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RCPSYCH Royal College of Psychiatrists

FEFTH

Fish's ED1TION

Clinical
Psychopathology
SIGNS AND SYMPTOIVIS IN PSYCHIATRY
Patricia Casey
B ren dan Kelly
CAMUMUUt McrfiCinc
 Fish’s Clinical
Psychopathology

Published online by Cambridge University Press

 Fish’s Clinical
Psychopathology
Signs and Symptoms in Psychiatry
Patricia Casey
University College Dublin

Brendan Kelly
Trinity College Dublin

Published online by Cambridge University Press

 Shaftesbury Road, Cambridge CB2 8EA, United Kingdom
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Cambridge University Press is part of Cambridge University Press & Assessment,

a department of the University of Cambridge.
We share the University’s mission to contribute to society through the pursuit of education,
learning and research at the highest international levels of excellence.

www.cambridge.org
Information on this title: www.cambridge.org/9781009372695
DOI: 10.1017/9781009372688
© The Royal College of Psychiatrists 2024
This publication is in copyright. Subject to statutory exception and to the provisions
of relevant collective licensing agreements, no reproduction of any part may take place without
the written permission of Cambridge University Press & Assessment.
First published 1967, John Wright & Sons Ltd.
Revised edition 1974, John Wright & Sons Ltd.
Second edition 1985, John Wright & Sons Ltd.
Third edition 2007, The Royal College of Psychiatrists
Fourth edition published by Cambridge University Press 2019
This fifth edition published by Cambridge University Press 2024
Printed in the United Kingdom by CPI Group Ltd, Croydon CR0 4YY
A catalogue record for this publication is available from the British Library
Library of Congress Cataloging-in-Publication Data
Names: Fish, F. J. (Frank James) author. | Casey, Patricia R., author. |
Kelly, Brendan (Brendan D.) author.
Title: Fish’s clinical psychopathology : signs and symptoms in psychiatry /
Patricia Casey, University College Dublin, Brendan Kelly, Trinity
College, Dublin.
Other titles: Clinical psychopathology
Description: 5 edition. | New York, NY : Cambridge University Press, 2023.
| Revised edition of Fish’s clinical psychopathology, 2019. | Includes
bibliographical references and index.
Identifiers: LCCN 2023029666 | ISBN 9781009372695 (paperback) | ISBN
9781009372688 (ebook)
Subjects: LCSH: Psychology, Pathological.
Classification: LCC RC454 .F57 2023 | DDC 616.89–dc23/eng/20230724
LC record available at https://lccn.loc.gov/2023029666
ISBN 978-1-009-37269-5 Paperback
Cambridge University Press & Assessment 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 book to provide accurate and up-to-date
information that is in accord with accepted standards and practice at the time of publication.
Although case histories are drawn from actual 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 from
the use of material contained in this book. Readers are strongly advised to pay careful attention to
information provided by the manufacturer of any drugs or equipment that they plan to use.

Published online by Cambridge University Press

 Contents
Preface vii

1 Classification of Psychiatric 7 Disorders of the Experience of

Disorders 1 Self 80
2 What Is Psychopathology? 8 Motor Disorders 86
Controversies in Classifying
9 Disorders of Consciousness 103
Psychiatric Disorder 11
10 Personality Disorders 108
3 Disorders of Perception 24
4 Disorders of Thought and
Speech 42
5 Disorders of Memory 63 Appendix I: Psychiatric Syndromes 122
Appendix II: Defences and
6 Disorders of Emotion 71
Distortions 127
Index 132

