephonetically linkedtotheoriginalmonosyllable,butpatientswhowereauditorilyhallucinatedheardwordsthatwerequitedifferentphoneticallyasoftenasthosethatwerelinked.

Itappearsthatauditoryhallucinationsaredependentonthemeaningfulnessofsensoryinput.Whenvarioustypesofauditoryinputwerepresentedtopatientswithschizophreniawhoexpe-riencedhallucinations,itwasfoundthatitwasnotthedegreeofexternalstimulationthatwasrequiredtodiminishhallucinationsbutthenatureofthestimulusandthedegreeofattentionitreceived.Whenactivemonitoringofmaterialwasrequiredbythesubjectreadingaloudaprosepassageanddecidingthecontentafterwards, thisproducedagreaterdecreaseofhallucinatoryexperiencethananyoftheconditionsinwhichsoundswereplayedtothesubjectthroughear-phones(Margoetal.,1981).Morley(1987)reportedthepsychologicaltreatmentofa30-year-oldmanwithauditoryhallucinations.Distractionbymeansofmusicpresentedbyaportablecassetteproducedatransientreductioninthefrequencyandclarityofhallucinations.Subsequently,thesehallucinationsweretotallyabolishedbytheunilateralplacementofawaxearplug:attentionwasconsideredmore effective thandistraction.Thepatient located thehallucination ‘about a footawayfrommyrightear’,andtheplugwasonlyeffectiveintherightear.

Patientswithschizophreniaexperiencingauditoryhallucinationswerefoundtobeimpairedin cognitive processing in the aspects of tolerance of ambiguity and availability of alternativemeanings.Tolerance of ambiguitywas testedbyasking thepatient to recognizea spokenword,which was obscured by a masking noise of people reading.The masking noise was graduallyreducedinvolumeuntilrecognitionoccurred.Alternative meaningsteststhesubject’sknowledgeoflessfamiliarmeaningsofwords.Thesetwoprocessesreducedthequalityofperception(result-ing in hallucination) by introducing errors of premature judgement without the safeguard ofsubsequentlyconsideredalternatives(HeilbrunandBlum,1984).

Some auditory hallucinations are considered to be ‘first rank symptoms of schizophrenia’(Schneider,1959);theseareaudible thoughts, voicesheardarguingwitheachotherandvoices com-menting on the patient’s behaviour. These three perceptual disturbances, as other first ranksymptoms,eachrepresentamassiveinterferencewiththeboundariesofself-image,thediscrimi-nationofwhatis‘I’fromwhatis‘notI’(Sims,1991).

ThemechanismsusedbypatientswithchronicschizophreniatocopewithpersistentauditoryhallucinationswerediscussedbyFalloon andTalbot (1981).The strategies used to copewithintrusivevoicescouldbeclassifiedaschanges inbehaviour, insensoryoraffectivestateandincognition.Changesinbehaviourincludedalterationofposture,suchaslyingdown,orseekingoutthecompanyofothers.Physiologicalarousalwasalteredtocopewithhallucinationsthroughrelaxationorphysicalexercisesuchasjogging.Cognitivemethodsincludedcontrolofattentionoractivesuppressionofhallucinations.Theseauthorsbelievethatthecommon-senseapplicationofstrategiesusedbypatientscanbebeneficialinthecontrolofthesedistressingsymptoms.


Finally, there is a vigorous debate about the presence of auditory/verbal hallucinations indisordersotherthanthepsychosessuchasborderlinepersonalitydisordersandalso innormalpopulations(McCarthy-Jones,2012).Thequestionthatremainstobeanswerediswhethertheformoftheseverbalhallucinationsisidenticaltotheformoftheverbalhallucinationsinschizo-phreniaforexample.

VISUAL HALLUCINATION

Visualhallucinationscharacteristicallyoccur inorganic states ratherthaninthefunctionalpsy-choses.A69-year-oldmarriedmanwasreferredtothedutypsychiatristinacasualtydepartmentforassessment.Hesaidthathislifewasatanendandhedeservedtodie,ashehadbeencaughtmasturbatingbyhisdaughter-in-lawandgrandchildrenthatafternoon.Hiswifesaidthatthiswasnottrue;hehadbecomeveryagitatedanddistressedover12hoursandnoonehadvisitedthehousethatday.Duringinterview,hewasintenselyagitatedandputhishandsinfrontofhisface.Heclaimedthathecouldseeclearlyasheetofglasshalfametreinfrontofhim,whichheattemptedtomove.Later,hedescribedseeingdustfallingdowneverywhereandwastryingtocatchit.Hemanifestedcloudingofconsciousness.Adiagnosisofviralencephalitiswasmadeonthebasisof thehistoryofpersistentheadache, theneurological signsand thefindingof lym-phocytosisinthecerebrospinalfluid.

Itisoftendifficulttodecidewhetherthefullcriteriaforthepresenceofahallucinationhavebeenfulfilledinthevisualmodality.Distortionofvisualpercepts,basedoneithersensationofexternalstimuliorinternalinterferencewiththevisualpathway,mayproducedisturbancesthatare similar to those occurring with entirely new perceptions. Sometimes, the account of hisexperiencegivenbythepatientsoundslikeasensorytransformationratherthanahallucination,but thebizarreandcomplexnatureof theexperiencerendersphenomenonologicaldescriptiondifficult.

Visualhallucinationsoccurwithoccipital lobe tumoursinvolvingthevisualcortex,forexampletuberculous granuloma in the left occipital lobe caused a ‘starburst’ effect in the right visualfield (Werring and Marsden, 1999). Hallucinations and other visual disturbances may occurwithotherphysical lesions, suchas loss of colour vision, homonymous hemianopia (lossofhalfofthefieldofvision,thesamehalfinbotheyes;Komel,1985),dyslexia(inabilitytoreadatalevelappropriate to the individual’s age and intelligence), alexia (word blindness) in a dominanthemispherelesionandcortical blindness(blindnessduetoa lesionofthecorticalvisualcentre).They may, as in delirium tremens, be associated with an affect of terror or with an affect ofhilariousabsurdity.Similarvisualhallucinations, illusionsandchanges inmoodoccur inotherformsofdelirium.Visualhallucinationsalsooccurinthepost-concussional state,inepileptic twilight statesandinmetabolicdisturbances,forexamplehepatic failure.Visualhallucinationshavealsobeendescribed inassociationwithvariousdementingprocesses, includingAlzheimer’sdisease(Burns etal., 1990), senile dementia (Haddad and Benbow, 1992), multi-infarct dementia(Cummingsetal.,1987),Pick’sdisease (Ey,1973)andHuntington’s chorea (Lishman,1989).Amongreferralstoapsychogeriatricservice,visualperceptualdisturbanceoccurredin30percentofpatients;therewasastrongcorrelationbetweenthepresenceofvisualhallucinationandeyepathology(BerriosandBrook,1984).Infact,visualhallucinationsarecommoninelderlypatientswith a wide variety of medical conditions and often no psychiatric history (Barodawala andMulley,1997).

Hallucinations have also been described by individuals after sniffing glue and petrol.Thedrugs mescaline and lysergic acid diethylamide are potent causes of visual perceptual change.Visual hallucinations are infinitely variable in their content. They range from quite crudelyformedflashesof lightorcolour(elementaryhallucinations),throughmoreorganizedpatternsand shapes, to complex, full, visual perceptions of people and scenes. Visual and auditory


hallucinationsmayoccursynchronouslyinorganicstates,forexampleintemporal lobe epilepsyavisualhallucinationofahumanfigurewasalsoheardtospeak.

Withpsychomimeticdrugs, therearealterations in spatialperception, in theperceptionofmovementandintheappreciationofcolour,andvisualillusionsandhallucinationsmayoccur.Visualhallucinationsareveryuncommoninschizophrenia(althoughsomeoftheearlierwritersused the termhallucination forothervisual abnormalities thatoccurred).PersaudandCutting(1991) cautiously refer to ‘anomalousperceptual experiences in thevisualmodality’ in schizo-phrenicpatients,forexample,asinthepatientwhoalthoughstillrecognizingafaceconsidersittobedistorted.Theseauthorsreportfoursuchcasesofperceptualdisturbanceinonevisualfield,alwaystheleftfield.Visualhallucinationsarenotreckonedtooccurinuncomplicatedaffectivepsychoses. It is common in schizophrenia for the patient to describe auditory hallucinationsassociatedwithvisualpseudohallucinations.Althoughthephonemesarecompleteandappeartohave all the characteristics, subjectively, of a normal percept, the visual experiences are ofteninferredonthebasisoftheauditoryhallucinationsandofcontemporaneousdelusions.Itispos-sibletosee,inmostinstances,howpsychoticallydisorderedfantasyaccountsforthecontentofthevisualexperiences.Vividelaboratescenichallucinationshavebeendescribedinoneiroidstatesofschizophrenia.Inthesestates,thereisalsoanalteredstateofconsciousness.

Sometimes, visualhallucinationsdonot appear tobe associatedwithanyotherpsychiatricabnormality.CharlesBonnet’ssyndrome(phantomvisualimages)isaconditioninwhichindi-viduals experience complex visual hallucinations in association with impaired vision withoutdemonstrablepsychopathologyordisturbanceofnormal consciousness (Schultz andMelzack,1991).Althoughmorecommonintheelderly,itcanoccuratanyageandisusuallyassociatedwithcentralorperipheralreductioninvision.Episodesmaylastfromdaystoyears,withimagesofpeople,animals,buildingsandscenerybeingmostfrequentlyreported,theimagesbeingstatic,movinginthevisualfieldoranimated.Clearly,thisconditionisofimportanceinthedifferentialdiagnosis.

InmostcasesofCharlesBonnet’ssyndrome,andinmusicalhallucinosisinthedeaf,towhichit has been likened, there is no demonstrable brain pathology (Fuchs and Lauter, 1992).ThefeaturesofthissyndromehavebeenconsideredbyPodolletal.(1990)tobeasfollows.

■ Elderlypersonswithnormalconsciousnessexperiencevisualhallucinations.■ Noneofthefollowingarepresent:delirium,dementia,organicaffectiveordelusionalsyn-

dromes,psychosis, intoxicationorneurologicaldisorderwith lesionsof thecentralvisualcortex.

■ Thereisreducedvision,resultingfromeyediseaseinmostcases.Hallucinationsinthisconditionarealwayslocatedinexternalspace,areusuallycolouredand

aremuchmorevividanddistinctthanthepatient’simpairedvisionwouldotherwisepermit.Thecontent is elementary in about one-third of cases, such as photisms or geometric patterns.Complexobjectsaremostoftenhumanfigures,lessoftenanimals,plantsandinanimateobjects;theseobjectsmaybefragmentedandmaychangeovertime–figuresglidingthroughtheroom.Theperceptsmaybemodifiablebyvoluntarycontrol,forexampleclosingtheeyelids,andthereisusually insightconcerningtheir‘unreality’.This issometimesassociatedwithfearofmentalillnessandwouldsuggestthatthesephenomenamaybepseudohallucinationsratherthan‘true’hallucinationsinsomecases.

The alcoholic withdrawal syndrome of delirium tremens is a specific form of acute organicsyndromeandischaracterizedbygrosschangesinperception,moodandconsciousnessstate(seeChapter3).Pareidolicoraffectiveillusionsareoftenprodromalindeliriumtremens,andtheseare followed by visual and haptic Lilliputian hallucinations, which are often of little animalsor diminutive men.There is a bizarre intermingling of affect so that the patient experiencesstark terror and, at the same time, a sort of crazy comicalness especially common with thesedisorders.


Thehallucinationsindeliriumtremensmaychangesorapidlythatthepatienthasdifficultyindescribingthem.ApatientexperiencingsuchvisualphenomenatriedtoportraythisinFigure7.2.Illusionsarefrequentlyassociatedwithhallucinations,especiallyaffectiveillusions,inwhich,throughthepredominantmoodstateofterror,cracksinthewalloftheward,orcurtainsmovinginthebreeze,maybemisinterpretedinafrighteningway.Atthesametime,suchpatientsarehighlysuggestibleandcanformabnormalvisualexperiencesasaresultofsuggestion.

HALLUCINATION OF BODILY SENSATION

IthasbeenconvincinglyarguedbyBerrios(1982)thatdiverse‘perceptionswithoutobject’werebroughttogetherbyEsquirol(1817)withinthetermhallucination,whichwasrelevantfor‘dis-tancesenses’suchasvision,hearingand,toalesserextent,smellandtaste,butnotreallyapplicabletotouch.So-calledtactile hallucinationsappeartobedifferentphenomenologicallyandtoonlysuperficiallyresemblehallucinationsofthedistancesenses.Itwouldseemfortactilehallucina-tionsthatthemostimportantcorroboratingdiagnosticfactoristheconcurrenceofadelusionalcomponent.Berriosconcludesthattheconceptsofhallucinationanddelusionmaybeclosertoeachotherthanhasoftenbeenconsidered,especiallyinBritishpsychiatry.

Hallucinationsofbodilysensationmaybesuperficial, kinaestheticorvisceral.Superficialhal-lucinationsaffectingskinsensationmaybethermic,anabnormalperceptionofheatandcold(‘myfeetonfire’);haptic,oftouch(‘adeadhandtouchedme’);orhygric,aperceptionoffluid(‘allmybloodhasdropped intomy legsandIcan feel awater level inmychest’).Paraesthesiae is thetermdescribingthesensationoftinglingor‘pinsandneedles’.Thesemaybedelusionallyascribed,althoughofcoursetheyareoftenneurologicallymediated,forexampleulnarnervecompressioncausingpinsandneedlesintheforearm.

Kinaesthetic hallucinations are those of muscle or joint sense. The patient feels that hislimbsarebeingbentor twistedorhismuscles squeezed.Suchhallucinations inschizophreniaareoftenlinkedwithbizarresomaticdelusions.Amansufferingfromschizophreniadescribedtheexperiencethus:‘Ithoughtmylifewasoutsidemyfeetandmadethemvibrate’–heexperi-encedkinaesthetichallucinationsofvibration.Kinaesthetichallucinationsmayoccurinorganicstates: ‘a feeling of being rocked about’. Abnormal kinaesthetic perceptions have also beendescribed in the withdrawal state from benzodiazepine drugs (Schopf, 1983) or from alcoholintoxication.Aman,afterrecovery,describedhisepisodeofdeliriumtremens,saying,‘IfeltasifIwasfloating in the air about 50 feet above the ground’.He illustrated this feelingwith thepictureinFigure7.2.

Figure 7.2 The experience of delirium tremens.


Visceralhallucinationsarefalseperceptionsoftheinnerorgans.Thereisonlyalimitedrangeofpossiblevisceral sensation, for examplepain,heaviness, stretchingordistension,palpitationand various combinations of these, such as throbbing. However, the possible range of bizarreschizophrenicfalseperceptionsandinterpretationsislimitless.Onemanbelievedthathecouldfeelsementravellinguphisvertebralcolumnintohisbrain,whereitbecamelaidoutinsheets.

Hallucinationsofbodilysensationarequitecommoninschizophreniaandarealmostalwaysdelusionallyelaborated,oftendelusions of control(Chapters8and9).Haptichallucinationsmaybe experienced as touch (‘like a hand stroking me’) or painful (‘knives stabbing my neck’). Apatientbelievedthatthesmokesensorinthewardwasaninfraredcamera,‘becauseIfeelitwarmonmyneck’.Anotherpatientdescribedahaptichallucinationinwhichsheexperiencedgenitalstimulation that she ascribed to having sexual intercourse simultaneously with ‘both Kennedybrothersallthetime’.Itisimportanttorealizethatthereisbothahallucinatoryandadelusionalcomponentinsuchexperiences.Oneparticularlyunpleasantformofhaptichallucinationiscalledformication(Latin:formica,‘ant’),thesensationoflittleanimalsorinsectscrawlingoverthebodyorjustundertheskin.Thisisespeciallyassociatedwithsomedrugstatesandwithdrawalsymp-toms,forexamplecocaineaddictionandalcoholwithdrawal.Itisoftenassociatedwithdelusions of infestation,butthelattermayoccurwithouthallucination.

OLFACTORY AND GUSTATORY HALLUCINATION

Hallucinationsofsmellandoftastefrequentlyoccurtogether,anditmaybedifficultorimpos-sible todistinguish them fromeachother.This isnot surprising, as a lotofwhat a laypersonascribestotasteisactuallysmell:‘theeucalyptusfragranceofthiswinefromtheBarossaValley’.

Olfactory Hallucinations

Olfactorysensationormemoryisoftenassociatedwithpowerfulemotionalresonances;itisnotsurprising therefore that hallucinations are also invested with a strong affective component.Olfactoryhallucinationsoccurinschizophrenia,inepilepsyandinsomeotherorganicstates.Thepatienthasahallucinationofsmell.Thesmellmayormaynotbeunpleasant,butitusuallyhasaspecialandpersonalsignificance(Aggernaes’qualityofrelevance),forexampleitmaybeassoci-atedwiththebeliefthatpeoplearepumpingapoisonousorananaestheticgasintothehouse,whichthepatientalonecansmell.Sometimes,patientshaveanolfactoryhallucinationrelatingtothemselves:‘Ismellrepulsive,unbearable–likeacorpse, likefaeces’.Thisparticularpatientkilledhimself.He felt thathecreatedsucha stench thathewas intolerable inany reasonablesociety.Sometimes,patientsmisinterpretandovervaluenormalbodyodours.Adelusioninwhichapatientbelieveshimselftosmellmalodorouslywithoutanaccompanyingolfactoryhallucinationisquitecommoninschizophreniaandrelatedparanoidstates.

Olfactoryhallucinationsoccurinepilepsy,especiallyinassociationwithatemporallobefocus,andcommonlyformtheaura(orearliestphase)ofsuchfits.Apatientdescribedasmellofburningrubberregularlyjustbeforehebecameunconscious.Visual,auditory,gustatoryandvisceralhal-lucinationsalsooccurintemporallobeepilepsy.

Gustatory Hallucinations

Gustatory hallucinations occur in various conditions. In schizophrenia, they sometimes occurwithdelusionsofbeingpoisoned.Theremaybeapersistenttaste,forexample‘onions’,‘ametallictaste’orsomemorebizarretypeoftaste.Indepressionandinschizophrenia,theflavouroffoodmaydisappearaltogetherorbecomeunpleasant.Changesingustatoryperceptionmayoccurwithsomeorganicstates,suchastemporallobeepilepsy,andalsowithsomepsychotropicdrugs,forexamplelithiumcarbonateordisulfiram.Itisoftendifficulttodescribehowthisdisturbanceoftasteismediatedand,therefore,whetheritishallucinatoryornot.


DIFFERENTIATION OF HALLUCINATIONS

Beforedecidingthatapatientishallucinated,thepossibilityofotherperceptualexperiencesmustbeconsidered.Thesearenotnecessarilyofpathologicalsignificance.Thedifferentialdiagnosisofhallucinationincludesillusion,pseudohallucination,hypnagogicandhypnopompicimagesand,ofcourse,vividimageryandnormalperception.

PseudohallucinationsPseudohallucinationisoneoftheleastunderstoodphenomenainpsychopathology.AsBerrios(1996)remarks,‘ithasbeenusedtorefertorealperceptionsperceivedas“unreal”,isolatedhal-lucinationswhichdonotfitintofavoureddiagnoses,sideeffectsofdrugs,withdrawalhallucina-tions,diabetichallucinations,etc’.Berriosgoesontosay:

‘Unrestrained, usage has strayed even wider, pseudohallucinations being sometimes applied to (i) phenomena which meet criteria for hallucinations or

illusions, (ii) hallucinations in people without mental illnesses (e.g., the bereaved), (iii) the false perceptions of people recovering from psychotic

illnesses, (iv) factitious hallucinations in malingerers, and (v) occasionally, normal but unusual perceptions which initially seem to be hallucinations (e.g.,

radio reception in dental amalgam or intracranial shrapnel fragments).’

Furthermore,partoftheconfusionoverthemeaningofthetermpseudohallucinationhasarisenbecauseit isoftenusedintwodifferentandmutuallycontradictoryways,accordingtoKräuplTaylor(1981).Ontheonehand,itreferstohallucinationswithinsight(Hare,1973),andontheotherhand tovivid internal images.Hallucinationswith insightwouldbe thosehallucinatoryexperiences inwhichthesubject isawarethatthehallucinatoryperceptsdonotcorrespondtoexternal reality despite the perceptions being veridical and in external objective space. Vividinternalimagesarethosephenomenathathavealltheclarityandvividnessofanormalperceptexceptthattheyoccurininnersubjectivespace.

Jaspers (1962) identifiedpseudohallucinationas similar tonormalperceptionexcept that itoccurs in inner subjective space. Pseudohallucination shares this characteristic with imagery.In other words, for Jaspers, pseudohallucination is a perceptual experience that is figurativeandoccursininnersubjectivespace,notinexternalobjectivespace.Butithasallthevividnessand clarity of a normal perception and can be retained unaltered. It occurs independently ofthesubject’swillandthereforecannotbedeliberatelyevoked.JaspersderivedthisdescriptionofpseudohallucinationfromKandinsky.

Kandinsky (1849–1889) based his description of pseudohallucination on his own personalexperiences.Hecommittedsuicideattheageof40yearswhileapatientatStNicholasHospital,StPetersburg,wherehehadoncebeenmedicalsuperintendent(Lerneretal.,2001).In1885,hedescribedpseudohallucinationasaseparateformofperceptionfromtruehallucinationandwrote,‘subjectiveperceptionswhichinvividnessandcharacterarerealhallucinationsexceptthattheydonothaveobjectivereality’(quotedinBerrios,1996).Pseudohallucinationscanbeidentifiedinthevisual,auditoryortactilemodalities.

Hare(1973)hasgivenasanexampleofpseudohallucinationthevoiceheardbyanobsessionalordepressedperson.Itisdescribedbythepatientasavoicebutisactuallyrecognizedashisownthoughts.Pseudohallucinationsarenotpathognomonicofanyparticularmentalillness.Apatientwithhistrionicpersonalitydisorder sawa robedfigure at the footofherbed liftinghis indexfingertohismouthtocautionhertosilence.Theimagewassharpandvividbutwasrecognizedasbeingseenwiththeinnereye.Thepatientknewthatthefigurewasnotatthefootofthebed


andthatotherpeopleintheroomcouldnotseehim.Whenshetriedtorelatethefigureinspacetothebackgroundofherfieldofvision,inthiscasethewallsandcurtainsoftheroom,shereal-izedthatshecouldnotdoso;ithadnodefinitelocationinexternalspace,thatisoutsideherself.

To summarize, the significance of hallucination is that it almost always denotes a morbidmentalstate.Thesignificanceofpseudohallucinationisinitsdifferentialdiagnosisfromhallu-cination,aspseudohallucinationisnotnecessarilypsychopathological.

Other Abnormalities of PerceptionAUTOSCOPY

Autoscopy is theexperienceof seeingan imageofoneself inexternal spaceandknowingthatit is oneself (see also visual hallucination). It is sometimes called the phantom mirror image.It is one of the abnormalities of unity of self described in Chapter 12, but in autoscopy theexperienceisnecessarilyvisual.Likesomanytopicsofconsiderablephenomenologicalinterest,the term autoscopy has been used with different meanings and definitions since its first usebyFéréin1891.Theexperienceconcernshowtheindividualregardstheboundariesofselfandisdiscussedfurtherwithotherdisordersofself-image.Itisbesttoreserveautoscopyforabnor-malitiesofvisualperception involving seeingoneself; ‘visualexperienceswhere subjects seeanimageofthemselvesinexternalspaceviewedfromwithintheirownphysicalbody’(DeningandBerrios,1994).

Althoughthistopichasbeenofconsiderableliteraryinterestovertheyears,clinicalcaseswithdefiniteperceptualabnormalityarenotcommon.DeningandBerrioshavereviewed56cases,53from the literature and three of their own.Males predominated,with a ratio of 2:1, and themeanageofsubjectswas40years.Bothneurologicalandpsychiatricdisorderoccurredinabout60 per cent of cases (different subjects), with epilepsy in approximately one-third. Decreasedconsciousnessoccurredin45percent,deliriumin18percentand9percentofsubjectsweredead within one year. Visual imagery or narcissism was present in one-third of subjects, anddepersonalizationin18percent.Thecommonestpsychiatricdiagnosiswasdepression.Usually,autoscopicepisodeslastedforlessthan30minutes.Almostalways,thesubjectsawhisownface;quiteoften,hewaslyinginbedatthetime.Theexperienceoftenprovokeddistress,fear,anxietyanddepression.Thissubjectiveexperiencewascomplex,withdifferentcomponentsandcausesratherthanunitary.

Negative autoscopy has also been described, in which, for instance, the patient looks in themirrorandseesnoimageatall.

EXTRACAMPINE HALLUCINATION (CONCRETE AWARENESS)

‘Iknowthatthereissomeonebehindmeontherightallthetime;hemoveswhenImove’,‘Ikeeponhearingthemtalkingaboutmydiseasedowninthepostoffice’(halfamileaway)–thesehallucinationsareexperiencedoutsidethelimitsofthesensoryfield,outsidethevisualfieldorbeyondtherangeofaudibility.Theyarenotofdiagnosticimportance,astheyoccurinschizo-phrenia,epilepsyandotherorganicstatesandalsoashypnagogic hallucinationsinhealthypeople.Thephenomenonisquitedefinitelyexperiencedasaperceptionbythepatientandnotjustasabelieforanidea.

HYPNAGOGIC AND HYPNOPOMPIC HALLUCINATION

Theseareperceptionsthatoccurwhilegoingtosleep(hypnagogic)andonwaking(hypnopompic).According to Zilboorg and Henry (1941), hypnagogic hallucinations were first mentioned by


Aristotle.It isknownthattheconsciousness levelfluctuatesconsiderablyindifferentstagesofsleep,andbothtypesofabnormalperceptionprobablyoccurinaphaseofincreasingdrowsiness:thestructureofthought,feelings,perceptions,fantasiesand,ultimately,self-awarenessbecomesblurredandmergesintooblivion.Theseexperiencesoccurinmanypeopleingoodhealth.Theyarealsodescribedwithnarcolepsy, cataplexyand sleep paralysis toformacharacteristictetradofsymptoms(seeNarcolepsyfordescriptions).Toxic statessuchasgluesniffing,acutefevers(espe-ciallyinchildren),postinfectivedepressive statesandphobicanxietyneurosesareotherconditionsthatmaybeassociatedwiththeseperceptions.

Theperceptionmaybevisual,auditoryortactile.Itissuddeninoccurrence,andthesubjectbelievesthatitwokehimup,forexamplealoudvoiceinthestreetbelowsaying‘worldwar!’,afeelingofsomeonepushinghimoverthebedorseeingamancomingacrossthebedroom.Theimportanceofthesephenomenainpsychopathologyistorecognizetheirnatureandrealizethattheyarenotnecessarilyabnormal,eventhoughtheymaybetrulyhallucinatory.

FUNCTIONAL HALLUCINATION

Thisisthestrangephenomenoninwhichanexternalstimulusisnecessarytoprovokehallucina-tion,butthenormalperceptionofthestimulusandthehallucinationinthesamemodalityareexperiencedsimultaneously.Aschizophrenicpatientheardhallucinatoryvoicesonlywhenwaterwas runningthroughthepipesofhisward.Heheardnophonemes formostof the time,butwhen he heard water rushing through the pipes along the wall he became very distressed byvoicesthattoldhimtodamagehimself.Hewasterrifiedofthecontentofthesevoicesbecausehewasafraidhemightactonthem.Hecouldreadilyseparatethenoiseofwaterfromthevoices,and the latternever occurred apart from the former, butbothperceptionswere recognized asdistinct and real.Another patientheard voiceswhen the radio or televisionwas switchedon,alongsidethebroadcastvoices;hehadpersecutorydelusionsthattheseactivitieswerecarriedoutdeliberatelytoupsethimandhebecameverydistressed,andattimesviolent,asaresult.

REFLEX HALLUCINATION

Asadoctorwaswriting inhiscasenotesduringhis interviewofa femalepatient, shesaid,‘Icanfeelyouwritinginmystomach’.Thepatientsawandheardtheactofwritingandwasquitesurethatitaccountedforthetactilesensationinherabdomen.Astimulusinonesensorymodalityproducingahallucinationinanotheriscalledareflex hallucination.Thisis,infact,ahallucinatoryformofsynaesthesia,mentionedearlierastheexperienceofastimulusimageinonesensemodalitysimultaneouslyproducinganimageinanother,forexamplethefeelingofdiscomfortcausedbyseeingandhearingsomebodyscratchablackboardwiththeirfingernails.Anotherreflexhallu-cinationoccurred inawomanwhoexperiencedpainwhenevercertainwordswerementioned.Functionalandreflexhallucinationsarenotthemselvesofdiagnosticortheoreticalsignificance,but they requirementioning forcompletenessandrecognition inorder to identifyothermoreimportantsymptomswithconfidence.

ABNORMAL IMAGERY

Mentalimagerytasksaredesignedtoassessasubject’scapacityformentalrepresentationoftheperceivedworld.Incasesofhemineglect,therehasbeeninterestinwhethertheobserveddeficitsin imagery are due to inattention or to impairment of mental imagery. Bisiach and Luzzatti(1978) described abnormalities in individuals with hemineglect.Their patients were asked todescribethePiazzadelDuomoinMilanfromtwostandpoints: facingthecathedralandwiththeir backs to the cathedral. From both standpoints, the subjects were unable to describe the


rightsideofthescenedespitehavingcorrectlydescribeditfromthepreviousstandpoint.Inotherwords,eveninimaginationthementalrepresentationofthepiazzawasunilaterallydeficientforthe right side. In these cases, inattention influenced the capacity for imagery. Guariglia etal.(1993)reportedapatientwithouthemineglect inwhomimpairmentof imagery forobjects intheleftvisualfieldwasdemonstrated.Forthefirsttime,thisshowedthatwithouthemineglect,thatis,visualinattentionforspace,failureofimagerywasstillpossible.

SENSORY DEPRIVATION

Continuingperceptionisnecessaryforconsciousness.Thefieldofsensationvariesallthetimeasindividual sensations in different modalities from the outside world and from inside oneselfcompeteforattention.Consciousnessconsistsoftheintegrationofthischangingfieldtoformacompositeawarenessofoneselfinone’senvironment.Theessentialnatureofsensationhasbeenexploredby studying its absence, as revealedby researchon the effectsof sensorydeprivation(Zubek,1969).Thistopicisonlygivenbriefmention,asitissomewhatperipheraltopsychiatry.

SensorydeprivationwasstudiedusingCanadiancollegestudentsasvolunteers(Bextonetal.,1954).Thesubjects,wearingtranslucentgogglesandgloveswithcardboardcuffs, layonabedinalightbutpartiallysoundproofroom;therewasacontinualbackgroundnoise.Thisexperiencewas found to be extremely unpleasant and, despite being paid, subjects were not prepared toremaininthisstateformorethanthreedays.

Thistechniquehasbeenrefinedsubsequentlytoblotoutexternalsensationsmorecompletely.Various perceptual abnormalities are experienced. Visual hallucinations of varying complexityweredescribed,butfurtherstudyoftheseperceptualchangesresultedintheirbeingconsidered,morecautiously,tobe‘reportedvisualsensations’and‘reportedauditorysensations’(Zuckermann,1969).Thesewereclassifiedinto‘meaninglesssensations’and‘meaningfulintegratedsensations’.Someofthe latteraremore likehallucinatoryexperiences.Dependingonthecompletenessofdeprivation of other sensations, abnormal perception occurs in modalities other than vision.Subjectsshowanalteredaffectivestate:theybecomepanicky,restless,irritableor,alternatively,boredandapathetic.

Despiteconsiderableneuropsychologicalresearchwithvaluablefindingsforinvestigatingthesensoryenvironmentingrowthanddevelopment,developingbraininterconnections,neurochem-istryandneurophysiology,thestudyofsensorydeprivationhasnotsofarmadeasbiganimpacton descriptive psychopathology as was initially expected. There are various difficulties to beaccountedfor.Whatpartoftheeffectsofdeprivationisduetofailureofdevelopmentandwhatto lossofbehaviours already established?Howcanoneuse animalwork to explore subjectivesymptoms? How can one extrapolate from the experience of normal individuals in a highlyabnormalenvironmenttothosewhoarepsychiatricallyill?ManystudiesinsensorydeprivationaredescribedbyRiesen (1975),who links the experimentaldata toneurological functionanddevelopment.

Thedistinctionhasbeenmadebetween sensory deprivation andperceptual deprivation.Thelatterisachievedbyrenderingthesensationspatternlessandmeaningless,ratherthanbyprevent-ing sensations,byusing suchdevices as translucentgoggles andcontinuous ‘white’noise.ThedeleteriouseffectsofsensorydeprivationhavebeenconsideredbySlade(1984)as:

■ inabilitytotoleratethesituation■ perceptualchanges■ intellectualandcognitiveimpairments■ psychomotoreffects■ physiologicalchangesinelectroencephalographandgalvanicskinresponsemeasures.Fantasyisoftenusedasameansofreducingtheunpleasantaffectivecomponentofsensory

deprivation.The subjectmaybecomedisorientedandshow increasingdifficultywithproblem


solvingandconcentration.Forperceptionandmaintenanceofthenormalstateofconsciousness,itisnecessarytohaveavarietyofsensorystimuliavailableandforthesestimulitobechangeable.Iftheobjectsofperceptiondonotthemselveschange,theobserverwillmovehispointofobser-vationinordertocreatechange.

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111

C H A P T E R 8

Delusions and Other Erroneous Ideas

SummaryDelusions are false judgements that are held with extraordinary conviction and incomparablesubjectivecertainty,andareimpervioustootherexperiencesandtocompellingcounterargument.Usuallydelusionsareeasilyrecognizedwhenoutofkeepingwiththeindividual’seducationalandsocioculturalbackground.Primarydelusionshavediagnosticsignificancewhereasthecontentofsecondarydelusionsmay signal thenatureof theprimaryabnormalphenomenon fromwhichtheyderive.Overvaluedideasarecomprehensiblebeliefsthatarisefromthehistoryandexperi-encesofanindividual.Theyareheldwithconvictionandmotivatebehaviourthatmaycausethepatientharmandsuffering.

I cannot pretend to agree with him, when I know that his mind is working altogether under a delusion.

Trollope (1869)

AnthonyTrollope,inhisnovelHe Knew He Was Right,describesnotonlythetotallydestruc-tiveeffectofdelusional jealousyonthe individualhimself,butalsotheextraordinarydilemmathisposesforotherpeoplewhocomeintocontactwithhim:whethertohumourtheindividualandriskreinforcement,ortoconfronthimandriskviolence.Fundamentaltoclinicalpracticeinpsychiatry,usingthephenomenologicalorempathicmethod,isobtainingaclearaccountoftheideasornotionsthatthesubject,thepatient,actuallyholds.Althoughdelusionsareoftenreferredtoasbeliefs,thereisagrowingliteraturequestioningwhethertheyarebeliefsatall.False beliefsincludeprimaryandsecondarydelusions,overvaluedideasandsensitive ideasofreference.

Ideas, Beliefs and DelusionsVery rarely does anyone claim to be deluded, and usually what such a patient thought was adelusiondoesnotprovetobeso.Adelusionisafalse,unshakeableideaorbeliefthatisoutofkeepingwiththepatient’seducational,culturalandsocialbackground;itisheldwithextraordi-naryconvictionandsubjectivecertainty.Subjectively,orphenomenologically,itisindistinguish-ablefromatruebelief.AmanwhoisaBachelorofMedicineoftheUniversityofLondonholdsadelusionthathe isbeingusedas‘anenvoyfromMars’.Hebelievesthathe isbothadoctorandanenvoy,andneitherthoughtseemstohimtobedelusionalorimaginary.HelikestoimaginehimselfarichmanwithanestateinGloucestershire.Hehasnottheslightestdifficultyiniden-tifyingthislatterideaasfantasy.Tothemanhimself,adelusionismuchclosertoatruebeliefthanimagination,andthereasonsenlistedtosupportitsveracityareproducedinthesamewaythatapersonwouldproveanyothernotiononwhichhewaschallenged.Normally, fantasy iseasilydistinguishedfromreality,althoughthesubjectmayshowgreatreluctanceinacceptinghisaspirationsas‘merefantasy’.Similarly,thereisusuallyverylittledifficultyfortheexternalobserverindecidingwhetherafalsebeliefisamisinterpretationofthefactsbasedonfalsereasoning,oradelusion.

Keywords: Delusion,DelusionalMisidentificationSyndrome,Koro,OvervaluedIdea.

8—DELUSIONS AND OThER ERRONEOUS IDEAS 111.e1


MEANING OF DELUSION

TheEnglishworddeludecomesfromLatinandimpliesplayingormocking,defraudingorcheat-ing.TheGermanequivalentWahnisawhim,falseopinionorfancy,andmakesnomorecommentthantheEnglishonthesubjectiveexperience.TheFrenchequivalent,délire,ismoreempathic;it impliestheploughshare jumpingoutofthefurrow(lira),perhapsasimilarmetaphortotheironical‘unhinged’.AsBayneandFernandez(2009)say:

On the face of things, it seems obvious that delusions involve departures – typically, quite radical departures – from the procedural norms of human

belief formation. Delusions stand out as exotic specimens in the garden of belief, as examples of what happens precisely when the mechanisms of belief

formation break down.

Inthischapter,thecomplexityofdelusionsasconcepts,experiencedsymptoms,andabnormalphenomenawillbeexplored,discussedandanalyzed.

Definition of Delusion

An additional video for this topic is available online.

Therecontinues tobemuchdebateandcontroversyabout thedefinitionofdelusions.ThestandardapproachistofollowJaspers’ (1959)claimthatdelusionsaremanifest in judgementsandariseintheprocessofthinkingandjudging.ForJaspers,thecharacteristicsofdelusionsarethat:

1. theyarefalsejudgements;2. theyareheldwithextraordinaryconvictionandincomparablesubjectivecertainty;3. theyareimpervioustootherexperiencesandtocompellingcounterargument;and4. theircontentisimpossible.Eachofthesecriteriahasbeensubjectedtocriticism.Delusionsmaynotbeobjectivelyfalse

insofarasthecontentisconcerned.Thisisbestexemplifiedindelusionaljealousy,wherebythebeliefmaycorrespondtoobjective truthand is thereforenot false.Delusionsmaynotbeheldwithextraordinaryconvictionbut,equally,normalbeliefsmaybeheldwithextraordinaryconvic-tion.Delusionalbeliefsmayalsobeamenabletocounterargument,althoughitisrarethatthisbyitselfwillalterthebelief.Finally,delusionalcontentneednotbeimpossible.

Thereisagrowingbodyofopinionthatdelusionsarenotbeliefsatall.Spitzer(1994),forexample,arguesthiscase.Hemakesthedistinctionbetween‘toknowthat’and‘tobelievethat’.InSpitzer’s view,delusionsmakeknowledge claims rather thanbelief claims. Inotherwords,patients areasserting that they ‘knowsuchand such’ rather than they ‘believe suchand such’,whichiswhydelusionalstatementsareexpressedwithconvictionandcertaintyandnotsubjecttodiscussionandinquiry.Berrios(1996)comestothesameconclusions.Hestatesthat‘delusionsareemptyspeechactswhichassertthemselvesasbeliefs’.Furthermore,hemakesthepointthatthecontentofdelusionsisincidentaltothefactofthephenomenonbeingadelusion.InBerrios’view,thecontentofdelusionsisrandomlychosen;thecontentmerelyreflectswhateverisintheenvironmentatthetimethedelusionisformed.Thecontentislackingininformationalqualityand is not a ‘symbolic expression of anything’.These critiques of the current definitions andunderstandingofdelusionsunderlinethecomplexityof theconceptualstatusofdelusionsandshowthatthereisstillfruitfultheoreticalworktobedoneinpsychopathology.

It is importanttoemphasizethatthetraditionthat locatesdelusionswithinthedomainofthinkingandjudgingderivesverysimplyfromtheneedtodistinguishhallucinations(abnormali-ties of perception) from delusions (abnormalities of thinking and judging). And, in any case

8—DELUSIONS AND OThER ERRONEOUS IDEAS 113

arguingthatdelusionsarenotabnormalitiesofbeliefislikearguingthatchorea(aninvoluntarymovement)isnotanabnormalityofmovementbecausetheobservedmovementsarenotpurpose-fulorintentional.Bortolloti(2010)hascriticallyexaminedtheargumentsagainsttheideathatdelusionsarebeliefsandconcludedthattheseargumentswhichsheclassedasprocedural,epis-temicandagential,applyequallytonormalbeliefs.Shethereforeconcludedthatthere is littlegoodreasontotreatdelusionsasanythingotherthanbeliefs.Withthisinmind,itisprofitabletocontinuetoclassifydelusionsasabnormalbeliefs.

Thedecisiontocallabelieforjudgementdelusionalisnotmadebythepersonholdingthebelief but by an external observer.There can be no phenomenological definition of delusion,becausethepatientislikelytoholdthisbeliefwiththesameconvictionandintensityasheholdsother non-delusional beliefs about himself, or as anyone else holds intensely personal non-delusionalbeliefs.Inthisrespect,delusionsaretoideationwhathallucinationsaretoperception.Subjectively,adelusionissimplyabelief,anotionoranidea.Stoddart’sdefinitionofadelusion(1908);‘ajudgementwhichcannotbeacceptedbypeopleofthesameclass,education,raceandperiodoflifeasthepersonwhoexperiencesit’,hassomeadvantages.However,itcouldincludeasdelusionalfallinginlovewithapersonothersregardasunsuitable,havingaminorityreligiousbelieforholdinganyunusualideawithoutacknowledgingreasonableargumenttothecontrary.

Hamilton(1978)defineddelusionas; ‘a falseunshakeablebeliefwhicharises frominternalmorbidprocesses.Itiseasilyrecognizablewhenitisoutofkeepingwiththeperson’seducationalandculturalbackground.’Thisdefinitionmakesthepointthatabeliefcanbeadelusionevenwhenitisnotoutofkeepingwiththepatient’seducationalandculturalbackground.

Rather than suggest a unitary definition for delusion, Kendler etal. (1983) have proposedseveralpoorlycorrelateddimensionsorvectorsofdelusionalseverity.

■ Conviction: thedegree towhich thepatient isconvincedof the realityof thedelusionalbeliefs.

■ Extension:thedegreetowhichthedelusionalbeliefinvolvesareasofthepatient’slife.■ Bizarreness:thedegreetowhichthedelusionalbeliefsdepartfromculturallydetermined

consensualreality.■ Disorganization:thedegreetowhichthedelusionalbeliefsareinternallyconsistent,logical

andsystematized.■ Pressure:thedegreetowhichthepatientispreoccupiedandconcernedwiththeexpressed

delusionalbeliefs.Twootherdimensionsthatmightalsobeconsideredareasfollows.■ Affective response: the degree to which the patient’s emotions are involved with such

beliefs.■ Deviantbehaviourresultingfromdelusions:patientssometimes,butnotalways,actontheir

delusions.

Primary and Secondary DelusionsTheconfusingsubjectofprimaryandsecondarydelusionsrequiressomeexplanation.Itisprob-ablymostmeaningfultousethetermprimarytoimplythatdelusionisnotoccurringin responseto another psychopathological form such as mood disorder. Secondary delusion is used in thesensethatthefalsebelief isunderstandable inpresentcircumstances–becauseofthepervasivemoodstateorbecauseoftheculturalcontent.

Gruhle (1915)considered thataprimarydelusionwasadisturbanceof symbolicmeaning,notanalterationinsensoryperception,apperceptionorintelligence.Primarydelusionsoccurinschizophreniaandnotinotherconditions;theyincludebothdelusionalperceptionanddelusionalintuition(Cutting,1985).However,delusionalintuitions,notionsorideasarenotpathognomonicofschizophrenia,becauseinanyindividualcasethereistoomuchscopeforarguingwhetherthis


delusionisindeedprimary,thatis,ultimatelyununderstandable,orsecondaryinnature.Secondarydelusionsoccurinmanyconditionsotherthanschizophreniaandcansometimesbeunderstoodinrelationtotheperson’sbackgroundcultureoremotionalstate.

Wernicke (1906) formulated theconceptofanautochthonous idea, an idea that is ‘native tothesoil’,aboriginal,arisingwithoutexternalcause.Thetroublewithfindingsupposedautoch-thonousorprimarydelusions is that itcanbedisputedwhether theyare trulyautochthonous.Forthisreason,theyarenotconsideredoffirst rankinSchneider’s(1957)classificationofsymp-toms. It is toodifficult todecide inmany caseswhether adelusion is autochthonous.Severalwritershaveclaimedthatalldelusionsareunderstandableifoneknowsenoughaboutthepatient.

The Ultimately Ununderstandable

Jaspers’ detailed exposition of delusion has been carefully reviewed byWalker (1991). Jaspers’conceptsoftheununderstandable,andofmeaningful connections,arerelevanthere.Ifweaskanoffender todescribe thepsychicworld inwhichhe lives–his attitudes,his feelings andhowthese developed through his childhood until now – we may be able to understand his sexualcruelty,whichatfirstseemedquiteincomprehensible:thebehaviourbecomesmeaningfulinthecontextofabusebyhisstepfatherandsurvivingasanadolescentinaharshurbansubculturewithviolence,humiliationandfrustration.However,whenweconsiderthemiddle-agedspinsterwithahistoryofschizophrenia,whobelievesthatmenunlockthedoorofherflat,anaesthetizeherandinterferewithhersexually,wefindanexperiencethatisultimatelynotunderstandable.Wecanunderstand,onobtainingmoredetailsofthehistory,howherdisturbancecentresonsexualexperience,whysheshouldbedistrustfulofmen,herdoubtsaboutherfemininityandherfeel-ingsofsocialisolation.However,thedelusion,herabsoluteconvictionthatthesethingsreallyarehappening to her, that they are true, is not understandable.The best we can do is to try tounderstandexternally,withoutreallybeingabletofeelourselvesintoherposition(genetic empathy,Chapter1),whatsheisthinkingandhowsheexperiencesit.Wecannotunderstandhowsuchanotioncouldhavedeveloped.

Thisisthecoreoftheprimaryorautochthonousdelusion:itisultimately ununderstandable.Thepatientdescribedabovealsobelievedthepolicewereusingraystoobserveher.Onedoesnothavetotrytofindwhichdelusioncamefirst,theanaesthesiaortheobservationbyrays,todecidewhichisprimary;primaryisnotdependentontemporalrelationships.Inthatbothdelu-sionsarenotultimatelyunderstandable,theyarebothprimarydelusions.Adelusioncanstillbeprimaryinthis,Jaspers’,sensealthoughitarisesonthebasisofamemory,anatmosphereoraperception.The protagonist in Gogol’s (1809–1852) Diary of a Madman (Gogol, 1972) says,‘There is aKingofSpain.Hehasbeen foundat last.Thatking isme. Ionlydiscovered thistoday.’Thissuddenandinexplicablebeliefaroseautonomouslyandunpremeditated.Thereafter,itdictatedtheprotagonist’severybehaviourandinfluencedhisviewoftheworld.

How Ideas and Delusions Are Initiated

Adelusionisabelief,anidea,athought,anotionoranintuition,anditarisesinthesametypeofsettingasanyotheridea–inthecontextofaperception,amemoryoranatmosphere–oritmaybeautochthonous,appearingtooccurspontaneously.

Ideasareinitiatedinthefollowingways.■ Anexampleofanideaoccurringonthebasisofapercept:Ismellfoodcookingandthen

formtheideathatIwillgoandeat.■ Ideasmay followmemory: I remember listening toa stringquartetand formthe ideaof

playingacompactdisc.■ Ideasmayariseoutofanatmosphereoramoodstate:Ialreadyfeel irritable,andwhenI

collectmycarfromthegarageanditmakesanunexplainednoiseIbecomeunreasonablyangryandblamethemechanicfornotrepairingitsatisfactorily.


■ Anideamaybeautochthonous.IvisitawardofthehospitalonanafternoonwhenInevernormallygothere.AlthoughIacceptthatallbehaviourhasanexplanationforitsoccur-rence,IdonotknowwhyonthisparticularoccasionIdidthis.Theoreticalexplanationsmaybegivenastowheresuchideascomefrom,forexampletheunconscious,butsubjectivelythey seem to have occurred de novo. Delusions occur in similar settings on the basis ofpercept,memory,atmosphereorde novo –‘outoftheblue’.

Inourdiscussionofprimarydelusions,wewillseehowthesamefoursituationsalsoaccountfortheonsetofdelusions:percept,memory,moodorautochthonous.Inthissense,delusionisanidea.

SECONDARY DELUSIONS

Primarydelusionsdifferfromsecondarydelusionsinthattheformerareultimatelynotunder-standable.Secondarydelusionsareunderstandableinthecontextofotherabnormalphenomenasuchasabnormalmood,abnormalperception,orindeedofaprimaryabnormalbelief.AmanicpatientclaimedtobeMary,QueenofScots.SheacceptedthatthequeeninquestionlivedanddiedcenturiesagobutclaimeddescentfromherandfeltfullyentitledtosaythatshewasMary,QueenofScots.Thebeliefcouldbeunderstood in relation toherelatedandexpansivemoodanddisappearedasheraffectivestatesubsided.Adepressedpatientbelievedthathehadcom-mittedthe‘unforgivablesin’.Discussionandpersuasion,evenwithapersonwhosereligiousviewsherespected,wasofnoavailingivinghimrelief.Thebeliefcouldbeseenasanintegralpartofhisdepressedmood.Depressivedelusionsmayremainaftertreatmenthasresultedinimprove-mentfromretardation,andtheyaccountforsuicideoccasionallyoccurringintherecoveryphaseofdepression.Ithasbeensuggestedthat theremaybeadecline in theprevalenceofdelusionoccurringwithdepressiveillness,butEagles(1983),studyingadmissionstohospitalinEdinburghfrom1892to1982,consideredtheretobenogenuinereduction.

Secondarydelusionscanbedistinguishedfromovervalued ideas(seebelow).Whereassecond-arydelusionsarederivedfromanotherabnormalphenomenon,overvaluedideasarecomprehen-sibleinthelightofthepatient’spersonalhistoryorsomeidentifiablehistoricaleventwhosevaluehasbecomeheightenedforsomereason.Nopriorabnormalphenomenonexplainsthepresenceofanovervaluedidea.

Types of Primary DelusionKurtSchneider(1957)discussesthedilemmaofprimarysymptomsinschizophreniaextremelylucidlybygivingsixdifferentpossiblemeanings for the termprimary,buthestill leavesus indoubtastowhetherthebeliefisprimaryornot.Hemakesitclear,however,thatprimarysymp-tomsarenotthesameasfirst rank symptomsofschizophrenia.Primarysymptomsarethosethatarisewithoutunderstandablecauseinthecontextofthepsychoticillness.Theyarethereforethenecessarymanifestationsoftheunderlyingpsychopathology,inthesamewaythatswellingandrednessareanecessaryconsequenceofphysicaltrauma.Firstranksymptoms,ontheotherhand,are,accordingtoSchneider,simplyausefulempiricallistofsymptomsthatarefoundcommonlyin schizophreniaandnot inother conditions.Describing theirpresencemakesnoclaimas tohowtheyarose.

True delusions, or delusions proper, are distinguished by Jaspers from delusion-like ideas. True delusions become, therefore, synonymous with primary delusions, and delusion-like ideaswith secondary delusions. Delusion-like ideas can be seen to emerge understandably from thepatient’sinternalandexternalenvironment,especiallyfromhismoodstate.Truedelusionscannotbesoexplained;theyarepsychologicallyirreducible.Theyhave,accordingtoJaspers,thefollow-ingtypes:


1. autochthonousdelusion(delusionalintuition);2. delusionalpercept;3. delusionalatmosphere;and4. delusionalmemory.

AUTOCHTHONOUS DELUSION (DELUSIONAL INTUITION)

Thesearedelusionsthatappeartoarisesuddenly‘outoftheblue’;theyarephenomenologicallyindistinguishablefromthesuddenarrivalofanormalidea.Thepatientgropesforexplanationsfortheoccurrenceofhisdelusioninansweringtheinterviewer’squestion,inthesamewaythatahealthypersonwouldfinditdifficulttoaccountforthearrivalofanyideaifhewereaskedtoexplainit.Thedifferenceliesintheabilityoftheobservertoempathizewith,tounderstand,anon-delusional idea even though itmaybebizarre anddestructive, buthe cannotunderstandhowapersoncanhavecometobelievehisdelusion.

Schneiderregardedthetermdelusional ideaasbasedonoutmodedpsychology,andhefeltitshouldthereforebeabandoned.It isoftenconfusedwithdelusion-like idea,even insometext-books,andthisisanothergoodreasonforabandoningit.Delusional intuitionisperhapsthemostsatisfactorytranslationoftheGermanWahneinfall.Delusionalintuitionoccursasasinglestage,unlikedelusional perception,whichoccursintwostages:perceptionandthenfalseinterpretation.Like delusional perceptions, delusional intuitions are self-referent and usually of momentousimporttothepatient.

DELUSIONAL PERCEPT

This is present when the patient receives a normal perception that is then interpreted withdelusionalmeaningandhas immensepersonal significance. It isafirst rank symptom of schizo-phrenia.Jaspersdelineatedtheconceptofdelusionalpercept,andGruhle(1915)usedthisdescrip-tiontocoveralmostalldelusions–heminimizedtheimportanceofdelusionalintuition.Schneider(1949)consideredtheessenceofdelusionalperceptiontobetheabnormalsignificanceattachedtoa realperceptwithoutanycause that isunderstandable inrationaloremotional terms; it isself-referent,momentous,urgent,ofoverwhelmingpersonalsignificanceand,ofcourse,false.

Itisoftendifficulttodecidewhetheradelusionistrulyadelusionalperceptorisbeingusedtoexplainthesignificanceofcertainobjectsofperceptionwithinadelusionalsystem.Awomansaid,‘everynightbloodisbeinginjectedoutofmyarms[sic]’.Whenaskedforherevidence,sheexplained that shehad littlebrown spotsonher armsand thereforeknew that shewasbeinginjected.Theinterviewerlookedatthespotsonherarms,rolleduphissleeveandshowedherspotsidenticalinappearanceonhisownarm.Hesaidthattheyhadbeenonhisarmaslongashecouldrememberandwerecalled‘freckles’.Sheagreedthatbothsetsofspotslookedsimilarandacceptedhisexplanationofhisownspots,butshestillinsistedthatherfrecklesprovedthatshewasbeinginjectedinhersleep.Thiswasadelusionalpercept.

Anotherexampleofwhatwasprobablyadelusionalperceptcausedconsiderableproblemsinsurgicalmanagement,ultimatelyresultinginthedeathofthepatient(PorterandWilliams,1997).A65-year-oldwomanhadfloodedherhousebyleavingallthetapson.

On admission she was unkempt, with unwashed hair, wearing a dirty dress and vest. She was bringing up bile-stained vomit and was reluctant to be

interviewed. She expressed delusional beliefs that her stomach had been blown up with ether over several weeks and that it was liable to burst as a result of a citizens band radio which was located in her stomach. She believed that the


IRA had been after her for years and experienced auditory hallucinations of voices which she identified as coming from the CB receiver. One ‘voice’ told

her not to let anyone examine her. There was no evidence of an acute confusional state and the diagnosis was consistent with a long-term paranoid

psychosis.On physical examination her abdomen was soft but distended with a hard,

craggy, immobile, central mass. The liver and spleen were of normal size and the kidneys were not palpable. Bowel sounds were loud. A diagnosis of

possible intra-abdominal malignancy was made.

Sherefusedanyinvestigationortreatment.Shedevelopedacuterenalfailureandultimatelydied;asciticfluidrevealedadenocarcinomatouscellsprobablyofovarianorigin.

Anotherpatient,whohadotherdelusionalsymptoms,believedthatmanyofthepatientsinthehospitalwerewell-knowncitizenscunninglydisguisedwithwigs,make-upandfalsebeards.Sherecognizedthattheydidnotlooklikethepeoplewhomshepresumedthemtobebutcon-sidered this to be part of a gigantic hoax, in which she was herself involved, to ‘help peoplespiritually’.Althoughherperceptswerenormalandherinterpretationsdelusional,thiswasnotconsideredtobeadelusionalperceptbutamisinterpretation.Allthecircumstances inher lifewereexplainedbyan immenselycomplicateddelusional system,and theseperceptionshadnoimmediate personal significance beyond the significance that she found in all the objects andeventsaroundher.

In a delusional percept, there is a direct experience of meaning for this particular normalpercept;itisnotsimplyaninterpretationofthispercepttofitinwithotherestablisheddelusionalbeliefs.Delusionalperceptionis, therefore,adirectexperienceofmeaningthatthepatientdidnothavepreviously.Objectsorpersonstakeonnewpersonalsignificancethat isdelusional innature,eventhoughtheperceptionitselfremainsunchanged.Thisisdifferentfromadelusionalmisinterpretation,inwhichthedelusionalsystemaffectsallaspectsofthepatient’slife,andsoeveryeventorperceptionisinterpretedasbeinginvolvedwiththatdelusion.Apatientseesthatadoorknob ismissing; this isnot theprecipitantof immediatenewpersonal significanceofadelusionalnature,rather,itfurtherconfirmsthebeliefhealreadyheldthatpeoplearetryingtotraphimandsubjecthimtovivisection.

Perception, when considering delusional percept, can be understood in quite a wide sense.Thereisnodifference,insubjectiveexperience,betweenperceivinganobjectbymeansofasenseorganandperceivingorunderstanding the senseofwrittenor spokenmessages, although theperceptual routes are different. Thus delusional perception includes delusional significanceattachedtowordsandsentencesaswellastopurelysensoryobjects.Forexample,anin-patientat Rubery Hill Hospital walked to an entrance of the hospital and saw a dilapidated notice:‘RUBE...ILL’.Shesuddenlyrealizedthatthiswasaconcealedmessagejustforher–‘Areyoube(ing)ill?’,thatpeoplewereconcernedtohelpherandthatshewouldgetbetter.Thedelusionalinterpretationwasattachedtothemeaningofthelettersofthenotice.

Therearetwodistinctstagesindelusionalperception:■ theobjectbecomesmeaningfulwithinafieldofsensationsandisperceived;thisisusually

visualperception(Mellor,1991)■ thatobjectbecomesinvestedwithdelusionalsignificance.Thesetwostagesneednotbesimultaneousfortheexperiencetobeadelusionalpercept.On

occasions,theyhavebeenseparatedbyanintervalofyears.Apatientbelievedthathismindwasbeingjammedbyanelectronicdevice.Heclaimedthatthishadstartedwhen,fiveyearsbefore,hehadliftedthetelephonereceiverandheardanunusualclickingnoise.Thedelusionalbeliefhehadheldforonlyafewmonths.


DELUSIONAL ATMOSPHERE

Forthepatientexperiencingdelusionalatmosphere,hisworldhasbeensubtlyaltered:‘Somethingfunnyisgoingon’,‘Ihavebeenofferedawholeworldofnewmeanings’.Heexperiencesevery-thingaroundhimassinister,portentous,uncanny,peculiarinanindefinableway.Heknowsthathepersonallyisinvolvedbutcannottellhow.Hehasafeelingofanticipation,sometimesevenofexcitement,thatsoonalltheseparatepartsofhisexperiencewillfittogethertorevealsome-thingimmenselysignificant.Thisis, infact,whatusuallyhappens,asdelusionalatmosphereispartoftheunderlyingprocessand,often,thefirstsymptomofschizophreniaandthecontextinwhichafullyformeddelusionalperceptorintuitionarises.Themoodoftheatmosphereisveryimportant,andthisexperienceisoftenreferredtoasdelusional mood.Thepatientfeelsprofoundlyuncomfortable,oftenextremelyperplexedandapprehensive.Whenthedelusionbecomesfullyformed,heoftenappearstoacceptitwithafeelingofrelieffromthepreviousunbearabletensionoftheatmosphere.

Amiddle-agedmanpresentedinitiallyasapsychiatricoutpatientwithapparentobsessionalsymptoms.Hekeptcheckingthathisneighbourscouldnothearwhathewassayinginhishome.Hehadresignedfromseveraljobsbecausehebelievedthathisemployerswouldnotaccepthisreligiousbeliefs.Hefelt thatpeoplearoundhimwerehostileand implacablyopposedtohim,althoughhecouldnotdefinequitehow–hejust‘feltit’.Hekeptmovinghouse,butthefeelingstayedwithhim.Thiscontinuedforseveralyears,andhethenarrivedatacasualtydepartmentclaiming thathisneighbourswere talkingabouthisactionsandcontrollinghis thoughts.Theatmospherehaddevelopedinsidiouslyoveryears,andeventuallyhemanifestedauditory hallucina-tionsandpassivity of thought(seeChapter9).

Germanpsychopathologistsneverusedthetermdelusional atmospherebutalwaysreferredtodelusional mood,accordingtoBerner(1991),butheconsidersthatatmosphereistobepreferred,asitallowsthedistinctiontobemadebetweenacognitive,perceptualdisturbanceprovokinganemotional response and a modification of mood causing a changed perception of the outsideworld.Itisconsideredthatdelusionalatmosphereisacommonendstateresultingfromdifferentpathways:vulnerabilitytocognitivedisturbance,asin‘Bleulerian’schizophrenia;dynamicderail-ment, as in affective disorders such as puerperal depression or psychogenic vulnerability; orwithouteitheroftheothertwo,withstressfullifeevents.Bernerconsidersthatthisstateisnotrestrictedtosufferersofschizophrenia.

The prodromal phases of schizophrenic illnesses are very variable in nature, and oftenanother diagnosis has been given before the definitive symptomatology becomes established.In an instructive review of the literature on the simulation of psychosis, and study of sixpatientswhowerethoughttobefeigningaschizophrenicpsychosis,Hay(1983)commentedonthenatureoffeigned psychosis.Inhisopinion,simulationofschizophreniaisgenerallyaprodromalphaseofaschizophrenicpsychosisoccurringinpeoplewithextremelydeviantpremorbidper-sonalities.Allbutoneofhispatientswerefoundtobesufferingfromschizophreniaatthetimeoffollow-up.

DELUSIONAL MEMORY

Inmuchthesamewaythatdelusionalperceptisadelusionalinterpretationofanormalpercept,delusionalmemory is thedelusional interpretationof anormalmemory.Theseare sometimescalledretrospective delusions.Aneventthatoccurredinthepastisexplainedinadelusionalway.Amanaged50whosementalillnesshadlastedforabouttwoyearsclaimedthathishealthhadbeenpermanently affected since the ageof 16,whenhehadhad ‘anoperation to removehisappendix’.Henowbelievedthattheoperationhadbeenanexcuseto‘implantagoldenconvol-vulus’inhisbowels.


Ifdelusionalmeaningisattachedtoanormalperceptthatisremembered,thisthenbecomesadelusional percept.Ithasthetwocomponentsthatweredescribedasbeingnecessaryfordelu-sional percept: the image of the remembered percept and the attachment to this percept ofdelusionalsignificance.Amarriedwomanrememberedyearspreviouslyseeingamanstandinginapub‘withasadlookonhisface’.She‘realized’,atthestartofherschizophrenicillnesstwoweeksbeforeadmissiontohospital,thathehadbeeninlovewithherthen,andshetriedtolocatehisnameinthetelephonedirectoryandmakecontactagain,feelingthattheywereinvolvedinaspecialrelationship.

Ofcourse,itisamistaketoexpectphenomenologicalsymptomstorevealthemselvestidilyfromthepatient’sconversation.There isnoabsolutedemarcationbetweendelusionalmemoryanddelusionalperceptor intuition.Thepatientdescribesadelusion.Didthisoccuronehour,oneweekortenyearsago?Atwhatpointwillthisbedelusionalmemory,notdelusionalintui-tion?Similarly,thereisnoabsolutedistinctionbetweenanormalevent,perceptionorideathatoccurredinthepastandisrememberedwithadelusionalinterpretation,andadelusionalevent,perceptionorideathatoccurredinthepastandisalsorememberedwithadelusionalinterpreta-tion.Inotherwords, therearetwosensestothetermdelusional memory.There is thesense inwhichanormalmemoryismisinterpretedinthepresent,andanothersenseinwhichtheactualmemoryisitselfafalsememorythatisimbuedwithdelusionalinterpretation.Bothofthesearedelusionalmemories,anditisnotalwayspossibletoknowhowmuchoftheeventwasfactualandhowmuchdelusional.Awomanwithschizophrenia,aged34,described12yearsagopickingupatelephonetoringamanshelikedverymuch:‘Godmovedmyarmandmademeputthetelephoneback’.Itwasnotpossibletodecideexactlywhatpartofthisexperiencewasfactualandwhatdelusional,andatwhattimethedelusionoccurred.

Finedistinctionsare sometimes imposedon theclassificationofprimarydelusionsbut aremore collector’s items than features of useful clinical significance. Delusional awareness is anexperiencethatisnotsensoryinnature,inwhichideasoreventstakeonanextremevividnessas if theyhadadditional reality.Delusional significance is thesecondstageof theoccurrenceofdelusionalperception.Objectsandpersonsareperceivednormallybuttakeonaspecialsignifi-cancethatcannotberationallyexplainedbythepatient.

The Origins of DelusionWhatistheoriginofdelusions?Thisquestiondrivesathowfardelusionsarebydefinitiondif-ferentfromnormalbeliefsand,iftheyaredifferentfromnormalbeliefs,whatthemechanismsarethatareinvolvedintheirdevelopmentandmanifestation.Jaspers’(1959)ownviewwasthatdelusionwasaprimaryphenomenonandthatitimpliesatransformationinthetotalawarenessofreality.Thismeansthatadelusionalbeliefinvolvesandimplicatespracticalactivity,behaviour,themeaningsthatareimmanentinobjects,andradicallytransformsthebasicexperienceoftheworld.Apersonwhoisdeludedthatheis lovedbyacelebrityapproachestheworldwiththiscertaintyandknowledgeandactsaccordingly,bywritingto,telephoningorattemptingtovisitthecelebrity.Thiserroneousbeliefinveststhepatient’sworldwithnewmeanings.Intheseterms,realityliesintheinterpretationof,orthesignificanceattachedto,eventsthatoccurinterpretedinthelightoftheprimaryerroneousbelief.

Anunderstandingofhowdelusionsradicallyalterthepatient’sworldasdescribeddoesnothelpustoexplainhowdelusionsforminthefirstplace.Thefactorsinvolvedindelusionforma-tionhavebeensummarizedbyBrockington(1991);seeBox8.1.

Fish(1967)hasmadeausefulprécisoftheearlierGermantheoriesoftheoriginsofdelusion.Conradproposedfivestagesinthedevelopmentofdelusionalpsychosis.

■ Trema:delusionalmoodrepresentingatotalchangeinperceptionoftheworld.■ Apophany:asearchfor,andthefindingof,newmeaningforpsychologicalevents.


■ Anastrophy:heighteningofthepsychosis.■ Consolidation:formingofanewworldorpsychologicalsetbasedonnewmeanings.■ Residuum:eventualautisticstate.Gruhle(1915)considereddelusional perceptiontobethemostsignificantformofdelusion,a

normalpercepttakingonanewmeaning.Thisresultsinadisturbedrelationshipoftheunder-standingofevents.Matussekconsideredthatwithdelusionalperceptionthereisachangeeitherinthesignificanceofthewordsusedorintheactualnatureoftheperceptionitself.Thesewriters,andalsoSchneider,regarddelusional perceptionasthekeytounderstandingthenatureofdelu-sionalexperience.

Hagenregardeddelusional atmosphereasprimary,arisingforreasonsunknownandresultinginarearrangementofmeaningsintheworldaroundthepatient,whogropesforananswertothisproblemofunderstandingandfindsitbycreatingadelusion.Itiseasiertobearthecertaintyofadelusionthantheuncertainforebodingoftheatmosphere.Jaspersconsideredthatthereisa subtle change of personality due to the illness itself, and this creates the condition for thedevelopmentofthedelusionalatmosphereinwhichthedelusionalintuitionarises.

Allthesetheoriesassumethatthedelusionisprimaryandultimately not understandableinthesame sense that Jaspers considers the experience of reality to be primary. Experience holds asymbolicimplicationbeyondthefactoftheeventitself;forexamplethedoctorwritingaprescrip-tion forhispatient in the consulting roommeansmuchmore to the latter than if thedoctorweredoodlingonhisprescriptionblock.(ApatientinNorthAfricainthenineteenthcenturyatethewrittenprescriptionhisdoctorgavehim,sogreatwashisconfidencein,andvenerationfor,thedoctor[Sims,1972]).Itseemsthatthesymbolicbeliefattachedtoeventsandperceptionsisalteredindelusion,andthisiswhythepatientdoesnotnecessarilyactonhisdelusions.Thedelusionalatmosphereisnotanessentialprerequisiteforadelusionalintuition,asthelattermayoccurapparentlyde novo.

Somewritershavenottriedtoexplaindelusions,becausetheyfindthemtotally incompre-hensibleandtheyconsiderthattheyaredirectlyduetoanabnormalityofthebrain(Schneider,1949).Bleulerconcentratedonthealteration in affectasprimaryratherthandelusionalatmos-phereorperception.Heconsideredthatheightenedaffectloosensthecapacitytoformassocia-tionsandthus facilitates thearrivalofadelusion.At thebeginningofaschizophrenic illness,thereisextremeaffect,perhapsintheformofanxietyorambivalence,whichthepatientcannotexpress.

Kretschmer(1927)stressedtheimportanceoftheunderlyingpersonality.Hedescribedthesensitive premorbid personalityoccurringinapersonwhoretainsaffect-laden complexesandhasalimitedcapacityforemotionalself-expression.Suchapersonisdrivenpainfullyby,forexample,powerfulsexualfeelings,buthehasgreatdifficultyincommunicatinghispassionandrelatingtootherpeople.Heisverymuchawareofsocialconstraintsandisrigidlycontrolledbyhissuperego.Suchaperson,somewhatrigid,narrow-mindedandsuspiciousinhisviews,readilyformssensitive ideas of reference. A key experiencemayoccur inhis lifecircumstances,andquitesuddenly theseideasbecomestructuredasdelusions of reference.

BOX 8.1 ■ Factors involved in the germination of delusions

■ Disorderofbrainfunctioning■ Backgroundinfluencesoftemperamentandpersonality■ Maintenanceofself-esteem■ Theroleofaffect■ Asaresponsetoperceptualdisturbance■ Asaresponsetodepersonalization■ Associatedwithcognitiveoverload


Agirlwasalwaysshy,reticentandsensitiveatschool.Quiteoften,shewasreluctanttogotoschool.Shewasmeticulousinherattentiontopersonalneatnessandcleanliness.Afterleavingschool,sherememberedvividlyseveraloccasionsasachildwhenshehadfelthumiliated.Attheageof18,whenshewasworkinginafactory,shewasinthewomen’scloakroombroodingbecauseherboyfriendhadtoldherthathewasleavingherforsomeoneelse.Sheheardoneoftheotherwomensay, ‘Ugh,doesn’t she smell?’ Immediately, sheapplied the statement toherself and toexplainherboyfriend’sbehaviour.Fromthenonwards,shewasconvincedthatshesmeltunpleas-ant all the time, although she could smell nothing herself.This delusion dominated her life,preventedhermixingandcausedhergreatdistress.Thisdevelopmentofadelusion(Sensitiver Beziehungswahn)fromsensitiveideasofreference,asthesequeltoakey experience,issometimesseenattheonsetofschizophreniabutisnotcommon.Thekeyexperience,asdemonstratedinthiscase,hastwoimportantqualities.First,ithasparticularappropriatenesstothepatient’sareasofconflictassensitiveideasofreference.Second,itoccursatatimeofmarkedemotionalturmoilanddistress,sothatthepsychicgroundispreparedforacatastrophicevent.

Attempts have been made to find all delusions understandable in relation to the person’sinternal experience or social background.Westphal considered that if one knew all about thepatient,thechangeinhisviewofhimselfandthebeliefthathehadbecomenoticeableinsomeway would explain the delusion (Fish, 1967). Freud’s (1907) theories on the development ofdelusionsalsoattemptedtomakethemultimatelyunderstandable throughthemechanismsofdenial,projectionandsoon.Otherauthorshaveclaimedthatdelusionsareunderstandableinasocialcontext.Laing(1961)consideredtheflightintomadnessasanecessarydefenceagainstahighlydestructivefamily–notonlyunderstandable,butadmirable,andevenworthemulating.

Whenfourdifferentpsychologicaltheorieswereappraisedtoexplainparanoidphenomena,abasis of shame-humiliationwas found tobe themost consistent (Colby, 1977).Winters andNeale (1983) consider that existing theoriesofdelusional thinkingdevelop twomain themes:motivational and defect.The motivational theme explains the arrival of a delusion to explainunusualperceptual experienceor to reduceuncomfortablepsychic states.Defect implies somefundamentalcognitive-attentionaldeficitresultingindelusion.

Thevarietyandrangeofexplanationsadducedastheoriginofdelusionsattesttheextentofourignoranceabouttheultimatenature,structureandderivationofdelusions.Itisprobablywisetoregard‘delusion’asatermdescribingamultitudeofabnormalitiesofthinkingthathavemerelyasuperficialfamilialrelationship.Toemployananalogy,‘delusion’isliketheterm‘ataxia’,atermthathidesseveraldifferentabnormalitiesofmovementwithdifferingunderlyinglesionsandmecha-nisms.Theterm‘delusion’isnotadescriptionofaunitary,homogenousabnormalityofthinking.Itismostlikelyanumbrellatermforacollectionofdisparateabnormalitiesofthinking.

COGNITION AND REASONING IN DELUSION

In trying tounderstand the roleof cognitionand reason indelusion formation, it isprobablyusefultothinkoftheformation,elaborationandpersistenceofdelusionalbeliefsasanexpressionofnumerouscausal influencesconverging;eachexertsadifferent influence in theevolutionofthebelief(Roberts,1992).Theprocessofreasoninginordertocometoconclusionsaboutone’ssituation in the outside environment appears to be altered in those experiencing delusions. A‘jump-to-conclusionsstyle’hasbeendemonstratedindeludedsubjectswhenaskedtoperformaprobabilistic reasoning task (Huqetal., 1988).Thiswas confirmedbyGarety etal. (1991) inshowingthat41percentofdeludedsubjectsbutonly4percentofcontrolsreachedaconclusiononthebasisofonlyoneitemof information.Acommoncauseinabnormalityof informationprocessinghasbeenproposedforthosesubjectswithabnormalreasoningandabnormalpercep-tion;failuretomakeuseofknowledge,previouslyacquired,ofregularitiesintheworld,resultingin over-reliance on information immediately present, may be a factor in delusion formation


(Garety,1991).Thismodelemphasizesthedeviantnatureofthethinkingprocessthatisassoci-ated with delusions in patients with schizophrenia. In Garety’s model, judgemental processesinvolvedindelusionformationinclude:

1. priorexpectationthatmaybemodifiedbyemotion;2. currentinformationthatwehaveatourdisposal,suchastheinformationreachingusby

wayofourperceptions;and3. thenatureofourinformationprocessingbiasorstyle.Inthismodel,ifperceptualabnormalitiespredominatetheroleofdeviantinformation,then

processingmechanismswillbeunderemphasized.Inotherwords,whendelusionsaresecondarytohallucinations,reasoningshouldremainintact.Theadvantageofthismodelisthatithighlightsthevaryingroutestodelusionformation.

Attribution in Delusion

Analternativepsychologicalexplanationfordelusioncomesfromsocial attribution theory.KaneyandBentall(1989,1992)foundthatdeludedpatientsmadeexcessivelyexternal,stableandglobalattributionsfornegativeevents(‘ThefactthatIbrokemylegprovesyetagainthattheWetherbyfreemasonsaregettingatme’)andexcessivelyinternal,stableandglobalattributionsforpositiveevents(‘EveryonesmilesandnodswhentheyseemebecauseIhavebeensentbyGodtocom-municatewithpeopleaboutevilandIhavealetterfromthePopeasproof ’).Deludedsubjectswereunwilling toattributenegative eventsofwhich theywere thevictim to theirowncause;also,injudgingthebehaviourofotherpeopletheywerereluctanttoattributenegativeeventstothevictimsthemselves.Theseandotherstudiessuggestthatpersecutorydelusionshaveafunctioninprotectingtheindividualfromlowself-esteem(Bentall,1993).

Deluded subjects were considered to evaluate their own causal statements in a distinctivemanner,andthisdifferencefromdepressedsubjectswasgreaterthanthedifferencesinthecausalstatementsthemselves;thatis,thedifferencebetweendeludedandothersubjectsininternalityforpositiveandnegativeeventsdoesnotreflectdifferencesinthecausalstatementsofthesesubjects,butratherdifferences in theirattributions(Kindermanetal.,1992).Onceagain,delusionsarelinkedbothtopersonalmeaningandtoboundariesofself.Thisinvestigationofattributionalstylewas further extended using obvious and opaque tests of attributional style. Deluded subjectsattributednegativeoutcomes toexternalcauses in theobviousor transparent testsbutamorecoverttestingtointernalcauses;thisfurthersupportedthehypothesisthatpersecutorydelusionsfunction as a defence against underlying feelings of low self-esteem (Lyon etal., 1994).Thispsychologicalexplorationisfurthersupportedbytheclinicalstudythatfollows.

Delusion and Meaning in Life

Roberts(1991)hasdevelopedthethesisthatdelusions,inthecontextofschizophrenicillness,maynotthemselvesbeanafflictionorillnessbutanadaptiveresponsetowhateverinitiatesthepsychoticbreak.Agroupofchronicallydeludedsubjectswascomparedwithpreviouslydeludedpatientsnowinremissionandwithtwonon-patientgroups.Persecutorydelusionswerecommoninbothpatientgroups,butgrandioseanderoticdelusionsanddelusionsof specialknowledgeweremostlyfoundinthecurrentlydeludedgroup.Thechronicallydeludedgroupscoredmuchhigher than the remittedpatients forpositivemeaning in life, andmuch lower fordepressionandsuicidalintention.Theyhadaveryhighlevelofperceivedpurposeandmeaninginlife.Itisconsideredthatforsometheformationofdelusionsisadaptiveincombatingpurposelessness,loneliness,senseofinferiority,hopelessness,isolationandpainfulawarenessofbrokenrelation-shipsandprovidesanewsenseofidentity,aclearersenseofdutyandresponsibility,anexperienceoffreedom,protectionfrompasthurts,andachangefromfear,worry,depressionandboredomtowards feeling lively, enthusiastic, interested and peaceful. One patient described this: ‘I’vehadagreattime.I’vegotthisonegreatthoughtinmymindthatIamJesus–that’senough…nothinghurtsmenow,Ineednothingnow.’


Content of DelusionsDelusions are, of course, infinitely variable in their content, but certaingeneral characteristicscommonlyoccur.Unliketheform,whichisdictatedbythetypeofillness,thecontent isdeter-minedbytheemotional,social,culturalandbiographicalbackgroundofthepatient:Napoleonsarenowrareinmentalhospitals;schizophreniasufferersfromtraditionalsocietiesmaydescribetheirthoughtsasbeinginterferedwithbythespiritsoftheirancestorsratherthanbytelevision.As computers and the Internet increasingly affect all aspects of our lives, we are beginningto have described by those with mental illness delusions of control concerning the Internet(Catalanoetal.,1991).

DELUSIONS OF PERSECUTION

Thisisthemostfrequentcontentofdelusion.ItwasdistinguishedfromothertypesofdelusionandfromotherformsofmelancholiabyLasègue(1852).Peoplewhobelievedelusionallythattheirlivesarebeinginterferedwithfromoutsidemoreoftenfeelthistobeharmfulthanbenefi-cial.Avariantontheusualbeliefsofpersecutionormalevolentintentaredelusionsofprejudice:the patient or victim believes that he is being slighted, overlooked, passed over in favour ofsomeoneelse.The interferingagent indelusionsofpersecutionmaybeanimateor inanimate,otherpeopleormachines;itmaybesystems,organizationsorinstitutionsratherthanindividuals.Sometimes, the patient experiences persecution as a vague influence without knowing who isresponsible.

Persecutorydelusionsoccurinmanydifferentconditions:inschizophrenia,inaffectivepsy-chosesofmanicanddepressive typeand inorganic states,bothacuteandchronic.Theaffectassociatedwiththebeliefofpersecutionmayvaryfromaninappropriateindifferenceandapathyinschizophreniatostarkterror,ascommonlyseenindeliriumtremens.

Manic patients with persecutory delusions show gross overactivity and flight of ideas inattemptingtoexpressanddealwiththeirbeliefs.Indepression,thepersecutorydelusionstakeonthecharacteristiccolouringofthedominantmoodstate.Persecutoryovervaluedideasareaprominentfacetofthelitigioustypeofparanoidpersonalitydisorder.

MORBID JEALOUSY AND DELUSION OF INFIDELITY

Morbidjealousy,adisorderofcontentdescribedbyEy(1950),maybemanifestedinvariousforms,forexampleasdelusion,overvaluedidea,depressiveaffectoranxietystate.Thefeelingofjealousy,coupledwithasensethatthelovedobject‘belongstome’and,therefore,‘Ibelongtotheother’,ispartofnormalhumanexperience; it isofsocialvalue inmaritalrelationshipsforpreservingthe family.Various termshavebeenused todescribeabnormal,morbidormalignant jealousy.Kraepelin(1905)usedthetermsexual jealousy.EnochandTrethowan(1979)haveconsidereditimportanttodistinguishpsychoticjealousyfromothertypes,andthisisdependentonthedem-onstrationofadelusion of infidelity.Itissometimesdifficulttodistinguishunderstandablejealousyfromthatwhichisdelusional.

Mullen(1997)classifiedmorbidjealousywithdisorders of passion,inwhichthereisanover-whelmingsenseofentitlementandaconvictionthatothersareabrogatingthesubject’srights:‘Themorbidlyjealousbelievethattheyarethevictimsofaninfidelitythathasdeprivedthemofthefealtywhichistheirdueandtheyaredriventoexposethisdisloyalty,reasserttheircontrolandpunishthetransgression’.Theothertwocategoriesarethequerulant,whoareindignantatinfringementsofrights,andtheerotomanic,whoaredriventoasserttheirrightsoflove.

Delusionofinfidelity,thatis,whenthesubjectunreasonablybelieveshimorherselftobethevictimoftheirpartner’sunfaithfulness,mayoccurwithoutotherpsychoticsymptoms.IthasbeendescribedbyToddandDewhurst(1955)andbyMullen(1990).This is identifiablydelusional


when thebelief of the spouse is basedondelusional evidence.Suchdelusions are resistant totreatmentanddonotchangewithtime.Apatientwasveryconcernedthathiswifewasbeingunfaithfulwithnumerouspeople, includinghisboss,hergeneralpractitionerandothers.Fouryearslater,despitevarioustreatments,hisbeliefwasunchanged,buthesaid,‘Idon’tblamehernow.SheismuchyoungerthanIamandeveryonedoesthatsortofthing’.Delusionsofjealousyarecommonwithalcoholabuse;forinstance,Shresthaetal.(1985)foundsexualjealousytobepresentin35percentofmenand31percentofwomenwhowerealcoholics.Asjealousyappearedtobejustifiedinsomecases,morbid jealousywasconsideredtobepresentin27percentofmenand15percentofwomen.Delusionaljealousy,oftenassociatedwithimpotence,alsooccursinsomeorganicstates,forexamplethepunchdrunksyndromeofboxersfollowingmultiplecon-trecoupcontusion.Quitefrequently,thespouse,weariedbycontinuedaccusationsof infidelity,doesformanothersexualinvolvement,whichmayresultinanacuteexacerbationinthementalstateofthepatientandfurthermaritalconflict.

Thesexualcontentofthedelusionisobvious;however,Enoch(1991)regardsthenatureoftherelationshipbetweenthetwopartnersasthekeyaspectofthecondition.Jealousyisdirectedtowardsthesexualpartner.Thedeludedpersonisveryattachedto,andoftenemotionallyutterlydependenton,theother;hemayhaveamisplacedsenseofowninghercompletely.Thevictimisoftenmuchmoresexuallyattractivethanthedeludedpartner,forinstanceayoungwifeorasociableandpopularhusband.Thedeludedpersonmayhavebeenpromiscuousinthepastandthereforeresignedlyexpectshisspousetoshowsimilarbehaviour.Hemayhavebecomeimpotentandprojected theblame forhis failureon toher.Hemayhavehomosexual fantasiesdirectedtowardsthemenwithwhomheclaimshiswife isconsorting.Morbid jealousyariseswiththebeliefthatthereisathreattotheexclusivepossessionofhiswife,butthisisjustaslikelytooccurfrom conflicts inside himself, his own inability to love or his sexual interest directed towardssomeoneelseasfromchangingcircumstancesinhisenvironmentorhiswife’sbehaviour.Husbandsorwivesmayshowsexualjealousy,asmaycohabiteesandhomosexualcouples.Crimesofviolencearenotoriously associatedwithmorbid jealousy; violence ismoreoften ventedon thepartnerthanonthesupposedrival,mostoftenbymenonwomen.Morbidjealousymakesamajorcon-tributiontothefrequencyofwifebatteringandisoneofthecommonestmotivationsforhomicide(Mullen,1990).

DELUSIONS OF LOVE

Thedelusionsassociatedwith lovingandbeing lovedarequitedifferent fromthebehaviouralandaffectiveabnormalitiesofnymphomania,thesituationofawomancharacterizedbymorbidoruncontrolledsexualdesire,andsatyriasis,themaleequivalentofexcessivesexualactivity.Boththeselatterconditionsexistinitiallyintheopinionofanexternalcommentator–thedoctor.

Approximatelytwiceasmanyschizophrenicpatientshadsexualpreoccupationsinthemid-twentiethcenturyascomparedwithinthemid-nineteenthcentury(KlafandHamilton,1961).ErotomaniawasdescribedbySirAlexanderMorrison(1848)asbeing:

characterized by delusions … the patient’s love is of the sentimental kind, he is wholly occupied by the object of his adoration, whom, if he approaches, it is

with respect … the fixed and permanent delusions attending erotomania sometimes prompt those labouring under it to destroy themselves or others, for

although in general tranquil and peaceful, the patient sometimes becomes irritable, passionate and jealous.

Erotomania iscommoner inwomenthaninmen,andavarietyhasbeencalled‘oldmaids’insanity’byHart(1921), inwhichpersecutorydelusionsoftendevelop.Thesehavesometimes


beenclassifiedasparanoiaratherthanparanoidschizophrenia;thesedelusionalsymptomssome-times occur in the context of manic-depressive psychosis (Guirguis, 1981).Trethowan (1967)demonstratedthesocialcharacteristicsoferotomania,relatingthepatient’spreviousdifficultiesinparentalrelationshipstothepresenterotomania.

Avariationoferotomaniawasdescribedby,andretainsthenameof,deClérambault(1942).Typically,awomanbelievesaman,whoisolderandofhighersocialstatusthanshe,isinlovewithher.Thevictimhasusuallydonenothingtodeserveherattentionandmaybequiteunawareofherexistence;sometimesheisawell-knownpublicfigurequiteremotefromthepatient.Inacaseoftheauthor’s,thevictimwasapreviousemployerofthepatient.Shebelievedthathewasthefatherofherchild(althoughatanothertimesheagreedthattherehadbeennosexualrela-tionshipwithheremployer).Shealsobelievedthathewassendinghermoney,andshewouldwritelettersthankinghimforhisgenerosityandaffirminghergratitudefortheevidenceofhislove(SimsandWhite,1973).

In a series of 16 erotomanic cases, Mullen and Pathé (1994) tried to distinguish betweenthosecasesinwhichthereisamorbidbeliefinbeinglovedandthosewithmorbidinfatuation.Theyfoundthatinmostcasesbothnotionsweredescribed:amixtureofbeinglovedandlovinginreturn.

DELUSIONAL MISIDENTIFICATION

Delusional misidentification syndromes include a number of discrete but related syndromesthathave incommontheconceptof thedouble.These syndromes includeCapgras’ syndrome(Capgras and Reboul-Lachaux, 1923), Frégoli’s syndrome (Courbon and Fail, 1927), the syn-dromeofintermetamorphosis(CourbonandTusques,1932)andthesyndromeofsubjective doubles(Christodoulou,1978).

Capgras’syndromeisregardedbyEnochandTrethowan(1979)as‘arare,colourfulsyndromeinwhichthepersonbelievesthataperson,usuallycloselyrelatedtohim,hasbeenreplacedbyanexactdouble’.Itisaspecificdelusionalmisidentificationofapersonwithwhomthesubjectusuallyhascloseemotionaltiesandtowardswhomthereisafeelingofambivalenceatthetimeofonset.Thebelief, inCapgras’ syndrome,has thefullcharacteristicsofdelusion(EnochandTrethowan,1979).Thebasic conceptof this syndrome isprominent inall cultures,hence thedelusion is universal (Christodoulou, 1991).Likeotherdelusions,delusion describes the form;thecontentisculture-dependent.Arecentpatientbelievedhismotherhadbeenreplacedbyanimpostorafterfallingthroughatimewarptoaparalleluniverse,andthisexplainedthehorriblethingsthathadhappenedinthepastthreeweeks.

Frégoli’s syndrome is thedelusionalmisidentificationof anunfamiliarperson as a familiarone, even though there is no physical resemblance. The syndrome of intermetamorphosis isthedelusionalbeliefthatothersundergoradicalchangesinphysicalandpsychologicalidentity,culminatinginadifferentpersonaltogether.Thesyndromeofsubjectivedoublesisthedelusionalbeliefintheexistenceofphysicalduplicatesoftheself,andtheseduplicatesareusuallythoughttohavedifferentpsychologicalidentities(seeMoselhyandOyebode,1997,forreview).

InaseriesofcasesreviewedbyBerson(1983),55percent(70patients)wereunquestionablydiagnosedas suffering fromschizophrenia,anda furthereightpatients (totalling61percent)wereprobablysufferingfromschizophrenia;13percentweresufferingfrombipolarmooddis-orderand24percentwereconsideredtohaveanorganicdiagnosis.Of133patients,57percentwerefemale;theagerangewasfrom12to78,withameanof42.8years.Majorityopinionwouldnotfavourdenotingthisasaseparatediseasebutratherasasymptomthatcolourstheclinicalstateanddominatesthesymptomatology.Thefourdifferentvarietiesofdelusionalmisidentifica-tionhaveincommonpsychopathologicallytheformofadelusion.Capgras’syndrome,whenitoccurs in schizophrenia, isbasedonadelusionalpercept (Sims,1986). InCapgras’ syndrome,


thereisnooutwardchangeintheappearanceoftheobject,andthereisnofalseperception,forthepatientoftenadmitsthatthedoubleexactlyresemblestheoriginal(EnochandTrethowan,1979),butcarefulquestioningusuallyrevealsthattherearedistinguishingstigmata.Sometimespatientswill say,‘Iknowthat it isnotmymotherbecauseshewouldneverstand like that’or‘thispersonmovestooslowlytobemyfather’.

Theambivalencetowardstheobjectofmisidentificationmaybeexpressedinthehistory,withaclearaccountofbothnegativeemotions,suchashostility,fearorcontempt,andaffectionanddependence.Onthosefewoccasionswhenanobject,ratherthanaperson,iswronglyidentified,thatobjecthasimportantemotionalconnotationsforthepatient,forexamplehomeoraletterfromarelative.ThesubjectsofmisidentificationinBerson’s(1983)reviewof133patientscom-prised60spousesandtwolovers;on29occasions,achildorchildren;40parents;24siblings;13therapists; four grandparents; three in-laws; two neighbours; two domestics; and one each offiancé,cousin,stepson,employerandpriest.Oneightoccasions,theselfwasmisidentifiedeithersolelyorwithotherevidenceofthesyndrome;ontwooccasions,animals,andeighttimesinani-mateobjectsweremisidentified.Thus,in31percentofoccasions,thedelusionalmisidentificationreferstoamaritalpartner,andin46percenttoafirst-degreerelative;inonlyfourpercentwasthemisidentificationofthepatienthim-orherself.

There is growing evidence that delusional misidentification syndromes are associated withorganicdisorders, includingdementia,acquiredbrain injury,epilepsyandcerebrovascularacci-dentsin25to40percentofcases,andneuroimagingstudiesrevealassociationwithrighthemi-sphere abnormalities, particularly in the frontal and temporal regions (Edelstyn etal., 1999).Furthermore, neuropsychological investigations have consistently shown impairments of faceprocessing in delusional misidentification syndromes (Edelstyn etal., 1996; Ellis etal., 1993;Oyebodeetal.,1996).Thesefindingsunderpintheassumptionofrighthemisphereabnormalitiesin delusional misidentification syndromes, because the right hemisphere is implicated in faceprocessingandrecognition.

GRANDIOSE DELUSIONS

Primary grandiose delusions occur in schizophrenia.The patient may believe himself to be afamouscelebrityortohavesupernaturalpowers.Hemaybelievehimselftobeinvolvedinsomeveryspecialandsecretmissionaboutwhichhehasnotyetbeenfullybriefedbutinanticipationofwhichheiswaitingwithexcitementforthedénouement.Beliefsofthissortaresometimescalleddelusionsofspecialpurposeandareoftheformofdelusionalintuition.

Expansive or grandiose delusional beliefs may extend to objects. Sometimes a psychoticpatientdemonstratesdelusionsofinventioninwhich,forexample,hebuildsamachinethathebelieves to have special capabilities, considering himself to be a creative prodigy. Secondarygrandiosedelusions,ordelusion-likeideas,occurinmanicstates.ApatientsaidthattherewasnolifeonMarsbecause‘iftherehadbeenIwouldhavebeenabletogetintouchbytelepathyusingmygreatgenius’.Heshowednoevidenceoftruepassivityexperiences.Amanicpatient,mentionedabove,believedthatshewasdescendedfromtheroyalStuartlineandthereforewasactuallyinsomewayMary,QueenofScots.SheinvitedtheQueenandthePrimeMinistertoapartyinherstudentflatbecauseshethoughttheywouldbehonouredtobeinvited:‘Itisonlyfairthattheyshouldhaveaninvitation.’Theexpansiveaffectofmaniacanbeveryclearlyseentorenderthisdelusionunderstandable.

RELIGIOUS DELUSIONS

Religiousdelusionsarecommon.However,theyformedahigherproportionofalldelusionsinthe nineteenth century than in the twentieth century: three times as many patients with


schizophrenia of both sexes had religious preoccupation in the nineteenth century (Klaf andHamilton,1961).Decisionastowhetherbeliefsaredelusionalornotmustrestontheprinciplesdescribedabove;thatis,onthewaythebeliefisheldandtheevidenceproducedinitssupport.Becauseareligiousbeliefisverybizarreandatvariancewiththoseheldbytheinterviewerdoesnotnecessarilymakeitadelusion.Religiousdelusionsmaybegrandioseinnature,forexampleapatientintheUKwhobelievedthatshewasanemissaryofGodtotheBirminghamHousingDepartment.Theymayalsobesecondarytodepressivemood,asinthepatientofEmilKraepelin(1905)quotedatthebeginningofChapter16:‘Icannot liveandIcannotdie,becauseIhavefailedsomuch,Ishallbringmyhusbandandchildrentohell’.

Thereligiousnatureofthedelusionisseenasadisorderofcontentdependentonthepatient’ssocialbackground,interestsandpeergroup.Theformofthedelusionisdictatedbythenatureoftheillness.Soreligiousdelusionsarenotcausedbyexcessivereligiousbelief,orbythewrong-doingthatthepatientattributesascause,buttheysimplyaccentuatethatwhenapersonbecomesmentallyillhisdelusionsreflect,intheircontent,hispredominantinterestsandconcerns.

Sometimes, it can be difficult to make the distinction between religious delusion and theexperienceofanunusual religiousbelieforpractice.Psychiatricmorbiditywouldbesuggestedbythefollowing(Sims,1992).

■ Boththesubjectiveexperienceandtheobservedbehaviourconformwithpsychiatricsymp-toms,thatis,theself-descriptionofthisparticularexperienceisrecognizableasbeingthesymptomatologyofaknownpsychiatricillness–ithastheformofdelusion.

■ Thereareotherrecognizablesymptomsofmentalillnessinotherareasoflife:otherdelu-sions,hallucinations,disturbanceofmood,thoughtdisorderandsoon.

■ Thelifestyle,behaviouranddirectionofpersonalgoalsoftheindividualsubsequenttotheevent or religious experience are consistent with the natural history of mental disorderratherthanwithapersonallyenrichinglifeexperience,compatiblewiththeconditionsinwhichdelusionsoccur.

DELUSIONS OF GUILT AND UNWORTHINESS

Such delusions are common in depressive illness. They often lead to suicide and, rarely, tohomicide,whenthekillingofacloserelativemaybefollowedbythepatient’ssuicide.Affectiveillness may be followed by the killing of children by depressed mothers, or the killing oftheir wife or sometimes also children by husbands; suicide may follow immediately or later(Higgins,1990).

Thebeliefsaboutguiltmaytotallydominatethepatient’sthinking.Anelderlywomanspentthedayrushingroundthehousewringingherhandsandtellingherworriedfamilythatshewaswretched, worthless and only deserved to die. She told her married daughters that they wereillegitimateandthatthehouseshelivedinwasnothersbutstolen,andshetoldherhusbandof30years’ standing that they were not legally married.When it was suggested to her that shecomeintohospital,sheassumedthatshewouldbekilledonarrival,andsheaskedwhetherthiscouldtakeplacethereandthensothatshecouldreceiveherjustdesserts.

DELUSIONS OF POVERTY AND NIHILISTIC DELUSIONS

Delusionsofpovertyarecommonindepression;anelderlypatientbelievedthat‘thenurses’hadbeensystematicallyraidingherpurseandthatshewasdestitute.Cotard’s syndromecontainsfea-turestypicalofpsychoticdepressionintheelderly:nihilisticandhypochondriacaldelusionsthatareoftenbizarre,dramaticandtingedwithgrandiosity;depressedmoodwitheitheragitationorretardation and a completely negative attitude. According to Griesinger (1845), ‘the patientconfusesthesubjectivechangeinhisownattitudetooutsidethings…therealworldseemsto


the patient to have disappeared completely, or to be dead’.This was graphically depicted byCotard(1882):

I would tentatively suggest the name ‘nihilistic delusions’ (délire de negations) to describe the condition of the patients to whom Griesinger was referring, in

whom the tendency towards negation is carried to its extreme. If they are asked their name or age, they have neither – where were they born? They were not born. Who were their father and mother? They have no father,

mother, wife or children. Have they a headache or pain in the stomach, or any other part of the body? They have no head or stomach and some even have no

body. If one shows them an object, a rose or some other flower they answer, ‘that is not a rose, not a flower at all’. In some cases negation is total.

