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This page intentionally left blank
Essential Psychiatry
Essential
Psychiatry
Fourth Edition

Edited by
Robin M. Murray
Kenneth S. Kendler
Peter McGuffin
Simon Wessely
David J. Castle
CAMBRIDGE UNIVERSITY PRESS
Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo

Cambridge University Press

The Edinburgh Building, Cambridge CB2 8RU, UK
Published in the United States of America by Cambridge University Press, New York
www.cambridge.org
Information on this title: www.cambridge.org/9780521604086

© Cambridge University Press 2008

This publication is in copyright. Subject to statutory exception and to the provision of

relevant collective licensing agreements, no reproduction of any part may take place
without the written permission of Cambridge University Press.
First published in print format 2008

ISBN-13 978-0-511-42896-8 eBook (EBL)

ISBN-13 978-0-521-60408-6 paperback

Cambridge University Press has no responsibility for the persistence or accuracy of urls
for external or third-party internet websites referred to in this publication, and does not
guarantee that any content on such websites is, or will remain, accurate or appropriate.

Every effort has been made in preparing this publication to provide accurate and
up-to-date information which is in accord with accepted standards and practice at
the time of publication. Although case histories are drawn fromactual cases, every
effort has been made to disguise the identities of the individuals involved.
Nevertheless, the authors, editors and publishers can make no warranties that the
information contained herein is totally free from error, not least because clinical
standards are constantly changing through research and regulation. The authors,
editors and publishers therefore disclaim all liability for direct or consequential
damages resulting fromthe use ofmaterial contained in this publication. Readers
are strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.
Contents

Contributors page vii

Preface to the fourth edition xii

Section 1 The Tools of Psychiatry 1

1 The mental state and states of mind 3
Paul E. Mullen

2 Current approaches to classification 39

Anne E. Farmer and Assen Jablensky

3 Research methods in psychiatry 53

Marieke Wichers and Jim van Os

4 Imaging of brain structure and func-

tion: relevance to psychiatric disorders 68
David Mamo and Shitij Kapur

5 Genetic epidemiology 80
Pak C. Sham and Kenneth S. Kendler

Section 2 Psychiatric Disorders 95

6 Psychiatric disorders in childhood and
adolescence 97
Ian M. Goodyer

7 Personality disorder 135

Peter Tyrer

8 Anxiety disorders 147

Paul Carey, David J. Castle and Dan J. Stein

9 Eating disorders 180

Janet Treasure and Ulrike Schmidt

10 Alcohol problems 198

Ilana B. Crome and Roger Bloor

v
vi Contents

11 Drug use and drug dependence 230 22 Community psychiatry and service
Wayne Hall and Michael Farrell delivery models 498
Michele Tansella, Graham Thornicroft and
12 Affective disorders 250
Ezra Susser
Peter McGuffin
23 General hospital psychiatry 515
13 Schizophrenia and related disorders 284
Matthew Hotopf and Simon Wessely
Robin M. Murray and Kimberlie Dean
24 Forensic psychiatry 540
14 Neuropsychiatry 320
Kimberlie Dean, Tom Fahy, David Ndegwa
Perminder Sachdev
and Elizabeth Walsh
15 The psychiatry of old age 350
E. Jane Byrne, Alistair Burns and Section 5 Treatments in Psychiatry 565
Sean Lennon
25 Biological treatments: general consid-
16 The psychiatry of intellectual disability 383 erations 567
Anthony Holland Evangelia M. Tsapakis and
Katherine J. Aitchison
17 Sexual problems 395
John Bancroft 26 Biological treatments for psychotic
disorders 586
Section 3 Special Topics 417 Ragy R. Girgis, Scott A. Schobel and Jeffrey
A. Lieberman
18 Social and cultural determinants of
mental health 419 27 Biological treatments of depression
Vikram Patel, Alan J. Flisher and Alex Cohen and anxiety 622
Peter McGuffin and Anne E. Farmer
19 Psychiatric disorders of menses,
pregnancy, postpartum and 28 Cognitive behavioural therapy 636
menopause 434 Jan Scott and Aaron T. Beck
Anne Buist, Kimberly Yonkers and Michael Craig 29 Interpersonal psychotherapy 652
20 Suicide and self-harm 451 Myrna M. Weissman and Marc B. J. Blom
Navneet Kapur and Louis Appleby 30 Psychodynamic psychotherapy 665
Glen O. Gabbard and Jessica R. Nittler
Section 4 Psychiatry in Specific Settings 477
31 Family therapy 678
21 Psychiatry in primary care 479 Edwin Harari and Sidney Bloch
Paul Walters, André Tylee and
Sir David Goldberg Index 692
Contributors

Katherine J. Aitchison
Senior Lecturer and Honorary Consultant Psychiatrist
MRC SGDP Centre and Division of Psychological
Medicine and Psychiatry
Institute of Psychiatry at King’s College London
London, UK

Louis Appleby
Director and Professor of Psychiatry
Centre for Suicide Prevention
Division of Psychiatry
University of Manchester
Manchester, UK

John Bancroft
Senior Research Fellow, previously Director
The Kinsey Institute for Research in Sex, Gender and
Reproduction
Barnhurst
Horpath, Oxon, UK

Aaron T. Beck
Emeritus Professor of Psychiatry
University of Pennsylvania and Director of the Beck
Institute
Philadelphia, Pennsylvania, USA

Sidney Bloch
Professor, Department of Psychiatry and Centre for the
Study of Health and Society
University of Melbourne
Melbourne, Australia

vii
viii Contributors

Marc B. J. Blom Michael Craig

Department of Mood Disorders Research Fellow and Lecturer of Psychological
PsyQ the Hague Medicine
The Netherlands Institute of Psychiatry
London, UK
Roger Bloor
Senior Lecturer in Addiction Psychiatry Ilana B. Crome
Keele University Medical School Professor of Addiction Psychiatry
Stoke-on-Trent, UK Keele University Medical School
Stoke-on-Trent, UK
Anne Buist
Professor of Psychiatry Kimberlie Dean
Austin and Northpark Clinical Lecturer and Honorary SpR in Forensic
University of Melbourne Psychiatry
Australia Institute of Psychiatry
London, UK
Alistair Burns
Department of Old Age Psychiatry Tom Fahy
Education and Research Centre Professor of Forensic Mental Health
Manchester, UK Institute of Psychiatry
King’s College London
E. Jane Byrne London, UK
School of Psychiatry and Behavioural Sciences
Wythenshawe Hospital Anne E. Farmer
Education and Research Centre Social, Generic and Developmental Psychiatry Centre
Manchester, UK Institute of Psychiatry
King’s College London
Paul Carey London, UK
MRC Research Unit on Anxiety Disorders
Department of Psychiatry Michael Farrell
University of Stellenbosch Reader in Addiction Psychiatry
Tygerberg, South Africa National Addiction Centre
London, UK
David J. Castle
Chair of Psychiatry Alan J. Flisher
St Vincent’s Hospital and University of Melbourne Professor in Psychiatry and Mental Health, Head of the
Fitzroy, Victoria, Australia Division of Child and Adolescent Psychiatry and
Director of the Adolescent Health Research Institute
Alex Cohen University of Cape Town
Assistant Professor South Africa
Department of Social Medicine Professor II, Research Centre for Health Promotion
Harvard Medical School University of Bergen
Boston, Massachusetts, USA Norway
 Contributors ix

Glen O. Gabbard Department of Psychological Medicine

Brown Foundation Chair of Psychoanalysis and Institute of Psychiatry
Professor of Psychiatry Weston Education Centre
Baylor College of Medicine London, UK
Houston, Texas, USA
Assen Jablensky
Ragy R. Girgis Professor of Psychiatry
Resident in General Adult Psychiatry Director, Centre for Clinical Research in
Department of Psychiatry Neuropsychiatry
College of Physicians and Surgeons The University of Western Australia
Columbia University and New York State Psychiatric Perth, Australia
Institute
New York, New York, USA Navneet Kapur
Head of Research and Reader in Psychiatry
Sir David Goldberg Centre for Suicide Prevention
Emeritus Professor Division of Psychiatry
Health Services Research Department University of Manchester
Institute of Psychiatry Manchester, UK
London, UK
Shitij Kapur
Ian M. Goodyer Vice Dean and Professor of Schizophrenia Imaging and
Developmental Psychiatry Section Therapeutics
Department of Psychiatry Department of Psychological Medicine
Cambridge, UK Institute of Psychiatry
King’s College London
Wayne Hall London, UK
Professor of Public Health Policy
School of Population Health Kenneth S. Kendler
University of Queensland Virginia Institute for Psychiatry and Behavioral
Australia Genetics
Departments of Psychiatry and Human Genetics,
Edwin Harari Medical College of Virginia of Virginia
Consultant Psychiatrist Commonwealth University
Department of Psychiatry Richmond, Virginia, USA
St Vincent’s Hospital
Melbourne, Australia Sean Lennon
Manchester Mental Health and Social Care Trust
Anthony Holland Wythenshawe Hospital
Section of Developmental Psychiatry Manchester, UK
Douglas House
Cambridge, UK Jeffrey A. Lieberman
Chairman, Department of Psychiatry
Matthew Hotopf Columbia University College of Physicians and
Professor of General Hospital Psychiatry Surgeons
King’s College London New York, New York, USA
x Contributors

David Mamo The Prince of Wales Hospital

Assistant Professor of Psychiatry, University of Toronto Sydney, Australia
Clinician Scientist, Centre for Addiction and Mental
Health Ulrike Schmidt
Toronto, Canada Professor of Eating Disorders
Section of Eating Disorders
Peter McGuffin Institute of Psychiatry
Dean and Professor of Psychiatric Genetics London, UK
Institute of Psychiatry
King’s College London Scott A. Schobel
London, UK Fellow in Schizophrenia Research
Department of Psychiatry
Paul E. Mullen Columbia University College of Physicians and
Professor of Forensic Psychiatry, Monash University Surgeons
Clinical Director, Victorian Institute of Forensic Mental New York, New York, USA
Health
Thomas Embling Hospital Jan Scott
Fairfield, Australia Professor of Psychological Medicine, University of
Newcastle and Honorary Professor, Psychological
Robin M. Murray
Treatments Research
Professor of Psychiatry, Institute of Psychiatry
Institute of Psychiatry
King’s College London
London
London, UK
University Department of Psychiatry
Royal Victoria Infirmary
David Ndegwa
Newcastle upon Tyne, UK
South London and Maudsley NHS Trust
Consultant Forensic Psychiatrist
Pak C. Sham
Adult Mental Health Unit
Department of Psychiatry and Genome Research
London, UK
Centre
Jessica R. Nittler Li Ka Shing Faculty of Medicine,
Assistant Professor The University of Hong Kong
University of Missouri – Columbia Hong Kong, China
School of Medicine
Dan J. Stein
Columbia, Missouri, USA
Chair, Department of Psychiatry and Mental Health
Vikram Patel University of Cape Town and Co-Director, MRC
Professor of International Mental Health and Research Unit on Anxiety Disorders
Wellcome Trust Senior Clinical Research Fellow in University of Stellenbosch
Tropical Medicine Cape Town, South Africa
London School of Hygiene and Tropical Medicine
London, UK Ezra Susser
Professor and Chair
Perminder Sachdev Department of Epidemiology
School of Psychiatry Mailman School of Public Health
University of New South Wales and Neuropsychiatric Columbia University
Institute New York, New York, USA
 Contributors xi

Michele Tansella Maastricht, The Netherlands

Professor of Psychiatry Division of Psychological Medicine, Institute of
Department of Medicine and Public Health Psychiatry
Section of Psychiatry and Clinical Psychology London, UK
University of Verona
Verona, Italy Elizabeth Walsh
Honorary Senior Lecturer and Consultant Forensic and
Graham Thornicroft General Adult Psychiatrist
Professor of Community Psychiatry Division of Psychological Medicine
Section of Community Mental Health Institute of Psychiatry
Health Service and Population Research Department London, UK
Institute of Psychiatry
King’s College London Paul Walters
London, UK MRC Fellow
Section of Primary Care Mental Health
Janet Treasure Health Services and Population Research Department
Department of Academic Psychiatry Institute of Psychiatry
Thomas Guy House London, UK
Guys Campus
London, UK Myrna M. Weissman
Professor of Epidemiology in Psychiatry
Evangelia M. Tsapakis College of Physicians and Surgeons
Clinical Research Fellow and Honorary Specialist Columbia University
Registrar in General Adult Psychiatry Chief, Division of Clinical and Genetic Epidemiology
MRC SGDP Centre and Division of Psychological New York State Psychiatric Institute
Medicine and Psychiatry New York, New York, USA
Institute of Psychiatry at King’s College
London, UK Simon Wessely
Professor of Liaison and Epidemiological Psychiatry
André Tylee King’s College London
Professor of Primary Care Mental Health Department of Psychological Medicine
Section of Primary Care Mental Health Institute of Psychiatry
Health Services Research Department Weston Education Centre
Institute of Psychiatry London, UK
London, UK
Marieke Wichers
Peter Tyrer Department of Psychiatry and Neuropsychology
Department of Psychological Medicine South Limburg Mental Health Research and Teaching
Imperial College Network
London, UK EURON, Maastricht University
Maastricht, The Netherlands
Jim van Os
Department of Psychiatry and Neuropsychology Kimberly Yonkers
South Limburg Mental Health Research and Teaching Associate Professor of Psychiatry
Network Yale University
EURON, Maastricht University New Haven, Connecticut, USA
 Preface to the fourth edition

Essential Psychiatry is a premium international psy- child and adolescent and old age psychiatry), Spe-
chiatric text with contributions from leaders in their cial Topics (e.g. social and transcultural aspects
respective fields. Whilst written essentially for the of psychiatry), Psychiatry in Specific Settings (e.g.
clinician, it encompasses the very latest research psychiatry in primary care; community psychiatry)
findings and has extensive and up-to-date referenc- and Treatments in Psychiatry (covering biological,
ing. It is a completely revised and updated version psychological and family interventions). Each chap-
of Essentials of Postgraduate Psychiatry, 3rd ed. (eds. ter has supportive material, including tables and
R. Murray, P. Hill, P. McGuffin; Cambridge Univer- clinically focused fact boxes. The result is a book
sity Press, 1997). Although it maintains the overall which can be read through from beginning to end,
structure of that volume, it expands and extends its particular chapters read separately or sections read
scope and includes cutting-edge contributions from together. Each chapter, whilst standing alone, is
a wide range of authors (from Europe, the Americas, cross-referenced to other chapters where relevant.
Australia, Asia and Africa). The use of headings and subheadings and a com-
Care has been taken to ensure that, whilst chap- prehensive index make quick reference to specific
ters present contemporary research and clinical topics easy.
practice, they also reflect the rich historical heritage We believe this book will be a major reference
of the field of psychiatry. Both the major classifi- work for psychiatrists and mental health profession-
cation systems – the American Psychiatric Associ- als across the world, as well as providing a com-
ation’s Diagnostic and Statistical Manual of Mental prehensive resource for psychiatric trainees which
Disorder and the World Health Organization’s Inter- will endure well beyond their trainee years, and con-
national Classification of Diseases – are referenced tinue to be a source of knowledge and wisdom for
throughout, with pointers to overlaps and differ- years to come.
ences between these systems.
The book is organized into sections, beginning Robin M. Murray, Kenneth S. Kendler,
with The Tools of Psychiatry and followed by Psy- Peter McGuffin, Simon Wessely,
chiatric Disorders (including discrete chapters on David J. Castle
June 2008

xii
 SECTION 1

The Tools of Psychiatry

 1

The mental state and states of mind

Paul E. Mullen

It is the duty, and should be the privilege of the medical Abnormalities of mental state as symptoms
examiner, to spend several days in the examination of a
lunatic before they pronounce a decided opinion. Abnormalities of mental state are frequently treated
Theodric Beck (1823) in psychiatry merely as symptoms that act as sign-
posts pointing towards particular diagnostic con-
The injunction of Dr Beck may seem whimsical in clusions. The theoretical structure underlining this
these days of brief admissions and etiolated com- approach is the familiar medical model in its most
munity psychiatry, but clinical psychiatry without basic form.
some curiosity and concern with the mental life Reservations can, however, be expressed about
of the patient would be an impoverished special- equating abnormalities of mental state with symp-
ity. This is as true for those psychiatrists whose pri- toms in a way analogous to symptoms in general
mary interest is in classification and diagnosis as medicine. In medicine itself the symptom can be
for those who seek first and foremost to explore the seen as expressing the effect of the disease pro-
meaningful connections and mental mechanisms of cess. The pain down the left arm on exertion can
their patients’ internal world. The information gen- reflect the physical changes accompanying car-
erated by such interest, if it is to be shared, requires diac ischaemia. The patient’s complaint is a direct
expression in an agreed language of sufficient clarity pointer to a physical lesion. The tone and qual-
and precision. Putting names to things is an essen- ity of the patient’s complaint may, in this situa-
tial prerequisite to any meaningful discourse. Allow- tion, be affected by the character and culture of the
ing definitions of such names to come to determine individual, but still the symptom can be employed
the supposed essence of those things is, however, as a signpost to the disease. In psychiatry, even if
the death of science and progress. Sadly this is one grants uncritically the claim that underlying
happening not only in attempts to impose oper- disturbances of mental state are disorders of the
ational definitions in psychopathology but also in brain, a straightforward expression of the disease
the classificatory approaches of both the Diagnostic by the symptom is less easily maintained. The so-
and Statistical Manual (DSM) and International called symptoms of psychiatric illness are virtually
Classification of Diseases (ICD) systems, or at least always disturbances of mental state. When patients
in how these symptoms are applied in some circum- give voice to their complaints, or, more often, try
stances (Mullen, 2006). to express the disturbances in their experience of

Essential Psychiatry, ed. Robin M. Murray, Kenneth S. Kendler, Peter McGuffin, Simon Wessely, David J. Castle.
Published by Cambridge University Press.
C Cambridge University Press 2008.

