Transcript Phenomenology - GEOCITIES.ws

“Listen to the patient. He is telling you the diagnosis”
(Osler)
Phenomenology
Dr. Muhd. Najib Mohd. Alwi
Jabatan Psikiatri
Pusat Pengajian Sains Perubatan
Universiti Sains Malaysia
Phenomenology
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Definition:
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The study of events, either psychological or physical,
without embellishing those events with explanation
of cause of function
In psychiatry, it involves the observation and
categorization of abnormal psychic events, the
internal experiences of the patient and his consequent
behaviour
Descriptive psychopathology:
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Empathic evaluation of patient’s subjective experience
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Phenomenology
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Symptoms:
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Signs:
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subjective experiences described by the patient
e.g. Depressed mood, poor concentration
objective findings observed by the clinician
e.g. Psychomotor retardation, restricted affect
Syndrome:
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a group of signs and symptoms that occur together as
a recognizable condition that may be less than
specific than a clear-cut disorder or disease
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Description of symptoms
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Significance:
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symptoms are more likely to indicate mental disorder
if they re intense and persistent.
Primary and Secondary:
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Temporal:
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Primary – antecedent
Secondary – subsequent
Causal:
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Primary – direct expression of the pathological process
Secondary – a reaction to the primary symptoms
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Description of symptoms
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Form:
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Normally is what the doctor is interested in
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e.g. Voices - internal/external, second/third person,
true voices/implanted thoughts etc.
Content:
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What the patient is pre-occupied in
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e.g. Voices - what the voices says, his feelings
towards them etc.
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Description of symptoms
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Asking the patient:
imagine someone asking you:
“Do you have any fixed, false beliefs that are out
of keeping with your culture or educational
background?”
 thus, it is very important to start off with
open-ended question (screening) and then
proceed to close-ended question (specific
symptoms)
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Description of symptoms
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Asking the patient:
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now imagine you asking the patient:
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Do you have any odd experiences lately?
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Well, like strange sensasations, feelings or thoughts?
If so, is it in the form of voices that other people cannot
hear?
..... And so on....
Sometimes people hear things when there is
nothing actually there to explain it, like a voice
calling their name. Do you have such an
experience?

can you tell me more about it?
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Classification of signs and
symptoms in Psychiatry
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Disorders of Perception
Disorders of Thinking
Disorders of Mood
Disorders of Cognition
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Perception:
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the process of becoming aware of what is
presented through the sense organs i.e. the
understanding of a sensory stimulus
c/f imagery: an experience within the mind,
usually without the sense of reality, can be
called out and terminated by voluntary effort.
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e.g. Eidetic imagery and pareidolia
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Alterations in Perception:
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intensity
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noise - louder or softer than normal
quality
shape - e.g. macropsia, micropsia, distorted
 food - bitter
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Two main disorders:
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illusion
hallucination
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Disorders of Perception
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Illusions
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misperceptions of external (objective) stimuli
conditions more likely to occur:
reduced level of sensory stimulation (e.g. at dusk)
 reduced level of consciousness (e.g. delirious pts.)
 when attention is not focussed on the sensory
modality (e.g. in darkness)
 when there is a strong affective state (e.g. stressed
up / angry)
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Disorders of Perception
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Hallucinations
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sensory perception without an objective
stimulus but with with a similar quality to a
true percept
experienced as originating in the outside
world and not in the mind (like imagery)
can be of all sensory modalities:
visual / auditory / tactile
 gustatory / vestibular / olfactory
 “presence”
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Disorders of Perception
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Hallucinations
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objective space
perceived via a
sensory modality
clear, distinct, vivid
beyond voluntary
control
no *insight (towards
the symptom)
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Pseudohallucinations
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subjective space
may not be
perceived by a
sensory modality
unclear, foggy
within voluntary
control of a person
there is insight
*about the absurdity of the perception
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Disorders of Perception
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Hallucinations
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objective space
perceived via a
sensory modality
clear, distinct, vivid
beyond voluntary
control
no insight (towards
the symptom)
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Pseudohallucinations
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subjective space
may not be
perceived by a
sensory modality
unclear, foggy
within voluntary
control of a person
there is insight
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Description of hallucinations
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According to complexity
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elementary
complex
According to sensory modality
According to special features
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auditory: 2nd or 3rd person
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Auditory hallucinations
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Elementary / complex
Voices
single/multiple
 male/female
 known/unknown person
 person
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1st person: “thought echo” - hearing own thoughts
spoken aloud (Gedankenlautwerden, echo de la pensee)
2nd person: calling patient by ‘you’
3rd person:calling patient by ‘he’ or ‘she’
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Auditory hallucinations
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Voices
commanding / running comentary / arguing with
each other
 timing:
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theme:
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day / night / all the time
circumstances when it occurs
continuous / intermittent / frequency
friendly, deragotory
patient’s response to the voices
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Visual Hallucinations
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elementary (e.g. flashes of light)
complex
semi-formed: with some structure
 fully-formed: e.g. human figures, trees
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black and white / coloured
static / mobile
stable form / changing design
size (e.g. lilliputian)
commonly associated with organicity
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Olfactory and gustatory hallucinations
often experienced together
 often unpleasant in nature (e.g. rotten fish, bitter)
 common in temporal lobe epilepsy
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Somatic (tactile and deep)
tactile (haptic): touched, pricked e.g. insect
crawling under the skin (e.g. formication in
coccaine abuse)
 deep sensation: e.g. viscera being pulled out,
sexual stimulation, electric shock
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Autoscopic hallucination
seeing own body projected into objective space
(can happen in depression)
 “negative autoscopy” also can occur!
