• Form = eg. Auditory hallucination; important for Dx; result of imbalance in brain
• Content = message of voice, identity of voice; important for understanding illness; influenced by different cultures

• Suspension of everyday interpretations
• Focus on raw description of experience (Ie. Restrain from making interpretation from an event (eg. Attempted suicide), and focus on what that person is feeling)
• Counter-intuitive and requires disciplined practice (even if you are disciplined; Pt and family will try to interpret experiences, therefore need to facilitate them in concentrating only in actual experience, not interpretation of experience)
• Reference: Karl Jasper's General Psychopathology

Verstehen

• Intuitive
• Empathic
• Individual
• Semantics important
• Use personal frameworks

Erklaren

• Explanation "from outside
• Scientific
• Objective
• Use of impersonal, non-semantic explanatory principles
• Both are important in medicine/ psychiatry
• If use only Verstehen: will get burnt out; will only be able to help a few (but have ignored the facts/ stats - Erklaren - which suggest a poor prognosis)

1. Experience of Symptom

2. Reconstruction of Symptom

Sensory Distortions

• Changes in intensity: eg. Mania: everything becomes brighter
• Changes in colour: uncommon on its own in psychiatric symptoms, xanthopsia in digoxin poisoning (everything has yellow tinge)
• Changes in size

• Illusions
• Hallucinations

• Definition: perception without an object (Esquirol)
• Application to any sensory modality
• Subjects reacts to them as if they were true perceptions - except for Pt's who have been having hallucinations for many years; they learn to recognise them as an illness

• Most common/ important in psychiatry
• Simple hallucinations and unintelligible noises
• Verbal Hallucinations
• Simple: Brief phrases or names
• Complex: lengthy, structured sentences

• Inner speech hypothesis (fail to ID inner thoughts, mistakenly believe that they come form the outside world)
• Laryngeal EMG correlates with subjective experience of hallucination (laryngeal muscles active at subthreshold level) - sometimes mouth moves, make soft sounds (not speech)

• Elementary: Organic states
• Complex: Confusional state or Functional psychosis
• Combined auditory and visual hallucinations (rare): in TLE (temporal lobe epilepsy), also suspect malingering

DIAG: complexity of visual hallucination and association cortex

• Information from primary visual cortex goes to the visual processing areas
• Ventral system: runs around inferior occipital and inferior temporal cortex -> analysis of shape and ID of object
• Most elementary analysis (shape, colour, movt) occurs in early areas
• More complex ID of shape occurs further along direction
• Reach temporal love proper: neurones respond only to very specific shapes (eg. Of hand, face)
• Therefore, neural system becomes more specific to complex information as it cascades into temporal lobe
• However, limbic system is inside medial surface of temporal lobe (therefore, end chain of visual processing ends in limbic system)
• Most functional psych disorders are related to abnormalities in limbic system
• Functional psychosis: these areas affected - results in more complex abnormal experience
• If more simple abnormal system, pathology further away from limbic system and closer to primary visual cortex

Note: hallucinations around time of sleep very normal (eg. Going to sleep, on waking up)

• False (not essential: eg. Delusion of jealousy)
• Unshakeable (most important characteristics): not open to contrary evidence, discussion (therefore Dx delusion: ask Pt how he came to form these ideas; then challenge Pt: under what circumstances would he revise he thoughts)
• Out of keeping with social and cultural background: soft and dangerous definition (eg. Religion is unshakeable and there is no proof, but not a delusion because many other people believe in it) (political dissidents in Russia and China have ended up in mental institutions)
• Usually self reference: content of delusion wrt Pt himself

• Delusions of persecution: belief that someone is going to harm you
• Delusions of reference: belief that something is related to you, when in fact it is not (eg. See someone talking on other side of street, and Pt thinks they're talking about him). Note: "cocktail party phenomenon" - ability to filter out what is connected to you and what is not. Milder form: idea of reference (eg. self-conscious person believes people are looking at them, but they are not)
• Delusions of influence: belief that something that has happened that is unrelated to you has been caused by you (eg. Pt believes he caused an earthquake by thinking a particular thought)
• Delusions of love/ erotomania: belief that someone is in love with you (more common in females; target is prominent male - including doctors)
• Delusions of jealousy: believe that spouse is being unfaithful; can lead to domestic violence
• Delusions of grandeur/ grandiose: belief that you are of high status (extreme cases: eg. Believed that he is the Messiah)
• Delusions of ill health: belief that you have serious/ fatal illness (can happen in serious depression). Note: someone doesn't have any symptoms (cf. somatic complaints) thinks they have illness
• Delusions of guilt: belief that you have done something wrong and deserve very heavy punishment (eg. Heavy depression). Note: need to check if Pt has done that thing, and if it's serious
• Delusions of negation (nihilism, Cotard syndrome): belief that already died, everything in body rotten, bowel blocked (esp. in depression in elderly)
• Delusions of poverty: belief that you have no money

Primary / secondary

... To other psychopathology

• Pervasive: affecting most areas of that Pt's concerns and function
• Encapsulated: has delusion when you talk about a particular topic (when you talk about another topic, Pt is normal). Eg. Pt believed that old neighbour wanted to harm him, has had Tx since, new neighbours, so is OK

• Structure of delusion
• Fragmented: many different abnormal thoughts, relationship of which are not logic
• Systematised: one complicated story which hangs together all anomalous experiences (systematised in intact neurological function)
• From structure of delusion: can deduce natural history of evolution of that delusion, pathology of delusion

