Psychosis: descriptive
psychopathology
Descriptive Psychopathology of
Psychosis
Adrian Lloyd
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Language/speech
Thought
Perception
Movement
Disorders of self
Language & Speech
Language & Speech
• Revise Thought/Language from
psychopathology covered in affective
disorders
• Relationship of thought & language
• Disorders of language & speech
• Psychotic language & speech disorders
Relationship of thought &
language
Thought
Language
1
Thought & language disturbance
e.g.
Flight of ideas
Derailment
Loose associations
Clang associations
Retardation
Circumstantiality
Overinclusiveness
Fusion
Thought block
Rhymes
Perseveration
Concrete thinking
Thought
Language
Speech disturbance
• Mutism (all major  s, organic disorders)
• Prosody & volume changes
• Unintelligible speech
– Paragrammatism / incoherent syntax
(>>> ‘word salad’)
– Neoligisms
– Stock words/phrases private symbolism
– Cryptolalia/graphia
Speech/language disorders of
localising value
• Sensory dysphasias
Speech/language disorders of
localising value
• Motor dysphasias
– Pure word deafness
– Pure word blindness
– 1º sensory dysphasia
– (Nominal dysphasia)
– Jargon aphasia
– Pure word dumbness
– Pure agraphia
– 1º motor dysphasia
– Alexia with agraphia
– Isolated speech area
Generation of language/speech
Speech areas
• Language development (phonemes - categorisation)
Organic speech disorders
further reading:
Strub RL & Black WF,
The mental status
Examination in
neurology;
FA Davis
AF
B
BA 44
W
BA 22
Lishman WA,
Organic psychiatry;
Blackwell
• Memory stores (verbs: frontal; nouns: temporal)
• Word generation (syllable production & connection:
posterior parietal)
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Grammar / syntax (revolves around verbs; ?frontal)
Prosody (largely R hemisphere)
Short term memory (for understanding of discourse)
Semantic processing (largely R hemisphere)
Phonation (motor)
Articulation (motor)
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Assessment of speech
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Phonation
Articulation
Quantity
Rate
Fluency
Spontaneity
Prososdy
Volume
Vocabulary
Syntax
Cohesive ties
Proposition
Language in affective psychoses
Mania
– Pressured ( quantity, rate & spontaneity),
loud,  cohesive links, clang associations
(terminal syllable)
Depression
–  quantity, rate, volume, spontaneity, prosody,
retardation
Language in schizophrenia
•Thought disorder as expressed in language
– Akataphasia
– Loss of continuity of
associations
– Asyndesis
– Metonyms
– Over-inclusive thinking
– Concrete thinking
– Poverty of speech (thought)
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Neologism
Block
Derailment
Loss of goal
Tangentiality
Illogicality
defect of deductive
reasoning
• empty speech
• alogia
• verbigeration
Language in schizophrenia
•Altered / misused words, phrases & grammar
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Stock words/phrases
Semantic halo
neoligism
intrusion of dominant
meanings
– Clang associations (initial
syllable)
– Repetitive speech (intrusion
of associations)
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Alogia
Paralogia
Paraphasia
Literal paraphasia
Verbal paraphasia
Agrammatism
Telegramese (loss of adverbs)
Paragrammatism
• Syntax preserved long after word use disturbance occurs
• Sz speech is less predictable than normal speech
Assessment of thought
• Form
– Quantity/rate
– Fluency/associations
– Judgement/reasoning
Thought
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Delusion
Overvalued
Obsessional
Normal
– Possession
• Passivity
– Themes
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Self-referent
Depressive/nihilistic
Grandiose
Persecutory
Religious
• Content
– Specific ideas of the
subject
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Al Qaeda are after me
I am God
I receive radio waves
The world is in ruin
Trees speak to me
– Mood congruence?
– Ideas of harm to others?
