Psychopathology 1

and Basic Concepts

The word Psychiatry is derived from ‘psyche’ Greek word „„ Depersonalization: Patient feels as if he does not exist
for soul or mind and ‘iatros’ Greek for healer. This medical anymore (occurs in dissociative disorder, panic disorder,
specialty deals with study, diagnosis, treatment and prevention schizophrenia)
of mental abnormalities and disorders. „„ Derealization: Patient feels as if the world does not exist
Psychology: This is a branch of science that deals with the mind (seen in dissociative hysteria, temporal lobe epilepsy,
and mental processes—consciousness, sensation, ideation and extreme fatigue or anxiety and psychotic illness of all sorts)
memory etc. „„ Echolalia: Repetition of phrases or sentences
(schizophrenia/Mental retardation/learning disability/
dementia/head injury/Tourette’s syndrome)
DICTIONARY OF PHENOMENOLOGY „„ Echopraxia: Repetition of acts done by examiner
„„ Perseveration: Persisting with same reply beyond point
„„ Hallucination: Abnormal perception without external
of relevance (Organic brain lesions) “where do you live?”,
stimuli
“Chennai”, “How old are you”, “Chennai”…
„„ Illusion: Abnormal perception in the presence of external „„ Palilalia: Perseverated word is repeated with increasing
stimuli frequency
„„ Apraxia: Inability to perform skilled motor movements with „„ Logoclonia: Perseveration of the last syllable of the last
normal comprehension, muscle strength and coordination word
„„ Aphasia: Loss or impairment of linguistic ability as a result „„ Magical thinking: It is a belief that some actions and
of brain damage outcomes are connected although there is no rational basis
„„ Agnosia: Deficits in self-experience (anosognosia – denial (if you step on a crack, your mother will break her back) seen
of illness) in OCD and psychotic patients
„„ Anhedonia: Lack of interest in pleasurable activities „„ Neologism: New word formation (schizophrenia)
(depression) „„ Obsession: A thought, idea, image or impulse which is
„„ Catastrophic reaction: Sudden agitation, anger when repetitive, intrusive, distressing, irrational and perceived as
demented persons or persons with head injury are asked patient’s own.
to perform tasks beyond their capacity „„ Palimpsest: Also called as alcoholic black out
„„ Compulsion: An act performed repeatedly to reduce anxiety „„ Pseudologia fantastica: Production of convincing false
in response to obsessive thought accounts with sincere conviction (seen in Munchausen’s
„„ Confabulation: Confabulation is defined as false memories syndrome)
occurring in clear consciousness. Lesion in Korsakoff’s „„ Stereotypy: Repetitive and bizarre movement, non-goal
psychosis occurs in hypothalamic-diencephalic region. directed (schizophrenia, autism)
Insight is usually preserved. There are two types of „„ Verbal stereotypy: Repetition of a word or phrase (Stock
confabulation: (1) Momentary- this type can be usually word) that has no immediate relevance to the context
traced to a time disembarked from actual facts, brief and „„ Mannerism: Abnormal goal directed movement (dramatic
requires provocation. (2) Fantastic – this type has elaboration way of walking)
of content, sustained and there is often involvement of „„ Abreaction: A process by which repressed material,
frontal lobe. particularly painful experience is brought back to
„„ Coprolalia: Forced vocalization of obscene words or consciousness.
phrases (Tourette syndrome) „„ Alexithymia: Inability to describe or being aware of one’s
„„ Déjà vu: Familiarity of unfamiliar situation emotions.
„„ Jamais vu: Unfamiliarity of the familiar situation (temporal „„ Dysprosody Loss of emotionally expressive component
lobe epilepsy/schizophrenia) of speech, such as normal speech melody, emphasis, and
„„ Delusion: Abnormal, false firm belief that persists in spite of gesture
evidence to contrary
 Disturbances of Consciousness Abnormal Expression of Emotion
Clouding: It is characterized by deterioration in thinking, „„ Denial or dissociation of affect—as seen in hysteria (La belle
attention, perception and memory. indifference)
Patient appears confused; agitated/excitable or quiet; „„ Emotional indifference—expected emotional response is
usually of organic origin. not shown to others
Examples include Oneiroid states and Twilight states „„ Perplexity—anxious and puzzled bewilderment; seen in
Drowsiness: In this the patient drifts off to sleep when left early schizophrenia, and confusional states
without sensory stimulation
„„ Emotional incongruity—apparent mismatch between the
There is slow, slurred, sluggish speech;
content of speech and the affect; characteristic of acute
Examples include Torpor (drowsy, readily falls asleep with
schizophrenic disorder
slowed thinking and narrowed perception).
Stupor (Medical): Patient can be aroused only by strong or „„ Emotional blunting—dulling of the normal emotional
painful stimulus responses; characteristic of chronic schizophrenia
Coma: Patient cannot be aroused even with painful stimuli „„ Emotional lability—rapid fluctuations of emotion
Twilight state: Commonly last from one to several hours; zz Seen in organic disorders, brain stem lesions, mania,
consciousness is always impaired; generally organic in origin; and personality disorders
characterized by: (1) abrupt onset and end (2) variable duration „„ Emotional incontinence—an extreme form of emotional
(3) unexpected violent acts or emotional behavior lability, with complete loss of control over the emotions
Automatism: A state of clouding of consciousness which zz Seen in organic disorders, especially pseudobulbar
occurs during, or immediately after, a seizure during which palsy