• Cannot get rid of a content of consciousness
• Senseless (key difference cf. delusion: fully believes in delusion. In Obsessions: realises that it is nonsense, but cannot stop it), repetitive, distressing, resisted

• Thought insertion: someone physically inserting thoughts into your mind (thoughts totally alien to yourself)
• Thought withdrawal: thoughts being removed from your brain
• Thought broadcasting: thoughts are being spoken aloud (element of hallucination) and broadcasted over a large distance Pt believes everyone 'knows' about him- therefore has ideas and delusion of reference

All First Rank Symptoms of schizophrenia

Flight of ideas

• Thought follows each other rapidly
• No connection between successive thoughts
• Divertable by external stimulus and superficial associations
• Clang associations: association based on phonetics (similar sounds); Pt rhymes words
• Because thoughts enter mind so fast, no time for meaningful association, so can only associate sounds

• Slow train of thought
• Eg. Depression
• Very difficult in examination!

Perseveration

• Mental operations persist beyond the point at which they are relevant
• Common in organic disorder: generalised or prefrontal (many functional psychoses affect frontal lobe)
• Eg. Ask Pt how old they are: they reply '50yo'. Go on to ask other questions: Pt keeps replying '50yo'

• Very rare
• Normally experience thought as a continuous stream
• Sudden arrest of a train of thought
• Characteristic of schizophrenia (believe that thought withdrawal has occurred)
• Distinguish from anxiety: 'mind goes blank'

• Blending of incongruous elements
• Loosening of Associations: similar to flight of ideas, previous idea not related to next idea
• Different degrees
• Mild: circumstantial thinking - topic being expressed drifts from one to next for long time before returning to original topic (direction not focused, only relatively normal if conversation goes for a long time)

• Loosening of Association (even smaller units of language are not connected - eg. Beginning of sentence does not match with end of sentence (severe; grammar not preserved)
• Derailment: specific but rare (trains of thought derail and shift to a different train of thought;
• Tangential thinking: less specific for schizophrenia (sentences not abnormal, paragraphs drift and content drifts off and fails to return to normal path)
• Neologisms

(1) Psychogenic

• Anxiety-related
• Dissociative: Pt forgotten entire past life

(2) Organic

• Retrograde amnesia: before time of damage
• Anterograde amnesia: failure to remember things since the accident
• Transient global amnesia
• Ribot's law: recent event lost before remote events (applies to amnesia, dementia) (if amnesia does not fit into this pattern -> psychogenic, malingering)

• False description of past event
• Could be influenced by the examiner (suggestibility)
• Occurs in amnesic syndrome and other organic conditions
• Construction based on inadequate data (influenced by what stimuli are around him)
• Lack of insight and critical faculty

2 phenomenon fail for confabulation to occur

1. Intrinsic tendency to come to interpretation
2. Counter-checked by additional supervisory system

• Missing information (up till now: normal)
• Supervisory deficit: Pt doesn't know that he doesn't have the information (up till now: amnesia)
• Confabulation: pools together what data he has to construct an answer

Deja vu

• Spurious familiarity
• Found in temporal lobe epilepsy and in normal individuals

• Capgras syndrome: emotionally related person as double; in schizophrenia, depression
• Fregoli syndrome: a familiar persecutor identified in strangers

• Autonomic component: Palpitations, tremor, sweating etc
• Motor component: Muscle tension
• Psychological component: Fear, dread

• Phobia: Fear directed to specific objects or situations
• Free-floating anxiety: Pervasive and not bound to situations

Biological component

• Early waking, diurnal fluctuation, anorexia, lethargy (sleep and appetite controlled by hypothalamus - therefore hypothalamus affected)

• Psychomotor retardation: Pt can become immobile/ stupurous

• Pessimism, self-blame, suicidal ideation

Biological component

• Insomnia, increased appetite, increased energy

• Psychomotor agitation

• Confidence, grandiosity, disinhibition

Emotional lability

• Excessive or inappropriate emotional response
• Rapidly changeable

• Lack of sophistication and sensitivity in emotional expression
• Not the absence of emotion
• Loss of refinement of complexity of emotional expression
• Eg. N = subtle, co-ordinated changes (like orchestra); Blunted affect: monotone one instrument only
• Seen in chronic schizophrenia

• Opposite of lability
• Lack of responsivity of emotional expression
• Incongruous affect
• Inappropriate emotional response

"Clouding of Consciousness"

• Decreased contact with environment
• Often accompanied by disorientation
• Found in acute confusional state (eg. Metabolic derangement, stroke)
• Most important: orientation to time, place, person
• However, dementia has decreased orientation to time, but no clouding of consciousness

• Patients conscious and alert (not a coma)
• Akinetic mutism (no motor verbal response)
• May be organic or psychogenic

• Goal directed: mannerisms (Eg. there is meaning in the movt - chronically ill Pt's directing traffic in the middle of hosp ward - inappropriate, but complete movement complex)
• Non-goal directed: stereotypy (less organised, cannot see meaning of movt)

• Tremor
• Dyskinesia: irregular movt
• Dystonia: abnormal position/ contraction of muscle groups

• Waxy flexibility: e.g. psychological pillow
• Stupor
• Echopraxia and Echolalia: Environment dependence syndrome
• Perseveration
• Mannerisms and Stereotypies
• Ambitendency: inability to complete motor programme due to fluctuation between opposite motor directions
• Mitgehen and automatic obedience: Excessive compliance to instruction
• Gegenhalten and negativism: Excessive resistance to instruction