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2015v1.0

Sims’ Symptoms in the Mind

For Elsevier
Senior Content Strategist: Pauline Graham Content Development Specialist: Katie Golsby Project Manager: Joanna Souch Designer/Design Direction: Miles Hitchen Illustration Manager: Nichole Beard

6th Edition

Sims’ Symptoms in the Mind

Textbook of Descriptive Psychopathology

Femi Oyebode

MBBS, MD, PhD, FRCPsych
Professor of Psychiatry & Consultant Psychiatrist
University of Birmingham, National Centre for Mental Health
Birmingham, UK

Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2018

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Contents

Preface to the Sixth Edition, vii

Additional Materials Within Accompanying Electronic Version, viii

Section I

CONCEPTS AND METHOD, 1

. 1 Fundamental Concepts of Descriptive Psychopathology, 3

. 2 Eliciting the Symptoms of Mental Illness, 19

Section II

CONSCIOUSNESS AND COGNITION, 29

. 3 Consciousness and Disturbed Consciousness, 31

. 4 Attention, Concentration, Orientation and Sleep, 43

. 5 Disturbance of Memory, 57

Section III

AWARENESS OF REALITY: TIME, PERCEPTION AND JUDGEMENT, 69

Section IV

SELF AND BODY, 169

12 The Disordered Self, 171

13 Depersonalization, 185

14 Disorder of the Awareness of the Body, 195

15 The Psychopathology of Pain, 219

Section V

EMOTIONS AND ACTION, 229

. 16 Affect and Emotional Disorders, 231

. 17 Anxiety, Panic, Irritability, Phobia and
Obsession, 251

. 18 Disorders of Volition and Execution, 263

Section VI

VARIATIONS OF HUMAN NATURE, 281

19 The Expression of Disordered Personality, 283 Section VII

DIAGNOSIS, 295

20 Psychopathology and Diagnosis, 297 Self-Assessment 1, 305
Self-Assessment 2, 311
Self-Assessment 1: Answers, 315 Self-Assessment 2: Answers, 319

Index, 323

6 Disorder of Time, 71
7 Pathology of Perception,
8 Delusions and Other Erroneous Ideas,

9 Disorder of the Thinking Process,
10 Disorder of Speech and Language, 147 11 Insight, 159

129

105

For my father, Jonathan Akinyemi Oyebode (1918–1971) Femi Oyebode

Preface to the Sixth Edition

It is 30 years this year since Sims’ Symptoms in the Mind was rst published. It is true to say that it is now well established as the leading textbook on clinical psycho- pathology. In this new sixth edition, as in the previous ve editions, I have retained the original structure of the book but made some changes and many additions. I have either introduced or developed some themes, notably on consciousness and its disorders, disturbance of memory, pathology of perception, the disordered self and disorder of the awareness of the body. The most striking additions are on the role of embodiment in the nature of self and of awareness of the body and of the nature of guilt and shame in emotional disorders. These changes have been prompted by my desire to ensure that readers fully appreciate that psychopathology is not a dead subject but one that is alive and is constantly in need of revision in response to conceptual changes or new empirical ndings.

In my preface to the fth edition I emphasized the fact that descriptive psychopathology, as a method, has endured the past 100 years. It is the pre-eminent foundation for the practice of clinical psychiatry. This method allows us to observe and describe abnormal subjective phenomena and behaviours, and to categorize these in order to communicate more precisely about the world that patients inhabit. The clinician trained in the phenomenological approach is all the more aware of the need for empathic understanding, for assuming

an atheoretical stance, and nally of the provisional status of our understanding and explanations regarding psychopathology. Descriptive psychopathology is today even more relevant to the endeavours of clinicians and researchers. The standard psychiatric nomenclature is under strain. This means that the fundamental abnormal phenomena, the infrastructure of nosology, must of necessity assume greater importance in clinical practice. Otherwise the ability to communicate meaningfully across the profession will markedly deteriorate.

I am indebted to many more people than I can list. The Birmingham Philosophy Group has been meeting monthly since 1992. Its members (Theo Arvantis, Lenia Constantine, Simon O’Loughlin, Kate Robertson, Sandy Robertson and Persephone Sextou) continue to in uence my thinking about psychiatric phenomena as do the members of the European Psychiatric Association Section of Psychopathology including John Cutting, Maria Luisa Figueira, Mircea Lazarescu, Luis Madeira, Michael Musalek, Gilberto di Petta and Pedro Varandas. Finally, without the patients who experience and endure these abnormal phenomena, and the students and psychiatric trainees who ask awkward questions and out of curiosity enquire into the nature of these phenomena, this book would de nitely be the poorer.

Femi Oyebode

vii

Additional Materials Within Accompanying Electronic Version

The searchable full text for Sims’ Symptoms in the Mind, sixth edition, is available at http://www.expertconsult.com, accessible via the enclosed pin code. Please follow the instructions on the inside front cover of this book. Additional materials integrated within this enhanced electronic version include the following:

• Four patient scenarios (videos with transcripts), exploring:

1. auditory verbal hallucinations,
2. persecutory delusion,
3. low mood, and
4. obsessive compulsive phenomenon.

Look out for alongside the related sections within this book.

• Nine author podcasts on the following topics: 1. What is psychopathology?
2. Consciousness
3. What are hallucinations?

4. Critique of the nature of delusions 5. Embodiment
6. The self in psychopathology
7. Affect, mood and emotions

8. Shame and Guilt

9. The nature of obsessions
Look out for alongside the related sections within this book.

• Interactive question-and-answer sections for each chapter to test your understanding of key topics.

viii

SECTION 1

CONCEPTS AND METHOD

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KEYWORDS

Descriptive psychopathology Phenomenology
Norms
Subjectivity

Summary

Descriptive psychopathology is the precise description, categorization and de nition of abnormal experiences as recounted by the patient and observed in his behav- iour. It relies on the method of phenomenology by focusing on experienced phenomena to establish their universal character. The aim is to listen attentively, to accurately observe and to understand the psychological event or phenomenon by empathy so that the clinician can, as far as possible, know what the patient’s experi- ence must feel like.

How the mind should be conceived for the purposes of psychopathology, what its faculties, functions or elements are (if there are any), how these can be distinguished, and how mental disorders can be comprehended by an application of these concepts are philosophic questions.

Manfred Spitzer (1990)

Psychiatry is that branch of medicine that deals with morbid psychological experiences. By de nition, in the medical conditions that are central to psychiatric practice, psychological phenomena are important as causes, symptoms and observable clinical signs and also as therapeutic agents. The scope of psychiatry can be said to include minor emotional disturbances that are meaningful reactions to environmental or psycho- social stress; profound psychological change that is unheralded by signi cant or meaningful stress; distur- bances of personality that have a pervasive in uence

on behaviour such that the person or others suffer; psychological changes that are directly the consequences of demonstrable organic brain change; and psychological and behavioural consequences of the use of substances such as alcohol, cannabis, cocaine or heroin. To describe, delineate and differentiate these conditions, the morbid psychological phenomena that constitute the subjective experience of patients need to be carefully assessed, elicited and recorded. This is the territory of descriptive psychopathology. In other words, descriptive psycho- pathology is concerned with the selection, delimitation, differentiation and description of particular phenomena of experience, which through the use of accepted terminology become both de ned and capable of repeated identi cation.

It can be said that descriptive psychopathology is the fundamental professional skill of the psychiatrist; it is, possibly, the only diagnostic skill unique to the psychiatrist. It is considerably more than just carrying out a clinical interview of a patient or even listening to the patient, although it necessarily involves both of these. Its accurate application involves the deployment of empathy and understanding (we shall return to these later). Of course, for the rational practice of psychiatry there is a need for knowledge of the basic neurosciences; appropriate factual knowledge of psychology, sociol- ogy and social anthropology is also required. With these, there is a need for a comprehensive working knowledge of general medicine, especially neurology and endocrinology. This could be considered to be the minimum knowledge base that is essential for practising psychiatry. However, it is descriptive psy- chopathology that provides the foundation of clinical psychiatric practice. The subjective phenomena that are revealed during the clinical assessment, coupled with observable behaviours, ultimately determine the clinical judgements that in uence treatment and management decisions.

CHAPTER 1

Fundamental Concepts of Descriptive Psychopathology

4 SECTION I Concepts and Method What Is Psychopathology?

Psychopathology is the systematic study of abnormal experience, cognition and behaviour – the study of the products of a disordered mind. It includes the explanatory psychopathologies, in which there are assumed explanations according to theoretical constructs (for example on a cognitive, behavioural, psychodynamic or existential basis and so on), and descriptive psychopathol- ogy, which is the precise description, categorization and de nition of abnormal experiences as recounted by the patient and observed in his behaviour (Fig. 1.1).

Descriptive psychopathology as distinct from other forms of psychopathology eschews explanation of the phenomena that it describes. It simply describes, thereby avoiding arguments about causation. Hence, descriptive psychopathology guards against and avoids theory, presupposition or prejudice. This constraint of descrip- tive psychopathology acts to secure the conceptual framework of phenomenology, restricting it to the actual experience of the patient. It is important to distinguish psychopathology from nosography, which is the descrip- tion of single illnesses with provisional and characteristic features that lay the foundation for diagnosis (Stang- hellini and Fuchs, 2013). Neither is it merely symp- tomatology nor pathology of the psyche (Stanghellini and Aragona, 2016; Stanghellini and Fuchs, 2013). It is, as elaborated later, a highly formalized and methodi- cal system designed to inquire into and describe abnormal mental phenomena.

Explanatory psychopathologies, in contrast, often assume that mental phenomena are meaningful. In psychoanalysis, for example, at least one of several basic

mechanisms are assumed to be taking place, and the mental state becomes understandable within this framework. Explanations of what occurs in thought or behaviour are based on these underlying theoretical processes, such as transference or ego defence mechanisms. For example, with a delusion descriptive psychopathology tries to describe what it is that the person believes, how he describes his experience of believing, what evidence he gives for its veracity and what is the signi cance of this belief or notion to his life situation. An attempt is made to assess whether this belief has the exact char- acteristics of a delusion and, if so, of what type of delusion. Having made this phenomenological evaluation, the information gained can be used diagnostically, prognosti- cally and hence therapeutically. Some of the contrasts between descriptive and psychoanalytic psychopathology are summarized in Table 1.1.

Analytical or dynamic psychopathology, however, would be more likely to attempt to explain the delusion in terms of early con icts repressed into the unconscious and now able to gain expression only in psychotic form, perhaps on a basis of projection. The content of the delusion would be considered an important key to the nature of the underlying con ict, which has its roots in early development. Descriptive psychopathology makes no attempt to say why a delusion is present; it solely observes, describes and classi es. Dynamic psychopathology aims to describe how the delusion arose, its psychological origins and, why it should be that particular delusion, on the evidence of that person’s experience in early life.

There are other radically different models of psychol- ogy that regard mental experience, including thoughts,

Psychopathology

Explanatory

Descriptive

Psychodynamic

Behavioural etc.

Observation

Phenomenology

FIG. 1.1 The psychopathologies.

1 Fundamental Concepts of Descriptive Psychopathology 5 n

TABLE 1.1 Psychopa

thology: Descriptive Versus Psychoa

Descriptive

alytic

Psychoanalytic

Summary

Terminology Methods

Differences in practical application

Empathic evaluation of patient’s subjective experience

Description of phenomena
Understanding the patient’s subjective state

through empathic interview
Makes distinction between understanding

and explanation: understanding through

observation and empathy
Form and content clearly separated: form of

importance for diagnosis
Process and development distinguished:

process interferes with development basis

Study of the roots of current behaviour and conscious experience through unconscious con icts

Theoretical processes demonstrated Free association, dreams, transference

Understanding in terms of notional theoretical processes

No distinction made; concerned with content

No distinction made; symptoms seen as having unconscious psychological basis

moods and drives, as epiphenomena, that is, as no more than froth on top of the beer. In these models (radical materialism or eliminative materialism), mental life is illusory; it is only the material, organic processes that are real. The signi cance the thinker attaches to subjective experience is regarded as purely illusory. Such a position poses dif culties for psychological enquiry and treatment and in any case is outside of the scope of this book.

Berrios (1996) has described two formulations of descriptive psychopathology in the nineteenth century. Psychologists and brain scientists predominantly tended to regard morbid phenomena as quantitative variations on normal mental functions – the continuity view. Psychiatrists, working directly with the mentally ill (alienists), considered that some symptoms were too bizarre to have a counterpart in normal behaviour – the discontinuity view. Both formulations have contributed to the current state of descriptive psychopathology. Undoubtedly, the quality of empathy shown by the doctor contributes to the extent of understanding of the patient that is achieved. However, there is a theoreti- cal limit to the psychological understanding that an interviewer can reach for some abnormal phenomena. It is often true that certain psychotic phenomena are such that the patient’s notions and behaviour may no longer be psychologically comprehensible through the use of empathy. In these situations the patient and doctor may have dif culty establishing a mutuality of understanding that, usually, readily underpins reciprocity and shared understanding. One of the consequences

is that patients may nd that their experiences are not fully comprehended by the clinician involved in their case. This fact underlines how alienating psychotic experiences can be. These two formulations, the continu- ity and discontinuity views, continue to in uence how abnormal phenomena are conceptualized even today.

There are two distinct parts to descriptive psycho- pathology – the empathic assessment of the patient’s subjective experience and the observation of the patient’s behaviour. Empathy is an important psychiatric term that literally means ‘feeling oneself into’ and in psy- chiatric practice emphasizes the imaginative experiencing of another person’s inner, subjective world. It can be distinguished from sympathy, which is ‘feeling with’. A way to appreciate the distinction between ‘empathy’ and ‘sympathy’ is to recognize the role of an objective stance towards the patient coupled with an active attempt to fully understand how certain thoughts rise from particular moods, wishes or fears and the nexus of connections between different aspects of the patient’s experiences that is integral to empathy.

In descriptive psychopathology, the concept of empathy is like a clinical instrument, conceptual in mode but no less incisive for that matter, that needs to be used with skill to explore, measure and represent to oneself another person’s internal subjective state. The observer’s own capacity for imaginatively re- presenting another person’s emotional and cognitive experience to himself acts as the necessary instrument in this clinical task. Empathy is achieved by precise,

6 SECTION I Concepts and Method

insightful, persistent and knowledgeable questioning until the doctor is able to give an account of the patient’s subjective experience that the patient recognizes as his own. If the doctor’s account of the patient’s internal experience is not recognized by the patient as his own, then the questioning must continue until the internal experience is recognizably described. Throughout the process, success depends on the capacity of the doctor as a human being to experience something like the internal experience of the other person, the patient; it is not an assessment that could be carried out by a microphone and computer. It depends absolutely on the shared capacity of both doctor and patient for human experience and feeling. It is empathy that allows the doctor to come to understand the patient’s experiences. In this sense, it is empathy that makes it possible for us to know what it is like for another person, another subject of experience, to be in a particular mental state. When empathy fails to render a patient’s subjective experience understandable, we can then talk about that experience as being un-understandable. In other words, the farthest reaches of our intuitive comprehen- sion of a phenomenon have been exceeded. This conclusion only ought to be reached after careful and exhaustive exploration and in-depth analysis.

Accurate observation of behaviour is the other component of descriptive psychopathology. Subjective human experience becomes available to us for examina- tion and exploration not only through verbal com- munication but also through meaningful gestures, bodily stance, behaviour and actions. Observation of the objective expression of subjective experience, that is, of behaviour, is extremely important and is a much more useful exercise than simply counting symptoms; the slavish use of a symptom checklist for their presence or absence is often an obstacle to genuine clinical observation, if not to the quality of doctor–patient communication. The objectivity that is facilitated by checklists is crucial, but there is a need also for the skilled observation of behaviour and for attentive and focused listening. Observation of behaviour includes observation of physical appearance, expressive gestures, facial emotional expressions, interpersonal stance and attitude, clothing, makeup, and so on. It is a complex skill requiring an understanding of human conduct in context and the degree to which behaviour is in uenced, accented and mediated by culture.

Phenomenology and Psychopathology

Psychopathology is concerned with abnormal experience, cognition and behaviour. Descriptive psychopathology avoids theoretical explanations for psychological events. It describes and categorizes the abnormal experience as recounted by the patient and observed in his behav- iour. In its historical context, Berrios (1984) de nes it as a cognitive system constituted by terms, assumptions and rules for its application, ‘the identi cation of classes of abnormal mental acts’. Phenomenology is a term that is closely allied to descriptive psychopathology. It has a long tradition in philosophy and is associated with the name of Edmund Husserl (1859–1938). It is usually used to denote enquiry into one’s conscious and intel- lectual processes, eschewing any preconceptions about external causes and preconceptions. The method of phenomenology aims to focus on experienced phe- nomena to establish their universal character. As used in psychiatry, phenomenology involves the elicitation and description of abnormal psychological events, the internal experiences of the patient and his consequent behaviour. An attempt is made to listen attentively, accurately observe and understand the psychological event or phenomenon so that the observer can, as far as is possible, know for oneself what the patient’s experience must feel like.

How can one use the word observer about someone else’s internal experience? This is where the process of empathy becomes relevant. Descriptive psychopathology therefore includes subjective aspects (phenomenology) and objective aspects (description of behaviour). It is concerned with the rich variety of human experience, but it is deliberately limited in its scope to what is clinically relevant; for example, it can say nothing about the religious validity of what James (1902) has called ‘saintliness’.

How does this work in practice? Mrs Jenkins complains that she is unhappy. It is the business of descriptive psychopathology both to elicit her thoughts and actions without trying to explain them and to observe and describe her behaviour – the listless sagging of her shoulders, the tense gripping and wringing of her hands or the strangely quiet and unrestrained sobbing. Phe- nomenology demands a very precise description of exactly how she feels inside herself: ‘that horrible feeling of not really existing’ and ‘not being able to feel any emotion’.

Some psychiatrists have held the method of phe- nomenology in derision as archaic, hair-splitting or hare-chasing pedantry, but the diagnostic evaluation of symptoms is a task that psychiatrists omit at their own, and their patient’s, peril. Studying phenomena whets diagnostic tools, sharpens clinical acumen and improves communication with the patient. Patients and their complaints deserve our scrupulous attention. If ‘the proper study of mankind is man’, the proper study of his mental illness starts with the description of how he thinks and feels inside – ‘chaos of thought and passion, all confused’ (Pope, 1688–1744).

A cavalier neglect of abnormal phenomena can have serious repercussions for care of the patient. Eight mentally well researchers were sent separately to 12 admission units in American mental hospitals on the pretence of complaining of hearing these words said aloud: empty, hollow and thud (Rosenhan, 1973). In all cases save one, they were diagnosed as suffering from schizophrenia. They produced no further psychiatric symptoms after admission to hospital but acted as normally as they could, answering questions truth- fully except to conceal their name and occupation. The ethics and good sense of the experiment can certainly be questioned, but what comes out clearly is not that psychiatrists should refrain from making a diagnosis but that their diagnosis should be made on a sound psychopathological basis. Rosenhan, his colleagues and the admitting psychiatrists gave no information as to what symptoms could reasonably be required for making a diagnosis of schizophrenia; this requires a method based on psychopathology. With adequate use of phenomenological psycho- pathology, this failure of diagnosis would not have occurred.

Jaspers (1997) wrote, ‘Phenomenology, though one of the foundation stones of psychopathology, is still very crude’. One of the great problems in using this method is the muddled nature of terminology. Almost identical ideas may be assigned different names by people from different theoretical backgrounds, for example the plethora of descriptions of how a person may conceptualize himself: self-image, cathexis, body awareness and so on.

There is considerable confusion over the meaning of the term phenomenology. Berrios has described four meanings in psychiatry:

P1 refers to its commonest clinical usage as a
mere synonym for ‘signs and symptoms’ (as in ‘phenomenological psychopathology’); this is a bastardized usage, and hence conceptually uninteresting. P2 refers to a pseudo-technical sense often used in dictionaries and which achieves spurious unity of meaning by simply cataloguing successive usages in chronological order; this approach is misleading in that it suggests false evolutionary lines and begs important questions relating to history of phenomenology. P3 refers to the idiosyncratic usage started by Karl Jaspers who dedicated his early clinical writings to the description of mental states in a manner which (according to him) was empathic and theoretically neutral. Finally, P4 refers

to a complex philosophical system started by Edmund Husserl and continued by writers collectively named the ‘Phenomenological Movement’.

Berrios (1992, p. 304)

Of these meanings, this chapter, and indeed this book, concentrates entirely on the Jaspersian meaning of phenomenology, P3 of Berrios. Jaspers de nes phe- nomenology perhaps 30 to 40 times in his writings in subtly different ways but always implying the study of subjective experience. Walker (1988, 1993a, 1993b, 1994) has argued, very elegantly, that even though Jaspers himself thought that he had been in uenced by Husserl and his system of phenomenology, this was not in fact so, and his psychopathology owed more to Kantian concepts such as form and content. Walker (1995a, 1995b) considers that Jaspers radically misconstrued Husserl’s phenomenology. This view has been rebutted by others (Wiggins, Schwartz and Spitzer, 1992). The implication for what follows in this chapter, and in the rest of the book, is that the concept of phenomenology used here comes directly from Jaspers and was probably in uenced by both Kant and Husserl.

Phenomenology, the empathic method for the eliciting of symptoms, cannot be learned from a book. Patients are the best teachers, but it is necessary to know what one is looking for – the practical, clinical aspects in which the patient describes himself, his feelings and his world. The doctor tries to unravel the nature of the sufferer’s experience, to understand it well enough and to feel it so poignantly that the account of his ndings evokes recognition from the patient. The method of

1 Fundamental Concepts of Descriptive Psychopathology 7

8 SECTION I Concepts and Method

phenomenology in psychiatry is entirely subjugated to its single purpose of rendering the patient’s experience understandable (this is a technical word in phenomenology and is described in more detail in the Understanding and Un-understandable section; however, it incorporates the capacity for putting oneself in the patient’s place) so that classi cation and rational therapy may proceed.

It is not the assimilation of abstruse facts or the accumulation of foreign eponyms that is most dif cult in phenomenology, although either of these may be hard: it is the comprehension of a method of investiga- tion, a rigorous approach and the ability to use new concepts. In an attempt to avoid the obscure and obvious, some of these concepts are discussed in the rest of this chapter.

Concepts

DISEASE AND ILLNESS

Psychopathology concerns itself with disease of the mind, but what is disease? And, how does it differ from disorder and illness? This is a vast subject that has received discussion from philosophers, theologians, administrators and lawyers as well as from physicians. Doctors who spend most of their working time dealing with disease rarely ask this question and even less frequently attempt to answer it. Talk of disease by de nition raises questions about the nature of health. But, an even more pressing issue is whether it is possible for the mind to be diseased in the same way or manner that the liver or the kidneys can be diseased. These questions are outside of the scope of this book, but it is important to be aware of the varied approaches that different authorities take to this matter. I outline the basic arguments in the following text.

The most compelling model of a disease is that which grounds a medical condition such as pulmonary tuberculosis on the basis of a distinctive morbid anatomy demonstrable on examination of the lungs and which is independent of any particular observer and is assumed to be value free. It is even better if there is an under- standing of the detailed pathophysiology – how the causative agent, in tuberculosis for instance, results in the recognized, typical morbid anatomy of the lungs. It is obvious from the foregoing that in most psychiatric diseases, no such typical morbid anatomy or patho- physiology has been described.

On the basis of the absence of demonstrable physical lesions, Szasz (1960) argued that psychiatric or mental diseases did not exist and that only behavioural deviance andmoralorsocialjudgementswereatplayinpsychiatry. He also argued that mental is an abstract concept and not an objective, physical thing, and hence it could not be diseased. Brain diseases, in his view, are real, but mental diseases are a logical impossibility; thus Szasz uses the term myth to characterize mental diseases.

Other writers including Scadding (1967), Kendell (1975), Boorse (1976) and Sedgwick (1973) have put forward arguments that stand in opposition to Szasz. Scadding and Kendell use the combination of statistical deviance and biological disadvantage de ned as reduced fertility to determine what a disease is. Boorse adds that a disease is any condition that interferes with any function of an organism (and in this view mental functioning counts) that is necessary for its survival and reproduction. Additionally, a disease becomes an illness when it is deemed undesirable, a title for special treatment and a valid excuse for particular behaviours. Finally Sedgwick makes the claim that all diseases start off as illnesses because the symptoms are negatively valued and hence become a focus of social and moral interest, and that in this way the symptoms later attain disease status. In this account both the so-called physical illnesses and mental illnesses start off as negatively valued states af icting human beings and there is no sharp distinction to be drawn between them. See Fulford, Thornton and Graham (2006) for further elaboration of these issues.

It is clear that there is no widely accepted view about the status of the conditions that fall under the interest of psychiatrists. A simple dictum is to regard disease as what doctors treat and illness as what persons suffer from. Although this distinction between normality and disease, health and illness, is by no means trivial:

A large part of medical ethics and much of the whole underpinning of current medical policy, private and public, are squarely based on the notion of disease and normality. Left to himself the physician (whether he realizes it or not) can do very well without a formal de nition of disease
… Unfortunately, the physician is not left alone to work his common sense. He is attacked from two angles: the predatory consumers and the pretentious advisers.

Murphy (1979)

NORMS, NORMAL AND ABNORMAL

The subject of psychiatry is the person, not an organ such as the liver, kidney or even the brain. Psychiatric diseases are distinct from mere neurologic diseases in the sense that in neurology the disease process leaves the self, the personhood of an individual, intact. This means that we can speak of a person who suffers from multiplesclerosisormotorneurondisease.Inpsychiatry, the diseases af ict the self (i.e., affect the person in a deep and not super cial sense). Mood disorders and schizophrenia have a pervasive in uence on aspects of the self in a way that strikes at what it means to be human.

The ability to experience and represent the world; the capacity to inhabit a social world including recogniz- ing the rules and conventions that operate therein; the ability to form relationships and to imagine the world of the Other; the ability to communicate, to use language and to understand symbols, that is to inhabit a world of meanings; the wherewithal to be an agent, the author of one’s own projects and the drive and will to act; the capacity to operate in a world of moral and aesthetic values; and, the possibility of having an attitude to time, an orientation to the future; these manifold aspects of the person and many more yet to be fully described are in uenced if not impaired by psychiatric diseases. Our understanding of these higher human functions is trivial. Abnormalities and pathology in these domains are manifest in social behaviour and are without independent or objective markers. So talk of norms, normality and abnormality are integral to any discussion of psychiatric phenomena because to recognize impair- ments in these areas of function, we need an understand- ing of what normal function entails, but more fundamentally what it means to talk about norms, normality and abnormality.

The word normal is used correctly in at least four senses in the English language according to Mowbray, Ferguson and Mellor (1979). These are the value norm, the statistical norm, the individual norm and the typologi- cal norm. The value norm takes the ideal as its concept of normality. Thus the statement ‘It is normal to have perfect teeth’ is using normal in a value sense; in practice, most people have something wrong with their teeth. The statistical norm is, of course, the preferred use; the abnormal is considered to be that which falls outside the average range. If a normal Englishman is

5 feet 8 inches tall, to be either 6 feet 2 inches or 5 feet 2 inches tall is equally abnormal statistically.

The individual norm is the consistent level of function- ing that an individual maintains over time. After brain damage, a person may experience a decline in intelligence that is certainly a deterioration from his previous individual level but may not represent any statistical abnormality from that of the general population (e.g., a decline in intelligence quotient from 125 to 105).

Typological abnormality is a necessary term to describe the situation in which a condition is regarded as normal in all the three meanings and yet represents abnormality, perhaps even disease. The example given by Mowbray et al. is the infective condition of pinta. The mottling of the skin of this condition is highly prized by the South American Indians who ‘suffer’ from it, to the extent that ‘non-sufferers’ are excluded from the tribe. Thus having the condition is normal in a value, statistical and individual sense, and yet it is pathologic in the sense that it is the result of a spirochaetal skin infection. The pursuit of thinness by models and dancers in our society would be an everyday example.

In addition, one can talk about social norms, by which we mean the rules, conventions and practices that determine in speci c cultures what behaviours are acceptable and approved of. These include the etiquette, mores and ethics underpinning behaviour. In fact for some people, psychiatric diseases are no more than behaviours classed as deviant by social rules and psychiatrists are no more than social police of cers.

There are other concepts implicit in discussions of norms, normality and abnormality. These are whether the discrete phenomena of interest to psychopathologists are categorically different from normal experience or whether the distinction between normal and abnormal phenomena is dimensional in nature. The distinction being drawn here is over and beyond whether psycho- pathological phenomena are statistically deviant. The question is whether the anxiety experienced by a psychiatric patient, for example, is only an exaggeration of that experienced by a ‘normal’ person or whether there is something categorically/qualitatively different about it.

UNDERSTANDING AND UN-UNDERSTANDABLE

It seems self-evident that understanding the patient’s story, grasping the inner logic of the narrative and

1 Fundamental Concepts of Descriptive Psychopathology 9

10 SECTION I Concepts and Method

representing to oneself the patient’s subjective experi- ences is fundamental to clinical practice. Understanding, in both an everyday and a phenomenological sense, cannot be complete unless the doctor has a detailed knowledge of the patient’s background culture and speci c information about his family and immediate environment. Neither can phenomenology concentrate solely on the individual isolated in a moment of time. It must be concerned with the person in a social setting; after all, a person’s experience is largely determined by his interactions with others. It must also be concerned with the mental state and environment of the individual before the event of immediate interest and with what occurs afterwards.

The method of phenomenology facilitates com- munication: its use makes it easier for the doctor to understand his patient. The patient is also helped to have con dence in the doctor, because he realizes that his symptoms are understood and therefore accepted as ‘real’. The precise description and evalua- tion of symptoms also helps communication between doctors.

Wilhelm Dilthey (1833–1911) argued that the natural sciences treat nature as objects and forces that can be explained through causal laws. In other words, the goal of such science is the formulation of general, universal laws, whereas the humanities, for example history and psychology, have the human subject as their focus and causal laws do not apply in these cir- cumstances. For Dilthey, science ‘explains’ natural phenomena by causal explanation. The humanities ‘understand’ human psychic phenomena through the interpretation of the meaning structures revealed in texts or through dialogue with another person. This distinction between ‘explanation’ and ‘understanding’ continues to be in uential in our thinking even today (Phillips, 2004). In science we come to know the object from outside, but in the humanities we are able to ‘know’ the subject from inside. We are able to represent to ourselves, if not to ‘know’, the inner life of another person because we too have an inner life. We are able to understand the other person through the network of meanings associated with their behaviour. We start with the premise that behaviour means something; that is, it arises with internal consistency from psychological events. Wittgenstein (1953) stated, ‘We explain human behaviour by giving reasons not causes’.

Jaspers drew on Dilthey’s formulation and contrasted understanding (verstehen) with explaining (erklären). He has shown how these terms may be used in both a static and a genetic sense. Static implies understanding or explaining the present situation from information that is available now; whereas the genetic (an unfortunate term given contemporary use) sense considers how the situation reached its present state by examining antecedents, the evolving process and emerging situ- ation. This is represented in Table 1.2.

Understanding and explanation are both necessary parts of the psychiatric investigation. Explanation is concerned with accounting for events from a point of observation outside them, understanding from inside them. One understands another person’s anger and its consequences; one explains the occurrence of snow in winter. Explanations also can be described as static or genetic (Boxes 1.1 and 1.2).

Jaspers makes an important distinction between that which is meaningful and allows empathy and that which is ultimately un-understandable, the essence of the psychotic experience. There is thus a limit to under- standing psychopathological phenomena. Although one can empathize with the content of a patient’s delusion and thereby understand how that content of the belief originated, the occurrence of the delusion itself is, in this model, more recalcitrant to our empathy and understanding. It can be said that our understanding reaches its limit when it confronts the fact of the delu- sion itself. For that, we need to appeal to cognitive mechanisms or other natural science processes. We are in need of scienti c explanation, not psychological understanding.

We can understand from a knowledge of the patient’s background why, if her thinking is going to be disor- dered in form, the topic or content of that thinking

TABLE 1.2 Diagram of Understanding and Explanation

Understanding

Explanation

Static Phenomenological description

Genetic Empathy established from what emerges

Observation through external sense perception

Cause and effect of scienti c method

BOX 1.1 STATIC AND GENETIC UNDERSTANDING

Fundamental Concepts of Descriptive Psychopathology 11 BOX 1.2 STATIC AND GENETIC EXPLANATION

• Static explanation is concerned with external sense perception, observing an event, for example ‘I witnessed the 1999 eclipse in Plymouth’.

• Genetic explanation consists of unravelling causal connections; it describes a chain of events and why they follow that sequence (‘visual perception of the eclipse
is the result of physiologic changes in my retina, which in turn produce changes in my occipital cortex that ultimately cause me to see the eclipse’).

Understanding is the perception of personal meaning of the patient’s subjective experience.

• If we want to nd meaning at a particular moment in time, the method of phenomenology is appropriate. The patient’s subjective experience is dissected out, and a static picture is formed of what that thought or event meant to him at that particular time. No comment is made on how the event arose, and no prediction is made as to what will happen next. The meaning is simply extracted as a description of what the patient is experiencing and what this signi es to him now. A man feels angry: static understanding uses empathy to describe in detail exactly what it

is like for him to feel angry. Have I, the examiner, experienced phenomena like these? Are they known to me through the experiences I have had in my lifetime?

• Genetic understanding, as opposed to static understanding, is concerned with a process. It
is understood that when this man is insulted,
he reacts with violence; when that woman hears voices commenting on her actions, she draws the curtains. For understanding the way that psychic events emerge one from another in the patient’s experience, the therapist uses empathy as a method or a tool. He feels himself into the patient’s situation. If that rst event were to have occurred to him personally in the patient’s total circumstances, the second event, which was the patient’s reaction to it, might reasonably be expected to have followed. He understands the feelings he ascribed to the patient by the action that results from these feelings. So if I were the patient with the same history, do I feel that I would have the same experiences and behave in the same way? An example would help to demonstrate the humanity of this approach and the universality
of human experience: I must put myself into the shoes of another young woman, aged 19, also
raised in an isolated shing community, the eldest
of eight siblings, who becomes stuporose during her second pregnancy. She is married to an alcoholic man aged 35, and her father is also alcoholic. I must understand how she dealt with her father’s alcoholic behaviour as a child, what her pregnancy meant to her, how she regarded her mother’s behaviour during her own pregnancies and so on.

should be concerned with persecution by the Nazis – perhaps because her parents escaped from Germany in 1937. But we can have no understanding of why she should believe something that is demonstrably false (e.g., that her persecutors are putting a tasteless uid into her drinking water that makes her feel ill). The delusion itself, as psychopathological form, is un- understandable. Meaningful connections, then, show the linkage between different psychological events by understanding how these events emerge one from another by a process of empathy.

This is a controversial concept in that it implies that there are aspects of another person’s mental life that are beyond our grasp and empathic understanding. It contradicts another axiom in psychiatric practice, namely that our purpose is to understand another person, and when understanding fails, it calls into question how conscientious and rigorous the psychiatrist has been in the pursuit of grasping the inner life of the patient.

EMPATHY

The classic method in medicine of gaining information about the patient is from the history and by physical examination. The use of phenomenology in psychiatry is an extension of the history, in that it ampli es the description of the present complaint to give more detailed information. It is also examination in that it reveals the mental state. It is not possible for me, the doctor, to observe my patient’s hallucination or in any direct way to measure it. However, what I can do to comprehend him is to use those human characteristics I hold in common with him: the fact that we inhabit the same world of meanings, that we communicate in language and that like him I have a rich inner life. It is also important to be intellectually curious and genu- inely interested in the inner life of another person. The

12 SECTION I Concepts and Method

inquiries that arise from this stance should aim to recreate for oneself or represent to oneself the subjective experiences of another person with the aim of under- standing and making sense of them. The aim is thus to explore and test, through dialogue, the patient’s subjective experience. I endeavour to create in my own mind what his experience must be like. I then test to see whether I am correct in my reconstruction of his experience by asking him to af rm or deny my descrip- tion. I also use my observation of his behaviour – the sad expression of his face or him thumping the desk with his st – to reconstruct his experiences.

Listening and observing are crucial for understand- ing. Great care must be taken with asking questions. Doctors not infrequently identify symptoms incorrectly and come to the wrong diagnosis because they have asked leading questions with which the patient, through his submissiveness to the doctor’s status and his anxiety to cooperate, is only too willing to concur.

The method of empathy implies using the ability to feel oneself into the situation of the other person by proceeding through an organized series of questions, rephrasing and reiterating when necessary until one is quite sure of what is being described by the patient. The sequence might proceed as follows.

Question: ‘You describe your thoughts changing; what happens to them?’

Answer: The patient gives a description of how he has a recurring thought of killing people, and this results from a pain in his stomach.

Question (trying to isolate the elements of his experi- ence): ‘What is your thought of killing people like?’ (obsession, delusion, fantasy, is likely to be acted on, etc.). ‘Do you believe that your stomach affects your thinking?’ ‘Is this different from people who know that they become irritable when hungry?’ ‘In what way is it different from that?’ What causes your pain in the stomach?’

Answer: The patient describes the details, which include, among irrelevant material, the sort of informa- tion required for determining what symptoms are present.

Question (the invitation for empathy): ‘Am I right in thinking that you are describing an experience in which rays are causing pain in your stomach, and that your stomach in some way quite independent of yourself causes this thought, which frightens you, that you must

kill somebody with a knife?’ This is an account of the relevant symptoms that he has described in language he should be able to recognize as his own.

Answer: ‘Yes’ (we have then achieved our goal); ‘No’ (therefore I must try again to elicit the symptoms, experience them for myself and describe them back to him again).

To give examples of what this implies in practice: how do I, a clinician, decide whether an individual patient is depressed or not? This is not done by imitating a machine that might record units of vocal tone or of facial expression, adding up to a diagnosis of depression. For the clinical assessment, I go through the following process:

• I am capable of feeling unhappy, miserable and depressed and know what this feeling is like inside myself.

• If I were feeling as I observe the patient to be looking, speaking, acting and so on, I would be feeling miserable, depressed and unhappy.

• Therefore I assess the mood of the patient to be that of depression.

Of course, this mental process of diagnosis is not usually verbalized.

In another example, a patient says, ‘The Martians are making me say swear words; it is not me doing it’. Empathic questioning reveals the false belief held by the patient that when swear words come from his mouth he believes that the cause is actually outside himself, ‘Martians’, rather than from inside himself. Questioning would include ‘Do you actually hear the Martians? How do you know that it is Martians and no one else?’ and so on.

A further, non-psychotic example would be a 20-year-old young woman who has fainting attacks when she is criticized at work. The clinician has to place oneself, even if he is a 55-year-old man from a different cultural background, into her position with knowledge not only of her social history but also of the way that she, in the present, perceives that history; only then may the development of her symptoms become understandable. For instance, when the clini- cians knows about her alcohol-abusing father; the rows he had with her mother, who suffered from epilepsy; the very restricted cultural background that they experienced in an isolated shing village; and how her mother would have a t when rows became intolerable,

then he may begin to understand something of the development of the patient’s own symptom. This is not achieved solely by explanation as an outside observer but by empathic understanding and the capacity for subjective experience by the doctor, who puts himself into, and therefore becomes, the 20-year-old woman for the process of the psychiatric interview.

It is the purpose of the phenomenological method therefore to (a) describe inner experiences, (b) order and classify them and (c) create a reliable terminology. Empathy is also invaluable therapeutically in establishing a relationship with the patient. Knowing that the doctor understands and is even to some extent able to share her feelings gives the patient con dence and a sense of relief. This method of empathy is also useful as a way of extending knowledge more generally in the eld of psychiatry because it allows a diagnostic ter- minology to be developed.

Empathy is nonetheless a problematic concept. It is unclear what Jaspers himself meant by it, and hence various potentially contradictory interpretations are possible including transferring oneself into another person’s mind, sharing the patient’s experience, or actualizing the patient’s experience for oneself (Fulford et al., 2006). The approach taken in this book is to emphasize the use of extended dialogue to discover and re-create a patient’s subjective experience in oneself. Stanghellini and Aragona (2016) make the important point that empathic understanding is neither emotional fusion with the patient nor cold distance but always an attempt to modulate distance by continuous oscil- lation between the extreme of fusion and cold detachment.

FORM AND CONTENT

Form and content are distinct in phenomenology. For Jaspers:

form must be kept distinct from content which may change from time to time, e.g., the fact of a hallucination is to be distinguished from its content, whether this is a man or a tree, threatening gures or peaceful landscapes. Perceptions, ideas, judgements, feelings, drives, self-awareness, are all forms of psychic phenomenon; they denote the particular mode of existence in which content is presented to us.

Jaspers (1997)

Thus like warp and woof, form and content are essentially different but inextricably woven together. One way to think of form is to regard it as the sense modality in which a perception is presented to us or the cognitive domain in which a particular aspect of psychic life is experienced or enacted. The form of a psychic experience is the description of its structure in phenomenological terms, for example a delusion, or, as Berrios (1996) says, ‘Form refers to those imper- sonal aspects of the mental symptoms that guarantee its stability in time and space; that is, its “constancy” elements’. Viewed in this way, content is the subjective colouring of the experience. The patient is concerned because he believes that people are stealing his money. His concern is that ‘people are taking my money’, not that ‘I hold on unacceptable grounds a false belief that people are taking my money’. He is concerned about the content. Clearly, form and content are both impor- tant but in different contexts. The patient is concerned only with the content, ‘that I am pursued by ten thousand hockey sticks’. The doctor is concerned with both form and content, but as a phenomenologist only with form, in this case a false belief of being pursued. As far as form is concerned, the hockey sticks are irrelevant. The patient nds the doctor’s interest in form unintelligible and a distraction from what he regards as important, and he often demonstrates his irritation.

In Chapter 7, a patient is described who said, ‘When I turn the tap on, I hear a voice whispering in the water pipe, “She’s on her way to the moon. Let’s hope she has a soft landing.” ’ The form of this experience is what demands the attention of the phenomenologist and is useful diagnostically. She is describing a perception; it is an auditory perception and a false or disordered auditory perception. It has the characteristics of a hallucination, and speci cally of a functional hallucina- tion. This is the form. While the psychiatrist is busy clarifying the form, the patient might be getting irritated because ‘he is not taking any notice of what I am saying’. She is worried that she is being sent to the moon. What will happen when she gets there? How will she get back? So the content is all-important to her, and the doctor’s absorption with form is incomprehensible and frustrating in the extreme.

The form is dependent on, and is therefore a diagnostic key to, the particular mental illness from

Fundamental Concepts of Descriptive Psychopathology 13

14 SECTION I Concepts and Method

which the patient suffers. For example, delusional percepts occur in schizophrenia, and when demonstrated as the form of the experience they indicate this condition. The nding of a visual hallucination suggests the likelihood of an organic brain disease (Chapter 7). The nature of the content of these two examples is irrelevant in coming to a diagnosis. The content can be understood by the patient’s life situation with regard to culture, peer group, status, sophistication, age, sex, life events and geographic location. For example, another patient described himself as having been sent to the moon and back during the night within a fortnight of the rst landing by man on the moon. Describing one’s thoughts as being controlled by television is neces- sarily con ned to those people who have seen that invention.

Hypochondriacal content can occur in more than one form. It could take the form of an auditory hal- lucination in which the patient hears a voice saying ‘You have cancer’. It could be a delusion, in that he holds with conviction the false belief that he has cancer. It could be an overvalued idea, in that the patient has a conviction arising from prior experience of a mistaken diagnosis of cancer, and this results in him spending a major part of every day checking on his health. It could be an abnormality of affect that manifests itself in extreme hypochondriacal anxiety or in depressive hypochondriacal despondency.

The signi cance of culture and individual variation in ascertaining the detailed complaint of the patient should be stressed. Because the psychiatrist needs to assess whether this notion of the patient demonstrates the speci c psychopathological form of delusion, it does not diminish the parallel need to understand the patient’s philosophic, religious, political and social beliefs and know how they t, or fail to t, into the patient’s larger, national and more intimate, subcultural social contexts (Fabrega, 2000).

Alongside the need of the psychiatrist to acquire skills in psychopathology and the elucidating of mental symptoms is the parallel requirement for cultural education and sensitivity. Both aspects are necessary for every patient–doctor interaction. If anything, the painstaking and detailed study of phenomenology increases the awareness of the cul- tural context and how it in uences cognition and behaviour.

PRIMARY AND SECONDARY PHENOMENA

Jaspers discusses the different meaning that can be given to the terms primary and secondary when applied to symptoms. The distinction may be in terms of understanding; what is primary is immediate and ultimate and therefore cannot be further reduced by understanding, for example hallucinations. What is secondary is what emerges from the primary in a way that can be understood, for example delusional elabora- tion arising from the healthy part of the psyche in response to hallucinations from the unhealthy part of the psyche. Again, the conceptual distinction of what is primary or secondary may be determined by the causal chain, in that what is primary is the proximate cause, whereas what is secondary is the discernible distal effect. A cerebrovascular accident causes sensory aphasia and is therefore primary; the aphasia is the distal effect and is therefore secondary to the cerebro- vascular accident.

These two distinct meanings of the term primary overlie the crucial distinction between meaningful connections and causal connections. For the avoidance of doubt in physics and chemistry, we make observations by experiment and then formulate causal connections and causal laws, whereas in psychopathology we experience another sort of connection, in which psychic events emerge out of one another in a way that can be understood – so-called meaningful connections.

SUBJECTIVITY AND OBJECTIVITY IN PSYCHOPATHOLOGY

Objectivity in science has come to be revered as the ideal, so that only what is external to the mind is considered to be real, measurable and valuable. This is a mistake, because objective assessments are neces- sarily subjectively value-laden in what the observer chooses to measure, and this subjective aspect can be made more precise and reliable. There are always value judgements associated with both subjective and objective assessments. The process of making a scienti c evalu- ation consists of various stages: receiving a sensory stimulus, perceiving, observing (making the percepts meaningful), noting, coding and formulating hypotheses. This is a progressive process of discarding information, and it is the subjective judgement of what information is valuable that determines the small amount from each

stage that is retained for transmission to the next part of the process. ‘There is no such thing as an unpreju- diced observation’ (Popper, 1974).

Objective assessments in psychiatry have covered many aspects of life. A few examples are, in addition to many physiologic measures, the measurement of body movements, facial expression, patients’ writings, learning capacity, responses to an operant condition- ing programme, memory span, work ef ciency and evaluation of logical content of the patients’ statements. All these can be quanti ed and analyzed objectively. Subjective analysis can be made, for example, from facial expression or from the patient’s description of himself, of his own writing or of his inner events. When a doctor says about a patient ‘She looks sad’, he is not measuring the patient’s facial expression in ‘units of sadness’ by some objective yardstick. He is going through this process: ‘I associate her facial expression with the affect that I recognize in myself as feeling sad; seeing her expression makes me feel sad’. Rapport is this quality that the patient establishes with the doctor during the clinical interview. For it to happen, the doctor has to be receptive to this com- munication. He has to be able to establish rapport himself, to have a capacity for human understanding. This is necessarily a subjective experience for the doctor but that is not to say that it is unreal or even that it cannot be measured. The method of phenomenol- ogy tries to increase our knowledge of subjective events so that they can be classi ed and ultimately quanti ed.

Aggernaes (1972) has de ned subjectivity and objectivity for immediate everyday experiences.

When an experienced something has a quality of ‘sensation’, it is also said to have a quality of ‘objectivity’ if the experiencer feels that under favourable circum- stances, he would be able to experience the same something with another modality of sensation than the one giving the quality of sensation. When an experi- enced something has a quality of ‘ideation’, that is, it is not being directly sensed at the moment, it is also said to have a quality of ‘objectivity’ if the experiencer feels that under favourable circumstances, he would nevertheless be able to experience the same something with at least two modalities of sensation.

An experienced something has a quality of ‘subjectiv- ity’ if the experiencer feels that under no circumstances

would he be able to experience this something with two or more modalities of sensation.

Thus I can look at the table in front of me as a visual perception or I can turn my head and still fantasize it as a visual image. As I ‘see’ it, in either way, the fact that I can imagine both hearing a sound if I were to hit it with a spoon and bruising my knuckles if I were to punch it con rms its quality of objectivity. If I use my imagination to create in my mind a visual image of a Chippendale chair that I have never actually seen but is a composite of objects and pictures I have seen, I know that I will never be able to feel or hear this actual chair; it is a subjective image without external, objective reality.

UNCONSCIOUS EXPERIENCE AND PHENOMENOLOGY

Phenomenology cannot be concerned with the uncon- scious because the patient cannot describe it, and so the doctor cannot empathize. Descriptive psychopathol- ogy has no theory of the unconscious, nor does it deny its existence. Strictly speaking, the unconscious is simply outside its terms of reference, and psychic events are described without recourse to explanations involving the unconscious. Dreams, the contents of hypnotic trance and slips of the tongue are described according to how the patient experienced them, that is, according to how they manifest in consciousness.

ORGANIC AND NEURAL SUBSTRATES AND PSYCHOPATHOLOGY

Psychopathology is the study of abnormal mental processes, so that even when the organic causes of a condition are known, psychopathology remains involved in describing, de ning and ordering the symptomatic phenomena and the experience of the patient rather than being preoccupied with its neural origin or pathophysiology. This is not to imply that underlying neural mechanisms are unimportant. To the contrary, they are undeniably important. However, the actual subjective experience of the patient is also important and psychopathology concentrates on this.

There are established links between different abnor- mal phenomena and identi able organic pathologies. However, it is not with these links that psychopathology is concerned, and its usefulness is not dependent on ultimately nding the localization in the brain of a

1 Fundamental Concepts of Descriptive Psychopathology 15

16 SECTION I Concepts and Method

delusion or any other psychic event. Early, organically oriented psychiatrists, such as Griesinger and Wernicke, were not concerned with the psychopathological in psychiatry but much more with charting the diseased brain. This paid a rich dividend, for example in elucidat- ing the nature and treatment of cerebral syphilis. Similarly, some modern behaviourists have been uninterested in phenomenology. Phenomenology is not ultimately concerned with organic pathology or with behaviour per se but with the patient’s subjective experience of his world.

For a long time, symptomatic psychiatry and descrip- tive psychopathology seemed to have lost contact with organic psychiatry, in which evidence of mental illness is sought in disease of the brain. There has now developed what Mundt (2000) describes as a ‘fresh wind from the experimental eld of psychopathology, neuropsychology and biological neurosciences’. This linkage is still at an early stage, but it has potential for the future study of symptoms and brain pathology. But for these investiga- tions to succeed and to come to fruition, a thorough appreciation of psychopathology is essential.

MIND–BRAIN DUALITY AND PSYCHOPATHOLOGY

Cartesian dualism is the view that mind and body are separate substances; the mind happens to be associated with a particular body but is ultimately self-suf cient and capable of independent existence. This view – expounded by René Descartes (1596–1650), in which he made a distinction between the material and physical world and the thinking human mind – continues to exert extraordinary in uence. Husserl’s philosophy, phenomenology, arose out of Husserl’s rejection of many of Descartes’ conclusions. There are a number of sig- ni cant problems with Cartesian dualism, not least how an immaterial substance like the mind can in uence a material substance like the body.

There are varied philosophic attempts to deal with the problem of dualism and an account of these is beyond the scope of this book. What is important is that psychiatry is bedevilled by this problem: how to reconcile the phenomena that patients report with the materiality of the brain. Is it possible or plausible to reduce mental events to physical events in the brain? And how far can the changes observable during func- tional magnetic resonance imaging scanning be interpreted as products of certain mental phenomena?

Phenomenology, as an approach, avoids this debate by leaving it to one side (bracketing it as Husserl would have said) while continuing to explore, investigate, describe, de ne and catalogue the mental events, the phenomena, reported by patients. Descriptive psycho- pathology is not concerned with causes but with descriptions of experience.

The philosophy of mind is a thriving area of research, in particular the elucidation of the nature of mind. The speci c theories are outside the scope of this book (see The Character of Mind: An Introduction to the Philosophy of Mind; McGinn 1997). That is not to say that those theories such as Spinoza’s token identity theory, the type identity theory (also known as reductive material- ism) or eliminative materialism or functionalism are not relevant to psychiatry or to experimental psycho- pathology, but merely to emphasize that psychopathol- ogy can develop in the absence of a full and nal theory of the nature of mind.

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KEYWORDS

Diagnosis
History
Mental state examination

Summary

The clinical assessment of patients, which includes history taking, mental state examination, physical examination and the synthesis of the ndings into a diagnosis that takes account of the patient’s biological, psychological and social environment, is the basis of psychiatric practice. Without it, no adequate treatment and further clinical management is possible. At the heart of this task is the importance of focusing on the patient as the centre of clinical attention, recognizing the value of respect for the dignity of the patient, and regarding the patient’s narrative account as valuable, rich and privileged. The ascendancy of a tick-box approach to clinical assessment is to be deplored. It fails to grasp that despite the fact that assessments have a structure to them and that they are systematic inquir- ies, assessments must be conducted in a conversational style and in a humane manner.

Human beings are like parts of a body,
Created from the same essence.
When one part is hurt and in pain,
The others cannot remain in peace and be quiet. If the misery of others leaves you indifferent And with no feelings of sorrow,

You cannot be called a human being.

Sa’adi, Persian (thirteenth century)

Eliciting the symptoms and signs of emotional distress involves actively listening to a narrative account of the person’s complaints and his internal state and observing the whole repertoire of behaviour and then reducing these to a few summarizing phrases. It is a dif cult task, requiring an ability to listen and com- municate, a sensitivity to the needs and feelings of a

person who is bewildered and distressed and a knowledge of the possible conditions giving rise to the complaint. A genuine interest in the human condition and its manifold expressions, as well as a curiosity about intrapsychic experiences, is essential. This cannot be learned from a book alone, but a structure for case taking that suggests likely areas for exploration is invaluable. There are many comprehensive schemes, and they can often be traced to earlier textbooks with only slight modi cation. A summary of the scheme on which this chapter is based is shown in Box 2.1. A practical guide to history taking and evaluation of the mental state, diagnosis, formulation and management is found in the Handbook for Trainee Psychiatrists (Rix, 1987), The Psychiatric Interview (Carlat, 2005), and Kaplan and Saddock’s Comprehensive Textbook of Psychiatry (9th edition; Saddock et al., 2009). A useful approach to making the patient information available for diagnosis and planning treatment is Making Sense of Psychiatric Cases (Greenberg et al., 1986), and there are more in-depth texts on the psychiatric interview, such as The Psychiatric Interview in Clinical Practice (MacKinnon et al., 2006) and The First Interview (Morrison, 2008). A further account of the areas to be considered and the modi cations of the history and examination required in particular circumstances is to be found in Sims and Curran (2001).

There is a signi cant con ict of interest between the patient and the interviewer. The patient describes untoward and distressing experiences. He wants to be rid of these experiences. One patient may, for example, say that he is depressed and miserable, and another may complain that his thoughts are being sucked out of his head by the Martians. In both instances, the patient wants the symptom to be relieved and feels that describing it to the doctor in the way that it is affecting him is the rst stage in achieving this. The doctor needs to learn a lot of things from the patient that the latter may consider irrelevant. She needs to have a precise description of the symptoms and of the patient’s state of mind. She needs to know about the

CHAPTER 2

Eliciting the Symptoms of Mental Illness

20 SECTION I Concepts and Method
BOX 2.1 OUTLINE FOR PSYCHIATRIC EXAMINATION

Patient’s name: Age:
Occupation: Marital status: Address:
Source of referral:

• Reason for referral
• Present illness: symptoms and their chronology • Previous medical history

i. Physical

ii. Psychiatric
• Family history: father, mother, siblings, other relations,

atmosphere at home • Personal history

i. Pregnancy
ii. Infancy
iii. Childhood and adolescence
iv. Education at school
v. Further education
vi. Occupation (and military service)
vii. Sexual history: puberty, menstruation viii. Marital history
ix. Children

• Social data
i. Life situation: currently working, housing situation,

nancial problems, relationships

ii. Crime, delinquency
iii. Alcohol, drugs, tobacco
iv. Social and religious af liations and beliefs

• Premorbid personality • Mental state

i. Appearance and behaviour
ii. Talk and thought
iii. Mood: subjective, objective, rapport
iv. Thoughts and beliefs: phobias, obsessions,

compulsions, suicidal thoughts, delusions,

misinterpretations
v. Experience and perception:

a. of the environment (hallucinations, illusions, derealization)

b. of the body (hypochondriasis, somatic hallucinations)

c. of the self (depersonalization, thought passivity)

d. cognitive state: orientation, attention,
concentration and memory

e. insight

• Diagnosis and assessment
i. Diagnosis and differential diagnosis ii. Evidence for diagnosis
iii. Aetiologic factors
iv. Management
v. Prognosis

context of the patient’s symptoms, including the patient’s developmental history and about his adjustment to his social environment in general and to his symptoms in particular. To return to our examples, the doctor needs to know not only that the patient feels depressed; she must enquire about the precise nature of the ‘depression’, what the word implies to the patient, how the affect disturbs the routine of his life and whether there are any other associated symptoms.

The person suffering at the hands of the Martians will be only too ready to talk about Martians. However, they are largely irrelevant to the interviewer, who is interested in exactly what the experience of ‘thoughts being extracted’ entails. What is the patient’s evidence that this happens? What other abnormal mental phenomena are experienced? The reader can perhaps understand the patient’s irritation if he can imagine that, after he had paid his gas bill, a nal demand notice with an intimation that his gas supply was to be cut off came through the letterbox. On explaining to the authorities that his bill was already paid, they

did not apologize or say that they would correct their computer, but they started interrogating the harassed consumer as to why he should be so upset about it, and what was his evidence that he had been espe- cially picked on by the authorities. Understandably, there is a potential con ict of interest between the patient’s wish for relief of symptoms and the doctor’s need to start by making a diagnosis. A compromise is necessary.

The patient will quite quickly tire of the effort required to answer questions that are aimed at establish- ing the phenomenological status of subjective experi- ences. Several short interviews are preferable to a marathon session: ‘never ask today what you can ask tomorrow’. This method should encourage the examiner to ‘bracket out’ all preconceptions and the patient to re ect on his experiences under guidance from the examiner, who should not be digging for phenomena like a dog at a rabbit hole. It is important for the examiner to distinguish clearly between observations and inferences.

Diagnosis and Labelling

Why make a diagnosis? The medical classi cation of diseases allows a cluster of symptoms to be brought under a single term that embodies the essence of a given condition. The diagnostic term carries information in an ef cient manner. But there are disadvantages, including the unreliability of diagnostic terms as well as the risk of undue labelling and the associated stigma of a psychiatric diagnosis. It is central to the work of a professional that her rst task is to carefully collect information so that she knows exactly what clinical problem confronts her within her professional compe- tence and therefore what action would be appropriate; this is what diagnosis implies. It is true that for many common medical diseases such as diabetes, the diagnostic term refers to underlying demonstrable pathophysiology for which independent markers exist, such as blood sugar levels. In psychiatry, practically all the major disorders are still recognized at a syndromal level, that is, by the cluster of signs and symptoms that are thought to be typical of the given disease. The diagnostic term does not, as yet, refer to any well-described pathophysiol- ogy or indeed to any independent or reliable marker. This is a signi cant problem for the status of psychiatric diseases as bona de medical diseases.

In psychiatry, a multifactorial approach to the understanding of disorder is the rule rather than the exception. This is the basis of the biopsychosocial approach to psychiatric disorders. This means that a narrow diagnosis, in purely organic or purely behav- ioural terms, is inadequate. The diagnosis needs to be made in the context of an understanding of the biologi- cal, psychological and social antecedents, which in turn determine the biological, psychological and social management of the condition.

The Psychiatric History

This account is chie y interested in the way that taking the history sheds light on the mental state. The nature and type of referral is noted and recorded, for example from a general practitioner as an urgent problem, from a solicitor for a court report and so on. After recording the reason for referral, the history will usually begin with the patient’s verbatim description of his present symptoms, including the duration of each symptom and

an account of the development of the illness. Using the patient’s own words is valuable in giving insight into his state of mind and how he himself views his symptoms. It is helpful after receiving a catalogue of complaints to ask ‘Which is the very worst of all these symptoms?’ or ‘What is your main concern?’ This reveals how the patient conceptualizes his problem and also suggests a preliminary target for treatment.

Often the patient’s history of his present complaint is literally his story; there is nothing wrong in recording this in narrative style provided this is accurate. A chronologic account of the present illness reveals how the patient regards the development of his symptoms as well as giving information on the actual history. In the history, one wants to know about the sequence of symptoms and the effects these symptoms had on the patient’s lifestyle, about changes in behaviour and about alterations in physical function. It is appropriate at this point to note psychiatric symptoms of which the patient has been aware in the past but for which he has never consulted a doctor or received treatment. They may have relevance in the total picture of how the illness developed, and it is known that the majority of people with psychiatric conditions of clinical severity do not seek medical consultation, let alone come to the atten- tion of a psychiatrist (Andrews et al., 2001).

The patient feels it to be innately reasonable to describe chronologically and meticulously his previous illnesses, operations and accidents. He also will appreci- ate the logic of giving details of hospital and general practice treatment for mental illness and will usually give accurate information with regard to dates, duration, nature of treatment, in what hospital and whether he was an inpatient or outpatient. Treatment received from the family doctor is recalled less well; the dates are less reliable, and often the patient does not know the nature of the treatment or what it was for.

The family history is concerned with the patient’s family of origin, the likelihood of genetic predisposition to mental illness, and the family relationships and their potential contribution to the patient’s presentation. History of mental illness, suicide, nature of treatment and so on is relevant for the rst-degree relatives (those sharing 50% of the genetic material with the patient: parents, siblings, children) and more distant relatives. It is important to know about the quality of relationships, emotional bonding and interpersonal con icts, both

2 Eliciting the Symptoms of Mental Illness 21

22 SECTION I Concepts and Method

for the family in which the patient was a child and for the family in which the patient may be a parent. Relation- ships between individual members of the family are described, as are the general emotional atmosphere and social and nancial problems. The occupations of different family members give information about the social context; a record of health may be relevant, as may a description of their personalities. Of course, the family is seen through the patient’s eyes; this means that it is not just a factual description but rather an account of the emotional impact the patient feels his family has had on him. If the history from the patient is supplemented by an account from another informant, this bias of the patient’s will itself give information that may be useful in subsequent treatment.

The personal history traces the stages of the patient’s development, health and formation of relationships from conception, birth and infancy through childhood, school experiences, adolescence and further education to occupational, marital and sexual history. The factual details of these stages need to be recorded, as do the way they have in uenced the personality development and attitudes of the patient, how he feels about them, how he has related to other people (for example, teachers and workmates) and how all these details may be connected to the psychiatric condition. There are at least two processes at play in taking a history. There is the simple business of taking a factually accurate account of a patient’s history of complaints as well as the family, personal and social history. In addition to this approach, there is the requirement to grasp the meaning of the patient’s history, that is, his story, to understand how he sees himself in relation to the world and how his development and circumstances have been in uential in provoking, exacerbating or ameliorating his present illness.

The factual history is the foundation of the clinical diagnosis. Human beings live in a world of meanings, and the symbolic and social dimension of the history are the basis of an adequate and humane response to the patient’s illness and distress. Accounts that empha- size, for example, the fact that the patient is an only child, a precious child, a victim of other people’s malicious intentions, a ghter who has struggled against the odds or an unlucky individual for whom only failure and rejection characterize his life all say something about the dominant themes, the prism through which

the individual analyzes and perceives the world. So although it is important to record the facts, the meanings and understanding that patients have of the trajectory of their life all communicate something that enriches the clinical encounter, and potentially make possible a deeper doctor–patient relationship that should be satisfying for both doctor and patient.

Premorbid, Previous or Usual Personality

Assessment of personality is the most complex and problematic task that a psychiatrist faces. In clinical interviews, the doctor assesses the patient’s personality using three areas of information. First, the examiner asks the patient to describe in detail his relationships with other people, his interests and his activities. Second, the examiner studies the way in which the patient reacts to the examiner in the interview situation. Third, the examiner tries to help the patient describe and demonstrate what he, the patient, is like as a person; how he feels inside himself in different situations; and his interests, goals and standards.

Personality assessment is not the exclusive preserve of psychiatrists or psychologists, but an important learned skill of many professionals who deal with people – for example, schoolteachers, lawyers and even bank managers, although their terminology is different. Personality is that part of a person, excepting his physical characteristics, that makes him individual and unique, that is, different from other people. Personality is revealed by a person’s characteristic behaviour, the enduring patterns of responding and reacting to given situations. If a clinician can attempt to predict how a patient will react in hypothetical situations, what his behaviour will be in particular circumstances, then the basis of that prediction is founded on a reasonable and relatively accurate evaluation of his personality. Sub- jectively, personality is shown in the totality of a person’s aims and goals, formed of everything that he values and to which he aspires. Personality is not a thing but an abstraction, a model. It is simply a way of thinking about human character, temperament and conduct. Furthermore, it is multidimensional and is best de ned in action. Verbal description is unlikely to exhaust the essence of any individual. Indeed, no description can exhaust the rich and complex essence of any individual person. It is a truism that human beings are full of

potential and continue to surprise and astonish with the capacity for change, for transformation and for moral conduct including virtues and vices, which may not be readily identi able on rst contact.

Categorization into normal and abnormal personality requires a further level of abstraction. Normal, an ordinary word in everyday use, needs to be used more rigorously in this context (see Chapter 1). In medicine, the term normal is often used to denote a statistical norm, that is, what occurs in the majority of people. Equally, the term is also sometimes used to mean ‘ideal’, in the sense of a description that conforms to an ‘ideal’ type. In relation to personality, classi cation and de ni- tions of personality disorders depend on deviance from the norm, but the de nitions depend on ‘ideal’ descrip- tions of personality types or better still a typology. This can sometimes be dif cult to grasp. We may have an ideal notion of what it is like to be ‘extrovert’ and then a particular individual is compared against this abstract notion. This comparison presupposes that the ideal notion, sometimes termed a trait, varies in a dimensional manner among people. An individual is more or less extroverted compared against this ideal notion. The implication is that abnormal personality has some characteristics that are either overdeveloped or under- developed compared with an ideal notion, to such an extent as to signi cantly deviate from the mass of people. In other words, abnormalities of personality are differ- ences of degree; the deviant traits are shared in common with others but exaggerated in expression.

In the clinical interview, there are various areas of dialogue with the patient that are likely to lead to useful information for depicting the detail and colouring of his personality – the personality type. Painting the picture and de ning the type are both necessary clinical exercises. Social relations are investigated. How does he relate to his family? Is he detached or overly depend- ent? What sort of friendships does he form, with what sort of people, and are they close-knit or super cial, with an exclusive few or an unlimited crowd? How do his interests and leisure activities involve him with others? Is he sociable or solitary? Are his relationships structured or informal? How does he relate to bosses, workmates and employees at work? Is he a leader or a follower, an organizer or a loner? Is he pliant or truculent, cooperative, sympathetic or clubbable? His sexual preferences and relationships should be noted.

The nature of his interests and activities is informative. What does he like doing in his spare time? If he is interested in sport, it is useful to know if he can feel partisan and involved and also whether he is a participant or an observer. Enquiry is made of his preference and interests in lms and literature: how he observes, criticizes and enjoys the material. To what social organizations does he belong? Religion requires more than a single word designating religious af liation in the case notes. The phenomenological method is equally relevant for this area of life. What is the individual’s self-experience of his religious beliefs, and how do these interact with psychiatric symptomatology (Sims, 1994)?

An account of the patient’s predominant mood is explored, and whether his mood is uctuating or stable, responsive to precipitants or endogenously determined. Character traits imply a detailed adjectival list, for example, irritable, reserved, fussy and so on. It will, of course, be helpful to corroborate his description with an account from another person. Enquiry is made about his attitudes and values; his views about himself and his body; how he regards others close to him; his more general social values in religion, morality, politics and economics; how he feels events occur and can be made to occur. Drive and energy and the way these are expressed in ambition, lethargy, effectiveness and persistence are all important aspects of personality.

Study of his fantasy life is made: the frequency and duration of daydreams and their content; whether these are goal-directed and realistic or dissociated from any expectation of ful llment. Dreams and other supposed signs of unconscious psychic activity are useful, espe- cially when the subject attempts to interpret them. We may comment on his habits of ingestion, inhalation and excretion – whether they are regular and to what extent he depends on this regularity. Is there an indica- tion that there should be a more detailed history and exploration of current habits of eating, smoking, drinking alcohol and taking other drugs? As the patient unfolds the facets of his personality, so the overall emphases that he puts on areas of description become illuminating in understanding him as a whole person.

Differentiation of Personality Disorder

Allocating the patient to a personality type without taking into account the in nite variability of individuals

2 Eliciting the Symptoms of Mental Illness 23

24 SECTION I Concepts and Method

is inadequate. However, certain characteristics tend to occur together and are of clinical signi cance. Allocation to a particular category of personality disorder is made on the relative predominance of these different character traits. Having decided that a certain de nite trait or traits are present in this individual to an abnormal extent, does the abnormality of personality cause the person himself or other people to suffer? That is, is personality disorder present?

More than one abnormal type of personality may be present in any individual; they are not mutually exclusive. In formulating the psychiatric history and evaluation of mental state, comment on premorbid personality should always be made, even if it is only to state that due to the ravages of the mental illness, it is impossible to accurately assess premorbid state. The predominant traits should be described, preferably with verbatim comments of the patient to illustrate them. The interviewer should decide whether these traits are there to a signi cantly abnormal extent and, if so, whether this amounts to personality disorder. The type of disorder should be differentiated.

THE MENTAL STATE EXAMINATION

The mental state examination is the special area of expertise of psychiatrists. It is the psychiatrist’s equiva- lent of the neurologic examination. The mental state examination is guided by the same principles and communication skills as any other clinical interview (Box 2.2). It is dependent on facility with language because that is the tool with which psychiatric practice is conducted. The clinician uses ‘open’ questions at the beginning of clinical enquiries and utilizes ‘closed’ questions to clarify speci c points. There are speci c techniques for signalling active listening. These include the use of summary statements to summarize what the clinician has made of what the patient is saying and to provide the opportunity for the patient to correct any misapprehension on the part of the clinician. Furthermore, normalizing statements can be used to introduce dif cult subjects; for example, the clinician could introduce the issue of suicidal thoughts by saying, ‘It is not uncommon for people who are depressed to nd that they feel hopeless and that life is not worth living; have you felt like that?’ Statements that comment on the emotional aspects of the patient’s communication or behaviour, such as ‘I can see that it must be very

BOX 2.2 COMMUNICATION SKILLS TECHNIQUES

• Introductory statements and setting the context: ‘My name is Dr Smith. I have a letter from your GP informing me that you have been feeling low for the past 6 weeks.’ etc.

• Open questions: ‘Can I start off by asking how you have been feeling lately?’

• Closed questions: ‘I understand that you have been hearing voices for several weeks now. Are these voices there all the time?’

• Summary statements: ‘From what you have been saying, I understand that you have been feeling low for the past 6 weeks and that this has been steadily getting worse
to the degree that you are now tearful all the time for
no good reason and that your sleep has also been badly
affected.’

• Normalizing statements: ‘It is not uncommon for people
in your kind of situation to feel so low that life no longer
seems worth living. Have you felt like that?’

• Re ective and empathic statements: ‘As I understand it, when your husband lost his job, you had a lot of money
worries. That must have been quite dif cult for you,
especially with the new baby.’

• Concluding statements: ‘I now have a good grasp of
how things have been for you in the past year. Are there things that you wanted to tell me that you have not yet had the opportunity to bring up?’

dif cult for you to talk about these experiences’, may help to deepen the rapport between clinician and patient. Further practical advice on conducting the psychiatric examination is found in Leff and Isaacs (1990).

As the interviewer asks each question, she should be thinking what the possible answers to that question could be from a reasonable person in this context. In everyday conversations, one is conditioned to avoid asking embarrassing questions and so, when someone makes an odd remark, the tendency is to ll in the meaning of the response to make it ordinary, sensible and avoid asking further questions in this area. This is exactly the opposite to phenomenological investiga- tion, in which the interviewer is looking for ways into the patient’s private way of thinking. When the patient says something unreasonable, odd or unexpected, the interviewer must note it and, without intending to embarrass or disturb the patient’s equanimity, clarify

the inner experience already partly revealed. This will entail the use of the empathic method described in Chapter 1. One of the dif culties for the aspiring phenomenologist is to know when to pursue what the patient reveals in more detail – that is, when to make the incision for the psychopathological operation. Clinical wisdom involves knowing when to do what.

Words limit as well as liberate. The clinical interviewer needs to be careful not to restrain her patient’s answers by imposing the shackles of psychiatric technical jargon. Careful attention must be paid to the patient’s use of language, and, as far as possible, the clinician should use language that mirrors the patient’s language. It is important to be certain that both clinician and patient are using words in the same sense. The question ‘Do you hear voices?’ is a good example of this. The patient may truthfully answer ‘No’ and yet be suffering from almost continuous auditory hallucinations. Although patients and their doctors quite often describe auditory verbal hallucinations as ‘voices’, the patient may regard phonemes in quite other terms. He may make no distinc- tion at all between these auditory perceptions, ‘voices’ he hears for which an outside observer realizes there is an appropriate stimulus, and auditory hallucinations. He may be largely oblivious of the form of the com- munication as auditory and hallucinatory because he is totally absorbed with its content (an order telling him to go to Strasbourg and preach). Obviously, another patient may answer the question ‘Do you hear voices?’ truthfully in the af rmative and yet have a quite different form of phenomenological experience from auditory hallucination (see Chapter 7).

Almost every technical term in general medicine has diagnostic implications. This is also true in psychiatry. A symptom may not be pathognomonic of a certain condition but nevertheless is predominantly found with that illness. If the doctor uses the term perseveration in describing her patient’s mental state to a colleague, she is by inference suggesting a diagnosis of an organic psychiatric state. If this is not the diagnosis, she has some dif cult explaining to do to justify the use of that word. Is it really perseveration or just the repetitious use of words and phrases in a person who has intel- lectual disability and shows poverty of expression? To avoid misunderstanding, it is best to use longer descrip- tions until the interviewer is sure that the symptom is truly present.

Observation of the appearance and behaviour of the patient is an invaluable supplement to his self- description. The observations of others, and at times other than the interview, need to be taken into account. As the interview proceeds, the interviewer more de – nitely pursues her real intention of nding out the meaning behind the words the patient uses. What is the patient feeling and experiencing? His own account may be a blind to prevent other people, or even himself, from seeing how bad he really feels. The empathic method is invaluable in working out what he is implying. So also is acute, insightful and trained observation. Observa- tion may reveal white lines across the knuckles of an anxious person talking about what upsets him most and which renders him impotently angry. Empathy allows the observer to employ his own capacity for emotion as a diagnostic and therapeutic tool. Training and experience are essential for knowing in which areas delving will be rewarded with useful information; how to ask questions that are comprehensible to patients of different verbal abilities and cultural backgrounds and that will result in appropriate answers; and how to avoid damaging the patient still further with well- directed but blunt questions that are likely to be perceived as brutal. Observation and empathy must always be used together in eliciting the mental state. Note also the double meaning of the word observant: it means not only noticing what is going on around oneself but also conforming with the cultural mores of the immediate society. A good phenomenologist will be observant in both senses of the word.

Systematic Enquiry

The appearance and behaviour of the patient are observed for the clinical medical information they carry. Does the patient look ill? Is he alert, oriented, fully conscious, uctuating in his mental state? Are there any behavioural or neurologic abnormalities? Observation is also useful for assessing nonverbal communication (Argyle, 1975). From his posture, gestures, facial expression and so on, he betrays his state of emotion, providing informa- tion about his personality and his attitude to the observer and to others despite his silence or contradic- tory verbal communication. Obviously, observation of behaviour also indicates psychiatric symptomatology such as tics, catatonic movements, possible hallucinatory

2 Eliciting the Symptoms of Mental Illness 25

26 SECTION I Concepts and Method

perception, feeding and excreting disorders. Posture can be revealing to the acute observer, for instance, the pharaonic posture and the slow deliberate movements of head and neck of the patient with schizophrenia. If the patient is mute, observed behaviour is the only source of clinical information, but the importance of observation needs to be stressed also for those patients who do speak. Observation may be valuable to cor- roborate the patient’s complaints, to make clear the degree of emotional involvement he has in his symp- toms, or sometimes to contradict his statement, for example, the person who manifests physically extreme anxiety yet denies any worries on enquiry.

Talk reveals thought. Listening to and studying the patient’s utterances is usually the most important part of assessing his mental state. Thought disorder and the interpretation of abnormalities in the use of words, syntax and association of ideas are discussed in more detail in Chapter 9. The ow of talk merits notice. Does he talk volubly and easily or in taciturn monosyl- lables? Does he just answer questions or speak spontane- ously? Is his conversation appropriate to the social context, and is it coherent? Is the train of thought readily distracted? Throughout the interview, as much of the patient’s speech as possible should be recorded verbatim. This provides a clearer picture of this indi- vidual person’s inner milieu, and also the data of self-experience will allow another person to evaluate the diagnosis.

As the interviewer enquires about and forms her own assessment of mood, she has three areas for explora- tion: subjective and objective description of mood and evaluation of rapport. There is much more to mood than just depression or elation; the ner nuances of this person’s subjective emotional experience must be carefully dug out like truf es, using a sensitive nose and delicate extraction. A person anticipating an event may be acutely apprehensive, exquisitely excited but rather anxious, hopelessly resigned and so on; ‘afraid of the future’ is not an adequate description. Mood can be studied for its direction (depression or elation), its consistency (stable or labile), its appropriateness, its amplitude and the degree of discrepancy between subjective description and objective observation.

Of course, there is really no such thing as wholly objective assessment of mood. The doctor comments on the mood state of her patient from her observation

of the patient’s demeanour and the general tone of his conversation during the interview. She makes the comment, ‘He appears depressed; he is agitated and tense’. In fact, this comment on her patient’s emotion abbreviates the empathic process through which she goes to make this judgement. The doctor observes the patient and picks up available cues for mood, relating these to her experience with other patients and other people through her life, and ultimately to her knowledge of her own affective state. Her assessment runs as follows: ‘If I felt how my patient looks, speaks and acts, I would feel profoundly depressed and agitated; he is, on observation, depressed and agitated.’

Rapport is a useful measure of the patient’s ability to communicate his feelings to another person. The interviewer needs to make herself into a yardstick, a constant rapport maker, against which the patient’s ability to make rapport can be measured. To do this, the doctor requires clinical experience and an objectivity in which she knows how she reacts to, and commu- nicates with, many different sorts of people. She knows herself and her own competence well enough to exclude this from the assessment of rapport so that, as far as possible, it is only the patient’s capacity for emotional communication that is being tested.

The ideas and beliefs the patient holds and abnormali- ties of perception he experiences are ascertained and explored during the interview. In ordinary conversation, there is a great deal of lling in or editing to eliminate the de ciencies of communication. A person talks and comes to a halt halfway through a sentence for loss of a word. The other person provides the word and thus continues the conversation to both parties’ satisfaction. There is a tendency for those coming new to dialogue with the mentally ill to bring into their conversation these social niceties that are used to save embarrassment. The doctor tends to note what she thinks the patient meant to say, as if the latter’s thinking processes were similar to her own, rather than concentrating on what he actually said. A lot of signi cant psychopathology is thus missed. Delusions and hallucinations are rarely, if ever, volunteered by the patient as symptoms for the obvious reason that they are not experienced as different from the rest of the person’s thinking or perceiving. To the patient, subjectively, a delusion is indistinguishable from any other idea she has, a hallucination is indis- tinguishable from any other normal perception. Skill

in interviewing therefore comes very much in knowing when to look for a delusion and how to make a clear distinction between what the person describes as experience and what it reveals phenomenologically.

Passivity or delusions of control, obsessions, compul- sions and depersonalization may be obvious or only made plain with some dif culty. It is important to try to categorize the type of experience as early in the course of exposure to professional enquiry as possible, because patients’ explanations tend to become contaminated on repeated questioning. When passivity, for example, is suspected, it is generally best to follow up the clues right away and decide once and for all whether the symptom is present.

Assessment of the cognitive state includes, at least brie y, testing for orientation, attention, concentration and memory. The Mini-Mental State Examination (Folstein et al., 1975) is a widely used standardized bedside test of cognitive function that is useful to administer in the clinical setting.

The doctor, from speci c questions and from the interview in general, needs to form an idea of her patient’s attitude toward his illness, dif culties and prospects. To what extent does he have insight into his condition? Any illness of some severity will alter the patient’s world and view of the world. Insight assesses the awareness of this change by the patient and the accurate labelling of this change as originating from a mental illness that requires treatment. Insight is therefore highly complex as a function. It is the ability of the individual to be self-aware and to be sensitive to inner subjective change. The capacity to correctly attribute the subjective psychological change to pathologic causes is evidence of intact self-awareness despite evidence of mental illness. It is potentially an extremely valuable part of the mental state examination, as it is associated with compliance with treatment and also with the

likelihood of treatment under compulsion. In summary, insight has three components: recognition of subjective psychological change, the labelling of this change as pathologic in nature and recognition of need for treat- ment as well as compliance with treatment (David, 1990; see Chapter 11).