the individual retains control of posture and muscle tone, and
performs simple or complex movements and actions without Disorders of Self
being aware of what is happening
Depersonalization: Sense of awareness of existence as a person
Dream-like (Oneiroid) state: The patient is disorientated,
is altered
confused and experiences elaborate hallucinations, usually
Derealization: The loss of the sense of reality of surroundings,
visual.
usually involving a visual perceptual distortion
Disorder of Emotions „„ May be seen in dissociative hysteria, temporal lobe epilepsy,
extreme fatigue or anxiety, and psychotic illness of all sorts
Mood: A pervasive and sustained emotion subjectively
„„ Usually associated with a change in mood
experienced and reported by patient.
Some types of mood are:
„„ Euthymic (normal) DISORDERS OF PERCEPTION
„„ Dysphoric (unpleasant)
„„ Elevated (elated, expansive, euphoric, or ecstatic) Perception: Mental process by which sensory stimuli are brought
„„ Depressed to awareness.
„„ Alexithymia (inability to or difficulty in describing or being
aware of one’s mood) Types: Sensory Distortions and Sensory
„„ Labile (rapid and abruptly changing mood). Deceptions
Affect: It is the observed expression of the mood. It is the feeling
Sensory Distortions
tone that accompanies an idea.
Range of affect: It is the full capacity of emotionality expressed Changes in the quality, intensity, or spatial form of a perception
by the patient may be distorted in terms of:
P Intensity of affect: Refers to the depth of affective response „„ Intensity:
S (e.g. restricted, blunted, flat) blunting refers to lack of emotional zz Hyperacusis - mania
sensitivity; flat affect refers to limitation of usual range of emotion Hyperthyroidism
Y
zz
Appropriateness (congruency) of affect – with reference to zz Depression
C the topic the patient is discussing zz Migraine
H zz Toxic States (E.g. Alcohol ‘hangover’) Hypoacusis - in
Abnormal Emotional Reactions
I Anxiety: A fear with no adequate cause; regarded as pathological
some organic states
Color: Xanthopsia - produced by psychedelics and temporal
A
„„
if it is excessive or prolonged, or interferes with normal life; lobe lesions
T usually accompanied by somatic and autonomic changes „„ Proportions: Dysmegalopsia – a disorder of visual
Depression: Feeling of misery, inner emptiness, hopelessness,
R and helplessness
processing causing subjective distortions in the size of the
object. It can be described as Macropsia or Micropsia.
Y Euphoria and ecstasy: Excessive and unrealistic cheerfulness
zz Macropsia – objects appear larger than their normal
and a feeling of extreme well being
size; Micropsia – objects appear smaller than their
Apathy: The loss of all feeling – no emotional response can be
446 elicited
normal size
Sensory Deceptions „„ Illusions: These are misinterpretations of real stimuli (e.g.
Hallucinations: These are false sensory perceptions in mistaking a rope for a snake)
absence of any real external stimuli. They are unwilled, occur Three types:
spontaneously and cannot be readily controlled by the patient. zz Affect illusion: Most common Misperception +
They are experienced as sensations (not as thought or fantasy). heightened emotion (for example, a tree moving in
Some types of hallucinations are: dark perceived as ghost)
„„ Structured hallucinations (e.g. hearing voices) zz Completion illusion: It depends on inattention such as
„„ Unstructured hallucinations (e.g. hearing sounds) misreading words in newspapers
„„ Elementary hallucinations (e.g. hearing noises or seeing zz Pareidolic illusion: Vivid mental images occurring
flashes of light) without conscious effort when perceiving ill-defined
„„ Complex hallucinations (e.g. hearing voices or seeing faces) stimuli (seeing faces in fire or clouds)
„„ First person hallucinations (voices echoing from outside) „„ Pseudohallucinations: Occur in the inner subjective space;
„„ Second person hallucinations (e.g. voices that address the are not concretely real; are transitory; and described as an
patient directly) ‘as-if’ experience.
„„ Third person hallucinations (e.g. voices referring to the „„ Imagery: An experience within the mind that is usually
patient as ‘he’ or ‘she’) without any sense of reality and which is usually part of a
„„ Command hallucinations (e.g. voices that command and perception. It occurs in subjective space, unclear, inconstant
which patient feels obliged to obey) and dependent on will. Insight is preserved and life like
„„ Auditory hallucinations (characteristic of schizophrenia) quality is absent.
„„ Visual hallucinations (most common in organic conditions) zz Eidetic imagery: A visual image that is so intense and
detailed that it has got photographic quality.
„„ Olfactory hallucinations (may be seen in delusional
disorders, schizophrenia, epilepsy and other organic states) zz Pareidolia: Vivid imagery that persists even when a
„„ Gustatory hallucinations (may be seen in uncinate seizures person looks at a poorly structured background like a
and temporal lobe epilepsy) plain wall.
Tactile hallucinations: These can be: Table 1:  
Difference between hallucination and pseudo-
„„ Superficial: hallucination
zz Thermic (e.g. sensation of heat or cold)
zz Haptic (e.g. formication seen in cocaine use) Hallucination Pseudohallucination
zz Hygric (e.g. fluid sensations) Occurs in objective space Occurs in subjective space
„„ Kinesthetic (e.g. sensations in muscle or joints) Its clear and vivid Not vivid
„„ Visceral also called somatic or kinesthetic hallucinations Constant and independent Inconstant and independent
(e.g. cutting sensation in the bone marrow) of will of will
Hypnopompic hallucinations: Hallucinations while awakening

