Transcript Clinical features of schizophrenia

Descriptive Psychopathology of
Psychosis and Schizophrenia
Dr. Emilio Fernandez-Egea
Consultant Psychiatrist
What is this talk NOT about
• Full Description of Schizophrenia Psychopathology.
– By content: Positive (=psychosis), AND negative,
cognitive, emotional disturbances…
– By course: premorbid, prodromal, acute, etc…
– By Diagnostic Categories: DSM-IV-TR / ICD-10.
• Psychopathology of Mental Disorders.
– Psychosis as an epiphenomena in many other
psychiatric and non psychiatric disorders.
Learning objectives
• Describing the main components of psychosis.
• Describing the most common psychotic
experiences in schizophrenia.
• To increase the “psychiatric” vocabulary.
• Useful references to increase your knowledge.
Structure of the seminar
• Definition of symptom.
• Classification / characteristics.
• Presence in Schizophrenia.
• Differential diagnosis.
Increasing the vocabulary…
• Patient’s info details
– House number
– Street
– Town
– Post Code
• Patient’s descriptive psychopathology of
psychosis
– “X presented paranoid delusions and hallucinations”.
What is Psychosis?
• Is the presence of positive symptoms (aka
psychotic phenomena).
– Delusions.
– Hallucinations and other abnormal experiences.
– Thought disorder.
– Catatonia.
Delusions
Definition
• Abnormal thought content.
• DSM-IIIR
– A false personal belief based on incorrect inference
about external reality.
– firmly sustained in spite of what almost everyone
else believes and in spite of what constitutes
incontrovertible and obvious proof or evidence to
the contrary.
– Is not one ordinarily accepted by other members of
the person’s culture or sub-culture.
• Jaspers’, Spitzer’s….
Delusions
Definition
Classification
• According to four INDEPENDENT principles.
– Degree of inexplicability.
– Nature of subverted mental function.
– Nosological significance.
– Thematic content.
Delusions
Definition
Classification
• According to DEGREE of INEXPLICABILITY
– Primary (AKA pure or true).
– Secondary, delusion-like ideas.
• According to the SUBVERTED MENTAL FUNCTION
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Delusional perception.
Delusional notion.
Delusional memory.
Delusional awareness.
Delusional atmosphere/mood.
Delusions
Definition
Classification
• According to NOSOLOGICAL SIGNIFICANCE
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Paranoia.
Delusional loving.
Monosymptomatic hypochondriacal psychosis.
Etc…
Delusions
Definition
Classification
• According to the THEMATIC CONTENT (1/2)
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Delusions of persecution (includes delusions of prejudice).
Morbid jealousy and delusions of infidelity.
Delusion of love / erotomania (includes Clerambault syndrome).
Delusional misidentification. (e.g. Capgras, Fregoli, …).
Grandiose delusions.
Religious delusions.
Delusions of guilt and unworthiness.
Delusions of poverty and nihilistic delusions (Cottard’s
Syndrome).
– Hypochondriacal delusions.
Delusions
Definition
Classification
• According to the THEMATIC CONTENT (2/2)
– Delusions of infestation (Ekbom’s syndrome).
– Communicated insanity – Folie a deux.
– Delusions of control of thinking (passivity of thought)
• Thought withdrawal.
• Thought broadcasting.
• Thought insertion.
– Delusions of control of experience (passivity of experiences)
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•
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Passivity of affect (‘made’ feelings).
Passivity of impulse (‘made’ drives).
Passivity of volition (‘made’ volitional acts).
Somatic passivity (influence playing on the body).
Delusions
Definition
Classification
Delusions in Schizophrenia
• Very frequent (90%).
• Paranoid ideas are not only persecutory.
• Schneider’s First-Rank symptoms.
– Delusions of perception.
– Thought withdrawal / insertion / broadcasting.
– Made feelings / impulses / volitional acts
– Somatic passivity.
Delusions
Definition
Classification
Delusions in Schizophrenia
Differential diagnosis
• Other abnormal NON DELUSIONAL thought
content:
– Poverty of thought.
– Erroneous Ideas (mistakes).
– Overvalued ideas.
– Obsessive Ideas.
– ….
Hallucinations
Definition
• Abnormal perception.
• Is a perception of something when in fact
nothing exists in the perceptual field. A
perception without object.
• It may be or NOT be followed by a delusional
interpretation of the content.
Hallucinations
Definition
Classification
• According to four INDEPENDENT principles.
– Modality.
– Timing with respect to sleep.
– Precipitation by a sensory stimulus.
– Content.
Hallucinations
Definition
Classification
• According to MODALITY
– Visual
– Auditory
– Olfactory
– Gustatory
– Tactile, somatic, kinaesthetic.
• According to TIMING WITH RESPECT TO SLEEP
– Hypnagogic: just before falling asleep.
– Hypnopompic: on just waking up.
