# 17 - 522_Descriptive_Psychopathology

# 01 - 1. Mood and Affect

# 1. Mood and Affect:

# 02 - Aspects of Affect

# Aspects of Affect:

# 03 - Coexisting features of mood disturbance

# Coexisting features of mood disturbance:

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1. Mood and Affect: 
The terms affective disorder and mood disorder are used interchangeably in clinical practice. The 
difference between mood and affect has been variously described. It is generally accepted that mood refers 
to a more pervasive emotional state than affect (as if climate = mood and weather = affect). Both mood 
and affect can have an objective and subjective components though one school of thought proposes to use 
the term mood for subjective and affect for objective components of emotional expression. 
Aspects of Affect: 
Descriptor 
 
Valence 
The quality of affect: i.e. happy, depressed, perplexed, anxious or angry 
Reactivity 
Responsiveness of affect to environmental cues - One expects affect to be reactive to 
cues in the environment; we laugh on hearing a joke, blush when embarrassed, etc. If 
the reactivity is conspicuously absent, then this is called blunted affect or parathymia, 
according to Bleuler. Bleuler proposed this feature as a primary schizophrenic 
symptom. 
Range of expression 
This may be restricted or constricted in depression and anxiety states. 
Congruence 
Incongruent affect may be seen in hebephrenic schizophrenia and learning disability. 
For example, a patient might maintain a silly, jocular affect in spite of receiving a bad 
news. 
Stability 
This refers to the reasonable maintenance of an affective state until a clear external 
stimulus demands a change in affect. The absence of such stability manifests as a 
sudden unprovoked change in affect; the patient may break down into tears for no 
reason or appear enlightened with apparently no environmental cues. This is called 
labile affect; it is seen in histrionic personality, borderline personality, and sometimes 
in PTSD. 
Control 
An extreme form of labile affect is termed as emotional incontinence; it is seen in 
organic states such as pseudo bulbar palsy where frontal lobe is damaged. Here the 
patient bursts out into laughter or tears within minutes with no control over these 
emotions – it appears as if the patient has developed an incontinence of the emotion 
filled ‘bladder’. He/she has little control over these expressions. 
 
Coexisting features of mood disturbance: 
Mania is characterized by extreme euphoria (disturbed emotion), pressured speech (disturbed thought) 
and too many ideas and plans to be carried out (disturbed will). It is not a pure mood or affective disorder 
in this sense. The terms euphoria, ecstasy and expansiveness, refer to various degrees of an elevated mood, 
but they do not include thought or will component. The same applies to the term ‘depression’ in clinical 
sense – it includes mood, will and thought components and not just sad affect. 
Melancholia is probably the oldest of terms used in psychopathology. It is defined as a quality of mood, 
which is distinct from grief, occurring in association with significant psychomotor retardation often with 
somatic symptoms of depression (as described in ICD-10). It is very characteristic of depression; patients 
often describe this as a deeply distressing affective state.

# 04 - Pain symptoms

# Pain symptoms:

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Mixed states: It is long appreciated that between the extremes of mania and depression various mixed 
states exist. In fact, mixed states are commoner than pure mania or depression, according to the recent 
literature. 
s. no 
Type 
Mood 
Will 
Thought 
Manic stupor 
High 
Low 
Low 
Mania with poverty of thought 
High 
High 
Low 
Inhibited mania 
High 
Low 
High 
Depressive mania 
Low 
High 
High 
Excited depression 
Low 
High 
Low 
Depression with flight of ideas 
Low 
Low 
High 
Over the years, the six Kraepelinian mixed states have dwindled into just two varieties: 1. Dysphoric 
Mania (when predominant mania is present with some depressive symptoms) and 2. Depressive Mixed 
State (when full depression is present with some manic symptoms). 
Other terms such as agitated depression (full depression with psychomotor agitation), anxious depression 
(depression with marked anxiety), irritable depression (depression with marked irritability), and mixed 
hypomania (hypomania with some depressive symptoms) are used in this context but are better avoided. 
Pain symptoms: 
Pain is frequently associated with mood disturbances. It is difficult to distinguish organic and non-organic 
pain as often there are mixed elements of both in a pain syndrome. Nevertheless certain differences exist 
as listed below. 
Psychiatric vs. Organic pain: 
Organic pain 
Non-organic pain 
Less diffuse 
More diffuse 
More anatomical confinement 
Less anatomical 
Often fluctuant and remits during intervals 
Often constant and unremitting 
Usually characteristic quality 
Difficult to describe the quality 
Progression, if occurs, will have tissue boundaries 
Progresses without tissue confinement generally 
Anywhere in the body 
Head and neck, back are the most common 
Can wake patients from sleep 
Rarely wakes one from sleep 
Tenderness may be present 
Tenderness very rare 
May have typical postural changes e.g. intracranial 
pathology 
Usually no postural variation

# 05 - Anhedonia & Alexithymia

# Anhedonia & Alexithymia:

# 06 - Mood and perception of time

# Mood and perception of time:

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For somatoform pain, head and neck are the most common sites. In somatisation disorder, 
musculoskeletal symptoms are the commonest. In hypochondriasis gastrointestinal symptoms 
predominate. 
Anhedonia & Alexithymia: 
Anhedonia was a term coined by Ribot; it refers to the inability to derive pleasure in life often leading to 
diminished interests in activities. It may be of two types: physical and social anhedonia. Physical 
anhedonia represents a defect in the ability to experience physical pleasures, such as pleasures of eating, 
touching etc., while social anhedonia represents a defect in the ability to experience interpersonal pleasure, 
such as pleasure of being with people, talking, etc. Anhedonia is common in melancholic depression with 
somatic syndrome where it is a core symptom. It is also observed as a part of the negative syndrome of 
schizophrenia. In schizophrenia, anhedonia is considered to be more social or interpersonal than a 
personal/physical deficit. 
Alexithymia was first described by Sifneos. A- Absence or defective + LEXI –words + THYMIA - emotion 
i.e. Difficulties in using words to express emotions. It is often accompanied by 
1. Diminution of fantasy. 
2. Reduced symbolic thinking 
3. Literal thinking concerned with details 
4. Difficulties in recognizing one's own feelings 
5. Difficulties in differentiating body sensations and emotional states. 
6. A ‘robot-like existence’ is suggested – but patients rarely complain in these terms. 
It is especially seen in psychosomatic illnesses, somatoform disorders, depression, PTSD, personality 
disorders and paraphilias. Note that in some cultures especially south Asian, somatic metaphors are used 
in describing emotions often. 
Mood and perception of time: 
This may be altered in patients with depression or mania. In a study of 32 acutely depressed, 30 acutely 
manic, and 31 control subjects, the experience of time was assessed both subjectively (with a visual analog 
scale) and objectively (with Chronotest software and the Trail Making Test (TMT)). Both manic and 
depressed subjects were slow in the TMT, but the subjective experience of time was slowed in the 
depressed, sped up in the manic, and unchanged in the control subjects (Bschor et al. 2004). 
An allied phenomenon seen in some patients with schizophrenia is the age disorientation. In chronic 
schizophrenia patients may lose the track of their age and may claim that they are of an age at least 5 years 
different from their actual age. Age disorientation is defined as misstating one's age by 5 or more years. It 
is observed in a substantial number of chronically ill, institutionalized schizophrenic patients. Prevalence 
estimates have been limited to data from surveys of hospitalized mental patients in chronic care facilities, 
where approximately 25% of patients are age disoriented. The majority of age-disoriented schizophrenic 
patients understate their age. In fact, an additional 10% of schizophrenic subjects report an incorrect 
subjective age that is within 5 years of their age at illness onset. Age-disoriented patients are generally 
older, have a longer current admission, and were younger at first admission than age-oriented patients. 
Age disorientation is associated with early onset and poor prognosis.

# 07 - 2. Disorders of perception

# 2. Disorders of perception

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2. Disorders of perception 
Perception consists of two parts – receiving information from a sensory modality (bottom up) and 
interpretation or processing of the sensation instantaneously using cognitive faculties (top down). 
Normally, any perceived object corresponds to the stimulus that elicited it. 
Perception occurs in visual, auditory, tactile, gustatory, olfactory, kinaesthetic or proprioceptive 
modalities – any distortions in perception could also occur in any of these domains. 
Perceptual errors can occur at different levels – 
Perceptual disorder 
Stimulus 
present? 
Corresponding object 
perceived? 
Error 
Perceptual distortions 
Yes 
Yes 
Object’s quality altered 
Illusions 
Yes 
No 
A different object is perceived 
Hallucinations 
No 
Yes 
Perception without a stimulus 
Negative hallucinations 
Yes 
No 
No object is perceived 
 
 If a stimulus is perceived as corresponding object but not accurately – changes in physical properties 
e.g. size, shape, intensity and colour - this is a perceptual distortion. In depression and hypoactive 
delirium there is dulled perception; intense perceptions can occur in mania, hyperactive delirium and 
drug-induced states (hallucinogens). Hyperacusis especially is seen in migraine and alcohol hangover. 
 
Changes in the shape of objects especially with the loss of symmetry are called dysmegalopsia. 
 
The objects can shrink in size – micropsia or enlarge - macropsia. 
 
These are usually organic – could be ictal (parietal) or ocular (accommodation errors – 
paralysed accommodation can cause micropsia), rarely in acute schizophrenia. Hallucinogens 
(Mescalin) can also change the colour of perceived objects or make components of an object e.g. 
body parts – to be seen detached in space. 
 Stimulus is perceived as an object but not corresponding to the source – both stimulus and object are 
present, but different from each other – illusions. 
 There is no stimulus but perception occurs – hallucinations. 
 There is a stimulus but no perception occurs – negative hallucinations.

# 08 - Imagery & Illusions

# Imagery & Illusions

© SPMM Course 
The above table has been pictorially represented below: 
 
 
Imagery & Illusions 
The imagery is not a perception because there is no stimulus involved and no object perceived; it is 
essentially a fantasy. Imagery refers to images produced voluntarily with complete insight that they 
are mental, not external phenomena. They also lack the objective quality of hallucinations and normal 
sense perceptions. 
One form of imagery called eidetic imagery is considered to be a special ability of memory wherein 
visual images are drawn from memory accurately at will and described as if being perceived currently. 
This is noted in children (2-15% school goers) and may be a part of religious experiences; no 
pathological association is noted consistently. 
Illusions may be difficult to differentiate from hallucinations if the source of stimulus is difficult to 
trace – e.g. ‘Did I see the devil on the wall or from the wallpaper pattern?’ But, fortunately, these are 
qualitatively different and so eliciting the description patiently can help. There are three major types of 
illusions: 
 
 
 
STIMULUS 
PERCEIVED 
OBJECT 
EXPERIENCE

# 09 - Pseudohallucinations

# Pseudohallucinations:

© SPMM Course 
Type of 
illusion 
Context 
Quality 
Effect of 
concentration 
Example 
Affect 
illusion 
Prevailing emotional state leads to 
misperceptions 
Often 
fearful, 
emotion 
provoking. 
Disappears on 
focussing the 
object with 
extra 
concentration 
A 
depresse
d patient 
reading 
‘deed’ as 
‘dead.' 
Pareidolic 
illusion 
Formed objects from ambiguous stimuli, 
coloured by prevailing emotion; not 
entirely due to inattention or affective 
change 
Often 
playful and 
whimsical. 
On paying 
extra effort, 
the object 
intensifies – 
does not 
disappear. 
Seeing 
cars in 
the cloud 
Completion 
illusion 
Stimulus that does not form a complete 
object might be perceived to be complete 
Due to 
inattention 
Disappearance 
on 
concentration 
is the rule. 
CCOK is 
read as 
COOK 
 
In pareidolia, fantasy and imagery play equal parts, apart from the actual sense perception. It is common 
in delirium especially in children when febrile, hallucinogen use. Pareidolia are under some degree of 
voluntary control and not characteristic of any psychotic illness. 
Pseudohallucinations: 
Though the distinction between these two is not always clinically relevant, presentation with consistent 
pseudo hallucinations with no other psychotic features should make one question the veracity of the 
psychopathology. 
Pseudohallucinations: There are two different definitions: 
o Involuntary hallucination-like experiences occurring in inner subjective space, with a vivid outline 
that are absolutely different from normal sense perceptions and hallucinations (Kandinsky, 
Jaspers & Sims). 
o Hallucinations that are recognized to be unreal and self-originating are pseudohallucinations 
according to Hare. European psychopathologists use the former definition more often. 
Pseudohallucinations are not pathognomonic of anything; they are not always pathological.