3
4 Section 1: The Tools of Psychiatry

themselves and their world, there lies behind their unable to think of anything but his supposed mal-
statements the whole mental life of that particu- function; the woman who has moved from doc-
lar individual. As Minkowski (1970) expressed it, tor to doctor for 30 years with a multiplicity of
“behind confusion always lies the confused person, aches and pains and despite accumulating oper-
behind melancholy the depressed, behind the syn- ations, vague diagnostic labels, and innumerable
drome of influence the influenced”. Abnormalities courses of treatment, continues to complain bit-
of mental state are not necessarily to be viewed as terly of being plagued by ill health. The symptom
disordered fragments but, on the contrary, can be hypochondriasis could be used for all. The context of
seen as reflecting the whole personality and men- the hypochondriasis in these particular cases could
tal functioning of that individual. This view suggests be further placed in the context of a syndrome such
that the syndrome in psychiatry cannot be equated as Briquet’s, a psychiatric disorder such as depres-
so easily with a simple association of symptoms, sion or even a clinicopathologic entity such as Pick’s
but becomes the expression of a modification in the disease. This further elaboration does not bring us
mental life and personality of this individual. much closer to understanding the state of mind
The clear and precise definition of clinical symp- which manifests in these four individuals through
toms has manifest utility and serves the medi- their worry and concern over the state of their
cal model of psychiatric disorder admirably. There physical health. Perhaps more importantly, if we do
must, however, be some disquiet over the extent to not recognise the qualitative differences in how the
which this detracts from the exploration and delin- hypochondriasis is experienced and expressed, we
eation of the patient’s actual experiences. A hallu- miss an all-important sign of the nature of the dis-
cination can be defined as a perception without turbance of which it is a part.
an object. Employing this definition, whether or If we have a real curiosity about the mental life of
not the particular patient has had a hallucinatory our patients and are not content to remain exclu-
experience, can be determined by asking the right sively within the reductionism of the currently fash-
questions. Having established the presence of the ionable diagnostic labels, then the exploration of
hallucination, the psychiatrist may feel they have mental state must extend beyond symptom collec-
exhausted this area of enquiry, but what has been tion. Symptoms are constructs which do not exist in
defined is a symptom; what has not occurred is the pure form but vary with the context, with the influ-
elucidation of the patient’s actual experience. ence of other disturbances in mental state, with the
To take an example, hypochondriasis has been situation in which they are experienced, with the
defined as painful or unpleasant worrying, specif- cultural and personal background of the individual
ically concentrated on the possibility of disease or and even with the theoretical assumptions of the
malfunction that is beyond the subject’s power to examiner who directs and constrains the patient’s
control and out of proportion to any actual ill- description.
ness or disorder that is present (Wing et al., 1974). Is descriptive psychopathology, then, an intel-
Hypochondriasis so defined may present in very dif- lectual indulgence for mental health professionals
ferent ways in the context of very different states with enough time on their hands for explorations
of mind: the severely depressed patient in a state beyond those necessary for effective care and treat-
of agitated despair who complains of the decay ment of the patient? Or is it of clinical and potential
and decomposition within her; the individual with research interest? It is hoped that this chapter sug-
dementia who repeats interminably a cry for help gests the latter. The symptoms checklist approach
and for a cure to some ill-defined malaise; the young is good enough most of the time, but the psychia-
man who travels from physician to physician with trist’s expertise should take them beyond the limits
a bizarre account of physical disorder, which he inherent in the health professional with a clipboard.
says leaves him without feeling, without will, and Not only will the ability to explore the mental state
 Chapter 1: The mental state and states of mind 5

provide a more rounded understanding of even but genuine confusion created by attempting to
the most mundane clinical situation, a competent read clinical reality through the categories of the
exploration will make the patient feel attended to diagnostic manuals.
and understood to a far greater extent than an inter- The situation with affective disorders is even
rogation based on a predetermined set of ques- more dramatic. Following the extension of the
tions. In the more complex case, such an explo- label depression to cover a vast range of distress
ration offers protection against error and the hope and dysphoria, we are left with supposed diag-
of more effective management. The trajectory for nostic entities, such as major depression, which
much social and biological research in psychiatry in have lost coherence from being stretched so widely.
recent years has been towards the use of standard- Under the tutelage of the pharmaceutical indus-
ised diagnostic instruments, for very good reasons. tries’ favoured experts, we are seeing a similar infla-
In some areas, we are beginning to come up against tion of the term mania. Today a diagnosis equals
the inherent limitations of this diagnostic approach an indication, and an expanding indication may be
which dominates both DSM-IV and ICD-10. worth a fortune to a pharmaceutical company. In a
The carefully articulated diagnostic classifica- medical world that is increasingly commercialised,
tions of DSM-IV and ICD-10 are generally accepted there is no innocence in psychiatric diagnostic sys-
to relate meaningfully to the world of mental dis- tems. Given that they remain essentially arbitrary,
orders. Nevertheless, the increasingly obvious gaps at least at the all-important margins, they become
between research findings and the definitions of the vehicles for some professors’ pursuit of power
mental disorders in today’s diagnostic manuals is and influence and for some pharmaceutical com-
beginning to raise questions about whether validity panies’ pursuit of profit. The DSMs and ICDs began
has been sacrificed on the altar of reliability. For as attempts to create a common language by codify-
example, schizophrenia as a diagnostic entity is ing what were accepted to be preliminary and tenta-
starting to fragment under the impact of genetic, tive assumptions about diagnostic categories. Today
neuroimaging, neuropsychological, social and DSM-IV and ICD-10 confront us not as hypothe-
other research methodologies for which findings ses about useful ways to conceptualise disordered
are difficult to make sense of within anything states of mind and behaviour, but as the very foun-
approaching the manual models of schizophre- dation of our research and clinical practice. In
nia. Bleuler’s plurality of the schizophrenias has today’s psychiatry, to be a researcher or even a main-
returned. Schizophrenia may even be in the process stream clinician plunges one into the very core of
of regressing from disorder to syndrome. The ques- the self-justifying and self-sustaining hermeneutic
tion is once again open as to what abnormalities world of today’s manuals of mental disorders. When
of mental state and behaviour best map onto the push comes to shove, however, diagnostic entities
developing research database – a question which depend on phenomenology at least until genuine
today’s self-confirming and fixed diagnostic cat- clinical pathological entities emerge from the cur-
egories with their simple symptom signposts are rent confusion of half-truths, good intentions, and
helpless to answer (Mullen, 2006). Mental health pure obscurantism.
clinicians with any critical faculties cannot but
notice that the better they know a patient and the
more information that is available, often the more Abnormal phenomena
problematic it becomes to fit them into any spe-
cific diagnostic category. This is the reverse of the In the following sections, abnormal phenomena
situation in well-established medical specialities. are discussed. The emphasis is on describing
The increasing use of the label schizoaffective dis- mental phenomena prior to their becoming part
order, for example, reflects not just sloppy practice of the formulation of particular disorders, but
6 Section 1: The Tools of Psychiatry

for convenience and coherence some common process that usually involves a knowing what as well
syndromes, such as mania, are used to draw as a sensing of. In stating that he hears a voice, the
together the associated phenomena. Space only patient is recognising the type and nature of what he
allows a restricted presentation. This chapter is no hears.
more than an advert for descriptive psychopathol-
ogy, which it is hoped will interest the reader to Disturbance in sensory function
explore the area further. The best place to begin
that exploration remains Karl Jaspers’s (1963) Gen- Disturbances in the sensory modalities themselves
eral Psychopathology, in particular pages 55–148. are largely the result of organic lesions and are dealt
with in standard texts of neurology. Occasionally
the absence of sensation (e.g. blindness or anaes-
Perceptual disorders
thesia), the perversion of sensation (e.g. tingling
Madmen are visionaries of the senses because they do not paraesthesia) or the abnormal heightening of sensa-
see things as they are and because they often see things that tion (e.g. hyperacusis) may be complained of with-
are not. (Malebranche, 1674/1980) out any obvious explanation in physical pathology.
The sensory modalities are the special senses of This, for example, will be seen in certain conver-
sight, hearing, smell and taste, as well as the sensa- sion symptoms of a hysterical type. In some patients
tions of touch, pain, temperature, point discrimina- with mania, all sensation may appear heightened, as
tion and position. Except in peculiar circumstances they may also be in depressed individuals, although
we experience perceptions, not sensations. Sensa- for one it is the source of pleasure and delight,
tions are transformed into perceptions by their ori- in the other an additional burden and imposi-
gin being experienced as arising from some external tion. A dulling of sensations with everything experi-
object. If I experience a smell without recognition or enced as lacklustre and bleak may also accompany
association, it would be a simple sensation, but after depression.
it is referred to some external object – say, a rose – it
forms part of a perception. In perception we usually Disturbances in perception
experience ourselves in relation to an object in the
Agnosias
world. Objects are normally perceived as particular
The disturbed ability to organise sensory impres-
things. This is especially true of visual perceptions in
sions so as to allow the recognition of objects (that
which, for example, if I look at a cube I tend to per-
is, to perceive objects) is known as agnosia. Agnosias
ceive it as a cube, although at most I can only imme-
may obviously affect different sensory modalities
diately apprehend three of its sides, and a possibil-
and usually reflect cortical damage.
ity exists, until I have examined every aspect, that
it is not truly a cube. Meanings tend, therefore, to Micropsia and macropsia
be imminent in perception. Perceived objects stand The relative proportions of perceived objects may
bodily before us resisting and infused with a qual- alter to render them enlarged (macropsia) or dimin-
ity of reality. In that we believe what we see, we do ished (micropsia). Such changes may occur, for
so usually without any verification or consideration. example, in severe fatigue, sleeplessness, toxic
Traditionally, theories of perception introduce into states, and temporal lobe epilepsy.
perception itself intellectual operations and a crit-
ical examination of the evidence of the senses to Synaesthesia
which we in fact resort only when direct observation This is where perceptions in one modality, for exam-
founders in ambiguity. Clearly, however, when we ple, hearing, are simultaneously experienced as if
deal with perception rather than sensation, we are they were also present in another modality, for
dealing not simply with the raw data itself but with a example, vision. This is encountered in some drug
 Chapter 1: The mental state and states of mind 7

intoxications. The visual effects which occur con- his eardrums with needles thus reducing the rest of
comitantly with music in states of cannabis intoxi- the world to silence.
cation are often highly prized by its habitués. Hallucinations do not yield to argument for the
immediateness of the experience is that of nor-
False perceptions mal perception, but the experienced reality of hal-
These are actual perceptual abnormalities and lucinations can vary. On more than one occasion,
imply that the experience involved is of perceiving I have had patients try to explain how the voices
something, not just believing something. or visions differ from actual perceptions. It has
been suggested that hallucinations owe as much
Hallucinations
to interpretation as perception, with patients elab-
There is a long tradition of distinguishing between
orating and constructing their experiences out of
illusions and hallucinations (Van Den Berg 1982).
more basic hallucinatory events (Horowitz, 1978).
Esquirol (1833), held that
Patients frequently find no difficulty in discrimi-
a person labours under an hallucination who has a thor- nating between their hallucinations and true per-
ough conviction of a sensation when no external object ceptions. Hallucinations are usually confined to a
suited to excite this sensation has impressed his senses, single sensory modality, and this or some other sub-
whereas it is an illusion if the senses are deceived respect- tle difference from normal perception may make
ing the qualities, relations, and causes of impressions actu-
the patient aware of the false nature of the percep-
ally received and cause them to form false judgements
tions. The ease with which hallucinations are dis-
respecting their internal and external sensations.
tinguished from real perceptions in some patients is
Hallucinations proper have the following character- illustrated by a telephonist who, despite being trou-
istics: bled by constant auditory hallucinations, continued
r They are actual false perceptions, not distortions to work efficiently, unerringly distinguishing them
of real perceptions. from the disembodied voices of callers. A particular
r They are experienced as being out there in the patient may suffer simultaneously from hallucina-
world and as inhabiting objective space. tions in several sensory modalities at the same time,
r They are experienced as having the qualities and but they will rarely be perceived as emanating from
force of the corresponding normal perceptions, a single entity. Occasionally multimodal or scenic
being just as vivid, whole and immediate. hallucinations are described in which a complex
r They are usually experienced alongside and visual and auditory hallucination is experienced,
simultaneously with normal perceptions (com- but if a patient reports a vision that also speaks, par-
plex visions may be an exception). ticularly if it answers back, the most likely explana-
r They are as independent of our will as is any nor- tions are malingering or hysteria.
mal perceptions, in that they cannot be conjured Hallucinations can be subdivided by sensory
up or dismissed. modality.
Auditory hallucinations may range from ill-
The hallucination may show a greater indepen- defined sounds to highly organised perceptions in
dence of our will and action than a normal percep- which, for example, a voice recognizable to the
tion for, although I can turn away from looking at patient as that of a relative or acquaintance will be
the page before me or cease attending to the dron- heard talking at length. One of my patients was con-
ing voice of a lecturer, my hallucinations will con- stantly plagued with the sound of the Beatles play-
tinue to force themselves to my attention. A halluci- ing “Strawberry Fields”, complete with full musi-
nated voice will usually penetrate the most efficient cal accompaniment, a phenomenon that despite
earmuffs, and one patient continued to be plagued his fondness for popular music palled after the
by hallucinated voices even after he had destroyed first few weeks. True auditory hallucinations usually
8 Section 1: The Tools of Psychiatry

have a directional quality, and the patient can Somatic hallucinations may accompany epileptic
describe from where they appear to be emanat- activity. One patient who described strange abdom-
ing. Certain modes of hearing voices were held by inal sensations that preceded his fits perceived them
Kurt Schneider (1974) to be of special diagnostic as writhing movements and, in turn, interpreted
importance in schizophrenia. The hearing of one’s that as snakes squirming around in his belly.
own thoughts read aloud, voices talking with one Disturbances of body image may occur in a vari-
another, and voices that maintain a running com- ety of organic brain disorders, in some psychiatric
mentary on the patient’s thoughts and actions were disorders and, probably most commonly, in normal
considered first-rank symptoms. Occasionally tinni- individuals under the influence of sleep deprivation,
tus and other disturbances due to local disease of exhaustion or intoxication. The most common dis-
the ear may be confused with hallucinations. turbances of body image are perceptions of changes
Visual hallucinations may also vary from ill- in size and shape of parts of the body (head and
defined shapes and colours through clearly recog- hands seem most common) or of the whole body.
nizable objects and persons to the complex visions The reported alteration in body image in anorexia
which may, for example, accompany ecstatic states. nervosa would appear a more subtle phenomenon.
Olfactory and gustatory hallucinations can occur Illusions are distortions of real perceptions, in
separately or, more commonly, together. They are contrast to hallucinations that arise without exter-
seen in some types of schizophrenic disorder, but nal stimulus. The perceptual stimulus arises from
may also be found in affective and epileptic distur- an actual object, and the illusion is formed by the
bances. The persecuted patient may taste and smell perception’s transformation. The other characteris-
the poisons placed in his food by his tormentors, tics are identical with those listed for hallucination.
the depressed may be assailed by the stench of his Illusions do, however, usually exhibit a more tran-
own decomposition, the oversensitive may squirm sient existence than hallucinations and often vanish
in embarrassment at what she perceives as her over- when attention is drawn to the misperception.
powering odour (the distinction from illusion may A common illusion occurs in the overwrought
often be difficult in these cases). individual whose vision on a dark night distorts
Tactile hallucinations refer to cutaneous percep- the branches blowing in the wind into a percep-
tions which vary from vague tingling or sensations tion of an attacker moving towards him. A depressed
of temperature change to perceptions experienced patient out driving reported being frozen in horror
as being held, hit or caressed. In certain intoxica- at the sound of a child screaming in pain, only to
tions, typically cocaine, the patient may experience realise later that she had misperceived the squeak-
formication in which what they perceive seems like ing of the brakes of her own car. It is important
bugs crawling around, on or under the skin. in this example that the patient heard distinctly a
Somatic hallucinations may be difficult to dis- scream of pain and did not misinterpret a squeal-
tinguish from tactile hallucinations and, at the ing of brakes for the squealing of a hurt child. The
other extreme, merge into delusional beliefs about patient with delirium tremens is often accosted by
bodily change. One patient described having his the transformation of the articles around them into
semen drawn out of him by ghouls. Clearly con- terrifying illusions.
nected with this bizarre delusional belief were Functional hallucinations. These hallucinations,
tactile hallucinations involving the perceptions of which may be confused with illusions, are rare phe-
being pricked with pins and tingling sensations nomena in which a hallucination occurs simulta-
around the base of his spine but also somatic hal- neously and in association with a real perception.
lucinations involving the experience of his testi- Thus hallucinatory voices may only be heard against
cles and penis shrinking into his abdomen and his the background of a running tap, and turning off
spine feeling as if it were “hollow and cracking”. the water abolishes the hallucination. The noise of
 Chapter 1: The mental state and states of mind 9

running water in this example is not transformed or the outside world of objects. Pseudo-hallucinations
distorted into a hallucinatory voice nor is it misin- are the patient’s own thoughts, and there is a feel-
terpreted as such, for the functional hallucination is ing of responsibility for them, although unlike the
heard alongside and separable from the accompa- images of normal mental life, the morbid pseudo-
nying real perception. A man complained that when hallucination is not under voluntary control. It con-
out driving, he was assailed by insulting voices. fronts the patient as within the mind; it is not there
These voices were only to be heard at traffic lights at their behest, nor will it evaporate in answer to
and were confined to periods when the amber sig- one’s wishes. Inner voices are the most commonly
nal was on. When the lights changed to red or green encountered examples, often being described as
the voices ceased. voices in the head or the voice of conscience.
Pareidolia. Another common and normal phe- Thoughts experienced as being read aloud are not
nomenon, pareidolia, are the perceptions conjured pseudo-hallucinations if the thoughts are alienated
up by ill-defined sense impressions such as those from the individual and become an auditory per-
that occur when staring into the dying embers of an ception confronting them as part of the external
open fire. reality.
A problem is created by patients who say they
know the voices or visions are in their mind, thus
Phenomena related to false perceptions
indicating that they have insight into the morbid
Misinterpretations nature of their experience. In such a case, it is
These are not false perceptions, for they consist important to distinguish whether the phenomenon
of a correct perception, the import of which is was experienced as a perception from objective
incorrectly deduced. Thus a wary prospector may space or was actually an image within subjective
mistake shiny metal for gold, the perception of space. Pseudo-hallucinations are sometimes char-
glitter being correct but its interpretation overly acterised as pathological perceptions in which the
hopeful. Misinterpretations frequently arise in para- sufferer is aware of their morbid nature and does
noid patients, for example, when every creak and not project them into the surrounding world. It
bang, although correctly perceived, may be misin- seems unwise to this author to call hallucinations
terpreted as the approaching footsteps of the perse- pseudo-hallucinations simply because the patient
cutor. has insight into their morbid nature (Fish, 1967;
Hare, 1973), for this is to make the classification of
Pseudo-hallucinations a perceptual disorder dependent on the patient’s
Pseudo-hallucinations, one of the most misunder- judgement at the moment of being interviewed and
stood and undervalued of abnormal phenomena, not on the nature of the experiences themselves.
are a form of imagery as distinct from hallucina- The term pseudo-hallucination has led to a ten-
tions and illusions, which are perceptual phenom- dency to approach the phenomenon as something
ena. An image is a product of thought and a reflec- to be excluded on the way to discovering “true” hal-
tion on the world, unlike a perception for which lucinations. As a result it is dismissed as noise of
there is a sensing of something external in the no inherent interest – or worse, as a sign of men-
real world. Although an image is a cognition, it dacity in those who report the experience. In real-
is experienced figuratively as if it were a percep- ity it is an abnormal experience found across a wide
tion. Pseudo-hallucinations are pathological images range of psychopathological states, from severe per-
experienced as emanating from the mind; they are sonality disorders to toxic confusional states. It is
seen in the mind’s eye and heard with the inner ear, no more or less a real phenomenon than a halluci-
not perceived by the actual eyes and ears. Pseudo- nation, and its presence, although of little diagnos-
hallucinations inhabit subjective inner space not tic import, is indicative of significant disturbance
10 Section 1: The Tools of Psychiatry

