Shorter Oxford Textbook of Psychiatry SEVENTH EDITION PDF

i Shorter Oxford Textbook of Psychiatry ii iii Shorter Oxford Textbook of Psychiatry SEVENTH EDITION Paul Harrison Philip Cowen Tom Burns Mina Fazel 1 iv 1 Great Clarendon Street, Oxford, OX2 6DP, United Kingdom...

i Shorter Oxford Textbook of Psychiatry ii iii Shorter Oxford Textbook of Psychiatry SEVENTH EDITION Paul Harrison Philip Cowen Tom Burns Mina Fazel 1 iv 1 Great Clarendon Street, Oxford, OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries © Oxford University Press 2018 The moral rights of the authors have been asserted First Edition published in 1983 Second Edition published in 1989 Third Edition published in 1996 Fourth Edition published in 2001 Fifth Edition published in 2006 Sixth Edition published in 2012 Seventh Edition published in 2018 Impression: 1 All rights reserved. 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These devel- chiatrist, and the first woman, to be an author of the opments have been incorporated into this substan- Shorter Oxford Textbook of Psychiatry since its inception. tially rewritten edition, which includes a new chapter We are delighted that both these unfortunate omissions on global mental health, and division of mood disor- have been corrected, and this edition benefits greatly ders into separate chapters on depression and bipolar from her contributions. disorder. We thank Sarah Atkinson, Linda Carter, and Sue As in previous editions, we have sought to provide Woods-Gantz for secretarial assistance. We are very information in a format, and at a level of detail, to grateful to Charlotte Allan, Chris Bass, Christopher assist those training in psychiatry. We hope the book Fairburn, and Kate Saunders for their expert advice and will also continue to be useful to medical students and helpful comments. other health professionals, including those working in PH primary care, community health, and the many profes- PC sions and groups contributing to multidisciplinary men- TB tal health care. More detailed information can be found MF in the companion reference textbook, the New Oxford Oxford, March 2017 vi vi Contents 1 Signs and symptoms of psychiatric disorders 1 2 Classification 21 3 Assessment 35 4 Ethics and civil law 71 5 Aetiology 87 6 Evidence-based approaches to psychiatry 119 7 Reactions to stressful experiences 135 8 Anxiety and obsessive–compulsive disorders 161 9 Depression 193 10 Bipolar disorder 233 11 Schizophrenia 253 12 Paranoid symptoms and syndromes 299 13 Eating, sleep, and sexual disorders 313 14 Dementia, delirium, and other neuropsychiatric disorders 345 15 Personality and personality disorder 391 16 Child psychiatry 415 17 Intellectual disability (mental retardation) 485 18 Forensic psychiatry 513 19 Psychiatry of the elderly 539 20 The misuse of alcohol and drugs 563 21 Suicide and deliberate self-harm 609 22 Psychiatry and medicine 631 23 Global psychiatry 675 24 Psychological treatments 681 25 Drugs and other physical treatments 709 26 Psychiatric services 777 References 801 Index 859 vi 1 CHAPTER 1 Signs and symptoms of psychiatric disorders Introduction 1 Descriptions of symptoms General issues 2 and signs 4 Introduction Psychiatrists require two distinct capacities. One is the psychiatric patients. In other words, he decides whether capacity to collect clinical data objectively and accur- the clinical features conform to a recognized syndrome. ately, and to organize and communicate the data in a He does this by combining observations about the systematic and balanced way. The other is the capacity patient’s present state with information about the history for intuitive understanding of each patient as an indi- of the condition. The value of identifying a syndrome is vidual. When the psychiatrist exercises the first cap- that it helps to predict prognosis and to select an effect- acity, he draws on his skills and knowledge of clinical ive treatment. It does this by directing the psychiatrist phenomena; when he exercises the second capacity, to the relevant body of accumulated knowledge about he draws on his knowledge of human nature and his the causes, treatment, and outcome in similar patients. experience with former patients to gain insights into the Diagnosis and classification are discussed in the next patient he is now seeing. Both capacities can be devel- chapter, and also in each of the chapters dealing with the oped by listening to patients, and by learning from more various psychiatric disorders. Chapter 3 discusses how to experienced psychiatrists. A textbook can provide the elicit and interpret the symptoms described in this chap- information and describe the procedures necessary to ter, and how to integrate the information to arrive at a develop the first capacity. The focus of the chapter on syndromal diagnosis, since this in turn is the basis for a the first capacity does not imply that intuitive under- rational approach to management and prognosis. standing is unimportant, but simply that it cannot be As much of the present chapter consists of defini- learned directly or solely from a textbook. tions and descriptions of symptoms and signs, it may Skill in examining patients depends on a sound know- be less easy to read than those that follow. It is sug- ledge of how symptoms and signs are defined. Without gested that the reader might approach it in two stages. such knowledge, the psychiatrist is liable to misclassify The first reading would be applied to the introductory phenomena and thereby make inaccurate diagnoses. For sections and to a general understanding of the more this reason, this chapter is concerned with the defin- frequently observed phenomena. The second reading ition of the key symptoms and signs of psychiatric dis- would focus on details of definition and the less com- orders. Having elicited a patient’s symptoms and signs, mon symptoms and signs, and might be done best in the psychiatrist needs to decide how far these phenom- conjunction with an opportunity to interview a patient ena fall into a pattern that has been observed in other exhibiting these. 2 2 Chapter 1 Signs and symptoms of psychiatric disorders General issues Before individual phenomena are described, some gen- of mental processes of which the patient is unaware (i.e. eral issues will be considered concerning the methods they are ‘unconscious’). For example, Freud explained of studying symptoms and signs, and the terms that are persecutory delusions as being evidence, in the con- used to describe them. scious mind, of activities in the unconscious mind, including the mechanisms of repression and projection (see p. 277). Psychopathology Subsequently, experimental psychopathology has The study of abnormal states of mind is known as psycho- focused on empirically measurable and verifiable con- pathology. The term embraces two distinct approaches to scious psychological processes, using experimental the subject—descriptive and experimental. This chapter is methods such as cognitive and behavioural psych- concerned almost exclusively with the former; the latter ology and functional brain imaging. For example, there is introduced here but is discussed in later chapters. are cognitive theories of the origin of delusions, panic attacks, and depression. Although experimental psycho- Descriptive psychopathology pathology is concerned with the causes of symptoms, Descriptive psychopathology is the objective description of it is usually conducted in the context of the syndromes abnormal states of mind avoiding, as far as possible, pre- in which the symptoms occur. Thus its findings are dis- conceived ideas or theories, and limited to the descrip- cussed in the chapter covering the disorder in question. tion of conscious experiences and observable behaviour. It is sometimes also called phenomenology or phenomeno- logical psychopathology, although the terms are not in Terms and concepts used in fact synonymous, and phenomenology has additional descriptive psychopathology meanings (Berrios, 1992). Likewise, descriptive psycho- pathology is more than just symptomatology (Stanghellini Symptoms and signs and Broome, 2014). In general medicine there is a clear definition of, and The aim of descriptive psychopathology is to eluci- separation between, a symptom and a sign. In psych- date the essential qualities of morbid mental experiences iatry the situation is different. There are few ‘signs’ in and to understand each patient’s experience of illness. It the medical sense (apart from the motor abnormalities therefore requires the ability to elicit, identify, and inter- of catatonic schizophrenia or the physical manifesta- pret the symptoms of psychiatric disorders, and as such tions of anorexia nervosa), with most diagnostic infor- is a key element of clinical practice; indeed, it has been mation coming from the history and observations of described as ‘the fundamental professional skill of the the patient’s