Psychopathology: Classification

E. Topographical memory

As the name suggests, the inability to orientate oneself represents a failure of topographical memory (E) which is fairly common in dementia. Autobiographical memory (A) refers to specific events and issues related to oneself such as one’s 60th birthday or the birth of one’s grandchild. Episodic memory (B) is essentially analagous to autobiographical memory. Procedural memory (C) is also known as ‘implicit memory’ (whereas autobiographical would be ‘explicit’) and refers to the memory or knowledge of ‘how to do things’. These are accessed unconsciously – motor skills (such as driving) would fall into this category for example. Semantic memory (D) refers to our ‘knowledge base’ and is unrelated to specific experiences or events – for example, knowing your nine times table or what the capital of Australia is.

E. Perseveration

Perseveration (E) is seen almost exclusively in organic brain disease, for example dementia. It involves giving an appropriate response to a stimulus the first time but then giving the same response (incorrectly) to a different second stimulus. Note, it is not limited to verbal statements, but may also occur with, for example, motor activity. Confabulation (A) is the phenomenon whereby false memories occur and results in incorrect answers being given. It is a complex concept, may result from the sufferer trying to ‘cover up’ not knowing the real answer and may be confused with deliberate attempts to deceive, or as is often seen in organic brain disease, the sufferer inventing ‘fantastical’ answers, which may be difficult to separate from delusions. Déjà vu (B) refers to the phenomenon whereby the person feels the sense of familiarity of having encountered an event before, even though it is a new experience for them. It may be a feature of temporal lobe epilepsy but is seen in non-pathological states and does not always indicate organic disease. Ganser’s syndrome (C) is an unusual phenomenon whereby people give ‘approximate’ answers, among other symptoms, such as, ‘How many legs does a cow have?’ ‘Five’. It has caused considerable debate as to whether it represents an organic psychotic disorder or a dissociative disorder. Jamais vu (D) refers to the sensation that a familiar event or place has never been encountered before.

A. Affect illusion

An illusion is a misinterpretation of a perception, as opposed to a hallucination, in which a new perception is experienced in the absence of a stimulus. Illusions are not usually pathological. An affect illusion (A) is one in which a perception is altered depending on the mood state; in this case a frightened woman wakes suddenly and misinterprets a hanging piece of clothing for an attacker. A completion illusion (B) occurs when there is a lack of attention, and a perception is ‘incorrectly’ interpreted, for example skipping over a misprint in a book because we are tired. Pareidolic illusions (C) consist of shapes being seen in other objects – the classic example being seeing images such as animals in cloud formations. In contrast to other illusions, pareidolic illusions become more vivid with concentration. A tactile hallucination (D) refers to a tactile (‘touch’) sensation in the absence of a stimulus. This scenario does not represent a visual hallucination (E) as the stimulus is real (the dressing gown), but it has been misinterpreted. Had there been no dressing gown and the woman had still seen an assailant, this may then have represented a visual hallucination.

A. Extracampine hallucination

An extracampine hallucination (A) is one which occurs beyond the usual range of sensation, in this case, beyond the limits of audibility – there is no possibility that the patient would be able to hear anyone speaking from Finland. These are definite hallucinations as the patient is hearing them, rather than them constituting delusional beliefs. A functional hallucination (B) occurs when a hallucination is experienced only when an external stimulus is present in the same modality. An example may be a patient hearing voices only when he hears classical music. Note that although the stimulus and the hallucination are in the same modality, they do not have to take the same form, e.g. in the example just given the stimulus is music, while the hallucination is voices. Hypnagogic (C) and hypnopompic (D) hallucinations refer to those that occur on falling asleep and waking respectively, and may occur in non-pathological states. An example would be the feeling of falling off a cliff when falling asleep. Reflex hallucinations (E) are similar to functional hallucinations but the stimulus is in a different modality to the hallucination, for example, a woman with schizophrenia hearing voices every time her child looks at her.

E. Delusional perception

A delusional perception (E) occurs when a normal perception (e.g. seeing a magazine cover) is invested with a delusional meaning (a cult is trying to kill me). The perception is given a whole new false, and usually bizarre, meaning that is specific to the patient and nearly always of monumentous importance. An autochthonous delusion (A) is one that arises out of the blue (and unlike delusional perception is not attached to a real stimulus). It should be distinguished from secondary delusions in which the beliefs are understandable in the context of the sufferer’s mood or history (e.g. a mood-congruent depressive delusion). A primary delusion is by definition un-understandable in any context. Autoscopy (B) refers to the sensation of seeing oneself, although its aetiology and precise psychopathology is controversial. Delusional atmosphere (C), also known as delusional mood, refers to the state of perplexity or bewilderment in which sufferers feel that something is ‘going on’ but without being able to state exactly what. It often occurs prior to a delusion forming and the sufferer will often describe feeling odd and that everything around them has new ‘meanings’ and significance to them in particular. Delusional memory (D) is when a patient recalls an event from the past and interprets it with a delusional meaning. Although this may seem similar to the answer ‘E’, the difference is that the event at the time will not have been invested with a delusional interpretation; it is only afterwards that this occurs.