# 10 - Hallucinations

# Hallucinations

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They are intermediate between fantasy (imagery) and hallucinations. Like fantasy they are in subjective 
space, lack quality of concrete reality, have quality of idea and so not sought in other modalities 
simultaneously (not searched for, no attempts to reach out etc.) and appreciated to be observer-dependent, 
self-originating. Like a hallucination, they have a clear outline, vivid, retained for the good length of time, 
cannot be dismissed at will and are behaviourally and emotionally relevant i.e. acted upon or felt for. 
The hallucinatory experiences of bereavement and in Ganser’s state are pseudohallucinations 
 
 
 
 
 
 
Hallucinations 
Hallucinations have several important qualities that are essential in differentiating from other mental 
phenomena: 
1. They take place at the same time as other sensory perceptions – e.g. the voice is heard even when 
music is playing, or someone is talking to me. So they are different from dreams where no real 
component exists alongside the false perception. 
2. They take place in the same space as other perceptions - angel is seen standing at the corner of my 
room. This is different from fantasy or imagery which takes place in subjective space. 
3. They are experienced as sensations – not as thoughts – contrast from obsessional images. 
4. The percept has all qualities of an object – i.e. it is believed that it can be experienced in other 
modalities too, like a real object which can be seen, felt, smelt and heard. This is why hallucinators 
search for the man behind the voice or try and reach out and touch visual percepts. 
5. They are involuntary – appearance cannot be controlled; independent – will exist even when not 
perceived by the hallucinators; may lack the quality of publicness – not every one could hear and see 
them. 
Auditory Hallucinations: 
 Elementary, unstructured hallucinations are seen in acute organic states. 
 Musical hallucinations are similar to Charles Bonnet syndrome in visual domain – can occur in 
those with deafness, also in organic conditions. Formed auditions like voices – as in thought echo – 
cannot be elementary. 
Phonemes are any auditory hallucinations that occur as human voices. Schizophrenic phonemes are 
usually multiple, may or may not be recognizable, usually male with a different accent, speaking in one’s 
mother tongue and usually episodic - almost never continuous. When a same word is repeated 
continuously, normal subjects hear phonetically linked but different words. Hallucinating schizophrenia 
TRUE HALLUCINATION 
PSEUDO HALLUCINATION 
 Objective, outside spatial location 
Absence of insight 
Sought in other modalities (see text) 
Often seen in psychosis 
Subjective spatial location 
The presence of insight, often. 
Not sought in other modalities usually. 
Often in personality disorders, following 
trauma, dissociative experiences.

© SPMM Course 
subjects hear different words that have no phonetic connection to the original repeated word – this is 
called verbal transformation effect. Patients could be distracted away from their voices, but it is the attention 
paid to the external stimulus which is more important than the degree of external stimulus used to distract. 
Alcoholic hallucinosis initially starts as fragmented voices, later organised into clear voices. 
Visual hallucinations: Occipital lobe tumours, postconcussional states, epileptic twilight state, hepatic 
failure (any toxic delirium), dementia are some causes for visual hallucinations. 30% of old age psychiatric 
referrals have visual hallucinations. Solvent sniffing and hallucinogens can cause elementary visual 
hallucinations like light flashes. Simultaneous visual-verbal hallucinations – green man speaking to me – 
is seen in TLE. Visual hallucinations are very uncommon in schizophrenia (But Andreasen quotes 30% in a 
series observed with acute schizophrenia). Reports of “black patch” psychosis were frequent following 
simultaneous bilateral cataract surgery in the early era of the procedure, attributed to sensory deprivation, 
leading to the recommendation that only one eye be operated on at a time. It was subsequently recognized 
that “black patch” psychosis was a relatively uncommon postoperative delirium partly due to 
anticholinergic eye drops.* 
Charles Bonnet Syndrome: Elderly patients, with normal consciousness and no brain pathology, with 
reduced visual acuity due to ocular problems, experience vivid, distinct, usually well-coloured (in contrast 
to real sensation that is blurred due to eye disease) formed hallucinations – mostly humans, at times 
animals and cartoons. These objects usually show movement, and can be voluntarily controlled – disappear 
on closing the eyes; insight about unreality is usually preserved – though they may evoke emotions 
including fear and joy. About 1/3rd are elementary; usually the hallucinations are located in external space. 
Podoll's criteria for diagnosis include: Elderly person with normal consciousness with visual 
hallucinations; not in the presence of delirium, dementia, psychosis, intoxication or neurological disorder 
with lesions of central visual cortex; reduced vision resulting from eye disease (most commonly macular 
degeneration). The syndrome can occur in people with normal vision1,2 
Lilliputian hallucinations can occur in visual or haptic mode – they usually involve seeing tiny people or 
animals (or feeling diminutive insects crawling if haptic) and are seen in delirium tremens and unlike 
other organic visual hallucinations, Lilliputian hallucinations can be accompanied by pleasure though 
often intermingled with terror. These are not the same as micropsia. Patients with DT often have a 
prodromal affect or pareidolic illusions before these hallucinations. 
Autoscopic hallucinations are the visual experience of seeing oneself. Males predominate 2:1, impaired 
consciousness is a common accompaniment and depression is the commonest psychiatric cause. They are 
also called phantom mirror images and may take the form of pseudohallucinations. Schizophrenia (usually 
pseudo), TLE, parietal lesions (organic states more likely to have true hallucinations) are also implicated. 
In negative autoscopy, one looks into a mirror and sees no image at all. 
Palinopsia: palin for "again" and opsia for "seeing". It is a visual disturbance that causes images to persist 
even after their corresponding stimulus has left. It is seen in LSD use, migraine, occipital epilepsy, head 
trauma. It is similar to afterimage, but colour inversion (usually shadows or distorted colours noted in 
afterimages) is conspicuously absent.

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Somatic hallucinations: These can be divided into superficial, visceral and kinaesthetic. The superficial 
somatic hallucinations are tactile (haptic - touch), hygric (fluid – wetness etc.) and thermic (heat or cold). 
Visceral hallucinations are usually pain-like sensations arising from deep viscera like liver. These are 
sometimes termed as coenesthetic hallucinations and suggest schizophrenia. Kinaesthetic or 
proprioceptive hallucinations refer to joint or muscle sense, often linked to bizarre somatic delusions. 
They are also seen in benzodiazepine withdrawal and alcohol intoxication. Formication (formic acid – from 
ant) is a special type of haptic hallucination – unpleasant sensation of little animals or insects crawling 
under the skin, seen in DT and cocaine intoxication. Tactile hallucinations can be seen in parietal seizures. 
Superficial somatic hallucinations are almost never noted in TLE though the visceral sense of ‘raising 
epigastrium’ is seen. The common experience of the phantom limb is a body image disturbance and not a 
hallucination; though it is in external space, it does not satisfy other qualities of hallucination and patients 
are aware of unreality usually. It is a body image disturbance with a neurological basis. Somatic 
hallucinations may or may not be accompanied by passivity delusions. Without the passivity delusions, 
they cannot be classed as a First rank symptom. 
Olfactory hallucinations can occur in the aura of TLE – usually burning smell or urine smell. In 
depression, this can be an adjunct to nihilism. 
Gustatory hallucinations e.g., bitter taste of poison can give rise to delusions of persecution in 
schizophrenia. They are also seen in TLE. 
Extracampine hallucinations: Hallucinations that occur outside the normal field of perception e.g., images 
seen behind your back, under your sternum or hearing voices from Inverness, etc. They occur in 
schizophrenia, epilepsy and also in hypnagogic hallucinations of healthy people – so not diagnostically 
important. 
Both illusions and hallucinations are not necessarily pathological though they both are false perceptions, 
along with pseudohallucinations. For example hypnagogic hallucinations (hallucinations when going to 
sleep – go for gogic - usually auditory. Also seen in Narcolepsy-cataplexy. They can be visual or tactile too. 
First noted by Aristotle) and hypnopompic 
hallucinations (hallucinations when waking up) 
can occur in normal individuals. Hallucinations 
also 
occur 
in 
glue 
sniffing, 
post-infective 
depression, children with fevers and in phobic 
anxiety. Sensory deprivation in normal healthy 
people can also produce hallucinations. They are 
not more frequent in schizophrenia than other 
conditions. 
Functional hallucinations: An external stimulus provokes hallucination, and both hallucination and 
stimulus are in same modality but individually perceived. e.g. voices heard whenever the noise of water 
running through the tap is heard. They are not illusions – as the stimulus is perceived appropriately 
(noise of water), but, in addition, there is another perception (voices) without any appropriate object. 
HYPNAGOGIC HALLUCINATIONS 
3 times more common than hypnopompic 
37% normal adults experience at least once 
Hypnopompic is more specific for narcolepsy 
EEG shows alpha rhythm (subject not awake) 
Hearing one’s name called is the most common

# 11 - Synaesthesia

# Synaesthesia:

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Reflex hallucinations: These are hallucinations in one modality provoked reflexively by a stimulus in 
another modality e.g. seeing an angel whenever listening to music. They are similar to functional 
hallucinations in that there is a stimulus, which is perceived normally, followed by a hallucinatory 
perception – only difference being the modality of stimulus and perception being same in functional while 
different in reflex hallucinations.It is important to differentiate synesthesia from reflex hallucinations in 
EMIs. In synesthesia it is the music that is seen – the stimulus and object of perception remain the same albeit in 
different modalities - the patient does not claim that she could see Jesus or angel. Also the perceptions are 
simple, unformed and non-bizarre in synesthesia e.g colours; in reflex hallucination these are formed voices, 
vivid images like angels etc. The stimulus –perception sequence is usually completed before hallucination 
occurs in reflex hallucination – ‘I heard the music and then came the angel’; in synesthesia music itself is 
seen as colour – the experiences are simultaneous. 
Synaesthesia: 
It was Francis Galton (1880) who first reported the condition called synaesthesia. He noticed that a certain 
number of people in the general population, who are otherwise completely normal, seemed to have a 
certain peculiarity: they experience sensations in multiple modalities in response to stimulation of one 
modality. The phenomenon of perceiving a stimulus of one modality in a different modality (may be 
single or multiple modalities) is called synesthesia. E.g. tasting the music, hearing colours and smelling 
voices. It is not a hallucination as the perceived object has an appropriate stimulus. The original stimulus 
is usually perceived in appropriate modality too when the cross modality perception occurs (syn – joint, 
simultaneous). It is common in females 4:1 to 6:1, runs in families and colour-number synesthesia is the 
most common form. It is thought to be due to extensive cross wiring between multimodal association 
regions in some people, probably due to failed selective pruning. Several pieces of evidence support the 
notion that indeed synesthetic experience has a neural basis: 
1. There is a remarkable consistency of associations (e.g., sound–color associations) over time. For 
example, Baron-Cohen et al. found a consistency of 92% of color–sound associations after 1 year in 
13 synesthetic subjects but only a 37% consistency (after 1 week) in a control group. 
2. There is evidence that synesthesia can be acquired in the course of neurological illnesses such as 
multiple sclerosis, temporal arteritis, tumors to the sella region, and others. 
3. Synesthetic experiences can be induced by ingestion of drugs such as mescaline. 
4. There appear to be differences between nonsynesthetes and synesthetes in measures of cerebral 
blood flow.