3
Form: Normal thought
Form: Flight of ideas
•Rate 
•Loss of determining
tendency
Initial thought
Goal
•Individual associations can
be recognised (but may be
unusual)
Determining tendency
After Sims
Form: Retardation
After Sims
Form: Circumstantiality
Goal
Goal
•Rate slowed •Determining T. intact •Fewer associations
•Rate normal •Determining T. intact •lots of unnecessary detail
After Sims
Form:
Derailment / knight’s move / entgleisen
•Loss of understandable associations
After Sims
Form:
Derailment / knight’s move / entgleisen
•Loss of understandable associations
After Sims
After Sims
4
Form: Thought block / entgleiten
Fusion / verschmelzung
Unexpected breaking off of chain of thought
Bringing together of various themes – conversation
difficult to follow
After Sims
After Sims
Judgement / reasoning
Form: Thought block / entgleiten
• Delusion
– Unshakeable false belief out of keeping with
social/cultural background
• Primary: un-understandable
• Secondary: evolve to explain other experiences (voices,
thought block etc)
• Overvalued idea (“as if” quality)
– Challengeable; open to reasoning but cannot be ignored
• Obsessional thought
– Own, recognised as illogical, resisted, intrusive
Unexpected breaking off of chain of thought
After Sims
Other aspects of thought form
• Passivity: Thoughts are not my own / are
controlled by something other than me
• Can also apply to interpretation of actions/behaviour
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Self referent ideas (= ‘paranoid’)
Grandiosity
Nihilism
etc
Can be
delusional
or overvalued
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Perception
Perception
Perception
• Revise Perception from psychopathology
covered in affective disorders
Normal
•Sensory perception
•Imagery
•Eidetic Imagery
• Perception in psychosis
False Perceptions
Illusions
Sensory Distortions in Psychosis
•  intensity
• mania, drug-induced, epilepsy
•  intensity
• depression
• micropsia/macropsia/dysmaegalopsia
/metamporphopsia(paraprosipia: faces)
Pseudohallucinations
Abnormal
Sensory Distortions
•Intensity
•Size
•Colour
Hallucinations
False Perceptions in Psychosis
• Hallucinations
•  normal perception, can percieve > 1 at once
• may not have corroborative evidence, may be
explained delusionally (as may the fact that others do not
have access to the experience)
• Organic states, epilepsy, Sz (rare), drug-induced
• Split perception
• organic states, Sz
6
Hallucinations
• Auditory
Hallucinations
• Visual
• Can be difficult to differentiate from other visual abnormalities
• Organic rather than ‘functional’ psychoses
– elementary
• noises: usually in organic states
» TLE, delerium, dementias, encephalopthies etc.
– complex
• Drug-induced
• Voices
» mescaline, LSD, solvents, mushrooms.
– organic states (including alcohol-inuced): simple words
– Affective psychoses & Sz - simple words, complex speech (2nd
&/or 3rd* pers. Gedenkenlautwerden*, running commentary*)
– behaviour observed 2º to hallucination
» distraction, verbal responses, actions ?vocalisation
(* = 1st rank)
• may have affective associations - e.g. DTs
• Association with other visual abnormalities
» e.g. cortical blindness, hemianopias, dyslexia etc.
• Sz: rare
» cf vis. pseudohallucinations related to auditory hallns.
» Scenic vis. hallns. in oneroid states.
• Charles Bonnet syndrome
• Autoscopic visual hallucination.