B. Derailment

Derailment (B) is a type of formal thought disorder in which there are disjointed thoughts with no meaningful connections. It is commonly seen in schizophrenia, but also presents sometimes in other disorders. Circumstantial thinking (A) is somewhat difficult to describe but occurs when the person talks around a subject exhaustively with only loosely relevant associations. They will usually return to the point but only after many detours of almost irrelevant (or certainly over-inclusive) information. Flight of ideas (C) occurs when thinking is accelerated – associations between ideas are logical to an extent, but the ‘goal’ of thinking changes rapidly, usually because of poor attention as a result of a manic state. Pressure of speech (D) is the ‘verbal’ description of this acceleration (whereas flight of ideas refers to the speed of thoughts as opposed to speech). Thought blocking (E) occurs most commonly in schizophrenia and manifests as the patient suddenly stopping in midsentence without them being able to explain why. It is not the same as thought withdrawal, in which the patient believes an external agency is removing thoughts from their head.

B. Persecutory delusions

Persecutory delusions (B) are certainly seen in schizophrenia but they do not form part of the core of ‘first-rank’ symptoms that Schneider described as core to the diagnosis. It should be noted that these symptoms are not pathognomonic of schizophrenia as they have also been observed in other disorders (e.g. 20 per cent of those with biploar disorder). Not everyone with schizophrenia has ‘first-rank’ symptoms. Delusional perception (A) has been described above and is a first-rank symptom. Running commentary (C) refers to third-person auditory hallucinations in which one or more voices discuss in great detail what the person is doing as they do it. Other types of auditory hallucination designated as firstrank include audible thoughts, in which the patient’s thoughts are ‘spoken out loud’, and voices heard arguing with each other. Somatic passivity (D) is the symptom whereby patients feel that their body is being controlled by an external source. While it may be present along with somatic or tactile hallucinations, in itself it is a delusional belief, not a hallucination. Other first-rank passivity phenomena include passivity of emotions or impulses. Thought alienation (E) is similar to the above but involves the patient’s thoughts rather than impulses or feelings. People may feel that their thoughts are being planted (thought insertion), taken away (thought withdrawal) or played out loud (thought broadcasting).

D. Logoclonia

Logoclonia (D) describes the symptom of repeating the last syllable of a word repeatedly and is often seen in Parkinson’s disease. It has a different aetiology to stammering or the tics seen in Tourette’s syndrome. Alogia (A) is the phenomenon of ‘not having any words’ and refers to extreme poverty of speech. It is commonly seen in severe negative schizophrenia or dementia. Dysarthria (B) refers to a difficulty in the manufacture of speech, and is usually caused by structural lesions either in the vocal cords or the brainstem. Echolalia (C) is the phenomenon whereby words or sentences that the patient hears are repeated back, sometimes continuously and incessantly. It often has an organic cause such as dementia or brain injury but may also be seen in functional disorders such as schizophrenia. Neologisms (E) are new words created by the patient that have a specific meaning for them, usually involved with their delusional beliefs. It is not the same as using a known word in a different way (known as metonymy). For example, when describing the machine used to trace his whereabouts, a man with schizophrenia referred to it as a ‘Labulizer’.

B. Delusion

This is a difficult question, but actually one that is seen with some regularity by GPs and psychiatrists. The key features here that make this most likely to be a delusion (B) is the thought that people are looking at him excessively, coupled with the intrusive thought that is not his own. In a rumination (D), the patient would recognize the thought as being their own. It is not a hallucination (C) because the thought is not spoken out loud. A compulsion (A) represents a repetitive act, driven by obsessive anxiety. Somatization (E) refers to physical symptoms that manifest as the result of intrapsychic anxiety with no adequate physical explanation. Usually these patients end up having exhaustive negative medical investigations and refuse to accept that there is nothing physical to be found. The important point of this question is that it would be easy to mistake this for obsessive–compulsive disorder or dysmorphophobia. Always assess for more ‘sinister’ symptoms such as psychosis as they can sometimes be hidden beneath more obvious diagnoses.

D. Hyperphagia

Hyperphagia (D), or increased consumption of food, is not a core symptom of depression according to ICD-10, although it certainly can be seen in depressive disorders, and forms part of the criteria for atypical depression. Anergia (A), or lack of energy, is a core symptom of depression, although obviously is non-specific. Anhedonia (B), or lack of enjoyment or inability to experience pleasure, is perhaps even more common than anergia. Anorexia (C) as a symptom means lack of appetite and most certainly does occur in depression – this should not be confused with anorexia nervosa which is a specific condition. Insomnia (E), particularly in the form of early morning wakening, is a common and extremely distressing symptom of depression. Do not underestimate how disabling lack of sleep can be for depression sufferers.