appearance and behaviour. Use of the word psychiatrist’. ‘sign’ in psychiatry is therefore less clear, and two dif- The most important exponent of descriptive psycho- ferent uses may be encountered. First, it may refer to pathology was the German psychiatrist and philosopher, a feature noted by the observer rather than something Karl Jaspers. His classic work, Allgemeine Psychopathologie spoken by the patient (e.g. a patient who appears to be (General Psychopathology), first published in 1913, still responding to a hallucination). Secondly, it may refer provides the most complete account of the subject, and to a group of symptoms that the observer interprets in the seventh edition is available in an English transla- aggregation as a sign of a particular disorder. In prac- tion (Jaspers, 1963). A briefer introduction can be found tice, the phrase ‘symptoms and signs’ is often used in Jaspers (1968), and Oyebode (2014) has provided interchangeably with ‘symptoms’ (as we have done in a highly readable contemporary text on descriptive this chapter) to refer collectively to the phenomena of psychopathology. psychiatric disorders, without a clear distinction being drawn between the two words. Experimental psychopathology This approach seeks to explain abnormal mental phe- Subjective and objective nomena, as well as to describe them. One of the first In general medicine, the terms subjective and objective are attempts was psychodynamic psychopathology, originating used as counterparts of symptoms and signs, respectively, in Freud’s psychoanalytic investigations (see p. 91). It with ‘objective’ being defined as something observed explains the causes of abnormal mental events in terms directly by the doctor (e.g. meningism, jaundice)—even 3 General issues 3 though, strictly speaking, it is a subjective judgement on content, not the form, that is of concern to the patient, his part as to what has been observed. whose priority will be to discuss the persecution and its In psychiatry, the terms have broadly similar mean- implications, and who may be irritated by what seem ings as they do in medicine, although with a blurring to be irrelevant questions about the form of the belief. between them, just as there is for symptoms and signs. The psychiatrist must be sensitive to this difference in ‘Objective’ refers to features observed during an inter- emphasis between the two parties. view (i.e. the patient’s appearance and behaviour). The term is usually used when the psychiatrist wants to com- Primary and secondary pare this with the patient’s description of symptoms. For With regard to symptoms, the terms primary and sec- example, in evaluation of depression, complaints of low ondary are often used, but unfortunately with two dif- mood and tearfulness are subjective features, whereas ferent meanings. The first meaning is temporal, simply observations of poor eye contact, psychomotor retarda- referring to which occurred first. The second meaning tion, and crying are objective ones. If both are present, is causal, whereby primary means ‘arising directly from the psychiatrist might record ‘subjective and objective the pathological process’, and secondary means ‘arising evidence of depression’, with the combination provid- as a reaction to a primary symptom’. The two meanings ing stronger evidence than either alone. However, if the often coincide, as symptoms that arise directly from patient’s behaviour and manner in the interview appear the pathological process usually appear first. However, entirely normal, he records ‘not objectively depressed’, although subsequent symptoms are often a reaction to despite the subjective complaints. It is then incumbent the first symptoms, they are not always of this kind, for on the psychiatrist to explore the reasons for the dis- they too may arise directly from the pathological pro- crepancy and to decide what diagnostic conclusions cess. The terms primary and secondary are used more he should draw. As a rule, objective signs are accorded often in the temporal sense because this usage does not greater weight. Thus he may diagnose a depressive dis- involve an inference about causality. However, many order if there is sufficient evidence of this kind, even if patients cannot say in what order their symptoms the patient denies the subjective experience of feeling appeared. In such cases, when it seems likely that one depressed. Conversely, the psychiatrist may question the symptom is a reaction to another—for example, that significance of complaints of low mood, however promi- a delusion of being followed by persecutors is a reac- nent, if there are none of the objective features associ- tion to hearing accusing voices—it is described as sec- ated with the diagnosis. ondary (using the word in the causal sense). The terms primary and secondary are also used in descriptions of Form and content syndromes. When psychiatric symptoms are described, it is useful to distinguish between form and content, a distinction Understanding and explanation that is best explained by an example. If a patient says Jaspers (1913) contrasted two forms of understanding that, when he is alone, he hears voices calling him a when applied to symptoms. The first, called Verstehen homosexual, the form of the experience is an auditory (‘understanding’), is the attempt to appreciate the hallucination (see below), whereas the content is the patient’s subjective experience: what does it feel like? statement that he is homosexual. Another patient might This important skill requires intuition and empathy. hear voices saying that she is about to be killed. Again The second approach, called Erklären (‘explanation’), the form is an auditory hallucination, but the content accounts for events in terms of external factors; for is different. A third patient might experience repeated example, the patient’s low mood can be ‘explained’ intrusive thoughts that he is homosexual, but he realizes by his recent redundancy. The latter approach requires that these are untrue. Here the content is the same as knowledge of psychiatric aetiology (Chapter 5). that of the first example, but the form is different. Form is often critical when making a diagnosis. From The significance of individual symptoms the examples given above, the presence of a hallucina- Psychiatric disorders are diagnosed when a defined tion indicates (by definition) a psychosis of one kind or group of symptoms (a syndrome) is present. Almost any another, whereas the third example suggests obsessive– single symptom can be experienced by a healthy per- compulsive disorder. Content is less diagnostically son; even hallucinations, often regarded as a hallmark useful, but can be very important in management; for of severe mental disorder, are experienced by some example, the content of a delusion may suggest that the otherwise healthy people. An exception to this is that patient could attack a supposed persecutor. It is also the a delusion, even if isolated, is generally considered to 4 4 Chapter 1 Signs and symptoms of psychiatric disorders be evidence of psychiatric disorder if it is unequivocal subject. This way of understanding is sometimes called and persistent (see Chapter 11). In general, however, the life-story approach. It is not something that can be the finding of a single symptom is not evidence of psy- readily assimilated from textbooks; it is best learned by chiatric disorder, but an indication for a thorough and, taking time to listen to patients. The psychiatrist may if necessary, repeated search for other symptoms and be helped by reading biographies or works of literature signs of psychiatric disorder. The dangers of not adher- that provide insights into the ways in which experi- ing to this principle are exemplified by the well-known ences throughout life shape the personality, and help study by Rosenhan (1973). Eight ‘patients’ presented to explain the diverse ways in which different people with the complaint that they heard the words ‘empty, respond to the same events. hollow, thud’ being said out loud. All eight individuals were admitted and diagnosed with schizophrenia, des- Cultural variations in psychopathology pite denying all other symptoms and behaving entirely The core symptoms of most serious mental disorders normally. This study also illustrates the importance of are present in culturally diverse individuals. However, descriptive psychopathology, and of reliable diagnos- there are cultural differences in how these symp- tic criteria (see Chapter 2), as fundamental aspects of toms present in clinical settings and to the meanings psychiatry. that are attributed to them. For example, depression can present with prominent somatic symptoms in The patient’s experience many Asian populations, such as those from India Symptoms and signs are only part of the subject mat- and China. The content of symptoms can also differ ter of psychopathology. The latter is also concerned