Nothing exists any longer, not even themselves.

Thecentral character inPatrickMcGrath’snovelSpider said, ‘Iwas contaminatedby it, itshrivelledme,itkilledsomethinginsideme,mademeaghost,adeadthing,inshortitturnedmebad’.Elsewhere,thesamecharactersays,‘asinglepipetakeswaterfrommystomach…andthispipealonedropsthroughthevoidandconnectstothethingbetweenmylegsthathardlyresemblesaformedmaleorganatallanymore’(McGrath,1990).

Nihilisticdelusionsarethereverseofgrandiosedelusions,inwhichoneself,objectsorsitua-tionsareexpansiveandenriched;thereisalsoaperversegrandiosityaboutthenihilisticdelusionsthemselves. Feelings of guilt and hypochondriacal ideas are developed to their most extreme,depressiveforminnihilisticdelusions.

HYPOCHONDRIACAL DELUSIONS

Averydepressedmansaidthathewasfullofwater,thattherewasnothingelseinsidehim,andthathecouldnotpasswaterbutthatifhedidthatwouldbetheendofhim.Hecouldnotdrinkor thewaterwouldflood the room.Other less strikinghypochondriacal beliefs anddelusionsoccurindepression,andSchneider(1920)hasconsideredthatlocatingtheexperienceofdepres-sionasasensationinabodilyorganisequivalenttoa‘firstranksymptom’ofdepressivepsychosis(seeChapter16).Anelderlywomanwithdepression,whohadhadamitralvalvereplacementforrheumaticheartdisease,saidthatshefeltworthlessandhopelessanddescribedherphysicalfunctionsas‘nothingisworking’.

Hypochondriacaldelusionsmayalsooccur inschizophreniaandhave thecharacteristicsofotherschizophrenicideas.Theyaremorelikelytobegivenapersecutorythananihilisticexpla-nation.Thus, a patient believed that his bodily functions were being interfered with by raysemitted fromaplanet and that thiswaspartof aplot to controlhis thoughts andbehaviour.HypochondriacaldelusionsarediscussedfurtherinassociationwithhypochondriasisinChapter14;however,otherfeaturesofhypochondriasis,suchasbodilypreoccupation,diseasephobiaandconvictionofthepresenceofdiseasewithnon-responsetoreassurance,areinfactmorecommonthan delusion (Pilowsky, 1967). Facial pain is described in Chapter 15 and other delusion-like ideasandovervalued ideasof thebody inChapter14.Delusionsconcerning thepatient’soriginsaresometimesdescribedandhavesomeaffinitytohypochondriacaldelusion.Thepatientbelieves,ondelusionalevidence,thatheisnothisparent’schild,orperhapsthatheisofroyalbirth,partanimalorsupernatural.Alternatively,hemaybelievethathedoesnotexistandwasneverborn.

Hypochondriacal delusions are commonly associated with delusional disorder in ICD-10(previouslyknownasparanoia;WorldHealthOrganization,1992).Munro(1988)hasdescribed


delusional disorder as an encapsulated mono-delusional disorder with several subtypes, such aserotomanic,grandiose,jealous,persecutory,somaticandunspecified;theconcepthasdevelopedfromtheoldertermparanoia(Munro,1997).Hehasdescribedthesomatictypeasmonosymp-tomatic hypochondriacal psychosisand,of50cases,thethreemaingroupswere:

■ delusionsofbodyodourandhalitosis■ infestationdelusion(insects,burrowingwormsorforeignbodiesundertheskin)■ delusionsofuglinessormisshapenness(dysmorphicdelusions).Inafactoranalysisofthefeaturesofdelusionaldisorder,fourindependentfactorswereidenti-

fied,suggestingconsiderableheterogeneityofthecondition(Serrettietal.,1999).Thefirstfactorincorporatedcoredepressivesymptoms,whichmaybeeitheradepressivesyndromereactivetostressesderivingfromdelusionalideationoracomorbidmooddisorder,orboth.Otherfactorswerehallucinations,delusionsandsymptomsofirritability.

Thecomplaintwasalwayspresentedwithgreatintensity,andpatientswereutterlyconvincedofthephysicalnatureofthedisorder.Hypochondriacaldelusionsmayalsooccurwithadministra-tionofdrugs,bothprescribedandthoseofabuse.

Koro(Lapierre,1972)isanunusualconditionthathasbeendescribedasanexampleofhypo-chondriacaldelusion.Thisviewisprobablyincorrect.Thefeaturesofkoroinclude:

1. thebeliefthatthepenisisshrinkingintotheabdomen;2. thebeliefthatwhenthepenisdisappearsintotheabdomen,deathwillensue;and3. extremeanxietyaccompanyingthisbelief.Yap (1965) describes this as a culture-bound depersonalization syndrome and considers it

tobeamanifestationofacuteanxietyassociatedwithfolkbeliefsconcerningsexualexhaustion.It has occurred in epidemic proportions among Malays in Singapore (Gwee, 1963) but hasalso been described in individual cases in a French Canadian (Lapierre, 1972), in a WestIndian,aGreekCypriot (AngandWeller,1984)and inanEnglishman (BerriosandMorley,1984).Oyebodeetal.(1986)haveshowninasinglecasestudythatthisbeliefisaccompaniedbyrealpenileshrinkageasmeasuredbyplethysmography.Thissuggeststhatthebeliefisbasedon physiological changes that are likely to be due to anxiety. In essence, the penile changeis similar to tachycardia, hyperhidrosis or other features of sympathetic arousal associatedwithanxiety.

A group of patients who in some respects are intermediate between those suffering fromsomaticdelusionsanddelusionsofinfestationarethosewhoweredescribedbyVidebech(1966)assufferingfromchronicolfactoryparanoidsyndromes;thesehavealsobeenreferredtoashaving‘olfactory reference syndrome’ (Pryse-Phillips, 1971). Characteristically, these patients have afixed and unalterable belief that they smell but do not have hallucinations or other olfactoryexperience.Itisusuallyseeninthecontextofsensitive,paranoidpersonalitydevelopment.Thereisaseverephobicreaction,withthebehaviourofotherpeopleinterpretedasfindingtheirsmelloffensiveandaversive.

Delusions of Infestation

Delusions of infestation have been described by Hopkinson (1970) and by Reilly (1988). InEkbom’s syndrome(Ekbom,1938),thepatientbelievesthatheisinfestedwithsmallbutmacro-scopicorganisms.Thepatient’sexperiencemaytaketheformofatactilehallucinatorystate,adelusionoranovervaluedidea.Theaetiologyisalsovariable.Itisprobablymostcommonasasymptomof circumscribedhypochondriasis in affectivepsychosis, alongwithotherdepressivesymptoms,butitalsooccursinparanoidschizophrenia,inmonosymptomatichypochondriacalpsychosis (delusional disorder), in organic brain syndromes or with neurotically determinedconditions.ThistopicisreviewedbyBerrios(1985)andbyMorris(1991).

Patientshavebelievedthattheyhadaspiderintheirhair,wormsandlicebeneaththeskinor infestation with various insects. The delusion may be accompanied by other depressive


delusions or overvalued ideas of beingdirty, guilty, unworthyor ill.Thesedelusionsmay alsooccurinschizophrenia,inwhichconditiontheycharacteristicallytakeonabizarrecharacterandareaccompaniedbyotherschizophrenicsymptoms.A49-year-oldmotheroffourchildren,oneofwhosesonshaddevelopedaschizophrenicillness,complainedofrecurrentpaininhervaginathat she explained as being caused by a parasite that had migrated from her stomach, whereithadbeenresponsibleforepigastricpaindiagnosedearlierashiatushernia(McLaughlinandSims,1984).Shedescribed theparasite aswandering throughherbloodstreamandashavingbeenresponsibleforvariousachesandpainsshehadexperiencedinthepast.Sherelatedhavingpassedmultiplesmallredwormsandwormcastsinherfaecesand,ononeoccasion,atwo-inchgreenfrog.

Delusionsof infestationmayoccur inorganicstateswithtactilehallucinations, indeliriumtremensduringalcoholwithdrawalandincocaineaddiction.Theymaybedescribedincerebro-vasculardisease, inseniledementiaand inotherbraindisease,andtheyhavebeenascribedtodisorderofthethalamus.Overvaluedideasanddelusion-likeideasofinfestationsometimesoccurinpeoplewithpersonalitydisorderofanankasticorparanoidtypewithnopsychoticillness.

Characteristically,theseideasoccurinpatientsagedover50years.Typically,thosewithdelu-sionsofinfestationhavealwayshadaparticularconcernforpersonalcleanliness.Sometimes,theconditionisprecipitatedbyaskindiseaseandbecomesadelusionalelaborationofexistingtactilesymptoms.Ithasbeensuggestedthatthesymptomdevelopsinstages:first,abnormalcutaneoussensation;thenanillusiondevelops;and,finally,thefullyformeddelusionofinfestationoccurs.Asmentionedabove,delusionalinfestationisnowviewedasoneformofdelusionaldisorder,inparticularbeingasubtypeofmonosymptomatichypochondriacalpsychosis.

COMMUNICATED INSANITY

LaségueandFalret(1877)described‘la folie à deux (ou folie communiquée)’.Occasionally,adelusion(delusionalintuition)istransferredfromapsychoticpersontooneormoreotherswithwhomthey have been in close association, so that the recipient shares the false belief: the principalacquiresthedelusionfirstandisdominant,theassociatebecomesdeludedthroughassociationwiththeprincipal.Thissituation,inwhichpartnersaccept,supportandshareeachother’sbeliefs,hasbeencalledthepsychosis of association.Theassociateisusuallysociallydeprivedordisadvan-taged,mentallyorphysically.

Gralnick(1942),inareviewoftheEnglishliteratureonfolie à deux,subdividedtheconditionintofourpossiblerelationshipsbetweenprincipalandassociate.

■ Infolie imposée,thedelusionsofamentallyillpersonaretransferredtosomeonewhowasnotpreviouslymentally ill,althoughcharacteristically thevictimhassomesocialorpsy-chologicaldisadvantage.Separationofthepairisoftenfollowedbyremissionofsymptomsintheassociate.

■ Folie communiquéeoccurswhenanormalpersonsuffersacontagionofhisideasafterresist-ing them for a long time. Once he acquires these beliefs, he maintains them despiteseparation.

■ Infolie induite,apersonwhoisalreadypsychoticaddsthedelusionsofacloselyassociatedpersontohisown.

■ Folie simultanéedescribesasituationinwhichtwoormorepeoplebecomepsychoticandsharethesamedelusionalsystemsimultaneously.Ithasbeenconsideredthattheprincipalis always psychotic (Soni and Rockley, 1974), but the associate may or may not bepsychotic.

However,thevalidityofthisclassificationhasbeenquestioned.Itisalsonotofanyparticularclinicalvalue,andthepsychopathologicaldifferencesarequestionable(HughesandSims,1997).

Inacasereportofafamilyaffectedwithfolie à quatre(Simsetal.,1977),theinitiallyreferredpatient believed that a large industrial concern had put ‘bugging’ devices in the walls of his


brother’shouse.Heclaimedthatemployeesofthefirmhadbeenfollowinghimeverywhereandinterferingwithhisownhouse.Hiswifebelievedthis story initiallyandproducedsupposedlycorroborativeevidence.Ayearlater,followinghisin-patienttreatment,shenolongeracceptedtheplotandshebelievedherhusbandtobementallyill.ShewasaveryanxiouspersonwhohadpreviouslyreceivedpsychiatrictreatmentandcamefromafamilyinwhichthreemembershadsufferedfromHuntington’schorea.Whenthepatient’sbrotherwasvisitedathome,itwasfoundthathe, and the sisterwho livedwithhim,bothbelieved in theplot andwerebothcurrentlyreceivingtreatmentforaschizophrenicillnessinwhichfirstranksymptomswerepresent.

Folie à deuxdemonstrateshowthecontentofbeliefisdictatedbysocialandenvironmentalcircumstances,butthepreciseformofthesymptomsvariesaccordingtothenatureoftheillness.Thusthenon-psychoticvictimoffolie imposéewillshowdelusion-likeideas,overvaluedideasormisinterpretationsbutwillnotshow‘true’delusionsordelusionalpercept.

Aninterestingvariationonfolie imposéewasdescribedbyAldridgeandTagg(1998).Thiswasthecaseofa7-year-oldboywhohadpresentedwithspuriouspsychoticsymptomsinducedbylivinginisolationwithhismother,whosufferedfromschizophrenia.Initially,hewaswithdrawn,uncommunicativeandritualistic,withdelayeddevelopment.Atschool,hewasfearfuloftoysandteachers,crouchingunderatable,andwasritualisticconcerningtimekeepingandtoileting,duringwhichhewouldremoveallhisclothingandreverseintothetoilet.Hisonlyspeechwastorepeatthe clock time in a ritualistic way. Foster placement was made with a single mature woman,experiencedwithchildren,andafterayearthisabnormalbehaviourhaddisappearedandhehadmadeprogressconsistentwithhismilddegreeoflearningdisability.

DELUSIONS OF CONTROL

Thesedelusions,otherwiseknownaspassivityormadeexperiences,arediscussedwithdisorderofthinkinginChapter9.

The Reality of DelusionsThedegreetowhichdelusionsinfluencetherealityoftheworldinhabitedbyapatientismostprobablybestjudgedbyhowfarpatientsactontheirbeliefs.Patientswithschizophreniadonotalwaysactontheirdelusions,butquitefrequentlytheydo.AmanwhobelievedthatAmericanbattleshipsweresailingdownthemainstreetofBirmingham,UnitedKingdom(100milesfromthesea)hadtherefinedsocialconsciencetoreportthistothepolice!Personsholdingdelusionsof morbid jealousy are potentially very dangerous: extreme physical violence and murder notuncommonlyoccurinthiscontext.Thepatientwithdepressivedelusionsofguiltandunworthi-nessmaywellactonthembykillinghimself.

Althoughthereisagrowingliteraturecastingdoubtonwhetherdelusionsarefalsebeliefsornot(seeabove),whatisinescapableisthefactthatpatientsdooftenactonthecontentofthesebeliefs.Forpracticalpurposes,thecontentofadelusionisimportantbecauseityieldsinformationaboutthelikelybehaviourofapatient.Inotherwords,thecontentofdelusionsactstomotivatebehaviour,togivereasontoactionandtojustifyconduct;thatis,ithaspredictivepower.Forthisreasonalone,thecontentofdelusionisrelevanttoclinicalpractice.HemsleyandGarety(1986)havecommentedon‘thelackofactionconsequentwithapparentlysincerelyheldbeliefs’while,paradoxically, forensicpsychiatric studieshavegenerally foundthatpsychoticsymptoms,espe-ciallydelusions,arefrequentlyamajorfactorresultingintheoffence(Taylor,1985).Buchanan(1993)hasreviewedthedescriptionsofsituationsinwhichpatientsactontheirdelusions.Heconsidersthatforaffectiveillnesses,bothdelusionalbeliefandactionmaybeconsequentontheabnormalmoodstate.Inothercircumstances,actioncanbeseenasbeingcausedbyacombina-tionof‘belief ’and‘desire’triggeredbyfactorssuchas‘noticings’:beliefclearlyisinfluencedbyoccurrenceofdelusion;desirecorrespondstoconceptssuchasmotivation,driveandinclination;


noticingisinfluencedbytheperceptualandcognitivechangesofthepsychoticstate.Tayloretal.(1998) conclude for an investigation into violence in a high-security hospital population,‘assymptomswereusuallyafactordrivingtheindexoffence,treatmentappearsasimportantforpublicsafetyas forpersonalhealth’.Theconclusionhere is thatdelusions, likenormalbeliefs,donotnecessarily result in action.Theymaybe expressed yetnot influencebehaviour in anydiscernibleway.But,likenormalbeliefs,theymaymotivatebehaviourinawaythatiscompre-hensiblegiventhecontentofthebelief.

Ingeneral,violentbehaviourinresponsetodelusionsisnotcommon;however,inasampleof83consecutivelyadmitteddeludedsubjects, someaspectof theactionsofhalfof themwascongruentwiththecontentoftheirdelusions(Wesselyetal.,1993).Whenactingonthedelu-sionswasdescribedbythesubjectsthemselves, itwasassociatedwithbeingawareofevidencethat supported their belief and with having actively sought out such evidence; a tendency toreducetheconvictionwithwhichabeliefwasheldwhenthatbeliefwaschallenged;andwithfeelingsad,frightenedoranxiousasaconsequenceofthedelusion(Buchananetal.,1993).

Erroneous IdeationOVERVALUED IDEA

An overvalued idea is an acceptable, comprehensible idea pursued by the patient beyond theboundsof reason.It isusuallyassociatedwithabnormalpersonality.DisordersassociatedwithovervaluedideashavebeenreviewedbyMcKenna(1984),whosedefinitionofovervaluedidea‘referstoasolitary,abnormalbeliefthatisneitherdelusionalnorobsessionalinnature,butwhichispreoccupyingtotheextentofdominatingthesufferer’slife’.Itisovervaluedinthesensethatitcausesdisturbedfunctioningorsufferingtothepersonhimselfortoothers.Thebackgroundonwhichanovervaluedideaisheldisnotnecessarilyunreasonableorfalse.Itbecomessodomi-nantthatallotherideasaresecondaryandrelatetoit:thepatient’swholelifecomestorevolvearoundthisoneidea.Itisusuallyassociatedwithverystrongaffectthattheperson,becauseofhistemperament,hasgreatdifficultyinexpressing.

AccordingtoMcKenna,thetermwasintroducedbyWernicke(1906),whodistinguisheditfromobsession,inthatitwasnotexperiencedsubjectivelyas‘senseless’,andfromdelusion.Jaspersconsideredthatdelusionisqualitativelydifferentfromnormalbelief,witharadicaltransforma-tionofthemeaningattachedtoeventsandincorrigibletoanextentquiteunlikenormalbelief.An overvalued idea, on the contrary, is an isolated notion associated with strong affect andabnormalpersonalityandsimilarinqualitytopassionatepolitical,religiousorethicalconviction.ForJaspers(1959),then,overvaluedideasare‘convictionsthatarestronglytonedbyaffectwhichisunderstandableintermsofthepersonalityanditshistory’.Furthermore,Jasperssays,‘theyareisolatednotionsthatdevelopcomprehensiblyoutofagivenpersonalityandsituation’.Fish(1967)consideredtherewasfrequentlyadiscrepancybetweenthedegreeofconvictionandtheextenttowhichthebeliefdirectedaction.Butthepatientwithanovervaluedideainvariablyactedonit,determinedlyandrepeatedly; it isalmostcarriedoutwiththedriveofan instinct, likenestbuilding. In many respects, these definitions attempt to locate overvalued ideas somewherebetweennormalbeliefsanddelusions.Overvaluedideasdifferfromdelusionsinthattheyarisecomprehensiblyfromwhatweknowaboutthepersonandhissituation.Theyaremorelikepas-sionatepolitical,religiousorethicalconvictionsthannormalbeliefs.Thissuggeststhatthereissomethingabout the tenacityof the conviction thatdistinguishes theseovervalued ideas fromnormalbeliefs,yetthedegreeofconvictionandincorrigibilityisthoughttobelessthanthatofdelusions.Itisobvious,though,thatthedegreeofconvictionisnotasafebasisfordistinguishingbetweendelusionsandover-valued ideas.Asaferapproach is toregardovervaluedascompre-hensibleinthecontextofthepatient’shistoryandlife.


McKenna lists the disorders of content commonly associated with the form of overvaluedidea.ThesearerepresentedinTable8.1.Thepsychopathologyisnotanovervaluedidea inallcasesofeachoftheseconditions;forinstancemorbidjealousymaybedelusionalandhypochon-driasismayoccursecondarytodepressedmood.However,whenanovervaluedideaisfounditisusuallyassociatedwithabnormalpersonality.

Morbid jealousy isoftenmanifestedasanovervalued idea.Ahusbandwas terrifiedthathiswifewasbeingunfaithfultohimbecauseofhercasuallyflirtatiousconduct.Hecheckedonhereverymovement, interrogatedherrepeatedly,examinedherunderwear,employeddetectives tofollowherandmisinterpretedanyinnocentcontactshehadwithothermen.Onexamination,hewasnotdeluded,buttheimportanceheattachedtoinvestigatingandmaintaininghiswife’sfidelity, and the time taken to do this, was excessive, destroyed his family life and lost himhisjob.

The form of the abnormal idea in many of the disturbances of body image, for exampledysmorphophobiaisusuallyanovervaluedidea.Apersonwithparanoid personalitydisorderbecameinvolved in a protracted lawsuit because a farmer ploughed across a public right of way. It isreasonablethathikersgetannoyedwhenafootpathisdestroyed,butthispersontookreasonableirritationtoextremelengthsandconstructedamantraptoeliminatethefarmer.Hisenthusiasmforfootpathshadbecomeanovervaluedidea.

PARANOID IDEAS AND SYNDROMES

Inpsychiatry,thewordparanoidistakentomean‘self-referent’andisnotlimitedtopersecutorydelusions; all delusions aredelusionsof reference in that they relate to thepatienthimself.Apersonwillnotformadelusionalbeliefconcerningsix-inchmenonMarsunlesshehimselfissignificantlyimplicatedinsomeway.Soaparanoiddelusionisadelusionofself-reference,notnecessarilypersecutoryinnature.Aparanoidpersonalitydisorderisthattypeofabnormalper-sonality inwhichtheperson’sreactiontootherpeople isundulyself-referent;aparanoidstate(seeChapter19)includesthosementalstatesinwhichself-referentphenomenaareconspicuous,that is, delusion-like ideas of reference or overvalued ideas predominate. A patient, all of whosedelusionsaregrandioseinnatureandnoneofthempersecutory,maystillbesufferingfrompara-noidschizophrenia.

Althoughprimarydelusionsarecharacteristicofschizophrenia,secondarydelusions(delusion-like ideas)occur inanumberofconditions, forexamplebipolarmooddisorder inbothmanic

TABLE 8.1 ■ Disorders with overvalued ideas

Content of Disorder Abnormality of Personality Reference(s)

Paranoid state: querulous or litigious type

Jaspers (1959), Kraepelin (1905)

Morbid jealousy Ey (1954), Shepherd (1961)

Hypochondriasis Abnormality of personality is usually present with overvalued ideas in all these conditions

Merskey (1979), Pilowsky (1970)

Dysmorphophobia Hay (1970), Munro (1980)

Parasitophobia (Ekbom’s syndrome)

Hopkinson (1973)

Anorexia nervosa Crisp (1980), Dally (1969)

Transsexualism Huxley et al. (1981)

(After McKenna, 1984, with permission.)


and depressive phases, epilepsy and other organic psychosyndromes, acute drug intoxication,variousalcoholicstatesand,ofcourse,schizophrenia.Thetermparanoidoriginallywassynony-mouswithdelusionalinsanity.Kraepelin(1905)usedthetermmorespecificallytodescribethecondition inwhich therearedelusionsbutnohallucinations.Thepersonality,moodstateandvolitionofthepatient,inKraepelin’sdescription,arewellpreserved.

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139

C H A P T E R 9

Disorder of the Thinking Process

SummaryThinking and its processes are little understood. This means that abnormalities of thinkingcannotbeeasilyrelatedtoanyclearlydescribedalreadyestablishednotionofwhatnormalproc-essesareandhowabnormalprocessesdepartfromthesenormalprocesses.Inthischapter,fantasythinking,imaginativethinkingandconceptualthinkingaredescribed.Againstthisbackground,amodelofthinkingdependingontheassociationofideasandgovernedbyadeterminingprin-cipleisdescribed.Thisthenprovidesthebasisforadiscussionofabnormalitiesoftheformofthinking,aparticularlycomplexareaofpsychopathology,asitrequirestheabilitybothtofollowcloselywhatsomeoneissayingandalsotoconcludethatthesequenceofideas,ortheassociationof ideasmaybeawry. In thefinal section,Schneider’sfirst rank symptomsaredescribedwithexamples.

With time and years the individual becomes so lazy in public life that he is not even capable of writing any more. On such a sheet of paper, one can

squeeze many letters if one is careful not to transgress by one ‘square shore’. In such fine weather one should be able to take a walk in the woods. Naturally,

not alone, but with a girl. At the end of the year one always renders the annual accounting. The sun is now in the sky yet it is not yet ten o’clock.

Eugene Bleuler (1857–1939)

Thischapterisconcernedwithdisorderofthinking,andthenextchapterwithdisordersoflanguage.Thinking and thought processes are little understood. Although there is increasinginterestinthesubjectbycognitiveneuroscientists,theirprimaryfocusofstudymisseswhatisofinteresttotheclinicalpsychopathologist,namelythesubjectiveexperienceofthinking,particu-larly as it relates to abnormalities of thinking. Cognitive neuroscientists are interested in thenatureofproblemsolving;inthevariouskindsofreasoning,includinganalogical,inductiveanddeductive;andinthenatureoflogicandbeliefformation.Theseareallimportantsubjectsandcanbeimpairedinpsychiatricdisorders.However,theprocessthatmakestheseaspectsofthink-ing possible; the unique relationship of the subject to his own thoughts, the experience ofthoughtsflowingcoherentlyandtheeffortlessyetgoal-drivendimensionofthinkingthoughtsthatunderpinproblemsolvingandreasoning,ispoorlyunderstoodandresearched.Admittedly,itisdifficulttostudythesubjectiveaspectsofthinking,andmostlyoneisconcernedwithobjec-tivephenomenaofpsychiclife–whatJaspers(1962)calls‘performance’.

Therearetwodistinctaspectsinstudyingdisorderofthinking:thepatient’ssubjectiveaware-ness of his own disturbed thinking patterns and the manifestation of abnormal thinking hebetraysinhisspeech(Chapter10).Thislatteristheexpressionofthoughtanddetermineswhattheobservermaydeduceaboutthepatient’sthinking.Weneedtoenquirealsoabouttheexperi-ence of thinking in the patient’s description of his subjective psychological processes. Formal thought disorder,fromthesubjective,phenomenologicalstandpoint,isabnormalityinthemecha-nismofthinkingdescribedbythepatientintrospectingintohisownprocessesofthought;that

Keywords: Formal Thought Disorder, Circumstantiality, Concrete Thinking, PassivityExperience.

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is,thepatientdescribesinhisownwordsaprocessofthinkingthatisclearlyabnormaltotheoutsideobserver.

Types of ThinkingTheprocessofthinkingwasdividedbyFish(1967)intothefollowingthreetypes:

■ undirectedfantasythinking–dereistic–autisticthinking■ imaginativethinking■ rationalorconceptualthinking.These three types have slightly different implications for psychopathology, the description

andcategorizationofmorbidprocesses.Theycanbeconsideredasfunctionsofthinking;thatis,theyarethenecessarymechanismsforthinkingtotakeplacebutarenotthemselvesmanifestinthephenomena.Wecancontrastthosephenomena,whicharetheproductsoftheperformanceofthinking,theperceptortheidea,withthefunctionsthatdonotbecomeexplicit.

FANTASY THINKING

Thismaybeofshortduration,forexamplethedaydreambeforegoingtosleep,oritmaybecomeanestablishedwayof life. JaspersquotesMontaigne:‘Plutarchsaysofpeoplewhowaste theirfeelingsonguinea-pigsandpetdogs,thattheloveelementinallofus,ifdeprivedofanyadequateobject,willseekoutsomethingtrivialandfalseratherthanletitselfstayunengaged.Sothepsycheinitspassionspreferstodeceiveitself,oreveninspiteofitselfinventsomenonsensicalobjectratherthangiveupalldriveoraim’.

Fantasy has an important function in the way we all carry out our everyday activities,forinstancewemodelourspeechandbehaviourinimaginationbeforeanimportantencounteror event, and afterwards we rehearse our performance in fantasy to evaluate it and assesswhetherwecouldhavedonebetter (see Imaginative thinking). Inorder tobeable toharnessour imagination constructively,we require the capacity forundirected fantasy and the learnedskilltostructurethoughts.Fantasyalsoallowsapersontoescapefromordenyreality,oralter-nativelytoconvertrealityintosomethingmoretolerableandlessrequiringofcorrectiveaction.A girl aged 20, who had a very deprived childhood and walked the city streets at night as aprostitute,listenedtoavicarbroadcastingonlocalradio.Shestartedtosendhimandhiswifeflowers and cards, made contact with them and began to call them ‘Mum’ and ‘Dad’. Whenquestionedbythepoliceonenight,shegavetheirnamesasnextofkinandsaidtheyreallywereherparents.

Shy, reservedpeople,notsuffering frommental illness,mayusedereistic thinkingtocom-pensateforthedisappointmentsoflife.Bleuler(1911)sawthisisolationfromtherealworldintoautisticthinkingascharacteristicofschizophrenia:‘Theverycommonpreoccupationofyounghebephrenics with “the deepest questions” is nothing but an autistic manifestation’. Fantasy,especiallyinsomewithneurotictraits,maydevelopfromthestageofbeingdeliberateandspo-radic intoanestablishedmode;thepersoncomestobelievethecontentsofhis fantasy,whichbecomesubjectively realandacceptedas fact.Freud, inhis laterwritings,considered that thiswassoinsomeoftheaccountshereceivedfromwomenofanincestuousrelationshipwiththeirfatherduring childhood ( Jones, 1962).However, inhis earlywritingshehad considered thattheyhadexperiencedactualsexualassaultbuthadusedunconsciousmechanismstorepressthisknowledge(IsräelsandSchatzman,1993;Webster,1995).Varioustypesofexperiencecomeintothe category of acting out fantasy, such as pathological lying (pseudologia fantastica), hysterical conversionanddissociation(somaticandpsychologicaldissociativesymptoms)andthedelusion-like ideas occurring in affective psychoses.These last types can be understood as arising from thepatient’saffectiveandsocialsetting.

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Fantasyisusuallyunderstoodtobethecreationofimagesorideasthathavenoexternalreality.However,fantasythinkingmayalsorevealitselfinthedenialofexternalevents.Theobservationsfor which the psychodynamic explanation of ego defence mechanisms have been described arerelevantinthiscontext.Theslipofthetongue,orthe‘forgetting’oftheemotionallyladenwordisnotaccidental;itisaformofself-deception.Theobvious,significant,butunpleasant,objectofperceptionmaybe‘overlooked’,andthisoftenrevealsfantasydenial.Fantasythinkingdeniesunpleasant reality, even though the fantasy itself may also be unpleasant.This rearranging ortransformation of reality is shown by neurotic patients habitually and all people occasionally.Jonathan Swift commented on it thus: ‘When man’s fancy gets astride of his reason; whenimaginationisatcuffswiththesenses;andcommonunderstanding,aswellascommonsense,iskickedoutofdoors,thefirstproselytehemakesishimself ’(Swift,1667–1745).

IMAGINATIVE THINKING

Thetermimaginationcoverspsychologicalstatessuchasfantasy(seeabove),thegenerationofnovelideasandthecreativeoutputsthatconstituteartordiscoveriesinscience.Thereareatleastthreecomponentsofimagination:mentalimagery,counterfactualthinkingandsymbolicrepre-sentation.Mentalimageryreferstotheabilitytocreateimage-basedmentalrepresentationsoftheworld.Counterfactual thinkingrefers to thecapacity todisengagefromreality inorder tothinkofeventsandexperiencesthathavenotoccurredandmayneveroccur.Symbolicrepresenta-tionistheuseofconceptsorimagestorepresentrealworldobjectsorentities(Roth,2004).Thisis,ofcourse,thebasisoflanguage,artandmathematics.

A facetof this typeof thinking that comes fromapsychoanalytic theoretical stance is theconceptofmaternal reverie(Bion,1962).Themother,whileinthesituation,bothphysicalandmental,of ‘holding thebaby’ (Winnicott,1957),hasacapacity for reverieordaydreamingonthebaby’sbehalf;thisusuallyconcernsthefuturehappinessandachievementsofthebaby.Bionwouldregardthisasanecessaryfactorinthehealthydevelopmentoftheself-sensationofthebaby;whenmaternalreveriebreaksdown,forexampleinpuerperaldepression,thebabyexperi-encesthisasdistress.Theprocessofmaternalreverie isclearlyanalogousinsomewaystotheprayersofareligiouspersononanother’sbehalf.

RATIONAL OR CONCEPTUAL THINKING

Problemsolvingandreasoningaretwokeyaspectsofrationalthinking.Problemsolvingisdefinedasthesetofcognitiveprocessesthatweapplytoreachagoalwhenwemustovercomeobstaclestoreachthatgoal,andreasoningisthecognitiveprocessthatweusetomakeinferencesfromknowledgeandtodrawconclusions.Theseaspectsof thinkingaredistinctbutrelated,sothatreasoningcanbeinvolvedinproblemsolving(SmithandKosslyn,2007).Strategiesforproblemsinvolvetheuseofheuristics,thatis,rulesofthumbthatusuallygivethecorrectanswer.Typically,reasoninginvolvesanalogies,inductionordeduction.Analogicreasoninginvolvestheapplicationofsolutionstoalreadyknownproblemstonewproblemswithsimilarcharacteristics.Forexample,ifyoulosethekeystoyourlockedbriefcase,youcanapplytheknowledgetothisnewproblemthatsharp-endedimplementscanbeusedtoopenpadlocks.Inductivereasoningdependsontheuseofspecificknowninstancestodrawaninferenceaboutunknowninstances.Commonly,thisisformulatedasgeneralizingfromasingleinstancetoallinstancesorfromsomemembersofacategoryknowntohaveagivenpropertytootherinstancesofthatcategory.This isknownascategory-basedinduction.Anexampleis‘mycathasfourlegs’,therefore‘allcatshavefourlegs’.Deductive reasoning involves an argument in which if the premises are true, the conclusioncannotbefalse.This isusuallystudiedbywayofsyllogism:(a)allMartiansaregreen, (b)myfatherisaMartian,(c)myfatherisgreen.


Problemsolvingandreasoningbothrequirethecapacitytoformconcepts.Thisisthecapacityforabstraction,theabilitytotheorizeabouttheworld,anditincludesthecategorizationofobjectsoreventsintheworldandtheclarificationoftheconceptsthatdeterminethecategoryorclassunderinvestigation.

The Processes of Disordered ThinkingA MODEL OF ASSOCIATIONS BASED ON JASPERS

Inthismodelof thinking(psychologicalperformance), thoughts(psychologicalevents)canbeseentoflowinanuninterruptedsequencesothatoneormoreassociations,withresultingfurtherpsychologicalevents,mayarisefromeachthought.Thesequenceofthoughts,withtheassocia-tionslinkingthem,formstheframeworkofthismodel,whichisrepresenteddiagrammaticallyinFigure9.1.

Figure 9.1 Model of association.

Associations Associations Associations

Possible thought

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Possible thought

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Constellation

Thinks ashe sits ina room

must talkto A

I feelcold

uncomfortablechair

sort outaccounts

there is adraught

perhaps I'mdevelopingflu

put on apullover

I canhear adrip inthe roof

Get aladderandtake abucket


Themassofpossibleassociationsresultingfromapsychiceventiscalledaconstellation.Thereare an enormous number of possible associations, but thinking usually proceeds in a definitedirectionforvariousimmediateandcompellingreasons.Thisconsistentflowofthinkingtowardsitsgoalisascribedtothedetermining tendency( Jaspers).Theideaofassociationsisnotintendedtoimplythatonepsychologicaleventevokesanotherbyanautomatic,unintelligent,non-verbalreflex,butthatthethought,whichmaybeexpressedverballyornot,isaconceptthatresultsintheformationofanumberofotherconcepts,oneofwhichisgivenprominencebyoperationofthedeterminingtendency.Thismodelisconjecturalbuthassomevalueinallowingdescriptionoftheabnormalitiesofthinkingandspeechthatoccurinmentalillness.

Weare subjectivelyawareofour thoughtprocessbeinga streamoraflow.Todevelop themetaphor,thoughtsarecapableofaccelerationandslowing,ofeddiesandcalms,ofprecipitousfalls,ofincreasedvolumeofflow,ofblockages.Thisanalogyshouldnotbetakentoofar,asitiswithoutneurophysiologicalbasis,butitisusefulforexaminingcertainabnormalitiesandisbasedonsubjectiveexperience.

ACCELERATION OF THINKING

Accelerationofflowof thinkingoccurs as flight of ideas. In this, there is a logical connectionbetweeneachoftwosequentialideasexpressed.However,thegoalofthinkingisnotmaintainedfor long. It is continuously changing because of the effect of frivolous affect and a very highdegreeofdistractibility.Thedeterminingtendencyisweakened,butassociationsarestillformednormally.The speed of forming such associations, and therefore of the pattern of thought, isgrosslyaccelerated.ThisisdemonstratedinFigure9.2.

Here is anexampleof suchflightof ideas froma femalemanicpatientaged45.She said,‘TheythoughtIwas in thepantryathome…Peekaboo…there’samagicbox.PoordarlingCatherine,youknow,CatherinetheGreat,thefiregrate,I’malwaysupthechimney.Iwanttoscreamwithjoy…Hallelujah!’Discussingthetranscriptofthisconversationwhenhermentalstatehadimproved,thepatientfounditquiteeasytopointoutthelogicalbridgesinherthinkingbetweeneachpairofstatements,buttherewasnosenseofbuildingupanargumentfromthefirsttothefinalstatement.

Markedlydifferentfromthemanicflightofideaswithpressureofspeechandmultiplebutlinkedassociationsistheconfusion psychosisdescribedbyFish(1962).Inthis,thinkingisdisor-deredwhilemoodandpsychomotoractivityareunimpaired.Intheexcitedformofthis,incoher-entpressureofspeechisprominent,thecontextofwhichisoutofkeepingwiththesituation.Theremaybetransient,almostplayful,misidentificationsofpeople;fleetingideasofreference;and auditory hallucinations. In the inhibited state of confusion psychosis, there is poverty ofspeech, almostmutism.Theremay alsobeperplexity, ideas of reference, ideas of significance,illusionsandhallucinations–auditory,visualorsomatic.Thisisusuallyacycloidpsychosisinitspresentation,andotherfeaturesofmanic-depressivepsychosismaybepresent.

Figure 9.2 Abnormal flow of thinking: flight of ideas.

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RETARDATION

Inretardation(suchasoccursindepression),thinking,althoughgoal-directed,proceedssoslowly,withsuchmorbidpreoccupationwithgloomythoughts,thatthepersonmayfailtoachievethosegoals.Thepatientislikelytoshowlittleinitiativeandtobeginneitherplanningnorspontaneousactivity.Whenaskedaquestion,hewillponderoverit,butasnothoughtcomestohimhemakesnoresponse.Eventually,afterconsiderabledelay,theanswerusuallycomes.Hehasdifficultyinmakingdecisionsandinconcentration;thereislossofclarityofthoughtandpoorregistrationofthoseeventsheneedstoremember.Intermsofthemodeloftheflowofthinking,inretarda-tionthereisapovertyintheformationofassociations;seeFigure9.3.

Depression,althoughusuallyassociatedwithretardationofthought,mayoccurwithagitation;theremaybeacomplexsituationwithimpairedconcentrationfromretardationandasubjectiveexperienceof restless, anxious thoughts.Thus,Sutherland (1976), amiddle-agedpsychologistdescribinghisownmentalillness,said,

I contemplated throwing myself off the cross-Channel ferry… We arrived in Naples… and my friends… were upset by my condition while feeling

powerless to help… whilst the others sat at the table I rolled around moaning in the dust. I revisited many of the places I had once loved: the Museo

Nazionale with its magnificent mosaics pillaged from Pompeii, Pompeii itself and Capri. None of them evoked a spark of interest – I stared listlessly and

uncomprehendingly at the pictures in the museum with harrowing thoughts still racing in my mind. I could not guide the children round Pompeii, since I could not concentrate sufficiently to follow the plan. Capri had lost its beauty

and charm. I could not even giggle at the vulgarity of the interior of Axel Munthe’s villa, though the beauty of the formal garden and the magnificent

view of the island and the sea from the belvedere evoked a slight response. The phrase ‘see Naples and die’ echoed through my mind: I was convinced I

would never return alive to England, let alone ever revisit Naples.

ThispossiblecombinationofdepressedaffectandacceleratedactivitycanbeseentoconformquitereadilywithKraepelin’s(1904)descriptionofmixed affective states.

CIRCUMSTANTIAL THINKING

Inbothflightofideasandretardation,affectinfluencesthespeedofthinking:itdictateswhichideatakesprecedenceandcanalsodistortjudgement.Incircumstantial thinking,theslowstreamofthoughtisnotimpededbyaffectbutbyadefectofintellectualgrasp,afailureofdifferentiationofthefigurefromground.Characteristically,thisoccursinpatientswithepilepsy,anditisseeninotherorganicstatesandinmentalretardation.Asomewhatsimilarprocessoccurswithobses-sional personality, but here the excess of detail is introduced anxiously to avoid any possibleomissions: i ’s are dotted, t ’s crossed to such an extent that the process of reaching a goal is

Figure 9.3 Retardation.

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substantiallyimpaired.Onbeingaskedaquestion,circumstantialthoughtisshownbythepatientinareplythatcontainsagreatwelterofunnecessarydetail,obscuringandimpedingtheanswertothequestion.Allsortsofunnecessaryassociationsareexploredexhaustivelybeforethepersonreturns to the point. His whole conversation becomes a mass of parentheses and subsidiaryclauses.Heevenhas to explain andapologize for thesedigressionsbeforehe cangetback tomovingtowardsthegoal.However,thedeterminingtendencyremains,andhedoeseventuallyanswerthequestion.Thisisacaseofnotbeingabletoseethewoodforthetrees.CircumstantialthinkingisrepresenteddiagrammaticallyinFigure9.4.

INTERRUPTION TO THE FLOW OF THOUGHT

There are many ways in which the continuity of flow of thinking may be disturbed. CarlSchneider (1930) has described some of these abnormalities: verschmelzung (fusion, literally‘melting’), faseln (muddling), entgleiten (snappingoff ), entgleisen (derailment).Theseprocesses(andothers)occurtogethertogivethepatientafeelingofconfusionandbewilderment.Heislikelytocomplainoffeelingbemused,tobelackinginconcentrationandtobeslightlyappre-hensiveofheknowsnotwhat.Hecannotpreciselydescribehisalteredthinkingandconsequentchangesinspeech.

Inderailment(Figure9.5),thereisabreakdowninassociationsothatthereappearstobeaninterpolationofthoughtsbearingnounderstandableconnectionwiththechainofthoughts:‘Thetrafficisrumblingalongthemainroad.Theyaregoingtothenorth.Whydogirlsalwaysplaypantomimeheroes?’Suchanexcerptfromthespeechofapatientwithschizophreniacontainsnomeaningfulconnections,eventothepatienthimself.Withderailment,thesubjectisunabletolinktheideasanddescribesachangeinhisdirectionofthinking.

With fusion, there is some preservation of the normal chain of associations, but there is abringingtogetherofheterogeneouselements.Theseformlinksthatcannotbeseenasalogicalprogression fromtheirconstituentorigins towards thegoalof thought.A femalepatientwithschizophrenia,aged38,wroteasfollows.

Figure 9.4 Model of circumstantial thinking.

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Two men are controlling the brain through telethapy [sic] or by means of ways of the spirit who open and closes the back channels of my brain releasing

words and holding back the truth, by no means will I speak but will answer only to written questions by means of writing, knowing full well the channels

of my brain is filtering and only half of what is the truth, also I knowing I am being read not only by a few but many very clever people but not at all acceptable they make people believe that I am some kind of miracle which I

am not, I only hold the name Holyland which came to me by marrying Alfred Holyland, only by doing this do they wish to make some false stories of me

coming from some special place which I have not.

Fusion is demonstrated at the beginning of this excerpt, where she says that the brain iscontrolled‘bymeans’andthenthiswordbecomesassociatedwith‘ways’.‘Telethapy’–notthesameastelepathy–isaneologism.Therearealsoexamplesofpassivity.‘Channels’and‘means’areusedasstockwords,thatis,theyareusedmoreofteninherconversationthantheirnormalmeaningcouldsuggest,andtheytakeonforheragreaterrangeofmeaningthanusual.Itisdif-ficulttorepresentthisdiagrammatically,andIhopetheresultinFigure9.6isnotmisleading.

Schneider’smixingormuddlingimpliesagrosslydisorderedamalgamoftheconstituentpartsofasinglethoughtprocessandrepresentsextremedegreesoffusionandderailment.Theresultantspeechdisorderhasbeencalleddrivelling.

Thought Blocking

Snapping off is the experience apatientwith schizophreniahas ofhis chainof thought, quiteunexpectedlyandunintentionally,breakingofforceasing.Itmayoccurinthemiddleofsorting

Figure 9.6 Model of fusion.

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Figure 9.5 Model of derailment.

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outaproblemoreveninmid-sentence.Itisnotcausedbydistractionbyotherthoughtsand,onintrospecting,thepatientcangivenoadequateexplanationforit;itsimplyoccurs.Itisotherwisedescribedasthought blocking,asomewhatmisleadingterm.Thepatientmayexplainitasthought withdrawal:‘Mythinkingstoppedbecausethethoughtsweresuddenlytakenoutofmyhead’.Figure9.7showsamodelofthoughtblocking.

CHANGES IN THE FLOW OF THINKING

Twofurtherabnormalitiesoftheflowofthoughtarecrowding of thoughtandperseveration.Crowding of thoughtoccursinschizophrenia.Thepatientdescribeshisthoughtsasbeingpas-

sivelyconcentratedandcompressedinhishead.Theassociationsareexperiencedasbeingexces-siveinamount,toofast,inexplicableandoutsidetheperson’scontrol.Thepatientmayevenlocatehisthinkinganatomicallyasbeing‘crowdedintothebackofmyhead’orelsewhere.Itbecomesaheadlongchaseordanceofthoughtsandhassomeofthecharacteristicsofflightofideas,butitalsoshowsaschizophrenicqualityofpassivity,beingcontrolledfromoutside.

Perseveration (Chapter 5) ismentionedhere as a disturbanceof theflowof thinking. It ischaracteristicallyanorganicsymptom.Thepatientretainsaconstellationofideaslongaftertheyhave ceased to be appropriate. An idea from that constellation which occurred in a previoussequenceofthoughtisgiveninanswertoadifferentquestion.Inperseveration,acorrectresponseisgivenbythepatienttothefirststimulus,forexample‘Wheredoyoulive?’–‘RowleyRegis’.However, any subsequent stimuli that demanddifferent responsesmayget this same, bynowinappropriate,firstresponse,forinstance‘WhatisthecapitalofFrance?’–‘RowleyRegis’,‘Wholivesathomewithyou?’–‘Rowley…mysonandhiswife’.

Disturbance of JudgementA judgement is a thought that expresses a view of reality.The word is used here in the senseof ‘in my judgement, such and such takes place’. To assess whether it is disturbed or not,oneneedstomeasureitagainstobjectivefact.Thiscanbedifficult,perhapsrequiringconsulta-tionwithanexpertinthesamefieldasthepatient.Assessmentoffaultyjudgementisnotmadesolelyonthebasisofthatparticularbelieforargumentbutontakingthewholeoftheperson’sbehaviourandopinionsintoaccount.Aman’sclaimstobeafigureofroyaltypersecutedbytheMarxists could, in fact, be true. But the opinion that his judgement was disturbed would beconfirmedifhehadsuddenlybecomeconvincedabouthisroyaltywhenapsychiatricnursehadcommentedtohimaboutthetattoosonhisarm,orifhewerealsofoundtobehoardingpebblesand dead spiders in an old tobacco tin. Delusions are, of course, a disturbance of judgement.Various forms of thought disorder and intellectual deficit may also result in disturbance ofjudgement.

Figure 9.7 Model of thought blocking.

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DISTURBANCE OF JUDGEMENT AND DELUSION

Thethinkingorpsychologicalperformancerequiredtoproduceadelusionisquiteindependentofintelligence.Itoccurs inclearconsciousnesswithnosignsoforganicdisturbanceofthebrain.Judgementinotherareasoflifeapartfromthedelusioncanbepreserved,andtheveryingenious-nessthepatientusestoexplainanddefendhisdelusionalbeliefdemonstratesthathisessentialcapacitytothinklogicallyislargelyintact;onlythefalselyheldbelief,thefalsepremiseforsubse-quentbeliefsappearsdisordered.Adelusion,inschizophrenia,isnotasimpledefectofreasoning;itsdevelopmentcannotbeunderstoodsolelyinrelationtothepatient’sreallifeexperience.Forinstance,notallthosewithdelusionsofpersecutionhaveanyfirsthandexperienceofbeingperse-cuted.It isanassumptionabouttheworldthepatientinhabits,whichhedoesnotcreatebyaprocessoflogicalconsciousthoughtbutfromfalsepremises.Themechanismunderpinningtheoftenspontaneousdevelopmentofthisfalsepremiseisyettobeunderstood.Thestartingpointsofthethinkingarealready‘deluded’,andthepatientapplieslogictoelaborateandsupporthisbelief.

Wecanunderstandwhythebeliefshouldbewithinthatparticularcontext(associatedwithhismother; relatedto interplanetarytravel),butwecannotexplainhowthe formofaprimarydelusionshouldhaveoccurred.Thisisafundamentaldistinctionfromdelusion-likeideas(sec-ondarydelusions),whichoccur,forexample,inaffectivepsychoses.Inthelatter,wecanseethecontentbeingprogressively influencedbythechangingmoodstatesothat,eventually,thefalsebeliefbecomesalogicaldevelopmentfromtheextremeabnormalityofmood.

Althoughitisusualtodescribedelusionsasdisordersofthoughtcontent,itisimportanttobeawarethatprimarydelusionsarenotmerelytobeunderstoodinthisway.Thewholeprocessof thought inprimarydelusion isdisordered,not just the content. If an ideawere formedondelusionalgrounds–‘IknewthatmywifewasunfaithfulimmediatelyIsawthebulbhadgoneout’(Chapter8)–butthenotionitselfwasnotfalsenorunacceptabletotheperson’speergroup(his wife subsequently admitted to being unfaithful), it would still be a delusion because thenotionwasformedondelusionalevidence.Thereisadifferencebetweendelusionandovervalued ideasinthat,althoughbothmaybeheldwithabsoluteconviction,thelatterisareasonable,pos-siblyeventrue,beliefbutisdominatingconsciousthoughttoanunreasonableextent.

CONCRETE THINKING

Abnormalprocessesofthinkinginschizophreniaandorganicstatesmayresultinaliteralnessofexpressionandunderstanding.Abstractionsandsymbolsareinterpretedsuperficiallywithouttact,finesseoranyawarenessofnuance; thepatient isunable to freehimself fromwhat thewordsliterally mean, excluding the more abstract ideas that are also conveyed.This abnormality isdescribedas concrete thinking.The termwasfirst introducedbyGoldstein (1936). It isusuallytestedforbyproverbinterpretationorbyotherpsychologicaltests,butitiswellacknowledgedthatthesetestsareunreliable.However,itisrecognizableclinically,oftenquitedramatically.Forexample, a femalepatientwith schizophrenia came into the roomfor interviewandpromptlytookhershoesoff,saying,‘IalwaysliketokeepmyfeetonthegroundwhenI’mtalking’.Anotherpatient with long-term schizophrenia was observed by his doctor walking sideways along thehospitalcorridor.Whenaskedwhyhewaswalkinglikethat,hesaidthatitwas‘becauseofthesideeffects’.Andanotherpatientsaid,‘IwasstartingtofeelhighandIdidn’twanttoflyoff,soI’vetiedthesedumb-bellweightsroundmyankle’.

Itisimportanttoemphasizethoughthat,despitethecompellingexamplesofconcretethink-ing above, current thinking is that if anything patients with schizophrenia are more likely tosubscribe toamoreabstract attitude thancontrols (Weiner,1966;Shimkunas,1972;Cutting,2011), so that for examplewhenasked‘inwhatway is a table anda chair alike?’ thepatientsmightanswer‘objectsintheuniverse’.


PSYCHOLOGICAL THEORIES OF THINKING IN SCHIZOPHRENIA

Thereareanumberofpsychologicaltheoriesthatattempttoexplainthinkinginpatientswithschizophrenia.These theories are hampered by the fact that there are no satisfactory generaltheoriesofthinking.Therearenowconsistentfindingsofdeficitsinattention,workingmemory,recognitionmemoryandexecutivefunctionsinschizophrenia.Theseempiricalfindingsareyetto be integrated into a coherent theory that explains the observed and self-reported thinkingabnormalitiesinthiscondition.

Over-Inclusive Thinking

Thedifferencebetweentheconcretethinkingoforganicpsychosyndromesandthatoccurringinschizophrenia was described by Cameron (1944), who considered that in schizophrenia thepatientisunabletopreserveconceptualboundaries.Thishecalledover-inclusive thinking:ideasthatareonlyremotelyrelatedtotheconceptunderconsiderationbecomeincorporatedwithinitinthepatient’sthinking.Thus,whenasked‘Whatofthefollowingareessentialpartsofaroom:walls,chairs,floor,awindow?’,theover-inclusivepersonwithschizophreniamightinclude‘chair’.This featureofover-inclusivenesscanbe seen inmanyaspectsof schizophrenic thinking,andquestionnaireshavebeendevisedto test for it,particularly involvingsorting tests.The lackofadequateconnectionbetweentwoconsecutivethoughtsiscalledasyndesis.

The concrete thinking of schizophrenia, however, could not be distinguished from that ofotherpsychoticandneuroticpatients(Payneetal.,1970),anditwasfoundtobeassociatedwithintelligence.Over-inclusivethinkingoccurredonlyinabouthalfofthepatientswithschizophre-niatested,usuallythosewhoweremoreacutelyill.Theotherhalf,usuallysufferingfrommorechronicillness,showedmuchmoremarkedretardation.McGhie(1969)foundthatPayne’stestsofover-inclusivenessdidnotselectschizophreniafromsomeotherdiagnoses,forexamplethosewithobsessionalormanicthoughtdisorder,andGathercole(1965)consideredthatthesetestsdemonstratedfluency of associationratherthanover-inclusivethinking.

Ayoungman,whohadsufferedfromschizophreniaforseveralyears,wasknowntohavebeenabusingdrugs recently.To thedoctor’senquiry‘Whatdrugshaveyoubeenusing?’,he replied‘LSD,health foodsandmarijuana’.This isanexampleofover-inclusive thinking.However, itwasvolunteeredspontaneously;hemightwellhavegivenanentirelycorrectresponsetoaformalquestionnairethatdidnottouchonsignificantareasofhisexperience.

IthasbeensuggestedbyChenetal.(1995)thattheremaybeabroadening of category boundary(forexample‘furniture’)withpreservationofinternalcategorystructureinpatientswithschizo-phrenia.Thisresults inrelated issuesthatareactuallyoutsidethecategorybeingprocessedbythepatientinawaythatissimilartothosewithinit.Cutting(2011)arguesthatwhatismostprominentisthatpatientswithschizophreniaovercategorize,findingmanymoreandoftenneed-lesscategoriestosubsumelistswithin.

Aggernaes(Aggernaesetal.,1976)hastakenthistheoryfurtherfromthepracticalandclinicalviewpoint.Heconsidersthatpatientswithschizophreniahavenotpartedfromreality;theyseemtoexperiencetherealworldasbeingrealinthesamewayasnormalpeopledo.However,theirdefectinrealitytestingresultsfromadiffusetendencytoexperiencesomefantasyitemsasbeingrealtoo.

Schizophrenic Inattention and Abnormality of Working Memory: Effect on Performance

McGhie(1969)hasconcentratedonthedisturbanceinthefunctionofattentioninschizophrenicpatients: that they are unable to filter and discount sensory data irrelevant to the task beingperformed.Heshowedthattheperformanceofschizophrenicpatientswasverypoorcomparedwiththatofnormalsubjects,buttheywerenotpronetodistractionbyauditoryorvisualexternal


stimuli in the way that normal people were. Hebephrenic patients especially showed lessdistractionandalsopoorperceptionandrecallofvisualinformation.Hebephrenicpatientswereconsideredtohavean:

inability to sweep out irrelevant extraneous information… especially where the situation demanded the rapid processing and short term storage of

information. This experience is described subjectively: ‘When people talk to me now it’s like a different kind of language. It’s too much to hold at once. My

head is overloaded and I can’t understand what they say. It makes you forget what you’ve just heard because you can’t get hearing it long enough. It’s all in

different bits that you have to put together in your head – just words in the air unless you can figure it out from their faces.’

TheeffectofthisinattentioninordinarysociallifewaswellobservedbyMorgan(1977)inhisdescriptionofthreeweekslivedincloseproximitytotwochronicschizophrenicpatients:

In the case of Vine our relationship remained just the same, but I did perhaps come to understand his disabilities a little better, and this helped. He would

keep ‘losing his thread’, to some extent in talk but even more noticeably in action. For example, although we went through the sequence of routine tests over 500 times together, he never once completed a sequence without having to be reminded of what came next and what remained to be done each time.

Vine’s other main trouble was a curious one. I would say to him, for example, ‘Let’s do the tests first and then I’d like you to get on with the washing up’,

and I would be surprised when his response to this was to dash off to the sink and start clattering the plates. Eventually I made out that he had some defect of attention. He would often jump like a startled rabbit when he realized he was being addressed anyway, and I think that by the time he had recovered

and collected himself from that, the first half of my sentence had gone and all he heard was the second half. Certainly I found that by inserting a little

preliminary padding, I got a more competent response.Frith(1992)hypothesizesthatthemechanismfordelusionsofcontrolwasalsoresponsible

forthethoughtorlanguageabnormalityinschizophrenia.Inthisscheme,itisafailureofself-monitoring that is responsible for thoughtor languagedisorder.Thus thepatient isunable toeditoutirrelevantorperseveratingphrases,andthisresultsinpoorcommunication.Thereisalsotherelatedpossibilitythatthefundamentalproblemisinplanning.Inthisscheme,thecoherenceofthepatient’sthoughtorlanguageisunderminedbytheabsenceofanexplicitgoalandplan,andfurthermorethereisintrusionofthoughtsthatdonotfitinwiththeoverallgoal,resultingindisorganizedthoughtorlanguage.Insummary,patientswithschizophrenia‘areonlyabletochecktheaccuracyofanutteranceafter[emphasisinoriginal]theyhavemadeit.Itisthereforedifficultforthemtoavoidproducingastringoffaultyutterances,evenduringattemptsatrepair’(Frith,1992).

Liddle (2001) defines the disorganization syndrome as consisting of disjointed thought,emotionandbehaviour.Butthecardinalsymptomsare formal thoughtdisorder, inappropriateaffectandbizarre,erraticbehaviour.Heconcludesthatdisorganizationisassociatedwithslowedperformance inneuropsychological tasks thatdemand selectionbetweencompeting responses,orwitherrorsofcommissionintasksthatrequiresuppressionofaninappropriateresponse.Inhisview,thissuggeststhatthedisorganizationfoundinschizophreniaderivesfromimpairmentoftheneuralcircuitsresponsibleforresponseselectionandinhibition.Thecircuitsinvolvedare


theventrolateralfrontalcortex,theleftsuperiortemporalgyrusandtheadjacentinferiorparietallobule.Thereisalsoinvolvementoftheanteriorcingulateandthalamus.

Disorder of Control of ThinkingUnderthisheading,wecoulddiscussthreedifferentpatternsofthinking:passivityofthought,or delusions of control of thinking; obsessions and compulsions, in which the unacceptablethoughtsareacceptedby thepatientasbeingunderhiscontrolbutare resisted;andthe rigidcontrolof thought and intolerance for variation thatbecomeshabitualwith the anankasticorobsessionalpersonality.ThelattertwowillbeconsideredinChapter19.

DELUSIONS OF THE CONTROL OF THOUGHT

Controlofthinkingmaybedisorganizedinthatthepatientascribeshisown,internalthoughtprocessestooutsideinfluences.Thesubjectivedisturbanceinthinkinginschizophreniaisexpe-riencedaspassivity.Theschizophrenicexperienceshisthoughtsasforeignoralien,notemanatingfrom himself and not within his control.There is a breakdown in the way he thinks of theboundarybetweenhimselfandtheoutsideworld,sothathecannolongeraccuratelydiscriminatebetweenthetwo.Hemaydescribepassivityofthought,thoughtwithdrawal,thoughtinsertionand/orthoughtbroadcasting;thesearefirst rank symptomsofschizophrenia(Schneider,1959).InTable9.1,thefirstranksymptomsarelisted.

Various forms of thought passivity are described. The patient may describe sharing histhoughtswithotherpeople:his thoughtsbeingcontrolledor influenced fromoutsidehimself.

TABLE 9.1 ■ First rank symptoms of schizophrenia and symptoms from the Present State Examination

First Rank SymptomaEquivalent Symptom from the Present State Examinationb

Delusion

Delusional percept Primary delusion

Auditory hallucinations

Audible thoughts Thought echo or commentary

Voices arguing or discussing Voices about the patient

Voices commenting on the patient’s action Voices about the patient

Thought disorder: passivity of thought

Thought withdrawal Thought block or withdrawal

Thought insertion Thought insertion

Thought broadcasting (diffusion of thought) Thought broadcast or thought sharing

Passivity experiences: delusion of control

Passivity of affect (‘made’ feelings) Delusions of control

Passivity of impulse (‘made’ drives) Delusions of control

Passivity of volition (‘made’ volitional acts) Delusions of control

Somatic passivity (influence playing on the body) Delusions of alien penetration

aSchneider (1959), bWing et al. (1974).


Thesedelusions of controlareoftenassociatedwithdelusionalexplanationsofhowhisthinkingcould be controlled, for example electronic devices, computers, telepathy. Thought insertion isdescribed,inwhichhebelievesthathisthoughtshavebeenplacedtherefromoutsidehimself.Correspondingly,hemaydescribehisthoughtsbeingtakenawayfromhimselfagainsthiswill:thought withdrawal.Thismaybegivenasanexplanationforthoughtblockingwhenthethoughtsstopandthemindsuddenlygoescompletelyblank.Thoughtinsertionandwithdrawalarefirstranksymptomsofschizophrenia.Thought blockingisnot,asitisdifficulttodecidewhetheritistrulythoughtblockingorsomeformofretardationorotherdifficultywiththinking,andblockingis also subjectively similar to epileptic absences. Thought broadcasting occurs in schizophreniawhenthepatientdescribeshisthoughtsasleavinghimselfandbeingdiffusedwidelyoutofhiscontrol.Italsoisapassivityexperienceandoffirstrank.

Afurthersubjectivesymptomassociatedwiththought,offirstrankimportance,istheexperi-enceofaudible thoughts:hearingone’sownthoughtsoutloud.Thepatientknowsthattheyarehisthoughts,yethehearsthemaudiblywhileheisthinkingthem,justbeforeorjustafter.Thisisofcourseadisorderofperception,anauditoryhallucination(Chapter7).

Wehavediscussedearlierinthechapterfusion,mixing,derailmentandcrowdingofthought,all of which occur in schizophrenia.The resultant confusion causes a loss of ability to thinkclearly,oftendescribedintermsofpassivity.Thepatientmayfeelthathisbrainisreplacedbycottonwoolorconvolutedrubber.Histhoughtsarejumbled,muzzy,vague,blurred:‘Itrytopartmywaythroughthembuttheyareliketreacleandkeeponcomingbackandmakingmestick’.

First Rank Symptoms of Schizophrenia

Firstranksymptomsofschizophreniaarediscussedinthissectionforconvenience,sincemanyofthemareexamplesofdisorderofcontrolorpossessionofthoughts.AccordingtoSchneider,thepresenceofoneormorefirstranksymptomsintheabsenceoforganicdiseasecanbeusedaspositiveevidenceforschizophrenia.Thesesymptomsoffirstrankarenotacomprehensivelistoftheclinicalfeaturesofschizophrenia,forthechangesinaffect,volitionandmotoractivitythatmayoccurintheconditionarenotincludedatall,andmanyothertypesofdelusion,hallucina-tionanddisorderofthinkingoccuralsoinschizophrenia.Forasymptomtoberegardedasfirstrank,itmusthavethefollowingcharacteristics.

■ Itmustoccurwithreasonablefrequencyinschizophrenia.■ Itmustgenerallynotoccurinconditionsotherthanschizophrenia.■ Itmustnotbetoodifficulttodecideifthesymptomisorisnotpresent.There are some symptoms that occur only in schizophrenia but occur too rarely to be of

practicaluseasfirstranksymptoms.Therearemanyfeaturesthatarecharacteristicofschizo-phreniabutmayalsooccurinotherconditions,forexampleunspecifiedauditoryhallucinations,povertyofaffect,over-inclusivethinking.Therearesomesymptomsthatoccuronlyinschizo-phrenia, but there is too much scope for argument as to whether it is, or is not, this precisesymptomforittobevaluedasoffirstrank.Anexampleofthisisaprimary delusion.Someclini-ciansmayregardaparticularbeliefofthepatientasprimarydelusion,whileothersdonot.

Althoughfirstranksymptomsareusedasadiagnosticchecklist,apatientwhoexhibitssevenofthemisnotmoreseverelyillthansomeonewhoshowsthree.Toelicitthemrequiresconsider-ableclinicalexperience; theycannotbecollectedquantitativelybyridingpast thepatientonabicycle!For apsychiatrist touse themclinically, shemustfirst know them.Second, shemustknowhowthispersonfromthissocialandracialbackgroundislikelytodescribeanyparticularfirstranksymptom(‘mythoughtsarecontrolledby…television,by…thespiritsofmydeadancestors’).Third,shemustasktheappropriatedirectquestionsskilfully,withoutputtingwordsinherpatient’smouth.Fourth, shemustbeable to interpret thepatient’sanswersanddecidewhetherafirstranksymptomisbeingdescribed.ThewholeprocessrequiresadextroususeofthephenomenologicalmethodasdescribedinChapter1.


Therearemanypractisingpsychiatristswhosecommentatthisstageofthediscussionoffirstranksymptomswouldbe‘Whybother?’Theywouldalsoagreethatitisoftendifficulttodiagnoseschizophrenia; that it is importantnottogivethis labeltopeoplewhodonotsufferfromtheillness;andthatitisequallyimportanttotreatthosewhodosufferfromitappropriately,effec-tivelyandasearlyinthecourseofillnessaspossible.

In clinical practice, the eliciting of first rank symptoms could best be seen as a means ofdecidingthedegreeofcertaintythatmaybeattachedtothediagnosis.Inapatientwhoshowsthegeneralfeaturesofschizophrenia(delusion,hallucination,thoughtdisorder,disorderedaffect,volition,motor activity, behaviour, social relationships, life history), thediagnosis ismadebutsome doubts remain. If first rank symptoms are found then, in the absence of clear organicpathology,onecanreckonthatthediagnosishasbeenconfirmed.Someofthefirstranksymptomsarefoundtobelessreliableatfollow-upthanothersasindicatorsofschizophrenia,forexamplevoicesheardarguing (Melloretal.,1981).Oneof theadvantagesoffirst rank symptomsasadiagnostictoolisthat,becauseoftheiremphasisonformratherthancontent,apersonwhoisfeigningmental illness isunlikely toproduce them.They thereforehave a subsidiaryuse as amethodofdistinguishingbetweentrueandsimulated psychosis,forexampleinprisoners.Despitethe value of first rank symptoms indicating schizophrenia when they are present, there areundoubtedlypatientsinwhomtheycannotbeelicited;schizophreniastillremains,tosomeextent,adiagnosisofexclusion(CarpenterandBuchanan,1994).

Examples of First Rank Symptoms

Theonlytypeofdelusionthatisregardedasoffirstrankisadelusional perception,thatis,anormalperception delusionally interpreted and regarded as being highly significant to the patient(Chapter8).Examplesofdelusionalpercept, andofotherfirst rank symptomsas follows, arecitedbyMellor(1970).Delusionalperceptisexemplifiedinthefollowingaccount.

A young Irishman was at breakfast with two fellow lodgers. He felt a sense of unease, that something frightening was going to happen. One of the lodgers

pushed the salt cellar towards him (he appreciated at the same time that this was an ordinary salt cellar and his friend’s intention was innocent). Almost before

the salt cellar reached him he knew he must return home, ‘to greet the Pope, who is visiting Ireland to see his family and to reward them… because Our Lord is going to be born again to one of the women… And because of this they (all the

women) are all born different with their private parts back to front.’(p. 18)

Threetypesofauditoryhallucinationsareregardedasbeingoffirstrank.Theseareaudible thoughts, voices heard arguingandvoices giving a running commentary.Whatismeantbyaudible thoughtsisthepatient’sexperienceofhearinghisownthoughtssaidoutloud.InBritishusage,thesymptomsometimescarriesitsGermanname,Gedankenlautwerden,oritsFrenchone,écho de pensées.Thepatientmayhearpeoplerepeatinghisthoughtsoutloudjustafterhehasthoughtthem,answeringhisthoughts,talkingaboutthemhavingsaidthemaudiblyorsayingaloudwhatheisabouttothinksothathisthoughtsrepeatthevoices.Heoftenbecomesveryupsetatthegross intrusion intohisprivacyandconcerned thathecannotmaintaincontrolof anypartofhimself,notevenhisthoughts.

A 35-year-old painter heard a quiet voice with ‘an Oxford accent’, which he attributed to the BBC. The volume was slightly lower than that of normal

conversation and could be heard equally well with either ear. He could locate


its source at the right mastoid process. The voice would say, ‘I can’t stand that man, the way he holds his hand he looks like a poof ’ … He immediately

experienced whatever the voice was saying as his own thoughts, to the exclusion of all other thoughts. When he read the newspaper the voice would

speak aloud whatever his eyes fell on. He had not time to think of what he was reading before it was uttered aloud.

(Mellor, 1970: 16)

Voices heard arguing with each other implies twoormorehallucinatory voices quarrellingordiscussingwitheachother.Thepatientusuallyfeaturesinthethirdpersoninthecontentofthesearguing voices.The symptom is not likely to be volunteered spontaneously in this form: thepatientdoesnotactuallysay,‘Ihearvoicesthatargueordiscusswitheachother’.Sothesymptomhastobecautiouslyandsubtlyenquiredfor.

A 24-year-old male patient reported hearing voices coming from the nurse’s office. One voice, deep in pitch and roughly spoken, repeatedly said, ‘G.T. is a

bloody paradox’, and another, higher in pitch, said, ‘He is that, he should be locked up.’ A female voice occasionally interrupted, saying ‘He is not, he is a

lovely man.’(Mellor, 1970: 16)

Hallucinatoryvoices giving a running commentaryonthepatient’sactivitiesoccurandareoffirst rank.The time sequence of the commentary may be such that it takes place just before,duringorafterthepatient’sactivities.Again,thesymptomisnotvolunteeredspontaneouslybutmayquiteoftenbeinferredfromthepatient’scomplaintsagainsthisvoices.Fortheinterviewer,thereisalwaystheproblemofaskingquestionsinsuchawaythatsheis‘let inontheinside’.Sheisaskingquestionsaboutperceptionsthatarequiteobvioustothepatient.Thepatientdoesnotknowthathisparticularperceptionisunique,thatotherpeopledonotsharehisperceptualexperience.Sotheinterviewerhasthedifficultyofaskingquestionsaboutsomethingofwhichshehasnopersonalexperience;thepatienthastoanswerquestionsthat,becauseofhissituation,seemtohavenopoint.Theabnormalthingaboutvoices commentingisthattheyshouldbeexpe-riencedasperceptionsandascomingfromoutsidetheself;manynormalpeoplehavethoughts,recognizedastheirownandcomingfrominsidethemselves,commentingontheiractions:

A 41-year-old housewife heard a voice coming from the house across the road… The voice went on incessantly in a flat monotone describing

everything she was doing, with an admixture of critical comments. ‘She is peeling potatoes, got hold of the peeler, she does not want that potato, she is

putting it back, because she thinks it has a knobble like a penis, she has a dirty mind, she is peeling potatoes, now she is washing them.’

(Mellor, 1970: 16)

Passivityexperiencesarethoseeventsintherealmofsensation,feeling,driveandvolitionthatareexperiencedasmadeorinfluencedbyothers.Theyhavebeenwelldescribedasdelusionsofcontrol,becausethepatient’sexperienceof theeventbeingmadetooccurtakestheformofadelusion. The terms disorders of passivity, made experiences, delusions of control and disorders of personal activity are, inpractice, synonymousand interchangeable.Theevent isexperiencedasalienbythepatientinthatitisnotexperiencedbythepatientashisownbutinsertedintotheself from outside. Passivity experiences of thinking occur as thought withdrawal, thought


insertionor thoughtbroadcasting. In thought withdrawal, it isbelievedby thepatient thathisthoughtsareinsomewaybeingtakenoutofhismind;hehassomefeelingoflossresultingfromthisprocess.Itmaybecoupledwithotherthoughtpassivityexperiences:

A 22-year-old woman said, ‘I am thinking about my mother, and suddenly my thoughts are sucked out of my mind by a phrenological vacuum extractor,

and there is nothing in my mind, it is empty.’(Mellor, 1970: 16)

In thought insertion, he experiences thoughts thatdonothave the feelingof familiarity, ofbeinghisown,buthefeelsthattheyhavebeenputinhismind,withouthisvolition,fromoutsidehimself.Asinthoughtwithdrawal,thereisclearlyadisturbanceintheself-image,andespeciallyintheboundarybetweenwhatisselfandwhatisnotself;thoughtsthathaveinfactariseninsidehimselfareconsideredtohavebeeninsertedintohisthinkingfromoutside.

A 29-year-old housewife said, ‘I look out of the window and I think the garden looks nice and the grass looks cool, but the thoughts of Eamonn

Andrews come into my mind. There are no other thoughts there, only his …. He treats my mind like a screen and flashes his thoughts onto it like you

flash a picture.’(Mellor, 1970: 17)

In thought broadcasting, thepatientexperienceshis thoughtswithdrawnfromhismindandthen,insomeway,madepublicandprojectedoverawidearea.Theexplanationhegivesforhowthiscanoccurwill,asusualforthecontentofadelusion,dependonhisbackgroundcultureandpredominantinterests:

A 21-year-old student said, ‘As I think, my thoughts leave my head on a type of mental ticker-tape. Everyone around has only to pass the tape through

their mind and they know my thoughts.’(Mellor, 1970: 17)

Obviously,carefulenquirymustbemadeaboutthenatureof‘influence’or‘control’.Thereisaphenomenologicalworldofdifferencebetweenthestatements‘Mythinkingis influencedbymyparentsinasmuchasmythoughtsarecrowdedfromthebackintothefrontofmyhead’–apassivityexperience,and‘WhatIdoisinfluencedbymyfatherinthatIponderwhathewoulddointhecircumstancesandthendothesame’(or‘dotheopposite’)–notpassivity.Allpassivityexperiencesare regardedasfirst ranksymptoms.It isnot reallyofgreat significance todecidewhichtypeofpassivityisdescribed–whetheritis,forexample,passivityofimpulseorofvolition–butitisimportantdiagnosticallytodecidewhetheritisapassivityexperienceornot.Passivity of emotionoccurswhentheaffect that thepatientexperiencesdoesnot seemtohimtobehisown.Hebelievesthathehasbeenmadetofeelit:

A 23-year-old female patient reported, ‘I cry, tears roll down my cheeks and I look unhappy, but inside I have a cold anger because they are using me in this

way, and it is not me who is unhappy, but they are projecting unhappiness onto my brain. They project upon me laughter, for no reason, and you have no

idea how terrible it is to laugh and look happy and know it is not your, but their reaction.’

(Mellor, 1970: 17)


In passivity of impulse, thepatient experiences adrive,whichhe feels is alien, to carry outsome motor activity. The impulse may be experienced without the subject carrying out thebehaviour.AJewishwoman,aged55,sufferingfromschizophreniasaid,‘Ifeelmyhandgoinguptosalute,andmylipssaying“HeilHitler”…Idon’tactuallysayit…Ihavetotryveryhardtostopmyarmfromgoingup…theyputdrugsinmyfood;thatiswhatmakesithappen’.Ifcarried out, the action is admitted to be the patient’s own, but he feels that the impulse thatprecipitatedhimintodoingitwasnothisown.

A 26-year-old engineer emptied the contents of a urine bottle over the ward dinner trolley. He said, ‘The sudden impulse came over me and I must do it. It was not my feeling, it came into me from the X-ray department, that was

why I was sent there for implants yesterday. It was nothing to do with me, they wanted it done. So I picked up the bottle and poured it in. It seemed

all I could do.’(Mellor, 1970: 17)

Similarly,withpassivity of volitionthepatientfeelsthatitisnothiswillthatcarriedouttheaction.

A 29-year-old shorthand typist described her actions as follows, ‘when I reach my hand for the comb it is my hand and arm which move, and my fingers

pick up the pen, but I don’t control them… I sit there wanting them to move, and they are quite independent, what they do is nothing to do with me … I

am just a puppet who is manipulated by cosmic strings. When the strings are pulled my body moves and I can’t prevent it.’

(Mellor, 1970: 17)

Somatic passivity is thebelief thatoutside influences areplayingon thebody. It isnot thesameashaptichallucination,butitisadelusionalbeliefthatthebodyisbeinginfluencedfromoutsidetheself.Itmayoccurinassociationwithvarioussomatichallucinations.Forexample,akinaesthetichallucinationoccurred,withapassivityexperiencegivenasexplanation,byapatientwhofeltthathishandwasbeingdrawnuptohisface.Hecouldfeelitmovingalthough,infact,itwasmotionless.Somaticpassivitymayalsooccurinassociationwithanormalpercept;theseexperiencesarequitecommoninschizophrenia.

A 38-year-old man had jumped from a bedroom window, injuring his right knee which was very painful. He described his physical experience as,

‘The sun-rays are directed by US army satellites in an intense beam which I can feel entering the centre of my knee and then radiating outwards causing

the pain.’(Mellor, 1970: 16)

Firstranksymptomsareofgeneraluse,diagnostically,inclinicalpractice,andtheyhavealsobeenadaptedforpsychiatricresearch.Themethodofascertainingandmeasuringschizophrenicsymptoms, among other symptoms, developed by Wing etal. (1974) in their Present StateExaminationusesfirstranksymptomsasabasisfordiagnosingschizophrenia.ThePresentStateExaminationprovidestheclinicianwithameansofascertainingwhichsymptomsandsyndromesarepresent.


Koehler(1979), inareviewofthewaydifferentauthorsdescribethepresenceoffirstranksymptomsintheEnglishliterature,consideredthattheyweresometimesusedinaverynarrowandsometimesaverywidesense.Hemakesthedistinctionbetweenalienationofthoughtandinfluenceofthought,andmakesapleaforclearstatementsontheboundarycriteriaforfirstranksymptomsandthenosologicalbiasattachedto thephenomena.FromthequotedexamplesofMellorabove,alienationisnecessary;thatis,adelusionofcontrolandnotjustanexperienceofinfluenceof thought.Similarly, thoughtbroadcastingwouldbe regardedasoffirst rankwhenthepatientdescribes this ashavingoccurredoutsidehis control, irrespectiveofwhether thesethoughtsaresharedwithothers.Thus,thischapterisrecommendinganarrowuseoffirstranksymptoms. First rank symptoms have been employed to establish the diagnosis; they are notnecessarilyusefulprognostically(BlandandOrn,1980).

This differencebetween alienationor experience of control and influence canbe exempli-fied by the schizophrenic symptom of thought insertion. Thought insertion is more concretethan the insertionof an idea intoone’s thinking.Anormalpersonmay say, ‘mymother gaveme the idea’ or even ‘the idea was put into my head by my mother’. Neither of these isthought insertion. The patient experiencing passivity believes that by some concrete processtheboundariesofhisself involvingthinkingaresoinvadedthathismotherisactuallyplacingthoughts inside his head (Chapter 12), so that he thinks her thoughts, or perhaps she, isthinkinginsidehim.

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59–62.GoldsteinK(1936)Themodificationofbehaviourconsequenttocerebrallesions.Psychiatric Quarterly10,

586–610.IsräelsHandSchatzmanM(1993)Theseductiontheory.History of Psychiatry4,23–60.JaspersK (1962)General Psychopathology (transl.Hoenig J andHamiltonMW).Manchester:Manchester

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159

C H A P T E R 10

Disorder of Speech and Language

SummarySpeechistheaspectoflanguagethatcorrespondstothemechanicalandarticulatoryfunctionsthat allow language to be vocalized, whereas language is itself a complex system based on anumberofelementsincludingphonemes,syntacticstructure,semantics,prosodyandpragmatics,alldesignedtoaidcommunicationandtoencodefactsinmemory.Abnormalitiesofspeecharecommon in neurology but rare in psychiatry. Language and thinking disorders are intricatelyaffectedinpsychiatricdisorders,particularly inschizophrenia.Theactualrelationshipbetweenthinkingandlanguageisyettobefullyelucidated.

To speak is not only to utter words, it is to propositionize. A proposition is such a relation of words that it makes one new meaning.

J. Hughlings Jackson (1932)

Itisveryobviousthatthefunctionsofthinkingandspeakingoverlapandcannotbereadilyseparatedfromeachother;atthesametime,theyareclearlydifferent.Thecontentsofthischaptercannotbeconsideredin isolationfromitspredecessor,althoughthisoneconsidersspeechandlanguagefromadifferentperspective.

Maher (1972)proposedamodel thatattempted todemonstrate the linkbetween thinkingandthebehaviourofspeechinlanguage:

conceptualizing the relationship between language and thought. The model might be likened to a typist copying from a script before her. Her copy may

appear to be distorted because the script is distorted although the communication channel of the typist’s eye and hand are functioning correctly.

Alternatively, the original script may be perfect, but the typist may be unskilled, making typing errors in the copy and thus distorting it. Finally, it

is possible for an inefficient typist to add errors to an already incoherent script. Unfortunately, the psychopathologist can observe only the copy

(language utterances): he cannot examine the script (the thought). In general most theorists concerned with schizophrenic language have accepted the first of

the three alternatives, namely that a good typist is transcribing a deviant script. The patient is correctly reporting a set of disordered thoughts. As

Critchley put it: ‘Any considerable aberration of thought or personality will be mirrored in the various levels of articulate speech – phonetic, phonemic,

semantic, syntactic and pragmatic’. The language is a mirror of the thought.(p. 3)

Thescriptis likenedtothoughtandthetypisttolanguage.Mostclinicianshavetakentheview that language closely mirrors thought and see the primary abnormality as the thinking

Keywords: Language,Speech,Aphasia,Mutism,Alogia.

10—DISORDER OF SPEECh AND LANGUAGE 159.e1


disorder(Beveridge,1985).Disorderedlanguageisthenseenasmerelyareflectionofthisunder-lyingdisturbance,withdiagnosisofthoughtdisorderonlypossibleonthebasisofwhatthepatientsays.Someofthemorerecent linguistictheoriesusedfortheanalysisofschizophrenicspeechcontradicttheprimacyofthinking.

The assumption that language directly mirrors thought can be challenged (Newby, 1995).Thereisatraditionthatarguesthatlanguageitselfstructuresthinkingandconcepts,anddeter-mineshowtheworldisunderstood.ThisviewderivesfromtheworksofEdwardSapir(1884–1939) and Benjamin Whorf (1897–1941). In essence, the Sapir–Whorf hypothesis says thatlanguageinfluencescognition.Thereisverylimitedempiricalsupportforthisview,andPinker(1994)concludesthat‘therepresentationsunderlyingthinking,ontheonehand,andthesen-tencesinalanguage,ontheother,areinmanywaysatcross-purposes.…PeopledonotthinkinEnglishorChineseorApache;theythinkinalanguageofthought.Thislanguageofthoughtprobablylooksabitlikealltheselanguages;presumablyithassymbolsforconcepts,andarrange-mentsofsymbolsthatcorrespondtowhodidwhattowhom’.Thisradicalviewcontradictsthepoint-to-pointrelationshipbetweenlanguageandthoughtimplicitinMaher’sproposition(seeabove)andthelinguisticdeterminismoftheSapir–Whorfhypothesis.

Therelationshipbetweenthinkingandlanguageisascomplicatedfororganicdisordersasitisforschizophrenia:therecanbequitemarkeddisturbanceintheuseoflanguagewithnoappar-ent thoughtdisorder.This is revealed in the rare isolatedabnormalitiesof specific functionoflanguage described in this chapter. An understanding of how the healthy person expressesthoughtsinlanguagecanbeachievedonlybystudyofthenormaldevelopmentoflanguage.Thisis outside the scope of this book but is discussed in relation to perception in Carterette andFriedman(1976).

Languageisbuiltupofanumberofelements.Phonemesarethemostbasicsoundsthatareavailableforuse in language,andanyparticular language,suchasEnglish,usesonlya limitedrepertoireofphonemes.Therepertoireused inEnglishmayshareonlya limitedoverlapwiththatused,forexample,inYoruba.Morphemesareproducedfromphonemesandarethesmallestmeaningfulunitofaword,andcombinationsofmorphemesmakeupwords.Amorphememaybeawordsuchas‘do’or‘un’.Syntax(grammar)istheallowablecombinationofwordsinphrasesandsentencesandincludestherulesthatdeterminewordorder.Semanticsarethemeaningsthatcorrespondtothewordsandincludethemeaningofallpossiblesentences.Prosodyreferstothemodulationofvocalintonationthatinfluencesaccents,andalsotheliteralandemotionalmean-ingsofwordsandsentences.Thepragmaticsof languagearethewaysthat language isusedinpractice.Thisisarelativelynewareaofstudy.Itreferstothemultiplepotentialmeaningsofanyutterance,whichrequiresknowledgeofcontextandof thespeakers for full interpretation.Forexample, the sentence ‘this room is cold’ can have any of several meanings depending on theidentityofthespeaker,thecontextoftheutteranceandwhoisbeingaddressed,thatisthesocialorrelativedistanceoftheaddressee.Itisperhapsimportanttodistinguishbetweenlanguageandspeechforourpurpose.Speechistheaspectoflanguagethatcorrespondstothemechanicalandarticulatoryfunctionsthatallowlanguagetobevocalized.Thus,forlanguagetobecomespeechthevocalcords,thepalate,thelipsandthetongueneedtoperformacomplexandsynchronizeddanceofintricatesteps.Thedissociationbetweenpoorlyarticulatedspeechandintactlanguageindicatesthatthesetwofunctionsareseparate.

Chomsky’stheoryoflanguageisthemostinfluential(Chomsky,1986).Essentially,Chomskyarguedthatlanguageislikeaninstinct,andfurthermorethat‘everysentencethatapersonuttersorunderstandsisabrandnewcombinationofwords,appearingforthefirsttimeinthehistoryoftheuniverse.Thereforealanguagecannotbearepertoireofresponses;thebrainmustcontainarecipeorprogrammethatcanbuildanunlimitedsetofsentencesoutofafinitelistofwords.Theprogrammemaybecalledamentalgrammar’(Pinker,1994).Inadditiontothis,childrenrapidlydevelopthesecomplexgrammarswithoutformalinstruction.Thissuggeststhattheymustbeinnatelyendowedwithaplancommontothegrammarsofalllanguages,auniversalgrammar.

10—DISORDER OF SPEECh AND LANGUAGE 161

Howlanguagedevelops,howwordmeaningislearnedandtheneuropsychologyoflanguageareallareasofincreasingstudy.

Speech DisturbancesThissubjectisdealtwithintextbooksofneurologyandhasbeenreviewedbyCritchley(1995);it is only summarized here. Many abnormalities, such as paraphasia, have both organic andpsychogenic causes (see above);diagnosiswill require fullmedical andpsychiatrichistory andneurologicalandmentalstateexamination.

APHONIA AND DYSPHONIA

Aphoniaisthelossoftheabilitytovocalize;thepatienttalksonlyinawhisper.Dysphoniadenotesimpairmentwithhoarsenessbutwithoutcomplete lossof function. Itoccurswithparalysisoftheninthcranialnerveorwithdiseaseofthevocalcords.

Aphoniamayalsooccurwithoutorganicdiseaseindissociative aphonia,notuncommonasapresentationamongear,noseandthroatoutpatients.Suchapatientmayspeakina‘stagewhisper’;phonationmayfluctuateaccordingtotheresponseofthosethepersonisaddressing.

DYSARTHRIA

Disordersofarticulationmaybecausedbylesionsofthebrainstemsuchasbulbarandpseudo-bulbarpalsy.Itmayalsooccurwithstructuralormusculardisordersofthemouth,pharynx,larynxandthorax.Idiosyncraticdisordersofarticulationaresometimesseeninschizophreniaandalso,perhaps,withpersonalitydisordersconsciouslyproduced.

STUTTERING AND STAMMERING

Thesehaveinthepastbeenenquiredaboutinthepsychiatrichistoryunderneuroticdisturbancesof childhood, along with such behaviour as nail biting. However, psychogenic aetiology hascertainlynowbeenproved,andanyassociationwithneuroticismmaywellbesecondarytothebarriersincommunicationthatstutteringcauses.

LOGOCLONIA

Thisdescribesthespasticrepetitionofsyllablesthatoccurswithparkinsonism(Scharfetter,1980).Thepatientmaygetstuckusingaparticularword.

ECHOLALIA

Thepatientrepeatswordsorpartsofsentencesthatarespokentohimorinhispresence.Thereisusuallynounderstandingofthemeaningofthewords.Itismostoftendemonstratedinexcitedschizophrenicstates,withmentalretardationandwithorganicstatessuchasdementia,especiallyifdysphasiaisalsopresent.

CHANGES IN THE VOLUME AND INTONATION OF SPEECH

Manydepressedpatientsspeakveryquietlywithamonotonousvoice.Manicpatientsoftenspeakloudlyandexcitablywithmuchvariationinpitch.Excitedpatientswithschizophreniamayalsospeakloudly;intonationandstressesonwordsmaybeidiosyncraticandinappropriate.Noneof


thesemodesofbehaviourhasdiagnosticsignificance.ThespeedandflowoftalkmirrorsthatofthoughtandhasbeendealtwithinChapter9.

UNINTELLIGIBLE SPEECH

Speechmaybeunintelligibleforseveralreasons,andmostoftheabnormalitiesdescribedhere,iftakentoextremes,willresultinincomprehensibility.

■ Dysphasia may be so profound that, although syllables are produced, speech isunintelligible.

■ Paragrammatism(disorderofgrammaticalconstruction)andincoherence of syntaxmayoccurin severaldisorders.Recognizablewordsmaybe soderanged in their sentencesas tobemeaningless–word salad, asoccurs in schizophrenia. Inmania, the speedof associationmaybesorapidastodisruptsentencestructurecompletelyandrenderitmeaningless,whileindepressionretardationmaysoinhibitspeechthatonlyunintelligiblesyllables,oftenofamoaningnature,areproduced.

■ Privatemeaningmayoccurinschizophreniawiththeuseof(a)newwordswithanidiosyn-cratic,personalmeaning–neologisms; (b) stock wordsandphrases inwhichexistingwordsareusedwithspecial individualsymbolicmeaning;or(c)aprivate languagethatmaybespoken(cryptolalia),orwritten(cryptographia).

Organic Disorders of LanguageDysphasicsymptomsareprobablymoreusefulclinicallythananyothercognitivedefectinindi-catingtheapproximatesiteofbrainpathology(Davidetal,2007).However,theauditory,visualandmotormechanismsofspeecharespreadthroughseveraldifferentpartsofthebrain;often,severalfunctionsareaffectedandlesionsareusuallydiffuse,andthusprecisebrainlocalizationisnotoftenpossible.Ninetyper centof right-handedpeoplewithout anybraindamagehavespeech located in the lefthemisphere,and10percenthave righthemisphere speech.Amongthosewhoareleft-handedorambidextrous,64percenthavelefthemispherespeech,20percentrighthemisphereand16percentbilateralspeechrepresentation.

SENSORY DYSPHASIA

Thetermsaphasia anddysphasia areoftenused interchangeably.However,aphasia implies thelossoflanguagealtogether,anddysphasiaimpairmentof,ordifficultywith,language.Dysphasiaisconventionallydividedforclassificationpurposesintosensory(receptive)andmotor(expressive)types.Veryfrequently,thereisaglobalimpairmentoflanguagewithevidenceofimpairmentofbothelements.Table10.1summarizessomeoftheabnormalitiesthatoccurwiththedifferentaspectsoflanguagethatareimpaired.

Pure Word Deafness (Subcortical Auditory Dysphasia)

Inpure word deafness,thepatientcanspeak,readandwritefluently,correctlyandwithcompre-hension.Hecannotunderstandspeech,eventhoughhearingisunimpairedforothersounds;hehearswordsassoundsbutcannotrecognizethemeaningeventhoughheknowsthattheyarewords.Thisisthereforeaformofagnosia(lackofrecognition)forthespokenword.

Pure Word Blindness (Subcortical Visual Aphasia)

Thepatientwithpure word blindness canspeaknormallyandunderstandthespokenword;hecanwritespontaneouslyandtodictationbutcannotreadwithunderstanding(alexia).Thecondi-tionisthereforeagnosic alexia without dysgraphia.Hemayhavemoredifficultywithprintedthan


handwrittenscript.Suchapatientwillalsosufferarighthomonymoushemianopia(lossoftherighthalfofthefieldofvisioninbotheyes)andaninabilitytonamecolourseventhoughtheycanbeperceived.

Primary Sensory Dysphasia (Receptive Dysphasia)

Patients with primary sensory dysphasia are unable to understand spoken speech, with loss ofcomprehensionofthemeaningofwordsandofthesignificanceofgrammar.Hearingotherwiseisnot impaired.Consequentonthisdeficit in theauditoryassociationcortex (Wernicke’s area),thereisalsoimpairmentofspeech,writingandreading.Speechisfluent,withnoappreciationofthemanyerrorsintheuseofwords,syntaxandgrammar.

Conduction dysphasiacouldbeconsideredtobeatypeofsensorydysphasiainwhichsensoryreception of speech and writing are impaired, in that the patient cannot repeat the messagealthoughhecanspeakandwrite.Ifheisquestionedonthemessage,heisabletogive‘yes’or‘no’answerscorrectly,thusdemonstratingcomprehension.Therearemarkederrorsofgrammarandsyntax(syntactical dysphasia).

TABLE 10.1 ■ Impairment of language function with different types of dysphasia

TypeSpontaneous Speech-Fluent Comprehension Repetition Naming Reading Writing

Pure word deafness

+ – – + + + (not to dictation)

Pure word blindness

– +

Primary sensory dysphasia

– – – –

Conduction dysphasia

– Aloud –, compr.n +

–

Nominal dysphasia

–

Pure word dumbness

– –

Pure agraphia

+ –

Primary motor dysphasia

– – ±, aloud –, compr.n ±

–

Alexia with agraphia

– – –

Isolated speech area

– – – – –

Transcortical motor dysphasia

– – Aloud –, compr.n +

Transcortical sensory dysphasia

– – – –

Compr.n, comprehension.(After Lishman, 1997, with permission of Blackwell Scientific.)


Nominal Dysphasia

Thepatientwithnominal dysphasiaisunabletoproducenamesandsoundsatwill.Hemaybeabletodescribetheobjectanditsfunctionandtorecognizethenamewhenpresented:apatientdescribedawatchasa‘clockvessel’.Typically,‘empty’nounssuchas‘thing’and‘object’areusedfrequentlywhile‘distinguishing’nounsrarely.Speechisflat,thestructureofsentencesgenerallycorrectandunderstandingunimpaired.

Jargon Dysphasia

Injargon dysphasiaspeechisfluent,butthereissuchgrossdisturbancetowordsandsyntaxthatitisunintelligible.Theintonationandrhythmofspeechareretained.Thisisconsideredaseveretypeofsensorydysphasia;thereisfailuretoevaluatethepatients’ownspeech,inthatpatientsarenotemotionallydisturbedwhenlisteningtorecordingsoftheirowngrosslyimpairedspeech.

MOTOR APHASIA

Pure Word Dumbness

Thepatientwithpure word dumbnessunderstandsspokenspeechandwritingandcanrespondtocomments.Writingispreservedbutspeechisindistinctandcannotbeproducedatwill.Thereisnolocaldisturbanceofmusclesrequiredinspeaking,andthedisabilityisanapraxialimitedtomovementsrequiredforspeech.

Pure Agraphia

Pure agraphia is an isolated inability to write which may also occur with unimpaired speech(agraphia without alexia);thereisnormalunderstandingofwrittenandspokenmaterial.Thisistheequivalentforwritingofpureworddumbnessinspeech.

Primary Motor Dysphasia

Inprimary motor dysphasiathereisdisturbancetotheprocessesofselectingwords,constructingsentencesandexpressingthem.Speechandwritingarebothaffected,andthereisdifficultyincarryingoutcomplexinstructions,eventhoughunderstandingforbothspeechandwritingmaybepreserved.Thepatientfindsitdifficulttochooseandpronouncewords,andspeechishesitantandslow;herecognizeshiserrors,triestocorrectthemandisclearlyupset.Gesturemaybeusedtoreplaceverbalcommunication.Speechisattemptedandrecognizedasspokenwords,butwordsareomitted,sentencesshortenedandperseverationoccurs.

Alexia with Agraphia

Visual aspects of language are construed as being more complex than auditory, in that visualschemataarerequired–‘seeingthewrittenwordinsidehishead’,in additiontoauditory–‘hearingthewordsinone’shead’.Inalexia with agraphia,thepatientisunabletoreadorwrite,butspeak-ingandunderstandingspeecharepreserved.Alexia inthisconditionissimilar tothatofpurewordblindness:thepatientcannotunderstandwordsthatarespeltoutaloud,showingthatheiseffectivelyilliteratebecauseofdisturbanceofthevisualsymbolismoflanguage.

Isolated Speech Area

Impairedcomprehensionmayoccurwithslow,hesitantspeechinanabnormalityinwhichitisassumedthattheanatomicalWernicke’sandBroca’sareasandtheconnectionsbetweenthemareintactbutconnections fromotherpartsof thecortexwith this languagesystemaredisturbed.Twotypes,expressiveandreceptive,aredescribed:transcortical motor dysphasiaandtranscortical sensory dysphasia.


Mostfrequently,ofcourse,withdysphasia,thereisamixtureofexpressiveandreceptiveele-mentsandtheclearsyndromescannotbedemonstrated,buttheirsignificanceispartlytheoreticalindemonstratingtherangeofanatomicallesionsandthespecificityofresultantsymptoms.Thisdescriptionhasbeenexclusivelyconcernedwiththesymptoms;precisedescriptionoftheana-tomicallesionsandofassociatedneurologicalsymptomsisoutsideourscope.Itisimportanttodistinguish thephenomenaofdysphasia,perhapswithneologismsanddefectsof syntax, fromthe word salad of schizophrenia with superficially similar defects of language. Verbigerationdescribes the repetition of words or syllables that expressive aphasic patients may use whiledesperatelysearchingforthecorrectword.