Published online by Cambridge University Press

 Preface
Psychopathology is the science and study of psychological and psychiatric symptoms. Clinical
psychopathology locates this study in the clinical context in which psychiatrists make diag-
nostic assessments and deliver mental health services. A clear understanding of clinical psy-
chopathology lies at the heart of effective and appropriate delivery of such services.
In 1967, Frank Fish produced a 128-page volume on psychopathology, entitled Clinical
Psychopathology: Signs and Symptoms in Psychiatry (Fish, 1967). Despite its brevity or, more
likely, because of its brevity, Fish’s Clinical Psychopathology soon became an essential text
for medical students, psychiatric trainees and all healthcare workers involved in the deliv-
ery of mental health services. A revised edition, edited by Max Hamilton, appeared in 1974
(Hamilton, 1974) and was reprinted as a second edition in 1985 (Hamilton, 1985).
In 2007, we produced a third edition because Clinical Psychopathology had been out of
print and essentially impossible to locate for many years (Casey & Kelly, 2007). The purpose
of the third edition was to introduce this classic text to a new generation of psychiatrists and
trainees, and to reacquaint existing aficionados with the elegant insights and enduring val-
ues of Fish’s original work. The third edition was translated into Italian (Centro Scientifico
Editore, 2009) and Japanese (Seiwa Shoten Publishers, 2010), and a South Asian edition was
published in 2019.
In 2019, our fourth edition of this modern classic presented the clinical descriptions
and psychopathological insights of Fish to yet another generation of students and prac-
titioners (Casey & Kelly, 2019). For the fourth edition, we updated references, included
new material relating to the most recent diagnostic classification systems and added a new
chapter (Chapter 2) looking at controversies in classifying psychiatric disorders in the first
instance, and the fundamental roles and uses of psychopathology.
More than half a century after its original publication, this book remains an essential text
for students of medicine, trainees in psychiatry and practising psychiatrists. It is also of inter-
est to psychiatric nurses, mental health social workers, clinical psychologists and all readers
who value concise descriptions of the symptoms of mental illness and astute accounts of the
many and varied manifestations of disordered psychological function.
Once again, revising Fish’s Clinical Psychopathology has been both a humbling and excit-
ing experience. While striving at all times to retain the spirit of Fish’s original work, we have
again revised the language in various areas to take account of continued changes in linguis-
tic conventions, although we have, for historical reasons, retained the use of he/his/she/her
pronouns in some parts to refer to a singular, hypothetical patient; all genders are implied,
except where specified otherwise. This new edition also includes updated referencing cover-
ing recent developments, as well as the World Health Organization’s ICD-11: International
Classification of Diseases (World Health Organization, 2019).
Notwithstanding these revisions, we still trust that this text remains true to the spirit of
Fish’s original Clinical Psychopathology, the volume that has now shaped the clinical education
and practice of several generations of psychiatrists. We hope that this edition proves similarly
useful to contemporary readers. If it succeeds, all credit lies with the original insights of Frank
Fish; if it does not, the fault lies with us.

vii

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 viii Preface

References Hamilton, M. (ed.) (1974) Fish’s Clinical

Psychopathology: Signs and Symptoms in
Casey, P., Kelly, B. (eds.) (2007) Fish’s Clinical Psychiatry (revised edn). Bristol: John Wright &
Psychopathology: Signs and Symptoms in Sons.
Psychiatry (3rd edn). London: Gaskell.
Hamilton, M. (ed.) (1985) Fish’s Clinical
Casey, P., Kelly, B. (eds.) (2019) Fish’s Clinical Psychopathology: Signs and Symptoms in
Psychopathology: Signs and Symptoms in Psychiatry (2nd edn). Bristol: John Wright &
Psychiatry (4th edn). Cambridge: Cambridge Sons.
University Press.
World Health Organization (2019) ICD-11:
Fish, F. (1967) Clinical Psychopathology: Signs International Classification of Diseases (11th
and Symptoms in Psychiatry. Bristol: John Wright edn). Geneva: World Health Organization.
& Sons.

https://doi.org/10.1017/9781009372688.001 Published online by Cambridge University Press

 Classification of Psychiatric

1 Disorders

Any discussion of the classification of psychiatric disorders should begin with the frank
admission that any definitive classification of disease must be based on aetiology. Until we
know the causes of the various mental illnesses, we must adopt a pragmatic approach to clas-
sification that will best enable us to care for our patients, to communicate with other health
professionals and to carry out high-quality research.
In physical medicine, syndromes existed long before the aetiology of these illnesses were
known. Some of these syndromes have subsequently been shown to be true disease entities
because they have one essential cause. Thus, smallpox and measles were carefully described
and differentiated by the Arabian physician Rhazes in the tenth century. With each new step
in the progress of medicine, such as auscultation, microscopy, immunology, electrophysi-
ology and so on, some syndromes have been found to be true disease entities, while others
have been split into discrete entities, and others still jettisoned. For example, diabetes mellitus
has been shown to be a syndrome that can have several different aetiologies. On that basis,
the modern approach to classification has been to establish syndromes in order to facilitate
research and to assist us in extending our knowledge of them so that, ultimately, specific dis-
eases can be identified. We must not forget that syndromes may or may not be true disease
entities, and some will argue that the multifactorial aetiology of psychiatric disorder, related
to both constitutional and environmental vulnerability, as well as to precipitants, may make
the goal of identifying psychiatric syndromes as discrete diseases an elusive ideal.