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Extracampine hallucinations:
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Reflex hallucinations:
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stimulus in one sensory modality causing a hallucination
in a different sensory modality
e.g. music causing visual hallucination (LSD abuse)
Hypnogogic and hypnopompic hallucinations
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perceiving a sensation from beyond the limits of the
sense organ
e.g. visions from outside visual field, hearing voices from
far far away
occurs at the point of falling to or waking from sleep
usually brief and elementary
Feeling of “Presence”
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feeling the presence of ‘somebody’ near but realises that
he is non-existent!
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Other Perceptual Disturbances
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Depersonalization: a feeling that his body
parts are abnormal, unreal
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Derealization: a feeling that the external
environment is abnormal, unreal
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e.g. “my brain becomes big until it fills the room”
e.g. people are 2 dimensional card board figures
both can occur in tiredness, TLE, depression
etc.
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Thinking
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Definition:
a goal directed flow of ideas, symbols or
associations, initiated by a problem/task, leading
to a reality orientated conclusion
 disorders of thinking are usually recognized from
speech and writing
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4 components of thinking:
form of thought
 flow (stream) of thought
 content
 possession
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Formal Thought Disorder
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Disorder in the form (structure) of thoughts
3 main subgroups:
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loosening of association
flights of ideas
perseveration
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Loosening of Association
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Loss of the normal structure of thinking
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muddled and illogical conversation that cannot be
clarified by further enquiry.
Several forms:
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Knight’s move / derailment:
 transition from one topic to another with no logical
connection between the two
Word salad:
 severe form of derailment affecting the grammatical
structure of speech
Talking past the point (vorbeireden) / tangentiality:
 touching the point just a little bit before going
Circumstantiality:
 going round and round before finally reaching the
point
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Flights of Ideas
Patient’s thoughts and conversation move quickly
from one topic to another so that one train of
thought is not completed before the another
appears but there is an apparent association
between them (clang (similar sound) or chance
associations)
 3 components have to be there:
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pressure of speech
 shifting topics
 apparent association (can be followed)
NB: if without pressure of speech = PROLIXITY
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Doctor: Kenapa R suka sangat hari ini?
R:
Merdeka! Merdeka! Merdeka! Malaysia sudah merdeka,
kesemuanya deka.. deka hee. Tanggal 31, bulan lapan lima
puluh tujuh... Pantai Sri Tujuh tempat berkelah yang sungguh
indah... doktor dah pernah pergi ke? Marilah kita ke sana... Kita
penunggu senja... mencari hakikat diri yang sebenarnya....
berjuanglah! Ehmmm.ehmm.... Jika takut menghadapi risiko
jangan bicara tentang perjuangan!!!
Marilah kita berjuang kerana mu Malaysia... Indonesia...
Tunisia.... “sia” tu maksudnya doktor.... “terhapus”.
Maka jadilah mereka seperti dinosaur yang telah pupus di atas
kelemahan mereka sendiri... sendiri... ada ertinya....(patient
sings)......erti perkataan... ya.. tekalah perkataan itu. Doktor
sukakah tengok Roda Impian... Ya, menagilah hadiah misteri
kali ini. Semisteri seperti ajaibnya Taj Mahal... Salam Taj
Mahal..... Oh, I love you M Nasir....sungguh mahal harganya.
Baju doktor smart, ni tentu mahalkan? Eleh... jual mahal pulak.
