Fish's Edition 3 Clinical Psychopathology PDF

Casey & Kelly     Fish’s Clinical Psychopathology has shaped the psychiatric training and clinical practice of several generations of psychiatrists but was out of print for many years. The third edition of this modern cla...

Casey & Kelly     Fish’s Clinical Psychopathology has shaped the psychiatric training and clinical practice of several generations of psychiatrists but was out of print for many years. The third edition of this modern classic now presents the clinical descriptions and psychopathological in- sights of Fish to a new generation of students and practitioners. This is an essential text for students of medicine, trainees in psychiatry and practising psychiatrists. It will also be of interest to psychiatric nurses, mental health social workers, clinical psychologists and all readers who value concise descriptions of the symptoms of mental illness and astute accounts of the many and varied manifestations of disordered psychological function. Fish’s completely revised edition of classic text Fish’s clinical psychopathology new sections on personality disorder, cognitive distortion, defence mechanisms, memory and unusual psychiatric syndromes updated references to relevant contemporary literature clinical psychopathology signs and symptoms in psychiatry third edition Patricia Casey GASKELL GASKELL Brendan Kelly The authors Patricia Casey is Professor of Psychiatry at University College Dublin and Consultant Psychiatrist at Mater Misericordiae University Hospital, School of Medicine and Medical Science, Eccles Street, Dublin 7, Ireland Brendan Kelly is Consultant Psychiatrist and Senior Lecturer in Psychiatry, Department of Adult Psychiatry, University College Dublin, Mater Misericordiae University Hospital, Dublin, Ireland iv Preface Psychopathology is the science and study of psychological and psychiatric symptoms. Clinical psychopathology locates this study in the clinical context in which psychiatrists make diagnostic assessments and deliver mental health services. A clear understanding of clinical psychopathology lies at the heart of effective and appropriate delivery of such services. In 1967, Frank Fish produced a 128-page volume on psychopathology, entitled Clinical Psychopathology: Signs and Symptoms in Psychiatry (Fish, 1967). Despite its brevity or more likely, because of its brevity, Fish’s Clinical Psychopathology soon became an essential text for medical students, psychiatric trainees and all healthcare workers involved in the delivery of mental health services. A revised edition, edited by Max Hamilton, appeared in 1974 (Hamilton, 1974) and was reprinted as a second edition in 1985 (Hamilton, 1985). In recent years, Fish’s Clinical Psychopathology has been out of print and essentially impossible to locate. The purpose of this third edition is to introduce this classic text to a new generation of psychiatrists and trainees, and to reacquaint existing aficionados with the elegant insights and enduring values of Fish’s original work. Revising Fish’s Clinical Psychopathology has been both a humbling and exciting experience. While striving at all times to retain the spirit of Fish’s original work, we have revised the language in various areas so as to take account of changes in linguistic conventions. We have also updated references and included new material relating to personality disorder, cognitive distortion, defence mechanisms, memory and unusual psychiatric syndromes. Notwithstanding these revisions, we trust that this text remains true to the spirit of Fish’s original Clinical Psychopathology, the volume that shaped the clinical education and practice of a generation of psychiatrists. We hope that this edition proves similarly useful to contemporary readers. If it succeeds, all credit lies with the original insights of Frank Fish; if it does not, the fault lies with us. Patricia Casey Brendan Kelly  Contents The authors iv Preface v 1 Classification of psychiatric disorders 1 2 Disorders of perception 14 3 Disorders of thought and speech 32 4 Disorders of memory 55 5 Disorders of emotion 65 6 Disorders of the experience of self 75 7 Disorders of consciousness 81 8 Motor disorders 87 9 Personality disorders 106 Appendix I: Psychiatric syndromes 121 Appendix II: Defences and distortions 126 Index 132 iii CHAptER 1 Classification of psychiatric disorders Any discussion of the classification of psychiatric disorders should begin with the frank admission that the definitive classification of disease must be based on aetiology. Until we know the cause of the various mental illnesses, we must adopt a pragmatic approach to classification that will best enable us to care for our patients, to communicate with other health professionals and to carry out high-quality research. In physical medicine, syndromes existed long before the aetiology of these illnesses were known. Some of these syndromes have subsequently been shown to be true disease entities because they have one essential cause. Thus, smallpox and measles were carefully described and differentiated by the Arabian physician Rhazes in the 10th century AD. With each new step in the progress of medicine, such as auscultation, microscopy, immunology, electrophysiology, etc., some syndromes have been found to be true disease entities, while others have been split into more discrete entities and others jettisoned. For example, diabetes mellitus has been shown to be a syndrome that can have several different aetiologies. On that basis the modern approach to classification has been to establish syndromes in order to facilitate research and to assist us in extending our knowledge of them so that ultimately specific diseases can be identified. We must not forget that syndromes may or may not be true disease entities and some will argue that the multifactorial aetiology of psychiatric disorder, related to both constitutional and environmental vulnerability, as well as to precipitants, may make the goal of identifying psychiatric syndromes as discrete diseases an elusive ideal. Syndromes and diseases A syndrome is a constellation of symptoms that are unique as a group. It may of course contain some symptoms that occur in other syndromes also, but it is the particular combination of symptoms that makes the syndrome specific. In psychiatry, as in other branches of medicine, many syndromes began as one specific and striking symptom. In the 19th century, stupor, furore and hallucinosis were syndromes based on one prominent symptom.  Fish’s clinical psychopathology Later, the recognition that certain other signs and symptoms co-occurred simultaneously led to the establishment of true syndromes. Korsakoff’s syndrome illustrates the progression from symptom to syndrome to disease. Initially, confabulation and impressibility among alcoholics were recognised by Korsakoff as significant symptoms. Later the presence of disorientation for time and place, euphoria, difficulty in registration, confabulation and ‘tram-line’ thinking were identified as key features of this syndrome. Finally, the discovery that in the alcoholic amnestic syndrome there was always severe damage to the mammillary bodies confirmed that Korsakoff ’s psychosis (syndrome) is a true disease with a neuropathological basis. Sometimes the symptoms of the syndrome seem to have a meaningful coherence. For example, in mania the cheerfulness, the overactivity, the pressure of speech and the flight of ideas can all be understood as arising from the elevated mood. The fact that we can empathise with and understand our patients’ symptoms has led to the distinction between those symptoms that are primary and which are said to be the immediate result of the disease process, and secondary symptoms, which are a psychological elaboration of, or reaction to, primary symptoms. The term is also used to describe symptoms that cannot be derived from any other psychological event. Early distinctions The first major classification of mental illness was based on the distinction between disorders arising from disease of the brain and those with no such obvious basis, i.e. organic versus functional states. These terms are still used, but as knowledge of the neurobiological processes associated with psychiatric disorders has increased, their original meaning has been lost. Schizophrenia and manic depression are typical examples of functional disorders, but the increasing evidence of the role of genetics and of neuropathological abnormalities shows that there is at least some organic basis for these disorders. Indeed the category of ‘organic mental syndromes and disorders’ has been renamed as ‘delirium, dementia and amnestic and other cognitive disorders’ in the Diagnostic and Statistical Manual of Mental Disorders (DSM)−IV (American Psychiatric Association, 1994), so that the recognition of the role of abnormal brain functioning is not confined to dementia and delirium only. In their literal meaning these categories of classification (i.e. organic versus functional) are absurd, yet they continue to be used through tradition. Organic syndromes The syndromes due to brain disorders can be classified into acute, subacute and chronic. In acute organic syndromes the most common feature is alteration of consciousness, which can be dream-like, depressed or restricted. This gives rise to four subtypes, i.e. delirium, subacute delirium, organic stupor or torpor, and the twilight state. Disorientation, incoherence of psychic life and some degree of anterograde amnesia are features of all of   Classification these acute organic states. In delirium there is a dream-like change in consciousness so that the patient may also be unable to distinguish between mental images and perceptions, leading to hallucinations and illusions. Usually there is severe anxiety and agitation. When stupor or torpor is established the patient responds poorly or not at all to stimuli and after recovery has no recollection of events during the episode. In subacute delirium there is a general lowering of awareness and marked incoherence of psychic activity, so that the patient is bewildered and perplexed. Isolated hallucinations, illusions and delusions may occur and the level of awareness varies but is lower at night-time. The subacute delirious state can be regarded as a transitional state between delirium and organic stupor. In twilight states consciousness is restricted, so that the mind is dominated by a small group of ideas, attitudes and images. These patients may appear to be perplexed but often their behaviour is well ordered and they can carry out complex actions. Hallucinations are commonly present. In organic stupor (torpor) the level of consciousness is generally lowered and the patient responds poorly or not at all to stimuli. After recovery the patient usually has amnesia for the events that occurred during the illness episode. In addition to the above, there are organic syndromes in which consciousness is not obviously disordered, for example organic hallucinosis due to alcohol abuse, which