Syndromes and Diseases

A syndrome is a constellation of symptoms that are unique as a group. It may of course contain
some symptoms that occur in other syndromes also, but it is the particular combination of
symptoms that makes the syndrome specific. In psychiatry, as in other branches of medicine,
many syndromes began with one specific and striking symptom. In the nineteenth century,
stupor, furore and hallucinosis were syndromes based on one prominent symptom.
Later, the recognition that certain other signs and symptoms co-occurred simultane-
ously led to the establishment of syndromes. Korsakoff ’s syndrome illustrates the progres-
sion from symptom to syndrome to disease. Initially, confabulation and impressionability
among alcoholics were recognised by Korsakoff as significant symptoms. Later, the pres-
ence of disorientation for time and place, euphoria, difficulty in registration, confabula-
tion and ‘tram-line’ thinking were identified as key features of this syndrome. Finally, the
discovery that in the alcoholic amnestic syndrome there was always severe damage to the
mammillary bodies confirmed that Korsakoff ’s psychosis (syndrome) is a true disease with
a ­neuropathological basis.

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 2 Fish’s Clinical Psychopathology

Sometimes, the symptoms of the syndrome seem to have a meaningful coherence. For
example, in mania the cheerfulness, the over-activity, the pressure of speech and the flight of
ideas can all be recognised as arising from the elevated mood. The fact that we can empathise
with and understand our patients’ symptoms by taking account of the context in which they
have arisen has led to the distinction between those symptoms that are primary, that is, are the
immediate result of the disease process, and secondary symptoms, which are a psychological
elaboration of, or reaction to, primary symptoms. The term ‘primary’ is also used to describe
symptoms that are not derived from any other psychological event.

Early Distinctions
The first major classification of mental illness was based on the distinction between disorders
arising from disease of the brain and those with no such obvious basis, that is, functional ver-
sus organic states. These terms are still used, but as knowledge of the neurobiological processes
associated with psychiatric disorders has increased and led to greater nuance, their original
meaning has been lost. Schizophrenia and manic depression are typical examples of func-
tional disorders, but the increasing evidence of the role of genetics and of neuropathological
abnormalities shows that there is at least some organic basis for these disorders. Indeed, the
category of ‘organic mental syndromes and disorders’ was renamed as ‘delirium, dementia
and amnestic and other cognitive disorders’ in the Diagnostic and Statistical Manual of Mental
Disorders (DSM−IV) (American Psychiatric Association, 1994), so that the recognition of the
role of abnormal brain functioning is not confined to dementia and delirium only. In their lit-
eral meaning, these categories of classification (i.e., organic versus functional) are absurd, yet
they continue to be used through tradition.

Organic Syndromes
The syndromes due to brain disorders can be classified into acute, subacute and chronic. In
acute organic syndromes, the most common feature is alteration of consciousness, which
can be dream-like, depressed or restricted. This gives rise to four subtypes: namely, delirium,
subacute delirium, organic stupor or torpor, and the twilight state. Disorientation, incoher-
ence of psychic life and some degree of anterograde amnesia are features of all of these acute
organic states. In delirium, there is a dream-like change in consciousness so that the patient
may also be unable to distinguish between mental images and perceptions, leading to hallu-
cinations and illusions. Usually there is severe anxiety and agitation. When stupor or torpor
is established, the patient responds poorly or not at all to stimuli and after recovery has no
recollection of events during the episode. In subacute delirium, there is a general lowering
of awareness and marked incoherence of psychic activity, so that the patient is bewildered
and perplexed. Isolated hallucinations, illusions and delusions may occur and the level of
awareness varies but is lower at night-time. The subacute delirious state can be regarded as
a transitional state between delirium and organic stupor. In twilight states, consciousness is
restricted such that the mind is dominated by a small group of ideas, attitudes and images.
These patients may appear to be perplexed but often their behaviour is well ordered and they
can carry out complex actions. Hallucinations are commonly present. In organic stupor (tor-
por), the level of consciousness is generally lowered and the patient responds poorly or not
at all to stimuli. After recovery, the patient usually has amnesia for the events that occurred
during the illness episode.
In addition, there are organic syndromes in which consciousness is not obviously disordered,
for example organic hallucinosis due to alcohol abuse, which is characterised by hallucinations,