Many textbooks and numerous psychiatric institu- tions have their own scheme for psychiatric interviewing. This account is a general commentary rather than yet another scheme. See Box 2.1 earlier in the chapter for a memorandum of key areas to be covered in the history and examination of a psychiatric patient.

REFERENCES

Andrews, G., Issakidis, C., Carter, G., 2001. The shortfall in mental health service utilisation. Br. J. Psychiatry 179, 417–425.

Argyle, M., 1975. Bodily Communication. Methuen, London. Carlat, D.J., 2005. The Psychiatric Interview, second ed. Lippincott

Williams & Wilkins, Philadelphia.
David, A.S., 1990. Insight and psychosis. Br. J. Psychiatry 156,

789–808.
Folstein, M.F., Folstein, S.E., McHugh, P.R., 1975. ‘Mini-mental state’.

A practical method of grading the cognitive state of patients for

the clinician. J. Psychiatr. Res. 12, 189–198.
Greenberg, M., Szmuckler, G., Tantam, D., 1986. Making Sense of

Psychiatric Cases. Oxford University Press, Oxford.
Leff, J.P., Isaacs, A.D., 1990. Psychiatric Examination in Clinical

Practice, third ed. Blackwell Scienti c, Oxford.
MacKinnon, R.A., Michels, R., Buckley, P.J., 2006. The Psychiatric

Interview in Clinical Practice. American Psychiatric Publishing,

Arlington, VA.
Morrison, J., 2008. The First Interview, third ed. Guildford Press,

London.
Rix, K.J.B., 1987. Handbook for Trainee Psychiatrists. Baillière Tindall,

London.
Saddock, B.J., Saddock, V.L., Ruiz, P., 2009. Kaplan and Saddock’s

Comprehensive Textbook of Psychiatry, ninth ed. Lippincott

Williams & Wilkins, Philadelphia.
Sims, A., 1994. Psyche’ – spirit as well as mind? Br. J. Psychiatry

165, 441–446.
Sims, A., Curran, S., 2001. Examination of the psychiatric patient.

In: Henn, F., Sartorius, N., Helmchen, H.Lauter, H. (Eds.), Contemporary Psychiatry. Springer, Berlin, pp. 479–496.

2 Eliciting the Symptoms of Mental Illness 27

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SECTION 2

CONSCIOUSNESS AND COGNITION

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KEYWORDS

Consciousness Delirium Stupor Twilight state Automatism

Summary

Consciousness is a de ning characteristic of animals, although conscious self-awareness may be particular to human beings. Abnormalities of consciousness are problematic from a phenomenology point of view because, by de nition, self-reports of pathologic states, unlike self-reports of conscious experience, are not immune from error. The unconscious state is not privileged because the subject is unable to report on the nature and quality of the experience, and even in situations when there is only minimal impairment of consciousness, self-reports are still open to quali cation and query. Hence the terminology is determined by the observation of either the quantitative degree of abnormality or the apparent qualitative changes in conscious state. The terminology is imprecise, and often several terms are used for identical or frankly indistin- guishable states. In this chapter, terms such as vigilance, lucidity, clouding of consciousness, delirium, stupor, coma and some others are introduced and de ned.

Psychiatry and neuropathology are not merely two closely related elds, they are but one eld in which only one language is spoken and the same laws rule.

Wilhelm Griesinger (1868)

I have always been intrigued by the speci c moment when, as we sit awaiting in the auditorium, the door to the stage opens and a performer steps into the light, or, to take the other perspective, the moment when a

performer who waits in semidarkness sees the same door open, revealing the lights, the stage, and the audience
… as I re ect on what I have written, I sense that stepping into the light is also a powerful metaphor for consciousness, for the birth of the knowing mind, for the simple and momentous coming of the self into the world of the mental.

Antonio Damasio (1999)

Consciousness is one of the most challenging philo- sophic problems of our times. In this chapter the focus is on the subjective state of awareness of the sensible world, which terminates when we go to sleep, are comatose or are dead. It is important to emphasize that the term consciousness does not refer merely to the distinction between being asleep or awake. To be awake presupposes being conscious. The focus is on the process of being conscious of something, rather than merely being awake. In other words, it is the process of being conscious of something, in the sense in which one is aware that he can see a particular object or hear a particular conversation.

At the outset it is important to distinguish conscious- ness from attention. Attention refers to the capacity to focus our interest or consciousness on speci c aspects of the objective world. This might entail selecting, shifting and thereby focusing attention, for example, on a passing vehicle rather than on a lamppost. No doubt both processes are related, but there is empirical work to show that both processes can operate inde- pendently of one another. The global workplace theory, an in uential psychological model of consciousness, uses a theatre metaphor in which attention resembles choosing a television channel and consciousness is the picture on the screen (Baars and Franklin, 2007). The distinction that is being drawn here is that between selecting an experience and being conscious of the selected event. It is a truism that we are only conscious

CHAPTER 3

Consciousness and Disturbed Consciousness

32 SECTION II Consciousness and Cognition

of a fraction of the information processing going on in our brain at any one time. The function of attention seems to be to select some aspects of stimulus input de ned by location in space, a given feature such as shape or by an object. In contrast, the function of consciousness pertains to summarizing all the informa- tion from the environment that we need to ensure that it is available for planning, decision-making, language, rational thought and setting long-term goals (Tononi and Koch, 2008). This is what Jaspers (1997) refers to as ‘the immediate experience of the total psychic state’.

Any theory of consciousness must attempt to explain certain basic facts about mental life, namely that (a) consciousness has a subjective nature that is united by a unique individual’s inner perspective; (b) that con- scious awareness appears to have a quality that is recalcitrant to physical or materialist description, that is, that it cannot simply be reduced to physic-chemical processes; and (c) that conscious experience is directed towards objects, that is, it is intentional in nature. It is the particularly striking inner subjective aspect of conscious awareness that is of prime concern to psychiatrists.

Consciousness has a pivotal role in Husserl’s (1859–1938) phenomenology. As previously described, phenomenology is the study or description of phe- nomenon and involves the description of things as one experiences them. In other words phenomenology is concerned with subjective conscious experience. It is therefore the case that one must be conscious to be able to experience the world. So the logical starting place for the study of symptoms, from a subjective standpoint, is that feature of mental life – namely, consciousness – that allows subjective experiences to exist. Until quite recently, studies of consciousness were looked on with suspicion by neuroscientists, thereby leaving clinicians, both neurologists and psychiatrists, in intellectual darkness. This has been recti ed in the past two decades by combining and sharing the perspec- tives of different disciplines: philosophy, psychology, medicine and neurosciences (Bock and Marsh, 1993).

Although it is essential for our clinical work concern- ing disturbances in consciousness that we use the principles of descriptive psychopathology and applied phenomenology, we need to be aware of the limitations (Dennett, 1991). Dennett has pointed out that from

Descartes via Locke, Berkeley and Hume, phenomenol- ogy has tended to describe consciousness from the rst-person plural: ‘according to longstanding philo- sophic tradition we all agree on what we nd when we “look inside” at our own phenomenology’. We may not all be the same inside, and even if we are, we may get it wrong when we try to describe our inner experi- ences. He also questions the purely third-person perspective of behavioural psychology and advocates the ‘Method of Heterophenomenology’. This depends, for its authenticity, on the meticulous precision of the questions asked, the objectivity of recording the transcript (three stenographers preparing separate documents from an audiotaped interview), adopting the ‘intentional stance’ (assuming that the subject of investigation was intending to make a statement about something) and scope for clari cation. When this process has been followed, the text ‘is taken to be the sincere, reliable expression and to be a single, uni ed subject of that very subject’s beliefs and opinions’. It becomes clear that this process is similar, although more highly structured for research purposes, to the separate steps in the method of empathy, as described in Chapter 1.

There is a further problem for phenomenological analysis as it concerns psychopathology, precisely in that it requires a description of subjective experience. However, abnormalities of consciousness, as usually construed in psychopathology, concern experiences that are characterized by demonstrable impairments of the capacity to accurately report subjective experiences.

Karl Jaspers (1883–1969) recognized this problem but was also additionally aware of another issue, namely that in Husserl’s phenomenology, there is an inseparabil- ity of acts of consciousness such as attention, perception and so on and the actual objects of consciousness. Jaspers gave an account that treated consciousness as distinct from acts of consciousness. He identi ed three aspects of consciousness, namely (a) actual inner awareness, (b) a subject-object dichotomy and (c) knowledge of a conscious self. In this account, Jaspers used the metaphor of a stage, very reminiscent of the metaphor of a theatre that has currency today and that of a medium. These metaphors allowed Jaspers to refer to the idea that ‘the stage can shrink (narrowing of consciousness) or the medium can grow dense (clouding of consciousness)’ (Jaspers, 1997). For Jaspers, loss of

actual inner awareness is synonymous with loss of consciousness. In Jaspers’ conception, attention is conceived as either an active or passive turning towards an object and the degree of clarity and distinctness of the content of consciousness is referred to as the eld of attention. Finally, Jaspers (1997) also commented on the role of attention for ‘rousing further associations … guiding notions, set tasks, target ideas’, and so on.

In summary, consciousness is pivotal in Husserl’s phenomenology, and hence it is equally important in clinical psychopathology. Abnormalities of consciousness are problematic insofar as the terminology is appallingly confused. In this and subsequent chapters, I attempt to clarify the words used, sometimes at the expense of sacri cing altogether terms with a long history and sometimes lumping as a single concept words between which there are only minute differences of meaning. One major problem is that different disciplines and medical specialties use different terms to cover partly overlapping concepts and meanings. I propose to deal with abnormalities of consciousness under the following major headings: (a) dimensional changes in levels of consciousness and (b) qualitative changes of consciousness.

Disorders of Consciousness

It has proved complicated to describe exactly what is disordered in pathologic states of consciousness, hence this rather convoluted de nition of a disturbed state of consciousness (DSC) by Aggernaes (1975):

A state in a person in which he has no experiences at all, or in which all of his experiences are deviant, concerning other or more qualities than tempo and mood colouring, from those he would have under similar stimulus conditions in his habitual waking state. The state is a DSC only if the individual cannot return to, and remain in, his habitual state by deciding to do so himself, and if others bring about a lasting return to his habitual state by the application of a simple social procedure.

DIMENSIONAL CHANGES IN LEVELS OF CONSCIOUSNESS

Impairment of consciousness can be seen as a continuum from alertness through to drowsiness and ultimately coma and death. In that sense, consciousness may be

regarded as lying on a quantitative dimension (Fig. 3.1). Lishman WA (1998) makes the point that ‘considerable dif culties can surround the conceptual levels of consciousness of patients with acute organic reactions, partly because of problems inherent in the use of certain terms and partly because of the expecta- tion that impaired consciousness must necessarily be accompanied by decreased responsiveness to stimuli … In most conditions impairment of consciousness is accompanied by diminished arousal and alertness’.

Unconsciousness

Unconscious, according to Jaspers (1997), ‘means something that is not an inner existence and does not occur as an experience; secondly, something that is not thought of as an object and has gone unregarded; thirdly, it is something which has not reached any knowledge of itself’.

In clinical practice, the term unconscious is used in three quite different ways that have in common only the phenomenological element in that there is no subjective experience (Fig. 3.2):

• A person suffering from serious brain disease may be unconscious; consciousness in this instance is seen as being on a continuum, with a normal state of consciousness at one end and death at the other.

• Someone who is asleep is unconscious; again, there is a continuum from full wakefulness to deep sleep.

• An alert and healthy person is aware of only certain parts of his environment both externally and internally; of the rest, he is unconscious. There is also a continuum here from full vigilance

3 Consciousness and Disturbed Consciousness 33

Normal consciousness: alert, vigilant, lucid

Clouding Drowsiness Sopor Coma

Death

FIG. 3.1 Levels or stages of diminished consciousness.

SECTION II Consciousness and Cognition

2. Deep sleep

3. Unconscious mind

Stages of sleep Reduced wakefulness

Organic impairment

Brain disease

Preconscious – not readily available

Normal sleeping

Attention awareness

Normal consciousness

Clouding Drowsiness Sopor

1. Coma (stages)

directed towards the immediate object of aware-

ness to total unawareness.
The organic state of the brain as, for instance,

demonstrated by the electroencephalogram is utterly different in these three situations.

The third meaning of unconsciousness implies that certain mental processes cannot be observed by intro- spection alone, even when the brain is normal and healthy. Among such processes, for which there is good evidence of their existence, frequency and complexity, there are some that have been, or may yet become, conscious. This is what Freud called the preconscious (Frith, 1979). Whereas there is a strict limit to the number of items available in the conscious state and that are therefore capable of being memorized (approxi- mately seven, for example, a number with seven digits), there is much more information stored at the precon- scious level. If a stimulus is ambiguous, only one interpretation is possible in consciousness at any one time; however, multiple meanings are available pre- consciously. It is dif cult to carry out more than one task at a time consciously, but undertaking parallel tasks is usual at a preconscious level. Preconscious processes are automatic, whereas conscious ones are exible and strategic. This function of the preconscious

Death

FIG. 3.2 Three dimensions of unconsciousness.

was well known long before Freud, for example, Brodie (1854):

But it seems to me that on some occasions a still more remarkable process takes place in the mind, which is even more independent of volition than that of which we are speaking; as if there were in the mind a principle

of order which operates without our being at the time conscious of it. It has often happened to me to have been occupied by a particular subject of inquiry; to have accumulated a store of facts connected with it; but to have been able to proceed no further. Then, after an interval of time, without any addition to my stock of knowledge, I have found the obscurity and confusion,

in which the subject was originally enveloped, to have cleared away; the facts have all seemed to have settled themselves in their right places, and their mutual relations to have become apparent, although I have not been sensible of having made any distinct effort for that purpose.

Unconscious in the preceding sense is a theory that psychiatrists and psychopathologists have to explain some aspects of observable behaviour, whereas in the other two senses of the term ‘unconscious’, it is the

fact that the individual is unconscious to the world – that is, he is unrousable and unable to participate with this awareness of the sensory world intact – that is at stake.

The three dimensions of consciousness (contrasted with unconsciousness, as in Fig. 3.1) are vigilance, lucidity and self-consciousness.

Abnormalities of Vigilance

Vigilance is taken to mean the faculty of deliberately remaining alert when otherwise one might be drowsy or asleep. This is not a uniform or unvarying state, but uctuates. Factors inside the individual that promote or adversely in uence vigilance are interest, anxiety, extreme fear or enjoyment, whereas boredom encourages drowsiness. The situation in the environment and the way the individual perceives that situation also affect one’s position on the vigilance–drowsiness axis. Some abnormal states of health increase vigilance, whereas many diminish it.

In addition to the contrast between vigilance and drowsiness, there are qualitative differences in the nature of wakefulness. The vigilant state of mind of a person scanning a radar screen for a possible enemy interceptor is very different from the rapt attention of a music lover listening to a symphony. These aspects of attention and their abnormalities are discussed in Chapter 4.

Drowsiness is a persistent state and is the next level of progressive impairment of consciousness. The patient is ‘awake’ but will drift into ‘sleep’ if left without sensory stimulation. He is slow in actions, slurred in speech, sluggish in intention and sleepy on subjective descrip- tion. There is an attempt at avoidance of painful stimuli. Re exes, including coughing and swallowing, are present but reduced; muscle tone is also diminished.

In psychiatric practice, this is commonly seen after overdosage with drugs that have a central nervous system depressant effect (for example, tricyclic anti- depressants). From the psychiatrist’s point of view, it means, of course, that interviewing the patient is impossible. These levels of diminished consciousness are quite nonspeci c and occur whatever the nature of the cause: head injury, tumour, epilepsy, infection, cerebrovascular disorder, metabolic disorder or toxic state.

In coma, the patient is unconscious, whereas the drowsy patient is conscious but lapsing at times into

unconsciousness. In lighter states, with strong stimuli, he may be momentarily rousable. There are no verbal responses or responses to painful stimuli. The righting response of posture has been lost; re exes and muscle tone are present but greatly reduced; breathing is slow, deep and rhythmic; the face and skin may be ushed.

In later stages, the patient is no longer rousable; he is deeply unconscious. Distinct stages of coma have identi able physical signs ultimately culminating in brain death, but these are not discussed further in this book – they are beyond psychiatry (Conference of Medical Royal Colleges and Their Faculties, 1976). Practical assessment of the depth and duration of impaired consciousness and coma has been quanti ed on the scale devised by Teasdale and Jennett (1974).

Abnormalities of Lucidity

Consciousness is inseparable from the object of con- scious attention: lucidity can be demonstrated only in clarity of thought on a particular topic. The sensorium, the total awareness of all internal and external sensations presenting themselves to the organism at any particular moment, may be clear or clouded. Obviously, lucidity is not unrelated to vigilance: unless the person is fully awake, he cannot be clear in consciousness.

Clouding of consciousness denotes the lesser stages of impairment of consciousness on a continuum from full alertness and awareness to coma (Lishman, 1998). The patient may be drowsy or agitated and is likely to show memory disturbance and disorientation. In clouding, most intellectual functions are impaired, including attention and concentration, comprehension and recognition, understanding, forming associations, logical judgement, communication by speech and purposeful action. This represents the lesser stages of impairment of consciousness, with deterioration in thinking, attention, perception and memory and, usually, drowsiness and reduced awareness of the environment. There are important differences between the reduced wakefulness before falling asleep and clouding in an organic state (Lipowski, 1967). Although the patient’s awareness is clouded, he may be agitated and excitable rather than drowsy.

Clouding may be seen in a wide variety of acute organic conditions, including drug and alcohol intoxica- tion, head injury, meningeal irritation caused by infection and so on. Drowsiness as a descriptive term

3 Consciousness and Disturbed Consciousness 35

36 SECTION II Consciousness and Cognition

simply means diminished alertness and attention that is not under the patient’s control.

The term clouding should be used for the psycho- pathological state: impairment of consciousness, slight drowsiness with or without agitation and dif culty with attention and concentration. This will usually occur with organic impairment of function, for instance, with cerebral tumour, after head injury or with raised intra- cranial pressure. If it occurs in schizophrenia, it is as a part of the cognitive de cit that has been shown sometimes to occur in this disease (Frith, 1979). It is suggested that in this condition there is an awareness of automatic processes that normally occur below the level of consciousness. These processes are concerned with the selection of appropriate interpretation of stimuli and of response.

Heightened lucidity is the opposite of clouding of consciousness described earlier. Even though most abnormal states of consciousness show a lowering or diminution of consciousness but heightened lucidity of consciousness occurs in which there is a subjective sense of richer perception: colours seem brighter and so on; there are changes in mood, usually exhilaration, perhaps amounting to ecstasy; there is subjective experi- ence of increased alertness and a greater capacity for intellectual activity, memory and understanding. Such states of heightening of consciousness may occur in normal, healthy people, especially in adolescence or at times of emotional, social or religious crisis: when falling in love, on winning a large sum of money, at sudden religious conversion and so on. Heightened lucidity is not uncommon with certain drugs, notably with the hallucinogens (for example, lysergic acid diethylamide) and central nervous system stimulants (e.g., amphetamine). A similar state of awareness may occur occasionally in early psychotic illness, especially mania or, less often, in schizophrenia.

Abnormalities of Consciousness of Self

Alongside full wakefulness and clear awareness is an ability to experience self, and an awareness of self, that is both immediate and complex. This is considered in more detail in Chapter 12.

QUALITATIVE CHANGES OF CONSCIOUSNESS

Various other organic disturbances in brain function are recognized. These are virtually always associated

with some degree of quantitative impairment. The use of terminology in this whole area of discourse is, unfortunately, muddled, with the same term sometimes having different meanings and similar phenomena being described by different words.

Delirium. Lipowski (1990) de nes delirium as ‘a transient organic mental syndrome of acute onset, char- acterized by global impairment of cognitive functions, a reduced level of consciousness, attentional abnormalities, increased or decreased psychomotor activity and a dis- ordered sleep–wake cycle’. The Diagnostic and Statistical Manual of Mental Disorders (5th edition; DSM-5) de nes delirium as a condition in which there is a disturbance in attention that develops over a short period of time and that may include other disturbances in cognition, including in memory, orientation, language and spatial ability or perception. In addition these disturbances are not the result of a preexisting neurocognitive disorder, and investigation reveals that the disturbance is a direct result of physiologic consequences of another medical condition (American Psychiatric Association, 2013). It is important to conceptually distinguish between the term ‘delirium’ in the sense of a subjective experience of a qualitatively altered state of consciousness as against the term when it refers to a nosologic entity as described in the DSM-5. This chapter’s focus is on the subjective experience of the altered state of consciousness denoted by the term ‘delirium’. A detailed account of delirium as a condition is outside the scope of this book but can be found in Maldonado (2015).

Subjective accounts of delirium are rare, and the few published descriptions are open to criticism given the established fact that consciousness is impaired in delirium and the descriptions have had to be constructed with hindsight. Nonetheless, Crammer’s (2002) account con rmed partial states of arousal during which some memory functions and belief formation can be present, despite apparent unconsciousness. He wrote:

During the period 26–30 November I was, for the most part, completely unconscious, unaware of the passage
of time, the presence of visitors, the attention of nurses and doctors or my transfer by trolley or ambulance from ward to ward and hospital to hospital. However, within that period there were several brief uctuations (perhaps 5 min or so) in degree of awareness, and subsequently

I could recall having some human contact and some idea (partly mistaken) about my whereabouts and state of health in these episodes. In the rst two episodes I accepted that I was ill in some quite unspeci ed way and thought that I was to be transferred for operation (unspeci ed) rst to India and then to Australia; in the fourth episode, although much the same in feeling, I thought that I was changing planes on the ight home from Australia.

Crammer describes his subjective experiences and also attempts to explain them in retrospect:

I come half-awake lying on a vague bed in a very vague room with two young women (in white coats?) standing by my side. I identify them as physiotherapists. One is dark-haired (Indian?) and says nothing; the other is fair, does the talking and laughingly tells me that I need an operation and it will be best for me to transfer to India for it, perhaps to a Christian Mission hospital, possibly called Vellore, with which they have a staff exchange programme (clearly the dark-haired girl). I receive this information passively without curiosity: I do not know or care where I am, or what is wrong with me, although I am prepared to believe I have something requiring treatment and am reassured that it will be well done.

I fail to be myself, not very aware of surroundings and with no recollection of any injury or hospitalization.

He continued: ‘the idea of India may have been prompted by the (Indian?) nurse and perhaps by an unconscious memory of a fall in India 3 years earlier’ and the idea of Australia by the fact that ‘on admission to hospital I had been struck by the Australian accents of some of the nurses (and I had read previously in the local paper that Oxford hospitals had imported numbers of Australians to help), although all this was out of the conscious mind. Perhaps an Australian nurse helped me into the ambulance’.

Crammer attempts to make sense of his experience in retrospect. He is fully aware of the vagaries of memory and the likelihood of bias but nonetheless his explana- tions demand our attention:

The impairment of understanding – disorientation, misidenti cation of others, development of false beliefs – which is the central disturbance in the confusional

state, developed slowly as consciousness declined and was based in memory failure and inattention. I believed that I was living in Australia, presumably because of
an overheard voice, and thereafter held to this belief
and denied that I could be or ever had been in the John Radcliffe Hospital (in reality, previously I had been both an out-patient and an in-patient). I thought that I had been at a doctor’s social and checking-in for a ight home. A woman in a white coat was a physiotherapist, not a doctor; the doctor who later inspected my monitors was a ight engineer and the nurse was a check-in
girl … These are not absurd answers to the self-posed questions (who, where, what is this?) but near-misses based on brief, limited sensory impression with limited associative memory, a sort of guess without any uncertainty or any correction in relation to previous experience or immediately subsequent events, processes that go on all the time in normal life.

In his comments on Crammer’s account, Fleminger (2002) drew attention to the fact that the experience of delirium is akin to dreaming but that delirium is remembered with greater vividness than dreams. Also, that whereas it is traditional to conceive of delirium as being a disturbance of consciousness, it might be more pro table to think of it as a disturbance of the sleep–wake cycle. This is why the experience of delirium is akin to dreaming and why there is evidence that delirium is more likely in individuals with sleep deprivation.

David Aaronovitch (2011) wrote another account of delirium in an intensive care ward setting. Although his account is similar to that of Crammer, there was a more obvious narrative structure to the account. This may, of course, be because Aaronovitch is a journalist and his account necessarily had this structure. Or it could be that even though delirium is experienced as isolated events occurring in the ward at the time of the experience, the tendency to structure experiences into a whole is retained and that this is what gives accounts of delirium their narrative quality. He wrote:

Every time I closed my eyes, the inside of my eyelids would display a kaleidoscope of red, black and yellow violent cartoon images. So for four days and nights I didn’t sleep and much of that time didn’t know if it was day or night. After a while I noticed the clock on the wall of the room opposite, so now I could see the time,

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38 SECTION II Consciousness and Cognition

but I didn’t know which 12-hour cycle I was in – whether it was 7 am or 7 pm, lunchtime or four hours before dawn. All I did know was that the nurses came and went in shifts, handing over to each other every 12 hours in a rather cacophonous atmosphere of greetings, innuendo and consultations over the patients’ notes, and that this handover was going on up and down the passageway.

In this passage it is clear that Aaronovitch’s time sense was compromised and that sleep disturbance was a characteristic aspect of his experience. In other parts of his account, he described heightened acuity of hearing, persecutory beliefs including that a cup of coffee was injected through a large syringe into his drip line and he had grandiose beliefs: ‘I told her of my plan to sue the hospital and everyone associated with it. I’d get £1 million, I told her. Hadn’t they nearly killed a leading journalist on one of Britain’s top newspapers? We’d also reach a settlement in which the millionaire consultants were forced to give me their 2012 Olympic tickets’.

Both Aaronovitch’s and Crammer’s accounts point to the extreme vividness of the experience and the dif culty in distinguishing reality from an experience within an altered state of consciousness, namely delirium.

Fluctuation of Consciousness

Fluctuations in consciousness levels are seen in various conditions. It occurs in health, in sleep and in fatigue. In patients with epilepsy, there is uctuation in relation to ts, and it may occur before, during or after the seizures. Alterations of consciousness level are described with third-ventricle tumours associated with variations in intracranial pressure (Sim, 1974). In delirious states, there may be considerable diurnal uctuation of consciousness. Characteristically, the patient becomes more disorientated, disturbed in mood and distracted perceptually with illusions and hallucinations in the late evening and shows greatest lucidity mid-morning. Such variation of consciousness level is also described and observed with drugs, such as mescaline, in which there may also be uctuations of time sense.

Confusion

The concept of confusion was originally developed in France (confusion mentale) and later in Germany

(Verwirrtheit) in the nineteenth century (Berrios, 1981). It is a term, imprecisely de ned, referring to subjective symptoms and objective signs indicating loss of capacity for clear and coherent thought. It is purely a descriptive word and does not only apply to clouding of conscious- ness. When physicians, psychiatrists and nurses were asked what confusion meant, marked discordance was found. The term should be used only if clearly de ned (Simpson, 1984). It occurs with impairment of con- sciousness in acute organic states and with disruption of thought processes due to brain damage in chronic organic states, but it is also seen in nonorganic distur- bance. Thus confusion of thinking may occur as part of the picture in functional psychoses and also in association with powerful emotion in neurotic disorders. It should therefore be used simply to describe these disturbances of thought and not as a term pathognomonic of organic psychosyndromes.

To simplify, therefore confusion of thinking can be described as occurring either when the individual describes his own thinking as being confused or when the external observer considers that the thought pro- cesses are disturbed and confused. Phenomenologically, therefore it is simply a description of the patient’s self-experience or the doctor’s observation.

OTHER TERMS

Twilight State

A twilight state is a well-de ned interruption of the continuity of consciousness (Sims et al., 2000). It is usually an organic condition and occurs in the context of epilepsy, alcoholism (mania à potu), brain trauma and general paresis; it may also occur with dissociative states. It is characterized by (a) abrupt onset and end; (b) variable duration, from a few hours to several weeks; and (c) the occurrence of unexpected violent acts or emotional outbursts during otherwise normal, quiet behaviour (Lishman, 1998). If the term is reserved for these three features in combination, as a psychopatho- logical entity, then it should be used whenever they concur, irrespective of cause.

The forensic implications of this condition are therefore important, and it has been used as a legal defence for violent behaviour for which the person had subsequent amnesia.

Consciousness may be markedly impaired or rela- tively normal between episodes. There may be associated

dream-like states, delusions or hallucinations. It is sometimes associated with the temporal lobe seizures of epilepsy; it may occur with other organic states without epilepsy; similar behaviour may occur in apparent hysterical dissociation; and it is also described as an acute reaction to massive catastrophe. In the forensic context, it is important to demonstrate (a) the occurrence of similar episodes with inexplicable behaviour before the key happening and (b) other, objective evidence of physical or mental illness. The Ganser state (described with memory disorders in Chapter 5) is, in practice, a sort of twilight state in which the organic element is often dubious.

Mania à Potu (Pathologic Intoxication)

This is one type of twilight state speci cally associated with alcoholism. It is important to distinguish this syndrome of acute pathologic intoxication with alcohol from delirium tremens, which is a symptom of with- drawal. Keller (1977) has de ned mania à potu as:

an extraordinarily severe response to alcohol, especially to small amounts, marked by apparently senseless violent behaviour, usually followed by exhaustion, sleep and amnesia for the episode. Intoxication is apparently not always involved and for this reason pathological reaction to alcohol is the preferred term. The reaction is thought to be associated with exhaustion, great strain or hypoglycaemia, and to occur especially in people poorly defended against their own violent impulses.

Coid (1979) describes four components:

• the condition follows the consumption of a variable
quantity of alcohol;

• senseless, violent behaviour then ensues;

• there is then prolonged sleep; and

• total or partial amnesia for the disturbed behaviour
occurs.
Because there is often doubt as to whether intoxica-
tion really followed the consumption of an inappro- priately small amount of alcohol, and because several of the other causal factors are diagnostic categories in their own right (hypoglycaemia, epilepsy), Coid would do away with the diagnostic category of pathologic intoxication in the preceding de nition, leaving only either acute drunkenness or another condition associated with alcohol intake.

3 Consciousness and Disturbed Consciousness 39 Automatism

Automatism implies action taking place in the absence of consciousness. It has been de ned by Fenwick (1990) as follows:

An automatism is an involuntary piece of behaviour over which an individual has no control. The behaviour itself is usually inappropriate to the circumstances, and may be out of character for the individual. It can be complex, co-ordinated, and apparently purposeful and directed, though lacking in judgement. Afterwards, the individual may have no recollection, or only partial and confused memory, of his actions.

Epileptic automatism may be de ned as a state of clouding of consciousness that occurs during, or immediately after, a seizure and during which the individual retains control of posture and muscle tone and performs simple or complex movements and actions without being aware of what is happening (Fenton, 1975). It occurs as part of the clinical presentation of psychomotor epilepsy, most often arising from discharge in the temporal lobes. It was particularly common in those patients with chronic epilepsy who were resident in an epilepsy colony or a mental hospital.

An aura may be the rst sign of an epileptic attack with temporal lobe automatism and may be manifested as abdominal sensations; feelings of confusion with thinking; sensations elsewhere in the body, especially the head; hallucinations or illusions (especially olfactory or gusta- tory); and motor abnormalities such as tonic contracture, masticatory movement, salivation or swallowing.

Behaviour during automatism is usually purposeful and often appropriate, for instance, continuing to dry the dishes. Awareness of the environment is impaired; the patient appears to be only partly aware of being spoken to and does not reply appropriately. Initially, activity is diminished, with staring eyes and slumped posture; it then becomes stereotyped, with repetitive movements, lip smacking, fumbling and other actions. Finally, more complex purposeful behaviour occurs, such as walking about, making irrelevant utterances, removing clothing and so on. Sometimes, the patient may continue during automatism with whatever he was doing before – for example, driving his car – although there is subsequent amnesia, and the behaviour or speech at the time never appears entirely normal.

40 SECTION II Consciousness and Cognition

Violence is rare during automatism, and when it occurs, it usually amounts to resisting restraint. However, automatism is, rarely, cited as an explanation for a person’s violent and criminal action of which he is unaware afterwards. The legal de nition then becomes ‘The state of a person who though capable of action, is not conscious of what he is doing … it means unconscious, involuntary action and it is a defence because the mind does not go with what is being done’ (Viscount Kilmuir, 1963). Clearly, when such violent behaviour occurs, automatism ful ls the criteria for the de nition of twilight state as de ned earlier.

Speech automatism occurs when there is utterance of identi able words or phrases at some stage during the epileptic attack of which the patient has no memory later. Phenomenologically, then, automatism is action without any knowledge of acting, and it is the latter claim that requires careful investigation.

Dream-Like (Oneiroid) State

This is an unsatisfactory term not clearly differentiated from twilight state or delirium. The patient is disorientated and confused and experiences elaborate hallucinations, usually visual. There is impairment of consciousness and marked emotional change, which may be terror or enjoyment of the hallucinatory experiences; there may also be auditory or tactile hallucinations. The patient may appear to be living in a dream world, and occupational delirium could be mentioned in this context, for instance, the ship’s petty of cer, admitted to hospital after a head injury at sea (associated with excess alcohol intake), who kept shouting ‘Man the boats’.

It is important to look for other symptoms or organic states to make the important distinction between physi- cal illness and a dissociative nonorganic condition.

Stupor

‘Stupor names a symptom complex whose central feature is a reduction in, or absence of, relational functions: that is, action and speech’ (Berrios, 1996). It is distinct from coma and does not lie on a continuum from wakefulness to coma. This term should be reserved for the syndrome in which mutism and akinesis occur; that is, the inability to initiate speech or action in a patient who appears awake and even alert. It usually occurs with some degree of clouding of consciousness but does not refer solely to a diminished level. The

patient may look ahead or his eyes may wander, but he appears to take nothing in.

This syndrome is characteristic of lesions in the area of the diencephalon and upper brainstem, and also the frontal lobe and basal ganglia, and the term akinetic mutism has sometimes been reserved by neurologists to describe a much more narrowly de ned organic syndrome. A rare but speci c condition involving the motor pathways in the ventral pons is called the locked-in syndrome, in which there is quadriplegia and anarthria with preserved consciousness and vertical eye movement (Plum and Posner, 1972; Smith and Delargy, 2005). It is important to realize, however, that the symptoms of akinesis and mutism in a conscious patient also occur with schizophrenia, with affective psychoses (both depressive and manic) and in dissociative states.

The difference between psychogenic (so-called functional) and neurologic (organic) causes of stupor can be clinically extremely perplexing. Psychiatric de ni- tions have demanded that the condition occurs when there is ‘a complete absence, in clear consciousness, of any voluntary movements’ (Wing et al., 1974). Of course, it is not possible at the time of observation to know whether consciousness is quite clear or not, and even for functional stupors, subsequent amnesia is common. A phenomenological de nition of stupor must therefore exclude the state of consciousness of a mute patient, and diagnosis of stupor must then be followed by investigation of the differential diag- nosis, which includes both organic and nonorganic conditions.

Sleep Disorders

These are discussed in Chapter 4. REFERENCES

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Aggernaes, A., 1975. The concepts: disturbed state of consciousness and psychosis. Acta Psychiatr. Scand. 51, 119–133.

American Psychiatric Association, 2013. Diagnostic and statistical manual of mental disorders, fth ed. American Psychiatric Publish- ing, Washington, DC.

Baars, B.J., Franklin, S., 2007. An architectural model of conscious and unconscious brain functions: Global workspace theory and IDA. Neural Netw. 20, 955–961.

Berrios, G.E., 1981. Delirium and confusion in the 19th century: a conceptual history. Br. J. Psychiatry 139, 439–449.

Berrios, G.E., 1996. The History of Mental Symptoms: Descriptive Psychopathology Since the Nineteenth Century. Cambridge University Press, Cambridge.

Bock, G.R., Marsh, J., 1993. Experimental and Theoretical Studies of Consciousness. John Wiley, Chichester.

Brodie, B.C., 1854. Psychological inquiries. In: A Series of Essays. Longman, Brown, Green & Longman, London.

Coid, J., 1979. Mania à potu: a critical review of pathological intoxication. Psychol. Med. 9, 709–719.

Conference of Medical Royal Colleges and Their Faculties, 1976. Diagnosis of brain death. Br. Med. J. 2, 1187–1188.

Crammer, J.L., 2002. Subjective experience of a confusional state. Br. J. Psychiatry 180, 71–75.

Damasio, A., 1999. The Feeling of What Happens: Body and Emotion in the Making of Consciousness. William Heinemann, London.

Dennett, D., 1991. Consciousness Explained. Allen Lane, London. Fenton, G.W., 1975. Epilepsy and automatism. In: Silverstone, T., Barraclough, B. (Eds.), Contemporary Psychiatry. Headley Brothers,

Ashford, pp. 429–439.
Fenwick, P., 1990. Automatism. In: Bluglass, R., Bowden, P. (Eds.),

Principles and Practice of Forensic Psychiatry. Churchill Livingstone,

Edinburgh.
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4–5.
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schizophrenia. Br. J. Psychiatry 134, 225–235.
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(Ed.), A History of Medical Psychology. W.W. Norton, New York. Jaspers, K., 1997. General Psychopathology (J. Hoenig, M.W. Hamilton, Trans) The Johns Hopkins University Press, Baltimore. Keller, M., 1977. A lexicon of disablements related to alcohol consumption. In: Alcohol Related Disabilities. World Health

Organization, Geneva.
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confusion. J. Nerv. Ment. Dis. 145, 227–255.

Lipowski, Z.J., 1990. Delirium: Acute Confusional States. Oxford University Press, Oxford.

Lishman, W.A., 1998. Organic Psychiatry: the Psychological Con- sequences of Cerebral Disorder, third ed. Blackwell Scienti c, Oxford.

Maldonado, J.R., 2015. Delirium – neurobiology, characteristics, and management. In: Fogel, B.S., Greenberg, D.B. (Eds.), Psychiatric care of the medical patient, third ed. Oxford University Press, Oxford.

Plum, F., Posner, J.B., 1972. Diagnosis of Stupor and Coma, second ed. F.A. Davis, Philadelphia.

Sim, M., 1974. Guide to Psychiatry. Churchill Livingstone, Edinburgh.

Simpson, C.J., 1984. Doctors and nurses use of the word ‘confused. Br. J. Psychiatry 145, 441–443.

Sims, A., Mundt, C., Berner, P., Barocka, A., 2000. Descriptive phenomenology. In: Gelder, M.G., López-Ibor, J.J., Andreasen, N. (Eds.), New Oxford Textbook of Psychiatry. Oxford University Press, Oxford.

Smith, E., Delargy, M., 2005. Locked-in syndrome. Br. Med. J. 330, 406–409.

Teasdale, G., Jennett, B., 1974. Assessment of coma and impaired consciousness: a practical scale. Lancet 2, 81–84.

Tononi, G., Koch, C., 2008. The neural correlates of consciousness: an update. Ann. N. Y. Acad. Sci. 1124, 239–261.

Viscount Kilmuir, 1963. Bratty v Attorney General for Northern Ireland AC 386, 1961. 3WLR965; (1961) 3 All ER 523.

Wing, J.K., Cooper, J.E., Sartorius, N., 1974. The Measurement and Classi cation of Psychiatric Symptoms. Cambridge University Press, Cambridge.

3 Consciousness and Disturbed Consciousness 41

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KEYWORDS

Attention Concentration Sleep Hypersomnia Parasomnia Hypnosis

Summary

Consciousness, attention, concentration and sleep are all interrelated phenomena. In the previous chapter, consciousness and its abnormalities were described. Attention is often likened to a beam of light that focuses on a limited area of interest within a general eld, but it is best to conceive of it as a limited-capacity channel that is dynamic in the selection and inhibition of information for further processing (Broadbent, 1958; Smith and Kosslyn, 2007). It is important for an organ- ism’s ability to engage with aspects of its environment. It is required for orientating the organism within its environment. Abnormalities of impairment therefore underlie such disparate phenomena as disorientation and impairment of new learning. The sleep–wake cycle is a physiologic mechanism that determines the alteration from wakefulness, that is, consciousness and the special temporary state of unconsciousness that is manifest as sleep. Abnormalities of this cycle including disturbances of amount, quality and so forth are described in this chapter.

Come, Sleep! O Sleep, the certain knot of peace The baiting–place of wit, the balm of woe,
The poor man’s wealth, the prisoner’s release, Th’ indifferent judge between the high and low.

Sir Philip Sidney (1554–1586), Astrophel and Stella, sonnet 39

The terms attention, concentration and orientation have often been used very loosely. It is suggested that their use is restricted to the following. Attention is the active or passive focusing of consciousness on an experience such as sensory inputs, motor programmes, memories or internal representations. It can be de ned as the process that enhances some information and inhibits others, thereby allowing us to select some information for further processing (Smith and Kosslyn, 2007). The concept overlaps with the terms alertness, awareness and responsiveness. Voluntary attention occurs when the subject focuses his attention on an internal or external event; involuntary when the event attracts the subject’s attention without his conscious effort. Concentration is only one aspect of attention. It involves focused or selective attention. Other aspects of attention include sustained attention or vigilance, divided attention and alternating attention. Orientation is an awareness of one’s setting in time and place and of the realities of one’s person and situation. It is not a discrete function but is closely bound up with memory and the clarity or coherence of thought.

This chapter is concerned with cognitive function, but it is not limited to the functions that are disturbed by organic lesions and covers a wider eld than just consciousness and its disorders.

Attention, Awareness and Concentration

Attention is a different function from consciousness, but it is dependent on it. Thus variable degrees of attention are possible with full consciousness, but complete attention and concentration are impossible with dimin- ished consciousness. William James’ (1842–1910) (1890) account is still a good starting point:

Attention is … the taking into possession of the mind, in clear and vivid form, of one out of what seem several

CHAPTER 4

Attention, Concentration, Orientation and Sleep

44 SECTION II Consciousness and Cognition

simultaneously possible objects or trains of thought. Focalization, concentration, of consciousness are of its essence.

There are passive and active modes of attention. In passive attention, the subject responds to, for example, a loud noise, whereas in active attention, an individual’s prior expectations and goals determine in a top-down fashion what is attended to (for a fuller description, see Eysenck and Keane, 2010). A central feature of attention is its limited capacity. This refers to the fact that only so much cognitive processing activity can be carried out at any one time. Attentional capacity is usually tested by the digit span, and although it is a relatively stable feature of attention, it is prone to in uence by, for example, fatigue, depression and brain injury. Components of attention include orientating to sensory events, detecting signals for focused processing and maintaining a vigilant and alert state. It is important to recognize that knowledge, prior beliefs, goals and expectations can alter the speed and accuracy of the processes that select meaningful or desirable information from the environment.

There are four other aspects of attention. Focused or selective attention refers to the capacity to highlight the one or two important stimuli or ideas being dealt with while suppressing awareness of competing distrac- tions. This aspect of attention is usually referred to as concentration. ‘Serial sevens’ are usually employed to assess this aspect of attention, and it requires focused attention as well as other cognitive processes. Sustained attention or vigilance involves the ability to maintain attentional activity over a period of time. It is usually measured by vigilance tests. Divided attention involves the ability to respond to more than one task at a time or to multiple elements within a task. Alternating atten- tion allows for shifts in focus of attention and tasks (Lezak et al., 2004; Table 4.1).

Automatic cognitive processes, that is, those that occur without intention, that are involuntary and that do not interfere with other ongoing activities, exist in parallel with those that require attentive processes (Kolb and Whishaw, 1996). These automatic processes allow for the effortless extraction of features of a perception in bottom-up fashion, whereas attentive processes allow for the top-down processing of information (Fig. 4.1).

TABLE 4.1 Asp Aspect of Attention

cts of Attention

De nition

Focused attention

Sustained attention or vigilance

Divided attention

Alternating attention Attentional

capacity

The capacity to highlight important stimuli while suppressing awareness of competing distractions

The capacity to maintain attentional activity over a prolonged period

The ability to respond to more than one task at a time, including taking account of the multiple elements within a complex task

The ability to shift attentional focus from task to task

The extent of the processing ability inherent in the attentional system; it is often considered to be a form of working memory

ALTERATION OF THE DEGREE OF ATTENTION

Attention is decreased in normal people in sleep, dreams, hypnotic states, fatigue and boredom. It may be pathologi- cally decreased in organic states, usually with lowering of consciousness, for instance, with head injury, acute toxic confusional states such as drug- and alcohol-induced conditions, epilepsy, raised intracranial pressure and brainstem lesions. In psychogenic states, attention may be altered, for example, it may be diminished in hysterical dissociation. Narrowing of attention is also prominent in depressive illness, in which the morbid mood state results in attention being limited to a restricted number of themes – mostly unhappy or morbid.

A severe de cit of attention is a prominent feature in the hyperkinetic disorders in childhood (World Health Organization, 1992) but also occurs in adult life (see Chapter 3). Observation of the child’s behaviour by adults such as parents or teachers concentrates on three aspects: inattention, impulsiveness and hyperactivity. Inattention is shown in that the child, most often a boy and usually aged between 3 and 10 years, fails to nish activities he starts, appears not to listen, is easily distracted, has dif culty concentrating on any task requiring sustained attention and has dif culty sticking to a play activity.

4 Attention, Concentration, Orientation and Sleep 45

Normal Object of awareness

Conscious awareness Unconscious

Conscious awareness

Unconscious

Field of attention

Clear consciousness with voluntary attention directed towards an object of awareness – e.g. watching a radar screen

Narrowing of consciousness with constriction of the field of attention – e.g. epileptic aura

Clear consciousness with involuntary attention drawn to a field of attention – e.g. thinking in a deck chair

Pathological

Lowering of consciousness with patchy areas of attention

Impairment of focused attention and concentration denotes an inability to exercise attention on an object in a purposeful way, implying weakening of the determin- ing tendency. This is a feature of mania and hypomania and also occurs in organic states. These features combine to show the symptoms of distractibility, which is prominent in mania and some organic states.

Narrowing of attention entails the ability of the subject to focus on a small part of the eld of awareness and occurs in conditions in which involuntary attention is directed elsewhere – by hallucinations, by delusions or by strong emotion. After an unpro table conversation with a patient with schizophrenia in which she repeatedly ignored questions, she said, ‘I wish you would not interrupt when I am being given my instructions’.

DISORDER OF ATTENTION IN PSYCHOSIS

To recapitulate, attention is designed to present to the mind, with clarity and vividness, an appropriate selection,

only of some of the objects in our environment, where there are several, simultaneous possible objects. It includes the capacity to focus, sustain, disengage and shift attention. There is a passive and an active element to attention, the former controlled in a bottom-up approach by external stimuli and the latter controlled in top-down approach by the individual’s goals or expectations. There is also an attentional capacity, which is the extent of the inherent or intrinsic processing capacity of the attentional system. A full description of the current cognitive neuroscience model of attention is outside of the scope of this chapter.

There is little doubt that there are attentional problems, demonstrable on formal cognitive neu- ropsychological testing, associated with psychiatric disorders. Thus impairments of attention and/or working memory are demonstrable in diverse conditions such as generalized anxiety disorder, depressive disorder, bipolar disorder, schizophrenia and organic brain disorders such

FIG. 4.1 Variations in level of awareness.

46 SECTION II Consciousness and Cognition

as delirium and dementia. Attentional disturbance is a core aspect of attention-de cit/hyperactivity disorder. Subjective accounts of abnormal attention in early schizophrenia are at their most rich and detailed in the seminal studies of McGhie and Chapman (1961). In Chapman’s (1966) later work, he gave several

examples of problems with attention:

I can’t shut things out of my mind and everything closes in on me. It stops me thinking and then the mind goes blank and everything gets switched off. I can’t pick things up to memorize because I am so absorbing everything around me and take in too much so that I can’t retain for any length of time – only a few seconds, and I can’t do simple habits like walking or cleaning my teeth. I have to use all my mind to do these things. (Case 10).

At times there is nothing to hold the mind and this is when I go into a trance. (Case 15).
It happens when I’m watching the television as well and my concentration drifts away and focuses on any point in the room and I can’t pick anything up that is going on. I go into a daze because I can’t concentrate long enough to keep up the conversation and something lifts up inside my head and puts me into a trance. (Case 12).
Nothing settles in my mind – not even for a second. It just comes in and then it’s out. My mind goes away – too many things come into my head at once and I lose control. I get afraid of walking when this happens. My feet just walk away from me and I’ve no control over myself. (Case 29).

These subjective descriptions draw attention to a number of cognitive dif culties, including problems with focusing attention, of disengaging from environ- mental cues and of selecting from a range of possible cues in the environment and thereby feeling over- whelmed by information. These are disparate dif culties and probably re ect distinct neural underpinnings. The most distinct subjective description refers to being overwhelmed by information. This speaks to Broadbent’s (1958) theory in which he proposed a sensory buffer that allows only certain sensory data to pass through a lter for later processing and that this lter prevents overloading of the limited capacity mechanism beyond the lter. McGhie and Chapman’s (1961) own view is expressed as follows:

Now let us suppose that there is a breakdown in this selective-inhibitory function of attention. Consciousness would be ooded with an undifferentiated mass of incoming sensory data, transmitted from the environment via the sense organs. To this involuntary tide of impressions there would be added the diverse internal images, and their associations, which would no longer be coordinated with incoming information. Perception would revert to the passive and involuntary assimilative process of early childhood and, if the incoming ood were to carry on unchecked, it would gradually sweep away the stable constructs of a former reality.

John Cutting interprets these accounts differently. He made the point that the patients had heightened attention rather than that the proposed sensory buffer was unable to streamline what information was available for processing (Cutting, 2011). Furthermore, Cutting used the term lures to describe features of the environ- ment that seemed to capture the attention of patients with schizophrenia in such a manner that they were unable to disengage their attention. In his view, the potential lures are inanimate objects in the physical environment. In cognitive neuroscience terms, this implies an impairment of passive attention so that the patient is excessively liable to passive attentional capture. In addition, there are problems with disengaging and shifting attention.

There is well-established evidence that in mood disorders, including bipolar mood disorders, during the acute phase as well as in the euthymic state, there are demonstrable impairments in sustained attention and working memory (Clark et al., 2002; Marvel and Paradiso, 2004; Thompson et al., 2005). In addition, however, depressed mood is often asso- ciated with a preoccupation with gloomy thoughts to such an extent that concentration and attention are impaired. This suggests that attention, whether active or passive, can be in thrall to negatively valued features of the individual’s inner or external world. In such a situation, misinterpretations of perception in uenced by the mood state frequently arise. Every hearse is believed to be there to carry the patient to the graveyard, and a passing black car is noticed just suf ciently to be considered as strengthening this belief. Similarly, acute anxiety often results in diminished attention.

Cutting (2011) argues that in mood disorder, what lures the individual’s attention are people and not objects, in contrast to schizophrenia where the reverse is true. The subjective description to support this view is drawn from Minkowski (1970):

I feel that, when you insist, I ought to submit to your will and do what you demand of me. It irritates me to be someone’s fool, but I am incapable of resisting; I feel that you have control of me. I don’t dare do anything unless you ask me to. I do everything unconsciously. If you insist that I go out, I will go out. I can’t resist anymore. It is atrocious! After dinner, when the others get up
from the table, I get up automatically, carried along by their movements. I am the re ection of others. In sum, I vibrate with people, I re ect their movements; it is their vibrations that make me vibrate myself.

Minkowski classi es this as an example of the in uence of events, words and people on patients in depressive states. I am uncertain that this is an example of passive attention, namely, of what Cutting terms lures. Nonethe- less, it is incontrovertible that depressed mood is associated with gloomy thoughts, memories of past morbid incidents to such a degree that there is marked impairment of concentration and attention. This suggests that both active and passive attention may be ‘lured’ by negative aspects of the patient’s inner world.

As described earlier, schizophrenia is recognized as involving de cits of attention (Posner et al., 1988). However, there is considerable dif culty in establishing what aspects of attention are impaired in schizophrenia because the tasks that are used to assess attention may involve other cognitive functions, particularly given that attention is closely tied to concepts of working memory and also to executive function. Current evi- dence suggests that schizophrenia is associated with signi cant impairment in the control of selection, the ability to identify and attend to task-relevant inputs, whereas there may not be impairment of the imple- mentation of selection – the processes that determine the processing of relevant informational inputs (Luck and Gold, 2008).

It seems likely that in schizophrenia, on the basis of these reports, there is a greater susceptibility to lures within the environment that capture the passive atten- tion of the patient. A good way to understand this is

to imagine how a sudden, unexpected noise captures our passive attention. It does seem as if patients with schizophrenia are in thrall to irrelevant features of their environment.

HEMI-INATTENTION

A number of neuropsychiatric conditions illustrate the relationship between disorders of attention and impaired conscious awareness of objects. These conditions are complex and not completely understood. They include unilateral neglect, anosodiaphoria (lack of concern about hemiparesis), defective appreciation of hemiparesis with rationalization, denial of hemiparesis and unawareness of hemiparesis (anosognosia).

In their seminal paper, Paterson and Zangwill (1944) described unilateral neglect in a previously healthy male who suffered a penetrating injury of the right parietal occipital region after an explosion in 1943. He lost consciousness for 2 or 3 minutes and showed minimal post-traumatic and retrograde amnesia. On recovery his most signi cant de cit was a strong neglect of the left side of space. He collided with objects on his left and ignored food on the left side of his dish. It was concluded that the lesion was on the upper borders of the supramarginal and angular gyrus on the right side (Mattingley, 1996).

The aim in this section is not to examine in detail the varying hypothesis and ndings regarding these disorders of conscious awareness but to draw out the fact that syndromes of unawareness exist, that these syndromes involve attentional systems and that these systems require intact brain function in particular hemispheres and regions. These conditions in which individuals demonstrate a degree of unawareness or denial of hemiplegia have been recognized for well over a century by among others Babinski (1857–1932), Lhermitte (1877–1959) and Cricthley (1900–1997).

Stuss and Benson (1986) described a classic case of denial of hemiplegia:

A 62-year old man suffered a subarachnoid haemorrhage. A right middle cerebral artery was demonstrated and successfully ligated, but the patient awoke with left hemiplegia. At rst he vehemently denied the hemiplegia. At this time he was disoriented and had a retrograde amnesia covering at least 2 years prior to the surgery. When evaluated early one morning about 2

4 Attention, Concentration, Orientation and Sleep 47

48 SECTION II Consciousness and Cognition

weeks post-operatively, he spontaneously described his paralysis, was oriented to both time and place, but had no memory of his cranial surgery.

In another case they described the extent to which individuals with anosognosia will go to deny their disability

A 57-year old hypertensive man sustained an acute intracerebral haemorrhage involving the right putamen. On admission to hospital he was stuporous with profound left hemiplegia, left hemisensory loss, and left hemianopsia … He was disoriented for time and place, could not remember his doctors’ names, and actively denied any physical disability. When asked if he could walk or dance, he would immediately say yes; when asked to raise his arms or legs, he would raise the right limbs and insist that both arms or legs had been raised. When his hemiplegia was demonstrated to him he would accept the obvious fact and repeat the examiner’s statement concerning the cause of his disability but within minutes, if asked whether he had any disability, he would adamantly deny disability.

These accounts of unilateral neglect and anosognosia emphasize that the neural systems underpinning atten- tion to both right and left visual elds are probably controlled by the right hemisphere, whereas the dominant hemisphere (the left hemisphere in right handed individuals) only oversees the contralateral visual elds. Hence damage to the dominant hemisphere is not followed by unilateral neglect or anosognosia because the right hemisphere continues to monitor sensory information from all elds. Damage to the right hemisphere, on the other hand, is accompanied by hemineglect and anosognosia for the left visual eld. However, these matters also pertain not merely to visual elds but also to how our bodies are experienced. This is made most manifest in a case that presented after embolism of the right cerebral artery reported by Critchley (1950):

it felt as if I was missing one side of my body (the left), but it also felt as if the dummy side was lined with a piece of iron so heavy that I could not move … I even fancied my head to be narrow, but the left side from the centre felt heavy, as if lled with bricks.

In summary, abnormalities of attention have a complex set of consequences, not merely inattentiveness or impaired concentration as measured by crude bedside tests but also signi cant abnormalities that would not normally be attributed to abnormalities of attention and that are demonstrable in schizophrenia, mood disorders and neuropsychiatric disorders.

Orientation

Orientation is the capacity of an individual to accurately gauge time, space and person in his current setting. This enables him to make sense of, and be at home in, his environment. This is virtually the same faculty as intellectual grasp, in that various perceptual cues are used, and with correct sense of time and place, the person is able to come to appropriate conclusions from his context. A man suffering from an advanced dementia was being interviewed by a doctor in the presence of a dozen student nurses, who were taking notes with pen and notebook. When asked where he was, he looked around the rather dingy hospital class- room and said, ‘Well, we’re waiting to see the doctor’. He had picked up certain clues that reminded him of a general practitioner’s waiting room; he had totally missed the fact that all the nurses were in uniform, that they were taking notes and that he was being asked formal questions. He was disorientated in place and in person.

Orientation in time is labile and quite readily dis- turbed by rapt concentration, strong emotion or organic brain factors (for example, alcoholic intoxication). Milder degrees of disorientation are shown by inaccuracy of more than half an hour for the time of day or duration of interview. More advanced states are demonstrated with incorrect day of the week, year or period of day. Yet further disturbance is shown when the season of the year is not known correctly.

Orientation in space is disturbed later in the disease process than time. A patient may be unable to nd his way, especially in an area that is relatively new to him. It may take him an inordinate length of time to learn his way to the dining table in the ward after admission. Disorientation in time and place are, when clearly established, evidence of an organic mental state; they may be the earliest signs in a dementing process.

In disorientation for person, the patient fails to remember his own name. Loss of knowledge of the patient’s own name and identity occurs at a very late stage of organic deterioration. Loss of intellectual grasp (apprehension) occurs in organic states as a form of disorientation, usually combined with other evidence of deterioration. Such a person cannot understand the context of his present situation and connects outside objects and events with himself. Disorientation may occur with a disturbance of consciousness, attention, perception or intelligence. In severe intellectual defect and severe disturbances of memory, orientation is impaired even when consciousness is clear (Scharfetter, 1980).

DISORIENTATION

Orientation may uctuate in some organic conditions; for example, a patient with an acute toxic state associated with congestive cardiac failure was disorientated in time every evening but quite clear mentally in the morning.

Disorientation in time and loss of intellectual grasp (situational disorientation) usually occur rst in a progressive illness; disorientation in place usually occurs later and, in person, last of all. Disorientation for one’s own identity occurs at a later stage than for that of other people. An elderly woman who knew who she was and her previous status as a professor’s wife kept on referring to her daughter as ‘that minx who comes in every time the doctor visits’.

Delusions That Mimic Disorientation

It is, of course, important to understand the phenom- enological distinction between disorientation and a delusion that results in misinterpretation of place, of situation or of person. Disorientation is usually associ- ated with other organic features, such as lowering of consciousness or disturbance of memory. Delusions of misorientation have the features of a delusion (Chapter 8): a person on the ward may believe himself to be in prison, and a visiting relative may be considered to be an interrogator from the Gestapo.

Dissociation and Disorientation

De nite, undisputed disorientation is indicative of either an acute organic brain syndrome, if coupled with lowering of consciousness, or chronic organic

deterioration. Hysterical dissociation may mimic this, however, with apparent disorientation. Careful examina- tion of the mental state is likely to reveal suggestive discrepancies; for example, disorientation for person may be much more marked than for time or may be bizarre to an excessive extent. A patient is described in the next chapter who lived in Birmingham, United Kingdom, but found himself after a hysterical fugue in Montreal. Although apparently disorientated, he actually showed an abnormality of memory as part of a dissociative state.

Sleep Disorders

Sleep – deep, satisfying and undisturbed – is convention- ally associated with well-being and good health, as exempli ed by the quotation with which this chapter begins; its absence or poor quality is equally held to account for disorder of mood and misery. There is a relationship between disturbed sleep and psychiatric disorder; mental illness may cause and manifest as sleep disturbance, disturbed sleep may precipitate psychiatric symptoms, or the two may occur together but independently. The International Classi cation of Sleep Disorders subsumes 85 sleep disorders into seven categories including:

1. insomnias,
2. sleep-related breathing disorders,
3. hypersomnias not due to a breathing disorder, 4. parasomnias,
5. sleep-related movements disorders,
6. other sleep disorders, and
7. isolated symptoms, apparently normal variants

and unresolved issues.
For a fuller account see American Academy of Sleep

Medicine (2005).
The objective assessment of sleep is usually carried

out electrophysiologically. Five stages of sleep can be identi ed (Rechtschaffen and Kales, 1968). Sleep is entered through non–rapid eye movement (NREM) sleep. NREM and rapid eye movement (REM) alternate with a period near 90 minutes. NREM sleep accounts for approximately 75% to 80% of sleep, and REM sleep accounts for 20% to 25% sleep occurring in four to six discrete episodes (Pelayo and Dement, 2017). Using an electroencephalogram and electromyogram of the external ocular muscles, the duration of the various

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50 SECTION II Consciousness and Cognition

stages is recorded. It has been shown that REM sleep is associated with dreaming. With current neuroimaging techniques, it is possible, by showing changes in regional cerebral blood ow, to localize and represent visually altered activity, especially in the medial thalamus, that is associated with different stages of sleep from relaxed wakefulness to the slow-wave sleep of stage 4. There are also changes in the visual and auditory cortex, possibly associated with dreaming (Ho e et al., 1997). When considering the quality and duration of sleep and its stages, and whether this amounts to a symptom, it is important to take into account the age of the patient, any medication he may be taking and whether he has slept during the day. The subjective experience, as described by the patient, may be very different from the objective ndings of observation and measurement. The psychiatrist should investigate the meaning of this discrepancy phenomenologically and consider the consequences for diagnosis and treatment.

INSOMNIA

Insomnia implies subjective dissatisfaction with the duration or quality of sleep (Oswald, 1981); however, in many psychiatric conditions there is also objective disturbance of sleep. There are several approaches to the de nition of insomnia from the subjective that merely speci es whether an individual has had trouble sleeping to the strictly formal that stipulates that there must be greater than 30 minutes of sleep onset latency or wake time after sleep onset (Lichstein et al., 2017).

Formally, insomnia is de ned as a complaint of dissatisfaction with sleep quality associated with dif- culty initiating sleep, dif culty maintaining sleep that is characterized by frequent awakenings or problems returning to sleep after awakenings or early-morning awakening with inability to return to sleep (Ahmed and Thorpy, 2010; American Psychiatric Association, 2013). The individual may complain that the duration of sleep is too short; that sleep feels broken, less refresh- ing or insuf ciently deep; or that the pattern of sleep has changed for the worse. Insomnia is more common in women and in older people and is more often associated with a feeling of excessive mental arousal than bodily disorder. Causes of dissatisfaction include unrealistic expectations from the elderly that they will

sleep for as long as they did when they were younger and from the sedentary that they will sleep as deeply as after exhausting physical activity.

A discussion of primary insomnia is outside the scope of this book. It is well recognized that complaints of sleeping poorly are common and occur in many psychiatric disorders, including depression, generalized anxiety, panic and phobia, hypochondriasis and per- sonality disorders. They are among the most frequent symptoms in anxiety-related disorders and affective disorders. Comparing those people with neuroses with a normal population, Jovanovic (1978) found that neurotic patients complained of more wakefulness in the rst third of the night; they spent more time lying awake in bed, they awoke during the night more frequently, they spent a relatively short period in deep sleep, and their sleep was more likely to be impaired by unfamiliar surroundings. Those with major depressive disorder suffer from disturbed sleep, in which they take longer to fall asleep and spend less time asleep because of periods of wakefulness during the night and early morning wakening.

Early insomnia, or dif culty in getting to sleep, occurs in normal people who are aroused through anxiety or excitement. Their thoughts tend to dwell on the affect- laden experiences of the immediate past and also to rehearse ways of dealing with problems. Fatigue is experienced, but there is also a high level of arousal that prevents the necessary relaxation and withdrawal from perception that is required for sleeping. Late insomnia or early-morning wakening is particularly characteristic of the depressive phase of affective dis- orders. The patient may wake frequently in the night after getting off to sleep satisfactorily and thenceforward sleep only tfully and lightly. Alternatively, he may wake early in the morning and be unable to get to sleep again. The important characteristic of depression is that there is a marked change in sleep rhythm from the normal pattern for that person. In depression, the early morning wakening is often associated with marked diurnality of mood, with the most severe feelings of despondency and retardation occurring in the early morning. There is also often a marked reduction of sleep requirement in mania.

The mean sleep requirement diminishes with increas- ing age. It is usually about 7 to 8 hours through the middle adult years but is markedly reduced from about

50 years of age onwards. With insomnia, intermediate stages of light, restless sleep occur. These are often associated with abnormal experience in the sleepy state, such as hypnagogic and hypnopompic hallucina- tions (Chapter 7). Pseudohallucinations also occur, as does vivid imagery that is dif cult to distinguish from hallucination. Normally, passage into sleep is rapid and occurs passively rather than with active intention to sleep. Waking is also normally rapid, and the slowing of this process of becoming awake may be described as a symptom: a complaint of feeling drowsy and being incompetent and uncoordinated for an excessive time on wakening – in other words, sleep drunkenness or more accurately confusional arousals from non-REM sleep in which confusion and disorientation, slowed speech and mentation occur (Ahmed and Thorpy, 2010; Lishman, 1997). Such patients may sleep for 17 hours or more and always require vigorous stimulation to wake them. The condition may persist throughout life.

HYPERSOMNIA

In hypersomnia the de ning characteristic is daytime sleepiness. These cases are more often seen by a neurolo- gist than a psychiatrist and are reported only brie y here.

In the Kleine-Levin syndrome, attacks of somnolence occur, usually in adolescents. The condition is rare. In earlier accounts, the patient sleeps excessively by day and night but is rousable as from normal sleep. When awake, the patient eats voraciously (megaphagia) and may show marked irritability (Critchley, 1962). More recently it has become clearer that the condition is characterized by relapsing–remitting episodes of severe hypersomnia, cognitive impairment, apathy, derealiza- tion and psychiatric and behavioural disturbances. Boys are more frequently affected than girls. Slightly more than half of patients have hyperphagia, are hypersexual (mainly boys) or have depressed mood (mainly girls), and about a third have other psychiatric symptoms, such as anxiety, delusions or hallucinations. The hal- lucinations are usually brief and visual in nature – for example, of snakes near the bed or of a dangerous man with a bear in the hospital elevator (Arnulf, 2017). The delusions are said to be grandiose or persecutory in nature. Although some symptoms are similar to those in patients with encephalopathy, imaging and laboratory

ndings are unremarkable. The rst episode of hyper- somnia is often triggered by an infection, with relapses occurring every 1 to 12 months for a median of 14 years. Between episodes, patients generally have normal sleep patterns, cognition, mood and eating habits. During episodes, electroencephalography might show diffuse or local slow activity. Functional imaging studies have revealed hypoactivity in thalamic and hypothalamic regions, and in the frontal and temporal lobes (Arnulf et al., 2012).

Narcolepsy is a form of hypersomnia and can occur either with or without cataplexy. Narcoleptic attacks are short episodes of sleep (10–15 minutes) that occur irresistibly during the day; they usually begin during adolescence and persist throughout life. Narcolepsy is often associated with cataplexy, during which the subject falls down because of sudden loss of muscle tone provoked by strong emotion. Hypnagogic hallucinations and sleep paralysis may also occur, but less commonly. Narcolepsy is associated with short sleep latency and sleep-onset REM periods. There is usually no structural brain disease present. Hypnagogic hallucinations are usually auditory but may be visual or tactile. They occur between wakefulness and sleep, less commonly between sleep and wakening (hypnopompic hallucina- tion). Sleep paralysis is the inability to move during the period between wakefulness and sleep (in either direction).

In the Pickwickian syndrome, named after the fat boy of The Pickwick Papers (Dickens, 1837), or more speci – cally obstructive sleep apnoea, profound daytime som- nolence is associated with gross obesity and cyanosis due to hypoventilation. Breathing is periodic during sleep and somnolence, with apnoeic phases that may last for up to a minute.

Sustained drowsiness may occur with organic lesions of the midbrain or hypothalamus from various causes. Hunger, weight gain, excessive thirst and polyuria may also occur. The most important conditions giving rise to secondary hypersomnia are brain tumours, neuro- sarcoidosis and Niemann-Pick type C disease.

Hypersomnia may also occur as a psychogenic symptom. There may be a state amounting to hysterical stupor, and other conversion symptoms may be present. Other patients with neurotic disorders complain per- sistently of daytime somnolence and an inability to concentrate.

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52 SECTION II Consciousness and Cognition PARASOMNIAS

The parasomnias are disorders of arousal and sleep-stage transition that consist of abnormal sleep-related move- ments, behaviours, emotions, perceptions, dreaming and autonomic nervous system functioning that accompany sleep (Ahmed and Thorpy, 2010). Sleepwalk- ing is an example and consists of a series of complex behaviours arising during slow-wave sleep and resulting in walking during a period of altered consciousness. It is more characteristic of children than adults, and of males than females. Activity is usually con ned to aimless wandering and purposeless repetitive behaviour for a few minutes. The sleepwalker may reply monosyl- labically to questions, and there is little awareness of the environment, but injury is unusual. Frequently there is a family history, and enuresis is often associated. As sleepwalking occurs in deep sleep (stages 3 and 4), usually during the rst third of the night, it is unlikely to be the acting out of dreams. It is not the same phenomenon as epileptic automatism, which may also result in a person, who is apparently asleep, getting up and walking around. It is important to establish the diagnosis in each case.

Night terrors also occur in deep sleep early in the night and often in the same individual who sleepwalks. Intense anxiety is manifested, the subject may shout and there is rapid pulse and respiration. Usually there is complete amnesia for the experience on waking. It is not the same experience as a nightmare because the latter is a type of dream, occurring in lighter states of sleep, and is remembered vividly if the person awakes immediately after the experience. Most children grow out of night terrors and sleepwalking.

Claims have been made that automatic, violent behaviour has taken place during a night terror. A person who commits a criminal act while asleep is not conscious of his actions and cannot be held legally responsible for them; the law calls this sane automatism (Ebrahim and Fenwick, 2010; Fenwick, 1986). If the act – for instance, homicide – is remembered by its perpetrator as following a chain of psychic events (‘being chased by Japanese soldiers’), these images are most likely to have occurred in the context of a nightmare, and the act therefore took place on waking from the dream and would be regarded as motivated. During

the nightmare itself, sleep paralysis will prevent violent emotions being acted on. For the act to be convincingly ascribed to night terror, neither the act nor its antecedent storyline should be remembered, and all the evidence should point to the individual being asleep at the time. Previous evidence of night terror and sleep activity is important for corroboration.

Less known are the reports of sexsomnia in which sexual behaviour occurs during sleep. These cases seem to occur in the setting of disorders of arousal, the so-called NREM parasomnias that include confusional arousal, sleep terror and sleepwalking; REM sleep behaviour disorder; nocturnal partial complex seizures; and obstructive sleep apnoea (Ebrahim and Fenwick, 2010).

Dreams

How does phenomenology view dreams, their signi – cance and their interpretation? First, phenomenology can be concerned only with what is conscious; it cannot comment on that which is unconscious, although it may infer the existence of unconscious insofar as it explains some observed behaviours and phenomena. Second, the meaning belongs to the dreamer and not to an interpreter or theorist. This has implications for the way in which the phenomenological approach will be used in therapy.

Phenomenology can make a contribution to the understanding of dreaming. Both by introspecting and by taking accounts from patients while actually dream- ing, we know that memory is accurate and detailed, sometimes very detailed. Also, the process of reasoning is faultless, both for when bizarre elements intrude and also for when they do not. These bizarre elements therefore demonstrate neither de cient memory nor incapacity for rational thinking. They appear to be premises – the Euclidean ‘let’. In dreaming, fantasy is permitted so that when we say, or dream, ‘let Bill Snooks (who lives in Heckmondwike and has never met the President of the United States of America) travel on a barge down the Amazon’; what, then, would happen next? This phenomenological theory of dreams could be explored experimentally; if attitudes can be changed in consciousness by cognitive reprocessing, then the constructs that are used in dreams should also be capable of change.

Orthodox sleep (stages 1–4) and paradoxical sleep (REM sleep) have been distinguished from each other through the use of sleep electroencephalographic trac- ings in human subjects (Oswald, 1980). Normal re ex activity occurs in the stages of orthodox sleep, but localized activity is seen in paradoxical sleep while other muscle actions are paralyzed. REMs in paradoxical sleep are to some extent associated with dreaming. Nightmares are unpleasant dreams; often the particular horror of a nightmare is that there is nothing the sufferer can do about the terrifying experience. Dreaming occurs in REM (paradoxical) sleep, and the trans xed sensation of the nightmare is an accurate representation of the sleep paralysis that occurs in that phase.

Dreams have been used to establish elaborate psychiatric theories concerning the origins of con ict; it is outside the scope of this book to enter into any discussion of this area. It is, of course, a topic that was extensively written about by Sigmund Freud (1976). More recently, the meaning of dreams has been explored empirically by Kramer et al. (1976). Dreams are remembered and described as a psychic event: night- mares (unpleasant dreams) are often complained of and may be a prominent symptom, for instance in depression. Dreams are highly complex experiences and, so far, have de ed adequate analysis and explana- tion. However, certain characteristics can be described.

There is a loss of some of the structures of waking consciousness, thus there is a loss of self-awareness and awareness of the con nes of one’s own body. The margin between self and not-self becomes inde nite. The dreamer may dream of himself merging or trans- forming into someone else without contradiction. Time sense is also lost: there is no sense of progression of events but only immediate awareness of the present. Events occurring in the dream include those in which the dreamer himself is instrumental. There is often a loss of the sense of his having circumstances within his control, and there is also a loss of the physical and mental associations between the different parts of a whole experience. There are, therefore, gaps unaccounted for in space as well as in time and causation.

As well as the loss of temporal and spatial connec- tions, there is a loss of the psychological associations between events. There is no progressive sequence of

serial ideas or pictures. The dream is often like a group of short excerpts from very different lms.

In addition to the loss of structure that is typical in the dreaming state, there are also elements that do not occur in the normal waking state. These are best called dream images because they are not accurately delusions, hallucinations, false memories or other abnormalities of perception or ideation characteristic of being awake. These images are more vivid than fantasy and have a characteristic of immediacy and importance, so it is not surprising that from the beginning of time, people have acted on their dreams as if they were instructions.

To regard dreaming as a symptom rather than merely a remembered experience, it has to become invested with unpleasant affect. A patient may describe pleasant dreams if requested, but he does not usually complain of these as symptoms or ask for their removal. However, if the dream is associated with anxiety, terror, gloom or foreboding, and especially if the content or the theme is recurrent, it will be complained of and will indicate a prevailing affect; possibly the areas of con ict that have precipitated the distress will be revealed in the content of the dream. Unpleasant dreams in which a part of the traumatic event is re-experienced are a diagnostic feature of post-traumatic stress disorder after major disaster or catastrophe.

Hypnosis

It has been suggested by Marcuse (1959) that we ‘de ne hypnosis by what it does rather than by what it is’. At one extreme, hypnosis is considered to be a very dif- ferent state of awareness from normal waking conscious- ness. At the other extreme, Merskey (1979) considers that ‘the phenomena of hypnosis are identical with those of hysteria: they involve self-deception and the production of alternative symptoms or behaviour to solve a problem, even if not a con ict’. Merskey further goes on to propose as de nition:

Hypnosis is a manoeuvre in which the subject and hypnotist have an implicit agreement that certain events (e.g., paralysis, hallucinations, amnesias) will occur, either during a special procedure or later, in accordance with the hypnotist’s instructions. Both try hard to put this agreement into effect and adopt appropriate

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54 SECTION II Consciousness and Cognition

behavioural rules, and the subject uses mechanisms of denial to report on the events in accordance with the implicit agreement. This situation is used to implement various motives, therapeutic or otherwise, on the part of both participants. There is no trance state, no detect- able cerebral physiological change and only such peripheral physiological responses as may be produced equally by nonhypnotic suggestions or other emotional changes.

Hypnosis in contemporary practice is de ned as a psychophysiological state of attentive, receptive con- centration, with a relative suspension of peripheral awareness, what is sometimes termed the trance-state. It is thought that the ability to enter the trance state is widely distributed in the general population (Mal- donado, 2015).

Super cially, hypnosis appears to resemble sleep, but there are no electroencephalographic ndings to distinguish hypnosis from other states of relaxed wakefulness. The trance in hypnosis is therefore pro- duced in a waking state by one person on another using suggestion with compliance (Marcuse, 1959).

It is understood that hypnosis involves three inter- connected factors: absorption, dissociation and suggestibility (Maldonado, 2015). Absorption involves the tendency to engage in self-altering and highly focused attention with complete immersion in a central experience at the expense of contextual orientation such that the hypnotized subject can be intensely absorbed in their trance experience that they often choose to ignore environmental cues. Dissociation is the capacity to separate mental processes so that they seem to occur independently from each other, and thus a past memory may be dissociated from current events. Finally, sug- gestibility refers to the ability in a subject to be easily in uenced because of heightened responsiveness to social cues including instructions given during the hypnotic trance.

Hypnosis has been claimed to occur in nonhuman species, but this state cannot necessarily be considered identical with hypnosis. Hypnosis has been used for the control of pain, in the treatment of hyperemesis gravidarum and especially in the control of anxiety (Waxman, 1984).

The induction of hypnosis requires the implicit contract Merskey implies. The subject must be willing and cooperative; he or she relaxes and exercises

imagination. The eld of consciousness is narrowed to include only the instructions of the hypnotist. The subject relinquishes some degree of control to the hypnotist and accepts reality distortion. After the suc- cessful induction of hypnosis, autohypnosis can become established. Marcuse considers the following to be the characteristics of a hypnotic state:

• The subject ceases to make his own plans.
• Attention is selectively directed – for example,

towards the voice of the hypnotist.
• Reality testing is diminished, and distortions are

accepted.
• Suggestibility is increased.
• The hypnotized subject readily enacts unusual

roles.
• Posthypnotic amnesia is often present. Suggestion, for the hypnotic subject, is straightfor-

ward and obvious; it does not imply gullibility or loss of willpower. It describes the emotion of trust occurring within the implicit relationship in which the subject accepts the hypnotist’s statements, acts on his commands and denies evidence from his own senses that would contradict those statements.

A capacity for fantasy is necessary for hypnosis to take place. The relaxation that accompanies hypnosis may progress to normal sleeping, even during a hypnotic session. The alteration in conscious awareness occurring in hypnosis is similar to that in dissociative states but different from the uctuations of consciousness level occurring in organic psychosyndromes.

Suggestion has been used to produce many physical sequelae (e.g., blisters, alterations in pulse and blood pressure, levitation of an arm, opisthotonos, absence of pain sensation and so on). The psychological effects are equally variable and include alterations to percep- tion, cognition, ideation, memory and affect. The subject enters a dramatically altered state in which he temporar- ily surrenders responsibility for his actions to the hypnotist. In his turn, the hypnotist retains the con – dence of the subject only as long as he keeps within the limits of behaviour that the subject nds acceptable; beyond this, the subject will relinquish his dependent relationship and come out of the hypnotic state.

Hypnosis remains an enigma. There is now emerging evidence of the underlying neural correlates of hypnotiz- ability and of the hypnotic state itself. These point to greater functional connectivity between the left

dorsolateral prefrontal cortex, an executive-control region of the brain, and the salience network composed of the dorsal anterior cingulate cortex, anterior insula, amygdala and ventral striatum, involved in detecting, integrating and ltering relevant somatic, autonomic and emotional information in highly hypnotizable subjects compared with less hypnotizable subjects (Hoeft et al., 2012). As for the hypnotic state itself, during mental imagery for rehabilitation of neurodisability, functional magnetic resonance imaging signal increases exclusively related to hypnosis have been observed in the left superior frontal cortex, the left anterior cingulate gyrus and left thalamus. Whereas the superior frontal cortex and the anterior cingulate were activated related more to movement performance than to imagery, the thalamus was activated only during motor imagery. These areas represent central nodes of the salience network linking primary and higher motor areas. This suggests hypnosis enhances motor imagery (Müller et al., 2012). Much work still needs to be done to unravel the physiology of hypnosis.

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KEYWORDS

Memory Confabulation Ganser state

Summary

Memory has a well-described and delineated architec- ture, namely, sensory memory, short-term memory and long-term memory. Short-term memory is itself sub- divided into a central executive and the slave systems, termed the visuospatial scratch pad and the phonological loop. This architecture allows for a systematic under- standing of the underlying processes at play in memory. It is helpful to conceptualize the memory processes as including registration, retention, retrieval, recall and recognition. These terms allow for an understanding of the anomalies that are exhibited in organic impairments of memory.

Cans’t thou not minister to a mind diseas’d; Pluck from the memory a rooted sorrow;
Raze out the written troubles of the brain; And with some sweet oblivious antidote Cleanse the stuff’d bosom of that perilous stuff Which weighs upon the heart?