of mental state. Interestingly its content may be far Tactile and somatic hallucinations require care-
more informative about the patient’s current pre- ful attention. If the patient has a tactile hallucina-
occupations and intentions than a hallucinatory tion, such as a strange tingling, she may say it is
experience. due to rays directed at her or “as if” there were
some electrical current. The sufferer from dissemi-
Eidetic images nated sclerosis may similarly describe a true paraes-
Eidetic images are perfectly normal phenomena thesia as if it were an electric current (Lhermitte’s
most frequently encountered in children. They are sign). Care must therefore always be exercised to
images of something once perceived, which can distinguish odd ways of expressing true sensory
be conjured up with almost all the original details disturbances from the elaborations, delusional or
intact. Thus a page of a book previously read may be otherwise, of false perceptions. Further, it is wise not
recalled as an image so vivid that the eidetic person to forget that a bizarre interpretation, particularly of
can read out the text as from the original. a somatic sensation in schizophrenia, may mask the
Perceptual disorders and pseudo-hallucinations symptom of a physical disorder.
occur in all forms of psychotic disturbance, in dis-
turbed states of consciousness and with surprising Feelings, emotions, affects and moods
frequency in normal individuals (Posey & Losch,
1983; Slade & Bentall, 1988). During the phase The terminology in this area is complicated because
which intervenes between the waking state and several common usages often attach to each word.
sleep, many people experience illusions and hal- For example, feelings in everyday parlance can refer
lucinations. The hallucinations on falling asleep to sensations, beliefs, presentiments, considera-
are termed hypnagogic, and those on awakening tions for others and may even be employed as being
hypnopompic. In the grief which follows a bereave- synonymous with the term emotions. Despite the
ment, hallucinations and pseudo-hallucinations of wide overlap in the various terms, some rough dis-
the lost one are a common and normal phe- tinction and hierarchy is worth attempting.
nomenon. In situations of extreme stress, be it phys- Feelings can be taken to be basic experiences of
ical or emotional, to which high levels of general pleasure and displeasure. Wundt (1903) suggested
arousal pertain, perceptual disturbances tend to that feelings vary according to their degree of pleas-
become more frequent, albeit fleetingly. Sensory antness or unpleasantness, the extent to which they
deprivation procedures have produced a wide vari- produce excitement and the degree of induced ten-
ety of perceptual abnormalities including organ- sion or conversely relaxation. A feeling need not be
ised hallucinatory experiences. A variety of organic about anything per se; it is simply an account of an
states are associated with perceptual disturbance, internal state.
and any major disruption of cerebral function can Emotions can be thought of as involving a more
produce such phenomena usually in association complex state of mind than feelings, for they are
with the clouded consciousness of a confusional usually intentional, being actively directed at some-
state. Meaningful auditory and visual hallucinations thing. If I am in love, it is love of someone, and it
are particularly associated with temporal lobe dys- is the charms of the beloved that I am aware of,
function, and it has been claimed that they may not the dissociated experience of being in love. An
actually be produced by direct stimulation at or near emotional state such as sadness could, of course,
the temporal lobe. Hallucinogenic drugs induce a become an object for consciousness, an abstrac-
wide range of perceptual disturbances, predomi- tion on which it is possible to reflect, but as soon
nantly visual in character, the form and content of as it becomes again the emotion of sadness, it is
which tend to be in constant flux, unlike the halluci- sadness about something. The distinction between
natory disturbances of schizophrenia. feeling and emotion may be illustrated by anger.
 Chapter 1: The mental state and states of mind 11

On arriving at work, an individual discovers that infidelity. There is a cause in the sense of a state of
the important documents they had been promised affairs that has aroused suspicions and a judgement
would be available without fail were not on their that the rights of the jealous have been infringed
desk as arranged and becomes angry. They are and disregarded. What constitutes fidelity and
now experiencing the emotion of anger about being therefore infidelity is in part culturally determined.
let down. A few moments later, they discover the It has an object in that there is jealousy of someone
reports on top of the filing cabinet: they can no and about something. Jealousy often brings with it
longer be angry about being let down, but the feel- vivid fantasies of the partner’s supposed infidelities,
ings accompany the emotion of anger – the sense sometimes described as visual images of such
of unpleasant arousal, palpitations and general per- immediacy that it is like watching the actual event.
turbation – may continue for some time. This exam- There is a tendency to certain types of behaviour,
ple also illustrates how a judgement, in this case of including checking, cross-questioning and verbal or
having been let down, is integral to an emotional even physical aggression. The “acceptable scripts”
experience, and with judgement comes the possibil- determining jealous behaviours are culturally
ity of choice (see Solomons, 1980). It also highlights sanctioned.
the autonomic changes which accompany the more Moods and affects designate more sustained and
vehement of our emotions. pervasive states of mind of which individual emo-
Emotions often involve what Frijda (1986) tions may be a part. It is the prevailing tone within
referred to as objectivity in that they are felt to occur which the emotional life of the individual proceeds.
to one, to come unbidden and to be independent of Jaspers (1963) argued that mood comes about with
one’s conscious choices. Emotions are experienced prolonged emotion, but in practice it often appears
as happening to us and often as being irrational and as if the mood precedes and constrains the emerg-
uncontrollable reactions. Thus although emotions ing emotional responses. Thus within the affective
are usually intentional, in the sense of being a con- state of depression, individuals may be predisposed
scious orientation towards something, they may be to experience a variety of emotions – shame, fear,
experienced as unintentional, in the sense of being anger – just as they are rendered impervious to oth-
beyond or outside of conscious control. Emotions ers, such as joy. Mood and affect are more global
may involve not only feelings about something but designations than emotion and represent a more
also behaviour or, more exactly, a disposition to complex conceptualisation of the person’s psychic
behave in a particular manner. Thus love would be experience. Mood and affect define to a significant
associated with a tendency to approach or behave extent our orientation to the world. The horizons
pleasantly towards the object of that affection, just of our existence can be profoundly influenced by
as fear would lead to a tendency to recoil or flee mood; for example, depression brings with it a nar-
from what was feared. Fantasies are so intimately rowing of possibility, a shrinkage of our sense of
related to most strong emotions that they can be agency and effectiveness, as well as a general dulling
regarded as an integral element in the experience. of experience.
Finally what gives rise to emotions, how they are Temperament is that aspect of the individual
expressed and possibly even how they are expe- which may be taken to be a lifelong predisposition
rienced are influenced by the social and cultural to particular kinds and types of emotional responses
context which mould expectations (Harré, 1986; and affective states.
Mullen, 1991). Thus a hierarchy moving from feelings through
Romantic jealously offers an example (Mullen, emotions, moods, and affective state to tempera-
1990). It involves the experience of painful feelings ment involves increasing complexity in terms of
associated with the fear related to loss and the state of mind and usually to an increasing duration
anger towards the person believed to be guilty of of that state.
12 Section 1: The Tools of Psychiatry

Pathology of feelings and emotions barren. This is seen in its most dramatic form in
the chronic schizophrenic state and is part of the
The pathology of emotions may be considered,
so-called negative symptomatology. The blunting
employing the model outlined, as involving alter-
of responsiveness should perhaps be distinguished
ations in the following aspects.
from flattening, although they often seem to be used
1. The types and quality of events and intentions interchangeably. Blunting strictly refers to a loss of
which call forth emotional responses sensitivity or indifference to the emotional import of
The alterations and pathologies involving the sit- an event as opposed to a poverty of response (Sims,
uations and intentions which call forth emotions 1988). It could be described in terms of a loss of
are of considerable importance in psychiatry but capacity for empathy, although it is not usually con-
usually receive scant attention in terms of pathol- ceptualised in this manner. Flattening, in contrast,
ogy of emotion. To use love as an example, it is is illustrated by those who are aware of the poten-
normally considered pathological in function of tial meaning of an event and the feelings it should
the abnormal ideas (delusions) that call it forth. evoke but lack the appropriate degree of response.
Clearly, however, there are pathologies of love in One articulate young woman with schizophrenia
which the degree of response, the types of situa- described that when with others, she would know
tions invoking it and the intentions of the emotion she should be sharing their laughter, their interest
can be grossly deviant within the accepted social and even their anger, but unlike them, she could
and cultural norms, without any involvement of only perform emotions, not experience them.
delusional beliefs about either the feelings of the Anhedonia is a related phenomenon in which
beloved or one’s own relationship to those feel- there is a loss of responsiveness specifically tied to
ings. Intense infatuation with unrealistic hopes for the experience of pleasure, which can either be in
a consummation of the passion may preoccupy the physical experiences or the pleasures derived from
individual. Except at moments when immersed in social interaction.
fantasy, some insight into the overly hopeful nature Incongruity occurs when the emotional responses
of the expectations may be retained, but this will of individuals to their experiences seem inappropri-
not stop someone in the grip of morbid infatuation ate to outside observers. Marked blunting or flatten-
from stalking their supposed beloved to the detri- ing can give the impression of incongruity, although
ment of themself and the unfortunate target (Mullen strictly the term should be restricted to situations in
& Pathé, 1994; Mullen et al., 2000). The pathology of which the emotion expressed is totally out of keep-
love could within this model be seen as occupying ing with the situation.
a wide range of disturbances, including some of the Rigidity and constriction of emotional responses
sexual perversions (Boss, 1949). occur when the patient is still capable of demon-
strating emotional responses, but they tend to be
2. The characteristics, tone and strength of limited and constricted in range and are relatively
feelings generated unresponsive to changes in context. Restricted
Traditionally the psychopathology of emotion has affect is a term covering a similar range of phenom-
concentrated primarily on alterations in the tone ena. In rigidity, the response persists without alter-
and character of the feeling generated. This is in ing to suit the changing situation.
keeping with the view of emotions as occurrences Lability is when sudden, short-lived but often
that simply happen in or to us. The disturbances intense changes in feeling occur in response to
described in this area are as follows. minor events. This is often encountered in manic
Poverty of emotional responsiveness, in which states but may be seen in depression and can be a
there is a loss in the intensity of feelings evoked feature of a variety of brain disorders, such as the
by events, and the emotional life becomes flat and post cerebrovascular syndromes.
 Chapter 1: The mental state and states of mind 13

Apathy is when an indifference to the individ- contact with another may induce not approaching
ual’s situation is expressed. At first glance, it may or affectionate behaviour but rather a total inabil-
seem similar to the poverty of emotional respon- ity to act, perhaps even resulting in avoidance and
siveness described, but it usually evokes a different flight. In some individuals, the difficulty in accept-
empathic response in the interviewer. In poverty of ing or coping with their emotions may lead to the
affect, the interviewer senses a profound emptiness exhibition of inappropriate behaviours: the man
in emotional responses; in apathy, it is a sense of unable to express anger who becomes increasingly
withdrawal and turning away from concern with the ingratiating and subservient as his internal rage
world rather than a loss of ability to respond. Apathy mounts; the desiring woman appalled by her own
involves a giving up with a loss of the will and moti- erotic needs who responds with coldness, anger
vation to respond. and condemnation towards the person she desires.
Ambivalence is when contradictory emotions and There can be few of us who are so blessed as always
intentions coexist at the same instant. In its com- to exhibit the behaviour appropriate to our emo-
mon usage, ambivalence refers to the relatively tions, and the vicissitudes that affect this area of
mundane experience of having a mixture of appar- function form a large part of the psychopathology
ently contradictory emotions about someone or of everyday life.
something that tend to alternate rapidly. The term
has also been employed by Bleuler (1950) to refer to
Pathology of affect
a far more fundamental split in the emotional life in
which radically incompatible emotions and desires Depressive states
coexist at the same moment. Bleuler considered this A search for a clear definition of symptoms rather
more extreme form of ambivalence one of the fun- than the description of phenomena dominates the
damental symptoms of schizophrenia. discourse on depression. In part this reflects the
Alexithymia is employed to describe a virtual clinical need to define a common and treatable dis-
inability to recognise or verbalise emotional experi- order. The exploration of the experience of depres-
ences and a paucity of associated fantasies (Sifneos, sion from which a phenomenology emerges may
1972). The concept has been widely, if not wisely, seem clinically irrelevant compared with a good
applied. diagnostic instrument on which sleep, mood, suici-
dal impulses and the like can be simply rated. After
3. Behavioural responses and coping mechanisms all, don’t we know what it is like to be depressed?
employed to deal with emotions Kraepelin (1921) suggested that “simple” depres-
The behaviour called forth by an emotion or affec- sion could be understood as the various manifesta-
tive state may be abnormal in its form and degree. tions of an inhibition of mental life with slowed cog-
In explosive reactions, there is a sudden discharge nitions, physical activity and speech, together with
of strong emotion accompanied by ill-controlled an associated impaired concentration and sense of
and ill-considered behaviour. Such explosive reac- enervation and exhaustion. This psychic inhibition
tions may occur in relatively normal individuals in can culminate in depressive stupor in which one’s
situations of extreme emotional stress or may be mental life drags to a virtual stop. Kraepelin (1921)
called forth by mundane emotional demands in suggested that, in addition to this slowing, patients
those of poorly disciplined and self-indulgent tem- experience themselves as cut off from both their
peraments. At the other extreme strong emotion thoughts and bodies; “thinking and acting go on
may induce an inappropriate inability to respond in without the cooperation of the patient; he appears
which the individual “freezes” or is “paralysed” by to himself to be an automatic machine” (Kraepelin,
the emotion. In shy and self-conscious individuals, 1921, p. 75). Schneider (1959) emphasised a sim-
the possibility of strongly desired social or sexual ilar flattening of mental life in which the world
14 Section 1: The Tools of Psychiatry

becomes valueless, and the subject’s own feelings Associated with the experience of depression are
are experienced as absent or alienated. Certainly what Kraepelin (1921) referred to as imperative
in many individuals with depression there is an ideas focussed on wickedness, worthlessness, per-
oppressive sense of being slowed up mentally and secution, degeneration and death. These themes
physically so that every movement is a struggle and impose themselves on the depressive and become
every thought seems to emerge only after prolonged not just concerns but overwhelming experiences.
effort. In a smaller proportion, depression is charac- The mental content of individuals with depression
terised by harried and agitated excitation in which may be dominated by ideas of inferiority with self-
the patient, tortured by ideas of guilt or hypochon- accusations, self-denigration and fears of damaging
driacal fears, is in a constant state of complaining others. The claims of guilt and sin can be tinged
restlessness (Leonhard, 1979). with grandiosity and hyperbole. Even mild to mod-
One obvious aspect of the experience of depres- erate depression may be associated with a sense of
sion is the hopelessness about oneself and one’s physical deterioration in both the fabric of the body
future. This involves not only a loss of optimism and of the world. In its most flamboyant manifesta-
but a shift of horizon so that people with depres- tions, this leads to hypochondriacal delusions and
sion live in an interminable present for which the ideas of annihilation in which the whole world is
only prospect is the past. It is possible to regard either about to be destroyed or has already disin-
the future as likely to be grim – or worse – with- tegrated, leaving the patient surrounded by wraiths
out being depressed. In depression the hopeless- and phantoms.
ness about the future is in large part a loss of any One of the many paradoxes encountered in
belief in a future. The past overwhelms the present, depressed individuals is the alternation between
and it becomes a past which ceases to be a source a suicidal despair, which disclaims any interest
of information and possibility for the future but a in survival, and an anxious hypochondria, which
past which leads nowhere and can only be an obses- ruminates fearfully on potentially lethal conditions.
sive and repeated lesson in failure and emptiness. To These imperative ideas often manifest both appar-
compound the problem is the sense of time slowing ent depth and an overwhelming immediacy but,
to a point at which some patients experience them- conversely, may have a peculiar ephemeracy. Thus
selves as frozen in time or outside of time. Jaspers one minute the agonised depressive patient grasps
(1963) wrote of depressive patients feeling as if it is one’s hand, contorted with grief and guilt over past
always the same moment, like a timeless void (p. 84). indiscretions, claiming a universal responsibility for
Curiously some people with depression have a sense the world’s evils; the next moment, the individual
of time as something external and separated from is complaining bitterly about the slights, lack of
themselves that rushes past. Their day lasts an eter- care and even active persecution by staff and fellow
nity, but the world passes by in a flash. patients. No punishment is too great but, equally, no
A sense of permanence pervades severe depres- service or kindness is adequate to slake the depres-
sion. Depression is experienced as a reality which sive’s sense of entitlement.
has no end and from which there is no escape; the One aspect of the phenomenology of the
past is transformed into a progression of memo- depressed which is often missed or misinterpreted
ries infused with regret and responsibility, and the is the experience of persecution. Suspiciousness
future is exhausted and empty (Minkowski, 1970). and persecutory ideas are to be found even in
There is a block on becoming, a halt in the process mild to moderate depression. This can become
of self-realisation; everything is final and lost, but a dominant theme with complaints of being fol-
equally there is often a sense of finally facing up to lowed, talked about, deprived and disadvantaged,
an immutable reality. Depression is real, all else was plotted against and even assailed by threatening
error and self-deception. voices. Sensitive ideas of reference and delusions of
 Chapter 1: The mental state and states of mind 15