MUTISM

Mutism, refraining from speech during consciousness, is an important sign in psychiatricillnesswithanextensivedifferentialdiagnosis.Eliciting thehistory andmental statebecomesimpossible in a mute patient. All the major categories of psychiatric disorder may manifestmutism:learningdisability,organicbraindisease(sometimesdrug-related),functionalpsychosisandneurosisandpersonalitydisorder.Somemorespecificcausesincludedepressiveillness,cata-tonicschizophreniaanddissociativedisorder.Mutismoccursasanessentialelementofstupor(Chapter3),anditisnecessarytoassessthelevelofconsciousnessaspartofafullneurologicalexaminationforallpatientswiththissign.Ifthereisnoloweringofconsciousness,asinfunctionalpsychoses and neuroses, it is likely that the mute patient understands everything that is saidaroundhim.Aswellasspecificbraindisorders,thecausesofstuporincludegeneralmetabolicdisorders that also affect the brain, such as hepatic failure, uraemia, hypothyroidism andhypoglycaemia.

Schizophrenic Language DisorderDefectivecommunicationin languageis thedefiningcharacteristicofschizophreniaaccordingtoCrow(1997),anditisassociatedwithgeneticvariationatthetimelanguagewasacquiredbyHomo sapiens.Theuseoflanguagebypeoplewithschizophreniacandifferfromthatinnormalpeople,andthisdifferencecanbesubtleandunrelatedtopositivesymptomssuchasdelusionsandhallucinations.There isgood reason tobelieve that theabnormalitiesof languageuseareassociatedwiththoughtdisorder.Theprecisenatureofthelanguageabnormalityhassofardefiedclarification,andthisaccountisprovisional; itdescribesthewaysomeofthephenomenahavebeenviewedandconceptualized.Thereisnosingleexplanatorytheorythatunifiesthedisparateabnormalitiesthathavebeenobservedanddescribed.InvestigationintolanguagedisordermaybeascribedtooneofthefourmodelsshowninTable10.2.

TABLE 10.2 ■ Models for investigating language disorder in schizophrenia

Model of Language Technique Employed

Concept of thought disorderBehavioural learning theoryStatistical modelLinguistic model

Psychiatric: clinical description of schizophrenic speechWord association test, multiple choice vocabulary testThe Cloze technique, type : token ratioAnalysis of syntax, cohesion or propositions

(After Beveridge, 1985, with permission.)


CLINICAL DESCRIPTION AND THOUGHT DISORDER

Theonlyunequivocaldemonstrationofdisorderofthinkingcanbethroughlanguage.Thoughtdisordermayberevealedintheflowoftalk(asinChapter9),disturbedcontentanduseofwordsandgrammar, and in the inability to conceptualize appropriately.Critchley (1964) consideredthatthe‘causationofschizophrenicspeechaffectionliesinanunderlyingthoughtdisorder,ratherthaninalinguisticinaccessibility’.Someofthewaysinwhichclinicianshavecategorizedschizo-phrenicthoughtdisordermanifestinginspeecharelinkedinTable10.3.

TheGermanpsychopathological literatureonschizophrenic languageandspeechdisorderswas concerned with the rules of language dysfunction; it consistently reported the patient’suncertainty in choosing the correct metaphorical level in communication (Mundt, 1995).Kraepelin (1919) defined akataphasia as a disorder in the expression of thought in speech.Loss of the continuity of associations,whichimpliedincompleteness inthedevelopmentof ideas,was thefirstof the functions includedamongthe fundamental symptomsofschizophreniabyBleuler(1911).

Gardner(1931)consideredthoughtdisordertobeaformofregression.Cameron(1944),indescribingasyndesis,consideredtheretobeaninabilitytopreserveconceptualboundariesandamarked paucity of genuinely causal links. He gave the example of a patient who, given thesealternatives, completed the sentence ‘I get warm when I run because …’ with all the words:‘quickness,blood,heartofdeer,length,drivenpower,motorizedcylinder,strength’.Thepatientwaspronetouseimpreciseexpressions–metonyms,forexampleapatientsaidhewasalive;

Because you really live physically, because you have menu three times a day; that’s the physical [What else is there beside the physical?] Then you are alive

mostly to serve a work from the standpoint of methodical business

andover-inclusive thinkinginwhichalooseassociationofconceptsthatwererelatedinsomewaytothedominantthemebecameinterwovenintoresponses,forexample;

[The wind blows] Due to velocity. [Question repeated] Due to loss of air, evaporation of water. [What gives the velocity?] the contact of trees, of air in

the trees

Concrete thinking,atermdenotinganinabilitytothinkabstractlywasproposedbyGoldstein(1944),butthevalidityofthishasbeenchallengedbyPayneetal.(1959).Allen(1984)considersthat speech-disordered patients with schizophrenia produce evidence of concrete thinking,

TABLE 10.3 ■ Categorization of thought disorder in speech

Clinician Categorization

Kraepelin Akataphasia

Bleuler Loosening of associations

Gardner Form of regression

Cameron Asyndesis

Goldstein Concrete thinking

Von Domarus Defect of deductive reasoning

Schneider Derailment, substitution, omission, fusion and drivelling


thinkingwithoutinferringandrestrictedtowhatisexplicitlystated,whilenon-speech-disorderedpatientswithschizophreniadonot.Whenthethematicorganizationofspeechwasanalyzedforpatients with positive speech disorder (incoherence of speech) or negative speech disorder(poverty of speech), there was no difference found: speech-disordered patients, positive aswellasnegative,showedcognitiverestrictionandproducedfewerinferencesthannon-speech-disorderedpatients.

A deficiency in the logic of deductive reasoning in schizophrenia was suggested by VonDomarus (1944). Some of the abnormalities of thinking expressed in speech observed bySchneiderhavebeendiscussedinChapter9.

AnattempthasbeenmadebyAndreasen(1979)toclassifythedescriptionofpatients’cogni-tiveandlinguisticbehaviouronthephenomenademonstratedwithoutmakinginferencesaboutconceptsof‘global’thoughtdisorder;theseabnormalitiesoccurinbothmaniaandschizophrenia.Sometypesofthoughtdisorder,suchasneologismandblocking,occurredtooinfrequentlytohavediagnosticsignificance.However,shefoundhighreliabilitybetweenraterswithmanytypesofthoughtdisorderandalsodiscriminationbetweendifferentpsychoticillnesses.Derailment,lossofgoal,povertyofcontentofspeech,tangentialityandillogicalitywereparticularlycharacteristicofschizophrenia.Derailment implies looseningofassociationsothat ideasslipontoeitheranobliquelyrelated,ortotallyunrelated,theme.Loss of goalisthefailuretofollowachainofthoughtthroughtoitsnaturalconclusion.Poverty of content of speechincludespovertyofthought,emptyspeech,alogia,verbigerationandnegativeformalthoughtdisorder;patients’statementsconveylittleinformationandtendtobevague,over-abstract,over-concrete,repetitiveandstereotyped.Tangentialitymeansreplying toaquestion inanobliqueoreven irrelevantmanner.Illogicalityimpliesdrawingconclusionsfromapremisebyinferencethatcannotbeseenaslogical.

Misuse of Words and Phrases

Thepatientwithschizophreniasometimesshowsmisuseofwordsinthathehas,intheterminol-ogyofKleist(1914),adefectofwordstorage.Hehasarestrictedvocabularyandsouseswordsidiosyncratically to cover a greater range of meaning than they usually encompass.These arecalledstock words or phrases,andtheirusewillsometimesbecomeobviousinalongerconversationinwhichanunusualwordorexpressionmaybeusedseveraltimes.Forexample,apatientused‘dispassionate’asastockword,anduseditfrequentlywithabizarreandidiosyncraticmeaninginthecourseofafewminutes’speech.Awomanwhowasdelusionallyconcernedthatthepolicewere intruding into her private affairs interspersed her conversation, often bizarrely, with theexpression‘confidentiallyspeaking’.

Thisabnormalityappearspartlytoreflectapovertyofwordsandsyntaxandalsoanactivetendencyforwordsorsyllablesbyassociationtointrudeintothoughts,andthereforespeech,soonafterutterance.InthesampleofspeechinChapter9,thefollowingwordscouldbeseenasstimuliandresponses,byintrusion:‘means’–‘ways’,‘opens’–‘closed’,‘holdingbackthetruth’–‘bynomeanswillIspeak’,‘writtenquestions’–‘bymeansofwriting’,‘miracle’–‘Holyland’.Theyalsoappear to be stock words or phrases in that they are used with greater frequency and with agreaterrangeofmeaningthanisnormalandcorrect.

Wordscarryasemantic halo,thatis,theirconstellationofassociationsisgreaterthanjustthedictionarymeaningoftheword.Aboyaged16stealsanapple.IfIcallhim‘atrespasser’,ithasbiblicalassociations;‘acriminal’suggestsagreaterdegreeofviciousnessthantheactionmerits;‘adelinquent’ is readily associatedwithhis youthfulnessbecauseof thephrase ‘juveniledelin-quent’. The constellations of associations in patients are disordered in that they often makeapparentlyirrelevantassociations.Thesemaybeexplainedbymisperceptionofauditorystimuliwithspecificinattention;theactualmediationofassociationsinpatientswithschizophreniamaybe similar to that inhealthypeople.This comes someway toexplainingwhy theassociationsseemappropriatesubjectivelytothepatienthimself,ashedoesnotrealizethathehasmisper-ceived the cue: it seems reasonable tohimbut isquite irrelevant to the interviewer.Toquote


Maher, ‘What seems to be bizarre is not the nature of the associations that intrude into theutterance,butthefactthattheyintrudeatall’(Maher1972,p.9).

Among the disorders of words, neologism is well recognized. A patient believed that histhoughtswereinfluencedfromoutsidehimselfbyaprocessof‘telegony’.Althoughsuchaworddoesactuallyexist,thepatienthadnonotionofthisnorwhatitmeant.Hecreatedthewordtodescribe a unique experience of his for which no adequate word existed. A 47-year-old malepatient with schizophrenia and expansive mood described himself thus: ‘I am the triplicateactimetric kilophilic telepathic multibillion million genius’ – which does suggest a certaingrandiosity!

TheunintentionalpunsofschizophreniahavebeenexplainedbyChapmanetal.(1964).Ifawordhasmorethanonemeaning,itislikelythatoneusageisdominant.Forexample,themajorityofpeople,inmostcontexts,wouldbemorelikelytousetheword‘bay’torefertoaninletofthesea than to a tree, thenoise ahoundmakes, the colour of ahorse, anopening in awall, thesecondbranchofastag’shorn,anuncomfortableplaceatwhichtostandoreven,phonetically,aTurkishgovernor!Thereisamarkedtendencyinschizophreniatoshowintrusionofthedomi-nantmeaningwhen thecontextdemands theuseofa lesscommonmeaning.Chapmanetal.(1964)usedasentencesuchas‘thetennisplayerleftthecourtbecausehewastired’andaskedpatientswithschizophreniatointerpretitsmeaningwithoneofthreedifferentexplanations:onereferring toa tenniscourt,one toacourtof lawandonealtogether irrelevant.Ananalysisofresponsesshowsthatdominantmeanings,hereacourtoflaw,intrudeintotheresponsesquitefrequently,butintrusionofminormeaningsislessfrequent.

Maherhasdescribeddisorderoflanguageinschizophreniainwhichintrusionoccursthroughclang associationswith the initial syllableof apreviousword: ‘the subterfuge and themistakenplannedsubstitutions’(Maher1972,p.13).Thisisunliketheclangassociationsthatoccurnor-mallyinpoetryandinhumourandalsoinmanicspeech,inwhichtheclangoccursinterminalsyllables.Therepetitivenessofspeechdisorderisalsothoughttobeassociatedwiththeintrusionofassociations:thenormalprocessofeliminatingirrelevantassociationsdoesnottakeplace,sothatawordinaclausewillprovokeassociationsbypun,clangandideationalsimilarity.Whenthatclauseiscompleted,asyntacticallycorrectclausemaythenbeinserted,disruptingmeaningbutdemonstrablyassociatedwiththatpreviouswordoridea.

Maherconsidersthataninabilitytomaintainattentionmayaccountforthelanguagedistur-bancesseeninsomepatients.Disturbedattentionallowsirrelevantassociationstointrudeintospeech,similarlytothedisturbanceaffectingthefilteringofsensoryinput.Inthistheory,normalcoherentspeechisseenastheprogressiveandinstantaneousinhibitionofirrelevantassociationstoeachutterance,andsothedeterminingtendencyproceedswiththeactiveeliminationofthoseassociations thatarenotgoal-directed.This isbutoneofmanypotential explanations for theobservedabnormalities.

Destruction of Words and Grammar

Alogiaisatermusedtodescribenegativethoughtdisorder,orpovertyofthoughtsasexpressedinwords.Correspondingly,paralogiaisusedtodescribepositivethoughtdisorder,ortheintrusionofirrelevantorbizarrethought.Paraphasiaisadestructionofwordswithinterpolationofmoreor lessgarbled sounds.Although thepatient isonlyable toproduce thisnon-verbal sound, itclearlyhassignificanceormeaningtohim.Literal paraphasiaisgrossmisuseofthemeaningofwordstosuchanextentthatstatementsnolongermakeanysense.Verbal paraphasiadescribesthe lossoftheappropriatewordbutthestatementsarestillmeaningful, forexampleapatientdescribedachairas‘afour-leggedsit-up’.

Disturbancesinthewordsandtheirmeaningsaremuchmorecommoninschizophreniathandisturbance of grammar and syntax. However, grammar is also sometimes altered; the loss ofpartsofspeechisdescribedasagrammatism.Adverbsareoccasionallylost,resultingincoarsening


andpovertyofsentences,aformoftelegramese.Forexample,‘richtableisworn;thewomanisrichtowrite;sonisalsolamentation’.This,aswellasshowingstock words(rich–lamentation),showslossofpartsofspeech,forexampletheindefinitearticle.Themeaningismoredisjointedthanthegrammar.Paragrammatismoccurswhenthereisamassofcomplicatedclausesthatmakenosense inachievingthegoalof thought.However, the individualphrasesare, in themselves,quitecomprehensible.

Itseemsprobablethattherulesofsyntaxarepreservedinschizophrenialongafteramarkeddisturbanceintheuseofwords,sothat,ifintheprecedingclauseanintrusiveassociationweretoreplacetheword‘rules’,thewordusedwouldprobably,correctly,beanoun.Forinstance,thepatientabovemighthavesaidinthiscontext‘thelamentationsofsyntaxare…’

Inadditiontotheobservedabnormalitiesdescribedabovetherearesuggestionsthatpatientswithschizophreniademonstratelackofuseofcohesivetiesindiscourse(seeMcKennaandOh,2005forafulldiscussion).Cohesivetiesindiscoursearedevicesthatareutilizedtolinksentencestogether, sothatspeech isnotmerelyacollectionofunrelatedsentences.Thereare fourmaintypesofcohesiveties:reference,conjunction, lexical cohesionandellipsis.References inEnglisharepersonalpronounssuchas‘he’,‘she’,‘they’,‘it’;demonstrativesaresuchwordsas‘this’and‘that’;andcomparatives such termsas ‘smaller than’, ‘equal to’, etc. In the following sentences ‘I met Peter yesterday.Hewas wearing a dark suit’.‘He’isareferencetie.Inthesentence‘She went to the High Street this morning and bought some cakes from the supermarket’.‘And’isaconjunctiontie.Alackofuseofcohesivetiesmeansthatthelistenerindialoguewithapatientwithschizophreniacanhavedifficultyfollowingthespeechofthepatient.

PSYCHOGENIC ABNORMALITIES

Andreasen(1979)showedthattheabnormalitiesoflanguagepresentinschizophreniawerealsopresentinmania.Furthermore,McKennaandOh(2005)makethecasethatthereisacontinuumoflanguageorthoughtdisturbancefromschizophreniathroughmooddisordertoorganicdis-orderssuchasepilepsyandfronto-temporaldementia.ThepointthatMcKennaandOhwantto emphasize is that language abnormalities in schizophrenia have a neurological substrate,linkingtheobserveddisturbancestoaphasia,areturntotheideasthatoriginatedwithKleistinthe20thcentury.

Manicspeechhasbeenanalyzed,andthespeechandnumberofassociationsdemonstratedinflight of ideas andpressure of talk is seen in thegreaternumberof cohesive linksoccurring inmanicspeech.Thecontentofdepressivespeechis,ofcourse,influencedbythemoodstate,andsoalsoisthechoiceofwords.Sentencestendtobeshortandhavefewerandsimplerassociations,withretardation.

Hysterical mutismmayoccurasanabnormalreactiontostress.Amanaged35hadbeenunabletotoleratethecontinualnaggingfromhiswifeandhertwosisterswholivedwiththem.Oneday,afterheavydrinkingthepreviousevening,hesmashedhiswife’sfurnitureathomeandthenbecamemutefor24hours.Hewaseventuallyreferredfromtheaccidentandemergencydepart-ment to the psychiatric ward, and speech returned gradually over the next two to three dayswithoutothertreatment.

With the phenomenon of approximate answers (Chapter 5), the patient gives an incorrectanswertoasimplequestion:‘Howmanylegshasasheep?’–‘Five’.Thisis,accordingtoAndersonandMallinson(1941),‘a falseresponseto theexaminer’squestionwheretheanswer,althoughwrong,indicatesthatthequestionhadbeengrasped’.Thissymptommayoccurinanumberofconditions,includingschizophreniainwhichitisoftenassociatedwithfatuousmood;dissociativedisorder,previouslydesignatedhystericalpseudodementia(beforemakingsuchadiagnosis,thewisepsychiatrist thoroughlyexcludesanorganiccause);Ganser’s syndrome;andotherorganicconditions.


Eccentricandpedanticuseofwordsmaysometimesbeseeninthosewithanankastic personal-ity;obsessionalityobtrudesintothechoiceofwordsandconstructionofsentences.

STATISTICAL MODEL OF LANGUAGE

TheClozeprocedureinvolvesdeletingwordsfromthetranscriptsofspeechandassessingwhetherthe omitted word can be predicted. Maher considered that, in schizophrenia, the greater theseverityoftheillness,thegreateristhedegreeofunpredictabilityoftheutteranceoflanguage.Innormal speech,a largepart of every sentence could be omittedwithout losing themeaning.Forexample,ifthewords‘a…part…couldbe…the’wereomittedfromthelastsentence,themeaningwouldstillbeobvious;ifletterswereomittedfromwords,forinstancenrml spech,themeaningisstillclear.Predictabilityistheabilitytopredictthemissingwordsaccurately;inthissense,schizophrenicsareunpredictableintheirspeech.Theyarelikelytouseunexpectedwordsandphrases.Intheperceptionoflanguage,theschizophrenicpatientislessabletogaininforma-tionfromtheredundancies,bothsemanticandsyntactic,ineverydayspeech.

AsophisticationoftheCloze procedurehasbeeninvestigatedbyNewby(1998).Thisinvolvesthefollowing.

■ ThemodifiedClozeprocedure,inwhichthenatureoftheinsertedwordisnoted,suchasitspartofspeech.

■ InthereverseClozeprocedure,thought-disorderedpatientswereaskedtomakesenseofascriptthathadbeenmutilatedbyinstitutingtheClozeprocedure,forexamplebydeletingeveryfourthorfifthword.Patientswithschizophreniaperformedsignificantlyworsethana control groupof orthopaedicpatients,withmanic-depressivepatients intermediate onbothmodifiedandreverseClozeprocedures.

Schizophrenicspeechisconsideredlesspredictablethannormalspeech,andlackofpredict-ability is more marked with clinically manifest thought disorder (Manschreck etal., 1979).AnexperimentwascarriedoutusingtheClozeprocedure,inwhichraterswereaskedtoassesspassages of schizophrenic ornormal speechwith the fourthorfifthworddeleted.Withfifthworddeletion, thought-disorderedschizophrenic speechwassignificantly lesspredictable thannormalornon-thought-disorderedschizophrenicspeech;thislatterwasnolesspredictablethannormalspeech.

WhetherschizophrenicspeechisreallylessredundantthannormalhasbeenquestionedbyRutter(1979),whowasabletodemonstratenodifference.TheviewthatschizophreniclanguagecanbereducedtosuchsimplemathematicalruleshasbeenrejectedbyMandelbrot(1965).Butstudiesusingthistechniquecontinue,evenifsporadically,anddemonstratethatthespeechandlanguageofpatientswithpsychosismaybelesspredictablethanthatofcontrols(AdewuyaandAdewuya,2006).

Thetype : token ratioisameasureofthenumberofdifferentwordsascomparedwiththetotalnumberofwords(Zipf,1935).Maherconcludedthatthetype:tokenratioofschizophrenicswaslowerthanfornormalsubjects.Thetendencyofschizophrenicpatientstorepeatcertainwordsandusetheminanidiosyncraticwayisreferredtoastheuseofstock words.

LINGUISTIC APPROACHES TO SCHIZOPHRENIA

Variouslinguistictheorieshavebeenappliedtoschizophrenia(forafulldiscussionseeMcKennaandOh,2005).Thesemethodsofanalysisofschizophrenic languageare tentativeanddonotyetcovertherangeofabnormalitiesoccurringinthecondition.Chomsky(1959)proposedthathumansareabletousestringsandcombinationsofwordstheyhaveneverheardbeforethroughuse of a limited set of integrative processes and generalized patterns. However, Moore andCarling(1982)havelabelledChomskyanlinguisticsacontainerviewoflanguage,separatedfrom


therealwayusersoflanguageapplyittotheirownmeaningsandcontexts.Individualcasestudieshaveusedtape-recordedinterviewswithpatientswithschizophreniatodemonstratedistinctiveabnormalities.However,on closer analysis suchabnormalities areoften found tooccur in thespeechofnormalpeople,althoughlessfrequently.Afurtherstudyofbilingualpatientsshowedpsychoticsymptomstobepresentintheirnativelanguagebutabsentintheirsecondlanguage.Theproblemofindividualstudiesis,ofcourse,theextenttowhichtheycanbegeneralizedtoallpatientswithschizophrenia.

Syntactical Analysis

Instudiesofspeechanalyzedforsyntax,comparedwithmanicandnormalcontrols,patientswithschizophrenia showed less complex speech, fewer well-formed sentences, more semantic andsyntactic errors and less fluency.There were also marked use of paraphrasias, agrammatisms,anomia,pronounwordproblems,circumlocutions,etc.Theseproblemsseemedtobeassociatedwithageneralintellectualimpairment(McKennaandOh,2005).Suchstudiesdonot,ofcourse,justifytheconclusionthatdifferencesareduedirectlytothediseaseortothoughtdisorder,nordoesittakeintoaccountthesocialcontextoremotionalaspects.However,markeddifferencesareofinterestwhenoneconsidersthatthemajorityofpatientswithschizophreniadonotshowovertdisorderoflanguage.

Propositional Analysis

Thisisaformoftextualanalysisinwhichthetextisbrokendownintoitscomponentproposi-tions,andthesearethenrepresenteddiagrammaticallytoshowthe‘mentalgeometry’(Hoffmanetal.,1982).Normalspeechisconsideredtoproceedasinasingletreediagramwithallbranchesleading from a single key proposition, but psychotic speech more often breaks the ‘rules’ ofpropositionalrelationships.

Observers, listening to the speech of schizophrenic patients, are often struck with itsoddityanddeviance.IthasbeenconsideredbyChaika(1995)thatthisisnotpurelyadeficitofsyntaxbutmoreaphenomenonlikesevereandrepeatedslipsofthetongue,inwhichtheerrorisalapseofexecutivecontrol,alapseofvolition.IthasbeenshownbyMorice(1995)thatwithincreasing complexity of syntax there is an increase in the number of errors in the speech ofschizophrenicpatients;speakersexpressingverysimplesentencesmaderelativelyfewerrors.Oneofhispatientsexpressedthis:‘andcommunicatingordinarilyIcanget lost inthechaosofthelanguage’.

Thisfindingwas confirmedbyThomasandLeudar (1995)using theHunt test, awrittentest in which subjects produce syntactically complex sentences from simple input phrases.Communication-disorderedschizophrenicpatientsmademoreerrorsthannon-communication-disorderedschizophrenicpatientsornormalcontrols,andtheseerrorsweremorelikelytooccurwithmorecomplexsyntacticstructures.Thepatientswerethereforethoughttohaveadiscretefailureoflanguageprocessingthatwasdistinctfromthemoregeneralcognitivedisordersofthecondition.

Althoughthesemethodsarestillexperimental,thepatient’suseoflanguageandsyntaxdoesenable a quantitative method of evaluating the mental state and subjective experience to bedeveloped.Studyoflanguagedisordershouldbeanareainwhichdescriptivepsychopathologycancontributetopsychiatricresearch.

ReferencesAdewuya OA and Adewuya AO (2006) Predictability of speech and language in Nigerian patients with

psychosis:acontrolledstudy.Psychiatric Research143,199–204.AllenHA(1984)Positiveandnegativesymptomsandthethematicorganisationofschizophrenicspeech.

British Journal of Psychiatry144,611–17.


AndersonWEandMallinsonWP(1941)Psychogenicepisodesinthecourseofmajorpsychoses.Journal of Mental Science87,383–96.

Andreasen NC (1979)Thought, language and communication disorder. Archives of General Psychiatry 36,1315–30.

BeveridgeA(1985)Language disorder in schizophrenia.MPhilthesis,UniversityofEdinburgh.Bleuler E (1911) Dementia Praecox: or the Group of Schizophrenias. New York: International University

Press.CameronN(1944)Experimentalanalysisofschizophrenicthinking.InKasaninJ(ed.)Language and Thought

in Schizophrenia.Berkeley:UniversityofCaliforniaPress.CarteretteGandFriedmanMP(1976)Handbook of Perception Volume VII, Language and Speech.NewYork:

AcademicPress.ChaikaE(1995)Onanalyzingschizophrenicspeech:whatmodelshouldweuse?InSimsACP(ed.)Speech

and Language Disorders in Psychiatry.London:Gaskell.ChapmanLJ,ChapmanJPandMillerGA(1964)Atheoryofverbalbehaviourinschizophrenia.InMaher

BA(ed.)Progress in Experimental Personality Research,vol. 1.NewYork:AcademicPress.ChomskyN(1959)ReviewofSkinner.Language35,26–58.ChomskyN(1986)Knowledge of Language: its Nature, Origin and Use.NewYork:PraegerPublishers.CritchleyM(1964)Theneurologyofpsychoticspeech.British Journal of Psychiatry110,353–64.CritchleyEMR(1995)Growthpoints intheneurologyofspeedandlanguage.InSimsACP(ed.)Speech

and Language Disorders in Psychiatry.London:Gaskell.CrowTJ(1997)IsschizophreniathepricethatHomo sapienspaysforlanguage?Schizophrenia Research28,

127–41.David AS, Fleminger S, Kopelman MD, Lovestone S, Mellers JDC (2007) Lishman’s Organic Psychiatry:

A Textbook of Neuropsychiatry.Chichester:Wiley-Blackwell.GardnerGE(1931)Themeasurementofpsychoticage:apreliminaryreport.American Journal of Psychiatry

10,963–75.GoldsteinK(1944)Methodologicalapproachtothestudyofschizophrenicthoughtdisorder.InKasaninJS

(ed.)Language and Thought in Schizophrenia.Berkeley:UniversityofCaliforniaPress.Hoffman RE, Kirstein L, Stopek S and Cicchetti DV (1982) Apprehending schizophrenic discourse: a

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(1968)Language.London:PenguinBooks.ManschreckTC,MaherBA,RucklosMEandWhiteMT(1979)Thepredictabilityofthought-disordered

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175

C H A P T E R 11

Insight

SummaryInsight,inpsychiatry,referstothecapacityofthepatienttorecognizethattheirmentalsymptomsareindicativeofmentalillnessandthatthesesymptomsrequiretreatment.Itisnowknowntobeassociatedwithimpairedcognitivefunction,andpredictspoorcompliancewithtreatmentandhencewithcompulsoryadmissionandtreatmentinhospital.Theunderlyingneuralmechanismofpoorinsightisstartingtobeilluminatedandislinkedmorewidelytodeficitsinself-awareness,self-monitoring,empathyandtheoryofmind.

A man who knows who and what he is, his position in the world, and what the persons and things are around him; who judges according to known, or intelligible rules; and who, if he has singular ideas or singular habits, can

give a reason for his opinions and his conduct; a man who, however wrong he may act, is not misled by any uncontrollable impulse or passion; who does not idly squander his means; who knows the legal consequences of his actions; who can distinguish between unseemly and seemly behaviour, who feels that which

is proper and that which is improper to utter, according to the circumstances in which he is placed; and who reverences the subject and the ministers of

religion; a man who, if he cannot always regulate his thoughts and his temper and his actions, is not continually in the extremes, and if he errs, errs as much

from benevolence and hesitation, as from passion and excitement, and more frequently: lastly, a man who can receive reproof, and acknowledge when he

has needed correction.John Perceval (1840)

Self-awarenessisabasichumanability.Itreferstotheabilitytorecognizeone’sownexistenceandexperienceandtheexistenceandexperienceofothers.Itincludesthefacilityformonitoringtheeventsinone’sownlife,andtheabilitytomakedecisionsaboutthefutureonthebasisofthatknowledge.Furthermore,itinvolvestheabilitytocommunicatethisawarenessofselfandothers tootherhumanbeings (Marková,1987).This characteristicallyhumanability ispartlythesubjectofSophocles’Oedipus the King,inwhichOedipus’questforself-knowledgeresultedinhisdiscoverythathehadkilledhisownfatherandfatheredchildrenbyhisownmother.Theaphorism‘KnowThyself ’wassaidtobe inscribedattheforecourtoftheTempletoApolloatDelphiandinThe Apology,Socratessays,‘Theunexaminedlifeisnotworthlivingforahumanbeing’.These references to self-knowledge in antiquity underline the place of this notion inhumanlife.

Self-awarenessobviouslytakesinmuchmorethananawarenessofillness,butitisplainthatthe psychiatric notion of insight is a subset of the general concept of self-awareness or self-knowledge.Insightasanotionismuchwiderthanjustknowingwhetheroneisillornot,andif so, having a sensible view regarding treatment. It involves our capacities for introspection,

Keywords: Insight,Self-awareness,Self-monitoring,TheoryofMind.

11—INSIGhT 175.e1


empathyandcommunication;notonlyisitglimpsingourselvesaswereallyarebutalsoourselvesasothersseeus,andthereforeothersastheyreallyarebecausetheygothroughthesamerepertoireofmentalmechanismsthatwedo.Evenforthemostprivateandinternalofinsights,socialsense,thecapacityforrelationships,empathy,knowinghowourbehaviourwillaffecttheemotionsandexperienceofotherpeopleisimportant.Insightisthedirectproductofknowingourselves.Itisaqualitythathasbeenhighlyvaluedbymostmentalhealthclinicians,becauseastronglinkisassumedbetweenhavinginsightandbetterqualityoflife(McGorryandMcConville,1999).

Although, in psychiatry, we concentrate mostly on the narrow meaning of insight withregardtomentalillness,weneedtoretainthisbroaderconcept.Often,ourworkwithpatientsinvolvesushavinginsightintotheirthinkingandbehaviourbecauseofourcapacityforempathyas fellow human beings and also helping them gain insight into themselves and the roots oftheirproblems.

Therelationshipbetweenthiscapacityforinsightinageneralsenseandthepracticalissuesof treatment is very close. A physician suffering from delusional disorder advertised and soldmagnetsforthemedicaltreatmentofarthritisandhayfever.Hestronglybelievedthatthisformoftreatmentwasofunequalledvalueforvirtuallyallmedicalconditions,andhehadphysicallyassaultedapharmacistwhohadtriedtopersuadehimotherwise.Hedecriedthevalidityofthewholeofpsychiatry, ‘because I ama scientist andeverythinghas tobeprovedwithevidence’.Becauseofhislackofinsightintohisownconditionandthenatureofhisbeliefs,itwasimpos-sibletoinitiatetreatment.Hissymptomspersistedlongterm.

Jaspers (1959) has written about the patient’s attitude to his illness under the followingheadings.

1. Understandableattitudestothesuddenonsetofacutepsychosis(perplexity,awarenessofchange).

2. Workingthroughtheeffectsofacutepsychoses.3. Workingthroughtheillnessinchronicstates.4. Thepatient’sjudgementofhisillness.5. Thedeterminationtofallill.6. Theattitudetoone’sownillness:itsmeaningandpossibleimplications.Allthesepointsabove,andespecially3,4and6,involvetheprocessofinsight,theknowledge

ofoneselfwithparticularreferencetoillness.Apersonwhobecomesseriouslyandsuddenlyill,whateverthenatureoftheillness,afterpreviouslyhavingbeenfitformanyyears,isastonishedbyhischangeofhealthstatus.Suchapersonislikelytoundergoaprofoundchangeinselfandbodyimage.Hehasbecomeapersonwho,frombeinghealthyandseeingillnessassomethingthathappenstootherpeople,nowseeshimselfaspotentiallyfrailandvulnerable.Thiscanbepersonallyenrichingandisnotnecessarilyawhollynegativeexperience.

Insight in Clinical PracticeSothatshecanbetterhelpherpatientwithapossiblementalillness,thepsychiatristasksspecificquestionsaboutthepatient’sopinionsconcerninghisillness.Theseincludehisdegreeofacknow-ledgementofillness,hisattitudestoillness,hisunderstandingoftheeffectsofhisillnessonhiscurrentcapabilitiesandfutureprospects.All thisaddsupto theassessmentof insight intohiscondition. Insight is not an absolute; it can vary in its impairment with different facets ofthe condition, for example, a patient could have some limited understanding concerning hisunlikelihoodtoobtainajobcompatiblewithhisqualifications,butvirtuallynounderstandingastohowhispsychoticsymptomsinterferewithrelationships.Thusinsightisnotnowconsideredto be an all-or-none phenomenon, in either clinical evaluation or measurement, but rather adimensionalone,sothatsubjectscanhavedifferentlevelsofawarenessoftheirillness(SurguladzeandDavid,1999).

11—INSIGhT 177

Allmentalillnesseswillalterthepatient’sworldviewandcapacitytocopewithcircumstances.Assessmentof insightmeasures theawarenessof this changeby thepatientandhisability toadapt to the change. Insight is highly complex as a function. It is the understanding of theindividual abouthisown stateofhealth, capacity andworth; it also relates this assessmentofinternalstatetootherpeopleandtheworldoutside.Inotherwords,insightrequiresbothinnerandouterorientation.This aspectof insightbecomesmoreapparent,below, in thediscussionaboutthecontributionofgestaltpsychologytotheconceptualizationofinsight.Insightingestaltpsychologyisorientedtowardsproblemsolvingintheexternalworld,whereasinsightinclinicalpracticeisinner-directed.

David(1990)regardsinsightascomposedofthreedistinct,overlappingdimensions,namely,the recognition of morbid psychological change, the labelling of this change as derivingfrom mental illness and the understanding that this change requires treatment that needs tobe complied with. An assessment schedule was constructed for determining the nature ofinsight, andquantitative lossof insight correlatedwith thedegreeofpsychopathology (Davidetal.,1992).

Oneofthemostfrustratingaspectsofpractisingpsychiatryis,fromthepointofviewofthetreatingprofessional,theapparentinabilityofpatientstorecognizeand/oradmitthattheyarementallyill.Patients,especiallythosewithschizophrenia,oftendenythattheirexperiencesareabnormalandthattheyareunwell.DanielSchreber(1842–1911)describedhisattitudetowardshisauditoryverbalhallucinationsinhisbookMemoirs of My Nervous Illness(Schreber,1955)asfollows:

I noticed therefore with interest that according to Kraepelin’s TEXTBOOK OF PSYCHIATRY (5th edition, Leipzig, 1896, p. 110 ff ) which had been

lent to me, the phenomenon of being in some supernatural communication with voices had frequently been observed before in human beings whose

nerves were in a state of morbid excitation. I do not dispute that in many of these cases one may be dealing with mere hallucinations, as which they are

treated in the mentioned textbook. In my opinion science would go very wrong to designate as ‘hallucinations’ all such phenomena that lack objective reality, and to throw them into the lumber room of things that do not exist.

FurthermoreSchrebercontinues:

Science seems to deny any reality background for hallucinations … In my opinion this is definitely erroneous, at least if so generalized.

ThesequotationsfromDanielSchreberdemonstrateoneofthemostcomplexaspectsofthenatureofinsight.Thisisthecapacitytohaveanattitudetowardsabnormalexperiencesinotherswhereonecanrecognizethemaspathological,buttodenytheabnormalityoftheexperienceinoneself, and to designate it as not being evidence of mental illness. This is so-called double book-keeping.

The resulting refusal to cooperatewith treatment and rehabilitation causes long-term suf-fering for thepatients and their carers. It is this capacityofpatients tounderstand theirownillnessthatisevaluatedclinicallyininsight.Likemanyotherconcepts,terminologicalconfusionexists,withtextbooksdescribinginsightasthepatient’scapacitytoformjudgementsabouttheirown illness and mental state. In recent years, there has been a resurgence of interest in theconcept,withattemptstodefineitreliablyandquantifiablyandtostudyitscorrelates(KumarandSims,1998).


Overview of the ConceptTheattitudeofthepatienttowardshisillnesshasobviousclinicalimplications,andinsighttriestoassesstheawarenessofthepatientconcerningtheimpacthisillnesshashadonhislifeandhiscapacitytoadapttothechangesbroughtaboutbyit.Asafunction,itishighlycomplexandhastodowithanindividual’sevaluationofhisselfandnon-selfandtheirrelatedness(seeChapter12).Inclinicalpractice,onlycertainaspectsaregivenimportance,suchasthepatient’sawarenessof illness and compliancewithprescribed treatment.The assessmentof insight assumesmoreimportanceinpsychosis,astheincongruencebetweenthepatient’sandothers’viewofhisillnessoftenleadstodifficultieswithtreatment.Theconventioninpsychiatryisthatinsightisunim-pairedinnon-psychoticconditions,butitcanbeseenthatabroaderviewnearertothelexicaldefinitionisrelevantwhenneuroticsymptomshamperthefullrealizationofaperson’spotential.

DEVELOPMENT OF THE CONCEPT

Contributionstothedevelopmentoftheconceptofinsightderivefrompsychopathology,gestaltpsychologyandpsychoanalysis.Ingestaltpsychology,insightisconceivedasasudden,unexpectedsolutiontoaproblem.AccordingtoMarkova(2005),the‘suddenness’specifiesanabruptsolutiontoaproblem,the‘unexpectedness’referstothesurpriseelementoftheeventandtheterm‘solu-tiontoaproblem’signalsthediscretenessoftheeventintime.Inessence,ingestaltpsychology,insightisbydefinitionrelatedtoaspecifictask,aproblemthatstandsinneedofsolutionintheexternalworld.Furthermore,therehasbeenextensivedebatewithingestaltpsychologyaboutthenatureofinsight,whetheritisauniquehumanfacilitythatisalsoaspecificcognitiveskill.Thefactthat,ingestaltpsychology,insightreferstoaproblemintheexternalworlddistinguishesitfromtheconceptofinsightinclinicalpractice.Inclinicalpractice,insightfocusesonunderstand-ingofchangesorhappeningswithinanindividual.

ForJaspers(1959),typicallythepatient’sattitudetohisillnessinvolves‘anawarenessofillness’inwhichthepatient‘expressesafeelingofbeingillandchanged,butthereisnoextensionofthisawarenesstoallhissymptomsnortotheillnessasawhole.Itdoesnotinvolveanyobjectivelycorrectestimateoftheseverityoftheillnessnoranyobjectivelycorrectjudgementofitsparticulartype’.ForJaspers,‘onlywhenallthisispresentandtherehasbeenacorrectjudgementofallthesymptoms and the illness as a whole according to type and severity, can we speak of insight[emphasisinoriginal]’.Thus,forJaspersinsightbecomesmanifestonlywhenthepatientisabletoturnawayfromthecontentofhispsychicexperiencestowardsmakingajudgementaboutitandinquiringintoitscausesandreasons.Lewis’(1934,p.333)definitionofinsightas‘acorrectattitudetomorbidchangeinoneself ’, isarestatementofJaspers’descriptionof insight.Freud(1981)usedtheterminsighttodenoteknowledgeofillnessbut,onthewhole,inpsychoanalytictherapythedevelopmentofadeeperawarenessofselfisconsideredtobethegoaloftreatment.Thisisanotherwayofsayingthatinpsychoanalysis,insightreferstoknowledgeandunderstand-ingofone’sunconsciousmentalprocesses.Thisisamorecomplexnotionofinsight,becauseitinvolvesthepatientacquiringunderstandingoftheunconsciousmotivationsofhisbehaviourand,inthelightofFreud’sstructureofthemind,itsuggestsadegreeofdepthofunderstanding.

David (1990) has proposed that insight is composed of the three overlapping dimensionsdescribedabove.Ithasbeensuggestedthatparallelscanbedrawnbetweenthelossofinsightinpsychiatricpatientsandthelossofawarenessofdiseaseofpartsofthebodyincertainneurologicalconditions.Incorticalblindness,left-sidedhemiplegiafollowingstrokeandamnesicsyndrome,lack of awareness of disease is well recognized.The term anosognosia was coined by Babinski(1857–1932) to refer to the unawareness or denial of hemiplegia seen in patients following astroke.Thereisadifference,though,betweenthelackofinsightseeninpsychiatryandthelackof awareness seen inneurologicaldisease. Inpsychiatry, lackof insight is often attendedby a

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wider lossof judgementbeyondmerelythesymptomsortheir implicationsforthepatient.Inneurological cases, the lack of awareness is focused on a discrete disability. Nonetheless, eventhoughthe lackof insight inpsychiatryand lackofawarenessofdisease inneurologyarenotidentical,itmaybethatcomparisonsmaypointtopossibleneurobiologicalbasesthattheyshareincommon.

Therearecertainphilosophicalproblemswhenweconsiderinsightinpatientswithpsychosis.Peoplewithoutanypsychiatric illnessvary in their ability toknowthemselvesand theconse-quencesoftheirpersonalities.Becauseatleastsomeconceptualizationsofpsychosisrelyonthelackofinsightasadefiningfeature,discussionconcerningtheconceptcanbecomecircular.Addedtothisisthefactthatvaryingdegreesofinsightcanoccurandthatnon-verbalizationofinsightmaybedifferent fromthe lackof it.Yetanotherproblemis thatapossiblyspeciousmodel inwhicha‘normal’partofthemindiscapableofpassingjudgementonthe‘abnormality’ofanotherparthastobeentertained.Thisworksforaslongastheclinicianrecognizesthatitismerelyawayofspeaking,notnecessarilyanaccuraterepresentationofhowself-monitoringtakesplace.

MEASUREMENT OF INSIGHT

Earlierattempts tomeasure insightcentredon its role inpsychodynamic therapies.TolorandReznikoff (1960) developed a test using hypothetical situations based on common defencemechanisms and found a correlation with intelligence. This test was used by Roback andAbramowitz(1979),whofoundacorrelationinthosewithschizophreniabetweengreatersubjec-tivedistressandbetterbehaviouraladjustment.Thevalidityofthistestforgeneralclinicalworkisaffectedbytheconceptofinsightbeingbasedonpsychodynamicratherthanpsychopathologi-calfeatures.

Anyreliableandvalidmeasureofinsightinclinicalpracticeshouldbebasedonthefollowingfourassumptions:

■ insightiscomplexandmultidimensional■ culturalfactorsneedtobetakenintoaccount■ thelevelofinsightcanvaryacrossthemanymanifestationsofmentalillnesses■ informationaboutthenatureofaperson’sillnessfromsituationsotherthantheinterview

shouldbetakenintoaccount(McGorryandMcConville,1999).McEvoyetal.(1989a)developedaquestionnairetomeasureinsight,definedasthepatient’s

awarenessofthepathologicalnatureofhisexperiencesandalsohisagreementwiththetreatingprofessionalsabouttheneedfortreatment.TheInsightandTreatmentAttitudesQuestionnaire(ITAQ)isavalidated11item,semi-structuredinterviewthatgeneratesascorefrom0(noinsight)to22 (maximum insight).Using thisquestionnaire, they foundno correlationwith aspectsofacutepsychopathology.

The Schedule for Assessment of Insight in Psychosis was published in 1992 (David etal.1992),inwhich,apartfromtherecognitionofmentalillnessandcompliancewithtreatment,theabilitytorelabelunusualmentaleventsaspathologicalwasalsoincluded.Thereweresevenitemswithamaximumpossiblescoreof14andanadditionalitemonhypotheticalcontradiction.

TheScaletoAssessUnawarenessofMentalDisorder(AmadorandStrauss,1993)isamuchmorecomprehensivescalewithsixgeneral itemsandfoursubscales, fromwhichtensummaryscorescanbecalculated.Other scalesavailableare theGlobal InsightScale (Greenfieldetal.,1989)andtheself-reportedInsightScale forPsychosis (Birchwoodetal.,1994).ThescalebyMarkova and Berrios (1991) is more directed to evaluating aspects of self-awareness and lesstoclinicaldefinitionof insightwithregard to illness.This isalso true for theBeckCognitiveInsightScale(Becketal.,2004)whichmeasuresawidernotionofinsight,encompassingpatients’capacityforevaluatingtheiranomalousexperiencesandtheirerroneousinferences.Thescaleiscomposedoftwosubscales:self-reflectivenessandself-certainty.


Otherapproacheshavebeentousethe‘lackofinsightandjudgement’itemofthePositiveandNegativeSyndromeScale(PANSS;Kayetal.,1987)asasingleglobalmeasureofinsight,andtheuseofpsychopathologyvignettes.McEvoyetal.(1993)usedvignettesthatcastspecificpsychopathologicalfeaturesineverydaylanguagetojudgewhetherpatientsdemonstratedthesefeaturesandthedegreetowhichtheyattributedthemtomentalillness.Theyfoundthatpatientsfailedtoacknowledgenegativesymptomsandfailedtoviewpositivesymptomsasevidenceofmentalillness.

From earlier impressionistic assessments of a global nature, measurement of insight hasmorerecentlyprogressedtotheuseofoperationalizeddefinitionsandstandardizedinstruments.Althoughthedifferentinstrumentsmightbemeasuringdifferentaspectsofacomplexphenom-enon,thereisatleastthefreedomtochooseonetosuitspecificclinicalorresearchaims.Thereisaninversecorrelationbetweeninsight,theseverityofpsychopathologyandpositiveaffectivedisturbance(Sanzetal.,1998).

SCHIZOPHRENIA

Itisnotreallysurprisingthatmostoftheresearchworkontheclinicalcorrelatesofinsighthasbeenonpatientswithschizophrenia.McEvoyetal. (1989a)reportedthat insightasmeasuredbytheITAQdidnotcorrelatewitheithertheseverityofacutepsychopathologyorthechangesin psychopathology with treatment.They speculated whether the mechanisms underlying theproductionofpositivesymptomsanddisturbedinsightwereindependentandwhetherthelatterwasmoreresistanttotheeffectiveuseofneurolepticmedication.Davidetal.(1992)foundthatthe‘totalinsightscore’intheirstudyhadamoderateinversecorrelationwiththePresentStateExamination(Wingetal.,1974)totalscore,whichwasanindicationoftheglobalseverityoftheillness.BothDavidetal.(1992)andMcEvoyetal.(1989b)foundthat,asagroup,involuntary(thatiscompulsorilyadmitted)patientshavelessinsight.Overall,itdoesappearthattherelation-shipbetweenpoorinsightandaspectsofpsychopathologyisnotlinearbutcomplicatedbyotherfactors,includingcompliancewithtreatment.

Insight and Cognitive ImpairmentIthasoftenbeenspeculatedthatpoorinsightmayhaveaneurologicalbasis.LysakerandBell(1994) found that subjects with impaired insight performed more poorly than subjects withunimpairedinsightontheWisconsinCardSortingTest(WCST).TheyusedthePANSSitemof‘lackofinsightandjudgement’tomeasureinsight.Thisitemhadbeenshownbyfactorana-lyticalstudiestobeamemberofthecomponentcomposedofsymptomsofcognitiveimpairmentsuchascognitivedisorganization,poorattention,stereotypedthinkingandpoorabstractthink-ing.However,usingadifferentmethodology,KempandDavid(1996)failedtoshowarelation-shipbetweeninsightandneuropsychologicaldeficits.Itispossiblethatchronicityoftheillnesscouldbeanadditionalvariable,whichpredisposestocognitiveimpairment.Davidetal.(1992)hadfoundarelationshipbetweenaspectsof insightandintellectualperformance.Cuestaetal.(1995) failed to showany relationshipbetween insight andpoorperformanceon theWCST.However,thestudydidnotuseanyofthestandardratingscalestomeasureinsight.Inanotherstudy,Upthegroveetal.(2002)showedthatimpaireddigitspanasameasureofworkingmemorywassignificantlyassociatedwithinsightasmeasuredbyastandardizedmeasure.Additionally,itisbecomingclearerthatinsightcorrelateswithindicesofcognitivefunctionsincludingmeasuresoferrormonitoring,empathyandtheoryofmind(Pegaroetal.,2013;Pijnenborgetal.,2013;Kaoetal.,2013).However,onbalance,theexactnatureandextentoftheserelationshipsisstillunresolved.Asinotherclinicalsituations,therelationshipmaynotbeastraightforwardone,asothervariables,suchasthechronicityofillness,treatmentfactors,andgendermayallbeinvolved.

11—INSIGhT 181

Outcome

Therelationshipbetweeninsightandoutcomeisacomplexone.Firstly,greaterinsightseemstopredicthopelessness,depressionandsuicide(Ampalametal.,2012;BalharaandVerma,2012;Schranketal.,2013).Awarenessoftheadversesocialimplicationsofmentalillnessmaybethemediatingfactorbetweeninsightanddepression(Thomasetal.,2012).

Secondly,McEvoyetal.(1989c)foundthatpatientswithgoodinsightweresignificantlylesslikely toberehospitalizedandtendedtobemorecompliantwithtreatment30daysafterdis-charge;theoverallrelationshipbetweeninsightandoutcomecloselyapproachedstatisticalsig-nificance.Theirmeasureof‘after-careenvironment’,whichaimedtoreflectthedegreetowhichothers’effortswerehelpfullyinvestedinmaintainingthepatientintreatment,wasnotrelatedtoinsight.AmadorandStrauss(1993)alsofoundtheirmeasuresof insighttobecorrelatedwiththecourseoftheillness.

Relatedtotheissueofprognosisandoutcomeiscompliancewithtreatment.Therelationshipbetween poor insight and poor compliance with treatment has been shown by Bartko etal.(1988),Linetal.(1979)andMcEvoyetal.(1989c).

Thebalanceofevidenceseemstobethathigherlevelsofawarenessofhavinganillnessareassociated with better medication compliance and clinical outcome (Amador etal., 1991) inschizophrenia.However, there isa riskofcircularityof logic, in that someof themeasuresofinsightarebasedondefinitionsofinsightthatincludenon-compliance.Moreover,compliancewithprescribedtreatmentisamuchmorecomplexphenomenonaffectedbysocialfactorsandbeliefs about health and sickness (Bebbington, 1995). It is also possible that the relationshipbetweencomplianceanddifferentaspectsofinsightmaybedifferent.Davidetal.(1992)foundthattreatmentcompliancewasnotstronglyrelatedtotheabilitytorecognizeone’sowndelusionsandhallucinationsandtorelabelthemasabnormal.

It is interestingthatpatientsmaycomplywithtreatment,eventhoughtheydonotbelievethemselvestobeill,ifthesocialmilieuisconducive(McEvoyetal.1989b,c).Theroleofhealthbeliefsand illness representation indeterminingcompliancewith treatment is recognized,buthow these interact with insight to influence treatment compliance has yet to be studied.Thedomains of illness representation are identity (the label of the disease), causes (explanatorymodels),timeline(onsetandanticipatedduration),control(beliefthatselfcaninfluenceoutcome)and consequences (functional aswell as other consequences) (Brownlee etal., 2000).What isobvious is that insight is not the only determinant of care-seeking and treatment adherence.McEvoyetal.(1993)proposedthatinsightwouldimprovewithattemptsatpsychosocialreha-bilitation.ThiswasfurtherstudiedbyLysakerandBell (1995)onasampleofpatientswithadiagnosisof schizophreniaor schizoaffectivedisorder.Earlier,Lysakeretal. (1994)had foundinsightasmeasuredbytheitemonPANSStobecorrelatedwithpoorlevelsofworkqualityandparticipationinrehabilitativeprogrammes.Intheirstudyreportedin1995,patientsenrolledinvocationalrehabilitativeprogrammeswerefoundtohaveimprovedinsightafterfivemonths.Thisimprovementwas greater for patientswith comparatively few cognitivedeficits, echoing theirearlier findings regarding a relationship with cognitive impairments. However, the lack of acontrolgrouplimitsthegeneralizabilityofthefindings.Itdoesseemaninterestingsuggestionthatvocationalrehabilitationcanfavourablyaffectinsightintheabsenceofcognitiveimpairment.McEvoyetal.(1993)haveproposedthatenhancedself-esteemfromrehabilitationmayunderlieimprovementininsight.

BIPOLAR DISORDERS

Ghaemietal.(1995)studiedinsightinacutelymanicpatientsusingtheITAQandfoundthatimprovement in insightdidnotcorrelatewith recovery fromother symptoms.However, as inschizophrenia, poor insight was correlated with involuntary admission. Swanson etal. (1995)


usedthecasevignettemethodtostudyinsightintwogroupsofpatientswithschizophreniaandmania.They foundaqualitativedifferencebetweenmania and schizophrenia, in thatpatientswithschizophreniabutnotmaniahadreducedawarenessoffeaturesoftheir illness.However,althoughthemanicpatientswereawareoftheirsymptoms,theydidnotagreethattheseema-nated from a mental illness. Amador etal. (1994) and Michalakes etal. (1994), on the otherhand,foundnosignificantdifferencebetweenschizophrenicandmanicpatientsonmeasuresofinsight.Theformerfoundthatseverelymanicpatientsweresimilartopatientswithschizophreniaonscoresofinsight,whereasdepressedandschizoaffectivepatientshadmoreinsight.Inconclu-sion,itseemstobethatbothschizophreniaandbipolardisorderpatientshaveimpairedinsightand the mediating factors may be severity of symptoms and cognitive impairment, especiallyworkingmemoryimpairment(Vargaetal.,2007).

CRITICISMS OF THE CONCEPT

Therecentresurgenceofinterestininsighthashaditsshareofcriticism.Medicalanthropologistshavecriticizedtheconceptofinsightforfailingtorecognizethatpeoplecanhavevariouscultur-allyshapedframeworkstoexplaintheirillnesses,allpossiblyvalid.Fromthispointofview,theconceptof insight is ‘Eurocentric and essentially arrogant’ (Perkins andMoodley, 1993), as itdictatesthatpatientsshould,apartfromagreeingthattheyarementallyillandrequiringtreat-ment, also agree to reconstruct their experiences within the terms and concepts of Westernpsychiatry. Johnson andOrrell (1995)have reviewedworkby social scientists on cultural andsocialvariationsinlayperceptionsofmentalillnessandarguethatthesewouldinfluenceinsight.Social and cultural backgrounds influence perceptions of stigma from mental illness and thecongruenceofthepatientswithWesternmedicalviewsofmentalillness.Theabilitytorelabelmentalphenomenaasabnormalmaybe less influencedby social factorswhencomparedwithbeliefs about the causationofmental illness.Although therearevery few studies in this area,evidenceseemstobeemergingthatsocialandculturalfactorsareimportantinthediagnosisofpoorinsight.Forexample,differencesintheethnicbackgroundofthepsychiatristandthepatientappeartoinfluencethejudgementoftheformeraboutinsight( JohnsonandOrrell,1996).

AETIOLOGY OF IMPAIRED INSIGHT

Attempts toexplain thecausationofpoor insighthave focusedon threehypotheses (Amadoretal.,1991;LysakerandBell,1994).Thefirsttwofocusonputativepsychologicalmechanisms.Ithasbeensuggestedthatrefusaltotakeprescribedmedication,implyingpoorinsight,isawilfulpreference for the experience of psychotic phenomenology over drug-induced normality.Thesecondformulationsuggeststhatpatientsdenyillnessatapsychologicalleveltohelpthemcopewithnormallifeastheyrecoverfromapsychosis.Athirdexplanationhassuggestedthatpoorinsightmayhavesomethingtodowithcognitiveimpairment,drawingonsimilaritieswithneu-rologicalconditionssuchasanosognosia.Asmentionedearlier,studieshavefoundasignificantcorrelation between impaired performance on the WCST and poor insight, suggesting thatcognitiveimpairmentsresultingfromfrontallobedeficitsmayunderliepoorinsightinschizo-phrenia.And,afourthexplanationisthatdisruptionofneuralmechanismsandnetworksunderly-ingself-andother-monitoringareinvolved.Inarecentstudy,schizophreniapatientsdemonstratedlessactivationintheposteriorcingulatecortexintheself-andother-reflectionconditionsandlessactivationintheprecuneusintheother-reflectionconditioncomparedwithhealthycontrols.Betterinsightwasassociatedwithgreaterresponseintheinferiorfrontalgyrus,anteriorinsula,andinferiorparietallobuleduringself-reflection.Inaddition,bettercognitiveinsightwasassoci-atedwithhigheractivationinventromedialprefrontalcortexduringself-reflection(vanderMeeretal.,2012).

11—INSIGhT 183

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S E C T I O N FOURSelf and Body

187

C H A P T E R 12

The Disordered Self

SummaryThe self isaconstruct thathaschanged inmeaningandsignificanceover theyears.Therearefiveputative,formalcharacteristicsoftheself:egovitality,egoactivity,unityoftheselfovertime,self-identityandboundaryoftheself.Theseformalaspectsoftheselfcanbeimpairedbypsy-chiatricdisorders.The senseof vitality canbe impaired toproduce a feelingofdeadness, theextremeexamplebeingnihilisticdelusions. Indisorderofactivity the‘my-ness’ofactions, thesenseofbeinganagentenactingone’swillintheworld,canbedisruptedasoccursinpassivityexperiences.Theunityof theselfover time ismarkedlyaffected inautoscopyanddissociativeidentity disorders. Additionally, disorder of self-identity is illustrated by possession states andphenomenasuchaslycanthropy.Finally,abnormalitiesofthedistinctionbetweenselfandnon-self (disturbance of boundary) is central to our understanding of such diverse experiences inschizophreniaaspassivityexperiences,thoughtinsertionandthoughtwithdrawal.

Often, when I was alone, I sat down on this stone, and then began an imaginary game that went something like this: ‘I am sitting on top of this

stone and it is underneath’. But the stone also could say ‘I’ and think: ‘I am lying here on this slope and he is sitting on top of me’. The question then

arose: ‘Am I the one who is sitting on the stone, or am I the stone on which he is sitting?’ This question always perplexed me, and I would stand up,

wondering who was what now.Jung (1963)

The self was never meant to be a solid object like a stone, a horse, or a weed, nor even a concept to be considered as semantically tantamount to changes in

blood flow or test scores. Of course, patients with disordered minds do sport hurting, afflicted and cursing selves but not as they do carcinomas or broken

legs. Their selves live in the same realm as do their virtues, vices, beliefs and aspirations, and that is where they should remain.

Berrios and Markova (2003)

Ego and SelfThe self is a construct that has changed in meaning and significance since the inception ofHellenisticphilosophy(BerriosandMarkova,2003).Fromthemid-nineteenthcenturyonwards,variousconceptsabouttheselfhavefoundtheirwayintopsychiatrysuchthatincontemporarypsychiatrythereisreckonedtobesomedisturbanceinthewayonethinksaboutandestimatesoneself;this,ofcourse,differsaccordingtothenatureoftheillness.Thereis,however,nocon-sensusonwhatexactly itmeanstobeaself.There isapluralityofconceptions, includingtheecologicalself, the interpersonalself, theextendedself, theprivateselfandtheconceptualself

Keywords: Ego,BodyImage,Self-image,Autoscopy,PossessionState.

12—ThE DiSOrDErED SELF 187.e1

188 FOUR—SELF AND BODY

amongmany(Zahavi,2003).Inthischapter,thetermsegoandselfareusedmoreorlessinter-changeably.Egohastheadvantageofbeingatechnicaltermandthereforemorecircumscribedinitsmeaning;thisisalsoadisadvantagewhenitissimplyoneself,asisusuallyunderstoodandsubjectivelyexperienced,thatisbeingreferredto.

Freud’suseofthewordegoechoesNietzsche(1901):

It is this which sees everywhere deed and doer; this which believes in will as cause in general; this which believes in the ‘ego’ as being, in the ego as

substance, and which projects its belief in the ego-substance on to all things.

Freud(1933)describedegoasstanding‘forreasonandgoodsensewhiletheidstandsfortheuntamedpassions’.Theego:

has been modified by the proximity of the external world with its threat of danger… The poor ego has to serve three severe masters and does what it can

to bring their claims and demands into harmony with one another. These demands are always divergent and often seem incompatible. No wonder that the ego so often fails in this task. Its three tyrannical masters are the external

world, the super-ego and the id.(Freud, 1933)

Self-Concept and Body ImageThebodyisuniqueinthatitisexperiencedbyapersonbothassubjectofexperienceandasanobjectwiththesamematerialityasanyotherphysicalobjectintheworld.ThereisawayinwhichIamsubjectivelyawareofmyownbodythatisdifferentfromhowIexperienceablockofwood.ButIamalsoawarethatmybodyisanobjectintheworld,tobeviewedandevenactedonbyothers.Formostofthetime,wearenotawareofourbodybut,forexampleinextremeanxiety,traumaticpainandsexualexcitement,thereisanawarenessofthebodyasanobject:‘myheartbanging,myfingerthrobbing’.Fortherestofthetimeweassumethepartsofthebodytobeintegrated, and this integratedbody, forpracticalpurposes, coincideswithand is coterminouswith the ‘self ’ of which we are not separately aware and which we take for granted. In otherwords it ismostly in timesofdistressorpain thatwebecomeawareofourbodiesasdistinctfrom ‘ourselves’. It is throughourbody thatwehave contactwith theworldoutsideour self:movementsofthebodyrelateustoexternalspace;ourhandshaveaprehensiletool-likeaspectto them that allow us to grasp objects in the world; and our bodies have a physicality aboutthemthatoccupy space,giveuspresence, locatingus asobjects in theworld.OneofEugeneMinkowski’s(1970)patientssaid:

I don’t want to attach so much attention to my movements, but I am only grub and defaecation. I am only a sort of animal function, and one that

injures himself. I have the feeling of being nothing but living tripe. I have neither sensations nor precise ideas. I have the feeling of being nothing but

vegetative functions, of being nothing but a mass.

Anothersaid:

One day out of two, my body is hard as wood. Today my body is thick like this wall (points to the wall).

12—ThE DiSOrDErED SELF 189

Minkowski referred to these experiences as exaggerated materiality in which the patientsdemonstrateanincreasedawarenessofthe‘objectified’aspectofthebodyandrenderingsalientforthecliniciananattitudetothebodythatisnotmanifestinday-to-daylife.

Manydifferenttermsareusedtodescribethewayapersonconceptualizeshimself.Neurologists,neuropsychiatrists,psychoanalystsandpsychologistshaveusedvariouslythetermsbody schema, body concept, body cathexis, body imageandperceived body.Theydescribeapproximatelythesamethingbutwithdifferentnuances.Forexample, self-concept tendstorefer tothefullyconsciousand abstract awareness of oneself, while body image is more concerned with unconscious andphysicalmattersandincludesexperientialaspectsofbodyawareness.Sometimesself-conceptisthesameasbodyconcept,andatothertimesconsciousselfisconceptualizedasbeingindepend-entofits‘cage’,thebody.Thebody schemaimpliesaspatialelementandismorethan,andusuallybiggerthan,thebodyitself.Forinstance,ifyouimagineyourselfonyourwaytowork,automati-callyincludedwithinyourschemaofyourselfareyourclothesandyourspectacles,ifworn.Thebodyschemachangeswithchangingcircumstances.WhenIdrivemycar,Iincorporatewithinmyconceptofmyphysicalsizethewidthofmycar,sothatIamunlikelytoattempttodrivethrough a doorway or up a flight of steps. Spectacles, a cigar, the carpenter’s screwdriver, theblindman’sstickallcontributetothatperson’sconceptofhisselfinaparticularsituation.Cathexisimpliesthenotionofpower,force,libido–perhapsanalogoustoelectricalcharge:theselfthatmakesthingshappen!

Social aspects are obviously important. A man with shoulder-length hair is not usually soendowedthroughneglect;morelikely,itrepresentsadeliberatechoice–howheseeshimselfinhissocialsetting.Itaccordswithhischosenpeergroupandalsodistinguisheshimfromthosefromwhomhewouldwishtobedisassociated.Critchley(1950)hascommentedon‘thatcuriousemotionalstateusuallyknownasbeinginlove’,inwhichthereis‘acompulsivetrendintwobodyimages of opposite sex towards propinquity and contiguity, eventually culminating in a totalfusionormerger’.Asaphenomenologist,onecouldtakeexceptiontoCritchley’smisuseofthetermcompulsive.AccordingtoSchilder(1935),bodyimagesareneverisolated;theyarealwaysencircled by the body images of others. Body images are more closely bound together in theerogenouszonesandaresocialinnature.Ourbodyimageandthewayotherpeopleseeusarenotexclusivelydependentoneachother.Aperson seeshimself and formshis self-image inasocial setting. He sees himself in relation to other people; his view of himself is not totallydependenton,butimportantlyinfluencedby,howanotherindividualseeshim.Itisalsodeter-minedbyhowhebelievesthatpeoplemightseehim.

ThedevelopmentofbodyimagehasbeenneatlysummarizeddiagrammaticallybyBahnson(1969).Heconsidersthatself-imageischangeableandamorphous.Atanyonetime,theindi-vidualperceivesonlyasmallsamplefromagalleryofpossibleself-images.InFigure12.1,themanner inwhich ‘phenomenological selves are superimposedoneachother like the layersof anonion’isdemonstrated.Differentaspectsofself-imagedevelopasthepersonincreasesthescopeand complexity of his relationships.The term ego is not phenomenologically describable, andtherehasbeenargumentthattheselfcannotobserve itself; that is,a thingandwhatobservesthatthingcannotbethesame.However,itisthenatureofselfandegotobeexperiencedaseithersubjectorobject:asmallnuisancelikeamouthulcercanmakemefeeluncomfortable(subjec-tively);Icandescribewhatapersonwithamouthulcerexperiences(objectively).

Self-Image and Non-Verbal CommunicationInasocialrelationship,apersonexpressesviewshehasabouthimself:hiswords,andthewayhesaysthem,conveyhowheviewshisrelationshipwiththeotherpersonandalsohowheseeshimself,forexampletheshopkeeper‘talkingdown’toachild.Probablymoreimportantthanthisverbal manner of expressing, often unconscious, views on how we see ourselves is non-verbal


Figure 12.1 Developmental phases of the self-image.

Somatic self: prenatal, 1 year

Self-differentiation from theenvironment: 1–3 years

Oedipus, family, role taking,externally derivedself-image: 4–10 years

Puberty, revival of bodyimage: 11–14 years

Redefinition of socialroles: 15–18 years

Adult investment in society,symbols, abstractions,family of procreation

communication.Allgesturesandpostures,movementsofthefaceandpausesinourconversationconveymeaningtothepersonwearetalkingto;partly,thisisalsoacommentonthewayweseeourselves.

‘Thecentral coreof self-imageconsists for apersonofhisname,hisbodily feelings,bodyimage,sexandage.Foramanthejobwillbecentral–unlessheissufferingfromjobalienation.Forawoman,herfamilyandherhusband’sjobmayalsobeimportant’(Argyle,1975).Thegenderdiscriminationofthatstatementisnowdated,butitemphasizesthatfordifferentpeopletherearevaryingaspectsthatformtheessentialconceptofself.Non-verbalaspectsofcommunicationareimportantinsendingandreceivinginformationaboutthepersonality.Theroleinsocietyonehasadoptedandthegroupwithwhichone identifiesare intentionallyconveyedandthereforedisplayself-image.Theseinclude‘age,sex,race,socialclass,rank,occupation,schoolorcollegeattended, nationality, regional origins, religious group and family connections’ (Argyle, 1975).Theseattributesofthepersonareoftendeliberatelydisplayed,butthereareothercharacteristicsthatwillbereceivednon-verballybyobserversevenwhenthepersonhasnointentionofrevealingthem,forexampletemperament,personalitytraitssuchasintroversion,intellect,beliefsandvaluesandpastexperiences.

Non-verbalcommunicationexpressestheattitudesofaperson,accordingtoArgyle,forthefollowingreasons.

■ Thereisinsomeareasofhumanconcernalackoflanguageor‘verbalcoding’,forexampleshapeismorereadilyexpressedwiththehandsthanverbally.Describingpersonality,ourownoranother’s,orcommentingonpersonalrelationshipsismoreeasilydonenon-verbally.Apersonwillattempttocommunicatenon-verballyhisorherownphysicalattractiveness,roleandattitudetowardstheotherperson.

■ Non-verbalsignalsaremorepowerful:actionsspeaklouderthanwords.Foraschoolteacher,beckoningmaybemorelikelytoresultinactionthanaverbalorder.

■ Non-verbalsignalsarelesscensoredandthereforemorelikelytobegenuine.Ifconflictingmessagesaregivenverballyandnon-verbally,thenon-verbalsignalisacceptedastruthful.


■ Somemessages,becauseof social censorship, cannotbemadeexplicit in a social settingandthereforecannotbeverbalizedbutcanbeconveyednon-verballybyappropriateposture,gestureandmovementinspace.Forexample,byfacialexpressionandturningaway,apersonmightsuggestwithoutmaking itexplicit‘Idonot likeyouandamboredwithspeakingtoyou’.

■ Verbalmessagesarepunctuatedandemphasizednon-verbally,forexamplethepauseattheendofaphraseorthecadenceofvoiceused.Theseembellishmentsaddmeaningtotheactualwordsused.

Apersoninteractswithothersbytheuseoflanguage.However,non-verbalsignalsarealsoimportantinexpressingmeaningandconveyingfeelings.Theegotalkswiththebodyaswellaswithwords.

Awareness of the BodyWehaveanawarenessofourselfandanawareness,whichoverlapswiththisbutisslightlydif-ferent,ofourbodies.What is thissenseofbodyimageorawareness?AccordingtoHeadandHolmes (1911), thebody schema is formedas thecompositeexperienceof sensations.Schilder(1935)developedfurthertheimportanceofperceivingsensationsinformingthebodyschema:‘thepictureofourownbodywhichweforminourmind,that istosay,thewayinwhichthebodyappearstoourselves’.Freud(1933)alsowasconcernedwithbodyimageinthedevelopmentofpersonality:‘theegoisfirstlythebodyego’.Clearly,abnormalityofbodyimagemaybetheresultofabnormal sensations,but this isnotalways so.For instance, theabnormalityofbodyimageofanamputeeisdirectlybecauseofthephysicaldamage,butahypochondriacalpatientmayhavenoabnormalsensationsyetbelieveshehascancer.Intranssexualism,amanmayhaveanormalsensoryexperienceofhisbodybutsaysthathehateshisbodyandespeciallyhispenis;hemayfeelthatheisactuallyawomantrappedinsideamalebody(Morris,1974).Hisdisturbedbody image isnot a resultofdisturbed sensation; there is a conflictbetweenego (thewayheexperienceshimselfandthegenderheascribestoit)andbodyimage.ThedistinctionmadeforconveniencebetweenthischapterandChapter14,betweenself-awarenessandawarenessofthebody,isartificial.

Thebodyimagecanbealteredthroughenhancement,diminution(orablation)ordistortion.Itincorporatesmorethanjustthebody,exceptperhapsforthosefewoccasionswhenapersonisbothunclothedandconceptualizinghimselfasnaked: tailorshave longtriedtopersuadeusthat‘clothesmaketheman’.Certainly,theyareaneffectivemeansofnon-verbalcommunication.Clothesgiveussomeinsightintothewayapersonseeshimself(orherself )andalsointhewayhe(orshe)proposestointeractwithotherpeople.Apersoncomplementshismoodandhissocialroleofthemomentinhischoiceofclothes.Hewearsclothes,asashiphoistsaflag,forsignal-ling,andparticularclothesareworntoconveyamessagetosomeonewhocanreadit.Amedicalstudentwearsasuitforanoralexamination,awomanundoesthetopbuttonofherblouseonleavingtheofficefor lunch.Asthepatientcomesintoadoctor’sconsultingroom,hestartstogiveinformationabouthimselffromhisappearancebeforeeitherofthemuttersaword.Apersonwhoseclothesarechosenforhim,asinmentalhospitalsinthepast,presentsapeculiarlybleakandmeaninglessappearance;thisaspectofhisbodyimageisexpressionlessandconveysnothingofhimself.

Disorders of SelfIndescriptivepsychopathology,oneusesthetermego disordersordisorders of selftodescribetheabnormal inner experiences of I-ness and my-ness that occur in psychiatric illness.These mayoccur in thepatient’s stateof inner awareness irrespectiveof any changeshemay show in hisattitude to, or experience of, the world outside himself. Jaspers (1959), with characteristic


clarity, described self-awareness, that is, the ability todistinguish I from not I, ashaving fourformalcharacteristics.Scharfetter(1981,1995,2003)addedafifthdimensionofego vitalitytothelistandhasmadeacaseforitsinclusionbasedonfactoranalysis.Previously,thischaracteristicwas incorporated within the awareness of activity, which subsumed ‘being’ and ‘existing’ withotherpresentparticiples.Thus,wenowhavethefollowingcharacteristicsofself-awareness:

■ The feeling of awareness of being or existing(egovitality):IknowthatIamaliveandexist,andthisisfundamentaltoawarenessofself.

■ The feeling of awareness of activity (egoactivity):IknowthatIamanagentwhoinitiatesandexecutesmythoughtsandactions.

■ An awareness of unity(egoconsistencyandcoherence):atanygivenmoment,IknowthatIamoneperson.

■ Awareness of identity (ego identity): there is continuity in my biography, physiognomy,gender,genealogicalorigin,etc.;Ihavebeenthesamepersonallthetime.

■ Awareness of the boundaries of self (egodemarcation):Iamdistinct fromotherthingsandbeings andcandistinguishwhat ismyself from theoutside world, and I amawareof theboundarybetweenselfandnon-self.

Thedisordersofinnerexperienceinwhichthesecharacteristicsaredisturbedarenowexploredinmoredetail.WewilldealwiththesefivefunctionsdescribedbyJaspersandScharfetterinorder.

DISORDER OF BEING OR EGO VITALITY

Ineverhavetoaskmyself thequestionas towhetherIexist. It isanassumptionthatImakewithunquestioningcertainty.Iamsosureofthisthatitdoesnotevencomeontotheagendaofdoubtsanduncertainties.MyonlyknowledgethateverythingelseexistsisbasedonthepremisethatIdo.

Being: thepatient’sexperienceofhisveryexistencemaybealtered:‘Idonotexist; there isnothinghere’or‘Iamnotaliveanymore’or‘Iamrotting’.Thisisthecoreexperienceofnihilistic delusions,whichmayoccurinaffectivepsychoses(Chapters8and16).Seebelowforanexample.

I do not sense myself anymore. I do not exist anymore. When someone speaks to me, I feel as if he were speaking to a dead person. I have to look at myself to be sure that it is I. I have the feeling of being an absent person. In sum, I

am a walking shadow. (Minkowski, 1970)

Lesspronouncednihilisticideas(notdelusions)areexperiencedasdepersonalization,analtera-tionof thewayoneexperiencesoneself,which isaccompaniedbya feelingofanalterationorlossofsignificanceforself:‘Ifeelunreal,abitwoozy,asthoughIcan’tbequitecertainofmyselfanymore’.

DISORDER OF ACTIVITY

IdosomethingandknowthatIamdoingit.EverythingIdo,ineverythingIexperience,througheveryeventthatimpingesonme,Iamawarethattheexperiencehastheuniquequalityofbeing mine.‘Itwasincredible.Ipinchedmyselftomakesureitwasreallyhappeningtome’expressesthe relationship we experience between awareness of reality and activity. It is in our actions,includingourthinking,thatwereinforceourselvesconcerningourexistence.

Movingmayshowabnormality,forexampleinthepassivityexperienceordelusionsofcon-trol of patients with schizophrenia (see below). Schreber described several examples of thisexperience:


The difficulties which were put in my way defy description. My fingers are paralysed, the direction of my gaze is changed in order to prevent my finding

the correct keys, the tempo is quickened by making the muscles of my fingers move prematurely: all these were and still are daily occurrences

and

the bellowing-miracle when my muscles serving the processes of respiration are set in motion by the lower God (Ariman) in such a way that I am forced

to emit the bellowing noises.

Memorizing and imaginingmaybe changed in that thepatientwithdepression feelshe isunable to initiate the act ofmemoryor fantasy; or, alternatively, a patientwith schizophreniafeelsthatthisactivitywhenitoccursisnotinitiatedbyhimbutfromoutsidehimself.Adepressedpatientsaid,‘mymemoryhasgone,Ihavenothoughts,Icannotthinkatall’.

Willingmaybealtered,forexamplethepatientwithschizophreniawhonolongerexperienceshiswillasbeinghisown.Commonly,neuroticpatientsdescribeaninabilitytoinitiateactivity,afeelingofpowerlessness,ofbeinggrounddowninthefaceoflife’svicissitudes.

Someoftheseabnormalitiesofexperienceofone’sownactivitiesarecloselyassociatedwithmood,forexamplethefeelingofthedepressedpatientwhobelievesthatheisincapableofdoinganythingat all: the alterationof self-concept isdirectly linked to themood state.Sometimes,however,itisnottheaffectassociatedwiththechangeofactivitybutthebeliefabouttheinitia-tionoftheactivitythatischanged.Thesearethepassivityexperiences(madeexperiences),whicharediscussedinmoredetailwithotherfirst-ranksymptomsofschizophreniainChapter9.

DISORDER OF SINGLENESS OR EGO CONSISTENCY AND COHERENCE

Inhealth, aperson is integrated inhis thinking andbehaviour so thathe isnot awareofhisfeelingofunity.Thereisanimplicitassumptionthatheisoneperson,andheknowshislimita-tionsandcapabilities.Thisassumptionofunitymaybelostinsomeconditions.Indreams,onesometimesseesoneself,evenperhapswithsomesurprise,inthedrama.Insomeformsoftran-scendentalmeditation,bycarryingoutrepetitivemonotonousactsthesubjectentersaself-inducedtranceinwhichhecanobservehimselfcarryingoutthebehaviour.‘Self ’isboththeobserverandalsotheobjectofobservation(seeBox12.1).

BOX 12.1 ■ Disorders of singleness

■ Therearesixtypesofautoscopy:feelingofpresence,negativeautoscopy,innerautoscopy,autoscopichallucination,outofbodyexperience,heautoscopyproper

■ Feelingofpresenceisadistinctfeelingofthephysicalpresenceofanotherperson■ Negativeautoscopyreferstothefailuretoperceiveone’sownbodyeitherinamirrororwhenlooked

atdirectly■ Innerautoscopyreferstotheexperienceofvisualhallucinationsofinternalorgansinextra-corporeal

space■ Out of body experience is characterizedby theprojectionof anobserving (psychological) self in

extra-personalspaceseeminglytotallydissociatedfromthephysicalbody■ Heautoscopydesignatesaconditioninwhichanindividualseeshisdoubleordoppelgänger


Autoscopy (Heautoscopy)

Autoscopyisaprofoundlyconceptuallychallengingphenomenoninwhichtheusualindivisibilityoftheselfappearstobecompromised.AccordingtoFish(1967),‘inthisstrangeexperiencethepatientseeshimselfandknowsthatitishe.Itisnotjustavisualhallucinationbecausekinaestheticandsomaticsensationmustalsobepresenttogivethesubjecttheimpressionthatthehallucina-tionishe’.Morerecently,BruggerandRegard(1997)haveidentifiedsixtypesofautoscopy:thefeeling of presence;negative heautoscopy;inner heautoscopy;autoscopic hallucination, out of body experi-ence;andheautoscopy proper.

Inthefeeling of presence,thepatienthasadistinctfeelingofthephysicalpresenceofanotherperson.Novisualperceptionisusuallyreported.Thefeelingofpresencemaybeconfinedtoonehemispaceespeciallywhentheexperienceoccursinassociationwithaseizure.

Negative heautoscopyreferstothefailuretoperceiveone’sownbodyeitherinamirrororwhenlookedatdirectly.Thisphenomenonisoftenassociatedwithdepersonalization.Inner heautoscopyreferstotheexperienceofvisualhallucinationsofinternalorgansinextra-corporealspace(Sollier,1903). Autoscopic hallucination is said to occur when a patient sees an exact mirror image ofhimself,orofhis faceor trunk.Thisexperience isdistinct fromheautoscopy properbecausethepatientdoesnotlocalizehimselfinthepositionofthemirrorimage.Thesehallucinatoryexperi-ences are usually brief, lasting seconds to minutes and followed by flash-like recurrences(Lhermitte,1951;Brugger,2002;Dewhurstetal,1955).

Out of body experiences are characterizedby theprojectionof anobserving (psychological)selfinextra-personalspaceseeminglytotallydissociatedfromthephysicalbody.Inthisphenom-enon, the patient sees himself and the world from a location distinct from his physical body.Therearethreephenomenologicalcharacteristicshere:disembodiment,theimpressionofseeingthe body from a distant and elevated visuo-spatial perspective (the so-called extra-corporealegocentricperspective)andtheimpressionofseeingone’sownbodyfromthiselevatedposition(Anzellottietal,2011).

Heautosocpy proper designates a condition in which an individual sees his double or dop-pelgänger.The double usually appears colourless, can behave independently, and may or maynot mirror the patient’s appearance.There is strong self-identification with the second body,often associated with the experience of existing at and perceiving the world from two placesat the same time (Heydrich and Blanke, 2013). There may be vestibular sensations suchasextremelightnessofthebody,sensationofflying,elevation,rotationandvertigo(Anzellottietal,2011;Blankeetal,2004).There isaNorthEuropeanmyth,sharedbyseveralcountries,thatsomeonemayseehisdouble(‘wraith’,‘fetch’)shortlybeforehisdeath,andithasthereforebecomeasinisteromen(ToddandDewhurst,1962).Theseauthorspresentinterestinghistoricalmaterialtosubstantiatethelinkbetweenperceptualdoppelgängeranddeath.Theusuallegendisthat,asthepersonliesdying,hiswraithfloatsbeforehiseyesandheseeshimselfperformingall themostdisreputable and reprehensible actionsofhis life; they areparadedbeforehimasheexpires.

Thereiscontinuingpopularinterestintheconceptofthedouble.ItisthesubjectofdiversefictionasinThe DoublebyFyodorDostoyevsky(1846),RobertLouisStevenson’sThe Master of Ballantrae(1889),andShusakuEndo’sScandal(1986).Theveryworstfeatureofthedoubleforthesubjecthimself iswell illustrated inWilliamStyron’sDarkness Visible (1991).Theterrible,inextricable involvement of the double with the subject in trying to mortify him, goad him,provokehimtodestroythedoubleand/ordestroyhimself.

the sense of being accompanied by a second self – a wraith-like observer, able to watch with dispassionate curiosity as his companion struggles against the

oncoming disaster, or decides to embrace it … I, the victim-to-be of


self-murder, was both the solitary actor and lone member of the audience … I watched myself in mingled terror and fascination.

There is growing evidence that autoscopic phenomena occur in association with seizures(Anzellottietal,2011).Furthermore,ithasbeenpostulatedthatautoscopyderivesfromafailureofintegrationofproprioceptive,tactileandvisualinformationaboutthebodyaccompaniedbyvestibulardysfunction (Blanke etal, 2004;Heydrich andBlanke,2013).Theanatomicalbasisandmechanismof autoscopy is yet tobe clarifiedbut there is tentative evidence that the leftposteriorinsularisinvolvedinheautoscopyandrightoccipitalcortexinautoscopichallucination(HeydrichandBlanke,2013).Becauseofthehypothesisthatautoscopyisafailureofintergration,themultimodaljunctionsbetweentheparietalandtemporallobesandbetweentheparietalandoccipitallobeshavebeenimplicated.And,thereisexperimentalworkderivingfromtheapplica-tionof transmagnetic stimulationof the left temporoparietal junction toproduceheautoscopy(doppelgänger)(BlankeandArzy,2005).

Inpractice,thesephenomenacanbeextremelydifficulttoidentifyanddelineate.Thefollow-ingdescriptionbya37-year-old,intelligentmanwithahistoryofepilepsy,receivingtreatmentwithphenobarbitone,isconsideredanexampleofautoscopichallucinationbutanalysishasfea-turesofheautoscopyaswell asout-of–the-bodyexperience.Thepatientheldhishead rigidlywithapparenttorticollistotheright.Ifherotatedittotheleft,therewasmarkedheadnodding,butnotifheturneditfurthertotheright.

I’m standing outside myself on the left hand side but only when I’m sitting down … it comes in short episodes for about 30 seconds … my true self loses

all its senses as all the senses are in my hallucinatory self … the true self is just a shell without any senses … the hallucinatory self can see the true self and

the whole surroundings, and it seems to me as though the hallucinatory self is looking at me and at other things in the room from a position standing to the

left hand side of me, and everything is in the right perspective. If it was occurring now, the hallucinatory self would see you more full face and from

higher up than I see you now because it is standing … I can’t see it or hear it but it can see the side of my head. It seems to be there. I know that it isn’t me

as such. It’s like having a dream and you know that it is a dream. I thought it was a dream but it has occurred when I am fully waking. It seems as clear as

a nightmare at the time but I know afterwards that it is a figment like a very vivid dream but more real than a dream. I would not see a fleck of dust on my

cheek or something like that. The other one is not a different personality.

Whenthisexperienceoccurred,thepatientfeltallsensationwasinthe‘hallucinatoryself ’,includinghearing,seeingandfeelingcold:‘Ifeltcoldonthebackofthehallucinatoryself ’.Therehadbeennoexperienceoftasteorsmell.Therehadbeenanexperienceofaffect.

I was talking to a representative. The hallucinatory self felt sorry for this man because he looked abnormal. It had no feelings for the real self. He looked

abnormal because I had stopped talking and a glazed expression had come into my eye.

AbizarreexampleofautoscopywasreportedbyAmes(1984):theself-shootingofaphantomhead.Thispatientwas suffering fromschizophrenia.Hedescribedseeingandhearingavoicefromanotherheadthatwassetonhisownshoulders,attachedtohisbodyandtryingtodominate


hisownhead.Hedescribedhimselfashavingtwoheadsbutbelievedthattheotherheadwasactuallythatofhiswife’sgynaecologist,whomhebelievedtobehavinganaffairwithher.Thevoicefromthesecondheadwasthatofthegynaecologist,andtherewerealsothevoicesofJesusandAbrahamaroundhim,conversingwitheachotherandtalkingabouthishavingtwoheads.Thepatienttriedtoremovetheotherheadbyshootingsixshotsatitandthroughhisownpalate,causingextensivedamagetohisbrain.Ameslabelledthisconditionthe‘phenomenonofpercep-tualdelusionalbicephaly’.

Multiple Personality (Dissociative Identity Disorder)

Indissociative(hysterical)states,so-calleddualandmultiplepersonalitieshavebeendescribed(Abse,1982;McDougall,1911;Prince,1905).SlaterandRoth(1969)comment:

A girl who is by turns ‘May’ and ‘Margaret’, may be quiet, studious and obedient as May, and unaware of Margaret’s existence. When she becomes

Margaret, however, she may be gay, headstrong and wilful, and refer to May in contemptuous terms. It seems that these multiple personalities are always artificial productions, the product of the medical attention that they arouse.

Theessenceofmultiplepersonalityistheembodimentofatleasttwopersonalities(identities).Thisphenomenonraisesdoubtsaboutournatural intuitionthatan individualhumanbeingisindivisibleandisanembodiedsingularperson.Prince’saccountgaveavividdescription:

Miss Christine L Beauchamp, the subject of this study, is a person in whom several personalities have become developed; that is to say, she may change

personality from time to time, often from hour to hour, and with each change her character becomes transformed and her memories altered. In addition to

the real, original or normal self, the self that was born and which was intended by nature to be, she may be anyone of the three persons. I say three different, because, although making use of the same body, each nevertheless,

has distinctly different character: a difference manifested by different trains of thought, by different views, and temperament, and by different acquisitive

tastes, habits, experiences, and memories.

InacharacteristiccasestudyofmultiplepersonalitybeforetheconditionsformedicalpracticeintheUnitedStatesresultedinaproliferationofcasesofso-calledmultiplepersonalitydisorder,Larmoreetal.(1977)described‘a35-year-oldwhitewomanofruralKentuckybackground’whohadmadesevensuicideattempts,ofwhichsheclaimedtohavenomemory.‘Shortlyafteradmis-sionahypnotic interviewwasconducted,duringwhichoneof thepersonalitiesspontaneouslyrevealedherselfandgavehintsoftheexistenceofotherpersonalities’.Fourdistinctpersonalitieswereidentified:Faith,‘theprimarypersonality…knownas“thelittleangel”bypersonalityAlicia…kind,lovingandhelpful…hasdifficultyinexpression…anger,andindealingwithcriticism’;Alicia,‘aSatanicagent…claimscontrolovermostofFaith’sphysiologicalfunctions…manifest-ingeitherassaultiveorself-destructivebehaviour’;Alicia–Faith,undertheinfluenceofAlicia,‘hasonlyperipheralawarenessofAliciaandnoknowledgeofFaithorGuardianAngel’;Guardian Angel,‘firstmadeitsappearancefollowingthegrandfather’sdeath…claimstobetheprotectorofFaith’.

Therehasbeenavastoutputofpsychiatric literatureonthesubjectofmultiplepersonalitydisorder, based on the diagnostic criteria of DSM-IIIR (American Psychiatric Association,1987) but often lacking in psychopathological precision. This has been well summarized byFahy(1988):


Recently there has been a dramatic rise in the number of case reports of multiple personality disorder (MPD)…. A review of the recent literature

reveals a poverty of information on reliability of diagnosis, prognosis, or the role of selection bias. It is argued that iatrogenic factors may contribute to

the development of the syndrome. There is little evidence from genetic or physiological studies to suggest that MPD represents a distinct

psychiatric disorder.

Absestatesthat‘one-wayamnesia’isusualformultiplepersonality;thatis,personalityAisamnesicfortheotherpersonalityB,butthesecond,B,candiscusstheexperiencesofA.Usually,AisinhibitedanddepressedandBisfreerandmoreelated.Theformsofmultiplepersonalityseeninpracticeareusually:

■ simultaneouspartialpersonalities■ successivewell-definedpartialpersonalities■ clusteredmultiplepartialpersonalities.When such patients have been treated in psychotherapy, ingenious explanations are often

givenbypatientandby therapist for theappearanceof theadditionalpersonalities.Althoughthisremainsadisputedarea,anauthoritativeopinionfromMerskey(2000)states:

In this author’s view there is no place for the diagnosis of multiple personality disorder in psychiatry, and the important question is how such a diagnosis

managed to achieve so much prominence in professional circles in North America, although generally not elsewhere.

Lability in the Awareness of Personality

Thelossofunityofselfinschizophreniawasexemplifiedbyapatientwhodescribedhow,everynight,hebecameahorseandtrotteddownWhitehall.Atthesametimeasthiswashappeninginhismind,healsobelievedhewasinWhitehallwatchingthehorse.Thistypeofsymptomhasbeen called lability in the awareness of personality and was described by Bonhoeffer (1907) asoccurringinparanoidpsychosis.

DISORDER OF IDENTITY

IamwhoIwas lastweekor30yearsago;IamwhoIwillbenextweekor in10years’ time.This truism, which we can claim without hesitation, is by no means certain for some peoplesufferingfromschizophreniaorfromorganicstates,fromneurosesorfromdepression,orevenfor somehealthypeople in abnormal situations (seepossession state, below).Thisdisorderofself-awarenessischaracterizedbychangesintheidentityofselfover time.

Apersonwhofeelsthreatenedinhisjobandisafraidofredundancyisnotlikelytofunctionwell,becauseofhisfeelingofimpermanence.Afeeling of continuityforoneselfandone’sroleisa fundamental assumption of life, without which competent behaviour cannot take place. Inhealth,wehavenodoubtsaboutthecontinuityofourselffromourpastintoourpresent.However,patients with schizophrenia sometimes deny that they have always been the same person.Characteristically,thistakestheformofapassivity experience,andthepatientclaimsthatatsometime in thepasthehas been completely changed frombeingoneperson toanother,whomhenowis.Jaspers(1959)givesanaccountofapatientwhosaid,

When telling my story I am aware that only part of my present self experienced all this. Up to 23rd December 1901, I cannot call myself my


present self; the past self now seems like a little dwarf inside me. It is an unpleasant feeling; it upsets my feelings of existence if I describe my previous

experiences in the first person. I can do it if I use an image and recall that the dwarf reigned up to that date, but since then his past has ended.

Thiscompletealterationinthesenseofidentityisexclusivelypsychotic;thereisabreakinthesenseofidentityofself,andthereisasubjectiveexperienceofsomeonecompletelydifferent,althoughstilldescribedasoneself,‘takingover’.

Afeelingoflossofcontinuity,whichis,however,oflesserintensitythanthepsychoticchangedescribedaboveandwithoutitselementofpassivity,maybeexperiencedinhealthandinneurosesandpersonalitydisorders.Thepersonknowsthatbothpeople,beforeandafter,aretrulyhimself,buthefeelsveryalteredfromwhathewas.Thismayoccurfollowinganoverwhelminglyimpor-tant lifesituationorduringemotionaldevelopmentwithoutanoutsideevent.Forexample,anadolescentmayquitesuddenlyfeelinthecourseofaweek‘asif ’heisquiteadifferentperson.Itshouldbestressedthatthesenseofrealityisneverlosttotheextentthatheactuallybelieveshimselftobeadifferentperson.Inthenon-psychotic,itismorethatthoughtsandfeelingsdonotseemtobeinkeepingwithhimselfashehascometoaccepthimself.

Inthenextchapter,amanisdescribedasdevelopinglong-termdepersonalizationafterexpe-riencingmassivestressatwork,culminatinginanextremelyharassingjourneyinwhichhewasthecardriver.Afterwards,hiswifesaidthathewasneveragainlikethemanshehadmarried,‘butlikehis(non-existent)twinbrother’.Shesaidthat,whereaspreviouslyhewasincisive,wasquick-thinkingandmadethedecisionsinthefamily,nowhelackedself-confidenceandshehadtodoeverything.Neitherpartnerwasinanydoubtthathewasthesameperson,buthiswholedemeanourhadchangedas ifhehadbecomesomeonesimilarbutnotidentical.

Thefeelingoflossofcontinuitycontributestotheinertiaofthepersonwithschizophreniaandtheapathyofthedepressive.Lackofaclearsenseofidentityfromthepastcontinuingintothefutureisastrongdisincentivetoconcertedactivity.Thepatient,withschizophrenia,aspartofdisturbanceofpassivity,mayhavedoubtsabouthiscontinuityfromthepasttothepresent;thedepressive,secondarytodisorderofmood,oftenseesnocontinuationintothefuture:‘eve-rythingisbleak,thereisnothingtolookforwardto’.

Apartofthesenseofcontinuityofself isacceptingthatthechangesinone’stotalstateatpresentaredue to illness.Thisisthecharacteristicusuallydescribedinthementalstateexamina-tionunder the term insight (David, 1990).The individual recognizes thathe is still the samepersonbutthathiscurrentchangeinsubjectivityisduetotheinterveningprocessofillness.

Possession State

ThisisclassifiedinICD-10underdissociative(conversion)disorders(F44)–tranceandposses-sion disorders (F44.3) (World Health Organization, 1992). However, although the trance oralteredstateofconsciousawarenessisaprerequisite,possessionstatedoesnotnecessarilyoccurin the context of dissociative or hysterical disorder. It can occur in normal, healthy people inunusualsituations,eitherasagroupphenomenon(masshypnosis)orindividually;suchacaseisdescribedbelow.Thereisatemporarylossofboththesenseofpersonalidentityandfullawarenessofthesurroundings.Thepersonactsasifhehas,andbelieveshimselftohavebeen,takenoverbyanother–aspirit,aforce,adeityorevenanotherperson.Thedifferencebetweenthosecondi-tions that constitute disorder and those that may be considered as being within a cultural orreligiouscontextaloneisthattheformerareunwanted,causedistresstotheindividualandthosearoundandmaybeprolongedbeyondtheimmediateeventorceremonyatwhichitwasinduced.

Possessionofayoung,entirelyhealthywomanwithahusbandandthreechildrenbytwo‘god-desses’ was witnessed in Sri Lanka.The woman had become a varama, a healer with special


powers,about2yearspreviously,whenshe‘saw’herdeceasedfather-in-law,whocametoherandsaid that she would have supernatural power to help other people and her own family. Herhusbandhadbecomeaddictedtoarak,alocalspirit,andhisdrinkinghadbythenbroughtthefamilyintoextremeeconomichardship.Afterthisexperience,sheofferedherservicesasahealerand solverofdomesticdifficulties toher village, and severalpeople consultedher eachdayathome,whereshehaddevotedonetinyroomtoasanctuaryandanothertoawaitingroom.Withher husband blowing a buffalo horn repeatedly and herself chanting, she induced a trance inherselfinwhichshespokewithdifferentvoicesaseitheroneoftwofemaledeitiesgivingadvicetoherclients,whichherhusbandinterpreted.Thevillagershadfoundherministrationstobehelpful,itgaveusefuloccupationtoherdelinquenthusbandandshehadcompletelysolvedherownfamily’sfinancialproblemsthroughthegiftsshereceivedforservicesrendered.

A different case, with psychiatric disorder present, was that of a 37-year-old Sri Lankanhousewifewhobelievedherselftobepossessedbyherlong-deadgrandmother;onthreeoccasionsshehadgoneintoatrance,lostcontactwiththeoutsideworldandseentheimageofhergrand-mothercomingclosetoherandtryingtosqueezeherneck.Theseepisodesweredescribedwithfear and distress. She showed symptoms of depressive illness, with poor sleep, early morningwakening, lossofappetiteandweight,anergia, fatigueandfeeling lowinmood;shehadbeenabandonedbyhermotherwhen7yearsold.