between cultures. For example, for sub-Saharan African with the patient’s experience of illness, and the way populations, delusions not infrequently centre upon in which psychiatric disorder changes his view of him- being cursed, a rare delusional theme in Europeans. self, his hopes for the future, and his view of the world Cultural differences also affect the person’s subjective (Stanghellini and Broome, 2014). This may be seen as experience of illness, and therefore influence that per- one example of the understanding (verstehen) men- son’s understanding of it (Fabrega, 2000). In some cul- tioned above. A depressive disorder may have a very tures, the effects of psychiatric disorder are ascribed to different effect on a person who has lived a satisfying witchcraft—a belief that adds to the patient’s distress. and happy life and has fulfilled his major ambitions, In many cultures, mental illness is greatly stigmatized, compared with a person who has had many previous and can, for example, hinder prospects of marriage. In misfortunes but has lived on hopes of future success. such a culture the effect of illness on the patient’s view To understand this aspect of the patient’s experience of himself and his future will be very different from of psychiatric disorder, the psychiatrist has to under- the effect on a patient living in a society that is more stand him in the way that a biographer understands his tolerant of mental disorder. Descriptions of symptoms and signs Disturbances of emotion The former usage is now uncommon. The latter usage is emphasized by the fact that, in current diagnostic sys- and mood tems, ‘mood disorders’ are those in which depression and Much of psychiatry is concerned with abnormal emo- mania are the defining characteristics, whereas disorders tional states, particularly disturbances of mood and defined by anxiety or other emotional disturbances are other emotions, especially anxiety. Before describing the categorized separately. In this section, features common main symptoms of this kind, it is worth clarifying two to both ‘mood’ and ‘other emotions’ are described first, areas of terminology that may cause confusion, in part before the specific features of anxiety, depression, and because their usage has changed over the years. mania are discussed separately. First, the term ‘mood’ can either be used as a broad The second point concerns the term ‘affect’. This is term to encompass all emotions (e.g. ‘anxious mood’), now usually used interchangeably with the term ‘mood’, or in a more restricted sense to mean the emotion that in the more limited meaning of the latter word (e.g. runs from depression at one end to mania at the other. ‘his affect was normal’, ‘he has an affective disorder’). 5 Descriptions of symptoms and signs 5 However, in the past, these words had different nuances Anxiety of meaning; mood referred to a prevailing and prolonged Anxiety is a normal response to danger. Anxiety is state, whereas affect was linked to a particular aspect or abnormal when its severity is out of proportion to the object, and was more transitory. threat of danger, or when it outlasts the threat. Anxious Emotions and mood may be abnormal in three ways: mood is closely coupled with somatic and autonomic Their nature may be altered components, and with psychological ones. All can be They may fluctuate more or less than usual thought of as equivalent to the preparations for deal- ing with danger seen in other mammals, ready for flight They may be inconsistent with the patient’s thoughts from, avoidance of, or fighting with a predator. Mild-to- or actions, or with his current circumstances. moderate anxiety enhances most kinds of performance, Changes in the nature of emotions and mood but very high levels interfere with it. The anxiety response is considered further in These can be towards anxiety, depression, elation, or Chapter 8. Here its main components can be summa- irritability and anger. Any of these changes may be asso- rized as follows. ciated with events in the person’s life, but they may arise without an apparent reason. They are usually accom- Psychological. The essential feelings of dread and appre- panied by other symptoms and signs. For example, an hension are accompanied by restlessness, narrowing of increase in anxiety is accompanied by autonomic over- attention to focus on the source of danger, worrying activity and increased muscle tension, and depression thoughts, increased alertness (with insomnia), and is accompanied by gloomy preoccupations and psycho- irritability (that is, a readiness to become angry). motor slowness. Somatic. Muscle tension and respiration increase. If Changes in the way that emotions these changes are not followed by physical activity, they may be experienced as muscle tension tremor, or and mood vary the effects of hyperventilation (e.g. dizziness). Emotions and mood vary in relation to the person’s Autonomic. Heart rate and sweating increase, the circumstances and preoccupations. In abnormal states, mouth becomes dry, and there may be an urge to uri- this variation with circumstances may continue, but the nate or defaecate. variations may be greater or less than normal. Increased variation is called lability of mood; extreme variation is Avoidance of danger. A phobia is a persistent, irrational sometimes called emotional incontinence. fear of a specific object or situation. Usually there is Reduced variation is called blunting or flattening. also a marked wish to avoid the object, although this These terms have been used with subtly different is not always the case—for example, fear of illness meanings, but are now usually used interchangeably. (hypochondriasis). The fear is out of proportion to the Blunting or flattening usually occurs in depression and objective threat, and is recognized as such by the per- schizophrenia. Severe flattening is sometimes called son experiencing it. Phobias include fear of animate apathy (note the difference from the layman’s meaning objects, natural phenomena, and situations. Phobic of the word). people feel anxious not only in the presence of the Emotion can also vary in a way that is not in keep- object or situation, but also when thinking about it ing with the person’s circumstances and thoughts, and (anticipatory anxiety). Phobias are discussed further in this is described as incongruous or inappropriate. For relation to anxiety disorders in Chapter 5. example, a patient may appear to be in high spirits and laugh when talking about the death of his mother. Such Clinical associations incongruity must be distinguished from the embarrassed Phobias are common among healthy children, becom- laughter which indicates that the person is ill at ease. ing less frequent in adolescence and adult life. Phobic symptoms occur in all kinds of anxiety disorder, but are Clinical associations of emotional the major feature in the phobic disorders. and mood disturbances Disturbances of emotions and mood are seen in essen- Depression tially all psychiatric disorders. They are the central fea- Depression is a normal response to loss or misfortune, ture of the mood disorders and anxiety disorders. They when it may be called grief or mourning. Depression are also common in eating disorders, substance-induced is abnormal when it is out of proportion to the misfor- disorders, delirium, dementia, and schizophrenia. tune, or is unduly prolonged. Depressed mood is closely 6 6 Chapter 1 Signs and symptoms of psychiatric disorders coupled with other changes, notably a lowering of self- data are acted on by cognitive processes that reassemble esteem, pessimistic or negative thinking, and a reduc- them and extract patterns. Perception can be attended tion in or loss of the experience of pleasure (anhedonia). to or ignored, but it cannot be terminated by an effort A depressed person has a characteristic expression and of will. appearance, with turned-down corners of the mouth, a Imagery is the awareness of a percept that has been furrowed brow, and a hunched, dejected posture. The generated within the mind. Imagery can be called up level of arousal is reduced in some depressed patients and terminated by an effort of will. Images are experi- (psychomotor retardation) but increased in others, with enced as lacking the sense of reality that characterizes a consequent feeling of restlessness or agitation. The perception, so that a healthy person can distinguish psychopathology of depression is discussed further in between images and percepts. A few people experience Chapter 9. eidetic imagery, which is visual imagery so intense and detailed that it has a ‘photographic’ quality akin to a Clinical associations percept, although in other ways it differs from a percept. Depression can occur in any psychiatric disorder. It is Imagery is generally terminated when perception starts. the defining feature of mood disorders, and commonly Occasionally, imagery persists