William Shakespeare (1606)

Disturbance of memory is always of signi cance for the sufferer; sometimes, however, forgetting is equally important and is an active process, as in the preceding quotation from Shakespeare. That memory disturbance was a speci c feature after head injury and other conditions was recognized in neuropsychiatric writings in the mid-nineteenth century. Hughlings Jackson (1835–1911) (1887) considered it to be an integral part of deterioration in organic mental functioning. The earliest detailed study of disordered memory from a psychological standpoint was by Théodule-Armand Ribot (1839–1916) (1882). Sergei Korsakov (1854–1900)

(1890) subsequently described his eponymous condi- tion, pointing out that gross disorder of memory may occur in patients in whom other intellectual functions and judgement are preserved.

Mechanisms of Memory

One of the major justi cations for using psychopathol- ogy in the description of memory disturbance is that there exists no good analogue of memory in animals. Conventionally, disturbance of memory is described by the length of time for which information has been retained. If one concentrates on the phenomenological aspects, the analysis of experience, it is in fact quite arbitrary to make a distinction between memory and perception because they are both stages in information processing (Weinman, 1981). Memory storage is organ- ized in three ways.

SENSORY MEMORY

Sensory memory is the initial and early phase of memory. It holds large amounts of incoming information brie y. It is a selecting and recording system via which percep- tions enter the memory system (Lezak et al., 2004). Fleeting visual image, iconic memory, lasts up to 200 milliseconds, whereas auditory, echoic memory, lasts up to 2000 milliseconds. The information selected and recorded at this level needs to be further processed as short-term memory or it quickly decays and is lost.

SHORT-TERM MEMORY

Short-term memory is conceptualized as a limited- capacity system that operates as a set of subsystems. Although it is theoretically distinguishable from attention, in practice it is pro tably equated with a simple span of attention limited to six or seven items and lasting 15 to 30 seconds unless the items are rehearsed. Baddeley and Hitch (1974) hypothesized a model of working memory comprising a central executive, a visuospatial scratch pad and a phonological loop. In this system, the

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central executive is the attentional controller assisted by the visuospatial scratch pad that allows for the temporary storage and manipulation of visual and spatial informa- tion. The phonological loop holds memory traces of verbal information for a couple of seconds combined with subvocal rehearsal (Baddeley, 1986, 2002).

LONG-TERM MEMORY

Long-term memory can be conceptualized into two retrieval systems: a declarative system, or explicit memory, that deals with facts and events and is available to consciousness for declaration, and a nondeclarative or implicit system (Lezak et al., 2004). The declarative system can be further divided into semantic (fact memory) and episodic (memory for speci c autobio- graphical incidents) memory. In other words, semantic memory is the storage of information in pure form without speci cation of time or place (‘General Psycho- pathology was written by Karl Jaspers’), whereas episodic memory refers to personally experienced events (‘I had a kipper for breakfast today’) (Baddeley, 1990). Long- term memory can hold information for periods of time from a few minutes to many decades, and the capacity is very large. Forgetting may be by loss of information or failure of retrieval. Normal forgetting rates are determined by such variables as personal meaningfulness of the material, conceptual style and age. Storage in, and also retrieval from, the long-term memory is impaired in the dysmnesic syndromes. Information is stored in reorganized and sometimes distorted form.

Description of the requirements for memory is chie y referable to long-term memory and can be subdivided phenomenologically into the following ve functions.

1. Registration or encoding is the capacity to add new information to the memory store.

2. Retention or storage is the ability to maintain knowledge that can subsequently be returned to consciousness.

3. Retrieval is the capacity to access stored informa- tion from memory by recognition, recall or implicitly by demonstrating that a relevant task is performed more ef ciently as a result of prior experience.

4. Recall is the effortful retrieval of stored informa- tion into consciousness at a chosen moment. It requires an active, complex search process. It is in uenced by primacy ( rst item) and recency

(last item) effects. The question ‘What is the

capital of France?’ requires the recall function. 5. Recognition is the retrieval of stored information that depends on the identi cation of items previ- ously learned and is based on either remembering (effortful recollection) or knowing (familiarity- based recollection). In this process, a stimulus triggers awareness; remembering or knowing then takes place. The question ‘Which of the following is the capital of France: Paris, Lille or Lyon?’ tests

the recognition function.
Abnormality of memory may occur in any of these

areas. In other words, there can be impairment of encod- ing, impairment of storage or impairment of retrieval.

Organic Impairment of Memory

Memory disturbances can be separated into those that are psychogenic, sometimes occurring in healthy people, and those that are organic, associated with disease of the brain. The latter are referred to as organic or true amnesias and can be described by the different functions of memory.

IMPAIRMENT OF REGISTRATION/ENCODING

In anterograde amnesia, the impairment is usually demonstrated in the failure of retrieval of information encountered after the onset of a clinical disorder. This impairment of retrieval may, of course, be due to problems at the registration (encoding) stage, particu- larly in patients with Korsakov’s syndrome. There is evidence that these patients may have dif culty in spontaneously encoding the semantic features of information to a suf cient level at input, and this failure results in poor memory (Mayes, 2002). It is therefore problems in the initial analysis and representation of information and the inability to select the salient semantic features of information that underlie impair- ment of registration. In a list-learning test situation, for example, the semantic features of the words, such as the fact that the words are derived from a list of the names of owers, fails to assist the subject to encode the new information.

IMPAIRMENT OF RETENTION

Retrograde amnesia is the loss of memory for events preceding the onset of brain injury. As with anterograde

amnesia, the de cit is demonstrated in the impairment of retrieval, but it is thought to be due to impairment of retention (storage), particularly in cases of cerebral trauma. Usually, it is of short duration of less than 30 minutes. Typically, it follows a temporal gradient in which newer memories are more vulnerable to loss than older ones. There is a dissociation between anterograde and retrograde amnesia such that registration may be impaired without any impairment of retention. This suggests that the anatomic structures involved in new learning and retention of old memories are distinct.

IMPAIRMENT OF RETRIEVAL OR RECALL

Retrieval is the capacity to access information from memory stores. Impairment of retrieval can be due to a de cit in either direct retrieval, in which a cue elicits a memory automatically, or strategic (indirect) retrieval, in which a cue provokes a strategic search process that produces a result. In direct retrieval, the question ‘Have you ever been to Lagos?’ acts as a cue that elicits a memory automatically. In strategic retrieval, the question ‘Who won the World Cup before the current champi- ons?’ instigates a strategic process that frames the memory problem, initiates the search and constrains it, guiding it towards local, proximal cues that then activate associative memory processes. The memory output is then monitored for accuracy and placed in a proper temporal-spatial context in relation to other memories (Gilboa and Moscovitch, 2002). Direct retrieval is thought to be dependent on medial temporal lobes and related structures, whereas strategic retrieval is dependent on the ventromedial prefrontal cortex. Confabulation is a good example of a condition that is a result of impairment of retrieval. It results from a faulty memory system creating faulty cue-memory associations, faulty search strategies and defective monitoring of faulty memories (DeLuca, 2009; Gilboa and Moscovitch, 2002).

IMPAIRMENT OF RECOGNITION

Recognition is the retrieval of stored information that depends on the identi cation of items previously learned. In episodic memory, that is, memory for events that includes the context, time, place and emotions associated with the event, recognition can take the form of either conscious recollection (remembering) or knowing based simply on a sense of familiarity. This is the so-called

remember–know paradigm, and it proposes a dual process memory system, one relying on conscious recollection and the other based on familiarity. In other words, the phenomenal experience that accompanies the recognition of a previously presented stimulus seems to take at least two forms. Recognition can occur when the stimulus evokes some speci c experience in which the stimulus was previously involved, or alter- natively the stimulus gives rise only to a feeling of familiarity without any recollective experience. A ‘remember’ response indicates that recognizing the stimulus brings back to mind some conscious recollection of its prior occurrence, whereas a ‘know’ response indicates that recognizing the stimulus is not accompanied by any conscious recollection of its prior occurrence (Dalla Barba, 1997; Tulving, 2000). Impairment of recognition has been described in Alzheimer’s disease (Dalla Barba, 1997) and in schizophrenia (Drakeford et al., 2006).

Disturbances of Memory

NORMAL VARIATIONS

Déjà Vu and Related Phenomena (Paramnesia)

Déjà vu is not primarily a memory disorder but a disturbance in which the associated feeling of familiarity that normally accompanies previously experienced events occurs with a novel event, that is, when the event is experienced for the rst time. An example might be having a strong feeling that one has been previously in a restaurant situated in a city that one is visiting for the rst time. In jamais vu, an experience that the patient knows he has experienced before is not associated with the appropriate feeling of familiarity. An example might be that of visiting a museum in one’s own hometown that one has visited several times in the past but, on this particular occasion, failing to have any sense of familiarity. The person may also have the feeling that some important memory is about to be recalled, although it does not actually arrive.

Déjà vu and jamais vu are relatively common, normal experiences but may also be signi cant symptoms of temporal lobe epilepsy or cerebrovascular disorder (Lishman, 1998). An epileptic patient said, ‘I feel that I’ve done something terribly wrong’. However, these experiences on their own, or associated only with vague

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feelings of depersonalization, should not be accepted as evidence of temporal lobe epilepsy, as these symptoms are also frequently experienced both in patients with anxiety-related disorders and in normal individuals.

Selective Forgetting

In normal forgetting, there is loss of or diminished access to recently acquired and stored information. Rates of forgetting are in uenced by the personal meaningfulness of the information, the conceptual style of the individual, the degree of processing and elabora- tion of the information and age. It is likely that normal forgetting is determined by disuse or interference by more recently learned or more vivid material and underpinned by physiologic or metabolic processes (Lezak et al., 2004). Additionally, there are two forms of interference: proactive and retroactive. In proactive interference, newly learned material interferes with the recall of previously learned material. In retroactive interference, previously learned material interferes with the recall of newly learned material (for a fuller discus- sion, see Eysenck and Keane, 2010).

The process of repression or selective forgetting, however, suggests that forgetting is not simply down to errors in the ling and retrieval mechanism. Forgetting is subject to the in uence of affect: which sensations are registered, what is retained and for how long and what information is available for recall. In Freud’s (1856–1939) account, traumatic or threaten- ing memories are kept out of conscious awareness by the mechanism of repression. Other forms of active forgetting exist, including motivated forgetting, which subsumes repression as an example. Directed forgetting is the term for the process by which we actively use executive control processes within the prefrontal cortex to forget items that we do not wish to recall. It is obvious from the foregoing that forgetting is an important and normative process.

Falsi cation of Memory

False memories concern report of events that never happened or distorted memories of events that happened with the result that an individual claims that something happened and they believe and remember that it hap- pened despite the fact their belief is erroneous (French et al., 2009). The mechanisms underpinning false memories in normal populations are relatively well

established. First, false memories are commonplace in nonclinical populations as demonstrated by the sig- ni cant numbers of people reporting alien abduction experiences. Secondly, studies of the ashbulb memories have shown that even for culturally signi cant and unique events such as the World Trade Centre attacks in New York in 2001, there is considerable distorted recall by witnesses of the event (French et al., 2009).

The mechanisms underlying the creation of false memories include exposure to postevent information and the role of misinformation in facilitating addition of nonexistent detail in reports. Susceptibility to false memory is at least partly determined by the quality of memory for the relevant observed event.

It is remarkable that it is practically impossible to distinguish between true and false memories in terms of the associated emotions or the degree of con dence with which the belief is held and as French et al. (2009) suggest, this probably means that both kinds of memories are constructed in the same way. Both involve source monitoring and plausibility. Source monitor- ing involves determining the source of the experience whether it be internal (imagination) or external (actually experienced). Plausibility refers to the degree to which the event is likely to occur in the real world. Mazzoni et al. (2001) propose that there are three steps neces- sary for people to develop a false memory: (1) they must believe that the speci c event could plausibly have happened, (2) they must develop a belief that the actually happened to them, and (3) they must make a source monitoring error and erroneously conclude that the details they remember must have come from a real experience.

The nature and origins of false memories in the normal population help to inform our understanding of false memories in clinical populations by drawing attention to the underlying mechanisms and to the similarities and differences in the nature, extent and behavioural consequences of false memories as described earlier. However, studies of false memories have not fully established any consistent ndings either with regards to personality factors or to motivational factors. Yet these factors probably play a signi cant role in clinical populations.

In pseudologia fantastica – uent plausible lying – the untruthful statements are often grandiose and extreme. Questions are answered with uency, and the story

appears to be believed implicitly by the pseudologic himself. Hence, it is often unclear the degree to which the patient believes the account. This usually occurs with an associated personality disorder, and often when the individual is experiencing a major life crisis such as facing criminal proceedings. The picture is of a very isolated person, without family or friends, drifting into the accident and emergency department of a large hospital in a strange city late at night, with stories of his own exploits and importance and the unfortunate vicissitudes he has experienced. There is overlap with factitious disorder.

With personality disorders and also with affective disorders, especially at times of heightened emotion, memory is falsi ed and distorted, and events and circumstances can be misrepresented. The advice of doctors may be grossly misconstrued. An ophthalmic surgeon examined a depressed patient’s eyes and informed her that her visual acuity was satisfactory and no treatment was required. She reported the fol- lowing to her psychiatrist: her ‘eyesight would be bad forevermore, and the surgeon has told me that nothing can be done about it’.

Inaccuracy of recall is sometimes called paramnesia. As well as occurring in the normal state and in per- sonality disorders, it is a prominent feature of affective disturbances. A woman with depressive illness falsi ed the events of her life: ‘I am not married. My children are illegitimate. We do not own this house. We are bankrupt.’ All these statements were untrue, and the falsi cation of her memory occurred in response to her severe depressive mood. Memory itself was accurate, but on remonstrating on any particular point of fact, further depressive explanations of events would be given. For instance, the marriage licence was described as a forgery, and complicated legal explanations were given as to why the house did not belong to her and her husband. In mania, unacceptable events or opinions may be brushed aside as not having occurred and unrealistic goals pursued as though there were nothing to prevent their attainment.

MEANINGFUL DISTURBANCES OF MEMORY

Psychogenic Disturbance of Memory

Cryptomnesia is the experience of not remembering that one is remembering. A person makes a witty

remark, or writes a haunting melody, without realizing that he is quoting (plagiarizing) rather than producing something original. The process is seen when words or phrases come into popular usage for a few months or years by some process of mass spread, in which people using the expression believe they are introducing a new idea.

Generally, unpleasant and uncomfortable experiences are not remembered accurately or completely – ‘forget- ting of the disagreeable’. This is a defect of recall that can be seen as a successful defence mechanism; it helps to maintain the integrity of the person’s sense of self. However, in the affect of hopelessness, reactivation of memories of previous failures is a frequent reason for perpetuating neurotic thinking and behaviour (Engel, 1968). Psychogenic amnesia may appear without any organic disease being present, but the presentation of organic brain disease is always modi ed by psychogenic factors (Pratt, 1977).

Misnaming objects and momentary loss of memory for words in healthy subjects may result from faulty retrieval from short- and long-term memory stores rather than from the psychoanalytic explanation of repression. Such errors may be categorized as acoustic or semantic; acoustic errors tending to occur in short- term stores of up to 30 seconds and semantic ones in long-term stores after more than 5 minutes (Shallice and McGill, 1977).

Dissociative Focal Retrograde Amnesia

This is a condition in which there is focal retrograde amnesia for autobiographical events. There is no demonstrable anterograde amnesia. A 20-year old student was found on the oor of his at. The retrograde amnesia was for a period of approximately 3 years. He was conscious when discovered, and there was no history of head injury or any physical illness. His magnetic resonance imaging scan and other investiga- tions including EEG were reported as normal. The social context included the fact that his parents were separating. However, he said that there was not a signi cant or stressful event. He slowly made a full recovery. This condition can also occur in the context of a neurologic amnesia, but the extent and severity of the amnesia are judged to exceed what is expected (see McKay and Kopelman, 2009). The assumption here is that the focal amnesia results from psychological

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stressors that the individual is inappropriately attempting to deal with amnesia. Usually it is assumed that there are unconscious processes at play.

Dissociative Fugue

The symptoms pertaining to dissociative (conversion) disorders in the International Classi cation of Diseases (10th revision [ICD-10]; World Health Organization, 1992) are of two types: conversion and dissociation. In dissociation, there is a narrowing of the eld of consciousness, with subsequent amnesia for the episode. In many ways, dissociative symptoms represent a lay- man’s impression of ‘madness’. In dissociative fugue states, there is narrowing of consciousness, wandering away from normal surroundings and subsequent amnesia. It involves loss of all autobiographical memo- ries including identity. The person appears to be in good contact with his environment and usually behaves appropriately, maintaining basic self-care, although he sometimes displays disinhibition. There is quite often loss of identity or assumption of another, false identity. The duration of the episode can be very variable, from a few hours to several weeks, and the subject may travel considerable distances. A citizen of Birmingham, United Kingdom, described a state in which he ‘came to’ in a city he did not recognize and where people were speaking French. As he walked about the streets, he found he was near an airport terminal and, to his surprise, he discovered that he was in Montreal. Germane to his adventure was the history of a cata- strophic row and the breakdown of his marriage just before he took off. Thus the features of dissociative fugue are dissociative amnesia, purposeful travel beyond the usual everyday range and maintenance of basic self-care (World Health Organization, 1992).

The predisposing factors include (a) precipitating stress resulting from relationship, marital or nancial problems; (b) depressed mood including suicidal thoughts and (c) a past history of transient organic amnesia (McKay and Kopelman, 2009).

Recovered Memory and False Memory Syndrome

This is one of the most hotly debated issues in psychiatry and clinical psychology. Those working with survivors of traumatic experiences noted in their patients the recovery of additional memories during clinical sessions after apparent psychogenic amnesia for a long time

– sometimes decades. Recovered memory has been particularly associated with the return of memory for childhood sexual abuse. Brewin (1996) reviews the evidence for such events being ‘forgotten’ and then recalled after many years and the mechanisms that may account for this amnesia. He concludes that memories may be recovered from total amnesia, and they may sometimes be essentially accurate. Equally, such ‘memories’ may sometimes be inaccurate in whole or in part. An example of recovered memory is a 45-year- old male patient who was being investigated for possible colon cancer after presentation with blood in his stool. His general practitioner conducted a rectal examination, and immediately after this examination, the patient recalled incidents from his childhood of sexual abuse that caused him great distress and required specialized counselling.

The term false memory syndrome came into use in 1992, when the False Memory Syndrome Foundation was set up to represent the interests of parents who had been accused of abusing their children sexually. In the opinion of Merskey (1998), sufferers from false memory syndrome are typically female and are usually participating in some type of psychotherapy. They report sexual abuse in childhood that is claimed to have been forgotten and subsequently recovered only in adult life, having been repressed from 8 to 40 years. It is considered that these ‘memories’ have been implanted during therapy by a process of suggestion similar to that thought to occur in multiple personality disorder. Another situation in which false memories have been thought to develop has been in nursery day care, when caregivers have been subjected to grave and bizarre accusations.

There is empirical evidence demonstrating that there are differences between individuals whose recovered memories have been recalled inside therapy, those whose memories were recalled outside therapy and a third group whose memories of abuse were continuous from childhood into adulthood. In the rst group there was 0% corroborative evidence, whereas for the other two groups, it was 45% and 37%. Furthermore, those who had recovered memories outside therapy were able to suppress anxiety-provoking thoughts relating to those events compared with the groups with recovered memory from within therapy and the group with continuous memories suggesting that women with

recovered memories from outside therapy are especially adept at suppressing emotional memories when under laboratory conditions, con rming their liability to remain unaware of traumatic memories for long periods before their recovery (Geraerts et al., 2007, 2008).

MEMORY DISTURBANCE SECONDARY TO PSYCHIATRIC DISORDER

Confabulation

This is a falsi cation of memory occurring in clear consciousness in association with an organically derived amnesia (Berlyne, 1972). It is probably best to conceive of confabulation as a loose term that covers a wide range of qualitatively different memory phenomena. The term is used to describe mild distortions of an actual memory, such as intrusions, embellishments, elaborations, paraphrasing or high false alarm rates on tests of anterograde amnesia. It can also refer to highly implausible bizarre descriptions of false realities such as claiming to be a space traveller temporarily resident on earth (Gilboa and Moscovitch, 2002; Box 5.1). However, it is also true that the term confabulation has been extended, unhelpfully in my view, to include the following:

1. memory confabulations;

2. confabulations about intentions and actions as
can occur in split-brain subjects or in hemiplegia of the left arm where the subject denies his or her disability;

3. perceptual confabulations that occur in Anton syndrome characterized by unawareness of blind- ness; and

BOX 5.1 CHARACTERISTICS OF CONFABULATION

4. confabulationaboutemotions(forafullerreview, see Hirstein, 2009).

Bonhoeffer (1901, cited in Berlyne, 1972) observed that confabulation in Korsakov’s syndrome could take two forms.

• Confabulationofembarrassmentwasadirectresult of the memory loss and depended for its presence on a certain attentiveness and activity. This form of confabulation is momentary, a term introduced by Berlyne (1972), in nature. The momentary form of confabulation is often provoked by questions probing the patient’s memory for particular events. The patient tries to cover an exposed memory gap by an ad hoc confabulated excuse relating to his recent behaviour. It does, therefore, reveal social awareness and some realization of the requirements of the situation in terms of social behaviour.

• In other cases, confabulation exceeded the needs of the memory impairment; the patient describes spontaneously adventurous experiences of a fantastic nature. The spontaneity is a key charac- teristic of this form of confabulation. Such memory disturbance may occur with organic deterioration after alcohol abuse and also in the ‘organic amnesic syndrome, not induced by alcohol and other psychoactive substances’ (ICD-10; World Health Organization, 1992), in which there is severe memory impairment, especially for recent memory; evidence for disorder of the brain; and absence of a defect in immediate recall, a disturbance of attention and consciousness, and global intellectual impairment.
The terms momentary and fantastic confabulation overlap somewhat with the terms provoked and spontane- ous confabulation introduced by Kopelman (1987). Provoked confabulation is said to be common in amnestic patients and resembles errors produced by healthy subjects at prolonged retention intervals during memory tests and may represent a normal response to a faulty memory. On the other hand, spontaneous confabulation is a rare pathologic phenomenon that probably results from the combination of frontal lobe pathology on an organic amnesia.
There is little doubt that the classi cation into subtypes of confabulation is work in progress. Schnider (2008) proposed an even more complex classi cation

5 Disturbance of Memory 63

• It is a falsely retrieved memory, often containing false details within its own context.

• The patient is unaware that he or she is confabulating and often unaware of the existence of memory de cit. In other words, confabulations are not intentionally produced.

• Patients may act on their confabulation, con rming their belief in the false memory.

• Confabulation is most apparent in autobiographical memory.

(From Gilboa and Moscovitch, 2002, with permission of John Wiley.)

64 SECTION II Consciousness and Cognition

into four subtypes: (1) intrusions in memory, (2) momentary confabulations, (3) fantastic confabulations and (4) behaviourally spontaneous confabulations. This classi cation was developed to accommodate the empiri- cal ndings about the distinctions between the varying proposed categories but is in my view cumbersome.

Suggestibility is a prominent feature of the confabulat- ing patient and was considered by Pick (1921, cited by Berlyne, 1972) to be dependent on clouding of consciousness, weakened judgement and the interplay of fantasy; it may, in fact, closely resemble daydreams. The confabulating patient may produce mutually contradictory statements consecutively and not make any attempt to correct them. The material of confabula- tions has been likened to dreams (Scheid, 1934, cited by Berlyne, 1972). It has also been explained, in terms of memory disturbance, that confabulations are actual experiences taken out of their chronologic order (Van der Horst, 1932) and that the individual’s wishes and interests guide confabulation in the same way as in dreams and fantasy.

It seems probable that confabulation is related to the normal mechanisms of recollection. For example, say that all the owners of a certain model of car were asked by the police, as part of a large-scale murder hunt, what they were doing on a particular Monday about 9 months previously. To answer this question, an individual would have no recollection for that particular Monday, so he would recreate a typical programme with regular movements and times of appointments for a Monday from about that period. It would seem that the mechanism of social confabulation is of that order. To the question ‘What did you do yesterday?’, the confabulating patient might say, ‘I pushed my baby in the pram down to the of ce to see my old workmates there’. This could indeed have happened 12 years previously after she had resigned her job in that of ce during her pregnancy. The fantastic type of confabulation is also directly associated with memory. Normally, one has a clear memory of which sensations and events were experienced and which were fantasized, yet with confabulation it is probable that distant fantasies are remembered, but it is not remem- bered that they were fantasy rather than reality. Such confabulations, like the momentary type, are autobio- graphical. The momentary or embarrassment confabula- tion is very much more common than the fantastic

type and is a true memory displaced in its time context (Berlyne, 1972).

Fantastic confabulation with persecutory content has been described by Roth and Myers (1969). This is a falsi cation of memory occurring in clear consciousness. Typically, the patient believes others are stealing his money or trying to defraud him. Memory falsi cations of various types occur in schizophrenia, depressive illness, antisocial personality disorder and obsessional states. The more de nite, fantastic and gap- lling features of organic confabulations are always associated with memory defect.

Central to the idea of confabulation is therefore a notion of false reports in the context of memory disorder. At a minimum, it involves distortions of both content and temporal context. The issue of distortions of temporal context has perhaps been understated in the literature. It refers to the nding that in confabulation there are often recollections of true events but that are incorrectly orientated in time and place. In other words it is an impairment of the chronologic order of events, what might be termed an impairment of temporal order or source monitoring. The confabulatory recollection, also, often includes additions, distortions or elaborations that either actually or plausibly occurred (DeLuca, 2009):

Doctor: What did you do today?
Patient VR: Today I got up this morning and visited
the rehabilitation unit … then I went home and was expecting some material and we received it. Then I came to the rehabilitation institute, no I actually went to Jimsburg store and we had a small meeting there. Then I came to the hospital and we had lunch and, then met with you.

The example rst illustrates content distortion because the patient had been in hospital for several months without going home and, second, impaired temporal context because the patient had owned Jimsburg store many years before and had sold it.

The current view is that memory confabulation usually derives from dual lesions taking in basal forebrain areas and frontal executive systems. These lesions appear to result in impaired strategic retrieval of memory and disturbed veri cation/monitoring of the abnormal memory output (DeLuca, 2009).

Perseveration

Perseveration usually occurs in association with dis- turbance of memory and is a sign of organic brain disease, perhaps the only pathognomonic sign in psychiatry. Perseveration is de ned as a response that was appropriate to a rst stimulus being given inap- propriately to a second, different stimulus. This may be demonstrated verbally or in motor activity. The interviewer, while conducting the mental state examina- tion, asks, ‘What is the capital of Italy?’ The patient responds, ‘Rome.’ Subsequently the interviewer asks, ‘What is the object that you wear that tells you the time?’ The patient again responds, ‘Rome.’ Alternatively, the examiner asks the patient to put his right hand on his left shoulder, which he does correctly, and then, on asking him to put his left hand on his left knee, he again puts his right hand on his left shoulder.

Memory Impairment in Schizophrenia

Earlier writers tended to play down the signi cance of intellectual impairment in schizophrenia (Bleuler, 1911; Kraepelin, 1913). However, decline in intel- lectual performance (Rogers, 1986), impairment in neuropsychological test batteries (Taylor and Abrams, 1984), sometimes a dementia-like syndrome (Liddle and Crow, 1984) and substantial memory de cit (Cutting, 1985; McKenna et al., 1990) have been demonstrated. Memory de cit has been shown not to be restricted to patients with chronic schizophrenia.

There are de cits in long-term memory, including evidence of impaired retrieval in both recall and recogni- tion. There is also evidence of impaired short-term memory, demonstrated by de cit of forward digit span. Furthermore, there is evidence of impairment of working memory and semantic memory, but procedural or implicit memory is intact. The memory de cit has been shown to be associated with severity and chronicity of illness, and with negative symptoms and formal thought disorder (McKenna et al., 2002; Tamlyn et al., 1992).

Furthermore, in schizophrenia, remembered circum- stances often take on a new meaning: ‘I remember last week three red cars following me at the traf c lights in Stafford … I realized that I have become involved in politics’. This was stated by a patient who had quite suddenly come to believe that all her actions were being observed and, subsequently, her behaviour

controlled. Memory is accurate, but its signi cance is distorted. A distinction should be made between delusional memories, in which the primary delusional experience is a true memory, with delusional interpreta- tion, and delusional retrospective falsi cation. This is a backdating of delusion to a time before the patient was ill, based on an admixture of remembered true events and delusional elaboration of the meaning of those events. This has been described by some authori- ties as a form of confabulation (Nathaniel-James and Frith, 1996). In the original study, when subjects were presented with narratives and asked to recall them, confabulation was de ned as recall of information not present in the original narrative. The degree of con- fabulation was related to problems in suppressing inappropriate responses and formal thought disorder. In summary there is little doubt that confabulation occurs in schizophrenia and is related to formal thought disorder but it has a different signature to confabulation in the setting of neurological disease (Lorente-Rovira et al., 2007).

Affective Disorder of Memory

Memory is not only disturbed by organic damage to the brain itself; it is also affected by emotion. This is certainly true of normal, healthy people, in whom the affective state strongly in uences the processes of remembering and forgetting. It is also true of those with affective and schizophrenic psychoses, and of neuroses and personality disorders. Depression is linked to self- reported memory problems. There is also substantial evidence of an association between depression and generic memory impairment. It is thought that mood disorder, such as depression, reduces the amount of cognitive processing resources available for a given task, and in the memory domain this is manifest as de cits in the elaboration, organization, encoding and retrieval of material into and out of memory (Dalgleish and Cox, 2002). There is also evidence of memory bias for affectively toned material, such that information that has an emotional valence is more likely to be retrieved if it is congruent with the individual’s mood during retrieval. This mood-congruent memory effect is similar but distinct from state-dependent memory, which refers to the memory bias for material that is learned in a particular mood and is more easily

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retrieved if the individual is in that same mood during

retrieval.

GANSER STATE

The original paper by Ganser (1898) has been much misunderstood. In it, he described four criminals who showed the following symptoms.

• Vorbeigehen (‘to pass by’) or approximate answers, described by Ganser thus: ‘In the choice of answers the patient appears to deliberately pass over the indicated correct answer and to select a false one, which any child could recognize as such’.

• Clouding of consciousness with disorientation.

• ‘Hysterical’ stigmata.

• Recent history of head injury, typhus or severe
emotional stress.

• ‘Hallucinations’, auditory and visual (from his
description, they are more like pseudohallucinations).

• Amnesia for the period during which the preceding
symptoms were manifest.
The Ganser state is rarely seen in English prisons,
but, when it does occur, it is more likely in those awaiting trial than in those already sentenced (Enoch, 1990).
There has been considerable argument as to whether this condition is primarily hysterical or an organic psychosis, with different authors supporting each contention (Latcham et al., 1978). A case that illustrated both the hysterical (dissociative) and organic elements was that of a female university student, aged 20 years, who experienced head injury with concussion when in Italy. Her premorbid personality was markedly histrionic and theatrical and, at the age of 13 years, she had developed a hysterical inability to walk for a few weeks. After transfer from the Italian hospital to Britain, she demonstrated approximate answers thus:
Question: ‘What is the capital of Italy?’ Answer: ‘Naples.’
Question: ‘How many legs has a centipede?’ Answer: ‘Seven.’
This was accompanied by interference in the treat- ment of other patients, irtatious behaviour towards male staff, lability of mood and a facetious manner. On serial testing of intellectual function on the Wechsler Adult Intelligence Scale, initial testing 12 days after

head injury had to be abandoned; after 1 month, there was marked impairment, worse for performance than for verbal items. Intellectual function had eventually returned to her premorbid, superior level by 9 months. Whitlock (1967) considers the distinction between the Ganser state and pseudodementia to lie in disturbed consciousness, present in the former and not the latter. However, sometimes clouding of consciousness in an organic state cannot be distinguished from the altered mental state of dissociative disorder in the absence of other organic signs.

Enoch and Trethowan (1979) have regarded the four main features of Ganser syndrome as:

• approximate answers,
• clouding of consciousness,
• somatic conversion features, and
• pseudohallucinations (not always present).
It should be noted that approximate answers are

not the random inaccuracies of the quick guess but responses that appear deliberately to miss the correct answer. These authors regard the syndrome as a hys- terical dissociative reaction and have pointed out the similarity of features with those exhibited by normal people asked to simulate mental disorder, the differ- ence being that the Ganser subjects were subsequently amnesic for their abnormal behaviour. Ungvari and Mullen (1997) have classi ed Ganser syndrome with the controversial group of reactive psychoses so that a stressful life event is the usual predisposing factor. Cutting (2011) has a novel and original approach to Ganser syndrome. On the basis of examination of a number of cases including two of his own he concludes that the Ganser syndrome is either part of a depressive illness or a transient disturbance in the left hemisphere’s lexical or semantic knowledge. Cutting argues that the knowledge de cit demonstrable in Ganser syndrome is not hysterical on any account but a manifestation of a particular kind of cognitive impairment.

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AWARENESS OF REALITY: TIME, PERCEPTION AND JUDGEMENT

SECTION 3

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KEYWORDS

Time
Circadian rhythm Disorientation

Summary

Time is integral to how human beings experience the world. Although it is dif cult to de ne, there are some overt aspects such as duration, sequence, synchrony, rhythm, past, present, future orientation and an arrow of time that are easily recognizable and understood by most people without the need for further elaboration. There is also an important relationship with space and with notions of the self. Abnormalities of time experience can, broadly speaking, be divided into those that affect objective time and those that affect the subjective aspects of time experience. There are also in uences of circadian rhythms, seasons, monthly cycles and life epochs that are worthy of noting.

Space and time are always present in sensory processes. They are not primary objects themselves but they invest all objectivity. Kant calls them ‘forms of intuition’. They are universal. No sensation, no sensible object, no image is exempt from them. Everything in the world that is presented to us comes to us in space and time and we experience it only in these terms.

Jaspers (1997)

In the preceding quotation, Jaspers draws attention to the way in which human beings live in space and time and how all subjective experience is mediated by space and time. Jaspers continues:

If we want to bring these primary things home to ourselves in some neat phraseology we may say that they both represent the sundered existence of Being, separated from itself. Space is extended being (the side-by-side) and time is sequential being (the one-after-the-other).

A sense of time is clearly central to the concept of self and its relationship with the outside world. But what exactly is time, and how is it experienced? Barbara Adam (1995) in her book Time Watch inter- viewed a number of people about how they experience time and some their responses are both instructive and helpful:

How time enters my life? I was born and now I am fteen years old. We use the word when we ask what time it is. We talk about closing time, lunch-time, getting up time, and that time is up. What time is, that is more dif cult to say. It is not a person, not a thing, not a vegetable. It’s a period and units, the day chopped up into hours, minutes and seconds. But it also divides
the past from the future … The time is now, this very second. But I do not know what it is we are chopping up into units. I think it’s an illusion since there isn’t anything to be chopped.
For me time is a dimension within which everything moves and happens. In conjunction with space it is a universal framework. We can’t move through space without time and vice versa which means that we
can’t pass, spend, or allocate time without occupying space. Nothing exists and happens without time and space.

Adam herself emphasizes various aspects of time as follows:

Thinking about time, therefore, involves rhythm with variation, a dynamic structure of framing, timing, synchronization, duration, sequence, tempo and intensity. This cluster of time characteristics is implicated at all levels of being, from the most physical of planetary movements via physiological rhythms to patterns of social organization, from the taken for granted via the invisible to the obvious, from the imposed via the lived to the culturally constructed.

Entailed within those processes is an irreversible unidirectionality, an arrow of time. There can be

CHAPTER 6

Disorder of Time

72 SECTION III Awareness of Reality: Time, Perception and Judgement

no rejuvenation, no unknowing, no reconstitution of pollution back into aeroplane.

These accounts indicate that time is dif cult to de ne but that there are some overt aspects such as duration, sequence, synchrony, rhythm, past, present, future orientation and an arrow of time. There is also an important relationship with space and with notions of the self, particularly with enduring self-identity that has been remarked upon by many thinkers including Immanuel Kant (1781/1929; see Critique of Pure Reason).

There is a sense in which time leaves a signature on the most diverse aspects of human life, yet in such a way that the in uence of time is often unrecognized. Aside from the obvious, such as overt ways of measuring time, there is a time dimension in memory, in language (given the reliance on word sequence and order for manifest meaning), through rhythm and note order on music, and in all actions including symbolic movements, dance, sports and so on. Covertly, time is involved in such concepts as expectation, desire, hope, prayer and even death. These latter ideas have evolved from the writings of Eugene Minkowski (1885–1972; 1970), a phenomenological psychiatrist.

Disturbance of sense of time or time-related disorder is a sensitive indicator that something is going wrong either in the self or its mechanisms. Sense of time and time-related disorders of biological rhythm will be considered separately in this chapter. There is no widely agreed classi cation of disorders of time. However, it is possible to divide the disorders of time into two broad categories: disorder of objective time and disorder of subjective time (Box 6.1).

BOX 6.1 CLASSIFICATION OF DISORDERS OF TIME

OBJECTIVE (CLOCK) TIME AND SUBJECTIVE (PERSONAL) TIME

An important distinction is that between objective (clock) time and subjective (personal) time. Objective time – chronologic, physical or historical time – is quantitative and independent of the self. It depends on accurate measurement and is objective to the degree that it is shared with others and veri able. Subjective time is the inner, subjective experience of time. Aspects of both kinds of time may be affected by psychiatric illnesses. Objective time may be altered so that the knowledge of time, that is, the orientation to time including age disorientation and appreciation of time duration and of chronology may be adversely affected. Subjective time may be altered so that the experience of time duration, ow of time, meaning of time, uniqueness of time and succession of time may be affected.

BIOLOGICAL RHYTHMS AND TIME

Although our units of time are to some extent arbitrary, natural and biological time operates within de nite periods. The four periods that have the most relevance to mental illness are circadian rhythms (about 24 hours – night and day), monthly cycles, seasonal variations and life epochs (from birth to death). All these rhythms are important for the mental state in times of health and form the basis for such conditions as early morning wakening in depression, premenstrual tension, seasonal affective disorder and involutional melancholia. Many of these biological rhythms with variation of mood are biochemically mediated through the endocrine system.

Personal time (and also, to a lesser extent, clock time) is often described in relation to these biological rhythms. Our whole notion of the progression of time is closely related to processes of physical function: birth, growth and decay.

Disorder of Objective Time

An ability to separate events into past, present and future, even if limited; the capacity to estimate duration; and the ability to put events in the correct sequence are necessary for intellectual processes to be carried out satisfactorily. Disorder of knowledge of time is closely associated with disturbance of consciousness, attention and memory.

DISORDER OF OBJECTIVE TIME

• Disorder of knowledge of time: disorientation in time; age disorientation

• Disorder of duration of time

• Disorder of chronology (temporal order)
DISORDER OF SUBJECTIVE TIME
• Disorder of ow of time
• Disorder of direction of time
• Disorder of uniqueness of time • Disorder of quality of time

DISORIENTATION IN TIME

Disorientation for time is demonstrated by the inability to correctly tell the time without recourse to a clock, to indicate the date, day and season. This impairment is closely associated with impairment of attention, con- centration, consciousness and memory. It is a feature of delirium and dementia. It is also a good clinical criterion for distinguishing between organic and functional disorders (Cutting, 1997). The second abnormality is impairment of the ability to assess the duration of time, and this is also disturbed in organic states.

AGE DISORIENTATION

The term age disorientation was rst used by Zangwill (1953) in relation to Korsakov’s syndrome to describe a ‘ xed, stable disorientation for age, which was impervi- ous to logical correction’. Age disorientation, now de ned as a 5-year discrepancy between the patient’s actual age and what the patient states to be his own age, has been considered to correlate clinically with intellectual impairment in chronic schizophrenia (Crow and Stevens, 1978). Such patients were much less able than chronic schizophrenic patients without age disorientation to answer questions about date and the duration of time. They systematically underestimated the present year and the duration of their stay in hospital, and sometimes their own age.

This gives quantitative support to the observation that for some chronic patients ‘time stands still’; they remain in the cultural set of the time when they developed their illness. Such patients tend to use the idiomatic language, sing the popular songs, wear the modish clothes and tell the characteristic jokes of the time before their illness became established. It is a mistake to believe that they are indulging in nostalgia; their cultural life is still rmly xed within that par- ticular period. Not only in the back ward of an old- fashioned mental hospital, but also in a hostel in the community, these patients live in their own time capsule with invisible, but impregnable, walls.

DISORDER OF TIME DURATION

Estimation of time duration has been studied using various methods, but the results have been inconsistent. Objective measures of estimation of the passage of time, for example, show that patients with depressive illness tend to underestimate the passage of 30 seconds, on

average, by 6 seconds. This is compared with overes- timation of the passage of time by normal control subjects by on average 10 seconds (Kuhs et al., 1991). That is to say that depressed patients on average estimated 30 seconds’ duration as 24 seconds and the normal controls estimated 30 seconds’ duration as 40 seconds. In other words, time appeared to ow more slowly for patients with depression than it did for normal controls. It is important to emphasize that this refers to estimation of the passage of momentary time. Other investigations have demonstrated an overestimation of time duration in depression (Kitamura and Kumar, 1984; Munzel et al., 1988). There is more consensus on the subjective experience of time in depression, as discussed subsequently.

DISORDER OF CHRONOLOGY (TEMPORAL ORDER)

Memory of the temporal order of events is an aspect of time sense that is often ignored. There is evidence that patients with diencephalic lesions compared with those with medial temporal lobe lesions have distinct de cits in temporal order memory tasks. These patients are unable to correctly indicate the temporal order of learned words on a list or the sequence of presentation of particular stimuli. This has led to the suggestion that diencephalic structures may have a function in the encoding of temporal information (O’Connor and Verfaellie, 2002). Frontal lobe lesions are also associated with impairment of function on temporal order tasks. In addition to this, an aspect of temporal order coding, namely frequency estimation, which involves estimating how often an event has happened, is known to be impaired by left frontal but not temporal lesions (Baldoa and Shimamura, 2002).

Clinically signi cant disorders of temporal order for past and current events have been reported. These take the form of intact memory for autobiographical events but impaired appreciation of the duration and timing of these events. These impairments are associated with organic lesions in the cingulate gyrus, the parietal lobes and the left anterior frontal areas (Cutting, 1997).

Disorder of Subjective (Personal) Time

Disorder of subjective time is characterized by abnor- malities in how time is experienced. This can involve the experience of (a) ow of time, (b) direction of time,

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74 SECTION III Awareness of Reality: Time, Perception and Judgement

(c) uniqueness of time and (d) quality of time. These disorders go to the heart of how the world is experi- enced. Any alteration in the way that time is experienced will by de nition in uence the experience of the objective world and may come to imbue perceptions of the objective world with an alien hue.

DISORDER OF FLOW OF TIME

The ow (passage) of time may slow down or speed up. In some instances, it may become arrested and stand still. Tolstoy’s (1895) short story ‘Master and Man’ is true to life – or death. Lost at night in a Russian snowdrift, his character, Vasilii Andreich

got up and lay down a couple of dozen times. The night seemed it would never end. It must be getting on for morning now, he thought once as he raised himself and looked around. Let’s have a look at my watch … He could not believe his eyes … It was only ten past twelve. The whole night still lay ahead.

Time, as a modality of personal experience, is dis- turbed in mood disorders. It has been observed both clinically and experimentally that those with depressive illness feel that time passes slowly (Wyrick and Wyrick, 1977). Lewis (1967) quotes a patient who was depressed with affective functional psychosis:

Everything seems very much longer. I should have said it was afternoon, though they say it is midday. They always tell me it is earlier than I think … and it looks as if I’m wrong and I can’t help feeling I’m right … I cannot see any end to anything, only end to the world.

The ow of time can also be arrested such that time appears to stand still. The patient feels that time is standing still, that in some way everything temporal has come to an end. This is described not uncom- monly with psychotic depression. A patient says, ‘I have stopped being, I have just stopped, everything else has just stopped as well’. The incessant sequential march of events no longer impresses the person with its inevitability.

This feeling of time standing still may also be experienced in ecstasy states, in which the person may feel that he is existing in the past, the present and the future all at the same time. Such states may

occur with mania, with some neurotic conditions or in normal people undergoing an exceptional psychological experience.

When the disturbance in the sense of the passage of time occurs in the setting of depression, the depressed mood is also apparent. Another of Lewis’ (1967) patients said,

I never know any moment what is going to happen. It’s the most terrible outlook I’ve ever had to look to. It’s all perpetual. I’ve got to suffer perpetually.

And one of Minkowski’s (1970) patients said:

I continue to live now in eternity; there are no more hours or days or nights. Outside things still go on, the fruits on trees move this way and that. The others walk to and fro in the room, but time does not ow for me. My watch runs just as before … Sometimes when people run quickly to and fro in the garden or if the wind stirs up the leaves, I would like to live again as before and be able to run interiorly with them in order that time would pass again.

In these examples, the patients are trying hard to describe the indescribable, the experience of time standing still. In addition to this experience there is also the related but distinct phenomenon of living in the instant and this feeling is allied to the notion of nality and lack of continuity:

I live in instantaneousness. I don’t have the feeling
of continuity anymore … When I nish something, I have the feeling of not being able to do anything else afterwards and of doing this thing, going to dinner for example, for the last time. (Minkowski, 1970)

This last sentence is perhaps the key to the abnormal psychopathology. It is the abnormal mood associated with time sense that is signi cant, so depressive inpa- tients were signi cantly more likely to feel that time was passing more slowly than healthy ‘control’ subjects (Kitamura and Kumar, 1982).

In mania, time passes rapidly, but the picture is uncertain in schizophrenia (Orme, 1966). The ow of time is also known to be affected in organic brain conditions. Patients with Korsakov’s syndrome

underestimate the passage of time, and subjects who have had thalamotomy experience the ow of time as speeded up (Cutting, 1997).

It is more usual to describe in dementias the diso- rientation for time, place and person. This disorientation refers to the disturbance in the appreciation of objective time. However, people who suffer from dementia also describe abnormalities of subjective experience of time. The most common is a disturbance in the ow of time. Christine Bryden (2005) described her experience as follows:

We have no sense of time passing, so we live in the present reality, with no past and no future. We put all our energy into now, not then or later. Sometimes this causes a lot of anxiety because we worry about the past or the future because we cannot ‘feel’ that it exists.

A distinct but related disturbance of the ow of time is the Zeitraffer phenomenon. This is literally a time-lapse phenomenon. It was rst described in the German literature in the 1930s, and Cutting (1997) has now brought it to the attention of the English- speaking world. The characteristic features are as follows:

1. the speeding up or slowing down of events,

2. its association with increased speed, pitch and
volume of auditory perceptions, and

3. alterations in the uency of observed move-
ments.

There may also be visual hallucinations, anomalous

experience of space such as distortions of horizontal and vertical lines. This phenomenon invariably occurs in the setting of acute organic brain disease such as cerebrovascular accident.

The original case was described by Hoff and Potzl (1934, quoted in Cutting, 1997):

Doctors and nurses were rst of all moving with a measured step, conspicuously, as if on a lm. Then the tempo of things became very erratic, sometimes coming at a furious pace, ‘like moving pictures speeded up’ as
if the people involved were ‘running a race’ … Music, whose source was to his left, sounded very loud and very fast, as if ‘several radios were all blaring away together … as if all the instruments wanted to show how much noise they could make’. Sometimes, other people’s speech

seemed excessively fast and incomprehensible ‘as if the doctors and nurses were practising for a world record’. However, if he were addressed directly, the rate appeared quite normal and he could understand it quite well. It was when someone was speaking away to the left that it sounded most peculiar – shriller, louder and faster than when to away to the right.

DISORDER OF DIRECTION OF TIME

It seems such a fundamental aspect of our experience of time that the arrow of time travels from the past through the present to the future. It is incomprehensible that anyone could experience time as if events were being played in ‘rewind mode’ backwards. This phe- nomenon was reported by one of Lewis’ patients (1967):

Whenever anyone said anything to me, it referred back to some part of my life … One mind was living back and my mind forward.

Another of Minkowski’s (1970) patients said:

There is no present anymore, only a sense of the past. Is there a future? There used to be, but now it is shrinking. The past is so obtrusive … I’ll give you an example of what it’s like. I’m like a machine that runs but does not move from its place. It goes at full speed, but it remains in place. I am like a burning arrow that you hurl before you; then it stops, falls back, and is nally extinguished as if in a space empty of air. It is hurled backwards.

DISORDER OF UNIQUENESS OF TIME

Part of our experience of time is the sense of uniqueness of the time, momentary or otherwise that we live through. This uniqueness of time experience is instanti- ated in the unique events that populate time. This means that every moment is given its singular identity by the context, by the events played out in a given place, by particular personalities and by association with speci c emotions. These coordinates of time stamp each moment with its speci c unique feeling.

The déjà vu experience can be conceptualized as an alteration of the feeling of uniqueness with which time and events are invested. When this sense of uniqueness is disrupted, novel events and the time and place in which they occur seem familiar. In this conceptualization, déjà vu is the experience of this feeling of familiarity

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76 SECTION III Awareness of Reality: Time, Perception and Judgement

for events and times that have not been previously encountered becoming associated with a novel situation. Jamais vu is the absence of this feeling of familiarity for events that have been previously encountered. In other words, even previously encountered situations are experienced as novel, that is, as unique. Although it is possible to conceptualize these experiences as disorders of time, it is probably more appropriate to regard them as aspects of memory disturbance (Chapter 5).

Déjà vu occurs in the normal state and in pathologic conditions. The composer Ralph Vaughan Williams, in describing his rst hearing of the tune used in Dives and Lazarus, explained, ‘I had that sense of recognition – here’s something which I have known all my life, only I didn’t know it’ (Kennedy, 1964). Most people can recall similar déjà vu experiences. It is also com- monly associated with temporal lobe epilepsy. A patient described his aura before a t experienced in hospital: ‘I went into the kitchen. The window looked as if I’d seen it before. I felt very peculiar’. Déjà vu and jamais vu are quite often described in schizophrenia.

Déjà vu has been produced with brain stimulation. Pen eld and Kristiensen (1951) were able to reproduce a sensation of familiarity with stimulation of a brain electrode in epileptic patients. This stimulation clearly produced an abnormality of the feeling of familiarity, not an abnormality of memory. It was a disturbance of the feeling of recognition that accompanies recall in the process of memory. Janet considered déjà vu to be a form of loss of reality or negation of the present (Taylor, 1947), whereas Freud (1901) regarded it as being associated with the recall of unconscious fantasies.

In a more extreme form, the disorder of the unique- ness of time presents as reduplication of time. The term was rst used by Weinstein et al. (1952). Petho (1985) described a case in which the patient’s central symptom was the belief that she had lived through this life once before. The patient experienced a reduplication of every event and, in relation to attending the 1976 Olympic Games said, ‘It could happen that I will go; I have a memory of it. But I also have a memory that I won’t go to those Games so that that memory won’t come back to me.’

DISORDER OF THE QUALITY OF TIME

In these conditions, the normal experience of the quality of time is either lost or distorted in some way. What

is central to these experiences is that the ‘taken for granted’ aspect of time is replaced by a degree of alienation from it such that time becomes salient, obtrusive and even unreal.

In depersonalization and derealization, there can be a loss of the feeling of reality for time experience; there may also be alteration in the sense of duration or in the perspective of time (Freeman and Melges, 1977). The person can assess a time span quite accu- rately, and there is no loss of memory. However, he has no feeling that things are happening or time is passing; the abnormality is always one of experience. Time itself takes on a feeling of unreality, and he feels unable to initiate action.

This phenomenon can also occur in schizophrenia. One of Cutting’s (1997) patients said:

Time is somewhat changed. Time isn’t supposed to be the way it is. I don’t know in what way.

Fischer described a number of cases (quoted in Cutting, 1997), of which one said:

Time stood still. Then it became different. Then it disappeared entirely … Then a new time emerged. This new time was endless, more manifold than the previous one, hardly deserving the name “time” as we know it. Suddenly it came to me that this time did not only lie in front of and behind me, but spread out in all directions.

Biological Rhythms and Their Relation to Psychiatry

Daily, there are profound changes in the body and brain associated with the external rhythm of the world. During the waking day, we are active, and at night we sleep, recuperate and repair our body parts. This biologi- cal rhythm is driven by an internal clock. The primary internal body clock is located in the suprachiasmatic nuclei, a cluster of approximately 100,000 neurons located on either side of the midline above the optic chiasma, about three centimetres above the eyes (Hast- ings, 1998). There is strong evidence that the clock is an autonomous property of the suprachiasmatic nuclei, and individual cells, in vitro, continue to re rhythmi- cally for several weeks with only the slightest deviation

from 24 hours. It is known that this clock can be desynchronized by jet lag, shift work and depression (Arendt, 1995). However, there is still a great deal of ignorance about the connections with different mental illnesses. In this section, brief reference is made to daily, monthly and annual rhythms and also to the association with the stage of life. Among psychiatric disorders, most information is available on affective disorder and its associations with daily and annual rhythms (Thompson, 1988).

CIRCADIAN RHYTHMS

Comparing internal time with clock time, repeated estimates of xed time spans show a gradual increase in time of the estimate, suggesting that there is a slowing of the internal clock. Subjects were asked repeatedly to guess a xed duration of time; their estimate started by being slightly longer than actual time and became progressively longer still. The intrinsic period of the circadian rhythm in humans is approximately 25 hours, but this is usually modi ed by external cues such as daylight (Wher and Goodwin, 1983). This has been likened to the nding in vigilance experiments, in which there is a gradual decrease of ef ciency. There was also found to be a greater overestimation of xed intervals in the morning, compared with in the afternoon, and this has been shown to correlate with body temperature. The internal clock accelerates when the body tempera- ture is raised.

A number of circadian rhythm sleep disorders have been described including shift-work type and jet-lag type (Sack et al., 2007). These conditions are conceived as recurrent or persistent patterns of sleep disturbance due primarily to alterations in the circadian timekeeping system or a misalignment between the endogenous circadian rhythm and exogenous factors that affect the timing or duration of sleep. In the shift-work type, sleep is disrupted by a broad spectrum of nonstandard work schedules such as occasional on-call overnight duty, to rotating schedules, to steady and permanent night work. In the jet-lag type, the sleep disruption is generated by circadian misalignment, the inevitable consequence of crossing time zones too quickly for the circadian system to keep pace. Depending on the number and direction of time zones crossed, it may take days for the circadian rhythm to resynchronize (Sack et al., 2007).

The clinical features of jet lag include daytime somnolence, fatigue, impaired alertness, and dif culty initiating and maintaining sleep. The sleep disturbance may be associated impairment of work performance (Spitzer et al., 1999).

There is considerable circumstantial, but little direct, evidence that circadian rhythms are causally associated with affective disorders (Thompson, 1984). Early- morning wakening and diurnal variation in mood, with the mood most depressed in the early morning, are considered biological symptoms of depression and have been postulated as phase advance of the sleep–wake cycle; that is, each point of the rhythm occurs earlier than usual relative to the light–dark cycle. There is a change in depression in that rapid eye movement sleep occurs earlier, rather than later, in the night, and this also may point to phase advance of the circadian rhythm. Sleep deprivation has been used with variable success in the treatment of depression; there has been research into the genetic and familial aspects of sleep disturbance, into sleep disorders in depression and other neuropsy- chiatric conditions and into the relationship of sleep disturbance in depression and other neuroendocrine changes (Linkowski and Mendlewicz, 1993; Vogel et al., 1980).

Although diurnality of mood usually manifests itself by the subject feeling worse in the early morning, sometimes this is reversed. Styron (1991) describes this for his own severe depressive illness:

there was now something that resembled bifurcation of mood: lucidity of sorts in the early hours of the day, gathering murk in the afternoon and evening.

In depression, changes of body temperature and cortisol levels over 24 hours have also been interpreted as phase advance of the circadian rhythm, but the results are equivocal. The action of antidepressant drugs on the rhythm has been investigated by lengthening the intrinsic cycles of rest, temperature and sleep, but again the evidence is not clear. Corroboration studies of air travellers crossing time zones have suggested that travel from east to west is more likely to be associated with depression, and from west to east with hypomania (Jauhar and Weller, 1982). However, physiologic studies of jet lag would not support such an association (Arendt and Marks, 1982).

6 Disorder of Time 77

78 SECTION III Awareness of Reality: Time, Perception and Judgement

Thinking in relation to circadian rhythms in mood disorders was given further impetus because of the discovery of clock genes and cellular clocks, even though there is no consistent nding that disruption of these clocks exist in mood disorders (McCarthy and Welsh, 2012). It may be that clock gene expression outside of the suprachiasmatic nucleus is involved in mood regulation (McClung, 2007). This is a matter for future research.

It has been suggested that there may be a shortened rhythm, of less than 24 hours, in patients with long- term schizophrenia. Abnormalities of circadian rhythm have also been described, but not fully substantiated, in anorexia nervosa and in people with abnormal personalities.

MONTHLY CYCLES

Clearly, the most obvious human biological rhythm to recur monthly is the menstrual cycle, and this has been linked with changes in the mental state, but premenstrual syndrome remains controversial in its de nition, manage- ment and politicosocial implications (Bancroft, 1993). Similar psychological mood swings with a monthly cycle have been sought in the male but not convincingly found. Estimates for the frequency of premenstrual syndrome have varied in the general population between 30% and 80% of women of reproductive age (Clare, 1982). Psychological symptoms include lethargy, anxiety, irritability and depression, but many symptoms are both psychological and physical (headache, feeling bloated, loss of energy). It is the timing rather than the nature of the symptoms that indicates the diagnosis, and there are clearly differing constellations of complaint within the syndrome (Sampson, 1989).

Much numeric data have been provided by Dalton (1984) to support the contention that there is increased psychopathology of various types during the 8 days of the premenstruum and the menstrual period itself relative to the rest of the cycle. She stated that 46% of emergency psychiatric admissions, 53% of attempted suicides, 47% of admissions for depression and 47% of admissions for schizophrenia of women of reproduc- tive age occur during these stages, but these gures have not yet been substantiated. However, reports of unusual manifestations of premenstrual syndrome include descriptions of auditory hallucinations and delusions of reference present only in the premenstrual

period, and hypomanic or manic states present in the 2- to 3-day period before the onset of menstruation (Hsiao and Liu, 2007).

The descriptions by Dalton (1984) are distinct from the carefully analysis of cases drawn from a review of cases of menstrual psychosis over the past 300 years conducted and published by Ian Brockington (2005). These are cases that present with acute onset against a background of normality, of short duration with psychotic symptoms including confusion, stupor, mutism, delusions and hallucinations and occurring in a circa-menstrual periodicity and in rhythm with the menstrual cycle. The relationship with the menstrual cycle included cases where there is premenstrual onset and abrupt cessation at the beginning of menstrual bleeding and the so-called catamenial psychosis in which the onset of psychosis is associated with the onset of menstrual ow. It is the relationship with the menstrual cycle rather than the phenomenology of the cases that makes them remarkable.

SEASONAL VARIATION

Season of the year has been invoked for the onset of episodes of many psychiatric illnesses. Understandably, this is more pronounced at increasingly higher latitudes in the northern hemisphere. Similar associations of illness with summer or winter have been observed in the Southern Hemisphere.

In both Northern and Southern Hemispheres, patients with a diagnosis of schizophrenia are more likely to have been born in the winter months (Hare, 1988); this is most strikingly found for those without a family history of the illness (O’Callaghan et al., 1991). There is a higher rate for admission to psychiatric hospital during the summer months.

For every decade since 1921, suicide rates in England and Wales have been highest in the quarter comprising April, May and June (Morgan, 1979). There appears to be no association between season of birth and affective illness; however, the onset of depressive illness and the administration of electroconvulsive therapy both become more common in spring and autumn (Rawnsley, 1982). Symonds and Williams (1976) found a peak for the admission of female manic patients in August and September.

Seasonal affective disorder (recurrent depressive disorder, F33 in the International Classi cation of Diseases,

Intellectual function

Psychotic phenomena

Mood

Coping behaviour

Mental handicap manifests

Infantile autism

Depression – rare

Traumatic

Hebephrenic schizophrenia

Korsakov’s syndrome

Huntington’s chorea

Paranoid schizophrenia

Multi-infarct dementia Presenile dementias

Enuresis

School refusal

Neurotic reaction with adverse life events

Alcohol dependence Sexual disorders

Chronic neurosis

Late-onset neurosis

Encopresis Truancy

Manic–depressive psychosis Puerperal disorders

Involutional melancholia

Depression remains common and treatable

Anorexia nervosa

Drug abuse

0 20 40 60 80

Age (years)

FIG. 6.1 Psychiatric disturbance and life epoch.

10th revision; World Health Organization, 1992) is characterized by repeated episodes of depression, which may vary in severity from mild to severe and recur with an onset at the same time of year, most often late winter or spring. It is more common in women than in men and tends to start later in life, often about the fth decade. There are often a large number of episodes of depression in seasonal affective disorder (10–17 per patient), each episode lasting from 17 to 23 weeks; anxiety, irritability, hypersomnia and gain in appetite and weight were prominent symptoms (Thompson and Isaacs, 1988). The distinctive symptoms of this condition have been measured using the Seasonal Pattern Assessment Questionnaire (Thompson et al., 1988). It occurs more frequently in higher latitudes in the northern hemisphere. In a study conducted in Finland (Saarijärvi et al., 1999), in which the prominent symptoms included lack of energy, hypersomnia, exces- sive eating, weight gain and a craving for carbohydrates in addition to other depressive symptoms, there was

lower prevalence among Lapps, who are ethnically and genetically different from Finns living at the same latitude.

LIFE EPOCHS

Virtually the whole of psychopathology is mediated through, and in uenced by, changes in situation and life epoch. It is important to take into account the relative preponderance of different factors: biological change, pressure of social context and individual perception of life situation. It is outside the scope of this book to chart these associations in detail, but an impressionistic sketch is offered in Fig. 6.1. The psychological effects of important life changes have been studied in primary care situations: birth of the rst child (Jewell, 1984), starting school (Pitt and Browne, 1984), puberty (Howe and Page, 1984) and leaving school (Brown, 1984).

Some of the abnormal mental states associated with life changes of female gender could equally well be discussed with life epoch.

Alzheimer’s syndrome

Paraphrenia

Senile dementia

Disorder of Time 79

80 SECTION III Awareness of Reality: Time, Perception and Judgement

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6 Disorder of Time 81

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KEYWORDS

Imagery
Form constants Synaesthesia Illusions Hallucination Pseudohallucination Autoscopy

Summary

Abnormalities of perception remain some of the most compelling experiences with which patients present. These experiences speak to the underlying structures of the perceptual world and the neural correlates that make perception itself possible. Sensory distortions and false perceptions between them point to the relative importance and the distinctions to be drawn between sensation and perception. Illusion, which is the mis- interpretation of a normal perception, and hallucina- tions, the perception of an object in the absence of a stimulus are the two most frequently encountered false perceptions in clinical practice.

For almost seven years – except during sleep – I have never had a single moment in which I did not hear voices. They accompany me to every place and at all times; they continue to sound even when I am in conversation with other people, they persist undeterred even when I concentrate on other things.

Daniel Schreber (1842–1911)

Disorders of perception, particularly auditory hallucina- tions or ‘hearing voices’, have a central place in psy- chopathology. Along with delusions (Chapter 8), they are thought of as synonymous with mental illness. This apparent association with mental illness has come to imply that ‘hearing voices’ is a sign of serious mental illness and that hallucinations portend madness. In this chapter, the nature of sensation, perception and

imagery is discussed as a prelude to examining the nature of disorders of perception.

Sensation and Perception

Sensation is only the rst stage in receiving information from outside the self. The sensory system includes the visual, auditory, tactile, olfactory, gustatory, kinaesthetic and proprioceptive pathways. These pathways deal with the receipt, transformation and transmission of raw and disparate sensory data from peripheral receptors to the central nervous system. The transformation of raw sensory stimuli into sensory information that is then decoded into meaningful perception at the cortical level involves active processes that are in uenced by attention, affect, cultural expectations, context, prior experiences, memory and, most importantly, prior concepts. It is therefore the case that perception is not a passive process but an active one that involves the construction of an external world that depends on internal templates.

Much of what we know about sensation and percep- tion derives from our understanding of the visual system. In the visual system, light sensation is received by the retina and transformed into a neural code that is transmitted from the retinal ganglion cells to the primary visual cortex via the lateral geniculate nucleus of the thalamus. Perception occurs when a stimulus has undergone processing according to its form, colour, motion and meaning.

The distinction between sensation and perception is well illustrated by the dissociation between intact sensation and impaired perception in the agnosias. In visual object agnosia, the subject is able to recognize that an object is in his eld of vision (that is, sensation is intact), but he is unable to recognize what the object or its function is (impaired perception). This visual model of perception is likely to have counterparts within the other sensory systems.

Oliver Sachs (1995) recounts the story of Virgil, a 51-year-old man who had been blind since infancy. He had a cataract extraction, but the return of visual

CHAPTER 7

Pathology of Perception

84 SECTION III Awareness of Reality: Time, Perception and Judgement

sensation was unaccompanied by uncomplicated percep- tion. Virgil was able to ‘pick up details incessantly – but would not be able to synthesize them, to form a complex perception at a glance. This was one reason the cat, visually, was so puzzling: he would see a paw, the nose, the tail, an ear, but could not see all of them together, see the cat as a whole’. This case is reminiscent of Gregory’s (2004) patient, S.B., who when he was rst shown a lathe after recovering his sight, ‘was quite unable to say anything about it, except he thought the nearest part was a handle … He complained that he could not see the cutting edge, or the metal being worked, or anything else about it, and appeared rather agitated … S.B. was allowed to touch the lathe. The result was startling … He ran his hands eagerly over the lathe, with his eyes shut. Then he stood back a little and opened his eyes and said: “Now that I’ve felt it I can see”.’ These two cases underline the distinction between sensation and perception and con rm that ‘we are not given the world: we make our world through incessant experience, categorization, memory, recon- nection’ (Sachs, 1995).

There are various competing models of the way that recognition is achieved by the visual system. A detailed description of these models is outside the scope of this chapter (see Smith and Kosslyn, 2007). Bottom-up processing consists of the primary processes that transform sensation into the perception of objects that have form, colour, motion and location in space. On the other hand, top-down processes involve the in u- ence of our learned experience of perceiving objects to narrow the competition between the possible interpretations of the sensory information. The alterna- tive models of the top-down processes that attempt to explain object recognition, that is, perception, are the template-matching model, the feature-matching model, the recognition-by-components model and the con- gural models.

The template-matching model requires an internal template in memory to which an object can be matched. The weakness of this model is that the template must accommodate object size and orientation, for example, and must still be rapid and reliable. The feature- matching model requires only that a distinct and discriminating feature of an object on its own should specify what the object is. Trees need only be speci ed by the fact that they have a trunk and branches. The

exact location of the branches and size of the trunk do not matter. The recognition-by-components model requires knowledge of the correct arrangement of parts in three-dimensional space. Thus irrespective of the perspective, a bicycle is still recognized as a bicycle. Finally, the con gural model is a re nement of the recognition-by-components model. It deals with the mechanism whereby individual examples of a class are recognized. This is the distinction between different makes of cars, the variation that determines that one car is a Mercedes and another is a Volvo.

IMAGERY

Imagery is the internal mental representation of the world and is actively drawn from memory. Imagery underlies our capacity for many crucial cognitive activities, such as mental arithmetic, map reading, visualizing and imagining places previously visited and recollecting spoken speech. In day-to-day life, it is common to refer to ‘seeing in the mind’s eyes’ or ‘hearing in the mind’s ears’. These terms refer to imagery. Jaspers (1997) described the formal characteristics of images as follows:

1. images are gurative and have a character of subjectivity;

2. they appear in inner subjective space;
3. they are not clearly delineated and come before

us incomplete;
4. although sensory elements are individually the

equal of those in perception, mostly they are

insuf cient;
5. images dissipate and always have to be recreated;

and
6. images are actively created and are dependent

on our will (Table 7.1).
Functional imaging studies have demonstrated that

the same cortical areas are implicated in visual imagery and visual perception (Kosslyn and Thompson, 2003), and transmagnetic resonance studies have also shown that transmagnetic resonance applied repeatedly to visual areas reduces the capacity for visual imagery (Kosslyn et al., 1999). Furthermore, behavioural experi- ments have shown that participants are able to construct mental images that have perceptual qualities such as colour, size, shape and orientation. These images are uneven, with the level of detail depending on the degree of visual attention (Smith and Kosslyn, 2007).

TABLE 7.1 Formal Characteristics of Normal Perception and Imagery

7 Pathology of Perception 85 on the mechanisms uniting imagery and abnormal

perceptions.

FORM CONSTANTS, EXTENSION AND SYNAESTHESIA

Synaesthesia is a rare condition that is not regarded as an example of abnormal experience but nonetheless provides some understanding of elementary perceptual neural systems that may help to clarify and illuminate the problem of abnormal perception. Synaesthesia can be de ned as the perception of an object, presented in one sensory modality, at the same time as in a different sensory modality. This is best illustrated by giving an example of music to colour synaethesia:

When I listen to music, I see the shapes on an externalized area about 12 inches in front of my face and about one foot high onto which the music is visually projected. Sounds are most easily likened to oscilloscope con gurations – lines moving in colour, often metallic, with height, width and, most importantly, depth. My favourite music has lines that extend horizontally beyond the ‘screen’ area. (Cytowic and Eagleman, 2009)

Various forms of synaesthesia have been reported including most commonly grapheme to colour; time unit to colour; musical sounds to colour; general sounds to colour; and, phoneme to colour. Other forms are sounds to taste; sound to touch; vision to taste; etc. Another example of sound to colour synaesthesia:

One of the things I love about my husband are the colours of his voice and his laugh. It’s a wonderful golden brown, like crisp, buttery toast, which sounds very odd, I know, but it is very real. (Cytowic and Eagleman, 2009)

These experiences seem to be spatially extended, but different from seeing or imagining. They are experienced close to the body, within limb’s reach, and within ‘peri- personal space’. These experiences raise the question of whether the extended space in synaesthesia is akin to the space in which visual or auditory verbal hallucinations are experienced. Furthermore, the synaesthetic experiences are consistent over time and are elementary and speci c in nature. The sensations do not evoke elaborate or complex perceptions, but rather elementary colours, shapes, bright-dark con gurations, jagged-smooth

Normal Perception

Imagery

Perceptions are of concrete reality.

Perceptions occur in external objective space.

Perceptions are clearly delineated.

The sensory elements are full and fresh.

Perceptions are constant and remain unaltered.

Perceptions are independent of our will.

Images are gurative and have a character of subjectivity.

Images appear in inner subjective space.

Images are incomplete and poorly delineated.

The sensory elements are relatively insuf cient.

Images dissipate and have to be recreated.

Images are dependent on our will.

(After Jaspers, 1997)

The study of imagery remains a controversial area within cognitive neuroscience. Theories of visual imagery have borrowed from the language and model of the camera; this is referred to as the pictorial or depiction theory of mental imagery. The foremost proponent of this approach is Kosslyn. A detailed account of the theory and its dif culties is outside the scope of this book (see Kosslyn, 2004; Pylyshyn, 2004). Kosslyn argues that a mental image is guratively accurate, as each point of the image corresponds to each point on the represented object. This means that there is a point-to-point repre- sentation such that performing particular operations on the image takes as much time as it would take to perform the same operation on the object. In other words, the time to scan a mental image is the same as the time to scan the object. Pylyshyn, on the other hand, argues that there are decisive differences between retinal or cortical images and mental images.

Imagery is important for psychopathology because an understanding of the formal characteristics or nature of imagery is required for examining the nature of perceptions, hallucinations and pseudohallucinations. Functional imaging studies and case reports have shown that the mechanisms responsible for the visual percep- tion of objects and those responsible for imagery may be similar. In other words, the neural substrates of perception and imagery at the very least overlap (Martin, 2006). Ultimately these investigations may shed light

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sensations and so on are provoked. Indeed, there is evidence that the sensations are examples or elaborations of form constants. Form constants in the visual domain are variations of tunnels and cones; central radiations; gratings and honeycombs; and spirals. Variations in colour, brightness, symmetry, replication, rotation and pulsation provide further gradations of the subjective experience of these percepts. What is signi cant is that these form constants seem to be a property of the visual cortex itself and are more commonly experienced in the aura phase of migraine or in periods of sensory deprivation (for a more detailed discussion, see Cytowic and Eagleman, 2009).

In summary, synaesthesia introduces the possibility of understanding some abnormal perceptions as occurring within peri-personal space, which is like neither imagery nor a normal percept. In other words, a ‘third space’ might exist in which some experiences such as those in synaesthesia take place. A good way to understand this is to recognize that normal perceptions are projected into the objective shared space where they coincide with the material world that is their source. In cases where no material objective origin exists, the exact location of the perceived object becomes problematic. In some people, it appears in objective and external space but in others the spatial con guration may be more ambiguous and indeterminate and that might be best considered as a ‘third space’. Additionally, fundamental and elementary features of the neural underpinning of perception might be involved in determining the form of abnormal perception, that is, the nature of abnormal perceptions is not randomly determined.

PRIVATE SPEECH AND INNER SPEECH

In addition to understanding the nature of imagery, extended space and form constants, there is a need to comprehend why auditory hallucinations have the syntactical structure that they have, namely, command format and second- and third-person syntax. An approach is Vygotsky’s (1896–1934) developmental model of thought and speech. He proposed that inner speech developed rst from the internalization of exter- nal dialogue into private speech and nally into inner speech (Fernyhough, 1996; Vygotsky, 1934/1987). For Vygotsky (1978) human forms of practical and abstract intelligence develop when speech and practical activ- ity, two independent lines of development, converge.

Egocentric or private speech is in Vygotsky’s view a transitional form between external and inner speech. A child might, for example, be instructed by a parent to ‘do this or that’, and the child internalizes this instruc- tion into private speech and later into inner speech. Or a child might use private speech to accompany action, to re ect in real time how a problem is being solved and ultimately the private speech becomes part of a planning process that precedes action. In other words, private speech is an overt, spoken language that is not aimed at communicating with others but is linked with thinking and action. This transformation of dialogic, external speech into inner speech may provide a basis for understanding the ubiquity of ‘command’ auditory hallucinations – the grammatical structure of private speech therefore serving as the template for the structure of command hallucinations. A similar case can be made for second- and third-person auditory hallucinations. What is important here is the manner in which Vygotsky’s claim links thinking, action and speech and also how his belief that inner speech and thinking are built on fragmentary and condensed images, make the phenomenology of verbal hallucinations, in particular, more comprehensible.

In his classic text Phenomenology of Perception, Merleau-Ponty (1962) proposes that to perceive is to see ‘standing forth from a cluster of data, an immanent signi cance’. For Merleau-Ponty perception is irreduc- ible to sensations and the perceived object is given directly and is already full of meaning, which gives it a function in the world. In other words, the subject of perception is not a mere spectator and the perception is not a spectacle. In Merleau-Ponty’s schema attention is important to perception because it creates a ‘ eld’ that can be surveyed. Objects of perception already have value and signi cance by being perceived. These ideas that are fundamental to Merleau-Ponty’s conception of perception remind us that objects of perception are relevant to the individual who perceives them. When we come to look at hallucinations and illusions, it becomes even clearer that what is seen or heard is never neutral, it is already full of signi cance and relevance for the person who perceives. The perceived voice in verbal hallucination is not experienced as eaves- dropping on matters that concern others but rather as hearing speech that has personal signi cance and importance.

Abnormal Perception

We will now divide abnormal perception into sensory distortions, in which a real perceptual object is perceived in a distorted way, and false perceptions, in which a new perception occurs that may or may not be in response to an external stimulus. Illusions, hallucinations and pseudohallucinations will be included under false percep- tions. The possibility of a neurologic de cit affecting perception also needs to be considered.

Subjectively, hallucination is similar to sense percep- tion: it is experienced as a normal perception, and it can be distinguished from the fantasy elements that invest it. In vivid imagery, the whole experience is imaginary. Pseudohallucination has a close af nity to imagery but also has some aspects that are character- istic of sense perception or hallucination: vividness, de nition, constancy and apparent independence from volition.

SENSORY DISTORTIONS

Disturbance of the mental state, with or without organic brain pathology, may cause sensory distortion. This distortion may involve any of the components or elemen- tary aspects of perception, such as uniqueness, size, shape, colour, location, motion or general quality. What is signi cant is that the perceived object is correctly recognized and identi ed yet there is a deviation from its customary appearance without prejudicing the knowledge of the kind of thing that it is (Cutting, 1997).

Elementary Aspects of Visual Perception

In visual perception, the recurrence or prolongation of a visual phenomenon beyond the customary limits of the appearance of the real event in the world is termed palinopsia (Cutting, 1997). Critchley (1951) gave a number of examples: a cat noticed in the street one day kept appearing at various times and various situations over the next few days, and the words ‘Pullman Springs’ noticed on the back of a van kept appearing on other vehicles over the next few months.

The size of the perception can be either larger (macropsia) or smaller (micropsia) than expected. In some cases, there can be apparent reduction in one hemi eld of vision (hemimicropsia). These anomalies are common in temporal lobe epilepsy. Alteration in

the customary shape of the perceived object is termed metamorphopsia. Usually, this may involve the appearance of things taking on a different aspect: ‘One woman saw people upside down, on their heads’ (Bleuler, 1950). This is an example of inversion. When metamorphopsia affects faces, it is referred to as paraprosopia. Typically, these perceptual distortions of faces are rapidly uctuant and dynamic. Schreber (1955) describes his experience as follows: ‘At the same time I repeatedly witnessed that [some patients] changed heads during their stay in the common room; that is to say without leaving the room and while I was observing them, they suddenly ran about with a different head’. Bleuler (1950) also describes, ‘Wardmates change their faces the very moment that one looks at them’. One of Cutting’s patients (1997) said, ‘Man behind a lorry was pulling hideous faces’.

Different aspects of colour perception can be affected. The intensity of the colour (visual hyperaesthesia), the actual hue and the quality of the colour can all be affected. Cutting (1997) gives several examples:

1. ‘colours are brighter’, ‘colours more vivid – red, yellow, orange stood out’;

2. ‘black looked brown sometimes’, ‘brown looked different; trouble with pink as it comes across as green’; and

3. ‘this colour looks like an old blue – something horrible’.

Bleuler (1950) describes ‘one patient sees everything as coloured red; another sees everything as white’, and Jaspers ‘I only see black; even when the sun is shining, it is still all black’. These perceptual distortions of colour occur in schizophrenia. In organic conditions, achro- matopsia, which is the complete absence of colour, has been described after unilateral or bilateral occipital lesions, usually of the lingual and fusiform gyri. Dys- chromatopsia refers to the perversion of colour perception and occurs after unilateral posterior lesions.

The spatial location of a perceived object may be distorted. Teleopsia involves the object appearing far away, and pelopsia the object appearing nearer than it should. Alloaesthesia is the term for when the perceived object is in a different position from what is expected, so that the patient, for example, experiences the transposition of objects from left to right.

Akinetopsia is the impairment of visual perception of motion in which the individual is unable to perceive

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the motion of objects. It is very rare and is said to follow bilateral posterior cortical damage. Zeki (1993) quotes Zihl’s case:

She had dif culty, for example, in pouring tea or coffee into a cup because the uid appeared to be frozen, like
a glacier. In addition, she could not stop pouring at the right time since she was unable to perceive the movement in the cup (or a pot) when the uid rose.

The general quality of perception can be affected. This usually involves an inde nable alteration in the visual appearance of the perceived world so that everything seems different from what it used to be: ‘People [look] like toys – almost dead and lifeless, carrying out automatic movements with special meaning’ (Cutting, 1997); ‘people look dead, pale, cold’ (Cutting, 1997); ‘A factory-worker sees a grasshopper and becomes very disturbed and excited at the sight of this very strange [my emphasis] and unknown animal’ (Bleuler, 1950). These experiences are examples of derealization. Normally, perception is accompanied by affect, which may be a feeling of familiarity, of enjoy- ment, of dislike, of involvement, of proximity and so on. This is usually appropriate and so ignored. However, changes in these feelings may present as symptoms, for example, ‘everything looks clear but it all looks miles away’, ‘I feel in seclusion. It is like looking through the wrong end of a telescope’. These, and many other feelings, are described under derealization (Chapter 13). There is a feeling of unreality in the perceptual eld, an alteration in the feelings associated with the objects of perception.

A patient who exempli ed both the loss of intensity of sensation and the change in feelings associated with perception in the context of a depressive illness was a 23-year-old Sri Lankan Buddhist priest. After a session of meditation, he became frightened on waking up to discover that he had assaulted another priest during the night. In the next few days, he felt that he had lost all sensation. Things he saw and heard he could not understand properly. He could see only the things that were nearby. He could not get any sensations from his skin. He said that he could not read nor understand, nor feel sadness or happiness. He said that he could not feel anything: ‘all is numbed, body and mind’. He admitted to feeling low, that life was not worth living

and that he had thought of ending his life. There was no neurologic or other physical abnormality.