Wijesingheetal.(1976)surveyedasemiurbanpopulationof7653peopleinSriLankaandidentified37subjects,9maleand28female,with‘possessiontrancestates’,showingalteredstateofconsciousawareness,behaviourforwhichthesubjectdidnotacknowledgeresponsibility,andhadamnesiafortheperiodofthetrance.Episodes,oftenlastingabout30minutes,wereusuallyprecipitatedeitherbyemotionalstressorculture-boundstimulisuchaswitnessinganexorcismceremony.Duringtrance,subjectsweremostoftenrestlesswithrhythmictremblingofthetrunkand exaggerated gesturing, speech was aggressive and commanding and, typically, mood wasangry;mostoften,thepossessingspiritwasthatofaclosebutdeadrelative.Infemalesespecially,as the condition continued they were increasingly likely to become permanent adepts.Theseauthorsregardedonlyoneoftheirsubjectsassufferingfromschizophrenia,although17of37manifestedactivepsychiatricdisorder,mostlyneuroticinnature.

Possessionandtrancestatesstraddletheboundarybetweennormativebehaviourandabnor-malbehaviourindicativeofadisorder.Moreira-AlmeidaandCardeña(2011)arguethatlackofpersonalsuffering,absenceofsocialorfunctionalimpairment,absenceofpsychiatriccomorbidity,self-controlovertheexperienceandpersonalgrowthallpointinthedirectionofanon-pathologicalspiritualexperience.Itisclearthoughthatpossessionandtrancestatescanoccurinthesettingofindubitableneurologicaldiseasesuchaslesionsinthebasalgangliaandfronto-parietallobes(Basuetal,2002),hencetheneedtohaveanintegrativemodelthatisgroundedinneurosciencebut admits sociocultural processes informed by aspects of how the self is socially constructed(SeligmanandKirmayer,2008).

Jaspers(1959),inwritingaboutdisordersofself-awareness,concernedhimselfwithdisorderofcontentaswellasofform.Indiscussingstatesofpossession,hecommentedontherarecondi-tionoflycanthropy,thepatientbelievingthathehasbeentransformedintoananimal,literallyawolf.LyncathropyhasalonghistoryinWesternsocietiesandidenticalbeliefsoftransformationinto other feared animals such as the fox in Japan, the tiger, hyena and crocodile in China,MalaysiaandIndiaaredocumented(Fahy,1989).Inantiquitytherewasbeliefinthepossibilityofradicalphysicaltransformationofthehumanbodyintothatofawolf.However,recentcasereportshaveadoptedarobustphenomenologicalapproachandidentifythebeliefoftransforma-tionasadelusionofnon-specificvaluebutprincipallyassociatedwithmooddisorders,schizo-phrenia,andoccasionallyorganicbraindisease(Kecketal,1988;Fahy,1989;Kulicketal,1990).Lyncathropyisusuallyatransientbeliefbutoccasionallythebeliefcanbeenduring,lastingformany years (Keck etal, 1988). Koehler etal. (1990) reviewed Jaspers’ work in relation to


lyncathropyandshowedthatJaspersdifferentiatedbetweenstatesofpossessionpresentingwithanalteredconsciousnessandstatesofpossessioninwhichconsciousnessremainsclear;theformerwereusuallydissociative(hysterical)inorigin,whilethelatterweremoreoftenassociatedwithschizophrenia.This emphasizes the importance for psychiatric diagnosis in assessing psycho-pathologicalform.

DISORDER OF THE BOUNDARIES OF SELF OR EGO DEMARCATION

DisorderoftheboundariesoftheselfreferstothedisturbanceinknowingwhereIendsandnot Ibegins.Abnormalityisnotconfinedtoschizophrenia.Forexample,inlysergicaciddiethylamideintoxicationthefeelingofimpendingegodissolutionassociatedwiththefeelingofself‘slippingaway’withconsiderableanxietyhasbeendescribed(AndersonandRawnsley,1954).Onesubjectputthisas:

I was being disorganized … the world around was looking very distorted indeed … things were pretty rocky so I decided to sit back quietly for a

moment and reassure myself by returning to my own private inner world. As soon as I introspected in this manner I felt to my dismay that ‘I’ myself was

somehow disturbed. The central core of the personality, the ego, the sense of personal identity, was itself fluctuating and, for want of a better

phrase, dissolving.

Anothersubjectsaid,‘IfanyonepresentwentoutoftheroomitfeltasthoughIwerebeingdeprivedofsomething.Ibecamesmaller–definitelyfeltvulnerable’.

Boundaries of Self in Schizophrenia

In schizophrenia, the senseof invasionof self appears tobe fundamental to thenatureof theconditionasitisexperienced;manybutnotallfirst-rank symptomshaveincommonpermeabilityofthebarrierbetweentheindividualandhisenvironment,lossofegoboundaries(Sims,1993).Thereisamergingbetweenselfandnot self ;thisisclearlyportrayedinFigure12.2,paintedbya young schizophrenic patient.The patient is not aware of the disturbance being one of egoboundaries;hedescribesaproblemonlyinasmuchas‘otherpeoplearedoingthingstome,eventsaretakingplaceoutsidemyself ’.Theexternalobserverfindsablurringorlossoftheboundariesofselfthatisnotapparenttothepatienthimself.

Allpassivity experiences falselyattribute functions tonot self influences fromoutside,whichare actually coming from inside the self. This is also true for disorders of the possession ofthought, such as thought insertion and thought withdrawal.Thought broadcasting obviouslyinvolvesprivatethoughtsbecomingpublicwithouttheconsentoractionofthepatient.Thisisanotherexampleofabreakdowninthenormalboundariesofwhatisselfandnon-self.Otherexperiences, such as auditory hallucinations, rely on the patient ascribing internally generatedactivity,thatis,internalspeech,toexternalagencies.

Passivity,delusion of control,isdiscussedinChapter9.Thesubjectiveexperienceofpassivityisadisorderofthedistinctionbetweenwhatisandwhatisnot self.Sensations,emotions,impulsesandactionsthatinobjectiverealitycomefrominsidetheselfareascribedtonot self.

Other Alterations to Boundaries

Instatesofecstasy,therearealsodisturbancesintheboundariesofself(Chapter16).Thepar-ticipant might describe feeling at one with the universe, merging with nirvana, experiencing


unitywiththesaints,identifyingwiththetreesandflowersoraonenesswithGod.Ecstasystatesoccurinnormalpeopleandinthosewithpersonalitydisorder,aswellasinsufferersfrompsy-chosesandinepilepsy.Inepilepsyitispartoftheauraandischaracterizedbyintensefeelingsofwell-beingandheightenedself-awareness.It isthoughttoemanatefromhyperactivationofthe anterior insula rather than the temporal lobe (Picard andCraig, 2009).This alteration inawarenessof theboundariesofself isdifferent fromthatofschizophreniadescribedabove.Inecstasy,itisanas if experience,anditismediatedaffectively.

ThephenomenondescribedbyJung inhimselfwithwhichthischapterbegins isa lackofdefinitionof theboundariesof self.However, therewasno lossof reality judgement; itwasagame,andJungdid infactknowwhatwashimselfandwhatwasthestone.Inpsychosis, thisability to discriminate is lost. A patient with schizophreia said, ‘I am invaded day and night.Ihavenomoreprivacysincetelevisioncameinsideme’.Anotherpatientbelievedthatwhilehewasinahospitalwardhewashelpingotherpatientsbecausehepermeatedthemedicalstaffandtherebyassistedthemintheirwork.

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C H A P T E R 13

Depersonalization

SummaryDepersonalizationisasubjectivestateofunrealityinwhichthereisafeelingofestrangement,either fromasenseof selfor fromtheexternalenvironment.Frequently, it isaccompaniedbythesymptomofderealization,atermdenotingasimilarfeelingofunrealitywithregardtoaware-nessoftheexternalworld.Thelocalizationofthisfeelingofunrealitytoaselectedpartofthebodyiscalleddesomatization.Theremaybeexperienceofchangesofsizeorquality,forexampleappearing largeor tiny,orempty,ordetachedorfilledwithwateror foam.Deaffectualizationhasbeenusedtodescribetheconsistentlossofthecapacitytofeelemotion,sothatthepersonseemsunabletocry,loveorhate.Theseexperiencesareassociatedwithanxietyandmooddis-orders,organicdiseasesuchasepilepsyandtraumaticbraininjury.Depersonalizationcanalsobetriggeredby theuseofcannabis,hallucinogens,ecstasyandalcohol. It canbeabriefor long-lastingexperience.Itisinvariablydistressingtothepatient.

I may be looking with some degree of attentiveness at a tumbler. As long as I say to myself that this tumbler is a glass or metal vessel made for the purpose

of putting liquid into it and carrying it into one’s lips without upsetting it – as long as I am able to represent the tumbler to myself in a convincing

manner – so long shall I feel that I have some sort of relationship with it, a relationship close enough to make me believe in its existence and also, on a

subordinate level, in my own. But once the tumbler withers away and loses its vitality… reveals itself to me as something with which I have no

relationship, once it appears to me as an absurd object – then from that very absurdity springs boredom, which when all is said and done is simply a kind

of incommunicability and the capacity to disengage oneself from it.(Alberto Moravia, 1960)

Definitions and DescriptionsDepersonalization is the term used to designate a peculiar change in the awareness of self,inwhichthe individual feelsas ifhe isunreal (Sedman,1972). It isbest to reserve theuseofthe word to this as if feeling rather than the experience of unreality that occurs in psychosis.Theas ifprefixisusedbythepatienttodenotethatheisnotusingwordsliterally(howcouldhe know what it would be like not ‘fitting into the world’, as all his experience has been intheworld?).Heisexpressinguncertaintyandpaintingapicture,and‘asif ’isthebestwayhecando it. It has been considered that, after depression and anxiety, depersonalization is the mostfrequentsymptomtooccurinpsychiatry(Stewart,1964)and12monthprevalenceestimatesfordepersonalizationandderealizationinaruralpopulationareputat19.1%and14.4%(Aderibigbeetal.,2001).

Keywords: Depersonalization,Derealization.

13—DEpErSONALizAtiON 205.e1


Schilder(1928),whoseclassicmonographin1914wasaturningpointinthestudyofdeper-sonalization,wrote:

To the depersonalized individual, the world appears strange, peculiar, foreign, dream-like. Objects appear at times strangely diminished in size, at times

flat. Sounds appear to come from a distance. The tactile characteristics of objects likewise seem strangely altered. Patients characterize their imagery as

pale, colourless and some complain that they have altogether lost the power of imagination. The emotions likewise undergo marked alteration. Patients

complain they are capable of experiencing neither pain nor pleasure; love and hate have perished with them. They experience a fundamental change in their

personality, and the climax is reached with their complaints that they have become strangers to themselves. It is as though they were dead, lifeless,

mere automatons.

DepersonalizationhasbeendefinedbyFewtrell (1986) as a subjective stateofunreality inwhich there is a feeling of estrangement, either from a sense of self or from the externalenvironment.

AmorecomprehensivedefinitionhasbeengivenbyAckner(1954).Definitivefeaturesare:■ depersonalizationisalwayssubjective;itisadisorderofexperience■ theexperienceisthatofaninternalorexternalchangecharacterizedbyafeelingofstrange-

nessorunreality■ theexperienceisunpleasant■ anymentalfunctionsmaybethesubjectofthischange,butaffectisinvariablyinvolved■ insightispreserved.Excludedfromdepersonalizationare:■ theexperienceofunrealityofselfwhenthereisdelusionalelaboration■ theegoboundarydisordersofschizophrenia■ thelossorattenuationofpersonalidentity.AnevenmorecomprehensivedescriptionisgiveninSierraandBerrios(2001).Thesymptoms

arelistedinBox13.1.

BOX 13.1 ■ Components of depersonalization

■ Emotionalnumbing■ Changesinbodyexperience■ Changesinvisualexperience■ Changesinauditoryexperience■ Changesintactileexperience■ Changesingustatoryexperience■ Changesinolfactoryexperience■ Lossoffeelingsofagency■ Distortionsintheexperiencingoftime■ Changesinthesubjectiveexperienceofmemory■ Feelingsofthoughtemptiness■ Subjectivefeelingsofaninabilitytoevokeimages■ Heightenedself-observation

(AfterSierraandBerrios,2001,withpermission.)

13—DEpErSONALizAtiON 207

Therelationshipbetweendepersonalizationandvarioustheoreticalaspectsofself-perceptioninphenomenologyhasbeenreviewedbyMellor(1988),whodiscussestheinfluencesofJaspers(1959),Mayer-Gross(1935),Schilder(1920)andSchneider(1958)ontheconcept.Mellorcom-mentson the frequencyof theconditionand thevarietyofdifferentpsychiatric illnesseswithwhichitmaybeassociated.Itmayoccurwithorganicpsychosyndromesincludingtraumaticbraindamage(GrigsbyandKaye,1993),epilepsyandmigraine(Lambertetal.,2002),cannabis,hal-lucinogensandecstasy(Matthewetal.,1993;Simeonetal.,2009).It isassociatedwithmooddisordersandanxietydisordersincludingsocialanxiety(Simeonetal.,1997;Michaletal.,2005).Thedepthofdepressionispositivelycorrelatedwithdepersonalizationandindepressedpatientswithanhedonia,depersonalizationwaspresentin75%ofcases(Zikićetal.,2009).

Althoughthesymptomhasbeendescribedforlonger,thetermwasusedbyHeymans(1904)and by Dugas and Moutier in 1911.The earliest theories implicate the sensory system, butlossofmoodandlossoffeelingswerealsoprominentinearlydescriptions(SierraandBerrios,1997). Frequently, depersonalization is accompanied by the symptom of derealization, a termused by Mapother (1935) to denote a similar change in the awareness of the external world.Depersonalizationandderealizationoftengotogether,becausetheegoanditsenvironmentareexperiencedasonecontinuouswhole.However,inMayer-Gross’cases,aboutaquarterofpatientshaddepersonalizationwithoutderealizationand15percenthadonlyderealization.Thelessapatient takes himself for granted, the more unfamiliar and alien does the world around himbecome(Scharfetter,1980).Ayoungfemalepatientsaid:

I felt as if I didn’t fit into the world … When I saw the moon, I felt I couldn’t cope. One day it wasn’t there and the next it was. I saw it and it

upset me and I went to pieces … I felt I did not want to be alive because I was not related to anything. I just seemed totally out of everything and I

started to cry. I couldn’t cope with the hurt and the pain. I felt I never would feel part of anything.

It is important to realize that depersonalization, the experience, like other non-psychoticphenomena,occursinhealthy,normalpeople.Somepeoplemayhavefeelingsof‘notbeingquitethemselves…lookinginonthemselvesfromtheoutside’andsoon,withoutprovocation.Othersmayhavesuchexperiencesat timesofpowerfulemotionalstimulior lifecrisisofanyvalence:extremehappiness, falling in love, the lossofbereavementor intensefearoranger.Theactualself-descriptionofdepersonalizationissimilarirrespectiveofcontext.

Thereisoneparticularfeaturedescribedbypatientsandnotoccurringinthedepersonaliza-tionthathealthypeople,especiallychildren,mayexperiencespontaneouslyinstatesoffatigue,afterprolongedsleepdeprivationorundersensorydeprivation.Thisisthepatient’sdescriptionoftheexperiencebeingintenselyunpleasantanddistressing(Ackner,1954).Itmaysubjectivelybemuchtheworstsymptominanaffective,reactiveillness.Ayoungmarriedwomansaid:

‘I feel very weird in my head. I have a great deal of torment. My mind will not leave me alone. It’s the surroundings; I cannot get my mind to myself. I felt as though I was going to fall over. I feel as if I’m lost in a fog. I just feel

as if I’m not in my head. I feel numb.’

Thesymptomisdescribedinanumberofdifferentways,anditisoftenimpossibletomakeadistinctionbetweendepersonalizationandderealization:‘everythingseemedtobegoingawayfromme’.ThefivequalitiesoftheexperienceofselfdescribedinChapter12mayeachbeinvolvedin the description of symptoms, although always with this as if character: vitality, activity,


singleness, identity (continuity) and boundaries or definition. There is virtually always otherevidenceofdisturbanceofmoodpresent:depressionoranxietyorboth.Coupledwiththisisafeelingoflossofself-esteemasaveryprominentsymptom:‘Ifeelunreal,flat,notproperlythere,lessofaperson,asthoughIcan’tgoandgetstuckin’;thatis,thefeelingofunrealityaboutoneselforone’senvironmenthasimplicationsforlackofcompetenceinrelationships.Thepatientnotonlyfeelsunrealbutalso‘detached’;thereisabarriertonormalcommunication.

At this point, it is important to emphasize the distinction between depersonalization as asymptom,occurringassociatedwithmanypsychiatricconditionsornodisorderatall,anddeper-sonalizationasasyndrome.Intheirdetaileddescriptionofthesymptomsofdepersonalizationdisorder,basedonclassicdescriptionsfromauthorsinthenineteenthandearlytwentiethcen-turies,SierraandBerrios(2001)havelistedthefollowingfoursymptomsasmostprevalentfordiagnosis: emotional numbing, changes in visual perception, changes in the experience of thebodyandlossoffeelingsofagency.Inamorerecentstudy,Simeonetal(2008)demonstratedthat the Cambridge Depersonalization Scale (Sierra and Berrios, 2000) yielded five factors:numbing,unrealityof self,perceptual alterations,unrealityof surroundings, and temporaldis-integration.Inadditionpatientswithdepersonalizationappeartohaveimpairedabilitytogener-ate visual imagery compared to normal controls. However in these individuals with impairedimagerytherewasnoassociatedabnormalityofperceptualprocessesasmeasuredbyabatteryofvisualperceptiontests(Lambertetal.,2001).

Thesesymptomsaresometimesincludedwithadescriptionofdepersonalizationbut,forthesake of clarity, should be separated and regarded as different psychopathological phenomena.Disturbancesofbodyimageorschema,disorderofsubjectivetimesense,hypochondriacalpre-occupation,déjà vuphenomenaormetamorphopsia(thedistortionofvisuallyperceivedobjects)maybedescribedbythesameindividualandmayoccurassymptomsofdepersonalizationsyn-drome. Langfeldt’s (1960) inclusion of schizophrenic passivity experiences within the termdepersonalizationisconfusing,andtheseexperiencesshouldbeexcludedfromdepersonalization,bothasasymptomandasadisorder.

SUBJECTIVE EXPERIENCE OF DEPERSONALIZATION

Depersonalizationisdifficultforthedoctortoportray;moreimportant,itisalsoextraordinarilydifficultforthepatienttodescribe.Heoftenprefaceshisattemptsatdescriptionbyembarrassedstatementssuchas‘sometimesIthinkImustbegoingmad’or‘youwillthinkmeverypeculiarwhenItellyouthisdoctor,but…’Thenfollowsahaltingandperplexedlistofdisjointed,unpleas-antexperiencesthatthepatientfeelstobeuniqueandforwhichheisunabletoconstruemeta-phorsthatsatisfyhim.Becauseofhisfailureindescription,hebelievesthatotherswillfindthesesymptomseitherbogusorclearevidenceofimminentmadness,soheomitsthemfromhisinitialaccount even though such symptoms are very common among psychiatric patients and causeenormous suffering. Depersonalization is the symptom the patient has when he experienceshimselfasbeingalteredordeficientinsomemanner;derealizationisitsequivalentwithregardtohis experienceof thingsoutsidehimself, that is, of the externalworld.Because there isnodefiniteandeasilyascertainedboundarycontainingself,itisnotalwayseasytodecidewhetherthe disorder is depersonalization or derealization. Neither is this important: they merge andoverlapandareoftensimplyincludedwithinthetermdepersonalization.

There is always a change in mood with depersonalization: the patient loses the feeling offamiliarityhehasforhimselforfortheworldoutsidehimself.Hemaydescribehimselfasfeelinglikeapuppet:hollow,detachedandstrange;on theoutside;uninvolvedwith life;nothimself;likeaghost,notsolid;astrangertohimself.Heexperiencesa lossofemotion.Similarly,withderealization he may describe his environment as flat, dim in colour, smaller, distant, cloudy,dream-like,still,‘nothingtodowithme’andalsolackinginemotionalsignificance.


Depersonalizationiscommon,butyettothepatientsoobscureandunpleasant,that,wheneverthedescriptionofsymptomsisinterruptedbythepatient’sbaffledhesitancy,heshouldbeques-tionedwithpossibledepersonalizationsymptomsinmind.Hisreliefatfindingsomeonepreparedtolisten,andevenperhapsunderstand,isoftenenormous.Schilder(1935)hasdescribedthesesymptomsthus:

In a case of depersonalization the individual feels completely changed from what he was previously. This change is present in the ego (self ) as well as in

the outside world and the individual does not recognize himself as a personality. His actions appear to him as automatic.

He observes his actions and behaviour from the point of view of a spectator. The outside world is foreign and new to him and is not as real as before.

Schilderisusingthewordpersonalityheretorefertothewholeperson,notonlypersonalityinthemodernsenseoftheword.Thischangedawarenessofselfanditsrelationshipswiththeenvironmentisalwaysexperiencedasbeingintenselyunpleasant.

Thelocalizationofthissymptomtoanindividualorganiscalleddesomatization.Therearemanydifferentpossibleparametersintheawarenessofdifferentorgans:changesofsizeorquality,for example appearing large or tiny, or empty, or detached or filled with water or foam.Thepatientmayhaveafeelingofhislegsbeingweightless,offloatingorofsimplybeingunfamiliar.Koro,aculture-bounddisorderdescribedbyYap(1965),issometimesdescribedasanexampleofdepersonalization.Itisprobablybesttoregardthisconditionasaculture-specificmanifestationofacuteanxietyinwhichthepatientbelieveshispenisisshrinkingandfearsthatitwillultimatelydisappear.Whilsttheremaybeassociatedfeelingsofunrealityandofwatchingthedramaasaspectator,theprimaryunderlyingabnormalityisoneofintenseanxiety.

Changeoffeelingconcerningthebodyordepersonalizationmaybeassociatedwithdistortionoftimesense,whenthepassageoftimeappearsalteredinsomeway:‘time,bothpastandpresent,seems quite unreal to me, as if it had never happened and was never going to happen’.Deaffectualizationhasbeenusedtodescribetheconsistentlossofthecapacitytofeelemotion,sothatthepersonseemsunabletocry,loveorhate(Anonymous,1972).

A patient says, ‘I am going mad inside my head’; on further questioning, he is describingfindinghisownmentalprocesses tobe strange.The feelingof familiarity thatoccurswhenapersonperceivespreviouslyknownobjects(openingthefrontdoorathomeandlookinginside)alsooccurswhenoneintrospectsintoone’sownthinking(rememberingorfantasizingmyfronthall).Iknowwhatisthereinmythoughts;IknowwhatIwillthinkaboutanyparticularobject,becauseitisunlikelytobeverydifferentfromwhatIthoughtaboutitlasttime.Ialsoknow,ingeneralterms,whatIwillthinkaboutmyselfbecauseofpastexperience.Itisthisassumedcer-tainty that disappears; the loss of familiarity of oneself occurring in depersonalization, or ofoutsideselfinderealization,issimilartotheabnormalityofthefeelingoffamiliarityoccurringin jamais vu (when there is no sense of previously having seen a well-known object) and itsopposite,déjà vu(whenanunfamiliarobjectorexperienceseemstobefamiliar).Thisassociationbetweenthesubjectiveexperiencesindepersonalizationanddéjà vuphenomena(includingjamais vu)andcommonalityinalterationinthefeelingoffamiliarityhasbeenknownsincetheworkofHeymansatthebeginningofthelastcentury(SnoandDraaisma,1993).

Like other aspects of self-experience, depersonalization has social and situational aspects.Frequently,thepersonfeelsthatheislessabletoaccepthimself,hispersonality,hisbehaviourthanotherpeopleaccepttheirown.Heconsidersthathisfeelingsabouthimself,hislossofreality,isunique.This is abarrier tohisgivinganaccountofhis symptoms, and this in its turn is abarrier to communication in all areas of life. He feels himself to be different, isolated and


estrangedfromothers.Depersonalizationisanexperiencewithinanindividual,butithascon-siderablesocialconsequences.

Itfrequentlyoccursinattacksthatmaybeofanyduration,fromsecondstomonths.Typically,indepersonalizationdisorderthealteredstatelastsforafewhours,intemporallobeepilepsyforafewminutesandinanxietydisorderforafewseconds.Improvementisusuallyfirstmanifestedin a gradual increase in time free from symptoms rather than a reduction in the symptomsthemselveswhenpresent.But,itcanpresentaswithachronicnon-remittingcourse.

Onsetmaybe insidiousandwithnoknown initiatingcause,or itmaybe in response toatrigger.Themostcommonimmediateprecipitantsareseverestress,depression,panicandmari-juanaingestion(Simeonetal.,2003).Amiddle-agedmanwhodescribedhisdepersonalization‘likesomethingsupernatural–mybodyseparatedfromme–alostfeeling’vividlyrecalledhisfirst attack at the age of 11, when undergoing anaesthesia for the reduction of a fracture.Subsequent attacks felt similar despite the absence of provocation. He had also experiencedattacksofsleepparalysissincetheageof25andhaddiscoveredthatbykeepinghimselfawakeuntilverytiredhewouldfallasleepmorequicklyandthusavoidit.Anothermanwasseverelystressedbyhisquiteunreasonableworkingconditions,hoursofwork,unsympatheticemployeranddifficultcarjourneysinthecourseofhiswork.Earlyonewintermorning,hehadanappall-ingjourneythroughfog,alongcrowdedmotorwaysblockedbyaccidents,andfinallysufferedalapseofrecallfor24hoursinwhichherememberednothingofdrivingtoanothertown,register-inghimself intoahotel,orderingameal,hanginguphisclothes tidilyandgoing tobed.Hisnextmemorywasarrivingatalocalhospitalthenextday.Heremaineddepersonalizedforyearssubsequently,andhiswifedescribedthisas‘he’snotthemanImarried;it’slikehistwinbrother’.

Depersonalization is frequently situational, both in its original context and in its repeatedoccurrences.Factorscommonlyassociatedwithsymptomexacerbationarenegativeaffects,stress,perceivedthreateningsocialinteractionandunfamiliarenvironments(Simeonetal.,2003).Manypolicemenwhowereinvolvedinamajordisasteratafootballgrounddescribeddepersonalizationamongothersymptomsofpost-traumaticstressdisorder,sometimeslastingforyearssubsequently(SimsandSims,1998).Onemandescribedfeeling‘switchedoff…IfeltIwasn’tonthisplanetanymore’.Becausedepersonalizationoccursattimesofgreatstress,itmayoccurintheperpetra-torofantisocialbehaviour,forexampleviolentcrime,aswellasinthevictim.RixandClarkson(1994)giveanaccountofamanwhosavagelyassaultedhiswifewithalargespanner:‘Itwasasifitwasadreamoranightmare.IrealizedlaterwhatIhaddonebutatthetimeitwasasifIwasn’tthere’.Itwasconsideredthatdepersonalizationinthiscasewaslinkedtodissociation,thatalthoughitrepresentedachangeintheindividual’sself-experienceitdidnotaffecthisvolitionorintent.

Although,inthesetwocasesdescribedabove,depersonalizationwasassociatedwithdissocia-tion,itisimportanttoregardthesetwoexperiencesasdistinctphenomena.Empiricalevidencealsosuggeststhattheseexperiencesevenwhenassociatedaredifferentanddonotlieonacon-tinuum(Putnametal.,1996;Simeonetal.,1998).Neitherdoesdepersonalizationoccurwithany greater frequency in chronic dissociative disorders such as dissociative identity disorder,formerlymultiplepersonalitydisorderinDSM-IV(Ross,1997).

Self-inducedepisodesofdepersonalization,asanunpleasant symptom,havebeenrecordedfollowingparticularpatternsofbehaviour.ThusKennedy(1976)describedself-induceddeper-sonalizationpersistingasacomplaintaftertranscendentalmeditationandyoga.

Organic and Psychological TheoriesTheories accounting for theoccurrenceofdepersonalization, includingorganic, psychological,psychoanalytical and those linking it with schizophrenia, were reviewed by Sedman (1970).Depersonalization is regularly cited as a common symptom associated with organic states,


especiallytemporallobeepilepsy(SedmanandKenna,1965).ThisisbasedonthecontentionofMayer-Gross(1935)thatdepersonalizationisapreformed functional responseofthebrain,thatis,anon-specificmechanismresultingfrommanydifferentinfluencesonthebrain,occurringinanidiosyncraticwayinindividualsinasimilarmannertoepilepticfitsordelirium.Hewas,inthis,followingtheneurophysiologicalhierarchicalconceptsofHughlingsJackson(1884),whocon-sideredthatthehighestlevelsofcerebralfunctionwerelostfirst,leavinguninterruptedtheactivityoflowerlevels.

Organic theoriespurporting toaccount fordepersonalizationwouldsuggest thatalterationofconsciousnessactsasareleasemechanism.However,Sedman(1970),inreviewingthelitera-ture,showedthat,eveninvariousformsoforganicpsychosyndromes,theincidenceofdeperson-alizationphenomenawassimilartothatfoundinthegeneralpopulation,atbetween25and50percent;inmoreseverechronicorganicpsychosis,theratewaslower.Fromavarietyofstudies,noquantitative relationshiphadbeendemonstratedbetween thedegreeof torpor (that is, thestageonthecontinuumfromfullalertnesstounconsciousness)andthedevelopmentofdeper-sonalization.On studying theperformanceof depersonalized subjects onpsychosomatic tests,theredidnotappeartobeevidencetosupportaspecificrelationshipbetweencloudingofcon-sciousness anddepersonalization.Thereappeared tobemany individualswho,despitevarioustypesofassaultontheirbrains,neverdevelopeddepersonalization.

Fromthisinformation,Sedman(1970)concludedthat:

there may well be a built in preformed mechanism in approximately 40 per cent of the population to exhibit depersonalization; that the factors which

initiate such a response are not specifically those associated with clouding of consciousness; or where clouding of consciousness appears to be playing a part,

it may well be the presence of another common factor that is more relevant.

Thus, the relationship between depersonalization and brain pathology remains unclear.Depersonalizationiscertainlynotpathognomonicoforganicdiseases;infact,thereisnoorganicorpsychoticabnormalityinthevastmajorityofsufferers.

The state of increased alertness observed in depersonalization is considered by Sierra andBerrios(1998)toresultfromactivationofprefrontalattentionalsystemsandreciprocalinhibitionof theanteriorcingulate, leading toexperiencesof ‘mindemptiness’ and‘indifference topain’.Thelackofemotionalcolouring,reportedasfeelingsofunreality,wouldbeaccountedforbyaleft-sided prefrontal mechanism with inhibition of the amygdala. Other authorities describeleft-hemispheric fronto-temporal activation coupled with decreased left caudate perfusion(Hollanderetal.,1992;PhillipsandSierra,2003).

Depersonalization is sometimesassociatedwith self-inducedorganic states.Thus, itoccursfollowing the ingestion of alcohol or drugs, especially psychotomimetics such as lysergic aciddiethylamide(SedmanandKenna,1964),mescaline,marijuanaorcannabis(Szymanski,1981;Carneyetal.,1984;Simeonetal.,2009)andwithsensorydeprivation.Itisalsodescribedasasideeffectwithprescribedpsychotropicdrugssuchasthetricyclicantidepressants,butbecauseof the common association between depersonalization and depression it is difficult always toattributecause.

Neurochemical findings have identified possible involvement of serotonergic, endogenousopioidandglutamatergicNMDApathways.Additionally,thereisevidenceofwidespreadmeta-bolicalterationsinthesensoryassociationcortexaswellasprefrontalhyperactivationandlimbicinhibitioninresponsetoaversivestimuli(Simeon,2004).Furthermore,thereisassociationwithchildhood interpersonal trauma, particularly emotional maltreatment (Simeon etal., 2001;Simeon,2004).


Depersonalization: Further ConsiderationsSometimestherehasbeenconsiderableconfusionoverwhetherdepersonalizationcanbedistin-guishedfromthedisordersofself-imagedescribedinChapter12asoccurringinschizophrenia.Infact,passivityexperienceshaveevenbeendescribedasavariantofdepersonalization.However,Meyer(1956),ascitedbySedman(1970),hasdistinguishedschizophrenicegodisturbancesfromdepersonalizationonphenomenologicalgrounds;thatis,onthedescriptionbythepatientofhisowninternalexperience.Itis,ofcourse,wellrecognizedthattruedepersonalizationsymptomsdooccurinschizophrenicpatients,especiallyintheearlystagesoftheillness,alongsidedefiniteschizophrenicpsychopathology.

Depersonalizationiscommonlydescribedinmanic-depressivedisorder;however,thesymp-tomsoccuronlyinthedepressivephaseandtherearenoreferencestodepersonalizationoccurringin mania (Sedman, 1970). Anderson (1938) considered that ecstasy states occurring in manic-depressivedisordersweretheobverseofdepersonalizationandthat,whiletheformeroccurredinmania, the latteroccurred indepression.Sedman(1972), inan investigationof threematchedgroups,eachof18subjectswithdepersonalizationanddepressiveandanxietysymptoms,con-sideredthat theresultsstressedthe importanceofdepressedmoodindepersonalization,whileanxietyseemedtocarrynosignificantrelationship.

Manyotherauthorshavestressedthecloseassociationbetweenthesymptomsofdeperson-alizationandanxiety.Forinstance,Roth(1959,1960)describedthephobic anxiety depersonaliza-tion syndrome as a separate nosological entity, but saw it as a form of anxiety on which theadditionalsymptomsaresuperimposedinaparticulargroupofindividuals.Heconsidereddeper-sonalizationtobemorecommonwithanxietythanwithotheraffectivedisorders, forexampledepression.The phobic symptoms are usually agoraphobic in nature.The patient, most oftenfemale,marriedandofteninthethirddecadeoflife,hasagreatfearofbeingconspicuousinanembarrassingway inpublic, for example faintingorbeing taken ill suddenlyonabusor in asupermarket.Fearofleavingthehouseunaccompanieddevelopsfromthis,sothatthepatientisfrightenedofbeingatadistancefromfamiliarsurroundingswithoutsomesupportingfiguretowhomshecanturn.Shemaybeunabletogooutofthehouseatall,evenwithherhusband.Shemayfeelpanickyonherownathomeandsokeepsherchildoffschool,apotentialprecipitatingfactorinsubsequentschoolrefusal.

Thesymptomofdizzinessisaverycommoncomplaintandfrequentlyresultsinreferraltoear,noseandthroatdepartments.FewtrellandO’Connor(1989)discusstwopossiblemodelsfortherelationshipofthisconditiontodepersonalization:onethatdizzinessanddepersonalizationarethesameexperiencedescribeddifferently;theother,abipolarhypothesis,proposesthatthetwo experiences form opposite ends of a dimension describing disturbed self–outside worldrelationships.

Although depersonalization is commonly described in association with agoraphobia, otherphobicstates,panicdisorder,varioustypesofdepressivecondition,post-traumaticstressdisorderandothernon-psychotic conditions, itmayalsoappearasapuredepersonalization syndrome,andDavison(1964)hasdescribedepisodicdepersonalizationinwhichotheraetiologicalfactorsorco-morbiddisordersarenotprominent.

In psychoanalytic theory, depersonalization has taken on a rather different meaning, andthereforetherearedifferentexplanationsforitsorigin.Psychoanalystshavebeenlessconcernedwithdescribing thephenomena than theunderlyingconceptof thealienationof theego.Forexample,intheworkoftheexistentialistschool,astypifiedbyBinswanger(1963),thereisdiscus-sionofthedepersonalization of man.

This depersonalization has by now gone so far that the psychiatrist (even more than the psychoanalyst) can no longer simply say, ‘I’, ‘you’, or ‘he’ wants,


wishes etc. the only phrases that would correspond to the phenomenal facts. Theoretical constructs dispose him, rather, to speak instead of my, your, or his Ego wishing something. In this depersonalization we see at work that aspect

of psychiatry’s founding charter that is most at odds with every attempt to establish a genuine psychology. An explanation of this baleful influence need

go no further than the clearly recognized task that psychiatry, since Griesinger, has set itself – namely, to create a psychology that, on the one hand, serves to

bring a reified functional complex into relation with a material ‘organ’ but that, on the other hand, allows this organ itself to be divided into and

understood in terms of its functions.

Thisclearlyisquiteadifferentsenseofthewordthanthephenomenological,withwhichthischapterhasbeenconcerned.

Thedistressingexperienceofdepersonalization,witha feelingofunreality, remainscentralto the description of the disordered self.The disturbance that causes this may be organic orenvironmental,psychoticorexistential.Concernabouttheexperienceofselfandoftheenviron-mentmostcommonlyoccurtogether.

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217

C H A P T E R 14

Disorder of the Awareness of the Body

SummaryThe body is the physical manifestation of the individual being. It is the material, corporealinterfacewiththeexternalworld.Theworldisexperiencedthroughthebody’ssenses.Thebody,also,isitselfexperiencedasanobjectintheworld.Inthischapter,weexamine:

1. disordersofbeliefsaboutthebodyincludingbeliefsofillness,diseaseanddeath,2. disordersofbodilyfunction,includingthelossofsensory,motororcognitivefunctionthat

occurintheconversionanddissociativedisorders,3. disordersoftheexperienceofthephysicalcharacteristicsofthebodyandoftheemotional

andaestheticvalue,and4. complexdisordersofthesensoryawarenessofthebodythatalmostexclusivelyderivefrom

neurologicallesions.Even though these abnormal experiences are disparate, what binds them together into a

coherentaspectofpsychopathologyisthatthebodyasexperiencedisattheirheart.

Beside fear and sorrow, ‘sharp belchings, fulsome crudities, heat in the bowels, wind and rumblings in the guts, vehement gripings, pain in the belly and

stomach sometimes after meat that is hard of concoction, much watering of the stomach, and moist spittle, cold sweat.’

Robert Burton (1577–1640), The Anatomy of Melancholia (1628)

To some, ill health isa way to be important,

Others are stoics,a few fanatics,

who won’t feel happy untilthey are cut open.W.H. Auden (1969)

Thephysicalityofthebodyiseverpresent:thereisdensity,mass,movement,action,speed,position,heat,coldandvariousdegreesoftouch,painandsoon.SinceDescartes(1596–1650),the relationship between mind and body has stimulated much investigation and discussion.Descartes’originalclaimwasthatthemindandbodyaredistinctanddifferent;furthermore,thatthemindcanexistwithoutthebody.Thereareother theories thatattempttoaccount for thenatureofmindandbody.Materialisttheoriesproposethatthebodyisallthereis,andvariationsofthesetheoriesaccountformindindifferentways,whereasidealisttheoriesmaketheoppositeclaimthatthemindisallthatexists.Thefactthatmanydescriptionsofmood,cognition,volitionandotherpsychologicalfunctionsareexpressedinphysicalterms–‘aheavyheart’,‘bone-headed’,

Keywords: Hypochondriasis, Disgust, Dysmorphophobia, Body Integrity Identity Disorder,AnorexiaNervosa,MuscleDysmorphia.

14—DiSOrDEr OF thE AwArENESS OF thE BODY 217.e1


‘gutsanddetermination’,‘apainintheneck’–underlinestheinextricablerelationshipbetweenmindandbodyandemphasizesthedegreetowhichthebodycanbecomeameansofcommu-nicating distress and bodily metaphors used to consciously or unconsciously express feelings.Whetherthesemetaphorsoriginallyderivefromthephysicalmanifestationsofemotionaldistressorwhetherthelanguage,thatis,themetaphor,structurestheexperienceisamootpoint.Whatisclearisthatthereisnoreadydivisionbetweenthesubjectiveexperienceofselfandofbody.Aten-year-oldgirlputthisrelationshipthus:‘Youfeelbetterifyou’vedoneyourhomework;ifyouhaven’tyougetahorriblepaininyourstomach’.Finally,sincethebodyisitselfanobjectintheworld,itinhabitsaworldofvaluesandnormssuchthatthereare‘good’and‘bad’bodies,‘desir-able’and‘undesirable’bodies.Inaddition,asubsetofvaluesisaesthetics,sothatthereare‘beauti-ful’and‘ugly’bodies.Thismeansthat individualsapproachboththeirownandotherpeople’sbodieswithanattitude:theyappraisebodieswithasetofbeliefsandexpectations,formjudge-mentsandacttowardsbodieswithapprovalordisapproval.

Inordertoformacohesiveframeworkforconceptualizingthedisordersofselfandtheverydiverseabnormalitiesofbodyimage,oneneedstoapplythemethodsofdescriptivepsychopathol-ogy.InChapter12,thenatureofselfandthepathologyoftheexperienceofselfwerediscussed.Inthischapter,disordersoftheawarenessofbodyarediscussed.

ClassificationCutting(1997)givesagoodoutlineoftheclassificationofdisordersofawarenessofthebody,whichhasbeenadaptedfor thischapter (Table14.1).Therearedisordersofbeliefsabout thebodyincludingbeliefsofillness,diseaseanddeath(seebelow).Inthisgrouparealsothedisordersofdissatisfactionwiththebody,whichoccurineatingdisorders.Thesedissatisfactionswiththebodyarebestunderstoodasarisingfromnegativecognitiveevaluations,thatis,beliefsaboutthebody.Next,therearedisordersofbodilyfunction,includingthelossofsensory,motororcognitivefunction thatoccurs in thedissociativedisorders.Therearedisordersof theexperienceof thephysicalcharacteristicsofthebody.Theseincludedisordersoftheexperienceofthesize,shape,structureorweightofthebody.And,finally,therearecomplexdisordersofthesensoryexperienceofthebodythatalmostexclusivelyderivefromneurologicallesions.

Disorders of Beliefs About the Body (Bodily Complaint Without Organic Cause)Classificationof thesedisorders isdifficult,partlybecause thesymptomsareobscure inoriginandpartlybecausetherearedifferenttheoreticalbasesforthewordsused.Forexample,conversion hysteriawasusedasatermthatreferredtothepresumedunconsciousconversionofanunaccept-ableaffectintoaphysicalsymptom.Hypochondriasisreferstoaconcernwithsymptomsandwithillnessthattheoutsideobserverregardsasexcessive;thesameamountofconcernorcomplaintassociatedwithpathology that thedoctor regardsas justifying itwouldnotbedeemedhypo-chondriacal.Dysmorphophobiaisaphenomenologicaltermandreferstothesubjectiveexperienceofdissatisfactionwithbodilyshapeorform(Figure14.1).

HYPOCHONDRIASIS

Hypochondriasisdescribesthesubjectiveandundueawarenessofphysicalsymptomswhichareinterpreted as signalling serious illness. It is a symptom and not a disease. There are manydifferentmodesofexpression:minorpainanddiscomfortdominatetheperson’slifeandoccupyhisattention;hemayhaveunreasonablefearsaboutthelikelihoodofdevelopingseriousillness,

14—DiSOrDEr OF thE AwArENESS OF thE BODY 219

andfeelsaneedtotakeexcessiveprecautions;hemaymisinterpretbenignblemishesashavingsinisterpathologicalsignificance.Theseexpressionsofdissatisfactionmayoccurontheirownorinanycombination,andtheycanaffectanybodilysystemorpsychologicalprocess.Hypochondriacalsymptomsareverycommonandusuallytransient.Onlyaminoritycometomedicalattention,andonlyaselectedatypicalproportionoftheseareseenbypsychiatrists.

Thereisadistinctionbetweenillnessfears,whentherearenobodilysymptoms,andthefearsanddistresswhicharenotassociatedwithbodilysymptomsbutmerelyariseoutofthepossibilityofseriousillness.Thisshowstheoverlapbetweenillnessphobias(unreasonablefearofdevelopingillness)andhypochondriasis(preoccupationwithsymptoms).Thereisoftendifficultyindiagnosiswhenapersonwithdemonstrablephysicalpathologycomplainsexcessivelyabouthissymptoms;hiscomplaintsappeartobeoutofproportiontotheanticipatedsufferinganddisabilityoftheillness.Necessaryandentirelyroutinemedicalexaminationandinvestigationtendtoreinforcethepatient’s symptoms.Somatic symptomswithoutorganicpathologyareextremelycommonand may result from misunderstanding the nature and significance of physiological activityaggravatedbyemotion(Kellner,1985).Themechanismsunderlyinghypochondriacalsymptomsincludemisinterpretationofnormalbodilysensations;conversionofunpleasantaffect,especially

TABLE 14.1 ■ Classification of disorders of awareness of the body

Classification Details

Beliefs about the body

Illness and disease Hypochondriacal symptoms

Body dissatisfaction Real and ideal body weight discrepancy

Function of the body

Sensory deficits For example dissociative sensory loss (blindness)

Experience of physical characteristics of the body

Size Microsomatognosia, macrosomatognosia and body image disturbance

Shape ‘My jaws are misshapen’

Colour Skin colour may be experienced as lighter

Structure ‘My lungs are connected to my abdomen’

Weight Feelings of lightness or heaviness

Experience of emotional value of the body

Anosognosic overestimation Exaggeration of body’s strength

Misoplegia Hatred of body part

Dysmorphophobia Feeling of ugliness or defect of body or one of its parts

Experience of sensory awareness of the body and the world

Palinaptia Persistence of sensation beyond the duration of contact with stimuli

Exosomesthesia Cutaneous sensation in extra-personal space

Alloaesthesia Experience of sensation on contralateral side to stimulation

(After Cutting, 1997, p. 317, with permission of Oxford University Press.)


depression,intophysicalsymptoms;andtheexperienceofautonomicsymptomsdirectlycausedbydisorderofmood.

Explicit in the identification of hypochondriasis is the condition of the patient himself.Implicit,however,isthedoctorwholabelshispatienthypochondriacalanddeemshimsick.Inasocietythatissoconsciousofphysicalhealthandexternalphysicalappearance,thepatientmayhavetoshout‘hypochondriacally’becausethedoctorwillonlylistenoutforphysicalcomplaints.Whatthesymptomscommunicatetootherpeopleisanimportantcomponentofalldisordersofbodilyawareness;concentrationonthesubjectiveaspectsofsymptomsshouldnotdetractfromtheirsocial implications.Hypochondriasisisnotuncommonlyaniatrogenicconditioninducedbythedoctor’sfailuretolistentohispatient’sstoryandinabilitytogiveappropriateweighttopsychologicalaspectscontributingtosymptoms.

What is Hypochondriasis?

Byderivation,thewordhypochondriumreferstotheanatomicalareabelowtheribcage(Figure14.2)andhencedysfunctionoftheliverorspleen.Suchwordsasatrabiliousormelancholiareferto the black bile that was considered to be associated with hypochondriacal complaint anddepressedmood.Kenyon(1965)hasdefinedhypochondraisisasmorbidpreoccupationwiththebodyorstateofhealth.

Ishypochondriasisaseparatecondition–asymptomorasyndrome,anounoranadjective?It is best to regardhyponchondriasis as a symptom rather than adistinct condition. It is notunitaryasaconditionbutadisorderofcontentratherthanofform.Thecontentistheexcessiveconcernwithhealth,eitherphysicalormentalandtheinterpretationofsubjectiveexperienceasderivingfromseriousillness.Theformoftheconditionmaybeveryvariable.Eventhoughtheterm hypochondriacal is best retained as description rather than as a discrete disease entity(Kenyon,1976),bothcurrentclassificationsystemshaveapurelyhypochondriacaldisorder.

BarskyandKlerman(1983)haveconsideredthatthewordhypochondriasisisusedtodescribefourquitedistinctconcepts:

■ Itdescribesapsychiatricsyndromecharacterizedbyphysical symptomsdisproportionatetodemonstrableorganicdisease,fearofdiseaseandtheconvictionthatoneissick,preoc-cupationwithone’sbodyandpursuitofmedicalcare.

Figure 14.1 Disorders of bodily complaint.

Undue concern with illness– hypochondriasis

Dislike of body– dysmorphophobia,

transsexualism

Undue concernwith appearance

– narcissism

Distortion of body image– anorexia nervosa,

obesity

Actual physical illness

Actual physicaldeformity


■ Hypochondriasis isseenpsychodynamicallyasaderivativeofaggressiveororaldrivesorasadefenceagainstguiltorlowself-esteem.

■ Itresultsfromaperceptualamplificationandaugmentationandacognitivemisinterpreta-tionofnormalbodilysensations.

■ Itissociallylearnedillnessbehaviourtowhichthephilosophyandpracticeofthemedicalprofessionlendssupport.

Onlythefirstoftheseispsychopathologicalinnature.Theseconceptsarenotalternativesbutareallpresenttoadifferentextentintheindividualsufferer.Someindividualsuseasomatic styletodescribetheirperceptionofinternaldiscomfort.Appleby(1987)pointsoutthatcloserexami-nationrevealsadescriptivetriadofthepatientbeingconvincedthathehasadisease,fearingthediseaseandbeingpreoccupiedwithhisbody.Heemphasizesthatthepatientneedstounderstandhissymptomsbeforeanyimprovementcanbeexpected.

BridgesandGoldberg (1985)haveassessed somaticpresentationofpsychiatricdisorder inprimarycare ina seriesof500 inceptions to illnessamong2,500attendees.Theiroperationalcriteriaforsomatizationwereasfollows:

■ Consulting behaviour:seekingmedicalhelpforsomaticmanifestationsandnotpresentingpsychologicalsymptoms.

■ Attribution:thepatientconsiderssomaticmanifestationstobecausedphysically.■ Psychiatric illness:psychiatricdiagnosisjustifiedbypsychiatrists.■ Response to intervention: the researchpsychiatrist is of theopinion that treatmentof the

psychiatricdisorderwouldbenefitsomaticsymptoms.Theseauthorsconsiderthatsomatizationisacommonmodeofpresentationofpsychiatric

illness and partly explains the failure of family doctors to detect psychiatric disorders inprimarycare.

Trying to distinguish between organic and psychological elements of disease or betweenmental andphysical illness is a fruitless taskbasedonanoutmodedandmisleading linguisticdistinction (Kendell, 2001).Psychological conflictmaybemediated via physical illness, and a

Figure 14.2 The hypochondrium.

Hypogastric

IliacIliac

LumbarLumbar Umbilical

Epigastric

Hypochondria


physicalillnessresultsinpsychosocialsequelae.Bothsomaticandpsychologicalsymptomsoccur,anditisperfectlypossibleforapatienttohaveahypochondriacalreactiontoaclearlydefinedorganicillness.

Apatientwhoregardshimselfashavingsymptomsofillnesscommunicatesthistorelativesandalsotothedoctorinatacitrequestforbothhelpandlabelling(Parsons,1951).Inordertocometomedicalattention,thepersonhastocarryoutaparticularsetofactions,thatis,undertakeillnessbehaviour(Mechanic,1962,1986).Illnessbehaviourincludesthemannerinwhichsymp-tomsaredifferentiallyperceived,evaluatedandacteduponbydifferentkindsofpeopleandindifferent social situations.Whilst somepeoplemaybeable tomake lightof symptoms, shrugthemoffandavoidseekingmedicalattention,othersmayrespondtotrivialpainanddiscomfortbyreadilyseekingcare.Itisclear,therefore,thatindividualcharacteristicsaswellassocialculturalonesdeterminehowanyoneindividualwillrespondtosymptoms.

Individualdeterminantsofhypochondriasisseemtoincludepreoccupationwithbodilyfunc-tionsorwiththeideaofharbouringanillness,ruminationaboutillness,suggestibility,unrealisticfearofinfection,fascinationwithmedicalinformationandfearofprescribedmedication(Finketal.,2004).Fearofdeathalsoseemstobeanintegralaspectofhypochondriasis(Noyesetal.,2002b),andchildhoodadversity(includingtraumaticeventsandseriousillnessandinjury)andparentalmodellingofillnessbehaviourinchildhoodarevulnerabilityfactors(Noyesetal.,2002a;Kirmayer and Looper, 2006). Anxiety (Olatunji etal., 2009) and disgust (Davey, 2011) alsoappeartounderliehypochondriasis.Disgust,inthiscontext,isconceivedofasadisease-avoidantemotion,anddisgustpropensityandsensitivityareregardedasvulnerabilityfactorsforanumberof disorders including blood-injection-injury phobia and hyponchodriasis. Cyberchondriasis, atermreferringtoexcessiveandrepeatedhealth-relatedsearchesontheInternet,revealsaspectsof hypochondriasis that may have remained covert, namely that behavioural aspects includesearchingforhealthinformationondiagnosedandundiagnoseddisorders,seekingoutdescrip-tions of other people’s experience of illness and using message boards and support groups.However,thesebehavioursonlyprovokemoredistressandanxiety(Museetal.,2012;StarcevicandBerle,2013).

There are very marked cultural differences in the presentation of symptoms of disorderedmood;somatizationofemotionaldistressappliestobothanxietyanddepression(Rack,1982).Thepredominanceofdescriptionofsomaticovermoodsymptomsindepressiveillnesshasbeenreported from India, Pakistan, Bangladesh, Hong Kong, theWest Indies and various Africancountries.Thereasonsforthisincludetheexpectationsthepatienthasofwhatthedoctorcando,theuseofsomaticsymptomsasmetaphorfordistressandthesocialunacceptabilityofpsy-chological symptoms. The Bradford Somatic Inventory has been devised for a multiethniccomparisonofthefrequencyofsomaticsymptoms,theiranatomicallocalizationandtheirasso-ciationwithpsychiatricdisorder(Mumfordetal.,1991).ImmigrantpopulationsfromPakistanintheUnitedKingdomdemonstratemoresomaticsymptomsontheBradfordSomaticInventorycomparedwiththenativepopulation.Thesesymptomsareassociatedwithrecognizableanxietyanddepressionasmeasuredbyvalidatedquestionnaires(Farooqetal.,1995).

Psychopathology of the Hypochondriacal Patient

The contentofhypochondriasis is theexcessiveconcernwithhealth,eitherphysicalormental.PossibleformsoftheconditionarelistedinBox14.1.Theseformsforacontentofconcernaboutcancercanincludethefollowing.

■ Ahallucinatoryvoicemaysaytothepatient,‘youhavecancer,youaremoribund’.■ Asecondary delusionassociatedwithaffectiveillnessmayoccurinwhichthepatientunrea-

sonablybelieveshehascancer;he isquiteunabletoaccepthisdoctor’s reassurance.Thebeliefisunderstandableinrelationtothepatient’soveralldepressedmoodstate.Thatsuchsecondarydelusionscouldbeassociatedwithaffectivepsychoseswasclearlydescribedby


Cotard (1882): ‘she blamed herself and felt guilty. After some months she entertainedhypochondriacaldelusions,believingthatshehadnostomachandthatherorganshadbeendestroyed; sheattributed thesebeliefs to theeffectsofanemeticwhichshehad, in fact,beengiven’.This associationofhypochondriacal andnihilisticdelusionswithdepressivepsychosisintheelderlyhasbeencalledCotard’ssyndrome.

■ Thedelusionmaybeprimaryinnature.Apatientwithschizophreniabelievedthathehadbeen inoculated under a general anaesthetic with a transmissible cancer because othersbelievedhimtobehomosexual.

■ Hypochondriasisoftenmanifestsasanovervalued idea.Suchapersonisconstantlyworriedandconcernedabouttheriskofillnessandtheneedtotakeprecautionsinwaysthathisfriendsfindridiculous,forinstanceinthelengthsthathewillgotoavoidapossiblecar-cinogen.Heconsidersitperfectlyreasonablethatheshouldtakeduecaretomaintainhishealth,butheagreesthathismeasuresareexcessive.Hecannotstophimself,nightorday,from thinking,worryingand trying toprevent illness.Suchanovervalued idea is foundreasonable, or at least not alien to the person’s nature, but preoccupies the mind to anunreasonable extent, in that the whole energy and being becomes directed towards thissingleidea.

■ The hypochondriacal idea may take the form of an obsessional rumination in which thepossibilityofaparticularillnessoraformofwords,as‘Ihavecancer’,mayrecur.Thisisrecognizedasbeingboth ‘alien tomynature’but also ‘coming from insidemyself ’. It isresistedyetoccursrepetitively.

■ Withoutitsamountingtoadelusion,patientsmayoftenhavehypochondriacalsymptomsofanon-specificnatureinthecourseofadepressiveillness.Itmaybepossibletoreassurethemconcerninganyparticularsymptom,butthisdoesnotmakethemfeelbetterintheirmoodnordoesitpreventtheoccurrenceoffurtherhypochondriacalsymptomsintheformofdepressiveruminations.

■ Inthecontextofacuteorchronicanxiety,thepatientmaybepronetomultitudinousworriesconcerningillnessandfearsofillness.Thenormalsensoriumisinterpretedassymptoms;symptomsareinterpretedasseriousillness.Mosthypochondriacalsymptomsoccurinrela-tiontoanxietyanddepression;theotherformsofdisorderaremuchlessfrequent.

The commonest bodily symptoms implicated in hypochondriasis are musculoskeletal; gas-trointestinal,includingindigestion,constipationandotherpreoccupationwithmalfunction;andcentralnervoussystem,includingheadache(Kenyon,1964).Themostcommonlyaffectedpartsof thebodyareheadandneck,abdomenandchest. In16percentofpatients, symptomsarepredominantlyunilateral,andofthese,73percent,accordingtoKenyon,wereleft-sided.Therewasnosignificantphysicalabnormalityfoundin47percentofthoseadmittedtoapsychiatricwardforhypochondriasis.Painwasprominentin70percentofpatients.

Hypochondriasis may be associated with smell; bodily appearance; sexual hypochondria;ear, nose and throat symptoms; and ophthalmological abnormalities (Karseras, 1976) such as

BOX 14.1 ■ Psychopathology of hypochondriasis

■ Hallucination■ Secondarydelusion■ Primarydelusion■ Overvaluedidea■ Obsessionalrumination■ Depressiverumination■ Anxiouspreoccupation


asthenopia,whichincludessuchcomplaintsasoculardiscomfort,achingeyes,soreness,pressurein or around the eyes, tiredness of eyes, grittiness, chronic redness, feelings that the eyes arepushedoutonstalks,tightnessoftheskinacrossthebridgeofthenoseorprickingoftheskinaroundtheeyes.Photophobiaisacommonhypochondriacalcomplaint,asare‘floaters’–muscaevolitantes,photopsiaandsometimesdiplopia.

Hypochondriacal complaint may relate to psychological symptoms and the fear of mentalillness.Inthiscontext,sleepisofteninvolved,withsubjectivefeelingsofsleepnotoccurringatall,notoccurringinsufficientamountornotbeingofsatisfactoryquality.Fearofmadnessandinevitablepsychiatricdeteriorationiscommonlyassociatedwithacuteanxietydisordersandalsowithdepressiveillness.

Disorders of Bodily Function – Conversion and DissociationPsychopathologyhas,asitssubjectmatter,actualconsciouspsychologicalphenomena.Althoughour main concern is with pathological phenomena, it is also necessary to know what peopleexperienceingeneralandhowtheyexperienceit;inshort,psychopathologyisinterestedinthefullrangeofconsciouspsychologicalphenomena.Theforegoingraisesthequestionofwhetherexperiencesthatarenotinconsciousawareness,suchasthosethatarethesubjectofthissection,caneverbethepropersubjectofpsychopathology,sincetheseexperiencesarenotinconsciousawareness.Theseexperiencesandbehaviourshaveanantiquepedigreeandhave,untilrecently,beendescribedbythetermhysteria.

Themeaningandvalidityof the termhysteriahasbeenarguedabout for centuries (Veith,1965).Slater (1965)wished to reject thediagnosisofhysteriawhile retaining theword as anadjectivetodescribecertaintypesofsymptomsandpersonality.Lewis(1975)summarizedthiscontroversy:‘Themajorityofpsychiatristswouldbehardputtoitiftheycouldnolongermakeadiagnosisof“hysteria”or“hystericalreaction”;andinanycaseatougholdwordlikehysteriadiesveryhard.Ittendstooutliveitsobituarists.’Classically,physicalsymptoms,usuallymimick-ingneurologicaldisturbancessuchasseizures,paralysis,tremors,blindness,andgaitabnormalitiesoccur inthesettingofpsychologicaldistresswithoutaccompanyingexpectedphysicalfindingson examination. The term conversion was used to denote the fact that emotional distress orpsychologicalconflicthadbeenconvertedintophysicalcomplaints.Arelatedtermisdissociation,referringtothedisturbanceofthebasicunityoftheselfresultingintheapparentseparationofaspectsoftheselffromoneanother.Forexample,aseeminglyconsciousindividualmayreportthatsheisunabletorecallvitalaspectsofherbiographydespitehavingnodemonstrableabnor-malitiesofmemory. It isobvious that the termdissociation ismerelyadescriptive concept forsomethingfactuallyexperiencedandencounteredinclinicalpractice,aswellasatheoryforwhathappensintheparticularstate,andthusitprovidesthehypothesisforanobservedclinicalfact.It is a concept that does not describe anything uniform but touches upon modes of extra-consciousexplanatorymechanism.

Theimplicationsthatmaybedrawnfromtheconceptualizationofconversionanddissocia-tionare:

1. thepresentingsymptomsarepsychologicallydetermineddespitebeingphysicalinnature;2. causationisthoughttobeunconsciousandhencethepatientisnotawareofthepsycho-

logicaldeterminants;3. symptomsmaycarrysomesortofadvantagetothepatient,thesocalledprimaryorsec-

ondarygain;and4. thesymptomsoccurbythemediationoftheputativeexplanatorybutill-definedprocesses

ofconversionordissociation.


At tenyear follow-upofpatientsdiagnosedwithhysteria at aneurologicalhospital,manywerefoundtohavesubsequentlydevelopedaseriousphysicalorpsychiatricillness,andforthisreason the existence of hysteria as a diagnostic category was questioned (Slater and Glithero,1965).Follow-upof113patientsdiagnosedashystericalbypsychiatrists revealed60per centwith evidence of affective disorder and only 13 per cent with a consistent picture of hysteria(Reed,1975).However,MerskeyandBuhrich(1975)carriedoutafollow-uponpatientsdiag-nosedashavingmotorconversionsymptomsataneurologicalhospitalandacontrolgroupofotherpatientsfromthesameclinicalsetting.Theyfoundahigherrateoforganicsymptomsatfollow-upinthecontrolgroup.Fromfollow-upstudiesofneurologicalorpsychiatricpatients,whenthediagnosisofhysteriahasbeenhighlyinclusive,otherorganicandpsychiatricconditionshavecommonlymanifested,but15to20percentstillretainthediagnosisofhysteria.

For a diagnosis of dissociative disorder or functional neurological symptom disorder to bemade,positivepsychologicalfeaturesmustbepresentandcharacteristicorganicfeaturesshouldbeabsent.Itisimportanttoemphasizethedangerofmisidentifyinggenuinephysicalillnessasfunctionaldisturbance.Thus, forastasia–abasia (seeFigure14.3) forexampletobeconsidereddissociative,thesymptomsshouldhavepsychogenicaetiology;thepatientisunawareofthis,andthesymptomscanbeseentobeawayofdealingwithstress.Ifsymptomsareclearlyconsciouslyproduced, deliberate disability, malingering or artefactual illness is present. One may have todistinguishbetweenthesymptomsoftheoriginalillness,forexampleheadinjury,andasecondaryhystericalreaction(Sims,1985).

Epidemic, communicatedormasshysterianowcommonlytermedmass psychogenic illnessormass sociogenic illness has been known and described from earliest times, for example the physicalsymptomsofconversiontypeassociatedwiththemillennialistmovementsoftheMiddleAges

Figure 14.3 Astasia-abasia. (From Merskey, 1979.)


(Cohn,1958);inaclosedfemalecommunityinaFrenchseventeenthcenturyconvent(Huxley,1952); and among Lancashire mill girls (St Clare, 1787). A rather similar epidemic spreadthroughaschoolinBlackburn180yearslater,withsymptomsofover-breathing,dizziness,faint-ing,headache,shivering,pinsandneedles,nausea,paininthebackorabdomen,hotfeelingsandgeneralweakness(MossandMcEvedy,1966).Thespreadofsuchepidemicshasbeendescribed:theyalmostalwaysoccurinyoungfemales;theyoftenstartwithagirlofhighstatusinherpeergroupwhoisunhappy;theytendtooccurinlargestnumbersintheyoungerchildreninasec-ondaryschool,thatis,justaftertheageofpuberty;theyappeartoaffectmostseverelythosewhoon subsequent testing are found to be the most unstable. What seems to characterize theseoutbreaksaresymptomsoccurringamongpeoplewithsharedbeliefsabouttherelevantsymptomsin the absenceof identifiable environmental cause and little clinical or laboratory evidenceofdisease.Oftensymptomsspreadby‘line-of-sight’transmissionandmayescalatewithvigorousor prolonged emergencyormedia response ( Jones, 2000).Theoutbreaks also seem tomirrorprominentsocialconcerns,changinginrelationtocontextandcircumstance.In latetwentiethcenturyonwards,symptomsappeartobetriggeredbysuddenexposuretoananxiety-generatingagent,mostcommonlyaninnocuousodourorfoodpoisoningrumoursorchemicalandbiologicalterrorismthemes(BartholomewandWessely,2002).Reportscontinuetobepublished(Aldousetal.,1994;Kharabshehetal.,2001;ChowdhuryandBrahma,2005;Kokota,2011).

Itwouldbeunrewardingtolistallthepossiblesymptomsthatmaybeofconversionordis-sociativeorigin:motor, sensory,pain and alterations in consciousness.With theuseof skilledexamination and additionalneurophysiological techniques, for example in the investigationofdissociativeblindness,itisveryoftenpossibletodemonstratediscrepancybetweentheseverityofsymptomsandphysiologicaldysfunction,whichmaybeminimalorabsent.ThephysiologicalimpossibilityofthesesymptomsiswelldemonstratedinFigure14.4,whichshowsthevisualfieldofapatientcomplainingofimpairedvision.

It is important to take into account the effect these symptoms have on other aspects of apatient’sbehaviourandsocialrelationships.Symptomsresultinthepatientbeingregardedasillordisabled,andthisaltersthewayheorsheisperceivedbothbyrelativesandfriendsandbythemedicalandrelatedprofessions.Theremaybelong-termphysicalconsequencesofmotorsymp-toms,forexamplecontractures;thisistheultimatemimicrythatconversionsymptomsshowoforganicconditions.

Figure 14.4 Visual fields of a hysterical patient.

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Classically,moodintheseconditionsisdescribedasbelle indifference.Suchamoodoccurredinagirlaged20withseveredisabilitythathadentailedherusingcrutchesforthepasttwoyears.Shesmiledwithsublimeresignationatherunfortunatesituation,andeveryonearoundherwasrelieved that she accepted her symptom so stoically! However, some patients with conversionsymptoms show higher autonomic arousal than do anxious and phobic patients (Lader andSartorius,1968).

Disorders of the Physical Characteristics and Emotional Value of the Body (Dislike of the Body)This sectiondealswithhow thebody is subjectively experiencedas aphysicalobject thathasboth symbolic and aesthetic value to the individual.These two aspects of a person’s attitudetowards their own body are distinct but interrelated. A distorted subjective experience of thebody,thesocalleddistortionofbodyimage,mayoccurindependentlyofapprovalordisapprovalorindeedofdislikeofthebody.Furthermore,thebodycanbeappraisedasugly,thatisasaes-theticallyunattractive,intheabsenceofdemonstrableabnormalityofbodyimage.

DYSMORPHOPHOBIA (BODY DYSMORPHIC DISORDER)

Many people are dissatisfied with the way they look and, of course, this does not of itselfconstitute a psychiatric symptom. However, unreasonable loathing or excessive preoccupationwithadislikedfeaturemayresultinpsychiatricreferral.Suchpeoplemayshowgeneralizeddisap-proval of their appearance, or it may be concentrated on one feature. Dysmorphophobia wasfirstdefinedbyMorselli(1886)as‘asubjectivefeelingofuglinessorphysicaldefectwhichthepatient feels is noticeable to others, although his appearance is within normal limits’. As themeaningofthetermphobiahaschangedinthepastcentury,Berrios(1996)considersthatdys-morphophobiaisatleastassatisfactoryatermasmodernequivalents.AccordingtoAndreasenandBardach(1977),theprimarysymptomofdysmorphophobiaisthepatient’sbeliefthatheorsheisunattractive.

Dysmorphophobia has been defined, more inclusively, as the primary complaint of someexternalphysicaldefectthoughttobenoticeabletootherpeoplebut,objectively,itsappearancelieswithinnormallimits(Hay,1970).Patientspresentingtoaplasticsurgeonforcosmeticrhi-noplastywere examinedpsychiatrically.Theywere, as agroup,moredisfigured thana controlgroup, and they showed some psychological disturbance in that 40 per cent showed disorderof personality.There was, however, no relationship between the degree of deformity and theamountofpsychologicaldisturbance.HayandHeather (1973)commented thatwhensurgerywascarriedout,thosepatientswithminimaldisfigurementdidaswellasthosewithmoremarkeddefects,bothsubjectively indescriptionof their self-imageandonpsychological testing.Theyconsideredthat thedegreeofdeformitywasnotofmajor importance incomingtoadecisionwithregardtooperation.Patientsreportedmarkedimprovementintheirappearancesixmonthsafterrhinoplasty,andthiswasassociatedwithreductionofpsychiatricsymptomscores(Robinetal.,1988).

Body dysmorphic disorder occurs most frequently in late adolescence; three-quarters ofpatientsarefemaleandmostareeithersingleordivorced(Vealeetal.,1996).Thereisfrequentcomorbiditywithmooddisorder, socialphobia andobsessive-compulsivedisorder, and72percentofcasesmanifestedpersonalitydisorder,usuallyofparanoid,avoidantorobsessive-compulsivetype.Twenty-fourpercentofthisgroupofpatientshadattemptedsuicide.InasimilarAmericanstudy,73percentofpatientsreportedexcessivemirrorchecking,63percentreportedattemptstocamouflagetheir‘deformities’andothersreportedgroomingorskinpicking(Phillipsetal.,


1993; Phillips etal., 2005). Almost all had severe limitations of their social activities. Mostpatientshadsufferedfromamajormooddisorderand17percenthadmadesuicideattempts.Themostfrequentlyreportedbodyparts,inorderofconcernareskin,hair,nose,stomach,teeth,weight,breasts,buttocks,eyes, thighs,eyebrows, legs, facesizeor shape,chin, lips,arms,hips,cheeksandears(Phillipsetal.,2005).

Thosecomplainingabouttheirface,andespeciallytheirnose,dosoinextremeandexagger-ated terms despite the deformity often being relatively slight. The dissatisfaction with theirappearance and the extent to which they feel others are aware of their disfigurement arequite out of proportion, as are the discomfort and disturbance in function: ‘agonizing pain’and ‘total inability to breathe’. At the same time, the actual description is often quite impre-cise: ‘theskinundermyeyes joinsmynose inafunnyway’(Birtchnell,1988).Becauseoftheextreme degree of reaction they show, they may contemplate radical remedies, for examplewishingtohavetheirnoseamputatedorthreateningtokillthemselves.Dysmorphophobiaisarelativelycommondisturbanceofselfandusuallytakesthepsychopathologicalformofanover-valued idea.

Thecomplaintofdysmorphophobia ismadeby thesubject in relationtoothersbut isnotusuallybasedontheopinionofothers.Soapatientcomplainsofhisnose,orthesmallsizeofherbreasts,andconsidersthatotherswillregardthemasuglyorunattractive.Often,theappear-anceiswellwithinnormal limits,withnodeformity,butthepatient isconvincedthatsurgerywillbebeneficial.Patientsoftenpresentintheirlateteensorearlytwenties.Thereisquiteoftenunderlyingpersonalitydisorderofanankasticordependenttypes;theremaybedepressedmooddisturbanceasareactiontothecomplaint;andsuchpatientsnotinfrequentlytalkof,andattempt,suicide.

A female student, aged 20, was referred to the psychiatric clinic following self-poisoning.When asked her problem, she burst into tears and said, describing the small size of herbreasts:

Basically there is a big difference between me and other girls. I’ve always been self-conscious. I used to pad myself. Even my mother made fun of me. I’ve tried

to convince myself I would change physically. I don’t feel like a total woman. I have to buy clothes that look ridiculous on top. My present boyfriend

I have been going out with for over a year always talks about other girls he has. He went to a dance and danced with another girl, I knew that it

was because she was bigger-busted than me. I was always aware of my figure, that I am not attractive… I detest myself, I hate my body… I don’t like

my boyfriend touching me there, I can’t wear nice clothes, I can’t make the best of what I already have…. even my little sister of 16 has more than I have

ever had.

Itisofinteresttonotethatsurgerycanresultinrestitutionofnormalbodyimage.Inastudyof11youngwomenwithnootherdiseaseandbreastsizenotgrosslyinappropriateforbodysizerequestingreductionmammoplasty,Hollymanetal.(1986)foundthataftersurgerybodyimagehadreturnedtonormal;self-confidence,feelingsaboutfemininityandsexualattractivenesswerealsoenhanced.

Symptomsofdysmorphophobiaaresometimesdescribedbypatientswithschizophrenia.Itmayoccurasthefirstsymptomastheconditiondevelops,andtheclinicianshouldthereforelookcarefullyforsuggestivesymptoms.Itmayalsobepresent intheestablishedcaseandwill thenshowcharacteristicschizophrenicsymptomatology.A19-year-oldAfrican-Caribbeangirl,previ-ouslydiagnosedwithschizophrenia,said:


The Spirit is a man, he feels warm and moves in me. I can’t feel yet. I’ve got to pray for my new body. I’ll have it in March. I will have to look beautiful, I don’t feel beautiful at the moment, I don’t look nice enough. I’ll have a nice

face, nice teeth, red eyebrows, red eyes, pupils red and smooth red lips. My skin will be light and I’ll have long fair thick hair down to my knees. My voice will be different and I’ll have a new tongue. I’ll speak many languages. I’ll

sing too. My brain and my mind will be the same. I’ll have long fingernails, a smaller waist, bigger breasts and my legs will be a bit shapelier. My figure

will change from 33” 24” 35” to 38” 18” 36”.

There is emergingevidence thatvisualprocessingof facesandobjectsmaybe impaired inindividuals with dysmorphic disorder. Abnormalities include inability to identify faces withemotional expressions under experimental conditions (Feusner etal., 2010a) and the use ofgreaterdetail-orientatedandpiecemealprocessingoffacescomparedtocontrols(Feusneretal.,2010b).Impairmentsoffaceprocessingappeartocorrelatewithdemonstrableabnormalitiesinfrontostriatal systems (Feusner etal., 2010c), and regional brain volumes of the left inferiorfrontalgyrusandamygdalaarepositivelycorrelatedwithseverityscoresofdysmorphicdisorder(Feusneretal.,2009).Thesefindingssuggestthat,despitetheabsenceofgrossabnormalitiesofperception,faceandvisualobjectprocessingimpairmentsmayunderliethenegativeevaluationsofthebodythatarecharacteristicofdysmorphophobia.

BODY INTEGRITY IDENTITY DISORDER

This isa rarecondition inwhichthere isanapparentmismatchbetweenthebody imageandthephysicalbody.Patientshaveastrongdesiretochangethephysicalbodysothatitcoincideswiththebodyimage.Themostcommondesireistoamputateamajorlimbortoseverthespinalcordinordertobecomeparalyzed.Patientsarereportedassaying‘Icanfeelexactlywheremylegshouldendandmystumpshouldbegin.Sometimesthislinehurtsorfeelsnumb’or‘mylimbsdonotfeelliketheybelongtome,andshouldnotbethere’(Blometal.,2012).Reportssuggestthat surgery is followedbya feelingofcompleteness,wholenessandsatisfaction.It isperhapssignificant that approximately half of a cohort of patients studied said that they felt sexuallyarousedwhentheysawadisabledpersonresemblingtheirowndesireddisabilityorfeltsexuallyarousedwhenimaginingthemselvesbeingdisabled(Blometal.,2012).

TRANSSEXUALISM

Inthiscondition,thereisadisturbanceofbodyimagewithadisorderofcoregenderidentity,adiscrepancybetweenanatomicalsexandthegenderthepersonascribestohimself.Intranssexual-ism,wearingclothingoftheoppositesex(transvestism)occurs,usually,asameansofpersonalgratificationwithoutgenitalexcitement.Itismuchcommonerinbiologicalmalesthaninfemales,butitoccursinbothsexes.Thesuffererofthisanomalyfeelsheshouldhavebeenoftheothergender, ‘a female spirit trapped in a male body’ (Morris, 1974). In adults, the disturbance ismanifestedbypreoccupationwithgettingridofprimaryandsecondarysexualcharacteristicsandthe request forhormone therapyor surgeryorothermeansof simulating the requiredgender(Green,2000).ThestrengthofthisconvictionisdescribedinConundrumbyJanMorris(1974)withliteraryéclat:‘IwasthreeorperhapsfouryearsoldwhenIrealizedthatIhadbeenbornintothewrongbody,andshouldreallybeagirl…througheachyearmyeveryinstinctseemedto become more feminine, my entombment within the male physique more terrible to me.’Anothertranssexualdescribedhimself:


I know that I am biologically a man but it is all a horrible freak of nature. Really I am a woman and by some accident I have got a male body. I think

as a woman and have female feelings and interests, and am only comfortable when wearing women’s clothes and in a feminine job. So, genuinely, I am a

woman… I am not against homosexuals although I am not one myself. When I have sex with a man, you must remember that I am really a woman.

Transsexualsdescribetheirfeelingsabouttheirbodyashavingbeenpresentfromearlychild-hood:thefeelingofcomfortand‘rightness’ theyexperiencedwhenwearingtheirsister’sdress,howthey‘fellnaturally’intofemalepursuitsandinterests.Thedifferenceofself-imagefromthebiologicalsexisusually,intheirownaccount,clearlyestablishedbeforepuberty.

The biological basis of transsexualism is uncertain. Blanchard in a series of papers (1989,1991,1993)proposedthatindividualspresentingwithmale-to-femaletranssexualismandwerecharacterizedashavingautogynephilia(sexuallyarousedbythethoughtorimageofthemselvesaswomen)weredistinctfromotherswhowerehomosexualinorientation.Thisclassificationiscontroversialandnotwidelyaccepted(Moser,2010).Thereisevidencethatchromosomalabnor-malitiesarerare(2.9%infemale-to-maletranssexualsand0.6%inmale-to-femaletranssexuals)andincludegonosomalaneuploidy,RobertsoniantranslocationsandKlinefeltersyndrome(Aueretal.,2013).Structuralimaginghasdemonstratedincreasedcorticalthicknessinmale-to-femaletranssexualsbutthesignificanceofthesefindingsisyettobedetermined(Ludersetal.,2012)and diffusion tensor imaging has shown white matter microstructure (superior longitudinalfasciculus,rightanteriorcingulate,rightforcepsminorandrightcorticospinaltract)inuntreatedmale-to-femaletranssexualsthatishalfwaybetweenthatofmaleandfemalecontrols(Ramettietal., 2011). Notwithstanding the fact that the biological basis of transsexualism is yet to beelucidated,whatisincontrovertibleisthatthedissatisfactionwiththebodyandwithsecondarysexualcharacteristicsandgenitaliaisrootedinbrainmechanismsthatunderliegenderidentity.

DISTURBANCE OF EATING AND BODY SIZE

Disturbanceofeatingoccurswithvariousconditions inwhichalterationofbody imageeithercauseseatingdisorderorresultsfromit.Threeconditionswillbediscussed:obesity,anorexiaandbulimianervosa.Onceagain,itisthesubjectiveaspects,theeffectonself-image,thatconcernsushereandnotthephysicalaspects.

Obesity

Obesity has become a major concern in the Western world. Both in Europe and in NorthAmerica,theprevalenceofobesityhasincreasedconsiderablysincethemid-1970s.Between1976and1980 intheUnitedStatesofAmerica,15percentof theadultpopulationaged20to74were obese, whereas by 2003 to 2004 the prevalence had risen to 33 per cent. It is currentlyestimatedat35.7percent(CentresforDiseaseControlandPrevention).Thesetrendsarealsoreplicated in Europe (World Health Organization Regional Office for Europe). Obesity isdefinedasabodymassindexofgreaterthan30kilogramspermetresquared;beingoverweightisabodymassindexofbetween25and29.9kilogramspermetresquared.Thereisalsoconcernabouttheriseofobesityinchildren.Itisnowestimatedthatapproximately17to20percentofchildrenareobese.Theconcernaboutobesityderivesfromtheassociatedhealthrisks;hyperlipi-daemia,insulinresistance,diabetes,hypertension,morbidityandprematuredeatharerecognizedcomplications. Thus, there are national and international health programmes to combat theapparentunrelentingriseintheprevalenceofobesity.

Indiscussionofthebodyimagephenomenaofobesity,Kalucy(1976)considersthatadoles-cenceisthecriticalstageofdevelopmentwhenprimarydisordersofshapeandbodyexperience


appear. Obesity in adolescents in diet-consciousWestern societies results in self-loathing andself-denigration.Thepresenceofanyphysicaldeformityatthisstageoflifeislikelytoprovokerevulsionfromtheself-image;individualsfeelespeciallyphysicallyloathsomewithregardtotheoppositesex.Theymayavoidmirrorsandanyotherreminderoftheirshape.Thereisalsopresentadistortionofbodysizeinthattheyoftenoverestimatetheirsize.Thisisinterestingincompari-sonwithanorexianervosapatients,whoalsooftenoverestimatetheirsizeandwhosebehaviourofdietingandfoodrejectionmaystartwhentheyaremildlyobeseatthetimeofpuberty.

Anorexia Nervosa

This is a condition that in the past was misplaced diagnostically; initially, sufferers wereusually thought to be physically ill. Marcé (1860), however, considered it to be one form ofhypochondriasis.Anorexianervosaisanillnessthatoccursmainlyinyoungwomen;thepropor-tionofmalecasesseenrangesfromonein20toaboutoneintenindifferentseries(DallyandGomez,1979)andtheproportionofboysishigherinchildhood.Thereisafailuretoeat,lowbodyweightandamenorrhoea.IthasbeenconsideredbyCrisp(1975)thatthedisorderispri-marilyaweight phobia,afearofincreasingbodyweight,andnotonlyafeedingdisordersimilartothoseofchildhood.Prominentisthefearoflossofcontrol;ifoneeatsnormally,onewillbeunabletostopandthereforebecomefat.Aswellasanabnormalself-image,therearealsoabnor-mal attitudes towards food, gender and sex. How does the patient with anorexia nervosa seeherself?ItisinpartanarcissisticdisorderaccordingtoBruch(1965),whohascalledit‘thepursuitofthinness’.InthedefinitioninICD-10,bodyimagedistortionisoneoffiveessentialfeatures:‘There isbody imagedistortion in the formofa specificpsychopathologywherebyadreadoffatnesspersistsasanintrusive,overvaluedideaandthepatientimposesalowweightthresholdonhimselforherself ’(WorldHealthOrganization,1992:p.177).Theotherfeaturesare:

■ bodyweightatleast15percentbelowthatexpected■ weightlossisself-induced■ amenorrhoea■ delayedorarrestedpuberty.Anorexia nervosa became more common in the United Kingdom in the latter part of

the twentieth century (Kendell etal., 1973). It is much rarer in, for example, India andother developing countries. This apparent difference in prevalence suggests that it may wellbe linked to social attitudes towards thinness, dieting and slimming. In the Western world,slimness is regarded as beautiful, and dieting may become a social norm that acts as a per-suasivepressureonanimpressionableadolescentfemalewhosebodyweighthasincreasedalittlemorethanaverageatpuberty.Ifthereareotherpsychologicaldifficultiesandsocialconflicts,theslimmingmaygetoutofcontrol.Inotherpartsoftheworld,wheretheaestheticnormsoffemi-ninebeautyarebasedonafulsomebody,thepressuretowardsthinnessislessbutthepressuretowardsobesitymaybegreater.EveninWesternsociety,theprevalenceofanorexianervosaisnot uniform within society but rather is determined by gender, age, socioeconomic class andethnicity.

Patientswithanorexianervosaoftendenytheirthinnessandsometimesclaimtobetoofat.Becauseoftheirextremeconcernovertheirphysicalsizeandweight,atechniquewasdevisedbySladeandRussell(1973)toinvestigatebodilyperceptioninanorexics.Thisinvolvedcomparingrealsizeinsubjects(measuredbyananthropometer)andperceivedsize,whichwasmeasuredbytheobservermovinghorizontallightstoadistancethatthesubjectestimatedasthewidthacrossfour body regions: face, chest, waist and hips.When compared with an age-matched normalcontrol group, anorexic patients significantly overestimated their own perceived width at allregions,withthefacebeingoverestimatedbymorethan50percent.Althoughactuallythinneratthechest,waistandhips,anorexicpatientssawthemselvesasfatterthannormalwomen.Thebodyimagedisturbancecouldnotbeaccountedforbyageneralperceptualdisorder,asanorexics


werefairlyaccurateatthemeasurementofwidthofwoodenblocksandalsoextremelyaccurateatmeasuringphysicalheight.Theytendedtooverestimatethewidthofotherpeople,butnotbyasmuchasthemselves.Thebodyimagedistortiontendedto lessenaspatientsputonweight,especiallyiftheydidsoslowly.Itwasshownthatagreaterdegreeofbodyimagedisorderhelda worse prognosis. Slade and Russell (1973) considered that ‘patients with anorexia nervosashowafaultyappreciationoftheirownbodyimageinthesensethattheyperceivetheirbodiesaspossessinganexaggeratedgirth’.ItwasfoundbyGarfinkeletal.(1979)thatsomeanorexicsubjectstendtooverestimatebodysizeandthatthisoverestimatewasstableoverayearandnotaffectedbyweightchange.

Experimental work by Button etal. (1977) called into doubt the finding that anorexicsalone overestimate their size while normal females are more accurate and that disturbance ofbodyperception is variable among anorexics.Thisfindinghasnowbeen confirmed in a largemeta-analysisbyCashandDeagle(1997).Bodyimagedisturbancedoesnotappeartobeassoci-ated with other features of either anorexia nervosa or bulimia nervosa and does not help todifferentiatenormalwomen frompatientswith eatingdisorder.Furthermore, attitudinalbodydissatisfaction as measured by questionnaires or self:ideal discrepancy best differentiated thepatients fromthenormalcontrols.Thus, the roleofperceptual sizeestimation inaccuracy, theformalmeasureofbodyimagedistortion,asadiagnosticcriterionofanorexianervosahastobecalledintoquestion.

Slade(1988)hasalsoshownthatnon-anorexicsubjectsoverestimatethedimensionsoftheirbody, especially normal females, neurotic subjects, those who are pregnant and patients withsecondary amenorrhoea. He has contrasted the use of full body techniques (with distortingmirrors,photographs,televisionimages)forinvestigatingthiswithpart of bodymethods(visualsizeestimation,callipers),andhasshownthatrelativelyfixedcognitiveattitudes towardsbodysizewith the formerdemonstrate irrationalbeliefs aboutbody shape,whileamorefluid stateoftheestimationofbodysizedependsmoreonemotionalfactorsthatchangeovertime.Hehasalso shown that themore ‘overfat’ the individual considersherself tobe, themoredissatisfiedshewillbe.

Manyrecentstudieshavebeencarriedoutinsupposedlynormalpopulations.Straumanetal.(1991)studiedtheviewsofselfinalargenumberoffemaleundergraduatesforthefactorstheydescribedas‘actual:idealself-discrepancy’and‘actual:oughtdiscrepancy’.Theyshowedthattheactual:idealdiscrepancycorrelatedwithbodyshapedissatisfaction.Theactual:oughtdiscrepancywas associated with what they described as anorexic-related attitudes and behaviours andactual:idealdiscrepancywithbulimic-relatedattitudesandbehaviours.Gustavsonetal.(1990)investigatedbodyimagedistortionandshoweddifferencesbetweennormalstudentsandthosesuffering from eating disorders. Moore (1988) surveyed 854 females aged between 12 and23yearsfromoutpatientclinics;67percentwerefoundtobedissatisfiedwiththeirweightand54percentwiththeirshape.

Zellneretal.(1989)studiedtheeffectsofeatingabnormalitiesandgenderontheperceptionofdesirablebodyshape,usingfiguredrawingsbytheirsubjects.Theyfoundthatwomendesiretobethinnerthantheythinktheyare,andthatwomenwitheatingdisordersdesiretobethinnerthanthatdegreeof thinnessthat theythinkthatmenwillfindattractive.Steigeretal. (1989)foundthatanorexics,butnotbulimics,exhibitedbody imagedistortion,andthatbodyweightpredicted thedegreeofbody imagedisturbance.Dolanetal. (1990)demonstrateddifferencesbetweenwhite,African-CaribbeanandAsianBritishwomenforsomeofthesymptomsofeatingdisordersbutnodifferencesforbodyimagedisorder.

Supportedbythesestudiesisthefindingofaclearassociationbetweenbodyimagedistur-banceandeatingdisorder.Thisisrelatedinverselytoweight,thatis,thelowertheweightthegreater thedegreeofbody imageabnormality.Thus, ingeneral, thosewithanorexia aremoreaffectedthanthosewithbulimianervosa.


Aperpetualquestionisthedegreetowhichcultureinfluencesbodyimageandtowhatextentthesocialenvironmenthasasignificantimpactonbodyimage.Thereisevidencethatbodydis-satisfactionisprevalentinfemalesacrossdifferentethnicgroupsinthesamecountryandacrossnational boundaries (Baillie and Copeland, 2013; Angelova and Utermohlen, 2013; Demuthetal., 2013; Santana etal., 2013). There are factors unique to particular settings. So, in theBulgariancontext, faithandtraditionalfastingdifferentiallyaffectedthebehavioursofwomendepending on their pre-existing predisposition to disordered eating. For vulnerable women,fastingactedviareinforcementofasceticismanddietaryrestrainttoinduceweightmanagementin order to achieve a desired thin figure consistent with sociocultural norms (Angelova andUtermohlen,2013).And,intheUnitedStatesofAmerica,EuropeanAmericanwomenendorsed‘a curvy-thin or athletic ideal body’ whereas African American women ‘resisted notions of asingularidealbody’(Webbetal.,2013).Inanelegantstudy,Bagrowiczetal(2013)investigatedasampleofJapanesestudentswhohadrecentlyarrivedinNewYorkcitytoseewhattheinflu-enceofendemicobesitywas.AftertwomonthsinNewYork,theJapanesestudentshadthinnerself-imagebut‘afatterideal-image’andconsequentlylessbodydissatisfaction.Thisstudysuggeststhatsocialenvironmentrapidlyinfluencesidealbodysize.

Itdoesseemthatabnormalityofselfandbodyimageisuniversal ineatingdisorders:‘IeatthereforeIam’.Thereareassociationsbetweenabnormaleating,especiallyinanorexianervosa,andlowbodyweight,withabelieforfearthat‘Iamtoofat’andwithamorepervasivedenialofself.Inattemptingtoinvestigatethefactorsthatinfluencethisoverestimationoftheirbodysizebyanorexicandbulimicwomen,HamiltonandWaller(1993)studiedtheinfluenceofmediaportrayal of idealized female bodies.They concluded that eating-disordered women overesti-matedthemselvessubstantiallymoreafterseeingsuchimagesthanafterseeingphotographsofneutralobjects.Such images in themediadoappear to influence femalebehaviour,at least insomevulnerablepeople.

Strober etal. (1979) assessedperceptionof body size, subjective experienceof body imagedistortionsanddifferentiationofbodyconceptsbyaskingadolescentanorexicpatientsandcon-trols todrawthehumanfiguresoonafter theirhospitaladmissionandsixmonths later.Bothgroupstendedtooverestimatesizeatbothtimes,butexperiencesdenotingestrangementfromthebody,insensitivitytobodysensationsandweaknessofbodyboundariesweremoreprevalentinanorexics,andtheypersistedathighlevelsafterfranksymptomsofweightandeatingdisorderhad subsided.Therewasagreaterdegreeof amorepersistentbody imagedistortion in thosewhovomited.Theseauthorsconsideredthat ‘defectsinbodyimageformationrendertheano-rexic vulnerable to theirmanifestpathology,which is itself activatedbymaturational conflictsuniquetoadolescence’.

Theunderlyingfearof lossofcontrol,andthe incessantneedforvigilanceconcerninganycaloriethatentersthemouth,influencesallotherareasofthepatient’slife.Obsessionaltidinessandcleanlinessmaybemanifested,andalsoanattempttocontrolthebehaviourofotherpeopleathome.Ananorexicpatientcontrolledthebehaviourofherparentsandtwinsisterbythreaten-ingtostarveherselfyetfurtheriftheywouldnotcooperate.Sheweighednotonlyherownfoodbutthatofalltheothermembersofthefamily.Beforeherillness,sheandhersisterbothweighedabout57kg,butasheranorexiaprogressedsheinsistedonhertwineatingherfoodalso,whichthepatientcooked.Asaresult, thepatientdroppedinweighttoabout32kg,whilehersisterreached83kg.

Bulimia Nervosa

ThisconditionwasfirstdescribedbyRussellin1979.Althoughthepatientiscurrentlyofnormalornear-normalweight, there isoftenahistoryofanorexianervosawithweight loss(FairburnandCooper, 1984).Body imagedistortion is also a featureof the condition,with thepatientbelievingherselftobetoofatandtooheavy.


Thecharacteristic eatingdisorder isofgrosspreoccupationwith food,withepisodicbingeeatingorgorging.This is frequentlycounteredwithself-inducedvomitingandothermethodsofweightreductionsuchasabuseofdrugs,forexamplelaxativesoramphetamine-likedrugs,orvoluntarystarvation.Weight is thusmaintainedwitha fragile stability; sometimesweight lossmayreachanorexicproportions,andsometimestheremaybemildobesitythatisassociatedwithfeelingsofguilt.Thefearofputtingonweightandthedominatingpreoccupationwithfoodisanovervalued idea.

There ismarkeddissatisfactionwith thebody inbulimianervosa that is similar to that inanorexianervosa (CashandDeagle,1997).There is evidence that thedissatisfactionwith thebodyderivesfromcognitiveevaluativedissatisfactionandisnotdependentonsensoryperception,although itmaybe influencedbymood (Gardner andBockenkamp,1996).Various abnormalbehaviours may occur, including alcohol abuse, shoplifting (especially involving stealing food)anddeliberate self-harm.Avarietyof seriousphysical complicationsmay result fromrigorousself-inducedvomitingorpurging.

Underlying factors are particularly centred on doubts concerning femininity (Lacey etal.,1986). Poor relationships with parents, academic striving, parental marital conflict and poorrelationshipswiththepatients’ownpeersalsooccur.Thesepatientsdescribedmajorlifeeventsintheareasofsexualconflict,majorchangesinlifecircumstancesandexperienceofloss.

Muscle Dysmorphia

Muscle dysmorphiaisatermusedtodescribethepathologicalpreoccupationwithmuscularity.Itischaracterizedbypreoccupationwitha)musclesizeandbuild,b)thebeliefthatone’smusclesaretoosmall,c)excessivetimespentingymnasiumweightlifting,d)useofanabolicsteroidsandbulkingdiets,ande)inextremeform,cosmeticsurgeryincludingpectoralimplants.Itissome-timesreferredtoas‘reverse anorexia’or‘bigorexia’(Popeetal.,1997;Choietal.,2002).Theexactnosologicalstatusofmuscledysmorphiaisuncertain.Someauthorshavedescribeditasavariantofbodydysmorphicdisorder (Choi etal., 2002), others as amale variantof anorexianervosa(Murray etal., 2010),whilst othershave commentedon the relationshipwithobsessive com-pulsivedisorder(Chung,2001).Itisprobablybestinthecurrentstateofknowledgetoregarditasaphenomenonthatcanoccurinavarietyofpsychiatricdisordersratherthanasadisorderinitsownright.

Thereisconsistentevidencethatmenwithmuscledysmorphiahavedisturbedbodyimage,disorderedeating,andexcessiveexercising(Murrayetal.,2012).Inweightlifters,itsprevalencehasbeenreportedas13.6%(BeharandMolinari,2010).Bodychecking,whichcanbeconstruedasevidenceofbodydissatisfactioniscommoninmuscledysmorphia(Cafrietal.,2008;Walkeretal.,2009). Incomparison toweightlifterswithoutmuscledysmorphia,patientswithmuscledysmorphiaweremorelikelytohavebodydissatisfaction,abnormaleatingattitudes,useanabolicsteroidsandhaveahistoryofanxietyordepression.Theyalsocomplainedofshameandembar-rassment,poorerqualityoflife,previousattemptedsuicideandtherewasevidenceofimpairedoccupationalandsocialfunctioning(Olivardiaetal.,2000;Popeetal.,2005).

Disorders of the Sensory Awareness of the Body (Organic Changes in Body Image)Disease of, and trauma to, the brain alter the body image in a variety of ways.This is eitherbecauseofdamageoftheconceptualizedobject,forexampleamputationwithphantomlimborblindnessnecessarilyalteringthewayoneperceivesoneself,ordamagetotheprocessofconcep-tualizationitself,forexamplesectionofthecorpuscallosum.Often,ofcourse,thereisscattereddamage,aswitharteriopathyormultiplesclerosis,andthesetwofeaturescannotbeseparated.


Theexpressionbody imageasusedinneurologywasdefinedbyCritchley(1950)asthementalidea that an individualpossesses abouthisownbodyand itsphysical andaesthetic attributes.Visualsensation,tactileimpulsesandproprioceptivestimulicontributetotheformationofbodyimagebutarenotessential; followingtheamputationofa limb,aphantomlimbretainingtheintegrityofthebodyimageoccursinthemajorityofcases.Thebodyimage‘livesonthefringeofawarenessandisbynomeansobtrusiveinordinarycircumstances.Itishoweveravailableandcanbebroughtintoconsciousnessassoonasthestreamofattentionvoluntarilyorinvoluntarilyfocusesuponit’(Critchley,1950).Morbidchangesinthebodyimagemayshowenhancement,diminution(orablation)ordistortion.Inneurology,thetermbody schemaisusedfortheaware-nessofspatialcharacteristicsofone’sownbody,involvingcurrentandprevioussensoryinforma-tion,whilebody experienceismorecomprehensive,includingpsychologicalandsituationalfactorsalso (Cumming, 1988).The parietal lobes play a major role, but the somatoaesthetic afferentsystemandthethalamusarealsoinvolved.

