Symptomatology (Descriptive Psychopathology)

Updated on January 18, 2025

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Table Of Contents

Disturbances of thought
Disturbances of perception
Disturbances of speech
Disturbances of emotions
Disturbances of motor behaviour
Disturbances of Consciousness
Disturbances of Cognition
Insight

Disturbances of thought

Disturbances of thought process

Thought process describes how the patient uses language and puts ideas together. Can be linear or non-linear.

Disorder of though process	Definition
Circumstantiality	Indirect speech that delays reaching the point BUT eventually does. The patient gives many unnecessary or trivial information (’beating about the bush’). This can be seen in OCD, since the patient is unable to leave out even minor details for the clinician
Tangentiality	Going off on particularly relevant details BUT the patient never reaches the point (patient gives “ball park” responses). The patient gives a reply that is appropriate to the general topic without actually answering the question.
Thought block	Abrupt cessation of the patient’s train of thought before the thought or idea is reached. The patient appears to go ‘blank’. This is characteristic of schizophrenia
Over-inclusive thinking	Inability of the patient to maintain conceptual boundaries. This is seen in schizophrenia.

Disturbances of thought form

Thought form describes the flow and structure of the thoughts expressed by the patient. Most of these disturbances are usually described under ‘speech’ in the mental state exam.

Disorder of thought form	Definition
Loosening of association	No logical connection from one thought to another, as well as there being loss of direction of the thoughts. Might appear similar to flight of ideas but there is no association between successive ideas. Includes ‘Knight’s move thinking’. This is characteristic of schizophrenia.
Derailment	Gradually deviates without blocking
Flight of ideas	Thought changes rapidly from one idea to another, and is often accompanied by pressured speech. This is characteristic of mania.
Clang associations	Words are connected by phonetics rather than actual meaning e.g. by rhyming or punning (different words that sound the same). Example: ‘I want to leave the ward tonight, it’s my right, otherwise I’ll fight’. This is seen in mania
Word salad	Incoherent collection of words
Neologisms	New words created by the patient or patient uses common words in an unconventional way. This is seen in schizophrenia
Irrelevant answers	Patient gives answers that are not in harmony with the questions asked (apparently ignore or not attend to the question)
Echolalia	Repetition of words or phrases said by another person (repetitive and persistent, at times mocking)
Glossolalia	The phenomenon of apparently speaking in an unknown language
Verbal Perseveration	Persistent response to a previous stimulus (question) even when a new stimulus (question) is asked. The patient repeats out of context words, phrases or ideas. Two types: recurrent (gives the same answer to different questions) and continuous (repeats a response unprompted several times) perserveration.
Palilalia	A type of perseveration. Involves repeating the last words or phrases during speech
Logoclonia	A type of perseveration. Involves repeating the last syllable of a word
Coprolalia	Involuntary and repetitive use of obscene language

Disturbances of thought content

Disorder of thought content	Definition
Delusions	false and fixed beliefs about external reality not consistent with a person’s education, social or cultural background; not changed by reasoning. They are held by the patient with conviction despite evidence to the contrary.
Overvalued ideas	False beliefs but less firmly held and can be reasoned (can occur in normal persons undergoing stressful experiences) e.g. anorexia nervosa or beliefs held by members of an extreme cult group
Obsessions	A repetitive, persistent, intrusive, and unpleasant thought (ego-dystonic) or urge that causes severe distress and anxiety. May invovle contamination, doubt, safety, summetry, religion, illness, sex, violence etc. Typically seen in OCD and is seen with ritualistic behaviours (compulsions)
Compulsions	Ritualistic, repetitive behaviors (e.g., touching, washing) or mental act (e.g., counting, repeating a word silently) carried out in an effort to relieve ur ok ges and decrease obsession-related distress.
Ruminations	Type of obsessional thinking involving excessive, repetitive thoughts that interfere with other forms of mental activity. Common in OCD and generalised anxiety disorder
Ideas of reference	The belief that random events are uniquely related to the patient
Suicidal/homicidal ideation	Does the patient have a plan, intent, or means for homicide/suicide?
Phobias	“Persistent irrational fears”. Persistent (≥ 6 months) and intense fear of one or more specific situations or objects (phobic stimuli).
Poverty of thought	Too little ideas
Overabundance of thought	Too many ideas

Bizarre vs non-bizarre delusions

Delusions	Description
Bizarre delusions	Delusions that involve a phenomenon that a person’s culture would consider completely absurd or implausible
Non-bizarre delusions	Delusions that involve a phenomenon that a person’s culture would consider plausible

