Descriptive psychopathology is the systematic description and classification of abnormal mental experiences as they are reported by the patient and observed by the clinician. It underpins the mental state examination and is tested in both Paper A (as foundational knowledge) and Paper B (as applied clinical skill). The SPMM syllabus section 5.22 covers this material in depth, and the exam rewards precise use of psychopathological terminology.
Disorders of Mood and Affect
Mood refers to a pervasive, sustained emotional state (the “climate” of the mind). Affect refers to the moment-to-moment expression of emotion (the “weather”). Both have subjective (patient’s report) and objective (clinician’s observation) components. Key aspects of affect: valence (quality: happy, sad, anxious, perplexed), reactivity (responsiveness to environmental cues), range (restricted or constricted in depression), congruence (matching between expressed affect and reported emotion), stability (absence of emotional lability), and control (emotional incontinence in organic states).
Blunted affect: Reduced intensity of emotional expression. Bleuler proposed this as a fundamental (primary) symptom of schizophrenia. Flat affect: Near-absence of any emotional expression. Labile affect: Rapid, abrupt changes in emotion, seen in histrionic PD, BPD, and PTSD. Emotional incontinence: Extreme lability with no control, seen in organic states (pseudobulbar palsy, frontal lobe damage). Incongruent affect: Affect that does not match the expressed emotion or situation (e.g., laughing while describing distressing events, seen in hebephrenic schizophrenia and learning disability).
Mixed affective states are common in bipolar disorder and are tested in the exam. A mixed state involves different combinations of mood, thought, and will components: manic stupor (high mood, low will, low thought), depressive mania (low mood, high will, high thought), and inhibited mania (high mood, low will, high thought).
Disorders of Perception
Hallucinations: Perceptions without an external stimulus, occurring in any sensory modality. True hallucinations have the full quality of a genuine perception (vivid, real, located in objective space). Pseudohallucinations: Perceptions without external stimulus that are less vivid, occur in subjective inner space (inside the head), and are often recognised as not real by the patient. The distinction is debated but tested: pseudohallucinations are more commonly associated with non-psychotic conditions (personality disorder, PTSD).
Illusions: Misinterpretations of a real external stimulus (e.g., seeing a shadow as a person). Distinguish from hallucinations (no stimulus) and delusions (false belief, not perceptual).
Auditory hallucinations: Second-person (addressing the patient directly, “you are stupid”) vs third-person (voices discussing the patient, “she deserves it”). Schneider’s first-rank symptoms: voices commenting, voices discussing, thought echo. Musical hallucinations occur in hearing impairment (Charles Bonnet syndrome, though Charles Bonnet syndrome classically involves visual hallucinations in the context of reduced eyesight).
Visual hallucinations: Formed (faces, people, animals) vs unformed (flashes, colours, patterns). Well-formed visual hallucinations with preserved insight suggest Charles Bonnet syndrome. Vivid, detailed, and accompanied by fluctuating cognition suggest DLB. Peduncular hallucinosis (Lhermitte syndrome) describes tiny figures (Lilliputian hallucinations) from midbrain lesions.
Functional hallucinations: A stimulus in one modality triggers a hallucination in the same modality (e.g., hearing voices triggered by the sound of running water). Reflex hallucinations: A stimulus in one modality triggers a hallucination in a different modality (e.g., seeing a face triggered by hearing a voice). These are rare but tested.
Extracampine hallucinations: Hallucinations occurring outside the sensory field (e.g., seeing someone who is behind the patient). Hypnagogic and hypnopompic: Hallucinations occurring while falling asleep (hypnagogic) or waking up (hypnopompic). These are normal experiences but also occur in narcolepsy.
Disorders of Thought
Thought form (stream of thought): The rate and rhythm of thinking. Disorders include: pressure (racing thoughts, flight of ideas in mania), poverty (reduced quantity in depression or schizophrenia), retardation (slow thinking in depression), circumstantiality (unnecessary detail, but eventually reaches the goal), tangentiality (never reaches the goal, veers off), perseveration (persistent repetition of words or themes), thought blocking (sudden interruption of the train of thought, characteristic of schizophrenia), and derailment (loose associations, illogical connections, characteristic of schizophrenia).
Thought content: Overvalued ideas (reasonable but preoccupying beliefs held with less than delusional conviction, e.g., health anxiety), obsessions (recurrent, intrusive thoughts, images or impulses that the person recognises as their own and tries to resist), compulsions (repetitive behaviours performed in response to an obsession), delusions (fixed, false, culturally inappropriate beliefs held with complete conviction).
