PhenomenologyPhenomenology

Dr. Muhd. Najib Mohd. Alwi

Jabatan Psikiatri

Pusat Pengajian Sains Perubatan

Universiti Sains Malaysia

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

(Osler)(Osler)

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PhenomenologyPhenomenology Definition:

- The study of events, either psychological or physical, without embellishing those events with explanation of cause of function

- In psychiatry, it involves the observation and categorization of abnormal psychic eventsabnormal psychic events, the internal experiencesinternal experiences of the patient and his consequent consequent behaviourbehaviour

- Descriptive psychopathology:Descriptive psychopathology:- Empathic evaluation of patient’s subjective experience

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PhenomenologyPhenomenology Symptoms:

- subjective experiences described by the patient- e.g. Depressed mood, poor concentration

Signs:- objective findings observed by the clinician- e.g. Psychomotor retardation, restricted affect

Syndrome:- a group of signs and symptoms that occur together as

a recognizable condition that may be less than specific than a clear-cut disorder or disease

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Description of symptoms Significance:

symptoms are more likely to indicate mental disorder if they re intense and persistent.

Primary and Secondary: Temporal:

Primary – antecedent Secondary – subsequent

Causal: Primary – direct expression of the pathological process Secondary – a reaction to the primary symptoms

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Description of symptoms Form:

Normally is what the doctor is interested in e.g. Voices - internal/external, second/third

person, true voices/implanted thoughts etc.

Content: What the patient is pre-occupied in

e.g. Voices - what the voices says, his feelings towards them etc.

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Description of symptoms Asking the patient:

imagine someone asking you:

““Do you have any fixed, false beliefs that are out Do you have any fixed, false beliefs that are out of keeping with your culture or educational of keeping with your culture or educational background?”background?”

thus, it is very important to start off with open-ended question (screening) and then proceed to close-ended question (specific symptoms)

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Description of symptoms Asking the patient:

now imagine you asking the patient: Do you have any odd experiences lately?

Well, like strange sensasations, feelings or thoughts? If so, is it in the form of voices that other people cannot

hear? ..... And so on....

Sometimes people hear things when there is nothing actually there to explain it, like a voice calling their name. Do you have such an experience?

can you tell me more about it?

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Classification of signs and symptoms in Psychiatry

Disorders of Perception Disorders of Thinking Disorders of Mood Disorders of Cognition

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Perception: the process of becoming aware of what is

presented through the sense organs i.e. the understanding of a sensory stimulus

c/f imagery: an experience within the mind, usually without the sense of reality, can be called out and terminated by voluntary effort. e.g. Eidetic imagery and pareidolia

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Alterations in Perception: intensity

noise - louder or softer than normal

quality shape - e.g. macropsia, micropsia, distorted food - bitter

Two main disorders: illusion hallucination

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Disorders of Perception

Illusions misperceptions of external (objective) stimuli conditions more likely to occur:

reduced level of sensory stimulation (e.g. at dusk) reduced level of consciousness (e.g. delirious pts.) when attention is not focussed on the sensory

modality (e.g. in darkness) when there is a strong affective state (e.g. stressed

up / angry)

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Disorders of Perception

Hallucinations sensory perception without an objective stimulus

but with with a similar quality to a true percept experienced as originating in the outside world

and not in the mind (like imagery) can be of all sensory modalities:

visual / auditory / tactile gustatory / vestibular / olfactory “presence”

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Disorders of Perception

Hallucinations objective space perceived via a

sensory modality clear, distinct, vivid beyond voluntary

control no *insight (towards

the symptom)

Pseudohallucinations subjective space may not be

perceived by a sensory modality

unclear, foggy within voluntary

control of a person there is insight

*about the absurdity of the perception

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Disorders of Perception

Hallucinations objective space perceived via a

sensory modality clear, distinct, vivid beyond voluntary beyond voluntary

controlcontrol no insight (towards no insight (towards

the symptom)the symptom)

Pseudohallucinations subjective space may not be

perceived by a sensory modality

unclear, foggy within voluntary within voluntary

control of a personcontrol of a person there is insightthere is insight

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Description of hallucinations According to complexity

elementary complex

According to sensory modality According to special features

auditory: 2nd or 3rd person

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Auditory hallucinations Elementary / complex Voices

single/multiple male/female known/unknown person person

1st person: “thought echo” - hearing own thoughts spoken aloud (Gedankenlautwerden, echo de la pensee)