Primary vs Secondary delusions

Delusions	Description
Primary (autochthonous) delusions	Occurs ‘out of the blue’ and is called primary since they cannot be understood in terms of the person’s previous experiences
Secondary delusions	Called secondary delusions since they are understandable in teh context of the patient’s previous experiences or delusions

Types of delusions

Delusions	Description
Delusional mood (’delusional atmosphere’)	Occurs during the period (hours to days) before the primary delusion becomes apparent. The patient may have an uncanny feeling e.g. ‘something strange is going on’ but does not exactly know what it is
Delusional perception	A primary delusion. It occurs when a normal perception is given a private and illogical meaning (experiences a normal sensory perception but assigns a false meaning to it). A two stage process where first a normal object is perceived then secondly there is a sudden intense delusional meaning into the objects meaning for the patient e.g “The doctor wore a red tie today therefore I am the president” or ‘ I saw the traffic light turn red, so I knew that my neigbour was a spy. This is one of the 11 first-rank symptoms of schizophrenia
Delusional misinterpretation	A secondary delusion. The patient gives a delusional meaning to his experinece in terms of a pre-existing delusion. Example: a patient already believes their neighbour is a spy, then sees the traffic light turn red which they say supports the belief that their neighbour is a spy
Shared delusions	Delusions that are shared by more than one person. Includes folie a deux (two people share it), folie a trois (three people share it), folie imposee (delusional belief is imposed on a dependent person by the psychotic patient – geographical separation resolves the delusion in the former), and folie simultanee (two or more people develop and share the delusional belief simultaneously – extremely rare)
Delusions of reference	A type of delusional belief in which a person interprets neutral or unrelated events, comments, or behaviors as having a special personal significance to them. In other words, they believe that things in their environment are specifically directed at them — often in a negative, secretive, or mysterious way.

Types of Delusions based on content

Type of delusion	Description
Persecutory (Paranoid) delusion	The central theme is that the individual (or someone close) is being attacked, harassed, cheated, persecuted, or conspired against. This is the most common type of delusion seen in clinical practice.
Grandiose delusion	Inflated self-worth, power, knowledge, identity or special relationship to a deity or famous person. They may act on their beliefs e.g. making expensive purchases despite not having enough money. Typically seen in mania.
Religious delusion	The patient may believes that they have divine powers, receive messages from God, or that they actually are God. The religious themes may be grandiose or non-grandiose.
Nihilistic delusion	Extreme negative beliefs e.g. ‘the world is going to end soon’, ‘I am going to die soon’, or that they may not have certain body parts.
Hypochondriac delusion	The patient believes that they may be suffering from a particular illness. Normally part of an anxiety disorder but can reach delusional intensity in depression
Delusion of jealousy/infidelity	Delusion that one’s sexual partner is unfaithful despite lacking evidence e.g. Othellos syndrome
Erotomania	Belief that another person usually of higher status is in love with the individual
Somatic delusion	Main content pertains to appearance or functioning of one’s body e.g. the patient sees themselves becoming tall or the patient feels their brain been taken out and put back in. An example = Cotard’s syndrome, where the patient believes that parts of their body are dying, dead or do not exist)

Disturbances of thought alienation/control

Disorder of though control	Description
Thought withdrawal	External forces remove patient’s thoughts from the mind
Thought insertion	External forces put thoughts into patient’s mind against their wish
Thought broadcasting	Patient’s thoughts are made public without being talked by the patient out loud
Thought echo	Voices repeating the patient’s thoughts

Disturbances of perception

Perception is the process by which sensory stimuli are given a meaning.

Disorders of perception	Description
Illusions	A sensory deception that is the misinterpretation of real external sensory stimuli. May affect any sensory modality (visual, auditory etc.). Can occur in normal or pathological conditions (eg. delirium)
Hallucinations	A sensory deception (false perception) in the absence of a real external stimulus.
Depersonalization	The patient perceives themselves, their body or parts of their body as different, unreal, or unfamiliar. Can occur in stress, anxiety disorders, mood disorders, schizophrenia, dissociative disorders and temporal lobe epilepsy
Derealization	The patient perceives the external world, objects, or people as different, strange or unreal. Can occur in stress, anxiety disorders, mood disorders, schizophrenia, dissociative disorders and temporal lobe epilepsy

Types of illusions

Illusion	Description
Pareidolia	A type of illusion that involves a vivid visual imagery (for example a face). Occurs with little conscious effort, while perceiving an ill-defined stimulus e.g. seeing a face in fire. Not pathological.
Eidetic imagery	A vivid visual imagery that is recalled from a previous perception. Aka ‘photographic memory’. Not pathological