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 Classification of Psychiatric Disorders 3

most commonly auditory and occurring in clear consciousness, as distinct from the hallucin-
ations of delirium tremens that occur in association with clouded consciousness. Amnestic dis-
orders, of which Korsakoff ’s syndrome is but one, also belong in this group of organic disorders,
and are characterised primarily by the single symptom of memory impairment in a setting of
clear consciousness and in the absence of other cognitive features of dementia.
The chronic organic states include the various dementias, generalised and focal, as well as
the amnestic disorders. Included among the generalised dementias are Lewy body disease,
Alzheimer’s disease and so on, while the best-known focal dementia is frontal lobe dementia
(or syndrome). The latter is associated with a lack of drive, lack of foresight, inability to plan
ahead and an indifference to the feelings of others, although there is no disorientation. Some
patients may also demonstrate a happy-go-lucky carelessness and a facetious humour, termed
Witzelsucht, whereas others are rigid in their thinking and have difficulty moving from one
topic to the next. The most common cause is trauma to the brain such as occurs in road traf-
fic accidents. The presence of frontal lobe damage may be assessed psychologically using the
Wisconsin Card Sorting Test or the Stroop Test. Amnestic disorders are chronic organic dis-
orders in which there is the single symptom of memory impairment; if other signs of cognitive
impairment are present (such as disorientation or impaired attention), then the diagnosis is
dementia. The major neuroanatomical structures involved are the thalamus, hippocampus,
mammillary bodies and the amygdala. Amnesia is usually the result of bilateral damage, but
some cases can occur with unilateral damage. Further, the left hemisphere appears to be more
critical than the right in its genesis.

Functional Syndromes
Functional syndromes (or disorders), a term seldom used nowadays, refers to those syn-
dromes in which there is no readily apparent coarse brain disease, although increasingly it is
recognised that some finer variety of brain disease may exist, often at a cellular level.
For many years, it was customary to divide these functional mental illnesses into neur-
oses and psychoses. The person with neurosis was believed to have insight into his illness,
with only part of the personality involved in the disorder, and to have intact reality testing.
The individual with psychosis, by contrast, was believed to lack insight, had the whole of his
personality distorted by the illness and constructed a false environment out of his distorted
subjective experience. Yet, such differences are an oversimplification, since many individuals
with neurotic conditions have no insight, and far from accepting their illness, may minimise
or deny it totally, whereas people with schizophrenia may seek help willingly during or before
episodes of relapse. Moreover, personality can be changed significantly by non-psychotic dis-
orders such as depressive illness, while it may remain intact in some people with psychotic
disorders, such as those with persistent delusional disorder.
Jaspers (1962) regarded the person with neurosis as an individual who has an abnormal
response to difficulties in which some specific defence mechanism has transformed their
experiences. For example, in conversion and dissociative disorders (formerly hysteria), the
mechanism of dissociation is used to transform the emotional experiences into physical
symptoms. Since we can all use this mechanism, the differences between the neurotic person
and the normal person is one of degree. Schneider (1959) has suggested that neuroses and per-
sonality disorders are variations of human existence that differ from the norm quantitatively
rather than qualitatively. However, this view of the neuroses breaks down when ­obsessive–
compulsive disorder is considered, since the symptoms are not variations of normal but differ
qualitatively from normal behaviours.

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 4 Fish’s Clinical Psychopathology

Over time, the use of the terms ‘neurotic’ and ‘psychotic’ changed, and instead of describ-
ing symptoms, particularly symptom types such as hallucinations or delusions, in the psy-
chotic person they were used to distinguish mild and severe disorders or to distinguish those
symptoms that are ego-syntonic (i.e., creating no distress for the person or compatible with
the individual’s self-concept or ego) from those that are ego-dystonic (i.e., causing distress
and incompatible with the person’s self-concept). Some practitioners also used the word ‘neu-
rotic’ as a term of opprobrium. Owing to the confusion that abounded in the various uses of
these terms, DSM-IV excluded the term ‘neurosis’ totally from its nomenclature, and this has
continued in DSM-5. The International Classification of Diseases (ICD-10) (World Health
Organization, 1992) named a group of disorders ‘neurotic, stress-related and somatoform
disorders’. However, ICD-11 does not use this term and the aforementioned group is now
divided between ‘anxiety and fear-related disorder’, ‘disorders of bodily distress’ and ‘disor-
ders specifically associated with stress’.