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# 12 - 3. Delusions

# 3. Delusions

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3. Delusions 
 
DSM-IV defines a delusion as “A false belief … that is firmly sustained despite what almost everyone else 
believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary”. 
This definition, though very useful, conceals the multidimensionality of delusional experience, which is 
now well endorsed by cognitive psychologists, phenomenologists, philosophers as well as clinicians. 
Do delusions exist in a continuum? 
Some authors suggest that ‘delusions and hallucinations are commonplace in healthy populations, with 
prevalence up to approximately 25% depending on the definitional criteria, and so psychosis exists in a 
continuum model’. This claim is yet to be validated and established. (Lincoln, 2007). 
Using data based solely on self-report measures, Lincoln (2007) found that high distress associated with 
beliefs seems to be a relevant characteristic of delusions in persons with schizophrenia, compared to 
‘delusion-like beliefs in common population’. The presence of hallucinatory experiences accompanying 
delusions did not differ between schizophrenia and ‘common’ population. 
Are delusions really persistent? 
Though classically defined as persistent belief, doubts have been cast on this of late. In a follow-up of 
nearly 1100 acutely hospitalized psychiatric patients who were re-interviewed at 10-week intervals for 1 
year, it was demonstrated that most delusions exhibited a high degree of plasticity; in nearly one-third 
delusions completely subsided on follow-up (Applebaum et al. 2004). 
Delusional ideation is more likely to persist in never married, older patients, those with schizophrenia, 
and with delusions of thought broadcasting, those with higher degree of preoccupation and higher 
behavioural relevance, and those with more than one primary delusion. Even when delusional experience 
persists in certain patients, this does not mean that the same delusion will be maintained; considerable 
change in content was noted during the follow-up. 
What are the dimensions of delusions? 
Kendler (AJP, 1983) has listed the dimensions of delusional experiences. 
The dimensions of delusions include 
1. Conviction: The extent to which the patient believes. 
2. Extension: The extent to which the belief extends to various spheres of life. 
3. Disorganisation (or organisation): the degree of internal consistency and systematisation of the 
belief. 
4. Bizarreness: The implausible quality of the belief (especially in schizophrenia). 4%–8% of patients 
receive a diagnosis of schizophrenia because of the presence of Bizarre Delusions. Bizarreness is 
defined using the following notions: physical (or logical) impossibility and overall implausibility or

© SPMM Course 
incomprehensibility with the lack of grounding in ordinary experience. Most bizarre delusions are 
Schneiderian (i.e. of FRS type). 
5. Pressure: The extent to which the patient is preoccupied and distressed. 
6. Acting on delusion: The extent to which the belief drives behaviour 
7. Seeking evidence: The extent to which the patient questions the veracity of belief or seeks to 
strengthen the belief. Often patients with delusions, do not need any external proof or evidence, 
and despite showing evidence to contrary, will continue to hold their delusional beliefs. 
8. Lack of insight. 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary delusions: 
 These are defined in two different ways 
1. Jaspers’ concept: primary delusions are the true, un-understandable beliefs that arrive fully 
formed and cannot be reduced further to any other mental experiences. This has been challenged 
recently. 
2. Primary delusions are the first psychopathology to occur in the course of symptoms (temporal 
sequence). 
Often both are true i.e. they are irreducible and precede other mental phenomena. 
There are 4 types: 
1. Autochthonous delusions or delusional intuitions or simply, primary/true delusions: These are 
ideas that occur de novo, or 'out of the blue' - takes form in an instant, without identifiable 
DELUSION 
Conviction 
Extension 
Disorganis
ation 
Bizareness 
Distress 
Action 
Evidence 
Insight

© SPMM Course 
preceding events, as if full awareness suddenly burst forth in an unexpected flash of insight, like a 
bolt from the blue. This can be a quite elaborate delusional system on arrival itself. Wernicke 
formulated the concept of autochthonous delusions. Autochthonous stands for ‘out of soil’, 
‘aboriginal’. 
2. In delusional perception, a normally perceived object is given a new meaning, usually in the sense 
of self-reference - the conclusion being entirely unwarranted, the perception is normal. Hence, it is 
a two-staged process – normal perception preceding the attachment of delusional significance; these 
two steps need not be simultaneous - might even be separated for years! The only type of delusion 
included in Schneider's first-rank symptoms is delusional perception. 
3. Delusional mood or atmosphere refers to the sense of perplexity and uncertainty that exists 
during a prodrome of psychosis, usually ending in an autochthonous delusion which will make 
sense of the perplexity on arrival. Delusional mood/atmosphere can precede other primary 
delusions. It is the only psychiatric phenomenon that can directly precede and causally related to 
primary autochthonous delusion. Note that delusional mood is a specific affective experience – not 
thought content. 
4. Delusional memory can be of two types. It can be a retrospective delusion where something that 
never happened and so false, irrational or bizarre is reported as if occurred in the past and 
recollected now. E.g.,. A male schizophrenia patient said I had a hysterectomy at age 3 and since 
then I became a man. Sometimes a normal memory might be delusionally elaborated – “My dad 
bought me a camera when I was seven, now I understand it is because he was homosexual”. It is 
difficult sometimes to say what is fact and what is not though the distinction between above two 
variants is more an academic exercise. More importantly delusional perception can mimic 
delusional memory when the first stage of normal perception is actually a ‘recollected’ normal 
perception from memory. But in spite of this delusional perception is a two stage process – e.g. “I 
saw an envelope yesterday (normal perception but recollected from memory), I realised my 
stomach is upturned”. 
Primary delusions do not carry any prognostic significance in schizophrenia though they have diagnostic 
relevance. While primary delusions can occur in epileptic psychoses, they are not generally associated with 
epilepsy when they occur in psychotic disorders. Primary delusional experiences occur more in acute 
stages of schizophrenia and are not seen in chronic schizophrenia, due to being mixed with secondary 
delusions, hallucinations, FTD, etc. Other delusions that follow a primary delusion or other mental 
phenomena like hallucinations, affective disturbances, etc. are termed as secondary delusions.

© SPMM Course 
In delusional perception, the delusional judgment or belief that follows a perception will be unrelated to the 
prior perception
 
 
 
Persecutory delusions: Primary delusions vary considerably in content and are not characteristically 
persecutory in nature. In contrast, most secondary delusions are often persecutory, making persecutory 
themes the commonest contents of delusions as a whole. 
Paranoid delusions: The term paranoid is very much misused in psychiatric practice. Paranoia stands for 
‘besides mind’. In the strict sense, the term paranoid can be used only for self-referential delusions, 
irrespective of their content. For example, grandiose delusion ‘God is sending a messiah to help me’, 
persecutory delusion ‘mafia is after me’, referential delusion ‘those kids are talking about me, cameras are 
fixed to watch me’, hypochondriacal delusion or nihilistic delusion ‘my body is rotting away’ etc are all 
paranoid delusions. 
Monothematic delusions: These can occur as single delusions in various disorders though in their 
commonest form they occur in major psychotic illnesses like schizophrenia or affective psychosis. 
Delusion 
Example Content of monothematic delusions 
Capgras delusion 
"That's not my wife; it is an impostor who looks just like her." 
Cotard delusion 
"I am dead." 
Fregoli delusion 
"I am constantly being followed by people I know, but I can't 
recognize them because they are always in disguise." 
Mirrored-self 
misidentification 
"The person I see when I look in the mirror isn't me; it is some stranger 
who looks like me." 
Perception 
(factual) 
Judgement 
Delusional 
perception 
Perception 
(factual) 
Perception 
(factual) 
Judgement 
Judgement 
Delusional 
Misinterpretati
on 
Delusional 
Misinterpretati
on

© SPMM Course 
De Clerambault's delusion 
(erotomania) 
"Person X is secretly in love with me" (Person X being some important 
or famous person who has never encouraged this idea) 
Othello syndrome 
(pathological jealousy) 
"My wife is having an affair." 
From Coltheart, M, et al. Schizophrenia and Monothematic Delusions. Schizophrenia Bulletin 2007 33(3):642-647 
Morbid jealousy can occur in various forms – delusion, overvalued idea, in depression and in anxiety 
states; it is not a misidentification syndrome. It was first described by Ey. It is common in alcoholics. It has 
a potential of violence, especially against rival than a partner and can occur among cohabiters and 
homosexual couples too. 
De Clerambault’s syndrome is a type of delusion of love, in which a woman believes that an older man 
who is of higher social status is in love with her. It is not related to delusional misidentification. It is also 
called Old Maid's insanity where persecutory beliefs coexist. 
Cotard’s syndrome is severe depression with nihilistic and hypochondriacal delusions tinged with 
grandiosity and a negative attitude. It is not related to delusional misidentification. Cotards syndrome is 
seen in schizophrenia though more commonly in depressive psychosis. It is generally seen in the elderly, 
with hypochondriacal and nihilistic delusions with a tinge of grandiosity amidst nihilism (not grandiose 
delusions!).It is also reported in organic lesions and migraine. 
Hypochondriacal delusions: These are seen typically in psychotic depression especially in elderly, as a 
part of Cotard’s syndrome. A specific type described by Munro called monosymptomatic 
hypochondriacal psychosis consists of 
1. Delusions of body odour and halitosis (olfactory delusions). Some of these may have olfactory 
reference syndrome – no olfactory experiences but only fixed belief about body order with anxiety 
reaction. Paranoid personality disorder is often associated with this syndrome. 
2. Delusional infestation (Ekbom’s syndrome) It is a delusion of parasitic – macroscopic - infestation 
with classical matchbox sign: An old lady comes to clinic with a match box, of skin scrapings 
usually, as evidence for the parasite that infests her causing itching. This can predate the onset of 
dementia. It may or may not be associated with a somatic hallucination. 
3. Dysmorphic delusions (misshaped nose, etc.). 
The various misidentification syndromes (Ellis, 2005) are 
1. In Capgras syndrome, a person believes that a person usually close to him has been replaced by an 
exact double. Capgras syndrome is sometimes referred to as the illusion of doubles though it is a 
delusion. First reported by Kahlbaum (1866) but more extensively described by Capgras and 
colleagues (1923, 1924). The Capgras delusion is classified as a dangerous delusion and may be 
associated with violence. Capgras delusion is etiologically heterogeneous – at least 15 different 
causes are recorded. It is now thought to be mostly due to organic brain damage (>50%, Lishman) 
apart from being seen as a part of schizophrenia or isolated delusional disorder including brain

