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