Elementary Aspects of Auditory Perception

The elementary elements of auditory perception that can be disturbed include the uniqueness of the experi- ence, the intensity and the spatial position (Cutting, 1997). In palinacousis, the uniqueness of a perceptual experience is disturbed and there is persistence of sounds that are heard. A subject returned to answer the door several times during a 30-minute period after the doorbell had actually rung (Jacobs et al., 1973). The intensity of auditory perception may be altered so that it is either heightened or diminished. For example, heightening in the auditory modality is called hypera- cusis, a symptom in which the patient complains of everything sounding abnormally loud, saying, ‘I can’t bear the noise’. Ordinary conversation may sound intolerably noisy, and even whispering at a distance may be found uncomfortable. There is, of course, no true improvement of auditory perception but simply a lowering of the threshold at which noise becomes unpleasant. The symptom occurs in depression, migraine and some toxic states, for example, the hangover after acute alcohol excess. The spatial position of a sound may be disturbed so that the sound appears as if it was nearer, further away or displaced in position.

Elementary Aspects of Tactile Perception

Palinaptia is the experience of tactile sensation outlasting the stimulus, so that an object held in the hand con- tinues to be perceived well after it has been discarded. Stacy (1987) reports a case of a patient with biparietal lesions who could feel her toothbrush in her hand 15 minutes after putting it away. The palinaptic experience occurred in the setting of astereognosis and palpatory apraxia. The palinaptia can be conceived as a complex haptic hallucination. Exosomesthesia is the ‘displacement of cutaneous sensation into extrapersonal space’ (Shapiro and Fink, 1952; Shapiro et al., 1952). This is a curious condition in which the individual experiences direct cutaneous touch sensation when a distal object that is in the same room is touched.

If the palm of his hand was in contact with some object (bed, table, book) and the dorsum of that pricked with a pin, the patient insisted that the bed or table had been touched and not his hand. This phenomenon

could be elicited only from the hand and only when the palm was in contact with some object.

This unusual phenomenon can be experimentally induced, and it has been suggested that the body image, despite its appearance of durability and permanence, is a transitory internal construct that can be altered by encountered stimulus contingencies and correlations (Ramachandran and Hirstein, 1998).

It is even possible to ‘project’ tactile sensations onto inanimate objects such as tables and shoes that do not resemble body parts. The subject is asked to place his right hand underneath a table surface (or behind a vertical screen) so that he cannot see it. The experi- menter then uses his right hand to randomly stroke and tap the subject’s right hand (under the table or behind the screen) and uses his left hand to simultane- ously stroke and tap the table in perfect synchrony. After 10 to 30 seconds, the subject starts developing the uncanny illusion that the sensations are now coming from the table and that the table is now part of his body.

Alloaesthesia is a neurologic condition seen after right-sided vascular lesions of the putamen that is characterized by a sensory stimulus on one side of the body being perceived on the contralateral side. It can also occur after spinal cord lesions such as cervical tumours, cervical disc herniation and multiple sclerosis (Fukutake et al., 1993; Kawamura et al., 1987).

Splitting of Perception

This rare phenomenon is described sometimes with organic states and also with schizophrenia: the patient is unable to form the usual, assumed links between two or more perceptions. A patient watching television experienced a feeling of competition between the visual and auditory perceptions. She felt that the two were not coming from the same source but were competing for her attention and conveying opposite messages. Splitting of perception occurs when the links between different sensory modalities fail to be made, and so the sensations themselves, although in fact associated, appear to be quite separate and even in con ict.

FALSE PERCEPTION

Now we turn from the altered perception of real objects to consider the perception of objects that are not there; these are new perceptions that include illusion,

hallucination and pseudohallucination. Illusions were separated phenomenonologically from hallucinations by Esquirol (1817) and later also by Hagen, who introduced the term pseudohallucination (Berrios, 1996). Esquirol described illusions as transformations of perceptions, coming about by a mixing of the repro- duced perceptions of the subject’s fantasy with natural perceptions.

Illusion

Three types of illusion are normally described: completion illusion, affect illusion and pareidolic illusion. Completion illusions depend on inattention for their occurrence. The faded lettering of an advertisement outside a garage is represented in Fig. 7.1. Being more interested in music than cars, this can be misread this as ‘Vivaldi’. We commonly miss the misprints in a newspaper because we read the words as if they were written correctly. As soon as our attention is drawn to the mistake, our perception alters. An incomplete perception that is meaningless in itself is lled in by a process of extrapolation from previous experience and prior expectation to produce signi cance.

Completion illusion demonstrates the principle of closure in Gestalt psychology: there is a human tendency to complete a familiar but not quite nished pattern (Beveridge, 1985). It is necessary for us to make sense of our environment, so when the sensory cues are nonsensical, we alter them slightly with remembered or fantasy material so that the whole perceptual experi- ence becomes meaningful.

FIG. 7.1 Illusion.

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When illusion arises through affect, the perception of everyday objects is changed. The illusion can be understood only in the context of the prevailing mood state. A child who is frightened of the dark wakes up in the half-light and mistakes a towel hanging by the wall for a person moving. The experience lasts only a short time and disappears when the intense fear goes: the illusion is banished by attention. Of course, there is no absolute distinction between these different types of illusion. The degree of completion, or of affect involved, is variable. For example, a man looking through advertisements for a post found a job that he liked and misread the written word suitable for the illusional word ‘superior … applicant is required’. Clearly, this was both an affective and a completion illusion. Similarly, in the stage of searching that occurs after bereavement, momentary recognition of the dead person may occur for someone in a crowd. Close observation of the individual immediately dispels the feeling of familiarity.

Pareidolia occurs in a considerable proportion of normal people. Pareidolia can also be provoked by psychomimetic drugs. Typically, images are seen in shapes in pareidolic illusion. For example, it is possible to see the head of a spaniel in a chip on a paving stone, the image being not just a of dog but de nitely a spaniel.

Pareidolic illusions are created out of sensory percepts by an admixture with imagination. The percept takes on a full and detailed appearance: ‘A Victorian lady with a crinoline and frilled bloomers’. The person experiencing it, like someone seeing a photograph, knows that it is not truly there as an object but that it is gurative. However, he cannot dismiss what he sees. Completion and affect illusions occur during inattention; they are banished by attention, which will, on the other hand, increase the intensity of pareidolic illusions as they become more intricate and detailed.

Pareidolic illusion occurs in children more than in adults. It should be distinguished from the following conditions.

• Perceptual misinterpretation, that is, simply making a mistake as to the nature of perception without that perception being particularly in uenced by emotion mixed with fantasy.

• Functional hallucination, which occurs when a certain percept is necessary for the production of a hallucination, but the hallucination is not a

transformation of that perception. For example, the patient hears voices when the tap is turned on; he hears voices in the running water, but the voices and the noise of water are quite distinct and can be heard separately and synchronously like any other voice that is heard against a back- ground noise. The perception of hearing running water is necessary to produce the hallucination, but the hallucination is not a transformation of that perception.

• Fantastic interpretations or elaborate daydreaming can be very similar to pareidolic illusions and, as we have already discussed, there is a large admix- ture of fantasy in such illusions.

Hallucination

Hallucinations are the most signi cant type of false perceptions. Here are ve de nitions of hallucination. • A perception without an object (Esquirol, 1817). • Hallucinations proper are false perceptions that are not in any way distortions of real perceptions but spring up on their own as something quite new and occur simultaneously with and alongside

real perception (Jaspers, 1997).
• A hallucination is an exteroceptive or interoceptive

percept that does not correspond to an actual

object (Smythies, 1956).
• According to Slade (1976a), three criteria are

essential for an operational de nition: (a) percept- like experience in the absence of an external stimulus; (b) percept-like experience that has the full force and impact of a real perception; and (c) percept-like experience that is unwilled, occurs spontaneously and cannot be readily controlled by the percipient. This de nition is derived from Jasper’s formal characteristics of a normal percep- tion (see Table 7.1).

• A hallucination is a perception without an object (within a realistic philosophic framework) or the appearance of an individual thing in the world without any corresponding material event (within a Kantian framework), according to Cutting (1997).

One of the simplest facts about hallucinations is often one of the most dif cult to comprehend: what the doctor calls a hallucination is a normal sensory experience to the patient. Although the standard

de nitions of hallucination imply that, subjectively, a hallucination is indistinguishable from a normal percept, some authors argue that hallucinatory percepts may be distinct from normal percepts (as discussed later). One of the clues that the sufferer uses to grasp the fact that he might be hallucinating is that there is no cor- roborative evidence for the percept in other modalities. A woman hears voices giving a commentary on her activity: ‘She is going to the sink. She is putting the coffee on’. She sees no one else in the room but rec- ognizes the voices of her neighbours. She cannot understand how she can be hearing them, but she is so convinced by the reality of the voices that she draws the curtains and takes the mirrors off the walls. There is some con ict in her mind: she hears voices but can see no person to account for them. However, she resolves this con ict in what is a rational way, assuming that she believes implicitly in the genuineness of the perception: ‘someone must have xed a device or altered my sense of hearing’. What is notable is that she does not doubt the reality of the percept.

Horowitz (1975) has investigated hallucinations using a cognitive approach, looking at each of the following four constructs in terms of coding, appraising and transforming information.

Hallucinations are mental images that (1) occur in the form of images, (2) are derived from internal sources of information, (3) are appraised incorrectly as if from external sources of information and (4) usually occur intrusively. Each of these four constructs refers to a separate set of psychological processes, although together they comprise a holistic experience.

This provides a conceptual framework for investigat- ing the phenomena of hallucination.

This idea has been further developed by Bentall (1990), who considers that hallucinations represent faulty judgements about the origin of their perceptions, tending to attribute them to an external source. The content of hallucination was thought to be explained, at least in part, by the need to defend the individual’s own self-esteem. Hallucinations may result from a failure of the metacognitive skills involved in discriminating between self-generated and external sources of informa- tion. This explanation was given further support by the nding that hallucinators more often misattributed auditorily presented answers to dif cult clues from an experimenter than either a deluded but not hallucinated

group of patients or normal control subjects (Bentall et al., 1991).

The current, most in uential explanatory model of verbal auditory hallucinations is the misattribution of inner speech model. In this model inner speech is assumed to be involved in cognitive planning, self- monitoring and in re ecting on action. Furthermore, there are possible roles for inner speech in regulating emotions and behaviour. Although, in many respects inner speech is akin to spoken language, it can also be an abbreviated version of spoken language, taking on a more condensed and telegraphic form. A full description of the dialogic model of inner speech and its proposed relationship to auditory verbal hallucination is outside the remit of this book but can found in Fernyhough’s book The Voices Within (Fernyhough, 2016). The importance of this model is that it points to the ubiquity of inner speech and lays the foundation for understanding the links between inner speech and the obvious abnormalities demonstrated in verbal hallucinations. It also draws attention, implicitly, to the distinctions that may exist between verbal hallucina- tions and hallucinations in other modalities. Misattribu- tion, in this model, implies that there is impairment of self-monitoring with the result that patients are unaware that the perceived auditory verbal hallucina- tions are indeed their own self-generated thoughts/ inner speech (Upthegrove et al, 2015).

Other theoretical explanations include alterations in the mechanisms for language production, speech production and perception. These mechanisms are implicated because of ndings that demonstrate activa- tion of left superior temporal cortex during auditory verbal hallucinations in patients with schizophrenia. Aberrant memory functions may also be at play, especially in those patients whose auditory hallucina- tions occur as a failure of inhibition of recall and unintended memory activation. This mechanism is thought to be more likely in those patients in whom auditory verbal hallucinations are best conceptualized as intrusive memories that arise out of context and are linked to past trauma. Finally, it is also possible that auditory verbal hallucinations occur as a result of faulty auditory processing in which auditory stimuli are misinterpreted as ‘voices’.

Attempts to explain hallucinations by underlying neurochemistry and neuropathology have so far not

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made much progress. An attempt has been made to incorporate concepts of biological vulnerability and psychological in uences in the aetiology and clinical presentation of hallucinations, but research has produced no single mechanism to account for them (Asaad and Shapiro, 1986).

Hallucinations take place at the same time as normal sensory stimuli are perceived. In this way, they are unlike dreams, which in fact have more of the characteristics of illusions. Hallucinations are like normal percepts, of which several can be perceived simultaneously or in rapid succession. Thus the patient can hear hallucinatory voices at the same time as he is seeing his interviewer and listening to him speak.

The sense of reality experienced by patients when they hallucinate was studied by Aggernaes (1972), developing the concepts of Rasmussen. He pointed out six qualities of which normal people can be aware when they experience a sensation, which also occurred in more than 90% of a series of hallucinations.

• With normal sensation, we are able to distinguish perceiving with our sense organs from imagining the same objects; hallucinations similarly are experienced as sensation and not as thought or fantasy.

• When a subject experiences something, he realizes its possible relevance for his own emotions, needs or actions; hallucinations also have this quality of behavioural relevance.

• Normal sensation has a quality of objectivity, in that the experiencer feels that under favourable circumstances he would be able to experience the same something with another modality of sensation; this is also the experience of the hallucinator.

• An object is considered to exist if the observer feels certain that it still exists even though nobody else is experiencing it at that time; perceived objects and hallucinations share this quality.

• Experience of object perception and hallucination is involuntary, in that the experiencer feels that it is impossible or extremely dif cult to alter or dismiss the experience simply by wishing to do so.

• Normally, the experiencer is aware, or through simple questioning becomes aware, that his

experience is not simply the result of being in an unusual mental state; this quality of independ- ence is present with normal perception and with hallucination.

One further quality of normal object perception was found to be absent more often than not with hallucina- tion. This is the quality of publicness, in which the experiencer would be aware that anybody else with normal sensory faculties would be able to perceive this something. Often, the hallucinator does not believe that others could share his experience (delusional explanation may be given for this).

Clearly, cultural factors in uence the manner in which subjects describe their abnormal perceptions. It has been claimed by Andrade (1988) that because patients in India were more prepared to accept para- normal explanations for phenomena, false perceptions or ‘true hallucinations’ are more likely to be ascribed with objectivity and veridicality. Even if this is so, and it is not proven, the qualities described by Aggernaes would still be useful in distinguishing hallucination from other abnormalities of perception.

Cutting (1997) has argued that hallucinatory experi- ences are hardly plausible everyday occurrences and that therefore it is not that hallucinatory percepts are indistinguishable from normal percepts, but rather that they are taken for reality despite the fact that they are distinct from everyday reality. He makes the point that, for example, Lilliputian hallucinations in delirium and complex hallucinations involving comic characters are obviously not plausible perceptions in the real world yet they are taken as real. However, Cutting ignores the fact that it is precisely because hallucinatory phenomena have the quality of a normal experience that they are taken for reality despite being, as he points out, implausible. Other authors, such as Spitzer (1994), argue that hallucinations are not like normal perceptions, in that patients can distinguish between real perceptual experiences and their hallucinatory experiences. This is one reason why patients are able to understand the reference to ‘hearing voices’ in interactions with clini- cians; both parties know what this way of speaking stands for. Indeed, Wernicke (1906) had already drawn attention to when he pointed out that the notion of ‘hearing voices’ was not invented by psychiatrists but rather was used by patients to indicate that somehow their experience was akin to hearing other people talk

but also different from this as well. Junginger and Frame (1985) showed that a substantial proportion of patients (40%) rated the voices they heard as more akin to inner speech than to external spoken or heard speech, thus emphasizing that hallucinations may not always have the hallmark of normal perception.

AUDITORY HALLUCINATION

An additional video for this topic is available online.

Hallucinations can occur in any of the areas of the ve special senses and also with somatic sensation. We will start by discussing auditory hallucinations because they are most often of supreme diagnostic signi cance. In acute organic states, the auditory hallucinations are usually unstructured sounds – elementary hallucinations, for example, the patient hears whirring noises or rattles, whistling, machinery or music. Often the noise is experienced as unpleasant and frightening. Of interest are musical hallucinations, which tend to occur in older women with deafness or brain disease and no history of psychiatric illness (Berrios, 1990). There are, therefore, similarities with Charles Bonnet’s syndrome, described later in the section on visual hallucinations.

Hearing voices is characteristic of schizophrenia, but it also occurs occasionally in other conditions, such as chronic alcoholic hallucinosis or affective psychoses. These voices are sometimes called phonemes (confusion exists, unfortunately, because the word is used with a totally different meaning in linguistics, in which phonemes are the units of speech-sound from which words are made). Usually in organic states, the phonemes are simple words or short sentences, often spoken to the patient in the second person as either peremptory orders or abusive remarks. These abusive or imperative phonemes also occur in schizophrenia, but other more complicated speech is also heard; the voices may be single or multiple, male or female or both, people known and recognized by the patient or not known. They are experienced as coming from outside his head or his self. The voice is clear, objective and de nite and is assumed by the patient to be a normal percept that at the same time may be baf ing and incomprehensible in its import. Particularly characteristic of schizophrenia are voices that say the patient’s own thoughts out loud, which give a running commentary on the patient’s actions

or voices, which argue or discuss vigorously with each other. They refer to the patient in the third person (Schneider, 1959).

In a series of 100 current patients experiencing auditory hallucinations, all of which were described as ‘hearing voices’, 61 suffered from schizophrenia and 78 from schizophrenia-related conditions (Nayani and David, 1996). Fifty-two percent of the patients had an experience of sadness, and 45% experienced churning or butter y sensations in the stomach at or before onset. Most voices spoke in conversational tones, but a few whispered and a few shouted; half of the sample heard their voices through their ears as external stimuli. Most voices were male, often a middle-aged man, usually speaking in a different accent from the patient, for example, ‘an upper-class voice’. Subjects heard a mean of 3.2 different voices and usually knew the identity of at least one; in half of the subjects, the voices signi ed forces of Good or Evil. Half of the subjects were able to exert some control over their voices, and two-thirds had developed coping mechanisms to deal with them; high levels of distress were found among those with little control and few means of coping. The majority of subjects ascribed reality characteristics to their voices. A long history of auditory hallucinations tended to be associated with more hallucinated words, more voices, a greater range of emotional expression and grammatical style and greater likelihood of delusional interpretations of the voices.

In a qualitative study of 25 subjects Upthegrove et al. (2016) reported that the research participants experienced the verbal hallucinations as an entity that was able to socially interact with them and had a well- developed character of its own. The experience was often real in the sense that the participants found it dif cult to distinguish between their experiences and reality and were surprised that other people could not hear the same ‘voices’. The voices were described as ‘demanding’ rather than ‘commanding’. The voices could also in uence the participant’s emotions by being threatening, blaming or mocking and tricking or manipulating the participants. Participants found the voices disruptive to the degree that their concentration was affected and simple tasks became arduous.

Auditory hallucinations in schizophrenia are generally private events, but several early writers observed vocalizations that corresponded with the content of

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the voices taking place at the same time as the hallucina- tions. Normal people occasionally vocalize their own thoughts sotto voce; in the psychotic equivalent of this, it seems that sometimes those with schizophrenia are vocalizing their hallucinations at the same time as they experience them. Green and Preston (1981) increased the audibility of the whispers of such a patient to an intelligible level using auditory feedback.

Sometimes patients with schizophrenia describe abnormal perceptions in both the visual and the auditory modalities. The examiner should be careful not to assume that there are both auditory and visual hallucina- tions present; there may be a different form, particularly for the visual experience. A man aged 45 years described his experience as follows: ‘I hear my nephews talking [about me]. “He is a poofter [homosexual] and a pervert” … I see them as well. The curtains move and I know that it is them moving them’. This is a description of a persecutory auditory hallucination, but the visual experience is a delusional interpretation of a normal perception, not a visual hallucination.

Patients’ descriptions of their phonemes vary greatly. Sometimes, patients talk openly and quite blandly about their ‘voices’. Not uncommonly, a patient may deny voices but assert that he hears ‘spoken messages’ or ‘transmissions’ or some other spoken sound, and it may be dif cult to decide whether this is a real percep- tion or an auditory hallucination. The phonemes may be so insistent, compelling and interesting that ordinary conversation with the doctor is found boring, and even unreal in comparison. The voices may form an insistent background to life, so ensuring that a large part of the patient’s speech and behaviour is occupied in answering and obeying the voices. Psychiatric nurses often observe that the auditory hallucinations described by patients are as real to them as any other remembered conversa- tions, and both hallucinatory and real auditory percep- tions form the memories on which patients base their life and behaviour in the present.

Auditory hallucinations occur when there is a combination of vivid mental imagery and poor reality testing in the auditory modality (Slade, 1976b). This has been investigated using a battery of tests including the verbal transformation effect. The word tress was repeated on a tape recorder to the subjects for ten minutes. After a time, subjects began to hear other words and syllables. Normal subjects and patients with

schizophrenia who were not auditorily hallucinated usually heard words that were phonetically linked to the original monosyllable, but patients who were experienced auditory hallucinations heard words that were quite different phonetically as often as those that were linked.

It appears that auditory hallucinations are dependent on the meaningfulness of sensory input. When various types of auditory input were presented to patients with schizophrenia who experienced hallucinations, it was found that it was not the degree of external stimulation that was required to diminish hallucinations but the nature of the stimulus and the degree of attention it received. When the subject was required to actively monitor the experimental material by reading aloud a prose passage and deciding the content afterwards, this produced a greater decrease of hallucinatory experience than any of the conditions in which sounds were played to the subject through earphones (Margo et al., 1981). Morley (1987) reported the psychological treatment of a 30-year-old man with auditory hallucinations. Distrac- tion by means of music presented by a portable cassette produced a transient reduction in the frequency and clarity of hallucinations. Subsequently, these hallucina- tions were totally abolished by the unilateral placement of a wax earplug: attention was considered more effective than distraction. The patient located the hallucination ‘about a foot away from my right ear’, and the plug was only effective in the right ear.

Patients with schizophrenia experiencing auditory hallucinations were found to be impaired in cognitive processing in the aspects of tolerance of ambiguity and availability of alternative meanings. Tolerance of ambiguity was tested by asking the patient to recognize a spoken word, which was obscured by a masking noise of people reading. The masking noise was gradually reduced in volume until recognition occurred. Alternative meanings tests the subject’s knowledge of less familiar meanings of words. These two processes reduced the quality of perception (resulting in hallucination) by introducing errors of premature judgement without the safeguard of subsequently considered alternatives (Heilbrun and Blum, 1984).

Some auditory hallucinations are considered to be ‘ rst rank symptoms of schizophrenia’ (Schneider, 1959); these are audible thoughts, voices heard arguing with each other and voices commenting on the patient’s

behaviour. These three perceptual disturbances, as other rst rank symptoms, each represent a massive interfer- ence with the boundaries of self-image, the discrimina- tion of what is ‘I’ from what is ‘not I’ (Sims, 1991).

The mechanisms used by patients with chronic schizophrenia to cope with persistent auditory hallucina- tions were discussed by Falloon and Talbot (1981). The strategies used to cope with intrusive voices could be classi ed as changes in behaviour, in sensory or affective state and in cognition. Changes in behaviour included alteration of posture, such as lying down, or seeking out the company of others. Physiologic arousal was altered to cope with hallucinations through relaxa- tion or physical exercise such as jogging. Cognitive methods included control of attention or active sup- pression of hallucinations. These authors believe that the commonsense application of strategies used by patients can be bene cial in the control of these distress- ing symptoms.

Finally, there is a vigorous debate about the presence of auditory/verbal hallucinations in disorders other than the psychoses such as borderline personality disorders and also in normal populations (McCarthy-Jones, 2012). In a recent report from the Adult Psychiatric Morbidity survey, it was reported that overall 12.6% of individuals with a mental disorder reported hallucinations compared with 3.7% of individuals who did not have a mental disorder. Surprisingly hallucinations were prevalent in agoraphobia, speci c phobia, social phobia, obsessive- compulsive disorder, panic disorder, depression, bor- derline personality disorder and generalized anxiety disorder (Kelleher and DeVylder, 2017). The question that remains to be answered is whether the form of these verbal hallucinations is identical to the form of the verbal hallucinations in schizophrenia, for example. Further, there is some evidence derived from functional neuroimaging that suggesting that the neural underpin- ning of auditory verbal hallucinations in schizophrenia may involve altered dopamine synthesis and reduced functional lateralization (Upthegrove et al., 2015).

VISUAL HALLUCINATION

Visual hallucinations characteristically occur in organic states rather than in the functional psychoses. A 69-year- old married man was referred to the duty psychiatrist in a casualty department for assessment. He said that his life was at an end and he deserved to die, as he

had been caught masturbating by his daughter-in-law and grandchildren that afternoon. His wife said that this was not true; he had become very agitated and distressed over 12 hours and no one had visited the house that day. During interview, he was intensely agitated and put his hands in front of his face. He claimed that he could see clearly a sheet of glass half a metre in front of him, which he attempted to move. Later, he described seeing dust falling down everywhere and was trying to catch it. He manifested clouding of consciousness. A diagnosis of viral encephalitis was made on the basis of the history of persistent headache, the neurologic signs and the nding of lymphocytosis in the cerebrospinal uid.

It is often dif cult to decide whether the full criteria for the presence of a hallucination have been ful lled in the visual modality. Distortion of visual percepts, based on either sensation of external stimuli or internal interference with the visual pathway, may produce disturbances that are similar to those occurring with entirely new perceptions. Sometimes the account of his experience given by the patient sounds like a sensory transformation rather than a hallucination, but the bizarre and complex nature of the experience renders phenomenonologic description dif cult.

Visual hallucinations occur with occipital lobe tumours involving the visual cortex, for example, tuberculous granuloma in the left occipital lobe caused a ‘starburst’ effect in the right visual eld (Werring and Marsden, 1999). Hallucinations and other visual disturbances may occur with other physical lesions, such as loss of colour vision, homonymous hemianopia (loss of half of the eld of vision, the same half in both eyes; Komel, 1985), dyslexia (inability to read at a level appropriate to the individual’s age and intelligence), alexia (word blindness) in a dominant hemisphere lesion and corti- cal blindness (blindness due to a lesion of the cortical visual centre). They may, as in delirium tremens, be associated with an affect of terror or with an affect of hilarious absurdity. Similar visual hallucinations, illusions and changes in mood occur in other forms of delirium. Visual hallucinations also occur in the post-concussional state, in epileptic twilight states and in metabolic disturbances, for example, hepatic failure. Visual hallucinations have also been described in association with various dementing processes, including Alzheimer’s disease (Burns et al., 1990), senile dementia

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(Haddad and Benbow, 1992), multi-infarct dementia (Cummings et al., 1987), Pick’s disease (Ey, 1973) and Huntington’s chorea (Lishman, 1989). Among referrals to a psychogeriatric service, visual perceptual disturbance occurred in 30% of patients; there was a strong correlation between the presence of visual hallucination and eye pathology (Berrios and Brook, 1984). In fact, visual hallucinations are common in elderly patients with a wide variety of medical condi- tions and often no psychiatric history (Barodawala and Mulley, 1997).

Hallucinations have also been described by individu- als after snif ng glue and petrol. The drugs mescaline and lysergic acid diethylamide are potent causes of visual perceptual change. Visual hallucinations are in nitely variable in their content. They range from quite crudely formed ashes of light or colour (elemen- tary hallucinations), through more organized patterns and shapes, to complex, full, visual perceptions of people and scenes. Visual and auditory hallucinations may occur synchronously in organic states, for example, in temporal lobe epilepsy a visual hallucination of a human gure was also heard to speak.

With psychomimetic drugs, there are alterations in spatial perception, in the perception of movement and in the appreciation of colour, and visual illusions and hallucinations may occur. Visual hallucinations are very uncommon in schizophrenia (although some of the earlier writers used the term hallucination for other visual abnormalities that occurred). Persaud and Cutting (1991) cautiously refer to ‘anomalous perceptual experiences in the visual modality’ in schizophrenic patients, for example, as in the patient who although still recognizing a face considers it to be distorted. These authors report four such cases of perceptual disturbance in one visual eld, always the left eld. Visual hallucinations are not reckoned to occur in uncomplicated affective psychoses. It is common in schizophrenia for the patient to describe auditory hal- lucinations associated with visual pseudohallucinations. Although the phonemes are complete and appear to have all the characteristics, subjectively, of a normal percept, the visual experiences are often inferred on the basis of the auditory hallucinations and of con- temporaneous delusions. It is possible to see, in most instances, how psychotically disordered fantasy accounts for the content of the visual experiences. Vivid elaborate

scenic hallucinations have been described in oneiroid states of schizophrenia. In these states, there is also an altered state of consciousness.

Sometimes, visual hallucinations do not appear to be associated with any other psychiatric abnormality. Charles Bonnet’s syndrome (phantom visual images) is a condition in which individuals experience complex visual hallucinations in association with impaired vision without demonstrable psychopathology or disturbance of normal consciousness (Schultz and Melzack, 1991). Although more common in the elderly, it can occur at any age and is usually associated with central or peripheral reduction in vision. Episodes may last from days to years, with images of people, animals, buildings and scenery being most frequently reported, the images being static, moving in the visual eld or animated. Clearly, this condition is of importance in the differential diagnosis.

In most cases of Charles Bonnet’s syndrome, and in musical hallucinosis in the deaf, to which it has been likened, there is no demonstrable brain pathology (Fuchs and Lauter, 1992). The features of this syndrome have been considered by Podoll et al. (1990) to be as follows.

• Elderly persons with normal consciousness experi- ence visual hallucinations.

• None of the following are present: delirium, demen- tia, organic affective or delusional syndromes, psychosis, intoxication or neurologic disorder with lesions of the central visual cortex.

• There is reduced vision, resulting from eye disease in most cases.

Hallucinations in this condition are always located in external space, are usually coloured and are much more vivid and distinct than the patient’s impaired vision would otherwise permit. The content is elementary in about one-third of cases, such as photisms or geo- metric patterns. Complex objects are most often human gures, less often animals, plants and inanimate objects; these objects may be fragmented and may change over time – gures gliding through the room. The percepts may be modi able by voluntary control, for example closing the eyelids, and there is usually insight concern- ing their ‘unreality’. This is sometimes associated with fear of mental illness and would suggest that these phenomena may be pseudohallucinations rather than ‘true’ hallucinations in some cases.

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FIG. 7.2 The experience of delirium tremens.

The alcoholic withdrawal syndrome of delirium tremens is a speci c form of acute organic syndrome and is characterized by gross changes in percep- tion, mood and consciousness state (see Chapter 3). Pareidolic or affective illusions are often prodromal in delirium tremens, and these are followed by visual and haptic Lilliputian hallucinations, which are often of little animals or diminutive men. There is a bizarre intermingling of affect so that the patient experiences stark terror and, at the same time, a humorous response to absurd experiences especially common with these disorders.

The hallucinations in delirium tremens may change so rapidly that the patient has dif culty describing them. A patient experiencing such visual phenomena tried to portray this in Fig. 7.2. Illusions are frequently associ- ated with hallucinations, especially affective illusions, in which, through the predominant mood state of terror, cracks in the wall of the ward, or curtains moving in the breeze, may be misinterpreted in a frightening way. At the same time, such patients are highly suggestible and can form abnormal visual experiences as a result of suggestion.

HALLUCINATION OF BODILY SENSATION

It has been convincingly argued by Berrios (1982) that diverse ‘perceptions without object’ were brought together by Esquirol (1817) within the term hallucina- tion, which was relevant for ‘distance senses’ such as vision, hearing and, to a lesser extent, smell and taste, but not really applicable to touch. So-called tactile hallucinations appear to be different phenomenologically

and to only super cially resemble hallucinations of the distance senses. It would seem for tactile hallucinations that the most important corroborating diagnostic factor is the concurrence of a delusional component. Berrios concludes that the concepts of hallucination and delu- sion may be closer to each other than has often been considered, especially in British psychiatry.

Hallucinations of bodily sensation may be super cial, kinaesthetic or visceral. Super cial hallucinations affecting skin sensation may be thermic, an abnormal perception of heat and cold (‘my feet on re’); haptic, of touch (‘a dead hand touched me’); or hygric, a perception of uid (‘all my blood has dropped into my legs and I can feel a water level in my chest’). Paraesthesiae is the term describing the sensation of tingling or ‘pins and needles’. These may be delusionally ascribed, although of course they are often neurologically mediated, for example, ulnar nerve compression causing pins and needles in the forearm.

Kinaesthetic hallucinations are those of muscle or joint sense. The patient feels that his limbs are being bent or twisted or his muscles squeezed. Such hallucina- tions in schizophrenia are often linked with bizarre somatic delusions. A man suffering from schizophrenia described the experience thus: ‘I thought my life was outside my feet and made them vibrate’ – he experienced kinaesthetic hallucinations of vibration. Kinaesthetic hallucinations may occur in organic states: ‘a feeling of being rocked about’. Abnormal kinaesthetic percep- tions have also been described in the withdrawal state from benzodiazepine drugs (Schopf, 1983) or from alcohol intoxication. A man, after recovery, described his episode of delirium tremens, saying, ‘I felt as if I was oating in the air about 50 feet above the ground’. He illustrated this feeling with the picture in Fig. 7.2.

Visceral hallucinations are false perceptions of the inner organs. There is only a limited range of possible visceral sensation, for example pain, heaviness, stretch- ing or distension, palpitation and various combinations of these, such as throbbing. However, the possible range of bizarre schizophrenic false perceptions and interpreta- tions is limitless. One man believed that he could feel semen travelling up his vertebral column into his brain, where it became laid out in sheets.

Hallucinations of bodily sensation are quite common in schizophrenia and are almost always delusionally elaborated, often by delusions of control (Chapters 8 and

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12). Haptic hallucinations may be experienced as touch (‘like a hand stroking me’) or painful (‘knives stabbing my neck’). A patient believed that the smoke sensor in the ward was an infrared camera, ‘because I feel it warm on my neck’. Another patient described a haptic hal- lucination in which she experienced genital stimulation that she ascribed to having sexual intercourse simultane- ously with ‘both Kennedy brothers all the time’. It is important to realize that there is both a hallucinatory and a delusional component in such experiences. One particularly unpleasant form of haptic hallucination is called formication (Latin: formica, ‘ant’), the sensation of little animals or insects crawling over the body or just under the skin. This is especially associated with some drug states and withdrawal symptoms, for example, cocaine addiction and alcohol withdrawal. It is often associated with delusions of infestation, but the latter may occur without hallucination.

OLFACTORY AND GUSTATORY HALLUCINATION

Hallucinations of smell and of taste frequently occur together, and it may be dif cult or impossible to dis- tinguish them from each other. This is not surprising, as a lot of what a layperson ascribes to taste is actually determined by smell: ‘the eucalyptus fragrance of this wine from the Barossa Valley’.

Olfactory Hallucinations

Olfactory sensation or memory is often associated with powerful emotional resonances; it is not surprising, therefore, that hallucinations are also invested with a strong affective component. Olfactory hallucinations occur in schizophrenia, in epilepsy and in some other organic states. The patient has a hallucination of smell. The smell may or may not be unpleasant, but it usually has a special and personal signi cance (Aggernaes’ quality of relevance), for example, it may be associated with the belief that people are pumping a poisonous or an anaesthetic gas into the house, which the patient alone can smell. Sometimes, patients have an olfactory hallucination relating to themselves: ‘I smell repulsive, unbearable – like a corpse, like faeces’. This particular patient killed himself. He felt that he created such a stench that he was intolerable in any reasonable society. Sometimes patients misinterpret and overvalue normal body odours. A delusion in which a patient believes himself to smell malodorously without an accompanying

olfactory hallucination is quite common in schizophrenia and related paranoid states.

Olfactory hallucinations occur in epilepsy, especially in association with a temporal lobe focus, and commonly form the aura (or earliest phase) of such ts. A patient described a smell of burning rubber regularly just before he became unconscious. Visual, auditory, gustatory and visceral hallucinations also occur in temporal lobe epilepsy.

Gustatory Hallucinations

Gustatory hallucinations occur in various conditions. In schizophrenia, they sometimes occur with delusions of being poisoned. There may be a persistent taste, for example, ‘onions’, ‘a metallic taste’ or some more bizarre type of taste. In depression and in schizophrenia, the avour of food may disappear altogether or become unpleasant. Changes in gustatory perception may occur with some organic states, such as temporal lobe epilepsy, and also with some psychotropic drugs, for example, lithium carbonate or disul ram. A relatively common condition is burning mouth syndrome. This is a condition that is seen in dentistry and maxillofacial surgery. This condition presents with a burning sensation on the tongue, palate, inner aspects of the cheeks and gums. It is often associated with altered taste sensation. The patients report metallic taste, viscid or gritty saliva or dryness of the mouth. It is often dif cult to describe how this disturbance of taste is mediated and, therefore, whether it is hallucinatory.

DIFFERENTIATION OF HALLUCINATIONS

Before deciding that a patient is hallucinated, the possibility of other perceptual experiences must be considered. These are not necessarily of pathologic signi cance. The differential diagnosis of hallucination includes illusion, pseudohallucination, hypnagogic and hypnopompic images and, of course, vivid imagery and normal perception.

Pseudohallucinations

Pseudohallucination is one of the least understood phenomena in psychopathology. As Berrios (1996) remarks, ‘it has been used to refer to real perceptions perceived as “unreal”, isolated hallucinations which do not t into favoured diagnoses, side effects of drugs,

withdrawal hallucinations, diabetic hallucinations, etc’. Berrios goes on to say:

Unrestrained, usage has strayed even wider, pseudohallucinations being sometimes applied to (i) phenomena which meet criteria for hallucinations or illusions, (ii) hallucinations in people without mental illnesses (e.g., the bereaved), (iii) the false perceptions of people recovering from psychotic illnesses, (iv) factitious hallucinations in malingerers, and (v) occasionally, normal but unusual perceptions which initially seem

to be hallucinations (e.g., radio reception in dental amalgam or intracranial shrapnel fragments).

Furthermore, part of the confusion over the meaning of the term pseudohallucination has arisen because it is often used in two different and mutually contradictory ways, according to Kräupl Taylor (1981). On one hand, it refers to hallucinations with insight (Hare, 1973), and on the other hand to vivid internal images. Hal- lucinations with insight would be those hallucinatory experiences in which the subject is aware that the hallucinatory percepts do not correspond to external reality despite the perceptions being veridical and in external objective space. Vivid internal images are those phenomena that have all the clarity and vividness of a normal percept except that they occur in inner subjec- tive space.

Jaspers (1997) identi ed pseudohallucination as similar to normal perception except that it occurs in inner subjective space. Pseudohallucination shares this characteristic with imagery. In other words, for Jaspers, pseudohallucination is a perceptual experience that is gurative and occurs in inner subjective space, not in external objective space. But it has all the vividness and clarity of a normal perception and can be retained unaltered. It occurs independently of the subject’s will and therefore cannot be deliberately evoked. Jaspers derived this description of pseudohallucination from Kandinsky.

Kandinsky (1849–1889) based his description of pseudohallucination on his own personal experiences. He committed suicide at age 40 years while a patient at St Nicholas Hospital, St Petersburg, where he had once been medical superintendent (Lerner et al., 2001). In 1885 he described pseudohallucination as a separate form of perception from true hallucination and wrote,

‘subjective perceptions which in vividness and character are real hallucinations except that they do not have objective reality’ (quoted in Berrios, 1996). Pseudohal- lucinations can be identi ed in the visual, auditory or tactile modalities.

Hare (1973) has given as an example of pseudohal- lucination the voice heard by an obsessional or depressed person. It is described by the patient as a voice but is actually recognized as his own thoughts. Pseudohal- lucinations are not pathognomonic of any particular mental illness. A patient with histrionic personality disorder saw a robed gure at the foot of her bed lifting his index nger to his mouth to caution her to silence. The image was sharp and vivid but was recognized as being seen with the inner eye. The patient knew that the gure was not at the foot of the bed and that other people in the room could not see him. When she tried to relate the gure in space to the background of her eld of vision, in this case the walls and curtains of the room, she realized that she could not do so; it had no de nite location in external space, that is, outside herself.

To summarize, the signi cance of hallucination is that it almost always denotes a morbid mental state. The signi cance of pseudohallucination is in its dif- ferential diagnosis from hallucination, as pseudohal- lucination is not necessarily psychopathologic.

Other Abnormalities of Perception

AUTOSCOPY

Autoscopy is the experience of seeing an image of oneself in external space and knowing that it is oneself (see also visual hallucination). It is sometimes called the phantom mirror image. It is one of the abnormalities of unity of self described in Chapter 12. Like so many topics of considerable phenomenologic interest, the term autoscopy has been used with different meanings and de nitions since its rst use by Féré in 1891. The experience concerns how the individual regards the boundaries of self and is discussed further with other disorders of self-image. It is best to reserve autoscopy for abnormalities of visual perception involving seeing oneself – ‘visual experiences where subjects see an image of themselves in external space viewed from within their own physical body’ (Dening and Berrios, 1994).

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Although this topic has been of considerable literary interest over the years, clinical cases with de nite perceptual abnormality are not common. Dening and Berrios have reviewed 56 cases, 53 from the literature and three of their own. Males predominated, with a ratio of two to one, and the mean age of subjects was 40 years. Both neurologic and psychiatric disorder occurred in about 60% of cases (different subjects), with epilepsy in approximately one-third. Decreased consciousness occurred in 45%, delirium in 18% and 9% of subjects were dead within 1 year. Visual imagery or narcissism was present in one-third of subjects, and depersonalization in 18%. The commonest psychiatric diagnosis was depression. Usually, autoscopic episodes lasted for less than 30 minutes. Almost always, the subject saw his own face; quite often, he was lying in bed at the time. The experience often provoked distress, fear, anxiety and depression. This subjective experience was complex, with different components and causes rather than unitary.

Negative autoscopy has also been described, in which, for instance, the patient looks in the mirror and sees no image at all.

EXTRACAMPINE HALLUCINATION (CONCRETE AWARENESS)

‘I know that there is someone behind me on the right all the time; he moves when I move’, ‘I keep on hearing them talking about my disease down in the post of ce’ (half a mile away) – these hallucinations are experienced outside the limits of the sensory eld, outside the visual eld or beyond the range of audibility. They are not of diagnostic importance, as they occur in schizophrenia, epilepsy and other organic states and also as hypnagogic hallucinations in healthy people. The phenomenon is quite de nitely experienced as a perception by the patient and not just as a belief or an idea.

HYPNAGOGIC AND HYPNOPOMPIC HALLUCINATION

These are perceptions that occur while going to sleep (hypnagogic) and on waking (hypnopompic). According to Zilboorg and Henry (1941), hypnagogic hallucina- tions were rst mentioned by Aristotle. It is known that the consciousness level uctuates considerably in different stages of sleep, and both types of abnormal perception probably occur in a phase of increasing

drowsiness: the structure of thought, feelings, percep- tions, fantasies and, ultimately, self-awareness becomes blurred and merges into oblivion. These experiences occur in many people in good health. They are also described with narcolepsy, cataplexy and sleep paralysis to form a characteristic tetrad of symptoms (see Nar- colepsy for descriptions). Toxic states such as glue snif ng, acute fevers (especially in children), postinfec- tive depressive states and phobic anxiety neuroses are other conditions that may be associated with these perceptions.

The perception may be visual, auditory or tactile. It is sudden in occurrence, and the subject believes that it woke him up, for example, a loud voice in the street below saying ‘world war!’, a feeling of someone pushing him over the bed or seeing a man coming across the bedroom. The importance of these phenom- ena in psychopathology is to recognize their nature and realize that they are not necessarily abnormal, even though they may be truly hallucinatory.

FUNCTIONAL HALLUCINATION

This is the strange phenomenon in which an external stimulus is necessary to provoke hallucination, but the normal perception of the stimulus and the hallucination in the same modality are experienced simultaneously. A schizophrenic patient heard hallucinatory voices only when water was running through the pipes of his ward. He heard no phonemes for most of the time, but when he heard water rushing through the pipes along the wall, he became very distressed by voices that told him to damage himself. He was terri ed of the content of these voices because he was afraid he might act on them. He could readily separate the noise of water from the voices, and the latter never occurred apart from the former, but both perceptions were recognized as distinct and real. Another patient heard voices when the radio or television was switched on, alongside the broadcast voices; he had persecutory delusions that these activities were carried out deliberately to upset him and he became very distressed, and at times violent, as a result.

REFLEX HALLUCINATION

As a doctor was writing in his case notes during his interview of a female patient, she said, ‘I can feel you writing in my stomach’. The patient saw and heard the

act of writing and was quite sure that it accounted for the tactile sensation in her abdomen. A stimulus in one sensory modality producing a hallucination in another is called a re ex hallucination. This is, in fact, a hallucinatory form of synaesthesia, mentioned earlier as the experience of a stimulus image in one sense modality simultaneously producing an image in another, for example, the feeling of discomfort caused by seeing and hearing somebody scratch a blackboard with their ngernails. Another re ex hallucination occurred in a woman who experienced pain whenever certain words were mentioned. Functional and re ex hallucinations are not themselves of diagnostic or theoretical signi – cance, but they require mentioning for completeness and recognition to identify other more important symptoms with con dence.

ABNORMAL IMAGERY

Mental imagery tasks are designed to assess a subject’s capacity for mental representation of the perceived world. In cases of hemineglect, there has been interest in whether the observed de cits in imagery are due to inattention or to impairment of mental imagery. Bisiach and Luzzatti (1978) described abnormalities in individu- als with hemineglect. Their patients were asked to describe the Piazza del Duomo in Milan from two standpoints: facing the cathedral and with their backs to the cathedral. From both standpoints, the subjects were unable to describe the right side of the scene despite having correctly described it from the previous standpoint. In other words, even in imagination the mental representation of the piazza was unilaterally de cient for the right side. In these cases, inattention in uenced the capacity for imagery. Guariglia et al. (1993) reported a patient without hemineglect in whom impairment of imagery for objects in the left visual eld was demonstrated. For the rst time, this showed that without hemineglect, that is, visual inattention for space, failure of imagery was still possible.

SENSORY DEPRIVATION

Continuing perception is necessary for consciousness. The eld of sensation varies all the time as individual sensations in different modalities from the outside world and from inside oneself compete for attention. Conscious- ness consists of the integration of this changing eld to form a composite awareness of oneself in one’s

environment. The essential nature of sensation has been explored by studying its absence, as revealed by research on the effects of sensory deprivation (Zubek, 1969). This topic is only given brief mention, as it is somewhat peripheral to psychiatry.

Sensory deprivation was studied using Canadian college students as volunteers (Bexton et al., 1954). The subjects, wearing translucent goggles and gloves with cardboard cuffs, lay on a bed in a light but partially soundproof room; there was a continual background noise. This experience was found to be extremely unpleasant and, despite being paid, subjects were not prepared to remain in this state for more than 3 days.

This technique has been re ned subsequently to blot out external sensations more completely. Various perceptual abnormalities are experienced. Visual hal- lucinations of varying complexity were described, but further study of these perceptual changes resulted in their being considered, more cautiously, to be ‘reported visual sensations’ and ‘reported auditory sensations’ (Zuckermann, 1969). These were classi ed into ‘mean- ingless sensations’ and ‘meaningful integrated sensa- tions’. Some of the latter are more like hallucinatory experiences. Depending on the completeness of depriva- tion of other sensations, abnormal perception occurs in modalities other than vision. Subjects show an altered affective state: they become panicky, restless, irritable or, alternatively, bored and apathetic.

Despite considerable neuropsychological research with valuable ndings for investigating the sensory environment in growth and development, developing brain interconnections, neurochemistry and neurophysi- ology, the study of sensory deprivation has not so far made as big an impact on descriptive psychopathology as was initially expected. There are various dif culties to be accounted for. What part of the effects of depriva- tion is due to failure of development and what to loss of behaviours already established? How can one use animal work to explore subjective symptoms? How can one extrapolate from the experience of normal individuals in a highly abnormal environment to those who are psychiatrically ill? Many studies in sensory deprivation are described by Riesen (1975), who links the experimental data to neurologic function and development.

The distinction has been made between sensory deprivation and perceptual deprivation. The latter is

7 Pathology of Perception 101

102 SECTION III Awareness of Reality: Time, Perception and Judgement

achieved by rendering the sensations patternless and meaningless, rather than by preventing sensations, by using such devices as translucent goggles and continuous ‘white’ noise. The deleterious effects of sensory depriva- tion have been considered by Slade (1984) as:

• inability to tolerate the situation,

• perceptual changes,

• intellectual and cognitive impairments,

• psychomotor effects, and

• physiologicchangesinelectroencephalographand
galvanic skin response measures.
Fantasy is often used as a means of reducing the
unpleasant affective component of sensory deprivation. The subject may become disoriented and show increas- ing dif culty with problem solving and concentration. For perception and maintenance of the normal state of consciousness, it is necessary to have a variety of sensory stimuli available and for these stimuli to be changeable. If the objects of perception do not them- selves change, the observer will move his point of observation to create change.
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KEYWORDS

Delusion
Delusional misidenti cation syndrome Koro
Overvalued idea

Summary

Delusions are false judgements that are held with extraordinary conviction and incomparable subjective certainty and are impervious to other experiences and to compelling counterargument. Usually delusions are easily recognized when out of keeping with the individual’s educational and sociocultural background. Primary delusions have diagnostic signi cance, whereas the content of secondary delusions may signal the nature of the primary abnormal phenomenon from which they derive. Overvalued ideas are comprehensible beliefs that arise from the history and experiences of an individual. They are held with conviction and moti- vate behaviour that may cause the patient harm and suffering.

I cannot pretend to agree with him, when I know that his mind is working altogether under a delusion.

Anthony Trollope (1869)

Anthony Trollope, in his novel He Knew He Was Right, describes not only the totally destructive effect of delusional jealousy on the individual, but also the extraordinary dilemma this poses for other people who come into contact with him: whether to humour the individual and risk reinforcement or to confront him and risk violence. Fundamental to clinical practice in psychiatry, using the phenomenologic or empathic method, is obtaining a clear account of the ideas or notions that the subject, the patient, actually holds. Although delusions are often referred to as beliefs, there is a growing literature questioning whether they are beliefs at all. False beliefs include primary and

secondary delusions, overvalued ideas and sensitive ideas of reference.

Ideas, Beliefs and Delusions

Rarely does anyone claim to be deluded, and usually what a delusional patient thought was true does not prove to be so. A delusion is a false, unshakeable idea or belief that is out of keeping with the patient’s educational, cultural and social background; it is held with extraordinary conviction and subjective certainty. Subjectively, or phenomenologically, it is indistinguish- able from a true belief. A man who is a bachelor of medicine of the University of London holds a delusion that he is being used as ‘an envoy from Mars’. He believes that he is both a doctor and an envoy, and neither thought seems to him to be delusional or imaginary. He likes to imagine himself a rich man with an estate in Gloucestershire. He has not the slightest dif culty in identifying this latter idea as fantasy. To the man himself, a delusion is much closer to a true belief than imagination, and the reasons enlisted to support its veracity are produced in the same way that a person would prove any other notion on which he was challenged. Normally, fantasy is easily distinguished from reality, although the subject may show great reluctance in accepting his aspirations as ‘mere fantasy’. Similarly, there is usually little dif culty for the external observer in deciding whether a false belief is a misin- terpretation of the facts based on false reasoning or a delusion.

MEANING OF DELUSION

The English word delude comes from Latin and implies playing or mocking, defrauding or cheating. The German equivalent Wahn is a whim, false opinion or fancy, and makes no more comment than the English on the subjective experience. The French equivalent, délire, is more empathic; it implies the ploughshare jumping out of the furrow (lira), perhaps a similar metaphor

CHAPTER 8

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Delusions and Other Erroneous Ideas

106 SECTION III Awareness of Reality: Time, Perception and Judgement

to the ironical ‘unhinged’. As Bayne and Fernandez (2009) say:

On the face of things, it seems obvious that delusions involve departures – typically, quite radical departures – from the procedural norms of human belief formation. Delusions stand out as exotic specimens in the garden of belief, as examples of what happens precisely when the mechanisms of belief formation break down.

In this chapter, the complexity of delusions as con- cepts, experienced symptoms, and abnormal phenomena is explored, discussed and analyzed.

De nition of Delusion

An additional video for this topic is available online.

There continues to be much debate and controversy about the de nition of delusions. The standard approach is to follow Jaspers’ (1997) claim that delusions are manifest in judgements and arise in the process of thinking and judging. For Jaspers, the characteristics of delusions are that:

• they are false judgements;

• they are held with extraordinary conviction and
incomparable subjective certainty;

• they are impervious to other experiences and to
compelling counterargument; and

• their content is impossible.
Each of these criteria has been subjected to criticism.
Delusions may not be objectively false insofar as the content is concerned. This is best exempli ed in delusional jealousy, whereby the belief may correspond to objective truth and is therefore not false. Delusions may not be held with extraordinary conviction but, equally, normal beliefs may be held with extraordinary conviction. Delusional beliefs may also be amenable to counterargument, although it is rare that this by itself will alter the belief. Finally, delusional content need not be impossible.
There is a growing body of opinion that delusions are not beliefs at all. Spitzer (1994), for example, argues this case. He makes the distinction between ‘to know that’ and ‘to believe that’. In Spitzer’s view, delusions make knowledge claims rather than belief claims. In other words, patients are asserting that they ‘know

such and such’ rather than they ‘believe such and such’, which is why delusional statements are expressed with conviction and certainty and not subject to discussion and inquiry. Berrios (1996) comes to the same conclu- sions. He states that ‘delusions are empty speech acts which assert themselves as beliefs’. Furthermore, he makes the point that the content of delusions is inci- dental to the fact of the phenomenon being a delusion. In Berrios’ view, the content of delusions is randomly chosen; the content merely re ects whatever is in the environment at the time the delusion is formed. The content is lacking in informational quality and is not a ‘symbolic expression of anything’. These critiques of the current de nitions and understanding of delusions underline the complexity of the conceptual status of delusions and show that there is still fruitful theoretical work to be done in psychopathology.

It is important to emphasize that the tradition that locates delusions within the domain of thinking and judging derives very simply from the need to distinguish hallucinations (abnormalities of perception) from delu- sions (abnormalities of thinking and judging). In any case, arguing that delusions are not abnormalities of belief is like arguing that chorea (an involuntary move- ment) is not an abnormality of movement because the observed movements are not purposeful or intentional. Bortolotti (2010) has critically examined the arguments against the idea that delusions are beliefs and concluded that these arguments that she classed as procedural, epistemic and agential apply equally to normal beliefs. She therefore concluded that there is little reason to treat delusions as anything other than beliefs. With this in mind, it is pro table to continue to classify delusions as abnormal beliefs.

The decision to call a belief or judgement delusional is not made by the person holding the belief but by an external observer. There can be no phenomenologic de nition of delusion because the patient is likely to hold this belief with the same conviction and intensity as he holds other nondelusional beliefs about himself, or as anyone else holds intensely personal nondelusional beliefs. In this respect, delusions are to ideation what hallucinations are to perception. Subjectively, a delusion is simply a belief, a notion or an idea. Stoddart’s (1908) de nition of a delusion – ‘a judgement which cannot be accepted by people of the same class, education, race and period of life as the person who experiences

it’ – has some advantages. However, it could include as delusional falling in love with a person others regard as unsuitable, having a minority religious belief or holding any unusual idea without acknowledging reasonable argument to the contrary.

Hamilton (1978) de ned delusion as ‘a false unshake- able belief which arises from internal morbid processes. It is easily recognizable when it is out of keeping with the person’s educational and cultural background.’ This de nition makes the point that a belief can be a delusion even when it is not out of keeping with the patient’s educational and cultural background.

Rather than suggest a unitary de nition for delu- sion, Kendler et al. (1983) have proposed several poorly correlated dimensions or vectors of delusional severity:

• Conviction: the degree to which the patient is convinced of the reality of the delusional beliefs.

• Extension: the degree to which the delusional
belief involves areas of the patient’s life.

• Bizarreness: the degree to which the delusional beliefs depart from culturally determined con-
sensual reality.

• Disorganization: the degree to which the delusional
beliefs are internally consistent, logical and
systematized.

• Pressure: the degree to which the patient is preoc-
cupied and concerned with the expressed delu-
sional beliefs.
Two other dimensions that might also be considered
are as follows.
• Affective response: the degree to which the patient’s
emotions are involved with such beliefs.
• Deviant behaviour resulting from delusions: patients sometimes, but not always, act on their
delusions.
It is clear that no single de nition of the term
delusion is without problems. It may be that in clinical practice a pragmatic approach is employed that includes the probability that the statement is true and, plausibility of what the patient says. In addi- tion, the manner of presenting the belief also matters. Parnas (2013) expresses this approach best when he writes: ‘Something more global may be at stake, e.g. something that transpires through the patient’s way of arguing. This gestalt-like whole comprises a fabric of branching, interconnected beliefs, attitudes,

background assumptions, which ultimately inhere in the overall structure of consciousness and experiencing. It is these contextual aspects, surrounding the focal propositional content, that help the clinician to classify a given statement as an instance of delusion’. This approach will not satisfy anyone who seeks a simplistic de nition, but nonetheless it captures the complexity of clinical judgements in the real world and concedes that the subjectivity of the clinician too is involved in decision-making.

Primary and Secondary Delusions

The confusing subject of primary and secondary delu- sions requires some explanation. It is probably most meaningful to use the term primary to imply that delusion is not occurring in response to another psy- chopathologic form such as mood disorder. Secondary delusion is used in the sense that the false belief is understandable in present circumstances because of the pervasive mood state or because of the cultural content. It is usual to consider delusions as secondary to another abnormal phenomenon.

Gruhle (1915) considered that a primary delusion was a disturbance of symbolic meaning, not an alteration in sensory perception, apperception or intelligence. Primary delusions occur in schizophrenia and not in other conditions; they include both delusional perception and delusional intuition (Cutting, 1985). However, delusional intuitions, notions or ideas are not pathognomonic of schizophrenia, because in any individual case there is too much scope for arguing whether this delusion is indeed primary, that is, ultimately ununderstandable, or secondary in nature. Secondary delusions occur in many conditions other than schizophrenia and can sometimes be understood in relation to the person’s background culture or emotional state.

Wernicke (1906) formulated the concept of an autochthonous idea, an idea that is ‘native to the soil’, aboriginal, arising without external cause. The trouble with nding supposed autochthonous or primary delusions is that it can be disputed whether they are truly autochthonous. For this reason, they are not considered of rst rank in Schneider’s (1957) classi cation of symptoms. It is too dif cult to decide in many cases whether a delusion is autochthonous.

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108 SECTION III Awareness of Reality: Time, Perception and Judgement

Several writers have claimed that all delusions are understandable if one knows enough about the patient.

The Ultimately Ununderstandable

Jaspers’ detailed exposition of delusion has been care- fully reviewed by Walker (1991). Jaspers’ concepts of the ununderstandable, and of meaningful connections, are relevant here. If we ask an offender to describe the psychic world in which he lives – his attitudes, his feelings and how these developed through his childhood until now – we may be able to understand his sexual cruelty, which at rst seemed quite incomprehensible: the behaviour becomes meaningful in the context of abuse by his stepfather and surviving as an adolescent in a harsh urban subculture with violence, humiliation and frustration. However, when we consider the middle- aged spinster with a history of schizophrenia, who believes that men unlock the door of her at, anaes- thetize her and interfere with her sexually, we nd an experience that is ultimately not understandable. We can understand, on obtaining more details of the history, how her disturbance centres on sexual experience, why she should be distrustful of men, her doubts about her femininity and her feelings of social isolation. However, the delusion, her absolute conviction that these things really are happening to her, that they are true, is not understandable. The best we can do is to try to under- stand externally, without really being able to feel ourselves into her position (genetic empathy, Chapter 1), what she is thinking and how she experiences it. We cannot understand how such a notion could have developed.

This is the core of the primary or autochthonous delusion: it is ultimately ununderstandable. The patient described above also believed the police were using rays to observe her. One does not have to try to nd which delusion came rst, the anaesthesia or the observation by rays, to decide which is primary; primary is not dependent on temporal relationships. In that both delusions are not ultimately understandable, they are both primary delusions. A delusion can still be primary in this, Jaspers’, sense although it arises on the basis of a memory, an atmosphere or a perception. The protagonist in Gogol’s (1809–1852) Diary of a Madman (Gogol, 1972) says, ‘There is a King of Spain. He has been found at last. That king is me. I only

discovered this today.’ This sudden and inexplicable belief arose autonomously and unpremeditated. There- after, it dictated the protagonist’s every behaviour and in uenced his view of the world.

How Ideas and Delusions Are Initiated

A delusion is a belief, an idea, a thought, a notion or an intuition, and it arises in the same type of setting as any other idea – in the context of a perception, a memory or an atmosphere – or it may be autochthonous, appearing to occur spontaneously.

Ideas are initiated in the following ways:
• An example of an idea occurring on the basis of a percept: I smell food cooking and then form the

idea that I will go and eat.
• Ideas may follow memory: I remember listening

to a string quartet and form the idea of playing

a compact disc.
• Ideas may arise out of an atmosphere or a mood

state: I already feel irritable, and when I collect my car from the garage and it makes an unex- plained noise, I become unreasonably angry and blame the mechanic for not repairing it satisfactorily.

• An idea may be autochthonous. I visit a ward of the hospital on an afternoon when I never nor- mally go there. Although I accept that all behaviour has an explanation for its occurrence, I do not know why on this particular occasion I did this. Theoretical explanations may be given as to where such ideas come from, for example the unconscious, but subjectively they seem to have occurred de novo. Delusions occur in similar settings on the basis of percept, memory, atmosphere or de novo – ‘out of the blue’.

In our discussion of primary delusions, we will see how the same four situations also account for the onset of delusions: percept, memory, mood or autochthonous. In this sense, delusion is an idea.

SECONDARY DELUSIONS

Primary delusions differ from secondary delusions in that the former are ultimately not understandable. Secondary delusions are understandable in the context of other abnormal phenomena such as abnormal mood, abnormal perception, or indeed of a primary abnormal belief. A manic patient claimed to be Mary, Queen of

Scots. She accepted that the queen in question lived and died centuries ago but claimed descent from her and felt fully entitled to say that she was Mary, Queen of Scots. The belief could be understood in relation to her elated and expansive mood and disappeared as her affective state subsided. A depressed patient believed that he had committed the ‘unforgivable sin’. Discussion and persuasion, even with a person whose religious views he respected, was of no avail in giving him relief. The belief could be seen as an integral part of his depressed mood. Depressive delusions may remain after treatment has resulted in improvement from retardation, and they account for suicide occasionally occurring in the recovery phase of depression. It has been suggested that there may be a decline in the prevalence of delusion occurring with depressive illness, but Eagles (1983), studying admissions to hospital in Edinburgh from 1892 to 1982, considered there to be no genuine reduction.

Secondary delusions can be distinguished from overvalued ideas (discussed later). Whereas secondary delusions are derived from another abnormal phenom- enon, overvalued ideas are comprehensible in the light of the patient’s personal history or some identi able historical event whose value has become heightened for some reason. No prior abnormal phenomenon explains the presence of an overvalued idea.

Types of Primary Delusion

Kurt Schneider (1957) discusses the dilemma of primary symptoms in schizophrenia extremely lucidly by giving six different possible meanings for the term primary, but he still leaves us in doubt as to whether the belief is primary or not. He makes it clear, however, that primary symptoms are not the same as rst-rank symptoms of schizophrenia. Primary symptoms are those that arise without understandable cause in the context of the psychotic illness. They are therefore the necessary manifestations of the underlying psychopathology, in the same way that swelling and redness are a necessary consequence of physical trauma. First-rank symptoms, on the other hand, are, according to Schneider, simply a useful empirical list of symptoms that are found commonly in schizophrenia and not in other conditions. Describing their presence makes no claim as to how they arose.

True delusions, or delusions proper, are distinguished by Jaspers from delusion-like ideas. True delusions therefore become synonymous with primary delusions, and delusion-like ideas with secondary delusions. Delusion- like ideas can be seen to emerge understandably from the patient’s internal and external environment, especially from his mood state. True delusions cannot be so explained; they are psychologically irreducible. They have, according to Jaspers, the following types:

• autochthonous delusion (delusional intuition); • delusional percept;
• delusional atmosphere; and
• delusional memory.

AUTOCHTHONOUS DELUSION (DELUSIONAL INTUITION)

These are delusions that appear to arise suddenly ‘out of the blue’; they are phenomenologically indistinguish- able from the sudden arrival of a normal idea. The patient gropes for explanations for the occurrence of his delusion in answering the interviewer’s question in the same way that a healthy person would nd it dif cult to account for the arrival of any idea if he were asked to explain it. The difference lies in the ability of the observer to empathize with – to understand – a non- delusional idea even though it may be bizarre and destructive, but he cannot understand how a person can have come to believe his delusion.

Schneider regarded the term delusional idea as based on outmoded psychology, and he felt it should therefore be abandoned. It is often confused with delusion-like idea, even in some textbooks, and this is another good reason for abandoning it. Delusional intuition is perhaps the most satisfactory translation of the German Wahneinfall. Delusional intuition occurs as a single stage, unlike delusional perception, which occurs in two stages: perception and then false interpretation. Like delusional perceptions, delusional intuitions are self-referent and usually of momentous import to the patient.

DELUSIONAL PERCEPT

This is present when the patient receives a normal perception that is then interpreted with delusional meaning and has immense personal signi cance. It is a rst-rank symptom of schizophrenia. Jaspers delineated the concept of delusional percept, and Gruhle (1915)

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used this description to cover almost all delusions – he minimized the importance of delusional intuition. Schneider (1949) considered the essence of delusional perception to be the abnormal signi cance attached to a real percept without any cause that is understandable in rational or emotional terms; it is self-referent, momentous, urgent, of overwhelming personal signi – cance and, of course, false.

It is often dif cult to decide whether a delusion is truly a delusional percept or is being used to explain the signi cance of certain objects of perception within a delusional system. A woman said, ‘every night blood is being injected out of my arms [sic]’. When asked for her evidence, she explained that she had little brown spots on her arms and therefore knew that she was being injected. The interviewer looked at the spots on her arms, rolled up his sleeve and showed her spots identical in appearance on his own arm. He said that they had been on his arm as long as he could remember and were called ‘freckles’. She agreed that both sets of spots looked similar and accepted his explanation of his own spots, but she still insisted that her freckles proved that she was being injected in her sleep. This was a delusional percept.

Another example of what was probably a delusional percept caused considerable problems in surgical management, ultimately resulting in the death of the patient (Porter and Williams, 1997). A 65-year-old woman had ooded her house by leaving all the taps on.

On admission she was unkempt, with unwashed hair, wearing a dirty dress and vest. She was bringing up bile-stained vomit and was reluctant to be inter- viewed. She expressed delusional beliefs that her stomach had been blown up with ether over several weeks and that it was liable to burst as a result of a citizens band radio that was located in her stomach. She believed that the IRA had been after her for years and experienced auditory hallucinations of voices, which she identi ed as coming from the CB receiver. One ‘voice’ told her not to let anyone examine her. There was no evidence of an acute confusional state, and the diagnosis was consistent with a long-term paranoid psychosis.

On physical examination her abdomen was soft but distended with a hard, craggy, immobile, central mass. The liver and spleen were of normal size, and the

kidneys were not palpable. Bowel sounds were loud. A diagnosis of possible intra-abdominal malignancy was made.

She refused any investigation or treatment. She developed acute renal failure and ultimately died; ascitic uid revealed adenocarcinomatous cells probably of ovarian origin.

Another patient, who had other delusional symptoms, believed that many of the patients in the hospital were well-known citizens cunningly disguised with wigs, makeup and false beards. She recognized that they did not look like the people whom she presumed them to be but considered this to be part of a gigantic hoax, in which she was herself involved, to ‘help people spiritually’. Although her percepts were normal and her interpretations delusional, this was not considered to be a delusional percept but a misinterpretation. All the circumstances in her life were explained by an immensely complicated delusional system, and these perceptions had no immediate personal signi cance beyond the signi cance that she found in all the objects and events around her.

In a delusional percept, there is a direct experience of meaning for this particular normal percept; it is not simply an interpretation of this percept to t in with other established delusional beliefs. Delusional percep- tion is, therefore, a direct experience of meaning that the patient did not have previously. Objects or persons take on new personal signi cance that is delusional in nature, even though the perception itself remains unchanged. This is different from a delusional misin- terpretation, in which the delusional system affects all aspects of the patient’s life, and so every event or percep- tion is interpreted as being involved with that delusion. A patient sees that a doorknob is missing; this is not the precipitant of immediate new personal signi cance of a delusional nature, but rather, it further con rms the belief he already held that people are trying to trap him and subject him to vivisection.

Perception, when considering delusional percept, can be understood in quite a wide sense. There is no dif- ference, in subjective experience, between perceiving an object by means of a sense organ and perceiving or understanding the sense of written or spoken messages, although the perceptual routes are different. Thus delusional perception includes delusional signi cance attached to words and sentences as well as to purely

sensory objects. For example, an inpatient at Rubery Hill Hospital walked to an entrance of the hospital and saw a dilapidated notice: ‘RUBE … ILL’. She suddenly realized that this was a concealed message just for her – ‘Are you be(ing) ill?’, that people were concerned to help her and that she would get better. The delusional interpretation was attached to the meaning of the letters of the notice.

There are two distinct stages in delusional percep- tion:

1. The object becomes meaningful within a eld of sensations and is perceived; this is usually visual perception (Mellor, 1991).

2. That object becomes invested with delusional signi cance.

These two stages need not be simultaneous for the experience to be a delusional percept. On occasions, they have been separated by an interval of years. A patient believed that his mind was being jammed by an electronic device. He claimed that this had started when, 5 years before, he had lifted the telephone receiver and heard an unusual clicking noise. The delusional belief he had held for only a few months.

DELUSIONAL ATMOSPHERE

For the patient experiencing delusional atmosphere, his world has been subtly altered: ‘Something funny is going on’, ‘I have been offered a whole world of new meanings’. He experiences everything around him as sinister, portentous, uncanny, peculiar in an inde nable way. He knows that he personally is involved but cannot tell how. He has a feeling of anticipation, sometimes even of excitement, that soon all the separate parts of his experience will t together to reveal something immensely signi cant. This is, in fact, what usually happens, as delusional atmosphere is part of the underlying process, and often, the rst symptom of schizophrenia and the context in which a fully formed delusional percept or intuition arises. The mood of the atmosphere is important, and this experience is often referred to as delusional mood. The patient feels profoundly uncomfortable, often extremely perplexed and appre- hensive. When the delusion becomes fully formed, he often appears to accept it with a feeling of relief from the previous unbearable tension of the atmosphere.

A middle-aged man presented initially as a psychiatric outpatient with apparent obsessional symptoms. He

kept checking that his neighbours could not hear what he was saying in his home. He had resigned from several jobs because he believed that his employers would not accept his religious beliefs. He felt that people around him were hostile and implacably opposed to him, although he could not de ne quite how – he just ‘felt it’. He kept moving house, but the feeling stayed with him. This continued for several years, and he then arrived at a casualty department claiming that his neighbours were talking about his actions and control- ling his thoughts. The atmosphere had developed insidiously over years, and eventually he manifested auditory hallucinations and passivity of thought (see Chapter 9).

German psychopathologists never used the term delusional atmosphere but always referred to delusional mood, according to Berner (1991), but he considers that atmosphere is to be preferred because it allows the distinction to be made between a cognitive, perceptual disturbance provoking an emotional response and a modi cation of mood causing a changed perception of the outside world. It is considered that delusional atmosphere is a common end state resulting from dif- ferent pathways: vulnerability to cognitive disturbance, as in ‘Bleulerian’ schizophrenia; dynamic derailment, as in affective disorders such as puerperal depression or psychogenic vulnerability; or without either of the other two, with stressful life events. Berner consid- ers that this state is not restricted to sufferers of schizophrenia.

The prodromal phases of schizophrenic illnesses are very variable in nature, and often another diagnosis has been given before the de nitive symptomatology becomes established. In an instructive review of the literature on the simulation of psychosis, and study of six patients who were thought to be feigning a schizo- phrenic psychosis, Hay (1983) commented on the nature of feigned psychosis. In his opinion, simulation of schizophrenia is generally a prodromal phase of a schizophrenic psychosis occurring in people with extremely deviant premorbid personalities. All but one of his patients were found to be suffering from schizo- phrenia at the time of follow-up.

DELUSIONAL MEMORY

In much the same way that delusional percept is a delusional interpretation of a normal percept, delusional

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memory is the delusional interpretation of a normal memory. These are sometimes called retrospective delu- sions. An event that occurred in the past is explained in a delusional way. A man aged 50 whose mental illness had lasted for about 2 years claimed that his health had been permanently affected since age 16, when he had had ‘an operation to remove his appendix’. He now believed that the operation had been an excuse to ‘implant a golden convolvulus’ in his bowels.

If delusional meaning is attached to a normal percept that is remembered, this then becomes a delusional percept. It has the two components that were described as being necessary for delusional percept: the image of the remembered percept and the attachment to this percept of delusional signi cance. A married woman remembered years previously seeing a man standing in a pub ‘with a sad look on his face’. She ‘realized’, at the start of her schizophrenic illness 2 weeks before admission to hospital, that he had been in love with her then, and she tried to locate his name in the tel- ephone directory and make contact again, feeling that they were involved in a special relationship.

Of course, it is a mistake to expect phenomenologic symptoms to reveal themselves tidily from the patient’s conversation. There is no absolute demarcation between delusional memory and delusional percept or intuition. The patient describes a delusion. Did this occur 1 hour, 1 week or 10 years ago? At what point will this be delusional memory, not delusional intuition? Similarly, there is no absolute distinction between a normal event, perception or idea that occurred in the past and is remembered with a delusional interpretation and a delusional event, perception or idea that occurred in the past and is also remembered with a delusional interpretation. In other words, there are two senses to the term delusional memory. There is the sense in which a normal memory is misinterpreted in the present, and another sense in which the actual memory is itself a false memory that is imbued with delusional interpreta- tion. Both of these are delusional memories, and it is not always possible to know how much of the event was factual and how much delusional. A woman with schizophrenia, aged 34, described 12 years ago picking up a telephone to ring a man she liked very much: ‘God moved my arm and made me put the telephone back’. It was not possible to decide exactly what part

of this experience was factual and what delusional, and at what time the delusion occurred.

Fine distinctions are sometimes imposed on the classi cation of primary delusions but are more col- lector’s items than features of useful clinical signi cance. Delusional awareness is an experience that is not sensory in nature, in which ideas or events take on an extreme vividness as if they had additional reality. Delusional signi cance is the second stage of the occurrence of delusional perception. Objects and persons are perceived normally but take on a special signi cance that cannot be rationally explained by the patient.

The Origins of Delusion

What is the origin of delusions? This question drives at how far delusions are by de nition different from normal beliefs, and, if they are different from normal beliefs, what mechanisms are involved in their develop- ment and manifestation. Jaspers’ (1997) own view was that delusion was a primary phenomenon and that it implies a transformation in the total awareness of reality. This means that a delusional belief involves and implicates practical activity, behaviour, the meanings that are immanent in objects, and radically transforms the basic experience of the world. A person who is deluded that he is loved by a celebrity approaches the world with this certainty and knowledge and acts accordingly by writing to, telephoning or attempting to visit the celebrity. This erroneous belief invests the patient’s world with new meanings. In these terms, reality lies in the interpretation of, or the signi cance attached to, events that occur interpreted in the light of the primary erroneous belief.

An understanding of how delusions radically alter the patient’s world as described does not help us to explain how delusions form in the rst place. The factors involved in delusion formation have been summarized by Brockington (1991); see Box 8.1.

Fish (1967) developed a useful précis of the earlier German theories of the origins of delusion. Conrad proposed ve stages in the development of delusional psychosis:

1. Trema: delusional mood representing a total change in perception of the world

2. Apophany: a search for, and the nding of, new meaning for psychological events

BOX 8.1 FACTORS INVOLVED IN THE GERMINATION OF DELUSIONS

in, and veneration for, the doctor; Sims, 1972). It seems that the symbolic belief attached to events and percep- tions is altered in delusion, and this is why the patient does not necessarily act on his delusions. The delusional atmosphere is not an essential prerequisite for a delu- sional intuition, as the latter may occur apparently de novo.

Some writers have not tried to explain delusions because they nd them totally incomprehensible and consider that they are directly due to an abnormality of the brain (Schneider, 1949). Bleuler concentrated on the alteration in affect as primary rather than delu- sional atmosphere or perception. He considered that heightened affect loosens the capacity to form associa- tions and thus facilitates the arrival of a delusion. At the beginning of a schizophrenic illness, there is extreme affect, perhaps in the form of anxiety or ambivalence, which the patient cannot express.

Kretschmer (1927) stressed the importance of the underlying personality. He described the sensitive premorbid personality occurring in a person who retains affect-laden complexes and has a limited capacity for emotional self-expression. Such a person is driven painfully by, for example, powerful sexual feelings, but he has great dif culty in communicating his passion and relating to other people. He is very much aware of social constraints and is rigidly controlled by his superego. Such a person, somewhat rigid, narrow- minded and suspicious in his views, readily forms sensitive ideas of reference. A key experience may occur in his life circumstances, and quite suddenly these ideas become structured as delusions of reference.

A girl was always shy, reticent and sensitive at school. Quite often, she was reluctant to go to school. She was meticulous in her attention to personal neatness and cleanliness. After leaving school, she remembered vividly several occasions as a child when she had felt humili- ated. At age 18, when she was working in a factory, she was in the women’s cloakroom brooding because her boyfriend had told her that he was leaving her for someone else. She heard one of the other women say, ‘Ugh, doesn’t she smell?’ Immediately, she applied the statement to herself and to explain her boyfriend’s behaviour. From then onwards, she was convinced that she smelt unpleasant all the time, although she could smell nothing herself. This delusion dominated her life, prevented her mixing and caused her great distress.

8 Delusions and Other Erroneous Ideas 113

• Disorder of brain functioning
• Background in uences of temperament and

personality
• Maintenance of self-esteem
• The role of affect
• As a response to perceptual disturbance • As a response to depersonalization
• Associated with cognitive overload

3. Anastrophy: heightening of the psychosis

4. Consolidation: forming of a new world or psy-
chological set based on new meanings

5. Residuum: eventual autistic state

Gruhle (1915) considered delusional perception to

be the most signi cant form of delusion, a normal percept taking on a new meaning. This results in a disturbed relationship of the understanding of events. Matussek considered that with delusional perception there is a change either in the signi cance of the words used or in the actual nature of the perception itself. These writers, and also Schneider, regard delusional perception as the key to understanding the nature of delusional experience.

Hagen regarded delusional atmosphere as primary, arising for reasons unknown and resulting in a rear- rangement of meanings in the world around the patient, who gropes for an answer to this problem of understand- ing and nds it by creating a delusion. It is easier to bear the certainty of a delusion than the uncertain foreboding of the atmosphere. Jaspers considered that there is a subtle change of personality due to the illness itself, and this creates the condition for the development of the delusional atmosphere in which the delusional intuition arises.

All these theories assume that the delusion is primary and ultimately not understandable in the same sense that Jaspers considers the experience of reality to be primary. Experience holds a symbolic implication beyond the fact of the event itself; for example the doctor writing a prescription for his patient in the consulting room means much more to the latter than if the doctor were doodling on his prescription block. (A patient in North Africa in the nineteenth century ate the written prescrip- tion his doctor gave him, so great was his con dence

114 SECTION III Awareness of Reality: Time, Perception and Judgement

This development of a delusion (Sensitiver Beziehung- swahn) from sensitive ideas of reference, as the sequel to a key experience, is sometimes seen at the onset of schizophrenia but is not common. The key experience, as demonstrated in this case, has two important qualities. First, it has particular appropriateness to the patient’s areas of con ict as sensitive ideas of reference. Second, it occurs at a time of marked emotional turmoil and distress, so that the psychic ground is prepared for a catastrophic event.

Attempts have been made to nd all delusions understandable in relation to the person’s internal experience or social background. Westphal considered that if one knew all about the patient, the change in his view of himself and the belief that he had become noticeable in some way would explain the delusion (Fish, 1967). Freud’s (1907) theories on the develop- ment of delusions also attempted to make them ulti- mately understandable through the mechanisms of denial, projection and so on. Other authors have claimed that delusions are understandable in a social context. Laing (1961) considered the ight into madness as a necessary defence against a highly destructive family – not only understandable, but admirable, and even worth emulating.

When four psychological theories were appraised to explain paranoid phenomena, a basis of shame- humiliation was found to be the most consistent (Colby, 1977). Winters and Neale (1983) consider that existing theories of delusional thinking develop two main themes: motivational and defect. The motivational theme explains the arrival of a delusion to explain unusual perceptual experience or to reduce uncomfortable psychic states. Defect implies some fundamental cognitive-attentional de cit resulting in delusion.

The variety and range of explanations adduced as the origin of delusions attest the extent of our ignorance about the ultimate nature, structure and derivation of delusions. It is probably wise to regard delusion as a term describing a multitude of abnormalities of thinking that have merely a super cial familial relationship. To employ an analogy, delusion is like the term ataxia, a term that describes several abnormalities of movement with differing underlying lesions and mechanisms. The term delusion is not a description of a unitary, homogenous abnormality of thinking; it is most likely an umbrella term for a collection of disparate abnormalities of thinking.