despite the presence of occurs in schizophrenia, anxiety, obsessive–compulsive percept (provided this is weak and unstructured). This disorder, eating disorders, and substance-induced disor- sort of imagery is called pareidolia. ders. It can also be a manifestation of an organic disorder. Percepts may alter in intensity and in quality. Anxious people may experience sensations as more intense than Elation usual; for example, they may be unusually sensitive Happy moods have been studied less than depressed to noise. In mania, perceptions seem more vivid than mood. Elation is an extreme degree of happy mood usual. Depressed patients may experience perceptions as which, like depression, is coupled with other changes, dull and lifeless. including increased feelings of self-confidence and well- being, increased activity, and increased arousal. The lat- Illusions ter is usually experienced as pleasant, but sometimes Illusions are misperceptions of external stimuli. They as an unpleasant feeling of restlessness. Elation occurs occur when the general level of sensory stimulation is most often in mania and hypomania. reduced and when attention is not focused on the rel- evant sensory modality. For example, at dusk the out- Irritability and anger line of a bush may be perceived at first as that of a man, Irritability is a state of increased readiness for anger. Both although not when attention is focused on the outline. irritability and anger may occur in many kinds of dis- Illusions are more likely to occur when the level of con- order, so they are of little value in diagnosis. However, sciousness is reduced, as in delirium, or when a person they are of great importance in risk assessment and is anxious. Illusions have no diagnostic significance, but risk management, as they may result in harm to others need to be distinguished from hallucinations. and self (see Chapter 3). Irritability may occur in anxi- ety disorders, depression, mania, dementia, and drug Hallucinations intoxication. A hallucination is a percept that is experienced in the absence of an external stimulus to the corresponding sense organ. It differs from an illusion in being expe- Disturbances of perception rienced as originating in the outside world or from Specific kinds of perceptual disturbance are symptoms within the person’s body (rather than as imagined). of severe psychiatric disorders. It is therefore important Hallucinations cannot be terminated at will. to be able to identify these symptoms and to distinguish Hallucinations are generally indications of signifi- them from the other, much less significant, alterations cant psychiatric disorder, and specific types of hallucin- in sensory experience which occur. We shall therefore ation are characteristic of different disorders, as outlined describe perceptual phenomena in some detail. below. However, as noted above, hallucinations do occur in some otherwise healthy people. It is also common to Perception and imagery experience them when falling asleep (hypnagogic hal- Perception is the process of becoming aware of what is lucinations) or on waking (hypnopompic hallucinations). presented through the sense organs. It is not a direct These two types of hallucination may be either visual awareness of data from the sense organs, because these or auditory, the latter sometimes as the experience of 7 Descriptions of symptoms and signs 7 hearing one’s name called. Such hallucinations are or to repeat them immediately after he has thought common in narcolepsy (see page 327). Some recently them (écho de la pensée). bereaved people experience hallucinations of the dead Visual hallucinations may also be elementary or com- person. Hallucinations can occur after sensory depriv- plex. The content may appear normal or abnormal in ation, in people with blindness or deafness of peripheral size; hallucinations of dwarf figures are sometimes origin, occasionally in neurological disorders that affect called lilliputian. Occasionally, patients describe the the visual pathways, in epilepsy (see page 379), and in experience of visual hallucinations located outside the Charles Bonnet syndrome (see page 555). field of vision, usually behind the head (extracampine hallucinations). Types of hallucination Olfactory hallucinations and gustatory hallucinations Hallucinations can be described in terms of their com- are frequently experienced together. The smells and plexity and their sensory modality (see Box 1.1). The tastes are often unpleasant. term elementary hallucination refers to experiences such Tactile hallucinations, sometimes called haptic hal- as bangs, whistles, and flashes of light, whereas the term lucinations, may be experienced as sensations of being complex hallucination refers to experiences such as hear- touched, pricked, or strangled. Sometimes they are felt ing voices or music, or seeing faces and scenes. as movements just below the skin, which the patient Auditory hallucinations may be experienced as noises, may attribute to insects, worms, or other small creatures music, or voices. Voices may be heard clearly or indis- burrowing through the tissues. Hallucinations of deep tinctly; they may seem to speak words, phrases, or sen- sensation may be experienced as feelings of the viscera tences. They may seem to address the patient directly being pulled upon or distended, or of sexual stimulation (second-person hallucinations), or talk to one another, or electric shocks. referring to the patient as ‘he’ or ‘she’ (third-person hal- An autoscopic hallucination is the experience of see- lucinations). Sometimes patients say that the voices ing one’s own body projected into external space, usu- anticipate what they are about to think a few moments ally in front of oneself, for short periods. The experience later. Sometimes the voices seem to speak the patient’s is reported occasionally by healthy people in situations thoughts as he is thinking them (Gedankenlautwerden), of sensory deprivation, when it is called an out-of-body experience, or after a near-fatal accident or heart attack, when it has been called a near-death experience. Rarely, the experience is accompanied by the conviction that Box 1.1 Description of hallucinations the person has a double (Doppelganger). Reflex hallucination is a rare phenomenon, in which a According to complexity stimulus in one sensory modality results in a hallucina- Elementary tion in another; for example, music may provoke visual Complex hallucinations. According to sensory modality Auditory Clinical associations of hallucinations Visual Hallucinations occur in diverse disorders, notably schiz- Olfactory and gustatory ophrenia, severe mood disorder, organic disorders, and Somatic (tactile and deep) dissociative states. Therefore the finding of hallucina- According to special features tions does not itself help much in diagnosis. However, as Auditory with delusions, there are certain kinds of hallucination Second-person which do have important implications for diagnosis of Third-person schizophrenia and other disorders. Gedankenlautwerden Auditory hallucination. Only clearly heard voices Écho de la pensée (not noises or music) have diagnostic significance. Visual Third-person hallucinations (introduced above) are Extracampine strongly associated with schizophrenia. Such voices Autoscopic hallucinations may be experienced as commenting on the patient’s Reflex hallucinations intentions (e.g. ‘He wants to make love to her’) Hypnagogic and hypnopompic or actions (e.g. ‘She is washing her face’), or may make critical comments. Second-person auditory 8 8 Chapter 1 Signs and symptoms of psychiatric disorders hallucinations (i.e. those that appear to address the a hallucination, the experience should be described, but patient) do not point to a particular diagnosis, but need not be labelled as one kind of pseudohallucination their content and the patient’s reaction to them may or the other. do so. Thus voices with derogatory content (e.g. ‘You Abnormalities in the meaning attached to percepts are a failure, you are wicked’) suggest severe depres- sive disorder, especially when the patient accepts A delusional perception is a delusion arising directly from them as justified. In schizophrenia, the patient more a normal percept. This is sometimes erroneously consid- often resents such comments. Voices which antici- ered to be a perceptual disturbance, but it is really a dis- pate, echo, or repeat the patient’s thoughts also sug- order of thought, and is therefore discussed in the next gest schizophrenia. section. Visual hallucinations should always suggest the possi- bility of an organic disorder, although they also occur Disturbances of thoughts in severe affective disorders, schizophrenia, and disso- Disturbances of thoughts and thought processes are ciative disorder. The content of visual hallucinations among the most diagnostically significant symptoms is of little significance in diagnosis. Autoscopic