is characterised by hallucinations, most commonly auditory and occurring in clear consciousness, as distinct from the hallucinations of delirium tremens that occur in association with clouded consciousness. Amnestic disorders, of which Korsakoff’s syndrome is but one, also belong in this group of organic disorders and are characterised primarily by the single symptom of memory impairment in a setting of clear consciousness and in the absence of other cognitive features of dementia. The chronic organic states include the various dementias, generalised and focal, as well as the amnestic disorders. Included among the generalised dementias are Lewy body disease, Alzheimer’s disease, etc., while the best known focal dementia is frontal lobe dementia (or syndrome). The latter is associated with a lack of drive, lack of foresight, inability to plan ahead and an indifference to the feelings of others, although there is no disorientation. Some patients may also demonstrate a happy-go-lucky carelessness and a facetious humour, termed Witzelsucht, whereas others are rigid in their thinking and have difficulty moving from one topic to the next. The most common cause is trauma to the brain such as occurs in road traffic accidents. The presence of frontal lobe damage may be assessed psychologically using the Wisconsin Card Sorting test or the Stroop test. Amnestic disorders are chronic organic disorders in which there is the single symptom of memory impairment; if other signs of cognitive impairment are present (such as disorientation or impaired attention) the diagnosis is dementia. The major neuroanatomical structures involved are the thalamus, hippocampus, mammillary bodies and the amygdala. Amnesia is usually the result of bilateral damage but some cases can occur with unilateral damage and the left hemisphere appears to be more critical than the right in its genesis.  Fish’s clinical psychopathology Functional syndromes Functional disorders, a phrase seldom used nowadays, refers to those syndromes in which there is no readily-apparent coarse brain disease, although increasingly it is recognised that some finer variety of brain disease may exist, often at a cellular level. For many years it was customary to divide these functional mental illnesses into neuroses and psychoses. The person with neurosis was believed to have insight into his illness, with only part of his personality involved in the disorder, and to have intact reality testing. The individual with psychosis, on the other hand, was believed to lack insight, had the whole of his personality distorted by the illness and constructed a false environment out of his distorted subjective experience. However, such differences are an oversimplification, since many individuals with neurotic conditions have no insight, and far from accepting their illness, may minimise or deny it totally, while people with schizophrenia may seek help willingly during or before episodes of relapse. Moreover, personality can be changed significantly by non-psychotic disorders such as depressive illness, while it may be intact in some people with psychotic disorders such as persistent delusional disorder. Jaspers (1962) regarded the person with neurosis as an individual who has an abnormal response to difficulties in which some specific defence mechanism has transformed their experiences. For example, in conversion and dissociative disorders (formerly hysteria) the mechanism of dissociation is used to transform the emotional experiences into physical symptoms. Since we can all use this mechanism, the differences between the neurotic person and the normal person is one of degree. Schneider (1959) has suggested the neuroses and personality disorders are variations of human existence that differ from the norm quantitatively rather than qualitatively. However, this view of the neuroses breaks down when obsessive–compulsive disorder is considered, since the symptoms are not variations of normal but differ qualitatively from normal behaviours. Over time the use of the terms neurotic and psychotic changed and instead of describing symptoms, particularly symptom types such as hallucinations or delusions, in the psychotic person they were used to distinguish mild and severe disorders or to distinguish those symptoms that were ego-syntonic (i.e. creating no distress for the person or compatible with the indiviudal’s self-concept or ego) or ego-dystonic (i.e. causing distress and incompatible with the person’s self-concept). Some practitioners also used the word ‘neurotic’ as a term of opprobrium. Owing to the confusion that abounded in the various uses of these terms, DSM−IV has excluded the term ‘neurosis’ totally from its nomenclature and International Classification of Diseases (ICD)−10 (World Health Organization, 1992) has limited its use to a group of disorders entitled ‘neurotic, stress-related and somatoform disorders’.   Classification Personality disorders and psychogenic reactions The status of personality disorder vis-à-vis other psychiatric disorders was historically regarded differently in the English-speaking world compared with the rest of the world. In the English-speaking world, it was customary to separate the neuroses from personality disorders, but in the German- speaking countries, epitomised by Schneider, the neuroses were regarded as reactions of abnormal personalities to moderate or mild stress and of normal personalities to severe stress. This difference in approach continues and is reflected in the differing approaches to personality disorder in DSM and ICD, with the former placing personality disorder on a separate axis from other disorders, while ICD−10 represents both on Axis I (see below). Psychogenic reactions constituted reversible prolonged psychological responses to trauma, the reactions being the consequence of the causative agent on the patient’s personality. Thus acute anxiety and hysteria were considered to be varieties of psychogenic reactions provoked by stress and determined by personality and cultural factors. Sometimes the stress was believed to cause psychotic reactions, termed symptomatic or psychogenic psychoses; for example the person with a paranoid personality who, in light of ongoing marital difficulties, begins to suspect his wife’s fidelity, finally becoming deluded about this. The idea of delusional states that were not due to functional psychoses was treated with skepticism by English-speaking psychiatrists, but had adherents in Scandinavia, particularly in what were termed psychogenic psychoses. These have gained increasing acceptance and are now called acute and transient psychotic disorders in ICD−10 and brief psychotic disorder with or without marked stressors in DSM−IV. In summary, Schneider (1959) considered that neuroses, psychogenic reactions and personality disorders were not illnesses in the sense that there was a morbid process in the nervous system, while he considered that functional psychoses did represent true illnesses. Modern classifications The 4th edition of the DSM (DSM−IV) (American Psychiatric Association, 1994) is the most recently published classification of mental disorders, although there has been a more recent text revision of the manual, entitled DSM−IV−TR (2000). DSM−IV is used in the USA and notwithstanding the fact that the World Health Organization has developed the 10th edition of the ICD (ICD−10) (World Health Organization, 1992), the latter has found little usage in the USA, although it remains the main classification used in Britain, Ireland and almost the whole of Europe. DSM−I, published by the American Psychiatric Association, first appeared in 1952 and since then it has evolved significantly, to the extent that DSM−IV includes large amounts of detail concerning each syndrome and, owing to its rigorous adherence to operational definitions for each disorder, it is suitable for use in both clinical practice and research. For this reason  Fish’s clinical psychopathology DSM−IV is considerably less user-friendly than ICD−10 and is also considered excessively procrustean by its critics. Interestingly, the billing codes for Medicare in the USA are mandated to follow the ICD system rather than their own DSM−IV. ICD−10 on the other hand is more clinically orientated and is not so rigid in its definitions, eschewing operational definitions in favour of general descriptions. It allows clinical judgement to inform diagnoses, but this freedom makes it unsuitable for research purposes, necessitating the devel­ opment of separate research diagnostic criteria. Thus, different versions of ICD−10 now exist and these include the clinical version (World Health Organization, 1992), a version with diagnostic criteria for research (World Health Organization, 1993) (which resembles DSM in its use of detailed operational criteria) and a version for use in primary care (ICD−10−PC; World Health Organization, 1996), the latter consisting of definitions for 25 common conditions as well as a shorter version of 6 disorders for use by other primary care workers. Management guidelines incorporate information for the patient as well as details of medical, social and psychological interventions. Finally, assistance on when to refer for specialist treatment is provided. DSM−IV also has a primary care version (DSM−IV−PC) that is similar to ICD−10−PC, focusing on the most common disorders seen in primary care (anxiety, depression, substance misuse, etc.). Although both ICD−10 and DSM−IV are broadly similar, the language used to describe each disorder differs significantly. The differences, both in general approach and in language, are illustrated in the descriptions of depressive episode (see Boxes 1.1 and 1.2). Comparison of DSM−IV and ICD−10 It is important to recognise that DSM−IV and ICD−10 are syndrome-based classifications, but as our knowledge increases, some classifications currently included may be removed or new categories may be added. For example, depressive personality disorder is not included in ICD−10 and is only incorporated in the section of DSM−IV entitled ‘Criteria sets and axes provided for further study’. On the other hand, passive−aggressive personality disorder was included in DSM−III but excluded from the subsequent edition, and has never been incorporated into the ICD system. ICD−10 does not distinguish bipolar I and II disorder, as does DSM−IV, as these conditions have only come to be recognised in the 1990s. Recurrent brief depressive disorder is a new addition to ICD−10 but only appears in the appendix of DSM−IV. Schizotypal disorder is classified with the schizophrenic disorders in ICD−10 and with the personality disorders in DSM−IV. Any belief, therefore, that the categories incorporated in either system of classification are ‘writ in stone’ is deeply misplaced. There are also differences in the number of axes used (see below) in each and in the level of operational definition (as mentioned above).   