Personality Disorders and Psychogenic Reactions

The status of personality disorder vis-à-vis other psychiatric disorders was historically
regarded differently in the English-speaking world compared with the rest of the world. In
the English-speaking world, it was customary to separate the neuroses from personality dis-
orders, but in the German-speaking countries, epitomised by Schneider, the neuroses were
regarded as reactions of abnormal personalities to moderate or mild stress and of normal
personalities to severe stress. This difference was reflected in the approach of DSM-IV in pla-
cing personality and other disorders (e.g., major depression) on separate axes, while ICD-10
did not. The DSM has now also removed the multiaxial approach in its entirety, including the
removal of the assessment of functioning.
Psychogenic reactions constituted reversible prolonged psychological responses to
trauma, the reactions being the consequence of the causative agent on the patient’s ­personality.
Thus, acute anxiety and hysteria were considered to be varieties of psychogenic reactions pro-
voked by stress and determined by personality and cultural factors. Sometimes, the stress
was believed to cause psychotic reactions, termed symptomatic or psychogenic psychoses:
for example, the person with a paranoid personality who, in light of ongoing marital diffi-
culties, begins to suspect his wife’s fidelity, finally becoming deluded about this. The idea of
delusional states that were not due to functional psychoses was treated with scepticism by
English-speaking psychiatrists, but had adherents in Scandinavia, particularly in what were
termed psychogenic psychoses. These have gained increasing acceptance and were included
in ICD-10 and retained in ICD-11 as acute and transient psychotic disorders. In DSM-IV and
5, they are called brief psychotic disorder. In both, they are regarded as being associated with
a stressor although this is not essential. They are classified in the group of disorders entitled
‘Schizophrenia and other primary psychotic disorders’. Other psychogenic reactions such
as dissociation and conversion disorders are now renamed as dissociative disorders in both
DSM-5 and ICD-11. The word ‘psychogenic’, like ‘neurotic’, has been eliminated from recent
iterations of both classifications.

Modern Classifications
Two modern systems of classification are in use. The DSM is used mainly in the United States
and is prepared by the American Psychiatric Association every few years. The International
Classification of Diseases (ICD) is a World Health Organization document and covers all
medical conditions; one chapter is devoted to mental and behavioural problems. International

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 Classification of Psychiatric Disorders 5

Table 1.1 Dates of publication of DSM and ICD

DSM ICD
DSM-I 1952 ICD-7 1955
DSM-II 1968 ICD-8 1965
DSM-III 1980 ICD-9 1978
DSM-IV 1994 ICD-10 1992
DSM-5 2013 ICD-11 2022

Classification of Diseases is in use throughout the world, although the DSM is often used in
research, including drug trials, because each disorder is operationally defined and these crite-
ria can be applied when attempting to obtain homogenous populations, as is required in drug
trials for the treatment of certain conditions.
DSM-I, published by the American Psychiatric Association, first appeared in 1952, and
since then it has evolved significantly, to the extent that DSM-5 includes large amounts of
detail concerning each syndrome and, owing to its rigorous adherence to operational defin-
itions for each disorder, is suitable for use in both clinical practice and research.
However, the DSM system is considerably less user-friendly than the ICD, since it is
viewed as Procrustean by its critics. Interestingly, the billing codes for Medicare in the United
States are mandated to follow the ICD system rather than their own DSM. The ICD, by con-
trast, is more clinically orientated and is not so rigid in its definitions, eschewing operational
definitions in favour of general descriptions. It allows clinical judgement to inform diagnoses,
but this freedom makes it unsuitable for research purposes, necessitating the development
of separate research diagnostic criteria. Thus, different versions of ICD-10 now exist; these
include the clinical version (World Health Organization, 1992), a version with diagnostic
criteria for research (World Health Organization, 1993) (which resembles DSM in its use
of detailed operational criteria) and a version for use in primary care (ICD-10−PC; World
Health Organization, 1996), the latter consisting of definitions for twenty-five common con-
ditions as well as a shorter version of six disorders for use by other primary care workers.
Management guidelines incorporate information for the patient as well as details of medical,
social and psychological interventions. Finally, assistance on when to refer for specialist treat-
ment is provided. DSM-5 was published in 2013, and ICD-11 has been officially in use since
2022 (American Psychiatric Association, 2013). The historical timeline of the DSM and ICD
systems are shown in Table 1.1.

Comparison of DSM-5 and ICD-11

The DSM-5 and ICD-11 are syndrome-based classifications. This means that they are based
on commonly co-occurring symptoms and not on aetiology, psychobiology or prognosis.
Hence, the removal of terms such as ‘psychogenic’, ‘neurotic’, ‘functional’ and ‘psychosomatic’,
which have connotations for the cause of particular disorders. Apart from the few condi-
tions classified under the stress-related rubric and substance misuse, both classifications are
­aetiology-free in thinking. It was envisaged by the authors of DSM-IV that by the time pub-
lication of DSM-5 was ready, our knowledge of the biological and genetic underpinnings of
many psychiatric disorders would have increased to the extent that classification based on the
­underlying psychobiology would be possible.