PATHOLOGICAL ACCENTUATION OF BODY IMAGE (HYPERSCHEMAZIA)

Painordiscomfortcausestheaffectedpartof thebodyto loomlarge.Afterdroppingaheavyweightonhisgreattoe,amanfelthisbodytobe‘aninsubstantialshellaroundahugethrobbingtoe’.Suchadescriptionofthepainfulorganseeminglargerinsizeisfrequentfollowingsurgeryand traumatic injury. When size is affected, the body may feel larger (macrosomatognosia).Critchleygivesseveralexamplesofneurologicallesionscausingenhancementofanorgan.

■ Withpartialparalysisof a limb, the affected segmentgives the impressionofbeing tooheavyandtoobig,forexamplewithBrown-Séquardparalysis(unilaterallesionofthespinalcord)thesidewiththepyramidalsignsishyperschematicwhiletheotherside,withlossofpainandtemperaturesensation,isperceivedasnormalinbodyschema.

■ Unilaterally,followingthrombosisoftheposteriorinferiorcerebellarartery.■ Inmultiplesclerosis,againunilaterally.Hyperschemaziamayalsooccurwithperipheralvasculardiseasewhentheaffectedlimbfeels

largerandheavier.Itmayalsooccurinacutetoxicstates.Non-organiccasesoccurwithhypo-chondriasis; in depersonalization states; with dissociation (conversion disorder), for examplepseudocyesis;andalso,occasionally,indreams.

DIMINISHED OR ABSENT BODY IMAGE (HYPOSCHEMAZIA, ASCHEMAZIA)

Thismayoccurwhenafferentandefferentinnervationis lost,forexamplewithtransectionofthespinalcordthepatientmayfeelsawnoffatthewaist.

Hyposchemaziaormicrosomatognosiamayaccompanythesensorydeprivationofweightlessness,for instanceunderwater.With vertigo, thepatientmay feel excessively light, as if floating intheair.

Parietal lobe lesions may result in complicated states of diminution of the body image.Critchley(1950)citesapatientwithembolismoftherightmiddlecerebralartery:

‘It felt as if I was missing one side of my body (the left), but it also felt as if the dummy side was lined with a piece of iron so heavy that I could not move it… I even fancied my head to be narrow, but the left side from the centre felt

heavy, as if filled with bricks’.

At one time he thought that his paralyzed leg belonged to the man in the next bed. Hisbody felt to him half as wide as it should have done. Lying on the left side gave him the


sensationthathewas‘lyingonavoid’, thathewasattheextremeedgeofthebedandwouldpresentlyfalloff.Intheearlydayshealsofeltthathehadnopenisatall.Onthisaccounthewasclumsywiththeurinalandthebedwasfrequentlysoiled.Hissensationsofowningapenisreturnedquitesuddenlyonemorninginassociationwithanerection,anditafterwardsfeltquitenormal.

Inhemisomatognosia(hemidepersonalization),whichwasdescribedbyL’Hermitte(1939)andisaunilateralmisperceptionofone’sownbody,thepatientbehavesasthoughthelimbsononesidearemissing;thismayoccuraspartofanepilepticauraormigraine.Anosognosiadescribesthelackofawarenessofdisability,whichmay,forinstance,occurwithneglectofahemiplegiclimb.Hemispatial neglectdescribesthosepatientswho,whenaskedtoperformavarietyofbehav-ioural tasks in space, neglect the hemispace contralateral to their lesion (Cumming, 1988).Gerstmann’s syndrome (Gerstmann, 1930) comprises finger agnosia, acalculia, agraphia andright–leftdisorientation.

Again,non-organicconditionssuchasdepersonalizationmayalsoshowdiminutionofbodyimage.Ananxiousanddepersonalizedpatientsaid,‘Idon’tfeelatallthesameperson.SometimesmyheadfeelssonumbwhenIwalktotheshops.IfeelI’velefthalfmybodybehind’.Thiswasclearlyanas ifexperience.

DISTORTION OF THE BODY IMAGE (PARASCHEMAZIA)

Thismayoccurwithenhancementordiminutionofthebodyimage.Itmayoccurwiththeuseofhallucinogenicdrugssuchasmescaline,marijuanaandlysergicaciddiethylamide.Partsofthebodymayfeeldistorted,twisted,separatedfromtherestofthebodyormergedwiththeexternalenvironment.Theseexperiencescanaffecteitherthewholebodyorpartofit,suchasthelimbsorhead.Theshapecanbeexperiencedasmisshapen:‘mylowerjawistwistedandmyteethnolongercloseproperly’or‘myleftarmisshrunkenandgnarled,abitlikeatreetrunk’.Whenthestructureofthebodyisaffected,oftenitistheinternalorgansthatarethefocusofconcern:

‘I assert therefore that on my body, particularly on my bosom, there are present the properties of a nervous system corresponding to a female body and

I am certain that a physical examination would confirm this’

and

‘Food and drink taken simply poured into the abdominal cavity and into the thighs, a process which however unbelievable it may sound, was beyond all

doubt for me as I distinctly remember the sensation.’(Schreber, 1955)

Changesintheexperienceofweightcaninvolveasenseofeitherheavinessorlightness.Withhashish:

the sensations produced were those of exquisite lightness and airiness… I expected to be lifted up and carried away by the first breeze… the walls of my

frame were burst outward and tumbled into ruin, and without thinking what form I wore… I felt that I existed throughout a vast extent of space.

The blood pulsed from my head, sped through uncounted leagues before it reached my extremities; the air drawn into my lungs expanded into seas of

limpid ether, and the arch of my skull was broader than the vault of heaven.


I was a mass of transparent jelly, and a confectioner poured me into a twisted mould.

(Taylor, 1856)

The value attached to the body can be disturbed.This disturbance can vary from strong,positiveovervaluationofthebodyoritspartstoadevaluationofthebodyextendingtodislikeorhatredofit.Inright-sidedhemiparesis,patientscansometimesmaintainthattheirweakarmisinfactstrongerandmoreusefulthanbefore.Thisisreferredtoasanosognosic overestimation(Cutting,1997).Misoplegiaisthehatredofalimbandisassociatedwithleft-sidedparietallesions(Cutting,1997).

Distortionofbodyimagemayoccurwithepilepticauraandalsorarelywithmigraine.

Phantom Limb

Thisoccursimmediatelyfollowingthelossofalimbinvirtuallyallpatients,anditisparticularlycommonfollowingthetraumaticlossofalimboriftherehadbeenapre-existingpainfulcondi-tionofthelimb.Theonsetappearsimmediatelyastheanaesthesiawearsoffinthemajorityofcasesbutmaybedelayedforuptoafewweeksinabout25percentofcases.Thephantommaylastforafewdaysorweeksthengraduallyfadesfromconsciousness.Thereare,however,casesthathavepersistedfordecades.Aswellasoccurringwiththelossofalimb,thistypeofdistortionofbody image is relativelycommonaftersurgical removalofaneye,partsof theface,breasts,therectumorthelarynx.Therearereportsofphantomulcerpainsafterpartialgastrectomyandofmenstrualcrampfollowinghysterectomy.Ifanamputeeexperiencesageneralizedperipheralneuritisinvolvingsensation,paraesthesiaewillalsooccurinthephantomlimb.Theamputeeisawareofthephantomlimbinspaceandalsoexperiencespaininthespaceconceivedasbeingoccupiedbythelimb.

Withtime,thelimbappearstochangeinsize.Theimageshrinks,butunevenly,distaljointsshrinking more slowly than proximal; this is the so called telescoping phenomenon. Thereare several postulated explanations for ‘telescoping’. In loss of the upper limb, telescoping isthoughttooccurbecausethereisover-representationofthehandinthesensorycortex,hencethisistheareafromwhichsensationsurviveslongest.Thereisalsothepossibilitythattelescopingoccursbecausetherepresentationofthelimbintheprimarysomatosensorymapchangesprogres-sively.Thepostureofthephantomisoftensaidtobe‘habitual’,forexamplepartiallyflexedattheelbow,withforearmpronated.The limbcansometimesfeelfixed inanawkwardposition,andthiscancausethepatientdifficulty,forinstanceinwalkingupstairs.Thelimbmayfeeltwistedandpainful.

Thereis increasingliteratureontheplasticityofthesomatosensorysystem,usingphantomlimbasanaturalexperiment todemonstratedeafferentation following lossofa limbandcor-responding reorganization of the somatosensory map (Ramachandran and Hirstein, 1998).Followinglossoftheupperlimb,sensoryinputfromthefaceandupperarmhavebeenshownto invade thehandterritory, suchthat sensorystimulus to the facecanbemislocalized in thephantomlimb.

OrbachandTallent(1965)describedthebodyconceptsofpatientsfivetotenyearsaftertheconstruction of a colostomy. These patients had a conviction that they had been seriouslydamaged.

They believed that their bodily intactness and integrity had been violated. In common with such beliefs many patients on a fantasy level perceived the

operation as a physical or sexual assault. Patients who fantasized the surgery as a sexual assault were supported in this belief by the colostomy stoma, a new opening in the front of the body. Most men regarded this opening as evidence


of having been feminized, while women often interpreted it as the addition of a second vagina. The bleeding from the stoma reinforced the fantasy of a second vagina because it was interpreted as comparable to menstruation.

Inonefifthofpatients,preoccupationaboutthebodilyprocessesconcernedfoodintakeandelimination was embodied in a replacement concept which attempted to establish equalitybetweenintakeandevacuationbyeatingapproximatelyasmuchashadrecentlybeenevacuated.Amajorityoftheremainingpatientscommunicatedasenseofconfusionaboutthemachineryandfunctioningoftheirbodies.

When colostomy patients were initially studied and reports published, the constriction ofactivityandofthelifespacewasemphasized.Itisnowapparentthattheconstrictionisparalleledbyabodyconceptofbeingdamagedandfragileasaconsequenceoftheinjury.

Mastectomyalso results in relatively severedisturbance in self-conceptandbody image.Apatientdescribedthisas‘Iwillneverbelikebefore…itislikeahole,likeagap…WhenIlieonthatside,it’slikebeingaman’(HopwoodandMaguire,1988).Bodyimageproblemsresultnotonlyfromthelossofbodypartordisfigurementbutalsofromthelossofbodilyfunction.Thedisorderofself-imageisfrequentlyassociatedwithdepressivesymptoms.

Phantom limbpainmaybepsychologicallydetermined (Parkes,1976).Forty-six amputeeswere studied four to eight weeks and 13months after amputation; a third to a half showedmoderatedisturbancetendingtopersistayearlater.

Bodyimagedisturbanceisnotnecessarilyassociatedwithabnormalsensationorperception.Thehypochondriacmaybelievehehascanceralthoughhehasnophysicalsymptoms.Thetrans-sexualexperienceshisbodynormally,buthebelievesthatheisinthewrongbody.Thenarcissistisinordinatelyconcernedwithhisbody;nevertheless,heisquiteaccurateinhisobjectivequan-titativeperceptionofself,thatis,heknowshowlonghisnoseisorhowfarhecanthrowacricketball.Whensensationisabnormalorevendeficientaltogetherinsomemodality,forexamplewithblindnessordeafness,bodyimageisundoubtedlyaltered,butthisalterationdoesnotinanywayimplymentalillness;thealterationofbodyimageisusuallyappropriatetothedisability.

Culture-Bound Disorders of Body ImageVarious culturally determined hysterical conditions have been described by Langness (1967).These conditionshave in commona sudden,dramaticonset related in time to apsychosocialupset.Manifestationsoftheseconditionsaregrosslyunusualbehaviour,volatilemood,transientoccurrencesofalterationsofspeech,depersonalizationwithalteredbodyawarenessandsymptomssomewhat similar to delusions and hallucinations. The course of these conditions is usuallylimitedtoonetothreeweeks,buttheymayrecurwithfurtherepisodes.Theyappeartobemorelikely in thosepredisposedwithhistrionic (hysterical)personalities.Theprecise symptomsareoftenlocalizedtothatparticularcultureanddemonstratehowneuroticsymptomsintheircontentcomply with the expectations of the society in which they occur. For instance, Adair, writingfromBathin1786,describedhowfashioninfluencedthegreatandopulentinthechoiceoftheirdiseasesandconsideredthatQueenAnne’snervousnessresultedinthetransferofsimilarsymp-toms‘toallwhohadtheleastpretensionstorankwithpersonsoffashion’.

SomeoftheculturallylocalizeddisordersofawarenessofthebodyaresummarizedinTable14.2 (fromKiev, 1972).The variability of such syndromes is immense, but thepreoccupationwithbodilyorgansandfunctionsiscommontomanyofthem.Thebizarrenatureofsymptoms,forexamplekoro,inwhichthereisfearofthepenisshrinkingintotheabdomen,isoftenexplainedbyafaultyknowledgeofhumananatomyandphysiologythatseemsnaivetodoctorspractisinginEurope.However,itisnotgenerallyknownhowignorantBritishpatientsareconcerningtheorganizationandfunctionsoftheorganstheycannotsee.Hospitaloutpatientswerecompared


withdoctorsbyBoyle(1970)intheirunderstandingofcommonlyusedmedicalterms.Asmightbeexpected,thedoctorswereconsistentintheiruseofterms,butpatientshadenormousvaria-tionintheirunderstandingofsuchtermsas‘piles’,‘leaststarchyfood’,‘palpitation’,‘jaundice’and‘f latulence’.Whenaskedtodetailthesurfaceanatomyofinternalorgans,forexamplebladder,kidneys and thyroidgland, thepatients showedgreat variationandweregenerallyquite inac-curate.TherearealsobizarreanomaliesofbodyimageandfunctionoccurringinpracticeintheUnited Kingdom. A young Lancashire woman working in a mill complained of migrainousheadachesandascribedthesetoinsufficientlyheavyperiods.Thisexplanationwasfoundtobeculturallyacceptabletoherpeers.

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TABLE 14.2 ■ Culture-bound disorders of body image

Disorder Diagnostic Equivalent Location Key Symptom(s)

Koro Anxiety state South-East Asia

Belief that the penis will retract into the abdomen and cause death

Frigophobia Obsessive–compulsive neurosis

East Asia Morbid fear of the cold, preoccupation with loss of vitality, compulsive wearing of layers of clothes

Latah Hysteria Malaysia Hypersuggestibility, automatic obedience, coprolalia, echolalia, echopraxia, echomimia, altered consciousness, disorganization, depression and anxiety

Evil eye Phobic neurosis Mexico, North Africa

Strong glances are harmful; precautions taken to avoid or counteract evil eye

Voodoo Phobic neurosis Haiti Violation of taboo may result in death

Windigo Depressive reaction Canada, First Nations

Fear of engaging in cannibalism and of becoming a sorcerer, depression of mood

Amok Dissociative state Malaysia Neuraesthenia, depersonalization, rage, automatism and violent acts

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C H A P T E R 15

The Psychopathology of Pain

SummaryPain is an unpleasant experience that involves the conscious awareness of noxious sensations,hurting and aversive feelings associated with actual or potential tissue damage (InternationalAssociationfortheStudyofPain,1994).Itisoftenconceptualizedasamoodstate.Inpsychiatry,pain can present as being heightened, markedly diminished or occurring in the absence ofdemonstrablecause.Themostproblematiccasesarethoseinwhichpainisthefocusofpresentationbutthereisanabsenceofidentifiablephysicalcause.Facialpain,burningmouthsyndrome,vulvodynia,andpsychogenicitchareillustrativeexamplesofthisproblem.

‘ You want to hear of me, my dear? That’s something new, I am sure, when anybody wants to hear of me. Not at all well, Louisa. Very faint and giddy.’

‘Are you in pain, dear mother?’‘I think there’s a pain somewhere in the room,’ said Mrs Gradgrind, ‘but I

couldn’t positively say that I have got it.’Charles Dickens (1854), Hard Times

Since Aristotle, pain has been classified not as a perception but as a mood state, and soexcludedfromthefivesenses.It isconceptuallyamostdifficult topic,hardtodescribeandtocategorize;theonlyaspectthatisclearisthatitrepresentsastateofsubjectivesufferingofthepatient.Butwhatdoeshemeanby‘mypain’?Whereisitandwhatisit?Certainly,themeaningofthepainismorethanthepainitself,andoftenitisthereasonforthesensationbeinginterpretedassuffering.Apatientwithsorenessofthethroatbelievedherselftohaveacancerofthethroat;hermotherhaddiedofthatcondition.Therelationbetweensymptomsandtheirmeaningis not straightforward. Another person believed herself to be suffering from venereal diseasewithouthavingbeen exposed to the risk.But shehadpreviouslybeen successfully treated forHodgkin’sdisease.Shehadnofearsconcerningherfactual,andpotentiallylethal,illnessbutonlyadmittedconsciouslytofearingtheimpossible.

Phenomenologicalaspectsoftheexperienceofpainarenotwellcharted,althoughingeneralmedicinethisis,aboveallothers,theareainwhichphenomenologycouldbemosthelpful:painisasubjectiveexperiencethatoccursonlyinconsciousness(Bond,1976).Thepsychiatristisoftenconfrontedwiththeproblemofwhetherthepainisphysicalormental, organicorfunctional, medicalorpsychiatric,and,ofcourse,theanswerforeachcontrastedpairisoftenboth.Wemaythenberequested toassesshowmuchof thepain ispsychogenic,although this isvirtually impossiblebecause,followingAristotle,painisastateofmind,evenwhenthereissuchanobviouscauseasahaematomaunderthefingernail.

Organic or Psychogenic Pain?The transmission of pain results in a subjective, conscious experience. For an account of theanatomicalbasisforpainandalsothephysiologicalandbiochemicalmechanisms,thereaderis

Keywords: PainAsymbolia,PhantomPain,BurningMouthSyndrome,Vulvodynia.

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referredtoWallandMelzack(1999).Thereisathresholdforpain:lightpressureisperceivedastouch,heavypressureaspain.Anexplanationforthishasbeensuggestedinthegate control theoryof Melzack andWall (1965), who considered that painful stimulation through the thin myelinatedandunmyelinatedfibresresults inpositivefeedbackinthesubstantiagelatinosa;this istransmitted inthe lateralspinothalamictract.However, thisgate isunder the influenceof thehigher centres,which canoverride the local input, asdemonstratedby the effect ofattention:sometimespainisnotfeltwhenattentionisdirectedawayfromtheaffectedsite.Currentbiochemicaltheoriesarealsoimportantinaccountingforthemediationofpain.

Othertheoriesinvolvethestudyofpresynapticandpostsynapticmechanismsinthecentralnervoussystem(Nathan,1980).Electricalstimulationinvarioussitesinthebrainstem,includingthemedullaoblongata,theperiaqueductalgreymatterandthehypothalamusaroundthethirdventricle,mayproduceanalgesia.Endogenousopiatesubstances(endorphins)havebeendiscovered to inhibit nerve fibres reporting noxious events. This was initially discovered followingelectricalstimulationintheperiaqueductalgreymatterofthebrainsteminratsbuthassubsequentlybeendemonstrated inhumans (Bond,1976).Centralnervous systemmechanisms forthe modulation of pain include descending modulatory control and an increasing number ofneurotransmitters,especiallyserotoninandendogenousopioids;itisalmostcertainlytheinteractionofthesedifferentsystemsthatiseffectiveinpainmodulation(FieldsandBasbaum,1994).And, there is increasing understanding of the molecular basis of pain. The role of sodiumchannelsfollowingnerveinjuryandthegenesencodingfortheexpressionofparticularsodiumchannelsinprimarysensoryneuronsisgraduallybeingelucidated(Waxmanetal.,1999;Waxman,1999).

Thetemptationtoregardpainsimplyasanyothersensationcreatescertaindilemmas.Forexample,whatisthesubjectiveexperienceofthepersonwhocomplainsofseverepainwithnoorganicpathologydetectable,orthepersonwithmildpathologywhocomplainsofexcruciatingpain?Howdoesoneassessthepersonwithanapparentlypainfulinjurywhoclaimshedidnotnoticeanypainatthetime?

Purelyorganic,physiologicalterms,andalsopsychological,emotionalwords,havebeenused.Beecher(1959)believedthatpaincouldbedefinedandlistedmanydistinguishedphysiologistsandpsychiatriststosupporthiscase.However,Merskey(1976)considersthatpainisapsychologicalexperience,privatetotheindividualbuttendingtobedescribedintermsofdamagetothebody, and sodefinedpain as ‘anunpleasant experiencewhichweprimarily associatewithtissuedamageordescribeintermsofsuchdamage,orboth’.

Clearly,irrespectiveofthephysicalstimulus,psychologicalfactorsareenormouslyimportantintheappreciationofpain.Forexample,psychological analgesia(educatedornaturalchildbirthinobstetriccare),usingpsychologicalpreparation,explanationandsometimeshypnosis,willresultin5to10percentofsubjectsexperiencinglittleornopain,15to20percentexperiencingonlymoderatepainandintherestpainisnotmodifiedbutfearandanxietyarediminished(Bonica,1994).Doctorshavefrequently,throughneglectingsubjectiveevaluation,missedtheimportantdistinction between the experience of pain and its physical causes (Noordenbos, 1959). Thepatientassumesthathispainindicatesthepresenceofphysicalillness,butpainofvarioustypesis a very common symptom in many psychiatric conditions without there being physicalpathology.

The experience of psychogenic pain has been associated with particular personality types(Engel,1959).Themost importanttraitsofpersonalityassociatedwithpainarethoseofanxiousness, depressiveness and the cyclothymic personality at its depressive pole – hysterical,hypochondriacal and obsessional traits (Bond, 1976). Subjects with such personality traitsdevelopedtoabnormalextentareespeciallylikelytorespondtolifestresseswithpain.Complaintsof pain are common in neurotic disorder, especially with chronic anxiety or hysterical traits(Merskey,1965).

15—ThE PSYchOPAThOLOgY OF PAiN 247

It is important tobeverycareful inattempting todistinguishpainofphysicalorigin fromthatwhichislargelypsychogenic:generalizationscanbedangerous.However,Trethowan(1988)considers that there are certain importantdifferencesbetweenpainofpsychiatric andorganicorigin.Theseareasfollows.

■ Painassociatedwithpsychiatricillnesstendstobemorediffuseandlesswelllocalizedthanpainduetoaphysicallesion.Itspreadswithanonanatomicaldistribution.

■ Painiscomplainedofasaconstantfeature.Itmaybecomeevenmoresevereattimes,butitpersistsunremittingly.Physicalpainsusuallyhavemoredefiniteprovocativeagentsandarerelievedbyspecificmeasures.

■ Psychogenicpainisclearlyseentobeassociatedwithanunderlyingdisturbanceofmoodthatappearstobeprimaryinbothtimeandcausation.

■ Itseemstobemuchmoredifficulttoaccuratelydescribethequalityofpsychogenicpain.Thepatientis innodoubtthatheissuffering,thatthepainisveryunpleasantandthathefeelshecannotbearit.Butincontrasttopainfuldamagetoadefinedorgan,whenpainmaybedescribedasburning(skin),shooting(nerve)orgripping(heartmuscle),thepatientwithnonorganicpaincanfindnoadequatewordsfordescription.

■ Afurtheradditiontothislististhefindingofprogressionoftheseverityandextentofthepain over time – unusual for a purely physically mediated pain without increased tissuedamage(Tyrer,1986).

Pain and Heightened SensationGeneralizedincreaseinsensoryinputmaybeexperiencedaspain.Thisisexemplifiedbyhyperacousia:thepatientcomplainsofnoisesbeinguncomfortablyloud.Thereisnoobjectiveimprovementinhiscapacitytohear,butthethresholdatwhichsoundisperceivedasunpleasantlyloudislowered.Noises,evenanormalspeakingvoice,aredescribedaspainfultolistento.

Withlysergicaciddiethylamide,intensepainmaybeexperiencedinthelimbs,whichseemto the sufferer tobe twistedorcontorted.Similarly, in theearly stagesof thiaminedeficiencytheremaybeincreasedsensitivitytopain.Inthesesituations,thereisanalterationtoperceptionofsensationssothattheyareexperiencedaspain.

Duringconsciousness,thepersonreceivescountlesssensationsfromalloverhisbody,suchasitching,distension,pressure,borborygmi,mildaching,thumping,warmthandsoon.Theseformthesensoriumofthebodyimage;theymakepossiblethelocationofselfinspace.Mostofthesesensationsescapeattentionformostofthetime.However,occasionallythepersonconcentratesandmaytakeactiontoeliminatethesensation–scratchhisearorcrosshis legs.Attentiontosuchsensations, especially if linked toanunpleasantemotion,mayoccasion theexperienceofpain.Noticingthesensationresultsinfear,andthedistressofthisemotionisperceivedaspain.

This would appear to be the explanation for the vital feelings of depression described inChapter16.Vital feelingsare the localizationofdepression inabodilyorgan, complainedof,perhapsaspain,intheheadorchestorelsewhere.Onfurtherquestioning,symptomsaredescribedasbeingunpleasant,painfulpressureorevenafeelingofmiseryanddepressioninthatorgan:morbidinterpretationsofordinarybodilysensations.Thesensationisunpleasantbutnormalandwouldbeignoredinhealth.Withdisorderofaffect,thesensationmaybemorbidlyinterpretedasbeingduetocancer,tuberculosisorvenerealdisease.Thereare,ofcourse,alsoactualphysicalchangesindepression,forexampleslowingofperistalsisanddecreasedgastrointestinalsecretions,andthesemayalsoprovokeunpleasantsensationssuchasspasmandconstipation.

Centralpain(thalamicsyndrome)isexperiencedasaspontaneousburningsensationthatcanbeactivatedbycutaneousstimulationortemperaturechanges.Itcanalsopresentastactileallodynia,coldallodyniaorongoingpain(Greenspanetal.,2004).Itisusuallyintractableandoccursinthesettingofcerebrovascularaccident,multiplesclerosis,syringomyeliaandspinalcordinjury.


Thecurrenthypothesis isthat itarisesasaresultofdisruptioninthespinothalamicpathwaysassociated with ectopic neuronal discharges and potentially involves adrenergic, GABAergic,glycineandotherneurotransmitters(Devuldeetal.,2002).

Diminished Pain Sensation and Pain CravingIncertainsituations,thereisadecreaseintheperceptionofpain.Pain asymboliaisaconditioninwhichsituationsthatshouldgiverisetopaindonot(SchilderandStengel,1931).Thiscondition can occur as a congenital or an acquired disorder. There are at present five recognizedhereditaryvarieties,usuallyassociatedwithautonomicneuropathiesincludinganhidrosis(Butleretal.,2006).Severalmutationsofnervegrowthfactorhavebeenidentified(Einarsdottiretal.,2004).Acquiredpainasymboliahasalsobeendescribed inpatientswithvascular lesions,predominantlyleftsidedandinvolvingtheinsular(Berthieretal.,1988).Patientswithpainasymbolia show an absent or inadequate response to painful stimuli over the entire body and aninabilityto learnappropriateescapeorprotectiveresponses.Otherfeatures includeanhidrosis,lack of thermal sensitivity, selfmutilation, intellectual disability, recurrent fever secondary toanhidrosisandfailuretothrive(DiasandCharki,2012).Inpatientswithschizophreniaandtheirrelatives,thereisevidenceofelevatedpainthresholdsandpaintolerancedemonstratedbyrelativeinsensitivitytofingerpressure(HooleyandDelgado,2001).Selfdamageofagrossnaturealsooccurssometimesinschizophrenia,forexampleselfcastration.Inothersituations,suchasacutedrunkenness, there isdiminished appreciationdue to the centraldepressant actionof alcohol,andopiatessimilarlyareanalgesicthroughtheiractiononthecentralappreciationofpain.

Attentionisalsoanimportantfactorintheperceptionofpain.Excitementoraggression,asinfootballersorsoldiers,mayrenderthesubjectoblivioustoseriousinjury.Whenawoundhasadvantages to thepatient, for exampleenablinga soldier to leave thebattlefield, it causes lesspainthanwhentheinjuryisseenaswhollydisadvantageous.Variouspsychologicaltechniquescanreducetheexperienceofpain,includinghypnosis,variousstratagemsinchildbirth,placebomedicationand,possibly,acupuncture.Indissociation(conversion),theremaybelocalizedanaesthesiaandanalgesiafortheaffectedlimb,forexamplethepatientmaydescribenoperceptionofpinpricksensation.

Abluntingandpervertingofpainperceptionisdescribedinseverementalretardation,resultingoccasionally ingross selfdamage.Thepatientmaybanghishead so that there is chronichaematoma formation, bite himself or otherwise harm himself repeatedly, causing permanentdamage.Meanwhile,he appears to experiencenopainor evendiscomfort.Selfapplicationofconstricting bands has been described in schizophrenia and organically disordered patients(DawsonButterworthetal.,1969).Thesearemostoftenappliedtotheleftarm;despiteextensivetissuedamage,thepatientdoesnotcomplainofpain.

Selfinflictedharmoccursalsointhoseofdisturbedpersonalitywithoutintellectualdeficiency.Suchbehaviourmay includeskincutting,wrist slashing,skinburning,selfhitting,severeskinscratchingandbonebreaking (McElroyetal.,2000).Thesepatientsareusually female (GraffandMallin,1967),andthebehaviourappearstobelinkedwiththedesiretorelievetensionandalleviatenegativeemotions.There is empirical evidence that itdoes relievenegativeemotions(Klonsky,2007).Thereisalsolimitedevidencethattheselfinjuriousbehaviourhasseveralpossiblegoals:asselfpunishment,toinfluencepersonalrelationships,toreducetendencytodissociationandalsotoinduceintensesensorystimulation(Box15.1).

Pain Without Organic CauseUnfortunately,painisanunpleasantfeaturecommontoalmostallmedicalsettings;itisafrequentcomplaint inmedical, surgical, gynaecological andpsychiatricpractice.Recalcitrant casesmay


bereferredtoapainclinic,andprominentamongsuchreferralsarethoseinwhomnoorganicbasiscanbefoundtoaccountforthecomplaintofpain(Tyrer,1985).Paininthebackandintheheadandface,particularly,isoftenfoundnottobeassociatedwithorganiclesions.From3to 5 per cent of patients, depending on how referrals are made, have measurable psychiatricdisturbance.

There are various possible mechanisms to explain the presence of pain without physicaldisease:autonomicnervousactivitymaybeinterpretedandelaboratedthroughfearofpossibleconsequences,normalsensationsmaybeexperiencedaspainfulinsituationsofstressorinfear,relatively minor pain and discomfort of benign cause may be misinterpreted as being moreominousthanitreallyis.

Classificationofnonorganicpainiscomplex.Aswellasoccurringasaprimarydisturbance,painalsomaybeconspicuouswithhypochondriasis,withsomatizationdisorderand,especially,withdepressioninmooddisorder.InTyrer’sseries,twothirdsofthosepatientswithoutorganiccause and with measurable psychiatric disturbance were diagnosed as suffering from majordepressive disorder.The remainder had personality disorders, anxiety state, hysteria and drugdependence;paraphreniaandorganicbrainsyndromealsooccurred,butrarely(Tyrer,1985).

Painwithoutadequateorganicexplanationisoneofthemostdifficultproblemspsychiatristsarecalledontotreat.Inastudyofpatientswithpainreferredtopsychiatristsinageneralhospital,theheadandneckwasthemostcommonsite,followedbytheback,abdomen,armorleg,rectumorgenitaliaandchest(Pillingetal.,1967).In32percentofthesemedicalandsurgicalpatients,painwasthepresentingcomplaint,anditwasconsideredthatthesepatients‘spoketotheirphysiciansintermsofpainorotherorganicsymptomsratherthananxiety,depressionandthelike’.Intheevaluationofthesignificanceofemotionalfactorsinchronicpain,adequatehistoryandexamination,includingtheassessmentofattributionandtherelationshipwithmoodstate,wasfoundtobemosthelpful(Tyrer,1992);themostusefulquestionnairesweretheHospitalAnxietyandDepressionScale(ZigmondandSnaith,1983)andtheWestHaven–YaleMultidimensionalPainInventory(Kernsetal.,1985).

Itis,ofcourse,whollyunderstandablethatsomeonesufferingpainshouldbemiserableandthatchronicpainortheanticipationofrecurrentpainshouldprovokedepressionofmood.This

BOX 15.1 ■ Examples of self-injurious behaviour

When SHE’s home alone, she cuts herself, slicing off her nose to spite other people’s faces. She always waits and waits for the moment when she can cut herself unobserved. No sooner does the sound of the closing door die down than she takes out her little talisman, the paternal all-purpose razor. SHE peels the blade out of its Sunday coat of five layers of virginal plastic. She is very skilled in the use of blades; after all, she has to shave her father, shave that soft paternal cheek under the completely empty paternal brow, which is now undimmed by any thought, unwrinkled by any will. This blade is destined for HER flesh. This thin, elegant foil of bluish steel, pliable, elastic. SHE sits down in front of the magnifying side of the shaving mirror; spreading her legs, she makes a cut, magnifying the aperture that is the doorway into her body. She knows from experience that such a razor cut doesn’t hurt, for her arms, hands, and legs have often served as guinea pigs. Her hobby is cutting her own body.

Elfriede Jelinek (1988), The Piano Teacher

Late at night I went into the bathroom and took the broken pieces of a razor blade which I had kept. I slashed my wrist again and again, as deeply as I could. I knew perfectly well that it would not kill me, not like the times before. They have been something quite different. As my writing to you comes to a close, the pain is so unbearable inside me that a force of such strength has driven me to inflict a physical pain on myself in the hope of appeasing the other.

Sarah Ferguson (1973), A Guard Within


isoftensomuchtakenforgrantedthatnostepsaretakentoalleviatethedepressedmoodifthecauseofthepainisobvious.However,iftheperceptionofpainisconsideredtohavetwoseparatecontributions–thesensoryperceptionandtheinvestingaffect–effortstorelievethe latter, ifsuccessful,willproduceaglobaldiminutionofpain.Paincanbeacauseofdepression,andinthissituationtreatmentforthedepressionisappropriate.

PAIN AND LOSS

Thebestknownmodelforthistopicisthephantom limbpainsooftenexperiencedinamputees.Painisexperiencedwithinalimbthatisnotthere;thatis,spatially,painislocatedoutsidethepatient.However,thisisnotahallucination.Thepersonknowsfullwellthathehaslosthislegandthatthefeelingofpainisinsidehimself.Thebodyimagetakesaverylongtimetoadjusttoachangesuchasanamputation,anditmayneverdosofully.RamachandranandHirstein(1998)provideathoroughreviewofthesubject.Thephantomlimbexperienceoccursalmostimmediatelyfollowingthe lossofa limbinthevastmajorityofcases,andtheincidencemaybeevenhigherfollowingatraumaticloss.Inthecaseofsurgicalamputations,phantomsappearassoonastheanaestheticwearsoff.Thephantomispresentforafewdaysorweeksandgraduallyfadesbutmaypersistforyearsorevendecadesinsomepeople.Indeed,somepeopleareabletorecallaphantomlimbatwillafteritsdisappearance.

Phantomsaremostcommonfollowingamputationofanarmoralegbuthavebeenreportedfollowingmastectomiesorremovalofpartsoftheface;evenphantominternalvisceracanproducesensationsofbowelmovementsandflatus.Thepostureofthelimbcanbecomehabitual,aswiththearm,oftenpartiallyflexedattheelbowwithforearmpronated,andwhenthephantomfadesfromconsciousness,especiallywiththeforearm,itbecomesprogressivelyshorteruntilthepatientisleftwithjustthephantomhand.Perhapsmostsurprisingly,childrenwithcongenitallymissinglimbs canexperiencephantoms.Originally, itwas thought that thephantompainwasdue tostumpneuromas,butgiventhatpatientsbornwithoutlimbscanhavephantompain,neuromasdonotseemnecessaryforphantompaintooccur.Thepersistenceofcentralrepresentationoftheamputatedlimbislargelyresponsibleforthephantomillusionandassociatedpain.

PSYCHOGENIC FACIAL PAIN

Ithasbeenknownforalongtimethatmanypatientswithchronicpainatavarietyofsitesdonothaveabnormalphysicalsignsanddonotmanifestseriousorganicillness.Atypical facial painisanespeciallyfrequentandintractableexample,manifestingnoorganicsignsbutcausinggreatsuffering;thepatientisreferredfromsurgeontodentisttopainclinicphysiciantopsychiatrist,often without benefit. Such pain has often been associated with depression. Lascelles (1966)describedaseriesof93patientssufferingfromprolongedfacialpain,ofwhomthemajoritysufferedfromatypical depressionwith intensefatigue, tensionandsleepdisordersuperimposedon‘obsessive’personality;53ofthesepatientsrespondedwelltoantidepressanttherapy.

More recently, Blumer and Heilbronn (1982) have seen chronic, intractable pain withoutorganiccauseasbeingavariantofdepressiveillness.Garveyetal.(1983)investigatedtheassociationbetweenheadacheanddepressionin116patientssufferingfrommajordepressivedisorder.Duringanondepressedperiod,thesepatientsexperiencedasimilarrateforheadachetothatofnondepressivecontrolsubjects,but theyhadamarkedly increasedrateduringdepressiveepisodes.Feinmannetal.(1984)investigatedtheefficacyofanantidepressant,dosulepin(dothiepin),inthetreatmentofpsychogenicfacialpain.Seventyonepercentofpatientswerefreeofsymptomsatnineweeks,comparedwith47percentinaplacebogroup;ata12monthfollowup,81 per cent of patients were painfree. Good prognostic indicators for successful treatmentincludedpainfollowinganadverselifeevent,minimalprevioussurgicalinterventionandfreedom


frompainafternineweeks’treatment.Suchstudieswouldsuggestanassociationbetweenfacialpainwithoutphysicalsignsanddepressiveillness.

BURNING MOUTH SYNDROME

Agroupofheterogeneousskinconditionsthatpresentwithunpleasantskinsensationsincludingitching, burning, stinging or numbness are well recognized as liable to affect face, scalp andperineum.Theseconditionsarepoorlyunderstoodbutdemonstrateaninterplaybetweenneuropathic pain, neuropathic itch, neurology and psychiatric disorders (Gupta and Gupta, 2013).When these conditions affect the oral cavity, it is referred to as “burning mouth syndrome”,a condition characterized by intraoral burning for which no medical or dental cause can beidentified(Ducasseetal.,2013).Theabnormaloralsensationsincludeburning,pricking(pinsandneedles),allodynia(painonbrushingtheteethandgums),tingling,numbness,itchingandsensationofelectricaldischarges(Braudetal.,2013).Thesesensationsoccurprincipallyonthetipofthetongue,thelateralaspectsofthetongue,lips,hardandsoftpalate(Sunetal.,2013)andmayinvolvepainradiatingtothelowerandupperjaws,theinneraspectsofthecheeksandthe gums. Despite normal salivation, patients often complain of xerostomia and dysgeusia.Burningmouthsyndromeseemstooccurmostfrequentlyinperimenopausalfemales(Dahiyaetal.,2013).

VULVODYNIA

Vulvodyniacanbedefinedaspersistent,spontaneous,unwelcomed,intrusiveanddistressingvulvalsensation(MarkosandDinsmore,2013).Itisalittleunderstoodcondition.Afrequentsubtypeistermed‘provokedvestibulodynia’inwhichtheexperiencedpainordiscomfortisprovokedbysexualintercourseratherthanmerelyoccurringspontaneously(Boisetal.,2013).Thereissomeevidencethatvulvodyniaisassociatedwithgeneralizedhyperalgesia.Furthermorethatthereareaugmentedbrain responses to thumbpressure, that is stimulationof an area remote from thevulva, demonstrable within the insula, dorsal midcingulate, posterior cingulate, and thalamuscomparedtonormalcontrols.Thisisinterpretedasshowingaugmentedcentralpainprocessinginvulvodynia(Hampsonetal.,2013).Infocalasopposedtodiffusevulvodynia,whenthepainislocalizedat1and11o’clockittendstobeexperiencedasdeeppainwithinthevestibuleandthepainisprovokedbysexualintercourseandtheinsertionofatampon.Painat5and7o’clockis lesssevere(DondersandBellen,2012).Thereareconsiderableassociatedadverseeffectsonqualityoflifeandonintimaterelationshipswithsexualpartners(Boisetal.,2013;Smithetal.,2013;Xieetal.,2012;Ponteetal.,2009).

Malepatientscanalsopresentwithaconditionsimilartovulvodynia.Thepatientspresentwithburningsensationinthepenisandscrotumandthisconditionistermed‘penoscrotodynia’.Thecurrentproposedclassificationis:generalized,focal,provoked,unprovoked,andmixedtypes(Markos,2011).

PSYCHOGENIC ITCH

Itchandthedesiretoscratchisanormalresponsetoskinsensations.Pruritogenicitch(physiological itch) is transmitted by dedicated afferent neurons much as is pain. Mediators of itchincludethe‘crosstalk’betweendermalMastcellsandadjacentcutaneousafferents.Inaddition,thereareanumberofneuropeptides(neurotensinandsubstancePforexample)involvedintheprocess (Greaves, 2010). Some cases, which are considered to be neuropathic in origin, arethoughttoberelatedtodamagetotheperipheralnervoussystemsuchasinpostherpeticneuralgia,brachioradialpruritus,notalgiaparesthetica,incentralnervousdamagetothespinalcord


bytumoursanddemyelinatingdiseasesuchasmultiplesclerosis(YosipovitchandSamuel,2008).The itch sensation in these conditions is analogous to neuropathic pain and overlaps withburning, aching and stinging sensations. Psychogenic itch, on the other hand, occurs in theabsenceofaphysicalcauseandisunrelatedtodemonstrablenervedamage.Itcanbeassociatedwithdepressionandobsessivecompulsivedisorder(Calikuşuetal.,2003),anxietyanddelusionsofparasitosis.TheFrenchpsychodermatologygrouphaveproposeddiagnosticcriteriatoincludethefollowingthree:localizedorgeneralizedpruritussinemateria,chronicprurituslastinglongerthansixweeksandtheabsenceofasomaticcause.Inadditionthereshouldbethreeadditionalcriteriafromthefollowingseven:chronologicalrelationshipofprurituswithoneorseverallifeeventsthatcouldhavepsychologicalrepercussions,variationsinintensityassociatedwithstress,nocturnal variations, predominance during rest or inaction, associated psychiatric disorders,improvementinresponsetopsychotropicagentsandimprovementinresponsetopsychotherapy(Miseryetal.,2007).

Pain and SufferingPainisanappropriatestudyforthephenomenologist,inthattheexternalsignsmaybeirrelevantandthesubjectiveexperienceallimportant.Thechiefprobleminassessingpainistheextraordinarydifficultyapatienthasindescribingthequalityofhispain:thegreaterthepsychogeniccomponentofthepain,themoredifficultitistofindtherightwordstodescribeit.Sometimes,itseemsthatpainmaybeneededasaneuroticsolutiontoaneuroticconflict:fortheequilibriumtoremain,itisnecessaryforthepaintoberetained.IthasbeenconsideredbyTrethowan(1988)thatsuchapatient‘isnotsufferingfrompainatall.Whatsheissufferingfromissuffering’.

Therearedifferencesbetweenthepersonsufferingfromorganicallydeterminedpainandthechronicsuffererwithmultiplesymptomswhosepainisconsideredpsychogenic.Thelattertrulysuffersbutdoesnotshowthephysicalcorrelatesofseverepain.Itseemsthatthestateofsufferinginwhichthispersonexistsfindsexpression,donsrespectabilityandcanonlybecommunicatedwhenitistransformedperipherallyintoaspecificpain.Painmayoccurwithlittlesuffering,asintheinjectionof localanaestheticthat,afterthesmallprick,bringsrelief fromaworsepain.Sufferingmayalsooccurwithoutpain,butitmayalsobedescribedaspain,andthismaybethenatureofmanyneuroticcomplaintsofpain.Thistranspositionofaffectiswhollyunderstandablewhenoneconsidersthesemanticsofsuffering.Sufferingofallnonphysicalkinds–indignation,humiliation, disappointment – finds expression in pain terms: taking pains, feeling crushed,bruisedselfesteem,rubbingsaltinthewound,gettingone’sfingersburnt,searingremarks.Itisnotjustthatpainisametaphorforsuffering,butinmanysituationssufferingcanbeexperiencedandexplainedbythesuffereronlyintermsofpain.

Sotheuseofpainwordscanbeconstruedmetaphorically,andtheneuroticpatientmayfollowthistoitslogicalconclusionanddescribeconcretelytheunbearableandhumiliatingsufferingofhisdailyexistenceascomplaintsoflocalizedphysicalpain.Theexperienceofpainisaphysicalsensationthattakesonanaffectivecomponentforitsexpressionandinterpretation.Thisaffectivecomponent–suffering–mayoccurwithoutphysicalperceptionandsometimesstillbeexperiencedbythepersonhimselfaspain.

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67,361–70.

S E C T I O N FIVEEmotions and Action

257

C H A P T E R 16

Affect and Emotional Disorders

SummaryMooddisturbanceisnotonlyacommonabnormalitypresentingtopsychiatristsbutofconsider-ableimportancebecauseofthesevereconsequencesthatpoorrecognitionortreatmentmayhaveinthelivesofpatients.Itisassociatedwithsuicide,homicide,recklessbehaviourandpotentialsignificantundesirable impactonsocial reputation.Affect isabroadtermthat isusedtocovermood,feeling,attitude,preferencesandevaluations.Inmodernusage,itreferstotheexpressionofemotionasjudgedbytheexternalmanifestationsthatareassociatedwithspecificfeelings;forexample laughter, cryingand fearfulappearance.Mood isamoreprolongedprevailingstateordisposition, whereas emotion is often used to refer to spontaneous and transitory experiencesimilartobutnotidenticaltofeeling,asitneednotincorporatethephysicalaccompanimentsoftheexperience.Abnormalitiesofmoodcanbeclassifiedas:a)morbidstatesofthebasicemotions,includingsadness,happiness,fear,anger,surpriseanddisgustthatcanbeaffectedintheintensity,duration, timing, quality of experience, expression and appropriateness to the object or socialsetting;b)abnormalitiesofthephysiologicalandarousalmechanismsassociatedwithemotions;andc)abnormalitiesofthecognitiveevaluationofthesocialworldandoftheperceptionoftheemotionsofothers.

I wish to inform you that I have received the cake. Many thanks, but I am not worthy. You sent it on the anniversary of my child’s death, for I am not

worthy of my birthday; I must weep myself to death; I cannot live and I cannot die, because I have failed so much, I shall bring my husband and

children to hell. We are all lost; we won’t see each other any more; I shall go to the convict prison and my two girls as well, if they do not make away with

themselves because they were born in my body.A patient of Emil Kraepelin (1905)

Assessingandobservingthestateof,andchangesin,moodisessentialinpsychiatrybutatthesametimerequiresskill.Partoftheproblemhasalwaysbeentheconceptualconfusionandlackofcohesivepsychopathologicaltheorythathastraditionallybeenassociatedwithdisturbanceofaffect (Berrios,1985).Inastudyofpatientswithunsolveddiagnosticproblemsat thetimeofdischargefromhospital,atypicalpsychoticdepressionwasfound,atfollow-up,tobetheconditionmostfrequentlyresponsiblefordoubt(AnsteeandFleminger,1977).Inanotherstudy,depressedaffect was a major cause of somatic problems without physical pathology (Brenner, 1979).However, the termsusedarenot standardized,normutuallyexclusive.Different languages, incontrasttothenamesgiventophysicalobjects,haveanentirelydifferentrangeofdescriptionsofmood,sothatoneisleftwonderingwhetheritisjustthetermsthatdifferindifferentcultures,or perhaps even the experience of emotion itself. So Angst cannot be translated exactly intoEnglishwithasingleequivalentword;neithercandepressionbepreciselytranslatedintoGerman.Thewordfeelingdescribesanactiveexperienceofsomaticsensation,touch,aswellasthepassivesubjectiveexperienceofemotion.Emotion,accordingtoWhybrow(1997),‘isactuallymemory

Keywords: Emotion,Ecstasy,Anhedonia,Alexithymia,Prosody.

16—AffECT AND EMOTIONAl DISOrDErS 257.e1

258 FIVE—EMOTIONS AND ACTION

and feeling intertwined’. Feelings are also personal convictions, predictive forecasts and socialsensibilities.Allthesenuancesofmeaningaresomewhatdifferentfromtheassociationsofthewordmood.

Traditionally,feelinghasbeenusedtodescribeapositiveornegativereactiontoanexperience;it ismarkedbut transitory.Affect isabroadtermthat isusedtocovermood, feeling,attitude,preferences andevaluations. Inpsychiatry, it is customary to limit itsuse to the expressionofemotionas judgedby theexternalmanifestations thatareassociatedwithspecific feelings, forexample laughter, crying or fearful appearance. Mood is a more prolonged prevailing state ordisposition, whereas emotion is often used to refer to spontaneous and transitory experiencesimilartobutnotidenticaltofeeling,asitneednotincorporatethephysicalaccompanimentsoftheexperience.Inpractice,thesetermsareusedmoreorlessinterchangeably,afactthatcontrib-utestomuchconfusion.

Mood describes the state of the self in relation to its environment.There is an enormousrangeofvariationofwhatcouldreasonablybecallednormalmood.Pathologicalmood,thatis,moodfromwhichthepatientsuffersormoodthatcausesdisturbanceorsufferingtoothers,alsovariesagreatdeal,andtheextenttowhichitisacceptabletoothersinitsexpressionisdifferentindifferentsocialcontexts.Theclinicianhastoasktwoquestionsconcerningthemoodofhispatient.First, is thepersonsuffering?Second, is theexpressionofmood inappropriate in thissocial setting? Psychopathology of mood is confined to those situations in which there is anaffirmativeanswertoatleastoneofthesequestions,andtreatmentisdirectedtowardsimprovingthemood.

Likeotherhumancharacteristics,pathologyofmoodarisesinthecontextofadiathesis.Itisthe physical constitution that forms the tendency for developing, for example, a prolapsedintervertebraldisc; in themental realm,personality is closelyassociatedwith the type,qualityanddirectionofmood.So,apersonofcyclothymicpersonalityismorepronetomorbidstatesofelationandexcessiveactivityortaciturndejectionandretardation.

Theories of EmotionThe James–Lange theory of emotion was developed independently by William James(1842–1910) and Carl Lange (1834–1900). Simply, it posits that emotions are the resultof self-awarenessofphysicalandbodilychanges in thepresenceofa stimulus.WilliamJames(1884)wrote:

My theory … is that the bodily changes follow directly the perception of the exciting fact, and that our feeling of the same changes as they occur is the

emotion. Common sense says, we lose our fortune, are sorry and weep; we meet a bear, are frightened and run; we are insulted by a rival, are angry

and strike. The hypothesis here to be defended says that this order of sequence is incorrect … and that the more rational statement is that we feel sorry

because we cry, angry because we strike, afraid because we tremble … Without the bodily states following on the perception, the latter would be

purely cognitive in form, pale, colorless, destitute of emotional warmth. We might then see the bear, and judge it best to run, receive the insult and deem

it right to strike, but we should not actually feel afraid or angry.

This theory was criticized by Walter Cannon (1871–1945) and Philip Bard (1898–1977).Visceral(physiological)responsestostimuliaretooslowtoaccountfortherapidityofemotionsthatariseinthepresenceofappropriatestimuli.Inotherwords,thetimelinessofmyawareness

16—AffECT AND EMOTIONAl DISOrDErS 259

oftheincreasedheartrateanddrymouththatoccurwhenIaminthepresenceofahostilelionisinadequatetoexplainmyfearofthelion.Furthermore,thevisceralresponsestovaryingstimuliaresimilar,yettheemotionsmaybeasdisparateasfear,surprise,joyandsoon.Andinjectionofadrenaline(epinephrine)isaccompaniedbyvisceralchangesbutnotnecessarilybyemotionalchange.Inaddition,animalsthathavespinallesionscontinuetoexperienceemotions.Instead,the Cannon–Bard theory argued that emotion has temporal primacy and that any visceral orbehaviouralchangefollowstheemotion.Inthistheory,Iseeahostilelionandbecomefearful.Myfearfulnessprovokesthetypicalphysiologicalresponseofincreasedheartrateetc.,andtheresultingbehaviouristhatIrunoff.Thistheoryobviouslyleavesnoroomforanycognitiveaspecttotheoriginofemotions.

TheotherinfluentialtheoryisSchachterandSinger’s(1962)two-factortheoryofemotion.Thetworelevantfactorsarephysiologicalarousalandcognition.Inthistheory,anindividualisin a given social context, and he responds to this situation with a physiological arousal.Themeaningattributed to this arousal isdeterminedbyhis cognitions. Ifhis appraisal is that thecontextisthreateningthenhewillfeelfear,butiftheappraisalisthatthesituationisfunnythentheemotionwillbeapositiveone.Thistheoryhasobviousimplicationsfortheclinicalevaluationofdisordersofmood.Itspecifiesthatthesocialcontextisimportant,thatthecognitionsoftheindividualarerelevantand,finally,thatcarefulconsiderationanddescriptionoftheaccompanyingemotionisalsoimportant.

Basic EmotionsEkmanandcolleagues(EkmanandFriesen,1971)haveshownthattherearesixbasicemotionsthatareexpressedintheface:anger,disgust, fear,happiness,sadnessandsurprise.Thesebasicexpressions of emotion are universal. Ekman’s findings were anticipated by Charles Darwin(1872). It isalso thecase thatdespite therebeinguniversals in facialexpressionsofemotions,theseexpressionsarenotuniversalineveryregard.InEkman’sfieldworkinPapuaNewGuineaamongtheForepeople,therewaslittledistinctionbetweensurpriseandfear.Furthermore,itisalsotruethatwhenpeopleexperiencestrongemotionstherearedisplayrulesthatdeterminewhocanshowwhichemotiontowhomandwhen.Culturesalsodifferonwhicheventsarelikelytoproduceparticularemotions.Thisiswellexemplifiedbywhatfoodonecultureregardsasadeli-cacy andwhat another regards as revolting.The importantpoint is that thegeneral theme isuniversal;ingestingsomethingrepulsiveisacausefordisgust(Ekman,1998).

Communication of Mood‘NomanisanIsland,entireof itself ’ ( JohnDonne,1571–1631),and innoareaof life is thismoretruethanthatoffeelings.Ourfeelingsareverymuchaffectedbythosearoundus.Theyareobservableandunderstandabletootherpeople,andthis isnotaccidental; theyareactuallysignalledasanonverbalmessage.Theaffectitselfisnotdirectedtowardsanotherperson,buttheexpressionoftheaffectisconveyedbothdeliberatelyandunintentionallytoothers.

Oneofthemostimportantfindingsinthepastdecadehasbeenthatofmirror neurons.Theseneuronshavebeenfoundinprimatesandbirds,andtheirexistenceinferredinhumans.Mirrorneurons fire when an animal performs an action and also when an animal observes the sameaction performed by another animal. In other words, these neurons mirror the behaviour ofanotheranimal.Inhumans,therelevantneuronsareinthepremotorcortexandinferiorparietalcortex.RizzolattiandFadiga(1998)showedthatinthemacaquemonkeytherearetwodistinctgroupsofneuronsintherostroventralpremotorcortexthatrespondtotheobservationofgraspingobjectsandgraspingactions.Thecanonicalneuronsrespondspecificallytothethree-dimensionalobjects, whereas the mirror neurons respond to the direct observation of the hand actions


performed by another animal. Rizzolatti and Craighero (2004) argue that this mirror neuronsystemunderlies imitative learning and is therefore important for thedevelopmentofhumancultureandtheacquisitionoflanguage.Morerecently,Gallese(2007)proposedthatthemirrorneuronsystemisanembodiedsimulationsystemwhereinwenotonlyseeanaction,emotionorsensation but form internal representations of these actions, emotions or sensations based onevocationsofthesameneuralsystemsaswhenweperformthesameactionsorexperiencethesameemotionsorsensations.Thus,bymeansofthissystem,theobjectifiedotherbecomesforusanotherexperiencingself. Inotherwords,empathyandthecapacity tounderstandanotherperson’semotionalstatehaveanalreadyidentifiedbasis.

Emotionsarecommunicatednonverballybydifferentpartsofthebody,forexamplebytheface(especially theeyes),gesture,posture, toneofvoiceandgeneralappearance,especially thechoiceofclothes.Whileassessinganother’saffectiveresponse,theassessorinpartinfluencesitbyhisownbehaviouranddisposition.Apersonwhoischeerfulonmeetingsomeoneelsewillgreethimcheerfullyandinduceafeelingofcheerfulness,eveniftransitory,whichhethenreadsastheotherpersonbeingcheerfulalso.Thishasimportantimplicationsinthewaythatmoodisassessed.Itwouldseemthatemotionisevaluatedempathically.Withouthavingtogothroughthiselaborateargumentinwords,theobserversaystohimself,‘ifIfelthowIestimatethefeelingsofthatpersonfromhisappearance,Iwouldfeelveryunhappy;heisunhappy’.Thisis,ofcourse,theempathicmethodasdescribedearlier,andittakesplacespontaneouslyandwithoutdeliberatetraining.Assessmentofothers’mooddoesnotneed tobecomeverbal tobeactedon. It takesplacerapidlyandisfollowedbytheappropriatebehaviouralresponsefromtheobserver.

Classification of Pathology of EmotionsThereisnoconsensusonhowtoclassifyabnormalitiesoftheexperienceanddisplayofemotions.Cutting (1997) provides a viable framework, which has been adapted for use in this chapter.Therearemorbidstatesofthebasicemotions,includingsadness,happiness,fear,anger,surpriseanddisgust.Thesebasicemotionscanbeaffectedintheirintensity,duration,timing,qualityofexperience,expressionandappropriatenesstotheobjectorsocialsetting.Thereareabnormalitiesofthephysiologicalandarousalmechanismsassociatedwithemotions.Finally,thereareabnor-malitiesofthecognitiveevaluationofthesocialworldandoftheperceptionoftheemotionsofothers(Box16.1).

BOX 16.1 ■ Classification of disorders of emotion

Abnormalities of basic emotions■ Intensityofemotions,includingdiminutionandexacerbation■ Duration, time and quality of experience, including lability of mood, pathological crying and

laughing,parathymiaandparamimia■ Expressionofemotion,includingbluntingandflatteningofaffect■ Appropriatenesstoobject,includingphobia

Abnormality of physiological arousal■ Alexithymia

Abnormalities of evaluation of social context■ Negativecognitiveschemas■ Prosopoaffectiveagnosia■ Receptivevocaldysprosody


Pathological Changes in Basic EmotionsCHANGES IN INTENSITY OF EMOTIONS

Mostofteninpsychiatricpractice,subjectivedescriptionofchangeintheexperienceofemotionisfortheworse–astateofdysphoria,meaningtheconditionof‘beingillatease’;morerarely,thepatientmaydescribetheonsetofecstasyoreuphoria.ThesubjectiveexperienceofchangeofmoodcanbequantifiedapproximatelyandrepresentedgraphicallyasinFigure16.1,whichshows part of a mood chart a previously depressed patient had recorded; he had noticed anassociationbetweenanacuteattackofbronchitisandexacerbationofdepressivesymptoms.

Diminution of Intensity: Feeling of a Loss of Feeling

Thisisexperiencedasalossoffeeling,adeficiencythatisall-pervasive,affectingallemotionsincludingsadness,joy,anger,fearandsoon.Thepatientresentsordoesnotunderstandit,suffersverygreatlyandoftenfeelsguiltyaboutthefeeling.Itisasubjectiveexperienceoflossoffeelingsthat were formerly present rather than an objectively observed absence. A depressed youngwomansaid,‘Ihavenofeelingsformychildren.Thatiswicked.Theyarebeautifulchildren’.Apersonwithreligiousbeliefmayexperiencethislossoffeelingwithareligiouscontent:theynolongerbelieveinGod.Onmoredetailedelicitingoftheirsubjectiveexperience,theyarelikelytodescribea lossof the feelingofassuranceassociatedwith their faith rather thananyactualchangeinthecontentoftheirbeliefs.Thisaffectoccursparticularlyindepressivepsychosisbutalsooccasionallywithpersonalitydisordersandschizophrenia.Milderformsareexperiencedasdepersonalization ordeaffectualization (seeChapter13): thepatient complains thathis feelingsarenumbed,diminished,maderemotefromhimself,towhichisascribedtheunmelodiousworddeaffectualization.

Anhedonia

Anhedoniaspecificallyreferstoalossofthecapacitytoexperiencejoyandpleasure.Itisasubsetof thediminutionof the intensityofemotions.Inanhedonia, there isa total inability toenjoyanythinginlifeorevengettheaccustomedsatisfactionfromeverydayeventsorobjects;a‘lossof ability to experiencepleasure’ (Snaith,1993).The termwasoriginally introducedbyRibot(1896)andconsideredtobeaprominentsymptomofdepressiveillnessbyKlein(1974),probablythebestclinicalmarkerpredictingresponsetotreatment.Thiswouldseemtobeafundamental

Figure 16.1 Mood chart kept by a depressed patient who had had acute bronchitis.

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symptomofdepressiveillness.Ahighlyintelligentandperceptivemansufferingfrompsychoticdepressionsaid,‘Ihaveasortofuncannyfeeling.IknowwhatIamreadingisamusingbutIamnotatallamusedbyit’.TheexperiencewasverywelldescribedbyJ.S.Mill(1806–1873):

It was the autumn of 1826. I was in a dull state of nerves, such as everybody is occasionally liable to; unsusceptible to enjoyment or pleasurable excitement;

one of these moods when what is pleasure at other times, becomes insipid or indifferent … In this frame of mind it occurred to me to put the question

directly to myself, ‘suppose that all your objects in life were realized; that all the changes in institutions and opinions which you are looking forward to,

could be completely effected at this very instant: would this be a great joy and happiness to you?’ And an irrepressible self-consciousness distinctly answered,

‘No!’ At this my heart sank within me.(Mill, 1873)

Anhedonia as anexperience is starting tobedeconstructed into its componentparts.Thisdeficitinthecapacitytoexperiencepleasureisnowthoughttoincludeimpairmentsintheproc-esses of reward valuation, decision making, anticipation and motivation. The neural circuitsunderlyingthesereward-relatedmechanismsincludetheventralstriatumandprefrontalcorticalregions(Gaillardetal.,2013;Der-AvakianandMarkou,2012).

Anhedoniaisalsodescribedasasymptominschizophrenia,inwhichitisespeciallylikelytobe social–anabsenceof theability to feelpleasure in relationships (Cutting,1985).There isevidence that the hedonic aspects of olfactory experience may be disturbed in schizophrenia.Malepatientswithschizophreniafailedtoattachtheappropriatehedonicvalencetoapleasantodour,despitecorrectlyperceivingchanges inodour intensity ina studywhere theodourwaspresentedbirhinally.Inastudyinwhichamylacetatewaspresentedunirhinally,bothmalesandfemaleswithschizophreniaunderevaluatedthehedoniccharacteristicsatlowconcentrationsandoverestimated itshedoniccharacteristicsatconcentrations judgedtobeunpleasantbycontrolsandrelatives.Thesepatient-specificfindingswerenotexplicablebymedication,smokinghabitor subjective ratings of odour intensity but rather were associated with increased levels ofanhedonia/asociality(Kamathetal.,2013).Oneoftheparadoxesofanhedoniainschizophreniais thatwhen assessedby ‘trait’measures of affect, there are robust andmarkeddeficits in thereportedexperienceofpleasure.But,whenaffectisassessedin‘themoment’bylaboratorymood-inductionproceduresthereisnoevidenceofanhedonia(Cohenetal.,2011;StraussandGold,2012). The reasons for this disjunction are unclear but may include a) anticipatory hedonicexperiencedeficit,b)affectiveregulationcontrol,c)encoding-retrievaldeficit,d)representationaldeficitande)social-specificdeficits.

Itisthereforelikelythatanhedoniaisnotasingular,homogenousabnormalityinwhichtheinabilitytoexperiencepleasureequallyaffectsallmodalitiesofexperience,butanexperiencethatiscomposedofdifferentcomponentparts.Thisconceptualizationofanhedoniaisgivenfurtheramplificationbyasinglecasereportofselectivelossofemotionalexperienceinlisteningtomusic(Satohetal.,2011).Pleasureindifferentkindsofsensoryexperiencemaybediscreteandopentoselectivedisruption.

Exacerbation of Emotions: Melancholia, Mania, Ecstasy

Inaffectivedisorders,themoodisusuallytheprimaryfocusoftheabnormality.Thepathologyofmoodcanbemanifestasintensificationofsadnessorjoy.Insadness,thismaypresentasfeel-ingsofsadnessandgloom,despondency,despairorhopelessness.Often,theactualexperienceisindescribablebutrecognizedasdifferentincharacterfromnormalsadness.Inotherwords,thecharacterisqualitativelydifferentfromsadnessandakintophysicalpain:


I was feeling in my mind a sensation close to, but indescribably different from actual pain.

(William Styron, 1990)

It is a positive and active anguish, a sort of psychical neuralgia wholly unknown to normal life.

(William James, 1902)

WilliamStyron(1990),inhisbookabouthispersonalexperienceofdepression,arguedthatthetermdepressionwasaweakwordfortheexperience.

‘Melancholia’ would appear to be a far more apt and evocative word for the blacker forms of the disorder, but it was usurped by a noun with a bland

tonality and lacking any magisterial presence, used indifferently to describe an economic decline or a rut in the ground, a true wimp of a word for such a

major illness … Nevertheless, for 75 years the word has slithered innocuously through the language like a slug, leaving little trace of its intrinsic

malevolence and preventing, by its insipidity, a general awareness of the horrible intensity of the disease when out of control.

Thepositivefeelingofjoyandpleasurecanalsobeintensified.Jamison(1995)describedherpersonalexperienceofmania:

When you’re high it’s tremendous. The ideas and feelings are fast and frequent like shooting stars and you follow them until you find better

and brighter ones. Shyness goes; the right words and gestures are suddenly there, the power to captivate others a felt certainty. There are interests

found in uninteresting people. Sensuality is pervasive and the desire to seduce and be seduced is irresistible … But somewhere this changes …

Everything previously moving with the grain is now against – you are irritable, angry, frightened, uncontrollable, and enmeshed in the

blackest caves of the mind.

It is clear that thepositive, joyful aspect of the elevationofmood canquickly turn into adysphoricsensationthatisuncomfortableandunwelcome,yetthatisnotavariantofdepression.Euphoriaisastateofexcessiveunreasonablecheerfulness;itmaybemanifestedasextremecheer-fulness,asdescribedaboveinmania,oritmayseeminappropriateandbizarre.Itiscommonlyseeninorganicstates,especiallyassociatedwithfrontallobeimpairment.

Heightenedstatesofhappinesssuchasecstasysometimesoccurinpeoplewithmentalillnessorabnormalityofpersonality.Understandably,mostpsychiatristswritingaboutthemoodstateofecstasyhavedescribeditsoccurrenceinpatientswithpsychosis.Butecstaticexperiencemayalso be reported in association with minor psychiatric symptoms.The patient may describe acalm,exaltedstateofhappinessamountingtoecstasy,althoughthistranquilmoodstateisrela-tivelyuncommonandusuallyshort-lived.Inschizophrenia,ecstaticmoodmaybeassociatedwithexalteddelusions, for example, thechronicpatientwho satplacidlyenrapturedona long-stayward,knowingherself tobetheQueenofHeavenandwaitingforamessengerto informherthatshewastotakeovertheruleoftheworld.Ecstaticstates,usuallywithahistrionicflavour,mayoccurindissociativedisorderandmaybeassociatedwithreligiousstigmata(Simpson,1984).Bizarre,masshystericalphenomena,oftenwithreligiousassociations,areusuallyofthistype,forexampleinthedevilsofLoudunasdescribedbyAldousHuxley(1952).Thesocial,institutional


andgrouppsychologicalprerequisitesforthedevelopmentofepidemicormasshysteria(Sirois,1982)areusuallypresentinthesesituations,andmismanagementisusuallyresponsibleforthedevelopmentfromisolatedhysteriainoneindividualtoanepidemic.Ecstasy,solemnelationorexcessiveexuberantexpansivenessmayalsobeseen inepilepsyand inotherorganicstates, forexampleingeneralparesis.

Characteristicofecstasyisthatitisself-referent;forexample,theflowersofspring‘openforme’.Thereisanalterationoftheboundariesofselfsothatthepersonmayfeel‘atonewiththeuniverse’,orhemay‘emptymyselfofallwill’sothat‘Iamnothingbutfeelings’.Thechangeinegoboundariesdoesnotusuallyhavetheaspectofinterferencewithselfthataccompaniespas-sivity experiences. In ecstasy, the abrogation of self is experienced as being voluntary. Expertknowledgeoftheabnormaldoesnotprecludeignoranceofthenormal,andthepsychiatristcannevergeneralizefromthesampleofpeopleselectivelyreferredtohimtothewholeofmankind.Thisdiscrepancycanbecomeveryobviousintheareaofecstaticandreligious experience.Thereisaneedtoacknowledge,takeintoaccount,haverespectforanduseintreatmentthepatient’sownsubjective experience in this area (Sims, 1994).The psychiatrist sees a most unrepresentativegroupofthosehavingsomeformofreligiousexperience,whichhasbeenconsideredtoamounttoover40percentoftheadultpopulationoftheUnitedStatesofAmerica,moreofwhomaremalesthanfemales,morearestablethanunstableandmorehappythanunhappy.

Theanthropologyofecstasy(Lewis,1971)canbetracedthroughChristianandotherculturesandmakescontactwithrecognizablementalillnessonlyatafewpoints.WilliamJames(1902),in The Variety of Religious Experience, demonstrated the vast extent of the phenomenology ofreligion and showed how unwise it would be to equate the surprising with the pathological.Accountsvaryastotheextentofpsychopathologyamongconvertstoreligiousgroupsandsects;it is probably associatedwith thenatureof thegroup.ThusUngerleider andWellisch (1979)foundnoevidenceofseverementalillnessinonestudy,whileGalanter(1982)describedevidenceof emotional problems among adherents to Divine Light, the Unification Church, Baba andSubud.

Suggestiveindicatorsforestablishingareligiousexperienceasprobablyassociatedwithpsy-chiatricmorbidityare:

■ thephenomenologyoftheexperienceconformswithpsychiatricillness■ thereareotherrecognizablesymptomsofmentaldisturbance■ thelifestyle,behaviouranddirectionofpersonalgoalsofthepersonsubsequenttotheevent

areconsistentwiththenaturalhistoryofmentaldisorderratherthanwithanenrichinglifeexperience

■ suchbehaviourisconsistentwithdisordersintheperson’spersonality.Withthefollowingsigns,theexperienceismorelikelytobeintrinsictotheperson’sbelief

andlesslikelytodenotepsychiatricillness:■ thepersonshowssomedegreeofreticencetodiscusstheexperience,especiallywiththose

heanticipateswillbeunsympathetic;■ itisdescribedunemotionallywithmatter-of-factconvictionandappears‘authentic’;■ thepersonunderstands,allowsforandevensympathizeswiththeincredulityofothers;■ heusuallyconsidersthattheexperienceimpliessomedemandsonhimself;■ the religiousexperienceconformswith thesubject’s recognizable religious traditionsand

peergroup.Ecstatic states can be conceptualized as an altered state of consciousness and can be self-

induced in meditation adepts. Jhanas are an example of such a self-induced meditative statecharacterizedbydimmingoftheawarenessofexternalexperience,fadingofinternalverbaliza-tions,alterationinthesenseofpersonalboundary,intensefocusontheobjectofmeditationandincreaseinjoy.Thisstatehasbeenshowntobeassociatedwiththeactivationofcorticalprocessesandofthenucleusaccumbensinthedopamine/opiodrewardsystem(Hagertyetal.,2013).


Intensification of Fear, Anger and Surprise

TheintensificationoffearandangerisdescribedinChapter17.Thesetwobasicemotionscanoccurinpureformbutcanalsocomplicatetheintensificationofsadnessorjoy,sothatitisnotuncommon for depressed or elated mood to be associated with anxiety or irritability. Morbidsurpriseisseeninlatah,aculture-bounddisorderdescribedinMalaysiainwhichthereappearstobeanexaggeratedstartle responsecharacterizedbyamyriadofechophenomena includingecholalia,echopraxiaandechomimia.Thereisalsocoprolalia,automaticobedienceandhypersug-gestibility(Bartholomew,1994).Hyperekplexiaisaheightenedstartlereflexthatoccurseitherasahereditaryneurologicalconditioninvolvingtheinhibitoryglycinereceptor,orasasymptomaticdisorder predominantly of epilepsy in which a surprise stimulus provokes a normal startleresponsethatthentriggersafocal,usuallyfrontallobe,seizure(Meinck,2006).Late-onsetcases,withoutdemonstrablepathology,havebeenreportedinwhichaudiogenic,visualortactilestimulitriggermyoclonicjerkscharacterizedbyeyeblinking,headflexion,abductionoftheupperarms,movementofthetrunkandbendingoftheknees(Hamelinetal.,2004).Inaddition,thestartlereflexcanbeexaggeratedinpost-traumaticstressdisorderandalcoholwithdrawalstates(HowardandFord,1992).

CHANGES IN TIMING, DURATION AND APPROPRIATENESS TO SITUATION

Timing, Duration and Appropriateness to Situation

The timing and duration of emotions are aspects of the emotional expression that determinewhethertheemotionisappropriatetoitscontext.Inpathologicalgrief,thetiminganddurationmaybealteredsuchthatthegriefisdelayedorprolonged.Delayedgriefisinessenceprolonga-tionoftheinitialnumbphase(seebelow).Labilityofmoodinvolvesbothaheighteningoranintensification of emotions accompanied by an instability in the persistence of emotions thatcommunicates itself to the observer as an inappropriateness to the social context. It can alsoappearasashallownessofemotionalexpressiondespitebeingintense,becauseitistransitoryandcanseemnottobedeeplyfelt.Itisoftenasignofbraindamageandisseenfollowingfrontallobeinjuryorcerebrovascularaccident.

Pathologicallaughterorcryingisusuallyanunprovokedemotionthatdoesnothaveanappar-ent object. In other words, the emotion is not related to any identifiable social situation.Pathologicallaughteroccursinepilepsy,inwhichitisknownasgelasticepilepsy,butitmayalsobe associated with acquired brain injury. It is commonly associated with pathological crying,whichisalsoassociatedwithfocalbraininjury.Itisnoteworthythatpathologicalcryingoccursasadiscreteconditionwithoutpathologicallaughter(PoeckandPilleri,1963,quotedinCutting,1997).

Inschizophrenia,Bleuler(1911)describedparathymiaandparamimia.Inparathymia,patientsreacttosadnewswithcheerfulnessorevenlaughter.Thesepatientsmaybecomesadorirritatedbyeventstowhichotherswillreactwithindifferenceorpleasure.Furthermore,thetermpara-thymiaisalsousedforunprovokedorinappropriateburstsoflaughter.Thisparticularaspectofparathymia is similar if not identical topathological laughter. Paramimia refers to the lackofunitybetweenthevariousmodesofexpressionofemotions:

A female catatonic patient approached one of the female attendants whom she liked and told her in the friendliest manner and in her sweetest tone of voice: ‘I really would like to slap your face, people like you are usually called s.o.b.s.’

A woman patient complained bitterly about her ‘voices’ and body-hallucinations; her mouth and her forehead manifested disgust, but her eyes


expressed happy eroticism. After a few minutes the mouth also assumed the expression of happiness while her forehead continued to appear gloomy

and wrinkled.

ABNORMALITIES OF EXPRESSION AND APPROPRIATENESS TO OBJECT

Blunting and Flattening of Feeling

Thetermsbluntingandflatteningareusedinterchangeablytorefertounchangingfacialexpres-sion,decreasedspontaneousmovements,povertyofexpressivegesture,pooreyecontact,affectiveunresponsivityandlackofvocal inflection(Andreasen,1979).Thus,thetermsrefertoacom-positeoffeaturesthatarerelatedbutarenotnecessarilypartofaunifiedabnormality.Bluntingimpliesalackofemotionalsensitivity,suchasthatdisplayedbythegirlwithschizophreniawho,withobviousrelishforthesensationaleffect,tookhervisitorsuptothebedroomtoshowthemhermother,whohadbeendead for 48hours. Flattening is a limitationof theusual rangeofemotionexpressedusuallybyfacialbutalsobodilygestures.Theindividualdoesnotexpressverymuchaffectinanydirection,althoughthatwhichisexpressedisappropriateindirection.Bothbluntingandflatteningoccurinschizophrenia.

Bodily Feelings Associated With Emotion

In the theoriesof emotion,physiological changes suchaspalpitations,drymouth, sweatiness,etc.haveakeydeterminingpartinthelabellingofemotion.Theseandotherchangescanbethesole features of emotional disorder in some individuals.The relationships between mood andsomaticsymptomshavebeendiscussedinChapter14.Inanumberofculturesandlanguages,depression isconsideredtohaveananatomical locationtosuchanextentthat themoodstateandthepartofthebodybecomesynonymous.Melancholialiterallymeans‘blackbile’;similarly,in Urdu the word jee, meaning self, describes the hypochondrium anatomically and comes tomeandepression,thatis,depressionisacentralassaultonthewell-beingoftheself.Changesinbodily feelingare important inanumberofconditions.Physical illness frequentlyprecipitatesa lossof theaccustomedsenseofwell-being.This is subjectivelyexperiencedasageneralizedloweringofvitalityandmaybeassociatedwithotherpsychologicalabnormalities, for instancehypochondriasisordissociation.Inthesesettings,theexpressionofemotionaldisturbanceislikelytoemphasizethephysicalratherthantheemotional:

And thence proceeds wind, palpitation of the heart, short breath, plenty of humidity in the stomach, heaviness of heart and heartache, and intolerable

stupidity and dullness of spirits. Their excrements or stool hard, black to some, and little. If the heart, brain, liver, spleen, be misaffected, as they usually are,

many inconveniences proceed from them, many diseases accompany … those frequent wakings and terrible dreams, intempestive laughing, weeping,

sighing, sobbing, bashfulness, blushing, trembling, sweating, swooning, etc.(Burton, 1577–1650, The Anatomy of Melancholia, 1628)

Vital feelings was a term used by Wernicke (1906) to describe certain somatic symptomsoccurring in the affective psychoses.The word vital comes from the concept of the vital self,whichdescribes thecloserelationshipof thebodytoawarenessofself, thewayweexperienceourbodiesandtheimpressionweconsiderourphysicalpresencemakesonothers.So,vitalfeel-ingsarethosethatmakeusawareofourvitalself.Thesearethefeelingsofmoodthatappearto


emanate from thebody itself: localized and somatized affect.For example, depressedpatientscommonlycomplainofheadache.Onmoreinformedenquiry,thepatientmaysay,‘it’snotexactlyapain,butmoreanunbearablefeelingofpressurelikeatightbandaroundthehead’,‘afeelingofmisery,likeablackcloudpressingonmyhead’.Theheadisthecommonestsiteforvitalfeel-ings, but theymay alsooccur in the abdomen– ‘I have adull feeling inmybowels, they areslowing down and blocking’, in the chest – ‘it feels like a weight bearing down on my chest,stoppingmebreathing’,intheeyes–‘everythinglooksblack,darkanddrab;myeyesareheavy,Icannotseeproperly’orinthelegs–‘mylegsareterriblyheavy;IcannotwalkIfeelsoexhausted’.Theymayoccurinotherregionsofthebody,forinstancethebladder,thefeet,thehairandsoon.Thefeaturesthatappeartobeconstantaretheassociationofthe localizedbodysensationwiththeprevailingdepressedmood;thesensationofweight,tension,heaviness,evendepressionintheparticularorgan;andaconsequentlossoffunction–‘Icannotthinkproperly…mybowelsareblocked’.

Schneider(1920)consideredvitalfeelingstobeofparamountdiagnosticsignificanceinde-pressiveillness,equivalenttothefirst-ranksymptomsinschizophrenia,thecoreofcyclothymicdepressionandautonomicinorigin.Heconsideredthesefeelingstobecommonindepression.ItwouldseemthatDupré(1913),writingaboutwhathecalledcoenestopathic states,wasdescribingthesamesymptom:‘Coenestopathicstatesare,indeed,socommonastofigureamongthemostfrequentfeaturesofthepsychoses’.Hedescribedcoenaesthesiaasthe‘deepbutmoreorlessin-definiteawarenessthatwehaveofourownbodiesandthegeneraltoneoffunctionalactivity’.Coenestopathicstatesare‘thedistressingfeelingswhichemanatefromoneorotheroftheco-enesthesicareas…achangeinthenormalqualityofphysicalfeelingincertainpartsofthebody’.Theyare localized,butthere isnolocalpathogenic lesion.Dupréclaimedthatcoenestopathicstateswereautonomous,andnotassociatedwithotherpsychiatricdisorders;but, indescribingtheaffectswithwhichtheyareassociated,heappearstodescribeaffectivedisorders.Themoodofdepressionmaybedescribedasagloballossofvitalityinwhichallfunctionsareaffectedandallperformancesdepressed.

Achangeinvitalfeelingsdoesnotoccuronlyindepression.Thebizarrefeelingsthatapatientwithschizophreniahasabouthisbodyisachangeinthewayheexpresseshimself,oftenfurtherelaboratedbydelusions.Itshouldbenotedthatthetermvitalisusedratherdifferentlyinvital anxiety states. These states have been described (López Ibor, 1966), in which the anxiety isthoughttobeendogenous,developingrelativelyacutelyinpeopleofstablepersonality.

Thedepressivecontentofwhatphenomenologistswouldconsidertobevitalfeelingsvariesverygreatly,forexample‘Ihaveturnedtostone…Ihaveafeelingofdepressioninmychest…itisapain,aknot,aweight…Ihaveacloudonmyhead,afeelingofnothingness’.Burns(1971)commented with regard to respiratory vital feelings, ‘A striking feature of the breathlessnessdescribedbythepatientswithdepressionwasitsfairlysuddenonsetandcessation,correspondingexactlywiththeonsetandresolutionofthedepressiveillness’.

Trethowan (1979) considered that lowering of vitality is fundamental to the experience ofdepressiveillness.Hedescribedthisas‘aloweringofvitalitywhichisall-pervasiveandleadstoamarkedlossofabilityofthesubjecttofunctionashedidbeforehebecameillintermsofbothmindandbody’.

Feelings Attached to the Perception of Objects

Objectsmayevokeanemotionalresponseinanormalperson,forinstanceacomfortablefeelingof familiarity towardsanarmchair inwhichone restsafteranenergeticwalk,orapprehensivedisliketowardsadentist’schair.Thisnormalaffectiveresponsemaybeexaggeratedpathologically.Excessivefeelingsoffearamountingtoterrormayremainassociatedwithobjects.Theobjectstowhichaffect isattachedmaynotonlybephysical, inanimateobjectsbutalsothoughts,and


patterns of thoughts, and people.The occurrence of certain ideas may regularly be associatedwithspecificpathologicalemotion,perhapsresultinginphobia(seeChapter17).Anyobjectofperceptionmaybeinvestedwithidiosyncraticaffect.

Feelings Directed Towards People

These may be disturbed in a number of different ways. Affect may be absent or deadened,increasedandexcessiveordistorted.Itmayalsobeambivalent–bothlovingandhating,rejectingand overprotecting synchronously. A girl described in Chapter 14, suffering from anorexianervosa,wouldtakegreatcaretocookenormousmealsforhertwinsister,towhomshewasveryclose;thesisterbecamegrosslyobesewhilethepatientvanishedalmosttoaskeleton.Inanswertoremonstrationsaboutfeedinghersister,shesaid,‘Ilookhorrible,sosheshouldlookhorribleaswell’.

Free-Floating Emotion

Thisiscommonlydescribedinpsychiatricdisturbance,andinhisoriginaldescriptionofanxietyneurosis,Freud(1895)consideredthattheconditionwascharacterizedbyfree-floatinganxiety.Apowerfulaffectseemstohavenogoalandisassociatedwithnoobject.Thepatientdescribeshimselfas feelinggenerallyanxious,notanxiousaboutanything inparticularbut justanxious.Thisfree-floatinganxietyhassomaticandpsychologicalconcomitants.Itmayseemtobelocal-ized physically in certain areas of the body. Other free-floating affects occur, such as dread,restlessness,tension,gloom,despondency,euphoria,irritabilityandsoon.

Abnormality of Experience and Physiological ActivityAspeculativehypothesis thatclinicianshavefoundhelpful is thetermalexithymia,whichwascoinedbySifneos(1972)todescribeaspecificdisturbanceinpsychicfunctioningcharacterizedby difficulties in the capacity to verbalize affect and elaborate fantasies. This was originallyintroducedtodescribepsychosomaticdisordersoccurringinindividualswithdifficultyexpressingtheiremotions.Thelinkwithabsenceordiminutionoffantasyisaconsistentfinding(NemiahandSifneos,1970).Thecommunicativestyleshowsmarkedlyreducedorabsentsymbolicthink-ingsothatinnerattitudes,feelings,wishesanddrivesarenotrevealed;fewdreamsandapaucityof fantasiesare reported (Taylor,1984).Thinking is literal,utilitarianandconcernedwith theminutiaeofexternalevents.Theseindividualshavegreatdifficultyinrecognizinganddescribingtheirownfeelingsandindiscriminatingbetweenemotionalstatesandbodilysensations.Theyshowastiff,robot-likeexistence,‘almostasiftheyarefollowinganinstructionbook’;theremaybestiffnessofpostureandlackoffacialexpression.Theyshowanimpairedcapacityforempathyintheirinterpersonalrelationships.Alexithymiccharacteristicshavebeenfoundespeciallyamongpatientswithpsychosomaticdisorders,somatoformdisorders,psychogenicpaindisorders,sub-stanceabusedisorders,post-traumaticstressdisorder,maskeddepression,characterneurosesandsexualperversions,butthesefindingshavenotbeenconsistentlyreplicated.

TheTorontoAlexithymiaScale,whichisthemostwidelyusedmeasureofalexithymia,hasfour factors:difficulty in identifyingfeelings,externallyorientedthinking,difficultyexpressingfeelingsandreduceddaydreaming(KirmayerandRobbins,1993).Thedifficultyinidentifyingfeelingsandthedifficultyinexpressingthembothappeartobecorrelatedwithsomatosensoryamplification(Nakaoetal.,2002).Thisprovidessomevalidationoftheideathatalexithymiaisthebasisforexcessivesomatizationandthatthismaybecausedbyundueawarenessofdiscrepantsensationsthatarethenmisconstruedasevidenceofphysicalillness.

Somatizationinpatientswithmentaldisordercanbedefinedastheselectiveperceptionandfocusonthesomaticmanifestationsofthedisorderwithdenialorminimizationoftheaffectiveandcognitivechanges(Katonetal.,1982).Asamethodofexpressionofemotion,itisfrequently


reportedintransculturalstudies,especiallyintheIndiansubcontinent,accordingtoRack(1982).Murphy and co-workers (1967) studiedbasic depressive symptomatology in 30 countries andshowedhowculturechangesillnessandthewaydysphoriaisexpressed.Bavington(1981),study-ingdepressioninapredominantlyPathancultureinPakistan,foundsomatizationtobeexpressedin 45 per cent of cases; hypochondriasis was present in 55 per cent, hysterical (dissociative)features in60percent, feelingsofguilt in50percent,paranoid ideas in38percent, suicidalthoughtsin75percent,diurnalvariationin18percent,retardationin50percentandirritabilityin 80 per cent of depressed patients. Bavington explains these somatic ideas by the presenceofvitalfeelingsratherthanpovertyoflanguage.Mumford(1992)foundthatpatientswithpsy-chiatric disorders originating from India and Pakistan typically communicate their distress assomaticsymptoms;somaticpresentationwascommoningeneralhospitalsettingswherepsychi-atricdisorderswereoftenunrecognizedanduntreated.Theuseofsomaticsymptomsandsomaticmetaphortocommunicateemotionaldistressisfoundinalllanguagesandcultures.Complainingofemotionaldysphoriaintermsofsomaticsymptomsmayreflectthelimitationofthemedicalprofessioninlisteningtocomplaintsratherthanapovertyoflanguageorpaucityofverbalexpres-sioninthepatient.

Abnormalities of EvaluationThe relationship between cognitions and emotions is difficult to disentangle. Initially, it wasthoughtthattheemotionalstatedeterminedtheassociatedcognitions.Thus,lowmoodprovokednegativethoughtsabouttheselfandtheworld.However,Beck(Beck1967;Becketal.,1979)proposed that a constellation of cognitive errors initiated or maintained depression. Theseincludedarbitraryinferences,selectiveabstractions,overgeneralizations,magnificationandmini-mization.Furthermore,therewerecognitiveschemas,thatis,underlyingassumptionsabouttheself, the world and the future, that developed from previous experiences and that habituallyinfluencedhoweventsintheworldwereappraisedandthesecouldinducemoodchange,eitherdirectly or via disruption in self-esteem.This proposal is in line with Schachter and Singer’stwo-factortheoryofemotion,inwhichcognitionsplayacentralrole.

Therearealsoabnormalitiesofappraisalofthefacialorvocalexpressionofemotionsinothers.Prosopoaffective agnosiareferstotheselectivedeficiencyinappreciatingtheemotionalexpressiondisplayedinthefaceofothers.Thisabnormalityisdistinctfromprosopagnosia,inwhichonlyrecognitionoffamiliarfacesisimpaired.Itisusuallyassociatedwithacquiredbraindiseaseandhas been reported in frontotemporal dementia, when it is also associated with impairment ofrecognitionofvocalexpressionofemotion(Keaneetal.,2002);followingrightthalamicinfarct(Vuillemieretal.,1998);andinsubjectswithright-sidedlimbicandheteromodalcorticallesions(Weniger and Irle, 2002). It has been reported in autism and Asperger’s syndrome, but it isnot part of a pervasive impairment of face-processing skills (Hofter etal., 2005). In otherwords, it occurs in some patients but not in others and dissociates from impairment of facerecognitionperse.

Prosodicaspectsofspeechsuchaspitch,durationandamplitudearepartof thenonverbalcuesthatmodifythemeaningofthespokenwordandindicatetheemotionalvalueofanutter-ance and the intention of the speaker (Mitchell and Ross, 2013). Expressive emotional prosodyreferstothegenerationofaffectinspeech.Themechanismsareunclearbutarethoughttoincludebilateralbasalgangliainvolvementinmotorproductionofspeechasafunctionofaffectivestateandrightlateralizationofcorticalprocessesinthemonitoringandproductionofacousticspeechparameters(PichonandKell,2013),andthedegreetowhichthere isunilateralright-sidedorbilateralfrontotemporalinvolvementinreceptive emotional prosodyisuncertain(Wittemanetal.,2012).Receptive emotional dysprosodyreferstotheselectivedeficitinrecognizingtheemotionaltone inspeech.This isoftenassociatedwithexpressive emotional dysprosody, the impairmentof


theproductionofemotionaltoneinspeech.BothabnormalitiesarefoundinParkinson’sdisease(Caekebekeetal.,1991;Pell,1996).

Theevolutionaryrelationshipbetweenmusicandlanguageisuncertainbutitisthoughtthatmusic and language may have a common origin as an emotional protolanguage that remainsevident inoverlapping functionsandsharedneural circuitry. Ina studyof12 individualswithcongenital amusia, a disorder characterized by deficits in acoustic and structural attributes ofmusic,amarkedimpairmentinreceptiveemotionalprosodywasdemonstrated;suggestingthatmusic and language share mechanisms that trigger emotional responses to acoustic attributes(Thompsonetal.,2012).

Abnormality of Mood in Bipolar DisorderCertainly since the writings of Kraepelin, the apparently opposite mood states of mania anddepressionhavebeenrecognizedasoccurringinthesameillness–frequentlyatdifferenttimesandstagesoftheillnessinthesamepatient,morerarelyatthesametimeinthesamepatient.Althoughtheyaredescribedseparately,itisimportanttorealizethatthesemoodstatesmayoccurtogether.Maniaanddepressionarenotoppositemoodstates;theyarebothpathological,andtheoppositeofeitherwouldbefreedomfrommorbidemotion.Agitationandoveractivitymayoccurwithdepression, irritabilityanda feelingof frustrationwithmania.Apatient,nowdepressed,havingpreviouslybeenmanic,describedthis:‘Thefirstfinecarelessrapturehasdisappeared.Ifeelmoretiredandmoody’.

Depression of MoodAn additional video for this topic is available online.

CORE EXPERIENCE: PSYCHOLOGICAL AND PHYSICAL

Depressionofmoodisverycommon,anddepressionofsuchpersistenceandintensityastoberegardedas illness frequentlyoccurs.There isconsiderablediscussionas towhat is thecentralcoreofdepression.Ofcourse,argumentsadvocatingbiochemical,psychodynamicorconditioningfactorsasinitiatingcausesarenotmutuallyexclusive.Depressionaffectsvirtuallyallphysicalandpsychologicalfunctions,forexample,usingatachistoscopicmethod,PowellandHemsley(1984)wereabletoshowthatdepressioninfluencedperception.

Theworddepressionisamisnomer,asdepressiveillnessmayoccurwithoutthepatientmakinga complaint of depression as a symptom (depressio sine depressione). For this reason, the termmelancholiamaybepreferred;althoughthisliterallymeans‘blackbile’,ithascometobeacceptedasamedicalillness.ItwasthetermusedbyLewis(1934)inhisclassicdescriptionofdepressivestates in a detailed study of 61 cases; this has influenced all subsequent investigation of thecondition.MelancholiaisthepreferredtermforWhybrow(1997),whoconsidersthatit‘bettercaptures the “veritable tempest in the brain” that marks the experience of inner turmoil andconfusedthinkingasharmonyandemotiondrainaway,oftentobereplacedbyawitheredimita-tionoflife’.

Thesubjectivesymptomsofdepressionareveryvariable.Themoodvariesfromindifferenceandapathytoprofounddejection,despondencyanddespair.Anhedonia,thecompleteinabilitytoexperiencepleasure, isaconstant feature; it isexperiencedas joylessnessandrevealed in facialexpression,speech,behaviour,lifestyleandthepatient’saccountofpersonalexperience.

Aslowingdownoftheabilitytoinitiatethoughtoractionisnotedbytheobserverasretarda-tion.Apatient,describingthisafterrecovery,said,‘itfeelsasiftreaclehasbeenpouredintomyhead throughyourears’.Psychic retardation is experienced subjectivelyasan inability to fulfilnormalobligations, as lossof coping.Theproneness to self-blameoften results in thepatient


describinghimselfaslazyandgoodfornothing.Thereisacatastrophicloweringofself-esteemasaprominentcognitivecomponent.

Agitation and purposeless restlessness add to the discomfort and to the inability of thedepressed person to achieve anything.This anxiety and preoccupation with gloomy thoughtsimpairsconcentration.Diurnalvariationofmoodisoftenprominent,withthepatientfeelingathisworst,andperhapsmostsuicidal,whenhewakesearlyinthemorningor,alternatively,some-whatlaterinthemorning.Thedegreeofdepressionandmiserymaysometimessuccessfullybeconcealed; this is thepresentationofdepressio sine depressione (smilingdepression) inapatientwhoappearsnottobedepressedintheconsultingroombutmay,muchtohisdoctor’sdismay,killhimself.Theconcealmentisprobablyconsciousandmaybeassociatedwithhabitualmaskingoftheexpressionofemotionoralternativelyaimedatavoidingtreatment.

Concentration, application and decision making become difficult, painful and sometimesimpossible.Thepersondescribesdifficultyorimpossibilityinfantasyandrecollectionofemotion.Thisisdescribedaslossofmemoryandlossoffeeling.Often,thislossofmentalfunctionmakesthe patient believe he is ‘going mad’ or ‘losing his mind’, a sort of mental hypochondriasis.Physical retardation may become the focus for hypochondriacal beliefs about the body: ‘I amconstipated…mybowelsaretotallyblocked’.Averydepressedmiddle-agedwomandescribedherbodilyfeelingsthus:‘Ihaveafeelinglikehavinganinjectionatthedentist’s.Myfacefeelsnumb,butatthesametimepainfulallover’.

Anxietyisacommonconcomitantwithdepressionandmaycompletelyobscurethelatter.Inagitateddepression,agitationandrestlessnessareextremeandthepatientcarriesaseriousriskofsuicide.Histrionicbehaviourmayalsoobscuretheunderlyingdepressiveillness.Apatientwhowasactuallyprofoundlydepressedkeptpickingherskinandpullingherhair,saying,‘look,Ican’tfeelanythingwhenIdothistomyself ’.

Theaffectofdepressionmaybelocalizedsomaticallyinvitalfeelings(seeabove).Itmaytaketheformofprofoundmiseryordejection.Thereisusuallyafeelingoflossofcapacity,helpless-nessandafeelingthatthepatientcannotcope.Absenceoffeelingsisoftendescribed,oritmaybedescribedasaninexplicablelossoffeelings‘thatoughttobethere’.

Feelingsofguiltandunworthinessareprominentindepressiveillnessoftheendogenoustype.Thishas longbeenknown; forexamplePlutarch, in thefirstcenturyAD,describedaperson:‘Helooksonhimselfasamanwhomthegodshateandpursuewiththeiranger…“Leaveme,”saysthewretchedman,“metheimpious,theaccursed,hatedofthegods,tosuffermypunish-ment.”’(ZilboorgandHenry,1941).Ontheotherhand,Shepherd(1993)considersthatguiltfeelingsdidnotfeaturepredominantlyindepressivestatesdescribedinpre-PuritanEngland.Thepatientmayblamehimselfforhavingallowedhimselftogetintothisstateofmind.Heisfullofself-reproachandrecriminationforallsortsofpeccadilloesfromthedistantpast.Forallthatgoeswrong aroundhimhe takespersonal blame; thismaybeofdelusional intensity.Using ascalefortheevaluationoffeelingsofguilt,itwaspossibletoidentifytwoseparatecomponents:‘delusional’guiltorshame(experiencedinrelationtoone’sactions)and‘affective’guilt(amoregeneralfeelingofunworthiness)(Berriosetal.,1992).Aswellasdelusionsofguiltandunworthi-ness, hypochondriacal and nihilistic delusions are relatively common in depression, especiallywhenitoccursintheelderly.

Delusionsoccur inpsychoticdepression.It is importanttomakethedistinctionbetweenabelief about the state of the world coloured by current mood – ‘I feel that I must have donesomethingtomybrainasIcan’tthinkproperly’,fromanactualdelusionalbelief–‘Ican’tthinkat all, it is impossible, my brain is dead’.The former is a metaphorical statement, the lattera belief held with conviction. In practice, there is often a grey area between frank depressivedelusionsandemotionallyladenviewsoftheworld.