Chapter 1  •  Psychopathology and Basic Concepts

Hypnagogic hallucinations: Hallucinations while falling asleep It has life like quality and Life like quality is absent and
Autoscopic hallucinations: Seeing oneself in the external space insight is absent insight is partial
viewed from within one’s own physical body; also called phantom Thought: A goal-directed flow of ideas, symbols and associations,
mirror image. Experience of seeing a visual hallucination of initiated by a problem or task, and leading towards a reality-
oneself (schizophrenia) oriented conclusion.
Negative autoscopy is the experience of looking into a mirror
and seeing nothing at all Table 2:  Disorders of thought
The double phenomenon: Doppelgänger is an awareness of
oneself as being both outside alongside, and inside oneself; Disorders of stream of Disorder of content of thought
is the subjective phenomenon of doubling; often a variety of thought
depersonalization Pressure of thought Thought insertion/withdrawal
Functional hallucination: Here an external stimulus is Poverty of thought Thought broadcast
necessary to provoke the hallucination. Normal perception and Thought blocking Delusion
the hallucination are in the same modality and experienced
simultaneously (e.g. hearing voices coming from a running tap) Disturbances in form of thought: For example, neologisms,
1.
Extracampine hallucination: Here the hallucinations are word salad, circumstantiality, loosening of associations,
experienced outside the limits of the sensory field (e.g. hearing tangentiality, derailment (i.e. knight’s-move thinking),
voices coming from outer space) vorbeireden (i.e. talking past the point), verbigeration,
Reflex hallucinations (also known as Synesthesia): Here a echolalia, perseveration.
stimulus in one sensory modality produces hallucination in Loosening of associations and tangentiality are classically
another sensory modality (e.g. sound is experienced as being seen in schizophrenia.
seen). for example, A patient felt a pain in the head when she Loosening of association: Thought disorder characterized
heard other people sneeze. It is a pathological variety of by obliquely related or completely unrelated responses and
synesthesia. disconnected ideas. 447
 Flight of ideas: Loss of coherent goal-directed thinking; something that is immensely significant.
connections between thoughts may be based on: Patient is profoundly uncomfortable,
zz Chance relationships, clang associations, distracting perplexed, and apprehensive. When the
stimuli, verbal associations delusion becomes fully formed there is often
zz Clang associations – vague connections prompted by a sense of relief!
rhyme and sounds of words Delusional memory (Retrospective
Circumstantial thinking: The slow stream of thought delusion): An event that occurred in the past
is affected by a defect of intellectual grasp, a failure of is explained in a delusional way.
differentiation of the figure ground – there is a great deal Secondary delusions (Delusion-like ideas):
of unnecessary detail which obscures the meaning. Delusions are understandable after taking
Occurs in: Epilepsy, mental retardation, obsessional detailed psychiatric history in terms of the
personality patient’s life history and current mood state
Perseveration is commonly associated with cognitive Systematized delusions: Delusions that are
disorders. united by a common theme
2. Disturbances in stream of thought: For example, pressure Mood-incongruent delusions: Delusions
of thought, retardation of thought, poverty of thought, that are not in keeping with the patient’s
thought block, flight of ideas current mood state.
3. Disorders of content of thought: For example, delusions, Types of delusions based on their content:
overvalued ideas, obsessions) i. Self-referential delusion: e.g. “people are
a. Delusion (term coined by Jaspers): talking about me”
|| False, firm, fixed belief based on incorrect ii. Persecutory delusion: e.g. “people are
inference about reality against me” or “people are out to harm
|| Patient holds this particular belief with same me”. Commonest type of delusion and
conviction and intensity as he holds other (non- seen in schizophrenia, alcoholism, mania,
delusional) beliefs (i.e. the belief is held with depression, or paranoid personalities
unusual conviction) iii. Grandiose delusion: e.g. talking big things
|| Belief cannot be corrected by reasoning or by or patient feels he has some “special powers”.
evidence to the contrary (i.e. the belief is not Seen in mania, schizophrenia.
amenable to logic) iv. Delusion of infidelity or morbid jealousy
|| Belief is not consistent with the patients’ (also called othello syndrome): Belief
intelligence and cultural background that your spouse is not loyal. Common with
Conrad proposed five stages in development of alcohol abuse and impotence.
delusion: v. Delusion of love: Belief that a person from a
i. Trema: A delusional mood which represents higher socioeconomic background is in love
a total change in the perception of the world with them. Erotomania, De Clerambault’s
syndrome, Clerambault – Kandinsky complex
ii. Apophony: The search for and the finding of
new meaning for one’s psychological events vi. Delusion of poverty: Patient believes that
he is poor and financially unstable when in
iii. Anastrophe: Heightening of psychosis
reality its not true; usually seen in depression
iv. Consolidation: Formation of a new world or
vii. Nihilistic delusion (also called as Cotard’s
a ‘psychological set’ based on new meanings
syndrome): Patients complain that they
v. Residuum: Eventual autistic state
have not only lost their possessions, status
Some of the various types of delusions are:
P Primary (True) delusions: Delusions
or strength but also their heart, blood and/
or intestines. Their world is reduced to total
S arising without any external cause. They are nothingness.
Y un-understandable. viii. Delusion of Guilt: patient believes that he
Types of Primary Delusions (according to
C Jaspers)
done a mistake in the past for which he is
being punished; common in depression
H Autochthonous delusion (Delusional ix. Hypochondriacal or Somatic delusion:
I intuition): Occurs suddenly and ‘out of the Delusion of a peculiar odor, ugliness or
blue’
A Delusional perception: Normal perception
misshapenness (e.g. Koro – a culture-based
delusion that penis is shrinking into the
T which is then interpreted by a delusional abdomen and death will soon follow).
R meaning. x. Delusion of infestation (Ekbom syndrome):
Delusional atmosphere (Delusional
Y mood): A feeling of anticipation on part
Person believes that insects or worms are
affecting his health; seen in delusional
of the patient that all the different parts of disorder, schizophrenia, organic mental
448 his experience will fit together to reveal disorders
 xi. Delusion of control: e.g. thought insertion or catatonic excitement, catatonic stupor, rigidity, posturing, waxy
thought withdrawal flexibility (cerea flexibilitas), akinesia
xii. Bizarre delusions: Absurd, totally Automatic obedience: (Despite instructions to the contrary, the
implausible delusions. patient permits the examiner’s light pressure to move his limbs
b. Overvalued idea: An acceptable, comprehensible idea into a new position)
pursued by the patient beyond the bounds of reason. It Ambitendency: (The patient appears “stuck” in an indecisive,
is usually associated with an abnormal personality. It hesitant movement)
was coined by Wernicke (1906) to distinguish it from an „„ Negativism—motiveless resistance
obsession in that it was not experienced subjectively as „„ Echopraxia—pathological imitation of movements of one
senseless. Seen in anorexia, hypochondriasis. person by another
c. Obsessions: Recurrent, intrusive thoughts, feelings, „„ Stereotypy—fixed repetitive pattern of physical action or
ideas or sensations which are persistent and irresistible; speech
associated with intense anxiety; cannot be eliminated „„ Mannerism—ingrained habitual movement that has lost its
by logical effort. Some common obsessional themes are purpose
contamination or dirt, pathological doubt, symmetry Differential diagnosis: Encephalopathy, noncatatonic stupor,
and sexual. locked in syndrome, parkinsons disease, nonconvulsive status
epilepticus
Disorders of Memory Benzodiazepines (Lorazepam): Drug of choice for functional
Amnesia: Partial or total inability to recall past experiences; may catatonia. 50 to 70% of patients with catatonia respond to
be organic or emotional in origin. lorazepam 2 mg every 3 to 8 hours (6–16 mg/day) over a period
Anterograde amnesia: Occurring after a particular point or of 3 to 5 days.
event in time. „„ ECT is beneficial in catatonia with affective subtype.
„„ Alcoholic black outs „„ Perseveration - persisting response to a previous stimulus
„„ Delirium even after a new one has been presented
„„ Twilight state due to epilepsy „„ Chorea - random quick jerky involuntary movement
„„ Pathological drunkenness „„ Tics - irregular repeated movements involving a group of
Retrograde amnesia: Occurring before a particular point or muscles
event in time; common in cases of head injury. „„ Akathisia - subjective feeling of muscular tension leading to
„„ Transient global amnesia = Sudden onset of retrograde restlessness caused by medications like antipsychotics
amnesia lasting for days to several years „„ Dystonia - medication-induced sustained contractions of a
„„ Perception and personal identity is normal group of muscles
„„ There is evidence of ischemia in the territory of posterior „„ Dyskinesia - involuntary movements such as those seen in
cerebral circulation extrapyramidal reactions
„„ Immediate cause is from bilateral thalamic or thalamic „„ Apraxia -is the inability to perform purposeful volitional acts