© SPMM Course 
injury and schizophrenia. It is thought to be cognitively mediated by the combination of reduced 
affective responsivity to familiar faces plus impaired belief evaluation, and neuropsychologically it 
is believed to be due to the combination of the disconnection of the face recognition system of the 
brain from the autonomic nervous system plus damage to a specific region of right frontal lobe. 
2. In Fregoli syndrome, there is the false identification of familiar persons in strangers. A familiar 
person is thought to be taking various disguises. First reported by Courbon and Fail (1927). They 
described a 27-year-old woman, a domestic servant with a passion for the theatre, who developed 
the delusion that the actresses Robin and Sarah Bernhardt were persecuting her in the guise of 
others. They suggested the term Frégoli delusion with reference to the celebrated Italian mimic 
Léopoldo Frégoli. The essential feature of this delusion is that there is no belief in actual physical 
change: instead the patient believes that his/her persecutors can invade the body of others. It is 
rare compared to Capgras. 
3. In the syndrome of subjective doubles, the patient believes that another person has been 
physically transformed into his own self and the patient is convinced that exact doubles of him- or 
herself exist. 
4. Intermetamorphosis - A becomes C, C becomes B etc. People keep transforming their physical and 
psychological identities. Courbon and Tusques (1932) described Sylvie G, a 49-year-old woman 
who claimed that objects and animals seemed altered. People could change gender as she looked at 
them. Many people looked like her son or her aunt. She could distinguish them from her true son 
only by examining their feet (his were large and were invariably shod in dirty shoes). Her husband 
might change appearance into that of a neighbour (all except his eye colour and missing finger). 
There were no further reports of intermetamorphosis for 46 years since when five cases have been 
described, including three by Young et al. (1990). 
Feature recognition 
(appearance) 
Affect recognition 
(warmth) 
RESPONSE 
SYNDROME 
 
 
Looks like my dad, but he is 
not my dad, probably an 
impostor 
Capgras syndrome 
 
 
 
My dad, but does not look 
like him… is he disguising 
himself? 
Fregoli syndrome 
 
 
Who is he? 
Prosopagnosia (Seen in 
neurological disorders)

© SPMM Course 
5. Paraprosopia: This is very rare, re-described by Ellis. Here, a face appears to transform within 
seconds into a grotesque mask, often described by patients as a "monster", "vampire" or "werewolf" 
[Krauss, 1852]. Most likely to be reported by schizophrenic children but also observed in adults 
(e.g. Daniel Paul Schreber, 1842-1911, President of the Court of Appeal in Dresden, saw two men 
"as devils with particularly red faces…"). 
The concept of misidentification is now being extended to misidentification of time, a place apart from the 
person (reduplication phenomenon). 
Other disturbances in thought content: 
Ideas of reference are seen in paranoid PD where the individual is unduly self-conscious and feels that 
people take notice of him or observe things about him that he would rather not be seen. It can also precede 
the development of full-blown schizophrenia where it is called sensitive ideas of reference or "sensitiver 
Beziehungswahn”! It is not characteristic of mania. 
Overvalued ideas: Overvalued ideas (Wernicke) are solitary abnormal beliefs that are neither delusional nor 
obsessional in nature, but which dominates a person’s life and his actions. They have a poor prognosis and 
tend to dominate the sufferer's life. Common conditions presenting with overvalued ideas are paranoid or 
anankastic personality disorder, Body Dysmorphophobia, anorexia nervosa, morbid jealousy & 
transsexualism. 
Folie a deux is a shared delusion, in which a psychotic person transfers his delusions to one or more 
people close to him. The non-psychotic victim usually exhibits dependent traits on the primary patient. 
Separation of the pair can result in remission. 
Doppelganger: This is also known as double phenomenon – it is the awareness of oneself as being both 
outside and inside oneself. It is a cognitive and ideational disturbance as opposed to autoscopy, which is a 
perceptual disturbance. It can occur in the absence of mental illness too. It is not a delusional 
misidentification syndrome; unlike doppelganger, the latter is the pathology of familiarity. 
How are delusions formed? 
1. Attentional biases: People with persecutory delusions preferentially attend to threat-related 
stimuli and preferentially recall threatening episodes. (Blackwood, AJP 2001) 
2. Attributional biases: An exaggeration of self-serving attribution bias is seen in psychosis. Patients 
excessively attribute hypothetical positive events to internal causes (stable and global – grandiose) 
and hypothetical negative events to external causes (stable and global- persecutory). The 
attribution bias in paranoid subjects shapes delusional content rather than form, as patients with 
non-persecutory delusions do not show this bias significantly. Paranoid patients specifically 
attribute negative self-referent events active malevolence on the part of the other person (external 
personal attribution) rather than circumstances or chance (external situational attribution). 
(Blackwood, AJP 2001). This might serve to preserve the self-esteem of paranoid patients, acting as 
a self-defence.

© SPMM Course 
3. Probabilistic reasoning bias: When deluded patients were shown sequences of black and white 
beads and were asked to decide which jar [jar A had majority black beads and B had majority 
white] the sequence was probably drawn from, they came to a conclusion with far lesser beads in a 
sequence than controls. They were also relatively overconfident about the accuracy of their 
judgement. This was hypothesized to be due to impaired probabilistic reasoning (generating 
hypothesis and testing statistical probability). But later studies showed that when allowed to see as 
many numbers of beads as controls generally do, patients reached similar correct conclusions – 
they were able to generate hypothesis and test the probability; the defect being deficient datagathering (less information before decision). This is called Jumping-to-conclusion style of 
reasoning. (JTC). 
4. Mentalising deficits/bias: Persecutory delusions reflect false beliefs about the intentions and 
behavior of others that could arise from the theory of mind deficits.

# 13 - 4. First Rank Symptoms

# 4. First Rank Symptoms:

© SPMM Course 
4. First Rank Symptoms: 
 
 
Kurt Schneider, a German psychiatrist and a pupil of Karl Jaspers, pointed out certain symptoms as 
being characteristic of schizophrenia and therefore exhibiting a "first-rank" status in the hierarchy of 
potentially diagnostic symptoms. 
 
The "first-rank" symptoms (FRS) have played an extremely important role in the recent diagnostic 
systems: in the International Statistical Classification of Diseases, tenth Revision (ICD-10) as well as in 
Diagnostic and Statistical Manual of Mental Disorder, (DSM-III-IV), the presence of one FRS is 
symptomatically sufficient for the schizophrenia diagnosis but FRS are not essential to diagnose 
schizophrenia. 
 
FRS may also be encountered in the nonschizophrenic conditions, and, therefore, they are not specific 
or diagnostic for schizophrenia (Palaniyappan, 2007). 
 
Kurt Schneider proposed an empirical cluster of symptoms, one or more of which in the absence of 
evidence of organic processes, could be used as a positive evidence for schizophrenia. He did not 
claim that they are comprehensive – but they are clearly identifiable, frequently occurring and occur 
more often in schizophrenia than any other disorder. 
 
FRS emphasizes on the form of the experience rather than content i.e. the feature that voices echo one’s 
thoughts is more important that what the voices actually said. 
 
Disturbance of self-image (ego-boundary) is the predominant underlying feature of all FRS. 
 
In a critical review of FRS studies published in English between 1970 and 2005, Nordgaard et al. (2008) 
report the following findings. The FRS are reported to occur in 22% to 29% of patients with affective 
disorders. Generally, the prevalence of FRS in schizophrenia is reported to range between 25% and 
88%. This range remains equally high in the reports from western and developing countries and in 
studies of different ethnic groups. 
 
In some studies, delusional perception is the most frequent FRS, whereas the same symptom is the 
least frequent in other studies. A number of studies find no single dominating type of FRS. 
 
Assessment of the diagnostic weight of individual FRS is absent with the exception of Mellor and 
colleagues who suggest that "voices discussing" should be given less diagnostic weight than other FRS. 
 
The majority of the reports conclude that FRS do not affect the outcome. No study finds that the 
outcome is related to the number of FRS observed in the individual patient. FRS are not of any 
prognostic importance at all. They do not specify any subgroups with the differential treatment 
response or heritability.

© SPMM Course 
The First Rank Symptoms 
3 hallucinations 
Audible thoughts (Thought echo) 
Voices heard arguing (3rd person) 
Voices heard commenting on one's actions (running commentary) 
3 ‘Made’ phenomena 
Made affect 
(Someone controlling the mood/affect) 
Made volition 
(Someone controlling the action – usually a completed act) 
Made impulse 
(Someone controlling the desire to act –not completed act but the drive. If the action has been carried 
out, patient admits to ownership of act, not the impulse behind it) 
3 Thought phenomena 
(Experiences themselves are more important than later explanations or how patient interprets them) 
Thought withdrawal 
Thought insertion 
(External agency inserting thoughts upon the patient) 
Thought broadcast 
(Also called thought diffusion – as if in television broadcast, everyone comes to know about the 
patient’s thinking as and when the patient thinks – refers to the loss of privacy of thoughts. Cf. 
referential delusion – ‘people act as if they know what I am thinking’) 
2 isolated symptoms 
Delusional perception 
Experience of sensations on the body caused by external agency (somatic passivity) 
Totally (3X3) +2. 
 
What is NOT FRS? 
Command hallucinations are not first rank symptoms. 
Somatic hallucinations are also NOT first rank symptoms unless there is a delusional elaboration and 
attribution of the origin of sensations to an external agency (i.e. unless they are presenting as somatic 
passivity). Note that somatic passivity can follow a normal sensation like a headache, ascribed to a 
‘Russian neurosurgeon who inserted a chip through my nose when I was sleeping’! 
Schneider described mood changes (depression or elation), emotional blunting, perplexity and sudden 
delusional ideas as symptoms of the second rank. 
Thought alienation:

© SPMM Course 
The three thought phenomena described above are sometimes grouped together as thought alienation or 
delusions of thought control. These are related to a primary disturbance in the subjective control of 
thinking. This is a high yield topic for MCQs – please study the table below. 
Phenomenon 
Self – nonself 
difference 
Where is the 
thought now? 
Who owns 
the thought? 
Who influences the 
thought? 
NORMAL 
THOUGHTS 
Preserved (we 
know that our 
thoughts are 
private) 
Self (in our 
subjective space) 
Self (it is our 
own 
thought) 
Self (we can stop thinking 
when we want) 
Thought 
insertion 
Violated 
Self (with the 
patient) 
External 
agency 
External agency produced 
and influenced the thought 
Thought 
withdrawal 
Violated 
Taken away (may be 
delusionally 
elaborated) 
Self 
Originally self-produced, 
now external agency 
influences 
Thought 
broadcast 
Violated 
Diffused everywhere Self 
External agency influences it 
as soon as it originated from 
self 
Thought 
blocking 
Not violated 
Unknown 
Self 
Self 
Obsessions (this 
is not a thought 
alienation) 
Not violated 
Self 
Self 
Self but disturbed (the 
thoughts may be against 
one’s values – so egodystonic but not fully 
disowned) 
Thought alienation table is modified from Mullins, S. & Spence, S.A. Re-examining thought insertion. The British 
Journal of Psychiatry (2003) 182: 293-298