Classification Box 1.1 DSM−IV–TR Criteria for major depressive episode (American Psychiatric Association, 2000. Reprinted by permission of the American Psychiatric Association, © 2000). DSM−IV–TR Criteria for Major Depressive Episode A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations. (1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: in children or adolescents, can be irritable mood (2) markedly diminished interest or pleasure in all, or almost all, activities of the day, nearly every day (as indicated by either subjective account or observation made by others) (3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains (4) insomnia or hypersomnia nearly every day (5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) (6) fatigue or loss of energy nearly every day (7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) (8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) (9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide B. The symptoms do not meet criteria for a Mixed Episode (see p. 365) C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.  Fish’s clinical psychopathology Box 1.2 ICD−10 Depressive episode criteria (World Health Organization, 1993. Reprinted by permission.) F32 Depressive episode G1. The depressive episode should last for at least 2 weeks. G2. There have been no hypomanic or manic symptoms sufficient to meet the criteria for hypomanic or manic episode (F30.–) at any time in the individual’s life. G3. Most commonly used exclusion clause. The episode is not attributable to psychoactive substance use (F10–F19) or to any organic mental disorder (in the sense of F00–F09). Somatic syndrome To qualify for the somatic syndrome, four of the following symptoms should be present: (1) marked loss of interest or pleasure in activities that are normally pleasurable; (2) lack of emotional reactions to events or activities that normally produce an emotional response; (3) waking in the morning 2 hours or more before the usual time; (4) depression worse in the morning; (5) objective evidence of marked psychomotor retardation or agitation (remarked on or reported by other people); (6) marked loss of appetite; (7) weight loss (5% or more of body weight in the past month); (8) marked loss of libido. F32.0 Mild depressive episode A. The general criteria for depressive episode (F32) must be met. B. At least two of the following three symptoms must be present: (1) depressed mood to a degree that is definitely abnormal for the individual, present for most of the day and almost every day, largely uninfluenced by circumstances, and sustained for at least 2 weeks; (2) loss of interest or pleasure in activities that are normally pleasurable; (3) decreased energy or increased fatiguability. C. An additional symptom or symptoms from the following list should be present, to give a total of at least four: (1) loss of confidence or self-esteem; (2) unreasonable feelings of self-reproach or excessive and inappropriate guilt; (3) recurrent thoughts of death or suicide, or any suicidal behaviour; (4) complaints or evidence of diminished ability to think or concentrate, such as indecisiveness or vacillation; (5) change in psychomotor activity, with agitation or retardation (either subjective or objective); (6) sleep disturbance of any type; (7) change in appetite (decrease or increase) with corresponding weight change. F32.1 Moderate depressive episode A. The general criteria for depressive episode (F32) must be met. B. At least two of the three symptoms listed for F32.0, criterion B, must be present. C. Additional symptoms from F32.0, criterion C, must be present, to give a total of at least six. continued   Classification Box 1.2 continued F32.2 Severe depressive episode without psychotic symptoms Note: If important symptoms such as agitation or retardation are marked, the patient may be unwilling or unable to describe many symptoms in detail. An overall grading of severe episode may still be justified in such a case. A. The general criteria for depressive episode (F32) must be met. B. All three of the symptoms in criterion B, F32.0, must be present. C. Additional symptoms from F32.0, criterion C, must be present, to give a total of at least eight. D. There must be no hallucinations, delusions, or depressive stupor. F32.3 Severe depressive episode with psychotic symptoms A. The general criteria for depressive episode (F32) must be met. B. The criteria for severe depressive episode without psychotic symptoms (F32.2) must be met with the exception of criterion D. C. The criteria for schizophrenia (F20.0–F20.3), or schizoaffective disorder, depressive type (F25.1) are not met. D. Either of the following must be present: (1) delusions or hallucinations, other than those listed as typically schizophrenic in criterion G1(1)b, c, and d for F20.0–F20.3 (i.e. delusions other than those that are completely impossible or culturally inappropriate and hallucinations that are not in third person or giving a running commentary); the commonest examples are those with depressive, guilty, hypochondriacal, nihilistic, self-referential, or persecutory content; (2) depressive stupor. F32.8 Other depressive episodes F32.9 Depressive episode, unspecified DSM−IV DSM−IV lists and operationally defines over 300 psychiatric disorders. Each disorder is systematically described in terms of its associated features such as age, gender and culture-related features, incidence risk and predisposing factors. Differential diagnosis is also included. Where relevant, laboratory findings are also described. However, this system is atheoretical and no consideration of causes or treatment is included, nor are controversies surrounding particular diagnoses outlined. It is therefore not a textbook. It also incorporates disorders that are worthy of further scientific examination. As well as providing detailed criteria for each disorder, DSM−IV is multiaxial in its diagnostic approach, leading to patient evaluation on each of 5 dimensions or axes as follows: Axis I Current mental state diagnosis (definite or provisional) Axis II Personality disorder and mental retardation  Fish’s clinical psychopathology Axis III Any physical condition whether related or not to the psychiatric disorder Axis IV Psychosocial or environmental factors contributing to the disorder Axis V Global Assessment of Functioning (GAF) scale. This is a measure of functioning at a specified time, for example at time of evaluation, highest level of functioning during past 6 months, at time of discharge, etc. This 100-point scale provides a composite measure of psychological, social and occupational functioning. It excludes impairment due to physical or environmental limitations. In addition, the disorders can be described as mild, moderate or severe, and as possibly being in partial or full remission. Where there is more than one Axis I diagnosis, they are listed in order of the focus of clinical attention. In addition, DSM−IV is hierarchical, so that some diagnoses subsume others, for example if the criteria for schizophrenia and for panic are met, the diagnosis listed is schizophrenia. Organic disorders override psychotic disorders, and these in turn subsume non-psychotic diagnoses. Affective disorders override anxiety disorders. Finally, DSM−IV incorporates, in its appendix, decision trees or algorithms to facilitate diagnosis. A diagnosis can be deemed provisional if there is a strong presumption that the full criteria for the disorder will ultimately be met even though at the time of evaluation it is not possible to make a definitive diagnosis. ICD−10 This system is now in use throughout Europe and it reflects a significant advance on its predecessor. Many confusing terms such as ‘neurotic’ are confined to a single category of ‘neurotic, stress-related and somatoform disorders’, and the older distinction between neurotic and psychotic has been replaced by a classification according to major common themes, for example, mood (affective) disorders (F30−39) and schizophrenia, schizotypal and delusional disorders (F20−29). Childhood disorders have also been incorporated under two broad categories, i.e. disorders of psychological development (F80−89) and behavioural and emotional disorder with onset usually occurring in childhood and adolescence (F90−98). The classification of mental retardation (F70−79) is still rudimentary and is expected to become more comprehensive in subsequent editions. ICD–10 includes a multiaxial approach although it is somewhat different from DSM in that only 3 axes are recognised and personality disorder is not separated from other mental state disorders. This system also recommends that where multiple Axis I diagnoses coexist (comorbidity) all should be recorded, beginning with the most prominent. Like DSM−IV, ICD−10 is also hierarchical, although diagnostic decision trees are not provided and operational definitions are less rigid than in DSM, allowing for the precedence of clinical judgement. 10  Classification The axes in ICD−10 are as follow: Axis I Current mental state diagnosis including personality disorder Axis II Disabilities Axis III Contextual factors. Diagnoses may be made with confidence when the diagnostic guidelines are clearly fulfilled. However, if they are only partially met or more information is required the diagnosis may be ‘provisional’, and the diagnosis is ‘tentative’ if further information is unlikely to become available. Although guidelines concerning duration are also provided in the criteria, these are not intended as strict requirements and clinicians should use their own judgement when assigning a particular diagnosis if the duration of particular symptoms is slightly shorter or longer than specified. Interview schedules In order to carry out epidemiological studies in which diagnoses are standardised, diagnostic interview schedules have been developed that meet the criteria for ICD−10 and DSM−IV diagnoses. In Europe the Schedule for Clinical Assessment in Neuropsychiatry (SCAN) (Wing et al, 1990) has evolved from the older Present State Examination (PSE) (Wing et al, 1974). SCAN itself is a set of instruments aimed at assessing and classifying psychopathology in adults. The four instruments include PSE−10 (the 10th edition of the Present State Examination), the SCAN glossary, which defines the symptoms; the Item Group Checklist (IGC) for symptoms that can be rated directly (for example from case notes), and the Clinical History Schedule (CHS). This instrument provides diagnoses according to both ICD−10 and DSM−IV criteria. The interview itself is semi-structured, the aim being to encapsulate the clinical interview while minimising its vagaries. There are probe questions with standard wording to elucidate the psychopathological symptoms, defined in the glossary and accompanied by severity ratings. Where there is doubt, the interviewer can proceed to a free-style interview to clarify the feature further and may, if necessary, include the patient’s phraseology in questioning to enhance clarity. It is designed for use by psychiatrists or clinical psychologists, thereby utilising clinical interviewing skills in evaluating each symptom. The symptoms ratings, provided they have been identified as defined in the glossary, are then entered into a computer algorithm and a computer diagnosis obtained according to either classification. The role of the interviewer is thus to rate symptoms rather than make diagnoses. SCAN can generate a current diagnosis, a lifetime diagnosis or a representative episode diagnosis. The use of mental health professionals in interviewing with SCAN makes this an expensive method but has the advantage of approximating the ‘gold standard’ diagnosis achieved by clinical interview. 