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 6 Fish’s Clinical Psychopathology

Yet, as work commenced on DSM-5, Dr Gerard Kupfer, who chaired the task force charged
with its development, commented:

Not one laboratory marker has been found to be specific in identifying any of the DSM-defined
syndromes. Epidemiologic and clinical studies have shown extremely high rates of comorbidity
among the disorders, undermining the hypothesis that the syndromes represent distinct ­etiologies.
Furthermore, epidemiologic studies have shown a high degree of short-term diagnostic instability
for many disorders. With regard to treatment, lack of treatment specificity is the rule rather than
the exception. (Kupfer et al., 2005)

Alas, the promise of a new approach to classification was not realised and both DSM-5
and ICD-11 continue to be based on predominant symptoms and syndromes, not disease
entities.
An accompaniment to ICD-11 will be the publication of Clinical Guidelines and
Diagnostic Requirements (or Guidelines) (CDDR or CDDG) for all the listed psychiatric
disorders. This will include expanded clinical descriptions, differential diagnosis, boundar-
ies with other disorders as well as cultural aspects of symptoms and their distinction from
normal emotional responses. This may assist in preventing the over-diagnosis of mood and
anxiety disorders.

(1) DSM-5
The latest DSM classification (2013) has jettisoned the five axes of classification used in DSM-IV.
This was the biggest change. This, together with the expansion in diagnoses, results in the over-
all package being the most controversial in the history of DSM. The debate began even while
DSM-5 was being developed (Wakefield, 2016), with charges of lack of transparency. Among
the controversies that arose following its publication, the removal of the bereavement exclusion
from the criteria for major depression was also widely criticised. Heretofore, major depression
could not be diagnosed in the presence of bereavement. In the current edition, this has been
removed following a successful argument made by some that even in the presence of grief, the
symptoms can be so severe as to constitute major depression. It is unclear if this has resulted in
this diagnosis being made in the presence of normal grief, and the criteria go to some lengths to
specify the features of normal grief so as to forestall this. A further area of controversy has been
the addition of fourteen new disorders in DSM-5 that were not included in DSM-IV. These are
listed in Table 1.2.
The failure to remove oppositional defiant disorder from DSM-5 was also greeted with
concern. These changes, or their absence, have been robustly criticised by several commenta-
tors within, and with links to, the profession (Frances, 2013; Wakefield, 2016).

(2) ICD-11
It was envisaged that ICD-11 and DSM-5 would be published simultaneously, but this has
not happened. ICD-11 did not come into use until 2022 (published by the World Health
Organization). Mental, behavioural and neurodevelopmental disorders are dealt with in
Chapter 6 of that document.
The process began with the establishment of various working groups to deal with broad
categories such as schizophrenia, substance misuse and so on. These surveyed mental health
professionals to obtain their views on classification, on their patterns of use and on possible
changes to ICD-10. This resulted in a set of preliminary guidelines which were used as a basis
for evaluative field trials using case material in the form of vignettes. They were international

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 Classification of Psychiatric Disorders 7

Table 1.2 New disorders in DSM-5

Mild neurocognitive disorder

Hoarding disorder
Disruptive mood disorder dysregulation
Social pragmatic communication disorder
Premenstrual dysphoric disorder
Caffeine withdrawal
Cannabis withdrawal
Excoriation (skin picking) disorder
Binge eating disorder
Rapid eye movement sleep disorder
Restless les syndrome
Major neuro-cognitive disorder with Lewy Body Disease
Disinhibited social engagement disorder
Reactive attachment disorder
Central sleep apnoea and sleep-related hypoventilation

and multilingual. Their purpose was to examine the diagnostic process and to compare the
accuracy and consistency with the proposed guidelines. The study by Keeley et al. (2016) in
respect of stress-related disorders serves as an example of the process in arriving at a final
classification for specific disorders. This study found that re-experiencing the trauma was
unclearly defined in ICD-11, that there were problems applying the functional impairment
criterion and that for adjustment disorder the criteria did not assist clearly enough in distin-
guishing adjustment disorder from the vignette in which no disorder was present. On the
other hand, clinicians were able to distinguish complex PTSD and prolonged grief disorder
from similar conditions and from normality. A recent study using real patients (n = 1,086)
across a range of disorders in thirteen countries has shown that clinicians’ rating of the pro-
posed diagnostic guidelines were positive overall and they were rated less favourably for
assessing treatment options and prognosis than for communicating with health professionals
(Reed et al., 2018).
These results assisted in clarifying the criteria that were applied in the next set of field
studies focusing on real patients in clinical settings. These were followed by reliability studies,
but not validity studies, in eighteen countries around the world. These will consider the clini-
cal utility of the criteria as well as their reliability but they do not test validity (see Chapter 2,
pp. 15, 16, 18). They are being carried out in eighteen countries across the globe.
Significant changes to a number of major groups in ICD-10 have been made. In ICD-
11, personality disorder has a much reduced number of categories and they will be based
on severity (see Chapter 10). Acute stress disorder has been moved from the stress-related
disorder conditions and placed in the section on factors affecting health. It is not considered
a psychiatric disorder, unlike DSM-5, where it resides in the Trauma and Stressor-Related
Disorder group. A number of new conditions have been added, including gaming disorder,
hoarding disorder and prolonged grief disorder. A welcome development is the addition of a
section on the boundaries between normal and human functioning and disorders.