hal- in psychiatry. As with disturbances of perception, there- lucinations also raise suspicion of an organic disorder, fore, this area of descriptive psychopathology merits such as temporal lobe epilepsy. relatively detailed description. It covers two kinds of Hallucinations of taste and smell are infrequent. They phenomena: may occur in schizophrenia, severe depressive dis- orders, and temporal lobe epilepsy, and in tumours Disturbance of thoughts themselves—that is, a change affecting the olfactory bulb or pathways. in the nature of individual thoughts. The category of Tactile and somatic hallucinations are suggestive of delusion is particularly important. Disturbances of schizophrenia, especially if they are bizarre in con- thought are covered in this section. tent or interpretation. The sensation of insects mov- Disturbance of the thinking process and the link- ing under the skin (formication) occurs in people who ing together of different thoughts; this may affect abuse cocaine. the speed or the form of the relationship between thoughts. It can occur even if individual thoughts are Pseudohallucinations unremarkable in nature. These phenomena are cov- This term refers to experiences that are similar to hallu- ered in the next section. cinations but which do not meet all of the requirements of the definition, nor have the same implications. The Delusions word has two distinct meanings, which correspond to A delusion is a belief that is firmly held on inadequate two of the ways in which an experience can fail to meet grounds, that is not affected by rational argument or the criteria for a hallucination. In the first meaning, evidence to the contrary, and that is not a conventional pseudohallucination is a sensory experience that dif- belief that the person might be expected to hold given fers from a hallucination in not seeming to the patient their educational, cultural, and religious background. to represent external reality, being located within the This definition is intended to separate delusions, which mind rather than in external space. In this way pseu- are cardinal symptoms of severe psychiatric disorder dohallucinations resemble imagery although, unlike (and specifically of psychosis), from other kinds of imagery, they cannot be dismissed by an effort of will. abnormal thoughts and from strongly held beliefs found In the second meaning, the sensory experience appears among healthy people. There are several problems with to originate in the external world, but it seems unreal. the definition, which is summarized in Box 1.2, but it For a more detailed discussion, see Hare (1973) and suffices as a starting point for more detailed discussion Taylor (1981). of delusions. Both definitions of pseudohallucinations are difficult Although not part of the definition, another charac- to apply clinically, because patients can seldom describe teristic feature of delusions is that they have a marked their experiences in adequate detail. In any event, it is effect on the person’s feeling and actions—in the usually sufficient to decide whether a perceptual experi- same way that strongly held normal beliefs do. Since ence is a ‘true’ hallucination or not, since it is only the the behavioural response to the delusion may itself former which carries diagnostic significance. If it is not be out of keeping or even bizarre, it is often this that 9 Descriptions of symptoms and signs 9 Box 1.2 Problems with the definition of delusions Delusions are firmly held delusion that hallucinated voices are those of people who despite evidence to the contrary are spying on the patient. The hallmark of a delusion is that it is held with such Delusions are not beliefs shared conviction that it cannot be altered by presenting evidence to the contrary. For example, a patient who by others in the same culture holds the delusion that there are persecutors in the This criterion is important when the patient is a mem- adjoining house will not be convinced by evidence ber of a culture or subculture (including a religious that the house is empty. Instead he may suggest that faith), because healthy people in such a group may hold the persecutors left the house shortly before it was beliefs that are not accepted outside it. Like delusions, searched. The problem with this criterion for delusions such cultural beliefs are generally impervious to contrary is that some of the ideas of normal people are equally evidence and reasoned argument—for example, beliefs impervious to contrary evidence. For example, the in evil spirits. Therefore, before deciding that an idea is beliefs of a convinced spiritualist are not undermined delusional, it is important to determine whether other by the counterarguments of a non-believer. Strongly members of the same culture share the belief. held non-delusional beliefs are called overvalued ideas (see page 14). Delusions as false beliefs A further problem with this part of the definition of Some definitions of delusions indicate that they are delusion relates to partial delusions. Although delu- false beliefs, but this criterion was not included in sions are usually held strongly from the start, some- the definition given above. This omission is because, times they are at first held with a degree of doubt. Also, in exceptional circumstances, a delusional belief can during recovery it is not uncommon for patients to pass be true or can subsequently become true. A well-rec- through a stage of increasing doubt about their delu- ognized example relates to pathological jealousy (see sions before finally rejecting them. The term ‘partial page 306). It is not falsity that determines whether the delusion’ refers to both these situations of doubt. It belief is delusional, but the nature of the mental pro- should be used during recovery only when it is known cesses that led up to it. (The difficulty with this state- that the beliefs were preceded by a full delusion, and ment is that we cannot define these mental processes applied to the development of a delusion only when it precisely.) There is a further practical problem concern- is known in retrospect that a full delusion developed ing the use of falsity as a criterion for delusion. It is that later. Partial delusions are not, in isolation, helpful in if the criterion is used, it may be assumed that, because diagnosis—akin to the status of pseudohallucinations a belief is highly improbable, it is false. This is certainly mentioned on page 8. not a sound assumption, because improbable stories— for example, of persecution by neighbours—sometimes Delusions are held on inadequate turn out to be true and arrived at through sound obser- grounds vations and logical thought. Therefore ideas should be Delusions are not arrived at by the ordinary processes of investigated thoroughly before they are accepted as observation and logic. Some delusions appear suddenly delusions. without any previous thinking about the subject (primary These issues are discussed further in Spitzer (1990) delusions). Other delusions appear to be attempts to and Butler and Braff (1991). See Garety and Freeman explain another abnormal experiences—for example, the (2013) for a cognitive account of delusions. first brings the person to psychiatric attention, and little influence on feelings and actions. For example, a leads to the delusion being elicited. For example, a man patient may believe that he is a member of the royal with the delusion that he was being irradiated by sonic family while living contentedly in a group home. This waves covered his windows with silver foil and barri- separation is called double orientation, and usually occurs caded his door. Occasionally, however, a delusion has in chronic schizophrenia. 