Descriptive Psychopathology: The Signs and Symptoms of ...

263 Chapter 10: Perceptual disturbancesSecondary delusional ideas that “explain” or elaborate upon the hallucination arecommon.Voices commenting and conversing are given separate status in some classifications,but the distinction is in content, not form, and of little clinical significance. Phonemesconstantly heard, comment on the patient’s actions, feelings, thoughts, and experiences.Sometimes two or more voices converse about the patient. Typically, thevoice or voices are hostile, commanding acts of violence or self-harm. The numberof voices, their gender and identity have no diagnostic implications, other than themore like a memory the experience seems, the more likely it represents temporal–limbic disease.Thought echo (écho de la pensée)Thought echo is the experience of hearing one’s thoughts repeated aloud bysome outside source, as if an echo. A variation is the experience of hearing voicesthat are saying what the patient is about to think or say (Gedankenlautwerden).Thought echo is typically revealed by the patient’s delusional statements such as“Everyone knows what I’m thinking.” The examiner’s response to such a statementand other delusional statements is always “How do you know that?” Thequestion can be “sugar-coated” by sympathetic comments such as “That must beupsetting.”The details of the experience are ascertained by questions such as: “Do youmean that you hear your thoughts repeated aloud to you as if listening to a radio?If I were standing next to you, could I also hear them?”Some patients are very specific: “I have the feeling, as if someone beside mesaid out loud what I think . . . As soon as the thought is in my head, they know ittoo . . . When I think anything I hear it immediately ...everyonecanreadmythoughts . . . When [I] read the newspapers, others hear it.” 47Further examination techniquesPatients who experience perceptual disturbances may not report the experiencesfor fear of being labeled “crazy”. The examination for these features is facilitatedby framing questions within the context of other symptoms. For example:“When people are as depressed as you are, they sometimes experience odd or disturbing things.Does that happen to you? Do you ever hear other people talking about you?”“Depression often makes the world seem different. Have you noticed anything like that . . .Does food taste odd ...doyousmell disturbing odors . . . do people look at you in oddways . . .?”Once the perceptual disturbance is identified, its contextual “story” is delineated.Frequency, fluctuations in intensity, triggers, and the pattern of the experience are