basic phenomenology

PHENOMENOLOGY(MED 4048) : 

PHENOMENOLOGY(MED 4048) Assoc Prof Dr Muhd. Najib Mohd. Alwi

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“Listen to the patient. He is telling you the diagnosis” (Osler)

PHENOMENOLOGY : 

PHENOMENOLOGY Definition: The study of events, either psychological or physical, without embellishing those events with explanation of cause or function In psychiatry, it involves the observation and categorization of abnormal psychic events, the internal experiences of the patient and his consequent behaviour NB: It is sometimes called “Descriptive Psychopathology”: Empathic evaluation of patient’s subjective experience 3

General objectives : 

General objectives To know the main headings under which the mental state is described. To know the main phenomenology concepts and their descriptions. 4

Specific Objectives : 

Specific Objectives To understand the definition of phenomenology and its importance in psychiatry. To comprehend how to elicit and describe common signs and symptoms in psychiatry. To understand the basic classification of signs and symptoms in psychiatry. To be aware of common perceptual disturbances. To distinguish the differences between true and pseudohallucinations. To define thinking and understand the basic components of thought and the disturbances associated with each one of them. 5

SOME DEFINITIONS….. : 

SOME DEFINITIONS….. Symptoms: subjective experiences described by the patient e.g. Depressed mood, poor concentration Signs: objective findings observed by the clinician e.g. Psychomotor retardation, restricted affect Syndrome: a group of signs and symptoms that occur together as a recognizable condition that may be less than specific than a clear-cut disorder or disease 6

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DESCRIPTION OF SYMPTOMS : 

DESCRIPTION OF SYMPTOMS Significance: symptoms are more likely to indicate mental disorder if they are intense and persistent. 9

DESCRIPTION OF SYMPTOMS : 

DESCRIPTION OF SYMPTOMS Primary and Secondary: Temporal: Primary – antecedent Secondary – subsequent Causal: Primary – direct expression of the pathological process Secondary – a reaction to the primary symptoms 10

DESCRIPTION OF SYMPTOMS : 

DESCRIPTION OF SYMPTOMS 11

DESCRIPTION OF SYMPTOMS : 

DESCRIPTION OF SYMPTOMS 12

DESCRIPTION OF SYMPTOMS : 

DESCRIPTION OF SYMPTOMS Asking the patient: now imagine you asking the patient: Do you have any odd experiences lately? Well, like strange sensasations, feelings or thoughts? If so, is it in the form of voices that other people cannot hear? ..... And so on.... Sometimes people hear things when there is nothing actually there to explain it, like a voice calling their name. Do you have such an experience? can you tell me more about it? 13

Quiz : 

Quiz Please indicate TRUE or FALSE: Doctors are more interested in the CONTENT of a symptom Psychopathology is determined by the INTENSITY of a symptom Closed ended questions should never be used in patient interview Secondary psychiatric symptoms do develop from physical causes 14

Classification of signs and symptoms in Psychiatry : 

Classification of signs and symptoms in Psychiatry Disorders of Perception Disorders of Thinking Disorders of Mood Disorders of Cognition 15

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16 “Do not adjust your mind, there is some fault in the reality...”

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17 Disorders of Perception

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Perception: the process of becoming aware of what is presented through the sense organs i.e. the understanding of a sensory stimulus c/f imagery (fantasy): an experience within the mind, usually without the sense of reality, can be called out and terminated by voluntary effort. e.g. Eidetic imagery: a visual image which is so intense and detailed that it has a ‘photographic’ quality Pareidolia: images created out of admixture of sensory percepts and imagination; maybe provoked by psychomimetic drugs 18

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Alterations in Perception: intensity E.g. Hyperacusis (a/w hangover, depression, migraine) Visual hyperaesthesia (colours more vivid/intense): LSD, mania, epileptic aura quality shape - e.g. macropsia, micropsia, dysmegalopsia (larger on one side), distorted food – bitter Changes occur in epilepsy, acute schizophrenia, mescalin 19