E. Night terrors

Night terrors (E) are not the same as nightmares, and they do not occur in rapid eye movement sleep – the sufferer (who is usually a child) does not tend to remember any bad dreams, but will awake from sleep in a state of abject terror and confusion, often shouting and sometimes lashing out. Hypnopompic hallucinations are common on waking, particularly seeing insects. Avoidance symptoms (A) are evident here in the form of the patient not wanting to drive his car. Detachment (B) is also present in feeling disconnected from his wife and children. A feeling of derealization or depersonalization may also occur, in which the sufferer feels in some way removed from the world around him or even from his own body. Insomnia is present (C) as the patient is purposefully not sleeping from fear of the nightmares. Note insomnia may be ‘induced’ by the patient in this way, it does not necessarily mean the person is trying to sleep. There is evidence of increased arousal (D) in terms of jumping at the sound of car engines.

E. Post-traumatic stress disorder (PTSD)

Note that the symptoms have been present for more than 1 month which is required for a diagnosis of PTSD (E). The criteria for diagnosis include exposure to a potentially life-threatening event, re-experiencing of the event in various ways such as nightmares or flashbacks, avoidance of stimuli that recall the event (e.g. driving) and increased arousal such as hypervigilance, increased startle reaction, insomnia and sometimes irritability and anger. Depressive symptoms (C) are also extremely common, but the diagnosis here is clearly one with a stressful precipitant. An acute stress (A) reaction must subside within hours or days of a stressful event and results in disorientation and confusion in response to the stressor. Panic and other symptoms of anxiety commonly occur. Adjustment disorders (B) occur in response to a significant and stressful change in life circumstances or events, such as bereavement or emigration. The main symptoms are those of depression or anxiety along with an inability to cope with daily tasks. A dissociative fugue (D) is one of the dissociative or conversion disorders, in which either the body or mind in some way lose their normal integration. They usually resolve after weeks or months and are manifestations of intrapsychic stress. They were originally known as ‘hysterical’ disorders but the term is no longer used because of its sexist overtones. In a dissociative fugue, the sufferer will have a period of amnesia during which he or she will travel, often for long distances, and certainly beyond their usual range of travel. Despite this they often appear normal to passers-by.

B. Clanging

Clanging (B) is a form of thought disorder whereby words are used based on their similar sounds or rhyming and the meaning becomes unimportant. For example, ‘A cat pat on my hat sack, ate the bait and skated’. It is seen in schizophrenia but would not be a typical feature of catatonia. Catatonia is a state of either stupor in which a patient is entirely unresponsive (E) or excited. It is associated with various conditions, not just schizophrenia, and its exact cause is not known. It appears to be less common than 50 years ago, but the reason for this is not clear. Catatonia can be associated with various symptoms, including catalepsy (A), in which the limbs become rigid. Sometimes patients’ limbs can be moved into unusual positions and will remain in place even if extremely uncomfortable. This is known as waxy flexibility. Catalepsy should not be confused with cataplexy, in which there is sudden and transient loss of muscle tone resulting in collapse. Echolalia (C) is the phenomenon whereby sufferers repeat the words of those speaking to them. Remember that not all catatonic patients are mute, and echolalia is often found in these patients. Negativism (D) is the symptom whereby catatonic patients will appear to automatically do the opposite of what they are asked to do. This is not just resisting instructions or movement but actually attempting to perform the opposite instruction or movement.

A. Dementia cannot be classified in either of the two

systems

Dementia (A) can certainly be classified in both ICD-10 and DSM-IV, although the various subtypes of dementia are not necessarily accurately definable. For instance, Lewy body dementia is not represented in ICD (or at least not in the section related to psychiatric disorders, it is mentioned in the neurological disease section, but this is not usually used in mental health settings). DSM-IV is a multiaxial system (B), in other words a diagnosis will be made up of several different axes. These are: Axis 1 – clinical disorders, Axis 2 – personality disorders and learning disability, Axis 3 – acute medical conditions and physical disorders, Axis 4 – psychosocial and environmental factors contributing to the disorder, and Axis 5 – global assessment of functioning. In this way it differs from ICD-10 which uses only a single category per diagnosis. Homosexuality was, to many people’s surprise, still included in the ICD (European) system until 1990 and the DSM (American) system until 1986. It can still be found vestigially as a category relating to ‘ego-dystonic sexual orientation’ in ICD-10. ICD-10 (D) is a WHO system of coding diseases, symptoms, social circumstances and injuries. The first categories in ICD-10 (E) are related to organic disorders (F00–F09). There has been some attempt by ICD-10 to classify disorders ‘hierachically’, with organic disorders needing to be excluded first and therefore placed first. This, however, is just one of the many various controversies surrounding the classification systems used currently in psychiatry, the scope of which is well beyond this book

B. An incompleteness of the development of ideas or thoughts, leading to

a lack of logical relationship between them

Loosening of associations (B) is seen in schizophrenia. It has various definitions but fundamentally describes a form of thought disorder in which links between ideas become illogical. (A) describes alogia and is seen in chronic schizophrenia among other disorders. (C) is a definition of nominal dysphasia, seen in dementia, stroke and other organic disorders. (D) refers to circumstantiality, often seen in hypomanic states. (E) is the definition for a neologism, which is most usually seen in schizophrenia.