reference may be prominent, even obscuring the The manic person is driven and buffeted by ele-
primary depressive disorder. The popularity of the vated and exaggerated emotions, desires and activi-
diagnosis of schizoaffective disorder in part, if not ties. There is an increased pace to existence, but the
in its entirety, reflects an ignorance of such basic price of this busyness is a dislocation in the inner
phenomenological evidence. unity which usually directs the coherent unfold-
The prevailing mood in depression is often ing of our ideas, intentions and activities. The frag-
described as sad. In practice the gentle quietness mentation and disruption in the manic individual’s
of sadness is rarely encountered. Gloom, active dis- activities increases with the more severe forms of
tress, dull despondency and irritable complaint are mania.
more frequent. It is also worth remembering that The mood in mania is heightened, but with
some socially adept depressed individuals present increased intensity comes an instability and labil-
with a self-depreciatory irony which can disguise ity. There can be sudden switches from jocular-
the underlying despair. Many great comedians have ity to accusatory irritability, from exultation to
been plagued by depression, and sometimes it is in despair. There may be an air of pompous superi-
depression that the capacity to amuse others is at its ority, but unlike the similar demeanour found in
height. some delusional disorders the manic person’s exag-
Central to depression are disturbances in bio- gerated self-confidence is usually a fragile and fugi-
logical processes, most particularly those concern- tive audacity.
ing appetites and circadian rhythm. Sleep is dis- States of ecstasy may occur in which the patient is
rupted. Attempts to link particular types of sleep transfigured by delight often remaining relatively or
disturbance, such as early-morning waking, to par- even completely immobile. Such patients are diffi-
ticular types of depression are often misleading. In cult to distract from their delighted state, accounts
depression there is usually a combination of diffi- of which can usually only be obtained retrospec-
culty initiating sleep, an unstable and restless sleep tively. They may be infused with a sense of joy and
and difficulty maintaining sleep with early waking. contentment and may describe an “oceanic feel-
Early waking is usually more prominent in older ing” in which they experience themselves as in some
subjects. Interest in food along with other plea- kind of mystical unity with humanity, life or even
sures is attenuated or lost, and the libido shrinks to the universe. Religious connotations are not sur-
nothing. prisingly attached to such experiences. One of my
patients, a philosopher previously bereft of religious
Manic states sympathies, was discomforted in a manic episode
There is a tendency to conceive of mania as the by such an ecstatic experience. He felt he had to in
mirror image of depression which, although use- some way integrate this into his materialist world
ful up to a point, can miss many of the salient fea- view. Like many who have ecstatic experiences, its
tures. Jaspers (1963) characterised mania as “pri- intensity and “realness” was too great to consign it
mary, unmotivated and superabundant hilarity and to a symptom of illness. On recovery manic patients
euphoria; as a delight in life, a lively optimism” (p. may have a clear insight into the fact that they have
596). Although individuals with mania may evince been mentally ill but still cling onto the relevance of
these charming characteristics, for all except the some of their experiences and revelations.
mildest of cases, a darker side alternates with, if not There is a sense in most manic individuals of
completely obscures, these elements of good cheer. the tempo and profundity of their thought pro-
Irritability manifests at the least frustration, intoler- cesses being enhanced. The speeding up is asso-
ance lies imminent in the exaggerated and overbear- ciated with difficulty sustaining attention and, in
ing ambitions, and the driven physical overactivity more severe states, the flight of ideas produces a
can all too easily explode into violence. dislocation and fragmentation sometimes termed
16 Section 1: The Tools of Psychiatry

secondary incoherence. The outward manifestation exaggerated expectations feed fleeting delusional
of pressured thinking is pressured speech and dis- notions and delusions of reference. Manic people
tractibility (see section in Disorders of Language). may believe that they have immense wealth from an
A physical restless or volitional excitement in inheritance that had previously slipped their mind;
manic individuals can be impressive. One manic that the latest pop song is adapted from a piece
patient strode repeatedly around my room in a cir- they strummed some years ago and the royalties will
cuit which included clambering from chair to desk, soon begin to flow; that they are the repository of the
across my desk and descending via the radiator. economic wisdom which will solve their, and every-
In severe mania, just as speech can disintegrate one else’s, unemployment. In mania delusions, like
into disjointed words and phrases, so may activi- other mental content, usually emerge rapidly but
ties descend to purposeless flapping. Even in mild are not sustained. This being said, states of so-called
mania, many tasks are initiated but few completed. delusional mania occur in which the dominant fea-
Perception is heightened in mania. The world ture is a fixed and often extensively elaborated delu-
becomes a source of colourful and intense expe- sional system, usually of religious or grandiose con-
riences, but some patients describe a fragility and tent, to which hallucinations and misinterpretations
falseness to these perceptions. One young woman are often linked but in which excitement and ela-
said it was like being on the set of some opu- tion are more muted. This state may have a remark-
lent stage show with everything multicoloured and able tenacity and can create diagnostic difficulties.
gleaming but that nothing seemed to have any real The elation and exaggerated sense of worth can pro-
substance or robustness, she said “it was as if I duce fantastic claims and stories in which fantasy
could reach out my finger and put it through walls, and fabrication combine to produce fluent confab-
furniture, even people”. Hallucinations, particularly ulations. This can be difficult at first glance to distin-
visual and auditory, occur in more severe mania. guish from the fluent confabulations seen in associ-
Complex visions can accompany severe mania. ation with some delusional systems, but the history
One patient on emerging from an ecstatic state, of its emergence, the content and the evanescence
described being able to see a great distance, and of manic phenomena usually suffice to separate the
what she saw was a great copulation with people phenomena.
making love in some extended garden of carnal In mania, heightened interest and engagement
delights (less colourful visions are, however, more with the world go together with increased appetites
common). of all kinds, but most obviously in the sexual area.
A sense of physical well-being and enhanced Increased and disinhibited sexual behaviour is com-
strength is common in mania and may lead to a mon. Again it is essential to relate the emergent
belief in invulnerability which can precipitate dan- behaviour to what is normal for the patient. A
gerous activities. One patient drove for several miles vicar’s wife showed, for her, the grossest of sex-
down the wrong side of a busy freeway happily ual disinhibition by tiptoeing around their subur-
bouncing his car against the sides of oncoming vehi- ban garden in the nude, albeit in the dead of night.
cles secure in the knowledge he was beyond injury A lack of prudence characterises the financial as
or the law (in fact he turned out to be correct on both well as the sexual activities of the manic individ-
counts). ual. Inflated self-confidence, a sense of invulner-
In even mild mania, there is a tendency to ability, and heightened acquisitiveness can com-
grandiosity and an exaggerated sense of personal bine to produce flights of financial mismanagement
worth. It is important to relate patients’ claims and which are ruinous not only to the patient but to any-
behaviour to what is usual for them. One of my one over whose money they exert control.
patients who was employed as a lavatory attendant Disturbed sleep is virtually universal, and the
entertained the idea that he was a station porter, change in sleep pattern is often the harbinger of a
which for him was grandiose. Grandiose ideas and manic episode. In severe mania, the sleep pattern is
 Chapter 1: The mental state and states of mind 17

totally disrupted with the patient having only brief currently experienced distress at an apprehended
naps or micro-sleeps. future threat. In straightforward fear, the arousal
States of mania exert a fascination and attraction relates to an obvious and imminent possibility, such
not only for observers but retrospectively for some as the danger presented by the snake on the path or
patients. Although some patients fear above all else the rapidly approaching vehicle. In anxiety, a more
the loss of control and the driven self-damaging distant and ambiguous future calamity is brought
behaviour of mania, others hark back nostalgi- forward to vex and distress. Severe forms of anxi-
cally to the elation, self-confidence and activity of ety usually concern a more nebulous but neverthe-
their previous mania. Not a few patients knowingly less overwhelming threat which seems to impinge
induce a manic episode in the mistaken belief that on one’s very survival. The state of being anxious
this time they will control it rather than letting it creates a sense of confusion and uncertainty which
control them. Manic states can and do lay waste our disrupts the individual’s capacity either to escape
patients’ lives, destroying their interpersonal, pro- the dread or to form, let alone realise, any effec-
fessional and economic existence. tive intentions. Anxiety often focuses on a particu-
The term bipolar illness incorporates into the lar threat of personal or social annihilation, such as
very essence of the syndrome a polar opposi- a heart attack or exposure to overwhelming social
tion between depression and mania. This does embarrassment, but is not exhausted or coexten-
not accord with phenomenological investigations in sive with its chosen object. The fear is of the dread
which states of mania and depression can merge consequences on the heart attack or the total social
and mix and in which, in more severe manifes- ostracism consequent on the exposure of the sup-
tations, the echoes of the alternative syndrome posed or actual transgression. Pathological anxiety
are often to be found. In her novel Mrs Dalloway, brings with it an inexhaustible vision of awfulness
Virginia Woolf (1925/1996) projects her own expe- in the face of which we stand confused, incapable
rience of severe affective illness into her character of action, crying out for help in a manner which will
Septimus Smith. This provides a vivid portrayal of inevitably be inadequate.
the manner in which the manic and depressive ele-
ments entwine in the lived experience of melan-
Obsessive and compulsive phenomena
cholic madness.
The essential feature of these phenomena were
Anxiety states described by Lewis (1967) as “the fruitless strug-
Anxiety plays a fundamental role in mental disor- gle against a disturbance that seems isolated from
ders, and we all experience it from time to time. the rest of mental activity”. This places the empha-
Nevertheless, it is an experience peculiarly diffi- sis on a conscious resistance to these “home-
cult to describe. It is relatively easy to speak of made but disowned” impulses. A distinction is often
what makes us anxious, be it fear of failure, illness, drawn between obsessions as recurrent cognitions
crowds, snakes or otherwise. The physical concomi- in the form of intrusive thoughts, impulses, ideas,
tants of anxiety such as palpitations, muscle ten- or images and compulsions as repetitive seem-
sions, tremulousness, and hyperacusis are equally ingly purposeful stereotyped behaviours (American
readily described. Attempts to capture the psycho- Psychiatric Association, 1987; Rachman & Hodg-
logical state of being anxious often tend to produce son, 1980). In practice compulsions are behavioural
only a list of similes such as worrying, dread, panic, responses to obsessions, although not all obsessions
terror and tension. lead to compulsions.
Anxiety occurs in response to the expectation of Central to the experience of an obsession is usu-
some approaching evil, and in essence it is the expe- ally a fear or phobia. Typical fears are of death, con-
rience of some feared future possibility brought for- tamination, acting violently and being blasphemous
ward to plague one in the present. Anxiety is a (Straus, 1948). The cognition, usually but not always
18 Section 1: The Tools of Psychiatry

a fear, is experienced in a particular manner in that behaviours to ward them off. Thus one patient over-
the sufferer recognises to some extent that it is irra- whelmed by compulsive hand washing to fend off
tional, or at least senselessly insistent. An act of will the feared contamination developed a complex set
is usually made to suppress or turn attention away of hand movements and gyrations to defend against
from this preoccupying cognition. Occasionally the the impulse to keep washing.
intrusive cognition will not appear to carry fright- The compulsions can become ritualised to cre-
ening connotations, as with an intrusive melody or ate a magical counter-charm to the intruding obses-
an impulse to carry out some form of exercise of sion. It is not enough for those obsessed by con-
mental agility. Usually, however, on further elabora- tamination to wash, they have to wash in a very
tion these will turn out to be either performances particular and usually increasingly complex man-
aimed at warding off what is feared (compulsions) ner. Failure to complete the precise and stereotyped
or displacement activities to blot out some feared ritual, or more particularly the fear of an incorrect
cognition. One patient, referred because of increas- performance, leads to a compulsion to repeat the
ing inability to function at work, reported an over- compulsion. The perfectionism so often found in
whelming preoccupation with mental arithmetic, the character of the obsessional individual com-
which he felt impelled to carry out despite attempts bines with magical thinking to produce a tangled
to resist and return his attention to matters at hand. web of obsessions, compulsions and rituals which
Only later did he acknowledge that he harboured enmesh the sufferer. In severe obsessional illness,
the belief that only through the successful com- patients can become so isolated within the multi-
pletion of increasingly complex arithmetical calcu- layered obsessions and compulsions that they are
lations could he prevent his wife’s infidelity. The overwhelmed and their consciousness of the basic
patent absurdity, if not of the fear of infidelity then irrationality of their thoughts and actions, as well as
at least of the remedy, made him believe that if he their resistance to these phenomenon, may become
revealed this notion, he would be locked up as mad. so attenuated as to be at times invisible. Not surpris-
Not only does the fear reverberate in the suf- ingly some regard severe examples of these disor-
ferer’s consciousness, the world itself often becomes ders as being close to, if not actually, psychotic (Insel
a source of constant reminders and provocations of and Akiskal, 1986).
that fear. Cut flowers conjure up images of death The term obsessional is on occasion stretched
and decay, the sight of a wristwatch provokes a fear in the current mental health literature to include
that it may have a luminous dial indicating the pres- obsessive concerns or behaviours which are not
ence of the feared radiation, the knife is a potential accompanied by any subjective resistance nor even
weapon, the spanner is a potential weapon, the glass by a consciousness of the absurdity or exces-
if broken could become a potential weapon, and so sive nature of the thoughts and urges. Obsessive
on. For the obsessional individual, the sign or sym- behaviours involving intense preoccupations asso-
bol of the feared is magically transformed into the ciated with, for example, stalking or some forms of
presence of what is feared. collecting may well be destructive to the individual
The compulsive element of the experience is and those around them (books and recorded music
usually secondary in that it develops to defend being excluded because their accumulation, how-
against the obsessing fear. Thus hand washing is a ever absorbing of time and money are so obviously
response to the preoccupying fear of contamination central to the good life). To refer to intense preoc-
(which itself may be generated by a fear of bring- cupations and obsessive pursuits as obsessional is
ing death or decay on oneself or others). As Lewis to miss their central characteristic, which is a per-
(1967) pointed out, the compulsions can themselves sonal commitment to a goal which, far from being
become obsessional; that is, the patient has to strug- resisted or rejected, is most of the time enthusiasti-
gle against them and may indeed develop defensive cally embraced and may even form a core aspect of
 Chapter 1: The mental state and states of mind 19

the individual’s identity. The occasional retrospec- Delusions usually have attributed to them the fol-
tive guilt, forced renunciation or claims of inabil- lowing characteristics:
ity to resist does not equate with the sense of the r They are held with absolute conviction and are
imposed absurdity at the centre of the obsessional experienced as self-evident reality, not as merely
experience. opinion or belief.
r They are not amenable to reason nor modifiable
by experience.
Delusion r They are experienced as being of great personal
significance and usually preoccupy the person to
Socrates declared we do not call those mad who err in the point of disrupting social and interpersonal
matters that lie outside the knowledge of ordinary people; functioning.
madness is the name they give to errors in matters of com- r Their content is often regarded by others as fan-
mon knowledge. . . . we don’t think a slight error implies tastic or at least inherently unlikely.
madness but just as they call strong desire love, so they r They consist of convictions which are highly per-
name a grand delusion madness. (Xenophon, 1923)
sonal and idiosyncratic that are unlikely to be
shared even by those of similar social and cultural
backgrounds.
The nature of delusional experience
These characteristics are not, however, sufficient
Delusion involves abnormal beliefs that arise in to separate delusions from nonpathological beliefs
the context of disturbed judgements and an altered and convictions. The addition of three further char-
experience of reality. Delusions become a source of acteristics assists in making such distinctions:
new and false meanings. In everyday language, the r They often emerge in a manner which suggests
term delusion is used simply to designate a belief their pathological origins.
considered patently false. In psychopathology, the r They often extend to contaminate a wide range of
implications of referring to someone as deluded patients’ beliefs about themselves and their world.
goes far beyond merely indicating that they harbour r They can evoke persistent idiosyncratic behavi-
false convictions or have made false judgements on ours which are potentially damaging to oneself
a particular topic. Delusion has long been regarded and others.
as one of the central characteristics of madness and These eight aspects of the delusional experience
involves more than false and arbitrary ideas devel- must be critically examined. The absolute convic-
oped without adequate proof. They are the mad tion in the truth of one’s beliefs is not confined to the
thoughts that mad people think. deluded subject. Further, the deluded patient may
To complicate further the description and defini- on occasion paradoxically combine an apparent
tion of delusion, the term encompasses a variety of total certainty with, at another level, an awareness
phenomena which may or may not be on a spec- of the delusional nature of their beliefs. Patients
trum and may or may not constitute a number of themselves illustrate this double-entry bookkeep-
distinct entities. Is this delusion? The question can ing when, for example, of their own volition they
determine not just the treatment of a patient but go to psychiatrists to tell of their divine mission
whether the patient is accorded the legitimacy of ill- rather than going to the relevant ecclesiastical
ness or even, in the forensic arena, anything from body.
amelioration of punishment to removal of guilt. The The imperviousness of a delusion to modifica-
question might be better phrased thus: “Is this indi- tion by reason or experience in no way distinguishes
vidual experiencing any of the many and various it from common error and opinion. Logical error
abnormal phenomena which we traditionally label is not the exclusive hallmark of delusion, nor is
delusion?”’ the failure to expose beliefs to the test of critical
20 Section 1: The Tools of Psychiatry

appraisal confined to the mad. The errors of most their convictions, spending money they do not have,
normal individuals are those common to their social entering into impossibly ambitious projects and
group and take their origin from shared misconcep- offering their unsolicited advice to all.
tions. The errors of the deluded patient tend to be The content of delusions is often fantastic, but
idiosyncratic in the extreme. Their origin is often to inherently unlikely notions are not unknown even
be sought in some as yet little understood disrup- among psychiatrists. It is not the truth or falsity of
tion and change of mental function, which funda- the belief that defines a delusion in psychiatry, for
mentally alters the patient’s knowledge of the world. delusions may partake of the truth. The potentially
The failure of deluded patients to change their opin- correct delusion is most commonly encountered in
ion when faced by contrary argument should per- morbid jealousy. One patient had the infidelity of
haps occasion no surprise. Our own mistaken, or his wife conclusively revealed to him on Christmas
more important, eccentric beliefs, recede before the Eve when, returning from work, he noted that the
changing structure of our environment and their lights on the festive tree in his front window were
gradual erosion by confrontation with the contrary flashing on and off in synchrony with those of his
opinions of our peers. The views of most of us shift neighbour’s tree. The actual nature of the wife’s rela-
more as a result of experiences wrought by the slow tionship to this particular neighbour is not critical
passage of time than they do before mere reason. to the phenomenological analysis of this belief as
Conversely, deluded individuals may on occasion a delusion, although it may, of course, be relevant
shift their beliefs in response to experience and to speculations about meaning. The way in which a
both the content, and the intensity of preoccupa- belief emerges and the reasons for its acceptance are
tion in some delusional states can be modified by therefore part of the way we recognise delusions.
cognitive-behavioural therapy. Delusions are not dependent on any defect in the
A person’s delusional system is usually a private patient’s intelligence nor of disruption in the fac-
and isolating series of beliefs about the world. It ulties for reason and logical thought. An intelligent
forms a central and overriding series of convic- and articulate individual who becomes deluded will
tions that influences, if not dominates, individu- put these abilities to the service of the delusion, and
als’ beliefs about themselves and their world. It is a luxuriant growth of bizarre ideas may result, which
perhaps surprising that delusional systems that are are argued and defended with all the subject’s usual
nearly always pre-eminent in governing individu- mental agility. An excellent example is provided by
als’ understanding of their experience are remark- Schreber’s (1955) memoirs.
ably variable in the extent to which they direct Delusions can relate to the belief systems of nor-
actions. A study by Wessely and colleagues (1993) mal individuals. False beliefs do not always indi-
suggested that half of their deluded subjects had cate psychopathology. Idiosyncratic and unshared
to some extent acted in a manner congruent with beliefs are not of necessity false, let alone morbid.
their morbid beliefs. Typical of the delusionally Take an original concept in science. At the moment
influenced behaviours were avoiding watching tele- of its inception it could be confined to one individ-
vision, not going out socially and avoiding foods ual and not shared by those of a similar social and
thought to be poisoned. The grandiose delusions cultural background. A concept in science would,
in the sufferer with general paralysis of the insane however, be directed at a circumscribed area, would
or the extensive system of beliefs to be found in be understandable within the accepted and shared
many chronic schizophrenic patients may, how- discourse of science and, although it might be of
ever, have little influence on the patient’s behaviour. great personal significance to its instigator, that sig-
The delusions in affective psychoses more often nificance would be primarily in terms of what it
call forth behaviour consistent with their beliefs. explained about the world in general, not about the
Manic individuals, for example, may well act on internal and intimate world of that individual. Such
 Chapter 1: The mental state and states of mind 21