Disorders of Perception : 

Disorders of Perception Illusions misperceptions of external (objective) stimuli conditions more likely to occur: reduced level of sensory stimulation (e.g. at dusk) reduced level of consciousness (e.g. delirious pts.) when attention is not focussed on the sensory modality (e.g. in darkness) when there is a strong affective state (e.g. stressed up / angry) 20

Disorders of Perception : 

Disorders of Perception Hallucinations sensory perception without an objective stimulus but with a similar quality to a true percept experienced as originating in the outside world and not in the mind (like imagery) can be of all sensory modalities: visual / auditory / tactile gustatory / vestibular / olfactory “presence” 21

Disorders of Perception : 

Disorders of Perception Hallucinations objective space perceived via a sensory modality clear, distinct, vivid beyond voluntary control no *insight (towards the symptom) Pseudohallucinations subjective space may not be perceived by a sensory modality unclear, foggy within voluntary control of a person there is insight 22 *about the absurdity of the perception True differentiating factors are only: voluntary control and insight. Other criteria can overlap.

Description of hallucinations : 

Description of hallucinations According to complexity elementary complex According to sensory modality According to special features auditory: 2nd or 3rd person 23

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Auditory hallucinations : 

Auditory hallucinations Elementary / complex Voices single/multiple male/female known/unknown person person 1st person: “thought echo” - hearing own thoughts spoken aloud (Gedankenlautwerden, echo de la pensee) 2nd person: calling patient by ‘you’ 3rd person:calling patient by ‘he’ or ‘she’ 25

Auditory hallucinations : 

Auditory hallucinations Voices commanding / running commentary / arguing with each other timing: day / night / all the time circumstances when it occurs continuous / intermittent / frequency theme: friendly, derogatory patient’s response to the voices 26

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27 Visual Hallucinations

Visual Hallucinations : 

Visual Hallucinations elementary (e.g. flashes of light) complex semi-formed: with some structure fully-formed: e.g. human figures, trees black and white / coloured static / mobile stable form / changing design size (e.g. lilliputian) commonly associated with organicity 28

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29 Other Hallucinations

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Olfactory and gustatory hallucinations often experienced together often unpleasant in nature (e.g. rotten fish, bitter) common in temporal lobe epilepsy Somatic (tactile and deep) tactile (haptic): touched, pricked e.g. insect crawling under the skin (e.g. formication in coccaine abuse) deep sensation: e.g. viscera being pulled out, sexual stimulation, electric shock 30

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Autoscopic hallucination seeing own body projected into objective space (can happen in depression) “negative autoscopy” also can occur! Extracampine hallucinations perceiving a sensation from beyond the limits of the sense organ e.g. visions from outside visual field, hearing voices from far far away Functional hallucination Normal perception of a stimulus and a hallucination in the same modality are experienced simultaneously E.g. hearing hallucinatory voices only when water was running through the pipes. 31

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Reflex hallucinations stimulus in one sensory modality causing a hallucination in a different sensory modality e.g. music causing visual hallucination (LSD abuse) Hypnogogic and hypnopompic hallucinations occurs at the point of falling to or waking from sleep usually brief and elementary Feeling of “Presence” feeling the presence of ‘somebody’ near but realises that he is non-existent! 32

Other Perceptual Disturbances : 

Other Perceptual Disturbances Depersonalization: a feeling that his body parts are abnormal, unreal e.g. “my brain becomes big until it fills the room” Derealization: a feeling that the external environment is abnormal, unreal e.g. people are 2 dimensional card board figures BOTH can occur in tiredness, TLE, depression etc. 33

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34 Disorders of Thinking

Thinking : 

Thinking Definition: a goal directed flow of ideas, symbols or associations, initiated by a problem/task, leading to a reality orientated conclusion disorders of thinking are usually recognized from speech and writing 4 components of thinking: form of thought flow (stream) of thought content possession 35

Formal Thought Disorder : 