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 8 Fish’s Clinical Psychopathology

The multiple areas of difference between DSM-5 and ICD-11 are explored in detail in the
paper by First et al. (2021).

Interview Schedules
In order to carry out epidemiological studies in which diagnoses are standardised, Diagnostic
Interview Schedules (DIS) were developed to meet the criteria for the ICD and the DSM
diagnoses.
The Structured Clinical Interview for DSM-5 (SCID-5) was developed from SCID-IV.
There are now four versions: a clinical version (SCID-5-CV) (First et al., 2016a), a research
version (SCID-5-R) (First et al., 2015a), a clinical trials version (SCID-5-CT) (First et al.,
2015b) and a personality disorders version (SCID-5-PD) (First et al., 2015). There is also a
screening version (SCID SPQ) (First et al., 2016) and one for personality disorder, termed an
alternate model for personality disorders (SCID-AMPD). SCID-AMPD differs from SCID-
5-PD as the former allows for a dimensional assessment of personality, while the latter is
based on the traditional categorical model of personality disorder. This is a semi-structured
interview since it allows some latitude in its administration to elaborate on questions.
Another schedule used to evaluate diagnoses based on the DSM criteria is the Composite
International Diagnostic Interview (CIDI) (Robins et al., 1989). It developed from the DIS
(Robins et al., 1985) but unlike SCID is not a semi-structured interview. Instead, it is stand-
ardised and is suitable for use with lay interviewers. No clinical judgement is brought to
bear in rating the symptoms since questions are asked in a rigid and prescribed manner. The
questions are clearly stated to elicit symptoms, followed by questions about frequency, dura-
tion and severity. The only judgement the interviewer has to make is whether the respond-
ent understood the question, and if not, it is repeated verbatim. Composite International
Diagnostic Interview is available in computer format also and so can be self-administered.
It was later explained to facilitate ICD-10 diagnoses. This resulted in the World Health
Organization World Mental Health-CIDI (WHO WMH-CIDI) (Kessler and Ustun, 2004). It
does not include personality disorders and only evaluates lifetime and twelve-month disor-
ders. It has a screening section and can also be used in modular form for evaluating specific
disorders. It has sections on functioning, services sought and family burden. CIDI-5 is cur-
rently being developed to coincide with the use of DSM-5.
As with Schedule for Clinical Assessment in Neuropsychiatry (SCAN) (see in the next par-
agraph), the symptoms are then entered into a computer algorithm for diagnosis according to
ICD or DSM. The advantage of this approach is that it is cheaper than using semi-­structured
interviews, since lay people can be trained in its use. However, the absence of clinical judge-
ment is an obvious disadvantage that has resulted in its validity being questioned. Some recent
reviews question the prevalence for some psychiatric disorders obtained using standardised
interviews such as CIDI and suggest that the high rates identified in some studies require
revision downwards (Regier et al., 1998). These different approaches are discussed in detail by
Brugha et al. (1999) and Wittchen et al. (1999).
In Europe, SCAN (Wing et al., 1990) has evolved from the older Present State Examination
(PSE) (Wing et al., 1974). Schedule for Clinical Assessment in Neuropsychiatry itself is a
set of instruments aimed at assessing and classifying psychopathology in adults. The four
instruments include PSE-10 (the tenth edition of the PSE); the SCAN glossary, which defines
the symptoms; the Item Group Checklist for symptoms that can be rated directly (e.g.,
from case notes); and the Clinical History Schedule. Schedule for Clinical Assessment in
Neuropsychiatry provides diagnoses according to both ICD-10 and DSM-IV criteria. The