COGNITION AND REASONING IN DELUSION

In trying to understand the role of cognition and reason in delusion formation, it is probably useful to think of the formation, elaboration and persistence of delusional beliefs as an expression of numerous causal in uences converging; each exerts a different in uence in the evolution of the belief (Roberts, 1992). The process of reasoning in order to come to conclusions about one’s situation in the outside environment appears to be altered in those experiencing delusions. A ‘jump-to- conclusions style’ has been demonstrated in deluded subjects when asked to perform a probabilistic reasoning task (Huq et al., 1988). This was con rmed by Garety et al. (1991) in showing that 41% of deluded subjects but only 4% of controls reached a conclusion on the basis of only one item of information. A common cause in abnormality of information processing has been proposed for those subjects with abnormal reasoning and abnormal perception; failure to make use of previ- ously acquired knowledge of regularities in the world, resulting in overreliance on information immediately present, may be a factor in delusion formation (Garety, 1991). This model emphasizes the deviant nature of the thinking process that is associated with delusions in patients with schizophrenia. In Garety’s model, judgemental processes involved in delusion formation include:

1. prior expectation that may be modi ed by emo- tion;

2. currentinformationthatwehaveatourdisposal, such as the information reaching us by way of our perceptions; and

3. the nature of our information processing bias or style.

In this model, if perceptual abnormalities predomi- nate the role of deviant information, then processing mechanisms will be underemphasized. In other words, when delusions are secondary to hallucinations, reason- ing should remain intact. The advantage of this model is that it highlights the varying routes to delusion formation.

Attribution in Delusion

An alternative psychological explanation for delusion comes from social attribution theory. Kaney and Bentall (1989, 1992) found that deluded patients made

excessively external, stable and global attributions for negative events (‘The fact that I broke my leg proves yet again that the Wetherby freemasons are getting at me’) and excessively internal, stable and global attribu- tions for positive events (‘Everyone smiles and nods when they see me because I have been sent by God to communicate with people about evil and I have a letter from the Pope as proof’). Deluded subjects were unwill- ing to attribute negative events of which they were the victim to their own cause; also, in judging the behaviour of other people they were reluctant to attribute negative events to the victims themselves. These and other studies suggest that persecutory delusions have a function in protecting the individual from low self-esteem (Bentall, 1993).

Deluded subjects were considered to evaluate their own causal statements in a distinctive manner, and this difference from depressed subjects was greater than the differences in the causal statements themselves; that is, the difference between deluded and other subjects in internality for positive and negative events does not re ect differences in the causal statements of these subjects but rather differences in their attributions (Kinderman et al., 1992). Once again, delusions are linked both to personal meaning and to boundaries of self. This investigation of attributional style was further extended using obvious and opaque tests of attributional style. Deluded subjects attributed negative outcomes to external causes in the obvious or transparent tests but a more covert testing to internal causes; this further supported the hypothesis that persecutory delusions function as a defence against underlying feelings of low self-esteem (Lyon et al., 1994). This psychological exploration is further supported by the clinical study that follows.

Delusion and Meaning in Life

Roberts (1991) has developed the thesis that delusions, in the context of schizophrenic illness, may not them- selves be an af iction or illness but an adaptive response to whatever initiates the psychotic break. A group of chronically deluded subjects was compared with previ- ously deluded patients now in remission and with two nonpatient groups. Persecutory delusions were common in both patient groups, but grandiose and erotic delu- sions and delusions of special knowledge were mostly found in the currently deluded group. The chronically

deluded group scored much higher than the remitted patients for positive meaning in life and much lower for depression and suicidal intention. They had a very high level of perceived purpose and meaning in life. It is considered that for some the formation of delusions is adaptive in combating purposelessness, loneliness, sense of inferiority, hopelessness, isolation and painful awareness of broken relationships and provides a new sense of identity, a clearer sense of duty and responsibil- ity, an experience of freedom, protection from past hurts, and a change from fear, worry, depression and boredom towards feeling lively, enthusiastic, interested and peaceful. One patient described this: ‘I’ve had a great time. I’ve got this one great thought in my mind that I am Jesus – that’s enough … nothing hurts me now, I need nothing now.’

Content of Delusions

Delusions are, of course, in nitely variable in their content, but certain general characteristics commonly occur. Unlike the form, which is dictated by the type of illness, the content is determined by the emotional, social, cultural and biographical background of the patient: Napoleons are now rare in mental hospitals; schizophrenia sufferers from traditional societies may describe their thoughts as being interfered with by the spirits of their ancestors rather than by television. As computers and the Internet increasingly affect all aspects of our lives, we are beginning to have described by those with mental illness delusions of control concerning the Internet (Catalano et al., 1991).

DELUSIONS OF PERSECUTION

This is the most frequent content of delusion. It was distinguished from other types of delusion and from other forms of melancholia by Lasègue (1852). People who believe delusionally that their lives are being interfered with from outside more often feel this to be harmful than bene cial. A variant on the usual beliefs of persecution or malevolent intent are delusions of prejudice: the patient or victim believes that he is being slighted, overlooked or passed over in favour of someone else. The interfering agent in delusions of persecution may be animate or inanimate, other people or machines; it may be systems, organizations or institutions rather than individuals. Sometimes the patient experiences

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persecution as a vague in uence without knowing who is responsible.

Persecutory delusions occur in many conditions: in schizophrenia, in affective psychoses of manic and depressive type and in organic states, both acute and chronic. The affect associated with the belief of persecu- tion may vary from an inappropriate indifference and apathy in schizophrenia to stark terror, as commonly seen in delirium tremens.

Manic patients with persecutory delusions show gross overactivity and ight of ideas in attempting to express and deal with their beliefs. In depression, the persecutory delusions take on the characteristic colour- ing of the dominant mood state. Persecutory overvalued ideas are a prominent facet of the litigious type of para- noid personality disorder.

MORBID JEALOUSY AND DELUSION OF INFIDELITY

Morbid jealousy, a disorder of content described by Ey (1950), may be manifested in various forms, for example as delusion, overvalued idea, depressive affect or anxiety state. The feeling of jealousy, coupled with a sense that the loved object ‘belongs to me’ and, therefore, ‘I belong to the other’, is part of normal human experience; it is of social value in marital relationships for preserving the family. Various terms have been used to describe abnormal, morbid or malignant jealousy. Kraepelin (1905) used the term sexual jealousy. Enoch and Tre- thowan (1979) have considered it important to distin- guish psychotic jealousy from other types, and this is dependent on the demonstration of a delusion of in delity. It is sometimes dif cult to distinguish understandable jealousy from that which is delusional.

Mullen (1997) classi ed morbid jealousy with disorders of passion, in which there is an overwhelming sense of entitlement and a conviction that others are abrogating the subject’s rights: ‘The morbidly jealous believe that they are the victims of an in delity that has deprived them of the fealty which is their due and they are driven to expose this disloyalty, reassert their control and punish the transgression’. The other two categories are the querulent, who are indignant at infringements of rights, and the erotomanic, who are driven to assert their rights of love.

Delusion of in delity, that is, when the subject unreasonably believes himself or herself to be the victim of their partner’s unfaithfulness, may occur without

other psychotic symptoms. It has been described by Todd and Dewhurst (1955) and by Mullen (1990). This is identi ably delusional when the belief of the spouse is based on delusional evidence. Such delusions are resistant to treatment and do not change with time. A patient was very concerned that his wife was being unfaithful with numerous people, including his boss, her general practitioner and others. Four years later, despite various treatments, his belief was unchanged, but he said, ‘I don’t blame her now. She is much younger than I am and everyone does that sort of thing’. Delusions of jealousy are common with alcohol abuse; for instance, Shrestha et al. (1985) found sexual jealousy to be present in 35% of men and 31% of women who abused alcohol or had alcohol dependence syndrome. As jealousy appeared to be justi ed in some cases, morbid jealousy was considered to be present in 27% of men and 15% of women. Delusional jealousy, often associated with impotence, also occurs in some organic states, for example, the punch-drunk syndrome of boxers after multiple contrecoup contusions. Quite frequently, the spouse, wearied by continued accusations of in delity, does form another sexual involvement, which may result in an acute exacerba- tion in the mental state of the patient and further marital con ict.

The sexual content of the delusion is obvious; however, Enoch (1991) regards the nature of the relationship between the two partners as the key aspect of the condition. Jealousy is directed towards the sexual partner. The deluded person is very attached to, and often emotionally utterly dependent on, the other; he may have a misplaced sense of owning her completely. The victim is often much more sexually attractive than the deluded partner, for instance, a young wife or a sociable and popular husband. The deluded person may have been promiscuous in the past and therefore resignedly expects his spouse to show similar behaviour. He may have become impotent and projected the blame for his failure on to her. He may have homosexual fantasies directed towards the men with whom he claims his wife is consorting. Morbid jealousy arises with the belief that there is a threat to the exclusive possession of his wife, but this is just as likely to occur from con icts inside himself, his own inability to love or his sexual interest directed towards someone else as from changing circumstances in his environment or

his wife’s behaviour. Husbands or wives may show sexual jealousy, as may cohabitees and homosexual couples. Crimes of violence are notoriously associated with morbid jealousy; violence is more often vented on the partner than on the supposed rival, most often by men on women. Morbid jealousy makes a major contribution to the frequency of wife battering and is one of the commonest motivations for homicide (Mullen, 1990).

DELUSIONS OF LOVE

The delusions associated with loving and being loved are quite different from the behavioural and affective abnormalities of nymphomania, the situation of a woman characterized by morbid or uncontrolled sexual desire, and satyriasis, the male equivalent of excessive sexual activity. Both these latter conditions exist initially in the opinion of an external commentator – the doctor.

Approximately twice as many schizophrenic patients had sexual preoccupations in the mid-twentieth century compared with in the mid-nineteenth century (Klaf and Hamilton, 1961). Erotomania was described by Sir Alexander Morrison (1848) as being:

characterized by delusions … the patient’s love is of the sentimental kind, he is wholly occupied by the object
of his adoration, whom, if he approaches, it is with respect … the xed and permanent delusions attending erotomania sometimes prompt those labouring under it to destroy themselves or others, for although in general tranquil and peaceful, the patient sometimes becomes irritable, passionate and jealous.

Erotomania is commoner in women than in men, and a variety was called ‘old maids’ insanity’ by Hart (1921), in which persecutory delusions often develop. These have sometimes been classi ed as paranoia rather than paranoid schizophrenia; these delusional symptoms sometimes occur in the con- text of manic-depressive psychosis (Guirguis, 1981). Trethowan (1967) demonstrated the social charac- teristics of erotomania, relating the patient’s previous dif culties in parental relationships to the present erotomania.

A variation of erotomania was described by, and retains the name of, de Clérambault (1942). Typically, a woman believes a man, who is older and of higher

social status than she, is in love with her. The victim has usually done nothing to deserve her attention and may be quite unaware of her existence; sometimes he is a well-known public gure quite remote from the patient. In a case of the author’s, the victim was a previous employer of the patient. She believed that he was the father of her child (although at another time she agreed that there had been no sexual rela- tionship with her employer). She also believed that he was sending her money, and she would write letters thanking him for his generosity and af rming her gratitude for the evidence of his love (Sims and White, 1973).

In a series of 16 erotomanic cases, Mullen and Pathé (1994) tried to distinguish between those cases in which there is a morbid belief in being loved and those with morbid infatuation. They found that in most cases both notions were described: a mixture of being loved and loving in return.

DELUSIONAL MISIDENTIFICATION

Delusional misidenti cation syndromes include a number of discrete but related syndromes that have in common the concept of the double. These syndromes include Capgras’ syndrome (Capgras and Reboul- Lachaux, 1923), Frégoli’s syndrome (Courbon and Fail, 1927), the syndrome of intermetamorphosis (Courbon and Tusques, 1932) and the syndrome of subjective doubles (Christodoulou, 1978).

Capgras’ syndrome is regarded by Enoch and Tre- thowan (1979) as ‘a rare, colourful syndrome in which the person believes that a person, usually closely related to him, has been replaced by an exact double’. It is a speci c delusional misidenti cation of a person with whom the subject usually has close emotional ties and towards whom there is a feeling of ambivalence at the time of onset. The belief in Capgras’ syndrome has the full characteristics of delusion (Enoch and Tre- thowan, 1979). The basic concept of this syndrome is prominent in all cultures, hence the delusion is uni- versal (Christodoulou, 1991). Like other delusions, delusion describes the form; the content is culture- dependent. A recent patient believed his mother had been replaced by an impostor after falling through a time warp to a parallel universe, and this explained the horrible things that had happened in the past 3 weeks.

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Frégoli’s syndrome is the delusional misidenti cation of an unfamiliar person as a familiar one, even though there is no physical resemblance. The syndrome of intermetamorphosis is the delusional belief that others undergo radical changes in physical and psychological identity, culminating in a different person altogether. The syndrome of subjective doubles is the delusional belief in the existence of physical duplicates of the self, and these duplicates are usually thought to have different psychological identities (for review, see Moselhy and Oyebode, 1997).

In a series of cases reviewed by Berson (1983), 55% (70 patients) were unquestionably diagnosed as suffering from schizophrenia, and a further eight patients (totalling 61%) were probably suffering from schizophrenia; 13% were suffering from bipolar mood disorder and 24% were considered to have an organic diagnosis. Of 133 patients, 57% were female; the age range was from 12 to 78, with a mean of 42.8 years. Majority opinion would not favour denoting this as a separate disease but rather as a symptom that colours the clinical state and dominates the symptomatology. The four varieties of delusional misidenti cation have in common psychopathologically the form of a delusion. Capgras’ syndrome, when it occurs in schizophrenia, is based on a delusional percept (Sims, 1986). In Capgras’ syndrome, there is no outward change in the appearance of the object, and there is no false perception, for the patient often admits that the double exactly resembles the original (Enoch and Trethowan, 1979), but careful questioning usually reveals that there are distinguishing stigmata. Sometimes patients will say, ‘I know that it is not my mother because she would never stand like that’ or ‘this person moves too slowly to be my father’.

The ambivalence towards the object of misidenti ca- tion may be expressed in the history, with a clear account of both negative emotions, such as hostility, fear or contempt, and affection and dependence. On those few occasions when an object, rather than a person, is wrongly identi ed, that object has important emo- tional connotations for the patient, for example home or a letter from a relative. The subjects of misidenti ca- tion in Berson’s (1983) review of 133 patients comprised 60 spouses and two lovers; on 29 occasions, a child or children; 40 parents; 24 siblings; 13 therapists; four grandparents; three in-laws; two neighbours; two domestics; and one each of ancé, cousin, stepson,

employer and priest. On eight occasions, the self was misidenti ed either solely or with other evidence of the syndrome; on two occasions, animals, and eight times inanimate objects were misidenti ed. Thus in 31% of occasions, the delusional misidenti cation refers to a marital partner, and in 46% to a rst-degree relative; in only 4% was the misidenti cation of the patient himself or herself.

There is growing evidence that delusional misi- denti cation syndromes are associated with organic disorders, including dementia, acquired brain injury, epilepsy and cerebrovascular accidents in 25% to 40% of cases, and neuroimaging studies reveal association with right hemisphere abnormalities, particularly in the frontal and temporal regions (Edelstyn et al., 1999). Furthermore, neuropsychological investigations have consistently shown impairments of face processing in delusional misidenti cation syndromes (Edelstyn et al., 1996; Ellis et al., 1993; Oyebode et al., 1996). These ndings underpin the assumption of right hemisphere abnormalities in delusional misidenti cation syndromes, because the right hemisphere is implicated in face processing and recognition.

GRANDIOSE DELUSIONS

Primary grandiose delusions occur in schizophrenia. The patient may believe himself to be a famous celebrity or to have supernatural powers. He may believe himself to be involved in some special and secret mission about which he has not yet been fully briefed but in anticipation of which he is waiting with excitement for the dénoue- ment. Beliefs of this sort are sometimes called delusions of special purpose and are of the form of delusional intuition.

Expansive or grandiose delusional beliefs may extend to objects. Sometimes a psychotic patient demonstrates delusions of invention in which, for example, he builds a machine that he believes to have special capabilities, considering himself to be a creative prodigy. Second- ary grandiose delusions, or delusion-like ideas, occur in manic states. A patient said that there was no life on Mars because ‘if there had been I would have been able to get in touch by telepathy using my great genius’. He showed no evidence of true passivity experi- ences. A manic patient, mentioned earlier, believed that she was descended from the royal Stuart line and therefore was actually in some way Mary, Queen of

Scots. She invited the queen and the prime minister to a party in her student at because she thought they would be honoured to be invited: ‘It is only fair that they should have an invitation.’ The expansive affect of mania can be clearly seen to render this delusion understandable.

RELIGIOUS DELUSIONS

Religious delusions are common. However, they formed a higher proportion of all delusions in the nineteenth century than in the twentieth century: three times as many patients with schizophrenia of both sexes had religious preoccupation in the nineteenth century (Klaf and Hamilton, 1961). Decision as to whether beliefs are delusional must rest on the principles described earlier – that is, on the way the belief is held and the evidence produced in its support. Because a religious belief is bizarre and at variance with those held by the interviewer does not necessarily make it a delusion. Religious delusions may be grandiose in nature, for example, a patient in the United Kingdom who believed that she was an emissary of God to the Birmingham Housing Department. They may also be secondary to depressive mood, as in the patient of Emil Kraepelin (1905) quoted at the beginning of Chapter 16: ‘I cannot live and I cannot die, because I have failed so much, I shall bring my husband and children to hell’.

The religious nature of the delusion is seen as a disorder of content dependent on the patient’s social background, interests and peer group. The form of the delusion is dictated by the nature of the illness. So religious delusions are not caused by excessive religious belief or by the wrongdoing that the patient attributes as cause, but they simply accentuate that when a person becomes mentally ill his delusions re ect, in their content, his predominant interests and concerns.

Sometimes, it can be dif cult to make the distinction between religious delusion and the experience of an unusual religious belief or practice. Psychiatric morbidity would be suggested by the following (Sims, 1992):

• Both the subjective experience and the observed behaviour conform with psychiatric symptoms, that is, the self-description of this particular experience is recognizable as being the symp- tomatology of a known psychiatric illness – it has the form of delusion.

• There are other recognizable symptoms of mental illness in other areas of life: other delusions, hallucinations, disturbance of mood, thought disorder and so on.

• The lifestyle, behaviour and direction of personal goals of the individual subsequent to the event or religious experience are consistent with the natural history of mental disorder rather than with a personally enriching life experience, compatible with the conditions in which delusions occur.

DELUSIONS OF GUILT AND UNWORTHINESS

Such delusions are common in depressive illness. They often lead to suicide and, rarely, to homicide, when the killing of a close relative may be followed by the patient’s suicide. Affective illness may be followed by the killing of children by depressed mothers or the killing of their wife or sometimes also children by husbands; suicide may follow immediately or later (Higgins, 1990).

The beliefs about guilt may totally dominate the patient’s thinking. An elderly woman spent the day rushing round the house wringing her hands and telling her worried family that she was wretched, worthless and only deserved to die. She told her married daughters that they were illegitimate and that the house she lived in was not hers but stolen, and she told her husband of 30 years’ standing that they were not legally married. When it was suggested to her that she come into hospital, she assumed that she would be killed on arrival, and she asked whether this could take place there and then so that she could receive her just desserts.

DELUSIONS OF POVERTY AND NIHILISTIC DELUSIONS

Delusions of poverty are common in depression; an elderly patient believed that ‘the nurses’ had been systematically raiding her purse and that she was destitute. Cotard’s syndrome contains features typical of psychotic depression in the elderly: nihilistic and hypochondriacal delusions that are often bizarre, dramatic and tinged with grandiosity; depressed mood with either agitation or retardation and a completely negative attitude. According to Griesinger (1845), ‘the patient confuses the subjective change in his own

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attitude to outside things … the real world seems to the patient to have disappeared completely, or to be dead’. This was graphically depicted by Cotard (1882):

I would tentatively suggest the name ‘nihilistic delusions’ (délire de negations) to describe the condition of the patients to whom Griesinger was referring, in whom the tendency towards negation is carried to its extreme. If they are asked their name or age, they have neither – where were they born? They were not born. Who were their father and mother? They have no father, mother, wife or children. Have they a headache or pain in the stomach, or any other part of the body? They have no head or stomach and some even have no body. If one shows them an object, a rose or some other ower they answer, ‘that is not a rose, not a ower at all’. In some cases negation is total. Nothing exists any longer, not even themselves.

The central character in Patrick McGrath’s novel Spider said, ‘I was contaminated by it, it shrivelled me, it killed something inside me, made me a ghost, a dead thing, in short it turned me bad’. Elsewhere, the same character says, ‘a single pipe takes water from my stomach … and this pipe alone drops through the void and connects to the thing between my legs that hardly resembles a formed male organ at all anymore’ (McGrath, 1990).

Nihilistic delusions are the reverse of grandiose delusions, in which oneself, objects or situations are expansive and enriched; there is also a perverse grandi- osity about the nihilistic delusions themselves. Feelings of guilt and hypochondriacal ideas are developed to their most extreme, depressive form in nihilistic delusions.

HYPOCHONDRIACAL DELUSIONS

A very depressed man said that he was full of water, that there was nothing else inside him, and that he could not pass water, but that if he did, that would be the end of him. He could not drink or the water would ood the room. Other less striking hypochondriacal beliefs and delusions occur in depression, and Schneider (1920) has considered that locating the experience of depression as a sensation in a bodily organ is equivalent to a ‘ rst-rank symptom’ of depressive psychosis (see Chapter 16). An elderly woman with depression who

had had a mitral valve replacement for rheumatic heart disease said that she felt worthless and hopeless and described her physical functions as ‘nothing is working’.

Hypochondriacal delusions may also occur in schizophrenia and have the characteristics of other schizophrenic ideas. They are more likely to be given a persecutory than a nihilistic explanation. Thus a patient believed that his bodily functions were being interfered with by rays emitted from a planet and that this was part of a plot to control his thoughts and behaviour. Hypochondriacal delusions are discussed further in association with hypochondriasis in Chapter 14; however, other features of hypochondriasis, such as bodily preoccupation, disease phobia and conviction of the presence of disease with nonresponse to reas- surance, are in fact more common than delusion (Pilowsky, 1967). Facial pain is described in Chapter 15 and other delusion-like ideas and overvalued ideas of the body in Chapter 14. Delusions concerning the patient’s origins are sometimes described and have some af nity to hypochondriacal delusion. The patient believes, on delusional evidence, that he is not his parent’s child, or perhaps that he is of royal birth, part animal or supernatural. Alternatively, he may believe that he does not exist and was never born.

Hypochondriacal delusions are commonly associated with delusional disorder in the International Classi cation of Diseases, 10th revision (previously known as paranoia; World Health Organization, 1992). Munro (1988) has described delusional disorder as an encapsulated mono- delusional disorder with several subtypes, such as erotomanic, grandiose, jealous, persecutory, somatic and unspeci ed; the concept has developed from the older term paranoia (Munro, 1997). He has described the somatic type as monosymptomatic hypochondriacal psychosis and, of 50 cases, the three main groups were:

1. delusions of body odour and halitosis,
2. infestation delusion (insects, burrowing worms

or foreign bodies under the skin), and
3. delusions of ugliness or misshapenness (dysmor-

phic delusions).
In a factor analysis of the features of delusional

disorder, four independent factors were identi ed, suggesting considerable heterogeneity of the condition (Serretti et al., 1999). The rst factor incorporated core depressive symptoms, which may be either a depressive syndrome reactive to stresses deriving from delusional

ideation or a comorbid mood disorder, or both. Other factors were hallucinations, delusions and symptoms of irritability.

The complaint was always presented with great intensity, and patients were utterly convinced of the physical nature of the disorder. Hypochondriacal delu- sions may also occur with administration of drugs, both prescribed and those of abuse.

Koro (Lapierre, 1972) is an unusual condition that has been described as an example of hypochondriacal delusion. This view is probably incorrect. The features of koro include:

• the belief that the penis is shrinking into the abdomen;

• the belief that when the penis disappears into the abdomen, death will ensue; and

• extreme anxiety accompanying this belief.
Yap (1965) describes this as a culture-bound depersonalization syndrome and considers it to be a manifestation of acute anxiety associated with folk beliefs concerning sexual exhaustion. It has occurred in epidemic proportions among Malays in Singapore (Gwee, 1963) but has also been described in individual cases in a French Canadian (Lapierre, 1972), in a West Indian, a Greek Cypriot (Ang and Weller, 1984) and in an Englishman (Berrios and Morley, 1984). Oyebode et al. (1986) have shown in a single case study that this belief is accompanied by real penile shrinkage as measured by plethysmography. This sug- gests that the belief is based on physiologic changes that are likely to be due to anxiety. In essence, the penile change is similar to tachycardia, hyperhidrosis or other features of sympathetic arousal associated with anxiety.
A group of patients who in some respects are intermediate between those suffering from somatic delusions and delusions of infestation are those who were described by Videbech (1966) as suffering from chronic olfactory paranoid syndromes; these have also been referred to as having olfactory reference syndrome (Pryse-Phillips, 1971). Characteristically, these patients have a xed and unalterable belief that they smell but do not have hallucinations or other olfactory experience. It is usually seen in the context of sensitive, paranoid personality development. There is a severe phobic reaction, with the behaviour of other people interpreted as nding their smell offensive and aversive.

8 Delusions and Other Erroneous Ideas 121 Delusions of Infestation

Delusions of infestation have been described by Hop- kinson (1970) and by Reilly (1988). In Ekbom’s syndrome (Ekbom, 1938), the patient believes that he is infested with small but macroscopic organisms. The patient’s experience may take the form of a tactile hallucinatory state, a delusion or an overvalued idea. The aetiology is also variable. It is probably most common as a symptom of circumscribed hypochondriasis in affective psychosis, along with other depressive symptoms, but it also occurs in paranoid schizophrenia, in mono- symptomatic hypochondriacal psychosis (delusional disorder), in organic brain syndromes or with neuroti- cally determined conditions. This topic is reviewed by Berrios (1985) and by Morris (1991).

Patients have believed that they had a spider in their hair, worms and lice beneath the skin or infestation with various insects. The delusion may be accompanied by other depressive delusions or overvalued ideas of being dirty, guilty, unworthy or ill. These delusions may also occur in schizophrenia, in which condition they characteristically take on a bizarre character and are accompanied by other schizophrenic symptoms. A 49-year-old mother of four children, one of whose sons had developed a schizophrenic illness, complained of recurrent pain in her vagina that she explained as being caused by a parasite that had migrated from her stomach, where it had been responsible for epigastric pain diagnosed earlier as hiatus hernia (McLaughlin and Sims, 1984). She described the parasite as wander- ing through her bloodstream and as having been responsible for various aches and pains she had experienced in the past. She related having passed multiple small red worms and worm casts in her faeces and, on one occasion, a two-inch green frog.

Delusions of infestation may occur in organic states with tactile hallucinations, in delirium tremens during alcohol withdrawal and in cocaine addiction. They may be described in cerebrovascular disease, in senile dementia and in other brain disease, and they have been ascribed to disorder of the thalamus. Overvalued ideas and delusion-like ideas of infestation sometimes occur in people with personality disorder of anankastic or paranoid type with no psychotic illness.

Characteristically, these ideas occur in patients older than 50 years. Typically, those with delusions

122 SECTION III Awareness of Reality: Time, Perception and Judgement

of infestation have always had a particular concern for personal cleanliness. Sometimes, the condition is precipitated by a skin disease and becomes a delusional elaboration of existing tactile symptoms. It has been suggested that the symptom develops in stages: rst, abnormal cutaneous sensation; then an illusion develops; and nally, the fully formed delusion of infestation occurs. As mentioned earlier, delusional infestation is now viewed as one form of delusional disorder, in particular being a subtype of monosymptomatic hypochondriacal psychosis.

COMMUNICATED INSANITY

Laségue and Falret (1877) described la folie à deux (or folie communiquée). Occasionally, a delusion (delusional intuition) is transferred from a psychotic person to one or more others with whom they have been in close association, so that the recipient shares the false belief: the principal acquires the delusion rst and is dominant, the associate becomes deluded through association with the principal. This situation, in which partners accept, support and share each other’s beliefs, has been called the psychosis of association. The associate is usually socially deprived or disadvantaged, mentally or physically.

Gralnick (1942), in a review of the English lit- erature on folie à deux, subdivided the condition into four possible relationships between principal and associate.

1. In folie imposée, the delusions of a mentally ill person are transferred to someone who was not previously mentally ill, although character- istically the victim has some social or psycho- logical disadvantage. Separation of the pair is often followed by remission of symptoms in the associate.

2. Folie communiquée occurs when a normal person suffers a contagion of his ideas after resisting them for a long time. Once he acquires these beliefs, he maintains them despite separation.

3. In folie induite, a person who is already psychotic adds the delusions of a closely associated person to his own.

4. Folie simultanée describes a situation in which two or more people become psychotic and share the same delusional system simultaneously. It has been considered that the principal is always

psychotic (Soni and Rockley, 1974), but the

associate may or may not be psychotic. However, the validity of this classi cation has been questioned. It is also not of any particular clinical value, and the psychopathologic differences are questionable

(Hughes and Sims, 1997).
In a case report of a family affected with folie à quatre

(Sims et al., 1977), the initially referred patient believed that a large industrial concern had put ‘bugging’ devices in the walls of his brother’s house. He claimed that employees of the rm had been following him every- where and interfering with his own house. His wife believed this story initially and produced supposedly corroborative evidence. A year later, following his inpatient treatment, she no longer accepted the plot and she believed her husband to be mentally ill. She was a very anxious person who had previously received psychiatric treatment and came from a family in which three members had suffered from Huntington’s chorea. When the patient’s brother was visited at home, it was found that he, and the sister who lived with him, both believed in the plot and were both currently receiving treatment for a schizophrenic illness in which rst-rank symptoms were present.

Folie à deux demonstrates how the content of belief is dictated by social and environmental circumstances, but the precise form of the symptoms varies according to the nature of the illness. Thus the nonpsychotic victim of folie imposée will show delusion-like ideas, overvalued ideas or misinterpretations but will not show ‘true’ delusions or delusional percept.

An interesting variation on folie imposée was described by Aldridge and Tagg (1998). This was the case of a 7-year-old boy who had presented with spurious psychotic symptoms induced by living in isolation with his mother, who suffered from schizophrenia. Initially, he was withdrawn, uncommunicative and ritualistic, with delayed development. At school, he was fearful of toys and teachers, crouching under a table, and was ritualistic concerning timekeeping and toileting, during which he would remove all his clothing and walk backwards into the toilet. His only speech was to repeat the clock time in a ritualistic way. Foster placement was made with a single mature woman, experienced with children, and after a year, this abnormal behaviour had disappeared, and he had made progress consistent with his mild degree of learning disability.

DELUSIONS OF CONTROL

These delusions, otherwise known as passivity or made experiences, are discussed with disorder of thinking in Chapter 9.

The Reality of Delusions

The degree to which delusions in uence the reality of the world inhabited by a patient is most probably best judged by how far patients act on their beliefs. Patients with schizophrenia do not always act on their delusions, but quite frequently they do. A man who believed that American battleships were sailing down the main street of Birmingham, United Kingdom (which is 100 miles from the sea) had the re ned social conscience to report this to the police. Persons holding delusions of morbid jealousy are potentially very dangerous: extreme physical violence and murder not uncommonly occur in this context. The patient with depressive delusions of guilt and unworthiness may well act on them by killing himself.

Although there is a growing literature casting doubt on whether delusions are false beliefs (as discussed earlier in the chapter), what is inescapable is that patients do often act on the content of these beliefs. For practical purposes, the content of a delusion is important because it yields information about the likely behaviour of a patient. In other words, the content of delusions acts to motivate behaviour, to give reason to action and to justify conduct; that is, it has predictive power. For this reason alone, the content of delusion is relevant to clinical practice. Hemsley and Garety (1986) have commented on ‘the lack of action conse- quent with apparently sincerely held beliefs’, whereas, paradoxically, forensic psychiatric studies have generally found that psychotic symptoms, especially delusions, are frequently a major factor resulting in the offence (Taylor, 1985). Buchanan (1993) has reviewed the descriptions of situations in which patients act on their delusions. He considers that for affective illnesses, both delusional belief and action may be consequent on the abnormal mood state. In other circumstances, action can be seen as being caused by a combination of ‘belief’ and ‘desire’ triggered by factors such as ‘noticings’: belief clearly is in uenced by occurrence of delusion; desire corresponds to concepts such as motivation, drive and inclination; noticing is in uenced by the

perceptual and cognitive changes of the psychotic state. For an investigation into violence in a high-security hospital population, Taylor et al. (1998) concluded, ‘as symptoms were usually a factor driving the index offence, treatment appears as important for public safety as for personal health’. The conclusion here is that delusions, like normal beliefs, do not necessar- ily result in action. They may be expressed yet not in uence behaviour in any discernible way. However, like normal beliefs, they may motivate behaviour in a way that is comprehensible given the content of the belief.

In general, violent behaviour in response to delusions is not common; however, in a sample of 83 consecutively admitted deluded subjects, some aspect of the actions of half of them was congruent with the content of their delusions (Wessely et al., 1993). When acting on the delusions was described by the subjects themselves, it was associated with being aware of evidence that sup- ported their belief and with having actively sought out such evidence; with a tendency to reduce the conviction with which a belief was held when that belief was challenged; and with feeling sad, frightened or anxious as a consequence of the delusion (Buchanan et al., 1993).

Erroneous Ideation

OVERVALUED IDEA

An overvalued idea is an acceptable, comprehensible idea pursued by the patient beyond the bounds of reason. It is usually associated with abnormal personality. Disorders associated with overvalued ideas have been reviewed by McKenna (1984), whose de nition of overvalued idea ‘refers to a solitary, abnormal belief that is neither delusional nor obsessional in nature, but which is preoccupying to the extent of dominating the sufferer’s life’. It is overvalued in the sense that it causes disturbed functioning or suffering to the person himself or to others. The background on which an overvalued idea is held is not necessarily unreasonable or false. It becomes so dominant that all other ideas are secondary and relate to it: the patient’s whole life comes to revolve around this one idea. It is usually associated with very strong affect that the person, because of his temperament, has great dif culty in expressing.

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According to McKenna, the term was introduced by Wernicke (1906), who distinguished it from obses- sion, in that it was not experienced subjectively as ‘senseless’, and from delusion. Jaspers considered that delusion is qualitatively different from normal belief, with a radical transformation of the meaning attached to events and incorrigible to an extent quite unlike normal belief. An overvalued idea, on the contrary, is an isolated notion associated with strong affect and abnormal personality and similar in quality to passionate political, religious or ethical conviction. For Jaspers (1959), then, overvalued ideas are ‘convictions that are strongly toned by affect which is understandable in terms of the personality and its history’. Furthermore, Jaspers says, ‘they are isolated notions that develop comprehensibly out of a given personality and situation’. Fish (1967) considered there was frequently a discrep- ancy between the degree of conviction and the extent to which the belief directed action. However, the patient with an overvalued idea invariably acted on it, deter- minedly and repeatedly; it is almost carried out with the drive of an instinct, like nest building. In many respects, these de nitions attempt to locate overvalued ideas somewhere between normal beliefs and delusions. Overvalued ideas differ from delusions in that they arise comprehensibly from what we know about the person and his situation. They are more like passionate political, religious or ethical convictions than normal beliefs. This suggests that there is something about the tenacity of the conviction that distinguishes these overvalued ideas from normal beliefs, yet the degree of conviction and incorrigibility is thought to be less than that of delusions. It is obvious, however, that the

degree of conviction is not a safe basis for distinguishing between delusions and overvalued ideas. A safer approach is to regard overvalued as comprehensible in the context of the patient’s history and life.

McKenna lists the disorders of content commonly associated with the form of overvalued idea. These are represented in Table 8.1. The psychopathology is not an overvalued idea in all cases of each of these condi- tions; for instance, morbid jealousy may be delusional and hypochondriasis may occur secondary to depressed mood. However, when an overvalued idea is found it is usually associated with abnormal personality.

Morbid jealousy is often manifested as an overvalued idea. A husband was terri ed that his wife was being unfaithful to him because of her casually irtatious conduct. He checked on her every movement, inter- rogated her repeatedly, examined her underwear, employed detectives to follow her and misinterpreted any innocent contact she had with other men. On examination, he was not deluded, but the importance he attached to investigating and maintaining his wife’s delity, and the time taken to do this, was excessive, destroyed his family life and lost him his job.

The form of the abnormal idea in many of the disturbances of body image; for example, dysmorphopho- bia is usually an overvalued idea. A person with paranoid personality disorder became involved in a protracted lawsuit because a farmer ploughed across a public right of way. It is reasonable that hikers get annoyed when a footpath is destroyed, but this person took reasonable irritation to extreme lengths and constructed a mantrap to eliminate the farmer. His enthusiasm for footpaths had become an overvalued idea.

TABLE 8.1 Disorders With Overv Content of Disorder

alued Ideas

Abnormality of Personality

Reference(s)

Paranoid state: querulous or litigious type

Morbid jealousy
Hypochondriasis
Dysmorphophobia
Parasitophobia (Ekbom’s syndrome) Anorexia nervosa

Transsexualism

}Abnormality of personality is usually present with overvalued ideas in all these conditions

Jaspers (1997), Kraepelin (1905)

Ey (1954), Shepherd (1961) Merskey (1979), Pilowsky (1970) Hay (1970), Munro (1980) Hopkinson (1973)
Crisp (1980), Dally (1969) Huxley et al. (1981)

(After McKenna, 1984, with permission.)

PARANOID IDEAS AND SYNDROMES

In psychiatry, the word paranoid is taken to mean ‘self-referent’ and is not limited to persecutory delusions; all delusions are delusions of reference in that they relate to the patient himself. A person will not form a delusional belief concerning 6-inch men on Mars unless he himself is signi cantly implicated in some way. So a paranoid delusion is a delusion of self-reference, not necessarily persecutory in nature. A paranoid personality disorder is that type of abnormal personality in which the person’s reaction to other people is unduly self- referent; a paranoid state (see Chapter 19) includes those mental states in which self-referent phenomena are conspicuous, that is, delusion-like ideas of reference or overvalued ideas predominate. A patient, all of whose delusions are grandiose in nature and none of them persecutory, may still be suffering from paranoid schizophrenia.

Although primary delusions are characteristic of schizophrenia, secondary delusions (delusion-like ideas) occur in a number of conditions, for example, bipolar mood disorder in both manic and depressive phases, epilepsy and other organic psychosyndromes, acute drug intoxication, various alcoholic states and, of course, schizophrenia. The term paranoid originally was syn- onymous with delusional insanity. Kraepelin (1905) used the term more speci cally to describe the condition in which there are delusions but no hallucinations. The personality, mood state and volition of the patient, in Kraepelin’s description, are well preserved.

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KEYWORDS

Formal thought disorder Circumstantiality Concrete thinking Passivity experience

Summary

Thinking and its processes are little understood. This means that abnormalities of thinking cannot be easily related to any clearly described, already established notion of what normal processes are and how abnor- mal processes depart from these normal processes. In this chapter, fantasy thinking, imaginative thinking and conceptual thinking are described. Against this background, a model of thinking depending on the association of ideas and governed by a determining principle is described. This then provides the basis for a discussion of abnormalities of the form of thinking, a particularly complex area of psychopathology, as it requires the ability both to follow closely what someone is saying and also to conclude that the sequence of ideas, or the association of ideas may be awry. In the nal section, Schneider’s rst-rank symptoms are described with examples.

With time and years the individual becomes so lazy in public life that he is not even capable of writing any more. On such a sheet of paper, one can squeeze many letters if one is careful not to transgress by one ‘square shore’. In such ne weather one should be able to take a walk in the woods. Naturally, not alone, but with a girl. At the end of the year one always renders the annual accounting. The sun is now in the sky yet it is not yet ten o’clock.

Eugene Bleuler (1857–1939)

This chapter is concerned with disorder of thinking, and the next chapter with disorders of language. Thinking and thought processes are little understood. Although there is increasing interest in the subject by cognitive

neuroscientists, their primary focus of study misses what is of interest to the clinical psychopathologist, namely, the subjective experience of thinking, particularly as it relates to abnormalities of thinking. Cognitive neuro- scientists are interested in the nature of problem-solving; in the various kinds of reasoning, including analogic, inductive and deductive; in the nature of logic and belief formation; and in understanding decision-making. These are important subjects and can be impaired in psychiatric disorders. However, the process that makes these aspects of thinking possible; the unique relationship of the subject to his own thoughts, the experience of thoughts owing coherently and the effortless yet goal- driven dimension of thinking thoughts that underpin problem-solving and reasoning, is poorly understood and researched. Admittedly, it is dif cult to study the subjective aspects of thinking, and mostly one is concerned with objective phenomena of psychic life – what Jaspers (1997) calls ‘performance’.

There are two distinct aspects in studying disorder of thinking: the patient’s subjective awareness of his own disturbed thinking patterns and the manifestation of abnormal thinking he betrays in his speech (Chapter 10). This latter is the expression of thought and determines what the observer may deduce about the patient’s thinking. We need to enquire also about the experience of thinking in the patient’s description of his subjective psychological processes. Formal thought disorder, from the subjective, phenomenologic stand- point, is abnormality in the mechanism of thinking described by the patient introspecting into his own processes of thought; that is, the patient describes in his own words a process of thinking that is clearly abnormal to the outside observer.

Types of Thinking

The process of thinking was divided by Fish (1967) into the following three types:

• undirected fantasy (dereistic) or autistic think- ing;

CHAPTER 9

129

Disorder of the Thinking Process

130 SECTION III Awareness of Reality: Time, Perception and Judgement

• imaginative thinking; and
• rational or conceptual thinking.
These three types have slightly different implications

for psychopathology, the description and categorization of morbid processes. They can be considered as functions of thinking; that is, they are the necessary mechanisms for thinking to take place but are not themselves manifest in the phenomena. We can contrast those phenomena, which are the products of the performance of thinking, the percept or the idea, with the functions that do not become explicit.

FANTASY THINKING

This may be of short duration, for example the daydream before going to sleep, or it may become an established way of life. Jaspers quotes Montaigne: ‘Plutarch says of people who waste their feelings on guinea-pigs and pet dogs, that the love element in all of us, if deprived of any adequate object, will seek out something trivial and false rather than let itself stay unengaged. So the psyche in its passions prefers to deceive itself, or even in spite of itself invent some nonsensical object rather than give up all drive or aim’.

Fantasy has an important function in the way we all carry out our everyday activities, for instance we model our speech and behaviour in imagination before an important encounter or event, and afterwards we rehearse our performance in fantasy to evaluate it and assess whether we could have done better (see ‘Imagina- tive Thinking’ later in the chapter). To be able to harness our imagination constructively, we require the capacity for undirected fantasy and the learned skill to structure thoughts. Fantasy also allows a person to escape from or deny reality, or alternatively to convert reality into something more tolerable and less requiring of corrective action. A 20-year-old young woman, who had a very deprived childhood and walked the city streets at night as a prostitute, listened to a vicar broadcasting on local radio. She started to send him and his wife owers and cards, made contact with them and began to call them ‘Mum’ and ‘Dad’. When questioned by the police one night, she gave their names as next of kin and said they really were her parents.

Shy, reserved people, not suffering from mental illness, may use dereistic thinking to compensate for the disappointments of life. Bleuler (1911) saw this isolation from the real world into autistic thinking as

characteristic of schizophrenia: ‘The very common preoccupation of young hebephrenics with “the deepest questions” is nothing but an autistic manifestation’. Fantasy, especially in some with neurotic traits, may develop from the stage of being deliberate and sporadic into an established mode; the person comes to believe the contents of his fantasy, which become subjectively real and accepted as fact. Freud, in his later writings, considered that this was so in some of the accounts he received from women of an incestuous relationship with their father during childhood (Jones, 1962). However, in his early writings he had considered that they had experienced actual sexual assault but had used unconscious mechanisms to repress this knowledge (Isräels and Schatzman, 1993; Webster, 1995). Various types of experience come into the category of acting out fantasy, such as pathologic lying (pseudologia fan- tastica), hysterical conversion and dissociation (somatic and psychological dissociative symptoms) and the delusion-like ideas occurring in affective psychoses. These last types can be understood as arising from the patient’s affective and social setting.

Fantasy is usually understood to be the creation of images or ideas that have no external reality. However, fantasy thinking may also reveal itself in the denial of external events. The observations for which the psychodynamic explanation of ego defence mechanisms has been described are relevant in this context. The slip of the tongue, or the ‘forgetting’ of the emotionally laden word is not accidental; it is a form of self- deception. The obvious, signi cant, but unpleasant, object of perception may be ‘overlooked’, and this often reveals fantasy denial. Fantasy thinking denies unpleas- ant reality, even though the fantasy itself may also be unpleasant. This rearranging or transformation of reality is shown by neurotic patients habitually and all people occasionally. Jonathan Swift commented on it thus: ‘When man’s fancy gets astride of his reason; when imagination is at cuffs with the senses; and common understanding, as well as common sense, is kicked out of doors, the rst proselyte he makes is himself’ (Swift, 1667–1745).

IMAGINATIVE THINKING

The term imagination covers psychological states such as fantasy (as just described), the generation of novel ideas and the creative outputs that constitute art or

discoveries in science. There are at least three compo- nents of imagination: mental imagery, counterfactual thinking and symbolic representation. Mental imagery refers to the ability to create image-based mental representations of the world. Counterfactual thinking refers to the capacity to disengage from reality to think of events and experiences that have not occurred and may never occur. Symbolic representation is the use of concepts or images to represent real-world objects or entities (Roth, 2004). This is, of course, the basis of language, art and mathematics.

A facet of this type of thinking that comes from a psychoanalytic theoretical stance is the concept of maternal reverie (Bion, 1962). The mother, while in the situation, both physical and mental, of ‘holding the baby’ (Winnicott, 1957), has a capacity for reverie or daydreaming on the baby’s behalf; this usually concerns the future happiness and achievements of the baby. Wilfred Bion (1897–1979) would regard this as a necessary factor in the healthy development of the self-sensation of the baby; when maternal reverie breaks down – for example, in puerperal depression – the baby experiences this as distress. The process of maternal reverie is clearly analogous in some ways to the prayers of a religious person on another’s behalf.

RATIONAL OR CONCEPTUAL THINKING

Problem-solving and reasoning are two key aspects of rational thinking. Problem-solving is de ned as the set of cognitive processes that we apply to reach a goal when we must overcome obstacles to reach that goal, and reasoning is the cognitive process that we use to make inferences from knowledge and to draw conclu- sions. These aspects of thinking are distinct but related, so that reasoning can be involved in problem-solving (Smith and Kosslyn, 2007). Strategies for problems involve the use of heuristics, that is, rules of thumb that usually give the correct answer. Typically, reasoning involves analogies, induction or deduction. Analogic reasoning involves the application of solutions to already known problems to new problems with similar char- acteristics. For example, if you lose the keys to your locked briefcase, you can apply the knowledge to this new problem that sharp-ended implements can be used to open padlocks. Inductive reasoning depends on the use of speci c known instances to draw an inference about unknown instances. Commonly, this is formulated

as generalizing from a single instance to all instances or from some members of a category known to have a given property to other instances of that category. This is known as category-based induction. An example is ‘my cat has four legs’, therefore ‘all cats have four legs’. Deductive reasoning involves an argument in which if the premises are true, the conclusion cannot be false. This is usually studied by way of syllogism: (a) all Martians are green, (b) my father is a Martian and (c) my father is green.

Problem-solving and reasoning both require the capacity to form concepts. This is the capacity for abstraction – the ability to theorize about the world – and it includes the categorization of objects or events in the world and the clari cation of the concepts that determine the category or class under investigation.

HEURISTICS AND DECISION-MAKING

There is emerging and robust evidence about the systems underlying decision-making processes. Super cially, these systems do not seem relevant to our understanding of the kinds of problems that are demonstrated in abnormalities of thinking but closer examination shows that they are likely to be important and relevant as they come under scrutiny in psychiatric disorders.

Kahneman (2011) summarizes the evidence for the involvement of two cognitive systems in decision- making: System 1, which operates automatically and quickly with little or no effort and no sense of voluntary control; and System 2, which allocates attention to the effortful mental activities that demand it, including complex computations. The operations of System 2 are said to be associated with subjective experience of agency, choice and concentration. In an earlier paper, Tversky and Kahneman (1974) argued that in situations where a judgement is made under conditions of uncertainty, certain heuristics are at play and often lead to errors of judgement. These are the representativeness heuristic, the availability heuristic, and the adjustment and anchoring heuristic. Representativeness, for example, refers to how similarity to a class of objects or events, in the absence of additional information biases judge- ments and hence resulting in errors of judgement. Availability refers to the degree to which the probability of an event occurring is determined by the ease with which instances or occurrences can be brought to mind. The risk of heart attacks in middle-aged men might

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be determined by how many instances can be readily brought to mind, a bias that is determined by the ease of retrievability of instances. Finally, adjustment and anchoring refer to the manner in which initial values are adjusted to yield nal answers; the best example of this is our differing responses to terms such as ‘90% fat free’ and ‘10% fat’. It is obvious that abnormalities in the use of these heuristics probably have a role either in the development of delusions or the maintenance of abnormal beliefs.

Kahneman (2011) concludes: ‘The attentive System 2 is who we think we are. System 2 articulates judge- ments and makes choices, but it often endorses or rationalizes ideas and feelings that were generated by System 1. You may not know that you are optimistic about a project because something about its leader reminds you of your beloved sister, or that you dislike a person who looks vaguely like your dentist. If asked for an explanation, however, you will search your memory for presentable reasons and will certainly nd some. Moreover, you will believe the story you make up.’

The Processes of Disordered Thinking

A MODEL OF ASSOCIATIONS BASED ON JASPERS

In this model of thinking (psychological performance), thoughts (psychological events) can be seen to ow in an uninterrupted sequence so that one or more associa- tions, with resulting further psychological events, may arise from each thought. The sequence of thoughts, with the associations linking them, forms the framework of this model, which is represented diagrammatically in Fig. 9.1.

The mass of possible associations resulting from a psychic event is called a constellation. There are an enormous number of possible associations, but thinking usually proceeds in a de nite direction for various immediate and compelling reasons. This consistent ow of thinking towards its goal is ascribed to the determining tendency (Jaspers). The idea of associations is not intended to imply that one psychological event evokes another by an automatic, unintelligent, nonverbal re ex but that the thought, which may be expressed verbally or not, is a concept that results in the formation of a number of other concepts, one of which is given prominence by operation of the determining tendency.

This model is conjectural but has some value in allowing description of the abnormalities of thinking and speech that occur in mental illness. In addition to Jaspers’ description of his model of associations, a description that has face validity given the cases seen in psychiatry, there are other models. For example, Kahneman’s (2011) in which the subject’s world is constructed ‘by associa- tions that link ideas of circumstances, events, actions, and outcomes that co-occur with some regularity, either at the same time or within a relatively short interval. As these links are formed and strengthened, the pattern of associated ideas comes to represent the structure of events’ in a subject’s life and also determines the way in which a subject interprets the present and predicts the future. In other words, the association of ideas is not random but is built on past experiences and is determined by memory functions.

We are subjectively aware of our thought process being a stream or a ow. To develop the metaphor, thoughts are capable of acceleration and slowing, of eddies and calms, of precipitous falls, of increased volume of ow, of blockages. This analogy should not be taken too far because it is without neurophysiologic basis, but it is useful for examining certain abnormalities and is based on subjective experience.

ACCELERATION OF THINKING

Acceleration of ow of thinking occurs as ight of ideas. In this, there is a logical connection between each of two sequential ideas expressed. However, the goal of thinking is not maintained for long. It is continuously changing because of the effect of frivolous affect and a very high degree of distractibility. The determining tendency is weakened, but associations are still formed normally. The speed of forming such associations, and therefore of the pattern of thought, is grossly accelerated. This is demonstrated in Fig. 9.2.

Here is an example of such ight of ideas from a female patient, aged 45, with mania. She said: ‘They thought I was in the pantry at home … Peekaboo … there’s a magic box. Poor darling Catherine, you know, Catherine the Great, the re grate, I’m always up the chimney. I want to scream with joy … Hallelujah!’ Discussing the transcript of this conversation when her mental state had improved, the patient found it quite easy to point out the logical bridges in her thinking between each pair of statements, but there was no

sense of building up an argument from the rst to the nal statement.

Markedly different from the manic ight of ideas with pressure of speech and multiple but linked associa- tion is the confusion psychosis described by Fish (1962).

In this, thinking is disordered but mood and psychomo- tor activity are unimpaired. In the excited form of this, incoherent pressure of speech is prominent, the context of which is out of keeping with the situation. There may be transient, almost playful, misidenti cations of

FIG. 9.1 Model of association.

9 Disorder of the Thinking Process 133

Associations

Thought

Associations
Possible thought

Possible thought Possible thought Actual thought

Associations

Determining tendency

Goal

Possible thought Actual thought Possible thought Possible thought

Constellation

Thinks as he sits in a room

must talk to A

I feel cold

uncomfortable chair

sort out accounts

there is a draught

perhaps I’m
developing Get a flu ladder

put on a pullover

I can hear a drip in the roof

and take a bucket

X XXX

FIG. 9.2 Abnormal ow of thinking: ight of ideas.

134 SECTION III Awareness of Reality: Time, Perception and Judgement

people; eeting ideas of reference; and auditory hal- lucinations. In the inhibited state of confusion psychosis, there is poverty of speech, almost mutism. There may also be perplexity, ideas of reference, ideas of signi – cance, illusions and hallucinations – auditory, visual or somatic. This is usually a cycloid psychosis in its presentation, and other features of manic-depressive psychosis may be present.

RETARDATION

In retardation (such as occurs in depression), thinking, although goal directed, proceeds so slowly, with such morbid preoccupation with gloomy thoughts, that the person may fail to achieve those goals. The patient is likely to show little initiative and to begin neither planning nor spontaneous activity. When asked a question, he will ponder it, but as no thought comes to him, he makes no response. Eventually, after consider- able delay, the answer usually comes. He has dif culty making decisions and concentrating; there is loss of clarity of thought and poor registration of those events he needs to remember. In terms of the model of the ow of thinking, in retardation there is both poverty and slowness in the formation and progression of associations (Fig. 9.3).

Depression, although usually associated with retarda- tion of thought, may occur with agitation; there may be a complex situation with impaired concentration from retardation and a subjective experience of restless, anxious thoughts. Thus Sutherland (1976), a middle- aged psychologist describing his own mental illness, said,

I contemplated throwing myself off the cross-Channel ferry … We arrived in Naples … and my friends … were upset by my condition while feeling powerless to help… whilst the others sat at the table I rolled around moaning in the dust. I revisited many of the places I had once loved: the Museo Nazionale with its magni cent

mosaics pillaged from Pompeii, Pompeii itself and Capri. None of them evoked a spark of interest – I stared listlessly and uncomprehendingly at the pictures in the museum with harrowing thoughts still racing in my mind. I could not guide the children round Pompeii, since I could not concentrate suf ciently to follow the plan. Capri had lost its beauty and charm. I could

not even giggle at the vulgarity of the interior of Axel Munthe’s villa, though the beauty of the formal garden and the magni cent view of the island and the sea from the belvedere evoked a slight response. The phrase ‘see Naples and die’ echoed through my mind: I was convinced I would never return alive to England, let alone ever revisit Naples.

This possible combination of depressed affect and accelerated activity can be seen to conform quite readily with Kraepelin’s (1904) description of mixed affective states.

CIRCUMSTANTIAL THINKING

In both ight of ideas and retardation, affect in uences the speed of thinking: it dictates which idea takes precedence and can also distort judgement. In circum- stantial thinking, the slow stream of thought is not impeded by affect but by a defect of intellectual grasp, a failure of differentiation of the gure from ground. Characteristically, this occurs in patients with epilepsy, and it is seen in other organic states and in mental retardation. A somewhat similar process occurs with obsessional personality, but here the excess of detail is introduced anxiously to avoid any possible omissions: i’s are dotted, t’s crossed to such an extent that the process of reaching a goal is substantially impaired. On being asked a question, circumstantial thought is shown by the patient in a reply that contains a great welter of unnecessary detail, obscuring and impeding the answer to the question. All sorts of unnecessary associations are explored exhaustively before the person

FIG. 9.3 Retardation.

returns to the point. His whole conversation becomes a mass of parentheses and subsidiary clauses. He even has to explain and apologize for these digressions before he can get back to moving towards the goal. However, the determining tendency remains, and he does eventu- ally answer the question. This is a case of not being able to see the wood for the trees. Circumstantial thinking is represented diagrammatically in Fig. 9.4.

INTERRUPTION TO THE FLOW OF THOUGHT

There are many ways in which the continuity of ow of thinking may be disturbed. Carl Schneider (1930) has described some of these abnormalities: verschmelzung (fusion, literally ‘melting’), faseln (muddling), entgleiten (snapping off) and entgleisen (derailment). These pro- cesses (and others) occur together to give the patient

a feeling of confusion and bewilderment. He is likely to complain of feeling bemused, to be lacking in concentration and to be slightly apprehensive of he knows not what. He cannot precisely describe his altered thinking and consequent changes in speech.

In derailment (Fig. 9.5), there is a breakdown in association so that there appears to be an interpolation of thoughts bearing no understandable connection with the chain of thoughts: ‘The traf c is rumbling along the main road. They are going to the north. Why do girls always play pantomime heroes?’ Such an excerpt from the speech of a patient with schizophrenia contains no meaningful connections, even to the patient himself. With derailment, the subject is unable to link the ideas and describes a change in his direction of thinking.

9 Disorder of the Thinking Process 135

X
X

X X

XX X

X X

FIG. 9.4 Model of circumstantial thinking.

X
X

FIG. 9.5 Model of derailment.

136 SECTION III Awareness of Reality: Time, Perception and Judgement

With fusion, there is some preservation of the normal chain of associations, but there is a bringing together of heterogeneous elements. These form links that cannot be seen as a logical progression from their constituent origins towards the goal of thought. A female patient with schizophrenia, aged 38, wrote the following:

Two men are controlling the brain through telethapy
[sic] or by means of ways of the spirit who open and closes the back channels of my brain releasing words and holding back the truth, by no means will I speak but will answer only to written questions by means of writing, knowing full well the channels of my brain is ltering and only half of what is the truth, also I knowing I
am being read not only by a few but many very clever people but not at all acceptable they make people believe that I am some kind of miracle which I am not, I only hold the name Holyland which came to me by marrying Alfred Holyland, only by doing this do they wish to make some false stories of me coming from some special place which I have not.

Fusion is demonstrated at the beginning of this excerpt, where she says that the brain is controlled ‘by means’ and then this word becomes associated with ‘ways’. ‘Telethapy’ – not the same as telepathy – is a neologism. There are also examples of passivity. ‘Chan- nels’ and ‘means’ are used as stock words, that is, they are used more often in her conversation than their normal meaning could suggest, and they take on for her a greater range of meaning than usual. It is dif cult to represent this diagrammatically, and I hope the result in Fig. 9.6 is not misleading.

Schneider’s mixing or muddling implies a grossly disordered amalgam of the constituent parts of a single thought process and represents extreme degrees of fusion and derailment. The resultant speech disorder has been called drivelling.

Thought Blocking

Snapping off is the experience a patient with schizo- phrenia has of his chain of thought, quite unexpectedly and unintentionally, breaking off or ceasing. It may occur in the middle of sorting out a problem or even in midsentence. It is not caused by distraction by other thoughts, and, on introspecting, the patient can give no adequate explanation for it; it simply occurs. It is otherwise described as thought blocking, a somewhat misleading term. The patient may explain it as thought withdrawal: ‘My thinking stopped because the thoughts were suddenly taken out of my head’. Fig. 9.7 shows a model of thought blocking.

CHANGES IN THE FLOW OF THINKING

Two further abnormalities of the ow of thought are crowding of thought and perseveration.

Crowding of thought occurs in schizophrenia. The patient describes his thoughts as being passively concentrated and compressed in his head. The associa- tions are experienced as being excessive in amount, too fast, inexplicable and outside the person’s control. The patient may even locate his thinking anatomically as being ‘crowded into the back of my head’ or else- where. It becomes a headlong chase or dance of thoughts and has some of the characteristics of ight of ideas, but it also shows a schizophrenic quality of passivity, being controlled from outside.

XX XXX

X
X

X XXX

FIG. 9.6 Model of fusion.

9 Disorder of the Thinking Process 137

X X

Perseveration (Chapter 5) is mentioned here as a disturbance of the ow of thinking. It is characteristically an organic symptom. The patient retains a constellation of ideas long after they have ceased to be appropriate. An idea from that constellation that occurred in a previous sequence of thought is given in answer to a different question. In perseveration, a correct response is given by the patient to the rst stimulus, for example ‘Where do you live?’ – ‘Rowley Regis’. However, any subsequent stimuli that demand different responses may get this same, by now inappropriate, rst response, for instance ‘What is the capital of France?’ – ‘Rowley Regis’, ‘Who lives at home with you?’ – ‘Rowley … my son and his wife’.

Disturbance of Judgement

A judgement is a thought that expresses a view of reality. The word is used here in the sense of ‘in my judgement, such and such takes place’. To assess whether it is disturbed or not, one needs to measure it against objective fact. This can be dif cult, perhaps requiring consultation with an expert in the same eld as the patient. Assessment of faulty judgement is not made solely on the basis of that particular belief or argument but on taking the whole of the person’s behaviour and opinions into account. A man’s claims to be a gure of royalty persecuted by the Marxists could, in fact, be true. But the opinion that his judgement was disturbed would be con rmed if he had suddenly become convinced about his royalty when a psychiatric nurse had commented to him about the tattoos on his arm, or if he were also found to be hoarding pebbles and dead spiders in an old tobacco tin. Delusions are, of course, a disturbance of judgement. Various forms of

thought disorder and intellectual de cit may also result in disturbance of judgement.

DISTURBANCE OF JUDGEMENT AND DELUSION

The thinking or psychological performance required to produce a delusion is quite independent of intelli- gence. It occurs in clear consciousness with no signs of organic disturbance of the brain. Judgement in other areas of life apart from the delusion can be preserved, and the very ingeniousness the patient uses to explain and defend his delusional belief demonstrates that his essential capacity to think logically is largely intact; only the falsely held belief, the false premise for sub- sequent beliefs appears disordered. A delusion in schizophrenia is not a simple defect of reasoning; its development cannot be understood solely in relation to the patient’s real-life experience. For instance, not all those with delusions of persecution have any rsthand experience of being persecuted. It is an assumption about the world the patient inhabits, which he does not create by a process of logical conscious thought but from false premises. The mechanism underpinning the often spontaneous development of this false premise is yet to be understood. The starting points of the thinking are already ‘deluded’, and the patient applies logic to elaborate and support his belief.

We can understand why the belief should be within that particular context (associated with his mother; related to interplanetary travel), but we cannot explain how the form of a primary delusion should have occurred. This is a fundamental distinction from delusion-like ideas (secondary delusions), which occur, for example, in affective psychoses. In the latter, we can see the content being progressively in uenced by the changing mood state so that, eventually, the false

FIG. 9.7 Model of thought blocking.

138 SECTION III Awareness of Reality: Time, Perception and Judgement

belief becomes a logical development from the extreme abnormality of mood.

Although it is usual to describe delusions as disorders of thought content, it is important to be aware that primary delusions are not merely to be understood in this way. The whole process of thought in primary delusion is disordered, not just the content. If an idea were formed on delusional grounds – ‘I knew that my wife was unfaithful immediately I saw the bulb had gone out’ (Chapter 8) – but the notion itself was not false nor unacceptable to the person’s peer group (his wife subsequently admitted to being unfaithful), it would still be a delusion because the notion was formed on delusional evidence. There is a difference between delusion and overvalued ideas in that, although both may be held with absolute conviction, the latter is a reasonable, possibly even true, belief but is dominating conscious thought to an unreasonable extent.

CONCRETE THINKING

Abnormal processes of thinking in schizophrenia and organic states may result in a literalness of expression and understanding. Abstractions and symbols are interpreted super cially without tact, nesse or any awareness of nuance; the patient is unable to free himself from what the words literally mean, excluding the more abstract ideas that are also conveyed. This abnormality is described as concrete thinking. The term was rst introduced by Goldstein (1936). It is usually tested for by proverb interpretation or by other psychological tests, but it is well acknowledged that these tests are unreliable. However, it is recognizable clinically, often quite dramatically. For example, a female patient with schizophrenia came into the room for interview and promptly took her shoes off, saying, ‘I always like to keep my feet on the ground when I’m talking’. Another patient with long-term schizophrenia was observed by his doctor walking sideways along the hospital corridor. When asked why he was walking like that, he said that it was ‘because of the side effects’. And another patient said, ‘I was starting to feel high and I didn’t want to y off, so I’ve tied these dumb-bell weights round my ankle’.

It is important to emphasize, however, that despite the compelling examples of concrete thinking just described, current thinking is that, if anything, patients with schizophrenia are more likely to subscribe to a

more abstract attitude than control subjects (Cutting, 2011; Shimkunas, 1972; Weiner, 1966;), so that for example when asked ‘in what way is a table and a chair alike?’ the patients might answer ‘objects in the universe’.

PSYCHOLOGICAL THEORIES OF THINKING IN SCHIZOPHRENIA

A number of psychological theories attempt to explain thinking in patients with schizophrenia. These theories are hampered by the fact that there are no satisfactory general theories of thinking. There are now consistent ndings of de cits in attention, working memory, recogni- tion memory and executive functions in schizophrenia. These empirical ndings are yet to be integrated into a coherent theory that explains the observed and self- reported thinking abnormalities in this condition.

Over-Inclusive Thinking

The difference between the concrete thinking of organic psychosyndromes and that occurring in schizophrenia was described by Cameron (1944), who considered that in schizophrenia, the patient is unable to preserve conceptual boundaries. This he called over-inclusive thinking: ideas that are only remotely related to the concept under consideration become incorporated within it in the patient’s thinking. Thus, when asked ‘What of the following are essential parts of a room: walls, chairs, oor, a window?’, the over-inclusive person with schizophrenia might include ‘chair’. This feature of over-inclusiveness can be seen in many aspects of thinking in schizophrenia, and questionnaires have been devised to test for it, particularly involving sorting tests. The lack of adequate connection between two consecutive thoughts is called asyndesis.

The concrete thinking of schizophrenia, however, could not be distinguished from that of other psychotic and neurotic patients (Payne et al., 1970), and it was found to be associated with intelligence. Over-inclusive thinking occurred only in about half of the patients with schizophrenia tested, usually those who were more acutely ill. The other half, usually suffering from more chronic illness, showed much more marked retardation. McGhie (1969) found that Payne’s tests of over- inclusiveness did not select schizophrenia from some other diagnoses, for example, those with obsessional or manic thought disorder, and Gathercole (1965)

considered that these tests demonstrated uency of association rather than over-inclusive thinking.

A young man, who had suffered from schizophrenia for several years was known to have recently been abusing drugs. To the doctor’s enquiry ‘What drugs have you been using?’, he replied ‘LSD, health foods and marijuana’. This is an example of over-inclusive thinking. However, it was volunteered spontaneously; he might well have given an entirely correct response to a formal questionnaire that did not touch on sig- ni cant areas of his experience.

It has been suggested by Chen et al. (1995) that there may be a broadening of category boundary (for example, ‘furniture’) with preservation of internal category structure in patients with schizophrenia. This results in related issues that are actually outside the category being processed by the patient in a way that is similar to those within it. Cutting (2011) argues that what is most prominent is that patients with schizo- phrenia overcategorize, nding many more and often needless categories to subsume lists within.

Aggernaes (Aggernaes et al., 1976) has taken this theory further from the practical and clinical viewpoint. He considers that patients with schizophrenia have not parted from reality; they seem to experience the real world as being real in the same way as normal people do. However, their defect in reality testing results from a diffuse tendency to experience some fantasy items as being real as well.

Schizophrenic Inattention and Abnormality of Working Memory: Effect on Performance

McGhie (1969) has focused on the disturbance in the function of attention in patients with schizophrenia: that they are unable to lter and discount sensory data irrelevant to the task being performed. He showed that the performance of patients with schizophrenia was very poor compared with that of normal subjects, but they were not prone to distraction by auditory or visual external stimuli in the way that normal people were. Hebephrenic patients especially showed less distraction and also poor perception and recall of visual informa- tion. Hebephrenic patients were considered to have an inability to sweep out irrelevant extraneous information … especially where the situation demanded the rapid processing and short term storage of information. This experience is described subjectively: ‘When people talk

to me now it’s like a different kind of language. It’s too much to hold at once. My head is overloaded and I can’t understand what they say. It makes you forget what you’ve just heard because you can’t get hearing it long enough. It’s all in different bits that you have to put together in your head – just words in the air unless you can gure it out from their faces.’

The effect of this inattention in ordinary social life was well observed by Morgan (1977) in his description of 3 weeks lived in close proximity to two patients with chronic schizophrenia:

In the case of Vine our relationship remained just
the same, but I did perhaps come to understand his disabilities a little better, and this helped. He would keep ‘losing his thread’, to some extent in talk but even more noticeably in action. For example, although we went through the sequence of routine tests over 500 times together, he never once completed a sequence without having to be reminded of what came next and what remained to be done each time. Vine’s other main trouble was a curious one. I would say to him, for example, ‘Let’s do the tests rst and then I’d like you to get on with the washing up’, and I would be surprised when
his response to this was to dash off to the sink and start clattering the plates. Eventually I made out that he had some defect of attention. He would often jump like a startled rabbit when he realized he was being addressed anyway, and I think that by the time he had recovered and collected himself from that, the rst half of my sentence had gone and all he heard was the second half. Certainly I found that by inserting a little preliminary padding, I got a more competent response.

Frith (1992) hypothesizes that the mechanism for delusions of control was also responsible for the thought or language abnormality in schizophrenia. In this scheme, it is a failure of self-monitoring that is respon- sible for thought or language disorder. Thus the patient is unable to edit out irrelevant or perseverating phrases, and this results in poor communication. There is also the related possibility that the fundamental problem is in planning. In this scheme, the coherence of the patient’s thought or language is undermined by the absence of an explicit goal and plan, and furthermore there is intrusion of thoughts that do not t in with the overall goal, resulting in disorganized thought or

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language. In summary, patients with schizophrenia ‘are only able to check the accuracy of an utterance after [emphasis in original] they have made it. It is therefore dif cult for them to avoid producing a string of faulty utterances, even during attempts at repair’ (Frith, 1992).

Liddle (2001) de nes the disorganization syndrome as consisting of disjointed thought, emotion and behaviour. However, the cardinal symptoms are formal thought disorder, inappropriate affect and bizarre, erratic behaviour. He concludes that disorganization is associ- ated with slowed performance in neuropsychological tasks that demand selection between competing responses or with errors of commission in tasks that require suppression of an inappropriate response. In his view, this suggests that the disorganization found in schizophrenia derives from impairment of the neural circuits responsible for response selection and inhibition. The circuits involved are the ventrolateral frontal cortex, the left superior temporal gyrus and the adjacent inferior parietal lobule. There is also involvement of the anterior cingulate and thalamus.

Disorder of Control of Thinking

Under this heading, we could discuss three patterns of thinking: passivity of thought, or delusions of control of thinking; obsessions and compulsions, in which the unacceptable thoughts are accepted by the patient as being under his control but are resisted; and the rigid control of thought and intolerance for variation that becomes habitual with the anankastic or obses- sional personality. The latter two are considered in Chapter 19.

DELUSIONS OF THE CONTROL OF THOUGHT

Control of thinking may be disorganized in that the patient ascribes his own, internal thought processes to outside in uences. The subjective disturbance in think- ing in schizophrenia is experienced as passivity. The patient with schizophrenia experiences his thoughts as foreign or alien, not emanating from himself and not within his control. There is a breakdown in the way he thinks of the boundary between himself and the outside world, so that he can no longer accurately discriminate between the two. He may describe passivity of thought, thought withdrawal, thought insertion and/ or thought broadcasting; these are rst-rank symptoms

TABLE 9.1 First-Rank Symptoms of Schizophrenia and Symptoms From the Present State Examination

First-Rank Symptoma

Equivalent Symptom From the Present State Examinationb

Delusion
Delusional percept Auditory hallucinations Audible thoughts

Voices arguing or discussing

Voices commenting on the patient’s action

Thought disorder: passivity of thought

Thought withdrawal

Thought insertion Thought broadcasting

(diffusion of thought) Passivity experiences:

delusion of control Passivity of affect (‘made’

feelings) Passivity of impulse

(‘made’ drives) Passivity of volition

(‘made’ volitional acts) Somatic passivity

(in uence playing on the body)

Primary delusion

Thought echo or commentary

Voices about the patient Voices about the patient

Thought block or withdrawal

Thought insertion Thought broadcast or

thought sharing

Delusions of control Delusions of control Delusions of control

Delusions of alien penetration

aSchneider (1959) bWing et al. (1974)

of schizophrenia (Schneider, 1959). In Table 9.1, the rst-rank symptoms are listed.

Various forms of thought passivity are described. The patient may describe sharing his thoughts with other people or his thoughts being controlled or in uenced from outside himself. These delusions of control are often associated with delusional explanations of how his thinking could be controlled, for example, with the use of electronic devices, computers or telepathy. Thought insertion is described, in which he believes that his thoughts have been placed there from outside himself. Correspondingly, he may describe his thoughts being taken away from himself against his will: thought withdrawal. This may be given as an

explanation for thought blocking when the thoughts stop and the mind suddenly goes completely blank. Thought insertion and withdrawal are rst-rank symptoms of schizophrenia; thought blocking is not because it is dif cult to decide whether it is truly thought blocking, some form of retardation or other dif culty with thinking, and blocking is also subjectively similar to epileptic absences. Thought broadcasting occurs in schizophrenia when the patient describes his thoughts as leaving himself and being diffused widely out of his control. It also is a passivity experience and of rst rank.

A further subjective symptom associated with thought, of rst-rank importance, is the experience of audible thoughts, that is, hearing one’s own thoughts out loud. The patient knows that they are his thoughts, yet he hears them audibly while he is thinking them, or just before or after thinking them. This is, of course, a disorder of perception, an auditory hallucination (Chapter 7).

Earlier in the chapter, we discussed fusion, mixing, derailment and crowding of thought, all of which occur in schizophrenia. The resultant confusion causes a loss of ability to think clearly, often described in terms of passivity. The patient may feel that his brain is replaced by cotton wool or convoluted rubber. His thoughts are jumbled, muzzy, vague, blurred: ‘I try to part my way through them but they are like treacle and keep on coming back and making me stick’.

First-Rank Symptoms of Schizophrenia

First-rank symptoms of schizophrenia are discussed in this section for convenience because many of them are examples of disorder of control or possession of thoughts. According to Schneider, the presence of one or more rst-rank symptoms in the absence of organic disease can be used as positive evidence for schizo- phrenia. These symptoms of rst rank are not a comprehensive list of the clinical features of schizo- phrenia, for the changes in affect, volition and motor activity that may occur in the condition are not included, and many other types of delusion, hallucination and disorder of thinking also occur in schizophrenia. For a symptom to be regarded as rst rank, it must have the following characteristics.

• It must occur with reasonable frequency in schizo- phrenia.

• It must generally not occur in conditions other than schizophrenia.

• It must not be too dif cult to decide whether the symptom is or is not present.

There are some symptoms that occur only in schizophrenia but occur too rarely to be of practical use as rst-rank symptoms. There are many features that are characteristic of schizophrenia but may also occur in other conditions, for example, unspeci ed auditory hallucinations, poverty of affect and over- inclusive thinking. There are some symptoms that occur only in schizophrenia, but there is too much scope for argument as to whether it is, or is not, this precise symptom for it to be valued as of rst rank. An example of this is a primary delusion. Some clinicians may regard a particular belief of the patient as primary delusion, whereas others do not.

Although rst-rank symptoms are used as a diag- nostic checklist, a patient who exhibits seven of them is not more severely ill than someone who shows three. To elicit them requires considerable clinical experience; they cannot be collected quantitatively by riding past the patient on a bicycle! For a psychiatrist to use them clinically, she must rst know them. Second, she must know how this person from this social and racial background is likely to describe any particular rst-rank symptom (‘my thoughts are controlled by television’, ‘my thoughts are controlled by the spirits of my dead ancestors’). Third, she must ask the appropriate direct questions skillfully, without putting words in her patient’s mouth. Fourth, she must be able to interpret the patient’s answers and decide whether a rst-rank symptom is being described. The whole process requires a dextrous use of the phenomenologic method as described in Chapter 1.

Many practising psychiatrists’ comment at this stage of the discussion of rst-rank symptoms would be ‘Why bother?’ They would also agree that it is often dif cult to diagnose schizophrenia, that it is important not to give this label to people who do not suffer from the illness and that it is equally important to treat those who do suffer from it appropriately, effectively and as early in the course of illness as possible.

In clinical practice, the eliciting of rst-rank symptoms could best be seen as a means of deciding the degree of certainty that may be attached to the diagnosis. In a patient who shows the general features of

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schizophrenia (delusion, hallucination, thought disorder, disordered affect, volition, motor activity, behaviour, social relationships, life history), the diagnosis is made, but some doubts remain. If rst-rank symptoms are found, then, in the absence of clear organic pathology, one can reckon that the diagnosis has been con rmed. Some of the rst-rank symptoms are found to be less reliable at follow-up than others as indicators of schizophrenia, for example, voices heard arguing (Mellor et al., 1981). One of the advantages of rst-rank symptoms as a diagnostic tool is that, because of their emphasis on form rather than content, a person who is feigning mental illness is unlikely to produce them. They therefore have a subsidiary use as a method of distinguishing between true and simulated psychosis, for example, in prisoners. Despite the value of rst- rank symptoms indicating schizophrenia when they are present, there are undoubtedly patients in whom they cannot be elicited; schizophrenia still remains, to some extent, a diagnosis of exclusion (Carpenter and Buchanan, 1994).

Examples of First-Rank Symptoms

The only type of delusion that is regarded as of rst rank is a delusional perception, that is, a normal percep- tion delusionally interpreted and regarded as being highly signi cant to the patient (Chapter 8). Examples of delusional percept, and of other rst-rank symptoms as follows, are cited by Mellor (1970, p. 18). Delusional perception is exempli ed in the following account.

A young Irishman was at breakfast with two fellow lodgers. He felt a sense of unease, that something frightening was going to happen. One of the lodgers pushed the salt cellar towards him (he appreciated at the same time that this was an ordinary salt cellar and his friend’s intention was innocent). Almost before the salt cellar reached him he knew he must return home, ‘to greet the Pope, who is visiting Ireland to see his family and to reward them … because Our Lord is going to be born again to one of the women … And because of this they (all the women) are all born different with their private parts back to front.’

Three types of auditory hallucinations are regarded as being of rst rank. These are audible thoughts, voices heard arguing and voices giving a running commentary.

What is meant by audible thoughts is the patient’s experi- ence of hearing his own thoughts said out loud. In British usage, the symptom sometimes carries its German name, Gedankenlautwerden, or its French one, écho de pensées. The patient may hear people repeating his thoughts out loud just after he has thought them, answering his thoughts, talking about them having said them audibly or saying aloud what he is about to think so that his thoughts repeat the voices. He often becomes very upset at the gross intrusion into his privacy and concerned that he cannot maintain control of any part of himself, not even his thoughts.

A 35-year-old painter heard a quiet voice with ‘an Oxford accent’, which he attributed to the BBC.
The volume was slightly lower than that of normal conversation and could be heard equally well with either ear. He could locate its source at the right mastoid process. The voice would say, ‘I can’t stand that man, the way he holds his hand he looks like a poof’ …

He immediately experienced whatever the voice was saying as his own thoughts, to the exclusion of all other thoughts. When he read the newspaper the voice would speak aloud whatever his eyes fell on. He had not time to think of what he was reading before it was uttered aloud. (Mellor, 1970, p. 16)

Voices heard arguing with each other implies two or more hallucinatory voices quarrelling or discussing with each other. The patient usually features in the third person in the content of these arguing voices. The symptom is not likely to be volunteered spontaneously in this form; the patient does not actually say, ‘I hear voices that argue or discuss with each other’. So the symptom has to be cautiously and subtly enquired for.