Formal Thought Disorder Disorder in the form (structure) of thoughts 3 main subgroups: loosening of association flights of ideas perseveration 36

Loosening of Association : 

Loosening of Association Loss of the normal structure of thinking muddled and illogical conversation that cannot be clarified by further enquiry. Several forms: Knight’s move / derailment: transition from one topic to another with no logical connection between the two Word salad: severe form of derailment affecting the grammatical structure of speech Talking past the point (vorbeireden) / tangentiality: touching the point just a little bit before going off Circumstantiality: going round and round before finally reaching the point 37

Flights of Ideas : 

Flights of Ideas Patient’s thoughts and conversation move quickly from one topic to another so that one train of thought is not completed before the another appears but there is an apparent association between them (clang (similar sound) or chance associations) 3 components have to be there: pressure of speech shifting topics apparent association (can be followed) NB: if without pressure of speech = PROLIXITY 38

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39 Doctor: Kenapa R suka sangat hari ini?   R: Merdeka! Merdeka! Merdeka! Malaysia sudah merdeka, kesemuanya deka.. deka hee. Tanggal 31, bulan lapan lima puluh tujuh... Pantai Sri Tujuh tempat berkelah yang sungguh indah... doktor dah pernah pergi ke? Marilah kita ke sana... Kita penunggu senja... mencari hakikat diri yang sebenarnya.... berjuanglah! Ehmmm.ehmm.... Jika takut menghadapi risiko jangan bicara tentang perjuangan!!!   Marilah kita berjuang kerana mu Malaysia... Indonesia... Tunisia.... “sia” tu maksudnya doktor.... “terhapus”.   Maka jadilah mereka seperti dinosaur yang telah pupus di atas kelemahan mereka sendiri... sendiri... ada ertinya....(patient sings)......erti perkataan... ya.. tekalah perkataan itu. Doktor sukakah tengok Roda Impian... Ya, menagilah hadiah misteri kali ini. Semisteri seperti ajaibnya Taj Mahal... Salam Taj Mahal..... Oh, I love you M Nasir....sungguh mahal harganya. Baju doktor smart, ni tentu mahalkan? Eleh... jual mahal pulak. Berhenti? OK saya berhenti... tapi doktor.............. (patient continues her conversation)

Other Formal Thought Disorders : 

Other Formal Thought Disorders Perseveration: Giving a response beyond the point of relevance i.e. same answer to each question (stimulus) c/f verbal stereotypy (verbigeration): words, sounds or phrase repeated in a senseless way (no stimulus) 40 Perseveration Verbal Stereotypy

Disorder of flow (stream) : 

Disorder of flow (stream) Both the amount and the speed of thoughts are changed Different levels: muteness poverty of thought thought block volubility:  amount & speed, still can interrupt pressure of speech:  amount & speed, cannot interrupt speech 41

Disorders of Content of Thought : 

Disorders of Content of Thought Delusion: false belief, unshakeable, inappropriate to a person’s educational and social background “double orientation”: wholly convinced about the truth of the delusional belief but the conviction may not influence his feelings and emotions Over-valued ideas: ideas held with a lot of emotion (highly charged) but with some degree of ambivalence and doubts about the belief. (Emotions are expressed to compensate for the ambivalence) Pre-occupation: ideas which comes to mind, again and again and may prevent the patient from performing his day to day activities 42

Classification of Delusions : 

Classification of Delusions According to fixity: complete / partial / over-valued ideas / ideas According to onset: Primary: autochthonous delusions sudden onset (out of the blue) of delusion other forms: delusional mood: anxiety, foreboding something to happen (Wahnstimmung) delusional perception: false meaning to a normal percept memory: attribute new meaning to old experience Secondary: derived from preceding morbid experience e.g. hallucinations, depressive mood etc. 43

Classification of Delusions : 

Classification of Delusions According to special features: Systematised delusion: chronic, presence of nucleus, well knitted, inter-connected, layered and well-encapsulated. Non-systematised delusion Shared delusion: folie a deux (two person, including patient) folie a mass (> than two person) According to theme 44