2nd person: calling patient by ‘you’ 3rd person:calling patient by ‘he’ or ‘she’

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Auditory hallucinations Voices

commanding / running comentary / arguing with each other

timing: day / night / all the time circumstances when it occurs continuous / intermittent / frequency

theme: friendly, deragotory

patient’s response to the voices

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Visual Hallucinations elementary (e.g. flashes of light) complex

semi-formed: with some structure fully-formed: e.g. human figures, trees

black and white / coloured static / mobile stable form / changing design size (e.g. lilliputian) commonly associated with organicity

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Olfactory and gustatory hallucinations often experienced together often unpleasant in nature (e.g. rotten fish, bitter) common in temporal lobe epilepsy

Somatic (tactile and deep) tactile (haptic): touched, pricked e.g. insect crawling

under the skin (e.g. formication in coccaine abuse) deep sensation: e.g. viscera being pulled out, sexual

stimulation, electric shock

Autoscopic hallucination seeing own body projected into objective space (can

happen in depression) “negative autoscopy” also can occur!

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Extracampine hallucinations: perceiving a sensation from beyond the limits of the sense

organ e.g. visions from outside visual field, hearing voices from

far far away

Reflex hallucinations: stimulus in one sensory modality causing a hallucination in

a different sensory modality e.g. music causing visual hallucination (LSD abuse)

Hypnogogic and hypnopompic hallucinations occurs at the point of falling to or waking from sleep usually brief and elementary

Feeling of “Presence” feeling the presence of ‘somebody’ near but realises that he

is non-existent!

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Other Perceptual Disturbances Depersonalization: a feeling that his body

parts are abnormal, unreal e.g. “my brain becomes big until it fills the room”

Derealization: a feeling that the external environment is abnormal, unreal e.g. people are 2 dimensional card board figures

both can occur in tiredness, TLE, depression etc.

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Thinking Definition:

a goal directed flow of ideas, symbols or associations, initiated by a problem/task, leading to a reality orientated conclusion

disorders of thinking are usually recognized from speech and writing

4 components of thinking: form of thought flow (stream) of thought content possession

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Formal Thought Disorder Disorder in the form (structure) of thoughts 3 main subgroups:

loosening of association flights of ideas perseveration

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Loosening of Association Loss of the normal structure of thinking

muddled and illogical conversation that cannot be clarified by further enquiry.

Several forms: Knight’s move / derailment:

transition from one topic to another with no logical connection between the two

Word salad: severe form of derailment affecting the grammatical

structure of speech Talking past the point (vorbeireden) / tangentiality:

touching the point just a little bit before going Circumstantiality:

going round and round before finally reaching the point

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Flights of Ideas

Patient’s thoughts and conversation move quickly from one topic to another so that one train of thought is not completed before the another appears but there is an apparent association between them (clang (similar sound) or chance associations)

3 components have to be there: pressure of speech shifting topics apparent association (can be followed)

NB: if without pressure of speech = PROLIXITY

Doctor: Kenapa R suka sangat hari ini?

R: Merdeka! Merdeka! Merdeka! Malaysia sudah merdeka,kesemuanya deka.. deka hee. Tanggal 31, bulan lapan limapuluh tujuh... Pantai Sri Tujuh tempat berkelah yang sungguhindah... doktor dah pernah pergi ke? Marilah kita ke sana... Kitapenunggu senja... mencari hakikat diri yang sebenarnya....berjuanglah! Ehmmm.ehmm.... Jika takut menghadapi risikojangan bicara tentang perjuangan!!!

Marilah kita berjuang kerana mu Malaysia... Indonesia...Tunisia.... “sia” tu maksudnya doktor.... “terhapus”.

Maka jadilah mereka seperti dinosaur yang telah pupus di ataskelemahan mereka sendiri... sendiri... ada ertinya....(patientsings)......erti perkataan... ya.. tekalah perkataan itu. Doktorsukakah tengok Roda Impian... Ya, menagilah hadiah misterikali ini. Semisteri seperti ajaibnya Taj Mahal... Salam TajMahal..... Oh, I love you M Nasir....sungguh mahal harganya.Baju doktor smart, ni tentu mahalkan? Eleh... jual mahal pulak.Berhenti? OK saya berhenti... tapi doktor.............. (patientcontinues her conversation)

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Others Formal Thought Disorders

Perseveration: Giving a response beyond the point of relevance i.e.