Hallucinations
• Bodily sensation
– Superficial
• Thermic
• Haptic
• Hygric
– Kinaesthetic
• Joint / muscle sensation
– Visceral
Hallucinations
• Olfactory / gustatory
Frequently delusionally
interpreted
• Often as passivity
• Common in Sz
– With both hallucinatory
& delusional components
•Affective psychoses
•Drug-induced / withdrawal
states
• Inner organs
False Perceptions in Psychosis
– Epilpsy (esp TLE)
– Sz
– Other organic pathology
– Affective psychoses
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Hallucinations
• Pseudohallucinations
– Nature
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Visual, auditory, tactile
Involuntary
Figurative
Not as real as normal perception
Internal subjective space (Kandinsky/Jaspers)
– Occur in many psychiatric (psychotic & nonpsychotic) disorders and in non-pathological states
• No diagnostic significance
May self-referentially
interpreted
– Strong link with memory
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• Persecutory
• Mood congruent
Distinguish from other
factors relating to
smell/tatse
• Medication
• Overvalued normal odours
• Delusion without
hallucination
PseudoHallucin’ns
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Fantasy
External space
Internal space
Internal space
Unwilled
Unwilled
Willed
Vivid/well defined
Vivid/well defd.
indef/incomplete
Concrete/real
Not completely
real; “inner eye”
Pictorial quality
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Could not do so
Could exist in other
sens. Modality
Independent of
observer
Dependent
Dependent
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Other specific sensory experiences
• Autoscopy
– Visual halln or pseudohalln
• Extracampine hallucination
– a perception outside normal sensory field
• Hypnagogic/Hypnopompic hallucinations
– falling asleep / waking respectively
– in narcolepsy, cataplexy & sleep paralysis
• Functional hallucination
– halln provoked by an external stimulus
• Reflex hallucination
– hallucinatory synaesthesia
• Abnormal imagery
– reduced or abnormally vivid
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Abnormal perception in sensory
deprivation
Movement disorders
• Classification
» none is all-encompassing
» none are mutually exclusive
Movement Disorders
– MSE
– Disorder-based
– Aetiological
– Form of movement
• Checklists
Classification - MSE
• Appearance
– facial expression
– posture
• Behaviour
– reflective of mood state
– independent of mood
– ‘bizarre’
Classification - disorder-based
• Motor symptoms characteristic of
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depression
mania
schizophrenia
Huntington’s
OCD
Hysteria
Dementias
etc etc etc
Huge overlap,
v non-specific as
regards description
of movement
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Classification - aetiological
Classification - form
agitation
organic
cerebellar
EPS
2 º to Sx of disorder
myoclonus
Drugs
1º Sx of disorder
/motor
retardation
catatonia
tics
Response
to hall’ns
/dell’ns
fear & distress
chorea
conversion
EPSE
• Adaptive movements
• Non-adaptive movements
– spontaneous
– induced
• Speech
• Posture
• Complex behavioural patterns
» From Sims (sx in the mind) + Hamilton M (Ed.) Fish’s Clinical
psychopathology 2nd edition 1985. Wright
» For summary see Buckley/Bird & Harrison; Examination notes in
psychiatry. Butterworth-Heinemann
intoxication
akathisia
tremor
Form – adaptive movements
• Expressive behaviour
Form – non-adaptive movements
• Spontaneous
– Facial expression, gesturing
• Reactive behaviour
– e.g. startle ( in PTSD/anx; in depn, Sz –ve Sx)
• Goal directed movements
– e.g. tics, tremor, EPS, conversion, choreo-athetosis,
dyskinesias, dystonias, stereotypies
(Can increase in anxiety)
• Induced
– Mannerisms
– e.g. in catatonia
– Abnormal, repetitive goal directed movements
– Obstruction (in catatonia)
– automatic obedience, mitgehen, echopraxia, echolalia,
negativism, perseveration, etc.
– Stopping in mid-goal directed movement
» ? Motor equivalent of thought block
Form – motor speech disturbances
• Attitude
– negativism, responding to voices, etc.
