Descriptive Psychopathology: The Signs and Symptoms of ...

276 Section 3: Examination domains“Have you noticed anything unusual/unsettling/frightening about your neighborhood . . .your neighbors . . . the physical appearances of your family members? Does everythingand everybody look and sound the same to you? When you look in a mirror, do you lookand sound the same as always?”(2) Is the patient in a sustained and intense abnormal emotional state thatexplains his beliefs? The examination of emotions guides this aspect of thedelusional process.(3) Have the patient’s self-monitoring and other executive functions been compromised?Queries about the patient’s recognition of symptoms and illness(i.e. does the patient exhibit denial of illness, anosagnosia), and self-assessmentof his performance on motor and cognitive tasks are considered.(4) Does the patient have a primary problem in thinking or memory that accountsfor his false ideas? Cognitive assessment addresses this concern and is discussedin Chapter 13.Forms of delusionsDelusions that derive from an abnormal emotional state or that are based onperceptual aberrations are characterized as secondary delusions. Delusionsemerging de novo from arbitrary conclusions or that are suddenly fully formedare characterized as “primary”. Primary delusions were thought associated withschizophrenia while secondary delusions were considered associated with manicdepression.The DSM employs this old viewpoint by defining schizophrenia with“bizarre” delusions that are primary in their form. Both primary and secondarydelusions, however, occur in many of the same conditions.Present classification also defines delusions by their content. However, becauseboth primary and secondary delusions derive from faulty thinking and inadequateself-assessment, differing content is of less diagnostic significance than thefact that the patient is delusional. Nevertheless, delusions of illness (hypochondriacaldelusions), poverty, sin, and nihilism (termed Cotard syndrome) areassociated with melancholia. 15 Delusions of grandeur, great wealth, power, statusor ability suggest mania. 16 Delusional jealousy (Othello syndrome) is seen indementing conditions and seizure disorder. 17 Delusions of familiar persons beingimpostors (Capgras syndrome) or that one has a double (Doppelgänger) suggest adefinable neurologic process. Delusions that unfamiliar persons are celebrities orpersons from the patient’s life (Fregoli syndrome) also suggest a definable neurologicprocess. 18 Patient 1.4, the woman with a right-sided stroke, believed herdaughter looked and acted differently and was an alien. She had Capgras syndrome.19 A man with vascular dementia and depressive illness with Capgras