10 10 Chapter 1 Signs and symptoms of psychiatric disorders Types of delusions he is changing sex. Not all primary delusional experi- ences start with an idea. Sometimes the first experience Several types of delusions are recognized, and they are is a delusional mood (see below) or a delusional percep- categorized either by the characteristics or by the theme tion (see below). Because patients do not find it easy to of the delusion (see Box 1.3). Many of the terms are sim- remember the exact sequence of such unusual and dis- ply useful descriptors, but a few of them carry particular tressing mental events, it is often difficult to be certain diagnostic implications; for example, specific types of which experience came first. Primary delusions are given delusions are first rank symptoms of schizophrenia (see considerable weight in the diagnosis of schizophrenia, page 255). Most categories of delusions can be diagnosed and they should be recorded only when it is certain that reliably (Bell et al., 2006). For further descriptions, see they are present. also Oyebode (2014). Secondary delusions are delusions apparently derived Primary and secondary delusions from a preceding morbid experience. The latter may be A primary or autochthonous delusion is one that appears of several kinds, including hallucinations (e.g. some- suddenly and with full conviction but without any men- one who hears voices may believe that he is being fol- tal events leading up to it. For example, a schizophrenic lowed), low mood (e.g. a profoundly depressed woman patient may be suddenly and completely convinced, for may believe people think that she is worthless), or an no reason and with no prior thoughts of this kind, that existing delusion (e.g. a person who is convinced he is being ‘framed’ may come to believe that he will be imprisoned). Some secondary delusions seem to have an integrative function, making the original experiences Box 1.3 Descriptions of delusions more comprehensible to the patient, as in the first exam- ple above. Others seem to do the opposite, increasing According to fixity the sense of persecution or failure, as in the third exam- Complete ple. Secondary delusions may accumulate until there is Partial a complicated and stable delusional system. When this According to onset happens the delusions are said to be systematized. Primary Delusional mood Secondary When a patient first experiences a delusion, he responds Other delusional experiences emotionally. For example, a person who believes that a Delusional mood group of people intends to kill him is likely to feel afraid. Delusional perception Occasionally, the change of mood precedes the delusion. Delusional memory This preceding mood is often a feeling of foreboding According to theme that some, as yet, unidentified sinister event is about Persecutory (paranoid) to take place. When the delusion follows, it appears to Delusions of reference explain this feeling. In German this antecedent mood Grandiose (expansive) is called Wahnstimmung. This term is usually translated Bizarre as delusional mood, although it is really the mood from Delusions of guilt which a delusion arises. Nihilistic Hypochondriacal Delusional perception Religious Sometimes the first abnormal experience is the attach- Jealous ing of a new significance to a familiar percept without Sexual or amorous any reason to do so. For example, the position of a letter Delusions of control that has been left on the patient’s desk may be inter- Delusions concerning possession of thought: preted as a signal that he is to die. This experience is Thought insertion called delusional perception. Note, however, that the per- Thought withdrawal ception is normal, and it is the delusional interpretation Thought broadcasting that is abnormal. According to other features Shared delusions Delusional misidentification Mood congruency This is the delusional misidentification of oneself or of specific other people. Several eponymous forms are 1 Descriptions of symptoms and signs 11 described, and have been considered to be both symptoms Delusions of reference and syndromes. In line with the latter view, ‘delusional These are concerned with the idea that objects, events, misidentification disorder’ is described in Chapter 12. or people that are unconnected with the patient have a personal significance for him. For example, the patient Delusional memory may believe that an article in a newspaper or a remark on In delusional memory, a delusional interpretation is television is directed specifically to him, either as a mes- attached to past events. Fish (1962) distinguishes two sage to him or to inform others about him. Delusions forms of delusional memory. In the commoner form, the of reference may also relate to actions or gestures made past event was genuine, and the term ‘delusional’ refers by other people which are thought to convey a message to the significance which has now become attached to it. about the patient. For example, a person who touches For example, a patient who believes that there is a cur- his hair may be thought by the patient to be signalling rent plot to poison her may remember (correctly) that that he, the patient, is turning into a woman. Although she vomited after a meal, eaten long before her psycho- most delusions of reference have persecutory associa- sis began, and now concludes (incorrectly) that she had tions, some relate to grandiose or reassuring themes. been intentionally poisoned. Alternatively, a sudden (autochthonous) delusion arises, which is wrongly dated Delusions of control (passivity phenomena) to a past event. This latter form might be viewed as a true A patient who has a delusion of control believes that delusional memory (i.e. the memory itself is the delu- his actions, impulses, or thoughts are controlled by an sion), whereas in the first kind described, the memory is outside agency. These are also called passivity phenomena. normal but a delusional interpretation is placed upon it. Delusions of control are strongly suggestive of schizo- phrenia, and have forensic implications, so particular Shared delusions care should be taken when eliciting and recording them. As a rule, other people recognize delusions as false and The symptom may be confused with voluntary obedi- argue with the patient in an attempt to correct them. ence to commands from hallucinatory voices, with reli- Occasionally, a person who lives with a deluded patient gious beliefs that God controls human actions, or with comes to share his delusional beliefs. This condition is a metaphorical view of one’s free will. By contrast, a known as shared delusions or folie à deux (see page 310). patient with a delusion of control firmly believes that Although the second person’s delusional conviction is as his movements or actions are brought about by an out- strong as the partner’s while the couple remain together, side agency (other than the divine), and are not willed it often recedes quickly when they are separated. by himself. Moreover, other symptoms of schizophrenia Delusional themes are usually present as well. For the purposes of clinical work, it is useful to group Delusions concerning the possession of thought delusions according to their main themes, since the Healthy people take it for granted that their thoughts themes have some diagnostic significance. However, it are their own. They also know that thoughts are private is first worth considering the word ‘paranoid’, which is experiences that become known to other people only if used widely but not always clearly in this context (see they are spoken aloud, or revealed in writing or through Box 1.4). facial expression, gesture, or action. Patients with delu- Persecutory delusions sions concerning the possession of thoughts lose these normal convictions in one or more of three ways, all of These are most commonly concerned with persons or which are strongly associated with schizophrenia: organizations that are thought to be trying to inflict harm on the patient, damage his reputation, or make Thought insertion is the delusion that certain thoughts him insane. Such delusions are common but of little are not the patient’s own but are implanted by an out- help in diagnosis, because they can occur in delusional side agency. Often there is an associated explanatory disorders, organic states, schizophrenia, and severe delusion—for example, that persecutors have used radio affective disorders. However, the patient’s attitude to waves to insert the thoughts. This experience must not the delusion may point to the diagnosis. In a severe be confused with that of the obsessional patient, who depressive disorder, a patient with persecutory delu- may be distressed by thoughts that he feels are alien to sions characteristically accepts the supposed activities his nature but who never doubts that these thoughts are of the persecutors as justified by his own wickedness. his own. The patient with a delusion of thought inser- In schizophrenia, however, he resents these activities as tion believes that the thoughts are not his own, but that unwarranted. they have been inserted into his mind. 12 12 Chapter 1 Signs and symptoms of psychiatric disorders Box 1.4 The term ‘paranoid’ The term ‘paranoid’ is often used as if it were equivalent now more common, as sanctioned in the diagnostic cat- to ‘persecutory’. Strictly interpreted, however, the word egory of paranoid personality disorder (see page 398). ‘paranoid’ has a wider meaning (Lewis, 1970). It was Because the term ‘paranoid’ has two possible meanings, used in ancient Greek writings to mean the equivalent the term ‘persecutory’ is preferable when the narrow of ‘out of his mind’. For example, Hippocrates used it to sense of paranoid is required. The issue also affects the describe patients with febrile delirium. Many later writ- use of the word to describe syndromes in which such ers applied the term to grandiose, erotic, jealous, and symptoms predominate; the older term ‘paranoid psy- religious delusions, as well as to persecutory delusions. choses’ (or ‘paranoid states’) is now replaced by ‘delu- Although for historical reasons it is