• Flow
– Mutism, slowed, staccato, pressure
Tic v
stereotypy
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mannerism
• Mannerisms
– Stress, inflection, rhythm, pronunciation etc
• Stereotypies
– Words & phrases used repeatedly
• Perseveration
– of words or themes
• Echolalia
– Speech equivalent of echopraxia
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Form - patterns of complex behaviour
Form – posture
Abnormal psychic events
• Catatonic posturing
Subjective
• including waxy flexibility
Consequent
behaviour
experience
• Postural mannerisms
• ‘Sagging’ in depression
• ‘Upright/tense’ in anxiety
= Phenomenology
= Observation
Assumption
Goal directed
OCD – rituals
hebephrenic ‘silliness’
mania
response to psychotic Sx
Make sure you know these!!
• Agitation
• Retardation
(psychomotor)
• Hyperactivity
• Hyperkinesis
• Mannerism
• Stereotypy
• Dystonia
• Dyskinesia
• Chorea
• Perseveration
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Athetosis
Myoclonus
Ataxia
EPS / EPSE
Tremors
Conversion
(Dissociation)
Tics
Stupor
Akinesis
Akathisia
Non-goal directed
Stupor 
catatonia
hysteria
organic
etc.
excitement
catatonia
anxiety
mania
etc.
Make sure you know these!!
– Excessive opposition
• Catatonia
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– Psychological pillow
– Posturing
– Excessive compliance
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Mitmachen
Mitgehen
Automatic obedience
Echopraxia
Echolalia
Forced grasping
Advertance
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Gegenhalten
Negativism
Aversion
mutism
Ambitendency
Schnauzkrampf
Stupor/akinetic mutism
Waxy flexibility
Obstruction
‘Self’
Social setting
Body Schema
Disorders of Self
Perceived body
Self-concept 1
Body concept
Self-concept 2
Body image
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Self awareness/experience
• Awareness of existence & activity of the self
• Mental
• Physical
Disorders of self
• Existence & activity: (possession of activity, perception,
movement, mental functions, cognition, emotions etc)
• changed experience of activity: depersonalization
(this is not psychotic)
• Awareness of being a unity at any given point of
time
• Awareness of continuity of identity over time
• Awareness of the boundaries of self
Jaspers.
Disorders of self
• Unity/singleness
• Autoscopy (=haeutoscopy, =phantom mirror image)
» seeing oneself (haeutoscopic hallucination)
» loss of feeling of familiarity
» Sz (rare), parietal lobe disorders
• Doppelganger (? “haeutoscopic depersonalization”)
» “being outside, alongside & inside oneself”
» ideational (form of depersonalization), delusional, &/or
perceptual
• Haeutoscopic delusion (rare)
• Multiple personality
» Hysterical dissociative states
• Lability in awareness of personality
» In Sz: believing one has become someone/something else
& simultaneously believing self to be separate from it (?)
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feel as if unreal
internal &/or external change
unpleasant
affect always involved
insight preserved
often assoc. with derealization
also desomatization/de-affectualization
• not existing: nihilistic delusions
• passivity phenomena
Disorders of self
• Identity
• Belief of having not always been the same person
» Exclusively psychotic
» Sz
» Characteristically a passivity experience: “been changed”
• Non-psychotic feeling: as if no longer truly self
» ie thoughts/feelings differ from previously accepted self
» no loss of contact with reality that is in fact the same person
• Loss of continuity of self over time
» Sz: changed person
» Depression: will not continue into future
» Role in insight
• Possession state
» Temporary, Cultural v Pathological, Conscious level
• Near death experiences
» Depersonaliz’n, autoscopy, alert, trancendental exp’nces
Disorders of self
Psychosis
Environment
• Boundaries
• Losing differentiation between I & not I
– Sz
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common feature of 1st rank Sx
blurred boundaries less apparent to patient than to observers
passivity
hallucinosis (esp. 3rd person & hearing own thoughts out loud)
delusional percept
– Ecstasy states
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Affectively mediated: ‘as if’
Normal
Personality disorders
Psychotic states
Movement/behaviour
Self
Perception
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g l
Thought
/language
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Time: flow / direction / uniqueness / quality
Loss of distinction of ‘I’ v ‘not I’
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