Table16.1showsthefrequencyofsymptoms,howeverslight,indepressiveillnessthatwererecordedquantitativelyusingaratingscalein239menand260women(Hamilton,1989).Itisseenthatanxietyisafrequentsymptomindepressiveillness.


SUICIDAL THOUGHTS

‘IfeelasthoughIwanttodestroymyself.Thereisnopointingoingon.’Suicidalideas,rumina-tions and impulses are common. Alvarez (1971) has written a detailed study of suicide froma literary point of view. He is concerned with the background and the reasons for suicideandattemptedsuicideinmanywell-knownwriters,especiallypoets.Hewritesaboutsuicideas‘lettinggo’:

I have to admit that I am a failed suicide … Seneca, the final authority on the subject, pointed out disdainfully that the exits are everywhere: each

precipice and river, each branch of each tree, every vein in your body will set you free… Yet despite all that, I never quite made it.

TABLE 16.1 ■ Frequency of symptoms in depressive illness

Males Females

Symptoms Subjects (%) Symptoms Subjects (%)

Depressed mood 100.0 Depressed mood 100.0

Loss of interest 99.6 Loss of interest 98.8

Anxiety, psychic 97.1 Anxiety, psychic 97.8

Anxiety, somatic 87.4 Somatic, general 94.2

Insomnia, initial 83.7 Anxiety, somatic 87.3

Suicide 82.0 Somatic, gastrointestinal 83.5

Somatic, general 82.0 Suicide 80.4

Somatic, gastrointestinal 80.3 Insomnia, initial 77.7

Insomnia, delayed 74.1 Guilt 72.7

Guilt 71.5 Insomnia, delayed 71.9

Insomnia, middle 71.5 Weight loss 68.8

Weight loss 69.0 Agitation 68.1

Agitation 68.1 Insomnia, middle 66.5

Libido 59.8 Libido 49.5

Retardation 52.3 Retardation 43.5

Hypochondriasis 33.1 Hypochondriasis 25.8

Loss of insight 28.0 Loss of insight 21.9

Paranoid symptoms 25.1 Depersonalization 21.1

Obsessional symptoms 13.3 Obsessional symptoms 20.7

Depersonalization 10.9 Paranoid symptoms 13.8

Diurnal variation: 59.4 Diurnal variation: 60.1

worse in morning 61.4 worse in morning 65.5

worse in evening 30.7 worse in evening 25.0

worse in afternoon 7.9 worse in afternoon 9.5

(After Hamilton, 1989, with permission.)


Theintertwinedthreadsofartisticcreativity,manic-depressiveillnessandsuicidehavebeenexploredbyGoodwinandJamison(1990).

BoththemuseandmadnessasgiftsofthegodshavebeenarecurringthemefromearliesttimesthroughsuchnineteenthcenturypoetsasBrowning,Shelley,ColeridgeandByrontothemodernAmericanpoetssuchasSylviaPlathandAnneSexton,amongwhomtherewasfoundtobeaveryhighprevalenceofmanic-depressiveillnessandmanysuicides.Inherenlighteningstudyofmanic-depressiveillnessandtheartistictemperament,Touched With Fire,Jamison(1993)demonstratesdifferentialratesfordepressiveillnessandsuicideinpoets,artistsandotherwritersandcommentsonthis.

Extrememoodswingsarefrequent,withenthusiasmandcreativityduringelationandstarkdespairwhenthepoetfindshimorherselflackingininspiration.Poetsandalsocreativemusi-cians(Schumann,Wolf,Rachmaninov,Tchaikovsky,etc.)showthispatternespeciallyfrequently,whileitismuchlesscommonamongbiographers–andpresumablywritersoftextbooks.Inthesamewaythatdepressionmayoccurwithoutsuicideorsuicidalideas,suicidemaybecarriedoutwithoutpredisposingpathologicaldepressivemood.

Depressionisregardedasthefinalcommonpathwayleadingtosuicide(VanHeeringenetal.,2000).Theseauthorsimplydepressiontheemotionandnotthediagnosticcategory.Theycon-siderthatpsychological,socialandbiologicalaetiologicalfactors,andtheincreasedratesassoci-atedwithmanypsychiatricdisorders,areallmediatedthroughhopelessnessresultinginsuicidalbehaviour.Thisemotionofhopelessnessarisesfromfeelingdefeatedinsomeimportantareaoflifeandfeelingclosedinwithnopossibleescapeorrescue.Suicidalbehaviouristhena‘cryofpain’,anattempttoescapethesefeelingsofentrapment.

Plansforsuicidemaynotbecarriedoutsolelybecauseofthedegreeofretardation;occasion-ally,electroconvulsivetherapymaylessenretardationafterthreeorfourtreatmentsandtherebyincrease the riskof suicide, because improvement fromdepressionofmood and lowered self-esteembecauseofguiltfeelingshasnotyetoccurred.Deathisoftenwelcomedwithasenseofrelief.Apsychoticallydepressedpatient,whenofferedadmissiontohospital,acceptedwithresig-nation,‘Iwillcomeinandthereyouwillkillme.ItiswhatIdeserve’.Itisfrequentlydescribedafterwardsbytherelativesofsuicidesthatinthedaysorhoursprecedingtheirdeaththeywerehappierandmoretranquilthantheyhadbeenforalongtime.

Homicideofoneormoreofthoseclosetothepatientfollowedbysuicideisarealdangerinasmallminorityofsufferersfromdepressiveillness.Aprofoundlydepressedmanfeltthat lifewasnotworthliving,thathehadfailedcompletelyandthattheworldwasintolerable.Theonlypersonhecaredforwashisfive-year-oldson,andhedidnotwanttocondemnhimtowhatheanticipatedwouldbealifetimeofmisery.Heputhissononthehandlebarsofhisbicycleandrodeoverthequayintotheharbour,intendingtokillthemboth.Theboywasdrownedbutthefatherwasrescued,resuscitatedandchargedwithmurder.Subsequently,herespondedtotreat-mentforhisseveredepressiveillness.

DEPRESSION AND LOSS

Anysocialsituationoftransitionisassociatedwithsomedisturbanceofemotion(Parkes,1971).Depressionistheaffectassociatedwithexperienceofloss.Itisnottheintentionheretoenterintotheoreticalaspectsbuttodiscussthesubjectiveexperience.Parkes(1976)hasdemonstratedhowlossofaperson, lossofa limbandeven lossofahomearestressful insimilarways,andthatthereisamentalprocessgoingoninwhichthepersonis‘makingrealinsidetheselfeventswhichhavealreadyoccurredinrealityoutside’.Thisprocess isassociatedwithmarkedpsychicpain andunhappiness.Anexampleofdepressionassociatedwith the threatof lossof a lovedobject was a taxi driver who owned his own car, which was the only thing he valued in life.Duringanepisodeofprofounddepression,hepolishedthetaxi toperfection, took it intothe


garage, connectedapipe to the exhaustof the car, started the engine andkilledhimself.Thedysphoricmoodassociatedwiththeexperienceoflossisalwaysexacerbatedifthereisanysenseofguiltorself-blameattachedtothecircumstancesoftheloss:‘ifonlyIhadcalledthedoctorintoseeMotherearlier;Ishallneverforgivemyself ’.

Grief

The immediateexperienceof loss is shockandnumbness.Thesuddenlybereavedpersonmaysaythathecannotbelievethatithashappenedtohim.Hejustfeelsnumbandempty.Hemaydescribedepersonalizationfeelings.Thereisatendencytodenythatthelosshashappened.Awomanwasreferredtoasurgeonforalumpinthebreast.Atoperation,themasswasfoundtobemalignantandthebreastwasamputated.Forseveraldaysaftertheoperation,shewasunabletoacceptthatthepainfulareaunderthedressingsignifiedthe lossofherbreastratherthanaminorexcision.

Followingtheinitialshockanddenialcomethepangsofgrief.Thisisanacutefeelingofloss,withanxietyprominent,aswellasgrieving–anxious searching.Theimplicationsoftheexperienceoflossbegintoberealized,andthismaycausethepersonfeelingsofanxietyamountingtopanic:‘HoweveramIgoingtocopewithouthim?’Thesomaticsymptomsofanxietymaybepresentaswellasthepsychological.

Threedistinctpatternsofmorbid grief havebeenobserved(Lieberman,1978):■ phobic avoidance of persons, places or things related to the deceased, combined with

extremeguiltandangeraboutthedeceasedandhis/herdeath■ a total lack of grieving, with anger directed towards others and over-idealization of the

deceased■ physicalillnessandrecurrentnightmaresinvolvingthedeceased.Thesepatternshaverelevancefortreatmentusingthebehavioralmethodofforcedorguided

mourning.Whentheexperienceoflosshasbeenacceptedasareality,depression,theaffectappertaining

toloss,occurs.Thepersonfeelsverylowandhopeless,perhapswiththeloweringofvitalityandapathyofdepression.Hebecomesresignedtohissituationbutseesnowayout:‘thereissimplyno future for me now’. Not surprisingly, this state is often associated with suicidal ideas andimpulses, and there is an increasedmortality fromsuicideandother causes in the sixmonthssubsequenttobereavement(Parkesetal.,1969).

Asthestateofgrievingisresolved,thepersongraduallyovercomesthisdespairinghopeless-ness.There is anattitudeofmind that results in reorganizationand redirection.Hegraduallymakesdecisionsandcarriesoutactivitiesthatdemonstratehisemotionalandintellectualaccept-ance of the loss and intention to continue his life as congenially as possible, although stillrememberingtheloss.Thisstageofresolutionmaybepostponedformanyyears,aswithQueenVictoria’sgrievingforPrinceAlbert.

Parkes (1976) discriminates between the subjective experience of external loss and internal change.Theexternal loss is shownbypining for the lostobject.Anxiety following lossoccursbothinbereavedpeopleandinamputees,andisassociatedwithanxioussearching:abereavedpersonusedtowalkupanddownthestreetwonderingifshewouldseeherhusband,whomsheknewtobedead.Inthesecircumstances,misperceptionofstrangersasbeingthelostrelativemayhappen.Amanwhosefatherhaddiedsomelongtimebeforethoughtheheardhisfather’svoiceinanotherroomandthenrealizeditwashisson.Peoplereturntoplacesassociatedwiththelostpersonorkeeparticlesthatbelongedtothemsacrosanct.

Internalchange,withasenseofmutilation,iscommontopeoplewithdifferenttypesofloss.Amputeesfeelthemselvestobebadlydamagedbothintheirfunctionandintheirself-image.Becauseamanhaslosthisleg,hewillbeunabletocarryouthispreviousactivitiesasbeforeandmayfeelhimselftobelessofaman.Similarly,thewomanwithanamputatedarmmayprefera


cosmeticbutuselessprosthesisratherthanamorefunctionalhook.Shemayfeeltheaffronttoherself-imageofamutilatedarmmorethanthelossoffunction.ParkesandNapier(1975)stressthesocialassociationsof loss in theirdiscussionofpreventionandalleviationof theproblemsresultingfromamputation.Widowsalsodescribeafeelingoflosswithinthemselvesduetotheirbereavement; there is,ofcourse,oftenareal lossofstatus.Thoserehousedoftendescribedaninternalchangeonmoving:‘somethingofmewentwhenIlefttheoldhome’.

ManiaManiaisawordwithalonghistory.Hare(1981)considersthattheearlydescriptionsofintel-lectualdeteriorationwithexcitementweremadebecauseoftheassociationwithorganicdeterio-ration from poor general health during the nineteenth century. As the physical health of thepopulationimproved,itwaspossibletodescribeseparateconditionswithdifferentnaturalhis-tories. However, mania still forms a much higher proportion of affective psychoses occurringpuerperallythanofaffectivedisordersoccurringatotherstagesoflife(DeanandKendell,1981).

Mania refers to elation of mood, acceleration of thinking and overactivity. Subjectively,althoughitmaybedescribedasadifferentstatefromnormal,itisrarelycomplainedofbythepatientasasymptom.Ayoung,manicin-patientdescribedhisinternalstatethus:‘Ifeelhyper-suffusedwithexperience…IamdevelopingaclosesecretarialrelationshipwithCamillaBrown(anotheryoungpatient)…Ifeellikearocketwiththebluepaperlit,standinginabottleandjust ready to takeoff ’. Ithasbecomeconventional to refer toallbut themost severecasesassufferingfromhypomania.Thisisunfortunate,asonedoesnotreferto‘hypodepression’andthepersonusingthetermhypomaniaoftengivestheimpressionthatwrongdiagnosisispermissibletoagreaterextentthanifthetermmaniahadbeenused.

Theearlystagesofmaniamaybeexperiencedasenjoyable,even‘wonderful’,andanenormousrelieffromthedepressionthatprecededit.ApatientquotedbyWhybrow(1997)putitthisway:‘IntheearlystagesofmaniaIfeelgood–abouttheworldandeverybodyinit.There’safasterbeat;asenseofexpectationthatmylifewillbefullandexciting’.Forthisreason,thepatientmaybereluctanttotakemedicationortoreporthisconditiontohisdoctor.Lateroninmanicillness,thepatient’sexperienceisusuallydescribedasunpleasantandevenfrightening.

In pure form, it is characterized by excessive cheerfulness, rapid train and association ofthoughtandoveractivity.Thespeedofthinkingandthereadyabilitytoformassociationsresultsin rapid and apparently sparkling conversation (see Chapter 9). Puns and clang associationsabound,forexampleinacasequotedbyBingham(1841):

A fine bold lady, well dressed and well known to the officers of a certain house, ‘a regular madwoman’, as they called her, was brought thither by her friends. She was no sooner announced than every missile and instrument of attack was carefully removed out of her way. She opened the conference by a familiar address to the physician under whose care she had been before and

was going to remain, by saying to him, ‘Well, Doctor M(orrison), but I beg pardon, I forgot whom I was speaking to – it is Sir A(lexander). Well, Sir A—, since I had the pleasure of seeing you last, I have been benighted, and

you have been knighted’.

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C H A P T E R 17

Anxiety, Panic, Irritability, Phobia and Obsession

SummaryResponsetostressisanintegralaspectofhumanexistence,andthealarmreactionsetsthecontextfor an understanding of anxiety and anxiety-related disorders. Hence free-floating anxietyincludesexperientialfeaturesofthealarmreactionbutmarkedoutasabnormalbytheintensity,the prolonged duration, the trivial nature of the triggering events and finally by the sociallydisruptiveanddisablingnatureoftheexperience.Anxietycanbefocusedonaspecifiedobjectorsituationandthisistermedphobia,itcanoccurasparoxysmalandepisodicattacksasinpanic,oritcanbediscomfortingifunregulatedasinobsessive-compulsivephenomena.

Montanus speaks of one that durst not walk alone from home for fear that he should swoon or die. A second fears every man he meets will rob him, quarrel

with him or kill him. A third dares not venture to walk alone, for fear he should meet the devil, a thief, be sick; fears all old women as witches; and

every black dog or cat he sees he suspecteth to be a devil; every person comes near him is malificiated; every creature, all intend to hurt him, seek his ruine;

another dares not go over a bridge, come near a pool, rock, steep hill, lye in a chamber where cross beams are for fear he be tempted to hang, drown or

precipitate himself. If he be in a silent auditory, as at a sermon, he is afraid he shall speak aloud, at unawares, something undecent, unfit to be said. If he

be locked in a close room, he is afraid of being stifled for want of air, and still carries bisket, aquavitae, or some strong waters about him for fear of deliquiums, or being sick; or if he be in a throng, middle of a church,

multitude, where he may not well get out, though he sit at ease he is certase affected. He will freely promise, undertake any business beforehand; but when it comes to be performed he dares not adventure, but fears an infinite number

of dangers, disasters, etc.…They are afraid of some loss, danger, that they shall surely lose their lives, goods, and all they have; but why they know not.

Robert Burton (1621)

Responsetostress isanintegralaspectofhumanexistence.Butwhatisstress?Thereareatleastthreeconceptualizationsofstress:stressasastimulus;stressasaresponse;andstressasaninteraction.Thenotionofstressasastimulusismodelledontheassumptionthatitisanexternalfactorthataffectsanindividual,whereasstressasaresponselocatesthestresswithintheindi-vidual.This latter notion was developed by Selye (1907–1982), who defined stress as a ‘non-specificresponseofthebodytoanydemandmadeuponit’(Selye,1956).ThenotionofstressasaninteractionbuiltonSelye’sworkandwasdevelopedbyLazarus(1922–2002):

Keywords: Anxiety,Panic,Phobia,Obsession,Compulsion,Irritability.

17—ANxIETy, PANIC, IrrITAbIlITy, PhObIA AND ObSESSION 279.e1


A particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and

endangers his or her well being.(Lazarus and Folkman, 1984)

Selye’sGeneralAdaptationSyndromedescribesthestressresponseascomprisingthreestages:alarmreaction,resistanceandexhaustion.Thealarmreaction,typicallytermedtheflight-or-fightresponse,involvesautonomicarousalmediatedbyreleaseofcatecholaminesandisexperiencedasfear,palpitationsorreadinessforaction,amongstotherthings.Intheeventthatthestressorpersists, there is decreased release of catecholamines and a switch to release of glucocorticoidhormonesduring the resistancephase.And,finally incontextsof chronic stress, exhaustion istheresultwiththepotentialforhypoglycaemiaanddeath.

AnunderstandingofSelye’sGeneralAdaptationSyndrome,particularlythephysiologicalandexperiential aspects of the alarm reaction (flight-or-fight response) sets anxiety and anxiety-relatedemotionaldisturbanceincontext.Thefiveabnormalphenomenaofthischapterarerela-tivelycommonhumanexperiencesandcanbeconstruedasemanatingfromdisturbancesoftheregulationofanxiety.Abnormalityinthiscontextismarkedoutbytheseverityandintensityoftheexperience,prolongedduration,occurrenceinreactiontowhatcouldbeconsideredaninad-equatesituationalstressandthedeleteriousanddisablingeffectonsocialfunctioning.Eachofthese phenomena has a normal, even necessary, aspect: it is appropriate to be anxious at thebeginningofaspeechinpublic;itisnormalforaparenttoexpressirritabilitywhenan8-year-oldsonbreaksawindow–itisanecessarylearningexperienceforhim;fearisnecessaryforcopingwhen an individual suddenly discovers him or herself to be surrounded by poisonous snakes;meticulouscheckingandcheckingagainisanimportantpartoflearningtobeacompetentairlinepilot;evenpanicisnormal,inastatisticalsense,insomesituationsofextrememassdisaster.

Inanymodernconsiderationofanxietydisorders,anxiety,panicandphobiawouldbeincludedbothasstatesofemotionandasdistinctsyndromes(NoyesandHoehn-Saric,1998).Irritabilityisadistinctandimportantmoodstatethatoccursinseveraldifferentconditions,andobsessionis both an individual symptom and an essential feature of obsessive-compulsive disorder.Superficially,obsessionandcompulsioncanseemunrelatedtoanxietybutbothcanbeconstruedasmeansofregulatinganxiety.

Patients may have insight and present themselves as suffering from ‘phobia’, ‘obsession’ or‘anxiety state’.However, the laymeaningofeachof these terms is significantlydifferent fromtheir psychiatric use, and it will be more usual for the clinician to diagnose the state from adescriptionofthemoodorthoughtprocess.

AnxietyAnxietyisauniversalandnormalemotion.Itisanecessaryandadaptiveresponseoftheorgan-ismtostress.It isclearthat levelsofarousalrelatetotheefficiencyofanorganism’sabilitytorespondappropriatelytoatask:toolittlearousalandexcessivearousalarebothassociatedwithpoorperformance(thisistheYerkes-DodsonLaw)(YerkesandDodson,1908).LaderandMarks(1971)havediscussedthefeaturesofanxietyintermsoftheemotionbeingnormalorpathologi-cal. In rather concrete terms, amanwhodiscovers thathe is sharing afieldwith a bull feelsacutelyanxiousandrunsattopspeedforthegate;if,sixweekslater,whenbackinthecity,hehasapanicattackandhastoliedownbecausesomeonementionsapartofthecitycalledtheBullring,hisresponseisclearlymaladaptiveandhisanxietypathological.

Anxietymayalso,arbitrarily,bepolarizedbetween stateand trait (SimsandSnaith,1988).Anxietystateisthequalityofbeinganxiousnow,atthisparticulartime,probablyasareactiontoprovokingcircumstances.Anxietytraitisthetendencyoveralongtime,perhapsthroughout

17—ANxIETy, PANIC, IrrITAbIlITy, PhObIA AND ObSESSION 281

life,tomeetallthevicissitudesoflifewithahabituallyexcessivedegreeofanxiety.Anxietyasadescriptionoftheexperienceofnormalemotionisnotdifferent inquality,onlyquantitatively,fromanxietystate(Hamilton,1959).Characteristicofthemoodofanxietyarefeelingsofconstriction. The word angst is etymologically associated with the idea of narrowness, stricture,‘straits’,andinearlyusagewaslocatedinthepraecordiumandprominentlyassociatedwithangina(Sims, 1985).The patient with anxiety state may feel restless, uncertain, vulnerable, trapped,breathless,choked.Aswellas feeling frightenedandworried,hypochondriacal ideasandevenfeelingsofguiltareoftenprominent.Symptomsofanxietyoccurpathologicallyinanxiety stateswithoutobviousexternalcause.Theanxietyisnotattachedtoanyspecificprovokingobject,andsoitistermedfreefloating anxiety.

There isalsoacontrastbetween theexperienceofanxietyasa subjectiveemotionand theobjectiveoccurrenceofphysiologicalsomaticchangesnormallyassociatedwiththataffect;someofthecommonersymptomsareshowninBox17.1(Tyrer,1982).Tyrerconsidersirritabilitytobeasymptomof anxietystate,butSnaithandTaylor(1985)madethecaseforirritabilitybeinganindependentmoodstatethatmaybeassociatedwithanxiety–oranyothermooddisorder.Althoughitisusualtofindthepsychologicalandphysicalaspectsofanxietyassociatedandrelatedinintensity,thismaynotnecessarilybeso.Thepatientmaycomplainoffeelingextremelyanxiousbut show minimal somatic expression; in dissociation, marked physical changes have beendescribedwhenthepatientdoesnotcomplainatalloffeelinganxious.ThesethreedichotomousaspectsofanxietyarerepresentedinFigure17.1.

Psychiatricnosologymakesadistinctionbetweenthreeprincipalanxietysyndromes:general-ized anxiety disorder, social and specific phobias and panic disorder. Those who suffer fromgeneralizedanxietydisorderexperiencepersistentanxietyandworrythatisoutofproportionto

BOX 17.1 ■ Symptoms of anxiety

Somatic and autonomic■ Palpitations■ Difficultyinbreathing■ Drymouth■ Nausea■ Frequencyofmicturition■ Dizziness■ Musculartension■ Sweating■ Abdominalchurning■ Tremor■ Coldskin

Psychic (psychological)■ Feelingsofdreadandthreat■ Irritability■ Panic■ Anxiousanticipation■ Inner(psychic)terror■ Worryingovertrivia■ Difficultyinconcentrating■ Initialinsomnia■ Inabilitytorelax

(FromTyrer,1982,withpermission.)


Figure 17.1 Three-dimensional model of anxiety symptoms.

'I feel anxious right now'

'I feel anxious without cause''I am anxiouswith good cause'

'I feel anxiousmost of the time'

'I feel anxious inside'

'My hands shake... Ihave palpitations' etc.

State

Somatic

Trait

Psychological

PathologicalNormal

actual events or circumstances (Spiegel and Barlow, 2000).The worry is typically focused oneverydaymatters,andovertimeitshiftsfromitemtoitem;thesubjectisalmostneverfreefromanxiety.

Patients with anxiety disorder describe characteristic ideational components, concentratingonthemesofpersonaldangerandespeciallyphysicalharm(Hibbert,1984).The‘mostimportant’thoughtofpatientsincluded‘Imaypanicinfrontofothers’,‘Imaydieofaheartattackwhileasleep’and‘Iamgoingtohaveaheartattack’.Fearofphysical,psychologicalorsocialdisasteralso occurred during panic attacks. Stressful life experiences in the preceding 12months, andsomephysiologicaldisturbanceotherthananxietyimmediatelybeforethesymptoms,werecom-monlydescribed.Theseideascanbeconstruedas‘worry’.Worryisnowrecognizedasacognitiveprocesscommonduringtheexperienceofanxiety.Ithasbeendefinedas:

A chain of thoughts and images, negatively affectladen and relatively uncontrollable. The worry process represents an attempt to engage in mental

problemsolving on an issue whose outcome is uncertain but contains the possibility of one or more negative outcomes. Consequently, worry relates

closely to fear process.(Borkovec et al., 1983)

Other psychological functions are affected by acute anxiety.The capacity for reflection isdecreased and thefieldof conscious awarenessnarrowed; this obviouslyhas survival value forinstantphysicalactionbut isadisadvantagewhenplanning, reviewingand takingavarietyofdifferentfactorsintoconsiderationareimportant.Thevariationsofactivitywithanxietyareseen,forinstance,aftertheexperienceofdisaster:somevictimswillbenumbandinert;otherstense,restless and constructively overactive; and others still terrified, almost literally ‘petrified’, andincapableofsustainedactivity.


InthePresentStateExamination(Wingetal.,1974),general anxietyiscontrastedwithsituational anxiety,thatis,thetendencytobecomeanxiousincertaindefinedsituations.Thislatterisdiscussedlaterwithphobicstates.Undergeneral anxietyareincludedfree-floatingautonomicanxiety;panicattacks;andtheobservationduringinterviewthatthepatientappearstobeanxious,tense,worriedorapprehensive.Free-floatinganxietycomprisessuchautonomiccomponentsasblushing, ‘butterflies in the stomach’, choking, difficulty in getting the breath, dizziness, drymouth, giddiness, palpitations, sweating and trembling, dilated pupils, raised blood pressure;parasympatheticaspectsincludenausea,vomiting,frequencyofmicturitionanddiarrhoea.

The psychological quality of feeling anxious or tense is more difficult to quantify than itsphysiologicalcorrelates.Wordsareidiosyncraticintheirmeaning,andsothereisatendencytojudgetheveracityofthepatient’sstatementthatheis‘terriblyanxious’accordingtotheseverityoftheautonomicsymptomsoccurringconcurrently.However,itispossiblebyusingserialratingscalestocomparethepatient’ssubjectiveexperienceatdifferenttimes;onemuch-usedexampleofthisistheHospitalAnxietyandDepressionScale(ZigmondandSnaith,1983).Serialrecord-ingsofapatientwhoshowedbothanxietyanddepressivesymptomsthatrespondedtotreatmentatdifferenttimesareshowninFigure17.2.Self-descriptionofanxietyincludesworry,brooding,sleeplessnessthroughpreoccupationwithcontentsofthethoughtsandsoon.

PANIC ATTACKS AND DISORDER

Panicattacksoccurasdiscreteepisodesofsomaticorautonomicanxietyassociatedwithmarkedpsychicanxietyasanextremesenseoffear.Theattackendseitherwithacompleteinterruptiontothepatient’scurrentstreamofbehavioursothatheliesonthefloor,rushesintotheopenair,runsbackintothehouseor‘collapses’,orheterminateshiscurrentbehaviourvoluntarilysothattheattackremitsmoregradually.Ineithercase,thereissomethingabouthismodeofactivitiesbefore the attack thatwasprecipitatingpanic.Thepatientmakes this association forhimself,andhegoestoelaboratelengthstoavoidprovokingapanicattack.Thismaybetheantecedentconditionfordevelopmentofaphobicstate.Thedurationoftheattackvariesfromlessthanaminutetoseveralhoursbutisnormallyabout10to20minutes.Theseattacksmayoccurmanytimesperday,althoughusually less frequently.Onset is sudden,withmanyanxiety symptomssuchaspalpitations,chestpainordiscomfort,chokingorsmotheringfeelings,dizziness,feelingsofunreality,dyspnoea,paraesthesiae,hotflushes,sweating,faintness,tremblingorfearofdyingorgoingmad.

Therearedistinctionsand similaritiesbetweenpanicdisorder andgeneralizedanxietydis-order.Forty-onegeneralized anxietydisorder subjects,whohadneverhadpanic attacks,were

Figure 17.2 Serial recordings of anxiety and depression in one patient on the Hospital, Anxiety and Depression Scale. (From Sims and Snaith, 1988, with permission of John Wiley.)

181410

Anxi

ety

62

181410

Dep

ress

ion

62


compared with 71 subjects with panic disorder (Noyes etal., 1992).The generalized anxietydisordersubjectshadanearlier,moregradualonsetofsymptomsandmoreoftensufferedfromsimplephobias,whilethepanicdisordersubjectstendedtoreportdepersonalizationandagora-phobia.Ingeneral,thosewithpanicdisorderhadamoreseveredegreeofillnessandweremorelikelytogiveahistoryofmajordepression.

There is growing recognition that there are at least two discrete and distinct experientialsubtypes of panic disorder: a respiratory type that is characterized by fear of dying, chestpainanddiscomfort,shortnessofbreath,paraesthesiasandthesensationofchoking;andanon-respiratorytype.Therespiratorysubtypeisassociatedwithspontaneouspanicexperienceratherthansituationallyinducedpanic.Furthermore,itismorelikelytobeprovoked,inchallengetests,byinhalationof35%carbondioxideorbyhyperventilationproducinghypocapnicalkalosis(FreireandNardi,2012).

PHOBIC STATES

Phobias,orunreasonablefears,havebeendescribedformanycenturies.Forexample,BenjaminRush(1798)definesphobiaas‘afearofanimaginaryevil,oranunduefearofarealone’andthenproducesalistof18phobias,partlyhumorouslyintended;thisisreproducedinBox17.2.Agoraphobia was originally described by Westphal (1871); this condition, literally ‘fear of themarketplace’,causesveryseveredisability.AnimalphobiashavebeencontrastedbyMarks(1970):

If ever we are tempted to think that all phobic states are a unity which reflects the same disorder and aetiology, we can quickly dispel this illusion

simply by looking at the startling contrast between animal phobias and agoraphobias. These two conditions differ radically in onset, course, symptomatology, response to treatment and psychological measures.

Solyometal.(1986)dividedthesymptomatologyof199patientsintothreecategories:ago-raphobia(80patients),socialphobia(47patients)andsimplephobia(72patients).Agoraphobia

BOX 17.2 ■ Species of phobia according to Rush (1798)

■ Thecatphobia■ Theratphobia■ Theinsectphobia■ Theodourphobia■ Thedirtphobia■ Therumphobia■ Thewaterphobia■ Thesolophobia■ Thepowerphobia■ Thefactionphobia■ Thewantphobia■ Thedoctorphobia■ Thebloodphobia■ Thethunderphobia■ Thehomephobia■ Thechurchphobia■ Theghostphobia■ Thedeathphobia


included‘fearofleavinghome,ofbeingaloneathomeoronthestreet,incrowds,oftravellingbycar,busortrain’.Socialphobiainvolvedanxietyinsocialsituations.Simplephobiadescribedasinglebut life-disruptingfear, suchasofanimals,heights,disease,aeroplanes, insectsandsoon.Whatiscommontoallthesephobicexperiencesisthatthefearisintenseandpersistentandthatfurthermoreitisprovokedbyexposureortheanticipationofexposuretocuesthatareclearlydiscernibleandcircumscribedobjectsorsituations.

A more comprehensive subdivision of phobic states is contained in Box 17.3 from Marks(1969).As agoraphobia literallymeans ‘fearof themarketplace’, this is frequently appropriatenowadays,asoftenthemostphobicsituationforsuchpeopleisinthesupermarket.Agoraphobiais, infact,aheterogeneouscollectionofdisordersandnotanentity; thepatientdoesnotonlyfearathrongofpeoplebuthasmultipleavoidanceresponsestomanydifferentstimuli(Snaith,1991).Itincludesboththosewhohaveafearofbeingunderpublicscrutiny,andthereforewhoavoidpublicplaces,andthosewithillnessfearsineitherapublicplacewheretheybecomenotice-ableoranexposedplacewheretheywillnotbeabletoreceivehelp.

Socialphobiasarecommonconditionsthathavebeenrelativelyneglectedoverrecentyears(Swinson,1992).Theyareparticularlylikelytooccurinassociationwithotherdisordersofmoodorothertypesofanxiety.Thereareavarietyofdifferentmanifestations,butsocialphobiacanbe considered tobe an extremevariantof shyness.However, avoidance ismore typical of theestablished disorder. It is characterized by excessive fear, self-consciousness and avoidance ofsocialsituationsduetothepossibilityofembarrassmentorhumiliation.Typicallythefearfocusesonsituationswherethereisthepossibilityofpublicperformancesuchaspublicspeaking,eatinginpublic,signingadocumentunderscrutiny,orformen,urinatinginapublictoilet.

Illnessphobiaisdifferentfromhypochondriacalpreoccupationinthat,withtheformer,avoid-anceoccurs.Thusthecriteriaforphobia,accordingtoMarks(1969),are:

■ fearisoutofproportiontothedemandsofthesituation■ itcannotbeexplainedorreasonedaway■ itisnotundervoluntarycontrol■ thefearleadstoanavoidanceofthefearedsituation.A28-year-oldmarriedwomansaid,

My fear problems are worst… I am afraid of catching cancer. I am afraid of catching it from the hospital [radiotherapy hospital] 1 mile away… I bought

a scarf from a shop and the assistant frightened me… the look of her, she hardly had any hair and looked very old… I thought I had caught it from her

and so I had to wash the house. I cleaned the whole house and it made me

BOX 17.3 ■ Subdivisions of phobic neurosis

Phobias of external stimuli■ Agoraphobia■ Socialphobias■ Animalphobias

Phobias of internal stimuli■ Illnessphobias■ Obsessivephobias■ Miscellaneousspecificphobias

(AfterMarks,1969,withpermission.)


poorly. I had to move house because of the hospital and I cannot go back to that shop ever again.

There is also some relationship between phobias, especially agoraphobia, and depression(Schapiraetal.,1970).Persistent fearandforeboding,oftenofasituationalnature,mayoccurwithotherdepressivesymptoms.Phobicstates,asalsopanicdisorder,mayrespondtoantidepres-santtherapy.

Phobiasareoverpoweringandcompellingintheirnature,dominatingthewholeoflife.Likeobsessions, they are repetitive, resistedunsuccessfully, regardedby the subject as senseless andirrationalbutatthesametimeascomingfrominsideofhimorherself.Someauthorsthereforedescribethemasobsessional fears.Oftencompulsivebehaviour,suchashandwashing,arisesoutofaphobia,forinstancefearofdirtandcontamination.Prominentinthesubject’sdescriptionofhisphobiaisthatheiscontrolledbyit,thatthefearissomethingfrominsidehimself(innowaycontrolledfromoutside).

ANXIETY IN OTHER DISORDERS

Obviously, most consideration of anxiety and its different forms and manifestations has beengiven in the context of the anxiety disorders. However, anxiety is a common symptom and isfrequentlyapartofotherillnesses,bothpsychiatricandphysical.Amongstpsychiatricconditions,themostfrequentcomorbidityiswithdepressiveillness;mostpatientswithdepressionhavesomeanxietysymptoms,mostofthosewithmoresevereanxietydisordersalsohavesomefeelingsofdepression.Anxietyisafrequentsymptomintheprodromalstagesofschizophreniaandisalsoassociatedwith relapse (TarrierandTurpin,1992).Anxietyoftenoccurswithorganicpsycho-syndromes,bothexacerbatingtherestlessnessofacuteorganicpsychosyndromesordeliriumandmanifestingasanadditionalcauseofsubjectivedistressinchronicorganicstatesordementia.

Anxiety is an understandable reaction to physical illness and its consequent distress, pain,physicalandsocialdisabilityandthreattolife(SimsandSnaith,1988).Inthefollowingcondi-tions,itmayalsobeadirectexpressionofthemorbidprocess:hypoglycaemia,hyperthyroidism,phaeochromocytoma,carcinoidsyndrome,somecardiacand ictaldisordersandstatesofwith-drawal frompsychoactive substances.These conditions thereforeneed tobe considered in thedifferentialdiagnosisofanxiety,andthecomponentofanxietyintheirsymptomatologymustbedealtwithintheirtreatment.

IrritabilityIrritabilityofthepatientmaybeobservedbyothersorexperiencedsubjectivelydirectedtowardsothers(outward)ortowardstheself(inward).Irritability,outwardlyexpressed,isconsideredtobeadisorderofmood in itsownrightand independentofanxiety,depressionorothermoodstate(SnaithandTaylor,1985):‘Outwardlyexpressedirritabilityisanindependentmooddisorderandnotmerelyonewhichissymptomaticofstatesofdepressionoranxiety’.Outwardlyexpressedirritability is particularly commonly associated with puerperal mood disorder, while inwardlydirectedirritabilitywasdescribedinthosewithobsessive–compulsivedisorder.IntheIrritability,DepressionandAnxietyScale,twosubscalesweredevelopedforirritability(Snaithetal.,1978):outwardlydirected irritabilityand inwardlydirected irritability.SnaithandTaylor (1985)havedefinedirritabilityforuseinthecontextofpsychopathologyas:

Irritability is a feeling state characterized by reduced control over temper – which usually results in irascible verbal or behavioural outbursts, although

the mood may be present without observed manifestation. It may be


experienced as brief episodes, in particular circumstances, or it may be prolonged and generalized. The experience of irritability is always unpleasant

for the individual and overt manifestation lacks the cathartic effect of justified outbursts of anger.

It isaprominent symptominpost-traumatic stressdisorder, inwhich it is listedasoneofthe symptoms of increased arousal. Relatives described an individual survivor of disaster: ‘Hehas completely changed his character. He has become nasty tempered and swears at us allthetime.’

Theseverityofirritabilityprobablyhasaninversecorrelationwithage;itoccursinbothmenandwomen.Itisusefultomakeadistinctionbetweenthesubjectivemoodofirritabilityandtheobservationofviolentbehaviour,althoughthesemayoverlap.Severeirritabilitymaycausecon-siderabledistresstopatients,relativesandhealthcareprofessionals;theremaybenootherpsy-chiatricsymptomatologypresent.Thefactorsthatpredisposetoirritabilityarenotclearlyknown.‘The stateof irritability isprimarily amoodwhichmaybe translated intobehaviour’ (Snaith,1991).

Obsessions and CompulsionsAn additional video for this topic is available online.

Thereisnonecessaryassociationbetweenobsessions,orobsessive–compulsivedisorder,andanxietyoranytypeofanxietydisorder.Isolatedobsessionsorobsessive–compulsivedisordermayoccur with or without anxiety; with or without depression; and with or without personalitydisorder,anankasticorotherwise.Itisadistinctandseparatephenomenon.

The patient may be troubled by thoughts that he knows to be his own but that he findsrepetitiveandstrange;hefindsheisunabletopreventtheirrepetition.Theseobsessionalthoughtshave, according toLewis (1936), threeessential features: a feelingof subjective compulsion, aresistancetoitandthepreservationofinsight.Thesefeaturesdistinguishobsessionfromvolun-taryrepetitiveactsandsocialceremonies.Thewordobsessionisusuallyreservedforthethoughtandcompulsionfortheact.Thesuffererknowsthatitishisownthought(oract),thatitarisesfrom within himself and that it is subject to his own will whether he continues to think (orperform)it;hecandecidenottothinkitonthisparticularoccasion(butitdoesandwillrecur).Heistormentedbythefearofwhatmayhappenifhedisturbstheroutine.Thereisnodistur-banceof consciousnessorof theawarenessof thepossessionofhisown thought.Thepersonusually functions satisfactorily in other areas of his life uncontaminated by the obsessionalthought,butastheobsessionsbecomemoreseverethereisincreasingsocialincapacityandmiserythatcangrosslydisrupthiswholelifestyle.

JohnBunyan,inhispoignantautobiographyGrace Abounding to the Chief of Sinners(1666),describesgross,obsessionalthoughtsandruminationsthatareconnectedwith,butcanbeclearlyseparatedfrom,hisunderlyingreligiousbeliefs.Forexample:

33. Now you must know, that before this I had taken much delight in ringing, but my Conscience beginning to be tender, I thought that such a

practice was but vain, and therefore forced myself to leave it, yet my mind hankered, wherefore I should go to the Steeple house, and look on: though I

durst not ring. But I thought this did not become Religion neither, yet I forced my self and would look on still; but quickly after, I began to think, How, if

one of the bells should fall: then I chose to stand under a main Beam that lay


over thwart the Steeple from side to side thinking there I might stand sure; But then I should think again, Should the Bell fall with a swing, it might first hit the Wall, and then rebounding upon me, might kill me for all this

Beam; this made me stand in the Steeple door, and now thought I, I am safe enough for if a Bell should fall, I can slip out behind these thick walls, and so

be preserved not withstanding.34. So after this, I would yet go to see them ring, but would not go further

than the Steeple door; but then it came into my head, how if the Steeple it self should fall, and this thought, (it

may fall for ought I know) would when I stood and looked on, continually so shake my mind, that I durst not stand at the Steeple door any longer, but was

forced to fly, for fear it should fall upon my head.(p. 13)

The obsessional symptom and the religious belief expressed in this passage are not the samephenomenologically,althoughtheyareinterconnected.Thenatureoftheobsessionalthoughtisdemonstrated in theway thatBunyan felt compelled to think through this elaborate chainofarguments;heresistedhisideas,butunsuccessfully.Thereisnolackofinsightintoitsbeinghisownbehaviour.Thebehaviourwascompulsiveinthatitwastheactingoutofambivalent,obses-sionalnotions.Thereismorethanahintofunderlyingobsessionalpersonality, for instanceinthenumberingoftheparagraphs.

Amidwife,aged32,keptthinkingaftershehadfinishedherspellofdutyathospitalthatshemighthavepushedanairwaydownthethroatofababythatshehaddelivered.Shewouldtele-phonethewardrepeatedlytocheckthattheinfantwaswell.Shefrequentlymadesurethatherdog’scollarwassecurewhenshewasoutwalking incaseheescapedandwaskilledbytraffic.Whenalittleboyandhismothervisitedherhome,shegavehimaglassof‘pop’.However,shehadtodrinkwhatshehadjustpouredoutforhimherself,althoughshedislikedit,tomakesureit reallywaspopandnot somethingharmful.Theaccumulationofmoreandmoresymptomseventuallypreventedherfromworkingorcarryingoutanyreasonablesociallife.Sheknewthatthesewereherownnotions,thattheywerestupid,butshecouldnotstopherselfthinkingandperformingthem.

The compulsive behaviour often provokes further anxiety in the patient, the need both toperform the action and to preserve social acceptability. Although wide areas of life are oftenimplicatedincompulsiverituals,itisoftenstrikinghowtheobsessionalpersonomitsotherareasfromhisobsessionality.Thepatientwhoexcoriateshishandsbyexcessivewashinganddevotesasubstantialportionofeachdaytothepursuitofcleanlinessmaydrivetoworkinadirtyandill-servicedcarandworkinanuntidyoffice!Thedilemmaofobsessionalsymptomsremainsthattheyarebothreckonedaspartofthepatient’sownbehaviourandresistedunsuccessfully,thatis,theyareundervoluntarycontrolbutnotaltogetherexperiencedasvoluntary.Thepatienthasanawarenessthatthisparticularactorthoughtisvoluntaryandcanberesisted,withdifficulty,buttheoverallpatternofthinkingorbehavingisexperiencedsubjectivelyasinevitable–it isulti-matelyfutiletostruggle.Theactionsometimes‘appearstobeagainstthewillofthepatient,andoftenseemstohavethequalityofdisgustorrepulsion;thisurgetodosomethingyettoberepelledbyit,issaidtobeasingularcharacteristicoftheobsessionalstate’(Beech,1974).

Obsessionmayoccurasthoughts,images,impulses,ruminationsorfears;compulsionsasacts,rituals,behaviours.Schneider’sdefinition(1959)emphasizesthatthereisnolossofcontactwithreality:‘Anobsessionoccurswhensomeonecannotgetridofacontentofconsciousness,althoughwhenitoccursherealizesthatitissenselessoratleastthatitisdominatingandpersistingwithoutcause’.Thus,hallucinations,delusionsandmooddisturbancescannotbeobsessionalinform;they


arenotexperiencedassenseless,nor isthereanattempttogetridofthem.Thecravingofanalcoholicforhisbeverageortheabnormaldriveofsexualdeviationisnotcompulsiveinastrictsense.Theydonotcontravene theperson’swill, althoughhemaydislikehimself intensely forhavingsuchwishes.

Obsessionalideasmaybesimpleorcomplicated.Atuneorafewmusicalnotesmaybecomerepetitive andbe resisted,or a sequenceofwords, for example ‘theBritishSocialistParty’,bereiterated irritatingly inside the person’s head. The obsessions or compulsions may be morecomplexandritualistic, forexampleapatientwhotried to shut thecardooraftergettingoutfoundthisverydifficultbecausehewasafraidthattheactofshuttingwouldproduceunpleasant,obscene,repetitivethoughts.Forthisreason,hehadtogotoelaboratelengthstoputthecarinacertainplace,checkallthedoorsbeforegettingout,checkthemallagainaftergettingoutandturnthekeywhilelookinginaparticulardirection.

Theimagesofobsessionalthinkingmaybevividbutarealwaysknownbythepatienttobeproductsofhisownmind.TheseimageshavebeenconsideredbyDeSilva(1986)tobeoneoffourtypes.

1. The obsessional image depicts repetitively the unwanted intrusive cognition – images ofbloodflowing,injuriesandsoon.

2. The compulsive image depicts compulsive behaviour by rectifying either an obsessionalimage–thewomanwhosawcorpsesincoffinsandhadtoimaginethesamepeoplestand-ing–oranindependentcompulsiveimage.

3. Thedisaster image affects compulsive checkerswhomaynotonly fear thatdisasterwilloccurunlesstheycheckbutalso‘see’thedisasterhappeninginfantasy–thehouseburningdownifthegastapsarenotturnedoff.

4. Thedisruptive imagemayintrudewhilecompulsiveritualsarebeingcarriedoutandneces-sitatetheritualbeingrecommenced.

Ruminationsareoftenpseudophilosophical,irritatinglyunnecessary,repetitiveandachievenoconclusion.Apriesthasaninnerimpulsetoutterswearwordsinchurch,oramotheranimpulsetoharmherchild–bothquitefrequentcomplaintsofobsessionalpatients.Reassurancethathewillnotharmhimselforothersoractontheimpulsescanbegiventotheobsessional,provideditistrulyobsessionalinform,thatheisnotconcurrentlydepressedandthatthereisnotcoexist-ingdissocialpersonalitydisorder.

Theconstituentelementsofobsessive-compulsiveexperiencearesaidtoinclude:1. atriggerwhichisaneventorcuethatsetsoffanobsession,afeelingofdiscomfort,ora

compulsiveurge;2. anobsessionitself;3. adiscomfortthatisexperiencedasageneralunease,tensionorasenseofguilt;4. acompulsiveurgeordrivetocarryoutaparticularbehaviour;5. discomfortreduction;6. fearsofdisaster that thepatientbelieveswill tocomepassbut thatcanbeavoidedby

engagingincompulsivebehaviour;7. inflatedsenseofresponsibilityevenforeventsoverwhichthepatienthasnocontrol;8. reassurance-seekingbehaviour;9. avoidanceofstimuliorsituationsthatmaytriggerobsessionsorcompulsions;

10. disruptionofsocialfunctioningbecauseofthelongandcomplicatedcompulsionswhichareoftentimeconsumingandexhausting;and

11. resistance–whichhasalreadybeendiscussedabove(deSilva,2003).Obsessionsoccur inthecontextofobsessive-compulsivedisorderasthemajorsymptomof

the condition. However, they also occasionally occur in other circumstances. The depressedpatient with obsessional (anankastic) personality may show obsessions and compulsions thatclearwhenhisillnessistreated.Obsessionalstatesaremorecommonwhenobsessionalpersonal-


ity ispresent,but thispersonality type isnotaprerequisite.Obsessional symptomsmayoccurin schizophrenia, when they usually have a bizarre character. Apparent obsessional symptomsmay arise de novo in an older person, associated with an organic psychosyndrome. However,theelementofresistancecharacteristicofobsessionalityisusuallynotpresent.Itseemsthatthepersoncarriesoutrepetitivebehaviourinordertocopewiththeuncertaintiesofhislifecausedby his failing memory and performance. Repetition and stereotyped behaviour in those withlearningdisabilityhassometimesbeenlabelledcompulsive;however,thisispsychopathologicallyincorrect,asthereisnoresistanceorconflictofurgeandrepulsion.Similarly,repetitivenessandstickinessofthinkingoccurwithepilepsy,followingheadinjuryandwithotherorganicstates,butagain,thisisnottrulyobsessionalinnature.

Thereisastrikingsimilaritybetweentheclinicalpresentationofobsessive-compulsivedis-orderinchildrenandadolescentsandinadults(Swedoetal.,1989).In70consecutivejuvenilepatients,washingandgrooming,repeating,checkingandtouchingritualswerethemostfrequentcompulsions, and obsessions were contamination fears, concerns about disasters happening tothepatient or those close tohim, symmetry and scrupulousness.Although the conditionwasfrequentlyfamilial,theactualpresentingsymptomswerenotsharedbyrelatives,evenbymonozy-gotictwins.

Thereissomeevidencethattherearecategoriesofobsessive-compulsivefearsandbehavioursthatareassociatedwithparticulartypesofthreat,orthreatdomains.Theseare:aggressivethreatdomain,which concerns fears aboutone’swellbeingand thatof lovedones;physical securitythreat that relates to the immediate home environment and includes checking, symmetry,and ‘just right’ symptoms; environmental cleanliness threat domain which relates to personalhygieneandcleanlinessandincludescontaminationfearsandwashingandcleaningrituals;and,privation threat domain and relates to essential resources and includes hoarding behaviours(Mathews,2009).

Theroleofdisgustinthepsychopathologyofanxietydisorders,andprincipallyinobsessionsandcompulsionsisgraduallybeingexaminedandunderstood.Disgustcanbeconsideredasanadaptivesystemthatevolvedtomotivatedisease-avoidantbehaviours.Itisarguedthatitarosetofacilitatetherecognitionofobjectsandsituationsassociatedwithriskofdiseaseandtodrivehygienicbehaviour.Furthermore,disgustassumedaroleinregulatingsocialbehaviourbyactingtomarkprohibitedanddisapprovedbehavioursasunacceptable. In this regard,disgustcanbeconceptualizedasastrongandvisceralemotionthatcanarousepowerfulaffectiveandbehaviouralresponses.Obsessionsandcompulsionscanbeunderstoodinthisschemaasdisordersofdisgustsystems:patientspresentwithcontaminationfears,sufferfromintrusivethoughtsofcontamina-tion, engage in excessive sanitation and disinfection of self and the environment (for a fullerexplorationanddiscussionoftheplaceofdisgustinpsychopathologyseeCurtis,2011).

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C H A P T E R 18

Disorders of Volition and Execution

SummaryIn this chapter, the experience of contentless non-directional urge; natural instinctual drivedirected towards some target and the volitional act with a consciously conceived goal and anawarenessofhowtoachieveitanditsconsequencesarediscussed.Abnormalitiesofurge,instinct,driveandwillaresomeofthemostcomplex inpsychopathology.Needisastrivingtowardsaparticularobject,stateoractionthatisexperiencedasadesire.Driveisaninclinationtosatisfycertainprimary,thatis, innate,needsandasactivity,theindividual’sbasicmodeofexpression.Instinctisaninnatepatternofbehaviourthatleadstodrivesatisfaction.Willisagoal-directedstrivingorintentionbasedoncognitivelyplannedmotivation.Disturbancesofthesebasicaspectsofbehaviouroccur inbothorganicand‘functional’psychiatricdisordersandaremanifest inavarietyofways,includingimpairmentsofappetites,impulsivity,aggression,motordisordersandgrossbehaviouralabnormalities.

For I know that in me (that is, in my flesh,) dwellethno good thing; for to will is present with me; but how to

perform that which is good I find not.For the good that I would I do not: but the evil which

I would not, that I do.Now if I do that I would not, it is no more I that

do it, but sin that dwelleth in me.I find then a law, that, when I would do good,

evil is present with me…But I see another law in my members, warring againstthe law of my mind, and bringing me into captivity to

the law of sin which is in my members.The Epistle of Paul the Apostle to the Romans (1662)

This is themostunsatisfactorysubjectarea inclinicalpsychopathology.Thedissatisfactionderivespartlyfromthelossofinterestinthesubjectsincetheendofthenineteenthcenturyandthelackofconceptualclaritythathasresultedfromtheimpoverishedliteraturebutalsobecauseoftheinherentcomplexityofthesubject.AsBerrios(1996)putit,‘The“will”nolongerplaysaroleinpsychiatryandpsychology.Ahundredyearsago,however,itwasanimportantdescriptiveandexplanatoryconcept,namingthehuman“power,potencyorfaculty”toinitiateaction’.Thedistinctionsbetweenrelatedbutdistinctconceptssuchasinstinct,urge,impetus,impulse,drive,motivation,will,involuntaryandvoluntarymovementsandresponsibilityhaveuntilveryrecentlyceasedtoberegardedaspropersubjectsofinquiry.Adistinctioncancorrectlybuttheoreticallybedrawnbetweentheinstinctandthusdesiretocarryoutanactioninordertosatisfyaparticularneed,thedriveandmotivationtoeffecttheactionandthewilltoexecutetheaction.Allthesearedifferentfromtheendproduct,theobservableactionorbehaviouritself(Figure18.1).

Keywords: Urge,Will,Drive,Movement,Behaviour.

18—DISOrDErS Of VOlITION AND ExECuTION 293.e1


Urge, Drive and Will, and Their DisturbanceJaspers (1959) distinguishes between the different experiences of primary, contentless non-directionalurge;naturalinstinctualdrivedirectedtowardssometarget;andthevolitional actwithaconsciouslyconceivedgoalandanawarenessofhowtoachieveitanditsconsequences.Thus,forJaspers,thereisadistinction,subjectively,betweenimpulsiveacts,awarenessofinhibitionofwillandawarenessoflossofwilloravailabilityofwill-power.

DefinitionsproposedbyScharfetter(1980)areasfollows.■ Need(aphenomenologicalconcept):astrivingtowardsaparticularobject,stateoraction

thatisexperiencedasadesire.■ Drive:

a. asaconstruct,aninclinationtosatisfycertainprimary,thatis,innate,needs;b. asactivity,theindividual’sbasicmodeofexpression.

■ Instinct(aconstruct):aninnatepatternofbehaviourthatleadstodrivesatisfaction.■ Motivation:

a. asaphenomenologicalconcept,amoreorlessclearlyexperiencedmoodoraffectthatisgovernedbyneedsandthatmovesustoactionsthatsatisfytheseneeds;

b. asaconstruct,ahypotheticalactivatingfactor.■ Will (aphenomenologicalconcept):agoal-directedstrivingor intentionbasedoncogni-

tivelyplannedmotivation.Scharfetterthendescribesthoseprimaryneedsthatareinnateandnotlearnedashunger, thirst,

breathing, urination anddefecation, sleep and self-preservation.Otherneedsarenotessential forsurvival; their demands can be postponed and they are more affected by acquired patterns ofbehaviour,suchassexualneedandprosocialneed.Secondaryneedsareacquiredandvarywiththeindividual,forexamplesmoking.Humanbeingsaresocomplexthat,althoughprimaryneedsrequirerapidsatisfaction,theyaccountforonlyasmallproportionoftheindividual’ssubjectiveexperienceandpsychologicalactivity.WhileIwritethis,Iallowmyselftobecomeawareoftheprimaryneedforbreathing,butI shallnotbegiving ita thought tenminutes fromnow.Theacquiredprimaryneedsandsecondaryneedshaveagreaterinfluenceontheindividualmentalstatethaninnateprimaryneeds.

Drive canbe conceivedas a stateof tension that initiatesdirectedbehaviour. In this view,it can either activate or determine selectivity or strength of actions. Hull (1943) introducedtheconceptofneedasapreliminarytointroducingthemoremechanicalconceptofdrive.ForHull,‘Whenaconditionarisesforwhichactiononthepartoftheorganismisaprerequisitetooptimumprobability of survival of either the individual or the species, a state of need is saidto exist’ and ‘Animals may almost be regarded as aggregations of need.The function of theeffectorapparatusistomediatethesatiationoftheseneeds.Thedriveapparatusissynonymouswitheffectorapparatus’.Inthisscheme,drivehastheroleof initiatingbehaviourthatsatisfiesneeds.

Instinctmaybedefinedas ‘an inheritedor innatepsycho-physicaldispositionwhichdeter-minesitspossessortoperceive,andtopayattentionto,objectsofacertainclass,toexperienceanemotionalexcitementofaparticularqualityandtoactinregardtoitinaparticularmanner,

Figure 18.1 Relationship between instinct, need and behaviour.

Urge and drive

Instinct Behaviour Need satisfaction

Motivation and cognition

18—DISOrDErS Of VOlITION AND ExECuTION 295

oratleasttoexperienceanimpulsetoact’(McDougall,1908).ForFreud,instinct‘appearsasaborderlineconcept,beingboththementalrepresentativeofthestimuliemanatingfromwithinandpenetrating to themind, andat the same timeameasureof thedemandmadeupon theenergyofthelatterinconsequenceofitsconnectionwiththebody’(Freud,1915).

Motivation,asaphenomenologicalconcept,isreadilyunderstoodbythelaymanbutisulti-matelytautologous:‘IdoitbecauseIammotivated’,‘Iammotivatedtodoit’.However,itisaconceptthatinpsychiatryandpsychologywecannotdowithout.Ithasbothanemotionalaspectaswellasacognitiveaspect.Inotherwords,itincludesthepleasurablerewardsthatgovernandregulatebehaviouraswellasthereasonsprofferedforbehaviour.Thereare intrinsicaswellasextrinsicmotivatingfactors.Intrinsicfactorsarethosethatareinternaltotheperson,andextrinsicfactors are those, such as supermarket reward cards, that are external incentives to behave inparticularways.Thus,thetermmotivationrefersnotonlytothegoaltowardswhichbehaviouris directed but also to emotional states that set it off as well as those that act to reward thebehaviour.Italsoreferstothereasons,justificationsorexplanationsofanaction.

Similarly,willisanecessaryconceptbutwehavegreatdifficultyincomprehendingit.ThomasReid(1710–1796),founderoftheScottishSchoolofCommonSense,regardedthewillasthepowertoputintoeffectourvoluntaryactions.ForReid(1863),‘allourpowerisdirectedbyourwill,wecanformnoconceptionofpower,properlysocalled,thatisnotunderthedirectionofwill.Andthereforeourexertions,ourdeliberations,ourpurposes,ourpromises,areonlyinthingsthatdependuponourwill.Our advices, exhortations, and commands, areonly in things thatdependuponthewillofthosetowhomtheyareaddressed.Weimputenoguilttoourselves,nortoothers,inthingswherethewillisnotconcerned’.Otherauthoritiesmakesimilarpointsbutemphasizedifferentaspectsofwill:‘Willhasaconsciouslyconceivedgoalandisaccompaniedwithanawarenessofthenecessarymeansandconsequences.Itimpliesdecisionmakingability,intentionandresponsibility’( Jaspers,1959).Hence,theoriesofwillhaveimplicationsfornotionsofmoralresponsibility,forwhatbeinganagententailsandforanydescriptionofguilt,shameandpunishment.

There are more modern attempts to clarify and delineate the phenomenology of will.Metzinger(2006)makesthepointthattheexperientialcontentofwillisfundamentallydifficultto pin down, what he terms ‘thin’ and evasive’ characteristics of the phenomenal content ofwill.Bythis,hemeansthefact that‘will’ lackssensoryconcretenessunlikesayvisionortaste;that the awareness of the process of ‘willing’ something is intermittent and not functionallystable;thatepisodesof‘will’arenottemporallysegmentedandareinherentlyfuzzy;andfinallythattheintendedgoalof‘will’isoftenlessthanclear.Toamplifythesepoints,BayneandLevy(2006)write:

We typically experience our actions as purposive. We do not simply find ourselves walking towards a door and, on the basis of this, form the belief that we must be intending to open it; instead, we experience ourselves as

walking towards the door in order to open it. The sense of goal-directedness can operate at a number of levels. For example, one might experience oneself: walking towards a door in order to open it; opening the door in order to feed the dog; and feeding the dog in order to keep him quiet. The phenomenology

of a single action can include the nested purposes for which the action is being performed.

The range of definitions and understandings of the various terms underlines the intrinsiccomplexityofthesubjectareaandthecurrentabsenceofaunifyingtheoryormodelformakingsenseofthesubject.


Abnormalities of Need, Instinct, Motivation and WillIn termsof the self-descriptionof the subject, anyof the followingphenomenological abnor-malitiesresultinginobserveddisturbanceofvolitionmayoccur.Theremaybeadisturbanceofneed, which may involve hunger, thirst, exploratory behaviour or sleep. An absence of hungercan result in anorexia occurring in chronic physical illness, an increase in hunger causinghyperphagia in Kleine–Levin syndrome and a perversion in pica. Abnormality of thirst cantake the form of increased thirst in lithium-induced polydipsia (diabetes insipidus) or ofcompulsivewaterdrinkinginpsychosis(Singhetal.,1985),whichcanresultinhyponatraemia.Abnormalityofexploratorybehaviourcantaketheformofdiminution,whichismanifestaslackofcuriosityandexplorationoftheenvironment.Thiscanbefoundinschizophreniaanddepres-sion.Exploratorybehaviourcanbeincreasedinmania.Abnormalitiesofsleeparecommonandvaried.Therearedifferentpatternsofinsomnia,includinginitialinsomnia,whichismoreoftenassociatedwithanxiety-baseddisorders,andearlymorningwakening,whichischaracteristicofdepression. Hypersomnia can occur in narcolepsy, Kleine–Levin syndrome and Pickwickiansyndrome.

Abnormality of drive can involve diminution, increase or perversion. Diminution of drivetowardsprimaryneedsoccursinschizophreniaanddepression,andisprobablyindistinguishablefromabnormalitiesofneed.It ismanifestasanabsenceoftheactivatingtensionthatinitiatesbehaviourandisobservableasapathy.Exacerbationofdrivetosatisfysexualneedismostpromi-nent in mania but can occur as part of Kleine–Levin syndrome or indeed following acquiredbrain injury or in L-dopa-induced hypersexuality in Parkinson’s disease. If drive determinesstrengthandselectivityofgoalofbehaviour,thenperversionofdrivewillincludesuchconditionsasfetishism.

Abnormality of motivation may involve diminution or exacerbation. In schizophrenia anddepression,thepleasurableintrinsicmotivationthatactsasincentiveforbehaviourmaybelost.This is most accurately described as anhedonia, the absence of pleasure in relation to usuallypleasurableactivities.Inmania, itmaybe increasedsothatmundaneactivitiesbecomeundulyfascinatingandrewarding.Disorderofmotivationcanalsobeunderstoodasinvolvingtheabnor-malitiesofreasoning,justificationandexplanation,asdescribedinthepsychoanalyticalliterature.Thisisoutsidethescopeofthisbook.

Disturbanceofwillcanbemanifestaslossofvolition.AsJeannerod(2006)putit,disorderofvolitionshouldonlyrefertothosepathologicalconditionsinwhichtheabilitytomakechoices,toexpresspreferences,orpossiblytoexperiencepleasureandfreedominmakingthesechoicesorexpressingthesepreferencesisaffected.Thiscantaketheformofimpairmentofthewilltoactinschizophreniaandseveredepression.Itisdifficulttodistinguishbetweenabsenceofneed,drive,motivationorwill.Theobservableendresultislackofactionintheabsenceofanymotorabnormalityimpairingaction.Otherabnormalitiesofwillincludeindecisivenessindepression,ambivalenceorambitendencyinschizophrenia.Theseabnormalitieshave,attheircore,contrast-ingconceivedgoalswithoscillatingdecisionmakingthatisobservableasindecisionoralternatingandcontrastedmotorbehaviours.Passivityexperiencesarebydefinitionabnormalitiesofvolition(Box18.1).Failureofvolitionasaresultofinabilitytoexperiencepleasure,thatis,asaresultofanhedoniahasbeendiscussedelsewhere(Chapter16).

ORGANIC CAUSES

Biologicaldrives suchas appetite, sleepand thirst are locatedanatomically inandaround themidbrain.Localizeddiseaseinthisarea,ofeitherastructuralorbiochemicalnature,isthereforelikelytoresultindisturbanceofdriveandhencevolition.Hormonal,metabolicandneurophysio-logicalmechanismsaffectvolition.Thus,theneedforfood,expressedinhungerandresultingin


seekingfood,isaffectedbythestateoffullnessofthegastrointestinaltract,bythesecretionofinsulinfromthepancreasandbysensoryinnervationofthegutwall,aswellasbyregulationina putative ‘appetite centre’. Physical illnesses have both a specific and a generalized effectonvolition.

Excessiveappetite(bulimia)mayoccurwithconditionssuchastumouraffectingthehypotha-lamusandresultingrossobesity,obesitymaybeassociatedwithhypoventilationandexcessivesleeping(hypersomnia)inthePickwickiansyndrome(Burwelletal.,1956),periodicsomnolenceandintensehungerwithvoraciousover-eatingoccurintheKleine–Levinsyndrome(Critchley,1962).Excessivethirstandfluidintake(polydipsia)occurwithdiseaseoftheposteriorpituitaryor the kidney (nephrogenic diabetes insipidus, for example, with lithium treatment). Loss ofappetite(anorexia)mayoccurwithlocalizeddiseaseofthemidbrain,resultinginseverecachexia;however,weightlossismuchmorecommonasageneralfeatureofanyseveredebilitatingphysicalillness.

DISTURBANCE OF VOLITION IN SCHIZOPHRENIA

Inschizophrenia,thedisturbanceofvolitionismuchmoreatthelevelofmotivationorwillthanofneed.Theremaybeabnormalityofappetitewithpolyphagiaandconsequentobesity,asoccursinsomechronicschizophrenicpatients;however,thisisnotusual.Patientswithschizophreniawhobelievethattheirfoodisbeingpoisonedmayrefrainfromeatingasaconsequence;thatis,

BOX 18.1 ■ Classification of abnormalities of need, drive, motivation and will

Abnormalities of need

Appetite■ Absenceinanorexia■ Increase,ashyperphagiainKleine–Levinsyndrome■ Perversioninpica

Thirst■ Increaseindiabetesinsipidus,resultinginpolydipsiaand,incompulsivewaterdrinking,resultingin

hyponatraemia

Exploratory Behaviour■ Decreaseinschizophreniaanddepression■ Increaseinmania

Sleep■ Decreaseinanxietyanddepressivedisorders■ IncreaseinhypersomniainKleine–LevinsyndromeandPickwickiansyndrome

Abnormalities of drive■ Decreaseinschizophreniaanddepression■ Increaseinmania■ Perversioninfetishism

Abnormalities of motivation■ Diminution,resultinginanhedoniaindepressionandschizophrenia■ Increaseinmania

Abnormalities of will■ Absenceorloss,resultinginapathyinschizophreniaanddepression■ Oscillatingwill,resultinginindecisiveness,ambivalenceorambitendency■ Anomalouswillinpassivityexperiencesandmadeactions


ofcourse,adeliberateactofwill.Themoreconspicuousdisturbance,however,isloss of volitionthatresultsinwithdrawalfromnormalsocialinteraction,forinstancelackofmotivationtoobtainandcontinueinemploymentordiminishedsexualdriveresultingindecreasedfecundity,espe-ciallyinmaleschizophrenicpatients.

This symptom was described by Bleuler (1911) as disturbance of initiative, according toLehmann(1967). It isalso recognizedamongthesocallednegative symptomsofwhatCrow(1980)hasdesignatedtype2schizophrenia.Thenegative traits –emotionalapathy,slownessofthoughtandmovement,underactivity,lackofdrive,povertyofspeechandsocialwithdrawal–area major barrier to effective rehabilitation in chronic schizophrenic patients (Wing, 1978).Althoughpositivesymptoms, suchasdelusions,hallucinationsandthoughtdisorder,aremoreconspicuous,especiallyintheearlierstagesofaschizophrenicillness,theprognosisisprobablyaffectedtoagreaterextentbythelossofvolition.

Andreasenhasdevelopedaninstrumentformeasuringthenegativesymptomsofschizophre-nia,theScalefortheAssessmentofNegativeSystems(Andreasen1982,1989).Itisveryobviousthatthepatient’squalityoflifeandalsothatofhiscarerisimpairedbytheconsequencesofthesenegativesymptoms,especiallyflatnessofaffectandlossofvolition.Whatisnotsocleariswhetherhehasasubjectiveawarenessofthesesymptomsorwhetherhesuffersasaresultofthem.Seltenetal.(1993)havedevelopedaself-ratingscale,theSubjectiveExperienceofNegativeSymptoms,tomeasurethesubjectiveexperienceofaffectiveflattening,alogia,avolitionandapathy,anhedoniaandasocialityandimpairedattention;thescalelooksatawareness,causalattribution,disruptionanddistress.

DISTURBANCE OF VOLITION IN MOOD DISORDERS

Abnormalitiesofvolitioninaffectiveillnessesareassociatedwithabnormalityofactivity,retarda-tion being prominent in depression and overactivity in mania. In depression, motivation isimpairedratherthanwill.Aseverelydepressedmanagingdirectorcontinuedtoworryabouthisplansforhiscompany,buthefoundhimselfunabletomakehimselfdoanythingaboutit.Lossofmotivationoccursalongsidelossofotheraffect.Anhedonia(seeChapter16)orlossofabilitytoexperienceenjoymentisaprominentsymptomindepressiveillness(Snaith,1993)whichalsooccurs inschizophrenia.Depressedpatientsnormallydescribe lossof interest intheirprevioushobbiesandenjoymentsinlife.Thisanhedoniacanbeconstruedaspartofthelossofmotivationtocarryouttheseactivities.Suchpatientsalsodescribelackofappetiteandlossofallinterestinfood;thismayresultinmarkedlossofweight.

A45-year-oldmalepatient,previouslyhighlysuccessfulasasalesman,developedsevereandpersistentdepressivesymptoms(Sims,1994).Asaresult, twoyearspriortoadmissionhehadlefthisjob,hishome,hiswifeandhistwochildrenanddriftedaroundthecountry,beingadmit-tedforshortperiodsoftimetoseveralpsychiatrichospitals.Hedescribedhissubjectivestate:‘Ifeelveryanxious,uncomfortableanddepressed. It is likehaving the sameperson in the samebodyasme.Itisliketwodifferentpeopleinsideonebody.Onepersonisholdingback–that’slike me.The other person is trying to let go – the other is different, quite strong’. ‘Me’ wasdescribed as ‘frightened, depressed, unsure’, and the ‘other person’ as ‘confident, affable, a greatsalesman’.‘Self ’andhis‘otherself ’arecomparedinFigure18.2.Whenhewashealthy,hewasenergetic,extrovertandabletofunctionwellinapressuredsituation.Whenhebecamedepressed,hewasmiserable,unsureofwhattodo,frightenedandlackinginallenergyforanysortofactiv-ity.Whendepressed,hesaw‘self ’asbeinghisrealidentityand‘otherself ’as‘likeafantasy’.

Inmania,commonlythereisincreasedactivity,asubjectivefeelingofgreaterenergy,effective-nessandself-confidence;suchapersonmayinitiateallsortsofnewprojects.Manicpatientsarepronetodrinktoomuchalcohol,buttheydonotusuallyovereat,perhapsbecausetheyarereadilydistractedandtendtointerrupttheirmealswithothernewenterprises.Suchpeopledescribeit


asbeingveryeasytomakedecisions,andtheirflightofideasresultsinstartingmanytasksthattheydonotcarrythroughtocompletion.

Anelderlyman livedwithhiswife ina latenineteenthcentury semidetachedhouse inanindustrialtown.Thefirst intimationofhismanicillnesswasadesperatecryforhelpfromhiswifetotheirfamilydoctorthathewasdestroyingthehouse.Atinterviewathome,onecouldseehismanyuncompletedbuildingprojectsinthehouse.Hesaidthathehadthoughtitimproperthateverytimehiswifewenttothetoiletsheshouldhavetogothroughthebackyard,whereshecouldbeseenbytheneighbours.Hehadthereforeknockedaholeinthewallbetweenthekitchenandtoilettogiveinternalaccess.Beforehecouldgetroundtotidyingthebrickworkandputtinginanewdoor,hehadrealizedthattheelectricwiringwasveryoldandsohehadremovedallthecablesfromthegroundfloorofthehouse.Hewasthinkingnextofrenewingthewiring,butthendecidedthathiswifewould likeabrandnewbathroom.Itwasatthispointthathiswiferealizedthathewasillandconsultedtheirdoctor.

Impulsive and Aggressive ActsThe term impulsivity is usually reserved for maladaptive behaviour. The behaviour universethought to reflect impulsivity encompasses actions that appear poorly conceived, prematurelyexpressed, unduly risky or inappropriate to the situation and that often result in undesirable

Figure 18.2 ‘Myself and my other self.’

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consequences.Whensuchactionshavepositiveoutcomes,theytendnottobeseenassignsofimpulsivitybutas indicatorsofboldness,quickness, spontaneity, courageousnessorunconven-tionality (Daruna and Barnes, 1993). Eysenck (1993) distinguishes between impulsivity andventuresomeness as follows: ‘Our concept of impulsiveness and venturesomeness can best bedescribedbyanalogytoadriverwhosteershiscararoundablindbendonthewrongsideoftheroad.AdriverwhoscoreshighonImpneverconsidersthedangerhemightbeexposinghimselftoandisgenuinelysurprisedwhenanaccidentoccurs.ThedriverwhoscoreshighonVent,ontheotherhand,considersthepositioncarefullyanddecidesconsciouslytotaketherisk.’

Impulsive actsare‘executedforcefullywithnodeliberationorreflection,undertheinfluenceof a compellingpressure that restricts the subject’s freedomofwill.Since reflective controlorconsiderationislacking,theconsequencesofsuchactsarenotthoughtoutortakenintoconsid-eration’ (Scharfetter, 1980). It will be seen that this is not an all-or-nothing phenomenon.Voluntary inhibitions will be present to a varying extent from completely preventing the act,modifyingitordelayingittonotexistingatall,whentheacttakesplaceunrestrained.

Inthepastdecadetherehasbeenincreasinginterestinimpulsivityasaconceptaswellasindefininganumberofimpulsecontroldisorders.Impulsivityisseenasapredispositiontowardsrapid,unplannedreactionstointernalorexternalstimuliandwithoutdueregardtothenegativeconsequencesof theseactions for the impulsive individualor forothers (Moelleretal.,2001).Theessentialelementsarepredisposition,rapidunplannedactionandlackofregardforconse-quences.This suggests that the term isnowbeingused to identifya trait rather than isolatedbehaviour that is associatedwithanepisodeof illness.Thecurrentpsychological literature, inturn,focusesonbehaviouristconceptsthatarederivedfromexperimentalanimalmodels.Theseschemesidentifythefeaturesofimpulsivityas:

1. perseveranceofbehavioursdespitepunishment;2. preferenceforasmallbutimmediaterewardoveradelayedlargerreward;and3. makingprematureresponses,orbeingunabletopreventaresponseinaresponsedisinhibi-

tionattentionalparadigm.Onceagain,theseconceptualizationsofimpulsivitysuggestthatimpulsivityisatrait.Ontheotherhand,theolderpsychiatricliteraturefocusedonimpulsivebehaviouraspartof

episodes of illness: ‘of all the morbid desires, the violent impulse [my emphasis] to muscularactivity, to bodily movement, is particularly to be noticed, as it is seen, especially in states ofmania, as a constantnecessity to restlessmotionhither and thither,beatingabout, screaming,etc.,astatewhichfrequentlyinvolvestheinjuryanddestructionofwhatiswithinreachofthepatient,withouthishavinganydefinitepurposeindoingso’and‘theinvoluntarynatureoftheseacts; the patient often complains that he cannot resist the desire; and further these acts havesomethinginstinctiveinthemannerinwhichtheyshowthemselves;theycomeoninfitswithlucidintervals,theyarefrequentlyaccompaniedbyothersymptomsofderangement’(Griesinger,1845). Bleuler (1911) distinguishes between impulsive acts and compulsive acts: ‘The actionappears tohimassomethingbeyondhisvoluntarycontrol.…Thepatientdoessomethinghedoesnotwanttodo;howeverhedoesnotofferanyresistance.’Thus,inthisview,itisresistancetotheimpulsetoactthatdefinescompulsion.

Disordersofimpulsecontrolincludeimpairmentofcontrolresultingindisinhibitionandcanbe manifest in acquired brain injury, schizophrenia, mania, episodic dyscontrol syndrome andantisocialandemotionallyunstablepersonalitydisorders.Excessivecontrolofimpulsescanresultin inhibited behaviour and lack of spontaneity, present in anxiety-related disorders includingavoidantpersonalitydisorder.

Aggression is defined as ‘a verbal or physical attack on other living creatures or things’(Scharfetter,1980),andaggressivenessasareadinesstobeaggressive.Ingeneralethologicalterms,this is required by animals for survival and by humans to cope with individual conflicts andproblems in their society. However, in a more restricted psychopathological sense, aggression


involvesdeliberateorrecklessdamageanddestructionandisaccompaniedbynegativeemotionssuchasanger,fear,despair,spiteorrage.

ThetwoconceptsofaggressionthatScharfettercontrastsareaninnate driveandanacquired response.TheformertheoryisfollowedbothbyethologistssuchasLorenz(1963)andinclassicalpsychoanalysisinthewritingsofFreudandofAdler(1929);ifaggressionisaninnatedrive,itmustfindsomeformofexpression.Learningtheorywouldsupposethataggressionisanacquiredreactioninresponsetoexternalstimuli,especiallytheexpressionofothers’aggressivebehaviour,anditisreinforcedbythesuccessitachieves.

Examplesofimpulsiveactsfollow.

We had a party. On the way home I was seized by an idea out of the blue – swim across the river in your clothes. It was not so much a compulsion to be reckoned with but simply one, colossal, powerful impulse. I did not think for a

minute but jumped straight in… only when I felt the water did I realize it was most extraordinary conduct and I climbed out again. The whole incident

gave me a lot to think about. For the first time something inexplicable, something quite sporadic and alien, had happened to me.

(Jaspers, 1923)

A 19-year-old was hospitalized for mutism. She sat motionless for prolonged periods, disinterested in her surroundings, although she appeared alert… She

ate and moved slowly but was not stiff. On the second day, suddenly and without warning, she leapt from the chair and grabbed the throat of a

passing therapist, severely damaging the therapist’s thyroid.(Fink and Taylor, 2003)

He complained of headaches, was irritable, and occasionally exploded in a rage with minimal or trivial precipitants. Destruction of property occurred,

including holes punched in walls and furniture broken plus poorly coordinated assaults on family members and some neighbours.

(Benson and Blumer, 1982)

Although impulsivity is often demonstrated by aggression, this is not invariably the case.Gambling,misuseof substances, sexual acts associatedwithdisinhibition and stealing arebutsomeofthebehavioursthatcanoccurimpulsively.

PSYCHOPATHOLOGY OF IMPULSIVE AND AGGRESSIVE BEHAVIOUR

Criminal acts may arise from delusions of one kind and another, from hallucinations of the various senses, from loss of control, which may act in

various different ways; the most difficult point of all to decide upon is the so called impulsive insanity, in which a patient loses self-control, and commits

an act, the details of which he remembers, but which he truthfully says he was unable to prevent. Such insane impulses undoubtedly do occur, and I have

been consulted by patients who have told me that loss of control of this kind would come upon them like a storm, and that they would seek shelter

anywhere to avoid the danger which might arise to themselves or others. It is


simple enough when these impulses occur in persons who have suffered from mental unsoundness, but it is much more difficult when the only evidence of

insanity is the existence of these impulses; for it may be said that they are but the result of uncontrolled pleasure of power, which is common to all. I should

hesitate before accepting impulses, unless I had evidences of insanity in other members of the family, or neuroses such as neuralgia or epilepsy in the

patient himself.(Savage, 1886)

Thereisnothingthatis likelytoresult inreferraltopsychiatricservicesmorequicklythanthepublicexhibitionofinexplicableimpulsiveandaggressiveacts.Also,thereisnothingmorelikely to be labelled as madness by the lay public. In practice, such public behaviour is quitecommonlyassociatedwithmentalillness.Inastudyofmentallydisturbedpeoplecomingtotheattentionofthepolice,therewasatendencyforsuchpeopletocreatetheirdisturbancenearthecity centre rather than at theperiphery.Of the situations resulting in the involvement of thepolice,assaultanddamagewerefrequent,butitwasthebizarrenessofthebehaviourthatmarkedthepersonasbeingmentallyill;forexampleamanwhoprofferedawindscreenwiperasfarefortravellingonabus,orawomanwhopresentedherselfmuteatahostel.Onsubsequentadmissiontohospital,diagnosiswaspredominantlyofpsychotic illness(57percent),withschizophreniaaccountingfor40percent(SimsandSymonds,1975).

Excessiveaggression,andespeciallyunprovoked inappropriateormisdirectedaggression, ismuch more often presented for psychiatric evaluation than a pathological lack of aggressivebehaviour.However,thelattermayalsobeamanifestationofillness.Excessiveaggressionmaybeconsideredbothinrelationtotheunderlyingpsychiatricillnessandaccordingtothespecificnatureofthebehaviour.

DIMINISHED AGGRESSION

Decreasedaggressivenessmayaccompanyreduceddrive;itisseensometimesinorganic,psychoticandpsychogenicdisturbance.It is frequentlyassociatedwithapathy inacuteorganicdisorderssuch as encephalitis, or in progressive dementia, although irritability and fractiousness mayalsooccur.Generalizeddebilitatingphysicalillnessisnormallyaccompaniedbylistlessnessandapathy.

Inschizophrenia,aggressionisusuallymarkedlyreduced,withlackofvolitionandfailuretoinitiate any directed activity; however, unprovoked violence may also occasionally occur. Indepressivepsychosisalso,reducedaggressionismuchthemostcommonpresentation;however,homicide, quite often associated with suicide, is certainly described among severely depressedindividualswithdepressivedelusions.

Aconsistentlylowlevelofaggressivenessmayoccurasapersonalitycharacteristic,forexamplewithdependentdisorderofpersonality.Itmaybeseenaspartofaneuroticreactionorduringadverselifesituations,forinstancewiththegriefofbereavementortheunhappinessoffeelinglonely.Acertaindegreeofaggressionisnecessaryformanyofthesocialactivitiesofnormallife,and its absence impairs functioning. Pathological lack of aggression is closely associated withdisorderofvolition.

Disturbance of Movement and BehaviourBehaviouralandmovementdisturbancesmayhavecrucialdiagnosticsignificance,especiallywhenthereisdifficultywithverbalexplanation.However,astheemphasisofthisbookisonsubjective


description of abnormality, these disorders are discussed only briefly.The distinction betweenmovement and behaviour is arbitrary, as will be shown, especially when schizophrenia isconsidered.

DISTURBANCE OF MOVEMENT

Movementmaybe increasedor speededup, reducedor sloweddown,or itmay showvariousqualitativeabnormalities.Someofthesedisordersofmovementareinvoluntaryandareappro-priatelyregardedasneurological,somearevoluntarybutcarriedoutunconsciouslyandsomearedeliberateactions(ofthewill).Thewordsusedmostlydescribetheobjectivecharacteristicsoftheactiontoanoutsideobserver,notthesubjectiveexperienceoftheactor.

These disorders of movement are now considered briefly, starting with abnormalities ofincreasedmovement–agitation andhyperactivity, anddecreasedmovement– retardation.Themovement disorders of some psychiatric conditions are then described.There are psychiatricsequelaeofprimarymovementdisordersincludingparkinsonism,andoftenthereisdisorderofmovementassociatedwithconditionsthatareprimarilypsychiatric.

Agitation

Agitation implies mental disturbance causing physical restlessness and increased arousal; it isphenomenologically a description of a subjective mood state associated with and resulting inphysical expression.Thepatientmaydescribehis affect as ‘feeling agitated’, andbothhe andtheexternalobserverseemotorrestlessnessasbeinglogicallyconnectedwiththis.Itisdemon-strated in many different mental states; pathologically, it may occur with affective psychoses,with schizophrenia, with organic psychosyndromes such as senile dementia or with neuroticand personality disorders, especially states of anxiety. Agitation is quite often a symptom ofphysicalillness,forexamplehyperthyroidismorhypoparathyroidism.Itisanimportantcompo-nentof some statesof severedepressive illness.Although retardation ismore commonly seenwith‘endogenousdepression’ormelancholia,agitationmayoccur,eitherwithoutretardationinalternating phase with retardation, or concurrently with retardation in a mixed affective state. Agitated depressionisanoldtermforonevariantofaseveredepressiveepisodewithorwithoutpsychoticcomponent.Itisalternativelyknownasmelancholia.Thepracticalclinicalimportanceofthismoodstateensuesfromthefactthat,whereassuicidalimpulsesmaybepreventedfromexpression by retardation, agitation with restlessness may render such behaviour more likely.An early response to treatment following electroconvulsive treatment or effective antidepres-sant medicationmayresult in thepatientbecoming less retardedandthereforeatgreater riskofsuicide.

Hyperactivity

Thisdescribesthestateinwhichthereisincreasedmotoractivity,possiblywithaggressiveness,over-talkativenessoruncoordinatedphysicalactivity.Thetermisdescriptiveofbehaviourratherthanofasubjectivepsychologicalstate.Restlessnessispoorlydefinedinthepsychiatricliteratureandhasdiverseandmultitudinouscauses (SachdevandKruk,1996).Restlesshyperactivityorhyperkinesismayoccurwithavarietyofdifferentphysicalassaultsonthebrainbutisespeciallyprominentasasequeltoheadinjuryinchildren,inwhomitmaybeassociatedwithimpulsivedisobedienceandexplosiveoutburstsofangerandirritability(Blacketal.,1969);itisalsoassoci-atedwithchildhoodepilepsywhenthereisbraindamage.

Overrecentyears,theconditionofattentiondeficit/hyperactivitydisorder,previouslydescribedasoccurringonlyinchildren,hasbeendiagnosedinadults;thechildhooddisorderdoessome-timespersistintoadultlife,buttheprevalenceofthedisorderinadulthoodislowcomparedwiththatinchildhood(Sachdev,1999).Thereisapatternofpersistentinattentioninallareasoflife,


overactivity with fidgeting and restlessness and impulsivity with impatience and difficulty indelayingresponses.Thesepsychologicalcharacteristicsresultindisturbedbehaviourinallareasoflife.Inadultlife,therearepersistentdifficultiesinrelationships,usuallyapoorworkrecordandsometimesalsoacriminalrecord.Theindividualisparticularlydistractibleandpronetobedisruptiveinagroupsetting.

Considerablecomorbidityinchildrenoccurswithconductdisorder,oppositionaldeficitdis-order,moodandanxietydisordersandmentalretardation(Biedermanetal.,1991).Between30and70percentofchildrenwhoarediagnosedashavingADHDwillcontinuetoshowsymptomsof the condition as adults (Bellak and Black, 1992). In a study of adults with ADHD, bothgendershadthemanifestationsoftheconditionbutfemales,whounlikethesituationinchild-hoodwereinthemajority,hadhigherratesofdepression,anxietydisordersandconductdisorderthannormalcontrolsubjects(Biedermanetal.,1994).Thisisclearlyaconditiontowhichthosepractisingingeneraladultpsychiatrywillhavetopaymoreattentioninfuture,anditisworthyofmoredetailedpsychopathologicalstudy.

Retardation

Retardationhastwoquitedifferentmeaningsinpsychiatry.Motor retardation,thesenseinwhichitisusedhere,impliesslownessoftheinitiation,executionandcompletionofphysicalactivity;it is frequentlyassociatedwithretardationof thought, forexample inseveredepressive illness.Thepatientsubjectivelydescribeshimselfashavingdifficultywiththinking–‘mythoughtsareslowedup’–andalsowithinitiatingandcarryingoutspontaneousactivity.Mental retardationisasynonymformentalhandicap,mentalsubnormalityorlearningdisability.Itisanunfortunatetermas,althoughthere is intellectualdeficit, theremaybenophysical slowness; in fact, theremaybeoveractivity,especially ifthereiscoexistingbraindamage.Also,thesufferer isunlikelytocomplain,subjectively,ofslownessinthethinkingprocess.

Retardationissoprominentasymptomofthesevereendogenoustypeofdepressionthatinthepastitwasusedtonamethecondition,retarded depression.Thereisrestrictedmovement,astatic posture of dejection and decrease of muscular tone. Gesticulation is reduced, as is theemotionalcomponentoffacialexpression.

Retardationwithslownessofmotoractivityisalsoseenwithothercausesofmentalslowness,as invariousorganicpsychosyndromesandwithphysical illnesses.Theextremeof retardation–novoluntarymovementatall–isknownasakinesisandoccurswithmutenessinstupor.

Disorder of Movement in Schizophrenia

For the sake of convenience, three types of abnormality may be recognized in schizophrenia:isolatedabnormalitiesofmovementandposture,whicharenowdiscussed;morecomplexpatternsofdisorderedbehaviour,describedlaterinthechapter;andthepresumedeffectsonmovementoftheantipsychoticdrugs,whichareoftenusedinlargedosagesandforalongtimeinschizo-phrenia.Extrapyramidalsideeffectsaredescribedlaterinthischapter,butbriefmentionshouldbemadeoftheneuroleptic malignant syndrome,withrapidonsetofseveregeneralizedmuscularhypertonicitywithhyperpyrexiaandakineticmutismandautonomicdisturbance;deathoccursinabout15percentofsufferers(Kellam,1987).Someoftheoddmotordisordersthatoccuraredescribedfirst,andthenthedisturbancesofchronicschizophreniaarementioned.

Isolated Disorders of Movement and Posture

Catatoniameansastateofincreasedtoneinmusclesatrest,abolishedbyvoluntaryactivitiesandthereby distinguished from extrapyramidal rigidity. The syndrome catatonic schizophrenia wasoriginally described by Kahlbaum (1873) and is characterized by the presence of the motordisordersdescribedbelow.InreviewingKahlbaum’sconcept,Johnson(1993)considerscatatonia,the ‘tension insanity’, to be a neuropsychiatric syndrome caused by a large variety of organic


diseaseprocessesmanifestingascatalepsywithanabnormalmentalstate.It isverydifficulttoclassify the precise nature of the odd and abnormal posture in catatonic schizophrenia. Waxy flexibility(flexibilitascerea)andpsychological pillowoccurbutarebothrareconditions.Inwaxyflexibility,whenthelimbsofthepatientareputintoanyposturebytheinterviewertheywillberetainedinthatpositionforasustainedperiod(aminuteormore).Psychologicalpillow,whenthesupinepatient’sheadismaintainedafewinchesabovethebed,maycontinueforhours.Instereotypy,abizarreuncomfortable-lookingposturealsomayberetainedforsomehours.

Theveryvariedsymptomsofcatatoniaalwaysinvolvemotoractivityandposture.Theremaybehyper-orhypoactivity,mutism,stereotypicalposturingandmovement,waxyflexibility,stuporand uncontrollable excitement (Fink, 1993). Some variants of catatonia are lethal (pernicious) catatonia,withhighfever,rigidityandextremehyperactivityand/orstupor;neuroleptic malignant syndrome,withrigidity,fever,autonomicinstabilityandstupor,associatedwiththeuseofanti-psychoticdrugs;periodic catatonia,characterizedbyperiodsofexcitementfollowedbycatatonicstupor;manic excitement,withconfusion;andstuporinthecontextofdelirium.Itisnowrecog-nizedthatcatatonicmovementdisturbanceispresentindisordersotherthanschizophreniaandhasbeenmostrecentlyidentifiedinanti-NMDARencephalitisandinself-injuriousbehavioursinautisticspectrumdisorderinchildhood(Fink,2013).

Thereare two typesofabnormalmovement in schizophrenia: idiosyncratic voluntary move-ments or mannerisms and spontaneous involuntary movements. Mannerisms are shown in odd,stilted,voluntarymovementsandpatternsofbehaviour.Thepatientmayclaimtobeunawareoftheseactsorexplainthemintermsofhisdelusions.

Itissometimesdifficulttodistinguishmannerismsfromthepurposelessmovementsorpos-turesthatarenotgoal-directedbutarecarriedoutinanunvaryingwayinanyindividualpatient.Itisimportanttoattempttodistinguisheitherofthesetypesofmovementfromtheabnormalmovements of parkinsonian syndromes, which occur quite frequently in schizophrenic patientstreated with typical (first generation) antipsychotic drugs. Grimacing is a common feature inschizophrenia; Schnauzkrampf (literally ‘snout spasm’) is a characteristic facial expression inwhichthenoseandlipsaredrawntogetherinapout.

Abnormality of the execution of movement may result from the internal experiences of theschizophrenicpatient.Attimes,heresistsstimuli,forexampletheinterviewer’srequesttoraisehis right arm, and shows negativism. At other times, he demonstrates excessive complianceamounting toautomatic obedience:notonlydoeshe raisehis rightarmbuthe raises theotherarmandthenstandsupwithbotharmsraisedindramaticresponsetotherequest.Thisalter-nation of cooperation and opposition produces the diffident, unpredictable behaviour ofambitendency.

Obstructionistheequivalentintheflowofactiontothoughtblockingintheflowofspeech.Whilecarryingoutamotoract,thepatientstopsstillinhistracks.Afterapause,hecontinueswiththeactorhemayproceedtodosomethingelse.Usually,hecannotaccountforhisobstruc-tionbutmaydosointermsofpassivity:‘myactionwasstopped’.

Abnormalmovementsmanifestedintheinteractionwiththeinterviewermayrevealexcessivecooperationoropposition.Mitgehen, echopraxia, automatic obedienceandadvertencearesymptomsofexcessivecooperation.InMitgehen(literally,German,‘togowith’),theinterviewercanmovethepatient’s limbsorbodybydirectinghimwithfingertippressure, ‘as ifonewasmovingananglepoiselamp’accordingtoHamilton(1984).Whenthepatientimitatestheinterviewer’severyaction, the symptom is called echopraxia; this occurs despite the doctor asking him not to.Automatic obedience denotes a condition in which the patient carries out every command in aliteral,concretefashion,likeanautomaton.Todemonstratethesesymptomsofexcessivecoopera-tion,thepatientshouldbeaskedtoresisttheinterviewer.Mitgehenandechopraxiastilloccur.This inability to accede to instructions to resist occurs with forced grasping. The interviewerpresentshishandtobeshakenbutatthesametimeasksthepatientnottoshakeit;everytime


thepatientdoesshakehands,theinterviewerhasgreatdifficultyingettinghishandawayagain.In advertence, the patient turns towards the examiner when he addresses him; again, it has abizarre,exaggeratedandinflexiblequality.

Oppositionoccursasanegativeresponsetoall theapproachesof theexaminer.Thepatientresists theexaminerwhenthe latterattempts tomovehis limbs.Whenaddressed, thepatientturnsaway–aversion. Negativismisnotjustarefusalbythepatienttodowhatheisasked:itisanactiveprocessofresistingallattemptstomakecontactwithhim.Oppositionmaysometimesmanifestitselfinmuteness.

Theabnormalmovementsofschizophreniaarestronglysuggestiveofneurologicalabnormal-ity.IntheopinionofCutting(1985),themovementdisordersofschizophreniaincludingcata-tonia,perseveration, involuntarymovementsanddisturbedvoluntarymovementsmay, insomecases, represent adisorderof conation resulting fromhemispheric imbalance.WhetherornotCutting’sformulationiscorrect,thereiscontinuinginterestinabnormalmovementsinschizo-phreniathataredistinctfromthosearisingfromtreatmentwithantipsychoticdrugs.Indeed,asweseebelowthereareavarietyofsubtleandnotsosubtlemovementdisturbancesprevalentinschizophreniawhichapparentlypre-datetreatment.

Finally,thereappearstobeimpairedgesturallanguageinschizophrenia.Thistakestheformofimpairedabilitytodemonstrateagesturefollowinginstruction,thesocalledpantomimeskillandadditionallyanimpairmentintheabilitytomimicdemonstratedgestures.Theseproblemsemphasizeimpairmentsinfundamentalgesturalcommunicatingskills(Waltheretal,2013).

Motor Disorders in Chronic Schizophrenia

Motordisorderinthementally illmaybeascribedtotheabnormalmentalstate,totreatmentortoindependentundiagnosedneurologicaldisease(Rogers,1985).Rogersstudiedmotordis-orders in 100 extremely chronic psychiatric in-patients, 59women and41men,with ameanlengthofcurrentadmissionof42.8years.Ninety-twoofthesepatientshadhadadiagnosisofschizophreniaatsometime,andallofthemshowedsomecurrentmotordisorder.

MotordisorderswerelistedunderthetencategoriesofTable18.1.Theseabnormalitieswereasfollows.

■ Difficulty with the initiation, efficient execution of or persistence with purposive motor activity,resultinginrestrictionofthemotorrepertoireavailable.

TABLE 18.1 ■ Percentage of patients with current motor disorder (n = 100)

Motor Disorder Percentage of Whole Group

Purposive movement 97

Speech production 95

Posture 86

Tone 85

Facial movements or postures 74

Head, trunk or limb movements 67

Activity 64

Stride or gait 48

Eye movements 48

Blinking 38

(From Rogers, 1985, with permission.)


■ Speech production,with22patientsusuallymute;25neverinitiatingspontaneousconversa-tion;53showing‘outbursts’of shouting, singingor talking;and51 inarticulateorbarelyaudibleatinterview.

