Advanced Descriptive Psychopathology

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Advanced (Descriptive) Psychopathology

• Abraham Rudnick, MD, PhD

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Learning Objectives

• Knowledge of psychopathology.
• Skill in conceptual analysis and case discussion
  of psychopathology.
• Critical attitude to psychopathology.

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Topics

• Nosology and diagnostics.
• General psychopathology.
• Categorical psychopathology.
• Dimensional psychopathology.
• Uncommon psychopathology.
• Culture-bound psychopathology.

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Teaching Methods and Evaluation

• Interactive lectures.
• Group discussions.
• Self-learning.
• Final exam.
• Student feedback.

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Course Requirements

• Background knowledge of basic descriptive
  psychopathology (including DSM, ICD).
• Reading material (minimally - Rudnick 2002
  Hamilton 1985 Klein and Riso 1993 Leff 1988).
• Student active participation.

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Exercise - Critical Thinking

• Critically read and discuss dicta of short paper
  (Lewis 1966).

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Nosology

• Definition - science of classification of
  diseases (Dorlands 1982) demarcation of
  ill-health phenomena (medical taxonomy).
• Importance - reliability (common language),
  validity (less misdiagnoses).

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External Demarcation - Disease and
Health (Rudnick 2002)

• Health as a positive or negative notion.
• Health as mechanistic or holistic.
• Health as the common, the ideal or the adaptive.
• Health as a state or process.

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Intermediate Demarcation - Disease and Related
Phenomena

• Disease and illness (Parsons 1951).
• Disease (impairment), disability and
  handicap/disadvantage (ICIDH).
• Physical and mental disease (Boorse 1975).

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Internal Demarcation

• Symptom, sign and lab test.
• Syndrome and disorder.
• Spectra.
• Etiology, pathogenesis, pathophysiology,
  pathology, course and comorbidity.
• Agent-host-environment
  (stress-vulnerability-coping).

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Diagnostics

• Diagnosis and differential diagnosis.
• Bayes theorem.
• Venn diagrams.
• Therapeutic trials.
• Differential therapeutics.

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Exercise - The
WHO Definition of Health

• Health is a state of complete physical, mental,
  and social well-being, and not merely the absence
  of disease or infirmity (Callahan 1973).
• Conduct a conceptual analysis of the WHO
  definition of health as applied to mental health.

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General Psychopathology

• Types of symptoms and signs.
• Specific symptoms and signs.

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Types of Symptoms and Signs (Hamilton 1985)

• Psychosis, neurosis and other entities.
• Impairments of perception, of thought and speech,
  of memory cognition, of emotion, of the
  experience of the self, of consciousness, of
  movement appearance, of personality.

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Exercise - Voices or Thoughts?

• Someone thinks he/she hears voices.
• How would you decide whether this is an
  impairment of perception or of thought (or a
  normal phenomenon)?
• Role play a simulated interview to practice
  deciding on this.
• Discuss the importance of deciding this.

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Specific Symptoms and Signs (mainly based on
Hamilton 1985)

• Impairments of perception -
• 1. Sensory distortions (intensity, quality,
  spatial form).
• 2. Sensory deceptions (illusions,
  hallucinations).
• 3. Impairments of the experience of time.

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Symptoms and Signs (cont)

• Impairments of thought and speech -
• 1. Intelligence.
• 2. Stream of thought (tempo, continuity).
• 3. Possession of thought (obsessions, thought
  alienation).
• 4. Content of thought (over-valued ideas,
  primary vs. secondary delusions,
  systematization).
• 5. Form of thought (e.g., condensation).
• 6. Speech (functional, aphasia).

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Symptoms and Signs (cont)

• Impairments of memory and cognition -
• 1. Amnesias (antero/retrograde, dissociative).
• 2. Memory distortions (recall, recognition).
• 3. Attention deficits (e.g., in concentration,
  in split attention).
• 4. Executive functions (e.g., planning).
• 5. Combined (e.g., working memory).
• 6. Others (e.g., apraxias, agnosias, social
  cognition).