11 Fish’s clinical psychopathology The DSM−IV equivalent, the Composite International Diagnostic Interview (CIDI) (Robins et al, 1989) developed from the Diagnostic Interview Schedule (DIS) (Robins et al, 1985), is not a semi-structured interview, but a standardised one, suitable for use with lay interviewers. No clinical judgement is brought to bear in rating the symptoms since questions are asked in a rigid and prescribed manner. The questions are clearly stated to elicit symptoms, followed by questions about frequency, duration and severity. The only judgement the interviewer has to make is whether the respondent understood the question, and if not, it is repeated verbatim. CIDI is available in computer format also and so can be self-administered. As with SCAN, the symptoms are then entered into a computer algorithm for diagnosis according to ICD –10 or DSM−IV. The advantage of this approach is that it is cheaper than using semi-structured interviews, since lay people can be trained in its use. However, the absence of clinical judgement is an obvious disadvantage that has resulted in its validity being questioned. Some recent reviews question the prevalence for some psychiatric disorders obtained using standardised interviews such as CIDI and suggest that the high rates identified in some studies require revision downwards (Regier et al, 1998). These mutually different approaches are discussed in detail by Brugha et al (1999) and by Wittchen et al (1999). Interviews such as SCAN pay little attention to personality disorder and it is only in the clinical history section that details of diagnoses not covered in PSE−10 are recorded, usually from other sources of information. Likewise CIDI also pays limited attention to personality disorders. Individual categories such as adjustment disorder are only incorporated peripherally in SCAN and not at all in CIDI, thus limiting their usefulness in certain populations where these categories may be common, for example, in primary care and general medical populations respectively. References American Psychiatric Association (1952) Diagnostic and Statistical Manual of Mental Disorders (1st edn) (DSM−I). Washington, DC: APA. American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM−IV). Washington, DC: APA. American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders (4th edn, text revision) (DSM−IV−TR). Washington, DC: APA. Brugha, T. S., Bebbington, P. E. & Jenkins, R. (1999) A difference that matters: comparisons of structured and semi-structured psychiatric diagnostic interviews in the general population. Psychological Medicine, 29, 1013−1020. Jaspers, K. (1962) General Psychopathology (7th edn), (trans. J. Hoenig & M. W. Hamilton). Manchester: Manchester University Press. Regier, D. A., Kaelber, C. T., Rae, D. S., et al (1998) Limitations of diagnostic criteria and assessment instruments for mental disorders. Implications for research and policy. Archives of General Psychiatry, 55, 105−115. Robins, L. N., Helzer, J. E., Orvaschel, H., et al (1985) The Diagnostic Interview Schedule. In Epidemiologic Field Methods in Psychiatry: The NIMH Epidemiologic Catchment Area Program (eds W. W. Eaton & L. G. Kessler), pp. 143−170. Orlando, Academic Press. 12  Classification Robins, L. N., Wing, J., Wittchen, H. U., et al (1989) The Composite International Diagnostic Interview: An epidemiologic instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Archives of General Psychiatry, 45, 1069−1077. Schneider, K. (1959) Clinical Psychopathology (5th edn), (trans. M. W. Hamilton). New York: Grune & Stratton. Wing, J. K., Cooper, J. & Sartorius, N. (1974) Measurement and Classification of Psychiatric Symptoms. New York: Cambridge University Press. Wing, J. K., Babor, T., Brugha, T., et al (1990) SCAN: Schedules for Clinical Assessment in Neuropsychiatry. Archives of General Psychiatry, 47, 589−593. Wittchen, H. -U., Ustun, T. B. & Kessler, R. C. (1999) Diagnosing mental disorders in the community. A difference that matters? Psychological Medicine, 29, 1021−1027. World Health Organization (1992) The ICD–10 Classification of Mental and Behavioural Disorders. Clinical Descriptions and Diagnostic Guidelines (10th edn). Geneva: WHO. World Health Organization (1993) The ICD–10 Classification of Mental and Behavioural Disorders. Diagnostic Criteria for Research (10th edn). Geneva: WHO. World Health Organization (1996) ICD–10 Diagnostic and Management Guidelines for Mental Disorders in Primary Care. Geneva: WHO. 13 CHAptER 2 Disorders of perception Disorders of perception can be divided into sensory distortions and sensory deceptions. In distortions there is a constant real perceptual object, which is perceived in a distorted way, while in sensory deceptions a new perception occurs that may or may not be in response to an external stimulus. Sensory distortions These are changes in perception that are the result of a change in the intensity and quality of the stimulus or the spatial form of the perception. Changes in intensity (hyper- or hypo-aesthesia) Increased intensity of sensations (hyperaesthesia) may be the result of intense emotions or a lowering of the physiological threshold. Thus a person may see roof tiles as a brilliant flaming red or hear the noise of a door closing like a clap of thunder. Anxiety and depressive disorders as well as hangover from alcohol and migraine are all associated with increased sensitivity to noise (hyperacusis) so that even day-to-day noises such as washing crockery are magnified to the point of discomfort. Those who are hypomanic, suffering an epileptic aura or under the influence of lysergic acid diethylamide (LSD) may see colours as very bright and intense, but this can also be a feature of intense normal emotions such as religious fervour or the unsurpassed happiness of being in love. Hypoacusis occurs in delirium, where the threshold for all sensations is raised. The defect of attention found in delirium further reduces sensory acuity. This highlights the importance of speaking to the delirious patient more slowly and louder than usual. Hypoacusis is also a feature of other disorders associated with attentional deficits such as depression and attention-deficit disorder. Visual and gustatory sensations may also be lowered in depression, for example, everything is black or all foods taste the same. 14  Disorders of perception Changes in quality It is mainly visual perceptions that are affected by this, brought about by toxic substances. Colouring of yellow, green and red have been named xanthopsia, chloropsia and erythropsia. These are mainly the result of drugs (for example, santonin, poisoning with mescaline or digitalis) used in the past to treat various disorders. The qualitative change most associated with drugs now is the metallic taste associated with the use of lithium, although this is not a hallucination but a true change in gustation. In derealisation everything appears unreal and strange, while in mania objects look perfect and beautiful. Changes in spatial form (dysmegalopsia) This refers to a change in the perceived shape of an object. Micropsia is a visual disorder in which the patient sees objects as smaller than they really are. The opposite kind of visual experience is known as macropsia or megalopsia. This definition of micropsia includes the experience of the retreat of objects into the distance without any change in size although some authors call this porropsia. The terms macropsia and micropsia have also been used to describe the changes of size in dreams and hallucinations (Lilliputian hallucinations). Some authors reserve the term dysmegalopsia to describe objects that are perceived to be larger (or smaller) on one side than the other (Sims, 2003), while others use the term generically to describe any change in perceived size (Hamilton, 1974). Others use the term metamorphosia rather than dysmegalopsia to describe objects that are irregular in shape. Dysmegalopsia can result from retinal disease, disorders of accommodation and convergence but most commonly from temporal and parietal lobe lesions. Rarely, it can be associated with schizophrenia. In oedema of the retina visual elements are separated so that the image falls on what is functionally a smaller part of the retina than usual. This gives rise to micropsia. Scarring of the retina with retraction naturally produces macropsia, but as the distortion produced by scarring is usually irregular, metamorphopsia is more likely to result. Complete paralysis of accommodation or overactivity of accommodation during near vision is likely to cause macropsia, while partial paralysis of accommodation will lead to the experience during near vision that the object is very near, i.e. micropsia will occur. If accommodation is normal but convergence is weakened, macropsia occurs and vice versa. Despite the fact that disorders of accommodation and convergence can cause dysmegalopsia, it is not common to meet cases in which the visual disorder is the result of a failure of these peripheral mechanisms. Occasionally dysmegalopsia may occur in poisoning with atropine or hyoscine. Although hypoxia and rapid acceleration of the body can disturb accommodation and convergence, dysmegalopsia is rare among high-altitude pilots. Sometimes the nerves controlling accommodation are affected by conditions such as 15 FISH’S Clinical psychopathology chronic arachnoiditis and this may give rise to dysmegalopsia. However, it is more common in central lesions, mainly those affecting the posterior temporal lobe, and macropsia, micropsia or irregular distortions may occur either during the aura or in the course of the fit itself. Distortions of the experience of time From the psychopathological point of view there are two varieties of time: physical and personal, the latter being determined by personal judgement of the passage of time. It is the latter that is affected by psychiatric disorders. We are all aware of the influence of mood on the passage of time, so that when we are happy ‘time flies’, and when we are sad it passes more slowly. In severe depression the patient may feel that time passes very slowly and even stands still. Slowing down of time is most marked in those with psychotic depressive symptoms. By contrast the manic patient feels that time speeds by and that the days are not long enough to do everything. Some patients with schizophrenia believe that time moves in fits and starts, and may have a delusional elaboration