a belief might be termed delusional by the scientists’ grievance at such terrible costs should establish for
colleagues out of incredulity or even envy, but it is the clinician some presumption of a delusional pro-
hoped that the belief would be unlikely to acquire cess (Mullen & Lester, 2006). Too often we attempt to
the epithet delusional within a psychopathologi- decide on whether a particular experience is delu-
cal framework. Religious belief, particularly sud- sionally based without taking into consideration the
den religious revelation, shares some of the char- history of the patient’s conduct whilst they have
acteristics of delusion, but again it would normally potentially been influenced by the delusional phe-
be distinguished by being recognisably part of an nomena. It is not wise to respond to the common
accepted area of religious experience and discourse. facile assumptions that strange and deeply offen-
Totally private religious revelation, independent of sive behaviour necessarily implies madness with the
any accepted theological context, could present equally facile assumption that delusional experi-
considerable problems separating from a morbid ence exists in and of itself prior to and indepen-
phenomenon. dent of the delusional person’s conduct. Behaviour
In distinguishing between delusion and novel driven by a set of eccentric ideas which is persis-
scientific ideas or religious beliefs, the dimension tently damaging to any reasonable calculation of the
termed extension by Kendler and colleagues (1983) individual’s own interests is not proof of delusion
is of value. Extension describes the extent to which but is supportive of such an assumption in the con-
a delusional belief spreads to involve various area of text of other phenomena.
the individual’s life. A scientific idea however fun-
damental is unlikely to explain why the scientist’s
Classification of delusion
neighbours seem unfriendly, why a colleague wears
a red tie, or why their food tastes bitter. A run-of- A number of attempts have been made to clas-
the-mill persecutory delusion, on the other hand, sify delusions (see reviews by Arthur, 1964; Bentall
can usually generate explanations for these and et al., 2001; Garety, 1985; Maher, 2001; Oltmanns &
many other mundane events. Even religious revela- Maher, 1987; Winters & Neale, 1993). Perhaps the
tions, however fervently believed, usually limit their simplest division that has been suggested is depen-
explanatory power to spiritual, ethical and moral dent on the degree of conviction with which the
issues. beliefs are expressed (Wing et al., 1974). Partial delu-
There is an understandable reluctance to add sions are those in which the individual is prepared to
behaviour to the constellation of experiences which entertain the possibility of being mistaken, whereas
characterise delusion. This is seen as running the delusions proper are held with a conviction which
risk of acting as agents of social control by strip- excludes the possibility of doubt. The problem with
ping the legitimacy from those whose behaviour this division is that the way in which opinions and
and opinion are disapproved of by society. Ignoring beliefs are expressed is largely a function of the
behaviour can also lead to problems, however. For interplay between educational and cultural back-
example, querulous individuals who pursue multi- ground and the personality of the individual. Some
ple complaints and claims through the courts and of us express trivial and peripheral assumptions
with agencies of accountability in the process lay with force and conviction, whereas others timidly
waste to their lives and create administrative chaos. advance their most heartfelt beliefs. Should delu-
They may at any given moment be able to defend sion supervene, this habitual method of present-
plausibly their quest for their particular vision of ing belief may mislead the observer as to the true
justice and be able to cloak themselves in the level of adherence to the conviction. There is also
appearance of social reformers and whistle-blowers. considerable fluctuation in individual patients over
The pattern of conduct which has led to their pur- time in how firmly they adhere to their delusional
suing what is usually a real but inherently trivial convictions.
22 Section 1: The Tools of Psychiatry

Delusions have been divided into those judge- the patient of many of his recent experiences and
ments that arise in an understandable way from much of his prior life; he realised his failures had
particular interactions or experiences and those been trials, his rejections, persecutions and sexual
that appear de novo like sudden intuitions or brain inadequacy part of divine inspiration. A totally new
waves. Those delusions for which no connection perspective on the world overthrowing most of his
can be comprehended between the emergence of previous concepts came with this revelation.
the belief and any precursor and which confront Secondary delusions or delusion-like ideas emerge
the observer as something absolute and irreducible understandably from other psychic events or the
have been termed primary or autochthonous delu- individual’s interaction with the world (Jaspers,
sions. Jaspers (1963) observed that in these pri- 1963). Their origin can be traced to affects, drives,
mary delusions there occurs an experience radi- fears or some devastating personal experience. They
cally alien to the healthy person that comes before are therefore amenable, at least theoretically, to
thought, although it becomes clear to itself only analysis in terms of the meaningful connections
in thought. The primary delusion emerges in the of psychic life. A morbid alteration in a subject’s
context of a radical change in normal mental func- mood may, for example, if it is towards elation,
tion and is indicative of a process at work. The precede the emergence of delusions of grandeur,
primary delusion is thus assumed to be an erup- or, conversely, a depressive swing may be followed
tion of an extraconscious process into the normal by delusions of poverty or guilt. The hallucinated
flow of intentional mental life (extraconscious in individual’s perverted senses may be the starting
the sense of neuropathological, not emanating from point of a delusional development, as may some real
any Freudian system unconscious). The primary experience of injustice in a paranoid personality. A
delusion cannot be fully explained by an appeal to suspicious, prickly individual with a propensity to
the meaningful connections that usually govern the self-reference was exposed to a series of personal
stream of consciousness. On the contrary, it is an disasters, including loss of job, money, and his
ultimately irreducible phenomenon not amenable home following mortgage foreclosure. The events
to psychological understanding and explicable only (partly self-induced) were explained by him initially
in terms of the causal connections governing the as due to a generally ill-disposed world towards a
presumed organic changes in the brain. Clearly this man of his obvious but unrecognised talents. As
is an untestable hypothesis. It does not, of course, he continued to ruminate on the events, a pat-
imply that the content of a primary delusion has tern became more and more obvious to him. Slowly
no connection with the patient’s past life or present over a period of many months, a delusional system
situation; it merely claims that the emergence of involving a complex plot by members of his fam-
the belief and part at least of its initial content will ily in league with the local constabulary and pub-
not be amendable to such an analysis. After the lic health officials emerged. This delusional system
primary delusion is established, the further elab- became the focal point of his life, dominating from
oration of any delusional system will in principle then onwards his thoughts and actions. The slow
be open to an analysis in terms of its meaningful emergence of this secondary delusional system was
connections. in the context of immense personal stress, probably
An example of a primary delusion is a patient associated with an unrecognised depressive mood
who, on asking a friend for a light for his cigarette, swing occurring in a person with a suspicious and
was passed a box of matches on which appeared oversensitive personality structure.
the slogan “the greatest match in the world”. This There is obviously a problem in a classification
revealed to the patient in a moment of intensely that relies on as subjective a criterion as “under-
experienced insight that he was the light of the standability”. Theoretically the division is attrac-
world. This delusional brain wave made sense for tive; in practice, it is often difficult and inconsistent
 Chapter 1: The mental state and states of mind 23

in application (Koehler, 1979). The distinction also A minor facial blemish, for example, will be the
relies on the content of the phenomena rather than centre not only of the individual’s attention, but
the form, which goes against the aim of classi- of all those whom they encounter. Their thoughts,
fying by form rather than content. To try to cir- particularly those involving sex and anger, will be
cumvent this problem to some extent, Schneider embarrassingly obvious from their facial expression.
(1959) divided delusions into two major forms, delu- Their actions will make them appear ridiculous in
sional perception and delusional notions. Delusional the eyes of all. Self-consciousness is the lot of most
perception he considered of particular significance of us at some time or another. It is usually more
in the diagnosis of schizophrenia. It was a two- marked in adolescence and when entering unfa-
stage phenomenon involving first a true percep- miliar social situations. At the extreme, it can pro-
tion of a real object and second the emergence of a duce extensive disruption of an individual’s ability
delusional insight generated by the perception, this to function socially.
delusion having no easily comprehensible connec- Sensitive self-reference is a propensity to interpret
tion to the perception. This new knowledge does habitually the words and actions of others and inci-
not derive from reflection on the perception but is dental happenings of the world as being directly
imminent within it; the perceiving and the knowing concerned with oneself. It is clearly related to self-
are directly and immediately linked, the one con- consciousness, and the two often occur together,
tained in the other. although essentially the self-conscious individual is
These classifications of delusion pay little direct turned in on themself, whereas the self-referring
attention to the extent of the restructuring of person is painfully aware of their surroundings. In
the patient’s knowledge of himself and his world. self-reference, there is not only heightened self-
The type of knowledge involved is also employed awareness but also a tendency to divine personal
only indirectly within these classifications. Delusion meanings in trivial and unrelated events. The world
involves both the elements of beliefs or knowledge becomes centred on the individual, and the mun-
about something and the interpretation or, more dane words and actions of others are seen as
precisely, the misinterpretation of occurrences or being directed at oneself. Self-reference normally
objects in the surroundings. It might be helpful has a persecutory flavour, and thus the remarks
to construct a hierarchical model according to the and actions of others are invested with unpleasant
degree to which patients’ views differ from normal and even sinister import. A couple laughing on the
convictions in terms of how firmly they are held, other side of a crowded room are laughing at the
how idiosyncratic they are and the extent to which self-referring person, the overheard snatch of con-
they influence their views of themselves and their versation in a bus is about them, the shrug of the
world. Delusion usually involves both belief and shoulders of the barman is a dismissive insult rather
interpretation; the balance between these two ele- than a mere gesture, and so on. In self-reference
ments varies, and two hierarchies are possible: those individuals are normally convinced at the time that
predominantly involving morbid belief and those the events they misinterpret were directed at them
that are morbid interpretations. and them alone, but in retrospect they will at least
entertain the possibility of error. In self-reference,
the meaning attached to the action or event is not
Morbid interpretations
impossible nor even necessarily improbable; people
Self-consciousness is characterised by heightened could be laughing at them, passing remarks being
self-awareness. The individual often believes that intentionally obstructive, and so on. It is the fre-
his or her own personal preoccupations with regard quency of the self-reference and its extension into
to appearance, actions, and even thought will be every area of social and personal interaction that
mirrored in the attention they receive from others. leads to its recognition as morbid.
24 Section 1: The Tools of Psychiatry

Delusional mood is characterised by an altered bizarre, is essentially limited and restricted; it may
experience of the world in which, in some intangible form part of the patient’s more extensive delusion
way, events take on an uncanny quality and tension. system, but only a part.
The events as well as the actions and words of oth-
ers seem to hint at hidden meanings and are infused
Beliefs about the world
with a direct and personal significance. The precise
nature of the meaning eludes them, and although Overvalued ideas have enormous personal signifi-
there is often a sense that a pattern of meaning is cance out of proportion to their overt content. They
about to emerge, it remains just out of grasp. The differ from the strongly held beliefs of the common-
individual in such a state often appears perplexed or ality in the degree of emotional investment and the
frankly fearful. This state differs from self-reference focal part they play in the mental life of the individ-
in that it involves an attribution of meaning to a far ual. Clearly some types of convictions, particularly
wider area of the patient’s experience of the world; the religious and political, are often invested with
everything is imbued with personal meaning. On great significance, but overvalued ideas normally
the other hand, the precise meaning of the occur- concern more mundane and specifically personal
rences is far less clear than in self-reference. Thus matters. Despite their importance to the individual,
although it is a somewhat less clearly defined abnor- they remain beliefs about the world, not the articu-
mal state of mind than self-reference, it is a more lation of self-evident reality. The content, although
extensive and pervasive disturbance and is less easy often eccentric, is not entirely removed from what
to relate to normal experience. Delusions of refer- peers regard as conceivable. The overvalued idea
ence may crystallise out of a delusional mood. often develops out of a conflict between a vulner-
Delusions of reference have a similar structure to able personality and some elements in the envi-
self-reference in that some event or aspect of the ronment (McKenna, 1984). The individual, although
environment is taken to indicate a personal and strongly protesting the accuracy of his or her beliefs,
direct meaning for the patient. The interpretation will entertain the possibility of error, albeit only the
placed on the event in delusions of reference is more dimmest and most distant possibility.
idiosyncratic and cannot so easily be seen as a pos- The use of the term overvalued ideas has become
sible, even if unlikely, interpretation. Thus a head- problematic. Too often it is employed to dismiss
line in a newspaper ostensibly about events in the the pathological significance of experiences in a
Middle East was interpreted as a direct reference to manner both premature and misguided. Wide areas
a patient’s homosexuality. The code numbers at the of traditional psychopathy around, for example,
top of a banal communication from the tax inspec- pathological jealousy, delusional claimants, and
tor was interpreted as further evidence of a conspir- dysmorphobias have been forced by some into the
acy. The colour of the tie worn by the doctor enables overvalued ideas box. In the process the significance
the patient to identify him as part of a sect dedicated of these morbid phenomena has been diluted or
to persecuting the patient. The television compere is lost. Given the choice, I would dismiss the term
understood as repeatedly making veiled references overvalued ideas from psychiatry; failing that, I sug-
to the patient’s sexual activity disguised as sports gest one approach its use with scepticism and start
commentary. In delusions of reference, the mean- from the assumption that phenomena so described
ing derived from the event is incomprehensible to are likely to be either delusional or nonmorbid pre-
others in the patient’s social group. The delusion of occupations.
reference remains an interpretation, thus a meaning Simple delusions are true delusions, in that they
is attributed to an event, but it is not open to doubt – are absolute convictions experienced as self-evident
it is experienced as self-evidently true. The informa- reality that are immutable in the face of contrary
tion contained in a delusion of reference, however argument or experiences. They are highly personal,
 Chapter 1: The mental state and states of mind 25

and their content is often fantastic. They normally, areas of the patient’s understanding of his or her
however, concern a relatively limited aspect of the position and relationships. The systematised delu-
individual’s beliefs about themselves or the world. sions may grow gradually by accretion over months
Depressive delusions of bizarre bodily afflictions, or years, or they may emerge rapidly, transform-
such as one’s blood drying up, heart being absent, ing almost at a stroke the patient’s mental life.
or bowels rotting away, are typical examples. The Systematised delusions, perhaps because of their
erotomanic delusions and circumscribed persecu- extended and extensive nature, change (if change
tory delusions that attribute malevolent intent to they do) slowly over time rather than in obvious
specific individuals or groups and do not spread response to alterations in the patient or their envi-
to affect the majority of the patient’s relationships to ronment. The systematised delusions offer no pos-
others, are further examples. The impression given sibility of refutation; all new experience and infor-
by patients with this type of morbid belief is that mation becomes incorporated within this morbid
their beliefs about other aspects of the world are knowledge.
largely consonant with those of their peers, except Systematised delusions may emerge on the basis
in the particular and often narrow area occupied by of delusions of reference either gradually or, on
the delusions. This type of delusion may fluctuate occasion, as an almost immediate and extensive
in intensity and in the extent to which it preoccu- restructuring of the patient’s view of themselves and
pies the patient. These fluctuations are often con- the world. Systematised delusions are usually sus-
nected to factors that appear to be related to the tained and extended by misinterpretations, misper-
genesis of the delusions. Thus as the mood fluc- ceptions, delusions of references and restructured,
tuates, the delusions associated with an affective if not frankly delusional, memories.
psychosis may wax and wane. In the persecutory A final point is that at the centre of many delu-
delusions of some paranoid patients, interpersonal sional systems lies an altered world view from which
conflict may exacerbate the problem, and the the details of the system spread. From the perse-
removal of a source of stress may at least temporar- cutory viewpoint, patients are acutely aware of the
ily allow the beliefs to recede into the background. outside world and its impact on them; all occur-
Unsystematised delusions are those in which a rences are potentially threatening and destructive
number of poorly organised and unintegrated delu- but, above all, meaningful and personalised. From
sional notions coexist. The patient’s account is often the depressive viewpoint, patients’ own internal
difficult to follow both because of the partial nature preoccupations with guilt, loss and disintegration
of the accounts provided and the frequent shifts come to colour the world in which they live and con-
in focus. In some cases, despite the poorly articu- stantly confirm and reflect their internal reality.
lated nature of the beliefs, they appear to have for
the patient profound significance; in others, there is
Delusions and reality
a superficial and almost trivial quality to the fluc-
tuating kaleidoscope of odd ideas and fragmented The relationship of patients’ private delusional
beliefs. world to the shared reality varies (Scharfetter, 1980).
Systematised delusions involve a profound delu- In some cases, the delusion comes to dominate
sional restructuring of the patient’s view of them- patients’ mental life, and they withdraw completely
selves and their surroundings. The delusional sys- into their private worlds. In other cases, although
tem contaminates wide areas of the patient’s beliefs the delusional reality is predominant, patients con-
about the world. There may appear a central core tinue to live to some extent within the shared social
to the belief system – for example, personal divin- context. In some the delusional reality exists side by
ity, a plot, or some damage or injury sustained – but side with the shared reality without either seeming
the delusional beliefs spread to contaminate wide to affect, or contaminate, the other (Bleuler’s double
26 Section 1: The Tools of Psychiatry