# 14 - 5. Psychopathology of speech

# 5. Psychopathology of speech

# 15 - Aspects of conversational speech

# Aspects of conversational speech:

# 16 - Disorders of phonationarticulation

# Disorders of phonation/articulation:

# 17 - Disturbed speech production

# Disturbed speech production:

# 18 - 1. Altered speed of speech

# 1. Altered speed of speech:

# 19 - 2. Altered amount of speech

# 2. Altered amount of speech:

© SPMM Course 
5. Psychopathology of speech 
Aspects of conversational speech: 
1. Spontaneity: Comments that are not just responses to questions is present in normal speech 
2. Turn-taking: Responses and comments are made only when the other speaker completes his 
sentences, or when natural pauses occur during conversations. 
3. Mutual topic: Content is focussed and related to the comments made by the other speaker 
4. Animation: Accompanying non-verbal behaviours are almost always present in normal speech 
Disorders of phonation/articulation: 
Aphonia refers to the inability to vocalize. It refers to sound production (phonation) rather than sound 
manipulation (articulation) – disturbance of the latter being dysarthria. In aphonia, whispering occurs; 
it may be due to paralysed vocal cords or due to hysteria. 
Dysarthria refers to disorders of articulation; it may be due to lesions in the brain stem (bulbar), cortex 
(pseudo bulbar), cerebellum or extrapyramidal system. Dysarthria can also be drug induced in 
schizophrenia. 
Stammering: In stammering the normal flow of speech is interrupted by pauses or by the repetition of 
fragments of words or parts of words. Tics often accompany stammers. Boys stammer more often than 
girls; usually reduced in adulthood. 
Stuttering is difficulty in uttering speech sounds at the beginning of words. Utterances are repetitive, 
prolonged and pauses are common. Primary stuttering is seen in children, in adults new onset stutter 
may be related to stroke or extrapyramidal symptoms. 
Disturbed speech production: 
1. Altered speed of speech: 
Quiet speech in low volume with poor intonation, reduced spontaneity and prolonged reaction time is 
seen in depression. The terms used here are bradyphasia (decelerated talking) while tachyphasia 
refers to accelerated talking seen in manic states. 
2. Altered amount of speech: 
2.1. Logorrhoea refers to increased quantity of speech, generally without the pressure of speech 
or formal thought disturbances (see below) and seen especially in early manic states. 
2.2. Alogia is a term used to denote poverty of speech and a decrease in spontaneous talking; it 
occurs in depression and schizophrenia. This must be differentiated from the poverty of 
content of speech where the amount of speech is adequate but conveys little information. 
This is often related to schizophrenic formal thought disorder (see below). 
2.3. Mutism: This denotes a complete lack of speech. Severe depression with psychomotor 
retardation may be associated with mutism though this is relatively rare in the absence of 
catatonia. Mutism is almost always present in a catatonic stupor. 
a. Elective mutism: Mostly seen in children who refuse to speak to certain people; for 
example, the child may not speak at school but speak at home.

# 20 - 3. Repetitive speech

# 3. Repetitive speech:

# 21 - Disturbed Language processing

# Disturbed Language processing:

© SPMM Course 
b. Hysterical mutism: This is relatively rare, and the most common hysterical disorder 
of speech is aphonia. 
c. Akinetic mutism is associated with lesions of the upper midbrain or posterior 
diencephalons and Crutzfeld Jakob Dementia. Here the patient is mute but remains 
aware of the environment though cannot move or respond. 
3. Repetitive speech: 
Verbigeration: Repetition of phrases or sentences. This occurs spontaneously and without any 
goal. This should not be confused with echolalia. This is not catatonia. 
Palilalia: Repetition of last uttered word, without any apparent purpose; seen in learning disabled, 
pervasive developmental disorders and in Tourette’s. Verbigeration is a closely associated 
phenomenon though neurologists prefer to use the term palilalia for both. 
Logoclonia: Repetition of last syllable of a word, seen in Parkinson’s. 
Disturbed Language processing: 
Sound received by ears is transmitted to Wernicke’s area and auditory association cortex, which processes 
the language component. Arcuate fasciculus connects Wernicke’s area to Broca’s area. Broca’s area is the 
higher motor area of language production. Signals from Broca’s area are relied on onto the motor area to 
coordinate the delivery of language via the tongue, lips and vocal cords.

© SPMM Course 
Arcuate 
Fasciculus 
(conduction 
aphasia)
 
 
 
Wernicke's 
area 
A 
Wernicke's 
area 
A 
Auditory 
association 
cortex 
Auditory 
association 
cortex 
Broca's area 
C 
Broca's area 
C 
Language 
association 
cortex 
Language 
association 
cortex 
Peripheral 
speech areas 
(tongue, 
lips) 
Peripheral 
speech areas 
(tongue, 
lips) 
Ears 
Ears

# 22 - Components of Language production

# Components of Language production:

# 23 - Aphasia

# Aphasia:

# 24 - Disorders of reading and writing

# Disorders of reading and writing:

© SPMM Course 
Components of Language production: 
1. Fluency: Production of meaningful words and sentences. Depends on intact Broca’s area and its 
forward connections. 
2. Comprehension: Understanding words and sentences spoken by others. Depends on intact 
Wernicke’s area and its connection with association cortex and sensory input 
3. Repetition: Repeating what others say. Requires no high-level processing; can take place if 
Broca's, Wernicke’s and arcuate fasciculus are intact. It does not need relay of higher association 
area to either Broca’s or Wernicke’s. 
4. Naming: Ability to use nouns especially the names of objects. Naming defects (anomia) 
accompanies any aphasia but in various degrees. 
Aphasia: 
This refers to a higher level ‘language’ problem – not sound production or manipulation error but the 
problem of language reception, production and processing. Aphasia is almost always organic. 
 
Adapted from 
Harrison’s 
Textbook of 
internal 
medicine; 15 e 
 
 
In Broca's aphasia the speech is nonfluent; it often appears laboured with any interruptions and pauses. 
Function words (prepositions, conjunctions) are most affected though the good degree of meaningappropriate nouns and verbs are still produced. Abnormal word order and a characteristic agrammatism 
are noted. Speech is telegraphic. Harrison textbook quotes the following example: "I see...the dotor, dotor 
sent me...Bosson. Go to hospital. Dotor...kept me beside. Two, tee days, doctor send me home”. 
In Wernicke's aphasia, the comprehension is impaired for both spoken and written language. Language 
output is fluent but is highly paraphasic, sometimes with string of neologisms and circumlocutions. Hence, 
it is also termed as "jargon aphasia." The speech contains large numbers of function words (e.g., 
prepositions, conjunctions) but few substantive nouns or verbs that refer to specific actions. The output is, 
therefore, voluminous but uninformative. 
Disorders of reading and writing: 
As aphasia is a disturbance of language production, reading and writing difficulties too accompany all 
aphasias. In addition, some disorders of isolated reading/writing problems have been described. 
Type of aphasia 
Fluency 
Repetition 
Comprehension 
Naming 
Wernicke’s sensory 
aphasia 
Intact 
Lost 
Lost 
Lost 
Broca’s motor aphasia 
Lost 
Lost 
Intact 
Lost 
Conduction aphasia 
Intact 
Lost 
Intact 
Lost 
Transcortical sensory 
aphasia 
Intact 
Intact 
Lost 
Lost 
Transcortical motor 
aphasia 
Lost 
Intact 
Intact 
Lost

© SPMM Course 
o Pure word blindness (alexia): Here the patient can speak normally and comprehend what is 
spoken; he can also write spontaneously and to dictation, but reading comprehension is 
impaired. 
o Pure agraphia: This is an isolated inability to write while other faculties of language are 
preserved. It is sometimes seen as a component of Gerstmann’s syndrome (parietal deficits) 
o Alexia with agraphia results in acquired illiteracy. 
o Pure word deafness: Patient can speak, read & write fluently, but comprehension is impaired 
only for spoken language. Bilateral (or left sided with disrupted connections to non-dominant 
circuit) damage to the superior temporal pole is suspected. 
o Pure word dumbness: Spoken language cannot be produced clearly, but the patient can 
comprehend language well, can read and write

# 25 - 6. Disorders of Thought

# 6. Disorders of Thought:

# 26 - Elements of thought

# Elements of thought:

© SPMM Course 
6. Disorders of Thought: 
 
Normal thinking: 
Normal thinking is of three types (or functions): 
1. Fantasy/dereistic thinking or autistic thinking: There is no goal direction, unrealistic - daydreaming 
type. Predominant in cluster A personality, dissociation and pseudologia fantastica. 
2. Imaginative thinking: Again fantasy elements but admixed with memory, involving abstract concepts 
but goal-directed and does not cross boundaries of possibility and realism. Determining the tendency of 
thoughts preserved e.g. lateral thinking. 
3. Rational or conceptual thinking: based on factual reality and uses logic. 
Psychopathology of thought includes 1. Disorders of thought content (e.g. delusions) 2. Disorders of 
thought form (e.g. tangentiality) 3. Disorders of thought stream (e.g. pressure of speech) 4. Disorders of 
thought control (e.g. obsessions) 
Elements of thought: 
Normally every thought we have has the following four properties: 1. Form 2. Stream 3. Content 4. 
Control. As a student of psychopathology, one wonders why should the authors make a fuss about the 
stream, form and content of thought; what is the real difference among this three concepts? A simple way 
of understanding this is through an analogy of buying fruits in the supermarket. 
Element 
Supermarket Analogy 
Refers to 
Disturbances 
Content 
Apples, pears or oranges? 
‘the material.' 
What is being 
thought about? 
Delusions of 
persecution, suicidal 
thoughts, etc. 
Form 
Bags, boxes, sold loose as 
single fruit? 
‘the package.' 
In what manner 
is the thought 
present? 
Loosened associations, 
tangentiality 
Stream or 
flow 
Packed as a dozen, a score, just 
four only, half a dozen, etc. 
‘the amount.' 
How is it being 
thought about? 
Fast, slow, etc. 
The poverty of thought, 
the pressure of speech 
and crowding of 
thoughts. 
Control of 
thought 
Mango is a produce of South 
Africa; tomatoes are from 
Spain, etc. 
‘the origin.' 
Where is it from? 
To some extent 
obsessions can be 
considered here, 
passivity and first rank 
thought disturbances. 
 
Thought content could be deciphered from ones’ behaviour, but thought form and stream, unless 
extremely deranged, cannot be studied without being expressed as speech. Formal thought disorder (FTD) 
refers to disturbances in form and not content; it is wrong to say ‘someone is deluded so he has a formal

# 27 - Formal thought disorders (FTD)

# Formal thought disorders (FTD):

© SPMM Course 
thought disorder’. But note that the term FTD increasingly includes both form and stream errors (not 
content errors) and scales that measure thought disorder do not differentiate stream from form anymore. 
Formal thought disorders (FTD): 
Note that various authors have used various terms to describe the FTD. Hence there is a significant 
overlap among the various terms – the following terms are not mutually exclusive of each other. 
Various terms denoting FTD: 
The term paralogia refers to positive FTD – i.e. symptoms of thought disorder that are identified as the 
presence/appearance of an abnormal element in thought processes (e.g. tangentiality). The term alogia is 
sometimes used to refer to negative FTD – symptoms considered due to the absence/disappearance of a 
normal element of thought/speech (e.g. poverty of speech content). 
Kraepelin used the term akataphasia for FTDs to convey the essence that speech disorders are a result of 
thought disorder. 
Blueler’s term ‘loosening of associations’ is often considered to indicate the presence of FTD. 
Classifications of FTD: 
Cameron proposed 4 characteristic formal thought disorders – 
Metonymy: imprecise approximate expressions used as substitute words. For example paperskate 
for a pen. 
Asyndesis: This refers to the lack of genuine causal links in speech. For example, ‘I got up at eight 
this morning as well as few birds of different colours on the painting, shrinking all the time to drop 
few coins. On the floor. All the time.’ 
Overinclusion: In overinclusive thinking ideas that are only remotely related to the concept 
under consideration become incorporated in the patient's thinking; Conceptual boundaries are lost. 
This is used to explain the thought disorders in schizophrenia and is different from the mechanism 
in the flight of ideas. Sorting tests can be used to test overinclusion. It occurs in nearly 50% of 
schizophrenia patients, especially when acutely ill. 
Interpenetration: Irrelevant thoughts penetrate ongoing stream of thoughts. 
Carl (not Kurt) Schneider proposed a different set of 5 elements of FTD 
Substitution: one thought – often inappropriate, fills the gap between other appropriate, more 
consistent thoughts. 
Omission: A chunk of thought goes missing from stream of conversation, patient being unaware – 
best analysed when written, 
Fusion: various thoughts fuse together, leading to loss of goal direction. 
Drivelling: disordered intermixture of constituent parts of one complex thought