that clocks are being interfered with. In acute organic states, disorders of personal time are shown in temporal disorientation and in milder forms there may be an overestimation of the progress of time. Some patients with temporal lobe lesions may complain that time either passes slowly or quickly. In recent years there is some evidence to suggest that patients with schizophrenia have abnormalities of time judgement, estimating intervals to be less than they are. Age disorientation is another feature present in patients with chronic schizophrenia, noted even in the absence of any other features of confusion (Tapp et al, 1993; Manschreck et al, 2000). Sensory deceptions These can be divided into illusions, which are misinterpretations of stimuli arising from an external object, and hallucinations, which are perceptions without an adequate external stimulus. Illusions In illusions, stimuli from a perceived object are combined with a mental image to produce a false perception. It is unfortunate that the word ‘illusion’ is also used for perceptions that do not agree with the physical stimuli, such as the Muller-Lyer illusion in which two lines of equal length can be made to appear unequal depending on the direction of the arrowheads at the end of each respectively. Illusions in themselves are not indicative of psychopathology since they can occur in the absence of psychiatric disorder, for example the person walking along a dark road may misinterpret innocuous shadows as threatening attackers. Illusions can occur in delirium when the perceptual threshold is raised and an anxious and bewildered patient misinterprets stimuli. While visual illusions are the most common, 16  Disorders of perception they can occur in any modality. For example, auditory illusions may occur when a person hears words in a conversation that resemble their own name and they believe they are being talked about. At times it is difficult to be certain that the patient is describing an illusion or whether he is actually hearing hallucinatory voices talking about him and attributing them to real people in his environment. The classic psychiatrists described fantastic illusions in which patients saw extraordinary modifications to their environment. One had a patient who looked in the mirror and instead of seeing his own head saw that of a pig. Fish (1974) had a patient who insisted that during an interview he saw the psychiatrist’s head change into that of a rabbit. This patient was given to exaggeration and confabulation. He would also invent non-existent puppies and tell other patients not to tread on them. However, fantastic illusions belong more in the worlds of fiction than in the realm of psychiatry (Hamilton, 1974). Three types of illusion are described (Sims, 2003) as follows: Completion illusions: these depend on inattention such as misreading words in newspapers or missing misprints because we read the word as if it were complete. Alternatively, if we see faded letters we may misread the word on the basis of our previous experience, our interests etc., for example, to the person with an interest in reading, the word ‘–ook’ might be misread as ‘book’ even though the faded letter was an ‘l’. Affect illusions: these arise in the context of a particular mood state. For example, a bereaved person may momentarily believe they ‘see’ the deceased person, or the delirious person in a perplexed and bewildered state may perceive the innocent gestures of others as threatening. In severe depression when delusions of guilt are present the person, believing that he is wicked, may also say that he hears people talking about killing him when he is in the company of others. In these circumstances it is difficult to know if he is experiencing illusions or hearing hallucinatory voices talking about him and attributing them to those around him. Pareidolia: this is an interesting type of illusion, in which vivid illusions occur without the patient making any effort. These illusions are the result of excessive fantasy thinking and a vivid visual imagery. They cannot therefore be explained as the result of affect or mind-set, so that they differ from the ordinary illusion. Pareidolias occur when the subject sees vivid pictures in fire or in clouds, without any conscious effort on his part and sometimes even against his will. Illusions have to be distinguished from intellectual misunderstanding and the latter is usually obvious. Thus when someone says that a piece of rock is a precious stone this may be a misunderstanding based on lack of knowledge. The distinction between an illusion and a functional hallucination (see p. 26) may be more difficult. Both occur in response to an environmental stimulus but in a functional hallucination both the stimulus and the 17 FISH’S Clinical psychopathology hallucination are perceived by the patient simultaneously, and can be identified as separate and not as a transformation of the stimulus. This contrasts with an illusion in which the stimulus from the environment changes but forms an essential and integral part of the new perception. Trailing phenomena, although not strictly illusions, are perceptual abnormalities in which moving objects are seen as a series of discreet and discontinuous images. They are associated with hallucinogenic drugs. Hallucinations Definitions The definition of a hallucination as ‘a perception without an object’ has the advantage of being simple and to the point but is does not quite cover functional hallucinations. To cover these and to exclude dreams Jaspers suggested the following definition ‘a false perception which is not a sensory distortion or a misinterpretation, but which occurs at the same time as real perceptions’. SCAN (World Health Organization, 1998) defines hallucinations as ‘false perceptions’. What distinguishes hallucinations from true perceptions is that they come from ‘within’, although the subject reacts to them as if they were true perceptions coming from ‘without’. This distinguishes them from vivid mental images that also come from within but are recognised as such. As with all abnormal mental phenomena, it is not possible to make an absolute distinction as the individual with eidetic imagery will examine his images as if they were external objects and some patients have sufficient insight to recognise that their hallucinations are not truly objective. A great deal of discussion has raged about the concept of the ‘pseudo- hallucination’. Most of the statements are derived from the work of Jaspers (1962), who, first of all, distinguished between true perceptions and mental images. Perceptions are substantial; appear in objective space; are clearly delineated, constant and independent of the will; and their sensory elements are full and fresh. Mental images are incomplete; are not clearly delineated; are dependent on the will; exist in subjective space; are inconstant and have to be recreated. Pseudo-hallucinations are a type of mental image that, although clear and vivid, lack the substantiality of perceptions; they are seen in full consciousness, known to be not real perceptions and are located not in objective space but in subjective space (for example, inside the head). Like true hallucinations they are involuntary. In his book General Psychopathology Jaspers (1962) gives two examples, one of a patient who had taken opium, making it unlikely therefore that the pseudo-hallucination appeared in clear consciousness. The second concerned a patient with a chronic psychotic illness who himself distinguished between hallucinatory voices in objective space and voices which he heard inwardly (pseudo- hallucinations). Pseudo-hallucinations can be identified in the auditory, tactile or visual modalities. 18  Disorders of perception The confusion over the meaning of ‘pseudo-hallucination’ stems from two different approaches to definition; one based on insight (Hare, 1973) and the other, as exemplified by Jaspers (1962), based on whether the image lies in inner or outer perceptual space. Jaspers believed that pseudo-hallucinations are variants of fantasy/mental imagery and, thus not carrying the same diagnostic implications, are true hallucinations. Hare argued that since insight often fluctuates and at times is partial, it was more profitable to think in terms of degree of insight. This, however, renders the concept of pseudo- hallucinations largely superfluous. SCAN (World Health Organization, 1998) does not use the term pseudo-hallucination, but does have an item for rating insight and for whether the experience occurs inside or outside the head. Jaspers insisted that there is no gradual transition between true and pseudo-hallucinations, but Fish, in a previous edition of this book (Hamilton, 1974) disagreed, citing an example of non-substantial hallucinations experienced in outer objective space; patients with substantial hallucinations also experienced these in outer objective space but they recognised these as the result of their active vivid imagination. Thus, Fish argued, there is a continuum from pseudo-hallucinations to hallucinations. This is confirmed by the work of Leff (1968) on sensory deprivation and perception. He found that subjects could not always distinguish between images and hallucinations and concluded that the perceptual experiences of normal people under conditions of sensory deprivation overlap considerably with those of psychiatric patients. The importance of pseudo-hallucinations is that their presence does not necessarily indicate psychopathology, unlike true hallucinations, which are indicative of serious mental illness. Although such a comment is found in many textbooks of psychiatry, its veracity must surely rest with the definition that is adopted, since, as Hare argues, if insight is the criterion and this fluctuates during illness, the meaning and relevance of pseudo-hallucinations becomes redundant. Causes Hallucinations can be the result of intense emotions or psychiatric disorder, suggestion, disorders of sense organs, sensory deprivation and disorders of the central nervous system. Emotion Very depressed patients with delusions of guilt may hear voices reproaching them. These are not the continuous voices of paranoid schizophrenia or organic hallucinosis but tend to be disjointed or fragmentary, uttering single words or short phrases such as ‘rotter’, ‘kill yourself’, etc. The occurrence of continuous persistent hallucinatory voices in severe depression should arouse the suspicion of schizophrenia or some intercurrent physical disease. On the other hand the hallucinations that occur in schizophrenia are often of a persecutory nature and may consist of voices giving a commentary on the person’s actions and discussing him in a hostile manner. 