Descriptive Psychopathology: The Signs and Symptoms of ...

262 Section 3: Examination domainsPhonemes are assessed for their specific features:Clarity: “Do you hear whispers or muffled voices as if they are coming fromanother room? Can you hear them as clearly as you hear my voice now?”Perceived source: “Where does the voice come from?”Constancy: “Do you hear only a few words here and there, or is the voiceconstantly bothering you?”Pattern and frequency: “Is there a particular time of the day when the voicesare at their worst? Do you only hear them after something else happens?Do you hear them all day long? Do you hear them every day? Are you hearingthem now?”Musical hallucinationsMusical hallucinations are experienced as vivid familiar tunes, instruments andlyrics. The most common cause is acquired deafness. 39 Other causes includestroke, epilepsy and neoplasm. When associated with seizure disorder, musicalhallucinations have an experiential element not reported in deaf patients (i.e.a sense of remembering the hearing of the music in a particular setting as wellas hearing the sounds). 40 They are uncommon in degenerative brain disease.Temporal lobe and brain stem lesions are the commonest associations. 41 Lesionsin both cerebral hemispheres are reported, but most commonly on the right. 42Musical hallucinations are also reported in patients with depressive illness,obsessive–compulsive disorder, alcoholism, and schizophrenia. Commonest amongpatients with OCD, it is unclear whether the experience is a true hallucinationor vivid mental activity as lyrics are experienced more so than musical sounds. 43Affected patient are typically middle-aged or older. In one large series, most werewomen. 44First rank symptoms (FRS)Kurt Schneider catalogued symptoms he believed pathognomonic of schizophreniain the absence of evidence of coarse neurologic disease. 45 The DSM permitsthe diagnosis of schizophrenia with the presence of one of these phenomena andno other features if there is also a decline in daily functioning.FRS occur in patients with manic-depressive illness, delirium or intoxication,dementia, seizure disorder, and stroke. They are not exclusive to schizophrenia. 46Delusions in this category are covered in Chapter 11.Complete auditory hallucinationsSustained hallucinated voices, clearly heard and perceived as originating outsidethe patient’s sense of self, are the most common FRS. They are the classic phoneme.