Chapter 1  •  Psychopathology and Basic Concepts

lesions -does not result from sensory loss, paresis, incoordination,
Paramnesias: Falsifications of memory by distortion of recall. or involuntary movements
They can be seen in normal people, temporal lobe epilepsy, „„ Ideational apraxia - inability to imitate or put together
psychosis or hysteria. For example complex gestures and actions, despite understanding the
„„ Fausse reconnaissance (false recognition) request is always bilateral
„„ Retrospective falsification – the subject modifies his „„ Dressing apraxia - a form of ideational apraxia
memories in terms of his general attitudes seen in zz Due to lesions of nondominant parietal lobe
„„ Confabulation (unconscious filling of memory gaps by „„ Constructional apraxia inability to copy designs and
untrue experiences) structures
„„ Déjà vu (new situation incorrectly regarded as a repetition of zz Twice as frequent in right- as in left-sided lesions
a previous memory) zz Closely associated with visuospatial agnosia
„„ Jamais vu (false feeling of unfamiliarity), Déjà entendu
(illusion of auditory recognition) Disorders of Speech
„„ Déjà pense (illusion of thought recognition) Psychogenic abnormalities
Dissociative amnesia: There is a complete loss of memory and „„ Hysterical mutism - often as reaction to stress
identity but the patient can carry out complicated patterns of „„ Approximate answers - seen in: hysterical pseudodementia,
behavior and is able to look after themselves. It is associated with Ganser syndrome, Organic brain disease
fugue. „„ Pseudologia fantastica - seen in histrionic personality
disorder, overlap with Munchausen syndrome
Disorders of Conation
Motor behavior. Some disturbances of conation are as follows: Speech Disturbances
Catatonia—Coined by Karl Kahlbaum. postural
„„ Aphonia
abnormalities seen in schizophrenia and some organic states
e.g. catalepsy (i.e. constantly maintained immobile position),
zz Loss of ability to vocalize 449
 „„ Dysphonia Insight
zz Impairment with hoarseness
It is defined as patient’s degree of awareness and understanding
zz Occurs in disease of the vocal cords and IXth cranial about being ill. There are 6 grades of insight from denial (grade
nerve lesions
1) to intellectual (grade 5) and true emotional insight (grade 6).
„„ Dysarthria
zz Lesions of the brain stem, e.g. bulbar/pseudobulbar Classificatory System
palsy
Classification enhances communication between professionals
zz Schizophrenia
and collaboration of care.
zz Personality disorders (perhaps consciously produced)
„„ Logorrhea
ICD 10 and DSM 5
zz Excessive production of the volume of speech, without
pressure of speech ICD: International classification of diseases – codes are for all
illnesses including mental illness and alphanumerical. Code F
„„ Logoclonia
and chapter 5 are for mental illness. ICD is available in multiple
zz Spastic repetition of syllables
versions and devised by WHO.
zz Occurs in Parkinsonism ICD-10: The International Classification of Diseases (ICD) is an
„„ Echolalia international standard diagnostic classification for all general
zz Repetition of words or phrases that are spoken to him epidemiological and many health management purposes,
zz Seen in published by WHO. It now exists in its tenth revision. Chapter V
|| Learning disability is relevant for mental and behavioral disorders.
|| Dementia The ICD-10-classification for mental disorders consists of 10
|| Head injury main groups:
|| Tourette’s syndrome „„ F0 Organic, including symptomatic, mental disorders
„„ Unintelligible speech „„ F1 Mental and behavioral disorders due to use of
zz Dysphasia psychoactive substances
zz Paragrammatism–disorder of grammatical construction „„ F2 Schizophrenia, schizotypal and delusional disorders
zz Private symbolism „„ F3 Mood [affective] disorders 
|| Neologisms – new word formation „„ F4 Neurotic, stress-related and somatoform disorders 
„„ Verbigeration „„ F5 Behavioral syndromes associated with physiological
zz Refers to the repetition of words or syllables that disturbances and physical factors 
expressive aphasic patients may use while searching for „„ F6 Disorders of personality and behavior in adult persons
the correct word „„ F7 Mental retardation 
„„ F8 Disorders of psychological development
„„ F9 Behavioral and emotional disorders with onset usually
COGNITIVE FUNCTIONS occurring in childhood and adolescence 
In addition, there is a group of “unspecified mental
„„Disturbance of:
disorders”.
zz Orientation: To time, place and person
For the chapter of mental disorders, every main group has
zz Attention and Concentration - Serial seven tests, the the identification letter “F”. For each group exist more specific
patient is asked to subtract 7 from 100. Up to 5 steps are
subcategories.
enough to evaluate the patient.
It is available in multiple version ICD 10 DCR, ICD 10
zz Memory
P || Immediate term memory → ask him to repeat your
Primary care version and translated into various languages.
Multiaxial system as per ICD 10 is
S words (3 unrelated words) Axis I: Mental illnesses (including personality disorders and
Y || Short term memory → give him a name of an intellectual disability) and Physical disorders
address with at least 7 items and ask him to repeat
C it after 5 minutes or an account of 24-hour events.
Axis II: Impairment in self-care, occupational, family and social
functioning
H || Long-term memory → ask him about personal Axis III: Psychosocial factors associated with mental illness
I and impersonal events
Visuospatial ability: Copy a figure DSM 5: (Diagnostic and Statistical Manual is proposed by
A
zz
zz Abstract thinking: Similarities and proverb American Psychiatric Association. Codes are only numerical and
T interpretation for mental illnesses)
R zz Fund of information and knowledge: Calculating Some of the changes in DSM 5 are as follows: (Must Know)
• Mental retardation is replaced by Intellectual disability
Y ability,name past presidents
 Intelligence: It is judged clinically based on above • OCD and Stress related disorders (PTSD) are separated from
information and confirmed by formal psychological anxiety disorders