preferable to retain sional disorders’, in part to avoid the ambiguities (see the broader meaning of the term, the narrower usage is also Chapter 12). Thought withdrawal is the delusion that thoughts have upon the patient, or that his sinfulness will lead to retri- been taken out of the mind. The delusion usually bution on his family. accompanies thought blocking, in which the patient Nihilistic delusions experiences a sudden break in the flow of thoughts and These are beliefs that some person or thing has ceased, believes that the ‘missing’ thoughts have been taken or is about to cease, to exist. Examples include a patient’s away by some outside agency. Often there are associ- delusion that he has no money, that his career is ruined, ated explanatory delusions comparable to those that or that the world is about to end. Nihilistic delusions are accompany delusions of thought insertion (see above). seen in severe depression. Occasionally, nihilistic delu- Thought broadcasting is the delusion that unspoken sions concern failures of bodily function (often that the thoughts are known to other people through radio, bowels are blocked), and are often referred to as Cotard’s telepathy, or in some other way. In addition, some syndrome (see page 196). patients believe that their thoughts can be heard out loud by other people, a belief that also accompanies Hypochondriacal delusions the experience of hearing one’s own thoughts spoken These are beliefs concerned with illness. The patient (Gedankenlautwerden), described above in the section believes, wrongly and in the face of all medical evidence on ‘Types of hallucination’. to the contrary, that he is suffering from a disease. Such delusions are more common in the elderly, reflecting the Grandiose delusions increasing concern with health among people in this age These are beliefs of exaggerated self-importance. The group. Other hypochondriacal delusions are concerned patient may consider himself to be wealthy, endowed with cancer or venereal disease, or with the appearance with unusual abilities, or a special person. Such expansive of parts of the body, especially the nose. They must be ideas occur particularly in mania, and in schizophrenia. distinguished from the health worries of hypochondria- Bizarre delusions sis (see page 650), which are not delusional. Delusions with highly improbable content (e.g. of con- Mood-congruent and mood-incongruent delusions trol by aliens who communicate via birds) are said to If a delusion ‘makes sense’ in terms of the person’s mood, be bizarre. They are often given particular weight in it is said to be mood-congruent. Hypochondriacal and the diagnosis of schizophrenia, but the category has nihilistic delusions in psychotic depression, and gran- problems of reliability and definition (Bell et al., 2006; diose delusions in mania, both fall into this category. Cermolacce et al., 2010), and it is not included in current In contrast, a delusion that is out of keeping with the diagnostic criteria. prevailing mood is mood-incongruent, and is suggestive of schizophrenia. The concept of congruency can also be Delusions of guilt applied to hallucinations. These beliefs are found most often in depressive illness, and for this reason are sometimes called depressive delu- Delusions of jealousy sions. Typical themes are that a minor infringement of These are more common among men than women. the law in the past will be discovered and bring shame Not all jealous ideas are delusions; less intense jealous 13 Descriptions of symptoms and signs 13 preoccupations and obsessions are common. Jealous persistence. Obsessional symptoms are also a trait in delusions are important because they may lead to aggres- anankastic personality disorder (see page 403). sive behaviour towards the person(s) who is thought Obsessions can take various forms (see Box 1.5). to be unfaithful. A patient with delusional jealousy is Obsessional thoughts are repeated and intrusive words not satisfied if he fails to find evidence supporting his or phrases that are upsetting to the patient—for exam- beliefs; his search will continue. These important and ple, repeated obscenities or blasphemous phrases potentially dangerous problems are discussed further in coming into the awareness of a religious person. Chapter 12. Obsessional ruminations are repeated worrying themes Sexual or amorous delusions of a more complex kind—for example, about the end- These are rare, and are more frequent in women than ing of the world. in men. Sexual delusions are occasionally secondary Obsessional doubts are repeated themes expressing to somatic hallucinations felt in the genitalia. A per- uncertainty about previous actions—for example, son with amorous delusions believes that she is loved whether or not the person turned off an electrical by a man who is usually inaccessible to her, and often appliance that might cause a fire. Whatever the nature of higher social status. In many cases she has never of the doubt, the person realizes that the degree of spoken to the person. Erotic delusions are the most uncertainty and consequent distress is unreasonable. prominent feature of De Clérambault’s syndrome (see Obsessional impulses are repeated urges to carry out page 308). actions, usually ones that are aggressive, dangerous, or socially embarrassing—for example, the urge to pick Obsessional and compulsive symptoms up a knife and stab another person, to jump in front Obsessions of a train, or to shout obscenities in church. Whatever Obsessions are recurrent persistent thoughts, impulses, the urge, the person has no wish to carry it out, resists or images that enter the mind despite efforts to exclude it strongly, and does not act on it. them. One characteristic feature is the subjective sense Obsessional phobias. This term denotes an obses- of a struggle—the patient resists the obsession, which sional symptom associated with avoidance as well nevertheless intrudes into awareness. Another charac- as anxiety—for example, the obsessional impulse to teristic feature is the conviction that to think something injure another person with a knife may lead to con- is to make it more likely to happen. Obsessions are rec- sequent avoidance of knives. Sometimes obsessional ognized by the person as his own and not implanted fears of illness are called illness phobias. from elsewhere (in contrast to delusions of thought Obsessional slowness. Many obsessional patients per- insertion). Another important distinction from delu- form actions slowly because their compulsive rituals or sions is that obsessions are regarded as untrue or sense- repeated doubts take time and distract them from their less. They are generally about matters that the patient main purpose. Occasionally, however, the slowness finds distressing or otherwise unpleasant. They are does not seem to be secondary to these other problems, often, but not always, accompanied by compulsions but appears to be a primary feature of unknown origin. (see page 14). The presence of resistance is important because, together with the lack of persistent or complete con- viction about the truth of the idea, it distinguishes obsessions from delusions. However, in practice this Box 1.5 Obsessional and compulsive distinction can, in isolation, be more difficult, since the symptoms resistance tends to diminish when obsessions have been longstanding. Furthermore, when obsessions are very Obsessions intense, patients may become less certain that they are Thoughts false. However, a careful history, not only of the symp- Ruminations tom but also of other relevant features (e.g. compulsions, Doubts other evidence of psychosis) should avoid diagnostic Impulses difficulties. It is also necessary to distinguish clinically Obsessional phobias significant obsessions from similar thoughts that occur Compulsions (rituals) in healthy people, especially when they are tired or Obsessional slowness under stress. This requires evidence of dysfunction and 14 14 Chapter 1 Signs and symptoms of psychiatric disorders Although the content (or themes) of obsessions are Checking rituals are often concerned with safety—for various, most of them can be grouped into one or other example, checking over and over again that the fire has of six categories: been turned off, or that the doors have been locked. Cleaning rituals often take the form of repeated hand dirt and contamination washing, but may involve household cleaning. aggression Counting rituals usually involve counting in some spe- orderliness cial way—for example, in threes—and are frequently illness associated with doubting thoughts such that the count sex must be repeated to make sure that it was carried out religion. adequately in the first place. The counting is often silent, so an onlooker may be unaware of the ritual. Thoughts about dirt and contamination are usually In dressing rituals the person lays out clothes, or puts associated with the idea of harm