19 FISH’S Clinical psychopathology Suggestion Several experimenters have shown that normal subjects can be persuaded to hallucinate. When asked to walk down a dimly lit corridor and stop when they saw a faint light over the door at the end, most subjects stopped walking at some time during the study saying they could see a light even though none was switched on. Similarly subjects can be persuaded to hallucinate visually or auditorily, either by hypnosis or by brief task-motivating instructions. This latter technique consists in asking the subject to try to hallucinate a tune or an animal and then telling him that much more must be done as most people can hallucinate if they try hard enough. A group in whom suggestion was believed to be relevant to the genesis of hallucinations (Hamilton, 1974) were those with a diagnosis of the so-called ‘hysterical psychosis’. The hallucinations, visual in nature, were said to conform to the patient’s fantasies and cultural background. However, this diagnosis is no longer specifically mentioned, either as a specific category or an inclusion category, in either ICD−10 or DSM−IV and so is only of historical interest. The belief that Ganser syndrome is psychogenic in origin (Ungvari & Mullen, 1997) opens the possibility of the role of suggestion in the genesis of the hallucinations in this condition, although others dispute this and regard it as an organic condition (Latcham et al, 1978). The syndrome is now recognised to occur in a variety of psychiatric disorders, including schizophrenia, dissociative disorder, malingering, organic states, etc. Disorders of a peripheral sense organ Hallucinatory voices may occur in ear disease and visual hallucinations in diseases of the eye, but often there is some disorder of the central nervous system as well. For example, a woman aged 66 suffered from glaucoma and then began to have continuous visual hallucinations. At the time she showed evidence of atherosclerotic dementia and had a focus of abnormal activity in the left posterior temporal lobe. Charles Bonnet syndrome (phantom visual images) is a condition in which complex visual hallucinations occur in the absence of any psychopathology and in clear consciousness. It is associated with either central or peripheral reduction in vision and not surprisingly is most common in the elderly but can occur in younger people also. The hallucinatory episodes are of variable duration and can last for years. The images may be static or in motion and the importance of this diagnosis is as a differential from psychopathological causes of hallucinations. Peripheral lesions of sense organs may play a part in hallucinations in organic states and it has been shown that negative scotomota are to be found in patients with alcohol misuse. Sensory deprivation If all incoming stimuli are reduced to a minimum in a normal subject, they will begin to hallucinate after a few hours. These hallucinations are usually changing visual hallucinations and repetitive words and phrases. It has been suggested that the sensory isolation produced by deafness may cause 20  Disorders of perception paranoid disorders in the deaf (Cooper, 1976). Similarly, sensory deprivation due to the use of protective patches may contribute to the delirium that follows cataract surgery, along with mild cognitive deficits due to ageing. There is an interesting case on record of a patient who had ‘black patch disease’ after an operation and was frightened by the prospect of another operation on her other eye a few years later. She was reassured by a psychiatrist, who saw her before and immediately afterwards and promised to see her whenever requested during the post-operative period. After the second operation she had no hallucinations of any kind. Disorders of the central nervous system Lesions of the diencephalons and the cortex can produce hallucinations that are usually visual but can be auditory. Hypnagogic and hypnopompic hallucinations are special kinds of organic hallucination (see below). Hallucinations of individual senses Before deciding that a patient is hallucinated, the possibility of other explanations must be considered; these are not necessarily of pathological significance. The differential diagnosis of hallucinations includes illusions, pseudo-hallucinations, hypnagogic and hypnopompic images, vivid imagery and normal perceptions. The possibility that the experience is a delusion without a hallucination, although described as if it were a perceptual abnormality, must also be considered, for example ‘people talk about me’ (when in fact the patient does not hear others talking but believes they are doing so). Hearing (auditory) Hallucinatory voices were called ‘phonemes’ by Wernicke in 1900, although this term, a technical one derived from linguistics, is rarely used now. Auditory hallucination may be elementary and unformed, and experienced as simple noises, bells, undifferentiated whispers or voices. Elementary auditory hallucinations can occur in organic states and noises, partly organised as music or completely organised as hallucinatory voices, in schizophrenia. In the latter they may form a part of the basis for the patient’s delusion that they are the victim of persecution or that their thoughts or actions are being controlled. ‘Voices’ are characteristic of schizophrenia and can occur at any stage of the illness. As well as occurring in organic states, such as delirium or dementia, they can occasionally occur in severe depression but they are usually less well formed than those described in schizophrenia. Hallucinatory voices vary in quality, ranging from those that are quite clear and can be ascribed to specific individuals to those that are vague and which the patient cannot describe with any clarity. Patients are often undisturbed by their inability to describe the direction from which the voices come or the sex of the person speaking. This is quite unlike the 21 FISH’S Clinical psychopathology experience of the healthy individual. The voices sometimes give instructions to the patient, who may or may not act upon them; these are termed ‘imperative hallucinations’. In some cases the voices speak about the person in the third person and may give a running commentary on their actions. These are among Schneider’s first-rank symptoms, and although this was one thought to be diagnostic of schizophrenia, this is no longer the case since these symptoms have also been described in mania (Gonzalez-Pinto et al, 2003). Auditory hallucinations may be abusive, neutral or even helpful in tone. At times they may speak incomprehensible nonsense or neologisms. The effect of the voices on the patient’s behaviour is variable. A number of patients (becoming fewer in number with advances in treatment) have continuous hallucinations that do not trouble them. For others the persistence of the hallucinations cuts across all activities so that the patient is seen to be listening and even replying to them at times. Sometimes activity may diminish due to preoccupation with the hallucinations. One type of auditory hallucination is hearing one’s own thoughts spoken aloud and is also one of Schneider’s first-rank symptoms. Known in German as Gedankenlautwerden, it describes hearing one’s thoughts spoken just before or at the same time as they are occurring. Echo de la pensée (French) is the phenomenon of hearing them spoken after the thoughts have occurred. Probably the best English term would be ‘thought echo’ or the alternative and more cumbersome ‘thought sonorisation’. Of note, SCAN classifies thought echo as a disorder of thought (World Health Organization, 1998) rather than as a hallucinatory experience. The patient may also complain that their thoughts are no longer private but are accessible to others. This is known as thought broadcasting or thought diffusion (also a first-rank symptom) and is best classified as a disorder of thought rather than a hallucinatory experience, since there is no necessary implication that thoughts must first be heard. However, there are different definitions of this phenomenon, some of which specify that the thoughts must first be audible, so that Gedankenlautwerden/echo de la pensee are prerequisites to thought broadcast (Pawar & Spence, 2003). Patients explain the origin of the voices in different ways. They may insist that the voices are the result of witchcraft, telepathy, radio, television, and so on. Sometimes they claim that the voices come from within their bodies such as their arms, legs, stomach, etc. For example, one patient heard the voices of two nurses and the Crown Prince of Germany coming from her chest. Some patients hallucinate speech movements and hear speech that comes from their own throat but has no connection with their thinking. One patient complained bitterly of her ‘talky-talky tongue’ because she was continuously auditorily hallucinated and felt speech movements in her tongue. Thus she had both auditory and possibly somatic hallucinations. However, it has been shown that sub-vocal speech movements occur in healthy subjects when they are thinking or reading silently, and it has also been demonstrated that patients hearing voices have slight movements of 22  Disorders of perception the lips, tongue and laryngeal muscles and that there is an increase in the action potentials in the laryngeal muscles. It is perhaps surprising that more patients do not complain of voices coming from their throat or tongue. A few patients deny hearing voices but assert that people are talking about them. Careful investigation of the content and nature of the things that others are alleged to have said may show that the patient has continuous hallucinations and attributes them to real people in the vicinity. As these are often abusive the patient may attack those whom they believe are responsible. A good example of this was a Greek woman who had been a patient in a long-stay ward for many years. She always denied hearing voices but from time to time would make unprovoked attacks on fellow patients. One day she was asked if she would like some Greek newspapers or visits from someone who spoke Greek. She said that this was not necessary because everybody in the hospital spoke Greek. It became obvious that she heard continuous voices in Greek that she attributed to real people, and that her seemingly motiveless attacks were prompted by this. This clearly represented a delusional elaboration of a hallucinatory experience. Vision These may be elementary in the form of flashes of light, partly organised in the form of patterns, or completely organised in the form of visions of people, objects or animals. Figures of living things and inanimate objects may appear against the normally perceived environment or scenic hallucinations can occur in which whole scenes are hallucinated rather like a cinema film. All varieties of visual hallucination are found in acute organic states but small animals and insects are most often hallucinated in delirium. One patient in delirium tremens described mice carrying suitcases on their backs as they boarded a flight to Lourdes. These hallucinations are usually associated with fear and terror. Patients with delirium tremens are extremely suggestible so that one may be able to persuade the patient to read a blank sheet of paper; one investigator produced a disc of light by pressing on