450 tests of intelligence. Contd…

• Pervasive developmental disorders (Autism) is replaced by Duration Criteria for Mental Illnesses
Autism Spectrum Disorders
Psychoses
• ASD includes autistic disorder, PDD NOS, Asperger’s and CDD
(rett’s removed) Acute and transient <2 weeks (ICD 10); Brief reactive
• ADHD – onset criterion changed from 7 years to 12 years psychosis psychosis – 1 month (DSM)
• Depression and bipolar disorders are given separate Schizophrenia 1 month (ICD 10) and 6 months (DSM 5)
categories rather under mood disorders
Delusional disorder 3 months
• Schizophrenia subtypes are abolished
• Hypochondriasis is replaced by Illness Anxiety Disorder Mood disorders
• Gender dysphoria is a new diagnostic category in children Major depressive disorder 2 weeks
Dysthymia 2 years
MULTIAXIAL CLASSIFICATION – DSM 5 Mania 1 week
Cyclothymia 2 years
Axis Disorder
Neurotic and stress related disorders
I Clinical psychiatric disorders, Bulimia nervosa
(e.g. Major depressive disorder, single episode, severe OCD 2 weeks
but without psychotic features, with postpartum onset) Acute stress reaction Within hours of stressful event and
II Personality disorders and Mental retardation remits within 2–3 days
(e.g. Antisocial personality disorder) Adjustment disorder Onset of symptoms within 1 month
III Medical conditions (e.g. TB) of life event

IV Abnormal Psychosocial circumstances (e.g. Spouse PTSD Onset within 6 months of trauma
relational problem)
V GAF - Global Assessment of Functioning Scale score DIFFERENCE BETWEEN PSYCHOSIS
Newer Diagnoses Diagnoses AND NEUROSIS
terminologies with revised requiring research
Psychosis: Presence of psychotic symptoms (delusions and
terminology
hallucinations); insight is usually absent. E.g. schizophrenia,
• Hoarding • Specific learning • Attenuated delusional disorder etc
disorder disorder  psychosis Neurosis: Presence of anxiety symptoms; insight, judgement,
• Binge eating • Removal of syndrome (a personality and contact with reality intact. E.g. phobia, panic
disorder  bereavement precursor to disorder etc.
• Excoriation exclusion in schizophrenia)

Chapter 1  •  Psychopathology and Basic Concepts

disorder diagnosis of • Suicidal
• Disruptive major depressive behavioral QUICK GLANCE
mood disorder  disorder
dysregulation • Illness anxiety • Internet use „„ Hallucination and illusion are disorders of perception
disorder autism gaming disorder „„ Delusion is a disorder of content of thought (ego syntonic)
disorder 
spectrum disorder  • Nonsuicidal self- „„ Obsession is a disorder of possession of thought (ego
Obsessive-
• Posttraumatic injury dystonic)
compulsive
and related stress disorder „„ Most common hallucination seen in mental illness is
disorders • Pedophilic auditory hallucination
Trauma- and disorder  „„ Visual hallucination is commonly seen in organic states
stressor-related • Substance use „„ Delusion of doubles is called as Capgras syndrome
disorders disorder  „„ Features of normal thinking are continuity, constancy and
organization
ICD -10 DSM IV Differences „„ Examples of formal thought disorder – circumstantiality,
loosening of association, flight of ideas, tangentiality
ICD 10 DSM IV
„„ Perseveration is seen in organic states (frontal lobe injuries)
Alphanumerical coding system Numerical coding for „„ Insight is a differentiating feature between neurotic and
disorders psychotic states.
Codes for all disorders including Codes are only for mental
mental illness (chapter 5 and code F) illness
Operational and clinical criteria Operational criteria used
for research purposes
Available in various languages and Available as a single 451
multiple versions such as Primary document in English
care version, for research etc.
 MULTIPLE CHOICE QUESTIONS