Types of hallucinations based on sensory modality

Hallucination	Description
Second person auditory hallucination	Voices addressing OR commanding the patient
Third person auditory hallucination	Voices are talking about the patient OR commenting on the patient’s actions without addressing him/ her directly
Echo de pensee (Though echo)	Voices repeating the patient’s thoughts
Visual hallucination	Common in delirium, substance intoxication and withdrawal, schizophrenia, severe mood disorders, OR dissociation disorders
Tactile hallucination	Phantom limb, crawling sensation in alcohol withdrawal (”Creepy crawlies”)
Olfactory and gustatory hallucinations	Occurs in temporal lobe epilepsy, schizophrenia, and mood disorders
Somatic hallucinations	False sensation of things occurring in the body (mostly visceral, seen in schizophrenia)

Other types of hallucinations

Hallucination	Description
Hypnogogic hallucinations	Occurs when a person is falling asleep. Tends to be auditory or visual e.g. hearing voices calling out one’s name. Can be non-pathological.
Hypnopompic hallucination	Occurs when a person is waking up. Tend to be auditory or visual. Can be non-pathological.
Functional hallucination	A hallucination that is always preceded by a particular sensory stimulus e.g. hearing voices whenever a tap is running
Reflex hallucination	A subtype of functional hallucination where a hallucination in one sensory modality occurs in response to a stimulus in another modality e..g voices occurring whenever the patients smells a certain aroma
Extracampine hallucination	A hallucination that occurs beyond the boundaries of a sensory field e.g. hearing voices coming from a different city
Synaesthesia	Perceiving a stimulus in one sensory modality as a sensation in another modality e.g. ‘I can see smells’, ‘I can hear colours’. Occurs in the abuse of hallucinogens e.g. LSD
Kinaesthetic hallucination	Somatic hallucinations involving muscles and joints e.g. ‘My arm is being twisted’
Autoscopy	Refers to the experience of seeing oneself outside oneself and ‘knowing’ that it is oneself. Aka ‘phantom mirror image’. This is rare.

Types of sensory distortions

Sensory distortion	Description
Hyperaesthesia	Excessive sensitivity to sensory stimuli, particularly pain. Organic and is typically seen in Herpes zoster
Dysmegalopsia	Altered perception of the shape or sieze of objects. Includes micropsia (smaller size), macropsia (larger) or metamorphopsia (irregular shape). Organic and is seen in retinal and brain lesions, delirium tremens and rarely schizophrenia

Disturbances of speech

Disorder of speech	Description
Poverty of speech	Scanty use of words, lacking in details and is very brief
Pressured speech	Talks a lot and rapidly, and may be difficult to follow. This is characteristic of mania.
Stuttering	Hesitation and involuntary repetition of certain words which may lead to markedly impaired speech fluency
Apraxia	Tongues and lips aren’t able to move in the correct way to produce sounds
Aphasia (motor and sensory)	A language disorder where the individual’s ability to understand and use verbal or written language is impaired.
Coprophasia	Use of markedly obscene or vulgar language
Alogia	Inability to speak due to mental deficiency or dementia
Dysarthria	Motor speech disorder in which the muscles that used for speech are weakened, paralyzed or damaged due to neurological injury leading to slow or slurred speech
Dysprosody	Loss of the normal melody of talk eg. the use of a constant low-pitch in a patient with depression
Mutism	Total loss of speech. This is seen in catatonia

Types of motor and sensory aphasia

Type	Location of the lesion	Type	Clinical features
Broca’s aphasia (Motor/ expressive aphasia/non-fluent aphasia)	Broca area (inferior frontal gyrus)	Non-fluent	Telegraphic and grammatically incorrect speech. Comprehension is largely spared, and the patient is aware of their difficulty in speech
Wernicke’s aphasia (receptive aphasia/ fluent aphasia)	Wernicke’s area (superior temporal gyrus)	Fluent	Fluent speech that lacks sense. Comprehension is impaired, and the patient is typically unaware of their deficits. Reading and writing are often severely impaired.
Global aphasia	Broca area, Wernicke’s area and arcuate fasciculus	Non-fluent	Severe impairment of speech production and comprehension
Anomic aphasia	Not easily pinpointed	Fluent	Isolated difficulty in finding words
Conduction aphasia	Arcuate fasciculus, but Broca and Wernicke’s area are preserved	Fluent	Subtle impairment, mostly in the ability to repeat words and phrases