Delusions: Classified by content: persecutory (most common), grandiose, referential, erotomanic (De Clerambault syndrome: belief that someone, usually of higher status, is in love with the patient), nihilistic (Cotard syndrome: belief that one is dead or does not exist), somatic (hypochondriacal delusions, Ekbom syndrome: delusional parasitosis), jealousy (Othello syndrome: belief that partner is unfaithful). Schneider distinguished primary delusions (true delusions, not psychologically understandable, arising de novo) from secondary delusions (delusion-like ideas that are psychologically understandable given the patient’s mood or life experience). Jaspers’ criteria: true delusions are held with absolute certainty, are not amenable to reason, and are impossible in content.
Delusional perception: A Schneiderian first-rank symptom. A normal perception is suddenly invested with a new, delusional meaning (“The traffic light turned red, which means the Mafia are controlling my thoughts”). This is distinct from a delusional idea (a belief that arises independently of a perception).
Disorders of Speech
Pressure of speech (rapid, abundant speech in mania), poverty of speech (reduced quantity in depression/schizophrenia), mutism (no speech, seen in catatonia, elective mutism), neologisms (new words created by the patient), word salad (incomprehensible jumble), clanging (speech driven by sound rather than meaning, e.g., rhyming), echolalia (pathological repetition of others’ words), palilalia (repeating own words), and schizophasia (severe thought disorder). Dysphasias: Broca’s (non-fluent, effortful, preserved comprehension), Wernicke’s (fluent but meaningless, impaired comprehension), conduction (fluent, good comprehension, poor repetition), anomic (word-finding difficulty, fluent with circumlocution), transcortical motor (similar to Broca’s but repetition preserved), transcortical sensory (similar to Wernicke’s but repetition preserved), and global (all aspects severely impaired).
Disorders of Experience of Self
Depersonalisation (feeling detached from one’s own mental processes or body), derealisation (feeling detached from one’s surroundings, the world feels unreal), and passivity phenomena (Schneiderian first-rank: the experience that one’s impulses, feelings, volitions, or bodily movements are controlled by an external force). Made impulses (actions imposed by external force), made volitions (acts of will replaced by external control), made affects (emotions imposed from outside), passivity of bodily function (bodily sensations imposed externally). These are pathognomonic for schizophrenia.
Memory Disorders
Amnesia (loss of memory): anterograde (difficulty forming new memories, hippocampal damage), retrograde (difficulty recalling past memories), transient global amnesia (temporary, affects both old and new memory, normal cognition otherwise). Paramnesias: delusional memory (false memory held with delusional conviction), confabulation (filling memory gaps with invented material, no intention to deceive, characteristic of Korsakoff syndrome), jamais vu (feeling of unfamiliarity with a familiar situation), deja vu (feeling of familiarity with a new situation).
Insight and Judgement
Insight is the patient’s awareness and understanding of their mental condition. The standard grading: complete denial of illness (Grade 1), slight awareness of being different/blaming external factors (Grade 2), awareness but blames organic causes (Grade 3), intellectual insight (acknowledges illness but does not apply the knowledge to modify behaviour, Grade 4), true emotional insight (awareness that leads to change in behaviour and feelings, Grade 5).
High-Yield Exam Patterns
- First-rank symptoms of schizophrenia (Schneider): Voices commenting, voices discussing, thought echo, thought insertion/withdrawal/broadcast, passivity phenomena (made impulses, volitions, affects), delusional perception
- Fundamental vs accessory symptoms (Bleuler): Four A’s (loose Associations, Autism, Ambivalence, Affective blunting) = fundamental. Hallucinations, delusions, catatonia = accessory.
- Verstehen vs erklären (Jaspers): True delusions cannot be understood (erklären, causal explanation only). Secondary delusions can be understood (verstehen, meaningful connections).
- Cotard: Nihilistic delusion (dead, organs missing)
- De Clerambault: Erotomania (someone of higher status loves the patient)
- Othello syndrome: Delusional jealousy
- Cappras syndrome: Delusion that familiar people have been replaced by imposters
- Fregoli delusion: Strangers are familiar people in disguise
- Charles Bonnet: Visual hallucinations with preserved insight, reduced eyesight
- Lhermitte / peduncular hallucinosis: Lilliputian hallucinations, midbrain lesion
- Ganser syndrome: Approximate answers (“2+2=5”), often in prisoners
- Kluver-Bucy: Bilateral temporal damage, hypersexuality, hyperorality
- Ekbom: Delusional parasitosis (also: restless legs)
PsychStar’s Paper A question bank covers descriptive psychopathology with questions calibrated to SPMM exam depth. Start with 5 free questions at psychstar.io/try.