1. The following is suggestive of an organic cause of the a. Q b. B

behavioral symptoms: (Recent Question) c. G d. F
a. Formal thought disorder 13. Term psychiatry was coined by: (JIPMER 2014)
b. Auditory hallucination a. Pinel b. Johann Christian Reil
c. Delusion of guilt c. Sigmund Freud d. Benjamin Rush
d. Prominent visual hallucination
14. A patient who is alert but not giving response is best
2. All of the following are features of hallucination except: categorized as: (JIPMER 2014)
(Recent Question) a. Stupor b. Coma
a. Depends on will of observer and is under voluntary c. Hysteria d. Delirium
control
15. Cataplexy is: (JIPMER 2013)
b. Occurs in inner subjective space
a. Sudden loss of muscle tone
c. It is vivid as sensory perception
b. Short term muscle relaxation
d. It occurs in absence of perceptual stimulus
c. Sudden muscle rigidity
3. Perseveration is: (Recent Question) d. Short period of loss of consciousness
a. Persistent and inappropriate repetition of the same
16. Which is not true regarding ‘affect’ in psychiatric
thoughts
interview? (JIPMER 2012)
b. When a patient feels very distressed about it
a. It has objective component
c. Characteristic of schizophrenia
b. Has subjective component
d. Characteristic of obsessive compulsive disorder
c. A cross-sectional manifestation of emotion
4. Lack of insight is not a feature of: (Recent Question) d. Persistent tone of feeling for a period of time
a. Panic disorder b. Schizophrenia
17. Sigmund Freud’s Primary Process of thinking is:
c. Mania d. Reactive psychosis
a. Absent in dreams (JIPMER 2011)
5. Mutism and akinesis in a person who appears awake and b. Illogical and primitive
even alert, is best described as: (Recent Question) c. Illogical and conscious
a. Twilight state b. Oneroid state d. Rational
c. Stupor d. Delirium
18. Ability to form a concept and generalize it is called:
6. Loosening of association is an example of: (JIPMER 2011)
a. Formal thought disorder  (Recent Question) a. Concrete thinking b. Abstract thinking
b. Schneider’s first rank symptoms c. Intellectualization d. Delusional thinking
c. Perseveration
19. True about memory except: (JIPMER 2010)
d. Concrete thinking
a. Consciously present
7. Altered (bizarre) perception/interpretation of real b. Form of working memory
objects is most appropriately known as: c. Type of sensory memory
a. Illusion b. Delusion (Recent Question) d. Stored in striatum
c. Hallucination d. Delirium
20. Déjà vu phenomenon means: (JIPMER 2007)
8. Which is not a perception disorder: (Recent Question) a. Feeling that familiar things look unfamiliar
a. Hallucinations b. Illusion b. Feeling that unfamiliar things look familiar
P c. Delusion d. None c. Unable to recall the familiar name
S 9. Tactile hallucinations are seen in all except:
(Recent Question)
d. Feeling detached from one’s own body
21. Mutism and akinesis in a person, who appears awake
Y a. Delirium tremens b. Amphetamine abuse and even alert, is best described as?
C c. Opioid withdrawl d. Frontal lobe tumor  (AIIMS May 2017, AIPG 2006)
H 10. 3rd person hallucination is characteristic of: a. Oneiroid state b. Stupor
(Recent Question) c. Twilight state d. Delirium
I a. Delusional disorder b. Schizophrenia 22. A 20-year-old female has thoughts of cutting her fingers,
A c. Delirium d. PTSD she plans and imagines doing it but never actually does
T 11. The term dementia precox was coined by: it. She says she is not having any guilt of having such
(Recent Question) thought. And also says the thoughts are distressing her
R a. Freud b. Bleuler and she is unable to control them. The thoughts vanish
Y c. Kraepelin d. Schneider either by ending with a seizure or automatically subsides
12. According to ICD-10, which letter is used to denote on its own. Which of the following is the cause?
mental illness? (JIPMER 2014)  (AIIMS May 2017)
452
 a. Obsession b. Thought insertion c. Neuropsychology
c. Forced thinking d. Crowding of thoughts d. Child psychology
23. In a patient with psychiatric disorder, the personal 27. Which of the following is not a disorder of form of
history does not include? (AIIMS May 2016) thought? (AIIMS May 2012)
a. Occupation history b. Academic history a. Derailment b. Tangentiality
c. Food preference d. Marital history c. Thought block d. Loosening of association
24. According to the ICD-10 revision, for establishing a 28. Cognitive model of depression is given by?
diagnosis of mania, the symptoms should persist for at a. Ellis b. Beck (AIIMS May 2011)
least? (AIIMS May 2014, Nov 2013) c. Godrey d. Meicheinbanon
a. 1 week b. 2 weeks 29. Formication and delusion of persecution occurs
c. 3 weeks d. 4 weeks together in? (AIIMS May 2011)
25. While performing a mental status examination (MSE), a. Cocaine b. Amphetamine
the awareness or understanding of a patient of his/her c. Cannabis d. LSD
illness is called? (AIIMS May 2013, Nov 2012) 30. Reflex hallucination is a morbid variety of? 
a. Insight b. Judgement  (AIIMS May 2011)
c. Orientation d. Cognition a. Kinesthesia b. Parasthesia
26. The study regarding the brain and behavioral changes in c. Hyperesthesia d. Synaesthesia
normal and damaged brain is known as? 31. Healthy thinking includes all except: (AIIMS May 2011)
a. Behavioral psychology (AIIMS Nov 2012) a. Continuity b. Constancy
b. Neurodevelopmental psychology c. Organization d. Clarity

ANSWERS WITH EXPLANATIONS

1. Ans. (d)  Prominent visual hallucination Add the following explanation

Ref: Kaplan and sadocks synopsis of psychiatry, 10th edn, P. •• Neurosis is a condition in which the predominant
No. 119 disturbance is that of anxiety.
•• It is characterized by symptoms that are distressing to
Atypical age of onset, lack of family history of mental illness,
the individual.
focal symptoms, visual hallucinations, focal neurological
•• Reality testing and personality organization are grossly
abnormalities, catatonia, difficulty in orientation or
intact.
memory, atypical response to treatment, atypical clinical
•• Behavior does not violate gross social norms.
course all are indicators of organic factors contributing to