© SPMM Course 
Derailment (aka entgleisen); In derailment normally flowing track of thoughts suddenly change. 
The determining tendency is preserved but is misdirected. 
Schneider also described desultory thinking, sometimes considered along with driveling. In 
desultory thinking, speech is grammatically correct but sudden ideas force their way in from time 
to time. Each one of these ideas is a simple thought that, if used at the right time would be quite 
appropriate. 
Kleist proposed that semantic disturbance of language was more common than grammatical or syntactical 
errors in schizophrenia. 
The impact of semantic problems in speech could result in 
1. Verbal paraphasia – where meaningful sentences produced in spite of the loss of appropriate 
words e.g. ‘food filling muscular carton’ for the stomach (a metonym). 
2. In literal paraphasia, no one can make out the meaning of sentence spoken except the patient. 
Grammatical or syntactical disturbances include 
1. Agrammatism refers to the loss of parts of speech – e.g. propositions leading to disordered word 
sequences. 
2. In paragrammatism, individual phrases are well constructed and meaningful but they do not fit in 
with the goal of thought. The content delivered appears mixed up, though individually 
understandable. 
 
Various features of FTD: 
Neologism refers to making up a totally new word that is not in dictionary or using a known word with a 
completely different meaning e.g. ‘Inkur’ for pen (new) or ‘roast’ for pen (different). 
Stock words are either newly synthesized or already known words but used in an idiosyncratic way 
repeatedly, often with many meanings and in different contexts, sometimes dominating any discourse. e.g. 
“The riposte (? dog) runs into my way, always active – when my riposte (?friend) is around, it’s OK, full of 
riposte (?energy), as everyone likes him, when you throw him some riposte (?food) he stops all that 
work… comes running.” 
Thought block is a negative FTD – involves sudden arrest in the flow of thoughts; sometimes resembles 
an absence seizure though there is no amnesia for the idea that was discussed and no motor 
accompaniments typical of absences. Patients can elaborate on thought blocking with a delusional content 
of thought withdrawal. 
Stilted speech: This refers to pompous, formal speech often in an inappropriate context. Impaired lexical 
retrieval may underlie stilted speech in schizophrenia. A patient said ‘ Pliant rectitude is a trait more 
appropriate for successful living than hot-headedness, which is either stubborn or crusady. (McKenna, 
1994). This patient would not have said’ pliant rectitude’ or ‘crusady’ unless more common words for the 
same concepts were not accessible.

© SPMM Course 
Flight of ideas is characteristic of mania. Here thoughts follow each other so rapidly, that there is no 
general direction for thinking. Hence, chance associations take place to connect succeeding thoughts. 
These chance associations may arise from distractions in the environment or distractions in the elements 
of one’s own or someone else’s speech. An external environment driven association could be the following 
one - when talking about his breakfast, hears rustling newspaper and jumps to the topic of Iraq war or 
cost of petrol or elections, etc. Being cued by verbal associations (i.e. sound of words spoken) can be of 
three types: 
1. Clang associations where thoughts are associated by the initial syllabic structure of words 
rather than their meaning. e.g., clover, cloud, clap, clan, etc. Others include 
2. Punning: Here words get associated as one word has dual meaning e.g. fast – ‘to starve’ or 
‘speed up’ and 
3. Rhyming: Here words get associated as they have similar sounds e.g. cat, rat, bat, etc. In 
schizophrenic FTD, clang occurs in more often with first syllables as opposed to clangs in poetry, 
humour and manic speech where they occur more at the end syllables. 
Vorbeireden is talking past the point leading to approximate but not accurate answers to questions asked 
in an interview. It is described as a type of formal thought disorder, different from the flight of ideas. 
Though often described along with the Ganser syndrome, it is not exclusive to Ganser’s syndrome. It is 
also seen in acute schizophrenia and hebephrenic schizophrenia. Vorbeireden (‘talking past the point’) is 
often used interchangeably with vorbeigehen (‘going past the point’), although the latter was originally 
defined as part of the ‘Ganser syndrome’, whereby some criminals would give incorrect answers 
(‘approximate answers’) to simple questions that none the less suggested that the correct answer was 
known (e.g. saying dogs have five legs). 
Circumstantiality: In circumstantiality, thinking proceeds slowly, with many unnecessary details and 
digressions, before returning to the point. It is seen in some patients with temporal lobe epilepsy or 
alcohol-induced persisting dementia, learning difficulty and in obsessional personalities. It is a formal 
thought disorder where figure-ground differentiation apparently fails but not due to affective changes 
such as mania. 
Tangentiality: Circumstantiality must be differentiated from tangentiality - the patient never reaches the 
point in tangentiality, whereas they do 
reach the point in 
circumstantiality. Imagine a spiral that 
eventually touches its 
centre, while tangent scrapes through the 
edge and never 
reaches the centre. Circumstantiality may 
be related to loosened 
associations and usually develops within 
the setting of a 
delusional mood in schizophrenia; it may 
be due to an 
impairment of a central filtering process 
that normally inhibits 
external sensations and internal thoughts that are irrelevant to a given focus of attention. 
Concrete thinking: It is seen as literalness of expression and understanding, with failed abstraction. It is 
recognisable clinically but difficult to measure using psychometry. Goldstein studied this loss of abstract

© SPMM Course 
thinking which can be tested using proverbs and similarities test. It seems concrete thinking is evident in 
speech-disordered (FTD) schizophrenia patients, but not the non-FTD group (Allen 1984). It is also seen in 
fronto temporal dementia. 
Testing the linguistics of schizophrenia: 
1. Word association tests are abnormal in schizophrenia – despite the context of usage, patients 
preferred dominant meaning of a word e.g. court means ‘law-room’ not tennis court, in spite of the 
context of discussion being sports. 
2. In cloze procedure parts of recorded speech are deleted to see if meaning could be still predicted; 
predictability was reduced in schizophrenia. In reverse cloze procedure patients are asked to 
predict the missing elements of someone else’s speech– again schizophrenia group performed 
worse in prediction. 
3. Type –token ratio refers to the ratio between number of different words used during a discourse 
and total number of spoken words. Impoverished vocabulary was noted with low type-token ratio 
among schizophrenia patients. 
4. Cohesion analysis (analysing links between sentences and words in a discourse) shows that 
schizophrenia patients use less referential ties (using pronouns without mentioning a subject in 
first place) and more lexical ties (connected words). Also, patients make more errors than controls 
when asked to construct complex sentences from simple phrases (Hunt test). 
Measuring FTD: 
Thought Language & Communication scale (TLC: Andreasen) and Thought and Language Index (TLI: 
Liddle) are commonly used scales. The latter uses projective stimuli from Thematic Apperception Test to 
elicit thought disturbances. 
Of various thought disorders classified by Andreasen, clanging and flight are more common in mania 
while derailment (loosening) and thought blocking and to some extent tangentiality, poverty of content of 
speech are seen often in schizophrenia - other items were largely non-specific. FTD is suggestive but not 
pathognomonic of schizophrenia; it is also seen in organic syndromes such as epilepsy. 
What causes Schizophrenic Speech Disturbance? There are various explanations from different scientific 
disciplines. 
1. Von Domarus proposed that FTD is a result of loss of deductive reasoning – illogical thinking. 
(Von Domarus law – Kiwi cannot fly (premise 1), Kiwi is a bird (premise 2) - so birds cannot fly 
(conclusion); note that the inferences are based on insufficient premises.) 
2. Schizophrenic thought disorder could be measured using Kelly’s personal construct theory - based 
repertory grids (Bannister). The patient is asked to score different elements (can be relatives or 
friends) under different constructs (qualities of them). Normally one would expect congruence 
between different constructs scored for an element, e.g. Mum is helpful, and she is also kind and 
supportive. But in schizophrenia the predictability of an element’s quality using prior constructs is 
affected. (Mum is helpful but scores low on kindness and support offered). This is called serial 
invalidation and is more pronounced for peoples than objects, showing that thought disorder 
affects interpersonal realm more than other spheres. The scores can be used to draw a semantic

# 28 - Stream of Thought

# Stream of Thought:

© SPMM Course 
space, demonstrating graphical connections between people and qualities in the patient’s personal 
world. 
3. Mortimer considered FTD to be a result of impaired semantic memory – so associations between 
words and qualities are lost. 
4. Words carry a semantic halo – e.g. the word ‘London’ is linked, through symbolic meaning to 
words like ‘tube’ and also ‘Britain’, ‘England’, etc. Imagine that these words are cross-wired in the 
brain. So whenever the word London is stimulated, the closely cross-wired words also become 
available readily for the thought process to proceed uninterrupted. This activation is called direct 
semantic priming. In Indirect semantic priming, London activates tube; tube activates light (as in 
tube light) or pipes, etc. This indirect priming is usually minimal, preventing inappropriate 
deviation in determining the tendency of thought flow. In schizophrenia, it is proposed that direct 
priming is impaired but indirect one is activated more, to explain FTD. 
5. Theory of mind refers to the ability to understand that other individuals have mental processes 
similar to self, leading to appropriate behaviour and conversation e.g. taking turns while 
conversing (as others also think and so want to speak). This is deficient in the development of 
autistic children and can become acutely deficient (but develops normally) in schizophrenia during 
psychotic episodes. This can explain some pragmatic errors in FTD. 
6. Dysexecutive problems are increasingly proposed as the basis of FTD. Frontal lobe plays 
significantly in formation of the human language ad so the loss of executive functions can result in 
poor planning, error monitoring and correction of speech production. 
 
Stream of Thought: 
The term pressure of speech refers to the phenomenon of having excessive thoughts in mind 
accompanied by rapid voluminous speech, often disjointed and non-pragmatic. This is seen in mania. 
Crowding of thought occurs in schizophrenia. Here the patient describes his thoughts as being passively 
concentrated and compressed in his head. The associations are experienced as being excessive in amount, 
too fast, inexplicable and outside the person's control. Experientially, this is different from the manic flight 
of ideas. 
Retardation of thinking: Seen in depression. Train of thought is slowed down, though goal-directed, it is 
characterised by little initiative or planning, the long latency of response, increased pause times when 
speech is initiated and during speech. In both the above the mood state of the patient dictates the flow of 
thoughts. 
Perseveration: This could be considered under a stream of thought though traditionally, it is considered 
pathognomonic of organic brain disease; it is also discussed with disorders of motor action. The thought 
process tends to persist beyond a point at which they are relevant. It presents itself as repeatedly same 
answer or motor act even if the stimulus that elicits the response has changed and demands a different 
answer or motor act. Perseveration also occurs if there is clouded consciousness.