Disturbances of emotions

Definition of mood and affect

Disorder of emotion	Description
Mood	A pervasive and sustained emotion or feeling that influences a person’s behavior and colors his or her perception of the world. Usually described in the patient’s own words and is subjective. Prolonged duration (several days) and reported. Terms: ‘sad’, ‘afraid’, ‘over the moon’
Affect	A short-lived emotional state that is observed objectively through a pattern of behaviors. It is variable over time, in response to changing emotional states. Seen at the moment by interviewer. Terms ‘euthymic’, ‘reactive’, ‘incongruous
Blunting	Loss of normal emotional sensitivity to experiences
Catastrophic reaction	An extreme emotional and behavioral over-reaction to trivial stimulus
Flattening	Loss of the range of normal emotional responses
Incongruity	Mismatch between the emotional expression and the associated thought
Lability	Superficial, rapidly changing and poorly controlled emotions

Some terms used to describe mood

Term	Description
Sad	Seen in depression
Afraid	Seen in paranoid schizophrenia
Over the moon	Seen in mania

Some terms used to describe affect

Term	Description
Euthymic	Seen in normal health
Reactive	Seen in normal health
Incongruous	A mismatch between the emotional expression and the associated thought. Seen in schizophrenia. e.g. giggling while describing a negative event in their life
Labile	Superficial, rapidly changing and poorly controlled emotions. Seen in mania e.g. the patient may seem very happy but suddenly start crying for no reason
Flat	Loss of the range of normal emotional response. A negative symptom of schizophrenia
Catastrophic reaction	An extreme emotional and behavioral over-reaction to trivial stimulus

Disturbances of motor behaviour

Disorder of motor behavior	Description
Catatonia	The pathological mental state is expressed in motor anomalies
Catalepsy	Muscular rigidity and fixed posture regardless of external stimulus, as well as reduced sensitivity to pain.
Cataplexy	Transient and sudden muscle weakness and loss of muscle tone
Mannerisms	Odd, idiosyncratic, and customary methods of performing a task. These are goal-oriented.
Stereotypies	Repetitive, abnormally frequent, non-functional behavior. These are not goal oriented movements. Seen in intellectual disability disorder.
Tics	A sudden, involuntary vocalization or contraction of a small group of muscles that is recurrent and nonrhythmic. Seen in Tourette’s syndrome, OCD, and ADHD. Can also be seen in organic disorders such as Huntington’s disease and Wilson’s disease
Psychomotor agitation	A state of restlessness accompanied by purposeless movements. Seen in agitated depression
Restlessness	Inability to remain at rest. AKA overactivity. Common in ADHD, delirium, stimulant abuse and akathisia.
Psychomotor retardation	A slowing down or inhibition of mental and physical activity, manifested as slow speech with long pauses before answers, slowness in thinking, and slow body movements
Apraxia	Difficulty performing targeted, voluntary movements despite having intact motor function and the willingness to perform the movement.
Echopraxia	Imitation of another person’s movements
Bradykinesia	Slow movement
Hypokinesia	Decreased movement

Examples of catatonia

Example of catatonia	Description
Catatonic stupor	Movement and speech ceases and the patient is unresponsive to the spoken word or even to painful stimuli. There is usually also the failure to take food or fluid. Therefore, the life of the patient may be in danger and active treatment is essential.
Catatonic posturing	The patient assumes a posture which is then maintained.
Catatonic rigidity	A posture is maintained against the interviewer’s attempts to move the limbs or the whole patient.
Waxy flexibility (Catalepsy)	The interviewer can change the position of the patient’s limbs, and in the process the limbs feel to the interviewer as if they are made of wax. The new posture is usually then maintained for at least a few seconds and sometimes minutes.
Mitmachen	A person’s body can be put into any position even if they have been instructed to resist movement. Mitmachen means “making along” or extreme compliance
Mitgehen	An extreme form of mitmachen. Slight pressure exerted on the body will cause movement in any direction. Mitgehen means “going along”
Negative or contrary catatonia	The patient does the opposite of what is expected. The most commonly described is when the patient extends their hand to the clinician, the clinician responds by extending his/her hand, and as this action is performed, the patient withdraws his/hers.
Catatonic excitement	Extreme activity, including potential violence, and automatic obedience.

Disturbances of Consciousness

Consciousness is the state of awareness of the self and teh environment. It varies from the awake state through drowsiness, somnolence, and coma to death.