Chapter 1  •  Psychopathology and Basic Concepts

•• Insight is usually preserved. Examples are phobia, panic
psychiatric presentation.
disorder, obsessive compulsive disorder.
2. Ans. (a and b)  a. Depends on will of observer and is Ref: Kaplan and Sadock’s Synopsis of Psychiatry, P. NO. 272.
under voluntary control; b. Occurs in inner subjective
space 5. Ans. (c)  Stupor
Ref: Kaplan and Sadock’s Synopsis of Psychiatry P. No. 278 Ref: Kaplan and Sadocks Synopsis of Psychiatry, 10th edn,
273, 282
True hallucination has four qualities (occurs in objective
space, is vivid, has life like quality and is involuntary). Stupor is defined as state of decreased response to
Hence in this both the options A and B are wrong. stimuli; In psychiatry, it is often used in conjunction with
mutism and is considered as an impairment in level of
3. Ans. (a)  Persistent and inappropriate repetition of the consciousness
same thoughts •• Akinesia is lack of physical movement as in the extreme
•• Persisting with same reply beyond point of relevance immobility of catatonic schizophrenia.
(Organic brain lesions) “where do you live?”, “London”,
6. Ans. (a)  Formal thought disorder
“How old are you”, “London”… Mannerism is habitual
involuntary movement. Ref: A short textbook of psychiatry, Niraj Ahuja, 7th edn, P.
•• But stererotypy is purposeless mechanical repetition of NO. 12, 55
speech or activities seen in schizophrenia. Disorders of form of thought include the following.
Kaplan and Sadock’s synopsis of Psychiatry, 10th edn, P. no. •• Pressure of speech - Increase in the amount of
234. spontaneous speech; rapid, loud, accelerated speech
which is uninterruptible.
4. Ans. (a)  Panic disorder
•• In tangentiality, there is oblique, digressive, or even
Panic disorder is a type of neurotic condition characterized irrelevant manner of speech in which the central idea is
by anxiety attacks with autonomic arousal symptoms not communicated. 453
 •• In circumstantiality, a patient digresses into Classification of Diseases, 10th Revision, 1992) Is WHO’s
unnecessary details and inappropriate thoughts before classification for all diseases and related health problems
communicating the central idea. (and not only psychiatric disorders). Chapter F classifies
•• In loosening of association, unrelated and unconnected psychiatric disorders as mental and behavioral disorders
ideas shift from one subject to another. and codes them on an alphanumeric system from F00 to
F99.
7. Ans. (a)  Illusion
Ref: Kaplan and Sadocks Synopsis of Psychiatry, 10th edn, 278 13. Ans. (b)  Johann Christian Reil
Perceptual misinterpretation of a real external stimulus. Ref: A short textbook of psychiatry by Niraj Ahuja, 7th edn,
Other perceptual disturbances include hallucination, 244
pseudohallucination and imagery. He coined the term psychiatry. He also founded the first
psychiatric journal.
8. Ans. (c)  Delusion
Delusion is a disorder of content of thought. 14. Ans. (a)  Stupor
Other disturbance of content of thought includes Ref: Comprehensive textbook of Psychiatry by Kaplan and
depressive ideation, preoccupation, hypochondrical ideas, Sadock, 9th edn, P. No. 928
referential ideas, persecutory ideas, ruminations, suicidal State of decreased reactivity to stimuli and less than full
thoughts, fear etc. awareness of ones surroundings; as a disturbance of
Ref: Kaplan and Sadock’s Synopsis of Psychiatry P. No. 239. consciousness, it indicates a condition of partial coma
or semicoma. In psychiatry, used synonymously with
9. Ans. (d)  Frontal lobe tumor
mutism and does not necessarily imply a disturbance of
Ref: Synopsis of Psychiatry by Kaplan and Sadock, 10th edn, consciousness; in catatonic stupor, patients are ordinarily
P. No. 411 aware of their surroundings.
•• The essential features of delirium includes autonomic
15. Ans. (a)  Sudden loss of muscle tone
hyperactivity, perceptual distortions, most frequently
visual or tactile hallucinations and fluctuating levels of Ref: Comprehensive textbook of psychiatry by Kaplan and
psychomotor activity. sadock, 9th edn, P. NO. 921
•• Cocaine induced tactile hallucination is called as Temporary sudden loss of muscle tone causing weakness
cocaine bugs or magnus symptom. and immobilization; can be precipitated by a variety of
•• Amphetamine as with cocaine can induce tactile emotional states and is often followed by sleep. Commonly
hallucinations during intoxication. seen in narcolepsy. Other features of narcolepsy includes
sleep attacks, hypnogogic/hypnopompic hallucinations
10. Ans. (b)  Schizophrenia
and sleep paralysis.
Ref: Kaplan and Sadocks Synopsis of Psychiatry, 10th edn,
482 16. Ans. (d)  Persistent tone of feeling for a period of time
•• The most common hallucinations in schizophrenia are Ref: Comprehensive textbook of psychiatry by Kaplan and
auditory with voices that are often threatening, obscene, sadock, 9th edn, P. No 920.
accusatory or insulting. The subjective and immediate experience of emotion
•• Two or more voices may converse among themselves, or attached to ideas or mental representations of objects.
a voice may comment on the patients life or behavior (3rd Affect has outward manifestations that may be classified as
person). restricted, blunted, flattened, broad, labile, appropriate or
in appropriate. Whereas mood is pervasive and sustained
11. Ans. (c)  Kraepelin
feeling that is experienced internally and that, in the
P Ref: Kaplan and Sadocks Synopsis of Psychiatry, 10th edn, extreme can markedly influence all aspects of a person’s
467
S behavior and perception of the world.
•• Emil kraepelin classified mental illness into dementia
Y precox (which later was renamed as schizophrenia) and
17. Ans. (b)  Illogical and primitive
C manic depressive illness. Ref: Comprehensive textbook of psychiatry by Kaplan and
sadock, 9th edn, P. No. 927
H •• Patients with dementia precox present with
hallucinations and delusions and have a deteriorating In psychoanalysis, the mental activity directly related to the
I course. This is distinguished from patients with manic- functions of the id and characteristic of unconscious mental
A depressive psychosis who exhibit alternating episodes of processes; marked by primitive, prelogical thinking and by
illness with normal functioning. the tendency to seek immediate discharge and gratification
T of instinctual demands. Includes thinking that is dereistic,
R 12. Ans. (d)  F
illogical, magical: normally found in dreams, abnormally in
Y Ref: A short text book of psychiatry by Niraj Ahuja, 7th edn
P. No. 2
psychosis. Whereas secondary process thinking is logical,
organized, reality oriented and influenced by the demands of
There are two major systems of diagnostic classification the environment; characterizes the mental activity of the ego.
454 in psychiatry (ICD-10 and DSM 5). ICD-10 (International
18. Ans. (b)  Abstract thinking military, educational, religion, social activity, legal and
Ref: Comprehensive textbook of psychiatry by Kaplan and sexual history.
sadock, 9th edn, P.No.897 24. Ans. (a)  1 week
It is the ability to shift back and forth between general Ref: Kaplan and Sadock’s Synopsis of psychiatry 10th edition
concepts and specific examples. Having the patient identify Page no 536.
similarities between like objects or concepts as well as
Mania: Mania is characterized by elevated, expansive or
interpreting proverbs can be useful in assessing one’s
irritable mood, increased psychomotor activity, decreased
ability to abstract.
need for sleep, distractibility, great physical and mental
19. Ans. (a)  Consciously present activity, and overinvolvement in pleasurable behavior
Ref: Synopsis of psychiatry by Kaplan and sadock, 10th edn, (e.g., engaging in unrestrained buying sprees, sexual
P.No.87 indiscretions, or foolish business investments). The
duration required is 1 week according to ICD 10.
Explicit memory is called as declarative memory whereas
implicit memory is called as non declarative memory. 25. Ans. (a)  Insight
Explicit memory has two types called as episodic and Ref: Synopsis of Psychiatry by Kaplan and Sadock, 10th edn
semantic memory. Episodic memory gives a record of p. no. 279.
personal experiences and medial temporal lobes are the
Conscious recognition of one’s own condition. In psychiatry,
primary structures involved. Semantic memory is ability to
it refers to the conscious awareness and understanding of
remember facts and information. Procedural memory and
one’s own psychodynamics and symptoms of maladaptive
priming are types of implicit memory and basal ganglia is
behavior; highly important in effecting changes in the
the structure implicated. Working memory is a type of short
personality and behavior of a person
term memory. It incorporats both immediate and recent
memory. 26. Ans. (c)  Neuropsychology
20. Ans. (d)  Feeling that unfamiliar things look familiar Ref: Kaplan and Saddock’s Synopsis of Psychiatry,
10thedition, pg no: 178
Ref: Comprehensive textbook of psychiatry by Kaplan and
sadock, 9th edn, P. No. 922. Neuropsychology
•• Neuropsychology studies the structure and function
Illusion of visual recognition in which a new situation
of the brain as they relate to specific psychological
(unfamiliar) is incorrectly regarded as a repetition of a
processes and behaviours.
previous thought (familiar). Deja en tendu is an illusion
•• The term neuropsychology has been applied to lesion
that what one is hearing one has heard previously; Deja
studies of brain in humans.
pense is a condition in which a thought never entertained
•• Clinical neuropsychology is the application of
before is incorrectly regarded as a repetition of a previous
neuropsychological knowledge to the assessment,
thought.
management, rehabilitation of the people who have