A 24-year-old male patient reported hearing voices coming from the nurse’s of ce. One voice, deep in pitch and roughly spoken, repeatedly said, ‘G.T. is a bloody paradox’, and another, higher in pitch, said, ‘He is that, he should be locked up.’ A female voice occasionally interrupted, saying ‘He is not, he is a lovely man.’ (Mellor, 1970, p. 16)

Hallucinatory voices giving a running commentary on the patient’s activities occur and are of rst rank. The time sequence of the commentary may be such that it

takes place just before, during or after the patient’s activities. Again, the symptom is not volunteered spontaneously but may quite often be inferred from the patient’s complaints against his voices. For the interviewer, there is always the problem of asking questions in such a way that she is ‘let in on the inside’. She is asking questions about perceptions that are quite obvious to the patient. The patient does not know that his particular perception is unique, that other people do not share his perceptual experience. So the inter- viewer has the dif culty of asking questions about something of which she has no personal experience; the patient has to answer questions that, because of his situation, seem to have no point. The abnormal thing about voices commenting is that they should be experienced as perceptions and as coming from outside the self; many normal people have thoughts, recognized as their own and coming from inside themselves, commenting on their actions:

A 41-year-old housewife heard a voice coming from the house across the road … The voice went on incessantly in a at monotone describing everything she was doing, with an admixture of critical comments. ‘She is peeling potatoes, got hold of the peeler, she does not want that potato, she is putting it back, because she thinks it has a knobble like a penis, she has a dirty mind, she is peeling potatoes, now she is washing them.’ (Mellor, 1970, p. 16)

Passivity experiences are those events in the realm of sensation, feeling, drive and volition that are expe- rienced as made or in uenced by others. They have been well described as delusions of control, because the patient’s experience of the event being made to occur takes the form of a delusion. The terms disorders of passivity, made experiences, delusions of control and disorders of personal activity are, in practice, synonymous and interchangeable. The event is experienced as alien by the patient in that it is not experienced by the patient as his own but inserted into the self from outside. Passivity experiences of thinking occur as thought withdrawal, thought insertion or thought broadcasting. In thought withdrawal, it is believed by the patient that his thoughts are in some way being taken out of his mind; he has some feeling of loss resulting from this process. It may be coupled with other thought passivity experiences:

A 22-year-old woman said, ‘I am thinking about my mother, and suddenly my thoughts are sucked out of my mind by a phrenological vacuum extractor, and there is nothing in my mind, it is empty.’ (Mellor, 1970, p. 16)

In thought insertion, the patient experiences thoughts that do not have the feeling of familiarity, of being his own, but he feels that they have been put in his mind, without his volition, from outside himself. As in thought withdrawal, there is clearly a disturbance in the self- image, and especially in the boundary between what is self and what is not self; thoughts that have in fact arisen inside himself are considered to have been inserted into his thinking from outside.

A 29-year-old housewife said, ‘I look out of the window and I think the garden looks nice and the grass looks cool, but the thoughts of Eamonn Andrews come into my mind. There are no other thoughts there, only his … He treats my mind like a screen and ashes his thoughts onto it like you ash a picture.’ (Mellor, 1970, p. 17)

In thought broadcasting, the patient experiences his thoughts withdrawn from his mind and then, in some way, made public and projected over a wide area. The explanation he gives for how this can occur will, as usual for the content of a delusion, depend on his background culture and predominant interests:

A 21-year-old student said, ‘As I think, my thoughts leave my head on a type of mental ticker-tape. Everyone around has only to pass the tape through their mind and they know my thoughts.’ (Mellor, 1970, p. 17)

Obviously, careful enquiry must be made about the nature of ‘in uence’ or ‘control’. There is a phenomeno- logic world of difference between the statements ‘My thinking is in uenced by my parents inasmuch as my thoughts are crowded from the back into the front of my head’ – a passivity experience, and ‘What I do is in uenced by my father in that I ponder what he would do in the circumstances and then do the same’ (or ‘do the opposite’) – not passivity. All passivity experiences are regarded as rst-rank symptoms. It is not of great signi cance to decide which type of passivity is described – whether it is, for example, passivity of impulse or of volition – but it is important diagnostically

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144 SECTION III Awareness of Reality: Time, Perception and Judgement

to decide whether it is a passivity experience. Passivity of emotion occurs when the affect that the patient experiences does not seem to him to be his own. He believes that he has been made to feel it:

A 23-year-old female patient reported, ‘I cry, tears roll down my cheeks and I look unhappy, but inside I have a cold anger because they are using me in this way, and it is not me who is unhappy, but they are projecting unhappiness onto my brain. They project upon me laughter, for no reason, and you have no idea how terrible it is to laugh and look happy and know it is not your, but their reaction.’ (Mellor, 1970: 17)

In passivity of impulse, the patient experiences a drive, which he feels is alien, to carry out some motor activity. The impulse may be experienced without the subject carrying out the behaviour. A Jewish woman, aged 55, suffering from schizophrenia said, ‘I feel my hand going up to salute, and my lips saying “Heil Hitler” … I don’t actually say it … I have to try very hard to stop my arm from going up … they put drugs in my food; that is what makes it happen’. If carried out, the action is admitted to be the patient’s own, but he feels that the impulse that precipitated him into doing it was not his own.

A 26-year-old engineer emptied the contents of a urine bottle over the ward dinner trolley. He said, ‘The sudden impulse came over me and I must do it. It was not my feeling, it came into me from the X-ray department, that was why I was sent there for implants yesterday. It was nothing to do with me, they wanted it done. So I picked up the bottle and poured it in. It seemed all I could do.’ (Mellor, 1970, p. 17)

Similarly, with passivity of volition the patient feels that it is not his will that carried out the action.

A 29-year-old shorthand typist described her actions as follows, ‘when I reach my hand for the comb it is my hand and arm which move, and my ngers pick up the pen, but I don’t control them … I sit there wanting them to move, and they are quite independent, what they do is nothing to do with me … I am just a puppet who is manipulated by cosmic strings. When the strings are pulled my body moves and I can’t prevent it.’ (Mellor, 1970, p. 17)

Somatic passivity is the belief that outside in uences are playing on the body. It is not the same as haptic hallucination, but it is a delusional belief that the body is being in uenced from outside the self. It may occur in association with various somatic hallucinations. For example, a kinaesthetic hallucination occurred, with a passivity experience given as explanation, by a patient who felt that his hand was being drawn up to his face. He could feel it moving although, in fact, it was motion- less. Somatic passivity may also occur in association with a normal percept; these experiences are quite common in schizophrenia.

A 38-year-old man had jumped from a bedroom window, injuring his right knee which was very painful. He described his physical experience as, ‘The sun-rays are directed by US army satellites in an intense beam which I can feel entering the centre of my knee and then radiating outwards causing the pain.’ (Mellor, 1970,
p. 16)

First rank symptoms are of general use, diagnostically, in clinical practice, and they have also been adapted for psychiatric research. The method of ascertaining and measuring schizophrenic symptoms, among other symptoms, developed by Wing et al. (1974) in their Present State Examination uses rst-rank symptoms as a basis for diagnosing schizophrenia. The Present State Examination provides the clinician with a means of ascertaining which symptoms and syndromes are present.

Koehler (1979), in a review of the way various authors describe the presence of rst-rank symptoms in the English literature, considered that they were sometimes used in a very narrow and sometimes a very wide sense. He makes the distinction between alienation of thought and in uence of thought and makes a plea for clear statements on the boundary criteria for rst- rank symptoms and the nosologic bias attached to the phenomena. From the preceding quoted examples of Mellor, alienation is necessary – that is, a delusion of control and not just an experience of in uence of thought. Similarly, thought broadcasting would be regarded as of rst rank when the patient describes this as having occurred outside his control, irrespective of whether these thoughts are shared with others. Thus this chapter is recommending a narrow use of rst-rank

symptoms. First-rank symptoms have been employed to establish the diagnosis; they are not necessarily useful prognostically (Bland and Orn, 1980).

This difference between alienation or experience of control and in uence can be exempli ed by the schizophrenic symptom of thought insertion. Thought insertion is more concrete than the insertion of an idea into one’s thinking. A normal person may say, ‘My mother gave me the idea’ or even ‘The idea was put into my head by my mother’. Neither of these is thought insertion. The patient experiencing passivity believes that by some concrete process, the boundaries of his self involving thinking are so invaded that his mother is actually placing thoughts inside his head (Chapter 12), so that he thinks her thoughts, or perhaps she, is thinking inside him.

REFERENCES

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Bion, W.R., 1962. The psycho-analytic study of thinking. Intern. J. Psychoanal. 43, 306–310.

Bland, R.C., Orn, H., 1980. Schizophrenia: Schneider’s rst-rank symptoms and outcome. Br. J. Psychiatry 137, 63–68.

Bleuler, E., 1911. Dementia Praecox or the Group of Schizophrenias (J. Zinkin, Trans, 1950). International Universities Press, New York.

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Carpenter, W.T., Buchanan, R.W., 1994. Schizophrenia. NEJM 330, 681–690.

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in schizophrenia and rst rank symptoms: an eight year follow-up.

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Payne, R.W., Hochberg, A.C., Hawks, D.V., 1970. Dichotic stimulation as a method of assessing the disorder of attention of an over- inclusive schizophrenic patient. J. Abnorm. Psychol. 76, 185–193. Roth, I., 2004. Imagination. In: Gregory, R.L. (Ed.), The Oxford

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KEYWORDS

Language Speech Aphasia Mutism Alogia

Summary

Speech is the aspect of language that corresponds to the mechanical and articulatory functions that allow language to be vocalized, whereas language is itself a complex system based on a number of elements includ- ing phonemes, syntactic structure, semantics, prosody and pragmatics, all designed to aid communication and to encode facts in memory. Abnormalities of speech are common in neurology but rare in psychiatry. Language and thinking disorders are intricately affected in psychiatric disorders, particularly in schizophrenia. The actual relationship between thinking and language is yet to be fully elucidated.

To speak is not only to utter words, it is to propositionize. A proposition is such a relation of words that it makes one new meaning.

J. Hughlings Jackson (1932)

It is very obvious that the functions of thinking and speaking overlap and cannot be readily separated from each other; at the same time, they are clearly different. The contents of this chapter cannot be considered in isolation from its predecessor, although this one consid- ers speech and language from a different perspective.

Maher (1972, p. 3) proposed a model that attempted to demonstrate the link between thinking and the behaviour of speech in language:

conceptualizing the relationship between language and thought. The model might be likened to a typist copying from a script before her. Her copy may appear to be distorted because the script is distorted although the

communication channel of the typist’s eye and hand
are functioning correctly. Alternatively, the original
script may be perfect, but the typist may be unskilled, making typing errors in the copy and thus distorting
it. Finally, it is possible for an inef cient typist to add errors to an already incoherent script. Unfortunately, the psychopathologist can observe only the copy (language utterances): he cannot examine the script (the thought). In general most theorists concerned with schizophrenic language have accepted the rst of the three alternatives, namely that a good typist is transcribing a deviant script. The patient is correctly reporting a set of disordered thoughts. As Critchley put it: ‘Any considerable aberration of thought or personality will be mirrored

in the various levels of articulate speech – phonetic, phonemic, semantic, syntactic and pragmatic’. The language is a mirror of the thought.

The script is likened to thought and the typist to language. Most clinicians have taken the view that language closely mirrors thought and see the primary abnormality as the thinking disorder (Beveridge, 1985). Disordered language is then seen as merely a re ection of this underlying disturbance, with diagnosis of thought disorder only possible on the basis of what the patient says. Some of the more recent linguistic theories used for the analysis of schizophrenic speech contradict the primacy of thinking.

The assumption that language directly mirrors thought can be challenged (Newby, 1995). One tradition argues that language itself structures thinking and concepts and determines how the world is understood. This view derives from the works of Edward Sapir (1884–1939) and Benjamin Whorf (1897–1941). In essence, the Sapir-Whorf hypothesis says that language in uences cognition. There is limited empirical support for this view, and Pinker (1994) concludes that ‘the representations underlying thinking, on the one hand, and the sentences in a language, on the other, are in many ways at cross-purposes … People do not think in English or Chinese or Apache; they think in a

CHAPTER 10

147

Disorder of Speech and Language

148 SECTION III Awareness of Reality: Time, Perception and Judgement

language of thought. This language of thought probably looks a bit like all these languages; presumably it has symbols for concepts, and arrangements of symbols that correspond to who did what to whom’. This radical view contradicts the point-to-point relationship between language and thought implicit in Maher’s proposition noted earlier and the linguistic determinism of the Sapir-Whorf hypothesis.

The relationship between thinking and language is as complicated for organic disorders as it is for schizo- phrenia: there can be quite marked disturbance in the use of language with no apparent thought disorder. This is revealed in the rare isolated abnormalities of speci c function of language described in this chapter. An understanding of how the healthy person expresses thoughts in language can be achieved only by study of the normal development of language. This is outside the scope of this book but is discussed in relation to perception in Carterette and Friedman (1976).

Language is built of a number of elements. Phonemes are the most basic sounds that are available for use in language, and any particular language, such as English, uses only a limited repertoire of phonemes. The reper- toire used in English may share only a limited overlap with that used, for example, in Yoruba. Morphemes are produced from phonemes and are the smallest meaning- ful unit of a word, and combinations of morphemes make up words. A morpheme may be a word such as ‘do’ or ‘un’. Syntax (grammar) is the allowable combination of words in phrases and sentences and includes the rules that determine word order. Semantics are the meanings that correspond to the words and include the meaning of all possible sentences. Prosody refers to the modulation of vocal intonation that in uences accents, and also the literal and emotional meanings of words and sentences. The pragmatics of language is the study of the ways that language is used in practice. This is a relatively new area of study. It refers to the multiple potential meanings of any utterance, which requires knowledge of context and of the speakers for full interpretation. For example, the sentence ‘this room is cold’ can have any of several meanings depending on the identity of the speaker, the context of the utterance and who is being addressed, that is the social or relative distance of the addressee. It is perhaps important to distinguish between language and speech for our purpose. Speech is the aspect of language that corresponds to the mechanical and articulatory

functions that allow language to be vocalized. Thus, for language to become speech the vocal cords, the palate, the lips and the tongue need to perform a complex and synchronized dance of intricate steps. The dissociation between poorly articulated speech and intact language indicates that these two functions are separate.

Chomsky’s (1986) theory of language is the most in uential. Essentially, Chomsky argued that language is like an instinct, and furthermore that ‘every sentence that a person utters or understands is a brand new combination of words, appearing for the rst time in the history of the universe. Therefore a language cannot be a repertoire of responses; the brain must contain a recipe or programme that can build an unlimited set of sentences out of a nite list of words. The programme may be called a mental grammar’ (Pinker, 1994). In addition to this, children rapidly develop these complex grammars without formal instruction. This suggests that they must be innately endowed with a plan common to the grammars of all languages, a universal grammar. How language develops, how word meaning is learned and the neuropsychology of language are all areas of increasing study.

Speech Disturbances

This subject is dealt with in textbooks of neurology and has been reviewed by Critchley (1995); it is only summarized here. Many abnormalities, such as para- phasia, have both organic and psychogenic causes (as described earlier); diagnosis will require full medical and psychiatric history and neurologic and mental state examination.

APHONIA AND DYSPHONIA

Aphonia is the loss of the ability to vocalize; the patient talks only in a whisper. Dysphonia denotes impairment with hoarseness but without complete loss of function. It occurs with paralysis of the ninth cranial nerve or with disease of the vocal cords.

Aphonia may also occur without organic disease in dissociative aphonia, not uncommon as a presentation among ear, nose and throat outpatients. Such a patient may speak in a ‘stage whisper’; phonation may uctuate according to the response of those the person is addressing.

DYSARTHRIA

Disorders of articulation may be caused by lesions of the brainstem such as bulbar and pseudobulbar palsy. It may also occur with structural or muscular disorders of the mouth, pharynx, larynx and thorax. Idiosyncratic disorders of articulation are sometimes seen in schizo- phrenia and also, perhaps, with personality disorders consciously produced.

STUTTERING AND STAMMERING

These have in the past been enquired about in the psychiatric history under neurotic disturbances of childhood, along with behaviours such as nail biting. However, psychogenic aetiology has certainly now been disproved, and any association with neuroticism may well be secondary to the barriers in communication that stuttering causes.

LOGOCLONIA

This describes the spastic repetition of syllables that occurs with parkinsonism (Scharfetter, 1980). The patient may get stuck using a particular word.

ECHOLALIA

The patient repeats words or parts of sentences that are spoken to him or in his presence. There is usually no understanding of the meaning of the words. It is most often demonstrated in excited schizophrenic states, with learning disability and with organic states such as dementia, especially if dysphasia is also present.

CHANGES IN THE VOLUME AND INTONATION OF SPEECH

Many depressed patients speak quietly with a monotonous voice. Manic patients often speak loudly and excitably with much variation in pitch. Excited patients with schizophrenia may also speak loudly; intonation and stresses on words may be idiosyncratic and inappropriate. None of these modes of behaviour has diagnostic sig- ni cance. The speed and ow of talk mirrors that of thought and is dealt with in Chapter 9.

UNINTELLIGIBLE SPEECH

Speech may be unintelligible for several reasons, and most of the abnormalities described here, if taken to extremes, will result in incomprehensibility.

• Dysphasia may be so profound that, although syllables are produced, speech is unintelligible.

• Paragrammatism(disorderofgrammaticalconstruc- tion) and incoherence of syntax may occur in several disorders. Recognizable words may be so deranged in their sentences as to be meaningless – word salad, as occurs in schizophrenia. In mania, the speed of association may be so rapid as to disrupt sentence structure completely and render it meaningless, whereas in depression retardation may so inhibit speech that only unintelligible syllables, often of a moaning nature, are produced.

• Private meaning may occur in schizophrenia with the use of (a) new words with an idiosyncratic, personal meaning – neologisms; (b) stock words and phrases in which existing words are used with special individual symbolic meaning; or (c) a private language that may be spoken (cryptolalia), or written (cryptographia).

Organic Disorders of Language

Dysphasic symptoms are probably more useful clinically than any other cognitive defect in indicating the approximate site of brain pathology (David et al., 2007). However, the auditory, visual and motor mechanisms of speech are spread through several parts of the brain; often several functions are affected and lesions are usually diffuse, and thus precise brain localization is often not possible. Ninety percent of right-handed people without any brain damage have speech located in the left hemisphere, and 10% have right hemisphere speech. Among those who are left-handed or ambi- dextrous, 64% have left hemisphere speech, 20% right hemisphere and 16% bilateral speech representation.

SENSORY DYSPHASIA

The terms aphasia and dysphasia are often used inter- changeably. However, aphasia implies the loss of lan- guage altogether, and dysphasia impairment of, or dif culty with, language. Dysphasia is conventionally divided for classi cation purposes into sensory (recep- tive) and motor (expressive) types. Frequently, there is a global impairment of language with evidence of impairment of both elements. Table 10.1 summarizes some of the abnormalities that occur with the different aspects of language that are impaired.

10 Disorder of Speech and Language 149

150 SECTION III Awareness of Reality: Time, Perception and Judgement a

TABLE 10.1 Im Type

pairment of L

Spontaneous Speech-Fluent

nguage Funct

Comprehension

ion With D

Repetition

ifferent T

Naming

ypes of Dysphasia

Reading

Writing

Pure word + – – + deafness

Pure word blindness

Primary sensory – – dysphasia

Conduction – dysphasia

Nominal – dysphasia

Pure word – – dumbness

Pure agraphia
Primary motor –

dysphasia Alexia with agraphia

Isolated speech – – area

Transcortical – motor

dysphasia
Transcortical –

sensory dysphasia

+ + (not to dictation)

– + – – Aloud –, compr.n + –

+ –

– ±, aloud –, compr.n ± –

– – –

– Aloud –, compr.n +

– – –

Compr.n, Comprehension.
(After Lishman, 1997, with permission of Blackwell Scienti c.)

Pure Word Deafness (Subcortical Auditory Dysphasia)

In pure word deafness, the patient can speak, read and write uently, correctly and with comprehension. He cannot understand speech, even though hearing is unimpaired for other sounds; he hears words as sounds but cannot recognize the meaning even though he knows that they are words. This is therefore a form of agnosia (lack of recognition) for the spoken word.

Pure Word Blindness (Subcortical Visual Aphasia)

The patient with pure word blindness can speak normally and understand the spoken word; he can write spontane- ously and to dictation but cannot read with understand- ing (alexia). The condition is therefore agnosic alexia without dysgraphia. He may have more dif culty with printed than hand written script. Such a patient will also suffer a right homonymous hemianopia (loss of the right half of the eld of vision in both eyes) and

an inability to name colours even though colour can be perceived.

Primary Sensory Dysphasia (Receptive Dysphasia)

Patients with primary sensory dysphasia are unable to understand spoken speech, with loss of comprehension of the meaning of words and of the signi cance of grammar. Hearing otherwise is not impaired. Conse- quent on this de cit in the auditory association cortex (Wernicke’s area), there is also impairment of speech, writing and reading. Speech is uent, with no apprecia- tion of the many errors in the use of words, syntax and grammar.

Conduction dysphasia could be considered to be a type of sensory dysphasia in which sensory reception of speech and writing are impaired, in that the patient cannot repeat the message although he can speak and write. If he is questioned on the message, he is able

to give ‘yes’ or ‘no’ answers correctly, thus demonstrating comprehension. There are marked errors of grammar and syntax (syntactical dysphasia).

Nominal Dysphasia

The patient with nominal dysphasia is unable to produce names and sounds at will. He may be able to describe the object and its function and to recognize the name when presented: a patient described a watch as a ‘clock vessel’. Typically, ‘empty’ nouns such as ‘thing’ and ‘object’ are used frequently, and ‘distinguishing’ nouns rarely. Speech is at, the structure of sentences generally correct and understanding unimpaired.

Jargon Dysphasia

In jargon dysphasia speech is uent, but there is such gross disturbance for words and syntax that speech is unintelligible. The intonation and rhythm of speech are retained. This is considered a severe type of sensory dysphasia; there is failure to evaluate the patients’ own speech, in that patients are not emotionally disturbed when listening to recordings of their own grossly impaired speech.

MOTOR APHASIA

Pure Word Dumbness

The patient with pure word dumbness understands spoken speech and writing and can respond to comments. Writing is preserved but speech is indistinct and cannot be produced at will. There is no local disturbance of muscles required in speaking, and the disability is an apraxia limited to movements required for speech.

Pure Agraphia

Pure agraphia is an isolated inability to write that may also occur with unimpaired speech (agraphia without alexia); there is normal understanding of written and spoken material. This is the equivalent for writing of pure word dumbness in speech.

Primary Motor Dysphasia

In primary motor dysphasia there is disturbance to the processes of selecting words, constructing sentences and expressing them. Speech and writing are both affected, and there is dif culty in carrying out complex instructions, even though understanding for both speech

and writing may be preserved. The patient nds it dif cult to choose and pronounce words, and speech is hesitant and slow; he recognizes his errors, tries to correct them and is clearly upset. Gesture may be used to replace verbal communication. Speech is attempted and recognized as spoken words, but words are omitted and sentences shortened, and perseveration occurs.

Alexia With Agraphia

Visual aspects of language are construed as being more complex than auditory, in that visual schemata are required – ‘seeing the written word inside his head’, in addition to auditory – ‘hearing the words in one’s head’. In alexia with agraphia, the patient is unable to read or write, but speaking and understanding speech are preserved. Alexia in this condition is similar to that of pure word blindness: the patient cannot understand words that are spelt out aloud, showing that he is effectively illiterate because of disturbance of the visual symbolism of language.

Isolated Speech Area

Impaired comprehension may occur with slow, hesitant speech in an abnormality in which it is assumed that the anatomic Wernicke’s and Broca’s areas and the connections between them are intact but connections from other parts of the cortex with this language system are disturbed. Two types, expressive and receptive, are described: transcortical motor dysphasia and transcortical sensory dysphasia.

Most frequently, of course, with dysphasia, there is a mixture of expressive and receptive elements and the clear syndromes cannot be demonstrated, but their signi cance is partly theoretical in demonstrating the range of anatomic lesions and the speci city of resultant symptoms. This description has been exclusively concerned with the symptoms; precise description of the anatomic lesions and of associated neurologic symptoms is outside our scope. It is important to distinguish the phenomena of dysphasia, perhaps with neologisms and defects of syntax, from the word salad of schizophrenia with super cially similar defects of language. Verbigeration describes the repetition of words or syllables that expressive aphasic patients may use while desperately searching for the correct word. In psychosis, most often in catatonia, verbigeration is an example of mannerisms or stereotypy of speech in which

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words or phrases are either spontaneously repeated or provoked by questions that result in repetition of words or phrases. Hamilton (1974) describes repetition of one or several sentences or strings of fragmented words, going on for hours at a time. Sometimes the string is of incomprehensible jargon in a monotonous voice. The example is from Kraepelin (1919): ‘Dear Emily, give me a kiss; we want to get well, a greeting and it would be nothing. We want to be brave and beautiful, follow, follow, mother, so that we can come home soon. The letter was for me; take care, that I get it’, and the patient repeated this for 3 hours without stop.

MUTISM

Mutism, refraining from speech during consciousness, is an important sign in psychiatric illness with an extensive differential diagnosis. Eliciting the history and mental state becomes impossible in a mute patient. All the major categories of psychiatric disorder may manifest mutism: learning disability, organic brain disease (sometimes drug related), functional psychosis and neurosis and personality disorder. Some more speci c causes include depressive illness, catatonic schizophrenia and dissociative disorder. Mutism occurs as an essential element of stupor (Chapter 3), and it is necessary to assess the level of consciousness as part of a full neurologic examination for all patients with this sign. If there is no lowering of consciousness, as in functional psychoses and neuroses, it is likely that the mute patient understands everything that is said around him. As well as speci c brain disorders, the causes of stupor include general metabolic disorders that also affect the brain, such as hepatic failure, uraemia, hypothyroidism and hypoglycaemia.

Schizophrenic Language Disorder

Defective communication in language is the de ning characteristic of schizophrenia according to Crow (1997), and it is associated with genetic variation at the time language was acquired by Homo sapiens. The use of language by people with schizophrenia can differ from that in normal people, and this difference can be subtle and unrelated to positive symptoms such as delusions and hallucinations. There is good reason to believe that the abnormalities of language use are associated with thought disorder. The precise nature

of the language abnormality has so far de ed clari ca- tion, and this account is provisional; it describes the way some of the phenomena have been viewed and conceptualized. There is no single explanatory theory that uni es the disparate abnormalities that have been observed and described. Investigation into language disorder may be ascribed to one of the four models shown in Table 10.2.

CLINICAL DESCRIPTION AND THOUGHT DISORDER

The only unequivocal demonstration of disorder of thinking can be through language. Thought disorder may be revealed in the ow of talk (as in Chapter 9), disturbed content and use of words and grammar, and in the inability to conceptualize appropriately. Critchley (1964) considered that the ‘causation of schizophrenic speech affection lies in an underlying thought disorder, rather than in a linguistic inaccessibility’. Some of the ways in which clinicians have categorized schizophrenic thought disorder manifesting in speech are linked in Table 10.3.

The German psychopathologic literature on schizo- phrenic language and speech disorders was concerned with the rules of language dysfunction; it consistently reported the patient’s uncertainty in choosing the correct metaphorical level in communication (Mundt, 1995). Kraepelin (1919) de ned akataphasia as a disorder in the expression of thought in speech. Loss of the continuity of associations, which implied incompleteness in the development of ideas, was the rst of the functions

TABLE 10.2 Models for Investigating Language Disorder in Schizophrenia

Model of Language

Technique Employed

Concept of thought disorder

Behavioural learning theory

Statistical model Linguistic model

Psychiatric: clinical description of schizophrenic speech

Word association test, multiple choice vocabulary test

The Cloze technique, type:token ratio

Analysis of syntax, cohesion or propositions

(After Beveridge, 1985, with permission.)

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TABLE 10.3 Categorization of Thought Disorder in Speech

patients with schizophrenia produce evidence of concrete thinking, thinking without inferring and restricted to what is explicitly stated, whereas nonspeech- disordered patients with schizophrenia do not. When the thematic organization of speech was analyzed for patients with positive speech disorder (incoherence of speech) or negative speech disorder (poverty of speech), there was no difference found: speech-disordered patients, positive as well as negative, showed cognitive restriction and produced fewer inferences than nonspeech-disordered patients.

A de ciency in the logic of deductive reasoning in schizophrenia was suggested by Von Domarus (1944). Some of the abnormalities of thinking expressed in speech observed by Schneider are discussed in Chapter 9.

An attempt has been made by Andreasen (1979) to classify the description of patients’ cognitive and linguistic behaviour on the phenomena demonstrated without making inferences about concepts of ‘global’ thought disorder; these abnormalities occur in both mania and schizophrenia. Some types of thought disorder, such as neologism and blocking, occurred too infrequently to have diagnostic signi cance. However, she found high reliability between raters with many types of thought disorder and also discrimination between different psychotic illnesses. Derailment, loss of goal, poverty of content of speech, tangentiality and illogicality were particularly characteristic of schizo- phrenia. Derailment implies loosening of association so that ideas slip on to either an obliquely related, or totally unrelated, theme. Loss of goal is the failure to follow a chain of thought through to its natural conclusion. Poverty of content of speech includes poverty of thought, empty speech, alogia, verbigeration and negative formal thought disorder; patients’ statements convey little information and tend to be vague, over- abstract, over-concrete, repetitive and stereotyped. Tangentiality means replying to a question in an oblique or even irrelevant manner. Illogicality implies drawing conclusions from a premise by inference that cannot be seen as logical.

Misuse of Words and Phrases

The patient with schizophrenia sometimes shows misuse of words in that he has, in the terminology of Kleist (1914), a defect of word storage. He has a restricted vocabulary and so uses words idiosyncratically to cover

Clinician

Categorization

Kraepelin Bleuler Gardner Cameron Goldstein Von Domarus

Schneider

Akataphasia
Loosening of associations Form of regression Asyndesis
Concrete thinking
Defect of deductive

reasoning
Derailment, substitution,

omission, fusion and drivelling

included among the fundamental symptoms of schizo- phrenia by Bleuler (1911).

Gardner (1931) considered thought disorder to be a form of regression. Cameron (1944), in describing asyndesis, considered there to be an inability to preserve conceptual boundaries and a marked paucity of genu- inely causal links. He gave the example of a patient who, given these alternatives, completed the sentence ‘I get warm when I run because …’ with all the words: ‘quickness, blood, heart of deer, length, driven power, motorized cylinder, strength’. The patient was prone to use imprecise expressions – metonyms, for example, a patient said he was alive:

Because you really live physically, because you have menu three times a day; that’s the physical [What else is there beside the physical?] Then you are alive mostly to serve a work from the standpoint of methodical business

He also demonstrated overinclusive thinking in which a loose association of concepts that were related in some way to the dominant theme became interwoven into responses, for example:

[The wind blows] Due to velocity. [Question repeated] Due to loss of air, evaporation of water. [What gives the velocity?] the contact of trees, of air in the trees

Concrete thinking, a term denoting an inability to think abstractly was proposed by Goldstein (1944), but the validity of this was challenged by Payne et al. (1959). Allen (1984) considers that speech-disordered

154 SECTION III Awareness of Reality: Time, Perception and Judgement

a greater range of meaning than they usually encompass. These are called stock words or phrases, and their use will sometimes become obvious in a longer conversation in which an unusual word or expression may be used several times. For example, a patient used ‘dispassionate’ as a stock word, and used it frequently with a bizarre and idiosyncratic meaning in the course of a few minutes’ speech. A woman who was delusionally concerned that the police were intruding into her private affairs interspersed her conversation, often bizarrely, with the expression ‘con dentially speaking’.

This abnormality appears partly to re ect a poverty of words and syntax and also an active tendency for words or syllables by association to intrude into thoughts, and therefore speech, soon after utterance. In the sample of speech in Chapter 9, the following words could be seen as stimuli and responses, by intrusion: ‘means’ – ‘ways’, ‘opens’ – ‘closed’, ‘holding back the truth’ – ‘by no means will I speak’, ‘written questions’ – ‘by means of writing’, ‘miracle’ – ‘Holyland’. They also appear to be stock words or phrases in that they are used with greater frequency and with a greater range of meaning than is normal and correct.

Words carry a semantic halo, that is, their constellation of associations is greater than just the dictionary meaning of the word. A boy aged 16 steals an apple. If I call him ‘a trespasser’, it has biblical associations; ‘a criminal’ suggests a greater degree of viciousness than the action merits; ‘a delinquent’ is readily associated with his youthfulness because of the phrase ‘juvenile delinquent’. The constellations of associations in patients are dis- ordered in that they often make apparently irrelevant associations. These may be explained by misperception of auditory stimuli with speci c inattention; the actual mediation of associations in patients with schizophrenia may be similar to that in healthy people. This comes some way to explaining why the associations seem appropriate subjectively to the patient himself, as he does not realize that he has misperceived the cue: it seems reasonable to him but is quite irrelevant to the interviewer. To quote Maher, ‘What seems to be bizarre is not the nature of the associations that intrude into the utterance, but the fact that they intrude at all’ (Maher, 1972).

Among the disorders of words, neologism is well recognized. A patient believed that his thoughts were in uenced from outside himself by a process of ‘telegony’.

Although such a word does actually exist, the patient had no notion of this nor what it meant. He created the word to describe a unique experience of his for which no adequate word existed. A 47-year-old male patient with schizophrenia and expansive mood described himself thus: ‘I am the triplicate actimetric kilophilic telepathic multibillion million genius’ – which does suggest a certain grandiosity!

The unintentional puns of schizophrenia have been explained by Chapman et al. (1964). If a word has more than one meaning, it is likely that one usage is dominant. For example, the majority of people, in most contexts, would be more likely to use the word ‘bay’ to refer to an inlet of the sea than to a tree, the noise a hound makes, the colour of a horse, an opening in a wall, the second branch of a stag’s horn, an uncomfortable place at which to stand or even, phonetically, a Turkish governor! There is a marked tendency in schizophrenia to show intrusion of the dominant meaning when the context demands the use of a less common meaning. Chapman et al. (1964) used a sentence such as ‘the tennis player left the court because he was tired’ and asked patients with schizophrenia to interpret its meaning with one of three explanations: one referring to a tennis court, one to a court of law and one altogether irrelevant. An analysis of responses shows that dominant meanings, here a court of law, intrude into the responses quite frequently, but intrusion of minor meanings is less frequent.

Maher (1972) has described disorder of language in schizophrenia in which intrusion occurs through clang associations with the initial syllable of a previous word: ‘the subterfuge and the mistaken planned substitu- tions’. This is unlike the clang associations that occur normally in poetry, in humour and also in manic speech, in which the clang occurs in terminal syllables. The repetitiveness of speech disorder is also thought to be associated with the intrusion of associations: the normal process of eliminating irrelevant associations does not take place, so that a word in a clause will provoke associations by pun, clang and ideational similarity. When that clause is completed, a syntactically correct clause may then be inserted, disrupting meaning but demonstrably associated with that previous word or idea.

Maher considers that an inability to maintain atten- tion may account for the language disturbances seen

in some patients. Disturbed attention allows irrelevant associations to intrude into speech, similarly to the disturbance affecting the ltering of sensory input. In this theory, normal coherent speech is seen as the progressive and instantaneous inhibition of irrelevant associations to each utterance, and so the determin- ing tendency proceeds with the active elimination of those associations that are not goal directed. This is but one of many potential explanations for the observed abnormalities.

Destruction of Words and Grammar

Alogia is a term used to describe negative thought disorder, or poverty of thoughts as expressed in words. Correspond- ingly, paralogia is used to describe positive thought disorder, or the intrusion of irrelevant or bizarre thought. Paraphasia is a destruction of words with interpolation of more or less garbled sounds. Although the patient is only able to produce this nonverbal sound, it clearly has signi cance or meaning to him. Literal paraphasia is gross misuse of the meaning of words to such an extent that statements no longer make any sense. Verbal paraphasia describes the loss of the appropriate word but the statements are still meaningful, for example a patient described a chair as ‘a four-legged sit-up’.

Disturbances in words and their meanings are much more common in schizophrenia than disturbance of grammar and syntax. However, grammar is also some- times altered; the loss of parts of speech is described as agrammatism. Adverbs are occasionally lost, resulting in coarsening and poverty of sentences, a form of telegramese. For example, ‘rich table is worn; the woman is rich to write; son is also lamentation’. This, as well as showing stock words (rich – lamentation), shows loss of parts of speech, for example, the inde nite article. The meaning is more disjointed than the grammar. Paragrammatism occurs when there is a mass of com- plicated clauses that make no sense in achieving the goal of thought. However, the individual phrases are, in themselves, quite comprehensible.

It seems probable that the rules of syntax are pre- served in schizophrenia long after a marked disturbance in the use of words, so that, if in the preceding clause an intrusive association were to replace the word ‘rules’, the word used would probably, correctly, be a noun. For instance, the patient just discussed might have said in this context ‘the lamentations of syntax are …’

In addition to the observed abnormalities already described, there are suggestions that patients with schizophrenia demonstrate lack of use of cohesive ties in discourse (for a full discussion, see McKenna and Oh, 2005). Cohesive ties in discourse are devices that are utilized to link sentences together, so that speech is not merely a collection of unrelated sentences. There are four main types of cohesive ties: reference, conjunction, lexical cohesion and ellipsis. References in English are personal pronouns such as ‘he’, ‘she’, ‘they’, ‘it’; demon- stratives are such words as ‘this’ and ‘that’; and compara- tives such terms as ‘smaller than’, ‘equal to’, etc. In the following sentences, ‘He’ is a reference tie: ‘I met Peter yesterday. He was wearing a dark suit’. In the sentence ‘She went to the High Street this morning and bought some cakes from the supermarket’, ‘and’ is a conjunction tie. A lack of use of cohesive ties means that the listener in dialogue with a patient with schizophrenia can have dif culty following the speech of the patient.

PSYCHOGENIC ABNORMALITIES

Andreasen (1979) showed that the abnormalities of language present in schizophrenia were also present in mania. Furthermore, McKenna and Oh (2005) make the case that there is a continuum of language or thought disturbance from schizophrenia through mood disorder to organic disorders such as epilepsy and frontotemporal dementia. The point that McKenna and Oh want to emphasize is that language abnormalities in schizo- phrenia have a neurologic substrate, linking the observed disturbances to aphasia, a return to the ideas that originated with Kleist in the twentieth century.

Manic speech has been analyzed, and the speech and number of associations demonstrated in ight of ideas and pressure of talk is seen in the greater number of cohesive links occurring in manic speech. The content of depressive speech is, of course, in uenced by the mood state, and so also is the choice of words. Sentences tend to be short and have fewer and simpler associations, with retardation.

Hysterical mutism may occur as an abnormal reaction to stress. A man aged 35 had been unable to tolerate the continual nagging from his wife and her two sisters who lived with them. One day, after heavy drinking the previous evening, he smashed his wife’s furniture at home and then became mute for 24 hours. He was eventually referred from the accident and emergency department

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to the psychiatric ward, and speech returned gradually over the next 2 to 3 days without other treatment.

With the phenomenon of approximate answers (Chapter 5), the patient gives an incorrect answer to a simple question: ‘How many legs has a sheep?’ – ‘Five’. This is, according to Anderson and Mallinson (1941), ‘a false response to the examiner’s question where the answer, although wrong, indicates that the question had been grasped’. This symptom may occur in a number of conditions, including schizophrenia in which it is often associated with fatuous mood; dissociative disorder, previously designated hysterical pseudode- mentia (before making such a diagnosis, the wise psychiatrist thoroughly excludes an organic cause); Ganser’s syndrome; and other organic conditions.

Eccentric and pedantic use of words may sometimes be seen in those with anankastic personality; obsessional- ity obtrudes into the choice of words and construction of sentences.

STATISTICAL MODEL OF LANGUAGE

The Cloze procedure involves deleting words from the transcripts of speech and assessing whether the omitted word can be predicted. Maher considered that, in schizophrenia, the greater the severity of the illness, the greater is the degree of unpredictability of the utterance of language. In normal speech, a large part of every sentence could be omitted without losing the meaning. For example, if the words ‘a … part … could be … the’ were omitted from the last sentence, the meaning would still be obvious; if letters were omitted from words, for instance nrml spech, the meaning is still clear. Predictability is the ability to predict the missing words accurately; in this sense, patients with schizophrenia are unpredictable in their speech. They are likely to use unexpected words and phrases. In the perception of language, the patient with schizophrenia is less able to gain information from the redundancies, both semantic and syntactic, in everyday speech.

A sophistication of the Cloze procedure has been investigated by Newby (1998). This involves the following:

• The modi ed Cloze procedure, in which the nature of the inserted word is noted, such as its part of speech.

• In the reverse Cloze procedure, thought-disordered patients were asked to make sense of a script that

had been mutilated by instituting the Cloze procedure, for example by deleting every fourth or fth word. Patients with schizophrenia per- formed signi cantly worse than a control group of orthopaedic patients, with manic-depressive patients intermediate on both modi ed and reverse Cloze procedures.

Schizophrenic speech is considered less predictable than normal speech, and lack of predictability is more marked with clinically manifest thought disorder (Manschreck et al., 1979). An experiment was carried out using the Cloze procedure, in which raters were asked to assess passages of schizophrenic or normal speech with the fourth or fth word deleted. With fth word deletion, thought-disordered schizophrenic speech was signi cantly less predictable than normal or nonthought-disordered schizophrenic speech; this latter was no less predictable than normal speech.

Whether schizophrenic speech is really less redun- dant than normal has been questioned by Rutter (1979), who was able to demonstrate no difference. The view that schizophrenic language can be reduced to such simple mathematical rules has been rejected by Man- delbrot (1965). But studies using this technique con- tinue, even if sporadically, and demonstrate that the speech and language of patients with psychosis may be less predictable than that of controls (Adewuya and Adewuya, 2006).

The type:token ratio is a measure of the number of different words compared with the total number of words used by a speaker (Zipf, 1935). Maher concluded that the type:token ratio of schizophrenic patients was lower than for normal subjects. The tendency of schizophrenic patients to repeat certain words and use them in an idiosyncratic way is referred to as the use of stock words.

LINGUISTIC APPROACHES TO SCHIZOPHRENIA

Various linguistic theories have been applied to schizo- phrenia (for a full discussion, see McKenna and Oh, 2005). These methods of analysis of schizophrenic language are tentative and do not yet cover the range of abnormalities occurring in the condition. Chomsky (1959) proposed that humans are able to use strings and combinations of words they have never heard before through use of a limited set of integrative processes and generalized patterns. However, Moore and Carling (1982)

have labelled Chomskyan linguistics a container view of language, separated from the real way users of language apply it to their own meanings and contexts. Individual case studies have used tape-recorded interviews with patients with schizophrenia to demonstrate distinctive abnormalities. However, on closer analysis, such abnor- malities are often found to occur in the speech of normal people, although less frequently. A further study of bilingual patients showed psychotic symptoms to be present in their native language but absent in their second language. The problem of individual studies is, of course, the extent to which they can be generalized to all patients with schizophrenia.

Syntactical Analysis

In studies of speech analyzed for syntax, compared with manic and normal controls, patients with schizophrenia showed less complex speech, fewer well-formed sentences, more semantic and syntactic errors and less uency. There were also marked use of paraphrasias, agrammatisms, anomia, pronoun word problems, circumlocutions, etc. These problems seemed to be associated with a general intellectual impairment (McKenna and Oh, 2005). Such studies do not, of course, justify the conclusion that differences are due directly to the disease or to thought disorder, nor does it take into account the social context or emotional aspects. However, marked differences are of interest when one considers that the majority of patients with schizophrenia do not show overt disorder of language.

Propositional Analysis

This is a form of textual analysis in which the text is broken down into its component propositions, and these are then represented diagrammatically to show the ‘mental geometry’ (Hoffman et al., 1982). Normal speech is considered to proceed as in a single tree diagram with all branches leading from a single key proposition, but psychotic speech more often breaks the ‘rules’ of propositional relationships.

Observers, listening to the speech of patients with schizophrenia, are often struck with its oddity and deviance. It has been considered by Chaika (1995) that this is not purely a de cit of syntax but more a phenomenon like severe and repeated slips of the tongue, in which the error is a lapse of executive control,

a lapse of volition. It has been shown by Morice (1995) that with increasing complexity of syntax there is an increase in the number of errors in the speech of patients with schizophrenia; speakers expressing very simple sentences made relatively few errors. One of his patients expressed this: ‘and communicating ordinarily I can get lost in the chaos of the language’.

This nding was con rmed by Thomas and Leudar (1995) using the Hunt test, a written test in which subjects produce syntactically complex sentences from simple input phrases. Communication-disordered patients with schizophrenia made more errors than noncommunication- disordered patients with schizophrenia or normal controls, and these errors were more likely to occur with more complex syntactic structures. The patients were therefore thought to have a discrete failure of language processing that was distinct from the more general cognitive disorders of the condition.

Although these methods are still experimental, the patient’s use of language and syntax does enable a quantitative method of evaluating the mental state and subjective experience to be developed. Study of language disorder should be an area in which descriptive psy- chopathology can contribute to psychiatric research.

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KEYWORDS

Insight Self-awareness Self-monitoring Theory of mind

Summary

Insight, in psychiatry, refers to the capacity of the patient to recognize that their mental symptoms are indicative of mental illness and that these symptoms require treatment. It is now known to be associated with impaired cognitive function, and predicts poor compli- ance with treatment, compulsory admission and coercive treatment in hospital. The underlying neural mechanism of poor insight is starting to be illuminated and is linked more widely to de cits in self-awareness, self- monitoring, empathy and theory of mind.

A man who knows who and what he is, his position in the world, and what the persons and things are around him; who judges according to known, or intelligible rules; and who, if he has singular ideas or singular habits, can give a reason for his opinions and his conduct; a man who, however wrong he may act, is not misled by any uncontrollable impulse or passion; who does not idly squander his means; who knows the legal consequences of his actions; who can distinguish between unseemly and seemly behaviour, who feels that which is proper and that which is improper to utter, according to the circumstances in which he is placed; and who reverences the subject and the ministers of religion; a man who, if he cannot always regulate his thoughts and his temper and his actions, is not continually in the extremes, and
if he errs, errs as much from benevolence and hesitation, as from passion and excitement, and more frequently: lastly, a man who can receive reproof, and acknowledge when he has needed correction.

John Perceval (1840)

Self-awareness is a basic human ability. It refers to the ability to recognize one’s own existence and expe- rience and the existence and experience of others. It includes the facility for monitoring the events in one’s own life and the ability to make decisions about the future on the basis of that knowledge. Furthermore, it involves the ability to communicate this awareness of self and others to other human beings (Marková, 1987). This characteristically human ability is partly the subject of Sophocles’ (496–406 BCE) Oedipus the King, in which Oedipus’ quest for self-knowledge resulted in his discovery that he had killed his own father and fathered children by his own mother. The aphorism ‘Know Thyself’ is said to have been inscribed at the forecourt of the Temple to Apollo at Delphi and in The Apology, Socrates (470–399 BCE) says, ‘The unexamined life is not worth living for a human being’. These references to self-knowledge in antiquity underline the place of this notion in human life.

Self-awareness obviously takes in much more than an awareness of illness, but it is plain that the psychiatric notion of insight is a subset of the general concept of self-awareness or self-knowledge. Insight, as a notion, is much wider than just knowing whether one is ill, and if so, having a sensible view regarding treatment. It involves our capacities for introspection, empathy and communication; not only is it glimps- ing ourselves as we really are but also ourselves as others see us, and therefore others as they really are because they go through the same repertoire of mental mechanisms that we do. Even for the most private and internal of insights, what might be termed our social awareness, the capacity for relationships, for empathy, and knowing and understanding how our behaviour will affect the emotions and experience of other people is important. Insight is the direct product of knowing ourselves. It is a quality that has been highly valued by most mental health clinicians, because a strong link is assumed between having insight and have better

CHAPTER 11

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quality of life and a more ful lling life (McGorry and McConville, 1999).

Although, in psychiatry, we concentrate mostly on the narrow meaning of insight with regard to mental illness, we need to retain this broader concept. Often, our work with patients involves us having insight into their thinking and behaviour because of our capacity for empathy as fellow human beings and also helping them gain insight into themselves and the roots of their problems.

The relationship between this capacity for insight in a general sense and the practical issues of treatment is close. A physician suffering from delusional disorder advertised and sold magnets for the medical treatment of arthritis and hay fever. He strongly believed that this form of treatment was of unequalled value for virtually all medical conditions, and he had physically assaulted a pharmacist who had tried to persuade him otherwise. He decried the validity of the whole of psychiatry, ‘because I am a scientist and everything has to be proved with evidence’. Because of his lack of insight into his own condition and the nature of his beliefs, it was impossible to initiate treatment. His symptoms persisted long term.

Jaspers (1997) has written about the patient’s attitude to his illness under the following headings:

1. Understandable attitudes to the sudden onset of acute psychosis (perplexity, awareness of change)

2. Working through the effects of acute psychoses

3. Working through the illness in chronic states

4. The patient’s judgement of his illness

5. The determination to fall ill

6. The attitude to one’s own illness: its meaning
and possible implications

All these points, and especially 3, 4 and 6, involve

the process of insight, the knowledge of oneself with particular reference to illness. A person who becomes seriously and suddenly ill, whatever the nature of the illness, after previously having been t for many years, is astonished by his change of health status. Such a person is likely to undergo a profound change in self and body image. He has become a person who, from being healthy and seeing illness as something that happens to other people, now sees himself as potentially frail and vulnerable. This can be person- ally enriching and is not necessarily a wholly negative experience.

Insight in Clinical Practice

So that she can better help her patient with a possible mental illness, the psychiatrist asks speci c questions about the patient’s opinions concerning his illness. These include his degree of acknowledgement of illness, his attitudes to illness, his understanding of the effects of his illness on his current capabilities and future pros- pects. All this adds up to the assessment of insight into his condition. Insight is not an absolute; it can vary in its impairment with different facets of the condition; for example, a patient could have some limited under- standing concerning his unlikelihood to obtain a job compatible with his quali cations but virtually no understanding as to how his psychotic symptoms interfere with relationships. Thus insight is now not considered to be an all-or-none phenomenon, in either clinical evaluation or measurement, but rather a dimensional one, so that subjects can have different levels of awareness of their illness (Surguladze and David, 1999).

All mental illnesses will alter the patient’s worldview and capacity to cope with circumstances. Assessment of insight measures the awareness of this change by the patient and his ability to adapt to the change. Insight is highly complex as a function. It is the understanding of the individual about his own state of health, capacity and worth; it also relates this assessment of internal state to other people and the world outside. In other words, insight requires both inner and outer orientation. This aspect of insight becomes more apparent later in this chapter, in the discussion of the contribution of Gestalt psychology to the conceptualization of insight. Insight in Gestalt psychology is oriented towards problem solving in the external world, whereas insight in clinical practice is inner-directed.

David (1990) regards insight as composed of three distinct, overlapping dimensions: the recognition of morbid psychological change, the labelling of this change as deriving from mental illness and the under- standing that this change requires treatment that needs to be complied with. An assessment schedule was constructed for determining the nature of insight and quantitative loss of insight correlated with the degree of psychopathology (David et al., 1992).

One of the most frustrating aspects of practising psychiatry is, from the point of view of the treating

professional, the apparent inability of patients to rec- ognize and/or admit that they are mentally ill. Patients, especially those with schizophrenia, often deny that their experiences are abnormal and that they are unwell. Daniel Schreber (1842–1911) described his attitude towards his auditory verbal hallucinations in his book Memoirs of My Nervous Illness (Schreber, 1955) as follows:

I noticed therefore with interest that according to Kraepelin’s TEXTBOOK OF PSYCHIATRY (5th
edition, Leipzig, 1896, p. 110 ff) which had been lent
to me, the phenomenon of being in some supernatural communication with voices had frequently been observed before in human beings whose nerves were in a state of morbid excitation. I do not dispute that in many of these cases one may be dealing with mere hallucinations, as which they are treated in the mentioned textbook. In

my opinion science would go very wrong to designate as ‘hallucinations’ all such phenomena that lack objective reality, and to throw them into the lumber room of things that do not exist.

Furthermore Schreber continues:

Science seems to deny any reality background for hallucinations … In my opinion this is de nitely erroneous, at least if so generalized.

These quotations from Daniel Schreber demonstrate one of the most complex aspects of the nature of insight. This is the capacity to have an attitude towards abnormal experiences in others where one can recognize them as pathologic, but to deny the abnormality of the experience in oneself, and to designate it as not being evidence of mental illness. This is the so-called double book-keeping.

The resulting refusal to cooperate with treatment and rehabilitation causes long-term suffering for the patients and their carers. It is this capacity of patients to understand their own illness that is evaluated clinically in insight. Like many other concepts, termi- nologic confusion exists, with textbooks describing insight as the patient’s capacity to form judgements about their own illness and mental state. In recent years, there has been a resurgence of interest in the concept, with attempts to de ne it reliably and

11 Insight 161 quanti ably and to study its correlates (Kumar and

Sims, 1998).
Overview of the Concept

The attitude of the patient towards his illness has obvious clinical implications, and insight tries to assess the awareness of the patient concerning the impact his illness has had on his life and his capacity to adapt to the changes brought about by it. As a function, it is highly complex and has to do with an individual’s evaluation of his self and non-self and their related- ness (see Chapter 12). In clinical practice, only certain aspects are given importance, such as the patient’s awareness of illness and compliance with prescribed treatment. The assessment of insight assumes more importance in psychosis, as the incongruence between the patient’s and others’ view of his illness often leads to dif culties with treatment. The convention in psy- chiatry is that insight is unimpaired in nonpsychotic conditions, but it can be seen that a broader view nearer to the lexical de nition is relevant when neurotic symptoms hamper the full realization of a person’s potential.

DEVELOPMENT OF THE CONCEPT

Contributions to the development of the concept of insight derive from psychopathology, Gestalt psychology and psychoanalysis. In Gestalt psychology, insight is conceived as a sudden, unexpected solution to a problem. According to Marková (2005), the ‘suddenness’ speci es an abrupt solution to a problem, the ‘unexpectedness’ refers to the surprise element of the event and the term ‘solution to a problem’ signals the discreteness of the event in time. In essence, in Gestalt psychology, insight is by de nition related to a speci c task, a problem that stands in need of solution in the external world. Fur- thermore, there has been extensive debate within Gestalt psychology about the nature of insight, whether it is a unique human facility that is also a speci c cognitive skill. The fact that, in Gestalt psychology, insight refers to a problem in the external world distinguishes it from the concept of insight in clinical practice. In clinical practice, insight focuses on understanding of changes or happenings within an individual.

For Jaspers (1997), typically the patient’s attitude to his illness involves ‘an awareness of illness’ in which

162 SECTION III Awareness of Reality: Time, Perception and Judgement

the patient ‘expresses a feeling of being ill and changed, but there is no extension of this awareness to all his symptoms nor to the illness as a whole. It does not involve any objectively correct estimate of the severity of the illness nor any objectively correct judgement of its particular type’. For Jaspers, ‘only when all this is present and there has been a correct judgement of all the symptoms and the illness as a whole according to type and severity, can we speak of insight [emphasis in original]’. Thus for Jaspers insight becomes manifest only when the patient is able to turn away from the content of his psychic experiences towards making a judgement about it and inquiring into its causes and reasons. Lewis’ (1934) de nition of insight as ‘a correct attitude to morbid change in oneself’, is a restatement of Jaspers’ description of insight. Freud (1981) used the term insight to denote knowledge of illness but, on the whole, in psychoanalytic therapy the development of a deeper awareness of self is considered to be the goal of treatment. This is another way of saying that in psychoanalysis, insight refers to knowledge and understanding of one’s unconscious mental processes. This is a more complex notion of insight because it involves the patient acquiring understanding of the unconscious motivations of his behaviour and, in the light of Freud’s structure of the mind, it suggests a degree of depth of understanding.

David (1990) has proposed that insight is composed of the three overlapping dimensions described earlier. It has been suggested that parallels can be drawn between the loss of insight in psychiatric patients and the loss of awareness of disease of parts of the body in certain neurologic conditions. In cortical blindness, left-sided hemiplegia after stroke and amnesic syndrome, lack of awareness of disease is well recognized. The term anosognosia was coined by Babinski (1857–1932) to refer to the unawareness or denial of hemiplegia seen in patients after a stroke. There is a difference, however, between the lack of insight seen in psychiatry and the lack of awareness seen in neurologic disease. In psychiatry, lack of insight is often attended by a wider loss of judgement beyond merely the symptoms or their implications for the patient. In neurologic cases, the lack of awareness is focused on a discrete disability. Nonetheless, even though the lack of insight in psy- chiatry and lack of awareness of disease in neurology are not identical, it may be that comparisons may point

to possible neurobiological bases that they share in common.

There are certain philosophic problems when we consider insight in patients with psychosis. People without any psychiatric illness vary in their ability to know themselves and the consequences of their per- sonalities. Because at least some conceptualizations of psychosis rely on the lack of insight as a de ning feature, discussion concerning the concept can become circular. Added to this is the fact that varying degrees of insight can occur and that nonverbalization of insight may be different from the lack of it. Yet another problem is that a possibly specious model in which a ‘normal’ part of the mind is capable of passing judgement on the ‘abnormality’ of another part has to be entertained. This works for as long as the clinician recognizes that it is merely a way of speaking, not necessarily an accurate representation of how self-monitoring takes place.

MEASUREMENT OF INSIGHT

Earlier attempts to measure insight centred on its role in psychodynamic therapies. Tolor and Reznikoff (1960) developed a test using hypothetical situations based on common defence mechanisms and found a correla- tion with intelligence. This test was used by Roback and Abramowitz (1979), who found a correlation in those with schizophrenia between greater subjective distress and better behavioural adjustment. The validity of this test for general clinical work is affected by the concept of insight being based on psychodynamic rather than psychopathologic features.

Any reliable and valid measure of insight in clinical practice should be based on the following four assumptions:

• insight is complex and multidimensional,
• cultural factors need to be taken into account, • the level of insight can vary across the many

manifestations of mental illnesses, and
• information about the nature of a person’s illness from situations other than the interview should be taken into account (McGorry and McConville,

1999).
McEvoy et al. (1989a) developed a questionnaire

to measure insight, de ned as the patient’s awareness of the pathologic nature of his experiences and also his agreement with the treating professionals about the

need for treatment. The Insight and Treatment Attitudes Questionnaire (ITAQ) is a validated 11-item, semi- structured interview that generates a score from 0 (no insight) to 22 (maximum insight). Using this question- naire, they found no correlation with aspects of acute psychopathology.

The Schedule for Assessment of Insight in Psy- chosis was published in 1992 (David et al. 1992), in which, apart from the recognition of mental illness and compliance with treatment, the ability to re-label unusual mental events as pathologic was also included. There were seven items with a maximum possible score of 14 and an additional item on hypothetical contradiction.

The Scale to Assess Unawareness of Mental Dis- order (Amador and Strauss, 1993) is a much more comprehensive scale with six general items and four subscales, from which 10 summary scores can be calculated. Other scales available are the Global Insight Scale (Green eld et al., 1989) and the self-reported Insight Scale for Psychosis (Birchwood et al., 1994). The scale by Markova and Berrios (1991) is more directed to evaluating aspects of self-awareness and less to clinical de nition of insight with regard to illness. This is also true for the Beck Cognitive Insight Scale (Beck et al., 2004) that measures a wider notion of insight, encompassing patients’ capacity for evaluat- ing their anomalous experiences and their erroneous inferences. The scale is composed of two subscales: self-re ectiveness and self-certainty.

Other approaches have been to use the ‘lack of insight and judgement’ item of the Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987) as a single global measure of insight, and the use of psychopathology vignettes. McEvoy et al. (1993) used vignettes that cast speci c psychopathologic features in everyday language to judge whether patients dem- onstrated these features and the degree to which they attributed them to mental illness. They found that patients failed to acknowledge negative symptoms and failed to view positive symptoms as evidence of mental illness.

From earlier impressionistic assessments of a global nature, measurement of insight has more recently progressed to the use of operationalized de nitions and standardized instruments. Although the different instruments might be measuring different aspects of

a complex phenomenon, there is at least the freedom to choose one to suit specific clinical or research aims. There is an inverse correlation between insight, the severity of psychopathology and positive affective disturbance (Sanz et al., 1998).

SCHIZOPHRENIA

It is not really surprising that most of the research work on the clinical correlates of insight has been on patients with schizophrenia. McEvoy et al. (1989a) reported that insight as measured by the ITAQ did not correlate with either the severity of acute psychopathol- ogy or the changes in psychopathology with treatment. They speculated whether the mechanisms underlying the production of positive symptoms and disturbed insight were independent and whether the latter was more resistant to the effective use of neuroleptic medica- tion. David et al. (1992) found that the ‘total insight score’ in their study had a moderate inverse correlation with the Present State Examination (Wing et al., 1974) total score, which was an indication of the global severity of the illness. Both David et al. (1992) and McEvoy et al. (1989b) found that, as a group, involuntary (that is compulsorily admitted) patients have less insight. Overall, it does appear that the relationship between poor insight and aspects of psychopathology is not linear but complicated by other factors, including compliance with treatment.

Insight and Cognitive Impairment

It has often been speculated that poor insight may have a neurologic basis. Lysaker and Bell (1994) found that subjects with impaired insight performed more poorly than subjects with unimpaired insight on the Wisconsin Card Sorting Test (WCST). They used the PANSS item of ‘lack of insight and judgement’ to measure insight. This item had been shown by factor analytical studies to be a member of the component composed of symptoms of cognitive impairment such as cognitive disorganization, poor attention, stereotyped thinking and poor abstract thinking. However, using a different methodology, Kemp and David (1996) failed to show a relationship between insight and neuropsychological de cits. It is possible that chronicity of the illness could be an additional variable, which predisposes to cognitive impairment. David et al. (1992) had found a relationship

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between aspects of insight and intellectual performance. Cuesta et al. (1995) failed to show any relationship between insight and poor performance on the WCST. However, the study did not use any of the standard rating scales to measure insight. In another study, Upthegrove et al. (2002) showed that impaired digit span as a measure of working memory was signi cantly associated with insight as measured by a standardized measure. Additionally, it is becoming clearer that insight correlates with indices of cognitive functions including measures of error monitoring, empathy and theory of mind (Pegaro et al., 2013; Pijnenborg et al., 2013; Kao et al., 2013). However, on balance, the exact nature and extent of these relationships is still unresolved. As in other clinical situations, the relationship may not be a straightforward one, as other variables, such as the chronicity of illness, treatment factors, and gender, may be involved.

Outcome

The relationship between insight and outcome is com- plex. First, greater insight seems to predict hopelessness, depression and suicide (Ampalam et al., 2012; Balhara and Verma, 2012; Schrank et al., 2014). Awareness of the adverse social implications of mental illness may be the mediating factor between insight and depression (Thomas et al., 2014).

Secondly, McEvoy et al. (1989c) found that patients with good insight were signi cantly less likely to be rehospitalized and tended to be more compliant with treatment 30 days after discharge; the overall relation- ship between insight and outcome closely approached statistical signi cance. Their measure of ‘after-care environment’, which aimed to re ect the degree to which others’ efforts were helpfully invested in maintain- ing the patient in treatment, was not related to insight. Amador and Strauss (1993) also found their measures of insight to be correlated with the course of the illness.

Related to the issue of prognosis and outcome is compliance with treatment. The relationship between poor insight and poor compliance with treatment has been shown by Bartko et al. (1988), Lin et al. (1979) and McEvoy et al. (1989c).

The balance of evidence seems to be that higher levels of awareness of having an illness are associated with better medication compliance and clinical outcome (Amador et al., 1991) in schizophrenia. However, there

is a risk of circularity of logic, in that some of the measures of insight are based on de nitions of insight that include non-compliance. Moreover, compliance with prescribed treatment is a much more complex phenomenon affected by social factors and beliefs about health and sickness (Bebbington, 1995). It is also possible that the relationship between compliance and different aspects of insight may be different. David et al. (1992) found that treatment compliance was not strongly related to the ability to recognize one’s own delusions and hallucinations and to re-label them as abnormal.

It is interesting that patients may comply with treatment, even though they do not believe themselves to be ill, if the social milieu is conducive (McEvoy et al., 1989b, 1989c). The role of health beliefs and illness representation in determining compliance with treatment is recognized, but how these interact with insight to in uence treatment compliance has yet to be studied. The domains of illness representation are identity (the label of the disease), causes (explanatory models), timeline (onset and anticipated duration), control (belief that self can in uence outcome) and consequences (functional as well as other consequences) (Brownlee et al., 2000). What is obvious is that insight is not the only determinant of care-seeking and treat- ment adherence. McEvoy et al. (1993) proposed that insight would improve with attempts at psychosocial rehabilitation. This was further studied by Lysaker and Bell (1995) on a sample of patients with a diagnosis of schizophrenia or schizoaffective disorder. Earlier, Lysaker et al. (1994) had found insight as measured by the item on PANSS to be correlated with poor levels of work quality and participation in rehabilitative programmes. In their study reported in 1995, patients enrolled in vocational rehabilitative programmes were found to have improved insight after 5 months. This improvement was greater for patients with comparatively few cognitive de cits, echoing their earlier ndings regarding a relationship with cognitive impairments. However, the lack of a control group limits the generaliz- ability of the ndings. It does seem an interesting suggestion that vocational rehabilitation can favourably affect insight in the absence of cognitive impairment. McEvoy et al. (1993) have proposed that enhanced self-esteem from rehabilitation may underlie improve- ment in insight.

BIPOLAR DISORDERS

Ghaemi et al. (1995) studied insight in patients in acute mania using the ITAQ and found that improvement in insight did not correlate with recovery from other symptoms. However, as in schizophrenia, poor insight was correlated with involuntary admission. Swanson et al. (1995) used the case vignette method to study insight in two groups of patients with schizophrenia and mania. They found a qualitative difference between mania and schizophrenia, in that patients with schizo- phrenia but not mania had reduced awareness of features of their illness. However, although the manic patients were aware of their symptoms, they did not agree that these emanated from a mental illness. Amador et al. (1994) and Michalakes et al. (1994), on the other hand, found no signi cant difference between patients with schizophrenia and mania on measures of insight. The former found that severely manic patients were similar to patients with schizophrenia on scores of insight, whereas depressed and schizoaffective patients had more insight. In conclusion, it seems to be that both schizo- phrenia and bipolar disorder patients have impaired insight and the mediating factors may be severity of symptoms and cognitive impairment, especially working memory impairment (Varga et al., 2007).

CRITICISMS OF THE CONCEPT

The recent resurgence of interest in insight has had its share of criticism. Medical anthropologists have criti- cized the concept of insight for failing to recognize that people can have various culturally shaped frame- works to explain their illnesses, all possibly valid. From this point of view, the concept of insight is ‘Eurocentric and essentially arrogant’ (Perkins and Moodley, 1993), as it dictates that patients should, apart from agreeing that they are mentally ill and requiring treatment, also agree to reconstruct their experiences within the terms and concepts of Western psychiatry. Johnson and Orrell (1995) have reviewed work by social scientists on cultural and social variations in lay perceptions of mental illness and argue that these would in uence insight. Social and cultural backgrounds in uence perceptions of stigma from mental illness and the congruence of the patients with Western medical views of mental illness. The ability to re-label mental phenomena as abnormal may be less in uenced by social factors

compared with beliefs about the causation of mental illness. Although there are few studies in this area, evidence seems to be emerging that social and cultural factors are important in the diagnosis of poor insight. For example, differences in the ethnic background of the psychiatrist and the patient appear to in uence the judgement of the former about insight (Johnson and Orrell, 1996).

AETIOLOGY OF IMPAIRED INSIGHT

Attempts to explain the causation of poor insight have focused on three hypotheses (Amador et al., 1991; Lysaker and Bell, 1994). The rst two focus on putative psychological mechanisms. It has been suggested that refusal to take prescribed medication, implying poor insight, is a wilful preference for the experience of psychotic phenomenology over drug-induced normality. The second formulation suggests that patients deny illness at a psychological level to help them cope with normal life as they recover from a psychosis. A third explanation has suggested that poor insight may have something to do with cognitive impairment, drawing on similarities with neurologic conditions such as anosognosia. As mentioned earlier, studies have found a signi cant correlation between impaired performance on the WCST and poor insight, suggesting that cognitive impairments resulting from frontal lobe de cits may underlie poor insight in schizophrenia. A fourth explana- tion is that disruption of neural mechanisms and networks underlying self- and other-monitoring are involved. In a 2012 study, patients with schizophrenia demonstrated less activation in the posterior cingulate cortex in the self- and other-re ection conditions and less activation in the precuneus in the other-re ection condition compared with healthy controls. Better insight was associated with greater response in the inferior frontal gyrus, anterior insula, and inferior parietal lobule during self-re ection. In addition, better cognitive insight was associated with higher activation in ven- tromedial prefrontal cortex during self-re ection (van der Meer et al., 2013). More recently, there is the suggestion that symptom unawareness may be distinct from symptom misattribution and that this distinction may be underpinned by differing neurobiology as demonstrated by functional magnetic resonance imaging investigation (Shad and Keshavan, 2015). Clearly, there is still much to learn about the true nature of insight.

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SELF AND BODY

169

SECTION 4

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KEYWORDS

Ego
Body image Self-image Autoscopy Possession state

Summary

The self is a construct that has changed in meaning and signi cance over the years. There are ve putative, formal characteristics of the self: ego vitality, ego activity, unity of the self over time, self-identity and boundary of the self. These formal aspects of the self can be impaired by psychiatric disorders. The sense of vitality can be impaired to produce a feeling of deadness, the extreme example being nihilistic delusions. In disorder of activity the ‘my-ness’ of actions, the sense of being an agent enacting one’s will in the world, can be disrupted as occurs in passivity experiences. The unity of the self over time is markedly affected in autoscopy and dissociative identity disorders. Additionally, disorder of self-identity is illustrated by possession states and phenomena such as lycanthropy. Finally, abnormalities of the distinction between self and non-self (distur- bance of boundary) is central to our understanding of such diverse experiences in schizophrenia as passivity experiences, thought insertion and thought withdrawal.

Often, when I was alone, I sat down on this stone, and then began an imaginary game that went something
like this: ‘I am sitting on top of this stone and it is underneath’. But the stone also could say ‘I’ and think:
‘I am lying here on this slope and he is sitting on top of me’. The question then arose: ‘Am I the one who is sitting on the stone, or am I the stone on which he is sitting?’ This question always perplexed me, and I would stand up, wondering who was what now.

Jung (1963)

The self was never meant to be a solid object like a stone, a horse, or a weed, nor even a concept to be considered as semantically tantamount to changes
in blood ow or test scores. Of course, patients with disordered minds do sport hurting, af icted and cursing selves but not as they do carcinomas or broken legs. Their selves live in the same realm as do their virtues, vices, beliefs and aspirations, and that is where they should remain.

Berrios and Marková (2003)

Ego and Self

The self is a construct that has changed in meaning and signi cance since the inception of Hellenistic philosophy (Berrios and Marková, 2003). From the mid-nineteenth century onwards, various concepts about the self have found their way into psychiatry such that in contemporary psychiatry there is reckoned to be some disturbance in the way one thinks about and estimates oneself; this, of course, differs accord- ing to the nature of the illness. There is, however, no consensus on what exactly it means to be a self. There is a plurality of conceptions, including the ecological self, the interpersonal self, the extended self, the private self and the conceptual self among many (Zahavi, 2003). In this chapter, the terms ego and self are used more or less interchangeably. Ego has the advantage of being a technical term and therefore more circumscribed in its meaning; this is also a disadvantage when it is simply oneself, as is usually understood and subjectively expe- rienced, that is being referred to.

Freud’s use of the word ego echoes Nietzsche (1901):

It is this which sees everywhere deed and doer; this which believes in will as cause in general; this which believes in the ‘ego’ as being, in the ego as substance, and which projects its belief in the ego-substance on to all things.

CHAPTER 12

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Freud (1933) described ego as standing ‘for reason and good sense while the id stands for the untamed passions’. The ego

has been modi ed by the proximity of the external world with its threat of danger… The poor ego has to serve three severe masters and does what it can to bring their claims and demands into harmony with one another. These demands are always divergent and often seem incompatible. No wonder that the ego so often fails in this task. Its three tyrannical masters are the external world, the super-ego and the id. (Freud, 1933)

Embodiment and the Self

There is a convention that separates out the body from the self. This approach dates back at least to Descartes’ (1596–1650) dualism in which the body is regarded as distinct from the thinking immaterial self. More recently, there has been a growing body of work both empirical and philosophic that makes the case for a complex interaction between the fact we as persons are embodied, that is that our experiences as a physical being permeates and in uences all the central features of consciousness such as thinking, memory, language and of course the nature of self.

Gibbs (2005) put it like this:

People’s subjective, felt experiences of their bodies in action provide part of the fundamental grounding for language and thought. Cognition is what occurs when the body engages the physical, cultural world and must be studied in terms of the dynamical interactions between people and the environment. Human language and thought emerge from recurring patterns of embodied activity that constrain ongoing intelligent behaviour.

We must not assume cognition to be purely internal, symbolic, computational, and disembodied, but seek out the gross and detailed ways that language and thought are inextricably shaped by embodied action.

This approach has profound implications not only for how we conceive of the self but also for our under- standing of perception, abstract concepts, language and cognitive processes, among other things. There is a natural link between a rst person bodily perspective and the self in the brute sense that there can be no self

without a body. Again as Gibbs (2005) puts it ‘I know who I am, and that I am, in part, because I see my body … as I move and experience speci c sensations as a result of action’. And, the distinction that is drawn between self and non-self is at least in part shaped and in uenced by the distinction between our body and the physical environment.

In summary, despite the deeply set convention to treat the self and the body as separate entities, it is important to keep in focus the fact the self and the body are truly inseparable and that the conceptual distinction is for convenience only.

Self-Concept and Body Image

The body is unique in that it is experienced by a person both as subject of experience and as an object with the same materiality as any other physical object in the world. There is a way in which I am subjectively aware of my own body that is different from how I experience a block of wood. But I am also aware that my body is an object in the world, to be viewed and even acted on by others. For most of the time, we are not aware of our body but, for example, in extreme anxiety, traumatic pain and sexual excitement, there is an awareness of the body as an object: ‘my heart banging, my nger throbbing’. For the rest of the time, we assume the parts of the body to be integrated, and this integrated body, for practical purposes, coincides with and is coterminous with the ‘self’ of which we are not sepa- rately aware and which we take for granted. In other words it is mostly in times of distress or pain that we become aware of our bodies as distinct from ‘ourselves’. It is through our body that we have contact with the world outside our self: movements of the body relate us to external space; our hands have a prehensile tool- like aspect to them that allow us to grasp objects in the world; and our bodies have a physicality about them that occupy space, give us presence, locating us as objects in the world. One of Eugene Minkowski’s (1970) patients said:

I don’t want to attach so much attention to my movements, but I am only grub and defaecation. I am only a sort of animal function, and one that injures himself. I have the feeling of being nothing but living tripe. I have neither sensations nor precise ideas. I have

the feeling of being nothing but vegetative functions, of being nothing but a mass.

Another said:

One day out of two, my body is hard as wood. Today my body is thick like this wall (points to the wall).

Minkowski referred to these experiences as exag- gerated materiality in which the patients demonstrate an increased awareness of the ‘objecti ed’ aspect of the body and rendering salient for the clinician an attitude to the body that is not manifest in day-to-day life.

Many terms are used to describe the way a person conceptualizes himself. Neurologists, neuropsychiatrists, psychoanalysts and psychologists have used variously the terms body schema, body concept, body cathexis, body image and perceived body. They describe approximately the same thing but with different nuances. For example, self-concept tends to refer to the fully conscious and abstract awareness of oneself, whereas body image is more concerned with unconscious and physical matters and includes experiential aspects of body awareness. Sometimes self-concept is the same as body concept, and at other times, conscious self is conceptualized as being independent of its ‘cage’, the body. The body schema implies a spatial element and is more than, and usually bigger than, the body itself. For instance, if you imagine yourself on your way to work, automatically included within your schema of yourself are your clothes and your spectacles, if worn. The body schema changes with changing circumstances. When I drive my car, I incorporate within my concept of my physical size the width of my car, so that I am unlikely to attempt to drive through a doorway or up a ight of steps. Spec- tacles, a cigar, the carpenter’s screwdriver and the blind man’s stick all contribute to that person’s concept of his self in a particular situation. Cathexis implies the notion of power, force, libido – perhaps analogous to electrical charge: the self that makes things happen!

Social aspects are obviously important. A man with shoulder-length hair is not usually so endowed through neglect; more likely, it represents a deliberate choice – how he sees himself in his social setting. It accords with his chosen peer group and also distin- guishes him from those from whom he would wish to be disassociated. Critchley (1950) has commented on

‘that curious emotional state usually known as being in love’, in which there is ‘a compulsive trend in two body images of opposite sex towards propinquity and contiguity, eventually culminating in a total fusion or merger’. As a phenomenologist, one could take exception to Critchley’s misuse of the term compulsive. According to Schilder (1935), body images are never isolated; they are always encircled by the body images of others. Body images are more closely bound together in the erogenous zones and are social in nature. Our body image and the way other people see us are not exclusively dependent on each other. A person sees himself and forms his self-image in a social setting. He sees himself in relation to other people; his view of himself is not totally dependent on, but importantly in uenced by, how another individual sees him. It is also determined by how he believes that people might see him.

The development of body image has been neatly summarized diagrammatically by Bahnson (1969). He considers that self-image is changeable and amorphous. At any one time, the individual perceives only a small sample from a gallery of possible self-images. In Fig. 12.1, the manner in which ‘phenomenological selves are

Somatic self: prenatal, 1 year

Self-differentiation from the environment: 1–3 years

Oedipus, family, role taking, externally derived self-image: 4–10 years

Puberty, revival of body image: 11–14 years

Redefinition of social roles: 15–18 years

Adult investment in society, symbols, abstractions, family of procreation

FIG. 12.1 Developmental phases of the self-image.

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superimposed on each other like the layers of an onion’ is demonstrated. Different aspects of self-image develop as the person increases the scope and complexity of his relationships. The term ego is not phenomenologi- cally describable, and there has been argument that the self cannot observe itself; that is, a thing and what observes that thing cannot be the same. However, it is the nature of self and ego to be experienced as either subject or object: a small nuisance like a mouth ulcer can make me feel uncomfortable (subjectively); I can describe what a person with a mouth ulcer experiences (objectively).

Self-Image and Nonverbal Communication

In a social relationship, a person expresses views he has about himself: his words, and the way he says them, convey how he views his relationship with the other person and also how he sees himself, for example the shopkeeper ‘talking down’ to a child. Probably more important than this verbal manner of expressing, often unconscious, views on how we see ourselves is nonverbal communication. All gestures and postures, movements of the face and pauses in our conversation convey meaning to the person we are talking to; partly, this is also a comment on the way we see ourselves.

‘The central core of self-image consists for a person of his name, his bodily feelings, body image, sex and age. For a man the job will be central – unless he is suffering from job alienation. For a woman, her family and her husband’s job may also be important’ (Argyle, 1975). The gender discrimination of that statement is now dated, but it emphasizes that for different people, there are varying aspects that form the essential concept of self. Nonverbal aspects of communication are important in sending and receiving information about the personality. The role in society one has adopted and the group with which one identi- es are intentionally conveyed and therefore display self-image. These include ‘age, sex, race, social class, rank, occupation, school or college attended, nationality, regional origins, religious group and family connections’ (Argyle, 1975). These attributes of the person are often deliberately displayed, but there are other character- istics that will be received nonverbally by observers even when the person has no intention of revealing them, for example, temperament, personality traits such

as introversion, intellect, beliefs and values and past experiences.

Nonverbal communication expresses the attitudes of a person, according to Argyle, for the following reasons.

• There is in some areas of human concern a lack of language or ‘verbal coding’; for example, shape is more readily expressed with the hands than verbally. Describing personality, our own or another’s, or commenting on personal relationships is more easily done nonverbally. A person will attempt to communicate nonverbally his or her own physical attractiveness, role and attitude towards the other person.

• Nonverbal signals are more powerful: actions speak louder than words. For a schoolteacher, beckoning may be more likely to result in action than a verbal order.

• Nonverbal signals are less censored and therefore more likely to be genuine. If con icting messages are given verbally and nonverbally, the nonverbal signal is accepted as truthful.

• Some messages, because of social censorship, cannot be made explicit in a social setting and therefore cannot be verbalized but can be conveyed nonverbally by appropriate posture, gesture and movement in space. For example, by facial expres- sion and turning away, a person might suggest without making it explicit ‘I do not like you and am bored with speaking to you’.

• Verbal messages are punctuated and emphasized nonverbally, for example, the pause at the end of a phrase or the cadence of voice used. These embellishments add meaning to the actual words used.

A person interacts with others by the use of language. However, nonverbal signals are also important in expressing meaning and conveying feelings. The ego talks with the body as well as with words.

Awareness of the Body

We have an awareness of our self and an awareness, which overlaps with this but is slightly different, of our bodies. What is this sense of body image or awareness? According to Head and Holmes (1911), the body schema is formed as the composite experience of sensations.

Schilder (1935) developed further the importance of perceiving sensations in forming the body schema: ‘the picture of our own body which we form in our mind, that is to say, the way in which the body appears to ourselves’. Freud (1933) also was concerned with body image in the development of personality: ‘the ego is rstly the body ego’. Clearly, abnormality of body image may be the result of abnormal sensations, but this is not always so. For instance, the abnormality of body image of an amputee is directly because of the physical damage, but a hypochondriacal patient may have no abnormal sensations yet believes he has cancer. In transsexualism, a man may have a normal sensory experience of his body but says that he hates his body and especially his penis; he may feel that he is actually a woman trapped inside a male body (Morris, 1974). His disturbed body image is not a result of disturbed sensation; there is a con ict between ego (the way he experiences himself and the gender he ascribes to it) and body image. The distinction made for convenience between this chapter and Chapter 14, between self-awareness and awareness of the body, is arti cial.