Themes of Delusion : 

Themes of Delusion Persecutory (paranoid): others/organizations trying to inflict harm on him Delusion of Reference: idea that objects/events/people have a personal significance for patient e.g. TV programmes, news Grandiose (expansive): beliefs of exaggerated self-importance e.g. wealth, special powers, beauty Religious: delusions with religious content e.g. chosen to be prophet, communicating directly to God 45

Themes of Delusion : 

Themes of Delusion Amorous Delusion more common in women (? stalking in men) De Clerambault’s Syndrome being loved by a man who is inaccessible, high status, never spoken before, unable to reveal his love for her Delusion of Jealousy: common in men delusion of unfaithfulness of spouse (infidelity) spying, checking on spouse, examine for sexual secretions 46

Themes of Delusion : 

Themes of Delusion Delusion of Guilt and Worthlessness: e.g. minor past faults will be exposed, being sinful, deserves to be punished Nihilistic Delusion belief about non-existence of some person / thing + pessimistic ideas e.g. career is gone Cotard’s Syndrome: failures of bodily functions e.g. bowels are rotting etc. Hypochondriacal Delusions belief of ill health despite contrary medical evidence usually of a particular theme & may have relative/friend suffering the supposed illness 47

OTHER DISORDERS OF THOUGHT CONTENT : 

OTHER DISORDERS OF THOUGHT CONTENT Obsessions: recurrent persistent thoughts, impulses or images that enter the mind despite efforts to exclude them subjective sense of struggle to resist them recognized as his own (not implanted) regarded as untrue and senseless Compulsions: repetitive, purposeful behaviours performed in a stereotyped way, accompanied with subjective sense that it must be carried out and an urge to resist most common: cleaning, counting, dressing 48

DESCRIPTION OF OBSESSIONS : 

DESCRIPTION OF OBSESSIONS Five forms: thoughts: intrusive words or phrases, upsetting e.g. blasphemous phrases rumination: worrying themes e.g. ending of the world doubts: uncertainty about previous action (realizes done) impulses: urges to carry out actions: dangerous or embarrassing obsessional phobia Six common themes: dirt & contamination aggressive thoughts: e.g. striking others orderliness: how things / work need to be arranged / done illness: e.g. dread about cancer sex: e.g. perverse sexual acts religion: doubts about fundamental beliefs e.g. “Does God exist?” 49

Disorders of Thought Possession : 

Disorders of Thought Possession Thought Insertion: delusion that some thoughts have been implanted by outside agency Thought Withdrawal: delusion that thoughts have taken out of his mind (may accompany/explain thought block) Thought Broadcasting: delusion that his unspoken thoughts are known to other people 50

SCHNEIDERIAN FIRST-RANK SYMPTOMS (FRS) : 

SCHNEIDERIAN FIRST-RANK SYMPTOMS (FRS) are specific types of delusions and hallucinations that involve themes of passivity.  FRS are highly suggestive of schizophrenia, rather than being sure signs of that disorder.  Patients with neurological impairment that produce pathological impulses or behaviors will commonly say "This behavior is not me," yet will readily accept responsibility for the behavior.  In contrast, patients with First Rank Symptoms deny responsibility for the strange behavior, claiming that "others made me do it." 51

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SCHNEIDER’S FIRST RANK SYMPTOMS : 

SCHNEIDER’S FIRST RANK SYMPTOMS Remembering Schneiderian First Rank symptoms is as easy as ABCD:   A= Auditory hallucinations - 3rd person (arguing & commenting)/thought echo B= Broadcasting of thoughts/ insertion/withdrawal C= Control experiences/ passivity phenomena (made act, feeling, sensation) D= Delusional perception 54 3A, 3B, 3C, 1D

References : 

References Oxford Textbook of Psychiatry (Third Edition) Gelder et al Symptoms in the Mind: An Introduction to Descriptive Psychopathology (Second Edition) Andrew Sims 55