Chapter 1  •  Psychopathology and Basic Concepts

21. Ans. (b)  Stupor suffered illness or injury (particularly to the brain),
Ref: Kaplan and Sadocks Synopsis of Psychiatry, 10thedn, which has caused neurocognitive problems.
273, 282. 27. Ans. (c)  Thought block
Stupor is defined as state of decreased response to Ref: A short textbook of psychiatry, Niraj Ahuja, 7th edn, P.
stimuli; In psychiatry, it is often used in conjunction with No. 12, 55.
mutism and is considered as an impairment in level of
Disorders of form of thought include the following.
consciousness
Pressure of speech: Increase in the amount of
Akinesia is lack of physical movement as in the extreme
spontaneous speech; rapid, loud, accelerated speech
immobility of catatonic schizophrenia.
which is uninterruptible. In tangentiality, there is oblique,
22. Ans. (c)  Forced thinking digressive, or even irrelevant manner of speech in which
Ref: Kaplan and sadock synopsis of psychiatry, 11th edn, p. the central idea is not communicated.
no 236 In circumstantiality, a patient digresses into unnecessary
details and inappropriate thoughts before communicating
It is manifested as recurrent intrusive thoughts and
the central idea. In loosening of association, unrelated and
crowding of thoughts seen in epilepsy.
unconnected ideas shift from one subject to another.
There is an urge to think on restricted topics and is often
seen in frontal lobe epilepsy. 28. Ans. (b)  Beck
23. Ans. (c)  Food preference history Ref: Synopsis of Psychiatry by Kaplan and Sadock, 10th edn
p. no. 534
Ref: Synopsis of Psychiatry by Kaplan and Sadock, 10th edn,
P. No. 228. Aaron Beck postulated a cognitive triad of depression that
consists of (1) views about the self - a negative self-precept;
Personal history (anamnesis) includes childhood and
(2) about the environment - a tendency to experience the
developmental history, occupational, marital/relationship,
world as hostile and demanding, and (3) about the future - 455
 the expectation of suffering and failure. Therapy consists of stimulus in one sensory modality producing hallucination
modifying these distortions. in other modality.
29. Ans. (a)  Cocaine 31. Ans. (d)  Clarity
Ref: Indian J Dermatol. 2013 Jan-Feb; 581: 49–52. Ref: Fish’s Clinical Psychopathology: Signs and Symptoms in
Delusions of parasitosis (DOP), also known as “delusional Psychiatry By Patricia R. Casey, Brendan Kelly 3/e p47
infestations,” “acarophobia,” “Ekbom syndrome” and Schneider suggested there were three features of healthy
“Morgellons,” is classified as a primary psychiatric disorder. thinking:
Drugs such as cocaine and amphetamines can induce Constancy: This is characteristic of a completed thought
formication and, at times, a delusional state that may be that does not change in content unless and until it is
similar to idiopathic DOP. superseded by another consciously-derived thought
Organisation: The contents of thought are related to each
30. Ans. (d)  Synesthesia
other in consciousness and do not blend with each other,
Ref: Synopsis of Psychiatry by Kaplan and Sadock, 10th edn but are separated in an organised way.
p. no. 282. Continuity: There is a continuity of the sense continuum,
Condition in which the stimulation of one sensory modality so that even the most heterogenous subsidiary thoughts,
is perceived as sensation in a different modality, as when a sudden ideas or observations that emerge are arranged in
sound produces a sensation of color. Reflex hallucination is order in the whole content of consciousness.

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