Class presentation 2: the language psychiatrists use to describe abnormalities of mental experience and behaviour. Ten questions plus the take-home question. Plan 15–20 minutes.
Purpose: understand the language psychiatrists use to describe abnormalities of mental experience and behaviour.
1. What is psychopathology?
- Psychopathology is the study of abnormal mental experience and behaviour: the description (what is abnormal and how), and the explanation (why it occurs).
- Descriptive psychopathology (Karl Jaspers) records exactly what the patient experiences (phenomenology) and what the examiner observes, without first interpreting it as a disorder.
- It is the vocabulary of psychiatry: the shared words that let one clinician understand another's examination.
2. Why must a medical student learn it before the disorders?
- Every psychiatric diagnosis is built from these symptoms and signs. You cannot understand "schizophrenia" without knowing hallucinations, delusions and thought disorder.
- It lets you take a precise history and mental state examination (MSE) and write it so others can use it.
- It prevents mislabelling: knowing what a delusion is stops you calling every strange belief a delusion.
- It is how psychiatry communicates, as signs and symptoms do in other specialties.
3. Major domains of mental functioning examined
The mental state examination follows these domains:
- Appearance and behaviour
- Speech
- Mood and affect
- Thought (form, content, possession)
- Perception
- Cognition (orientation, attention, memory, executive function)
- Insight and judgement
(Risk to self and others is assessed throughout.)
4. Abnormalities in each domain
Appearance and behaviour
- Self-neglect, bizarre or inappropriate dress, odd posture.
- Psychomotor agitation or retardation; overactivity and disinhibition (mania).
- Catatonia: stupor, mutism, posturing, waxy flexibility, negativism, stereotypies, echolalia and echopraxia.
- Tics, tremor, akathisia (inner restlessness from antipsychotics), mannerisms, eye contact, rapport.
Speech (rate, amount, volume, tone)
- Pressured speech (mania); poverty of speech and mutism (depression, schizophrenia); slow, monotonous (depression); dysarthria or slurring (neurological, intoxication).
Mood and affect
- Mood: depressed, elated, euphoric, irritable, anxious, anhedonia.
- Affect: blunted, flat, restricted, labile, incongruent, inappropriate.
Thought
- Form: flight of ideas, loosening of associations (derailment), tangentiality, circumstantiality, thought block, neologisms, word salad, perseveration.
- Content: delusions, overvalued ideas, obsessions, phobias, preoccupations, suicidal or homicidal ideas.
- Possession (passivity phenomena): thought insertion, withdrawal, broadcasting.
Perception
- Hallucinations (auditory, visual, olfactory, gustatory, tactile), illusions, pseudo-hallucinations, depersonalisation and derealisation.
Cognition
- Disorientation, impaired attention, memory loss, poor executive function, impaired abstraction, intellectual disability. Acute, fluctuating: delirium. Gradual, progressive: dementia.
Insight and judgement
- Insight: from complete denial of illness, through awareness with blame on others or external factors, to true emotional insight.
- Judgement: impaired decisions about treatment, safety, money, relationships.
5. Form versus content of thought
| Form | Content | |
|---|---|---|
| Question | How does the person think and speak? | What is the person thinking about? |
| Concerns | Flow, speed and connection of ideas | Beliefs, preoccupations, ideas |
| Abnormalities | Flight of ideas, derailment, thought block, word salad | Delusions, obsessions, overvalued ideas, suicidal thoughts |
| Typical example | Rapid jumping between topics with rhyming (mania) | "My neighbours are poisoning my food" |
The same patient can have normal form with abnormal content (a patient with a well-organised delusion) or the reverse.
6. Delusion, hallucination and illusion
| Delusion | Hallucination | Illusion | |
|---|---|---|---|
| Disorder of | Thought (belief) | Perception | Perception |
| Definition | A fixed, false belief, held with unshakeable conviction, out of keeping with the person's education and culture, not changed by evidence | A perception without an external stimulus | A misinterpretation of a real stimulus |
| Example | "The president is sending me secret messages" | Hearing a voice commenting when nobody is present | Seeing a coat on a door as a person in the dark |
| Seen in | Schizophrenia, mania, psychotic depression, delirium | Schizophrenia, delirium, substance use, epilepsy | Delirium, anxiety, fatigue; can be normal |
Types of delusion: persecutory, grandiose, delusion of reference, jealousy (Othello), erotomanic, somatic, guilt, and nihilistic (Cotard). Primary delusions arise "out of the blue"; secondary delusions follow another experience (for example mood). Always check the cultural and religious context before calling a belief a delusion.
7. Mood versus affect
- Mood: the sustained emotional state the patient reports (the climate).
- Affect: the observed emotional expression (the weather).
- Example: a patient says "I'm fine" (mood) but looks tearful and flat (affect).
8. Insight
- Insight is the patient's awareness and understanding that they have a mental illness, that their symptoms are part of it, and that treatment is needed.
- Three components: recognising the illness, relabelling unusual experiences as symptoms, and accepting treatment.
- It is a continuum, not yes or no, and it changes over the course of illness.
- Good insight predicts better adherence and outcome; poor insight is typical of mania and psychosis.
9. Why describe psychopathology before interpreting it?
- Avoids premature closure: the first diagnosis you think of may be wrong.
- Lets you separate evidence from conclusion so others can check your reasoning.
- The same symptom occurs in many disorders (hallucinations in schizophrenia, delirium, substance use, epilepsy).
- Prevents cultural error: a belief or experience may be normal in the patient's culture.
- Provides a record that stays useful even if the diagnosis changes.
- Method: observe and describe → name the phenomena → consider the syndrome → consider the diagnosis.
10. Clinical application: describe, do not diagnose
Patient statement: "The people next door talk about me all day. I hear them through the wall, saying I am dirty. Last night a machine put thoughts into my head and now they are not mine. I've stopped eating because they poison my food. I am not sick; I just need them to stop."
Description of the psychopathology (no diagnosis):
- Perception: auditory hallucinations, third-person, derogatory.
- Thought possession: thought insertion (a passivity phenomenon).
- Thought content: persecutory delusions (poisoning) leading to food refusal.
- Insight: absent: denies illness ("I am not sick").
- Behaviour: reduced eating (secondary to the delusion).
- Still needed: mood and affect, speech and form of thought, cognition, risk, substance use, duration. Only then consider the syndrome and the diagnosis.
Take-home question: what did you observe or establish, and what conclusion are you making from it?
- Observed (data): what you saw, heard and were told, in the patient's own words and your own description.
- Concluded (interpretation): what you think it means (a delusion, a hallucination, a syndrome, a diagnosis).
- Keep them separate. Write "the patient says he hears voices commenting on him", then "this is consistent with third-person auditory hallucinations", and only then "which raises a psychotic disorder".
- Observations are facts you can defend; conclusions are hypotheses you must test.