The body image can be altered through enhancement, diminution (or ablation) or distortion. It incorporates more than just the body, except perhaps for those few occasions when a person is both unclothed and conceptualizing himself as naked: tailors have long tried to persuade us that ‘clothes make the man’. Certainly, they are an effective means of nonverbal communication. Clothes give us some insight into the way a person sees himself or herself and also in the way he or she proposes to interact with other people. A person complements his mood and his social role of the moment in his choice of clothes. He wears clothes, as a ship hoists a ag, for signalling, and particular clothes are worn to convey a message to someone who can read it. A medical student wears a suit for an oral examination, a woman undoes the top button of her blouse on leaving the of ce for lunch. As the patient comes into a doctor’s consulting room, he starts to give information about himself from his appearance before either of them utters a word. A person whose clothes are chosen for him, as in mental hospitals in the past, presents a peculiarly bleak and meaningless appearance; this aspect of his body image is expressionless and conveys nothing of himself.

Disorders of Self

In descriptive psychopathology, one uses the term ego disorders or disorders of self to describe the abnormal inner experiences of I-ness and my-ness that occur in psychiatric illness. These may occur in the patient’s state of inner awareness irrespective of any changes he may show in his attitude to, or experience of, the world outside himself. Jaspers (1997), with charac- teristic clarity, described self-awareness – that is, the ability to distinguish I from not I – as having four formal characteristics. Scharfetter (1981, 1995, 2003) added a fth dimension of ego vitality to the list and has made a case for its inclusion based on factor analysis. Previously, this characteristic was incorporated within the awareness of activity, which subsumed ‘being’ and ‘existing’ with other present participles. Thus we now have the following characteristics of self-awareness:

• The feeling of awareness of being or existing (ego vitality): I know that I am alive and exist, and this is fundamental to awareness of self.

• The feeling of awareness of activity (ego activity): I know that I am an agent who initiates and executes my thoughts and actions.

• An awareness of unity (ego consistency and coher- ence): at any given moment, I know that I am one person.

• Awareness of identity (ego identity): there is con- tinuity in my biography, physiognomy, gender, genealogic origin, etc.; I have been the same person all the time.

• Awarenessoftheboundariesofself(egodemarcation): I am distinct from other things and beings and can distinguish what is myself from the outside world, and I am aware of the boundary between self and non-self.
The disorders of inner experience in which these characteristics are disturbed are now explored in more detail. We will deal with these ve functions described by Jaspers and Scharfetter in order.
DISORDER OF BEING OR EGO VITALITY
I never have to ask myself the question as to whether I exist. It is an assumption that I make with unquestion- ing certainty. I am so sure of this that it does not even come on to the agenda of doubts and uncertainties.

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My only knowledge that everything else exists is based on the premise that I do.

Being: the patient’s experience of his very existence may be altered: ‘I do not exist; there is nothing here’ or ‘I am not alive any more’ or ‘I am rotting’. This is the core experience of nihilistic delusions, which may occur in affective psychoses (Chapters 8 and 16). See below for an example.

I do not sense myself anymore. I do not exist anymore. When someone speaks to me, I feel as if he were speaking to a dead person. I have to look at myself to be sure that it is I. I have the feeling of being an absent person. In sum, I am a walking shadow. (Minkowski, 1970)

Less pronounced nihilistic ideas (not delusions) are experienced as depersonalization, an alteration of the way one experiences oneself, which is accompanied by a feeling of an alteration or loss of signi cance for self: ‘I feel unreal, a bit woozy, as though I can’t be quite certain of myself any more’.

DISORDER OF ACTIVITY

I do something and know that I am doing it. Everything I do, in everything I experience, through every event that impinges on me, I am aware that the experience has the unique quality of being mine. ‘It was incredible. I pinched myself to make sure it was really happening to me’ expresses the relationship we experience between awareness of reality and activity. It is in our actions, including our thinking, that we reinforce ourselves concerning our existence.

Moving may show abnormality – for example, in the passivity experience or delusions of control of patients with schizophrenia. Schreber described several examples of this experience:

The dif culties which were put in my way defy description. My ngers are paralysed, the direction of my gaze is changed in order to prevent my nding the correct keys, the tempo is quickened by making the muscles of my ngers move prematurely: all these were and still are daily occurrences.

and

the bellowing-miracle when my muscles serving the processes of respiration are set in motion by the lower

God (Ariman) in such a way that I am forced to emit the bellowing noises.

Memorizing and imagining may be changed in that the patient with depression feels he is unable to initiate the act of memory or fantasy; or, alternatively, a patient with schizophrenia feels that this activity when it occurs is not initiated by him but from outside himself. A depressed patient said, ‘my memory has gone, I have no thoughts, I cannot think at all’.

Willing may be altered – for example, the patient with schizophrenia who no longer experiences his will as being his own. Commonly, neurotic patients describe an inability to initiate activity, a feeling of powerlessness, of being ground down in the face of life’s vicissitudes.

Some of these abnormalities of experience of one’s own activities are closely associated with mood – for example, the feeling of the depressed patient who believes that he is incapable of doing anything at all: the alteration of self-concept is directly linked to the mood state. Sometimes, however, it is not the affect associated with the change of activity but the belief about the initiation of the activity that is changed. These are the passivity experiences (made experiences), which are discussed in more detail with other rst-rank symptoms of schizophrenia in Chapter 9.

DISORDER OF SINGLENESS OR EGO CONSISTENCY AND COHERENCE

In health, a person is integrated in his thinking and behaviour so that he is not aware of his feeling of unity. There is an implicit assumption that he is one person, and he knows his limitations and capabilities. This assumption of unity may be lost in some conditions. In dreams, one sometimes sees oneself, even perhaps with some surprise, in the drama. In some forms of transcendental meditation, by carrying out repetitive monotonous acts the subject enters a self-induced trance in which he can observe himself carrying out the behaviour. ‘Self’ is both the observer and also the object of observation (Box 12.1).

Autoscopy (Heautoscopy)

Autoscopy is a profoundly conceptually challenging phenomenon in which the usual indivisibility of the self appears to be compromised. According to Fish

BOX 12.1 DISORDERS OF SINGLENESS

extra-personal space seemingly totally dissociated from the physical body. In this phenomenon, the patient sees himself and the world from a location distinct from his physical body. There are three phenomenologi- cal characteristics here: disembodiment, the impression of seeing the body from a distant and elevated visuo- spatial perspective (the so-called extra-corporeal ego- centric perspective) and the impression of seeing one’s own body from this elevated position (Anzellotti et al., 2011).

Heautosocpy proper designates a condition in which an individual sees his double or doppelgänger. The double usually appears colourless, can behave independently and may or may not mirror the patient’s appearance. There is strong self-identi cation with the second body, often associated with the experience of existing at and perceiving the world from two places at the same time (Heydrich and Blanke, 2013). There may be vestibular sensations such as extreme lightness of the body, sensa- tion of ying, elevation, rotation and vertigo (Anzellotti et al., 2011 Blanke et al., 2004). There is a North European myth, shared by several countries, that someone may see his double (‘wraith’, ‘fetch’) shortly before his death, and it has therefore become a sinister omen (Todd and Dewhurst, 1962). These authors present interesting historical material to substantiate the link between perceptual doppelgänger and death. The usual legend is that, as the person lies dying, his wraith oats before his eyes, and he sees himself performing all the most disreputable and reprehensible actions of his life; they are paraded before him as he expires.

There is continuing popular interest in the concept of the double. It is the subject of diverse ction as in The Double by Fyodor Dostoevsky (1846), Robert Louis Stevenson’s The Master of Ballantrae (1889) and Shusaku Endo’s Scandal (1986). The very worst feature of the double for the subject himself is well illustrated in William Styron’s Darkness Visible (1991). The terrible, inextricable involvement of the double with the subject in trying to mortify him, goad him, provoke him to destroy the double and/or destroy himself.

the sense of being accompanied by a second self – a wraith-like observer, able to watch with dispassionate curiosity as his companion struggles against the oncoming disaster, or decides to embrace it … I, the

12 The Disordered Self 177

• There are six types of autoscopy: feeling of presence, negative autoscopy, inner autoscopy, autoscopic hallucination, out-of-body experience, heautoscopy proper

• Feeling of presence is a distinct feeling of the physical presence of another person

• Negative autoscopy refers to the failure to perceive one’s own body either in a mirror or when looked at directly

• Inner autoscopy refers to the experience of visual hallucinations of internal organs in extra-corporeal space

• Out-of-body experience is characterized by the projection
of an observing (psychological) self in extra-personal space seemingly totally dissociated from the physical body

• Heautoscopy designates a condition in which an individual sees his double or doppelgänger

(1967), ‘in this strange experience the patient sees himself and knows that it is he. It is not just a visual hallucination because kinaesthetic and somatic sensation must also be present to give the subject the impression that the hallucination is he’. More recently, Brugger and Regard (1997) have identi ed six types of autos- copy: the feeling of presence; negative heautoscopy; inner heautoscopy; autoscopic hallucination, out of body experi- ence; and heautoscopy proper.

In the feeling of presence, the patient has a distinct feeling of the physical presence of another person. No visual perception is usually reported. The feeling of presence may be con ned to one hemispace especially when the experience occurs in association with a seizure.

Negative heautoscopy refers to the failure to perceive one’s own body either in a mirror or when looked at directly. This phenomenon is often associated with depersonalization. Inner heautoscopy refers to the experi- ence of visual hallucinations of internal organs in extra-corporeal space (Sollier, 1903). Autoscopic hal- lucination is said to occur when a patient sees an exact mirror image of himself, or of his face or trunk. This experience is distinct from heautoscopy proper because the patient does not localize himself in the position of the mirror image. These hallucinatory experiences are usually brief, lasting seconds to minutes and followed by ash-like recurrences (Brugger, 2002; Dewhurst et al., 1955; Lhermitte, 1951).

Out-of-body experiences are characterized by the projection of an observing (psychological) self in

178 SECTION IV Self and Body

victim-to-be of self-murder, was both the solitary actor and lone member of the audience … I watched myself in mingled terror and fascination.

There is growing evidence that autoscopic phenom- ena occur in association with seizures (Anzellotti et al., 2011). Furthermore, it has been postulated that autoscopy derives from a failure of integration of proprioceptive, tactile and visual information about the body accompanied by vestibular dysfunction (Blanke et al., 2004; Heydrich and Blanke, 2013). The anatomic basis and mechanism of autoscopy is yet to be clari ed but there is tentative evidence that the left posterior insular is involved in heautoscopy and right occipital cortex in autoscopic hallucination (Heydrich and Blanke, 2013). Because of the hypothesis that autoscopy is a failure of integration, the multimodal junctions between the parietal and temporal lobes and between the parietal and occipital lobes have been implicated. There is experimental work deriving from the application of transmagnetic stimulation of the left temporoparietal junction to produce heautoscopy (doppelgänger) (Blanke and Arzy, 2005).

In practice, these phenomena can be extremely dif cult to identify and delineate. The following descrip- tion by a 37-year-old, intelligent man with a history of epilepsy, receiving treatment with phenobarbitone, is considered an example of autoscopic hallucination, but analysis demonstrates features of heautoscopy as well as out-of-the-body experience. The patient held his head rigidly with apparent torticollis to the right. If he rotated it to the left, there was marked head nodding, but not if he turned it further to the right.

I’m standing outside myself on the left hand side
but only when I’m sitting down … it comes in short episodes for about 30 seconds … my true self loses
all its senses as all the senses are in my hallucinatory self … the true self is just a shell without any senses
… the hallucinatory self can see the true self and the whole surroundings, and it seems to me as though the hallucinatory self is looking at me and at other things in the room from a position standing to the left hand side of me, and everything is in the right perspective. If it was occurring now, the hallucinatory self would see you more full face and from higher up than I see you now because it is standing … I can’t see it or hear it but it

can see the side of my head. It seems to be there. I know that it isn’t me as such. It’s like having a dream and you know that it is a dream. I thought it was a dream but it has occurred when I am fully waking. It seems as clear as a nightmare at the time but I know afterwards that it is a gment like a very vivid dream but more real than a dream. I would not see a eck of dust on my cheek

or something like that. The other one is not a different personality.
When this experience occurred, the patient felt all sensation was in the ‘hallucinatory self’, including hearing, seeing and feeling cold: ‘I felt cold on the back of the hallucinatory self’. There had been no experience of taste or smell but there had been an experience of affect.

I was talking to a representative. The hallucinatory self felt sorry for this man because he looked abnormal. It had no feelings for the real self. He looked abnormal because I had stopped talking and a glazed expression had come into my eye.

A bizarre example of autoscopy was reported by Ames (1984): the self-shooting of a phantom head. This patient was suffering from schizophrenia. He described seeing and hearing a voice from another head that was set on his own shoulders, attached to his body and trying to dominate his own head. He described himself as having two heads but believed that the other head was actually that of his wife’s gynaecologist, whom he believed to be having an affair with her. The voice from the second head was that of the gynaecologist, and there were also the voices of Jesus and Abraham around him, conversing with each other and talking about his having two heads. The patient tried to remove the other head by shooting six shots at it and through his own palate, causing extensive damage to his brain. Ames labelled this condition the ‘phenomenon of perceptual delusional bicephaly’.

Multiple Personality (Dissociative Identity Disorder)

In dissociative (hysterical) states, so-called dual and multiple personalities have been described (Abse, 1982; McDougall, 1911; Prince, 1905). Slater and Roth (1969) comment:

A girl who is by turns ‘May’ and ‘Margaret’, may be quiet, studious and obedient as May, and unaware of

Margaret’s existence. When she becomes Margaret, however, she may be gay, headstrong and wilful, and refer to May in contemptuous terms. It seems that these multiple personalities are always arti cial productions, the product of the medical attention that they arouse.

The essence of multiple personality is the embodi- ment of at least two personalities (identities). This phenomenon raises doubts about our natural intuition that an individual human being is indivisible and is an embodied singular person. Prince’s account gave a vivid description:

Miss Christine L Beauchamp, the subject of this study,
is a person in whom several personalities have become developed; that is to say, she may change personality from time to time, often from hour to hour, and with each change her character becomes transformed and her memories altered. In addition to the real, original or normal self,
the self that was born and which was intended by nature
to be, she may be anyone of the three persons. I say
three different, because, although making use of the same body, each nevertheless, has distinctly different character:
a difference manifested by different trains of thought,
by different views, and temperament, and by different acquisitive tastes, habits, experiences, and memories.

In a characteristic case study of multiple personality before the conditions for medical practice in the United States resulted in a proliferation of cases of so-called multiple personality disorder, Larmore et al. (1977) described ‘a 35-year-old white woman of rural Kentucky background’ who had made seven suicide attempts, of which she claimed to have no memory. ‘Shortly after admission a hypnotic interview was conducted, during which one of the personalities spontaneously revealed herself and gave hints of the existence of other personali- ties’. Four distinct personalities were identi ed: Faith, ‘the primary personality … known as “the little angel” by personality Alicia … kind, loving and helpful … has dif culty in expression … anger, and in dealing with criticism’; Alicia, ‘a Satanic agent … claims control over most of Faith’s physiological functions … manifest- ing either assaultive or self-destructive behaviour’; Alicia–Faith, under the in uence of Alicia, ‘has only peripheral awareness of Alicia and no knowledge of Faith or Guardian Angel’; Guardian Angel, ‘ rst made

its appearance following the grandfather’s death … claims to be the protector of Faith’.

There has been a vast output of psychiatric literature on the subject of multiple personality disorder, based initially on the diagnostic criteria of third revision, revised, of the Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Associa- tion, 1987) and renamed Dissociative Identity Disorder in DSM-5 (American Psychiatric Association, 2013) but often lacking in psychopathologic precision. This has been well summarized by Fahy (1988):

Recently there has been a dramatic rise in the number of case reports of multiple personality disorder (MPD) … A review of the recent literature reveals a poverty of information on reliability of diagnosis, prognosis, or the role of selection bias. It is argued that iatrogenic factors may contribute to the development of the syndrome. There is little evidence from genetic or physiological studies to suggest that MPD represents a distinct psychiatric disorder.

Abse states that ‘one-way amnesia’ is usual for multiple personality; that is, personality A is amnesic for the other personality B, but the second, B, can discuss the experiences of A. Usually, A is inhibited and depressed and B is freer and more elated. The forms of multiple personality seen in practice are usually:

• simultaneous partial personalities,
• successive well-de ned partial personalities, or • clustered multiple partial personalities.
When such patients have been treated in psycho-

therapy, ingenious explanations are often given by patient and by therapist for the appearance of the additional personalities. Although this remains a dis- puted area, an authoritative opinion from Merskey (2000) states:

In this author’s view there is no place for the diagnosis of multiple personality disorder in psychiatry, and the important question is how such a diagnosis managed to achieve so much prominence in professional circles in North America, although generally not elsewhere.

Lability in the Awareness of Personality

The loss of unity of self in schizophrenia was exempli ed by a patient who described how, every night, he became

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a horse and trotted down Whitehall. At the same time as this was happening in his mind, he also believed he was in Whitehall watching the horse. This type of symptom has been called lability in the awareness of personality and was described by Bonhoeffer (1907) as occurring in paranoid psychosis.

DISORDER OF IDENTITY

I am who I was last week or 30 years ago; I am who I will be next week or in 10 years’ time. This truism, which we can claim without hesitation, is by no means certain for some people suffering from schizophrenia or organic states, from neuroses or from depression, or even for some healthy people in abnormal situations (see possession state later in the chapter). This disorder of self-awareness is characterized by changes in the identity of self over time.

A person who feels threatened in his job and is afraid of redundancy is not likely to function well because of his feeling of impermanence. A feeling of continuity for oneself and one’s role is a fundamental assumption of life, without which competent behaviour cannot take place. In health, we have no doubts about the continuity of oneself from our past into our present. However, patients with schizophrenia sometimes deny that they have always been the same person. Charac- teristically, this takes the form of a passivity experience, and the patient claims that at some time in the past he has been completely changed from being one person to another, whom he now is. Jaspers (1997) gives an account of one patient who said,

When telling my story I am aware that only part of my present self experienced all this. Up to 23rd December 1901, I cannot call myself my present self; the past
self now seems like a little dwarf inside me. It is an unpleasant feeling; it upsets my feelings of existence if

I describe my previous experiences in the rst person. I can do it if I use an image and recall that the dwarf reigned up to that date, but since then his past has ended.

This complete alteration in the sense of identity is exclusively psychotic; there is a break in the sense of identity of self, and there is a subjective experience of someone completely different, although still described as oneself, ‘taking over’.

A feeling of loss of continuity, which is, however, of lesser intensity than the psychotic change described earlier and without its element of passivity, may be experienced in health and in neuroses and personality disorders. The person knows that both people, before and after, are truly he, but he feels very altered from what he was. This may occur after an overwhelm- ingly important life situation or during emotional development without an outside event. For example, an adolescent may quite suddenly feel in the course of a week ‘as if’ he is quite a different person. It should be stressed that the sense of reality is never lost to the extent that he actually believes himself to be a different person. In the nonpsychotic, it is more that thoughts and feelings do not seem to be in keeping with his previous self as he has come to accept himself.

In the next chapter, a man is described as developing long-term depersonalization after experiencing massive stress at work, culminating in an extremely harassing journey in which he was the car driver. Afterwards, his wife said that he was never again like the man she had married, ‘but like his (non-existent) twin brother’. She said that, whereas previously he was incisive, was quick thinking and made the decisions in the family, now he lacked self-con dence and she had to do everything. Neither partner was in any doubt that he was the same person, but his whole demeanour had changed as if he had become someone similar but not identical.

The feeling of loss of continuity contributes to the inertia of the person with schizophrenia and the apathy of the depressive. Lack of a clear sense of identity from the past continuing into the future is a strong disincen- tive to concerted activity. The patient, with schizophre- nia, as part of disturbance of passivity, may have doubts about his continuity from the past to the present; the depressive, secondary to disorder of mood, often sees no continuation into the future: ‘everything is bleak, there is nothing to look forward to’.

A part of the sense of continuity of self is accepting that the changes in one’s total state at present are due to illness. This is the characteristic usually described in the mental state examination under the term insight (David, 1990). The individual recognizes that he is still the same person but that his current change in subjectivity is due to the intervening process of illness.

Possession State

This is classi ed in 10th revision of the International Classi cation of Disease under dissociative (conversion) disorders (F44) – trance and possession disorders (F44.3) (World Health Organization, 1992). However, although the trance or altered state of conscious aware- ness is a prerequisite, possession state does not neces- sarily occur in the context of dissociative or hysterical disorder. It can occur in normal, healthy people in unusual situations, either as a group phenomenon (mass hypnosis) or individually; such a case is described subsequently. There is a temporary loss of both the sense of personal identity and full awareness of the surroundings. The person acts as if he has, and believes himself to have been, taken over by another – a spirit, a force, a deity or even another person. The difference between those conditions that constitute disorder and those that may be considered as being within a cultural or religious context alone is that the former are unwanted, cause distress to the individual and those around and may be prolonged beyond the immediate event or ceremony at which it was induced.

Possession of a young, entirely healthy woman with a husband and three children by two ‘goddesses’ was witnessed in Sri Lanka. The woman had become a varama, a healer with special powers, about 2 years previously, when she ‘saw’ her deceased father-in-law, who came to her and said that she would have super- natural power to help other people and her own family. Her husband had become addicted to arak, a local spirit, and his drinking had by then brought the family into extreme economic hardship. After this experience, she offered her services as a healer and solver of domestic dif culties to her village, and several people consulted her each day at home, where she had devoted one tiny room to a sanctuary and another to a waiting room. With her husband blowing a buffalo horn repeat- edly and herself chanting, she induced a trance in herself in which she spoke with different voices as either one of two female deities giving advice to her clients, which her husband interpreted. The villagers had found her ministrations to be helpful, it gave useful occupation to her delinquent husband and she had completely solved her own family’s nancial problems through the gifts she received for services rendered.

A different case, with psychiatric disorder present, was that of a 37-year-old Sri Lankan housewife who

believed herself to be possessed by her long-dead grandmother; on three occasions she had gone into a trance, lost contact with the outside world and seen the image of her grandmother coming close to her and trying to squeeze her neck. These episodes were described with fear and distress. She showed symptoms of depressive illness, with poor sleep, early morning wakening, loss of appetite and weight, anergia, fatigue and feeling low in mood; she had been abandoned by her mother when 7 years old.

Wijesinghe et al. (1976) surveyed a semiurban population of 7653 people in Sri Lanka and identi ed 37 subjects, 9 male and 28 female, with ‘possession trance states’, showing altered state of conscious aware- ness, behaviour for which the subject did not acknowl- edge responsibility, and had amnesia for the period of the trance. Episodes, often lasting about 30 minutes, were usually precipitated either by emotional stress or culture-bound stimuli such as witnessing an exorcism ceremony. During trance, subjects were most often restless with rhythmic trembling of the trunk and exaggerated gesturing, speech was aggressive and commanding and, typically, mood was angry; most often, the possessing spirit was that of a close but dead relative. In females especially, as the condition continued they were increasingly likely to become permanent adepts. These authors regarded only one of their subjects as suffering from schizophrenia, although 17 of 37 manifested active psychiatric disorder, mostly neurotic in nature.

Possession and trance states straddle the boundary between normative behaviour and abnormal behaviour indicative of a disorder. Moreira-Almeida and Cardeña (2011) argue that lack of personal suffering, absence of social or functional impairment, absence of psychiatric comorbidity, self-control over the experience and personal growth all point in the direction of a non- pathologic spiritual experience. It is clear, however, that possession and trance states can occur in the setting of indubitable neurologic disease such as lesions in the basal ganglia and fronto-parietal lobes (Basu et al, 2002), hence the need to have an integrative model that is grounded in neuroscience but admits sociocultural processes informed by aspects of how the self is socially constructed (Seligman and Kirmayer, 2008).

Jaspers (1997), in writing about disorders of self- awareness, concerned himself with disorder of content

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as well as of form. In discussing states of possession, he commented on the rare condition of lycanthropy, the patient believing that he has been transformed into an animal, literally a wolf. Lyncathropy has a long history in Western societies and identical beliefs of transforma- tion into other feared animals such as the fox in Japan, the tiger, hyena and crocodile in China, Malaysia and India are documented (Fahy, 1989). In antiquity there was belief in the possibility of radical physical trans- formation of the human body into that of a wolf. However, recent case reports have adopted a robust phenomenologic approach and identify the belief of transformation as a delusion of nonspeci c value but principally associated with mood disorders, schizo- phrenia and occasionally organic brain disease (Fahy, 1989; Keck et al., 1988; Kulick et al., 1990). Lyncath- ropy is usually a transient belief but occasionally the belief can be enduring, lasting for many years (Keck et al., 1988). Koehler et al. (1990) reviewed Jaspers’ work in relation to lyncathropy and showed that Jaspers differentiated between states of possession presenting with an altered consciousness and states of possession in which consciousness remains clear; the former were usually dissociative (hysterical) in origin, whereas the latter were more often associated with schizophrenia. This emphasizes the importance for psychiatric diagnosis in assessing psychopathologic form.

DISORDER OF THE BOUNDARIES OF SELF OR EGO DEMARCATION

Disorder of the boundaries of the self refers to the disturbance in knowing where I ends and not I begins. Abnormality is not con ned to schizophrenia. For example, in lysergic acid diethylamide intoxication, the feeling of impending ego dissolution associated with the feeling of self ‘slipping away’ with considerable anxiety has been described (Anderson and Rawnsley, 1954). One subject put this as:

I was being disorganized … the world around was looking very distorted indeed … things were pretty rocky so I decided to sit back quietly for a moment and reassure myself by returning to my own private inner world. As soon as I introspected in this manner I felt

to my dismay that ‘I’ myself was somehow disturbed. The central core of the personality, the ego, the sense of

personal identity, was itself uctuating and, for want of a better phrase, dissolving.

Another subject said, ‘If anyone present went out of the room it felt as though I were being deprived of something. I became smaller – de nitely felt vulnerable’.

Boundaries of Self in Schizophrenia

In schizophrenia, the sense of invasion of self appears to be fundamental to the nature of the condition as it is experienced; many but not all rst-rank symptoms have in common permeability of the barrier between the individual and his environment, loss of ego bounda- ries (Sims, 1993). There is a merging between self and not self; this is clearly portrayed in Fig. 12.2, painted by a young patient with schizophrenia. The patient is not aware of the disturbance being one of ego bounda- ries; he describes a problem only inasmuch as ‘other people are doing things to me, events are taking place outside myself’. The external observer nds a blurring or loss of the boundaries of self that is not apparent to the patient himself.

All passivity experiences falsely attribute functions to not self in uences from outside, which are actually

FIG. 12.2 Picture by a young schizophrenic patient.

coming from inside the self. This is also true for dis- orders of the possession of thought, such as thought insertion and thought withdrawal. Thought broadcasting obviously involves private thoughts becoming public without the consent or action of the patient. This is another example of a breakdown in the normal bounda- ries of what is self and nonself. Other experiences, such as auditory hallucinations, rely on the patient ascribing internally generated activity, that is, internal speech, to external agencies.

Passivity, delusion of control, is discussed in Chapter 9. The subjective experience of passivity is a disorder of the distinction between what is and what is not self. Sensations, emotions, impulses and actions that in objective reality come from inside the self are ascribed to not self.

Other Alterations to Boundaries

In states of ecstasy, there are also disturbances in the boundaries of self (Chapter 16). The participant might describe feeling at one with the universe, merging with nirvana, experiencing unity with the saints, identifying with the trees and owers or a oneness with God. Ecstasy states occur in normal people and in those with personality disorder, as well as in sufferers from psychoses and in epilepsy. In epilepsy it is part of the aura and is characterized by intense feelings of well- being and heightened self-awareness. It is thought to emanate from hyperactivation of the anterior insula rather than the temporal lobe (Picard and Craig, 2009). This alteration in awareness of the boundaries of self is different from that of schizophrenia described earlier. In ecstasy, it is an as if experience, and it is mediated affectively.

The phenomenon described by Jung in himself with which this chapter begins is a lack of de nition of the boundaries of self. However, there was no loss of reality judgement; it was a game, and Jung did in fact know what was himself and what was the stone. In psychosis, this ability to discriminate is lost. A patient with schizophrenia said, ‘I am invaded day and night. I have no more privacy since television came inside me’. Another patient believed that while he was in a hospital ward he was helping other patients because he perme- ated the medical staff and thereby assisted them in their work.

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KEYWORDS

Depersonalization Derealization

Summary

Depersonalization is a subjective state of unreality in which there is a feeling of estrangement, either from a sense of self or from the external environ- ment. Frequently, it is accompanied by the symptom of derealization, a term denoting a similar feeling of unreality with regard to awareness of the external world. The localization of this feeling of unreality to a selected part of the body is called desomatization. There may be experience of changes of size or quality, for example, appearing large or small, empty, detached or lled with water or foam. Deaffectualization has been used to describe the consistent loss of the capacity to feel emotion, so that the person seems unable to cry, love or hate. These experiences are associated with anxiety and mood disorders, organic disease such as epilepsy and traumatic brain injury. Depersonalization can also be triggered by the use of cannabis, hal- lucinogens, ecstasy and alcohol. It can be a brief or long-lasting experience. It is invariably distressing to the patient.

I may be looking with some degree of attentiveness at a tumbler. As long as I say to myself that this tumbler is a glass or metal vessel made for the purpose of putting liquid into it and carrying it into one’s lips without upsetting it – as long as I am able to represent the tumbler to myself in a convincing manner – so long shall I feel that I have some sort of relationship with it, a relationship close enough to make me believe in its existence and also, on a subordinate level, in my own. But once the tumbler withers away and loses its vitality … reveals itself to me as something with which I have no relationship, once it appears to me as an absurd object – then from that very absurdity springs boredom, which when all is said and done is simply a kind of

incommunicability and the capacity to disengage oneself from it.

Alberto Moravia (1960) De nitions and Descriptions

Depersonalization is the term used to designate a peculiar change in the awareness of self, in which the individual feels as if he is unreal (Sedman, 1972). It is best to reserve the use of the word to this as if feeling rather than the experience of unreality that occurs in psychosis. The as if pre x is used by the patient, to denote that he is not using words literally (how could he know what it would be like not ‘ tting into the world’, as all his experience has been in the world?). He is expressing uncertainty and painting a picture, and ‘as if’ is the best way he can do it. It has been considered that, after depression and anxiety, depersonalization is the most frequent symptom to occur in psychiatry (Stewart, 1964) and 12-month prevalence estimates for deper- sonalization and derealization in a rural population are put at 19.1% and 14.4% (Aderibigbe et al., 2001).

Schilder (1928), whose classic monograph in 1914 was a turning point in the study of depersonalization, wrote:

To the depersonalized individual, the world appears strange, peculiar, foreign, dream-like. Objects appear
at times strangely diminished in size, at times at. Sounds appear to come from a distance. The tactile characteristics of objects likewise seem strangely altered. Patients characterize their imagery as pale, colourless and some complain that they have altogether lost the power of imagination. The emotions likewise undergo marked alteration. Patients complain they are capable
of experiencing neither pain nor pleasure; love and hate have perished with them. They experience a fundamental change in their personality, and the climax is reached with their complaints that they have become strangers to themselves. It is as though they were dead, lifeless, mere

CHAPTER 13

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Depersonalization

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automatons. The objective examination of such patients reveals not only an intact sensory apparatus, but also
an intact emotional apparatus. All these patients exhibit natural affective reactions in their facial expressions, attitudes, etc.; so that it is impossible to assume that they are incapable of emotional response.

Depersonalization has been de ned by Fewtrell (1986) as a subjective state of unreality in which there is a feeling of estrangement, either from a sense of self or from the external environment.

A more comprehensive de nition has been given by Ackner (1954). De nitive features are as follows:

• Depersonalization is always subjective; it is a disorder of experience.

• The experience is that of an internal or external change characterized by a feeling of strangeness or unreality.

• The experience is unpleasant.

• Any mental functions may be the subject of this
change, but affect is invariably involved.

• Insight is preserved.
Excluded from depersonalization are:

• the experience of unreality of self when there is
delusional elaboration,

• the ego boundary disorders of schizophrenia, and

• the loss or attenuation of personal identity.
An even more comprehensive description is given
in Sierra and Berrios (2001). The symptoms are listed in Box 13.1. There is consensus that there are four or ve principal domains including (a) anomalous body
BOX 13.1 COMPONENTS OF DEPERSONALIZATION

experience, (b) emotional numbing, (c) anomalous subjective recall, (d) alienation from surrounding, and (e) body distortion (Sierra, 2009).

The relationship between depersonalization and various theoretical aspects of self-perception in phe- nomenology has been reviewed by Mellor (1988), who discusses the in uences of Jaspers (1997), Mayer-Gross (1935), Schilder (1920) and Schneider (1958) on the concept. Mellor comments on the frequency of the condition and the variety of different psychiatric ill- nesses with which it may be associated. It may occur with organic psychosyndromes including traumatic brain damage (Grigsby and Kaye, 1993), epilepsy and migraine (Lambert et al., 2002), cannabis, hal- lucinogens and ecstasy (Matthew et al., 1993; Simeon et al., 2009). It is associated with mood disorders and anxiety disorders including social anxiety (Simeon et al., 1997; Michal et al., 2005). The depth of depression is positively correlated with depersonalization and in depressed patients with anhedonia, depersonalization was present in 75% of cases (Zikić et al., 2009).

Although the symptom has been described for longer, the term was used by Heymans (1904) and by Dugas and Moutier in 1911. The earliest theories implicate the sensory system, but loss of mood and loss of feelings were also prominent in early descriptions (Sierra and Berrios, 1997). Frequently, depersonalization is accom- panied by the symptom of derealization, a term used by Mapother (1935) to denote a similar change in the awareness of the external world. Depersonalization and derealization often go together, because the ego and its environment are experienced as one continuous whole. However, in Mayer-Gross’ cases, about a quarter of patients had depersonalization without derealization, and 15% had only derealization. The less a patient takes himself for granted, the more unfamiliar and alien the world around him becomes (Scharfetter, 1980). A young female patient said:

I felt as if I didn’t t into the world … When I saw the moon, I felt I couldn’t cope. One day it wasn’t there and the next it was. I saw it and it upset me and I went
to pieces … I felt I did not want to be alive because I was not related to anything. I just seemed totally out

of everything and I started to cry. I couldn’t cope with the hurt and the pain. I felt I never would feel part of anything.

• Emotional numbing
• Changes in body experience
• Changes in visual experience
• Changes in auditory experience
• Changes in tactile experience
• Changes in gustatory experience
• Changes in olfactory experience
• Loss of feelings of agency
• Distortions in the experiencing of time
• Changes in the subjective experience of memory • Feelings of thought emptiness
• Subjective feelings of an inability to evoke images • Heightened self-observation

(After Sierra and Berrios, 2001, with permission.)

It is important to realize that depersonalization, the experience, like other non-psychotic phenomena, occurs in healthy, normal people. Some people may have feelings of ‘not being quite themselves … looking in on themselves from the outside’ and so on, without provocation. Others may have such experiences at times of powerful emotional stimuli or life crisis of any valence: extreme happiness, falling in love, the loss of bereavement or intense fear or anger. The actual self- description of depersonalization is similar irrespective of context.

There is one particular feature described by patients and not occurring in the depersonalization that healthy people, especially children, may experience spontane- ously in states of fatigue, after prolonged sleep depriva- tion or under sensory deprivation. This is the patient’s description of the experience being intensely unpleasant and distressing (Ackner, 1954). It may subjectively be much the worst symptom in an affective, reactive illness. A young married woman said:

I feel very weird in my head. I have a great deal of torment. My mind will not leave me alone. It’s the surroundings; I cannot get my mind to myself. I felt as though I was going to fall over. I feel as if I’m lost in a fog. I just feel as if I’m not in my head. I feel numb.

The symptom is described in a number of ways, and it is often impossible to make a distinction between depersonalization and derealization: ‘everything seemed to be going away from me’. The ve qualities of the experience of self described in Chapter 12 may each be involved in the description of symptoms, although always with this as if character: vitality, activity, single- ness, identity (continuity) and boundaries or de nition. There is virtually always other evidence of disturbance of mood present: depression or anxiety or both. Coupled with this is a feeling of loss of self-esteem as a very prominent symptom: ‘I feel unreal, at, not properly there, less of a person, as though I can’t go and get stuck in’; that is, the feeling of unreality about oneself or one’s environment has implications for lack of competence in relationships. The patient not only feels unreal but also ‘detached’; there is a barrier to normal communication.

At this point, it is important to emphasize the distinc- tion between depersonalization as a symptom, occurring

associated with many psychiatric conditions or no disorder at all, and depersonalization as a syndrome. In their detailed description of the symptoms of depersonalization disorder, based on classic descriptions from authors in the nineteenth and early twentieth centuries, Sierra and Berrios (2001) have listed the following four symptoms as most prevalent for diagnosis: emotional numbing, changes in visual perception, changes in the experience of the body and loss of feelings of agency. In a more recent study, Simeon et al. (2008) demonstrated that the Cambridge Depersonalization Scale (Sierra and Berrios, 2000) yielded ve factors: numbing, unreality of self, perceptual alterations, unreality of surroundings, and temporal disintegration. In addition patients with depersonalization appear to have impaired ability to generate visual imagery com- pared with normal control subjects. However in these individuals with impaired imagery, there was no associated abnormality of perceptual processes as measured by a battery of visual perception tests (Lambert et al., 2001).

These symptoms are sometimes included with a description of depersonalization but, for the sake of clarity, should be separated and regarded as different psychopathologic phenomena. Disturbances of body image or schema, disorder of subjective time sense, hypochondriacal preoccupation, déjà vu phenomena or metamorphopsia (the distortion of visually perceived objects) may be described by the same individual and may occur as symptoms of depersonalization syndrome. Langfeldt’s (1960) inclusion of schizophrenic passiv- ity experiences within the term depersonalization is confusing, and these experiences should be excluded from depersonalization, both as a symptom and as a disorder.

SUBJECTIVE EXPERIENCE OF DEPERSONALIZATION

Depersonalization is dif cult for the doctor to portray; more important, it is also extraordinarily dif cult for the patient to describe. He often prefaces his attempts at description by embarrassed statements such as ‘sometimes I think I must be going mad’ or ‘you will think me very peculiar when I tell you this doctor, but …’ Then follows a halting and perplexed list of disjointed, unpleasant experiences that the patient feels to be unique and for which he is unable to construe metaphors that satisfy him. Because of his failure in

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description, he believes that others will nd these symptoms either bogus or clear evidence of imminent madness, so he omits them from his initial account even though such symptoms are common among psychiatric patients and cause enormous suffering. Depersonalization is the symptom the patient has when he experiences himself as being altered or de cient in some manner; derealization is its equivalent with regard to his experience of things outside himself, that is, of the external world. Because there is no de nite and easily ascertained boundary containing self, it is not always easy to decide whether the disorder is deper- sonalization or derealization. Neither is this important: they merge and overlap and are often simply included within the term depersonalization.

There is always a change in mood with depersonaliza- tion: the patient loses the feeling of familiarity he has for himself or for the world outside himself. He may describe himself as feeling like a puppet: hollow, detached and strange; on the outside; uninvolved with life; not himself; like a ghost, not solid; a stranger to himself. He experiences a loss of emotion. Similarly, with derealization he may describe his environment as at, dim in colour, smaller, distant, cloudy, dream-like, still, ‘nothing to do with me’ and also lacking in emotional signi cance.

Depersonalization is common, but yet to the patient so obscure and unpleasant, that, whenever the descrip- tion of symptoms is interrupted by the patient’s baf ed hesitancy, he should be questioned with possible depersonalization symptoms in mind. His relief at nding someone prepared to listen, and even perhaps understand, is often enormous. Schilder (1935) has described these symptoms thus:

In a case of depersonalization the individual feels completely changed from what he was previously. This change is present in the ego (self) as well as in the outside world and the individual does not recognize himself as a personality. His actions appear to him as automatic. He observes his actions and behaviour from the point of view of a spectator. The outside world is foreign and new to him and is not as real as before.

Schilder is using the word personality here to refer to the whole person, not only personality in the modern sense of the word. This changed awareness of self and

its relationships with the environment is always expe- rienced as being intensely unpleasant.

The localization of this symptom to an individual organ is called desomatization. There are many different possible parameters in the awareness of different organs: changes of size or quality – for example, appearing large or tiny, empty, detached or lled with water or foam. Sometimes the body or parts of it may be experienced as nonexistent: ‘I do not feel I have a body’. The patient may have a feeling of his legs being weightless, of oating or of simply being unfamiliar. Koro, a culture-bound disorder described by Yap (1965) (see also Chapter 8 of this volume), is sometimes described as an example of depersonalization. It is probably best to regard this condition as a culture- speci c manifestation of acute anxiety in which the patient believes his penis is shrinking and fears that it will ultimately disappear. Although there may be associated feelings of unreality and watching the drama as a spectator, the primary underlying abnormality is one of intense anxiety. There are reports of a loss of the feeling of agency, that is, as if actions occur as a mechanical process unrelated to the patient. In some patients there are also reports of heightened self-scrutiny (Sierra, 2009).

Change of feeling concerning the body or deper- sonalization may be associated with distortion of time sense, when the passage of time appears altered in some way: ‘time, both past and present, seems quite unreal to me, as if it had never happened and was never going to happen’. Sometimes, the complaint is that memories of events seem to have happened to somebody else. Deaffectualization has been used to describe the consistent loss of the capacity to feel emotion, so that the person seems unable to cry, love or hate (Anonymous, 1972). Indeed, some patients are unable to have an emotional response to music or retain empathy for the suffering of others.

A patient says, ‘I am going mad inside my head’; on further questioning, he is describing nding his own mental processes to be strange. The feeling of familiarity that occurs when a person perceives previ- ously known objects (opening the front door at home and looking inside) also occurs when one introspects into one’s own thinking (remembering or fantasizing my front hall). I know what is there in my thoughts; I know what I will think about any particular object,

because it is unlikely to be very different from what I thought about it last time. I also know, in general terms, what I will think about myself because of past experi- ence. It is this assumed certainty that disappears; the loss of familiarity of oneself occurring in depersonaliza- tion, or of outside self in derealization, is similar to the abnormality of the feeling of familiarity occurring in jamais vu (when there is no sense of previously having seen a well-known object) and its opposite, déjà vu (when an unfamiliar object or experience seems to be familiar). This association between the subjective experiences in depersonalization and déjà vu phenomena (including jamais vu) and commonality in alteration in the feeling of familiarity has been known since the work of Heymans at the beginning of the twentieth century (Sno and Draaisma, 1993).

Like other aspects of self-experience, depersonaliza- tion has social and situational aspects. Frequently, the person feels that he is less able to accept himself, his personality, his behaviour than other people accept their own. He considers that his feelings about him- self, his loss of reality, is unique. This is a barrier to his giving an account of his symptoms, and this in its turn is a barrier to communication in all areas of life. He feels himself to be different, isolated and estranged from others. Depersonalization is an experi- ence within an individual, but it has considerable social consequences.

It frequently occurs in attacks that may be of any duration, from seconds to months. Typically, in dep- ersonalization disorder the altered state lasts for a few hours, in temporal lobe epilepsy for a few minutes and in anxiety disorder for a few seconds. Improvement is usually rst manifested in a gradual increase in time free from symptoms rather than a reduction in the symptoms themselves when present. However, it can present as with a chronic non-remitting course.

Onset may be insidious and with no known initiating cause, or it may be in response to a trigger. The most common immediate precipitants are severe stress, depression, panic and marijuana ingestion (Simeon et al., 2003). A middle-aged man who described his depersonalization ‘like something supernatural – my body separated from me – a lost feeling’ vividly recalled his rst attack at the age of 11, when undergoing anaesthesia for the reduction of a fracture. Subsequent attacks felt similar despite the absence of provocation.

He had also experienced attacks of sleep paralysis since age 25 and had discovered that by keeping himself awake until very tired, he would fall asleep more quickly and thus avoid it. Another man was severely stressed by his quite unreasonable working conditions, hours of work, unsympathetic employer and dif cult car journeys in the course of his work. Early one winter morning, he had an appalling journey through fog along crowded motorways blocked by accidents, and ultimately suffered a lapse of recall for 24 hours in which he remembered nothing of driving to another town, registering himself into a hotel, ordering a meal, hanging up his clothes tidily and going to bed. His next memory was arriving at a local hospital the next day. He remained depersonalized for years subsequently, and his wife described this as ‘he’s not the man I married; it’s like his twin brother’.

Depersonalization is frequently situational, both in its original context and in its repeated occurrences. Factors commonly associated with symptom exacerba- tion are negative affects, stress, perceived threatening social interaction and unfamiliar environments (Simeon et al., 2003). Many policemen who were involved in a major disaster at a football ground described deper- sonalization among other symptoms of post-traumatic stress disorder, sometimes lasting for years subsequently (Sims and Sims, 1998). One man described feeling ‘switched off … I felt I wasn’t on this planet any more’. Because depersonalization occurs at times of great stress, it may occur in the perpetrator of antisocial behaviour (for example, violent crime), as well as in the victim. Rix and Clarkson (1994) give an account of a man who savagely assaulted his wife with a large spanner: ‘It was as if it was a dream or a nightmare. I realized later what I had done but at the time it was as if I wasn’t there’. It was considered that depersonalization in this case was linked to dissociation, that although it represented a change in the individual’s self-experience it did not affect his volition or intent.

Although in the two preceding cases depersonaliza- tion was associated with dissociation, it is important to regard these experiences as distinct phenomena. Empirical evidence also suggests that these experi- ences even when associated are different and do not lie on a continuum (Putnam et al., 1996; Simeon et al., 1998). Neither does depersonalization occur with any greater frequency in chronic dissociative

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disorders such as dissociative identity disorder, formerly multiple personality disorder in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (Ross, 1997).

Self-induced episodes of depersonalization, as an unpleasant symptom, have been recorded after particular patterns of behaviour. Thus Kennedy (1976) described self-induced depersonalization persisting as a complaint after transcendental meditation and yoga.

Organic and Psychological Theories

Theories accounting for the occurrence of depersonaliza- tion, including organic, psychological, psychoanalytical and those linking it with schizophrenia, were reviewed by Sedman (1970). Depersonalization is regularly cited as a common symptom associated with organic states, especially temporal lobe epilepsy (Sedman and Kenna, 1965). This is based on the contention of Mayer-Gross (1935) that depersonalization is a preformed functional response of the brain, that is, a nonspeci c mechanism resulting from many in uences on the brain, occurring in an idiosyncratic way in individuals in a similar manner to epileptic ts or delirium. He was, in this, following the neurophysiologic hierarchical concepts of Hughlings Jackson (1884), who considered that the highest levels of cerebral function were lost rst, leaving uninterrupted the activity of lower levels.

Organic theories purporting to account for deperson- alization would suggest that alteration of consciousness acts as a release mechanism. However, Sedman (1970), in reviewing the literature, showed that, even in various forms of organic psychosyndromes, the incidence of depersonalization phenomena was similar to that found in the general population, at between 25 and 50%; in more severe chronic organic psychosis, the rate was lower. From a variety of studies, no quantitative relationship had been demonstrated between the degree of torpor (that is, the stage on the continuum from full alertness to unconsciousness) and the development of depersonalization. On studying the performance of depersonalized subjects on psychosomatic tests, there did not appear to be evidence to support a speci c relationship between clouding of consciousness and depersonalization. There appeared to be many individu- als who, despite various types of assault on their brains, never developed depersonalization.

From this information, Sedman (1970) concluded that

there may well be a built in preformed mechanism in approximately 40 per cent of the population to exhibit depersonalization; that the factors which initiate such a response are not speci cally those associated with clouding of consciousness; or where clouding of consciousness appears to be playing a part, it may well be the presence of another common factor that is more relevant.

Thus the relationship between depersonalization and brain pathology remains unclear. Depersonalization is certainly not pathognomonic of organic diseases; in fact, there is no organic or psychotic abnormality in the vast majority of sufferers.

The state of increased alertness observed in deper- sonalization is considered by Sierra and Berrios (1998) to result from activation of prefrontal attentional systems and reciprocal inhibition of the anterior cingulate, leading to experiences of ‘mind emptiness’ and ‘indif- ference to pain’. The lack of emotional colouring, reported as feelings of unreality, would be accounted for by a left-sided prefrontal mechanism with inhibition of the amygdala. Other authorities describe left- hemispheric frontotemporal activation coupled with decreased left caudate perfusion (Hollander et al., 1992; Phillips and Sierra, 2003).

Depersonalization is sometimes associated with self-induced organic states. Thus it occurs after the ingestion of alcohol or drugs, especially psychotomimet- ics such as lysergic acid diethylamide (Sedman and Kenna, 1964), mescaline, marijuana or cannabis (Carney et al., 1984; Simeon et al., 2009; Szymanski, 1981) and with sensory deprivation. It is also described as a side effect with prescribed psychotropic drugs such as the tricyclic antidepressants, but because of the common association between depersonalization and depression, it may be dif cult to attribute causation.

Neurochemical ndings have identi ed possible involvement of serotonergic, endogenous opioid and gluta- matergic N-methyl-D-aspartic acid pathways. Additionally, there is evidence of widespread metabolic alterations in the sensory association cortex as well as prefrontal hyperactivation and limbic inhibition in response to aversive stimuli (Simeon, 2004). Furthermore, there is association with childhood interpersonal trauma,

particularly emotional maltreatment (Simeon, 2004; Simeon et al., 2001).

Depersonalization: Further Considerations

Sometimes there has been considerable confusion over whether depersonalization can be distinguished from the disorders of self-image described in Chapter 12 as occurring in schizophrenia. In fact, passivity experiences have even been described as a variant of depersonaliza- tion. However, Meyer (1956), as cited by Sedman (1970), has distinguished schizophrenic ego distur- bances from depersonalization on phenomenological grounds; that is, on the description by the patient of his own internal experience. It is of course well rec- ognized that true depersonalization symptoms do occur in patients with schizophrenia, especially in the early stages of the illness, alongside de nite schizophrenic psychopathology.

Depersonalization is commonly described in bipolar affective disorder; however, the symptoms occur only in the depressive phase and there are no references to depersonalization occurring in mania (Sedman, 1970). Anderson (1938) considered that ecstasy states occurring in bipolar affective disorders were the obverse of depersonalization and that, although the former occurred in mania, the latter occurred in depression. Sedman (1972), in an investigation of three matched groups, each of 18 subjects with depersonalization and depres- sive and anxiety symptoms, considered that the results stressed the importance of depressed mood in deper- sonalization, whereas anxiety seemed to carry no signi cant relationship.

Many other authors have stressed the close associa- tion between the symptoms of depersonalization and anxiety. For instance, Roth (1959, 1960) described the phobic anxiety depersonalization syndrome as a separate nosologic entity, but saw it as a form of anxiety on which the additional symptoms are superimposed in a particular group of individuals. He considered depersonalization to be more common with anxiety than with other affective disorders, for example depres- sion. The phobic symptoms are usually agoraphobic in nature. The patient, most often female, married and often in the third decade of life, has a great fear of being conspicuous in an embarrassing way in public, for example fainting or being taken ill suddenly on a

bus or in a supermarket. Fear of leaving the house unaccompanied develops from this, so that the patient is frightened of being at a distance from familiar sur- roundings without some supporting gure to whom she can turn. She may be unable to go out of the house at all, even with her husband. She may feel panicky on her own at home and so keeps her child off school, a potential precipitating factor in subsequent school refusal.

The symptom of dizziness is a very common com- plaint and frequently results in referral to ear, nose and throat departments. Fewtrell and O’Connor (1989) discuss two possible models for the relationship of this condition to depersonalization: one that dizzi- ness and depersonalization are the same experience described differently; the other, a bipolar hypothesis, proposes that the two experiences form opposite ends of a dimension describing disturbed self–outside world relationships.

Although depersonalization is commonly described in association with agoraphobia, other phobic states, panic disorder, various types of depressive condition, post-traumatic stress disorder and other nonpsychotic conditions, it may also appear as a pure depersonaliza- tion syndrome, and Davison (1964) has described episodic depersonalization in which other aetiologic factors or comorbid disorders are not prominent.

In psychoanalytic theory, depersonalization has taken on a rather different meaning, and therefore there are different explanations for its origin. Psychoanalysts have been less concerned with describing the phenomena than the underlying concept of the alienation of the ego. For example, in the work of the existentialist school, as typi ed by Binswanger (1963), there is discussion of the depersonalization of man.

This depersonalization has by now gone so far that the psychiatrist (even more than the psychoanalyst) can no longer simply say, ‘I’, ‘you’, or ‘he’ wants, wishes and so forth, the only phrases that would correspond to the phenomenal facts. Theoretical constructs dispose him, rather, to speak instead of my, your, or his Ego wishing something. In this depersonalization we see at work that aspect of psychiatry’s founding charter that is most at odds with every attempt to establish a genuine psychology. An explanation of this baleful in uence need go no further than the clearly recognized task that psychiatry, since Griesinger, has set itself

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– namely, to create a psychology that, on the one hand, serves to bring a rei ed functional complex into relation with a material ‘organ’ but that, on the other hand, allows this organ itself to be divided into and understood in terms of its functions.

This clearly is quite a different sense of the word than the phenomenological, with which this chapter has been concerned.

The distressing experience of depersonalization, with a feeling of unreality, remains central to the description of the disordered self. The disturbance that causes this may be organic or environmental, psychotic or exis- tential. Concern about the experience of self and of the environment most commonly occur together.

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KEYWORDS

Hypochondriasis
Disgust
Dysmorphophobia
Body integrity identity disorder Anorexia nervosa

Muscle dysmorphia

Summary

The body is the physical manifestation of the individual being. It is the material, corporeal interface with the external world. The world is experienced through the body’s senses. The body, also, is itself experienced as an object in the world. In this chapter, we examine the following:

1. disorders of beliefs about the body including beliefs of illness, disease and death,

2. disorders of bodily function, including the loss of sensory, motor or cognitive function that occur in the conversion and dissociative disorders,

3. disorders of the experience of the physical characteristics of the body and of the emotional and aesthetic value and

4. complex disorders of the sensory awareness of the body that almost exclusively derive from neurologic lesions.

Even though these abnormal experiences are dis- parate, what binds them together into a coherent aspect of psychopathology is that the body as experienced is at their heart.

Beside fear and sorrow, ‘sharp belchings, fulsome crudities, heat in the bowels, wind and rumblings in the guts, vehement gripings, pain in the belly and stomach sometimes after meat that is hard of concoction, much watering of the stomach, and moist spittle, cold sweat.’

Robert Burton (1577–1640),

The Anatomy of Melancholia (1628)

To some, ill health is
a way to be important, Others are stoics,
a few fanatics,
who won’t feel happy until they are cut open.

The physicality of the body is ever present: there is density, mass, movement, action, speed, position, heat, cold and various degrees of touch, pain and so on. Since Descartes (1596–1650), the relationship between mind and body has stimulated much investigation and discussion. Descartes’ original claim was that the mind and body are distinct and different; furthermore, that the mind can exist without the body. There are other theories that attempt to account for the nature of mind and body. Materialist theories propose that the body is all there is, and variations of these theories account for mind in different ways, whereas idealist theories make the opposite claim that the mind is all that exists. The fact that many descriptions of mood, cognition, volition and other psychological functions are expressed in physical terms – ‘a heavy heart’, ‘bone-headed’, ‘guts and determination’, ‘a pain in the neck’ – underlines the inextricable relationship between mind and body and emphasizes the degree to which the body can become a means of communicating distress and bodily metaphors used to consciously or unconsciously express feelings. Whether these metaphors originally derive from the physical manifestations of emotional distress or whether the language, that is, the metaphor, struc- tures the experience is a moot point. What is clear is that there is no ready division between the subjective experience of self and body. A 10-year-old girl put this relationship thus: ‘You feel better if you’ve done your homework; if you haven’t you get a horrible pain in your stomach’. Finally, because the body is itself an object in the world, it inhabits a world of values and

CHAPTER 14

W.H. Auden (1969)

195

Disorder of the Awareness of the Body

196 SECTION IV Self and Body

norms such that there are ‘good’ and ‘bad’ bodies, ‘desirable’ and ‘undesirable’ bodies. In addition, a subset of values is aesthetics, so that there are ‘beautiful’ and ‘ugly’ bodies. This means that individuals approach both their own and other people’s bodies with an attitude: they appraise bodies with a set of beliefs and expectations, form judgements and act towards bodies with approval or disapproval.

The Body in Psychopathology

Our bodies have an objective, physicality like all other material objects in the world. However, there is also the subjective, animated body that is alive and with which we deeply identify. These two aspects of our bodies have different words in German that denote them: Körper refers to the body as an object and Leib to the subjectively experienced body. Pollio et al. (2008) conducted a phenomenological investigation of adults’ intuitions of their daily-embodied experiences. The participants’ responses focused on eight situations

1. Awareness of the body when engaged in an activity;

2. Awareness of the body when experiencing aches, pains, illness and fatigue;

3. Awareness of the body as presented to other people in posture and dress;

4. Awareness of the body during pregnancy and during sexual intimacy and arousal;

5. Awareness of changes in the body over time;

6. Awareness of the body as an aspect of identity,
for example as a Christian;

7. Awareness of the presence or absence of others;
and,

8. Awareness of strong emotions.

In addition to awareness of the body in these situ-

ations, the respondents also had three unique modes of experiencing their bodies. These modes include the experience of engagement, corporeality, and interper- sonal meaning. Experience of engagement was subdi- vided into (a) body in vitality during episodes the person is fully engaged in the world with no sense of the body as physical, but there is a consciousness of well-being and (b) body in activity during activities when the person experiences the concrete movements as central to the experience, for example, during running. Experi- ence of corporeality includes (a) the body as instrument,

that is, as a tool, and (b) as an object that has limits and that can be impaired by illness. Finally, experiences of interpersonal meaning refers to the social and symbolic meaning of our bodies.

The experience of interpersonal meaning of our bodies is dealt with in studies of the sociology of the body. We engage with others and interact with them from the rst-person perspective of a person who is embodied. The physical characteristics of our bodies including size, shape, mannerisms, gait and so on signi cantly in uence our relationships, perceptions of others and how we too are perceived. Furthermore, our bodily conduct, how we control our bodily urges, the quality and standard of self-grooming and personal hygiene contribute to our identity and personal char- acteristics and de ne how others appraise us. In short, the body in society has profound implications for issues relating to health, gender, sexual preference, ethnicity, disability, social status and politics. It is therefore self- evident that any description of abnormalities of body awareness will have implications far beyond the scope of medicine or psychiatry. For a detailed examination of these matters, see Howson (2013).

Finally, the body is central to Merleau-Ponty’s (1962) phenomenology. His claim is that although the body is an object, it is like no other object because it is the medium by which we experience all other objects. He writes, ‘I observe external objects with my body, I handle them, examine them, walk round them, but my body itself is a thing which I do not observe: in order to be able to do so, I should need the use of a second body which itself would be unobservable’. These ideas have been further developed in more modern studies – and the suggestion is not merely that our bodies are central to our experience of the material world but that such brain functions such as perception, memory, concept formation, language and so forth are in uenced by the con guration and activities of our bodies. Gibbs (2005) exempli es this point:

Perception cannot be understood without reference to action. People do not perceive the world statically, but by actively exploring the environment. For instance,
if I move closer to the table in front of me, I see the textured lines in the wood surface better. If I turn my head, I distinctly hear the music playing softly on the stereo behind me. If I move to the steaming cup of coffee

14 Disorder of the Awareness of the Body 197

TABLE 14.1 Classi cation of Disorders of Awareness of the Body

depend on the body in action. The separation of abnormalities of self and of body in distinct chapters are merely for convenience and by convention.

To form a cohesive framework for conceptualizing the disorders of self and the diverse abnormalities of body image, one needs to apply the methods of descrip- tive psychopathology. In Chapter 12, the nature of self and the pathology of the experience of self were dis- cussed. In this chapter, disorders of the awareness of body are discussed.

Classi cation

Cutting (1997) gives a good outline of the classi cation of disorders of awareness of the body, which has been adapted for this chapter (Table 14.1). There are disorders of beliefs about the body, including beliefs of illness, disease and death (discussed subsequently). In this group are also the disorders of dissatisfaction with the body, which occur in eating disorders. These dissatisfac- tions with the body are best understood as arising from negative cognitive evaluations, that is, beliefs about the body. Next, there are disorders of bodily function, including the loss of sensory, motor or cognitive function that occurs in the dissociative disorders. There are disorders of the experience of the physical characteristics of the body. These include disorders of the experience of the size, shape, structure or weight of the body. Finally, there are complex disorders of the sensory experience of the body that almost exclusively derive from neurologic lesions.

Disorders of Beliefs About the Body (Bodily Complaint Without Organic Cause)

Classi cation of these disorders is dif cult, partly because the symptoms are obscure in origin and partly because there are different theoretical bases for the words used. For example, conversion hysteria was used as a term that referred to the presumed unconscious conversion of an unacceptable affect into a physical symptom. Hypochondriasis refers to a concern with symptoms and with illness that the outside observer regards as excessive; the same amount of concern or complaint associated with pathology that the doctor regards as justifying it would not be deemed hypo- chondriacal. Dysmorphophobia is a phenomenological

Classi cation

Details

Beliefs About the Body

Illness and disease Hypochondriacal symptoms Body dissatisfaction Real and ideal body weight

discrepancy

Function of the Body

Sensory de cits For example, dissociative sensory loss (blindness)

Experience of Physical Characteristics of the Body

Size

Shape Colour

Structure Weight

Microsomatognosia, macrosomatognosia and body image disturbance

‘My jaws are misshapen’ Skin colour may be

experienced as lighter ‘My lungs are connected to

my abdomen’ Feelings of lightness or

heaviness

Experience of Emotional Value of the Body

Anosognosic overestimation

Misoplegia Dysmorphophobia

Exaggeration of body’s strength

Hatred of body part
Feeling of ugliness or defect

of body or one of its parts

Experience of Sensory Awareness of the Body and the World

Palinaptia

Exosomesthesia Alloaesthesia

Persistence of sensation beyond the duration of contact with stimuli

Cutaneous sensation in extra-personal space

Experience of sensation on contralateral side to stimulation

(After Cutting, 1997, p. 317, with permission of Oxford University Press.)

on the counter, and lean over close by, I clearly smell the scent of coffee beans. Each bodily movement enables my sensory organs to do their work depending on my motivations and goals.

It is obvious from the foregoing that the body and self are conceptually linked and that brain functions

198 SECTION IV Self and Body

Actual physical illness

Actual physical deformity

FIG. 14.1 Disorders of bodily complaint.

Undue concern with appearance – narcissism

term and refers to the subjective experience of dis- satisfaction with bodily shape or form (Fig. 14.1).

HYPOCHONDRIASIS

Hypochondriasis describes the subjective and undue awareness of physical symptoms, which are interpreted as signalling serious illness. It is a symptom and not a disease. There are many different modes of expression: minor pain and discomfort dominate the person’s life and occupy his attention; he may have unreasonable fears about the likelihood of developing serious illness, and feels a need to take excessive precautions; he may misinterpret benign blemishes as having sinister pathologic signi cance. These expressions of dissatisfac- tion may occur on their own or in any combination, and they can affect any bodily system or psychological process. Hypochondriacal symptoms are common and usually transient. Only a minority come to medical attention, and only a selected atypical proportion of these are seen by psychiatrists.

There is a distinction between illness fears, when there are no bodily symptoms, and the fears and distress, which are not associated with bodily symptoms but merely arise out of the possibility of serious illness. This shows the overlap between illness phobias (unrea- sonable fear of developing illness) and hypochondriasis (preoccupation with symptoms). There is often dif culty in diagnosis when a person with demonstrable physical

pathology complains excessively about his symptoms; his complaints appear to be out of proportion to the anticipated suffering and disability of the illness. Neces- sary and entirely routine medical examination and investigation tend to reinforce the patient’s symptoms. Somatic symptoms without organic pathology are extremely common and may result from misunderstand- ing the nature and signi cance of physiologic activity aggravated by emotion (Kellner, 1985). The mechanisms underlying hypochondriacal symptoms include misin- terpretation of normal bodily sensations; conversion of unpleasant affect, especially depression, into physical symptoms; and the experience of autonomic symptoms directly caused by disorder of mood.

Explicit in the identi cation of hypochondriasis is the condition of the patient himself. Implicit, however, is the doctor who labels his patient hypochondriacal and deems him sick. In a society that is so conscious of physical health and external physical appearance, the patient may have to shout ‘hypochondriacally’ because the doctor will only listen out for physical complaints. What the symptoms communicate to other people is an important component of all disorders of bodily awareness; concentration on the subjective aspects of symptoms should not detract from their social implications. Hypochondriasis is not uncommonly an iatrogenic condition induced by the doctor’s failure to listen to his patient’s story and inability to give

Undue concern with illness – hypochondriasis

Dislike of body
– dysmorphophobia, transsexualism

Distortion of body image – anorexia nervosa, obesity

Hypochondria

Epigastric

Barsky and Klerman (1983) have considered that the word hypochondriasis is used to describe four quite distinct concepts:

• It describes a psychiatric syndrome characterized by physical symptoms disproportionate to demon- strable organic disease, fear of disease and the conviction that one is sick, preoccupation with one’s body and pursuit of medical care.

• Hypochondriasis is seen psychodynamically as a derivative of aggressive or oral drives or as a defence against guilt or low self-esteem.

• It results from a perceptual ampli cation and augmentation and a cognitive misinterpretation of normal bodily sensations.

• It is socially learned illness behaviour to which the philosophy and practice of the medical profes- sion lends support.
Only the rst of these is psychopathologic in nature. These concepts are not alternatives but are all present to a different extent in the individual sufferer. Some individuals use a somatic style to describe their perception of internal discomfort. Appleby (1987) points out that closer examination reveals a descrip- tive triad of the patient being convinced that he has a disease, fearing the disease and being preoccupied with his body. He emphasizes that the patient needs to understand his symptoms before any improvement can be expected.
Bridges and Goldberg (1985) have assessed somatic presentation of psychiatric disorder in primary care in a series of 500 inceptions to illness among 2500 attendees. Their operational criteria for somatization were as follows:
• Consulting behaviour: seeking medical help for somatic manifestations and not presenting psy- chological symptoms.
• Attribution: the patient considers somatic manifesta- tions to be caused physically.
• Psychiatric illness: psychiatric diagnosis justi ed by psychiatrists.
• Response to intervention: the research psychiatrist is of the opinion that treatment of the psychiatric disorder would bene t somatic symptoms.
These authors consider that somatization is a common mode of presentation of psychiatric illness and partly explains the failure of family doctors to detect psychiatric disorders in primary care.

14 Disorder of the Awareness of the Body 199

Lumbar

Iliac

Lumbar

Iliac

Umbilical

Hypogastric

FIG. 14.2 The hypochondrium.
appropriate weight to psychological aspects contributing

to symptoms.

What Is Hypochondriasis?

By derivation, the word hypochondrium refers to the anatomic area below the rib cage (Fig. 14.2) and hence dysfunction of the liver or spleen. Such words as atrabilious or melancholia refer to the black bile that was considered to be associated with hypochondriacal complaint and depressed mood. Kenyon (1965) has de ned hypochondriasis as morbid preoccupation with the body or state of health.

Is hypochondriasis a separate condition – a symptom or a syndrome, a noun or an adjective? It is best to regard hypochondriasis as a symptom rather than a distinct condition. It is not unitary as a condition but a disorder of content rather than of form. The content is the excessive concern with health, either physical or mental and the interpretation of subjective experience as deriving from serious illness. The form of the condi- tion may be quite variable. Even though the term hypochondriacal is best retained as description rather than as a discrete disease entity (Kenyon, 1976), current classi cation systems have a purely hypochondriacal disorder.

200 SECTION IV Self and Body

Trying to distinguish between organic and psycho- logical elements of disease or between mental and physical illness is a fruitless task based on an outmoded and misleading linguistic distinction (Kendell, 2001). Psychological con ict may be mediated via physical illness, and a physical illness results in psychosocial sequelae. Both somatic and psychological symptoms occur, and it is perfectly possible for a patient to have a hypochondriacal reaction to a clearly de ned organic illness.

A patient who regards himself as having symptoms of illness communicates this to relatives and also to the doctor in a tacit request for both help and labelling (Parsons, 1951). To come to medical attention, the person has to carry out a particular set of actions, that is, undertake illness behaviour (Mechanic, 1962, 1986). Illness behaviour includes the manner in which symp- toms are differentially perceived, evaluated and acted upon by different kinds of people and in different social situations. Whereas some people may be able to make light of symptoms, shrug them off and avoid seeking medical attention, others may respond to trivial pain and discomfort by readily seeking care. It is clear, therefore, that individual characteristics as well as social cultural ones determine how any one individual will respond to symptoms.

Individual determinants of hypochondriasis seem to include preoccupation with bodily functions or with the idea of harbouring an illness, rumination about illness, suggestibility, unrealistic fear of infection, fascination with medical information and fear of prescribed medica- tion (Fink et al., 2004). Fear of death also seems to be an integral aspect of hypochondriasis (Noyes et al., 2002b), and childhood adversity (including traumatic events and serious illness and injury) and parental modelling of illness behaviour in childhood are vulnerability factors (Noyes et al., 2002a; Kirmayer and Looper, 2006). Anxiety (Olatunji et al., 2009) and disgust (Davey, 2011) also appear to underlie hypochondriasis. Disgust, in this context, is conceived of as a disease-avoidant emotion, and disgust propensity and sensitivity are regarded as vulnerability factors for a number of disorders including blood-injection-injury phobia and hypochondriasis. Cyberchondriasis, a term referring to excessive and repeated health-related searches on the Internet, reveals aspects of hypochondriasis that may have remained covert, namely, that behavioural aspects

include searching for health information on diagnosed and undiagnosed disorders, seeking out descriptions of other people’s experience of illness and using message boards and support groups. However, these behaviours only provoke more distress and anxiety (Muse et al., 2012; Starcevic and Berle, 2013).

There are very marked cultural differences in the presentation of symptoms of disordered mood; somatiza- tion of emotional distress applies to both anxiety and depression (Rack, 1982). The predominance of descrip- tion of somatic over mood symptoms in depressive illness has been reported from India, Pakistan, Bang- ladesh, Hong Kong, the West Indies and various African countries. The reasons for this include the expectations the patient has of what the doctor can do, the use of somatic symptoms as metaphor for distress and the social unacceptability of psychological symptoms. The Bradford Somatic Inventory has been devised for a multiethnic comparison of the frequency of somatic symptoms, their anatomic localization and their associa- tion with psychiatric disorder (Mumford et al., 1991). Immigrant populations from Pakistan in the United Kingdom demonstrate more somatic symptoms on the Bradford Somatic Inventory compared with the native population. These symptoms are associated with rec- ognizable anxiety and depression as measured by vali- dated questionnaires (Farooq et al., 1995).

Psychopathology of the Hypochondriacal Patient

The content of hypochondriasis is the excessive concern with health, either physical or mental. Possible forms of the condition are listed below. These forms of the content of concern about cancer can include the following:

• A hallucinatory voice may say to the patient, ‘You have cancer, you are moribund’.

• A secondary delusion associated with affective illness may occur in which the patient unreasonably believes he has cancer; he is quite unable to accept his doctor’s reassurance. The belief is understand- able in relation to the patient’s overall depressed mood state. That such secondary delusions could be associated with affective psychoses was clearly described by Cotard (1882): ‘she blamed herself and felt guilty. After some months she entertained hypochondriacal delusions, believing that she had no stomach and that her organs had been destroyed; she attributed these beliefs to the effects

of an emetic which she had, in fact, been given’. This association of hypochondriacal and nihilistic delusions with depressive psychosis in the elderly has been called Cotard’s syndrome.

• The delusion may be primary in nature. A patient with schizophrenia believed that he had been inoculated under a general anaesthetic with a transmissible cancer because others believed him to be homosexual.

• Hypochondriasis often manifests as an overvalued idea. Such a person is constantly worried and concerned about the risk of illness and the need to take precautions in ways that his friends nd ridiculous, for instance in the lengths that he will go to avoid a possible carcinogen. He considers it perfectly reasonable that he should take due care to maintain his health, but he agrees that his measures are excessive. He cannot stop himself, night or day, from thinking, worrying and trying to prevent illness. Such an overvalued idea is found reasonable, or at least not alien to the person’s nature, but preoccupies the mind to an unreasonable extent, in that the whole energy and being becomes directed towards this single idea.

• The hypochondriacal idea may take the form of an obsessional rumination in which the possibility of a particular illness or a form of words, as ‘I have cancer’, may recur. This is recognized as being both ‘alien to my nature’ but also ‘coming from inside myself’. It is resisted yet occurs repetitively.

• Without its amounting to a delusion, patients may often have hypochondriacal symptoms of a nonspeci c nature in the course of a depres- sive illness. It may be possible to reassure them concerning any particular symptom, but this does not make them feel better in their mood nor does it prevent the occurrence of further hypo- chondriacal symptoms in the form of depressive ruminations.

• In the context of acute or chronic anxiety, the patient may be prone to multitudinous worries concerning illness and fears of illness. The normal sensorium is interpreted as symptoms; symptoms are interpreted as serious illness. Most hypochon- driacal symptoms occur in relation to anxiety and

depression; the other forms of disorder are much

less frequent.
The commonest bodily symptoms implicated in

hypochondriasis are musculoskeletal; gastrointestinal, including indigestion, constipation and other preoc- cupation with malfunction; and central nervous system, including headache (Kenyon, 1964). The most com- monly affected parts of the body are head and neck, abdomen and chest. In 16% of patients, symptoms are predominantly unilateral, and of these, 73%, according to Kenyon, were left-sided. There was no signi cant physical abnormality found in 47% of those admitted to a psychiatric ward for hypochondriasis. Pain was prominent in 70% of patients.

Hypochondriasis may be associated with smell; bodily appearance; sexual hypochondria; ear, nose and throat symptoms; and ophthalmologic abnormalities (Karseras, 1976) such as asthenopia, which includes such complaints as ocular discomfort, aching eyes, soreness, pressure in or around the eyes, tiredness of eyes, grittiness, chronic redness, feelings that the eyes are pushed out on stalks, tightness of the skin across the bridge of the nose or pricking of the skin around the eyes. Photophobia is a common hypochondriacal complaint, as are ‘ oaters’ – muscae volitantes, photopsia and sometimes diplopia.

Hypochondriacal complaint may relate to psychologi- cal symptoms and the fear of mental illness. In this context, sleep is often involved, with subjective feelings of sleep not occurring at all, not occurring in suf cient amount or not being of satisfactory quality. Fear of madness and inevitable psychiatric deterioration is commonly associated with acute anxiety disorders and also with depressive illness.

Disorders of Bodily Function – Conversion and Dissociation

Psychopathology has, as its subject matter, actual conscious psychological phenomena. Although our main concern is with pathologic phenomena, it is also necessary to know what people experience in general and how they experience it; in short, psychopathology is interested in the full range of conscious psychologi- cal phenomena. The foregoing raises the question of whether experiences that are not in conscious awareness, such as those that are the subject of this section, can

14 Disorder of the Awareness of the Body 201

202 SECTION IV Self and Body

ever be the proper subject of psychopathology because these experiences are not in conscious awareness. These experiences and behaviours have an antique pedigree and were, until recently, described by the term hysteria.

The meaning and validity of the term hysteria has been argued about for centuries (Veith, 1965). Slater (1965) wished to reject the diagnosis of hysteria while retaining the word as an adjective to describe certain types of symptoms and personality. Lewis (1975) sum- marized this controversy: ‘The majority of psychiatrists would be hard put to it if they could no longer make a diagnosis of “hysteria” or “hysterical reaction”; and in any case a tough old word like hysteria dies very hard. It tends to outlive its obituarists.’ Classically, physical symptoms, usually mimicking neurologic disturbances such as seizures, paralysis, tremors, blind- ness, and gait abnormalities occur in the setting of psychological distress without accompanying expected physical ndings on examination. The term conversion was used to denote the fact that emotional distress or psychological con ict had been converted into physical complaints. A related term is dissociation, referring to the disturbance of the basic unity of the self, resulting in the apparent separation of aspects of the self from one another. For example, a seemingly conscious individual may report that she is unable to recall vital aspects of her biography despite having no demonstrable abnormalities of memory. It is obvious that the term dissociation is merely a descriptive concept for something factually experienced and encountered in clinical practice, as well as a theory for what happens in the particular state, and thus it provides the hypothesis for explaining an observed clinical fact. It is a concept that does not describe anything uniform but touches on modes of extra-conscious explanatory mechanism.

The implications that may be drawn from the conceptualization of conversion and dissociation are as follows:

1. The presenting symptoms are psychologically determined despite being physical in nature;

2. Causation is thought to be unconscious and hence
the patient is not aware of the psychological
determinants;

3. Symptoms may carry some sort of advantage to
the patient, the so-called primary or secondary gain; and

4. The symptoms occur by the mediation of the putative explanatory but ill-de ned processes of conversion or dissociation.

At 10-year follow-up of patients diagnosed with hysteria at a neurologic hospital, many were found to have subsequently developed a serious physical or psychiatric illness, and for this reason, the existence of hysteria as a diagnostic category was questioned (Slater and Glithero, 1965). Follow-up of 113 patients diagnosed as hysterical by psychiatrists revealed 60% with evidence of affective disorder and only 13% with a consistent picture of hysteria (Reed, 1975). However, Merskey and Buhrich (1975) carried out a follow-up on patients diagnosed as having motor conversion symptoms at a neurologic hospital and a control group of other patients from the same clinical setting. They found a higher rate of organic symptoms at follow-up in the control group. From follow-up studies of neu- rologic or psychiatric patients, when the diagnosis of hysteria has been highly inclusive, other organic and psychiatric conditions have commonly manifested, but 15% to 20% still retain the diagnosis of hysteria.

For a diagnosis of dissociative disorder or functional neurologic symptom disorder to be made, positive psychological features must be present and characteristic organic features should be absent. It is important to emphasize the danger of misidentifying genuine physical illness as functional disturbance. Thus for astasia–abasia (Fig. 14.3) for example to be considered dissociative, the symptoms should have psychogenic aetiology; the patient is unaware of this, and the symptoms can be seen to be a way of dealing with stress. If symptoms are clearly consciously produced, deliberate disability, malingering or artefactual illness is present. One may have to distinguish between the symptoms of the original illness – for example, head injury – and a secondary hysterical reaction (Sims, 1985).

Epidemic, communicated or mass hysteria now com- monly termed mass psychogenic illness or mass sociogenic illness has been known and described from earliest times, for example, the physical symptoms of conversion type associated with the millennialist movements of the Middle Ages (Cohn, 1958), in a closed female community in a French seventeenth-century convent (Huxley, 1952), and among Lancashire mill girls (St Clare, 1787). A rather similar epidemic spread through a school in Blackburn 180 years later, with symptoms

14 Disorder of the Awareness of the Body 203

FIG. 14.3 Astasia-abasia. (From Merskey, 1979.)

of over-breathing, dizziness, fainting, headache, shiver- ing, pins and needles, nausea, pain in the back or abdomen, hot feelings and general weakness (Moss and McEvedy, 1966). The spread of such epidemics has been described: they almost always occur in young females; they often start with a girl of high status in her peer group who is unhappy; they tend to occur in largest numbers in the younger children in a secondary school, that is, just after the age of puberty; they appear to affect most severely those who on subsequent testing are found to be the most unstable. What seems to characterize these outbreaks are symptoms occurring among people with shared beliefs about the relevant symptoms in the absence of identi able environmental cause and little clinical or laboratory evidence of disease. Often symptoms spread by ‘line-of-sight’ transmission and may escalate with vigorous or prolonged emergency or media response (Jones, 2000). The outbreaks also seem to mirror prominent social concerns, changing in relation to context and circumstance. From the late twentieth-century onwards, symptoms appear to be triggered by sudden exposure to an anxiety-generating

agent, most commonly an innocuous odour or food poisoning rumours or chemical and biological terrorism themes (Bartholomew and Wessely, 2002). Reports continue to be published (Aldous et al., 1994; Chowd- hury and Brahma, 2005; Kharabsheh et al., 2001; Kokota, 2011).

It would be unrewarding to list all the possible symptoms that may be of conversion or dissociative origin: motor, sensory, pain and alterations in con- sciousness. With the use of skilled examination and additional neurophysiologic techniques, for example, in the investigation of dissociative blindness, it is often possible to demonstrate discrepancy between the severity of symptoms and physiologic dysfunction, which may be minimal or absent. The physiologic impossibility of these symptoms is well demonstrated in Fig. 14.4, which shows the visual eld of a patient complaining of impaired vision.