same answer to each question (stimulus) c/f verbal stereotypy (verbigeration): words, sounds or

phrase repeated in a senseless way (no stimulus)

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Disorder of flow (stream)

Both the amount and the speed of thoughts are changed

Different levels: muteness poverty of thought thought block volubility: amount & speed, still can interrupt pressure of speech: amount & speed, cannot

interrupt speech

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Disorders of Content of Thought Delusion:

false belief, unshakeable, inappropriate to a person’s educational and social background

“double orientation”: wholly convinced about the truth of the delusional belief but the conviction may not influence his feelings and emotions

Over-valued ideas: ideas held with a lot of emotion (highly charged) but with

some degree of ambivalence and doubts about the belief. (Emotions are expressed to compensate for the ambivalence)

Pre-occupation: ideas which comes to mind, again and again and may

prevent the patient from performing his day to day activities

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Classification of Delusions According to fixity:

complete / partial / over-valued ideas / ideas

According to onset: Primary: autochtonous delusions

sudden onset (out of the blue) of delusion other forms:

delusional mood: anxiety, foreboding something to happen (Wahnstimmung)

delusional perception: false meaning to a normal percept

memory: attribute new meaning to old experience

Secondary: derived from preceding morbid experience e.g. hallucinations, depressive mood etc.

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Classification of Delusions According to special features:

Systematised delusion: chronic, presence of nucleus, well knitted, inter-

connected, layered and well-encapsulated.

Non-systematised delusion Shared delusion:

folie a deux (two person, including patient) folie a mass (> than two person)

According to theme

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Themes of Delusion Persecutory (paranoid):

others/organizations trying to inflict harm on him

Delusion of Reference: idea that objects/events/people have a personal

significance for patient e.g. TV programmes, news

Grandiose (expansive): beliefs of exaggerated self-importance

e.g. wealth, special powers, beauty

Religious: delusions with religious content

e.g. chosen to be prophet, communicating directly to God

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Themes of Delusion Amorous Delusion

more common in women (? stalking in men)

De Clerambault’s Syndrome being loved by a man who is unaccessible, high status,

never spoken before, unable to reveal his love for her

Delusion of Jealousy: common in men delusion of unfaithfulness of spouse (infedility) spying, checking on spouse, examine for sexual

secretions

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Themes of Delusion Delusion of Guilt and Worthlessness:

e.g. minor past faults will be exposed, being sinful, deserves to be punished

Nihilistic Delusion belief about non-existence of some person / thing

+ pessimistic ideas e.g. career is gone Cotard’s Syndrome: failures of bodily functions

e.g. bowels are rotting etc.

Hypochondriacal Delusions belief of ill health despite contrary medical

evidence usually of a particular theme & may have

relative/friend suffering the supposed illness

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Other Disorders of Thought Content Obsessions:

recurrent persistent thoughts, impulses or images that enter the mind despite efforts to exclude them

subjective sense of struggle to resist them recognized as his own (not implanted) regarded as untrue and senseless

Compulsions: repetitive, purposeful behaviours performed in a

stereotyped way, accompanied with subjective sense that it must be carried out and an urge to resist

most common: cleaning, counting, dressing

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Description of Obsessions SixSix common themes:

dirt & contamination aggressive thoughts:

e.g. striking others orderliness: how things /

work need to be arranged / done

illness: e.g. dread about cancer

sex: e.g. perverse sexual acts

religion: doubts about fundamental belifs e.g. “Does God exist?”

FiveFive forms: thoughts: intrusive

words or phrases, upsetting e.g. blasphemous phrases

rumination: worrying themes e.g. ending of the world

doubts: uncertainty about previous action (realizes done)

impulses: urges to carry out actions: dangerous or embarrassing

obsessional phobia

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Disorders of Thought Possession

Thought Insertion: delusion that some thoughts have been implanted

by outside agency

Thought Withdrawal: delusion that thoughts have taken out of his mind

(may accompany/explain thought block)

Thought Broadcasting: delusion that his unspoken thoughts are known to

other people

Reference Oxford Textbook of Psychiatry (Third Oxford Textbook of Psychiatry (Third

Edition) Gelder et alEdition) Gelder et al Sypmtoms in the Mind: An Introduction Sypmtoms in the Mind: An Introduction

to Descriptive Psychopathology (Second to Descriptive Psychopathology (Second Edition) Andrew SimsEdition) Andrew Sims