Berhenti? OK saya berhenti... tapi doktor.............. (patient
continues her conversation)
Others Formal Thought Disorders
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Perseveration:
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Giving a response beyond the point of relevance i.e. same
answer to each question (stimulus)
c/f verbal stereotypy (verbigeration): words, sounds or
phrase repeated in a senseless way (no stimulus)
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Disorder of flow (stream)
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Both the amount and the speed of thoughts
are changed
Different levels:
muteness
 poverty of thought
 thought block
 volubility:  amount & speed, still can interrupt
 pressure of speech:  amount & speed, cannot
interrupt speech
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Disorders of Content of Thought
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Delusion:
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Over-valued ideas:
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false belief, unshakeable, inappropriate to a person’s
educational and social background
“double orientation”: wholly convinced about the truth of
the delusional belief but the conviction may not influence
his feelings and emotions
ideas held with a lot of emotion (highly charged) but with
some degree of ambivalence and doubts about the belief.
(Emotions are expressed to compensate for the
ambivalence)
Pre-occupation:
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ideas which comes to mind, again and again and may
prevent the patient from performing his day to day
activities
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Classification of Delusions
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According to fixity:
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complete / partial / over-valued ideas / ideas
According to onset:
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Primary: autochtonous delusions
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sudden onset (out of the blue) of delusion
other forms:
 delusional mood: anxiety, foreboding something to
happen (Wahnstimmung)
 delusional perception: false meaning to a normal
percept
 memory: attribute new meaning to old experience
Secondary: derived from preceding morbid
experience e.g. hallucinations, depressive mood
etc.
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Classification of Delusions
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According to special features:
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Systematised delusion:
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chronic, presence of nucleus, well knitted, interconnected, layered and well-encapsulated.
Non-systematised delusion
 Shared delusion:
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folie a deux (two person, including patient)
folie a mass (> than two person)
According to theme
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Themes of Delusion
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Persecutory (paranoid):
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Delusion of Reference:
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others/organizations trying to inflict harm on him
idea that objects/events/people have a personal
significance for patient e.g. TV programmes, news
Grandiose (expansive):
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beliefs of exaggerated self-importance
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e.g. wealth, special powers, beauty
Religious:
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delusions with religious content
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e.g. chosen to be prophet, communicating directly to God
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Themes of Delusion
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Amorous Delusion
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more common in women
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De Clerambault’s Syndrome
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(? stalking in men)
being loved by a man who is unaccessible, high status,
never spoken before, unable to reveal his love for her
Delusion of Jealousy:
common in men
 delusion of unfaithfulness of spouse (infedility)
 spying, checking on spouse, examine for sexual
secretions
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Themes of Delusion
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Delusion of Guilt and Worthlessness:
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e.g. minor past faults will be exposed, being
sinful, deserves to be punished
Nihilistic Delusion
belief about non-existence of some person / thing
+ pessimistic ideas e.g. career is gone
 Cotard’s Syndrome: failures of bodily functions
e.g. bowels are rotting etc.
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Hypochondriacal Delusions
belief of ill health despite contrary medical
evidence
 usually of a particular theme & may have
relative/friend suffering the supposed illness
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Other Disorders of Thought Content
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Obsessions:
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recurrent persistent thoughts, impulses or images that
enter the mind despite efforts to exclude them
subjective sense of struggle to resist them
recognized as his own (not implanted)
regarded as untrue and senseless
Compulsions:
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repetitive, purposeful behaviours performed in a
stereotyped way, accompanied with subjective sense
that it must be carried out and an urge to resist
most common: cleaning, counting, dressing
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Description of Obsessions
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Five forms:
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thoughts: intrusive
words or phrases,
upsetting e.g.
blasphemous phrases
rumination: worrying
themes e.g. ending of the
world
doubts: uncertainty
about previous action
(realizes done)
impulses: urges to carry
out actions: dangerous or
embarrassing
obsessional phobia
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Six common themes:
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dirt & contamination
aggressive thoughts:
e.g. striking others
orderliness: how things /
work need to be arranged
/ done
illness: e.g. dread about
cancer
sex: e.g. perverse sexual
acts
religion: doubts about
fundamental belifs e.g.
“Does God exist?”
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Disorders of Thought Possession
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Thought Insertion:
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Thought Withdrawal:
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delusion that some thoughts have been implanted
by outside agency
delusion that thoughts have taken out of his mind
(may accompany/explain thought block)
Thought Broadcasting:
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delusion that his unspoken thoughts are known to
other people
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Reference
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Oxford Textbook of Psychiatry (Third
Edition) Gelder et al
Sypmtoms in the Mind: An Introduction
to Descriptive Psychopathology (Second
Edition) Andrew Sims