Hallucinations
Definition
Classification
• According to PRECIPITATION BY SENSORY STIMULUS
– Synaesthetic: precipitation by sensation in a different
modality from hallucination.
– Functional (or reflex): precipitation by sensation in same
modality.
• According to CONTENT
– Verbal / (simple, complex…)
– Music.
– Autostopic
– Teichopsia, Lilliputian, etc….
Hallucinations
Definition
Classification
Hallucinations in Schizophrenia
• Very common (50%).
– Auditory
– Visual
– Tactile
50%
15%
5%
• Voice is the most common hallucination
– It is usually heard in a grammatical form that is
different from how we experience our own thoughts.
– The sex of the voice is nearly always identified.
– Voices diminish if there is a meaningful conversation.
– Experienced in the head, poorly localized.
Hallucinations
Definition
Classification
Hallucinations in Schizophrenia
• Schneider’s first-rank symptoms
– Voices speaking thoughts aloud.
– Voices arguing (two or more hallucinatory voices
discussing the person in the third person), and
– Voices commenting on the subject’s actions.
Hallucinations
Definition
Classification
Schizophrenia
Differential diagnosis
Not every abnormal perception is a psychotic hallucination
Hallucinations
Definition
Classification
Schizophrenia
Differential diagnosis
Not every abnormal perception is a psychotic hallucination
Anomalous
Experiences
Illusions
Pseudohallucinations
Hallucination
Does the object exists?
YES
YES
NO
No
Is that completely
misrecognized?
NO
YES
N/A
N/A
YES
NO
Preserved Insight?
Thought Disorder
Definition
• Disturbance of the form of thinking.
• Covers a variety of positive and negative
symptoms of schizophrenia.
Thought Disorder
Definition
Classification
• Two main categories:
– Intrinsic disturbance of thinking (mechanics of
thinking).
– Disorder of language and speech.
Thought Disorder
Definition
Classification
• Two main categories:
– Intrinsic disturbance of thinking (mechanics of
thinking).
– Disorder of language and speech.
Thought Disorder
Definition
Classification
• Intrinsic disturbance of thinking
– Concrete thinking
– Loosening of associations.
– Overinclusion (circumstancial thinking).
– Illogicality.
– Thought blocking.
Thought Disorder
Definition
Classification
• Disorder of language and speech:
– Derailment.
– Neologism (paraphasia)
– Poverty of speech (alogia).
– Poverty of content of speech.
– Incoherence: lack of grammatical structure.
– Pressure of speech.
– Retardation, including mutism.
– Echolalia.
– Tangentiality.
Thought Disorder
Definition
Classification
Thought disorder in Schizophrenia
Schizophrenia
Bipolar Affective Disorder –
Manic episode
Derailment
56%
Similar
Poverty of content of speech
40%
20%
Pressure of speech
27%
70%
Neologism
2%
0%
Loosening associations
5%
Overinclusion
25%
Illogicality
10%
Thought Disorder
Definition
Classification
Schizophrenia
Differential diagnosis
• Other forms of Thinking processes….
– Fantasy Thinking.
– Imaginative Thinking.
– Rational or conceptual thinking.
Catatonia
Definition
• It is not about the nosologic entity called
Catatonia (Kahlbaum’s catatonia).
• Set of abnormal involuntary movements
associated to Mental Disorders.
Catatonia
Definition
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Classification
Stupor
Catalepsy (waxy flexibility).
Automatism
Mannerisms
Stereotypies
Posturing and Grimacing
Negativism
Echopraxia.
Catatonia
Definition
Classification
Catatonia in Schizophrenia
• Rare: 5-10%
• The most common: mannerism, then stereotypies,
stupor, negativism, automatism, echopraxia,….
• None is specific.
• Decreasing frequency (from 20% to 5%) in the last
100 years.
• More common in schizophrenics from developing
countries.
Catatonia
Definition
Classification
Schizophrenia
• Other involuntary movement
– Tics
– Chorea
– Dyskinesia
– Athetosis
– Balismus….
• Voluntary movement
– Malingering.
– Factitious disorder, etc….
Differential diagnosis
Further reading
Hirsch and Weinberger.
Schizophrenia. 2nd Ed.
(2003).
Harrison and Weinberger.
Schizophrenia. 3rd Ed
(2011).
Berrios.
History of Mental
Symptoms. (1998)
Jaspers.
General
Psychopathology.
(1965)
Oyebode. Sims’
Symptoms in the Mind.
4th Ed. (2008)
Cardinal and Bullmore.
The Diagnosis of
Psychosis. 1st Edition.
(2011)
Take home messages
• Psychotic symptoms are more frequent in, but
not specific to, psychotic disorders.
• All psychotic disorders may also present nonpsychotic symptoms.
• Psychotic phenomena should be thoroughly
explored.
Emilio Fernandez-Egea’s email:
[email protected] or [email protected]