registration). Finally, delusional reality may be inex- possessors I have encountered are devils, holy
tricably intermingled with the shared reality. spirits, dead relatives, warrior ancestors and the
spirit of a dead rabbit (!). Beliefs in being possessed
are distinct from the experience of being influenced
Delusions of specific content
by outside forces and the belief in being someone
Delusions may be classified according to content. else. Thus one of my patients believed he was Elvis
This is usually self-explanatory (e.g. delusions of Presley and that an impostor was entombed at
grandeur, delusions of guilt, delusions of persecu- Graceland, whereas another believed she was on
tion, delusions of poverty, etc.), but a few specific occasion possessed by the spirit of the departed
types require brief mention. rock star. In the state of possession, a tension exists
Nihilistic delusions involve a delusional belief that between oneself and the interloping possessor, and
something is dead or nonexistent. This may involve even when the possession is welcome, as with holy
a belief that some organ or part of the body has spirits, it remains to some extent a separate and
gone or rotted away or that the individual is them- intruding presence.
self dead. The term nihilistic delusions is often Misidentification syndromes involve a conviction,
employed loosely to cover all delusional ideas about often delusional, that the people a patient encoun-
bodily dysfunction and decay in depression. When ters are not who and what they appear or claim
nihilistic delusions form a prominent feature within to be (Coleman, 1933). This can involve denying
the clinical picture, the term Cotard’s syndrome is the identity of familiar individuals or claiming that
occasionally employed. strangers or chance acquaintances are in fact rel-
Erotomanic delusions usually involve the delu- atives or significant figures from the patient’s past
sional belief that someone, often a person of life. The misidentification may involve a belief that
power and influence in the patient’s life, is secretly, familiar and often closely related individuals are not
but passionately, in love with them. This phe- really who they appear but merely have the same
nomenon is sometimes known by the eponymous outward appearance, the inner psychological iden-
title of de Clerambault’s syndrome which is unfor- tity being different. This can lead to claims that the
tunate because this type of delusion had been patient is being duped by doubles disguised as rel-
well described for over a century when Cleram- atives or, as in one patient of mine, that his fam-
bault (1942) wrote about passionate psychosis. The ily’s bodies had been taken over by a race of aliens.
currently accepted definitions of erotomania fail Sometimes it is a physical rather than a psychologi-
to incorporate the morbid infatuations in which, cal identity which is at issue; subtle differences dis-
although sufferers do not claim they are loved, they cernable to the individuals’ appearance reveal them
do have an unshakeable conviction that their love as impostors, or chance or subtle similarities of
will eventually be reciprocated despite clear evi- appearance vouchsafe identity. This phenomenon is
dence of the continuing indifference or open hos- not as uncommon in severe psychotic disturbance,
tility of their supposed love (Mullen & Pathé, 1994). as the literature sometimes suggests. It is graced by
Delusions of possession are those in which the eponym Capgras syndrome (Capgras & Reboul-
patients are convinced they are possessed by some Lachand, 1923; Christodoulou, 1977). Misidentifica-
spirit or force. These tend to be found among those tions can be bizarre when, for example, a patient
whose cultural background provides some basis for seems utterly convinced that a young nurse is his
beliefs in possession, which can make it difficult to dead mother or ignores the “minor issue” of gen-
separate them from an overly dramatic presentation der when concluding that the man in the next
of a culturally appropriate belief. Occasionally in bed is really his wife. More frequently, the delu-
forensic practice, claims of being possessed are sional misidentification is based on some minor
advanced to exculpate some offence. Among the similarity of appearance or mannerism between the
 Chapter 1: The mental state and states of mind 27

individual and who they are claimed to be by the ever more curious accounts, often incorporating the
patient. On occasion this type of misidentification queries and comments of the examiner. Such people
is referred to as the illusion of Fregoli, but the term are prone to be dismissed as malingerers because of
is misleading on several counts. the ease with which they respond to suggestion and
Delusions may come to be shared within a fam- shift their stories in response to expressions of scep-
ily, and these shared delusions may be referred to as ticism. Sitting listening to such patients for a few
folie a deux, folie a trois, and so on; as psychosis of hours usually dispels such scepticism.
association; or as double or multiple insanity. Sev- Dysmorphophobia is an intense and unshakeable
eral variants have been described, as follows: conviction on the patient’s part that an aspect of
r Simultaneous emergence of delusion in closely their appearance or body is misshapen and conspic-
associated individuals in which the content is uously ugly. This phenomenon is associated with an
shared, probably as a result of shared environ- intense preoccupation with the supposed deformity
ment, but the origin is independent on which the patient ruminates at length. The actual
r Imposed delusions in which a dominant figure experience and perception of the individual’s own
within a relationship or group imposes their delu- body seems altered in that the patient claims slight
sional view on the others to such an extent that the deviations from normal shape or size to be gross
delusional system seems eventually to be totally and obviously different from normal. There is often
shared associated despondency, and this phenomenon can
r Communicated delusions in which two individ- be secondary to depressive disorders. The narcissis-
uals living in close association, both of whom tic elements are usually obvious. This phenomenon
have a propensity to psychotic disturbance, come can, in clinical practice, therefore partake in part at
to influence and share each others delusional least in delusion, perceptual disturbance, obsessive
world ruminations, phobia and mood disturbance. The
Delusional memory is a phenomenon in which a placement of body dysmorphic disorder into the
delusional insight occurs not as an intuition about categories of both delusional disorder and somato-
the world or as a change in knowledge of or about form disorder in DSM-IV probably represent the
the world but in the form of a memory. An exam- heterogeneity of the phenomena in clinical practice
ple is provided by a patient who suddenly “remem- and the extent to which they can be seen as forming
bered” that a few weeks previously she had been a spectrum with varying levels of insight (Phillips,
attacked and raped by her brother and brother-in- 2004).
law in the midst of a family gathering. The convic-
tion that this had occurred emerged de novo; the Passivity phenomena (disturbances of
woman could point to nothing that suggested such ego boundary)
an event. On the contrary, she was constantly sur-
prised that everything and everybody around her Passivity experiences are a group of phenomena
were so normal and apparently unaware of the ter- disparate in many ways but having in common
rible happening, even those she believed to have a disturbance in the experienced integrity of the
been involved. The belief continued without seem- self. They are sometimes referred to as distur-
ing to alter this woman’s experience of her world or bances of ego boundary because of this experi-
even her relationship to the central figures in the ence of the breaking down, or violation, in the
memory. unity of the self. The boundaries are breached
Confabutory paranoia is a curious state in which between the patient’s internal private world of
fluent confabulation occurs around an often fluc- thought and fantasy and the external world of
tuating set of delusional beliefs. When challenged objects and other people (including the internal
or cross-questioned, individuals will launch into thoughts, wishes and intentions of others). These
28 Section 1: The Tools of Psychiatry

phenomena are occasionally classified as delusions not merely that they divine their secret thoughts
(Sims, 1988; Spitzer & Endicott, 1978) presumably from their words, actions or facial expressions but
on the grounds that they constitute not an experi- that the thoughts themselves are directly available
ence of, for example, influence or thought broad- and can be, in a real sense, read by others. There is
casting but a belief in being influenced or broad- a sense of having become transparent, making ones
casted. The distinction may on occasion be so subtle innermost thoughts open to direct observation. In
as to appear entirely academic but for most patients, florid form, there can be the experience of one’s
these are direct experiences, not beliefs, although own thoughts being shared and participated in by
they may give rise to delusional explanations. One everyone around them. This experience may lead
patient complained that a “filthy word” was repeat- to delusions of explanation. One of my patients
edly inserted into her mind. This occurred several described a complicated plot in which a neighbour,
times a day and would occasion her considerable who was a BBC journalist, would nightly broad-
embarrassment. She had noted that these insertions cast her every secret thought to the nation; this
tended to occur when she was near or in sight of a explained why everybody knew about them and
tower at a Salvation Army citadel. On the basis of shared them.
this observation, she had become increasingly con-
vinced that she was being persecuted by the Sal- Thought withdrawal
vation Army, which had a radio transmitter beam- This occurs when patients experience their
ing the words into her brain. She experienced the thoughts as removed or ablated by some out-
thought insertion, but she became convinced that side influence. This experience has been claimed to
its origins lay in the transmitter in the tower. One underlie the abnormality of expressive behaviour
is an experience, the other an explanatory belief. known as thought blocking (Fish, 1967).
I have a pain in my belly. I am convinced it is an
appendicitis. The experience of pain and explana- Directed inwards
tory beliefs are distinct phenomena. Thought control involves patients’ experience of
These experiences are of two basic types in that their innermost thoughts as falling under exter-
they can be directed inwards or outwards. In the nal influence. Thought insertion occurs when alien
first there is an experience of influences or intrusion thoughts are imposed on them.
from the outside into the internal world. In the sec-
ond, there is an experience of the thoughts, wishes
Intentions, will and actions
or intentions of the individual diffusing or emanat-
ing out to influence, or become available to, others. Directed outwards
These effects can involve the content of thoughts Patients experience themselves as able to influence
and fantasies, the intentions and actions and the the apparently volitional acts of others. One patient
emotions and desires of the patient. explained to me that he could make people move
The types of passivity experiences are now dis- and speak as he wished and pointed out from the
cussed under the headings of thoughts, emotions, window of the office how he was willing the people
intentions and actions. outside to walk along the street. In another case a
patient described how every move or action he ini-
tiated was simultaneously mirrored in those around
Thoughts
him because his will controlled theirs, but this dis-
Directed outwards rupted his life because when, for example, he went
Thought diffusion and thought broadcasting shopping, the shops were always full of other peo-
involve a conviction on a patient’s part that those ple who, because of his influence, were on identical
around them know their innermost thoughts. It is errands.
 Chapter 1: The mental state and states of mind 29

Directed inwards r One’s body image may be altered, producing not

The experience is of made impulses and made voli- only experienced unfamiliarity in one’s physical
tional acts. This can again involve the experience of being but a nonrecognition of body parts.
the patient’s intentions and will falling under out- r Emotions, feelings and affects lose their subjec-
side control or of the imposition by an outside force tive impact, although the individual is not with-
of action upon them. An elderly and normally prim out emotion; on the contrary, there is usually
and proper lady periodically lifted her skirts and fear and agitation consequent on the changed
performed a brief dance. This she explained had experiences.
nothing to do with her but was the result of the r Actions appear to be carried out automatically
actions of a malevolent race of aliens she called “fan- without personal involvement or intent as if, as
tasias” who were imposing the actions upon her. one patient put it, “I was trapped inside a machine
Here both the control of the acts and the acts them- which I could only watch but not control”. What-
selves were alien. More commonly, what is experi- ever the subjective sense of being out of control,
enced is simply a loss of control over will and action the actions remain those of the individual, reflect-
as a result of outside influence. ing their intentions and commitments even if sub-
sequently disowned.
Emotions Depersonalisation is to be distinguished from
passivity experiences in which there is an experi-
“Made” feelings and emotions occur when patients
ence not of alienation from subjective experience
experience their emotional life as coming under
but of alien influence on such experiences. Deper-
outside influence, either in that they are made to feel
sonalisation appears in DSM-IV not as an abnormal
a certain way or that alien emotions are imposed on
phenomenon but as one of the currently fashion-
them. Patients more frequently report being robbed
able constructions of dissociative disorders. These
of feelings or of having their emotional responses
disorders are assumed to arise from a disruption in
blocked by alien influence.
the functions of consciousness to create amnesia,
dissociative identity disorder and depersonalisation
Depersonalisation and derealisation disorder. This construction is given coherence by
an unstated but implicit appeal to the reality of
Depersonalisation and derealisation refer to experi- a system unconscious. No such archaic frippery is
ences which, although most frequently encountered required for the description or recognition of the
in those afflicted by depressive or anxiety disorders, phenomena of depersonalisation provided here.
can occur in normal individuals when they are over- In normal mental function, there is only a tangen-
tired, stressed or intoxicated. The basic disturbance tial and passing awareness of the process of think-
involves an alteration from the usual of the experi- ing or perceiving. We can by an effort of will reflect
ence of both the self and the world. It can manifest on our experience and activities, but it is neither
in such features as: usual nor sustainable. In depersonalisation, there is
r Surroundings take on a quality of strangeness. an unbidden and unwanted self-awareness in that
r A sense of unreality pervades not only the percep- we become conscious of our mental activities. Per-
tions of the external world but one’s own cogni- ceptions are disrupted by sensations being sepa-
tions and conations. rated from the meanings usually inherent in them,
r The experience of the passage of time is altered by and our cognitions and conations become objects of
a slowing or slippage. scrutiny, not lived experiences. This pervasive self-
r Spatial relationships seem altered, which can pro- reflection totally disrupts the normal flow of psy-
duce distortions and may even be associated with chic life and imbues it with an alien character. We no
micropsia or macropsia. longer reach out for the pen, we become conscious
30 Section 1: The Tools of Psychiatry

of the act of reaching out for the pen; we no longer disorders. It consists of disturbances in volitional
see our reflection, we become conscious of seeing a movement and language. Several aspects of the syn-
reflection which we assume must be ours. In deper- drome seem to be polar opposites. There may be
sonalisation, we remain conscious of our activi- periods of uncoordinated and violent overactivity
ties, and they remain accessible to normal aware- (catatonic excitement); at the other extreme, the
ness. This contrasts with the dissociations of DSM- patient may remain immobile for long periods,
IV in which there is assumed to be a separation or often appearing as if frozen to the spot. Posturing
removal of selective mental events from conscious- occurs when bizarre and uncomfortable poses may
ness or an emergence of previously unconscious be held for long periods, as do reiterated stereo-
factors into consciousness, often in a form quaran- typed movements, where the same action is end-
tined from the rest of the individual’s mental life. lessly repeated. The normal fluidity of voluntary
Depersonalisation and derealisation are a morbid motor activity may be disrupted to produce an awk-
exaggeration of self-awareness and self-reflection, ward and stilted quality, which is most obvious in
which disrupts the sense of being part of, and at one the odd gaits encountered in this disturbance. Auto-
with, one’s own cognitions, conations and actions. matic obedience can be a feature with unhesitat-
ing compliance to any command or request without
apparent conscious control, but so can the reverse,
Volition negativism, in which there is a positive effort to
resist and often do the opposite or some eccen-
Pathological disturbances of action and movement trically unrelated performance rather than what is
largely fall within the rubric of neurology; however, requested or required. Ambivalence, in the Bleule-
certain syndromes that include characteristic dis- rian sense, may effect motor action – the patient
turbances of motor behaviour require brief men- commences an act and then before completing it,
tion (see Lohr & Wisniewski, 1987, for a thorough reverses his or her movements and begins once
review). more, only again to halt and reverse.
Echolalia and echopraxia occur where the patient
Tics repeats or imitates the words or actions of those
These are repetitive stereotyped movements involv- around them. In echolalia the repetition seems to
ing voluntary musculature. Although usually capa- occur in an automatic fashion without any appar-
ble of brief inhibition by an act of will and to ent understanding. Echophenomena are not con-
some extent responsive to mood and situation, they fined to catatonic syndromes but occur in a range
are for the most part outside of the patient’s con- of pathological conditions (Ford, 1989). Just as the
trol. Tics cover a spectrum from minor repetitive fluidity of voluntary movement is disrupted, so
twitches involving the small muscles of the face the usual flow of speech is disrupted to produce
to complex movements, which may involve sev- hesitancy with a stuttering or explosive quality.
eral large muscle blocks. In Gilles de la Tourette Verbigeration, described by Kahlbaum (1874/1973)
syndrome, motor tics are combined with repeated as speech composed of oft-repeated, meaningless
vocalizations, often in the form of obscenities and words and sentences, may also be present in cata-
profanity (coprolalia). tonia. A characteristic disturbance of muscle tone,
in which there appears to be present a waxy flexi-
Catatonia bility (flexibilitas cerea), can accompany posturing
First described by Kahlbaum in 1874 (1874/1973), and immobility in the catatonic syndrome. Pouting
catatonia is a syndrome which can be seen in both movements of the lips are also described to accom-
predominantly affective and schizophrenic disor- pany catatonic states (Schnauzkrampf), as are facial
ders and may be mimicked by a number of organic grimacing and tics. Subtle catatonic disturbances
 Chapter 1: The mental state and states of mind 31

are often either not recognised or dismissed as side the period of stupor and on occasion will give expla-
effects of antipsychotics. nations of their immobility – for example, they were
directed by God or under some external control.
Cataplexy
States of stupor can follow extreme stress and then
This is a sudden, partial or complete loss of tone in
can be conceptualised as dissociative states or as an
the voluntary musculature without disturbance of
extreme reaction, as if paralysed by fear. These lat-
consciousness. It occurs in narcolepsy.
ter may be encountered under battle conditions and
Stupor following catastrophes.
This describes a syndrome in which the most promi-
nent features are gross reductions in voluntary
movement (akinesia) and speech (mutism). There Disturbance of language
is a suspension of expressive and reactive move-
ments. Incontinence may occur. In neurology, stu- Thought can never be directly observed. The
por is often used rather loosely to describe a state attempt to study it must therefore rely on language
of reduced consciousness bordering on coma. In in the form of speech, writing or other symbolic
contradistinction, attempts have been made in psy- creation (Sims, 1995). The entrenched tradition
chiatry to define stupor as an absence of voluntary of speaking of thought disorder, when actually
movement in the presence of clear consciousness. confronted with disturbed language, rests on the
This is helpful in as far as it distinguishes “func- assumption that language directly mirrors thought.
tional” from “neurological” stupor, but the attribu- Speech disorder is usually separated from lan-
tion of clear consciousness to functional stupor is guage and thought disorder. It is confined to
clinically questionable (Berrios, 1981). disturbance in the actual articulation due to a dis-
Kraepelin (1919) attempted to distinguish four ruption with the mechanics of speaking. Stutter-
types of stupor: depressive, manic, catatonic, and ing is a typical example, and the lalling speech
hysterical. In depressive illness, stupor usually fol- of cerebellar dysfunction would be another. A dis-
lows a period of increasing motor retardation and tinction between language as a system of symbol
withdrawal; the patient may still radiate a sense of and sign formation and thought as the content and
melancholy by facial expression and by a passive import of those symbols and signs is occasionally
turning away from proffered assistance. The refusal made. Thus, employing this division, thought disor-
to eat and drink in depressive stupor may repre- der would include delusions and other disturbances
sent a total lack of interest, although one of my of the content of thought. This section is concerned
patients retrospectively described being convinced with the disturbance of language.
his insides had disappeared, so he felt anything The structure of language can be analysed in
that passed his lips would enter his abdominal cav- terms of semantics, which concerns itself with
ity and kill him. In mania, stupor may supervene meaning, and of syntax, which are the rules gov-
on the excited disturbances of delirious mania in erning the combination of words to form sentences.
which extreme restlessness, hallucinosis and some In most of the language disorders observed clin-
clouding of consciousness give way to a state of ically by psychiatrists, the disorder is in the area
mute immobility. In this state, some signs of the of meaning, the semantics, rather than the syntax,
previous gross overactivity may remain in brief the latter only being significantly disrupted in the
outbursts of motor restlessness and in constant most florid forms of psychotic speech. Meaning lies
movements of the head and eyes. In schizophrenia, not only in the words used but also in the situa-
stupor may supervene on a catatonic picture. Retro- tional context of the utterances. Statements occur in
spectively, schizophrenic patients can often provide particular spatiotemporal situations, which include
quite detailed accounts of the happenings during speaker and hearer, the actions they are performing
32 Section 1: The Tools of Psychiatry