■ Postureand■ tone,with a tendency toflexionassociatedwithvaryingdegreesof rigidity and typically

affectingtheheadorneck.■ Abnormal movementorposturesoforofacial muscles,withrapidorslowcontractionsofdif-

ferentmusclegroups.■ Abnormalmovementsof thehead, trunkor limbs,whichmightbebrief, jerkyandsemi-

purposiveinquality.■ Abnormal activitymightoccurinoutburstsorcontinuouslywithbehaviour,suchashitting

outatothers,stamping,touchingorfollowingotherpeople.■ Strideorgaitmightshowshuffling,slowness,notswingingthearms,orturningwithhead

andneck‘inonepiece’.■ Conjugatedeviationof theeyes,oftenupand laterallywithdeviationof thehead in the

samedirection.■ Blinkingmarkedlyincreasedordecreasedinrate,sometimesin‘bursts’.Ninety-eight of these100patientshadhadmotordisorder recordedprior to1955, before

therewasanytreatmentwithneurolepticdrugs.Therewasconsiderablevariabilitybetweenthetypeofmotordisorderrecordedbefore1955andobservedcurrently.Disorderofeyemovements,tone, gait and blinking were recorded less commonly in the past. Movement disorder in thisgroupofpatientswascomparedbetweenthosecurrentlyreceivingneurolepticdrugs;thosenottreatedforonemonth,oneyearorfiveyears;andthoseneverhavingreceivedmedication.Withthepossibleexceptionoffacialmovements,whichweremorefrequentinthosehavingreceivedtreatment in the past year, there was no difference in the frequency of abnormal movements.In addition to the description of abnormal movements above, overflow movements havebeendescribed.Thesearedefinedasinvoluntarymovementsthattendtoaccompanyvoluntarymovementsandarerecognizedasneurologicalsoftsignsandarethoughttobecharacteristicofschizophrenia(D’Agatietal,2012).

Motor Disorder in Brain Disease

The disturbance of basal ganglia resulting in parkinsonian symptoms has two main causes ofrelevancetopsychiatry:Parkinson’sdiseaseandsymptomssecondarytoexposuretopsychotropicdrugs.Someofthemotorsymptomsaresimilarinthesetwoconditions,buttheoverallclinicalpicturediffers.

Parkinson’s Disease. InParkinson’sdisease,aswellasmotorsymptoms,thereareoftensensory,autonomic and psychiatric abnormalities. Parkinson’s original description in 1817 implied anabsenceofperceptual(asopposedtosensory)abnormalityanddoesnotcommenton‘psychiatricstatus’,whichwouldthenhavebeenanunknownconcept.

Primaryorsecondarysensoryabnormalitiesmayoccur,andtheremaybeautonomicunder-or overactivity. However, the most conspicuous symptoms are in motor function: slowing ofemotional and voluntary movement (Walton, 1985); muscular rigidity; akinesia; tremor; anddisordersofgait,speechandposture.Thereisnotnecessarilyanymentalchange;however,depres-sion is very common (Mindham, 1970), intellectual deterioration may occur and personalitydisorderissometimesassociated.Psychoticepisodeshavealsobeendescribed.Agraphicdescrip-tion of the symptoms and subjective experience of parkinsonism is given in Sacks’ account,Awakenings(1973).

Extrapyramidal Side Effects of Antipsychotic Drugs. TheextrapyramidalmovementdisordersproducedbyantipsychoticdrugsaredescribedindetailbyMarsdenetal.(1986).Theseinclude


drug-induced parkinsonism with the classic parkinsonian triad of muscle rigidity, tremor andakinesia,andalsosuchsymptomsasabnormalitiesofgait,speech,andposture;excessivesaliva-tion; difficulty with swallowing; the characteristic facies; and greasy skin. Akinesia varies frombeingmild indegree(dyskinesia),withan immobile,blank,expressionless face; limitedmove-mentswithlossofsuchassociatedmotoractivityasthearmsswingingwhenwalking;andlackofspontaneity;tomoresevereandgeneralizedabsenceofmovement–thismaystartsoonafterbeginningantipsychoticmedication.Cogwheelrigidityand‘pillrolling’ofthefingers,tremorofthehandsorperiorbital tremormayoccurbutare lesscommonthanakinesia.ExtrapyramidalsideeffectsofantipsychoticdrugsarelistedinBox18.2(fromGervinandBarnes,2000).

Akathisia, motor restlessness, occurs frequently. There is a subjective experience of motorunease,withafeelingofbeingunabletositstill,aneedtogetupandmoveaboutandtostretchthe legs, tap the feet, rock thebody (Box18.3).Akathisiamayoccurat the same timeas theakinesiaofdrug-inducedparkinsonismandpresentsthecontrastingstateofasubjectiveurgetomoveandphysicalimpairmentofmovement.Inordertodistinguishakathisiafromothercausesofinnerrestlessness,restlessnessofthelegsshouldbefoundtobeespeciallyprominent.

Acute dystonic reactions include a variety of intermittent or sustained muscular spasms andabnormalpostures.Dystoniahasbeendefined as ‘a syndromedominatedby sustainedmusclecontractions,frequentlycausingtwistingandrepetitivemovements,orabnormalpostures’(Fahnetal.,1987).Theremaybeprotrusionofthetongue,grimacing,oculogyriccrises,blepharospasm,

BOX 18.2 ■ Extrapyramidal side effects of antipsychotic drugs

Acute movement disorders■ Parkinsonism■ Acuteakathisia■ Acutedystonia

Chronic movement disorders■ Tardivedystonia■ Chronicakathisia■ Tardivedyskinesia

(FromGervinandBarnes,2000,withpermission.)

BOX 18.3 ■ Subjective components of akathisia

Commonly experienced■ Senseofinnerrestlessness■ Mentalunease■ Unrestordysphoria■ Feelingunabletokeepstill■ Anirresistibleurgetomovethelegs■ Mountinginnertensionwhenrequiredtostandstill

Less commonly experienced■ Tensionanddiscomfortinthelimbs■ Paraesthesiaeandunpleasantpullingordrawingsensationsinthemusclesofthelegs

(FromGervinandBarnes,2000,withpermission.)


torticollis,opisthotonusandotherhyperkineticexaggeratedactionsof the face,head, trunkorlimbs.Owens(1990)hasconsideredthemajorclinicaltypesofdystoniatobeacutedystonias,oculogyricspasms,focaldystoniasincludingtorticollis,blepharospasm,writer’scrampandotheroccupationaldystonias,andlaryngopharyngealdystonia,segmentaldystonias,generalizeddysto-nia,drug-related(symptomatic)dystoniasandpsychogenicdystonia.

Thefrequencyofassociationofsocalledtardivedyskinesia,inwhichrepetitive,purposelessmovementsofthefacialmuscles,mouthandtongueoccur(sometimeswithchoreoathetoticlimbmovementandrespiratorygrunting)withexposuretopsychotropicdrugs isdisputed.There isnodoubtthatfaciobuccolinguomasticatorydyskinesiaoccursinmanychronic,especiallyelderly,psychoticpatientsonneurolepticmedication,butisitcausallyconnectedwithdrugs?Thewordtardive is used, as the syndrome was considered to be a late consequence of drug treatment;however, there are casesdescribed inpatientswhohavenever receivedneurolepticdrugs, andthepreciserelationshipremains tobeelucidated– itmaybesimplya latestageof the illness.In practice, the extrapyramidal symptoms secondary to medication are difficult to evaluateand measure by severity – problematic in accounting for aetiologically but important in thesatisfactorytreatmentofthepatient.Atathreeyearfollow-upofpsychiatricpatientsreceivingantipsychoticmedication,orofacialdyskinesiaincreasedfrom39percentto47percentofthesample,withafewindividualsdevelopingthedisorderanewandafewremitting(Barnesetal.,1983).Therewasanassociationbetweendyskinesiaandageover50yearsandthepresenceofakathisia,butnonewiththeuseofantipsychoticdrugs;infact,thoseonhighdosagewereunlikelytohavethecondition.ThesedyskinesicsymptomsalsooccurinHuntington’schoreaandinsenilechorea.

Huntington’s Chorea

This isahereditarycondition, inheritedasaMendeliandominant,whichmanifestsusually inearly middle life and is characterized by choreiform movements and dementia. Jerky, rapid,involuntarymovementsstart inthefaceandupperlimbs.Dysarthriaanddisordersofgaitcanalso occur before intellectual impairment develops. The progressive dementia, with inertiaand apathy, may be accompanied by irritability and occasional outbursts of excited behaviour.Occasionally,thedementiaoccursasthefirstsignoftheillness.

Variouspsychologicalabnormalitieshavebeendescribedintheprodromalstagebeforemani-festationofchoreaanddementia.Thesemaybeanxiety,reactivedepressionandthefeaturesofpersonality disorder, especially antisocial behaviour. It is not known if this is truly an earlysymptomof the illness or part of thepsychosocial reaction to this appalling anddoom-ladencondition.

Tics and Gilles De La Tourette’s Syndrome

Ticsarerapid,repetitive,coordinatedandstereotypedmovements,mostofwhichcanbemim-icked,andareusually reproduced faithfullyby the individual (Macleod,1987). InGillesde laTourette’s syndrome,multiple ticsareaccompaniedby forcedvocalizations thatoften take theformofobscenewordsorphrases–coprolalia(Lishman,1997).Theconditionstartsinchildhood,under the age of 16; there are multiple motor tics and unprovoked loud utterances that mayamounttoshoutedobscenities.

Theconditionismorecommoninboysthaningirlsandusuallystartsbetweentheagesoffiveandeightwithsimpletics.Thevocalizationsusuallybeginasunrecognizablesoundsbutmayprogressto‘four-letter’swearwords.Bothticsandutterancesarelikelytooccurwithemotionalstress.Thesubjectoftentriesdesperatelyhardnottovocalizetheword,andthismaybeaccom-panied by considerable anxiety. An interesting study compared adult sufferers with depressedadults and normal controls on measures of obsessionality, depression and anxiety (Robertsonetal.,1993).GillesdelaTourette’ssyndromesufferersscoredashighasdepressivesonmeasures


ofobsessionalitybutwereintermediatebetweenthemandnormalsubjectsforbothdepressionandanxiety.

DISTURBANCE OF BEHAVIOUR

There is no clear demarcation between disturbance of movement and of behaviour, and thedistinctionmadehereisarbitrary.Thuswithparkinsonism,andtoanevengreaterextentcatatonicschizophrenia,an individualabnormalmovementmaybeelaborated intoanabnormalpatternofbehaviour.

Behavioural Disorders of Schizophrenia

Disorderofmovementischaracteristicofcatatonia,inwhichthepatientmaybecomeimmobi-lizedinoneattitudebecauseofincreasedmuscletoneatrest;itisusuallyseeninschizophreniabuthasbeendescribedwithfrontallobetumourandsomeotherorganicconditions.Thereareabnormalitiesofpostureandofmovement,frequentlyshownintheactionsmadeinrelationtoanotherperson–theinterviewer.Thus,inwaxy flexibilitythepostureofthelimbsissodescribedbecauseitismaintainedindefinitelyafterbeingmanipulatedintothatattitudebytheobserver.Behaviour,thecompositeofmovements,mayalsobeabnormal,andthisischaracteristicofcata-tonic schizophrenia,withmore than justone isolatedabnormalityofposture. Ithasoftenbeencommented that the incidence of catatonic schizophrenia has markedly declined. However,Mahendra(1981)hasqueriedtheexistenceofcatatonicschizophreniaasaconditionwithclassicKraepelinianschizophrenicfeaturesandcatatoniainthesamepatient.Hebelievesmanyofthepatients with catatonia suffered from neurological disease, perhaps postencephalitis, followingepidemicandendemicviralinfections.Ifthiswereso,thepresumedassociationbetweenschizo-phreniaandcatatoniawasaccidental.

Onecouldmakeavastcatalogueofthebizarre,andsometimesunpleasant,behaviourdem-onstratedbypatientswith chronic schizophrenia,but thiswouldneverbe exhaustive.Certaintypesofbehaviourpatternaredescribedherewithexamples.Schizophrenicstuporoccurs,althoughrarely.Thepatientismuteandakinetic,althoughfromthealertnessoftheeyesandtheoccasionalexcursion into abrupt activity or speech he is clearly conscious. It can be distinguished fromdepressiveormanicstuporbytheobviousabnormalitiesofmoodinthestuporoftheaffectivepsychoses.Apatientwithschizophreniasatmuteandmotionlesswithherarmsheldinstereo-typed, twistedposture forhoursata time.This symptomisalmostneverseennowadayswithadequatetreatmentofschizophrenicsymptoms.

Negativism, as described above under motor disorders, may influence the behaviour of thepatientsubstantially.Aschizophrenicpatientwasinterviewedinprison.Hewasbroughttothedoorofthedoctor’sexaminationroom.Whenthedoctorinvitedhimtoenter,hetooktwostepsbackwards.Togethimtoenter,thedoctorhadtoaskhimtogoaway.Whenthedoctorputhishandouttoshakehands,thepatientputhishandbehindhisbackandreversedbehindthedesk.Hewouldnotsitdownuntilhewaspolitelyaskedtoremainstanding.

Excitementmayoccurassociatedwithcatatoniabutcanalsobeseenwithoutthisstate;some-times,apatient ismuteandmotionless fora timeand thenunpredictablybecomesoveractiveandaimlesslydestructive.Achronicschizophrenicpatient,normallycalm,wouldsuddenlyandunaccountablyrushheadlongacrossthewardandchargeheadfirstintothewall.Onoccasionthisbehaviourwasdirectedatawindow,andhehadcuthimselfseverelyontheglassinthepast.

Impulsive behaviour may not always be manifested as excitement; it may be carried out incontradistinctiontothepatient’shabitualbehaviour.Anormallyrespectableandtranquilelderlyfemale patient would suddenly and unpredictably make sexual assaults on unsuspecting malevisitorstothehospital.


Hoarding is a common feature in chronic schizophrenics and is not confined to those ininstitutions.Apatientusedtoputinsectsandpiecesofrubbishfoundaroundthehospital,suchascigaretteendsandsmallpiecesofstring,intoasmalltin.Shedidnotappeartouseherassort-mentbutwasconstantlycollectingmoreitems.

Water intoxicationduetogrosslyexcessivewaterdrinkinghasbeendescribedinschizophrenia,althoughitmayoccur,butmuchlesscommonly,inalmostanypsychiatricdisorder(Ferrier,1985).The symptom ispotentiallydangerous (Singhet al.,1985)andcaneven result indeath fromhyponatraemia,oftenassociatedwithconvulsions.Thewaterdrinkingmaybeexplainedbythepatientintermsofdelusions,ortheremaybeafailureofthenormalthirst-fluidintakehomeo-staticmechanism,orboth.

Theremaybe mannerisms and idiosyncrasies of behaviour aswell as of singlemovements.One totallymutemale chronicpatientused to retire to the topof a remote staircase above award,whereheingeniouslyanddelicatelycutkeysthatwouldopenanydoorinthehospital.Hewouldexchangetheseforcigaretteswithotherpatients,despiteremainingutterlysilent.

Grossself-neglecthasbeendescribed,especiallyamongelderlyreclusiveswhohavesometimesbeenwelleducated,intelligentandwealthy.Thissyndromehas,ratherunfortunately,beencalledtheDiogenessyndromeaftertheGreekphilosopherwhorejectedsocialnormsandworldlyluxu-ries(Clarketal.,1975).AnearlycasewasdescribedbyDanielHackTuke(1874)ofaricholdman,‘madLucas’,whodiedinafilthystate,half-nakedandaloneinhisdecayingmansion.Heremainedasahermitfor25years,continuallyterrifiedthathisyoungerbrotherwouldseizehishouseandkillhim.Heandsimilarreclusesusuallysufferfromaparanoidschizophrenicillness,althoughthetermDiogenessyndromeitselfispurelydescriptive(Aquilina,1992).

Multitudinousotherformsofabnormalbehaviouraremanifestedinschizophrenia.Flagrantstealingoccurs,sometimeswithamanneristicflavour,suchasthehospitalin-patientwho‘stole’bedsprings, much to the discomfort of the occupants. Unprovoked aggression and ‘nastiness’sometimes occur. Patients may exhibit childish naughtiness or grotesque dirtiness, and self-immolationandsuicidehaveoccasionallyoccurred.Thismaytakeplaceinobediencetoauditoryhallucinationsoraspartofadelusion.Onepatientregularlyheardavoicethatinstructedhimtojumpoutofthewindow;hewaspreventedonmanyoccasionsbutfinallytookthereinforcedwindowframeswithhiminleapingtohisdeath.

Behavioural Signs of Emotional Disturbance

Psychiatristshave learnedthattheymust listen totheirpatients; it isalso importanttoobservethem and form useful, testable hypotheses from these observations. Internal medicine has,traditionally,madegreatdiagnosticuseofphysicalsigns,andpsychiatryalsowoulddowell touse behavioural signs as possible indicators, not positive proof, of psychological disturbance.Trethowan (1977) has noted, in addition to the evidence for catatonia and parkinsonism, thefollowingbehavioural,asopposedtoneurological,signs,whichmaybeofvaluediagnosticallyinpsychiatry.

■ The handshakemaybelimpandlifeless,asintheasthenicadolescentorsuffererfromsimpleschizophrenia,orvice-likeinmania.Thehandoftheschizophrenicpatientwithnegativismmaybewithdrawnwhentheintervieweroffershis,orthemanicorpersonalitydisorderedpatientmayinsistonshakinghands,contrarytothedoctor’sintention.

■ Other forms of hand behaviourthatmaybesignificantincludebittenorpickednails,clenchedhandswithblanchedknucklesandrestlessfidgetingwiththefingers;allthesemayindicateacuteorchronicanxiety.Heavilycigarette-stainedfingersobviouslyreflectthelargenumberofcigarettessmokedandtheextenttowhicheachcigaretteisconsumed;thismaydem-onstrate a degree of tension.Tremor may reveal alcoholism with alcohol withdrawal. In‘Trethowan’sweddingringsign’,awomanduringhistorytakingunconsciouslyrevealshermaritaldifficultiesbyconstantlyslidingherweddingringonandoffherfinger.


■ The feetmaybeusedforrestlesspacinginagitateddepression.Akathisia,asdescribedonp. 308, with an inability to keep the feet still, may indicate excessive medication withphenothiazinedrugs.

■ Depressive facies and posture sometimes lead to diagnosis before the patient speaks.Thepatientmaybe slumped in thechairwithafixedexpressionofunmitigatedgriefonhisfaceandaprominent‘crow’sfoot’betweentheeyebrows.Trethowan(1977)hascommentedonthegreatlyreducedblinkratewithseverelyretardeddepressives.

■ Clothinginmaniamaybedistinctiveandsuggestiveofboththediagnosisandthehyper-eroticism that sometimes accompanies it. Hair, make-up and dress may be unequivocaldemonstrationsofmanicmood:‘ThusStella,normallyafairlymodestgirl,appearedonedayinmyconsultingroomwearinganallblackoutfitconsistingofnetstockings,amini-skirtwhichextendedbarelytovulvalevel,andatopwithsodeepacleavageasalmosttoexposeherumbilicus.Asifthiswerenotenoughshehadstuffedherred,whiteandbluejubileepantiesintothetopofheropenhandbag,foralltosee’(Trethowan,1977).

■ Stroking the cheekmaybeanindicatorofemotionaldistress,asdescribedbyGillett(1986):‘During the initialhistory takingandassessment, therewasoneover-ridingly importantemotiveissue,asevidentfromobservationofherbodylanguagesigns.Whenshespokeofher son dying at the age of three, her body stiffened, the muscle tension in her faceincreased,asiftryingtostifleexpression,lacrimationincreased(thoughonlyjustpercep-tibly),andhervoice rose inpitchandwavered.She then lightly strokedher rightcheekwiththetipofherfore-finger,asifwipingawayanimaginarytear–acommonsignwhichusuallyindicatesadesiretocryatthesametimeasawishnottoshowit’.

This list is far fromexhaustive.Thepoint is thatcliniciansshoulduse theireyesandtheirpreviousclinicalexperiencetoformhypothesesinobservationthattheycansubsequentlytestinthehistoryorexaminationofmentalstate.

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S E C T I O N SIXVariations of Human Nature

317

C H A P T E R 19

The Expression of Disordered Personality

SummaryPersonalityistheuniquewaythatanindividualexpresseshimself.Itincludeshischaracteristicgait,hismodeofexperiencingtheworldandreactingtoit.Histypicalaffectiveresponses,hisconductandmoralattitude,whatvaluesguidehimandwhathedoes,whathecreatesandhowheacts.Abnormalitiesofpersonalityontheotherhandareenduringpatternsofexperienceandbehavioraffectingcognition,affect,interpersonalfunctioning,andimpulsecontrolthatareinflex-ible,pervasive,and lead toclinically significant impairment. It is important toemphasise thatthe types of abnormal personality currently described are at most tentative and inconclusiveattemptstorenderinwordscomplexaspectsofhumanfunctioning.Thecategorieshaveclinicalutilitybutareproblematicformanyreasonsincludinglackofreliability,validityandinstabilityovertime.

But the impressions and actions of human beings are not solely the result of their present circumstances, but the joint result of those circumstances and of the characters of the individuals: and the agencies which determine human

character are so numerous, (nothing which has happened to the person throughout life being without its portion of influence), that in the aggregate they are never in any two cases exactly similar. Hence, even if our science of

human nature were theoretically perfect, that is, if we could calculate any character as we can calculate the orbit of any planet, from given data; still, as

the data are never all given, nor even precisely alike in different cases, we could neither make positive predictions, nor lay down universal propositions.

John Stuart Mill (1811)

MillinaSystem of Logicasquotedabovestatessuccinctlythedifficultyofformingatheoryofpersonality that is useful in clinical practice in predicting behaviour. Nonetheless, theories ofpersonalityabound.Jaspers’(1913)definitionofpersonalityisasgoodaplacetostartasanyotherdefinition

‘We see the personality in the particular way an individual expresses himself, in the way he moves, how he experiences and reacts to situations, how he

loves, grows jealous, how he conducts his life in general, what needs he has, what are his longings and aims, what are his ideals and how he shapes them,

what values guide him and what he does, what he creates and how he acts. In short, personality is the term we to the individually differing and

characteristic totality of meaningful connections in any one psychic life’

Keywords:Personality,PersonalityDisorder,ParanoidPersonalityDisorder,SchizoidPersonalityDisorder,DissocialPersonalityDisorder,EmotionallyUnstablePersonalityDisorder,HistrionicPersonalityDisorder,AnakasticPersonalityDisorder,Anxious(Avoidant)PersonalityDisorder,DependentPersonalityDisorder.

19—THE ExPRESSION OF DISORDERED PERSONAlITy 317.e1

318 SIX—VARIATIONS OF HUMAN NATURE

Thereisanimplicitbuterroneousnotionthatadescriptionofpersonalitysomehowcapturesallthatthereistosayaboutaperson.Reflectionmakesobviousthatitisimpossibletodescribethetotalityofanyhumanbeinginasingle,simpleterm.Furthermore,asJaspersremarked‘Thepersonalityasunderstoodisnotwhatanindividualactuallyisbutanempiricalandinconclusivephenomenon’ that is limited in itsscopepreciselybecausehumanbeingsare freetoact intheworld and ‘at any moment freedom can have birth and give everything a different meaning’.Descriptions of personality, in other words, are tentative and fragile.The individual’s life andchoicesarenotfixedandpre-determinedbyanydescriptionthatwemayhave.Everyindividualhasaninfiniterealityandpotential.Ourfeebleattemptsatdescriptionaremainlytomakecom-municationbetweenpractitionersefficient.

Attemptsatclassifyingpersonalityfallintotwomaincategories:nomotheticandidiographic.The nomothetic approach assumes that human beings only vary to the degree in which theyshare certain traits or personality dimensions. On the other hand, the idiographic approachassumesthathumanbeingsareuniqueindividualsandthetheoriesherepointtothecharacter-isticsthatmakeindividualsuniqueanddistinctive.Sadly,thereisagulfbetweenpsychologicalpersonalitytheoriessuchasthatbyfiguressuchasGordonAllport(1897–1967),HansEysenck(1916–1997),andRaymondCattell(1905–1998)andtheapproachthatisfavouredbypsychia-tristswhichdealspredominantlywithabnormalitiesofpersonality.

Thetermpersonality disorderisanabstractionbuiltonseveraltenuoustheories.Itisanuntidyconcept,butitcarriesclinicalusefulness.Thewayinwhichthetermhasbeendevelopedanditsrelationship with neurosis is dealt with elsewhere (Sims, 1983).The intention here is only todiscusstheeffectsthatdifferenttypesofpersonalityhaveonactionsandbehaviour.Theclinicianbuildsonaprofileforpersonalitydisorder.Thisleadstoacharacteristicpatternofbehaviourthatallowsus,tosomeextent,topredicthisfutureactionsandtodescribewhatmakesthisindividualdifferent.Theclinicaldesignationofpersonalityispurelydescriptiveandcarriesnotheoreticalimplications,otherwisethereisalogicalflawindescribingpersonalitytypeintermsofconsistentbehaviour and at the same time claiming the type accounts fordefinitepatterns of behaviour.Acuteanddetailedobservationofthecharacteristicsofpersonalityanditsevaluationisausefulpsychiatricskillthathas,regrettably,beenmuchneglectedformanyyears.

Thesecharacteristicsofbehaviour,includingthecapacityforandnatureofrelationshipswithotherpeople,arebroughttogethertodescribetraitsorpersonality types;obviously,tobeclinicallyrelevantthesetraitsmusthaveimplicationsforthefunctioningoftheindividual.Thedistinctionbetweentrait,thepredispositionassociatedwithpersonality,andstate,thecurrentmentalcondi-tion,isveryimportant.Theseclassificationsofpersonalitydisorder,basedonsuchlistsoftraits,werecategorizedbySchneider(1923)andmorerecentlyinICD-10(WorldHealthOrganization,1992) and in DSM-V (American Psychiatric Association, 2013). Certain characteristics haveclinicalsignificance,suchasthedegreetowhichthepersonisawareofthefeelings,andissensi-tivetothejudgements,ofotherpeople.Abnormalpersonalityisfoundwhenapersonalitytraitconsidered to be clinically significant is present to either too small or too great an extent toconform statistically with the mass of mankind.The concepts of personality and personalitydisorder were discussed by Tantam (1988), and more recently personality disorder has beenreviewedbyTyrerandStein (1993).Thereareconsiderableproblemswith thedescriptionsoftypesofpersonalitydisorders.Themostsignificantarethelackofspecificityinthedefinitionsofpersonalitydisorders,theexcessivecomorbidityamongpersonalitydisorders,thequestionablevalidityoftheidentifiedcategoriesandtheinstabilityofthesediagnostictermsovertime(Skodol,2012). Furthermore, it is recognized that part of the problem with the current classificationsystemistheunsatisfactorynatureofpersonalitytypologiesandtheneedforanintegrationofdimensional thinking into how personality and personality disorder are conceptualized. Thisdevelopmentinthinkingaboutpersonalitydisordersisalsodrawingattentiontotheneedtobasediscussions about personality disorder on what is understood about normal personality traits.

19—THE ExPRESSION OF DISORDERED PERSONAlITy 319

ThishasledtoanevaluationoftheFive-Factormodelofpersonalityasapotentialfoundationforatheoryofabnormalpersonality(Widigeretal.,2012).TheFive-Factormodelofpersonalityincludesneuroticism,extraversion,openness,agreeablenessandconscientiousnessastherelevantfactors.Thehopeisthatanintegrationofnormalandabnormalpersonalitywithinacommonhierarchicalstructurewouldallowforamorepreciseandindividualizeddescriptionofperson-ality structure for each individual (Widiger etal., 2012) but this hope is not widely shared(Paris,2013).

Abnormality of personality has been described in terms of trait. What then is personality disorder?HereSchneider’sdefinitionisagoodstartingpoint:‘Personalitydisorderispresentwhenthat abnormality of personality causes either the patient himself or other people to suffer’(Schneider,1958).Alternatively,fromDSM-IV(APA,1994):‘Anenduringpatternofexperienceandbehaviouraffectingcognition,affect, interpersonalfunctioningandimpulsecontrolthatisinflexible,pervasiveandleadstoclinicallysignificantimpairment’.

■ AhighlyconscientiousandmeticulousPostOfficesorterwaspromotedtoforemansorteraftermanyyears’reliableservice.Theappropriateresponsemighthavebeentobepleasedattheincreasedpayandtospendthefirstweek’sincrementbeforereceivingit.However,thismanwasfearfulaboutthepromotion.Heworriedthathemightnotbeabletocopewiththejob,thathemightnotbeabletopersuadethemeninhischargetosortletterstohisownhighstandards,thathewouldnotbeabletomixsociallywithhissuperiorsandequals, thathewouldmakea foolofhimselfandthatotherpeoplewould laughathim.Hebecamemiserable,anxiousandlackingconfidence,andhehadtostopwork.Becauseofhisabnormal,obsessional(anankastic)personality,herespondedtothestressofpromo-tionbybecomingacutelydistressedanddevelopingneuroticdepressivesymptoms.

■ Ablandandplausible confidence trickster extractedwithout compunction themeansofsubsistencefromanelderlywidow.Hispsychopathicbluntingofappreciationforthewayotherswouldexperiencehisbehaviourandtheirconsequentfeelingsresultedinhimcausingsufferingtoothers.

Personalityabnormalityisapartoftheindividual’sconstitution.Whetherornotitmanifestsaspersonalitydisorderdependstoaconsiderableextentonsocialcircumstances.Ahighlyabnor-malpersonalitythatinonesituationmaybeconsideredcriminalpsychopathyandbepossessedbyaconvictedprisoner,inanothersituationwillbethedrivingforceinahighlysuccessfulandrelativelycreativepoliticalrevolutionary.Personalityinanindividualcannotbedivorcedfromitssocialandculturalsetting.Indeed,somehavearguedthatthepersonalitydisorderconstructsthatwecurrentlyutilizearederivedfromandcalibratedagainstWesternmiddle-classculturalnorms(Mulder,2012).

Having ascertained whether personality disorder is present, its type should be categorizedusinganacceptedsystem.However,acautionisneededhere.Itisoftenextremelydifficulttofitpeopleintoarbitrarycategoriesofpersonality,andthewholetopicofclassificationisstillhighlyunsatisfactory.Itmaybemuchbettertouseafewdescriptivesentencesforthepersonality,andprobablyitisbesttocombinedescriptionwithcategorization.ThesystemsusedinICD-10andDSM-V canbe recommended; the typological classificationofpersonalitydisorder introducedbyTyrerandAlexander(1979)wasalsosatisfactorybuthasnotbeenwidelyused.Table19.1isacompositeoftheseclassifications.Theyallstartfromthesamebases:thedefinitionofpersonal-ity,theevaluationofabnormalityandtheobservationofcertaininfluentialandregularlyoccurringtraits.Tyrer and Alexander’s five discrete categories of abnormal personality followed from acluster analysis of personality data and is therefore a simplification of ICD-9 (World HealthOrganization,1977),whichitselfwasbasedoriginallyonSchneider.DSM-IVandDSM-VhavecertaindifferenttermsthathaveprovedimportantinAmericanpsychiatry,althoughtheyarenotnecessarilyfoundhelpfulelsewhere.Theseincludenarcissisticpersonalitydisorder,whichisdis-cussedlaterinthischapter;avoidant,whichissimilartoanxiouspersonalitydisorderinICD-10;


andschizotypalpersonalitydisorder,whichICD-10classifieswithschizophrenia, schizotypicalanddelusional disorders(F2).

ThefollowingdescriptionsarebasedonthecategorizationfoundinICD-10.Itisimportantto realize that these categories are not mutually exclusive: mixed personality types are morefrequent than a single personality type in pure form. Readers in the United Kingdom or incountries influencedbyBritishpsychiatry shouldbe awareof anongoing sourceof confusionperpetuatedbyrecentdiscussionof the legalandadministrativeaspectsconcerning‘dangerouspeople with severe personality disorder’ (Haddock etal., 2001; Mullen, 1999). In descriptivepsychopathology,thisdebateisalmostentirelyconcernedwithdissocialpersonalitydisorder,butthosetakingpartinthediscussiontendtoignoreotherpersonalitytypes,thuscausingconfusionfortheassessmentandclassificationofthosewithotherpersonalitydisorderssuchasanankasticor anxious avoidantpersonalitydisorder.This can result in inappropriate treatmentor lackoftreatment being administered by mental health professionals and unjustifiable stigmatizationbeingexperiencedbythesufferers.

Paranoid Personality DisorderTheessentialfeatureofthistypeofpersonalitydisorderisself-reference,theproperpsychiatricsenseofthewordparanoid;suchpeoplemisinterpretthewordsandactionsofothersashavingspecialsignificancefor,andbeingdirectedagainst,themselves.Theoretically,self-referentideascouldimplythatothersarealwaysnoticingtheminanadmiringandbenevolentway;inpractice,suchpeoplewouldnot consult apsychiatrist and thosepresenting inpsychiatryhave ideasofpersecution.They mistrust other people and are very sensitive and suspicious, believing thatothersareagainstthemandthatwhattheysayaboutthemisderogatory.Thereareactiveandpassive typesofparanoidpersonalitydisorder;both types feel thatothersare‘gettingat them’buttheirresponsediffers.

Theactiveparanoidpersonalitymanifestssuspiciousnessandishostileanduntrusting.Sucha person is quarrelsome, litigious, quick to take offence, intensely suspicious and sometimesviolent;hewillgotoenormouslengthstodefendhisrightsortoaddressrealorimaginedinjus-tices.Heisextremelyvigilantandtenaciousintakingprecautionsagainstanyperceivedthreat.

TABLE 19.1 ■ Comparison of personality types

Tyrer and Alexander (1979)a ICD-10b DSM-IVc

F60.0 Paranoid ParanoidSchizoid F60.1 Schizoid SchizoidSociopathic Schizotypal

F60.2 Dissocial AntisocialF60.3 Emotionally unstable .30 Impulsive .31 Borderline BorderlineF60.4 Histrionic Histrionic

Anankastic F60.5 Anankastic Obsessive-compulsiveDysthymic F60.6 Anxious AvoidantPassive dependent F60.7 Dependent Dependent

F60.8 ‘Other’ Narcissistic

aTyrer and Alexander (1979).bWorld Health Organization (1992).cAmerican Psychiatric Association (1994).


Thisisthesortofpersonwhowillmarchfearlesslyacrossafieldofyoungcornbecauseheseesthereisapublicrightofwayonhismapandthefarmerhasnorighttoviolatethis.Theyrepudi-ateblameandmayberegardedbyothersasdevious,schemingandsecretive.Suchapersonisintenselyjealousofwhatheregardsashisownbelongings,whichmaybepeopleaswellasobjects,andhespendsalotoftimeplanningto‘gethisownback’.Hemaybeself-importantandfanati-cal.Morbidjealousymaybeshown,andsuchapersonmaybeinvolvedinactsofviolencebecauseofimaginedinjustice.Suchapersonalitymayfindcreativeexpressioninsocialandpoliticallifebut is likely tobeverydestructivewithin the family.Apatientcommentedon this ruefully, ‘Ihavescarcely talked tomywife for the last tenyears’,becauseofhis successionofcourtcasesagainstthosewithwhomhecameintocontact.

Apersonwithpassiveparanoidpersonalityfacestheworldfromapositionofsubmissionandhumiliation.Heassumesthatwhateverhappenstohimwillbedamaging.Liketheactivetype,heissuspicious,sensitiveandself-referentandmisconstruescircumstancesandotherpeople.Hebelievesthatotherpeoplewilldislikehimandthattheywillultimatelylethimdown.However,heaccepts‘theslingsandarrowsofoutrageousfortune’passively,bowingtotheinevitable;heisvulnerable and frequently feels humiliated and unable to initiate any assertive activity. Otherpeopletendtotakeadvantageofhim,thusfulfillinghispessimisticexpectations.

A frequentmanifestationofpsychopathologywithin thecontextofparanoidpersonality isthepresenceofanovervaluedidea(Chapter8).This,alternativelydescribedasafixedidea(idéefixe),isabeliefthatmightseemreasonablebothtothepatientandtootherpeople.However,itcomestocompletelydominatetheperson’sthinkingandlife,andinsteadoftestingitsvalidityhetendstoconsiderthateverycircumstanceoflifesubstantiatesit;itbecomesthebasisforactionthatissometimesaggressiveorself-destructive.Itisquitedistinctphenomenologicallyfrombothdelusionandobsessional ideas.

Schizoid Personality DisorderThispersonalitydisorder is characterizedby a lackofneed for, anddefect in, the capacity toformsocialrelationships.Suchpeopleshowwithdrawalfromsocialinvolvement;emotionalcool-nessanddetachment;andindifferencetothepraise,criticismandfeelingsofotherpeople.

Theseindividualsare‘loners’withadisinclinationtomix,andtheyappearsomewhataloof.Theylacktenderfeelings,havelittleinterestinsexualexperienceandarenotinterestedinthecompanyofothers.Theyarenotdepressedinmood,noraretheyshyorsensitivetowardsotherpeople,buttheyaresolitaryandprefernottobeinvolvedinsocialoccupations.Theirinterestsandhobbiesusuallytendtoincreasetheirisolationfromotherpeople,astheyaremoreinterestedinthings,objectsandmachines.

Close relativesmaycomplainof the subject’semotionaldetachment,an inability to inspirestrongfeelingsinothers,alackofanyrealsenseofpleasure,oddnessandeccentricityandcallousindifferencetoothers’suffering.Inafollow-upofformerschizoidsubjects,theywerefoundtousepsychologicalconstructslessthanacontrolgroup,andthispointedtotheschizoidindividual’slackofempathy(Chicketal.,1979).

Thosewithschizoidpersonalityandpoorsocialadjustmenthavebeenconsideredmorelikelytodevelopschizophrenia.Inalargestudybasedonthepreviouspersonalityassessmentof50,054malerecruits to theSwedisharmy,aspectsofpersonalitywere foundtoberisk factors for thesubsequentdevelopmentofschizophrenia(Malmbergetal.,1998).

Dissocial Personality DisorderThe essential, phenomenological abnormality of dissocial (asocial, antisocial or psychopathic)personalitydisorderisprimarilyoneofempathy.Thereisadefectinthecapacitytoappreciate


otherpeople’sfeelings,especiallyincomprehendinghowotherpeoplefeelabouttheconsequencesofthisperson’sownactions.Thispersonalitytype,orabnormality,includesthosepeopleconsid-eredtosufferfrompsychopathicpersonalitywithinthemeaningoftheMentalHealthAct,1983(Bluglass,1983).Anormalpersonispreventedmostofthetime,byshameorbyhiscapacityforempathy, fromcarryingoutunpleasant actions towardsotherpeople.Hedoesnotwant tobedislikedandfeelsverykeenlyhowitwouldbepassivelytobetherecipientofsuchbehaviour.Itisthisinabilitytofeelforhimselfthediscomfortthatothersexperienceasaresultofhisantisocialactivitiesthatappearstobeabsentinthepsychopath.DespitesuchcomprehensivedescriptionsasthatofCleckley(1941),inThe Mask of Sanity,andothers,therearestillconsiderabledoubtsas towhether thispersonality type formsadistinct categoryornot, and if itdoes,whether itshouldbeconsideredwithinoroutsidepsychiatry.ThisissuccinctlyexpressedbyWooton(1959):psychopathsare‘extremelyselfishpersonsandnooneknowswhatmakesthemso’.

Theconfusionofterminologyisexplainedpartlybythevariednatureofpresentation;partlybytheconflictingdesiresofprofessionalsnottostigmatizeandalsonottocastblameonthosewhocannotcontrol theiractions;andpartlyby the requirementsofclassification fordifferentprofessionalgroupsandsettings–lawyers,criminologists,psychiatrists,psychologistsandsoon.Acomprehensiveaccountofdiagnosticissues,developmentalhistoryandmethodsoftreatmentistobefoundinDolanandCoid(1993).

Theconceptofmoral derangementwas introducedbyBenjaminRush (1812), andofmoral insanitybyPrichard(1835),whoconsideredthistooccuramongcriminalswhoshowedlossoffeeling,ofcontrol,andofethicalsense,equivalenttomentaldiseasebutatadifferentlevel.Itisimportant to stress that not all psychopaths are criminal, nor are all criminals psychopathic.Henderson (1939)described creative, inadequate andaggressive psychopathy, citingLawrenceofArabiaasanexampleofacreativepsychopath.Dissocialpersonalitydisorder,withconspicuouslackofconscienceandhumansympathy,isfoundmoreofteninmalesthaninfemales.

Thispersonalitydisorder shouldnotbediagnosedunless the subject isagedover18years.However, inchildhoodoradolescencemanyof the followingmayhavebeendemonstratedbythepersonsubsequentlydiagnosedasdissocial:truancy,expulsionorsuspensionfromschoolformisbehaviour, delinquency, running away from home, persistent lying, repeated casual sexualintercourse,repeateddrunkenness,substanceabuse,theft,vandalism,schoolperformancebelowexpectation,repeatedviolationofrulesathomeandschoolandfighting.Ofcourse,suchbehav-iourmayoccurinnormalchildren,especiallywithsocialdeprivation,butitistheirpersistenceandthepresenceofsomanyofthesesignsofdisturbedbehaviourthatmaypredictsubsequentpsychopathy.There isalsodebateconcerningthemanifestationofattentiondeficitdisorder inchildhoodandsubsequentantisocialbehaviourinyoungadultlife(Hinshaw,1994).

Suchapersonmaybemeaninglesslycruel,callous,aggressiveandemotionallycold,rejectingsocialnormsand showing irresponsibility inhis relationships.He isoftenunable tomaintainconsistencyatwork,withfrequentunemployment,changesofoccupation,absenteeismandpoorrelationships.Similarly,thereareunsatisfactoryrelationshipswithsexualpartners,withahistoryof several separations or divorces, promiscuity with heterosexual or homosexual preferences,desertion and repeated marital arguments. Poor parenting results in conspicuous physical andpsychologicalproblemsamonghischildren,andtheindividual’saggressivenessmayresultinchildabusewithnon-accidentalinjury.Asheages,heislesslikelytobeinconflictwiththelawandlesslikelytobeviolent,buthisaffectionlessinabilitytoseetheconsequencesofhisactionsandthewayotherpeoplesufferbecauseofthem,remainsdestructivewithinthefamilyandinotherinstitutions.There is a failure to accept society’snormsas regards socialbehaviour,drugs andalcoholandpersonalproperty.Alengthycriminalrecordisfrequentlyseen,ashefailstolearnfromhis experiences (Craft, 1966).Suchapersonmay feelmiserable andeven suicidalwhendiscoveredinanunacceptableact,butthisdoesnotamounttothenormalsenseoffeelingguilt.Thereisafailuretoidentifywiththevictim.


ThedefinitionofpsychopathyproposedbyWhiteley(1975)isasfollows:thepsychopathisanindividual:

1. whopersistentlybehavesinawaythatisnotinaccordwiththeacceptedsocialnormsofthecultureortimesinwhichhelives;

2. whoappearstobeunawarethathisbehaviourisseriouslyatfault;and3. whoseabnormalitycannotbereadilyexplainedasresultingfromthe‘madness’wecom-

monlyrecognizenorfrom‘badness’alone.Failuretoplanaheadandfailuretohonourobligations,forexamplematrimonialorfinancial

commitments,arerepeated.Thereisadisregardfortruthandalsoforsafety,bothfortheindi-vidualhimselfandforothers.

Emotionally Unstable Personality DisorderIMPULSIVE TYPE

Thispersonalitydisorderisnotoftenencountered.Theessentialfeatureisliabilitytointemperateanduncontrolledoutburstsofmood,mostfrequentlyviolentangerbutoccasionallyinconsolablegrief,extremeanxietyoruproarioushilarity. It isusuallyaggressiveness thatbrings individualswiththisdisordertotheattentionofthepsychiatrist;withveryslightprovocation,theymayhavebecomeirritableandonoccasionsviolent.Theyaretreatedwithextremecircumspectionbyotherpeople,and their illhumour thereforebecomes reinforcedas itenables themtoget theirownway.Theymayexploitotherpeople’sfearsofthemtoachievetheirobjectives,forexamplethearbitrarilyviolenthusbandwhosewifeiscompletelydominatedbyhimthroughfear.Suchper-sonalitiesaredisruptiveandunpopular.

Thosewiththispersonalitystructurebehavenormallyformostofthetimeandonlyoccasion-allyexplodeinimpulsiveirritability,whichismorecommoninyoungerpeopleandmayappearineithersex(SnaithandTaylor,1985).InthesystemofclassificationadvocatedbyTyrerandAlexander,thispersonalitytypeisnotretainedasdistinctbutcombinedwithparanoidandasocialpersonalitytoformacategoryofsociopathic personality disorder.

BORDERLINE TYPE

This very confuseddiagnostic termhasbeenusedvariously todescribe agroupof apparentlyneuroticallydisturbedpatientswhobecamepsychoticwhileundergoingpsychoanalysis;anendur-ing, unstable and vulnerable personality structure; and a group of patients who ‘almost’ hadschizophrenia(Anonymous,1986).Itisconsideredthatatleastfiveofthefollowingshouldbepresentforthediagnosistobemade(DSM-V;AmericanPsychiatricAssociation,2013):

■ franticeffortstoavoidrealorimaginedabandonment■ apatternofunstableandintenseinterpersonalrelationships■ identitydisturbanceinareassuchasself-image,genderidentityorlong-termgoals■ impulsivityorunpredictabilityinareasthatarepotentiallyself-damaging■ recurrentsuicidalbehaviour,gesturesorthreatsorself-mutilatingbehaviour■ affectiveinstabilityduetoamarkedreactivityofmood■ chronicfeelingsofemptiness■ inappropriateintenseangerordifficultyincontrollinganger■ transient,stress-relatedparanoidideationorseveredissociativesymptoms.Althoughpsychodynamicallyinclinedpsychiatristshaveusedthiscategoryextensively,there

appearstobenophenomenologicalthreadlinkingtheverydifferentcriteriathatarerequiredforits diagnosis. Carrasco and Lecic-Tosevski (2000) have described it as the most controversialof all personality disorders and ‘best understood as a heterogeneous syndrome manifested by


egosyntonic affective instability and impulsivity (behavioural dys-control) and propensity tocognitive-perceptualdistortionsinthecontextofchronicallyunstableinterpersonalrelationships’.Bothgeneticfactorsandearlychildhoodadversityareimplicatedinitsaetiologywithimplica-tionsfortheneuralcircuitsthatregulateaffect,behaviourandcognition(Hooleyetal.,2012).

Histrionic Personality DisorderThewordhistrionic isderivedfrom‘playingonthestage’; it isabettertermthanhysterical forthisdisorder,whichischaracterizedbytheatricalbehaviour,cravingforattentionandexcitement,excessivereactiontominoreventsandoutburstsofmood,especiallytempertantrums.Insum-marizingthedescriptionsof22differentauthors,DeAlarcon(1973)foundthegreatestagree-mentforhystericalpersonalitydisorderinthefollowingfeatures:histrionicbehaviour,egocentricity,emotionallability,excitability,dependency,suggestibilityandseductiveness.

Characteristicofthedisturbanceofhistrionicpersonalityisthenatureofrelationships,withlimitedabilitytoexperienceprofoundaffectandcommunicatesuchfeelings.Thereisashallow-nessandlabilityofemotion,andthisisseenbyothersas lackingingenuineness,eventhoughtheyaresuperficiallycharming–‘thelifeandsouloftheparty’.Theyformexcellentandrapidacquaintanceshipswithnewpeople,buttheyhavegreatdifficultysustainingacloselong-term,mutuallyrewarding,exclusiverelationship.

Mood is fluctuating and inconsistent, and they display towards other people a craving forattention,affectionandappreciation.Theyareseenasegocentric,self-indulgentandinconsider-ateofothers.Thereisoftenextremebutsuperficialinvolvementwithmanydifferentpeopleinashortspaceoftime,andsuchapersonisseenasbeingmanipulative,vainanddemanding;themanipulativenessisoftenineffectualandself-destructive.Theyareoftensuperficiallyfoundveryattractiveandachievetheirshort-termgoalswhilebeingunabletosustain long-termrelation-ships; for instance marriage frequently ends in divorce.They may be dependent and helpless,constantly seeking reassurance and the approval of others. Gestures of deliberate self-harm,hysterical conversion symptoms and abuse of alcohol and other drugs are common. Reactivedepressionisalsofrequentlyencountered,especiallywhenabreakdownofrelationshipsoccurs.Inahospitalstudyofthosewithhystericalpersonalitydisorder,Thompson(1980)found83percentofsubjectstobefemale;therewasaclearassociationwithneuroticdepression,overdosage,self-mutilation,abuseofalcoholandahistoryofcriminalityandsometimesviolence.TyrerandAlexanderdonot regardthisasadistinctpersonalitydisorderbutcombine itwithdependentpersonalitydisorderinacategoryofpassive dependence.

Anankastic Personality DisorderAnankasticpersonalitytraitsinmoderateamountarevaluableinsocietyandforthesuccessoftheindividual;theyarefrequentlyobservedinprofessionalssuchaslawyersordoctors.However,when these are developed to an abnormal extent and interfere with the person’s functioning,personalitydisorderispresentandischaracterizedbyperfectionism,rigidity,sensitivity,indeci-siveness,alackofcapacitytoexpressstronglyfeltemotionandexcessiveconscientiousness.Theanankast’s pervading sense of insecurity is associated with extreme self-doubt and feelings ofsensitivityconcerninghowotherpeopleviewhim.

Perfectionismandexcessiveattentiontodetailinterferewiththeoverallgraspofsubjectsorsituations.Thereisgrosspreoccupationwithrules,efficiency,trivialdetails,proceduresandpro-tocol.Onepatientwasmakinglistsofthelistsshehadpreviouslysetherself.Shecouldnotthrowawayalistuntileverythingonithadbeencompletedand,assomeoftheitemsonthelistswerethings that shewished to remindherself todo regularly, shewas accumulating such an ever-increasingnumberoflistsastobeunmanageable.Efficiencyandperfectionareaimedat,butthe


excessivelydetailedmannerinwhichtheattempttoachievethemismadeunderminesthepos-sibilityofsuccess.Often,extremeorderlinessinoneareaofliferesultsinchaosinanother,forexamplethemedicalpractitionerwhokeptthetopofhisdeskinimmaculatetidinessbuttippedallhiscasenotesandotherpapersintothebackofhiscar.

Rigidity inpatternsofbehaviour ischaracteristic.Theindividualvaluesaccuracyandthor-oughnesshighlyandrespectsotherobsessionalpeopleforthesequalities.Hetendstokeepfixedtimesandlivetoaregularprogramme,alteredonlywiththegreatestmisgivings.Theseconstraintsareextendedtootherpeopleinthatheinsiststhattheysubmittohiswayofdoingthings.Thereisoftena lackofawarenessof the feelings inothersevokedbyhisbehaviour.ThisanankasticcontrolofotherpeopleistypifiedbyMrsOgmore-PritchardinDylanThomas’Under Milk Wood(1954),who imposesonherdeadhusband thedictum‘Imustputmypyjamas in thedrawermarkedpyjamas…Imusttakemycoldbathwhichisgoodforme’.

Theanankast is extremely sensitive to thecriticism, realor suspected,ofotherpeople; theslightestcensureis‘takenverymuchtoheart’.Thisawarenessofotherpeople’sopinionmakeshimaconformist,notpreparedtostepoutofline,alwayswishing‘tokeepupwiththeJoneses’.Heisrigid,formalandself-controlled,notonlyinhispublicbusinessbutalsoathomeandwithhis more intimate relationships. Insecurity about his abilities and his relationships makes theanankast indecisive.Hedoubtshisowncapacityandonlytooeasily finds himself agreeing insecret with those who criticize him. He vacillates and has great difficulty inmakingchoices,constantly lookingatsituationsfromdifferentpointsofview,‘weighinguptheprosandcons’.Heoftenfindshimselfinapositionofambivalenceandmayovercompensateforthisindecisive-nessbymakingarbitrarydecisionsthatthenbecomeimmutable on insufficient evidence, or hemay compensate for his legalistic rigidity by flaunting thelawostentatiously.Eveninthis,hisbasic obsessionality and perfectionism are still manifest.The anankast finds the initiation orcompletion of any activity very difficult, but hard work is highly prized, and he is thereforepreparedtocarryonthemiddlepartofthetaskindefinitely.

Theobsessional’sneedfor formality,andhis feelingsofsensitivityabouthowotherpeopleviewhim,resultsinrestrictedabilitytoexpresstenderemotion.Heisundulyconventional,seriousandformal.Stinginessmaybeshownbothwithmoneyandwiththeexpressionoffeelings.Suchapersonactuallyexperiencesverystrongaffectbutisquiteunabletoexpressthisappropriatelytowardsotherpeople.

Thedifferentfacetsoftheanankasticpersonalitydisorderare,ofcourse,interlocked.Astraitsofpersonality,theyareseenveryfrequently,notleastamongmembersofthemedicalprofession.However,developedasapersonalitydisorder, thiswayof lifemaybe incapacitating,especiallythe indecisiveness and inability to express strong emotion. Depression, obsessive-compulsivedisorder,eatingdisorderandhypochondriasisarenotuncommonlyassociatedwiththisabnor-malityofpersonality(SamuelsandCosta,2012).

Anxious (Avoidant) Personality DisorderThisisadisorderoftrait,whileanxietydisorderisadisorderofstate(seeChapter17).Thereisoftenfree-floatinganxietythatisexacerbatedbyanyovertpredisposingcause.Suchpeopleoftenfindthepublicsideoflife,forexampleatwork,verymuchmorestressfulthantheprivateside,withinthefamily.Traitanxietyispresentwhenthedevelopmentoftheindividual’spersonalityresultsinsomelevelofabnormalanxietybeingapersistentbackgroundpartoftheirconstitution(SimsandSnaith,1988);thiscouldalternativelybedescribedasanxioustemperamentoranxiety-pronepersonality.Suchpeopledescribethemselvesas‘bornworriers’.

Thispersonalitydisorder is characterizedbypersistentandpervasive feelingsof terrorandapprehension;abeliefthatoneissociallyinept,unattractiveorinferior;excessivepreoccupationwithcriticismandrejectionbyothers;hesitancyinnewsocialrelationships;restrictionoflifestyle


because of the need for security; and avoidance of those social situations that might provokedisapproval(ICD-10;WorldHealthOrganization,1992).

Dependent Personality DisorderThedependentpersonalityischaracterizedbyfeelingsofinadequacyconcerningselfanddepend-enceonotherpeople.Thereisgrosslackofself-confidence,initiativeanddrive.Suchapersonisunabletoreacttothechangingdemandsoflifeandallowsotherpeople,sometimesoneotherperson, to assume responsibility for major areas of life. He may function reasonably well andappearinconspicuouswhencarriedalongthroughlifebyadominantcloserelationship.However,whenexternalstressoccurshelacksconfidence,isunabletocopeandcraveslong-termsupportandencouragementfromrelatives,aclosefriend,hisfamilydoctor,hissocialworker,hisminister,hisemployerorhissurroundingsocialorganizations.Hemay,forexample,flourishinthearmedforcesbutbeunabletoadjusttocivilianlife.

Suchpeopletendtogothroughlifewithonedominantdependentrelationship;foraman,thismaybeinitiallyhismotherandsubsequentlyhiswife,whotakesoverhismother’srole.Crisesresultinginpsychiatricreferralmayoccurwhenaparentdiesorbecomesincapable,hismarriagebreaksdown,heloseshisjob,afterdetectionincrimeorfollowingphysicalillness.Itisusuallyonlyaftersuchsituationsthatapersonwiththistypeofpersonalitydisordercomestotheatten-tionof the caringprofessions.Dependenceamounts topassive compliancewith theaimsanddemandsofthemoredominantpartner.Thereisalackofvigourinmaintainingaimsandgoalsandinattemptingtoachievethese.Theymaydescribethemselvesasdepressed,butitismoreafeelingof inertiaandan inability tocopewith theirproblems than the symptomsofaffectivedisorder.Originally, thispersonalitydisorderwas conceptualizedas arisingoutofproblematicearlyparent-child relationshipsbutpathologicaldependency isnow seen as stemming fromaperceptionof the‘self ’asweakaccompaniedby thebelief thatotherpeoplearecomparativelycompetentandconfident.Asaresultofthistheindividualbecomespreoccupiedwithobtainingandmaintainingrelationshipswithpotentialcaregivers(Bornstein,2012).

Persistent Mood DisordersIn ICD-9 (WorldHealthOrganization, 1977), these conditionswere classified asdisorder ofpersonality. However, in ICD-10 they have been listed as a subcategory of affective disordersbecause they are genetically related to mood disorders and sometimes respond to the samemethodsoftreatment.Theyareretainedinthischapterbecausetheyconformwiththepsycho-pathology of personality disorders. Akiskal (1993) has made a convincing case for depressivepersonalitytobereturnedtothegenericcategoryofpersonalitydisordersratherthanbeingclas-sifiedwithaxis 1 mood (affective) disorders.There is apersistent lifelongabnormalityofmood,notamountingtoillness,asopposedtothosereactiveorendogenousdisturbancesofaffectthatareofshorterdurationandareregardedasillness.Themostfrequenttypesofaffectivepersonalitydisorder show excessive lability of mood or persistent depressive stance towards life. Otherabnormalitiesofpersonalitymayoccur,suchaspersistenthypomania,buttheserarelypresenttothepsychiatrist.

Thosewithcyclothymiashowmarkedfluctuationsofmood,forinstanceforadayoraweekthey may be optimistic, energetic, creative and garrulous, then for a period they may becomegloomy, morose, taciturn and unable to turn themselves to any useful activity. These cyclesmaybelinkedtootherbiologicalrhythmssuchasthemenstrualcycle;theymay,however,appearout of the blue, apparently unprovoked. A premorbid cyclothymic personality is thought topredisposetomanic-depressivepsychosis.Certainly,GoodwinandJamison(1990),inastudyof


manic-depressiveillnessandcreativity,foundthatamongpoetsespeciallytherewasanexcessofcyclothymicpersonality,depressiveillnessandsuicide.

Dysthymiaismanifestedbyall-pervasiveandpermanentgloomandapprehension.Itleadstothediagnosticquandary‘isthisdepressivestateordepressivetrait?’Suchpeopleareusuallygentleandsensitive;theytakethemselvesandtheiractivitiesseriously;theyareoftensafety-consciousand hypochondriacal. An acquaintance with this personality structure coined aphorisms thatrevealedhismentalstate,suchas‘thereisnosituationinlifesobadastobeincapableoffurtherdeterioration’or‘everysilverlininghasitscloud’.

Other Personality DisordersDSM-V(AmericanPsychiatricAssociation,1994)includestwootherpersonalitydisorders.Theyaredescribedbelow,inbrief,forcompleteness.

NARCISSISTIC PERSONALITY DISORDER

This iscategorizedbyagrandiosesenseofself-importanceoruniqueness;preoccupationwithfantasiesofunlimitedsuccess,power,brilliance,beautyorideallove;anexhibitionisticneedforconstantattentionandadmiration;indifference,angerorhumiliationinresponsetocriticismorindifference fromothers;andcharacteristicdisturbances in interpersonal relationships, suchasfeelingsof entitlement to special favours, takingadvantageofotherpeople, relationshipswithothers that alternate between the extremes of over-idealization and devaluation and lack ofempathy.

AVOIDANT PERSONALITY DISORDER

Thispersonalitydisorderis,infact,veryclosetotheanxiouspersonalitydisorderofICD-10;itischaracterizedbyexcessivesensitivitytorejection,humiliationorshame.Thereisunwillingnesstoenterintoarelationshipunlessthepersonreceivesstrongguaranteesofuncriticalacceptance.Thereissocialwithdrawal,despiteaneedforaffectionandacceptance,andthepersonhasverylowself-esteem,devaluinghisownachievementsandisveryawareofhispersonalshortcomings.Suchpeopleareexquisitelysensitivetothewaytheybelieveotherswillreacttothem.

In DSM-V, thehelpful notionof three clusters of personality types is basedondescriptivesimilarities.ClusterA includesparanoid, schizoid and schizotypal personality disorders. InclusterBareantisocial, borderline, histrionic and narcissistic personality disorders.ClusterCcontainsavoid-ant, dependent and obsessive-compulsive personality disorders. Inpractice, of course, patientsmayshow features from different clusters, and the validity of this subclassification is still beingquestioned.

Whyisatextonpsychopathologyconcernedwithpersonalityclassificationanddisorder?Theaccurateobservationanddelineationofpersonalitycharacteristicsisvaluableinclinicalpracticefordiagnosis,prognosisandtherationalplanningoftreatment.Theskillsofatrainedpsycho-pathologistareideallysuitedtotheobservationofconsistentpersonalitytraitsandforminganopinionunprejudicedbypreconceivedtheoreticalconsiderations.

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S E C T I O N SEVENDiagnosis

333

C H A P T E R 20

Psychopathology and Diagnosis

SummaryDiagnosisallowsthenaming,thedefining,andidentificationofasingularmaladysothatitcanbecome an object for consideration, comparison, explanation and control. It is therefore self-evidentthatthediagnosticprocessisfundamentaltothepracticeofpsychiatry.Theimportanceandrelevanceofpsychopathologyisthatitistheconstellationofabnormalphenomenathatareelicitedbytheclinical interview,reinforcedbythephenomenologicalapproach,thatconstitutepsychiatricsyndromes.Inotherwords,psychopathology is thefoundationuponwhichclinicalpsychiatryisbuilt.

‘There’s glory for you!’ ‘I don’t know what you mean by “glory”,’ Alice said. ‘I meant, there’s a nice knock-down argument for you!’ ‘But “glory” doesn’t mean “a nice knock-down argument”,’ Alice objected. ‘When I use a word,’ Humpty

Dumpty said in a rather scornful tone, ‘it means just what I choose it to mean, – neither more nor less.’

Lewis Carroll (1872), Through the Looking Glass

Diagnosisismuchmorethanawordpluckedoutoftheairandpinnedontoahapless‘patient’.Itconveysmeaningabouttheantecedentsofthepresentstate,aboutotherconditionsthataresimilarand,most importantofall,aboutwhat is likelytohappeninthefutureand,therefore,whatshouldbedoneaboutit.Diagnosisisameansofcommunicationbetweendoctors;itshouldencompassafullformulation(seeChapter2)ratherthanjustasinglewordusedinanidiosyn-craticmanner.

Theimportanceofmakingadiagnosis,andtherangeofdiagnoses,isasgreatinpsychiatryasintherestofmedicine;theconceptualdifferencesbetweendifferentdiagnosticcategoriesareactuallygreater,asmental disorders includesituational, social,emotionalandpsychologicaldis-turbanceaswellasphysicalillness.Understandably,mostofthemedicalillnessesthathavebeendescribedarebasedonsignsorsymptoms;thisistruealsoforpsychiatry.Thereis,therefore,avery close association between the observation and classification of ‘symptoms in the mind’(Burton,1621)andpsychiatricdiagnosis.

Theimportancewithwhichdiagnosisisregardedinpsychiatryhasdevelopedalongsidetheintroductionofeffectiveremediesformanyconditions.TherehasbeenasubstantialchangeintheattitudeofpsychiatristssinceStengelwrotein1959thattherewas‘almostgeneraldissatisfac-tionwiththestateofpsychiatricclassification,nationalandinternational’.Muchoftheprogressmadehasarisendirectly fromthemorecarefulapplicationofdescriptivepsychopathology, forinstance Kendell (1975). Schwartz and Wiggins (1987) have shown that in order to make adiagnosis an experienced clinician uses a mechanism of typification: ‘This more fundamentalcapacitytorecognizevariousmentaldisordersarises,notthroughmasteringconceptualdefini-tions,butratherthroughdirectlyencounteringindividualpatientswhomanifestthesedisorders.Through such direct encounters we learn the typical forms of the various mental disorders.

Keywords:Diagnosis,Health.

20—PSychOPAthOlOGy AND DIAGNOSIS 333.e1

334 SEVEN—DIAGNOSIS

We learn what is distinctive to each condition and how to distinguish these conditions fromone another’.This process of ‘typification’ seeks to recognize what is emblematic of differentconditions,whatisunusualbutyetrepresentative,andwhatisuntypicalandsohighlyunusualas tobeuncharacteristic.Thus, thedetailed examinationof psychopathological functions thatforms the substanceof this text is aprerequisite to this, thefirst step for clinicaldiagnosis inpsychiatry.

Abnormal phenomena, then, are the foundation of the diagnostic process. And diagnosisallowsthenaming,thedefining,andidentificationofasingularmaladysothatitcanbecomeanobjectforconsideration,comparison,explanationandcontrol(Sadler,2004).

In general medicine, diagnosis is based on the complete clinical process: detailed historytaking,examinationofthepatientandcarryingoutappropriatespecialinvestigations.Thisistruealso forpsychiatry.However,becauseof the limitationsof its subject, thisbookdoesnotdealwithphysicalexaminationnorwithphysical(radiological,laboratory)orpsychological(psycho-metric)investigations.

Concepts of Health and PsychopathologyThelatePeterSedgwick(1981)madetheimportantpointthat‘diseaseisahumaninvention…therearenoillnessesordiseasesinnature’,hencethequotationatthebeginningofthischapter.Herightlypointedoutthathumanbeingsdescribepotatoblightasadiseasesolelybecausetheywanttogrowpotatoes:‘ifmanwishedtocultivateparasites(ratherthanpotatoes)therewouldbeno“blight”butsimplythenecessaryfodderingoftheparasitecrop’.Sedgwickclaimedthatitwasthehumansocialmeaningattachedtothefractureofaseptuagenarianfemurthatconstitutedillnessordisease.

Out of his anthropocentric self-interest, man has chosen to consider as ‘illness’ or ‘diseases’ those natural circumstances which precipitate the death (or the

failure to function according to certain rules) of a limited number of biological species; man himself, his pets and other cherished livestock, and the plant

varieties he cultivates for gain or pleasure.

Suchargumentspointustothefactthatmedicineisnot‘objective,scientific’appliedbiologybut isnecessarilyvalue-laden.This is trueof thedisruptionof the internalstate that‘patients’bringas‘complaints’tothedoctor,andtruealsoofthosecomplaintsthatthedoctorregardsas‘symptoms’.ForSedgwick(1982),alldiseasesstartasillnessstatesrecognizedassuchbecauseofthenegativevalueattachedtothesymptomsorcomplaints.

Allillness, whether conceived in localized bodily terms or within a larger view of human functioning, expresses both a social value judgement

(contrasting a person’s condition with certain understood and accepted norms) and an attempt at explanation (with a view to controlling the disvalued

condition).

Anotherviewoftheeffectofsocialvaluesonthepresentationofillnessisthenotionofthesick roleasdevelopedbyTalcottParsons(1902–1979)(1951a).Whatevertheunderlyingcausesofconditions,therolethatthesubjecthimself,thepatient,choosestoplayandtherolethatisforcedonhimbythosearoundhimbecauseofhis illnessarehighlysignificant inthewayhissymptomsmanifest.Parsons(1951b)arguedthathealth is included inthefunctionalneedsoftheindividualmemberofsociety,sothatfromthepointofviewofthefunctioningofthesocial

20—PSychOPAthOlOGy AND DIAGNOSIS 335

system, too lowageneral levelofhealth,or toohighan incidenceof illness, isdysfunctional.Disease in this formulation incapacitates theeffectiveperformanceof social roles and there isthereforesocial interest in thealleviationofdisease.Toput this inanotherway,disease isnotpurely or merely a natural phenomenon but a state of disturbance of the total human being,includingthestateoftheorganismasabiologicalsystemandofhispersonalandsocialadjust-ments,includinghisabilitytofulfilsocialroles.

This approach introduces the notion that behavioural deviance itself can be the source ofdisease.But,howissuchdeviancetoberecognizedanddefined?Socialdeviancecanberecog-nizedbyself-definition.The individualmaycometoholdthebelief thathehasaproblemortheremaybeasocietalreactionthatindicatesthatanindividual’sbehaviourconstitutesaproblem.Societalreactionofthistypemightoccurwhenacommunitycomestorecognizeaperson’sinabil-ityorreluctancetorespondinaparticularexpectedway.AccordingtoDavidMechanic(1968),‘theviewtakenof thedeviantdepends in largepartontheframeofreferenceof theobserverand the extent to which the deviant appears to be able or willing to control his responses.The evaluator views the act within the context of what he believes the actor’s motivation tobe.Iftheactionappearsreasonableintermsoftheassumedmotivationoftheactor,thereisaverygoodchancethatdeviantbehaviourwillbedefinedintermsofthegoodness–badnessdimen-sion.Ifthebehaviourappearstobepeculiarandatoddswithexpectationsofhowareasonablepersonmightbemotivated, suchbehaviour ismore likely tobe characterized in termsof thesicknessdimension’.Theproblemwiththisisself-evident.Diseasedefinitioninthisformulationseems significantly prone to error, to subjective judgement, and liable to be used as a tool ofsocialcontrol.

Withregardtoself-definitionofillness,peopledifferinthewaytheyperceive,evaluateandacton,orfailtoacton,thesymptomstheyexperience.Mechanic(1986)hascalledthis illness behaviour.This is influencedby the salienceof the complaint, thedegree towhich itdisturbssocial roles, the folk understanding of the seriousness and consequences of the complaint orimplieddisease,andthecompetingclaimsontheperson’stimeandresources.

Somaticorpsychologicalsymptomsdo,ofcourse,frequentlyoccurwithoutanyevidenceoforganicdisease.Whenattemptingtodescribeandclassifysuchsymptoms,itishelpfultoestablishaphenomenologicalbasis;conditionsarerecognizedbecauseoftheparticularcharacteristicsofthepatient’scomplaints,notbecauseofsomepresumedtheoreticalnotionofcause.Thebizarrelengthsthatresultfromtheapplicationofapreformedtheoryofdiseaseaetiologytosymptoms,ratherthandevelopingfromsymptomstotheory, isadmirablyillustratedinEngelhardt’s(1981)essay‘The disease of masturbation’. Inthenineteenthcentury,masturbationwaswidelybelievedtoproducemanysignsandsymptomsincludingdyspepsia,constrictionoftheurethra,epilepsy,blindness,vertigo,lossofhearing,headache,impotence,lossofmemory,insanity,cardiacarrhyth-mia,rickets,leucorrhoeainwomen,conjunctivitisandgeneralizedweakness,anditwasheldtobeadangerousdiseaseentity.

Lewis(1953)pointedoutthatmentalillnesscouldbecharacterizedintermsofpsychopathol-ogy:‘disturbanceofpartfunctionsaswellasgeneralefficiency’.Part functionsrefertothedifferentaspectsofpsychologicalexperienceandbehaviourdescribedinpreviouschapters:memory,per-ception, forming beliefs and so on.Thus Lewis saw a disturbance in perception, for examplehallucination,asareasonforestablishingacaseofmentalillness–onpsychopathologicalgrounds.ThisapproachantedatedChristopherBoorse’scontributiontoourunderstandingofthenatureof mental disorders. His distinction between disease and illness is deservedly influential. Hearguedthatanorganismishealthytothedegreethatitisnotdiseased.And,hedefinedadiseaseasatypeofinternalstateofanorganismthatinterfereswithsomefunctionthatcontributestosurvivalandreproduction.Inaddition,thatthediseasestateisnotsimplyinthenatureofthespecies;i.e.,itiseitheratypicalofthespeciesor,iftypical,mainlyduetoenvironmentalcauses.Diseasesbecome illnessesonlywhentheysatisfycertain further,andnormative,conditions.A


diseaseisanillnessonlyifitisseriousenoughtobeincapacitating,andthereforeisregardedasundesirable,a title for special treatmentandavalidexcuse fornormallycriticizablebehaviour.For Boorse, mental functions such as perceptual processing, intelligence, and memory clearlyserve to provide information about the world that can guide effective action. Drives serve tomotivate it. Anxiety and pain function as signals of danger, language as a device for culturalco-operationandcognitiveenrichment,andsoon.Heconcludes:‘itseemscertainthatafewoftherecognizedmentaldisordersaregenuinediseases,whethermentalorphysical.Evenwithoutanyknowledgeoftherelevantfunctionalsystems,onecansometimesinferinternalmalfunctionimmediatelyfrombiologicallyincompetentbehaviour’.Finally,Boorsethoughtthatdiseasesarewhatdoctorstreatandillnessesarewhatpeoplesufferfrom(Boorse,1976).

Use of Symptoms to Form Diagnostic CategoriesThe relationship between signs and symptoms in psychiatry was discussed in Chapter 1.Traditionally,symptomshavebeendividedintothosecausingsufferingandpain(distress)andthosecausinglossoffunction(disability).Whentheonlydisharmonyisbetweentheindividualandhissociety,thedisturbanceisnotregardedasmentalillness.Forthegreatmajorityofmentaldisorders, diagnostic classification is made according to the profile of symptoms presented.Exceptionstothisare:

1. when the aetiology is known, for example dementia in human immunodeficiency virusdisease;

2. when the genetic basis and structural pathology are known, for example Huntingtondisease;and

3. when cause is hypothesized to result from a process without conclusive evidence, forexampledissociativefugue.

Descriptivepsychopathologyisalmostatheoreticalinnatureandthusallowsthedevelopmentofagenerallydescriptivediagnosticterminology.

Symptoms are collected into constellations that commonly occur together to form thesyndromes of mental illness. It is usual to make a distinction between illness, with a definiteonset after normal health, and the lifelong characteristics of learning disability or personalitydisorder.

Another fundamentaldistinctionoftenmadebypsychiatristsandbasedultimatelyonpsy-chopathologyisthatbetweenpsychosesandneuroses.Psychoses‘aremajormentalillness.Theyareexceedinglyhardtodefinealthoughtheyareusuallysaidtobecharacterizedbyseveresymptoms,suchasdelusionsandhallucinations,andbylackofinsight’(Gelderetal.,1983);thereislossofcontactwithreality.Itisprobablethattheeverydayuseoftheconceptofpsychosisbycliniciansisbasedonthenotionof‘unitarypsychosis’;thedevelopmentofthisconcepthasbeendiscussedbyBerriosandBeer(1994).Neurosis‘isapsychologicalreactiontoacuteorcontinuousperceivedstress, expressed in emotion or behaviour ultimately inappropriate in dealing with that stress’(Sims,1983:3);phenomenologicalcharacteristicsheldincommonbyneuroticpatientsincludedisturbancesofself-image,oftheexperienceofrelationshipsand,often,bodilysymptomswithoutorganiccause (Sims,1983).Although the termneurosishas fallenoutof favour, theconceptsthatthetermreferstoarestillimportantasorganizingprinciples:anunderstandablereactiontostress; the emotionaldisturbance is a variantofnormal response,possiblyonly exaggerated indegreeandintensity;aconditioninwhichinsightisretained;and,finallytheextentofdisruptiontopersonalityandself-identityisminimal.

Psychiatricdiagnosis isoftenhierarchical,organic syndromes takingprecedenceover func-tionalpsychoses, theseoverneuroses andneurosesover situationalor adjustment reactions.Apatient with schizophrenia and super-added anxiety will usually receive only the diagnosis ofschizophrenia. This can be a considerable disadvantage in practice for planning treatment


programmesas,forinstance,theprognosisofchronicschizophreniamaybedeterminedmorebythepresenceofneuroticsymptomsthanbytheresponseofschizophrenicsymptomstotreatment(Cheadle etal., 1978). Foulds (1976) used this hierarchical approach to establish a system ofclassificationof personal illness,with delusions of disintegration at the apex, takingpriority overinterveninglevelsdowntodysthymic statesasthelowestlevel.

AnexampleofcategoricalclassificationisshowninBox20.1.Variousnon-categoricalmethodsofclassificationhavealsobeenused.InthedimensionalapproachasadvocatedbyEysenck(1970),thevariationsofpresentationofmentalillnessareaccountedforonjustthreedimensions:psy-choticism,neuroticismandextroversion/introversion.Multiaxialclassificationcodesdifferentsetsofinformationseparately.

THE PRESENT STATE EXAMINATION

AnexampleofpsychiatricphenomenologyappliedinnosologicalresearchisthedevelopmentofthePresentStateExamination(PSE;Wingetal.,1974):‘ThePresentStateExamination(PSE)schedule is aguide to structuringa clinical interview,with theobjectof assessing thepresent

BOX 20.1 ■ Classification of mental disorders

Psychoses■ Organicdisorders:

acuteorganicsyndromechronicorganicsyndrome(dementia)dysamnesticsyndrome

■ Schizophrenia:schizoaffectivedisordersparanoidstates

■ Affectivedisorders:maniadepressivedisorder

Neuroses and related disorders■ Neuroses:

depressiveneurosisanxietyneurosisphobicneurosisobsessionalneurosishysteriadepersonalizationsyndromenon-specificandmixed

■ Personalitydisorders■ Adjustmentdisorder■ Otherdisorders:

sexualdysfunctionandsexualdeviationsalcoholanddrugdependencemiscellaneoussyndromespsychologicalfactorsassociatedwithmedicalconditions

■ Mentalretardation■ Disordersspecifictochildhood

(AfterGelderetal.,1983,withpermissionofOxfordUniversityPress.)


mentalstateofadultpatientssufferingfromoneoftheneurosesorfunctionalpsychoses.’Itaimstoenquireabout thepatient’s conditionandsubjective stateand to record this informationassymptoms.Whenthereisconflictbetweenclinicalandstatisticaljudgements,clinicaljudgementis allowed to prevail. Symptoms are aggregated into a list of syndromes.The classification ofsymptomsiscarriedoutonaprogrammeknownas‘Catego’,whichreducesthe500PSEitemstoamaximumofsixdescriptivecategoriesandthenceintoonedescriptivegroupfortheindi-vidualpatient.

AnaimofthePSEhasbeentodeterminewhetherthereareclinicallyrecognizablesymptomson which all psychiatrists can agree and label in the same way. Wing etal. (1974) pose twoquestions:

First, whether certain psychological and behavioural phenomena which have generally been thought by psychiatrists to be symptoms of mental illnesses can be reliably recognized and described, irrespective of the language and culture

of the doctor or patient; secondly, whether rules of classification can be specified with such precision that an individual with a given pattern of symptoms will

also be allocated to the same clinical grouping.

ThusthePSEstartsfromapsychopathologicalstandpoint.Theintervieweristrainedtonotethepresenceorabsenceof listedsymptoms in theglossary.Groupsofsymptomsarecollectedtogether intosyndromesbyuseofcomputerizedCategoclass.TheendproductofthePSEisdiagnosisasaresearchtoolbasedonphenomenologyandavailableforstudybyotherworkersinothercultures.AnexampleoftherelationshipbetweensyndromesandsymptomsinthePSEisshowninFigure20.1.

This example of an excerpt from the PSE involves the terms used for the symptoms ofschizophrenia.The nuclear syndrome ofWing etal. (1974) is composed of Schneider’s (1958)first-ranksymptoms.ThesymptomstheylistedascomprisingthissyndromeinthenintheditionofthePSEarethought intrusion, thought insertion, thought broadcast, thought commentary, thought withdrawal, voices about the patient, delusions of control, delusions of alien penetrationandprimary delusions.Theymaketheusefulpointthatthought insertionislikelytoberatedwithafalseposi-tiveiftheexaminerdoesnothavethesymptominmindbutsomegeneralapproximationtoit.

Figure 20.1 Excerpt from the Present State Examination. (From Wing et al., 1974, with permission.)

Syndrome no. Syndrome name Symptoms (list II)

(a) (b) (c)

1 (NS) Nuclear syndrome 55 Thought intrusion 62 Voices about patient

56 Thought broadcast 71 Delusions of control

57 Thought commentary 81 Delusions of alien penetration

58 Thought withdrawal 82 Primary delusions

0 No symptoms

1 NS? = partial delusions only

2 NS+ = 1 symptom

3 NS+ = 2+ symptoms


Voices about the patient impliesnon-affective verbalhallucinationsheardby the subject talkingabout him in the third person. Delusions of control refers, of course, to passivity experiences.Delusions of alien forces penetrating or controllingthemindorbodyisaspecialformofsymptomalready listed as belonging to the nuclear syndrome. By primary delusions, Wing etal. implydelusional perception and give the example of a patient undergoing liver biopsy who came tobelieve,astheneedlewasinserted,thathehadbeenchosenbyGod.

ThetentheditionofthePSEwasfurtherdevelopedintotheSchedulesforClinicalAssessmentinNeuropsychiatry(SCAN)(Wingetal.,1990)whichthenmappedintothediagnosticcatego-ries in ICD-10 (WHO,1992) andDSM-IIIR (AmericanPsychiatricAssociation,1987).TheemphasisplacedhereonthePSEisintendedbecauseitissuchadirectapplicationofdescriptivepsychopathologytopsychiatricdiagnosis(seeTable20.1).

PostscriptFundamentaltopsychiatryistheneedtounderstandwhatthepatientisexperiencing.Eisenberg(1986)hassuccinctlysummarizedtheaspirationsofthebiologicalschoolofpsychiatry:‘Foreverytwistedthoughtthereisatwistedmolecule.’Ironically,ifthisassociationweretobeachieveditwouldmaketheneedforexpertphenomenologicalskillsmore,ratherthanless,important,asitislikelytoremain,fromthepatient’spointofview,morecomfortabletohavehisthoughtsthanhismoleculesexplored.At theoppositepoleofpsychiatry,psychodynamics, there isalsogreatvalue in descriptive psychopathology, unembellished by interpretation, as a starting point forfurtherunderstanding.

TABLE 20.1 ■ First-rank symptoms of schizophreniaa and symptoms from the Present State Examinationb

First-Rank SymptomEquivalent Symptom from Present State Examination

DelusionalDelusional percept Primary delusion

Auditory hallucinationsAudible thoughts Thought echo or commentary

Voices arguing or discussing Voices about the patient

Voices commenting on the patient’s action Voices about the patient

Thought disorder: passivity of thoughtThought withdrawal Thought block or withdrawal

Thought insertion Thought insertion

Thought broadcasting (diffusion of thought) Thought broadcast or thought sharing

Passivity experiences: delusion of controlPassivity of affect (‘made’ feelings) Delusions of control

Passivity of impulse (‘made’ drives) Delusions of control

Passivity of volition (‘made’ volitional acts) Delusions of control

Somatic passivity (influence playing on the body) Delusions of alien penetration

aSchneider (1958).bWing et al. (1974).


USES OF PSYCHOPATHOLOGY

IthasbeensaidofWilliamofOckham,whosocourageouslynavigatedthemurkyanddangerouswatersofmedievalphilosophyandscience,thathewas‘anempiricistrefusingtostretchknowl-edgebeyondtheboundsofascertainableexperience’(Leff,1958).Thisisthepositionofdescrip-tivepsychopathology:aimingnot todrawconclusionsbeyondthesubjectiveexperienceof thepatientanditsjudiciousexplorationbytheinterviewer.Everypsychiatristusesphenomenologytosomeextent,butitisamuchmorevaluabletoolifusedrigorously.

Thefourpracticalapplicationsofdescriptivepsychopathology,then,areasfollows.■ Communication.Itenablesclinicianstospeakandwritetoeachotherabouttheproblems

oftheirpatientsinamutuallycomprehensibleway.Thisisclearlyofvaluebothinclinicalpracticeandforresearch.

■ Diagnosis.Psychiatricdiagnosisisbasedtoaconsiderableextentonpsychopathology,andthisiswhollyappropriate,especiallyuntilthereismoreevidenceforaetiologyandunderly-ingpathologyforthedifferentconditions.

■ Therapy.The method of empathy, that is using phenomenology to explore the patient’ssubjectiveexperience,isarationalwayofestablishingatherapeuticrelationship.Itenablesthe therapist to understand the subjective experience of his patient and will give thepatient confidence in further entrusting the secrets of his internal environment to thetherapist.

■ The law.Descriptivepsychopathology is theonlyreasonablewayofdeterminingwhat ismentalillnessandwhatarethedifferencesbetweenmentalillnesses,fromaforensicpointofview.Mutualenlightenmentintheareabetweenthelawandpsychiatry,wherethereisatpresentsomuchmisunderstanding,will result fromacleareracknowledgementofthevalueofpsychopathologybylawyersanddoctors.

Thepatient’ssymptoms,hissufferings,arealogicalstartingpointforthedoctor’ssympathy,curiosityandtherapeuticendeavour.Tostartelsewhereturnsmedicineonitsheadand,ultimately,onearrivesinatopsy-turvyworldlikeSamuelButler’sErewhon(1872),where‘illnessofanysortisconsidered…tobehighlycriminalandimmoral;andthatIwasliable,forcatchingcold,tobehadupbeforetheMagistratesandimprisonedforaconsiderableperiod…’and‘ifamanforgesacheque,orsetshishomeonfireorrobswithviolencefromaperson,ordoesanysuchthingsthatarecriminalinourowncountry,heiseithertakentoahospitalandiscarefullytendedatthepublicexpense,orifhewasingoodcircumstances,heletsitbeknowntoallhisfriendsthatheissufferingfromaseverefitofimmorality…andtheycomeandvisithimwithgreatsolici-tude…’Youmaythinkthisistoofar-fetched;however,thelesspleasantaspectsofthiscertainlyappeartohavebeenthesituationforsomeofthedissidentsinpsychiatriccustodyinthepreviousUSSR(BlochandReddaway,1977).

Theultimateaimofpsychiatryisnot,ofcourse,knowledge,buttohelppeopletofunctionandfeelbetter;phenomenologyisavaluabletherapeutictool.Ideally,itgivesthepatient,inhisdoctor,apersonwhounderstandswhatheisfeelingbutdoesnottrytoexplaincausesintermsoftheory,whichthepatientmayfindunconvincing.Thepatientoftenhasagreatsenseofreliefwhenthedoctor,howeverfalteringly,describesbacktohimthesymptoms,ortheinternalexperi-ence,thathe,thepatient,hasfoundsodifficulttodescribe.

NEED FOR RESEARCH

Psychopathologywasintroducedintopsychiatrybeforethecurrentemphasisonquantification,populationsurveysandexperimentalmethod.Itisnowimperativebothforthefurtherdevelop-mentofdescriptivepsychopathologyand,moreimportantly,forcontinuedprogressinpsychiatricresearch that more rigorous research methods be applied. Phenomenology has a place in


psychiatric research that has not yet been fully exploited. It forms a logical bridge betweenresearchfindingsemanatingfromclinicalandappliedpsychologyandtheincreasingknowledgeofdisorderedneuroanatomy–physiologyandchemistry–thatisresultingfrommoresophisti-cated methods of neuroimaging and assay. This is the direction that research in descriptivepsychopathologyshouldgo.

Investigationoftheexperienceoftheindividualhastobelinkedtoanunderstandingofhisbiology, and it is also important to assess how normal phenomena are distributed within thepopulation.Thescientificbasesofpsychiatryinclude,aswellasbiologicalandbehaviouralsci-ences,epidemiologyandphenomenology.Recognitionofhomogeneityincludesboththesymp-tomswithinanindividualpatientandthefeaturesofanaffectedpopulation.ThePSEhasbeendiscussedearlierasamethodofquantifyingpsychopathologicalinformation.

Tointroduceexperimentalmethodsintoresearchindescriptivepsychopathologywillsome-timesinvolvesinglecasestudiesinwhichvariablesthathavebeenevaluatedphenomenologicallyarealtered.Forexample,GreenandPreston(1981)amplifiedthequietwhisperingofachronicschizophrenicpatientduringthetimehewasauditorilyhallucinated.Hewhisperedatthesametimeasheheardvoices,andthecontentofhisvocalizationcorrespondedtowhatthevoiceswerereportedtohavesaid,thusdemonstratingthedisturbanceofboundariesofselffoundinschizo-phrenia.Thistypeofinvestigationhasbeenextendedfurther,andthereareseveralexamplesinthisbook,forexampleinChapters7and8.Therehasbeenadangerinthatsomeotherpsycho-logical studies,notquotedhere,haveusedphenomenology impreciselyandhencevitiated thesignificanceoftheirfindings.

Aninterestingdevelopmentinresearchbasedondescriptivepsychopathologyistheapplica-tionof particular psychological techniques to specificphenomenological entities.Examples ofthisaretheuseofcognitivebehaviourtherapyinthetreatmentofpersistentauditoryhallucina-tions(Bentalletal.,1994)andmoregeneralapplicationofpsychologicalinterventionsinschizo-phrenia(HaddockandLewis,1996).

It is important thatprogress in the treatmentofpatients and in research that advances inbiologicalaspectsofpsychiatryareassistedbyaccuratepsychiatricdiagnosisbasedonphenom-enologythatisbothreliable(thatis,capableofreproductionbythesameintervieweratadifferenttime,orbydifferentinterviewers)andquantifiable.Neverweretheskillsoftheclinicalphenom-enologistmorenecessaryormorelikelytoyieldbeneficialresultsbothinunderstandingandintherapy.The introductionof improvedneuropsychiatricmethodsof investigation increases theneed for reliable findings from descriptive psychopathology rather than rendering it obsolete.Jaspers(1959)commented,‘phenomenology,thoughoneofthefoundationstonesofpsychopa-thology,isstillverycrude’.Thisisstilltrue,butitisnowhightimethatdescriptivepsychopa-thologybecamemoresophisticated.

Phenomenologytakesthedoctor’sartanddisciplineofobservationinsidehispatient’smind.DavidHume(1804)describedtheabsenceofphysicalexaminationinmedicineinhisessay‘Of Polygamy and Divorces’.He tellsof thephysicianbrought into theGrandSignior’s seraglio inConstantinople.

He was not a little surprised, in looking along a gallery, to see a great number of naked arms standing out from the sides of the room. He could not

imagine what this could mean; till he was told that those arms belonged to bodies, which he must cure, without knowing any more about them than

what he could learn from the arms. He was not allowed to ask a question of the patient, or even of her attendants, lest he might find it necessary to

enquire concerning circumstances which the delicacy of the seraglio allows not to be revealed. Hence physicians in the east pretend to know all diseases from


the pulse, as our quacks in Europe undertake to cure a person merely from seeing his water.

Psychiatrymustnowcomeoutoftheseraglioanduseallavailableinformationintheserviceofitspatients,includingphenomenology,fordiagnosis,forunderstandingandfortreatment.

ReferencesBentallRP,HaddockGandSladePD(1994)Cognitivebehaviourtherapyforpersistentauditoryhallucina-

tions:fromtheorytotherapy.Behaviour Psychotherapy25,51–6.BerriosGEandBeerD(1994)Thenotionofunitarypsychosis:aconceptualhistory.History of Psychiatry

V,13–36.BlochSandReddawayP(1977)Russia’s Political Hospital.London:Gollancz.Boorse C (1976) What a theory of mental health should be. Journal of the Theory of Social Behaviour 6,

61–84.BurtonR(1621)The Anatomy of Melancholy, What it is. With all the Kinds, Causes, Symptoms, Prognostickes,

and Severall Cures of it by Democritus Junior.Oxford:Cripps.ButlerS(1872)Erewhon.London:Cape.CarrollL(1872)Through the Looking Glass, and What Alice Found There.London:Macmillan.Cheadle AJ, Freeman HL and Korer J (1978) Chronic schizophrenic patients in the community. British

Journal of Psychiatry132,221–7.Eisenberg L (1986) Mindlessness and brainlessness in psychiatry. British Journal of Psychiatry 148,

497–508.Engelhardt HT (1981) The disease of masturbation: values and the concept of disease. In Caplan AL,

EngelhardtDTandMcCartneyJJ(eds.)Concepts of Health and Disease.Reading:Addison-Wesley.Eysenck HJ (1970) A dimensional system of psychodiagnosis. In Mahrer AR (ed.) New Approaches to

Personality Classification,pp.169–207.NewYork:ColumbiaUniversityPress.FouldsGA(1976)The Hierarchical Nature of Personal Illness.London:AcademicPress.GelderM,GathDandMayouR(1983)Oxford Textbook of Psychiatry.Oxford:OxfordUniversityPress.GreenPandPrestonM(1981)Reinforcementofvocalcorrelatesofauditoryhallucinationsusingauditory

feedback:acasestudy.British Journal of Psychiatry139,204–8.HaddockGandLewisSW(1996)Newpsychologicaltreatmentsinschizophrenia.Advances in Psychiatric

Treatment2,110–6.HumeD(1804)Essays and Treaties on Several Subjects,vol.1.Edinburgh:BellandBradfute.JaspersK(1959)General Psychopathology,7thedn.(transl.HoenigJandHamiltonMW,1963).Manchester:

ManchesterUniversityPress.KendellRE(1975)The Role of Diagnosis in Psychiatry.Oxford:Blackwell.LeffG(1958)Medieval Thoughts.Harmondsworth:Penguin.LewisAJ(1953)Healthasasocialconcept.British Journal of Sociology4,109–24.MechanicD(1968).Medical Sociology.NewYork:TheFreePress.Mechanic D (1986) The concept of illness behaviour: culture, situation and personal predisposition.

Psychological Medicine16,1–7.Parsons T (1951a) Illness and the role of the physician: a sociological perspective. American Journal of

Orthopsychiatry21,452–60.ParsonsT(1951b).The Social System.NewYork:TheFreePress.SadlerJZ(2004)Values and Psychiatric Diagnosis.Oxford:OxfordUniversityPress.SchneiderK(1958)Clinical Psychopathology,5thedn.(transl.HamiltonMW,1959).NewYork:Gruneand

Stratton.SchwartzMAandWigginsOP(1987)Typifications:thefirststepforclinicaldiagnosisinpsychiatry.Journal

of Nervous and Mental Disease175,65–77.SedgwickP(1981)Illness–mentalandotherwise.InCaplanAL,EngelhardtHTandMcCartneyJJ(eds.)

Concepts of Health and Disease: Interdisciplinary Perspectives,pp.119–30.Reading:Addison-Wesley.SedgwickP(1982)Psycho politics.NewYork:HarperandRow.


SimsACP(1983)Neurosis in Society.London:Macmillan.StengelE(1959)Classificationofmentaldisorders.Bulletin of the World Health Organization21,601–3.Wing JK, Babor T, Brugha T, Burke J, Cooper E, Giel R, Jablenski A, Regier D and Sartorius N

(1990)SCAN:Schedules forClinicalAssessment inNeuropsychiatry.Archives of General Psychiatry47,589–93.

WingJK,CooperJEandSartoriusN(1974)The Measurement and Classification of Psychiatric Symptoms: an Instruction Manual for the PSE and Category Program.Cambridge:CambridgeUniversityPress.

WorldHealthOrganization(1992)The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Description and Diagnostic Guidelines.Geneva:WorldHealthOrganization.

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S E L F - A S S E S S M E N T 1

Instructions

Each set of numbered items is followed by five lettered options. Select the ONE lettered option that is BEST in each case.