# 29 - Possession Control of thought

# Possession /Control of thought:

© SPMM Course 
Possession /Control of thought: 
Obsessions are unwanted, intrusive, repetitive, senseless thoughts experienced by patients as 
troublesome and resisted; though the appearance of the thoughts themselves is appreciated to be beyond 
their control, they are not claimed to be due to external agency. Patients often regard them to be the 
products of one's own mind but against their values and needs; therefore they are termed as ego-alien. 
Intrusive thoughts occur before motor (compulsive) acts. But it is not necessary that every compulsion is 
preceded by an obsession or vice versa. Often during the course of OCD primary obsessions fade while 
compulsions dominate clinical picture; some compulsions can be mental compulsions like praying, 
counting, etc. Obsessional slowness can occur either when obsessional thoughts occur as part of a 
depressive illness or in cases of severe OCD where primary obsessional slowness ensues. Still another 
pattern is the obsession with symmetry or precision, which leads to a compulsion of slowness. Patients 
take hours to eat a meal or shave, in an attempt to do things ‘just right’. Unlike other patients with OCD, 
these patients do not resist their symptoms! 
The most common obsession is the fear of contamination, followed by pathological doubt, a need for 
symmetry, and aggressive obsessions. The most common compulsion is checking, which is followed by 
washing, symmetry, the need to ask or confess, and counting. Children with OCD present most 
commonly with washing compulsions, which are followed by repeating rituals. 
Thought alienation is a general term used to describe the experience that one’s thoughts are under the 
control of outside influences or that others participate in one’s thinking. This term is often confusing and 
better replaced with components of first rank symptoms – thought insertion, withdrawal and broadcast.

# 30 - 7. Motor symptoms

# 7. Motor symptoms

# 31 - Catatonic symptoms

# Catatonic symptoms:

© SPMM Course 
7. Motor symptoms 
Fish classified motor symptoms into 
a. Abnormal spontaneous movements: Tremors, Tics, chorea, athetosis and stereotypy noted in autistic 
spectrum disorders, hemi-ballismus, etc. 
b. 
Abnormal induced movement: Perseveration, automatic obedience, echo phenomenon and other 
catatonic signs 
Catatonic symptoms: 
Fink & Taylor have argued to include catatonia as a separate taxonomy in psychiatric nosology. Catatonia 
is decreasing in frequency in its classical form, largely due to early diagnosis, treatment and 
deinstitutionalisation. Catatonia is defined as rigidity during involuntary movements while volitional 
movement is carried out normally. Note that in neurological spasticity the tone is increased irrespective of 
passive or active movements. A patient with catatonia can use the affected limb or muscle group when 
needed with completely normal tone – for example, running out when there is a fire. Catatonia persists in 
sleep and can continue for weeks without improvement. Catatonia is mostly seen in advanced primary 
mood or psychotic illnesses. Among inpatients with catatonic presentation, 25 to 50 percent are related to 
mood disorders and approximately 10 percent are associated with schizophrenia. Catatonia results in both 
speech and motor disturbances. 
 
Ambitendence: Here a schizophrenic patient brings the spoon to his mouth dozens of times but never 
completes the act. In ambitendency, the patient makes a series of tentative, opposing alternate movements 
that do not reach the intended goal. This becomes evident when the patient is asked to carry out a motor 
act e.g. asking the patient to show his tongue will elicit repeated protrusion and retraction of tongue as if 
Prominent catatonic symptoms 
Non-catatonic motor symptoms seen in 
psychiatry 
Ambitendence 
Akathisia 
Automatic Obedience 
Perseveration 
Catalepsy 
Blepharospasm 
Echo-phenomenon 
Dystonia 
Gegenhalten 
Tardive dyskinesia 
Grimacing 
Tics 
Mannerism 
Astasia-abasia 
Mutism 
Chorea* 
Negativism 
Tremors* 
Posturing 
Athetosis* 
Stereotypy 
Hemiballismus* 
Stuporous immobility/excitement 
* Mostly neurological cause

© SPMM Course 
the patient is undecided about showing his tongue. (Note ambivalence: Inability to make a decision – 
dilemma of the volitional faculty. It may also appear as affective ambivalence- e.g., To love and hate the 
same person at the same time or intellectual ambivalence-E.g. Assertion and denial of the same idea. This 
is not a catatonic symptom.) 
Automatic obedience: Exaggerated cooperation with examiner’s request or spontaneous continuation of 
movement requested. To demonstrate this, the examiner must ask the patient not to cooperate, but still the 
patient will carry out motor instructions. In days where ethics did not hamper research, Kraepelin 
demonstrated automatic obedience by pinching his patient’s tongue with a pin every time he protruded it; 
but the patient continued to obey Kraeplin’s commands in spite of this! 
Mitmachen and mitgehen are closely related to automatic obedience: 
 
Mitmachen can be considered as a mildest form of automatic obedience where despite requests to 
resist manipulation, the patient yields himself to be placed in abnormal postures. 
 
Mitgehen or “Anglepoise lamp” sign: The patient yields to slightest of pressures, without much 
resistance, similar to an angle poise lamp that bends easily. This happens even if the patient is 
instructed to resist any manipulation. This may be a milder form of automatic obedience. It is also 
called ‘magnet reaction’ as the patient may even follow the examiner around the room with light 
touch as if pulled by a magnet. 
Catalepsy or Waxy flexibility: Also called flexibilitas cerea. Here the patient shows wax-like plastic 
‘mouldable’ quality. His limbs can be moved by the examiner to occupy certain postures, which are then 
maintained, even if these are uncomfortable and bizarre. 
Differentiating this from mitmachen / mitgehen (Automatic Obedience) 
 Unlike flexibilitas cerea, there is an explicit request to resist manipulation in mitmachen 
 The arm comes back to resting position when released by the examiner in mitmachen, but not in 
catalepsy 
 Unlike mitgehen, the manipulation is not gentle with finger tip but full and complete in catalepsy 
Echo-phenomenon: This is seen in catatonia, Latah (a culture-bound disorder) and also in Tourette’s 
syndrome. 
Echopraxia: mimicking examiner’s movements 
Echolalia: mimicking examiner’s speech. 
In Gegenhalten (aka paratonia or opposition) there is a resistance to passive movements with the 
proportional strength to the increase of muscle tone which seems to be voluntarily controlled by the patient. 
Patients with negativism resist or oppose all passive movements attempted by the examiner. This is an 
extreme form of opposition where apparently motiveless resistance to all interference is found. 
Negativism can be a frustrating symptom especially for carers involved in offering nursing assistance to 
the patient. The catatonic symptom of blocking or obstruction (or Sperrung) refers to a phenomenon

# 32 - Non Catatonic symptoms

# Non-Catatonic symptoms:

© SPMM Course 
similar to thought blocking but occurs while carrying out motor acts. A patient with obstruction suddenly 
stops a motor act for no reason, without any warning. This may be demonstrated by asking the patient to 
move a part of his body; the movement is generally well begun, but then stops halfway without any 
indication. 
Grimacing refers to the maintenance of odd facial expressions. An odd variant of grimacing is called 
schnauzkrampf, where the patient cups his lips as if they are spastic (snout spasm). 
Stupor presents as immobility (usually the extreme opposite of excitement where no activity is noticeable 
though the patient is able to perceive stimuli). This is akin to akinetic mutism of neurological states. 
Paradoxically in extreme mania too, stuporous immobility can occur. But it is more common in depression. 
Catatonic excitement is characterised by extreme apparently non-purposeful hyperactivity, which 
presents as constant motor unrest. Unlike 
akathisia, this is often dramatic with no 
subjective component. 
Mannerisms: Odd, but purposeful 
movements (hopping, saluting passers-by or 
mundane movements). 
They are also known as idiosyncratic voluntary movements though the patient may claim unawareness. 
These often have a delusional meaning in schizophrenia. They are different from stereotypes as 
mannerisms appear as goal-directed movements. 
Mutism is discussed in detail along with speech disorders. 
Negativism is an extreme form of opposition – see above. 
Posturing refers to the maintenance of odd and bizarre postures. These might be spontaneously undertaken 
or derived from an arrested motor activity e.g. posture with swung arms as if one is frozen when walking. 
This is maintained despite efforts to be moved. It is also called catalepsy. Psychological Pillow: This is an 
extreme form of posturing. The patient holds their head several inches above the bed while lying and can 
maintain this uncomfortable posture for long periods of time. 
Stereotypes are non-goal directed motor activity (e.g., spinning one's hands, repeated touching, patting, 
rubbing self). These are seen in catatonia and also in pervasive developmental disorder and severe 
learning disabilities. 
Non-Catatonic symptoms: 
Agitation vs. akathisia: Psychotic agitation is very difficult to distinguish from akathisia secondary to 
antipsychotics. But such distinction is important, as the latter requires a decrease, not increase, in 
medications administered. Akathisia has a subjective component of restlessness together with objective 
evidence of unrest; at times one may have to resort to benzodiazepines when the distinction is unclear 
Some common mannerisms 
Tiptoe walking 
Finger to lip moves 
(‘shushing’) 
Clicking sounds during 
speech 
Odd robotic speech, without 
contractions (can not instead of 
can’t) 
Shrugging 
Grimacing 
Parakinesia (contracting 
entire facial muscles) 
Tapping, adjusting, saluting

© SPMM Course 
though the dose required to treat one may be different from the dose required for the other. 
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1289895/ 
Astasia-abasia: Inability to walk, sit or stand upright without any obvious neurological deficits in motor 
strength and innervations. It is described that some patients with this syndrome cannot balance 
themselves upright but can run with a bizarre posture. Occurs as a motor conversion disorder. 
Blepharospasm is a type of focal cranial dystonia that must not be confused with catatonia. 
Blepharospasm may be seen in Tardive Dyskinesia. It usually begins gradually with excessive blinking. 
Initially, episodes are triggered by specific stressors, e.g., bright lights, fatigue, distress etc., and disappear 
with sleep. Concentrating on a specific task (such as watching TV) often decreases the frequency of the 
spasms. With time, the spasms may become progressively intense, functionally blinding the patient 
during each episode wherein the eyelids remain vehemently closed for longer periods. 
Perseveration: This refers to repeatedly same response – either verbal or motor, when different stimuli are 
delivered (questions or instructions). Irrespective of changes in stimuli that demand variation in responses, 
the response here remains the same. It is different from Verbigeration (see below) where verbal repetition 
occurs spontaneously, not just in response to questions or commands. Also note that perseverative 
responses are goal directed – they intend to answer a question or carry out an instruction, but stereotypes 
on other hand are not goal directed. It differs from echo phenomenon; the latter is a copying of other 
person’s responses, not repeating self-responses. 
Tics: These are sudden involuntary (but temporarily suppressible) jerking movements often seen in facial 
and vocal musculatures though it can affect any skeletal muscle group in the body. They typically have a 
waxing and waning course, worsening with low mood and fatigue and not seen in sleep. Some tics may 
appear as coordinated complex acts such as grunting, uttering syllables that may amount to coprolalia 
(obscenities) or echophenomenon. Tics seen in Tourette’s differ from other simple tics in that they are 
preceded by a palpable urge or prodromal sensation before the motor act. Tics have been conceived to 
share the pathophysiology of obsessions. 
Verbigeration: Repetition of phrases or sentences. This occurs spontaneously and without any goal. This 
should not be confused with echolalia. This is not catatonia. 
Stereotypy 
Mannerism 
Meaningless motor expression 
 
Behaviour has a special purpose or meaning 
 
Often repetitive 
 
Not particularly repetitive 
 
e.g. Repeated hand-wringing, or rocking 
movements 
e.g. wearing black goggles all the time, 
Patient cannot explain the behaviour 
At times, patient can come up with some 
explanation that may / may not be delusional