and various external objects and events. Further, a a previous word or phrase. Thus, “I feel like going
shared knowledge of what has been said earlier and out, stout, a drink would be nice, ice, I suppose
its relationship to current statements is assumed. I’ll stay, lay down for a while” or “everybody seems
Thus what Searle (1969) termed speech acts con- to revolve around me, involve and resolve around
sist of language in its context which communi- me” is termed a clang association.
cates to the receiver. This understanding of utter- Words may be invented in language disorders.
ances in their context is referred to as pragmatics, These idiosyncratic words of no generally agreed
and it is argued that it is a derangement in this significance are termed neologisms. They may con-
pragmatic function of language which characterises sist of entirely new words, which even the patient
schizophrenic speech (Cutting, 1985). may be hard pressed to explain, or be created by
In an ideal language, one word or sign would exist compressing or running together existing words.
for one meaning. In practice, there are many syn- A patient referred to a “mongery ridicule”, and
onyms for which a particular meaning is designated although he could spell the word, the only defini-
by several distinct words (e.g. hide, conceal, secrete) tion he offered was that it “wasn’t quite nice”. In this
and frequent homonyms for which single words sig- example the phonetic or sound structure is accept-
nify more than one meaning (e.g. bank of river, Bank able for a word in English. On occasion sounds
of England; elephant’s trunk, trunk – a piece of lug- entirely foreign to English phonetics will be emit-
gage). Words may also be used literally or metaphor- ted apparently as words. An example of a word cre-
ically (a man’s head, the head of a company; a glar- ated by condensing existing terms is “a misachrist”,
ing light, a glaring error). In the language disorders which was used by a patient to describe a psychi-
psychiatrists encounter, there may be semantic dis- atrist who misunderstood him (a mistaken psychia-
ruption arising from a confusion of homonym, syn- trist). Jaspers (1963) suggested neologisms may arise
onym and metaphor. A patient, for example, when from the patient’s struggle to express unique and
asked if the pills were making him better, replied, essentially incommunicable experiences.
“Healed? I have no heels (glancing at the bottom of Idiosyncratic similes and metaphors may be
his slippers), I’m only brought to heel”. The word encountered. A schizophrenic patient of Bleuler
healed is employed as a synonym for getting bet- (1950) announced her forthcoming pregnancy with
ter, then confused with its homonym, the heel of a “I hear a stork clapping in my body”. A patient of
shoe, and in this example the metaphorical use of mine replied to the enquiry about his religious views
heel is employed to produce a nice resolution that with “I’m for the elected by a puff of smoke from
allows the patient to comment on his resentment the chimney”, referring obliquely to the process that
at being compulsorily detained. Bleuler reports a heralds the election of a new pope in the Roman
patient who when asked if anything was weighing Catholic Church.
heavily on his mind replied, “Yes, iron is heavy”. A Words, phrases and occasionally syllables seem
patient in a group asked if he was down, immedi- to recur far more frequently in the language of
ately left saying, “Yes, I need to lie down”. This tak- the schizophrenic patient than in healthy people.
ing of the literal rather than the metaphorical use of This is in part connected to the phenomena of
words was referred to by Goldstein (1944) as concrete stereotopy and perseveration. In the perseveration
thinking, although whether it is truly a preference of course organic brain disease, identical words
for the concrete sense or just a tendency to asso- and phrases tend to be simply repeated. In those
ciate to the commonest usage of a particular word with schizophrenia, it manifests as a repeated use
is uncertain. of similar words and phrases in different contexts.
A word may be chosen in language disorder not An extreme example is provided by a patient who,
because of its relationship to the meaning of the when asked if he understood a question, replied,
utterance but because of an association of sound to “I see something like I might be wrong like, but
Exploring the Variety of Random
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c'est que il luy troublast son laict et que quant eulx deux seroyent
ensemble pour faire leurs besongnes ou parler de conseil que
sadicte nourrice laissast son enfant crier tout par luy a son ayse et
que lors il cheust en quelque lieu et s'affolast par ce que quant on
est en ce cas il n'en chault guieres ne n'en souvient nomplus que
des vieilles matines & quant est de la poursuite que elle en faisoit de
present n'estoit que pour l'interest de son enfant & nompas de
ladicte nourrice. A quoy ledit galant pour ses duplices disoit que de
sadicte nourrice n'avoit cure & quant il vouldroit il trouveroit bien
ailleurs a jouer en concluant comme dessus Finablement les parties
ont esté apointees en droit et au conseil et a la court veu ledit
procés et consideré la court dit que ladicte dame ne fait a recepvoir
a soy complaindre dudit galant & l'a condampnee es despens
 ¶ Le .xxxiii. arrest

En la court de ceans c'est complaint ung vieillart d'une jeune

dame par ce qu'elle ne le vouloit aymer/ disant que il luy a ja donné
plusieurs ceintures & chaperons affin de estre en sa grace/ mais elle
n'en tient compte/ trop bien quant elle veult avoir de luy aucune
chose elle le scet le mieulx entretenir du monde en le baisant et
acolant mais quant vient au fort luy respondit nescio vos en luy
faisant la renchiere/ & brief il ne scet ou il en est car quant il cuide
avoir fait c'est lors que il est a recommencer. et pource requeroit que
veu que il a si grant amour en elle et qu'il l'a servie et encores a
intencion de faire qu'elle fust condampnee a l'aymer et a luy faire
des biens comme dame doit faire a son serviteur/ & de la partie de
ceste dame fut deffendu au contraire & disoit que c'est contre nature
a une jeune femme d'aimer vieillart car ce sont choses contraires
comme blanc et noir & incompatibles comme chault & froit aussi par
ordonnance d'amours que quant ung homme est vieil il est excusé
de servir. disoit qu'elle ne luy sçavoit bien faire il cuide que on doive
tout laisser pour entendre a luy & qu'on le doyve chauffer & froter la
teste pour le endormir qui est chose mal sortyssant a jeune femme
& quant est des dons que ledit vieillart se vantoit luy avoir donné.
Respondit qu'il n'estoit pas vray & que en sa vie ne luy avoit donné
q'une armerie a .xvi. pampes que elle garda & mist en sa quenoulle
pour la paour de luy/ & estoit donc l'accointance bonne. Disoit oultre
que elle aymeroit myeulx estre bruslee que de riens avoir prins de
lui/ car il ne le valoit pas. Et quant est de se aymer il y seroit avant
autant que charlemaigne en espaigne/ & aussi l'avoit elle ja par
plusieurs fois reffusé. Et concluoit affin de non recepvoir allias
soubstenoit son reffus & demandoit les despens A quoy il replicquoit
et si disoit que se elle ne le voulloit aymer pour l'amour de luy/ au
moins pour son argent qu'il fust aymé/ car il lui avoit du tout bouté
son cueur en elle/ mais la dame respondit que pour luy ne feroit rien
et pour son argent encores moins en disant que ledict vieillart avoit
plus grant mestier d'une bouteille et d'une bassinouere pour son lict
eschauffer que de tous les biens d'amours Finablement partyes ont
esté appointees en droict et au conseil. Si a la court veu ledict
procés et tout ce qu'il failloit veoir en ceste matiere : et tout veu dict
que a tort et maulvaise cause ledict vieillart c'est doulu et complaint
de ladite dame et que a bonne et juste cause elle l'a reffusé et le
condempne es despens de la tauxation reservee.
 ¶ Le .xxxiiii. arrest

En la court de ceans c'est assis ung aultre procés entre d'eux

beaux jeunes enfans portans le noir en leurs devises heritiers et
ayant cause d'ung amant trespassé de dueil de sa feue dame
demandeurs en cas d'excés d'une part et la mort deffenderesse audit
cas d'aultre part Et disoyent lesditz demandeurs que ja pieça dame
nature de beaulté pour monstrer l'excellence de leur ouvraige ilz
allerent produirent et formerent ung corps de femme le plus bel
qu'on pourroit guieres choisir dont le deffunct fut serviteur et estoit
ceste femme avecques la beauté qu'elle avoit d'elle & remplie de
toutes les vertus especiales que jamais femme peult avoir c'est
assavoir de doulceur d'honneur de humilité de gratieuseté de beau
maintien et doulx regard tant que nulle ne la passoit Et advint que
pour les grans biens qui estoyent en elle que tout chascun luy
souhaitoit des biens largement ce luy portoit grant honneur mais
ladicte mort qui en eut desplaisance et pour l'oster de ce monde luy
getta son dart et l'occist piteusement de laquelle chose ledict
deffunct son amy et serviteur/ print telle desplaisance en luy qu'il en
cheut mallade au lict : et aprés ce qu'il eut faict son testament ne
demoura gueres qu'il n'allast aprés elle Or disoyent leurs heritiers
que veu que cesditz deux personnaiges estoient en saufconduit
d'amours et en la sauvegarde/ que ladite mort n'y avoit que
congnoistre et/ que par ainsi de les avoir tués elle en estoit tout du
long tenue et estoit le cas digne de reparation/ attendu qu'il y avoyt
eu meurdre et occision qui estoit inreparable et pource concluoient
lesditz heritiers et heritieres a l'encontre d'icelle mort qu'elle fust
condampnee restituer et remettre la vie es corps dudit feu amant et
de sadicte dame qu'elle avoit ainsi tués s'il estoit possible & faire se
pouoit/ et a tout le moins a restablir le corps par figure & a les faire
paindre au vif ainsi et en la maniere qu'ilz estoyent au temps de leur
bonne santé/ affin que leur pourtraicture demourast sur terre & qu'il
fust encore memoire d'eux Et avec ce que iceulx heritiers desditz
deffunctz fussent declairés exemps de ladite mort au moins jusques
a ce qu'ilz fussent aagés que avoit esté abregee la vie desditz
deffunctz leur fut donnee et prolongee de temps de vivre en ce lieu.
Et pour reparacion des excés qui estoyent grans concluoyt en
amendes honnorables et prouffitables a la discretion des gens
d'amours. De la partie de ladicte mort fut tendu affin de non
proceder disant que toutes choses crees sur terre sont en sa
subjection et qu'il n'y a personne tant soit fort qui se puisse
exempter d'elle/ car elle a seigneurie et domination sur toutes
creatures humaines soient hommes ou femmes bestes ou oyseaulx
arbres et raciers voire et telle maniere qu'elle leur peut abreger leur
vie et les prendre sans ce qu'il en soit plus parlé : & de ce qu'elle en
faict soit bien ou mal n'est tenue de respondre que devant le grant
juge et n'y a justice d'amours ne d'aultre ou elle soit subgette et par
ainsi perseveroyt en sa declinatoire & concluoit affin de non
proceder Lesditz heritiers demandeurs disoient au contraire que en
ceste matiere estoit question de sauvegarde et entreprinses faictes/
sur les droitz d'amours/ parquoy la congnoissance en appartient a la
court de ceans et non a aultre : aussi estoit ce court souveraine & y
avoit esté la cause commise de par amours et les lettres expresse au
cas/ sy que n'estoit par ce moyen ledict declinatoire recepvable ains
debvoyt ladicte deffenderesse aultre ou les conclusions requesté par
iceulx demandeurs leur debvoyt estre adjugez. En requerant
l'adjonction des gens d'amours qui de leur costé disoient que c'estoit
mal fait aux advocatz de proposer telles declinatoires contre
l'honneur et prerogatives de la court de ceans ou ilz avoyent esté
nourris car il estoit tout notoire que des abbus et entreprinses faictes
au prejudice d'amours et de ses subjectz la court en devoit
congnoistre disoyent oultres lesdictes gens d'amours que par beaulx
previleges et anciens droitz du demaine/ la mort n'a que congnoistre
sur amant qui sont en la sauvegarde d'amours/ et qu'elle ne les
pouoit prendre ou faire mourir sinon qu'ilz feussent/ ou soyent hors
d'aage/ ou que ilz ayent renoncé a l'amoureuse aliance d'amours : et
sur ce alleguoient plusieurs loix : disoyent aussy que ces
amoureuses n'estoyent exemptees de la mort au moyen desdis
previleges jamais ne se mettroyent au service veu que ilz seroyent
tous les jours en danger de leurs personnes/ & qu'il soit vray que la
mort n'avoit point de congnoyssance sus eulx il en apparoissoit
assez/ & que par experience des amoureux qui montent et devallent
de nuyct du hault de deux ou troys estaiges par une touaille ou
longiere pour entrer en une maison sans eulx blesser ou mal faire
quelconque. pareillement de ceulx qui couchent entre deux goutieres
toute la nuict voire quant il gelle a pierre fendant & si n'ont point de
la couverture ne de froit & aussi de ceulx qui se font avaller par
souspiraulx/ qui endurent aulcunesfoys aux baingz l'eaue si chaulde
qu'ilz sont tous bruslez & si ne sentent point le feu ne la chaleur/
ainçoys par cela guarissent toutes maladies et de tous maulx/ et
toutesfois raison est que la ou il seroit ainsi que la mort eust
puissance sur telz parens il n'en eschapperoit pas ung veu les peines
et tormens qu'ilz seuffrent et les dangers ou ilz se mettent dont
touteffoys l'en ne peult veoir du contraire et que ladicte mort n'a
pouoir ne auctorité sus ceulx qui sont ainsi au service et en la
sauvegarde d'amours/ aultres soyent exemptz d'elle parquoy ne se
pouoit ladicte mort excuser qu'elle ne deust estre contraincte a
proceder en la court de ceans au regard mesmement que les excés
par elle commis avoyent esté faitz en enfraingnant la saulvegarde
d'amours ou lesditz deffunctz amoureux estoyent quant il les laissit
mourir/ mais ladicte mort en perseverant tousjours en sa declinatoire
disoit que la court de ceans ne pouoit estre son juge car elle n'y
estoit subjecte ne obeissante & oultre plus disoit que de avoir prins
et tué lesditz deffunctz n'avoit aulcun exemptz ne sauvegarde
enfraindre parquoy n'en pouoit congnoistre. Et supposé qu'il y eust
excés si n'en pouoyt la matiere estre ceans traitee car elle avoit a
somer ses garans comme fortune & aultres qui n'y respondroyent
pas & au regart ces previleges & exemptions dont les gens d'amours
avoyent parlé respondit ladicte mort qu'elle a previlege sur amours
et par tout et que avant qu'il fust oncques nouvelles d'amours ne
d'amytié elle estoit nee & usant en terre de sa puissance & s'elle
differoit a faire mourir tels jeunes amans qui ainsi se advanturent &
mettent en danger de leurs personnes par leurs folies mondaines/
c'estoit de grace et de permission seulement qu'on ne luy pouoit
retorquer au prejudice/ & voit on tous les jours les plus huppez
passer par la quant il luy plaist. Et si la mort ne les prent pas quant
ilz sont malades Ains laisse faire nature son debvoir/ et attend bien
souvent que telz amans soyent tous secz/ & qu'il leur ennuye d'estre
au monde en la soubhaictant pour les biens d'amours qui leur
deffaillent en concluant comme dessus Surquoy les heritiers d'iceulx
deffunctz demandeurs disoyent que si leur failloit faire ailleurs leur
poursuite ilz seroient destruitz a tousjours et n'auroyent dequoy
fournir Et oultre disoyent que veu l'enormité du cas la court en
debvoit retenir la congnoissance & quant aux gens d'amours ilz
dupplicquoyent et disoient que la mort ne pouoit avoir previlleges
contre ceulx d'amours/ car avant que oncques la mort feust/ estoit
nee amyctié/ et ne fut la mort ordonnee fors que pour appaiser les
debatz de cedit monde/ et oster ceulx qui s'entrehayent qui font les
noyses & que nature ne peult plus soubstenir : Or estoit il ainsi que
ces deux trespassez dont estoit question estoient en la plus grande
amyctié et aliance d'amours qu'il se pouoit faire en sa sauvegarde.
parquoy d'avoir ainsi exploité la mort avoit trop mesprins et excedé/
Et failloit qu'elle en respondist ceans & non ailleurs. Ouyes lesquelles
parties en tout ce qu'elles ont voulu dire et alleguer/ elles ont esté
apointees en droit & a mettre par devers la court et au conseil. Si a
la court finablement veu ledit procés & tout ce qu'il failloit veoir en
ceste matiere a grant et meure deliberation. et tout veu la court dit
que ladicte mort deffenderesse procedera en la court de ceans
nonobstant chose par elle proposee au contraire dont elle deboute et
deffend a tous les advocatz de ladicte court que ilz ne proposent ou
alleguent telles declinatoires sur peine de l'amende.
 ¶ Le .xxxv. arrest

A la requeste du procureur general d'amours une vieille femme a

esté prinse & constituee prisonniere pour raison & a cause de
certaines parolles mal sonnantes qui ont esté dictes et proferees de
sa bouche. Si a depuis esté interroguee sus les charges/ et
informations faictes a l'encontre d'elle sus quoy en effect elle a
deposé et confessé que veritablement en haine et despit de ce
qu'elle ne estoit appellee de aller aux grans chieres comme sont
bancquetz & nopces ainsi que les aultres elle mal meue & de de
felon couraige avoit et a dit que ce n'estoit pas tout acquest d'y
estre & que s'elle estoit homme aussi bien qu'elle estoit femme elle
n'y laisseroit pas de leger aller sa femme ne ses filles avec plusieurs
autres choses au prejudice d'amours/ et de ses droitz declairees a
plain en sa confession qui a esté monstree aux gens d'amours
lesquelz ont par ycelle prins droict et baillé leurs conclusions tendant
affin que ladicte vieille qui avoit parlé contre la souveraineté
d'amours fust pugnie de pugnition corporelle et oblicque pour
monstrer exemple aux autres/ et en ce faisant qu'elle eust la langue
couppee ou que on luy plantast ung fer chault et ardant au visage.
Et aussi qu'elle feust bannye a tousjours hors du royaulme d'amours
et ses biens declarez confisquez. A l'encontre desquelles conclusions
ladicte vieille deffenderesse pour la diminution de la paine/ disoit
que l'en ne doit pas de si pres prendre garde aux parolles des
femmes Car souvent parlent de legier et contre elles mesmes/ mais
entant qu'il luy touchoit elle sçavoit bien voirement que elle avoit
failly/ et mal parlé. Mais la court devoit avoir regard a ce que se
avoit esté par chaulde colle & sans y penser et aussi par la
desplaisance de ce que n'en ne tenoit compte d'elle et qu'on ne
daignoit la mander ausdictes festes & bancquetz. Si a la court veues
les charges et informations/ la confession de ladicte deffenderesse/
les conclusions des gens d'amours/ et les deffences baillees au
contraire & tout ce que il failloit veoir en ceste matiere a grande &
meure deliberation. Et tout veu et consideré ce qu'il failloit a
considerer. Ladicte court condampne ycelle vieille deffenderesse pour
les excés et delictz par elle commys alentour l'escripteau qui
s'ensuyt.