to others or self through them on, in a particular way or order. The ritual is the spread of disease. Aggressive thoughts may be about often accompanied by doubting thoughts that lead to striking another person or shouting angry or obscene seemingly endless repetition. remarks in public. Thoughts about orderliness may be about the way objects are to be arranged or work is to be Overvalued ideas organized. Thoughts about illness are usually of a fearful Overvalued ideas were first described by Wernicke in kind—for example, a dread of cancer. Obsessional ideas 1900, and were reviewed by McKenna (1984). An over- about sex usually concern practices that the individual valued idea is a comprehensible and understandable would find shameful. Obsessions about religion often idea which is pursued beyond the bounds of reason. It take the form of doubts about the fundamentals of belief may preoccupy and dominate a person’s life for many (e.g. ‘does God exist?’) or repeated doubts about whether years, and affect their actions. It therefore shares some sins have been adequately confessed (‘scruples’). characteristics of delusions. However, it is essential to Compulsions distinguish the two types of belief, as their diagnostic implications are very different. Overvalued ideas differ Compulsions are repetitive and seemingly purposeful from delusions in two main ways. behaviours that are performed in a stereotyped way (hence the alternative name, ‘compulsive rituals’) in The content of, and basis for, the overvalued idea response to an obsession. They are accompanied by a is usually understandable when the person’s back- subjective sense that the behaviour must be carried ground is known, whereas delusions and the person’s out and by an urge to resist it. The compulsion usually explanation of them tend to be bizarre. For example, a makes sense given the content of the obsession. For person whose mother and sister suffered from cancer example, a compulsion to wash the hands repeatedly is one after the other may understandably become con- usually driven by obsessional thoughts that the hands vinced that cancer is contagious. are contaminated. Sometimes obsessional ideas concern The theme also tends to be culturally common and the consequences of failing to carry out the compulsion acceptable, as in the overvalued ideas about body in the ‘correct’ way—for example, that another person shape that characterize anorexia nervosa. will suffer an accident. Compulsions may cause prob- lems for several reasons. With an overvalued idea, there is a small degree of insight and willingness to at least entertain alternative They may cause direct harm (e.g. dermatitis from views, even though this is not persistent and the patient excessive washing). always returns to and retains the belief. They may interfere with normal life because of the Overvalued ideas must also be distinguished from time they require. obsessions. This is usually easier than the distinction Although the compulsive act transiently reduces the from delusions, since there is no sense of intrusiveness anxiety associated with the obsession, in fact the com- or senselessness of the thought, nor is there resistance to pulsions help to maintain the condition. Strategies to it. Overvalued ideas differ from normal religious beliefs reduce them are central to behavioural treatments of in that the latter are shared by a wider group, arise from obsessive–compulsive disorder. religious instruction, and are subject to periodic doubts. There are many kinds of compulsive acts, but four Despite these differences, it can on occasion be dif- types are particularly common. ficult to recognize an overvalued idea and distinguish 15 Descriptions of symptoms and signs 15 it unequivocally from a delusion, obsession, or normal Disorders of the form of thought belief. However, this should rarely lead to practical prob- Disorder of the form of thought (also known as formal lems, because diagnosis depends on more than the pres- thought disorder) is usually recognized from speech and ence or absence of a single symptom. writing, but is sometimes evident from the patient’s The beliefs concerning body shape and weight that behaviour—for example, he may be unable to file papers are held in anorexia nervosa are perhaps the clearest under appropriate category headings. Disorders of the example of overvalued ideas. According to McKenna form of thought can be divided into several kinds, as (1984), the term also applies to abnormal beliefs in described below. Each kind has associations with a par- many other conditions, including dysmorphophobia, ticular mental disorder, but none of the associations is hypochondriasis, paranoid personality disorder, and strong enough to be diagnostic. morbid jealousy. However, it is important to emphasize that overvalued ideas are defined by their form, not their Perseveration content, and they have no inviolable relationship with, Perseveration is the persistent and inappropriate rep- or implication for, any particular diagnostic category. etition of the same thoughts. The disorder is detected Thus some cases of morbid jealousy are clearly delu- by examining the person’s words or actions. Thus, in sional, whereas in hypochondriasis or dysmorphopho- response to a series of simple questions, the person may bia the belief often has the character of an obsession or give the correct answer to the first question, but con- a worry, not of an overvalued idea. tinue to give the same answer inappropriately to sub- sequent questions. Perseveration occurs in, but is not limited to, dementia and frontal lobe injury. Disturbances of thinking processes Flight of ideas In flight of ideas, thoughts and speech move quickly Disturbances of the stream of thought from one topic to another so that one train of thought is In disturbances of the stream of thought, the amount not carried to completion before another takes its place. and speed of thinking are changed. In pressure of The normal logical sequence of ideas is generally pre- thought, ideas arise in unusual variety and abundance served, although ideas may be linked by distracting cues and pass through the mind rapidly. In poverty of in the surroundings and by distractions arising from the thought, the patient has few thoughts, and these lack words that have been spoken. These verbal distractions variety and richness and seem to move slowly through are of three kinds, namely clang associations (a second the mind. Pressure of thought occurs in mania; pov- word with a sound similar to the first), puns (a second erty of thought occurs in depressive disorders. Either meaning of the first word), and rhymes. In practice, it is may be experienced in schizophrenia. Given that the difficult to distinguish between flight of ideas and loos- phenomena are recognized through the person’s use of ening of associations (see below), especially when the language, they are also known as pressure of speech or patient speaks rapidly. When this happens it is often poverty of speech. helpful to record a sample of speech. Flight of ideas is characteristic of mania. Thought block Sometimes the stream of thought is interrupted sud- Loosening of associations denly. The patient feels that his mind has gone blank, This denotes a loss of the normal structure of thinking. and an observer notices a sudden interruption in the To the interviewer the patient’s discourse seems mud- patient’s speech. In a minor degree this experience is dled, illogical, or tangential to the matter in hand. It common, particularly when a person is tired, anxious, does not become clearer when the patient is questioned or distracted. In thought blocking, the interruptions are further; indeed, the interviewer has the experience that sudden, striking, and repeated, and are experienced by the more he tries to clarify the patient’s thinking (or the the patient as an abrupt and complete emptying of his longer he allows the patient to speak without interrup- mind. Thought blocking is an important symptom, as tion), the less he understands it. Several specific features it strongly suggests schizophrenia. The diagnostic asso- of this muddled thinking have been described, but they ciation with schizophrenia is stronger when the patient are difficult to identify with certainty, and the most interprets the experience in an unusual way—for exam- striking clinical impression is often a general lack of clar- ple, when he says that another person has removed his ity, best described by recording an example of the speech thoughts. and the impression made on the interviewer. This lack 16 16 Chapter 1 Signs and symptoms of psychiatric disorders of clarity differs from that of people who are anxious or as highly unpleasant experiences. These central features of low intelligence. Anxious people give a more coherent are often accompanied by other morbid experiences, account when they have been put at ease, and people including cha