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Symptoms and Signs (cont)

• Impairments of emotion -
• 1. Abnormal emotional predisposition (e.g.,
  dysthymia).
• 2. Abnormal emotional reaction (e.g., panic,
  dysphoria).
• 3. Abnormal expressions of emotion (e.g.,
  lability, affect dissociation and restriction).
• 4. Morbid emotions (e.g., agitation, mania).
• 5. Morbid emotional expression (e.g., affect
  inadequacy, flatness).

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Symptoms and Signs (cont)

• Impairments of the experience of the self -
• 1. Awareness of self-activity
  (depersonalization, derealization, loss of
  emotional resonance).
• 2. Immediate awareness of self-unity (e.g.,
  demoniac possession).
• 3. Continuity of self (e.g., fugue, multiple
  personality).
• 4. Boundaries of self (e.g., body image
  distortions such as dysmorphophobia, passivity
  feelings).

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Symptoms and Signs (cont)

• Impairments of consciousness (confusion) -
• 1. Dream-like changes (delirium).
• 2. Lowering of consciousness (torpor).
• 3. Restricted consciousness (twilight state).

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Symptoms and Signs (cont)

• Impairments of movement and appearance -
• 1. Adaptive (e.g., mannerisms).
• 2. Non-adaptive (e.g., stereotypy).
• 3. Motor speech (e.g., echolalia).
• 4. Posture (e.g., waxy flexibility).
• 5. Abnormal complex (e.g., compulsions).
• 6. Physical appearance (e.g., pallor).
• 7. Social appearance (e.g, grooming).

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Symptoms and Signs (cont)

• Impairments of personality -
• 1. Exaggerated traits (e.g., shyness).
• 2. Morbid traits (e.g., sadism).

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Exercise - Tests for Delusions

• Suggest and discuss a test for delusions of
  jealousy (as distinguished from normal jealousy).
• Suggest and discuss a test for religious
  delusions (as distinguished from normal religion).

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Categorical Psychopathology (Klein and Riso 1993)

• History.
• ICD.
• DSM.

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History - Formal Categorical Psychopathology

• 1840 (US) - 1 category (idiocy/insanity).
• 1880 (US) - 7 categories.
• 1889 (Paris) - 11 categories.
• 1917 (APA) - chronic inpatients.
• 1935 (AMA) - similar to 1917
  (mostly psychoses and neuropsychiatric).
• 1948 (ICD-6) - 26 categories (psychoses,
  neuroses, personality and behavior disorders, and
  mental retardation).

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History (cont) - Categorical Classification of
Schizophrenia

• Kraepelin - hallucinations and delusions down
  course (vs. mania-depression and paranoia).
• Bleuler - primarily 4 As (associations, affect,
  autism, ambivalence), and secondarily
  hallucinations and delusions variable course.
• Schneider - first rank (e.g., passivity feelings
  and commenting voices) and second rank symptoms
  (e.g, persecutory delusions and mood changes).
• WHO International Pilot Study of Schizophrenia.

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ICD-10 (1992)

• Organic mental disorders.
• Psychoactive substance abuse.
• Schizophrenia, schizotypal and delusional
  disorders.
• Mood affective disorders.
• Neurotic stress-related and somatoform disorders.
• Behavioral syndromes with bodily aspects.
• Disorders of adult personality and behaviour.
• Mental retardation.
• Disorders of psychological development.
• Disorders with onset usually before adulthood.

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DSM

• DSM-I - 1952.
• DSM-III - 1980 (diagnostic criteria, no
  reactions, no neurosis, multiaxial evaluation,
  diagnostic hierarchies).
• DSM-IV - 1994 (specific axes I-V changes, e.g.,
  GAD, PDD, NMS, stressors, GAF).

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Exercise - Comparison of
ICD and DSM

• Compare ICD-10 and DSM-IV on schizophrenia, major
  depression, PTSD and personality disorders
  derive and discuss general differences between
  ICD-10 and DSM-IV.