the patient’s eyeball and persuaded him that he could see a dog. Scenic hallucinations are common in psychiatric disorders associated with epilepsy and these patients may also have visions of fire and religious scenes such as the Crucifixion. Often, visual hallucinations are isolated and do not have any accompanying voices. Sometimes, however, visual and auditory hallucinations co-occur to form a coherent whole. Patients with temporal-lobe epilepsy may have combined auditory and visual hallucinations and some patients with schizophrenia of late onset (especially when the illness is protracted) may see and hear people being tortured, murdered and mutilated. In some patients, micropsia affects visual hallucinations so that they see tiny people or objects, so-called Lilliputian hallucinations. Unlike the usual organic visual hallucinations, these are accompanied by pleasure and amusement. For example, one patient with delirium tremens was very 23 FISH’S Clinical psychopathology pleased when she saw a tiny German band playing on her counterpane. When these occur in delirium tremens the patient exhibits a combination of child-like pleasure and terror. Visual hallucinations are more common in acute organic states with clouding of consciousness than in functional psychosis. The disturbance of consciousness makes it difficult for the patient to distinguish between mental images and perceptions, although this is sometimes possible. Visual hallucinations are extremely rare in schizophrenia, so much so that they should raise a doubt about the diagnosis. Some patients with schizophrenia describe visions and these appear to be pseudo-hallucinations, but on occasion others will insist that their hallucinations are substantial. Occasionally visual hallucinations occur in the absence of any psychopathology or brain disease and Charles Bonnet syndrome must then be considered as the most likely differential diagnosis. Smell (olfactory) Hallucinations of odour can occur in schizophrenia and organic states and, uncommonly, in depressive psychosis. It may be difficult to be sure if there is a hallucination or an illusion. There may also be a problem distinguishing olfactory hallucination from delusion since there are some people who insist that they emit a smell. It is important to ascertain if they actually smell this odour, since many seem to base their belief on the behaviour of other people who, they say, wrinkle their noses or make reference to the smell. Some patients with schizophrenia claim that they smell gas and that their enemies are poisoning them by pumping gas into the room. Episodes of temporal lobe disturbance are often ushered in by an aura involving an unpleasant odour such as burning paint or rubber. At times, the hallucination may occur without any fit so that the patient then complains of a strange smell in the house. For example one patient with a temporal lobe focus had no fits but, from time to time, would complain of a smell of stale cabbage water in the house and would turn the house upside down trying to locate the offending object. Sometimes the smell may be pleasant, for example when some religious people can smell roses around certain saints; this is known as the Padre Pio phenomenon. Taste (gustatory) Hallucinations of taste occur in schizophrenia and acute organic states but it is not always easy to know whether the patient actually tastes something odd or if it is a delusional explanation of the effect of feeling strangely changed. Depressed patients often describe a loss of taste or state that all food tastes the same. Touch (tactile) This may take the form of small animals crawling over the body, so-called formication. This is not uncommon in acute organic states. In cocaine psychosis this type of hallucination commonly occurs together with delusions of persecution and is known as the ‘cocaine bug’. Some patients 24  Disorders of perception experience the feeling of cold winds blowing on them, sensations of heat, electrical shocks and sexual sensations, and the patient is convinced that these are produced by outside agencies. In the absence of coarse brain disease, the most likely diagnosis is schizophrenia. Indeed, Sims (2003) points out that there is almost always a concomitant delusional elaboration of tactile hallucinatory experiences. Sexual hallucinations can occur in both acute and chronic schizophrenia, for example, one patient complained that she could feel the penis of her son’s employer in her vagina no matter what she did and although she could not see the man she was certain of this. Sims (2003) classifies tactile hallucinations into three main types: superficial, kinaestethic and visceral (see below). Sims further divides superficial hallucinations, which affect the skin, into four types: thermic (e.g. a cold wind blowing across the face), haptic (e.g. feeling a hand brushing against the skin), hygric (e.g. feeling fluid such as water running from the head into the stomach) and paraestethic (pins and needles), although the latter most often have an organic origin. Kinaestethic hallucinations affect the muscles and joints and the patient feels that their limbs are being twisted, pulled or moved. They occur in schizophrenia, where they can be distinguished from delusions of passivity by the presence of definite sensations. Vestibular sensations such as sinking in the bed or flying through the air can also be hallucinated and are best regarded as a variant of kinaestethic hallucinations and occur in organic states, most commonly delirium tremens. Kinaestethic or vestibular perceptions occur in organic states such as alcohol intoxication and during benzodiazepine withdrawal and may also occur in the absence of any abnormality, for example after a week’s sailing an undulating feeling may persist for a few days. Pain and deep sensation These are termed visceral hallucinations by Sims (2003). Some patients with chronic schizophrenia may complain of twisting and tearing pains. These may be very bizarre when the patient complains that his organs are being torn out or the flesh ripped away from his body. For example, a patient described sensations in his brain as layers of tissue were being peeled off so as to bring to completion the battle between good and evil. An interesting and unusual variety of hallucinosis is delusional zoopathy. This may take the form of a delusional belief that there is an animal crawling about in the body. There is also a hallucinatory component since the patient feels it (hallucination) and can describe it in detail. In some cases this is associated with an organic disorder, as in the patient who said he was infested with an animal several centimetres long that he could feel in his stomach. He eventually died and at post mortem was found to have a tumour invading the thalamus. The sense of ‘presence’ It is difficult to classify an abnormal sense of presence because, although it is not strictly a sense deception, it cannot be regarded as a delusion either. 25 FISH’S Clinical psychopathology Most normal people have from time to time the sense that someone is present when they are alone, on a dark street or climbing a dimly lit staircase. Often the feeling is that there is somebody behind them. Usually this is dismissed as imagination but nevertheless they look behind them to be certain. However, sometimes there is the feeling that someone is present, whom they cannot see, and may or may not be able to name. For example, Saint Teresa of Avila wrote, ‘One day when I was at prayer – it was the feast-day of the glorious Saint Peter – I saw Christ at my side – or, to put it better, I was conscious of Him, for I saw nothing with the eyes of the body or the eyes of the soul. He seemed quite close to me, and I saw that it was He’. She says a little later, ‘But I felt most clearly that he was all the time on my right, and was a witness of everything that I was doing’. This experience was probably the result of lack of sleep, hunger and religious enthusiasm. It may also have been a metaphorical way of describing closeness to God/Christ. One patient described a presence over her right shoulder that followed her from room to room and even though she knew that there was nobody there, the feeling was intense and distressing, so much so that at times she hid under the bedclothes to escape. The sense of a presence can occur in healthy people as well as in organic states, schizophrenia or hysteria and the patient described above also had a diagnosis of borderline personality disorder. Hallucinatory syndromes Hallucinatory syndromes, also termed hallucinosis, refer to those disorders in which there are persistent hallucinations in any sensory modality in the absence of other psychotic features. The main hallucinatory syndromes that are identified are: alcoholic hallucinosis; these hallucinations are usually auditory and occur during periods of relative abstinence. They may be threatening or reproachful, although some patients report benign voices. Sensorium is clear and hallucinations rarely persist longer than 1 week and are associated with long-standing alcohol misuse organic hallucinosis; these are present in 20−30% of patients with dementia, especially of the Alzheimer type, and are most commonly auditory or visual. There is also disorientation and memory is impaired. Special kinds of hallucination Functional hallucinations An auditory stimulus causes a hallucination but the stimulus is experienced as well as the hallucination. In other words the hallucination requires the presence of another real sensation. For example, a patient with schizophrenia first heard the voice of God as her clock ticked; later she heard voices coming from the running tap and voices coming from the chirruping of the birds. 