En ma vie je ne fuz meurdriere

Ne larronnesse : ne coustumiere
De amans blecer & ravaler
Mais affin que mon cas declaire.
J'ay eu la bouche trop legiere.
Gardez voz langues de parler.
 ¶ Le .xxxvi. arrest.

En la court de ceans c'est assis ung aultre procés entre les

heritiers de une dame naguere trespassee demandeurs d'une part et
les official vicaire et prometeur d'amours deffendeur d'aultre. Et
disoyent lesditz demandeurs que la deffuncte estoit en son temps
bien gente & gaillarde/ sage et sçavante et soubz laquelle s'elle eust
vescu plusieurs vaillans cueurs amoureux eussent peu apprendre du
bien Or estoit vray qu'elle qui estoit de noble couraige voulloit bien
adviser tousjours en son faict. et fust en nopces ou en aultre festes
et gardoit bien qu'on ne se moquast de chose qu'elle fist mais il
advint que ung jeune gallant mal habillé & ressemblant a ung varlet
dimencheret qu'elle encores ne congnoissoit la vint prier de dancer
et pource qu'il n'estoit pas lors en point et aussi que son costé estoit
lasse et n'en faisoit que venir elle l'esconduit bien gracieusement
disant qu'elle ne voulloyt plus dancer dont il se deporta & s'en alla
sans dire a dieu Mais encore il ne fut pas content de cela ainçoys
quant vint de rechef a dancer au chapelet ledit gallant se mist a
dancer et aprés ce qu'il eut le chapellet a son tour il le vint presenter
a elle laquelle le receut mais quant vint ledit galant tendoit la bouche
pour la baiser/ elle se torna la teste de l'autre costé en le reffusant
tout court dont il conceut hayne et malveillance mortelle contre
ladicte deffuncte Pour laquelle mettre a execution il la fist citer
devant ledit official d'amours par devant lequel elle voyant qu'il
n'estoit point son juge ne capable de congnoistre de la matiere ne
comparut point Si fut mise en coustumace. au moyen de laquelle elle
fut ainsi que l'en veult dire excommuniee & depuis est advenu
qu'elle est encheute en aucune maladie de fievres qui l'en ont
emportee/ et a finé ses jours bien honnorablement et faict son
testament et toutes aultres choses que bonne et tres loyalle dame
doit faire. Mais avant est venu a l'encontre ledict official vicaire et
prometeur soubz umbre de ce que il vouloit dire qu'elle estoit
excommuniee pour raison de ce que dit est : ilz n'ont voulu donner
congé ne licence de l'enterrer ou elle avoyt ordonné : mais l'ont faict
porter aux champs et enterrer en une grande piece de terre toute
pleine d'orties et de chardons : laquelle chose redonde au vitupere
et honneur de tous les parens et amys de ladicte deffuncte qui sont
gens de bien et des plus notables : par quoy l'excés en estoit plus
grant Et par ses moyens concluoient lesditz heritiers demandeurs a
l'encontre desditz official vicaire et prometeur d'amours. Et
pareillement aussi contre le galant qui avoit faict citer icelle
deffuncte qu'ilz et chascun d'eulx fussent condempnez et contrains a
revocquer casser et adnuller lesditz citacion sentence et
excommuniement donné contre ladicte deffuncte par prinses de
leurs personnes et du temporel desditz official et promoteur de
l'eglise et a publier devant ung chascun que a tort et sans cause
icelle deffuncte avoit esté citee et excommuniee Et avec ce ilz
fussent condampnez a la faire deterrer et apporter son corps et ses
os en ung des cimetieres d'amours et contrains a estre tous au
convoy du corps affin de reparer et restituer le deshonneur qu'ilz luy
avoient fait. Et semblablement que ung chascun d'eulx fust
condampné a une bonne amende proffitable. A ces fins offroyent a
prouver et demandoient despens dommaiges & interestz a
l'adjonction des gens d'amours De la partie desdictz official vicaire
prometeur et gallant fut deffendu au contraire : et disoient qu'il
estoyt permis de citer et excommunier tous ceulx & celles qui
detiennent des biens d'amours ou qui injurent et se mocquent de
ceux qui sont en la poursuite : et dont la congnoissance et pugnition
en appartenoit audit official Or estoit vray que ladicte deffuncte avoit
reffusé detenu et occuppé le bien qui estoyt deu a ce gallant icy/ et
encores l'avoit farcé et mocqué/ parquoy il c'estoit rendu plaintif
d'elle & l'avoit fait citer a certain jour auquel elle se reputant
coulpable du cas et mesprisant la court n'avoit daigné venir ne
comparer. Mais c'estoit laissee mettre en coustumace et
excommuniement qui fut publié. Or est advenu voirement qu'elle est
trespassee sans soy faire absouldre : parquoy l'en l'avoit faicte
enterrer ou elle devoit Et a ceste cause apparoissoit clerement que
l'en n'y pouoit avoir aulcun mal ne excés et au regard de la
deffuncte/ posé qu'elle eust bonne cause d'avoir reffusé le galant
touteffoys elle devoit venir declairer ou en faire proposer au jour
qu'elle fut citee sa declinatoire sans soy laisser mettre en
coustumace et sentence d'excommuniement qui donnee estoit
justement Et quant est de l'enterrement par consequent il avoit esté
fait ainsi que faire ce devoit Et aussi se les sentences ne sortissoient
en effect/ l'en ne tiendroit plus compte de justice ne de faire mal. Et
a ce que les heritiers disoient que la deffuncte n'estoit subgette a la
court dudit official : respondoyent que ouy/ car aussy le jeune galant
estoyt clerc non marié/ lequel entant qu'il touchoit sa personne disoit
que la deffuncte ne devoit point estre desheritee et mise en aultre
lieu qu'elle estoyt car pour le reffus qu'elle luy fist il avoit esté en
danger de mort de la paine et de la honte qu'il en eut devant tant de
gens. Et s'elle eust voulu dancer ung tour avec luy il n'en eust jamais
parlé. Et quant est de ce que les demandeurs ont fait dire qu'elle ne
le congnoissoyt et qu'il estoit habillé en varlet dimencheret c'estoit
mal dit a eulx car il la valoit bien ou myeulx et le congnoissoit assez
bien. Mais elle estoit tant fiere & orgueilleuse qu'elle fist semblant de
ne l'avoir jamais veu. Et le reffus qu'elle luy fist ne vint que par
presumption et oultrecuydance qui la conduisoit Et concluoient en
effect lesditz deffendeurs affin d'absolution & despens. Et au regard
des gens d'amours ilz disoient que entant qu'il touchoit le droict des
deux parties. C'est assavoir se la deffuncte avoit eu juste cause de le
refuser ou non/ ilz n'en pouoient rien dire pour le present/ Car ilz
n'avoyent veu les informacions. Aussi n'en estoit de present question
entant que touchoit la citacion/ procés et excommuniement faictz
par ledit official d'amours tout devoyt estre dict et desclairé nul et de
nul effect. Lesdictz deffendeurs grandement abbusans car du faict
du chappellet ne de quelconque aultre dance n'en appartenoit la
congnoissance que a la justice seculiere d'amours trop bien des
promesses secretes qui se font en dançant peuent bien congnoistre
de ce cas icy non Et pource c'estoit une vraye entreprinse contre la
justice laye qui se devoit reparer par une tresgrande et merveilleuse
punition/ car combien que lesdiz official vicaire et prometeur
sceussent bien qu'ilz ne pouoient sçavoir ne avoir la congnoissance
de ceste matiere et que la citacion et sentence d'excommuniement
ne se peult bonement soubstenir/ neantmoins comme obstinez en
leur maulvaise voulenté l'ont voulu faire sortir en effect en
contraingnant ceste povre femme que Dieu absolve a estre au
moyen de ce enterree et en terre prophanee qui a esté certainement
tresmal faict a eulx. Et pource concluoient lesdites gens d'amours/
que tout ce qui par eulx avoyt esté faict fust declairé nul et de nulle
valeur comme faict en abusant et entreprenant sur la justice et
juridition laye. Et avecques ce que ledit official prometeur et officiers
et aussi que lesditz amoureux fussent condempnés a reparer lesdictz
excés & en ce faisant qu'ilz fussent contrainctz de desterrer eulx
mesmes ladicte deffuncte et la porter en ung cercueil devant tout le
monde jusques au cymettiere d'amours et qu'elle ordonne a estre
enterree/ Et pareillement de assister et estre presens tous tout du
long du servyce qu'on fera a celle deffuncte. Et en oultre que ilz
fussent condampnés a publier ou faire publyer/ par le crieur qui yra
devant le corps a toute sa sonnecte que la deffuncte avoyt esté
injustement excommuniee. A quoy lesdictz deffendeurs disoient que
de prendre les conclusions contre eulx lesdictes gens d'amours
n'estoient pas recepvables/ car ce que ilz avoyent faict avoyt esté en
excersant la jusridicion espirituelle d'amours. Et quelque chose qu'il
leur pleust a dire/ la congnoyssance du faict du chappellet leur
appartenoyt et ainsi en avoient congneu & usé Et quant a la
deffuncte elle fut cause dudict excommuniement entant qu'elle ne
vouloit comparer Au regard de l'absolucion ilz ne l'eussent peu bailler
sans le vouloir de partie qui n'y consentit oncques/ et ainsi estoyent
lesditz deffendeurs en voye d'absolucion/ mais les gens d'amours
disoyent au contraire qu'ilz ne pouoient toucher au fait dudit
chappellet non plus que au feu. Et s'ilz en ont congneu au temps
passé ce a esté par entreprise et en abusant. Et aussi disoyent les
heritiers d'icelle deffuncte que veu que ledit official n'estoit point
juge d'elle/ elle n'y debvoyt comparoir ne envoyer. et au regard des
charges que ledict galant bailloit a ladicte feu dame ne pouoit estre
plus humble et gracieuse qu'elle estoit comme l'en pourroit sçavoir
par tous ceulx qui l'avoyent hantee. Et aussi n'y avoit point
d'apparence de aller baiser ung homme a la vollee sans le
congnoistre/ et qui estoit habillé comme ung vielleux en concluant
comme dessus. Ouyes lesquelles parties en tout ce qu'elles ont
voullu dire et alleguer elles ont esté appointees en droict. Si a la
court veu et visité ledict procés et tout veu/ et consideré ce que il
failloyt considerer/ ladicte court condampne ledict official vicaire et
prometeur d'amours et aussi ledict amoureux et chascun de eulx
entant qu'il luy touche a revocquer/ casser/ et adnuller lesdictes
citations excommuniemens procés et procedures faictes par devant
ledict official et a mettre au neant a leurs propres coustz/ et
despens. Et avecques ce je condampne tous ensemble a deterrer et
oster/ ou faire deterrer et oster ladicte deffuncte du lieu la ou elle
est pour porter & enterrer au cymetiere d'amours dedans ung beau
carreau de girofflee/ & au lieu ou elle a esleu sa sepulture par son
testament. Et si les condampne en oultre a aller tous au pres du
corps jusques en l'esglise/ et y estre tout du long du service de
ladicte deffuncte. et deffend ladicte court audit official que
desormais de telle matiere qui touche ledict chappellet ne les
despendences il n'entrepreigne congnoissance sur peine d'amende
arbitraire.
 ¶ Le .xxxvii. arrest.

En la court de ceans c'est assis ung aultre procés entre une

gracieuse dame demanderesse d'une part et les religieux cordeliers
de l'observance d'amours deffendeurs d'autre part. et disoit ladicte
dame que ja pyeça elle eust grande acointance de familiarité
singuliere avec ung jeune religieux nouvellement rendu de l'ordre &
tellement qu'ilz se donnerent l'ung a l'autre & promisrent ne separer
l'alliance d'entre eulx d'eux pour quelque temps ou fortune qui leur
peust advenir. et sur ces choses y eut encores veuz fais en amours
confermatoires d'ycelle aliance tant et si avant que faire se pourroit
en tel cas mais ce nonobstant ledit amoureux cordelier et pour une
petite fumee ou quelque desplaisance qu'il a eue/ puis n'a guieres de
temps en ça s'en est de son auctorité et sans le consentement ne
prendre congié de sadicte dame aller bouter et rendre en ladicte
religion ce qu'il ne pouoit ne debvoit faire/ ainçoys venoit
directement encontre son premier veu et serment. Et pource que
ceste dame se sentoit tenue quant a l'ame de le declairer une foys/
et qu'elle avoit tresgrant interest d'avoir quitance & renonciation de
sa promesse pour se pourveoir ailleurs en lieu de luy d'ung aultre
amant et serviteurs elle concluoit et requeroit que lesditz religieux
cordeliers fussent condampnez a faire exhibition audit amoureux
rendu cordelier & de le amener en justice pour le contraindre et
entretenir a ses premiers veuz et promesses ou y renoncer/ et la
quitter au regard d'elle ne voulloit pas empescher le sauvement de
son ame et qu'il ne demourast religieux de l'ordre s'il en avoit la
voulenté. De la partie desdictz religieux de l'observance si fut
deffendu au contraire et disoyent que la demande que faisoyt la
dame n'estoit pas recepvable car l'amant religieux rendu cordelier
dont estoit question estoit ja cordelier vestu/ et avoit fait les veuz de
l'observance d'amours par les trois Esquelz veuz d'ycelle observance
il est deffendu expressement de ne parler jamais a femme/ parquoy
donc de le voulloir contraindre maintenant a le veoir & parler a elle
dessoubz umbre de renonciation n'y avoit apparence et estoit trop
tard de venir aprés ladicte reduction ramentevoir Et mettre en lieu
de present lesdictes aliances promesses et follyes du temps passé.
Disoient oultre lesditz religieux que quant ledit amant fut rendu &
vestu de l'habit de l'ordre/ ladicte dame deffenderesse y estoit
presente & luy veit faire les veuz pourquoy lors debvoit declairez
lesdictes promesses et se opposer pour le droyct que elle veult
deduire Et sembloyt soubz correction que c'est grant abbus a elle de
venir maintenant par telz moyens pour troubler ledict religieux rendu
et le mettre es choses mondaines qu'il a ja oubliees Si disoyent par
ces moyens lesditz religieux qu'ilz n'estoyent tenus de exiber ledict
cordelier/ et pour chose que on peust faire jamais ne partiroit de
ladicte religion. A quoy ladicte dame pour ses replicques disoit/ que
elle ne voulloit pas le retraire hors de religion ne de le mouvoir de
son entreprinse/ mais requeroit seulement pour sa descharge que il
renonçast a sa promesse qu'il luy avoit faicte/ et tout ce qui avoit
esté faict/ et dict entre eulx deux feust declairé nul et comme non
advenu Et disoit oultre ladite dame que cela se debvoit faire avant
toute oeuvre/ car elle voulloyt obvier au dangier d'amours qui s'en
pouoit ensuivir/ elle vouloit avoir enseignement de la renonciation
desdictz promesses et pour monstrer qu'elle aymoit entretenir sa foy
mieulx que luy affin qu'on ne luy en peust reproucher riens. Et au
regard de ce que lesdis cordeliers disoient que icelle dame estoit
presente quant ledit nouveau cordelier fut rendu & qu'elle luy vit
faire les veux respondit qu'il estoit bien vray qu'elle y fut avecques
ses autres cousines & parentes/ Mais a la verité quant elle veit qu'on
le deshabilloit tout nud pour le vestir en cordelier les lermes luy
vindrent aux yeulx a si grant affluence qu'elle ne sceut qu'elle devint
& luy commença a soubzlever le cueur par telle façon que elle
s'esvanouyt en plain chappitre et ne luy souvenoit alors d'aliance ne
de promesse/ car il n'est au monde si grant douleur a femme que de
veoir son amy rendu en religion. parquoy fault la excuser Et quant
elle n'eust point esté troublee si n'eust elle pour rien entreprins
d'aller desclairer devant tout le monde qui ne se pouoit rendre pour
blasme et deshonneur qu'il en eust peu avoir. Et a ce que lesditz
deffendeurs disoient en oultre que pour rien ne le laisseroient partir
de religion respondit ladicte demanderesse que par force ilz
devoyent estre contrains/ et que au regard d'elle elle avoyt contenné
de ne parler point a luy sinon en la presence de deux ou trois
religieux telz qu'on vouldroit amener/ mais il estoit force que a la
quitance & renonciation desditz promesse ce fist en jugement/ car il
y avoit lettres signees de leur main de l'ung et de l'autre qu'il
convenoit rompre et casser devant la justice d'amours en concluant
au surplus comme dessus Mais lesditz cordeliers deffendeurs
perseverant tousjours en ce qu'ilz avoient proposé disoient que ce
n'estoit pas raison que ledict amant rendu cordelier vint en jugement
ne qu'il vist plus ladicte dame. Primo car se seroit contre son veu
qu'il a faict de ne partir jamais de la religion sans licence du general
Secundo : car par la reigle de l'observance d'amours telle comme
chascun scet ceulx qui y sont rendus jamais n'en peuent saillir sinon
que le feu les contraingne a ce faire & sont reputez mors au monde/
ne n'y a nul qui en puisse partir dehors excepté ceulx qui sont
deputez a leur tour pour aller querir la pitance & la pourveance du
couvent Et pource de requerir maintenant par ladite dame que ce
jeune cordelier qui a renoncé aux joyes et a la pompe du monde et
qu'il voyt ce quel a cuidé faire perdre a tousjours il n'y avoit nulle
apparence et posé que icelle demanderesse fust troublee quant elle
le veit ainsi vestir et entrer en la religion touteffoys cela ne la pouoyt
pas excuser du tout/ car entre le temps qui vint premierement
d'amours en la religion & celluy de la redicion elle avoit eu bon loysir
de soy venir opposer et remonstrer lesdites aliances et promesses.
Ouyes les parties en tout ce qu'ilz ont voullu dire et alleguer elles ont
esté appointees a mettre par devers la court et au conseil. Si a la
court veu ledict procés et a grant et meure deliberation avec tout ce
qu'il failloit veoir en ceste matiere. Et tout veu la court dit que non
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