# 33 - 8. Miscellaneous topics

# 8. Miscellaneous topics

# 34 - Pathology of familiarity

# Pathology of familiarity:

# 35 - Memory and dissociation

# Memory and dissociation:

© SPMM Course 
8. Miscellaneous topics 
 
Pathology of familiarity: 
 Déjà vu is the feeling of having seen or experienced an event, which is being experienced for the first time. 
The most consistent finding in the de´ja` vu literature is that the incidence with which it is experienced 
decreases with age. Brown (2003) estimates that 60% of people have experienced it. De´ja` vu occurs more 
frequently under stress and fatigue while it declines with age. Reports of de´ja` vu are greater in 
schizophrenics and temporal lobe (TL) epileptics. This suggests that neurophysiological stimulation or 
dysfunction of the TL may be involved in de´ja` vu. However, the nature and duration of de´ja` vu in these 
populations is different to that experienced by the general population, e.g. lasting for hours in 
schizophrenia and minutes in TL epilepsy, compared to the typical duration of seconds. De´ja` vecu refers 
to the perception that events happening now have been lived 
through before. Déjà pensee refers to the pathological familiarity for a thought or idea. Déjà entendu is a 
pathological familiarity for someone’s voice. 
Jamais vu is an experience that has been experienced before is not associated with feelings of familiarity. 
Both can occur in normal people, and also can occur in Temporal Lobe Epilepsy*. 
Note that some authors (Ellis, Young) include delusional misidentification syndromes with the pathology 
of familiarity. 
Memory and dissociation: 
Confabulation is a falsification of memory occurring in clear consciousness associated with organic states. 
Suggestibility is a prominent feature of confabulation. It is often described in Korsakov syndrome. There 
can either be confabulation of embarrassment or of fantastic nature. 
In pseudologia fantastica, there is fluent plausible lying (falsification of memory), with the statements 
made extreme and of grandiose nature. Is usually associated with dissocial or histrionic personality 
disorders. 
In a dissociative fugue, there is narrowing of consciousness, wandering away from surroundings and 
subsequent amnesia for the episode. There is marked memory loss and loss of identity, but the patient can 
carry out complicated patterns of behaviour and is able to look after himself. There is a gross discrepancy 
between memory loss and intact personality. 
For some reason, there always seems to be an MCQ on Ganser’s syndrome, considered as a hysterical 
dissociative disorder. Ganser’s syndrome includes: 
 Approximate answers 
 Clouding of consciousness with disorientation 
 Psychogenic, physical symptoms – analgesia & hyperaesthesia 
 Pseudohallucinations – not always present. 
 Patients with Ganser’s syndrome are amnesic for their abnormal behaviour. 
Couvade syndrome describes a sympathetic pregnancy that affects husbands (rarely other family 
members) during their wives pregnancies. Most frequent between 3-9 months of pregnancy - it is a

# 36 - Depersonalisation

# Depersonalisation:

© SPMM Course 
conversion symptom not delusional as the husband does not think he is pregnant! Pseudocyesis is a 
condition where a woman experiences clinical signs of pregnancy without being pregnant, and the patient 
is convinced of pregnancy. 
Koro is a culture-bound anxiety state where the patient believes that his penis is shrinking into his 
abdomen, and he will die as a result. This is considered to be a desomatization (organ specific 
depersonalization) experience associated with folk beliefs (hence not a delusion as culturally relevant). It 
is seen in Malaysia and Singapore. 
In multiple personality disorders, one-way amnesia is common. (A knows B’s existence, B is not aware). 
Possession states can occur as a part of dissociation or in normal religious experiences, or under hypnosis. 
Possession states, where consciousness is preserved, can occur in schizophrenia. Consciousness is altered 
in dissociative states. Lycanthropy is a form of possession where the patient loses awareness and identity 
and believes he has been transformed into an animal, usually wolf. 
Out of body experiences, autoscopy, depersonalisation and transcendental experiences are clustered often 
in Near Death Experiences. The neurophysiological basis of near death experience (NDE) is unknown. 
Clinical observations suggest that REM state intrusion contributes to NDE. REM intrusion during 
wakefulness is a frequent normal occurrence and NDE elements can be explained by REM intrusion. 
A feeling of impending ego dissolution is noted in LSD intoxication. 
Depersonalisation: 
It is the third most common symptom in psychiatric clinics. It is defined as a change in self-awareness and 
the individual feels as if he is unreal. The ‘as if’ quality differentiates it from psychotic states. When a 
similar feeling occurs for objects and environment around an individual, it is termed as derealization 
(Mapother). It is always subjective, unpleasant with affective change invariably, and insight preserved. 
Emotional numbing, loss of feelings of agency and self-esteem, disturbed body image, altered perception 
of time, memory and sensory experiences of all modalities are reported. Temporal lobe epilepsy (lasts for 
minutes), hysterical dissociation, depression, any anxiety state (lasts for seconds) including anankastic 
personality, using tricyclic antidepressants, hallucinogens and cannabis can cause depersonalisation apart 
from fatigue or meditation/yoga in normal people. ECT can worsen depersonalisation by unknown 
mechanisms. In psychiatric population, the affect associated with the experience is extremely unpleasant 
as opposed to the normal population. The most common psychiatric diagnosis is depression followed by 
anxiety disorders. Dissociation is only infrequently associated. Depersonalisation is often difficult to 
distinguish from derealization, and they often occur together though the former being commoner. The 
patients often do not report the symptom as it is difficult to express. This may be related to the pathology 
of familiarity wherein familiarity of self being lost. Depersonalisation is associated with déjà vu / jamais 
vu where place familiarity is error prone. Depersonalisation is frequently situational and almost always 
episodic. In depersonalisation disorder (classified as a dissociative disorder in DSM 4) the experience lasts 
for hours. Roth described a PAD – Phobic anxiety depersonalisation syndrome. Typically a married 
female in thirties with agoraphobia and anxiety – worsens with ECT treatment. This is now relevant only 
historically.

# 37 - Insight

# Insight:

# 38 - Phenomenology of epilepsy

# Phenomenology of epilepsy:

© SPMM Course 
Desomatisation refers to depersonalisation that is localised to a body part. Deaffectualisation is an 
extreme form of anhedonia wherein not only pleasure but also the capacity to feel any emotion is 
consistently lost. It is not specific to any organic syndrome. It is never reported in mania. Patients score 
high on neuroticism with introversion being predominant. 
 
Insight: 
Insight refers to a multidimensional concept which includes 4 A’s: 
 Awareness of one’s own symptoms (absence - anautognosia) 
 Attribution of symptoms to mental disorder appropriately (absence – dysautognosia) 
 Appraisal or analysis of consequences of such symptoms 
 Acceptance of treatment 
Insight is not an all or none phenomenon; it fluctuates within an illness for the same patient. More patients 
with psychoses have poor insight than those with neuroses. Loss of insight is not always related to the 
presence of delusions; as in manic states even without delusions nearly 50% patients show no insight 
during the acute episode. This may be different from schizophrenic insight loss that is seen even in the 
chronic stage. Insight has not been consistently associated with any psychopathology of schizophrenia; 
some studies show an association with disorganisation symptoms. In depression, insight may be higher 
than usual, called depressive realism. In acute psychosis presence of insight is associated with more selfharm and suicides. Loss of insight has been compared to anosognosia following stroke. Fronto parietal 
circuit may play an important role in insight. 
Levels of insight: 
1. Complete denial 
2. Slight awareness of being sick but denying it at the same time 
3. Awareness of being sick but blaming it on others, on external factors 
4. Awareness that illness is caused by something unknown in the patient 
5. Intellectual insight: admission that the patient is ill and that symptoms or failures in social 
adjustment are caused by the patient's own particular irrational feelings or disturbances without 
applying this knowledge to future experiences 
6. True emotional insight: emotional awareness of the motives and feelings of the patient and the 
important persons in his or her life, which can lead to basic changes in behaviour. 
Phenomenology of epilepsy: 
Temporal lobe epilepsy TLE: 
 Autonomic sensations are the most common of auras, causing epigastric aura, salivation, 
sometimes vertigo, etc. 
 Forced thinking The individual has a compulsion to think on a certain restricted topic. 
 The evocation of thought: Intrusion of stereotyped words or thoughts.

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 Sudden obstruction to thought flow similar to schizophrenic thought block is also reported. 
 Panoramic memory: Here the individual recalls expansive memories in incredible detail as if 
running a video show of the past. 
 Psychic seizures: Isolated auras with hallucinations, depersonalization, micropsia or macropsia, 
déjà vu or jamais vu (especially if right sided origin) can occur. 
 Uncinate crises: Hallucinations of taste and smell of uncinate origin associated with dream-like 
reminiscence and altered consciousness. 
 Strong affective experiences are reported – fear and anxiety being very common. Dostoevsky’s 
epilepsy refers to ecstatic content in the epileptic aura. TLEs are the most common seizures with 
auras. The term complex partial seizure refers to TLE generally. 
Parietal lobe epilepsy: 
Somatosensory seizures: The most common type of seizure in parietal epilepsies - patients describe 
physical sensations of numbness and tingling, heat, pressure, electricity and/or pain. Some patients 
describe a typical “Jacksonian march”, in which the sensation “marches” in a predictable pattern from the 
face to the hand up the arm and down the leg. 
Pain is a rare symptom of seizures as such but is quite common in parietal seizures, occurring in up to 25% 
of patients. 
Somatic Illusions: During a somatic illusion patients may feel that their posture is distorted, that their 
arms or legs are in a weird position or are in motion when they are not (kinaesthetic hallucination), or 
that a part of their body is missing or feels like it does not belong (body image distortion). Vertigo is also 
reported. 
Visual illusions: Patients may experience objects as being too close, too far, too large, too small, slanted, 
moving or otherwise not right. 
Frontal lobe seizures: Complex partial seizures of frontal lobe origin are usually quite different from 
temporal lobe seizures. Frontal lobe seizures tend to be short (less than 1 minute), occur in clusters and 
during sleep, include strange automatisms such as bicycling movements, screaming, or even sexual 
activity. Sometimes a person may remain fully aware at the same time having wild movements of the 
arms and legs. A seizure from the frontal lobe may even involve laughing or crying as the only symptom, 
the former is called gelastic and the latter dacrystic seizures. These are also noted in temporal lobe 
seizures. 
Automatisms: Epileptic automatism is a state of clouding of consciousness which occurs during or 
immediately after a seizure. The impairment of awareness varies. The individual retains control of 
posture and muscle tone but performs simple or complex movements without being aware of what is 
happening. To the onlooker, the patient appears confused, and there is subsequent amnesia for the 
episode. Simple stereotyped behaviours (gesturing, grasping, lip-smacking and chewing movements) are 
often exhibited lasting few seconds to minutes. Very occasionally, automatisms are prolonged (fugue

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states), or complex actions are carried out. If violent, these are never premeditated, seldom goal-directed, 
rarely involve the use of complex tools/weapons and are especially likely if restraining was attempted. 
 
 
 
 
 
DISCLAIMER: This material is developed from various revision notes assembled while preparing for 
MRCPsych exams. The content is periodically updated with excerpts from various published 
sources including peer-reviewed journals, websites, patient information leaflets and books. These 
sources are cited and acknowledged wherever possible; due to the structure of this material, 
acknowledgements have not been possible for every passage/fact that is common knowledge 
in psychiatry. We do not check the accuracy of drug-related information using external sources; 
no part of these notes should be used as prescribing information.

© SPMM Course 
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