Disorder of consciousness	Description
Coma	Deep/profound unconsciousness. Scores low on the Glasgow Coma Scale (GCS < 8).
Stupor	A lack of response and unawareness of surrounding. Stupor = akinesis + mutism. The patient does not move and does not say anything. Can occur in catatonia due to organic and functional disorders
Clouding of consciousness	The patient is disoriented to time, place and person and has little recall following recovery. Suggests an organic pathology and is commonly accompanied by hallucinations
Fluctuation of consciousness	Also suggestive of organic pathology e.g. in delirium the patient becomes more disturbed and disoriented in the evening while being lucid in the daytime
Delirium	A dream-like change in consciousness often accompanied by an impaired reality testing. The patient may be anxious, restless, confused, and experience hallucinations
Oneroid (dream-like) state	The patient is confused, disturbed, hallucinating and prone to exhibit emotions like extreme fear. Difficult to distinguish from delirium. Physical causes need to be excluded before a dissociative functional mental condition is diagnosed
Twilight state	Consciousness is impaired with emotional changes and perceptual disturbances. Has an abrupt onset and end, and the patient has amnesia for the episode. Occurs in temporal lobe epilepsy. Can also be used as a defence against violent acts committed by the patient
Automatism	Consciousness is impaired but the patient retains posture control and performs simple or complex movmenets. The patient is unaware of what they are doing and has little recollection after the episode. Also a feature of temporal lobe epilepsy. Can also be used as a defence against violent acts committed by the patient
Hysterical (Dissociative) fugue	Wandering away from usual surrounding into unfamiliar areas with loss of personal identity. The patient maintains basic self-care and appears to behave appropriately during the episode. Amnesia occurs following recovery.
Ganser’s syndrome	Includes clouding of consciousness (’hysterical twilight state), approximate answers (Vorbeighen), pseudohallucinations (not as consistent or well formed as true hallucinations, has insight that the experience is abnormal), and amnesia after recovery. Originally described in prisoners awaiting trial. Others consider it to be a rare dissociative disorder.
Drowsiness	A state of impaired awareness associated with a desire or inclination to sleep
Somnolence	Abnormal drowsiness

Disturbances of Cognition

Assessment of cognition usually invovles testing orientation, attention/concentration and memory. A more detailed assessment of cognition is warranted for some patients e.g. Dementia

Disturbances of orientation

Orientation in time, place and person is preserved in functional mental illness. Acute disorientation in the presence of clouding of consciousness suggests delirium. Chronic disorientation without clouding of consciousness suggests dementia.

Disturbances of attention and concentration

Attention is the ability to focus one’s mind while concentration is the ability to sustain attention. Can be tested using serial 7s test, spelling WORLD backwards, or months of the year/days of the week backwords.

Disorder of attention	Description
Distractibility	Inability to concentrate, that is, attention is easily diverted to other activities that are irrelevant. Patients with mania and depression may perform poorly.
Trance	A dream-like state when attention is focused on one thing and the person seems oblivious of his surrounding
Selective inattention	One blocks away from consciousness things that generate anxiety
Hyper-vigilance	Excessive attention is concentrated on a stimulus

Disturbances of memory

Memory impairment usually suggests an organic cause e.g. dementia. It may occur in depression – pseudo-dementia – due to a slowing of the cognitive process. In dementia, long-term memory tends to be spared until relatively late in the illness (usually have an inability to learn new information)

How to assess memory

Memory	Method of testing
Registration	Tested by asking the patient to repeat a name and address immediately (or names of 3 objects)
Short-term memory	Tested by asking the patient to recall the address or 3 object after about 5 minutes
Long-term memory	Assessed by testing recall of past events

Disorder of memory	Description
Amnesia	Loss of memory
Retrograde amnesia	Amnesia of events or information acquired prior to the incident/injury.
Anterograde amnesia	Amnesia of events or information acquired after the incident/injury. Also known as post-traumatic amnesia (PTA). The duration of PTA is an important prognostic factor.
Confabulation	Subconscious filling of gaps in memory by imagined or untrue experiences that a person believes but that are not true. It is not deliberate lying. A feature of Korsakoff’s psychosis in alcoholics
Déjà vu	A feeling of familiarity in an unfamiliar situation. Occurs in healty people but can also occur in temporal lobe epilepsy
Jamais vu	A feeling of unfamiliarity in a familiar situation. Occurs in healty people but can also occur in temporal lobe epilepsy
Deje entendu	A feeling of familiarity with an unfamiliary auditory stimulus
Deja pense	A feelin of familiarity with an unfamiliary thought
Para amnesias	Falsification of memory by distortion of recall; may occur in some patients going through stressful life experiences e.g. terminal illness, bereavement, or after alcohol abuse

Insight

Insight may be defined as the correct attitude to morbid change in oneself. Mere compliance with treatment does not indicate good insight

Requirments for total insight
- Recognise one’s illness
- Attribute it to a psychiatric disorder
- Realise the potential benefits of treatment
- Comply with treatment
- Be aware of the potential conseuqences of the illness on oneself and others