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Dimensional Psychopathology (Klein and Riso 1993)

• Inter-categorical dimensional assessment.
• Intra-categorical dimensional assessment.
• Dimensional operationalization.

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Inter-Categorical Dimensional Assessment

• State assessment (e.g., the SCL-90-R
  somatization, obsessive-compulsive, interpersonal
  sensitivity, depression, anxiety, hostility,
  phobic anxiety, paranoid ideation, psychoticism,
  additional items).
• Trait assessment (e.g., the MMPI
  hypochondriasis, depression, hysteria,
  psychopathic deviance, masculinity-femininity,
  paranoia, psychasthenia, schizophrenia,
  hypomania).

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Inter-Categorical Dimensional Assessment (cont)

• General assessment (e.g., Eysencks
  neuroticism/psychoticism scale).
• Generalized assessment (e.g., CGI for total
  severity of symptoms).
• Related assessment (e.g., Allens RTI for ADLs).

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Intra-Categorical Dimensional Assessment

• Schizophrenia (e.g., the PANSS).
• Depression (e.g., the BDI).
• PTSD (e.g., the IES).
• And many more...

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Dimensional Operationalization

• Scoring (e.g., yes/no, likert).
• Reporting (e.g., self-report, clinician-rated).
• Sub-scaling (e.g., exploratory and confirmatory
  factor analysis).
• Psychometrics (e.g., reliability, internal
  consistency, validity).
• Feasibility.

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Exercise -Scale Construction

• Construct a scale to measure a psychopathological
  dimension and discuss its objectives and its pros
  and cons. Suggest ways to test it.

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Uncommon Psychopathology

• Rare or unusual?
• Uncommon psychiatric syndromes.

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Uncommon Psychiatric Syndromes (Enoch and Ball
2001)

• Capgras syndrome.
• De Clerambaults syndrome.
• The Othello syndrome.
• Gansers syndrome.
• Munchausens syndrome.
• Gilles de la Tourettes syndrome.
• Cotards syndrome.
• Folie a deux/plusiers.
• Ekboms syndrome.

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Exercise - Catatonia

• Discuss whether catatonia is an uncommon
  psychiatric syndrome.

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Culture-Bound Psychopathology

• Universality of form, relativity of content (and
  course and outcome)?
• Culture-bound syndromes.

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Culture-Bound Syndromes (Leff 1988)

• Koro.
• Wihtigo.
• Amok.
• Latah.
• Possession.

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Exercise - Jerusalem Syndrome

• Discuss whether the Jerusalem syndrome is
  culture-bound.

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PBL - Page 1

• Presenting problem - Mr. B. is a 73 year old
  secular married man that is being detained in
  custody for attempting to suffocate his 3 year
  old grandson. You are asked to assess him.

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PBL - Page 2

• History - Mr. B. immigrated here from the former
  USSR 2 years ago. He lives with his wife, and his
  2 married sons live near him. He retired when he
  was 65, after working as a civil servant for 43
  years. He has had no known criminal or
  psychiatric issues till now, and he has no
  physical disorders except for hypertension. Since
  immigrating, he has become gradually withdrawn
  and forgetful. Last month he told his wife that
  his grandson, who has mild Down syndrome, might
  be better dead than alive due to his
  disadvantage. His wife swore him to secrecy about
  these morbid thoughts, so as not to upset the
  family.

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PBL - Page 3

• Examination (via Russian translator) - Mr. B. is
  very thin, tired-looking, poorly shaved, with
  partial eye contact, oriented to place and person
  but not to time (except for year and season),
  moderately agitated, with dysphoric affect,
  ruminates that the world is cruel to
  disadvantaged males and expresses a wish to put
  them out of their misery, denies hallucinations
  and suicidal intent. He remembers reasonably
  well, except for dates and names, but denies
  recollection of any happenings to him during the
  last few days (including his assault on his
  grandson, to which he responds by extreme
  withdrawal).