It is important to take into account the effect these symptoms have on other aspects of a patient’s behaviour and social relationships. Symptoms result in the patient being regarded as ill or disabled, and this alters the way he or she is perceived both by relatives and friends and by the medical and related professions. There may be long-term physical consequences of motor symp- toms, for example, contractures; this is the ultimate mimicry that conversion symptoms show of organic conditions.

Classically, mood in these conditions is described as belle indifference. Such a mood occurred in a girl aged 20 with severe disability that had entailed her using crutches for the previous 2 years. She smiled with sublime resignation at her unfortunate situation, and everyone around her was relieved that she accepted her symptom so stoically! However, some patients with conversion symptoms show higher autonomic arousal than do anxious and phobic patients (Lader and Sar- torius, 1968).

Disorders of the Physical Characteristics and Emotional Value of the Body (Dislike of the Body)

This section deals with how the body is subjectively experienced as a physical object that has both symbolic and aesthetic value to the individual. These two aspects of a person’s attitude towards their own body are distinct

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but interrelated. A distorted subjective experience of the body, the so-called distortion of body image, may occur independently of approval or disapproval or indeed of dislike of the body. Furthermore, the body can be appraised as ugly, that is, as aesthetically unat- tractive, in the absence of demonstrable abnormality of body image.

DYSMORPHOPHOBIA
(BODY DYSMORPHIC DISORDER)

Many people are dissatis ed with the way they look and, of course, this does not of itself constitute a psychiatric symptom. However, unreasonable loathing or excessive preoccupation with a disliked feature may result in psychiatric referral. Such people may show generalized disapproval of their appearance, or it may be concentrated on one feature. Dysmorphophobia was rst de ned by Morselli (1886) as ‘a subjective feeling of ugliness or physical defect which the patient feels is noticeable to others, although his appearance is within normal limits’. As the meaning of the term phobia has changed in the past century, Berrios (1996) considers that dysmorphophobia is at least as satisfactory a term as modern equivalents such as body dysmorphic disorder. According to Andreasen and Bardach (1977), the primary symptom of dysmorphophobia is the patient’s belief that he or she is unattractive.

Dysmorphophobia has been de ned, more inclusively, as the primary complaint of some external physical

defect thought to be noticeable to other people, but, objectively, its appearance lies within normal limits (Hay, 1970). Patients presenting to a plastic surgeon for cosmetic rhinoplasty were examined psychiatrically. They were, as a group, more dis gured than a control group, and they showed some psychological disturbance in that 40% showed disorder of personality. There was, however, no relationship between the degree of deformity and the amount of psychological disturbance. Hay and Heather (1973) commented that when surgery was carried out, those patients with minimal dis gurement did as well as those with more marked defects, both subjectively in description of their self-image and on psychological testing. They considered that the degree of deformity was not of major importance in coming to a decision with regard to operation. Patients reported marked improvement in their appearance 6 months after rhinoplasty, and this was associated with reduction of psychiatric symptom scores (Robin et al., 1988).

Body dysmorphic disorder occurs most frequently in late adolescence; three-quarters of patients are female, and most are either single or divorced (Veale et al., 1996). There is frequent comorbidity with mood disorder, social phobia and obsessive-compulsive disor- der, and 72% of cases manifested personality disorder, usually of paranoid, avoidant or obsessive-compulsive type. Twenty-four percent of this group of patients had attempted suicide. In a similar American study, 73% of patients reported excessive mirror checking, 63%

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reported attempts to camou age their ‘deformities’, and others reported grooming or skin picking (Phillips et al., 1993, 2005). Almost all had severe limitations of their social activities. Most patients had suffered from a major mood disorder and 17% had made suicide attempts. The most frequently reported body parts, in order of concern are skin, hair, nose, stomach, teeth, weight, breasts, buttocks, eyes, thighs, eyebrows, legs, face size or shape, chin, lips, arms, hips, cheeks and ears (Phillips et al., 2005).

Those complaining about their face, and especially their nose, do so in extreme and exaggerated terms despite the deformity often being relatively slight. The dissatisfaction with their appearance and the extent to which they feel others are aware of their dis gurement are quite out of proportion, as are the discomfort and disturbance in function: ‘agonizing pain’ and ‘total inability to breathe’. At the same time, the actual description is often quite imprecise: ‘the skin under my eyes joins my nose in a funny way’ (Birtchnell, 1988). Because of the extreme degree of reaction they show, they may contemplate radical remedies, for example, wishing to have their nose amputated or threatening to kill themselves. Dysmorphophobia is a relatively common disturbance of self and usually takes the psychopathologic form of an overvalued idea.

The complaint of dysmorphophobia is made by the subject in relation to others but is not usually based on the opinion of others. So a patient complains of his nose, or the small size of her breasts, and considers that others will regard them as ugly or unattractive. Often the appearance is well within normal limits, with no deformity, but the patient is convinced that surgery will be bene cial. Patients often present in their late teens or early 20s. There is quite often underlying personality disorder of anankastic or dependent types; there may be depressed mood disturbance as a reaction to the complaint, and such patients not infrequently talk of, and attempt, suicide.

A female student, aged 20, was referred to the psychiatric clinic after self-poisoning. When asked her problem, she burst into tears and said, describing the small size of her breasts:

Basically there is a big difference between me and other girls. I’ve always been self-conscious. I used to pad myself. Even my mother made fun of me. I’ve

tried to convince myself I would change physically. I don’t feel like a total woman. I have to buy clothes that look ridiculous on top. My present boyfriend I have
been going out with for over a year always talks about other girls he has. He went to a dance and danced
with another girl, I knew that it was because she was bigger-busted than me. I was always aware of my gure, that I am not attractive … I detest myself, I hate my body … I don’t like my boyfriend touching me there, I can’t wear nice clothes, I can’t make the best of what
I already have … even my little sister of 16 has more than I have ever had.

It is of interest to note that surgery can result in restitution of normal body image. In a study of 11 young women with no other disease and breast size not grossly inappropriate for body size requesting reduction mammoplasty, Hollyman et al. (1986) found that after surgery body image had returned to normal; self-con dence, feelings about femininity and sexual attractiveness were also enhanced.

Symptoms of dysmorphophobia are sometimes de- scribed by patients with schizophrenia. It may occur as the rst symptom as the condition develops, and the clinician should therefore look carefully for suggestive symptoms. It may also be present in the established case and will then show characteristic schizophrenic symptomatology. A 19-year-old African-Caribbean girl, previously diagnosed with schizophrenia, said:

The Spirit is a man, he feels warm and moves in me.
I can’t feel yet. I’ve got to pray for my new body. I’ll have it in March. I will have to look beautiful, I don’t feel beautiful at the moment, I don’t look nice enough. I’ll have a nice face, nice teeth, red eyebrows, red eyes, pupils red and smooth red lips. My skin will be light and I’ll have long fair thick hair down to my knees. My voice will be different and I’ll have a new tongue. I’ll speak many languages. I’ll sing too. My brain and my mind will be the same. I’ll have long ngernails, a smaller waist, bigger breasts and my legs will be a bit shapelier. My gure will change from 33′′ 24′′ 35′′ to 38′′ 18′′ 36′′.

There is emerging evidence that visual processing of faces and objects may be impaired in individuals with body dysmorphic disorder. Abnormalities include inability to identify faces with emotional expressions

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under experimental conditions (Feusner et al., 2010a) and the use of greater detail-orientated and piecemeal processing of faces compared with controls (Feusner et al., 2010b). Impairments of face processing appear to correlate with demonstrable abnormalities in fron- tostriatal systems (Feusner et al., 2010c), and regional brain volumes of the left inferior frontal gyrus and amygdala are positively correlated with severity scores of dysmorphic disorder (Feusner et al., 2009). These ndings suggest that, despite the absence of gross abnormalities of perception, face and visual object processing impairments may underlie the negative evaluations of the body that are characteristic of dysmorphophobia.

BODY INTEGRITY IDENTITY DISORDER

This is a rare condition in which there is an apparent mismatch between the body image and the physical body. Patients have a strong desire to change the physical body so that it coincides with the body image. The most common desire is to amputate a major limb or to sever the spinal cord to become paralyzed. Patients are reported as saying, ‘I can feel exactly where my leg should end and my stump should begin. Sometimes this line hurts or feels numb’ or ‘my limbs do not feel like they belong to me, and should not be there’ (Blom et al., 2012). Reports suggest that surgery is followed by a feeling of completeness, wholeness and satisfaction. It is perhaps signi cant that approximately half of a cohort of patients studied said that they felt sexually aroused when they saw a disabled person resembling their own desired disability or felt sexually aroused when imagining themselves being disabled (Blom et al., 2012).

TRANSSEXUALISM

In this condition, there is a disturbance of body image with a disorder of core gender identity, a discrepancy between anatomic sex and the gender the person ascribes to himself. In transsexualism, wearing clothing of the opposite sex (transvestism) occurs, usually as a means of personal grati cation without genital excite- ment. It is much commoner in biological males than in females, but it occurs in both sexes. The sufferer of this anomaly feels he should have been of the other gender, ‘a female spirit trapped in a male body’ (Morris, 1974). In adults, the disturbance is manifested by

preoccupation with getting rid of primary and secondary sexual characteristics and the request for hormone therapy or surgery or other means of simulating the required gender (Green, 2000). The strength of this conviction is described in Conundrum by Jan Morris (1974) with literary éclat: ‘I was three or perhaps 4 years old when I realized that I had been born into the wrong body, and should really be a girl … through each year my every instinct seemed to become more feminine, my entombment within the male physique more terrible to me.’ Another transsexual described himself:

I know that I am biologically a man but it is all a horrible freak of nature. Really I am a woman and
by some accident I have got a male body. I think as a woman and have female feelings and interests, and am only comfortable when wearing women’s clothes and in a feminine job. So, genuinely, I am a woman … I am not against homosexuals although I am not one myself. When I have sex with a man, you must remember that I am really a woman.

Transsexuals describe their feelings about their body as having been present from early childhood: the feeling of comfort and ‘rightness’ they experienced when wearing their sister’s dress, how they ‘fell naturally’ into female pursuits and interests. The difference of self-image from the biological sex is usually, in their own account, clearly established before puberty.

The biological basis of transsexualism is uncertain.

Blanchard in a series of papers (1989, 1991, 1993)

proposed that individuals presenting with male-to- female transsexualism and were characterized as having autogynephilia (sexually aroused by the thought or image of themselves as women) were distinct from others who were homosexual in orientation. This classi cation is controversial and not widely accepted (Moser, 2010). There is evidence that chromosomal abnormalities are rare (2.9% in female-to-male trans- sexuals and 0.6% in male-to-female transsexuals) and include gonosomal aneuploidy, Robertsonian transloca- tions and Klinefelter syndrome (Auer et al., 2013). Structural imaging has demonstrated increased cortical thickness in male-to-female transsexuals but the sig- ni cance of these ndings is yet to be determined (Luders et al., 2012) and diffusion tensor imaging has

shown white matter microstructure (superior longi- tudinal fasciculus, right anterior cingulate, right forceps minor and right corticospinal tract) in untreated male- to-female transsexuals that is halfway between that of male and female controls (Rametti et al., 2011). Not- withstanding the fact that the biological basis of transsexualism is yet to be elucidated, what is incon- trovertible is that the dissatisfaction with the body and with secondary sexual characteristics and genitalia is rooted in brain mechanisms that underlie gender identity.

DISTURBANCE OF EATING AND BODY SIZE

Disturbance of eating occurs with various conditions in which alteration of body image either causes eating disorder or results from it. Three conditions are dis- cussed: obesity, anorexia and bulimia nervosa. Once again, it is the subjective aspects, the effect on self-image, that concerns us here and not the physical aspects.

Obesity

Obesity has become a major concern in the Western world. Both in Europe and in North America, the prevalence of obesity has increased considerably since the mid-1970s. Between 1976 and 1980 in the United States, 15% of the adult population aged 20 to 74 was obese, whereas by 2003 to 2004 the prevalence had risen to 33%. In 2017 it was estimated at 36.7% (Centers for Disease Control and Prevention, 2017). These trends are replicated in Europe (World Health Organization Regional Of ce for Europe, n.d.). In the United Kingdom in 2015, 58% of women and 68% of men were over- weight or obese, and obesity prevalence increased from 15% in 1993 to 27% in 2015. Perhaps more signi cantly in 2015–2016, more than one in ve children in recep- tion and more than one in three children in Year 6 were measured as obese or overweight (Health and Social Care Information Centre, 2017). Obesity is de ned as a body mass index of greater than 30 kilo- grams per metre squared; being overweight is a body mass index of between 25 and 29.9 kilograms per metre squared. There is also concern about the rise of obesity in children. It is now estimated that approxi- mately 17% to 20% of children are obese. The concern about obesity derives from the associated health risks; hyperlipidaemia, insulin resistance, diabetes, hyperten- sion, morbidity and premature death are recognized

complications. Thus there are national and international health programmes to combat the apparent unrelenting rise in the prevalence of obesity.

In discussion of the body image phenomena of obesity, Kalucy (1976) considers that adolescence is the critical stage of development when primary disor- ders of shape and body experience appear. Obesity in adolescents in diet-conscious Western societies results in self-loathing and self-denigration. The presence of any physical deformity at this stage of life is likely to provoke revulsion for the self-image; individuals feel especially physically loathsome with regard to potential romantic partners. They may avoid mirrors and any other reminder of their shape. There is also present a distortion of body size in that they often overestimate their size. This is interesting compared with anorexia nervosa patients, who also often overestimate their size and whose behaviour of dieting and food rejection may start when they are mildly obese at the time of puberty.

Anorexia Nervosa

This is a condition that in the past was misplaced diagnostically; initially, sufferers were usually thought to be physically ill. Marcé (1860), however, considered it to be one form of hypochondriasis. Anorexia nervosa is an illness that occurs mainly in young women; the proportion of male cases seen ranges from one in 20 to about one in ten in different series (Dally and Gomez, 1979) and the proportion of boys is higher in childhood. There is a failure to eat, low body weight and amenorrhoea. It has been considered by Crisp (1975) that the disorder is primarily a weight phobia, a fear of increasing body weight, and not only a feeding disorder similar to those of childhood. Prominent is the fear of loss of control; if one eats normally, one will be unable to stop and therefore become fat. As well as an abnormal self-image, there are also abnormal attitudes towards food, gender and sex. How does the patient with anorexia nervosa see herself? It is in part a narcissistic disorder according to Bruch (1965), who has called it ‘the pursuit of thinness’. In the de nition in International Classi cation of Diseases (10th revi- sion), body image distortion is one of ve essential features: ‘There is body image distortion in the form of a speci c psychopathology whereby a dread of fatness persists as an intrusive, overvalued idea and the patient

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imposes a low weight threshold on himself or herself’ (World Health Organization, 1992, p. 177). The other features are:

• body weight at least 15% below that expected, • weight loss is self-induced,
• amenorrhoea and
• delayed or arrested puberty.

Anorexia nervosa became more common in the United Kingdom in the latter part of the twentieth century (Kendell et al., 1973). It is much rarer in, for example, India and other developing countries. This apparent difference in prevalence suggests that it may well be linked to social attitudes towards thinness, dieting and slimming. In the Western world, slimness is regarded as beautiful, and dieting may become a social norm that acts as a persuasive pressure on an impressionable adolescent female whose body weight has increased a little more than average at puberty. If there are other psychological dif culties and social con icts, the slimming may get out of control. In other parts of the world, where the aesthetic norms of feminine beauty are based on a fulsome body, the pressure towards thinness is less but the pressure towards obesity may be greater. Even in Western society, the prevalence of anorexia nervosa is not uniform within society but rather is determined by gender, age, socioeconomic class and ethnicity.

Patients with anorexia nervosa often deny their thinness and sometimes claim to be too fat. Because of their extreme concern over their physical size and weight, a technique was devised by Slade and Russell (1973) to investigate bodily perception in anorexics. This involved comparing real size in subjects (measured by an anthropometer) and perceived size, which was measured by the observer moving horizontal lights to a distance that the subject estimated as the width across four body regions: face, chest, waist and hips. Compared with an age-matched normal control group, anorexic patients signi cantly overestimated their own perceived width at all regions, with the face being overestimated by more than 50%. Although actually thinner at the chest, waist and hips, anorexic patients saw themselves as fatter than normal women. The body image distur- bance could not be accounted for by a general perceptual disorder because anorexics were fairly accurate at the measurement of width of wooden blocks and also extremely accurate at measuring physical height. They

tended to overestimate the width of other people, but not by as much as themselves. The body image distor- tion tended to lessen as patients put on weight, especially if they did so slowly. It was shown that a greater degree of body image disorder held a worse prognosis. Slade and Russell (1973) considered that ‘patients with anorexia nervosa show a faulty appreciation of their own body image in the sense that they perceive their bodies as possessing an exaggerated girth’. It was found by Gar nkel et al. (1979) that some anorexic subjects tend to overestimate body size and that this overestimate was stable over a year and not affected by weight change.

Experimental work by Button et al. (1977) called into doubt the ndings that anorexics alone overesti- mate their size and normal females are more accurate and that disturbance of body perception is variable among anorexic patients. This nding has now been con rmed in a large meta-analysis by Cash and Deagle (1997). Body image disturbance does not appear to be associated with other features of either anorexia nervosa or bulimia nervosa and does not help to differentiate normal women from patients with eating disorder. Furthermore, attitudinal body dissatisfaction as measured by questionnaires or self: ideal discrepancy best differentiated the patients from the normal control subjects. Thus the role of perceptual size estimation inaccuracy, the formal measure of body image distortion, as a diagnostic criterion of anorexia nervosa has to be called into question.

Slade (1988) has also shown that nonanorexic subjects overestimate the dimensions of their body, especially normal females, neurotic subjects, those who are pregnant and patients with secondary amenorrhoea. He has contrasted the use of full body techniques (with distorting mirrors, photographs, television images) for investigating this with part of body methods (visual size estimation, callipers), and has shown that relatively xed cognitive attitudes towards body size with the former demonstrate irrational beliefs about body shape, whereas a more uid state of the estimation of body size depends more on emotional factors that change over time. He has also shown that the more ‘overfat’ the individual considers herself to be, the more dis- satis ed she will be.

Many recent studies have been carried out in sup- posedly normal populations. Strauman et al. (1991) studied the views of self in a large number of female

undergraduates for the factors they described as ‘actual: ideal self-discrepancy’ and ‘actual:ought discrepancy’. They showed that the actual:ideal discrepancy cor- related with body shape dissatisfaction. The actual: ought discrepancy was associated with what they described as anorexic-related attitudes and behaviours and actual:ideal discrepancy with bulimic-related attitudes and behaviours. Gustavson et al. (1990) inves- tigated body image distortion and showed differences between normal students and those suffering from eating disorders. Moore (1988) surveyed 854 females aged between 12 and 23 years from outpatient clinics; 67% were found to be dissatis ed with their weight and 54% with their shape.

Zellner et al. (1989) studied the effects of eating abnormalities and gender on the perception of desirable body shape, using gure drawings by their subjects. They found that women desire to be thinner than they think they are and that women with eating disorders desire to be thinner than that degree of thinness that they think that men will nd attractive. Steiger et al. (1989) found that anorexics, but not bulimics, exhibited body image distortion and that body weight predicted the degree of body image disturbance. Dolan et al. (1990) demonstrated differences between white, African- Caribbean and Asian British women for some of the symptoms of eating disorders but no differences for body image disorder.

Supported by these studies is the nding of a clear association between body image disturbance and eating disorder. This is related inversely to weight – that is, the lower the weight, the greater the degree of body image abnormality. Thus, in general, those with anorexia are more affected than those with bulimia nervosa.

A perpetual question is the degree to which culture in uences body image and to what extent the social environment has a signi cant impact on body image. There is evidence that body dissatisfaction is prevalent in females across ethnic groups in the same country and across national boundaries (Angelova and Uter- mohlen, 2013; Baillie and Copeland, 2013; Demuth et al., 2013; Santana et al., 2013). There are factors unique to particular settings. So in the Bulgarian context, faith and traditional fasting differentially affected the behaviours of women depending on their pre-existing predisposition to disordered eating. For vulnerable women, fasting acted via reinforcement of asceticism

and dietary restraint to induce weight management to achieve a desired thin gure consistent with sociocultural norms (Angelova and Utermohlen, 2013). In the United States, European American women endorsed ‘a curvy- thin or athletic ideal body’, whereas African American women ‘resisted notions of a singular ideal body’ (Webb et al., 2013). In an elegant study, Bagrowicz et al (2013) investigated a sample of Japanese students who had recently arrived in New York City to see what the in uence of endemic obesity was. After 2 months in New York, the Japanese students had thinner self-image but ‘a fatter ideal-image’ and consequently less body dissatisfaction. This study suggests that social environ- ment rapidly in uences ideal body size.

It does seem that abnormality of self and body image is universal in eating disorders: ‘I eat therefore I am’. There are associations between abnormal eating, especially in anorexia nervosa, and low body weight, with a belief or fear that ‘I am too fat’ and with a more pervasive denial of self. In attempting to investigate the factors that in uence this overestimation of their body size by anorexic and bulimic women, Hamilton and Waller (1993) studied the in uence of media por- trayal of idealized female bodies. They concluded that women with eating disorders overestimated themselves substantially more after seeing such images than after seeing photographs of neutral objects. Such images in the media do appear to in uence female behaviour, at least in some vulnerable people.

Strober et al. (1979) assessed perception of body size, subjective experience of body image distortions and differentiation of body concepts by asking adolescent anorexic patients and controls to draw the human gure soon after their hospital admission and 6 months later. Both groups tended to overestimate size at both times, but experiences denoting estrangement from the body, insensitivity to body sensations and weakness of body boundaries were more prevalent in anorexics, and they persisted at high levels after frank symptoms of weight and eating disorder had subsided. There was a greater degree of a more persistent body image distortion in those who vomited. These authors considered that ‘defects in body image formation render the anorexic vulnerable to their manifest pathology, which is itself activated by maturational con icts unique to adolescence’.

The underlying fear of loss of control, and the incessant need for vigilance concerning any calorie that

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enters the mouth, in uences all other areas of the patient’s life. Obsessional tidiness and cleanliness may be manifested, as well as attempts to control the behaviour of other people at home. An anorexic patient controlled the behaviour of her parents and twin sister by threatening to starve herself yet further if they would not cooperate. She weighed not only her own food but that of all the other members of the family. Before her illness, she and her sister both weighed about 57 kg, but as her anorexia progressed she insisted on her twin eating her food also, which the patient cooked. As a result, the patient dropped in weight to about 32 kg, while her sister reached 83 kg.

Bulimia Nervosa

This condition was rst described by Russell in 1979. Although the patient is currently of normal or near- normal weight, there is often a history of anorexia nervosa with weight loss (Fairburn and Cooper, 1984). Body image distortion is also a feature of the condition, with the patient believing herself to be too fat and too heavy.

The characteristic eating disorder is of gross preoc- cupation with food, with episodic binge eating or gorging. This is frequently countered with self-induced vomiting and other methods of weight reduction such as abuse of drugs, such as laxatives or amphetamine-like drugs, or voluntary starvation. Weight is thus maintained with a fragile stability; sometimes weight loss may reach anorexic proportions, and sometimes there may be mild obesity that is associated with feelings of guilt. The fear of putting on weight and the dominating preoc- cupation with food is an overvalued idea.

There is marked dissatisfaction with the body in bulimia nervosa that is similar to that in anorexia nervosa (Cash and Deagle, 1997). There is evidence that the dissatisfaction with the body derives from cognitive evaluative dissatisfaction and is not dependent on sensory perception, although it may be in uenced by mood (Gardner and Bockenkamp, 1996). Various abnormal behaviours may occur, including alcohol abuse, shoplifting (especially involving stealing food) and deliberate self-harm. A variety of serious physical complications may result from rigorous self-induced vomiting or purging.

Underlying factors are particularly centred on doubts concerning femininity (Lacey et al., 1986). Poor

relationships with parents, academic striving, parental marital con ict and poor relationships with the patients’ own peers also occur. These patients described major life events in the areas of sexual con ict, major changes in life circumstances and experience of loss.

Muscle Dysmorphia

Muscle dysmorphia is a term used to describe the pathologic preoccupation with muscularity. It is characterized by preoccupation with (a) muscle size and build, (b) the belief that one’s muscles are too small, (c) excessive time spent in the gymnasium weightlifting, (d) use of anabolic steroids and bulking diets, and (e) in extreme form, cosmetic surgery including pectoral implants. It is sometimes referred to as reverse anorexia or bigorexia (Choi et al., 2002; Pope et al., 1997). The exact nosologic status of muscle dysmorphia is uncertain. Some authors have described it as a variant of body dysmorphic disorder (Choi et al., 2002), others as a male variant of anorexia nervosa (Murray et al., 2010), and others have com- mented on the relationship with obsessive compulsive disorder (Chung, 2001). It is probably best in the current state of knowledge to regard it as a phenomenon that can occur in a variety of psychiatric disorders rather than as a disorder in its own right.

There is consistent evidence that men with muscle dysmorphia have disturbed body image, disordered eating, and excessive exercising (Murray et al., 2012). In weightlifters, its prevalence has been reported as 13.6% (Behar and Molinari, 2010). Body checking, which can be construed as evidence of body dissatisfaction is common in muscle dysmorphia (Cafri et al., 2008; Walker et al., 2009). In comparison to weightlifters without muscle dysmorphia, patients with muscle dysmorphia were more likely to have body dissatisfaction, abnormal eating attitudes, use anabolic steroids and have a history of anxiety or depression. They also complained of shame and embarrassment, poorer quality of life and previous attempted suicide, and there was evidence of impaired occupational and social functioning (Olivardia et al., 2000; Pope et al., 2005).

Disorders of the Sensory Awareness of the Body (Organic Changes in Body Image)

Disease of, and trauma to, the brain alter the body image in a variety of ways. This is either because of

damage of the conceptualized object, for example, amputation with phantom limb or blindness necessarily altering the way one perceives oneself, or damage to the process of conceptualization itself, for example, damage to a section of the corpus callosum. Often, of course, there is scattered damage, as with arteriopathy or multiple sclerosis, and these two features cannot be separated.

The expression body image as used in neurology was de ned by Critchley (1950) as the mental idea that an individual possesses about his own body and its physical and aesthetic attributes. Visual sensation, tactile impulses and proprioceptive stimuli contribute to the formation of body image but are not essential; after the amputation of a limb, a phantom limb retaining the integrity of the body image occurs in the majority of cases. The body image ‘lives on the fringe of awareness and is by no means obtrusive in ordinary circumstances. It is however available and can be brought into consciousness as soon as the stream of attention voluntarily or involuntarily focuses upon it’ (Critchley, 1950). Morbid changes in the body image may show enhancement, diminution (or ablation) or distortion. In neurology, the term body schema is used for the awareness of spatial characteristics of one’s own body, involving current and previous sensory information, whereas body experi- ence is more comprehensive, including psychological and situational factors also (Cumming, 1988). The parietal lobes play a major role, but the somatoaesthetic afferent system and the thalamus are also involved.

PATHOLOGIC ACCENTUATION OF BODY IMAGE (HYPERSCHEMAZIA)

Pain or discomfort causes the affected part of the body to loom large. After dropping a heavy weight on his great toe, a man felt his body to be ‘an insubstantial shell around a huge throbbing toe’. Such a description of the painful organ seeming larger in size is frequent after surgery and traumatic injury. When size is affected, the body may feel larger (macrosomatognosia). Critchley gives several examples of neurologic lesions causing enhancement of an organ.

• With partial paralysis of a limb, the affected segment gives the impression of being too heavy and too big; for example, with Brown-Séquard paralysis (unilateral lesion of the spinal cord), the side with the pyramidal signs is hyperschematic,

whereas the other side, with loss of pain and temperature sensation, is perceived as normal in body schema.

• Unilaterally, after thrombosis of the posterior inferior cerebellar artery.

• In multiple sclerosis, again unilaterally.

Hyperschemazia may also occur with peripheral vascular disease when the affected limb feels larger and heavier. It may also occur in acute toxic states. Nonorganic cases occur with hypochondriasis, in dep- ersonalization states, with dissociation (conversion dis- order, for example pseudocyesis), and also, occasionally, in dreams.

DIMINISHED OR ABSENT BODY IMAGE (HYPOSCHEMAZIA, ASCHEMAZIA)

This may occur when afferent and efferent innervation is lost; for example, with transection of the spinal cord, the patient may feel sawn off at the waist.

Hyposchemazia or microsomatognosia may accompany the sensory deprivation of weightlessness, for instance, under water. With vertigo, the patient may feel exces- sively light, as if oating in the air.

Parietal lobe lesions may result in complicated states of diminution of the body image. Critchley (1950) cites a patient with embolism of the right middle cerebral artery:

It felt as if I was missing one side of my body (the left), but it also felt as if the dummy side was lined with a piece of iron so heavy that I could not move it … I even fancied my head to be narrow, but the left side from the centre felt heavy, as if lled with bricks.

At one time he thought that his paralyzed leg belonged to the man in the next bed. His body felt to him half as wide as it should have done. Lying on the left side gave him the sensation that he was ‘lying on a void’, that he was at the extreme edge of the bed and would presently fall off. In the early days he also felt that he had no penis at all. On this account he was clumsy with the urinal and the bed was frequently soiled. His sensations of owning a penis returned quite suddenly one morning in association with an erection, and it afterwards felt quite normal.

In hemisomatognosia (hemidepersonalization), which was described by L’Hermitte (1939) and is a unilateral

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212 SECTION IV Self and Body

misperception of one’s own body, the patient behaves as though the limbs on one side are missing; this may occur as part of an epileptic aura or migraine. Anosognosia describes the lack of awareness of disability, which may, for instance, occur with neglect of a hemiplegic limb. Hemispatial neglect describes those patients who, when asked to perform a variety of behavioural tasks in space, neglect the hemispace contralateral to their lesion (Cumming, 1988). Gerstmann’s syndrome (Gerstmann, 1930) comprises nger agnosia, acalculia, agraphia and right–left disorientation.

The most severe example of an absent body image is that of Ian Waterman, who at the age of 19 years suffered a total deafferentation of his body from the neck down, resulting in damage to the sensory nerves underpinning touch, the sense of movement and posi- tion (proprioception) but sparing sensations of tem- perature, pain and the motor nerves involved in movement. As Jonathan Cole describes it, ‘At that point unable to feel or move, he felt completely disembodied, he had lost touch – literally – with his own body; if he did not look, he did not know it [his body] was there. He was without body in the sense that he could no longer make use of it … He was terri ed’ (Cole, 2016). It took tremendous effort to move his limbs under visual guidance, every movement was a perfor- mance: ‘I rarely touch on why I put so much effort into “performing”, because I don’t want to be perceived as arti cial or false’. This rare case emphasizes the marked distinction between the body as experienced and the self that does the experiencing. In Ian Water- man’s case, he continued to be a self even when he could not feel his body. Although, strictly speaking, this is not the whole story because he could visualize his body but not feel it.

Again, nonorganic conditions such as depersonaliza- tion may also show diminution of body image. An anxious and depersonalized patient said, ‘I don’t feel at all the same person. Sometimes my head feels so numb when I walk to the shops. I feel I’ve left half my body behind’. This was clearly an as if experience.

DISTORTION OF THE BODY IMAGE (PARASCHEMAZIA)

This may occur with enhancement or diminution of the body image. It may occur with the use of halluci- nogenic drugs such as mescaline, marijuana and lysergic

acid diethylamide. Parts of the body may feel distorted, twisted, separated from the rest of the body or merged with the external environment. These experiences can affect either the whole body or part of it, such as the limbs or head. The shape can be experienced as mis- shapen: ‘my lower jaw is twisted and my teeth no longer close properly’ or ‘my left arm is shrunken and gnarled, a bit like a tree trunk’. When the structure of the body is affected, often it is the internal organs that are the focus of concern:

I assert therefore that on my body, particularly on my bosom, there are present the properties of a nervous system corresponding to a female body and I am certain that a physical examination would con rm this.

and

Food and drink taken simply poured into the abdominal cavity and into the thighs, a process which however unbelievable it may sound, was beyond all doubt for me as I distinctly remember the sensation. (Schreber, 1955)

Changes in the experience of weight can involve a sense of either heaviness or lightness. With hashish:

the sensations produced were those of exquisite lightness and airiness … I expected to be lifted up and carried away by the rst breeze … the walls of my frame were burst outward and tumbled into ruin, and without thinking what form I wore… I felt that I existed throughout a vast extent of space. The blood pulsed from my head, sped through uncounted leagues before

it reached my extremities; the air drawn into my lungs expanded into seas of limpid ether, and the arch of my skull was broader than the vault of heaven. I was a mass of transparent jelly, and a confectioner poured me into a twisted mould. (Taylor, 1856)

The value attached to the body can be disturbed. This disturbance can vary from strong, positive overvalu- ation of the body or its parts to a devaluation of the body extending to dislike or hatred of it. In right-sided hemiparesis, patients can sometimes maintain that their weak arm is in fact stronger and more useful than before. This is referred to as anosognosic overestimation (Cutting, 1997). Misoplegia is the hatred of a limb and

is associated with left-sided parietal lesions (Cutting, 1997).

Distortion of body image may occur with epileptic aura and also, rarely, with migraine.

Phantom Limb

This occurs immediately after the loss of a limb in virtually all patients, and it is particularly common after the traumatic loss of a limb or if there had been a pre-existing painful condition of the limb. The onset appears immediately as the anaesthesia wears off in the majority of cases but may be delayed for up to a few weeks in about 25% of cases. The phantom may last for a few days or weeks then gradually fades from consciousness. There are, however, cases that have persisted for decades. As well as occurring with the loss of a limb, this type of distortion of body image is relatively common after surgical removal of an eye, parts of the face, breasts, the rectum or the larynx. There are reports of phantom ulcer pains after partial gastrectomy and of menstrual cramp after hysterectomy. If an amputee experiences a generalized peripheral neuritis involving sensation, paraesthesia will also occur in the phantom limb. The amputee is aware of the phantom limb in space and also experiences pain in the space conceived as being occupied by the limb.

With time, the limb appears to change in size. The image shrinks, but unevenly, distal joints shrinking more slowly than proximal; this is the so-called telescop- ing phenomenon. There are several postulated explana- tions for telescoping. In loss of the upper limb, telescoping is thought to occur because there is over-representation of the hand in the sensory cortex, hence this is the area from which sensation survives longest. There is also the possibility that telescoping occurs because the representation of the limb in the primary somatosensory map changes progressively. The posture of the phantom is often said to be ‘habitual’, for example, partially exed at the elbow, with forearm pronated. The limb can sometimes feel xed in an awkward position, and this can cause the patient dif culty, for instance, in walking upstairs. The limb may feel twisted and painful.

There is increasing literature on the plasticity of the somatosensory system, using phantom limb as a natural experiment to demonstrate deafferentation after loss of a limb and corresponding reorganization of the somatosensory map (Ramachandran and Hirstein, 1998).

After loss of the upper limb, sensory input from the face and upper arm have been shown to invade the hand territory, such that sensory stimulus to the face can be mislocalized in the phantom limb.

Orbach and Tallent (1965) described the body concepts of patients 5 to 10 years after the construction of a colostomy. These patients had a conviction that they had been seriously damaged.

They believed that their bodily intactness and integrity had been violated. In common with such beliefs many patients on a fantasy level perceived the operation as a physical or sexual assault. Patients who fantasized the surgery as a sexual assault were supported in this belief by the colostomy stoma, a new opening in the front of the body. Most men regarded this opening as evidence of having been feminized, whereas women often interpreted it as the addition of a second vagina. The bleeding from the stoma reinforced the fantasy of a second vagina because it was interpreted as comparable to menstruation.

In one- fth of patients, preoccupation about the bodily processes concerned food intake and elimina- tion was embodied in a replacement concept, which attempted to establish equality between intake and evacuation by eating approximately as much as had recently been evacuated. A majority of the remaining patients communicated a sense of confusion about the machinery and functioning of their bodies.

When colostomy patients were initially studied and the reports published, the constriction of activity and of the life space were emphasized. It is now apparent that the constriction is paralleled by a body concept of being damaged and fragile as a consequence of the injury.

Mastectomy also results in relatively severe dis- turbance in self-concept and body image. A patient described this as ‘I will never be like before … it is like a hole, like a gap … When I lie on that side, it’s like being a man’ (Hopwood and Maguire, 1988). Body image problems result not only from the loss of body part or dis gurement but also from the loss of bodily function. The disorder of self-image is frequently associated with depressive symptoms.

Phantom limb pain may be psychologically deter- mined (Parkes, 1976). Forty-six amputees were studied 4 to 8 weeks and 13 months after amputation; a third to a half showed moderate disturbance tending to persist a year later.

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214 SECTION IV Self and Body

Body image disturbance is not necessarily associated with abnormal sensation or perception. The hypochon- driac may believe he has cancer although he has no physical symptoms. The transsexual experiences his body normally, but he believes that he is in the wrong body. The narcissist is inordinately concerned with his body; nevertheless, he is quite accurate in his ob- jective quantitative perception of self, that is, he knows how long his nose is or how far he can throw a cricket ball. When sensation is abnormal or even de cient altogether in some modality, for example, with blindness or deafness, body image is undoubtedly altered, but this alteration does not in any way imply mental illness; the alteration of body image is usually appropriate to the disability.

Culture-Bound Disorders of Body Image

Various culturally determined ‘hysterical’ conditions have been described by Langness (1967). These condi- tions have in common a sudden, dramatic onset related in time to a psychosocial upset. Manifestations of these conditions are grossly unusual behaviour, volatile mood, transient occurrences of alterations of speech, deper- sonalization with altered body awareness and symptoms somewhat similar to delusions and hallucinations. The course of these conditions is usually limited to 1 to 3

weeks, but they may recur with further episodes. They appear to be more likely in those predisposed with histrionic (hysterical) personalities. The precise symp- toms are often localized to that particular culture and demonstrate how neurotic symptoms in their content comply with the expectations of the society in which they occur. For instance, Adair, writing from Bath in 1786, described how fashion in uenced the great and opulent in the choice of their diseases and considered that Queen Anne’s nervousness resulted in the transfer of similar symptoms ‘to all who had the least pretensions to rank with persons of fashion’.

Some of the culturally localized disorders of aware- ness of the body are summarized in Table 14.2 (from Kiev, 1972). The variability of such syndromes is immense, but the preoccupation with bodily organs and functions is common to many of them. The bizarre nature of symptoms – for example, koro, in which there is fear of the penis shrinking into the abdomen – is often explained by a faulty knowledge of human anatomy and physiology that seems naive to doctors practising in Europe. However, it is not generally known how ignorant British patients are concerning the organization and functions of the organs they cannot see. Hospital outpatients were compared with doctors by Boyle (1970) in their understanding of commonly used medical terms. As might be expected, the doctors

TABLE 14.2 Disorder

Culture-Bound Diso

Diagnostic Equivalent

ders of Body Image

Location

Key Symptom(s)

Koro Frigophobia Latah

Evil eye

Voodoo Windigo

Amok

Anxiety state

Obsessive-compulsive neurosis

Hysteria

Phobic neurosis

Phobic neurosis Depressive reaction

Dissociative state

Southeast Asia East Asia Malaysia

Mexico, North Africa

Haiti
Canada, First Nations

Malaysia

Belief that the penis will retract into the abdomen and cause death

Morbid fear of the cold, preoccupation with loss of vitality, compulsive wearing of layers of clothes

Hyper-suggestibility, automatic obedience, coprolalia, echolalia, echopraxia, echomimia, altered consciousness, disorganization, depression and anxiety

Strong glances are harmful; precautions taken to avoid or counteract evil eye

Violation of taboo may result in death
Fear of engaging in cannibalism and of becoming

a sorcerer, depression of mood Neurasthenia, depersonalization, rage,

automatism and violent acts

(After Kiev, 1972, with permission of Penguin.)

were consistent in their use of terms, but patients had enormous variation in their understanding of such terms as ‘piles’, ‘least starchy food’, ‘palpitation’, ‘jaundice’ and ‘ atulence’. When asked to detail the surface anatomy of internal organs – for example, bladder, kidneys and thyroid gland – the patients showed great variation and were generally quite inaccurate. There are also bizarre anomalies of body image and function occurring in practice in the United Kingdom. A young Lancashire woman working in a mill complained of migrainous headaches and ascribed these to insuf – ciently heavy periods. This explanation was found to be culturally acceptable to her peers.

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KEYWORDS

Pain asymbolia
Phantom pain
Burning mouth syndrome Vulvodynia

Summary

Pain is an unpleasant experience that involves the conscious awareness of noxious sensations, hurting and aversive feelings associated with actual or potential tissue damage (International Association for the Study of Pain, 1994). It is often conceptualized as a mood state. In psychiatry, pain can present as being heightened, markedly diminished or occurring in the absence of demonstrable cause. The most problematic cases are those in which pain is the focus of presentation but there is an absence of identi able physical cause. Facial pain, burning mouth syndrome, vulvodynia, and psychogenic itch are illustrative examples of this problem.

‘You want to hear of me, my dear? That’s something new, I am sure, when anybody wants to hear of me. Not at
all well, Louisa. Very faint and giddy.’ ‘Are you in pain, dear mother?’

‘I think there’s a pain somewhere in the room,’ said
Mrs Gradgrind, ‘but I couldn’t positively say that I have got it.’

Charles Dickens (1854), Hard Times

Since Aristotle, pain has been classi ed not as a perception but as a mood state, and so excluded from the ve senses. It is conceptually a most dif cult topic, hard to describe and to categorize; the only aspect that is clear is that it represents a state of subjective suffering of the patient. But what does he mean by ‘my pain’? Where is it and what is it? Certainly, the meaning of the pain is more than the pain itself, and often it is the reason for the sensation being interpreted as suffering.

A patient with soreness of the throat believed herself to have cancer of the throat; her mother had died of that condition. The relation between symptoms and their meaning is not straightforward. Another person believed herself to be suffering from venereal disease without having been exposed to the risk. But she had previously been successfully treated for Hodgkin’s disease. She had no fears concerning her factual, and potentially lethal, illness but only admitted consciously to fearing the impossible.

Phenomenological aspects of the experience of pain are not well charted, although in general medicine this is, above all others, the area in which phenomenology could be most helpful: pain is a subjective experience that occurs only in consciousness (Bond, 1976). The psychiatrist is often confronted with the problem of whether the pain is physical or mental, organic or functional, medical or psychiatric, and, of course, the answer for each contrasted pair is often both. We may then be requested to assess how much of the pain is psychogenic, although this is virtually impossible because, following Aristotle, pain is a state of mind, even when there is such an obvious cause as a haema- toma under the ngernail.

Organic or Psychogenic Pain?

The transmission of pain results in a subjective, con- scious experience. For an account of the anatomic basis for pain and also the physiologic and biochemical mechanisms, the reader is referred to Wall and Melzack (1999). There is a threshold for pain: light pressure is perceived as touch, heavy pressure as pain. An explana- tion for this has been suggested in the gate control theory of Melzack and Wall (1965), who considered that painful stimulation through the thin myelinated and unmyeli- nated bres results in positive feedback in the substantia gelatinosa; this is transmitted in the lateral spinothalamic tract. However, this gate is under the in uence of the higher centres, which can override the local input, as

CHAPTER 15

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220 SECTION IV Self and Body

demonstrated by the effect of attention: sometimes pain is not felt when attention is directed away from the affected site. Current biochemical theories are also important in accounting for the mediation of pain.

Other theories involve the study of presynaptic and postsynaptic mechanisms in the central nervous system (Nathan, 1980). Electrical stimulation in various sites in the brainstem, including the medulla oblongata, the periaqueductal grey matter and the hypothalamus around the third ventricle, may produce analgesia. Endogenous opiate substances (endorphins) have been discovered to inhibit nerve bres reporting noxious events. This was initially discovered after electrical stimulation in the periaqueductal grey matter of the brainstem in rats but has subsequently been demon- strated in humans (Bond, 1976). Central nervous system mechanisms for the modulation of pain include descend- ing modulatory control and an increasing number of neurotransmitters, especially serotonin and endogenous opioids; it is almost certainly the interaction of these different systems that is effective in pain modulation (Fields and Basbaum, 1994). There is also increasing understanding of the molecular basis of pain. The role of sodium channels after nerve injury and the genes encoding for the expression of particular sodium chan- nels in primary sensory neurons is gradually being elucidated (Waxman, 1999; Waxman et al., 1999).

The temptation to regard pain simply as any other sensation creates certain dilemmas. For example, what is the subjective experience of the person who complains of severe pain with no organic pathology detectable, or the person with mild pathology who complains of excruciating pain? How does one assess the person with an apparently painful injury who claims he did not notice any pain at the time?

Purely organic, physiologic terms, and also psycho- logical, emotional words have been used. Beecher (1959) believed that pain could be de ned and listed many distinguished physiologists and psychiatrists to support his case. However, Merskey (1976) considers that pain is a psychological experience, private to the individual but tending to be described in terms of damage to the body, and so de ned pain as ‘an unpleasant experience which we primarily associate with tissue damage or describe in terms of such damage, or both’.

Clearly, irrespective of the physical stimulus, psy- chological factors are enormously important in the

appreciation of pain. For example, psychological analgesia in obstetric care, using psychological preparation, explanation and sometimes hypnosis, will result in 5% to 10% of subjects experiencing little or no pain, 15% to 20% experiencing only moderate pain and in the rest, pain is not modi ed, but fear and anxiety are diminished (Bonica, 1994). Doctors have frequently, through neglecting subjective evaluation, missed the important distinction between the experience of pain and its physical causes (Noordenbos, 1959). The patient assumes that his pain indicates the presence of physical illness, but pain of various types is a common symptom in many psychiatric conditions without there being physical pathology.

The experience of psychogenic pain has been associ- ated with particular personality types (Engel, 1959). The most important traits of personality associated with pain are those of anxiousness, depressiveness and the cyclothymic personality at its depressive pole – hysteri- cal, hypochondriacal and obsessional traits (Bond, 1976). Subjects with such personality traits developed to abnormal extent are especially likely to respond to life stresses with pain. Complaints of pain are common in neurotic disorder, especially with chronic anxiety or hysterical traits (Merskey, 1965).

It is important to be careful in attempting to dis- tinguish pain of physical origin from that which is largely psychogenic: generalizations can be dangerous. However, Trethowan (1988) considers that there are certain important differences between pain of psychiatric and organic origin. These are as follows.

• Pain associated with psychiatric illness tends to be more diffuse and less well localized than pain due to a physical lesion. It spreads with a nonana- tomic distribution.

• Pain is complained of as a constant feature. It may become more severe at times, but it persists unremittingly. Physical pains usually have more de nite provocative agents and are relieved by speci c measures.

• Psychogenic pain is clearly seen to be associ- ated with an underlying disturbance of mood that appears to be primary in both time and causation.

• It seems to be much more dif cult to accurately describe the quality of psychogenic pain. The patient is in no doubt that he is suffering, that

the pain is very unpleasant and that he feels he cannot bear it. But in contrast to painful damage to a de ned organ, when pain may be described as burning (skin), shooting (nerve) or gripping (heart muscle), the patient with nonorganic pain can nd no adequate words for description.

• A further addition to this list is the nding of progression of the severity and extent of the pain over time – unusual for a purely physically medi- ated pain without increased tissue damage (Tyrer, 1986).

Pain and Heightened Sensation

Generalized increase in sensory input may be experi- enced as pain. This is exempli ed by hyperacousia: the patient complains of noises being uncomfortably loud. There is no objective improvement in his capacity to hear, but the threshold at which sound is perceived as unpleasantly loud is lowered. Noises, even a normal speaking voice, are described as painful to listen to.

With lysergic acid diethylamide, intense pain may be experienced in the limbs, which seem to the sufferer to be twisted or contorted. Similarly, in the early stages of thiamine de ciency, there may be increased sensitivity to pain. In these situations, there is an alteration to perception of sensations so that they are experienced as pain.

During consciousness, the person receives countless sensations from all over his body, such as itching, distension, pressure, borborygmi, mild aching, thump- ing, warmth and so on. These form the sensorium of the body image; they make possible the location of self in space. Most of these sensations escape attention for most of the time. However, occasionally the person concentrates and may take action to eliminate the sensation – scratch his ear or cross his legs. Attention to such sensations, especially if linked to an unpleasant emotion, may occasion the experience of pain. Noticing the sensation results in fear, and the distress of this emotion is perceived as pain.

This would appear to be the explanation for the vital feelings of depression described in Chapter 16. Vital feelings are the localization of depression in a bodily organ, complained of, perhaps as pain, in the head or chest or elsewhere. On further questioning, symptoms are described as being unpleasant, painful pressure or

even a feeling of misery and depression in that organ: morbid interpretations of ordinary bodily sensations. The sensation is unpleasant but normal and would be ignored in health. With disorder of affect, the sensation may be morbidly interpreted as being due to cancer, tuberculosis or venereal disease. There are, of course, also actual physical changes in depression, for example, slowing of peristalsis and decreased gastrointestinal secretions, and these may also provoke unpleasant sensations such as spasm and constipation.

Central pain (thalamic syndrome) is experienced as a spontaneous burning sensation that can be activated by cutaneous stimulation or temperature changes. It can also present as tactile allodynia, cold allodynia or ongoing pain (Greenspan et al., 2004). It is usually intractable and occurs in the setting of cerebrovascular accident, multiple sclerosis, syringomyelia and spinal cord injury. The current hypothesis is that it arises as a result of disruption in the spinothalamic pathways associated with ectopic neuronal discharges and poten- tially involves adrenergic, GABAergic, glycine and other neurotransmitters (Devulde et al., 2002).

Diminished Pain Sensation and Pain Craving

In certain situations, there is a decrease in the percep- tion of pain. Pain asymbolia is a condition in which situations that should give rise to pain do not (Schilder and Stengel, 1931). This condition can occur as a congenital or an acquired disorder. There are at present ve recognized hereditary varieties, usually associated with autonomic neuropathies including anhidrosis (Butler et al., 2006). Several mutations of nerve growth factor have been identi ed (Einarsdottir et al., 2004). Acquired pain asymbolia has also been described in patients with vascular lesions, predominantly left-sided and involving the insular (Berthier et al., 1988). Patients with pain asymbolia show an absent or inadequate response to painful stimuli over the entire body and an inability to learn appropriate escape or protective responses. Other features include anhidrosis, lack of thermal sensitivity, self-mutilation, intellectual dis- ability, recurrent fever secondary to anhidrosis and failure to thrive (Dias and Charki, 2012). In patients with schizophrenia and their relatives, there is evi- dence of elevated pain thresholds and pain tolerance

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demonstrated by relative insensitivity to nger pressure (Hooley and Delgado, 2001). Self-damage of a gross nature also occurs sometimes in schizophrenia, for example, self-castration. In other situations, such as acute drunkenness, there is diminished appreciation due to the central depressant action of alcohol, and opiates similarly are analgesic through their action on the central appreciation of pain.

Attention is also an important factor in the perception of pain. Excitement or aggression, as in footballers or soldiers, may render the subject oblivious to serious injury. When a wound has advantages to the patient – for example, enabling a soldier to leave the battle eld – it causes less pain than when the injury is seen as wholly disadvantageous. Various psychological tech- niques can reduce the experience of pain, including hypnosis, various stratagems in childbirth, placebo medication and, possibly, acupuncture. In dissociation (conversion), there may be localized anaesthesia and analgesia for the affected limb; for example, the patient may describe no perception of pinprick sensation.

A blunting and perverting of pain perception is described in severe mental retardation, resulting occasionally in gross self-damage. The patient may bang his head so that there is chronic haematoma formation, bite himself or otherwise harm himself repeatedly, causing permanent damage. Meanwhile, he appears to experience no pain or even discomfort. Self-application of constricting bands has been described in schizo- phrenia and organically disordered patients (Dawson- Butterworth et al., 1969). These are most often applied to the left arm; despite extensive tissue damage, the patient does not complain of pain.

Self-in icted harm occurs also in those of disturbed personality without intellectual de ciency. Such behav- iour may include skin cutting, wrist slashing, skin burning, self-hitting, severe skin scratching and bone breaking (McElroy et al., 2000). These patients are usually female (Graff and Mallin, 1967), and the behaviour appears to be linked with the desire to relieve tension and alleviate negative emotions. There is empiri- cal evidence that it does relieve negative emotions (Klonsky, 2007). There is also limited evidence that the self-injurious behaviour has several possible goals: as self-punishment, to in uence personal relationships, to reduce tendency to dissociation and also to induce intense sensory stimulation (Box 15.1).

BOX 15.1 EXAMPLES OF SELF-INJURIOUS BEHAVIOUR

When SHE’s home alone, she cuts herself, slicing off
her nose to spite other people’s faces. She always waits and waits for the moment when she can cut herself unobserved. No sooner does the sound of the closing door die down than she takes out her little talisman, the paternal all-purpose razor. SHE peels the blade out of its Sunday coat of ve layers of virginal plastic. She is very skilled in the use of blades; after all, she has to shave her father, shave that soft paternal cheek under the completely empty paternal brow, which is now undimmed by any thought, unwrinkled by any will. This blade is destined for HER esh. This thin, elegant foil of bluish steel, pliable, elastic. SHE sits down in front of the magnifying side of the shaving mirror; spreading her legs, she makes a cut, magnifying the aperture that is the doorway into her
body. She knows from experience that such a razor cut doesn’t hurt, for her arms, hands, and legs have often served as guinea pigs. Her hobby is cutting her own
body.

Elfriede Jelinek (1988), The Piano Teacher

Late at night I went into the bathroom and took the broken pieces of a razor blade which I had kept. I slashed my wrist again and again, as deeply as I could. I knew perfectly well that it would not kill me, not like the times before. They have been something quite different. As my writing to you comes to a close, the pain is so unbearable inside me that a force of such strength has driven me to in ict a physical pain on myself in the hope of appeasing the other.

Sarah Ferguson (1973), A Guard Within

Pain Without Organic Cause

Unfortunately, pain is an unpleasant feature common to almost all medical settings; it is a frequent complaint in medical, surgical, gynaecologic and psychiatric practice. Recalcitrant cases may be referred to a pain clinic, and prominent among such referrals are those in whom no organic basis can be found to account for the complaint of pain (Tyrer, 1985). Pain in the back and in the head and face, particularly, is often found not to be associated with organic lesions. From 3% to 5% of patients, depending on how referrals are made, have measurable psychiatric disturbance.

There are various possible mechanisms to explain the presence of pain without physical disease: autonomic nervous activity may be interpreted and elaborated through fear of possible consequences, normal sensations

may be experienced as painful in situations of stress or in fear, relatively minor pain and discomfort of benign cause may be misinterpreted as being more ominous than it really is.

Classi cation of nonorganic pain is complex. As well as occurring as a primary disturbance, pain also may be conspicuous with hypochondriasis, with soma- tization disorder and, especially, with depression in mood disorder. In Tyrer’s series, two-thirds of those patients without organic cause and with measurable psychiatric disturbance were diagnosed as suffering from major depressive disorder. The remainder had personality disorders, anxiety state, hysteria (disso- ciative disorder) and drug dependence; paraphrenia and organic brain syndrome also occurred, but rarely (Tyrer, 1985).

Pain without adequate organic explanation is one of the most dif cult problems psychiatrists are called on to treat. In a study of patients with pain referred to psychiatrists in a general hospital, the head and neck was the most common site, followed by the back, abdomen, arm or leg, rectum or genitalia and chest (Pilling et al., 1967). In 32% of these medical and surgical patients, pain was the presenting complaint, and it was considered that these patients ‘spoke to their physicians in terms of pain or other organic symptoms rather than anxiety, depression and the like’. In the evaluation of the signi cance of emotional factors in chronic pain, adequate history and examination, includ- ing the assessment of attribution and the relationship with mood state, was found to be most helpful (Tyrer, 1992); the most useful questionnaires were the Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983) and the West Haven – Yale Multidimensional Pain Inventory (Kerns et al., 1985).

It is, of course, wholly understandable that someone suffering pain should be miserable and that chronic pain or the anticipation of recurrent pain should provoke depression of mood. This is often so much taken for granted that no steps are taken to alleviate the depressed mood if the cause of the pain is obvious. However, if the perception of pain is considered to have two separate contributions – the sensory perception and the investing affect – efforts to relieve the latter, if successful, will produce a global diminution of pain. Pain can be a cause of depression, and in this situation treatment for the depression is appropriate.

PAIN AND LOSS

The best known model for this topic is the phantom limb pain so often experienced in amputees (see Chapter 14). Pain is experienced within a limb that is not there; that is, spatially, pain is located outside the patient. However, this is not a hallucination. The person knows full well that he has lost his leg and that the feeling of pain is inside himself. The body image takes a long time to adjust to a change such as an amputation, and it may never do so fully. Ramachandran and Hirstein (1998) provide a thorough review of the subject. The phantom limb experience occurs almost immediately after the loss of a limb in the vast majority of cases, and the incidence may be even higher after a traumatic loss. In the case of surgical amputations, phantoms appear as soon as the anaesthetic wears off. The phantom is present for a few days or weeks and gradually fades but may persist for years or even decades in some people. Indeed, some people are able to recall a phantom limb at will after its disappearance.

Phantoms are most common after amputation of an arm or a leg but have been reported after mastectomies or removal of parts of the face; even phantom internal viscera can produce sensations of bowel movements and atus. The posture of the limb can become habitual, as with the arm, often partially exed at the elbow with forearm pronated, and when the phantom fades from consciousness, especially with the forearm, it becomes progressively shorter until the patient is left with just the phantom hand. Perhaps most surprisingly, children with congenitally missing limbs can experience phantoms. Originally, it was thought that the phantom pain was due to stump neuromas, but given that patients born without limbs can have phantom pain, neuromas do not seem necessary for phantom pain to occur. The persistence of central representation of the amputated limb is largely responsible for the phantom illusion and associated pain.

PSYCHOGENIC FACIAL PAIN

It has been known for a long time that many patients with chronic pain at a variety of sites do not have abnormal physical signs and do not manifest serious organic illness. Atypical facial pain is an especially frequent and intractable example, manifesting no organic signs but causing great suffering; the patient

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is referred from surgeon to dentist to pain clinic physi- cian to psychiatrist, often without bene t. It tends to occur in the nonmuscular areas of the face, either unilaterally or bilaterally. It is poorly localized and does not tend to follow any de nable nerve distribution. It is described as a throbbing, deep, diffuse, boring or nagging pain. It can last for years and can be continuous or episodic in nature (Zakrezewska, 2002, 2013). Such pain has often been associated with depression. Lascelles (1966) described a series of 93 patients suffering from prolonged facial pain, of whom the majority suffered from atypical depression with intense fatigue, tension and sleep disorder superimposed on ‘obsessive’ per- sonality; 53 of these patients responded well to anti- depressant therapy. Blumer and Heilbronn (1982) have seen chronic, intractable pain without organic cause as being a variant of depressive illness. Garvey et al. (1983) investigated the association between headache and depression in 116 patients suffering from major depressive disorder. During a nondepressed period, these patients experienced a similar rate for headache to that of nondepressive control subjects, but they had a markedly increased rate during depressive episodes. Feinmann et al. (1984) investigated the ef cacy of an antidepressant, dosulepin (dothiepin), in the treatment of psychogenic facial pain. Seventy-one percent of patients were free of symptoms at 9 weeks, compared with 47% in a placebo group; at a 12-month follow-up, 81% of patients were pain-free. Good prognostic indicators for successful treatment included pain after an adverse life event, minimal previous surgical intervention and freedom from pain after 9 weeks’ treatment. Such studies would suggest an association between facial pain without physical signs and depres- sive illness.

BURNING MOUTH SYNDROME

A group of heterogeneous skin conditions that present with unpleasant skin sensations including itching, burning, stinging or numbness are well recognized as liable to affect face, scalp and perineum. These condi- tions are poorly understood but demonstrate an interplay among neuropathic pain, neuropathic itch, neurology and psychiatric disorders (Gupta and Gupta, 2013). When these conditions affect the oral cavity, it is referred to as burning mouth syndrome, a condition characterized by intraoral burning for which no medical or dental

cause can be identi ed (Ducasse et al., 2013). The abnormal oral sensations include burning, pricking (pins and needles), allodynia (pain on brushing the teeth and gums), tingling, numbness, itching and sensation of electrical discharges (Braud et al., 2013). These sensations occur principally on the tip of the tongue, the lateral aspects of the tongue, lips, hard and soft palate (Sun et al., 2013) and may involve pain radiating to the lower and upper jaws, the inner aspects of the cheeks and the gums. Despite normal salivation, patients often complain of xerostomia and dysgeusia. Burning mouth syndrome seems to occur most frequently in perimenopausal females (Dahiya et al., 2013).

VULVODYNIA

Vulvodynia can be de ned as persistent, spontaneous, unwelcomed, intrusive and distressing vulval sensation (Markos and Dinsmore, 2013). It is a little-understood condition. A frequent subtype is termed ‘provoked vestibulodynia’ in which the experienced pain or discomfort is provoked by sexual intercourse rather than merely occurring spontaneously (Bois et al., 2013). There is some evidence that vulvodynia is associated with generalized hyperalgesia and that there are aug- mented brain responses to thumb pressure, that is, stimulation of an area remote from the vulva, demon- strable within the insula, dorsal midcingulate, posterior cingulate and thalamus, compared with normal control subjects. This is interpreted as showing augmented central pain processing in vulvodynia (Hampson et al., 2013). In focal as opposed to diffuse vulvodynia, when the pain is localized at 1 and 11 o’clock, it tends to be experienced as deep pain within the vestibule, and the pain is provoked by sexual intercourse or the insertion of a tampon. Pain at 5 and 7 o’clock is less severe (Donders and Bellen, 2012). There are considerable associated adverse effects on quality of life and on intimate relationships with sexual partners (Bois et al., 2013; Ponte et al., 2009; Smith et al., 2013; Xie et al., 2012).

Male patients can also present with a condition similar to vulvodynia. The patients present with burning sensation in the penis and scrotum and this condition is termed penoscrotodynia. The current proposed clas- si cation is generalized, focal, provoked, unprovoked and mixed types (Markos, 2011).

PSYCHOGENIC ITCH

Itch and the desire to scratch is a normal response to skin sensations. Pruritogenic itch (physiologic itch) is transmitted by dedicated afferent neurons much as is pain. Mediators of itch include the ‘cross-talk’ between dermal Mast cells and adjacent cutaneous afferents. In addition, there are a number of neuropeptides (neurotensin and substance P, for example) involved in the process (Greaves, 2010). Some cases, which are considered to be neuropathic in origin, are thought to be related to damage to the peripheral nervous system, such as in post-herpetic neuralgia, brachioradial pru- ritus, notalgia paresthetica, central nervous damage to the spinal cord by tumours and demyelinating disease such as multiple sclerosis (Yosipovitch and Samuel, 2008). The itch sensation in these conditions is analo- gous to neuropathic pain and overlaps with burning, aching and stinging sensations. Psychogenic itch, on the other hand, occurs in the absence of a physical cause and is unrelated to demonstrable nerve damage. It can be associated with depression and obsessive- compulsive disorder (Calikuşu et al., 2003), anxiety and delusions of parasitosis. The French psychoder- matology group has proposed diagnostic criteria to include the following three: localized or generalized pruritus sine materia, chronic pruritus lasting longer than 6 weeks and the absence of a somatic cause. In addition, there should be three additional criteria from the following seven: chronological relationship of pruritus with one or several life events that could have psychological repercussions, variations in intensity associated with stress, nocturnal variations, predomi- nance during rest or inaction, associated psychiatric disorders, improvement in response to psychotropic agents and improvement in response to psychotherapy (Misery et al., 2007).

Pain and Suffering

Pain is an appropriate study for the phenomenologist, in that the external signs may be irrelevant and the subjective experience all-important. The chief problem in assessing pain is the extraordinary dif culty a patient has in describing the quality of his pain: the greater the psychogenic component of the pain, the more dif cult it is to nd the right words to describe it. Sometimes, it seems that pain may be needed as a

neurotic solution to a neurotic con ict: for the equi- librium to remain, it is necessary for the pain to be retained. It has been considered by Trethowan (1988) that such a patient ‘is not suffering from pain at all. What she is suffering from is suffering’.

There are differences between the person suffering from organically determined pain and the chronic sufferer with multiple symptoms whose pain is con- sidered psychogenic. The latter truly suffers but does not show the physical correlates of severe pain. It seems that the state of suffering in which this person exists nds expression, dons respectability and can only be communicated when it is transformed peripherally into a speci c pain. Pain may occur with little suffering, as in the injection of local anaesthetic that, after the small prick, brings relief from a worse pain. Suffering may also occur without pain, but it may also be described as pain, and this may be the nature of many neurotic complaints of pain. This transposition of affect is wholly understandable when one considers the semantics of suffering. Suffering of all nonphysical kinds – indigna- tion, humiliation, disappointment – nds expression in pain terms: taking pains, feeling crushed, bruised self-esteem, rubbing salt in the wound, getting one’s ngers burnt, searing remarks. It is not just that pain is a metaphor for suffering, but in many situations suffering can be experienced and explained by the sufferer only in terms of pain.

So the use of pain words can be construed metaphori- cally, and the neurotic patient may follow this to its logical conclusion and describe concretely the unbear- able and humiliating suffering of his daily existence as complaints of localized physical pain. The experience of pain is a physical sensation that takes on an affective component for its expression and interpretation. This affective component – suffering – may occur without physical perception and sometimes still be experienced by the person himself as pain.

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EMOTIONS AND ACTION

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SECTION 5

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KEYWORDS

Emotion Ecstasy Anhedonia Alexithymia Prosody

Summary

Mood disturbance is not only a common abnormal- ity presenting to psychiatrists but is of considerable importance because of the severe consequences that poor recognition or treatment may have in the lives of patients. It is associated with suicide, homicide and reckless behaviour and has potentially signi cant, undesirable impact on social reputation. Affect is a broad term that is used to cover mood, feeling, attitude, prefer- ences and evaluations. In modern usage, it refers to the expression of emotion as judged by the external manifestations that are associated with speci c feelings – for example, laughter, crying and fearful appearance. Mood is a more prolonged, prevailing state or disposition, whereas emotion is often used to refer to spontaneous and transitory experience similar to but not identical to feeling because it need not incorporate the physical accompaniments of the experience. Abnormalities of mood can be classi ed as follows: (a) morbid states of the basic emotions, including sadness, happiness, fear, anger, surprise and disgust that can be affected in the intensity, duration, timing, quality of experi- ence, expression and appropriateness to the object or social setting; (b) abnormalities of the physiologic and arousal mechanisms associated with emotions; and (c) abnormalities of the cognitive evaluation of the social world and of the perception of the emotions of others.

I wish to inform you that I have received the cake. Many thanks, but I am not worthy. You sent it on the anniversary of my child’s death, for I am not worthy of my birthday; I must weep myself to death; I cannot live

and I cannot die, because I have failed so much, I shall bring my husband and children to hell. We are all lost; we won’t see each other any more; I shall go to the convict prison and my two girls as well, if they do not make away with themselves because they were born in my body.

A patient of Emil Kraepelin (1905)

Assessing and observing the state of, and changes in, mood is essential in psychiatry but at the same time requires skill. Part of the problem has always been the conceptual confusion and lack of cohesive psychopatho- logic theory that has traditionally been associated with disturbance of affect (Berrios, 1985). In a study of patients with unsolved diagnostic problems at the time of discharge from hospital, atypical psychotic depression was found, at follow-up, to be the condition most frequently responsible for doubt (Anstee and Fleminger, 1977). In another study, depressed affect was a major cause of somatic problems without physical pathology (Brenner, 1979). However, the terms used are not standardized, nor mutually exclusive. Different lan- guages, in contrast to the names given to physical objects, have an entirely different range of descriptions of mood, so that one is left wondering whether it is just the terms that differ in different cultures, or perhaps even the experience of emotion itself. So Angst cannot be translated exactly into English with a single equivalent word; neither can depression be precisely translated into German. The word feeling describes an active experience of somatic sensation, touch, as well as the passive subjective experience of emotion. Emotion, according to Whybrow (1997), ‘is actually memory and feeling intertwined’. Feelings are also personal convictions, predictive forecasts and social sensibilities. All these nuances of meaning are somewhat different from the associations of the word mood.

Traditionally, feeling has been used to describe a positive or negative reaction to an experience; it is marked but transitory. Affect is a broad term that is used to cover mood, feeling, attitude, preferences and

CHAPTER 16

231

Affect and Emotional Disorders

232 SECTION V Emotions and Action

evaluations. In psychiatry, it is customary to limit its use to the expression of emotion as judged by the external manifestations that are associated with speci c feelings, for example laughter, crying or fearful appear- ance. Mood is a more prolonged prevailing state or disposition, whereas emotion is often used to refer to spontaneous and transitory experience similar to but not identical to feeling, as it need not incorporate the physical accompaniments of the experience. In practice, these terms are used more or less interchangeably, a fact that contributes to much confusion.

Mood describes the state of the self in relation to its environment. There is an enormous range of variation of what could reasonably be called normal mood. Pathologic mood, that is, mood from which the patient suffers or mood that causes disturbance or suffering to others, also varies a great deal, and the extent to which it is acceptable to others in its expression is different in different social contexts. The clinician has to ask two questions concerning the mood of his patient. First, is the person suffering? Second, is the expression of mood inappropriate in this social setting? Psycho- pathology of mood is con ned to those situations in which there is an af rmative answer to at least one of these questions, and treatment is directed towards improving the mood.

Like other human characteristics, pathology of mood arises in the context of a diathesis. It is the physical constitution that forms the tendency for developing, for example, a prolapsed intervertebral disc; in the mental realm, personality is closely associated with the type, quality and direction of mood. So, a person of cyclothymic personality is more prone to morbid states of elation and excessive activity or taciturn dejection and retardation.

Theories of Emotion

The James-Lange theory of emotion was developed independently by William James (1842–1910) and Carl Lange (1834–1900). Simply, it posits that emotions are the result of self-awareness of physical and bodily changes in the presence of a stimulus. William James (1884) wrote:

My theory … is that the bodily changes follow directly the perception of the exciting fact, and that our feeling

of the same changes as they occur is the emotion. Common sense says, we lose our fortune, are sorry and weep; we meet a bear, are frightened and run; we are insulted by a rival, are angry and strike. The hypothesis here to be defended says that this order of sequence is incorrect … and that the more rational statement is that we feel sorry because we cry, angry because we strike, afraid because we tremble … Without the bodily states following on the perception, the latter would be purely cognitive in form, pale, colorless, destitute of emotional warmth. We might then see the bear, and judge it best to run, receive the insult and deem it right to strike, but we should not actually feel afraid or angry.

This theory was criticized by Walter Cannon (1871–1945) and Philip Bard (1898–1977). Visceral (physiologic) responses to stimuli are too slow to account for the rapidity of emotions that arise in the presence of appropriate stimuli. In other words, the timeliness of my awareness of the increased heart rate and dry mouth that occur when I am in the presence of a hostile lion is inadequate to explain my fear of the lion. Furthermore, the visceral responses to varying stimuli are similar, yet the emotions may be as disparate as fear, surprise, joy and so on. And injection of adrenaline (epinephrine) is accompanied by visceral changes but not necessarily by emotional change. In addition, animals that have spinal lesions continue to experience emotions. Instead, the Cannon–Bard theory argued that emotion has temporal primacy and that any visceral or behavioural change follows the emotion. In this theory, I see a hostile lion and become fearful. My fearfulness provokes the typical physiologic response of increased heart rate, among others, and the resulting behaviour is that I run off. This theory obviously leaves no room for any cognitive aspect to the origin of emotions.

The other in uential theory is Schachter and Singer’s (1962) two-factor theory of emotion. The two relevant factors are physiologic arousal and cognition. In this theory, an individual is in a given social context, and he responds to this situation with a physiologic arousal. The meaning attributed to this arousal is determined by his cognitions. If his appraisal is that the context is threatening then he will feel fear, but if the appraisal is that the situation is funny then the emotion will be a positive one. This theory has obvious implications

for the clinical evaluation of disorders of mood. It speci es that the social context is important, that the cognitions of the individual are relevant and, nally, that careful consideration and description of the accompanying emotion is also important.

Basic Emotions

Ekman and colleagues (Ekman and Friesen, 1971) have shown that there are six basic emotions that are expressed in the face: anger, disgust, fear, happiness, sadness and surprise. These basic expressions of emotion are universal. Ekman’s ndings were anticipated by Charles Darwin (1872). It is also the case that despite there being universals in facial expressions of emotions, these expressions are not universal in every regard. In Ekman’s eldwork in Papua New Guinea among the Fore people, there was little distinction between surprise and fear. Furthermore, it is also true that when people experience strong emotions there are display rules that determine who can show which emotion to whom and when. Cultures also differ on which events are likely to produce particular emotions. This is well exempli ed by what food one culture regards as a delicacy and what another regards as revolting. The important point is that the general theme is universal; ingesting something repulsive is a cause for disgust (Ekman, 1998).

Communication of Mood

‘No man is an Island, entire of itself’ (John Donne, 1571–1631), and in no area of life is this more true than that of feelings. Our feelings are very much affected by those around us. They are observable and under- standable to other people, and this is not accidental; they are actually signalled as a nonverbal message. The affect itself is not directed towards another person, but the expression of the affect is conveyed both deliberately and unintentionally to others.

One of the most important ndings in the past decade has been that of mirror neurons. These neurons have been found in primates and birds, and their existence inferred in humans. Mirror neurons re when an animal performs an action and also when an animal observes the same action performed by another animal. In other words, these neurons mirror the behaviour

of another animal. In humans, the relevant neurons are in the premotor cortex and inferior parietal cortex. Rizzolatti and Fadiga (1998) showed that in the macaque monkey there are two distinct groups of neurons in the rostroventral premotor cortex that respond to the observation of grasping objects and grasping actions. The canonical neurons respond speci cally to the three-dimensional objects, whereas the mirror neurons respond to the direct observation of the hand actions performed by another animal. Rizzolatti and Craighero (2004) argue that this mirror neuron system underlies imitative learning and is therefore important for the development of human culture and the acquisition of language. More recently, Gallese (2007) proposed that the mirror neuron system is an embodied simulation system wherein we not only see an action, emotion or sensation but form internal representations of these actions, emotions or sensations based on evocations of the same neural systems as when we perform the same actions or experience the same emotions or sensations. Thus by means of this system, the objecti ed other becomes for us another experiencing self. In other words, empathy and the capacity to understand another person’s emotional state have an already identi ed basis.

Emotions are communicated nonverbally by different parts of the body, for example by the face (especially the eyes), gesture, posture, tone of voice and general appearance, especially the choice of clothes. While assessing another’s affective response, the assessor in part in uences it by his own behaviour and disposition. A person who is cheerful on meeting someone else will greet him cheerfully and induce a feeling of cheerful- ness, even if transitory, which he then reads as the other person being cheerful also. This has important implications in the way that mood is assessed. It would seem that emotion is evaluated empathically. Without having to go through this elaborate argument in words, the observer says to himself, ‘if I felt how I estimate the feelings of that person from his appearance, I would feel very unhappy; he is unhappy’. This is, of course, the empathic method as described earlier, and it takes place spontaneously and without deliberate training. Assessment of others’ mood does not need to become verbal to be acted on. It takes place rapidly and is followed by the appropriate behavioural response from the observer.

16 Affect and Emotional Disorders 233

234 SECTION V Emotions and Action Classi cation of Pathology of Emotions

There is no consensus on how to classify abnormalities of the experience and display of emotions. Cutting (1997) provides a viable framework, which has been adapted for use in this chapter. There are morbid states of the basic emotions, including sadness, happiness, fear, anger, surprise and disgust. These basic emotions can be affected in their intensity, duration, timing, quality of experience, expression and appropriateness to the object or social setting. There are abnormalities of the physiologic and arousal mechanisms associated with emotions. Finally, there are abnormalities of the cognitive evaluation of the social world and of the perception of the emotions of others (Box 16.1).

Pathologic Changes in Basic Emotions

CHANGES IN INTENSITY OF EMOTIONS

Most often in psychiatric practice, subjective description of change in the experience of emotion is for the worse – a state of dysphoria, meaning the condition of ‘being ill at ease’; more rarely, the patient may describe the onset of ecstasy or euphoria. The subjective experience of change of mood can be quanti ed approximately and represented graphically as in Fig. 16.1, which shows part of a mood chart a previously depressed patient had recorded; he had noticed an association between an acute attack of bronchitis and exacerbation of depressive symptoms.

Diminution of Intensity: Feeling of a Loss of Feeling

This is experienced as a loss of feeling, a de ciency that is all-pervasive, affecting all emotions including sadness, joy, anger, fear and so on. The patient resents or does not understand it, suffers very greatly and often feels guilty about the feeling. It is a subjective experience of loss of feelings that were formerly present rather than an objectively observed absence. A depressed young woman said, ‘I have no feelings for my children. That is wicked. They are beautiful children’. A person with religious belief may experience this loss of feeling

BOX 16.1 CLASSIFICATION OF DISORDERS OF EMOTION

ABNORMALITIES OF BASIC EMOTIONS

• Intensity of emotions, including diminution and exacerbation

• Duration, time and quality of experience, including lability of mood, pathologic crying and laughing, parathymia and paramimia

• Expression of emotion, including blunting and attening of affect

• Appropriateness to object, including phobia
ABNORMALITY OF PHYSIOLOGIC AROUSAL
• Alexithymia
ABNORMALITIES OF EVALUATION OF SOCIAL CONTEXT
• Negative cognitive schemas • Prosopoaffective agnosia
• Receptive vocal dysprosody

High 10 8 6 4 2 Normal 0 2 4 6 8 Low 10

Mild
Moderate
Severe
Most severe in previous episodes

1 5 10 15 20 25 301 5 10 15 Start date: 1 Dec 1985 Days Jan 1986

FIG. 16.1 Mood chart kept by a depressed patient who had had acute bronchitis.

Mood

with a religious content: they no longer believe in God. On more detailed eliciting of their subjective experience, they are likely to describe a loss of the feeling of assur- ance associated with their faith rather than any actual change in the content of their beliefs. This affect occurs particularly in depressive psychosis but also occasionally with personality disorders and schizophrenia. Milder forms are experienced as depersonalization or deaffec- tualization (see Chapter 13): the patient complains that his feelings are numbed, diminished, made remote from himself, to which is ascribed the unmelodious word deaffectualization.

Anhedonia

Anhedonia speci cally refers to a loss of the capacity to experience joy and pleasure. It is a subset of the diminution of the intensity of emotions. In anhedonia, there is a total inability to enjoy anything in life or even get the accustomed satisfaction from everyday events or objects; a ‘loss of ability to experience pleasure’ (Snaith, 1993). The term was originally introduced by Ribot (1896) and considered to be a prominent symptom of depressive illness by Klein (1974), probably the best clinical marker predicting response to treatment. This would seem to be a fundamental symptom of depressive illness. A highly intelligent and perceptive man suffering from psychotic depression said, ‘I have a sort of uncanny feeling. I know what I am reading is amusing but I am not at all amused by it’. The experience was very well described by J.S. Mill (1806–1873):

It was the autumn of 1826. I was in a dull state of nerves, such as everybody is occasionally liable to; unsusceptible to enjoyment or pleasurable excitement; one of these moods when what is pleasure at other times, becomes insipid or indifferent … In this frame of mind

it occurred to me to put the question directly to myself, ‘suppose that all your objects in life were realized; that all the changes in institutions and opinions which you are looking forward to, could be completely effected at this very instant: would this be a great joy and happiness to you?’ And an irrepressible self-consciousness distinctly answered, ‘No!’ At this my heart sank within me.

(Mill, 1873)

Anhedonia as an experience is starting to be decon- structed into its component parts. This de cit in the

capacity to experience pleasure is now thought to include impairments in the processes of reward valu- ation, decision-making, anticipation and motivation. The neural circuits underlying these reward-related mechanisms include the ventral striatum and prefrontal cortical regions (Der-Avakian and Markou, 2012; Gail- lard et al., 2013).

Anhedonia is also described as a symptom in schizophrenia, in which it is especially likely to be social – an absence of the ability to feel pleasure in relationships (Cutting, 1985). There is evidence that the hedonic aspects of olfactory experience may be disturbed in schizophrenia. Male patients with schizo- phrenia failed to attach the appropriate hedonic valence to a pleasant odour, despite correctly perceiving changes in odour intensity in a study where the odour was presented birhinally. In a study in which amyl acetate was presented unirhinally, both males and females with schizophrenia underevaluated the hedonic characteristics at low concentrations and overestimated its hedonic characteristics at concentrations judged to be unpleasant by controls and relatives. These patient-speci c ndings were not explicable by medication, smoking habit or subjective ratings of odour intensity but rather were associated with increased levels of anhedonia/asociality (Kamath et al., 2013). One of the paradoxes of anhe- donia in schizophrenia is that when assessed by ‘trait’ measures of affect, there are robust and marked de cits in the reported experience of pleasure. However, when affect is assessed in ‘the moment’ by laboratory mood- induction procedures, there is no evidence of anhedonia (Cohen et al., 2011; Strauss and Gold, 2012). The reasons for this disjunction are unclear but may include (a) anticipator

deemagclinic

Sims’ Symptoms in the Mind