Psychopathology: The Foundational Discipline of Psychiatry
This article is based on the talk by Prof Femi Oyebode at RCPsych 2019.
Prof Femi Oyebode is an expert in descriptive and clinical psychopathology. He is an authority on the cognitive neuropsychiatry of delusional misidentification syndromes and on other rare and unusual psychiatric syndromes. He is the author of Sims’ Symptoms in the Mind: textbook of descriptive psychopathology.
Importance of psychopathology in psychiatry: [Stanghellini G & Broome M, 2014]
- As psychiatry is a heterogeneous discipline which allows practitioners to conceptualise conditions within multiple perspectives e.g neuroscience, dynamic psychology, and sociology, psychiatrists, therefore, need a common language.
Psychopathology aspires to respect the phenomenon rather than to market a specific, inflexible theory. Psychopathology can be understood as a shared language that allows clinicians with different theoretical backgrounds to understand each other when dealing with mental disorders.
- Psychopathology helps in diagnosis in psychiatry where many conditions are syndromes underpinned by abnormal subjective experiences of the patient.
- Psychopathology functions as a bridge between the human and clinical sciences, providing the basic tools to make sense of mental suffering. It, therefore, allows psychiatrists to not only understand the phenomenon relevant to diagnosis but also to understand the varied patient experiences opening the possibility to the discovery of new psychopathological knowledge.
- Psychopathology attempts to separate the normal experience from the abnormal in the context of illness.
- Psychopathology bridges the gap between understanding of the illness and caring attempting to establish a methodological as well as an ethical framework for this.
- Psychopathology attempts to bridge understanding (meaningfulness) and explanation (causality) in research and clinical settings.
Delusions are considered to be false beliefs that have no bearing on a person’s level of intelligence, cultural, or religious background. Most clinicians refer to these as primary or secondary delusions. If we consider the term ‘delusion’ as a general statement similar to ‘amnesia’ or ‘dementia,’ then the distinctions of primary and secondary delusions become unhelpful. What is needed is an understanding of the origins of the behaviour.
Delusional misidentification syndromes:
- They are of interest to psychiatrists as they mimic the neurological condition known as prosopagnosia, where discrete structural abnormalities occur in the lingual and fusiform gyri of the brain, and both occipital lobes are likely affected by stroke.
- Given the similarity between the psychotic condition and the neurological condition, and that we are dealing with face recognition, we might ask if a relationship exists. Individuals with delusional misidentification syndrome have impaired facial recognition, but intact recognition of facial emotions.
- Neuroimaging evidence suggests a link between Capgras syndrome and right hemisphere abnormalities, particularly in the frontal and temporal regions. [Edelstyn N & Oyebode F, 1999]
- The origin of delusional misidentification syndrome is different from that of delusional/morbid jealousy, which comes from an understanding of the evolutionary biology of mating. The energetics of the investment in parenting for males and females is different, much greater energy investment is associated with the production of finite eggs, and carefully signalling fertility in order to select the most suitable mate. This knowledge provides us with a clue that the beliefs and behaviours associated with jealousy are entwined in biological systems.
Folie à deux:
- Another completely different form of delusion is folie à deux disorder, where symptoms of a delusional belief are shared with another individual to the same tenacity as the person who is ill. The origins of this delusion come from the nature of persuasive communication and show us a different route into delusional thinking.
- Folie à deux shows us that the affected people have to be living in close proximity to each other and that the delusional belief of one of them needs to be believable.
The message must be that delusions deemed as primary or secondary delusions should be considered more like abnormal movements, i.e. the nature of the abnormal movement tells something about the origins of the problem, and this may be a safer and more thoughtful method of approaching delusional patients.
In hallucinations, the emphasis here is very much on the experience of the patient.
Hallucinations are perceptions in the absence of an external stimulus and, importantly, third-person hallucinations are distinct from common hallucinations, and we must consider the origins of each. Therefore, hallucinations cannot be grouped as one entity if we are to obtain meaningful results from neuroimaging studies.
Dimensional models propose auditory verbal hallucinations (AVHs) as a continuum of normal experience.
Cognitive neurobiological models of AVHs include misattribution of inner speech, aberrant memory, semantic processing errors, and abnormal connectivity. [Upthegrove R et al., 2016]