26  Disorders of perception So both the noises and the voices were audible. Patients can distinguish both features from each other and crucially, the hallucination does not occur without the stimulus. Some patients who discover that noises induce hallucinatory voices put plugs in their ears to reduce the intensity of the stimulus and hence the hallucinations. One patient recently described that she saw the mouths of her collection of dolls moving. The perception of dolls was necessary to produce the hallucination but the movement of their mouths was distinct and separate and did not represent a transformation of that perception, thus making this a functional hallucination rather than an illusion. Functional hallucinations are not uncommon in chronic schizophrenia and they may be mistaken for illusions. Reflex hallucinations Synaesthesia is the experience of a stimulus in one sense modality producing a sensory experience in another. For example, the feeling of cold in one’s spine on hearing a fingernail scratch a blackboard. One patient described hearing his own reflection and said that when attempting to carry out some action he could hear himself doing so. Although rare, synaesthesia can occur under the influence of hallucinogenic drugs such as LSD or mescaline when the subject might describe feeling, tasting and hearing flowers simultaneously. Reflex hallucinations are a morbid form of synaesthesia. In a reflex hallucination a stimulus in one sensory field produces a hallucination in another. For example, a patient felt a pain in her head (somatic hallucination) when she heard other people sneeze (the stimulus) and was convinced that sneezing caused the pain. Extracampine hallucinations The patient has a hallucination that is outside the limits of the sensory field. For example, a patient sees somebody standing behind them when they are looking straight ahead or hear voices talking in London when they are in Liverpool. These hallucinations can occur in healthy people as hypnagogic hallucinations but also in schizophrenia or organic conditions, including epilepsy. Autoscopy or phantom mirror-image Autoscopy, also called phantom mirror-image, is the experience of seeing oneself and knowing that it is oneself. It is not just a visual hallucination because kinaestethic and somatic sensation must also be present to give the subject the impression that the hallucination is oneself. This symptom can occur in healthy subjects when they are emotionally upset or when exhausted. In these cases there is some change in the state of consciousness. Occasionally autoscopy is a hysterical symptom. Occasionally patients with schizophrenia have autoscopic hallucinations but they are more common in acute and sub-acute delirious states. The organic states most associated with autoscopy are epilepsy, focal lesions affecting the parieto−occipital region and toxic infective states whose effect is greatest in the basal regions of the brain. The fact that autoscopy is often associated with disorders of 27 FISH’S Clinical psychopathology the parietal lobe due to cerebrovascular disorders or severe infectious diseases accounts for the German folklore belief that when someone sees their double or Doppelganger it indicates that they are about to die. Sometimes these may be pseudo-hallucinations occurring in internal space and described by the patient as being ‘in the mind’s eye’. A few patients suffering from organic states look in the mirror and see no image, known as negative autoscopy. Some psychiatrists describe internal autoscopy in which the subject sees their own internal organs, although this is rare. The description of the internal organs is that which would be expected from a layperson, with a crude knowledge of anatomy. Hypnagogic and hypnopompic hallucinations First mentioned by Aristotle, these hallucinations occur when the subject is falling asleep or waking up respectively. It has been suggested that hypnopompic hallucinations are often hypnagogic experiences that occur in the morning when the subject is waking and dosing-off again, so that they actually happen when the subject is falling asleep. The term ‘hypnopompic’ should be reserved for those hallucinatory experiences that persist from sleep when the eyes are open. Hypnagogic hallucinations occur during drowsiness, are discontinuous, appear to force themselves on the subject and do not form part of an experience in which the subject participates as they do in a dream. They are about three times more common (described by 37% of the adult population) than hypnopompic hallucinations, although the latter are a better indicator of narcolepsy. The subject believes that the hallucination has woken them up (for example, hearing the telephone ring even though it has not) and although the auditory modality is the most common it can also be visual, kinaestethic or tactile and is sudden in occurrence. Subjects describing hypnagogic hallucinations often assert that they are fully awake. This is not so and electroencephalogram (EEG) records show that there is a low of alpha rhythm at the time of the hallucination. Hypnagogic visual hallucinations may be geometrical designs, abstract shapes, faces, figures or scenes from nature. Auditory hallucinations may be animal noises, music or voices. One of the most common is that of hearing one’s name called or a voice saying a sentence or phrase that has no discoverable meaning. In a subject deprived of sleep a hypnagogic state may occur, in which case there are hallucinatory voices, visual hallucinations, ideas of reference and no insight into the morbid phenomena. It resolves once the subject has a good sleep. The importance of hypnagogic and hypnopompic phenomena is to recognise that they are not indicative of any psychopathology even though they are true hallucinatory experiences (Ohayon et al, 1996). They also occur in narcolepsy. Organic hallucinations Organic hallucinations can occur in any sensory modality and they may occur in a variety of neurological and psychiatric disorders. The focus in this section will be on the psychiatric causes. 28  Disorders of perception Organic visual hallucinations occur in eye disorders as well as in disorders of the central nervous system and lesions of the optic tract. Complex scenic hallucinations occur in temporal lobe lesions. Charles Bonnet syndrome consists of visual hallucinations in the absence of any other psychopathology, although impaired vision is present. All the dementias as well as delirium and substance abuse are associated with visual hallucinations. The phantom limb is the most common organic somatic hallucination of psychiatric origin. In this case the patient feels that they have a limb from which in fact they are not receiving any sensations either because it has been amputated or because the sensory pathways from it have been destroyed. In rare cases with thalamo−parietal lesions the patient describes a third limb. In most phantom limbs the phenomenon is produced by peripheral and central disorders. Phantom limb occurs in about 95% of all amputations after the age of 6 years. Occasionally a phantom limb develops after a lesion of the peripheral nerve or the medulla or spinal cord. The phantom limb does not necessarily correspond to the previous image of the limb in that it may be shorter or consist only of the distal portion so that the phantom hand arises from the shoulder. If there is clouding of consciousness, the patient may be deluded that the limb is real. Equivalent perceptions of phantom organs may also occur after other surgical procedures such as mastectomy, enuleation of the eye, removal of the larynx or the construction of a colostomy. The person is aware of the existence of the organ or limb and describes pain or paraesthesia in the space occupied by the phantom organ and this persists in a minority of patients. When the experience is related to a limb the perception shrinks over time, with distal parts disappearing more quickly than those that are proximal. Lesions of the parietal lobe can also produce somatic hallucinations with distortion or splitting-off of body parts. Lesions of the temporal lobe are associated with multi-sensory hallucinations but they do not include somatic hallucinations, which is to be expected because the somatic sensory area is separated from the temporal lobe by the Sylvian fissure. The patient’s attitude to hallucinations In organic hallucinations the patient is usually terrified by the visual hallucinations and may try desperately to get away from them. Most delirious patients feel threatened and are generally suspicious. The combination of the persecuted attitude and the visual hallucinations may lead to resistance to all nursing care and to impulsive attempts to escape from the threatening situation, so that they may jump out of windows and jeopardise their lives. The exception is Lilliputian hallucinations, which are usually regarded with amusement by the patient and may be watched with delight. Patients with depression often hear disjointed voices abusing them or telling them to kill themselves. They are not terrified by the voices, as they believe they are wicked and deserve to hear what is being said of them. The instructions to kill themselves are not frightening since they may have thought of this for some time anyway. 29 FISH’S Clinical psychopathology The onset of voices in acute schizophrenia is often very frightening and the patient at times may attack the person he believes to be their source. Those with chronic schizophrenia on the other hand are often not troubled by the voices and may treat them as old friends, but a few patients complain bitterly about them. Those patients who are knowledgeable about their illness or who have insight into it may deny hallucinations, since they know this is an abnormal feature. Sometimes it is obvious that a patient is hallucinating if they stop talking and appear to be listening to something else or if they attempt to reply to the voices. Body image distortions Hyperschemazia, or the perceived magnification of body parts, can occur with a variety of organic and psychiatric conditions. When part of the body is painful it may feel larger than normal. When there is partial paralysis of a limb, the affected segment feels heavy and large, as in Brown–Sequard paralysis when the side with the extrapyramidal signs is hyperschematic, in peripheral vascular disease, in multiple sclerosis and following thrombosis of the posterior inferior cerebellar artery. In the latter two the hyperschemazia is unilateral. It may also occur in non-organic conditions such as hypochondriasis, depersonalisation and conversions disorder, and the distortion of image that is associated with feelings of fatness in anorexia nervosa is probably the best known. The perception of body parts as absent or diminished is known as aschemazia or hyposchemazia respectively and is most likely to occur in parietal lobe lesions such as in thrombosis of the right middle cerebral artery, following transaction of the spinal cord or in health volunteers when underwater. Hyposchemazia must be distinguished from nihilistic delusions. Sims’ (2003) comprehensive description of body image distortions cites Critchley (1950) as describing a patient with a parietal lobe infarct who had complex hyper- and hyposchemazia, ‘It felt as if I was missing one side of my body (the left), but it also felt as if the dummy side was lined with a piece of iron so heavy that I could not move it … I even fancied my head to be narrow, but the left side from the centre felt heavy, as if filled with bricks’. Koro or the belief that the penis is shrinking and will retract into the abdomen and cause death is found in South-East Asia and is thought to be due to a faulty understanding of anatomy. The diagnostic equivalent is probably anxiety disorder. Paraschemazia or distortion of body image is described as a feeling that parts of the body are distorted or twisted or separated from the rest of the body and can occur in association with hallucinogenic use, with an epileptic aura and with migraine on rare occasions. Hemisomatognosia is a unilateral lack of body image in which the person behaves as if one side of the body is missing and it occurs in migraine or during an epileptic aura. Anosognosia is ‘denial of illness’ and one study (Cutting, 1