Chapter 1Descriptivepsychopathologyis:

a) Thestudyofegodefencemechanismsthatunderliebehaviourchangeb) Concernedwiththeselection,delimitation,differentiationanddescriptionofabnormalpsycho-

logicalphenomenac) Directlytheoutcomeofanalyzingthecontentofdreamsd) Amethodofdescribingtheinteractionbetweendoctorsandpatientse) Anintrospectivesystemofunderstandinganddescribingabnormalcognitions

Empathyindescriptivepsychopathologyis:a) Achieved by precise, insightful, persistent and knowledgeable exploration of the patient’s

experienceb) Acommunicationtechniqueaimedatputtingthepatientathiseasec) Meta-communicationd) Thebasisofsympathyforthepatient’ssituatione) Anaspectoftransference

Theterm‘understanding’inpsychopathology:a) DerivesfromFreud’sstructuraltheoryofthepsycheb) Describesthecausalmechanismsunderlyingabnormalexperiencesc) Hasnolimitinthecapacitytodescribeandcomprehendexperienced) DerivesfromDilthey’sconceptionofthedistinctionbetweenthesciencesandhumanitiese) Hasnoplaceincontemporarypsychiatry

Chapter 2SpecificcommunicationskilltechniquesincludethefollowingEXCEPT:

a) Summarystatementsb) Attentivelisteningc) Normalizingstatementsd) Loopedquestionse) Openquestions

AspectsofobservationofappearanceandbehaviourincludethefollowingEXCEPT:a) Postureb) Gesturec) Talkd) Facialexpressione) Self-hygiene

AssessmentofinsightinvolvesthefollowingdomainsEXCEPT:a) Fluencyoftalkb) Recognitionofsubjectivepsychologicalchangec) Attributionofthechangetopathologyd) Recognitionofneedfortreatmente) Compliancewithtreatment

346 Self-ASSeSSment 1

Chapter 3AutomatismischaracterizedbythefollowingEXCEPT:

a) Involuntarybehaviourb) Behaviourthatisinappropriatetothecircumstancesc) Complexandcoordinatedbehaviourd) Unimpairedjudgemente) Apparentlypurposefulanddirectedbehaviour

Mania à potuisasyndromecharacterizedbythefollowingEXCEPT:a) Insomniab) Totalorpartialamnesiafortheaberrantbehaviourc) Alcoholconsumptiond) Senselessviolencee) Prolongedsleep

DeliriumisaconditioncharacterizedbythefollowingEXCEPT:a) Insidiousonsetb) Globalimpairmentofcognitivefunctionsc) Reducedlevelofconsciousnessd) Impairedattentione) Disorderedsleep-wakecycle

Chapter 4Dreams:

a) Occurinnon-REMsleepb) Areassociatedwithparalysisc) Involveanaccentuationofself-awarenessd) Involveconsolidationofspatialandtemporalconnectionse) Aresynonymouswithnightterror

Kleine–Levinsyndromeischaracterizedby:a) Severehypersomniab) Sleepparalysisc) ShortREMlatencyd) Hypnogogichallucinationse) Cataplexy

Attention:a) Isthefocusingofconsciousnessonanyaspectofexperienceb) Issynonymouswithconcentrationc) Involvesdisinhibitionofmemoryd) Isdistinctfromvigilancee) Reliessolelyonactiveprocesses

Chapter 5ThefollowingareTRUEofconfabulationEXCEPT:

a) Itisafalsememoryb) Itisassociatedwithorganicamnesiac) Itcaninvolveembellishmentofactualmemoriesd) Itistypically‘fantastic’innaturee) Suggestibilityisaprominentfeature

Short-termmemory:a) Isanunlimitedcapacitysystemb) Comprisesofacentralactionsystemc) Involvesa‘phonologicalloop’thatholdsmemorytracesforuptofiveminutesd) Involvesavisuospatialscratchpadthatallowsformanipulationofvisualinformatione) Cannotbedistinguishedfromattention

Self-ASSeSSment 1 347

LongtermmemoryfunctionsincludethefollowingEXCEPT:a) Registrationb) Retentionc) Repressiond) Retrievale) Recall

Chapter 6Formalcharacteristicsoftimeinclude:

a) Durationb) Sequencec) Synchronyd) Rhythme) Bi-directionality

Déjàvuexperienceisanexampleofabnormalityof:a) Rhythmb) Senseofuniquenessoftimec) Timedurationd) Temporalordere) Directionoftime

FeaturesofseasonalaffectivedisorderincludethefollowingEXCEPT:a) Hypersomniab) Insomniac) Cravingforcarbohydratesd) Overeatinge) Lethargy

Chapter 7AbnormalitiesoftheelementaryaspectsofvisualperceptionincludethefollowingEXCEPT:

a) Palinopsiab) Macropsiac) Hemacropsiad) Palinacousise) Achromatopsia

Insynaesthesia:a) Theperceptionofasensoryobjectispresentedinanothersensorymodalityb) Theperceptionoccursinperi-personalspacec) Musictocolourtransformationsoccurd) ElaborationofFormConstantsisafeaturee) Emotionaldistressisacommonaccompaniment

FormalcharacteristicsofimagesincludethefollowingEXCEPT:a) Imagesarenotclearlydelineatedb) Imageshaveacharacterofobjectivityc) Imagesappearininnersubjectivespaced) Imagesareactivelycreatede) Imagesdissipaterapidlyandhavetobere-created

Chapter 8Thefollowingareexamplesofprimarydelusions:

a) Autochthonousdelusionsb) Delusionalperceptc) Persecutorydelusionsd) Delusionalatmospheree) Delusionalmemory


Secondarydelusionsare:a) Secondarytootherabnormalexperiencesb) Understandableinthelightofthepatient’ssocialcontextc) Notheldwithconvictiond) Amenabletocounterargumente) Transient

Delusionsareexamplesof:a) Perseverationb) Impairmentofconsciousnessc) Falseperceptiond) Falsebeliefse) Autoscopy

Chapter 9Schneider’sFirstRankSymptomsincludethefollowingEXCEPT:

a) Somatichallucinationsb) Audiblethoughtsc) Passivityexperiencesd) Thoughtwithdrawale) Thoughtinsertion

Delusionsofcontrolofthoughtinclude:a) Thoughtbroadcastingb) Thoughtechoc) Thoughtinsertiond) Thoughtwithdrawale) Thoughtblocking

Theterm‘circumstantiality’refersto:a) Flightofideasb) Looseningofassociationc) Concretethinkingd) Over-inclusivethinkinge) Impedanceofflowofthinkingbyunnecessarydetail

Chapter 10RecognizedabnormalitiesoflanguageinschizophreniaincludethefollowingEXCEPT:

a) Lackofuseofcohesivetiesb) Alogiac) Neologismd) Clangassociationse) Telegony

TheClozetechniqueisameasureof:a) Predictabilityofspeechb) Theproportionofthenumberofdifferentwordstothetotalnumberofwordsc) Cohesivetiesd) Rulesofpropositione) Fluencyoflanguage

Primarysensorydysphasiais:a) Theinabilitytoproducenamesorsoundsatwillb) Agrossdisturbanceofwordsandsyntaxresultinginunintelligiblespeechc) Adisorderofindistinctspeechd) Thelossofcomprehensionofthemeaningofwordse) Theinabilitytoreadwithunderstanding


Chapter 11InsightinschizophreniahasbeenshowntobepositivelycorrelatedwiththefollowingEXCEPT:

a) Thelikelihoodofdevelopingdepressionb) Thelikelihoodofhospitalizationsc) Compliancewithtreatmentd) Long-termoutcomee) Workingmemory

ValidmeasuresofinsightmusttakeintoconsiderationthefollowingEXCEPT:a) Themultidimensionalaspectofinsightb) Therelationshipofinsighttoaffectc) Theinfluenceofculturalfactorsd) Thevariationofinsightacrossdifferentsymptomdomainse) Theaddedvalueofbehaviouralobservations

InsightinvolvesallofthefollowingEXCEPT:a) Awarenessofchangeb) Recognitionofillnessinothersc) Attributionofchangetoillnessd) Recognitionoftheneedfortreatmente) Co-operationwithtreatment

Chapter 12AutoscopycaninvolveallofthefollowingEXCEPT:

a) Feelingofpresenceb) Failuretoperceiveselfinamirrorc) Visualhallucinationofinternalorganswithinbodilyspaced) Visualhallucinationofexactcopyoftheselfinmirrorimagee) Projectionoftheobservingselfinextra-personalspace

Egovitalityis:a) Awarenessofbeinganagentb) Awarenessofunityandcoherenceofselfc) Awarenessofbeingd) Awarenessofcontinuityofselfovertimee) Awarenessofboundariestotheself

Nihilisticdelusionisanexampleof:a) Disorderofegoboundaryb) Disorderofcontinuityofselfovertimec) Disorderofactivityd) Disorderofvitalitye) Disorderofunityofself

Chapter 13DefinitivefeaturesofdepersonalizationincludethefollowingEXCEPT:

a) Theexperienceispleasantb) Thereisafeelingofstrangenessc) Itisasubjectiveexperienced) Insightispreservede) Itcanaffectbodilysensation


DepersonalizationhasshowntoconsistofanumberofcomponentsincludingthefollowingEXCEPT:a) Perceptualalterationb) Unrealityofsurroundingsc) Temporalintegrationd) Unrealityofselfe) Emotionalnumbing

DepersonalizationisknowntobeassociatedwiththefollowingEXCEPT:a) LSDb) Cannabisc) Mescalined) Sensorydeprivatione) Narcolepsy

Chapter 14IndividualdeterminantsofhypochondriasisincludethefollowingEXCEPT:

a) Feelingsofdisgustb) Preoccupationwithbodilyfunctionc) Seriousillnessorinjuryinchildhoodd) Fearofinfectione) FascinationwiththeInternet

Masspsychogenicillness:a) Occursmostcommonlyinyoungmalesb) Oftenstartsinachildoflowstatusinthepeergroupc) Affectsmostseverelythemostadjustedpeopled) Symptomsspreadbyline-of-sighttransmissione) Isunaffectedbymediaresponse

Theconceptsof‘conversion’and‘dissociation’suggest:a) Thatphysicalsymptomscanonlyhaveanorganicbasisb) Thatcausationisunconsciousc) Thatsymptomscarrynoobviousadvantageforthepatientd) Thatsymptomsareunlikelytobepsychologicallymeaningfule) Thatthepatientisactingapart

Chapter 15Painasymbolia:

a) Presentswithabsentpainresponseb) Isassociatedwithincreasedthermalsensitivityc) Isassociatedwithhyperhidrosisd) Presentswithself-stimulatione) Isusuallyanacquireddisorderfollowingvascularlesions

Painassociatedwithpsychopathologyis:a) Betterlocalizedb) Clearlydelineatedalongrecognizedneuroanatomicaldistributionc) Easyforthepatienttodescribed) Constantandunremittinge) Tendstobeprovokedbydefiniteagents

Centralpain(thalamicsyndrome):a) Presentswithacuttingsensationb) Isactivatedbycutaneousstimulationc) Presentsashypoalgesiad) Isunaffectedbytemperaturechangee) Doesnotpresentwithallodynia


Chapter 16Alexithymiarefersto:

a) Inabilitytoexperiencepleasureb) Reactingtosadnewswithlaughterc) Absenceofunitybetweendifferentmodesofexperienceofemotionsd) Inabilitytoverbalizeaffectandelaboratefantasye) Selectivedeficiencyincorrectlyappraisingvocalexpressionofemotion

Ekman’sbasicemotionsincludeallthefollowingEXCEPT:a) Angerb) Disgustc) Feard) Jealousye) Sadness

Moodisdefinedas:a) Apositiveornegativereactiontoanexperienceb) Aprolongedprevailinginnerstateorpredispositionc) Aspontaneousandtransitoryexperienceinresponsetoanexperienced) Theexternalbehaviouralmanifestationofinnerstatee) Anevaluativeattitudetowardsanobject

Chapter 17TherespiratorysubtypeofpanicdisorderischaracterizedbyallthefollowingEXCEPT:

a) Fearofdyingb) Chestpainanddiscomfortc) Shortnessofbreathd) Provocationbyinhalationof35%carbondioxidee) Inducedbyspecificsituations

Selye’sGeneralAdaptationSyndromeincludesoneofthefollowingstages:a) Shockandnumbnessb) Sadnessc) Guiltandhostilityd) Flight-or-fightresponsee) Resolution

TheconstituentelementsofobsessivecompulsivephenomenonincludeallthefollowingEXCEPT:a) Inflatedsenseofresponsibilityevenforeventsoverwhichthepatienthasnocontrolb) Avoidanceofcueslikelytotriggerobsessionc) Fearofdisasterthatthepatientbelieveswillcometopassd) Resistancee) Increaseddiscomfortfollowingcompulsiveact

Chapter 18AbnormalmovementincatatoniaincludeallthefollowingEXCEPT:

a) Waxyflexibilityb) Psychologicalpillowc) Stereotypyd) Cataplexye) Mitgehen

Motivationcanbedefinedas:a) Innatedispositionthatdetermineswhatobjectstoattendtointheworldb) Astatethatinitiatesdirectedactionc) Astrivingtowardsanobjectthatisexperiencedasadesired) Arewardsystemthatgovernsandregulatesbehavioure) Thepowertoputintoeffectvoluntaryaction


ImpulsivityinvolvesallthefollowingEXCEPT:a) Predispositiontowardsrapid,unplannedactionb) Lackofregardforconsequencesc) Preferencefordelayedlargerrewardoversmallbutimmediaterewardd) Perseveranceofbehaviourdespitepunishmente) Inabilitytopreventresponseinresponsedisinhibitionattentionalparadigm

Chapter 19Paranoidpersonalitydisordercanbedefinedasadisorderinwhich:

a) Anindividualmistrustsothersandisundulysuspiciousb) Thereisalackofneedforanddefectincapacitytoformrelationshipsc) Adefectinempathyisevidentd) Uncontrollableoutburstsofintemperateanduncontrolledmoodoccurse) Theatricalbehaviourandcravingforattentionoccurs

InDependentPersonalityDisorderthefollowingfeaturesalloccurEXCEPT:a) Lackofselfconfidenceb) Perfectionisticdispositionc) Cravingforsupportandencouragementofothersd) Difficultyincopingwithchangingdemandsoflifee) Presenceofadominantcloserelationship

The following conditions have been shown to be frequently associated with anankastic personalitydisorderEXCEPT:

a) Eatingdisorderb) Hypochondriasisc) Alcoholdependencesyndromed) Obsessivecompulsivedisordere) Recurrentdepressivedisorder

Chapter 20IllnessbehaviourisinfluencedbyallthefollowingEXCEPT:

a) Salienceofthecomplaintb) Extentofdisturbanceofsocialrolesc) Culturalunderstandingoftheseriousnessofthecomplaintd) Competingclaimsonthesufferer’sresourcese) Theunderlyingbiologyofthecondition

All the following individuals have made contributions to our understanding of health and diseaseEXCEPT:

a) ChristopherBoorseb) AaronBeckc) PeterSedgwickd) TalcottParsonse) DavidMechanic

PracticalapplicationsofpsychopathologyincludeallthefollowingEXCEPT:a) Communicationbetweencliniciansb) Cognitiveneuroscienceresearchc) Diagnosisd) Nosologye) Therapy

353

S E L F - A S S E S S M E N T 2

Instructions

Each set of matching questions consists of a list of ten lettered options (A–J) followed by four numbered items. For each numbered item, select the appropriate lettered option. Each lettered option may be selected only once.

Chapters 3 and 4A. ConfusionB. ComaC. DeliriumD. DisorientationE. HypersomniaF. InsomniaG. OneiroidstateH. ParasomniaI. StuporJ. Twilightstate

1. A75-year-oldfemalepatientisfoundwanderingthestreets.Onexaminationshedoesnotknowthedate,day,time,season,placewheresheisorherownaddress.

2. An18-year-oldmalepatientpresentswithahistoryofseveralandirresistibleperiodsofdrowsi-nessduringtheday.Atnighthereportsperiodswhenheisfullyawakebutunabletomovehislimbs.

3. Thepartnerofa25-year-oldmalepatientaccompanieshimtotheoutpatientappointment.Shereportsthathetalksinhissleep,wandersaimlesslyinthebedroomforafewminutesatnightandthathehasnorecollectionoftheseincidents.

4. A47-year-oldfemalepatientwithahistoryofrecurrentdepressionisadmittedinamutestate.She is immobilebut fully conscious andalert.She is able tomake eye contactbutdoesnotrespondtoanyattemptatverbalcommunication.

Chapter 5A. AnterogradeamnesiaB. ConfabulationC. CryptamnesiaD. DissociativefugueE. FalsememoryF. GanserstateG. PerseverationH. PseudologiafantasticaI. RecoveredmemoryJ. Retrogradeamnesia

1. A20-year-oldmalepatientwasinvolvedinaroadtrafficaccident.Hesustainedaheadinjury.He was only able to recall events that happened approximately five minutes before thecollision.

2. A20-year-oldmalepatientpresentedinprisonwhilstonremand.WhenexaminedherespondedtoquestionsaboutthedateandthecapitalofFrancewithapproximateanswers,disorientationfortimeandplace.

354 Self-aSSeSSment 2

3. A45-year-oldmalepatientwasinvolvedinanaccidentatworkwherehesustainedaseriousheadinjuryandlostconsciousness.Onregaininghisconsciousnesshecouldonlyrecalleventsthathappenedapproximately36hoursaftertheincident.

4. A57-year-oldmalepatientwithanestablishedhistoryofimpairmentofshort-termmemoryinthecontextofalcoholabuserespondedtoquestionsaboutwhathehadspentthepreviousdaywithobjectivelyfalseaccountsthatincludedembellishmentsandintrusionsfrompreviousoccasions.

Chapter 7A. ImageryB. PalinopsiaC. MacropsiaD. MicropsiaE. ParaprosopiaF. AlloaesthesiaG. PelopsiaH. DyschromatopsiaI. TeleopsiaJ. Metamorphopsia

1. A45-yearmanpresentswithacomplaintthathefirstsawablackcatatthecornerwherehisdrivejoinedthemainstreet.Afterthis,forthenext72hoursorso,hekeptseeingthesamecatatvarioustimesandsituations.Whatisthetermforthisexperience?

2. A19-year-oldmanwitharecentdiagnosisofschizophreniacomplainedthatthefacesofpeoplelookingathimwouldsuddenlylookdifferent,asiftheywerepullingfacesathim.Sometimes,thefaceswouldappearsinister,lopsidedandstrange.Whatisthetermforthisexperience?

3. A25-year-oldfemalepatientwithahistoryofcomplexfocalseizurescomplainedofscenesandobjectsbecomingsmallerbeforeaseizure.Whatisthisexperiencetermed?

4. A25-year-oldmalepatientcomplainedthatobjectslookfaraway.Hefoundthissurprisinganddistressing.Whatisthisexperiencetermed?

Chapter 8A. DelusionalperceptB. DelusionalintuitionC. DelusionalmemoryD. DelusionalatmosphereE. SecondarydelusionF. Over-valuedideaG. DelusionofloveH. DelusionalmisidentificationI. DelusionofpersecutionJ. Delusionaljealousy

1. A20-year-oldmalepatientwasadmittedintohospitalfollowinganattackuponhisfather.Hereportedthathisfatherhadbeenreplacedbyarobotwholookedalmostexactlylikehimbutwasdefinitelynothim.Hefearedthatthis‘robot’hadmalignintentionsandthathislifewasindanger.Whatisthisbeliefcalled?

2. A40-year-oldfemalepatientcomplainedthatherlocalpriestwassendinghersecretmessages,declaringhisfeelingsforher.Shecomplainedthatalthoughhewasthefatherofherchildhewasyettovisitthem.

3. A21-year-oldfemalepatientsuddenlybecameconvincedthatshewastherightfulheirtothethroneofNorway.ShewasnotNorwegianbybirthorancestry.Whenaskedthereasonforthisbelief, shesaidthatshehadsuddenlycometothisrealization.Shedeniedanyotherunusualexperience.

Self-aSSeSSment 2 355

4. A54-year-oldmalepatientwith a longstandinghistoryof schizophrenia reportedpersistentandstressfulauditoryverbalhallucinationsofderogatoryandthreateningcontent.ThevoiceswouldoftentellhimthathedeservedtobekilledandthatnewimmigrantsintohislocalareafromRomaniaweregoingtomurderhim.Hethenheldafirmbeliefthathewasatriskfromimmigrants,particularlyRomanians.Thisbeliefwasheldwithconvictionandwasimpervioustocounterargument.

Chapter 9A. FantasythinkingB. ImaginativethinkingC. ConceptualthinkingD. CircumstantialthinkingE. ThoughtblockF. ConcretethinkingG. Over-inclusivethinkingH. ThoughtinsertionI. ThoughtwithdrawalJ. Audiblethought

1. A 21-year-old male university student described spending a lot of time thinking about thefuture,aboutthepossibilityofbecomingafamousmusician,becomingrichandabletoliveinamansioninFlorida.

2. A25-year-oldfemalepatient,newlyadmittedintohospitalcomplainedthatherthoughtswerebeing interfered with. She was particularly distressed by the experience of having thoughtsmanipulatedandtakenfromher.

3. Inatest,a19-year-oldpatientwithadiagnosisofschizophreniarespondedtoaquestioninthefollowingway:‘Whichofthefollowingareessentialpartsofaroom:walls,chairs,floor,window?’‘Chairs’.

4. A57-year-oldfemalepatientsaid:‘IwasstartingtofeelhighsoItieddumb-bellweightsroundmyankle’.

Chapter 10A. AphoniaB. LogocloniaC. EcholaliaD. ParagrammatismE. NominaldysphasiaF. AsyndesisG. MetonymH. JargonaphasiaI. ReceptivedysphasiaJ. Neologism

1. A 65-year-old right-handed male patient, who was recovering from a left-sided stroke, wasunabletofollowtheverbalcommand:‘Takethepaperwithyourlefthand,folditintwoandputitonthefloor’.

2. A25-year-oldpatientsaid,‘Phlogonshave invadedmy lungs turningfirst sidewaysandnowmedways’.

3. A64-year-oldmalepatientwithalongstandinghistoryofschizophreniarepliedtothequestion,‘Whathaveyougotinyourcup?’‘Afluidthatwhilstbeingcolourlessturnsdarkonbrewing’.

4. A72-year-oldmalepatientwithadiagnosisofParkinsondiseasesaid,‘I’mstar…,star…,start-ingtothinkofmo…,mo…,mo…,movinghouse’.

356 Self-aSSeSSment 2

Chapter 14A. MisoplegiaB. DysmorphophobiaC. PalinaptiaD. AlloaesthesiaE. ExosomesthesiaF. MicrosomatognosiaG. MacrosomatognosiaH. MuscledysmorphiaI. ParaschemaziaJ. Aschemazia

1. A23-year-oldmalepatientpresentedwiththebeliefthathismusclesweretoosmall,apreoc-cupationwithphysicalbuild,excessiveexercisinganddisturbedeating.

2. A56-year-oldfemalepatientcomplainedofhatingherlefthand.Althoughitlookednormal,shesaidthatshehateditandhadalwayswishedthatitwasdifferentinsize,shapeandfeel.

3. A 27-year-old male patient presented with a longstanding belief that his face was ugly, inparticularhisnosethathethoughtwasfartoolargeandcrooked.Objectively,hisnosewasnotexcessivelylargeorcrooked.

4. A40-year-oldfemalepatientpresentedwiththecomplaintthatshecouldcontinuetofeelhertoothbrushinherhandsforupto15minutesaftersheusedit.

Chapter 16A. AnhedoniaB. EcholaliaC. HyperekplexiaD. CoenaesthesiaE. ProsopoaffectiveagnosiaF. ReceptiveemotionaldysprosodyG. CyclothymiaH. EcstasyI. EchomimiaJ. Alexithymia

1. An8-year-oldmalepatientpresentedwithahistoryofheightenedstartlereflexcharacterizedbyeyeblinking,headflexion,abductionoftheupperarms,movementofthetrunkandbendingofthekneesinresponsetoaloudnoise.

2. A40-year-oldfemalepatientwithahistoryofrecurrentdepression,andcurrentlydepressed,gaveahistoryofinabilitytoexperiencepleasureinherusualhobbiesandinterestsaswellasageneralinabilitytoexperienceanyfeeling.

3. A36-year-oldmalepatientpresentedtothelocaldentalhospitalwithanachingpaininbothsidesofthelowerjawradiatingtothetemporo-mandibularjointsandtotheneck.Inresponseto thequestion, ‘Howare you feeling in your spirits?’, he seemedpuzzled and asked for thequestiontoberepeated.Hethensaid,‘MybodyisheavyandIamachingallover’.

4. A75-year-oldmalepatientwithadiagnosisofParkinsondiseasespokeinamonotonousvoice.Inadditionheseemednottorecognizetheemotionalmeaningofvariationsintoneofvoice.

Chapter 17A. AnxietyB. AnankasticpersonalityC. CompulsionD. DisgustE. Irritability

Self-aSSeSSment 2 357

F. PanicG. PhobiaH. ObsessionI. RuminationJ. Socialphobia

1. A32-year-oldfemalepatientpresentedwithdiscreteepisodesofintenseandextremefear.2. A23-year-oldfemalepatientpresentedwithexcessivefear,self-consciousnessandavoidanceof

socialsituationsduetothepossibilityofembarrassmentorhumiliation.3. A 27-year-old male accountancy trainee presented with a history of repetitive and intrusive

thoughts about cleanliness and hygiene, which were associated with increasing tension andworry, and which he recognized as his own thoughts. He tried to resist these thoughts, butfoundthattheybecameevenmoreurgentandintrusive.

4. A32-year-oldfemalepatient,whohadrecentlygivenbirth,presentedwithasixweekhistoryoftemperoutbursts,feelingsofhostilitytowardsherhusband,anunpleasantfeelingofdistressandimpatiencewithherchildren.

Chapter 18A. AkathisiaB. AnhedoniaC. CatatoniaD. DriveE. ImpulsivityF. InstinctG. Kleine–LevinsyndromeH. MotivationI. UrgeJ. Will

1. A21-year-oldmalerecentlydiagnosedwithschizophreniaandtreatedwithrisperidonecom-plainsofmotorrestlessness,inneragitationandaninabilitytositstill.

2. A17-year-oldmalepatient isbroughttotheattentionofhisgeneralpractitionerbecausehenewly recognized a problem with gambling, drinking excessively and misusing cannabis. Inadditionhe is reportedasprone to losinghis temperand liable to say thingswhichhe laterregrets.

3. A21-year-oldmalepatientpresentedwithahistoryofepisodesofexcessivesleeping(amount-ing to up 15hours a day), excessive eating, increased sexual libido, low mood and transientpersecutorybeliefs.

4. A28-yearfemalepatientpresentedforthefirsttimewithmarkedlyslowedmovements,some-timesresultingin immobility,strangeposturesandmuteness.Onexaminationsheallowsherupperlimbstobeputinuncomfortableposturesthatsheholdsforlongperiodsoftime.

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Chapter 1Descriptivepsychopathologyis:

b) Concernedwith the selection,delimitation,differentiation anddescriptionof abnormalpsychologicalphenomena(seepage3)

Empathyindescriptivepsychopathologyis:a) Achievedbyprecise,insightful,persistentandknowledgeableexplorationofthepatient’s

experience(seepage5)Theterm‘understanding’inpsychopathology:

d) DerivesfromDilthey’sconceptionofthedistinctionbetweenthesciencesandhumanities(seepage10)

Chapter 2SpecificcommunicationskilltechniquesincludethefollowingEXCEPT:

d) Loopedquestions(seepage25)AspectsofobservationofappearanceandbehaviourincludethefollowingEXCEPT:

c) Talk(seepage26)AssessmentofinsightinvolvesthefollowingdomainsEXCEPT:

a) Fluencyoftalk(seepage28)

Chapter 3AutomatismischaracterizedbythefollowingEXCEPT:

d) Unimpairedjudgment(seepage41)Mania à potuisasyndromecharacterizedbythefollowingEXCEPT:

a) Insomnia(seepage40)DeliriumisaconditioncharacterizedbythefollowingEXCEPT:

a) Insidiousonset(seepage39)

Chapter 4Dreams:

b) Areassociatedwithparalysis(seepage53)Kleine–Levinsyndromeischaracterizedby:

a) Severehypersomnia(seepage52)Attention:

a) Isthefocusingofconsciousnessonanyaspectofexperience(seepage45)

Chapter 5ThefollowingareTRUEforconfabulationEXCEPT:

d) Itistypically‘fantastic’innature(seepage62)

360 Self-ASSeSSment 1: AnSwerS

Short-termmemory:d) Involvesavisuospatialscratchpadthatallowsformanipulationofvisualinformation(see

page60)Long-termmemoryfunctionsincludethefollowingEXCEPT:

c) Repression(seepage60)

Chapter 6Formalcharacteristicsoftimeinclude:

e) Bi-directionality(seepage76)Déjàvuexperienceisanexampleofabnormalityof:

b) Senseofuniquenessoftime(seepage81)FeaturesofseasonalaffectivedisorderincludethefollowingEXCEPT:

b) Insomnia(seepage84)

Chapter 7AbnormalitiesoftheelementaryaspectsofvisualperceptionincludethefollowingEXCEPT:

d) Palinacousis(seepage91)Insynaesthesia:

e) Emotionaldistressisacommonaccompaniment(seepage89)FormalcharacteristicsofimagesincludethefollowingEXCEPT:

b) Imageshaveacharacterofobjectivity(seepage88)

Chapter 8Thefollowingareexamplesofprimarydelusions:

c) Persecutorydelusions(seepage123)Secondarydelusionsare:

a) Secondarytootherabnormalexperiences(seepage115)Delusionsareexamplesof:

d) Falsebeliefs(seepage112)

Chapter 9Schneider’sFirstRankSymptomsincludethefollowingEXCEPT:

a) Somatichallucinations(seepage151)Delusionsofcontrolofthoughtinclude:

b) Thoughtecho(seepage151)Theterm‘circumstantiality’refersto:

e) Impedanceofflowofthinkingbyunnecessarydetail(seepage114)

Chapter 10RecognizedabnormalitiesoflanguageinschizophreniaincludethefollowingEXCEPT:

e) Telegony(seepage165)TheClozetechniqueisameasureof:

a) Predictabilityofspeech(seepage170)Primarysensorydysphasiais:

d) Thelossofcomprehensionofthemeaningofwords(seepage163)

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Chapter 11InsightinschizophreniahasbeenshowntobepositivelycorrelatedwiththefollowingEXCEPT:

b) Thelikelihoodofhospitalizations(seepage180)ValidmeasuresofinsightmusttakeintoconsiderationthefollowingEXCEPT:

b) Therelationshipofinsighttoaffect(seepage179)InsightinvolvesallofthefollowingEXCEPT:

b) Recognitionofillnessinothers(seepage176)

Chapter 12AutoscopycaninvolveallofthefollowingEXCEPT:

c) Visualhallucinationofinternalorganswithinbodilyspace(seepage194)Egovitalityis:

c) Awarenessofbeing(seepage192)Nihilisticdelusionisanexampleof:

d) Disorderofvitality(seepage192)

Chapter 13DefinitivefeaturesofdepersonalizationincludethefollowingEXCEPT:

a) Theexperienceispleasant(seepage206)Depersonalization has shown to consist of a number of components including the followingEXCEPT:

c) Temporalintegration(seepage206)DepersonalizationisknowntobeassociatedwiththefollowingEXCEPT:

e) Narcolepsy(seepage52)

Chapter 14IndividualdeterminantsofhypochondriasisincludethefollowingEXCEPT:

e) FascinationwiththeInternet(seepage220)Masspsychogenicillness:

d) Symptomsspreadbyline-of-sighttransmission(seepage225)Theconceptsof‘conversion’and‘dissociation’suggest:

b) Thatcausationisunconscious(seepage224)

Chapter 15Painasymbolia:

a) Presentswithabsentpainresponse(seepage248)Painassociatedwithpsychopathologyis:

d) Constantandunremitting(seepage247)Centralpain(thalamicsyndrome):

b) Isactivatedbycutaneousstimulation(seepage247)

Chapter 16Alexithymiarefersto:

d) Inabilitytoverbalizeaffectandelaboratefantasy(seepage268)


Ekman’sbasicemotionsincludeallthefollowingEXCEPT:d) Jealousy(seepage259)

Moodisdefinedas:b) Aprolongedprevailinginnerstateorpredisposition(seepage257)

Chapter 17TherespiratorysubtypeofpanicdisorderischaracterizedbyallthefollowingEXCEPT:

e) Inducedbyspecificsituations(seepage284)Selye’sGeneralAdaptationSyndromeincludesoneofthefollowingstages:

d) Flight-or-fightresponse(seepage280)The constituent elements of obsessive compulsive phenomenon include all the followingEXCEPT:

e) Increaseddiscomfortfollowingcompulsiveact(seepage289)

Chapter 18AbnormalmovementincatatoniaincludeallthefollowingEXCEPT:

d) Cataplexy(seepage304)Motivationcanbedefinedas:

d) Arewardsystemthatgovernsandregulatesbehaviour(seepage295)ImpulsivityinvolvesallthefollowingEXCEPT:

c) Preferencefordelayedlargerrewardoversmallbutimmediatereward(seepage300)

Chapter 19Paranoidpersonalitydisordercanbedefinedasadisorderinwhich:

a) Anindividualmistrustsothersandisundulysuspicious(seepage320)InDependentPersonalityDisorderthefollowingfeaturesalloccurEXCEPT:

b) Perfectionisticdisposition(seepage326)ThefollowingconditionshavebeenshowntobefrequentlyassociatedwithanankasticpersonalitydisorderEXCEPT:

c) Alcoholdependencesyndrome(seepage324)

Chapter 20IllnessbehaviourisinfluencedbyallthefollowingEXCEPT:

e) Theunderlyingbiologyofthecondition(seepage335)AllthefollowingindividualshavemadecontributionstoourunderstandingofhealthanddiseaseEXCEPT:

b) AaronBeck (well-known topsychiatrists as creatorof cognitivebehavioral therapyandnotanauthorityonconceptofillnessanddisease)

PracticalapplicationsofpsychopathologyincludeallthefollowingEXCEPT:d) Nosology(seepage340)

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Chapters 3 and 41. A75-year-oldfemalepatientisfoundwanderingthestreets.Onexaminationshedoesnot

knowthedate,day,time,season,placewheresheisandherownaddress.D. Disorientation(seepage49)

2. An 18-year-old male patient presents with a history of several and irresistible periods ofdrowsinessduringtheday.Atnighthereportsperiodswhenheisfullyawakebutunabletomovehislimbs.

E. Hypersomnia(seepage52)3. Thepartnerofa25-year-oldmalepatientaccompanieshimtotheoutpatientappointment.

Shereportsthathetalksinhissleep,wandersaimlesslyinthebedroomforafewminutesatnightandthathehasnorecollectionoftheseincidents.

H. Parasomnia(seepage52)4. A47-year-old femalepatientwith ahistoryof recurrentdepression is admitted in amute

state.Sheisimmobilebutfullyconsciousandalert.Sheisabletomakeeyecontactbutdoesnotrespondtoanyattemptatverbalcommunication.

I. Stupor(seepage52)

Chapter 51. A20-year-oldmalepatientwasinvolvedinaroadtrafficaccident.Hesustainedheadinjury.

He was only able to recall events that happened approximately five minutes before thecollision.

J. Retrogradeamnesia(seepage61)2. A 20-year-old male patient presented in prison whilst on remand. When examined he

respondedtoquestionsaboutthedateandthecapitalofFrancewithapproximateanswers,disorientationfortimeandplace.

F. Ganserstate(seepage68)3. A45-year-oldmalepatientwasinvolvedinanaccidentatworkwherehesustainedaserious

headinjuryandlostconsciousness.Onregaininghisconsciousnesshecouldonlyrecalleventsthathappenedapproximately36hoursaftertheincident.

A. Anterogradeamnesia(seepage61)4. A57-year-oldmalepatientwithanestablishedhistoryofimpairmentofshort-termmemory

inthecontextofalcoholabuserespondedtoquestionsaboutwhathehadspentthepreviousdaywithobjectivelyfalseaccountsthatincludedembellishmentsandintrusionsfrompreviousoccasions.

B. Confabulation(seepage62)

Chapter 71. A45-yearmanpresentswithacomplaintthathefirstsawablackcatatthecornerwherehis

drivejoinedthemainstreet.Afterthis,forthenext72hoursorso,hekeptseeingthesamecatatvarioustimesandsituations.Whatisthetermforthisexperience?

B. Palinopsia(seepage91)


2. A 19-year-old man with a recent diagnosis of schizophrenia complained that the faces ofpeople looking athimwould suddenly lookdifferent, as if theywerepulling faces athim.Sometimes, the faces would sinister, lopsided and strange. What is the term for thisexperience?

E. Paraprosopia(seepage91)3. A25-year-oldfemalepatientwithahistoryofcomplexfocalseizurescomplainedofscenes

andobjectsbecomingsmallerbeforeaseizure.Whatisthisexperiencetermed?D. Micropsia(seepage91)

4. A25-year-oldmalepatientcomplainedthatobjectslookedfaraway.Hefoundthissurprisinganddistressing.Whatisthisexperiencetermed?

G. Pelopsia(seepage92)

Chapter 81. A20-year-oldmalepatientwasadmittedintohospitalfollowinganattackuponhisfather.

Hereportedthathisfatherhadbeenreplacedbyarobotwholookedalmostexactlylikehimbutwasdefinitelynothim.Hefearedthatthis‘robot’hadmalignintentionsandthathislifewasindanger.Whatisthisbeliefcalled?

H. Delusionalmisidentification(seepage125)2. A40-year-oldfemalepatientcomplainedthatherlocalpriestwassendinghersecretmessages,

declaringhisfeelingsforher.Shecomplainedthatalthoughhewasthefatherofherchildhewasyettovisitthem.

G. Delusionoflove(seepage124)3. A21-year-old femalepatient suddenlybecameconvinced that shewas the rightfulheir to

thethroneofNorway.ShewasnotNorwegianbybirthorancestry.Whenaskedthereasonforthisbelief,shesaidthatshehadsuddenlycometothisrealization.Shedeniedanyotherunusualexperience.

B. Delusionalintuition(seepage116)4. A54-year-oldmalepatientwithalongstandinghistoryofschizophreniareportedpersistent

andstressfulauditoryverbalhallucinationsofderogatoryandthreateningcontent.ThevoiceswouldoftentellhimthathedeservedtobekilledandthatnewimmigrantsintohislocalareafromRomaniaweregoingtomurderhim.Hethenheldafirmbeliefthathewasatriskfromimmigrants,particularlyRomanians.Thisbeliefwasheldwithconvictionandwasimpervioustocounterargument.

E. Secondarydelusion(seepage113)

Chapter 91. A21-year-oldmaleuniversitystudentdescribedspendinga lotof timethinkingaboutthe

future,aboutthepossibilityofbecomingafamousmusician,becomingrichandabletoliveinamansioninFlorida.

A. Fantasythinking(seepage140)2. A 25-year-old female patient, newly admitted into hospital complained that her thoughts

were being interfered with. She was particularly distressed by the experience of havingthoughtsmanipulatedandtakenfromher.

I. Thoughtwithdrawal(seepage155)3. Inatest,a19-year-oldpatientwithadiagnosisofschizophreniarespondedtoaquestionin

thefollowingway:‘Whichofthefollowingareessentialpartsofaroom:walls,chairs,floor,window?’‘Chairs’.

G. Over-inclusivethinking(seepage149)

Self-ASSeSSment 2: AnSwerS 365

4. A57-year-old femalepatient said: ‘Iwas starting to feelhigh so I tieddumb-bellweightsroundmyankle’.

F. Concretethinking(seepage148)

Chapter 101. A65-year-oldright-handedmalepatient,whowasrecoveringfromaleft-sidedstroke,was

unabletofollowtheverbalcommand:‘Takethepaperwithyourlefthand,folditintwoandputitonthefloor’.

I. Receptivedysphasia(seepage163)2. A25-year-oldpatientsaid,‘Phlogonshaveinvadedmylungsturningfirstsidewaysandnow

medways’.J. Neologism(seepage168)

3. A64-year-oldmalepatientwithalongstandinghistoryofschizophreniarepliedtotheques-tion, ‘What have you got in your cup?’ ‘A fluid that whilst being colourless turns dark onbrewing’.

G. Metonym(seepage166)4. A 72-year-old male patient with a diagnosis of Parkinson disease said, ‘I’m star…, star…,

startingtothinkofmo…,mo…,mo…,movinghouse’.B. Logoclonia(seepage161)

Chapter 141. A23-year-oldmalepatientpresentedwiththebeliefthathismusclesweretoosmall,apreoc-

cupationwithphysicalbuild,excessiveexercisinganddisturbedeating.H. Muscledysmorphia(seepage234)

2. A 56-year-old female patient complained of hating her left hand. Although it lookednormal,shesaidthatshehateditandhadalwayswishedthatitwasdifferentinsize,shapeandfeel.

A. Misoplegia(seepage237)3. A27-year-oldmalepatientpresentedwith a longstandingbelief thathis facewasugly, in

particularhisnosethathethoughtwasfartoolargeandcrooked.Objectively,hisnosewasnotexcessivelylargeorcrooked.

B. Dysmorphophobia(seepage227)4. A40-year-old femalepatientpresentedwiththecomplaint thatshecouldcontinueto feel

hertoothbrushinherhandsforupto15minutesaftersheusedit.C. Palinaptia(seepage219)

Chapter 161. An8-year-oldmalepatientpresentedwithahistoryofheightenedstartlereflexcharacterized

by eye blinking, head flexion, abduction of the upper arms, movement of the trunk andbendingofthekneesinresponsetoaloudnoise.

C. Hyperekplexia(seepage265)2. A40-year-oldfemalepatientwithahistoryofrecurrentdepression,andcurrentlydepressed,

gaveahistoryofinabilitytoexperiencepleasureinherusualhobbiesandinterestsaswellasageneralinabilitytoexperienceanyfeeling.

A. Anhedonia(seepage261)3. A36-year-oldmalepatientpresentedtothelocaldentalhospitalwithanachingpaininboth

sidesofthelowerjawradiatingtothetemporo-mandibularjointsandtotheneck.Inresponse


tothequestion,‘Howareyoufeelinginyourspirits?’,heseemedpuzzledandaskedforthequestiontoberepeated.Hethensaid,‘MybodyisheavyandIamachingallover’.

J. Alexithymia(seepage268)4. A75-year-oldmalepatientwithadiagnosisofParkinsondiseasespokewithamonotonous

voice.Inadditionheseemednottorecognizetheemotionalmeaningofvariationsintoneofvoice.

F. Receptiveemotionaldysprosody(seepage269)

Chapter 171. A32-year-oldfemalepatientpresentedwithdiscreteepisodesofintenseandextremefear.

F. Panic(seepage283)2. A23-year-oldfemalepatientpresentedwithexcessivefear,self-consciousnessandavoidance

ofsocialsituationsduetothepossibilityofembarrassmentorhumiliation.J. Socialphobia(seepage285)

3. A27-year-oldmaleaccountancytraineepresentedwithahistoryofrepetitiveandintrusivethoughtsaboutcleanlinessandhygiene,whichwereassociatedwith increasingtensionandworry,andwhichherecognizedashisownthoughts.Hetriedtoresistthesethoughts,butfoundthattheybecameevenmoreurgentandintrusive.

H. Obsession(seepage287)4. A32-year-oldfemalepatient,whohadrecentlygiven,birthpresentedwithasixweekhistory

oftemperoutbursts,feelingsofhostilitytowardsherhusband,anunpleasantfeelingofdistressandimpatiencewithherchildren.

E. Irritability(seepage286)

Chapter 181. A 21-year-old male recently diagnosed with schizophrenia and treated with risperidone

complainsofmotorrestlessness,inneragitationandaninabilitytositstill.A. Akathisia(seepage308)

2. A17-year-oldmalepatientisbroughttotheattentionofhisgeneralpractitionerbecausehenewlyrecognizedaproblemwithgambling,drinkingexcessivelyandmisusingcannabis.Inadditionheisreportedaspronetolosinghistemperandliabletosaythingswhichhelaterregrets.

E. Impulsivity(seepage299)3. A21-year-oldmalepatientpresentedwithahistoryofepisodesofexcessivesleeping(amount-

ingtoup15hoursaday),excessiveeating,increasedsexuallibido,lowmoodandtransientpersecutorybeliefs.

G. Kleine–Levinsyndrome(seepage296)4. A 28-year female patient presented for the first time with markedly slowed movements,

sometimesresultinginimmobility,strangeposturesandmuteness.Onexaminationsheallowsherupperlimbstobeputinuncomfortableposturesthatsheholdsforlongperiodsoftime.

C. Catatonia(seepage304)

367

Pagenumbersfollowedby‘f ’indicatefigures,‘t’indicatetables,and‘b’indicateboxes.

AAbnormalpersonality,23,318–319Abnormality,9–10

typological,10Abstractions,142Achromatopsia,92Acquiredbraininjury,ofdelusional

misidentification,126Activity

disorderof,192–193inpersonalityassessment,24physiological,abnormalityof,268–269

Actual:idealself-discrepancy,232Actual:oughtdiscrepancy,232Adolescents

dissocialpersonalitydisorder,322obesity,230–231obsessive-compulsivedisorder,290

Adrenaline(epinephrine),258–259Advertence,305–306Affect

alterationin,delusions,120blunting,266definitionof,257–258difficultiesinthecapacitytoverbalize,268ofhopelessness,67perceptionassociated,92selectiveforgettingassociated,66

Affectillusions,94–95Affect-ladencomplexes,120Affectivedisorders,257–278

circadianrhythmsassociatedwith,82–83exacerbationofemotions,262–264falsificationofmemory,66volitionaldisturbances,298

Affectivepsychoses,auditoryhallucinations,98Affectiveresponse,todelusions,113After-image,96Age

disorientationin,77–78severityofirritability,287

Aggernaes,A.consciousness,disturbedstateof,37defectinrealitytestinginschizophrenia,149hallucinationsvs.perceptiondefects,96–97subjectivityandobjectivity,16

I N D E X

Aggression,300–301diminished,302excessive,302innatedriveandacquiredresponse,301

Aggressiveacts,299–302Aggressivebehaviours

inemotionallyunstablepersonalitydisorder,323psychiatricillnessand,302psychopathology,301–302inschizophrenia,302

Aggressivenessdecreased,302definition,300–301

Agitation,144,303indepression,303inphysicalillness,303

Agnosia,162prosopoaffective,269visualobject,87–88

Agnosicalexiawithoutdysgraphia,162–163Agoraphobia,212,284Agrammatism,168–169Agraphia

alexiawith,164pure,164

Akataphasia,166Akathisia,308,357,366

dyskinesiaassociation,309subjectivecomponents,308b

Akinesia,307–308Akinesis,304Akineticmutism,42Akinetopsia,92Alcohol

craving,288–289diminishedpainsensation,248mania,298–299pathologicalintoxication,40–41withdrawalstates,exaggeratedstartlereflex,265

Alcoholabuse,delusionsofjealousyand,123–124Alcoholichallucinosis,chronic,98Alertness,45

increased,depersonalisation,211Alexia,100,162–163

withagraphia,164withoutdysgraphia,162–163

Alexithymia,351,356,361,366Alloaesthesia,92–93,219tAlogia,168Alteration,depersonalisationtheories,211

368 Index

Alzheimer’sdisease,visualhallucination,100Ambiguity,toleranceof,99Ambitendency,305Amnesia

anterograde,61dissociative(hysterical)fugue,67–68one-way,197organic(true),61psychogenic,67retrograde,61

Amnesicsyndrome,178–179Amok,239tAmputee/amputation

bodyimage,234grief,274phantomlimb,237,250

Analgesia,psychological,246Analogicreasoning,141Analytical(dynamic)psychopathology,4–5Anankasticpersonalitydisorder,324–325,352,

362Anankasticpersonalitytraits,324Anastrophy,120Anger,intensificationof,265Angst,280–281Anhedonia,261–262,270,296,356,365

indepression,298Animalphobias,284Anorexia,297Anorexianervosa,231–233Anosognosia,178–179,236Anosognosicoverestimation,237Anterogradeamnesia,354,363Antipsychoticdrugs,extrapyramidalsideeffects,

307–309,308bAntisocialbehaviour,322Antisocial(dissocial)personalitydisorder,321–322Anxiety,280–286

acute,282characteristicof,280–281depersonalisation,212free-floating,280–281general,283inhypochondriasis,222–223normal,280inotherdisorders,286pathological,280self-description,283situational,283stressassociated,280symptomsof,280–281,281b

three-dimensionalmodel,282fAnxietydisorders,286

depersonalisation,210ideationalcomponents,282

Anxietystates,280–281Anxiousfeeling,283Anxiouspersonalitydisorder,327Anxioussearching,ingrief,274Apathy,ofdepression,274Aphasia,162

motor,164–165subcorticalvisual,162–163

Aphonia,161dissociative,161

Apophany,119Appearanceofpatient,observationof,26,345,

359Appetite

abnormalities,297bexcessive,297loss(anorexia),297inschizophrenia,297–298

‘Appetitecentre,’296–297Apprehension(lossofintellectualgrasp),49Approximateanswers,68,169Argyle,M.,non-verbalcommunication,190–191Arousal,physiological,abnormalitiesof,260bArousalsystems,ofconsciousness,37f‘Asif ’feeling,205Aschemazia,235–236Asocial(dissocial)personalitydisorder,321–322Associations

clang,168constellationof,167–168modelsbasedonJaspers,142–143,142fpsychosisof,130ofthoughts,lossofcontinuityof,166

Astasia-abasia,225,225fAsthenopia,223–224Asyndesis,149,166Atmosphere

delusional,118ideasarisingfrom,114

Atrabilious,220Attention,46–49,346,359

alterationofdegreeof,46–48alternating,46,47tcapacity,46,47tdeficits,48divided,46,47tfocused/selective,46,47tinvoluntary,45narrowingof,46inpainperception,248psychosisand,48–49sustained(vigilance),46,47tvoluntary,45

Attentiondeficit/hyperactivitydisorder,303–304Attitudinalbodydissatisfaction,232

Index 369

Attributionindelusion,122hypochondriasis,221

Atypicalfacialpain,250Auditoryhallucinations,15,97–100

conditionsassociatedwith,98delusionalatmospheremanifestingas,118elementary,97–98inmentalstateexamination,26persecutory,98schizophrenia,341

Auditoryperception,14Aura,epileptic,41Autochthonousdelusions,116Autochthonousidea,114Autogynephilia,230Autohypnosis,55Automaticcognitiveprocesses,46Automaticobedience,305–306Automatism,41–42,346,359

epileptic,41,52–53sane,53

Autoscopy(heautoscopy),105,194–196,349,361

Aversion,306Avoidantpersonalitydisorder,325–327Awareness,46–49

delusional,119ofexperience,36heightened,37inner,191–192ofpersonality,labilityin,197variationsinlevelof,47f

BBehaviours

aggressive.seeAggressivebehavioursantisocial,322duringautomatism,41characteristic,personalityrevealedby,23indescriptivepsychopathology,4,4fdeviant,duetodelusions,113disturbance,310–312

schizophrenia,310–311exploratory,abnormalities,296,297bmaladaptive,299–300observationof,5–6,26,345,359relationshiptoneedandinstinct,294fviolent.seeViolentbehaviours(violence)

Being,disorderof,192Beliefs,111–113

aboutthebody,disordersof,218–224,220fassessmentof,27–28delusional,112

false,111delusionsas,131–132

folk,129non-delusional,113religious.seeReligiousbeliefssymbolic,120

Belleindifference,227Bereavement,feelingofloss,274–275Berner,P.,delusionalatmosphere,118Berrios,G.E.

delusions,112pseudohallucinations,104

Bias,informant,22Bigorexia,234Biologicaldisadvantage,8–9Biologicalrhythms,77

andpsychiatry,82–85Bipolardisorders

insightand,181–182moodin,abnormalityof,270

‘Blackbile,’266Blindness

bodyimage,234cortical,100,178–179pureword,162–163

Blunting,offeeling,266Bodilyfeelings,associatedwithemotion,266–267Bodilyfunction,disordersof,224–227Bodilysensation,hallucinationof,102–103Body

disordersofthephysicalcharacteristics/emotionalvalueof,227–234

dissatisfaction,bulimianervosa,234experience,235physicalityof,217–218size,disturbanceof,230–234

Bodyawareness,191disorderof,217–244

classificationof,218,219tsensory,234–238

Bodycathexis,189Bodychecking,234Bodyclock,primaryinternal,82Bodyconcept,189Bodydysmorphicdisorder.seeDysmorphophobiaBodyimage,188–189,235

culture-bounddisordersof,238–239,239tdevelopmentof,189,190fdiminished/absent,235–236distortion,233,236–238disturbance,238organicchangesin,234–238pathologicalaccentuationof,235sensoriumof,247socialaspects,189

370 Index

Bodyintegrityidentitydisorder,229Bodyschema,189,235Borderlinetypepersonalitydisorder,323–324Bottom-upprocessing,visualrecognition,88Braintrauma,40

retrogradeamnesia,61Brainstemlesions,dysarthria,161Broca’sarea,164Bulimia,297Bulimianervosa,233–234Burningmouthsyndrome,251

CCannabis,depersonalisation,211Cannon-Bardtheoryofemotion,258–259Capacity,forinsight,176Capgras’syndrome,125Cartesiandualism,17Casevignettemethod,181–182Cataplexy,52Catatonia,304–305,310,351,357,362,366

lethal(pernicious),305Catatonicschizophrenia,304–305,310Catego,classificationofsymptoms,337–338Category-basedinduction,141Categoryboundary,broadeningof,149Centralexecutive,short-termmemory,60Cerebrovascularaccidents

delusionalmisidentification,126intime-lapsephenomenon,80

CharlesBonnet’ssyndrome,101Cheek,stroking,312Children

attentiondeficit/hyperactivitydisorder,303–304

dissocialpersonalitydisorder,322non-accidentalinjury,322

Chomsky’stheoryoflanguage,160–161Chronology,disorderof,78Circadianrhythms,82–83Circumstantiality,348,360Cleanliness,obsessional,288Closure,principle,completionillusionand,

94Clothing

choice,bodyimageand,191inmania,312

Clozeprocedure,170modified,170reverse,170

Clozetechnique,348,360Cocaineaddiction,130Coenaesthesia,267Coenestopathicstates,267

Cognition(s)indelusions,121–122emotions,relationship,259,269languagerelationship,160

Cognitiveimpairment,insightand,180–182Cognitiveprocessing,impairment,inauditory

hallucinations,99Cognitivestate,assessmentof,28Cohesiveties(links),169Coid,J.,maniaàpotu,components,41Colostomy,bodyimageafter,238Colourperception,91–92Colourvision,lossof,100Coma,38–39Communicatedinsanity,130–131Communication

descriptivepsychopathologyapplication,340

ofemotions,260phenomenologyinvolving,10skillsandtechniques,345,359

mentalstateexamination,25bforunderstandingofpatient’ssymptoms,10

Compliancewithtreatment,insightand,181Comprehensionofspeech,disordersof,163tCompulsions,assessmentof,28Compulsions/compulsivebehaviours,287–290

nolackofinsight,288Compulsiveideas,explanationfordoubling,

189Compulsiveimage,289Concentration,46–49Conceptualthinking,141–142Concretethinking,148,355,365Confabulation,62–64,346,354,359,363

characteristics,63bofembarrassment,62–63fantastic,63

persecutorycontent,63–64momentary,63schizophrenia,63–64social,63

Configuralmodel,88Conflictofinterest,20–21Confusion,40Confusionpsychosis,143Consciousness,34

arousalsystemsof,37fchangesof,qualitative,39–40cloudingof,36,38definition/meaningof,34dimensionsof,36diminished,levels(stages)of,38fdisturbed,33–43fluctuationof,39–40

Index 371

heightened,37intentional,34limittonumberofitemsin,35loweringof,quantitative,37–39pathologyof,37–42ofself,36

Consolidation,delusionorigin,120Constellation

ofassociations,143ofsymptoms,336

Constriction,inanxiety,280–281Consultingbehaviour,hypochondriasis,221Content

ofdelusions,131–132disorder,inmorbidjealousy,123ofexperience,14–15hypochondriacal,15

Continuity,feelingof,197Continuityview,5Conversion,67–68,224–227,361

conceptof,350Conversionhysteria,218Copingbehaviour,andlifeepoch,84fCoprolalia,309Cortisol,levelof,changesindepression,83Cotard’ssyndrome,127–128Counterfactualthinking,141Creative,inadequateandaggressivepsychopathy,

322Criminalpsychopathy,319Crowdingofthought,147Cryptamnesia,67Cryptographia,162Cryptolalia,162Cues,formemoryretrieval,61Culturalfactors

bodyimagedisorders,238–239,239temotions,259hallucinations,97insight,182

Cutting,J.hallucinations,95pathologyofemotions,260

Cyberchondriasis,222Cycloidpsychosis,143Cyclothymia,326–327Cyclothymicpersonality,258

DDaydreams,63

pareidolicillusionsvs.,95personalityassessment,24

Deaffectualisation,209,261Decision-making,mania,298–299

Defencemechanismsdefectofmemoryrecall,67ego,4

Déjàvu,62,81,209,347,360brainstimulationand,81temporallobedisorder,65intemporallobeepilepsy,81

Delirium,39,346,359definitionof,39occupational,42

Deliriumtremens,visualhallucination,100,102fDelusions,111–137,348,360

actingon,132affectiveresponseto,113ofalienforcescontrolling,338–339assessmentof,27–28attributionin,122autochthonous,116characteristicsof,112cleanlinessinvolvement,130cognitionandreasoningin,121–122communicatedinsanityand,130–131contentof,123–131ofcontrol,28,103,150–152,154–155,338–339

internetinvolvement,123ofthought,348,360

defect,theme,121definitionof,112–113delusion-likeideasvs.,115–116deviantbehaviourdueto,113disturbanceof,148dysmorphic,129factorsinvolvedin,120basfalsebeliefs,131–132asfalsejudgements,111grandiose,126ofguilt,127inhypochondriasis,223ofinfestation,129–130ofinfidelity,123–124ofintegration,336–337oflove,124–125,354,364andmeaninginlife,122meaningof,112–113mimickingdisorientation,49–50ofmisorientation,49–50motivationaltheme,121nihilistic,127–128,349,361originsof,119–122

factorsinvolved,119Garety’smodel,121–122Germantheories,119–120

overvaluedideavs.,132paranoid,133patient’sviewof,27–28

372 Index

ofpersecution,123ofpoverty,127–128primary,113–115,338–339,347,360

typesof,115–119realityof,131–132ofreference,133religious,126–127retrospective,118secondary.seeDelusion-likeideas(secondary

delusions)sexualcontentof,124ofunworthiness,127violentbehaviourinresponseto,132

Delusion-likeideas(secondarydelusions),133–134,140,148,222–223,348,355,360,364

Delusionalatmosphere,118Delusionalawareness,119Delusionaldisorder,128–129Delusionalevidence,128Delusionalidea,116Delusionalintuition,354,364Delusionaljealousy,123–124Delusionalmemory,66–67,118–119

delusionalretrospectivefalsificationvs.,66–67Delusionalmisidentification,125–126,354,364Delusionalmisinterpretation,117Delusionalmood,118Delusionalperception,120,153Delusionalpercepts,14–15,116–117

examplesof,153Delusionalretrospectivefalsification,66–67Delusionalsignificance,119Dementia

ofdelusionalmisidentification,126disorientation,49

Dependentpersonalitydisorder,326,352,362Depersonalisation,192,205–215,350,361

alterationofconsciousness,211anxiety,212assessmentof,28componentsof,206b,350,361considerations,212–213definitions/descriptions,205–210definitivefeaturesof,349,361indepression,212derealisationwith,207diminutionofintensity,261dissociationassociated,210dizziness,212drugscausing,211fatiguein,207manic-depressive,212moodchangewith,208onset,210

organicandpsychologicaltheories,210–211personality,209aspreformedfunctionalresponse,210–211psychoanalytictheory,212self-inducedepisodes,210self-perceptionrelationship,207socialandsituationalaspects,209–210subjectiveexperience,208–210assymptom,207timesensedistorted,209

Depersonalisationsyndrome,129,208,212culture-bound,koro,209symptoms,208

Depictiontheory,ofmentalimagery,89Depressiosinedepressione,270Depression,144,257–258,270,274

agitated,303anhedonia,298atypical,250biologicalrhythmdisorderin,82–83circadianrhythmchangesin,83clinicalassessment,13coreexperience(psychological/physical),

270–271delusions

ofguiltandunworthiness,127hypochondriacal,128ofpersecution,123ofpoverty,127–128religious,126–127

depersonalisation,212emotionsof,265andloss,273–275memoryimpairment,65moodchart,261fmotivationimpairment,298passageoftimedisorders,78posture,312preoccupationwithgloomythoughts,48reactive,histrionicpersonalitydisorder,324retardation,298,304smiling,271suicidalthoughtsin,272–273symptomsof,frequencyof,272tvitalfeelingsof,247

Depressivefacies,312Derailment,inthinking,145,146f,167Derealisation,92,208

depersonalisationwith,207timeexperienceloss,81

Descriptivepsychopathology,336,345,359applicationsof,340behaviourdescriptionin,4,4fcontinuityanddiscontinuityviews,5definitionof,3–4

Index 373

egodisordersandselfdisorders,191–192empathyin,3–4,6,345fundamentalconceptsof,3–18mind-brainduality,17organicandneuralsubstrates,17phenomenologyand,6–8research,340–341unconsciousexperience,16understandingin,345vs.psychoanalytic,5t

Desomatization,209Determiningtendency,47,143Diabetesinsipidus,nephrogenic,297Diagnosis,psychiatric,21

definitionof,333descriptivepsychopathologyapplication,340hierarchical,336–337importanceof,333postscript,339–342PresentStateExamination,283psychopathologyand,333–343symptomstoformdiagnosticcategories,

336–339Diencephaliclesions,inchronologydisorders,

78Digitspan,180Disasterimage,289Discontinuityview,5Diseases,definition,8–9Disgust,222,290Disinhibition,300Disorderedself.seeSelf,disordersofDisorganisationsyndrome,150–151Disorientation,49–50,353,363

inage,77–78delusionsmimicking,49–50dissociationand,50hysterical,50ofidentity,49forperson,49situational,49intime,49,77

Disruptiveimage,289Dissocialpersonalitydisorder,321–323Dissociation,67–68,140,224–227,361

inanxiety,281conceptof,350depersonalisationassociation,210disorientationand,50

Dissociativedisorders,depersonalisationas,210

Dissociative(hysterical)fugue,67–68Distractibility,47Distraction,auditoryhallucinationreduction,

99

Dizziness,depersonalisationand,212Doppelgänger,194Dosulepin(dothiepin),250–251Doublebook-keeping,177Dream-like(oneiroid)state,42Dreams,24,53–54,193,346,359

inREMsleep,53–54unpleasant,53–54

Drive,294–295abnormalities,296,297b

organiccauses,296–297biological,296–297definition,294diminution,296exacerbation,296innate,aggressive,301

Drivelling,146Drowsiness,36,38

incloudingofconsciousness,38Drugs

antipsychotic,extrapyramidalsideeffects,307–309,308b

depersonalisationdueto,211visualhallucinationsdueto,101

DSM-IV(DiagnosticandStatisticalManualofMentalDisorders,fourthedition)

delirium,39personalitydisorders,319,320t

Duality,mind-brain,17Dynamic(analytical)psychopathology,4–5Dysarthria,161Dyschromatopsia,92Dyskinesia,tardive,akathisiaassociation,309Dyslexia,100Dysmnesticsyndromes,60Dysmorphicdelusions,129Dysmorphophobia,133,218,219t,220f,227–229,

356,365abnormalitiesin,229complaintof,228

Dysphasia,162conduction,163jargon,164motor,162

primary,164transcortical,164

nominal,164receptive,163sensory,162–164

primary,163transcortical,164

subcorticalauditory,162syntactical,163types,163t

Dysphonia,161

374 Index

Dysphoria,emotional,261Dysprosody

expressiveemotional,269–270receptiveemotional,269–270,356,366

Dysthymia,327Dystonia,308–309Dystonicreactions,acute,308–309

EEating,disturbanceof,230–234Echolalia,161Echopraxia,305–306Ecstasy,200–201,262–264

anthropologyof,264characteristicof,264inmania,212

Ecstaticexperiences,religiousexperiencesvs.,264

Ego,187–188disturbances,schizophrenia,212Freud’sconcept,188pluralityofconceptions,187–188

Egoactivity,192–193Egoboundaries

changein,ecstasy,264loss,200

Egoconsistency,193–197,193bEgodefencemechanisms,4,141Egodemarcation,197–201Egovitality,192,349,361Ekbom’ssyndrome,129Ekman’sbasicemotions,351,362Electroconvulsivetherapy(ECT),memory

disturbance,64–65Emotions

abnormalitiesofappropriateness,266–268abnormalitiesofevaluation,269–270abnormalitiesofexpression,266–268basictypesof,259

pathologicalchangesin,260bodilyfeelingsassociatedwith,266–267changesinintensity,261–265changesintiming,duration,andappropriateness

tosituation,265–266cognitionrelationship,269culturalinfluences,259

definition,257–258definitionof,257disordersof,257–278exacerbationof,262–264expression,shallownessof,265free-floating,268lability,histrionicpersonalitydisorder,324nonverbalcommunicationof,260

pathologicalchangesin,261–268classificationof,260

inpsychiatry,258theoriesof,258–259

Emotionaldetachment,inschizoidpersonalitydisorder,321

Emotionaldisordersbehaviouralsigns,311–312classificationof,260b

Emotionaldistress,symptomsandsignsof,eliciting,19–20

Emotionalnumbness,208,274Emotionalsensitivity,lackof,266Emotionallyunstablepersonalitydisorder,323–324

borderlinetype,323–324impulsivetype,323

Empathy,12–14,359assessmentofsubjectiveexperience,5indescriptivepsychopathology,3–5,345genetic,114lackof,schizoidpersonalitydisorder,321meaningfulunderstanding,11–12method,13,26therapeutictool,14

Endorphins,246Epidemichysteria,263–264Epilepsy

ofdelusionalmisidentification,126ecstasyin,263–264fluctuationofconsciousness,39–40gelastic,265pathologicallaughter/cryingin,265

Epilepticaura,41bodyimagedistortion,237

Epiphenomena,5Erotomania,124–125Erroneousideas,delusionsand,111–137Euphoria,263Evileye,239tExcitement,inschizophrenia,310Execution,disordersof,293–314Exosomesthesia,93,219tExpansive(grandiose)delusionalbeliefs,126Experience

abnormalityof,268–269formandcontent,14–15subjectivityandobjectivityin,15–16

Explanation,11staticandgenetic,12bunderstandingvs.,11t

Explanatorypsychopathology,4Exploratorybehaviour,abnormalities,296,297bExpressiveemotionaldysprosody,269–270Expressiveemotionalprosody,269–270

Index 375

FFaceprocessing,impairmentsof,229Facialexpression,unchanging(bluntingoffeeling),

266Facialpain,atypical,250Faciobuccolinguomasticatorydyskinesia,309Factualhistory,22–23Falseidentity,67–68Falsememorysyndrome,69Falsification

delusionalretrospective,66–67memory.seeMemory,falsification

Familiarityfeelingof,208

lossof,depersonalisation,208knowingbasedon,61–62

Familyhistory,22Fantasticinterpretations,pareidolicillusionsvs.,

95Fantasy,111

capacityfor,55dream,53explanationfordoubling,193inhypnosis,55

Fantasylife,studyof,personalityassessment,24Fantasythinking,140–141,355,364

andsexualassault,140Fatigue,depersonalisationassociated,207Fear

ofdeath,222illness,285intensificationof,265obsessional,286performance,285

Feature-matchingmodel,88Feelings

anxious,tense,283attachedtoperceptionofobjects,267–268bluntingof,266definitionof,257–258directedtowardpeople,268flatteningof,266lossof,261

Fenwick,P.,automatismdefinition,41Five-Factormodel,ofpersonality,318–319Fixedidea,321Flattening,offeeling,266Flightofideas,143,143f,169

mania,298–299Flowofthought,interruptionto,145–147Fluencyofassociation,149Folieàdeux,131Foliecommuniquée,130Folieimposée,130Folieinduite,130

Foliesimultanée,130Forcedgrasping,305–306Forgetting,60

ofdisagreeable,67influenceofaffect,66rates,66selective,66

Form,14–15definitionof,14

Formconstants,90Formalthoughtdisorder,139–140Formication,103Free-floatingemotion,268Frégoli’ssyndrome,125Freud,S.

dreams,54insight,178instinct,294–295

Frigophobia,239tFrontallobelesions,chronology(temporalorder),

disorderof,78Fullbodytechniques,232Functionalimaging,visualimagery,89Functionalneurologicalsymptomdisorder,

225Fusion,ofthoughts,145,146f

GGanserstate,40,68–69,353,363Ganser’ssyndrome,featuresof,68–69Generalparesis,40,263–264

falsificationofmemory,66Generalizedanxietydisorder,281–282

panicdisordervs.,283–284Genuineness,lacking,inhistrionicpersonality

disorder,324Gerstmann’ssyndrome,236Gestaltpsychology,insightconcept,178Gesticulation,reducedinretardation,304Gestures,164

non-verbalcommunication,189–190,260GillesdelaTourette’ssyndrome,309–310GlobalInsightScale,179Grammar,160

destructionof,inschizophrenia,168–169mental,160–161

Grammaticalconstruction,disorderof(paragrammatism),162

Grandiosedelusions,126Grief,274–275

delayed,265morbid,patternsof,274pathological,265

Grimacing,305

376 Index

Guiltdelusionsof,127feelingsof

indepression,271eatingdisorder,234

Gustatoryhallucination,103

HHallucination,91,95–104

autoscopic,194characteristics,95cognitiveapproachtoinvestigation,96conceptsofRasmussen,96–97culturalfactors,97elementary,97–98extracampine,105functional,14,106

pareidolicillusionvs.,95gustatory,103haptic,103hygric,102hypnagogic,51–52,105–106hypnopompic,51,105–106kinaesthetic,102Lilliputian,97musical,97–98normalperceptsrelationship,95–96asnormalsensoryexperience,95–96olfactory,103reflex,106thermic,102visceral,103visual.seeVisualhallucinations

Handbehaviour,311Handwashing,286Handshake,311Hangover,92–93Happiness,heightenedstatesof,263–264Headinjury

hyperactivityafter,303obsessionalbehaviour,289–290

Healthconceptsof,334–336normal,9–10

Healthbeliefs,181Heautoscopyproper,194Hebephrenicpatients,schizophrenia,149–150Hemianopia,homonymous,162–163Hemidepersonalisation,236Hemimicropsia,91Hemiplegia,left-sided,178–179Hemisomatognosia,236Hemispatialneglect,236Heterophenomenology,methodof,33–34

History,takingof,22family,22past,22personalhistory,22–23

Histrionicbehaviourindepression,271ecstaticstateof,263–264

Histrionicpersonalitydisorder,104–105,324Hoarding,schizophrenia,311Homicide,delusionsofguilt,127Homonymoushemianopia,100HospitalAnxietyandDepressionScale,283,

283fHunger,296Hunttest,171Huntington’schorea,309Hyperacousia,247Hyperactivity,303–304

restless,303Hyperacusis,92–93Hyperekplexia,265,356,365Hyperkinesis,303Hyperkineticdisordersinchildhood,46–47Hyperschemazia,235Hypersomnia,51–52,296,353,363Hypnosis,54–56

fantasyin,55inductionof,55

Hypochondriacaldelusions,128–130Hypochondriacalpsychosis,monosymptomatic,

129Hypochondriasis,128,218–224,220f,361

contentof,222–223determinantsof,350psychopathologyof,222–224,223b

Hypochondrium,220,221f,266Hypomania,275Hyposchemazia,235–236Hysteria,224,249

conversion,218epidemic,263–264mass,263–264symptoms,67–68visualfieldsofpatientwith,226f

Hystericalconversion,140

II-ness,191–192ICD-9,persistentmooddisorders,326ICD-10

delirium,39delusionaldisorders,128–129persistentmooddisorders,326personality,319–320

Index 377

‘Ideal,’normalas,23Ideas,111–113

assessmentof,27–28delusion-like,115–116delusional,116fixed,321ofpersecution,320self-referent,320

Ideation,16erroneous,132–134

Idéefixe,321Identity

disorderof,197–200temporaryloss,198

Illness,8–9behaviour,335fear,285aslossofwell-being,266personal,336–337physical,anxietyin,286

Illnessbehaviour,222,352,362Illogicality,167Illusion,94–95,94f

affect,94–95completion,94pareidolic,95

Imagery,88–89abnormal,106–107characteristicsof,88–89,89tvisual,89vivid,91

Imagescharacteristicsof,360formalcharacteristicsof,347vividinternal,pseudohallucinations,104

Imagination,141Impulse

insane,301–302resistance,300

Impulsecontroldisorders,300excessivecontrol,300

Impulsiveacts,294,299–302examples,301violent,300voluntaryinhibitions,300

Impulsivebehaviour,300emotionallyunstablepersonalitydisorder,

323psychopathology,301–302inschizophrenia,310

Impulsiveinsanity,301–302Impulsivity,300,352,357,362,366

features,300venturesomenessversus,299–300

Inattention,children,46–47

Infestations,delusionsof,129–130Infidelity,delusionof,123–124Informationprocessing,abnormality,delusions,

121–122Innerheautoscopy,194Insanity

communicated,130–131moral,322

Insight,175–184,349,361assessmentof,28,176–177,345inbipolardisorders,181–182capacity,176inclinicalpractice,176–177cognitiveimpairmentand,180–182compliancewithtreatment,179,181concept,178–180

criticisms,182development,178–179Gestaltpsychology,178socialandculturalfactors,182

intoillness,176impaired,aetiology,182intellectualperformanceand,180lackof,178–179measurement,179–180neurologicalbasis,180inschizophrenia,180assudden,unexpectedsolutiontoproblem,

178treatmentaffectedby

outcome,181validmeasuresof,349,361

InsightandTreatmentAttitudesQuestionnaire(ITAQ),179

InsightScaleforPsychosis,179Insomnia,50–51

early,51late,51

Instinctabnormalities,296–299definition,294relationshiptoneedandbehaviour,294f

Instinctualdrive,294Insulin,296–297Intellectualfunction,andlifeepoch,84fIntellectualgrasp,loss(apprehension),49Intellectualperformance,insightand,180Intentionalstance,33–34

consciousnessand,34Interests

loss,indepression,298inpersonalityassessment,24

Interviewsshort,21speechandthoughtassessment,27

378 Index

Irritability,286–287,357,366andanxiety,286outwardlyexpressed,286severityandageaffecting,287

Itchpruritogenic,251–252psychogenic,251–252

JJamaisvu,62,81,209

temporallobedisorder,65James-Langetheoryofemotion,258Jaspers,K.

delusions,132disorderofidentity,197hallucination,95imagesandimagery,88–89insight,176phenomenology,7pseudohallucinations,104self-awareness,191–192timedisorders,75unconsciousness,34understandingvs.explaining,11urge,instinctualdriveandvolitionalact,294

Jealousy,morbid,123–124,320–321Jee,266Jetlag,82Judgement,147

disturbanceof,147–151false,delusionsas,111

‘Jump-to-conclusions’style,121–122

KKeyexperience,delusionsorigin,120Kleine-Levinsyndrome,52,296–297,346,357,

359,366Knowing,rememberingvs.,61–62Koro,129,209,238–239,239tKorsakov’ssyndrome,61

confabulation,62–63passageoftimedisorders,80

Kraepelin,Emilreligiousdelusions,126–127sexualjealousy,123

LLabelling,ofdisorders,21Language

Chomsky’stheoryof,160–161disordersof,159–173

organic,162–165

pragmatics,160psychogenicabnormalities,169–170statisticalmodelof,170

Latah,239t,265Law,descriptivepsychopathologyapplication,340Learningdisability,anxietyin,289–290Learningtheory,301Lifeepochs,85

psychiatricdisturbanceand,84fListening,forunderstandingofpatient’ssymptoms,

12–13Locked-in-syndrome,42Logoclonia,161,355,365‘Loners,’321Long-termmemory,347,360Loss

anddepression,273–275external,subjectexperience,274

Lovebeing‘inlove,’189delusionsof,124–125

Lucidity-clouding,36Lycanthropy,199–200Lying,fluentplausible(pseudologiafantastica),66Lysergicaciddiethylamide

depersonalisation,211painsensationincreased,247

MMacropsia,91Macrosomatognosia,235Madeexperiences,154–155Maher,BA,inlanguagedisorders,168Mania

affectandemotionaldisorderin,275clothing,312exacerbationofemotions,262–264falsificationofmemory,67flightofideas,298–299grandiosedelusion-likeideas(secondary

delusions),126insight,181–182joyandpleasurefeelingsof,263motivationabnormality,296passageoftimedisorders,80speech,162volitionaldisturbance,298–299

Maniaàpotu(pathologicalintoxication),40–41,346,359

Manic-depressivedisorder,depersonalisation,212

Manic-depressivepsychosis,143Manipulativeness,histrionicpersonalitydisorder,

324

Index 379

Mannerisms,305,311Masshypnosis,198Masspsychogenicillness,225–226,350,361Masssociogenicillness,225–226Mastectomy,238Masturbation,335Maternalreverie,141Meaning,alternativetests,99Meaningfulconnections,15

delusionsand,114Medialthalamus,sleepstagesand,50Megaphagia,52Melancholia,220,262–264,266,270,303

delusionsofpersecutionvs.,123Memory

acoustic,errors,67bias,inaffectivedisorder,65cueforretrieval,61declarative(explicit),60delusional,66–67,118–119disturbanceof,59–71

ECTand,64–65psychogenic,67–69

dualprocesssystem,61–62echoic,59–60episodic(autobiographicalincidents),60–62false,delusionalmemoryas,119falsification,66–67

see alsoConfabulationiconic,59–60impairment/disorder

affective,65–69organic,61–62inschizophrenia,65temporallobedisorder,65see alsoAmnesia

implanted,falsememorysyndrome,69long-term,60,347

functions,60lossforwords,67mechanisms,59–60mood-congruent,65non-declarative(implicit),60recall,60

impairment,61inaccuracy,67panoramic,65

recognition,60impairment,61–62

recovered,69registration/encoding,60

impairment,61retention,60

defectinducedbyECT,64impairment,61

retrieval,60direct,61impairment,61indirect(strategic),61

semantic(factmemory),60errors,67

sensory,59–60short-term,60,346state-dependent,65storage,60working,60

Menstrualcycle,83Mentalarousal,excessive,ininsomnia,50–51Mentalillness,8–9

classification,337bcategoricalvs.dimensional,337

elicitingsymptomsof,19–29onsetafternormalhealth,336syndromes,336

Mentalimagery,89,141auditoryhallucinations,99

Mentalimages,hallucinationas,96Mentalretardation,304

diminishedpainsensation,248Mentalstate,22

examination,25–26Mescaline

depersonalisation,211visualhallucinationdueto,100–101

Metamorphopsia,91Metonyms,166,355,365Micropsia,91,354,364Microsomatognosia,235Mind,philosophyof,17Mini-MentalStateExamination,28Mirrorneurons,259–260Misidentification,delusional,125–126Misnamingobjects,67Misoplegia,219t,237,356,365Mitgehen,305–306Mixedaffectivestates,144,303Mixedpersonalitytypes,320Mixing,146Monthlycycles,83Mood,351,362

abnormalitiesof,classificationof,257inbipolardisorder,abnormalityof,270communicationof,259–260definitionof,257delusional,118depersonalisation,208indepression,270–275disturbance,257diurnalityof,83elevationof,263

380 Index

histrionicpersonalitydisorder,324labilityof,265lifeepochand,84fnormal,258persistentdisorders,326–327inpersonalityassessment,24inpsychiatry,258subjectiveandobjectivedescriptionsof,27swings

extreme,suicidalthoughtsin,273inpremenstrualsyndrome,83

Moodchart,261fMooddisorders

circadianrhythmsin,83inflowoftimedisorders,79

Moralderangement,322Moralinsanity,322Morphemes,160Motivation,351,362

abnormalities,296–299,297binschizophrenia,297–298

definition,294intrinsicandextrinsicfactors,295

Motordisorders,306–307see alsoMovement,disturbancesinbraindisease,307–309inParkinson’sdisease.seeParkinson’sdisease

Mourning,forced/guided,274Movement,disturbances,303–310

agitation.seeAgitationincatatonia,304–305inexecutionofmovement,305hyperactivity,303–304isolateddisordersofmovement,304–306obstructionofflowofaction,305inschizophrenia,304,306–307

see alsoMotordisordersMuddling,146Multiplepersonality(dissociativeidentitydisorder),

196–197Muscledysmorphia,234,356,365Mutism,165

akinetic,42hysterical,169instupor,42

My-ness,191–192Myoclonicjerks,265

NNailbiting,161Naming,impairmentoflanguagefunction,163tNarcissism,105Narcissisticpersonalitydisorder,327Narcolepsy,52

Needabnormalities,296–299,297bdefinition,294primary/innate,294relationshiptoinstinctandbehaviour,294fsecondary,294

Negativeheautoscopy,194Negativetraits,ofschizophrenia,298Negativism,306

inschizophrenia,305Neologism,162,167–168,355,365Neuroanatomy,340–341Neurolepticmalignantsyndrome,304–305Neuromas,stump,250Neuropsychiatricmethods,341Neurosis

andstress,336vs.psychosis,336

Nightterrors,53Nightmares,53–54Nihilisticdelusions,127–128,192,349Non-accidentalinjury,children,322Non-verbalcommunication,260

assessment,26–27self-imageand,189–191

Norm,9–10individual,10social,10statistical,9value,9

Normal,definitionof,9,23Normalpersonality,23‘Normalisingstatement,’25Nuclearsyndrome,338–339Nymphomania,124

OObesity,230–231,297

schizophrenia,297–298Objectiveassessments,16Objective(clock)time,77

disorderof,76b,77–78Objectivity,15–16

definitionof,16ofnormalsensation,97

Object(s),delusionalmisidentification,126Observant,26Observation

ofappearanceandbehaviour,5,26forunderstandingofpatient’ssymptoms,12–13

Observer,6Obsession,287–290,357,366

assessmentof,28definitionof,287

Index 381

religiousbeliefsand,288inschizophrenia,289–290

Obsessional(anankastic)personality,289–290Obsessionalideas,289Obsessionalimage,289Obsessionalrumination,223Obsessive-compulsivedisorder,287Obsessivecompulsivephenomenon,elementsof,

351,362Obstruction,offlowofaction,305Obstructivesleepapnoea,52Occipitallobetumours,visualhallucinationswith,

100‘Oldmaids’insanity,124–125Olfactoryparanoidsyndromes,129‘Olfactoryreferencesyndrome,’129Oneiroidstates,visualhallucination,101Opposition,tomovement,306Organicamnesicsyndrome,63Organicbraindisease,acute,intime-lapse

phenomenon,80Organicpain,psychogenicpainvs.,245–247Organicpsychiatry,symptomaticpsychiatryvs.,17Organicpsychosyndromes,anxietyin,286Orientation,49–50

definitionof,49inspace,49intime,49

Orthodoxsleep,53–54Outofbodyexperiences,194‘Outoftheblue,’delusions,116Over-inclusivethinking,149,166,355,364Overactivity,inmania,298Overvaluedideas,132–133,148,223,228,234

disordersofcontentassociated,133tmorbidjealousyas,133inparanoidpersonalitydisorder,133,321

PPain

associatedwithpsychopathology,361attentionand,245–246atypicalfacial,250centralnervoussystemmodulationof,246central(thalamicsyndrome),247–248,350,361craving,248definitionof,245depressionand,249diminishedsensation,248gatecontroltheory,245–246andheightenedsensation,247–248lossand,250non-organic,classificationof,249organicorpsychogenic,245–247

perception,245phenomenologicalaspectsof,245inpsychiatricillness,247psychopathology,245–254,350recalcitrant,248–249subjectiveexperience,252andsuffering,252thresholdfor,245–246transmissionof,245–246withoutorganiccause,248–252

Painasymbolia,248,350,361acquired,248

Palinacousis,92–93Palinaptia,93,219t,356,365Palinopsia,91,354,363Panic,357,366Panicattacks,283–284Panicdisorder,283–284

generalizedanxietydisordervs.,283–284respiratorysubtypeof,351,362

Panoramicrecall,65Paradoxicalsleep(REMsleep),53–54Paraesthesiae,102Paragrammatism,162,168–169Paralogia,168Paramimia,265Paramnesia,67Paranoia,128–129Paranoid,133,320Paranoidideas,133–134Paranoidpersonalitydisorder,320–321,352,362

active,320–321passive,321

Paraphasia,168literal,168verbal,168

Paraprosopia,91,354,364Paraschemazia,236–238Parasomnias,52–53,353,363Parathymia,265Pareidolia,95Parietallobes,235

lesions,inhyposchemazia,235Parkinsoniansyndromes,305Parkinson’sdisease,307

exacerbationofdrive,296Partfunctions,335–336Passivedependence,324Passivity,28

disordersof,154–155ofemotion,155experiences,197

first-ranksymptomsofschizophrenia,154–155

asvolitionabnormality,296

382 Index

ofimpulse,156somatic,156ofthought,151

indelusionalatmosphere,118ofvolition,156

Pathologicallying,140Pelopsia,92,354,364Penilechange,hypochondriacaldelusions,129Penoscrotodynia,251Perceivedbody,189Perception,14

abnormalitiesof,87,91–95assessment,27–28falseperception,94–95sensorydistortions,91–94

auditory,14elementaryaspectsof,92–93

characteristicsof,89tfalse,94–95meaningindelusion,117misinterpretation,pareidolicillusionsvs.,95ofobjects,feelingattachedto,267–268pathologyof,87–110qualityof,92sensationand,87–91splittingof,93–94tactile,elementaryaspectsof,93visual,89

Perceptualdelusionalbicephaly,195–196Perfectionism,324–325Periodiccatatonia,305Persecution,ideas,320Perseveration,26,64,147Persistentmooddisorders,326–327Personalactivity,disordersof,154–155Personalhistory,22–23Personality

abnormal,23assessmentof,23definitionof,23depersonalisation,209double,194labilityinawarenessof,197multiple,196–197normalvs.abnormal,23premorbid(previous/usual),23–24sensitivepremorbid,120

Personalitydisorders,317–329anankastic,324–325anxious(avoidant),325–326avoidant,327classificationsof,318–319definition,319dependent,326differentiationof,24–25

dissocial,321–323falsificationofmemory,66histrionic,324mixed,320schizoid,321sociopathic,323theoryof,317

Personalitytraits,324Personalitytype,24Phantomhead,195–196Phantomlimb,237–238,250

bodyimage,235pain,238

Phenomenologicalselves,189Phenomenology,340–341

definitionof,6confusionover,7

diagnosticuse,14methodof,7

communicationfacilitation,10andpsychopathology,6–8purposeof,14

Phobias,284animal,284indepression,286illness,285simple,284–285social,284–285speciesof,284b

Phobicanxietydepersonalisationsyndrome,212Phobicneurosis,subdivisionsof,285bPhobicstates,284–286Phonemes,98,160Phonologicalloop,short-termmemory,60Photophobia,223–224Phrases,misuseof,inschizophrenia,167–168Pickwickiansyndrome,52Pictorialtheory,ofmentalimagery,89Pinta,10Plagiarising,cryptamnesiaand,67Polydipsia,297PositiveandNegativeSyndromeScale(PANSS),

180Possessionstate,198–200

andtrance,198Post-traumaticstressdisorder

irritabilityin,287startlereflex,exaggeratedin,265unpleasantdreams,54

Posture,26–27incatatonia,304–305incatatonicschizophrenia,304–305isolateddisordersof,304–306non-verbalcommunication,189–190pharaonic,26–27

Index 383

Poverty,delusionsof,127–128Preconsciousprocesses,35Premenstrualsyndrome,83Presence,feelingof,194PresentStateExamination(PSE),156,283,

337–339first-ranksymptomsofschizophreniaand,339t‘totalinsightscore’and,180

Primarydelusions,148,152,347Primarysensorydysphasia,348,360Problemsolving,141Prognosis,insightand,181Propositionalanalysis,171Prosody,160Prosopoaffectiveagnosia,269Pseudohallucinations,51,91,94,104–105Pseudologiafantastica,66,140Psychiatricexamination,outlinefor,20bPsychiatrichistory,22–23Psychiatricillness,221Psychiatry

biologicalschoolof,339definitionof,3scopeof,3

Psychoanalysis,insight,178Psychoanalyticpsychopathology

vs.descriptive,5tPsychoanalytictheory,depersonalisation,212Psychodynamics,339Psychogenicabnormalities,inschizophrenic

languagedisorder,169–170Psychogenicpain

facial,250–251organicpainvs.,245–247

Psychogenicsymptom,hypersomnia,52Psychologicalpillow,304–305Psychologicaltechniques,applicationof,341Psychomimeticdrugs,visualhallucinationsdueto,

101Psychopathicpersonalitydisorder,321–322Psychopathology,4–6,4f

conceptsof,334–336definitionof,4descriptive.seeDescriptivepsychopathologyanddiagnosis,333–343explanatory,4increased,inpremenstrualperiod,83mind-braindualityand,17organicandneuralsubstrates,17phenomenologyand,6–8practicalapplicationsof,352,362usesof,340

Psychopathycreative,inadequateandaggressive,322definitionof,323

Psychosisofassociation,130attentionand,48–49feigned,118insightofpatient’s,178

Psychosocialrehabilitation,insightimproving,181Psychoticphenomena,lifeepochand,84fPublicness,normalobjectperceptionand

hallucination,97Puns,unintentional,inschizophrenia,168Purewordblindness,162–163Pureworddeafness,162

QQualia,34Questions

empathic,13leading,12–13inmentalstateexamination

‘closed,’25‘open,’25

RRapideyemovement(REM)sleep,50Rapport,16,27

evaluationof,27Rasmussen,conceptsof,96–97Rationalthinking,141–142Reading,disordersof,163tReality

ofdelusions,131–132senseof,hallucinationsand,96–97

Realitytesting,poor,auditoryhallucinations,99Reasoning,141

deductive,141inschizophrenia,167

inductive,141Receptivedysphasia,355,365Receptiveemotionaldysprosody,269–270,356,

366Receptiveemotionalprosody,269–270Recognition-by-componentsmodel,88Reference

delusion-likeideasof,133delusionsof,120sensitiveideasof,120

Referenceties,169Referral

psychiatric,impulsiveandaggressivebehaviour,302

psychiatric,natureandtypeof,22Regression,thoughtdisorderas,166Religiousbeliefs,religiousdelusionsvs.,126–127

384 Index

Religiousdelusions,126–127Religiousexperiences

indicatorsfor,264vs.ecstaticexperiences,264

Remember-knowparadigm,61–62Remembering,61–62Repetitionofspeech,disordersof,163tResearch,psychiatric,340–341Residuum,120Resolution,274Responsetointervention,221Responsiveness,45Retardation,144,144f,149

indepression,270,298,304mental.seeMentalretardationmotor,304psychic,270

Retrogradeamnesia,353,363Reverseanorexia,234Rewards,motivationand,295Rituals,compulsive,288Ruminations,289

obsessional,223

SSachs,O.,visualperception,88Sadness,affectivedisorders,262Sapir-Whorfhypothesis,inlanguage,160Satyriasis,124ScalefortheAssessmentofNegativeSystems,

298ScaletoAssessUnawarenessofMentalDisorder,

179Schachter-Singer’stwo-factortheoryofemotion,

259ScheduleforAssessmentofInsightinPsychosis,

179Schizoidpersonalitydisorder,321Schizophrenia

abnormalitiesoflanguagein,348,360anhedoniain,262anxiety,286auditoryhallucinations,98,341behaviouraldisorders,310–311Bleulerian,118bluntingoffeelingin,266boundariesofself,200,201fchronic,inagedisorientation,77circadianrhythmabnormalities,83cloudingofconsciousness,38concretethinking,166–167confabulationin,63–64deductivereasoningin,deficiency,167delusionalpercept,116

delusionshypochondriacal,128ofinfestation,129–130oflove,124

diminishedpainsensation,248egodisturbances,212first-ranksymptomsof,116,151–153,151t,

200examplesof,153–157PresentStateExamination,339t

flatteningoffeelingin,266insightand,180–182,349,361languagedisorderin,165–171

modelsforinvestigating,165tlinguisticapproachesto,170–171memoryimpairment,65motordisorder,306–307

categories,306tmovementdisorder,304negativetraits,298paranoid,133parathymiaandparamimiain,265primarysymptomsin,115prodromalphases,118psychologicaltheoriesofthinkingin,149–151qualityoftimedisorder,82riskinschizoidpersonalitydisorder,321seasonalvariationand,84speech,170

lackofpredictability,170thoughtdisordersin,170

symptoms,7thoughtdisordersin

andclinicaldescription,166–169destructionofwords/grammar,168–169misuseofwords/phrases,167–168inspeech,166ttypesof,167

volitionaldisturbances,297–298Schizophrenicinattention,149–151Schizotypalpersonalitydisorders,327Schnauzkrampf,305Schneider,Kurt

delusionalidea,116firstranksymptoms,115

Schneider’sFirstRankSymptoms,348,360Searching,stage,afterbereavement,94–95Seasonalaffectivedisorder,84–85,347,360SeasonalPatternAssessmentQuestionnaire,84–85Seasonalvariations,84–85Self,187

abrogation,inecstasy,264boundaries

disorderof,200–201inschizophrenia,200,201f

Index 385

consciousnessof,36continuity,lossof,198disordersof,187–203misidentification,126and‘other,’298,299f

Self-concept,188–189Self-deception,141Self-esteem,feelingoflossof,207–208Self-image

centralcore,190andnon-verbalcommunication,189–191

Self-inducedvomiting,234Self-inflictedharm,248Self-injuriousbehaviour,248,249bSelf-monitoring,failureof,150Self-outsideworldrelationships,disturbed,212Self-perception,depersonalisationrelationship,

207‘Self-referent,’133Self-referentideas,320Selye’sGeneralAdaptationSyndrome,351,362Semantichalo,towords,167–168Semantics,160Sensation

experiencing,bodyschema,191andperception,87–91

Sensorium,36ofthebodyimage,247

Sensorydeprivation,107–108Sensorydistortions,91–94Sensoryexperience,normal,95–96Serialsevenstest,46Sexsomnia,53Sexualabuse,childhood,recoveredmemories,69Sexualneed,exacerbation,296Shame-humiliation,121Shiftwork,82Short-termmemory,346,360Sickrole,334–335Simulatedpsychosis,153Singleness,disorderof,193–197,193bSituationalaspects,depersonalisation,209–210Sleep,45–57

abnormalitiesofneedfor,296,297bdeprivation,82–83drunkenness,51objectiveassessmentof,50paralysis,52REM,50requirements,51stagesof,50

Sleepdisorders,50–53hypersomnia,51–52insomnia,50–51parasomnias,52–53

Sleep-wakecycle,phaseadvanceof,82–83Sleepwalking,52–53Snappingoff,146–147Socialaspects,depersonalisation,209–210Socialcensorship,191Socialcontext,ofemotions,abnormalitiesof,

260bSocialdeprivation,322Socialfactors,insight,182Socialphobia,357,366Sociopathicpersonalitydisorder,323Somaticpassivity,156Somatization,221,268–269Space,senseof,75Speech

assessmentof,27automatism,42disorderof,159–173flightofideas,169fluency,disordersof,163themisphereassociatedwith,162hesitant,164indistinct,164inner,90–91intonationchanges,161–162isolatedareafor,164–165inmania,162povertyofcontentof,167pressureof,169private,90–91repetitionof,163tunintelligible,162volumeof,changesin,161–162

Spinothalamicpathways,disruptionin,247–248

Spitzer,M.,delusionsvs.beliefs,112Spontaneousinvoluntarymovements,in

schizophrenia,305Spontaneousspeech-fluent,disordersof,163tStammering,161Startlereflex,heightened,265State,318–319

vs.trait,280–281,325Stereotypy,304–305Stockwords/phrases,167–170

exampleof,167Stress

abnormalreaction,hystericalmutism,169andanxiety,280

Structuralimaging,230Stupor,42,165,353,363

psychogenicvs.neurologicalcauses,42Stuttering,161Subjectiveanalysis,16Subjectivedoubles,syndromeof,125

386 Index

Subjectiveexperienceheightenedconsciousness,37studyof,7–8

SubjectiveExperienceofNegativeSymptoms,scale,298

Subjective(personal)time,77disorderof,76b

Subjectivity,15–16definitionof,16

Suffering,252painand,252

Suggestibility,63Suicidalthoughts,depression,272–273Suicide

delusionsofguiltandunworthiness,127rateof,seasonalvariationand,84

‘Summarystatements,’inmentalstateexamination,25

Suprachiasmaticnuclei,biologicalrhythmcontrolin,82

Surpriseintensificationof,265morbid,265

Symbolicrepresentation,141Sympathy,5Symptomaticpsychiatry,organicpsychiatryvs.,17Symptoms

classificationof,337–338constellationsof,336diagnosticcategoriesformedfrom,336–339eliciting,19–29present,22primaryvs.secondary,15understanding,10–12

Synaesthesiae,37,89–90,347,360Syndromes,336Syntacticalanalysis,171Syntax,160

incoherenceof,162Systematicenquiry,26–28

TTactilehallucinations,102Tangentiality,167Technicalterm,diagnosticimplicationsof,26Telegramese,168–169Teleopsia,92Telescopingphenomenon,237Temperature,body,changesindepression,83Template-matchingmodel,88Temporallobedisorder

déjàvu,65jamaisvu,65memoryimpairment,65

Temporallobeepilepsydéjàvu,62,81twilightstateand,40visualhallucination,100–101

Temporalorder,disorderof,78‘Tensioninsanity,’304–305Thalamicsyndrome,247–248Therapy,descriptivepsychopathologyapplication,

340Thinking

accelerationof,143autistic,140changesintheflowof,147circumstantial,144–145,145fconcrete,166–167confusionof,40disorderofthecontrolof,151–157functionsof,140imaginative,141andlanguage,relationshipbetween,160over-inclusive,166performanceof,140process,disorderof,139–158typesof,140–142

Thirst,abnormalities,296,297bThoughts

alienationof,157assessmentof,27audible,152–153blocking,146–147,147f,151–152,167broadcasting,151–152,155coherent,40disorders,27influenceof,157insertion,151–152,155,157,338–339lossofgoal,167withdrawal,146–147,151–152,154–155,355,

364Thoughtdisorder,inspeech,categorizationof,166tTics,309–310Time

biologicalrhythmsand,77,82–85characteristicsof,360chronology,disordersof,78directionof,disorderof,80–81disorderof,75–86

classificationof,76bobjective(clock)time,77–78subjective(personal)time,78–82

disorientation,49durationof,disorderof,78flowof,disorderof,78–80formalcharacteristicsof,347objective(clock),77

disorderof,77–78

Index 387

qualityof,disorderof,81–82reduplicationof,81subjective(personal),77

disorderof,78–82uniquenessof,disorderof,81

Time-lapsephenomenon,80Timesense,75

alteration,depersonalisationandderealisation,81–82

distortion,depersonalisation,209loss,indreams,54

‘Timestandsstill,’observationof,78Top-downprocess,visualrecognition,88Torpor,211Traits,318–319

anxiety,280–281negative,ofschizophrenia,298personality,324statevs.,325vs.state,280–281

Trance,self-induced,193Transcendentalmeditation,193,210Transference,4Transsexualism,229–230

bodyimage,191Transvestism,229Travel,purposeful,dissociative(hysterical)fugue,

67–68Trema,119Tricyclicantidepressants,depersonalisationdueto,

211Twilightstate,40Two-factortheoryofemotion,259Type:tokenratio,170Typification,333–334TyrerandAlexander’spersonalitydisorder,

319–320

UUnconsciousexperience,phenomenologyand,

16Unconsciousstate,33Unconsciousness,34–36

definition,34threedimensionsof,35f

Understandableexperience,primarydelusions,114

Understandingindescriptivepsychopathology,3–4,345explanationvs.,11tofindividual’shealthanddisease,352,362ofpatient’ssymptoms,10–12inpsychopathology,359staticandgenetic,11b

Unityawarenessof(egoconsistencyandcoherence),

193lackof,inexpressionofemotions,265lossof,inschizophrenia,197

Un-understandableexperience,6Unworthiness

delusionsof,127feelingsof,indepression,271

Urge,non-directional,294

VVenturesomeness,299–300Verbalcoding,190Verbalmessages,191Verbigeration,165Vertigo,hyposchemaziawith,235Vigilance-drowsinessaxis,36Vigilance(wakefulness),36Vignettes,psychopathology,180Violentbehaviours(violence)

associatedwithdelusions,132duringautomatism,42depersonalisationafter,210emotionallyunstablepersonalitydisorder,

323irritabilityleadingto,287morbidjealousy,124twilightstateand,42

Violentimpulse,300Visualhallucinations,14–15,100–102

auditoryhallucinationsand,101elementary,100–101organicstatesassociated,100

Visualhyperaesthesia,91–92Visualobjectagnosia,87–88Visualperception

colour,91–92elementaryaspectsof,91–92

abnormalities,347,360ofmotion,92sizeabnormalities,91spatiallocation,92

Visualpseudohallucinations,101Visualsystem

recognitionin,88sensationandperception,87–91

Visuospatialscratchpad,short-termmemory,60

Vitalanxietystates,267Vitalfeelings,266–267

indepression,247sites/regionsofbody,266–267

Vitalself,266–267

388 Index

Vocationalrehabilitation,insightimproving,181Voices,hearing,338–339

arguing,154givingarunningcommentary,154schizophrenia,98

Volitionaffectiveillnessesof,298disorders,293–314disturbance

inmooddisorders,298–299inschizophrenia,297–298

loss,296–298Volitionalact,294Voluntarymovements,idiosyncratic,in

schizophrenia,305Vomiting,self-induced,234Voodoo,239tVorbeigehen,68Vulvodynia,251

WWahneinfall(delusionalintuition),116Waterintoxication,schizophrenia,311Waxyflexibility,304–305,310WechslerAdultIntelligenceScale,68Weightphobia,231Well-being,loss,266Wernicke’sarea,164

deficitof,163

Will,294–295abnormalities,296–299,297b

inschizophrenia,297–298concept,295definition,294

Windigo,239tWisconsinCardSortingTest(WCST),180Words

blindness,pure,162–163choice,inmentalstateexamination,26deafness,pure,162destructionof,inschizophrenia,168–169dumbness,pure,164intrusionof,168lossofmemoryfor,67misuseof,inschizophrenia,167–168predictability,170semantichaloto,167–168stock.seeStockwords/phrases

Wordsalad,165Workingmemory,abnormalityof,149–151Writing,disordersof,163t

YYoga,210

ZZeitrafferphenomenon,80

sims' symptoms in the mind

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