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 Classification of Psychiatric Disorders 9

interview itself is semi-structured, the aim being to encapsulate the clinical interview while
minimising its vagaries. There are probe questions with standard wording to elucidate the
psychopathological symptoms, defined in the glossary and accompanied by severity ratings.
Where there is doubt, the interviewer can proceed to a free-style interview to clarify the fea-
ture further and may, if necessary, include the patient’s phraseology in questioning to enhance
clarity. It is designed for use by psychiatrists or clinical psychologists, thereby utilising clinical
interviewing skills in evaluating each symptom. The symptoms ratings are then entered into
a computer algorithm and a computer diagnosis obtained according to either classification.
The role of the interviewer is to rate symptoms rather than make diagnoses. Schedule for
Clinical Assessment in Neuropsychiatry can generate a current diagnosis, a lifetime diagnosis
or a representative episode diagnosis. The use of mental health professionals in interviewing
with SCAN makes this an expensive method but has the advantage of approximating the
‘gold standard’ diagnosis achieved by clinical interview. Schedule for Clinical Assessment in
Neuropsychiatry pays little attention to personality disorder and it is only in the clinical his-
tory section that details of diagnoses that are not covered in PSE-10 are recorded, usually from
other sources of information. It is unclear if there will be changes to SCID and SCAN so that
epidemiological research can follow the publication of ICD-11.

References First, M. B., Skodol, A. E., Bender, D. S., &

Oldham, J. M. (2018) Module I: Structured
American Psychiatric Association (1952) Clinical Interview for the Level of Personality
Diagnostic and Statistical Manual of Mental Functioning Scale. In Structured Clinical
Disorders (1st ed.) (DSM-I). Washington, DC: Interview for the DSM-5 Alternative Model
American Psychiatric Association. for Personality Disorders (SCID-AMPD) (eds.
American Psychiatric Association (1994) M. B. First, A. E. Skodol, D. S. Bender, & J.
Diagnostic and Statistical Manual of Mental M. Oldham), 5–56 Arlington, VA: American
Disorders (4th ed.) (DSM-IV). Washington, DC: Psychiatric Association.
American Psychiatric Association. First, M. B., Williams, J. B. W., Benjamin, L. S.,
American Psychiatric Association (2000) & Spitzer, R. L. (2015) User’s Guide for the SCID-
Diagnostic and Statistical Manual of Mental 5-PD (Structured Clinical Interview for DSM-5
Disorders (4th ed., text revision) (DSM-IV-TR). Personality Disorder). Arlington, VA: American
Washington, DC: American Psychiatric Psychiatric Association.
Association. First, M. B., Williams, J. B. W., Benjamin, L. S., &
American Psychiatric Association (2013) Spitzer, R. L. (2016) Structured Clinical Interview
Diagnostic and Statistical Manual of Mental for DSM-5: Screening Personality Questionnaire
Disorders (5th ed.) (DSM-5). Washington, DC: (SCID-5-SPQ). Arlington, VA: American
American Psychiatric Publishing. Psychiatric Association.
Brugha, T. S., Bebbington, P. E., & Jenkins, R. First, M. B., Williams, J. B. W., Karg, R. S.,
(1999) A Difference that Matters: Comparisons & Spitzer, R. L. (2015a) Structured Clinical
of Structured and Semi-structured Psychiatric Interview for DSM-5: Research Version
Diagnostic Interviews in the General (SCID-5 for DSM-5, Research Version (SCID-
Population. Psychological Medicine, 29, 5-RV)). Arlington, VA: American Psychiatric
1013–20. Association.
First M. B., Gaebel W., Maj M. et al. (2021) First, M. B., Williams, J. B. W., Karg, R. S.,
An Organisation- and Category-Level & Spitzer, R. L. (2015b) Structured Clinical
Comparison of Diagnostic Requirements for Interview for DSM-5 Disorders: Clinical Trials
Mental Disorders in ICD-11 and DSM-5. World Version (SCID-5-CT). Arlington, VA: American
Psychiatry, 1, 34–51. Psychiatric Association.

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 10 Fish’s Clinical Psychopathology

First, M. B., Williams, J. B. W., Karg, R. S., Robins, L. N., Wing, J., Wittchen, H. U. et al.
& Spitzer, R. L. (2016a) Structured Clinical (1989) The Composite International Diagnostic
Interview for DSM-5 Disorders: Clinician Interview: An Epidemiologic Instrument
Version (SCID-5-CV). Arlington, VA: American Suitable for Use in Conjunction with Different
Psychiatric Association. Diagnostic Systems and in Different Cultures.
Frances, A. J. (2013) Saving Normal: An Insider’s Archives of General Psychiatry, 45, 1069–77.
Revolt against Out-of-Control Psychiatric Schneider, K. (1959) Clinical Psychopathology
Diagnosis, DSM-5: Big Pharma, and the (5th ed.), (trans. M. W. Hamilton). New York:
Medicalization of Ordinary Life. New York: Grune & Stratton.
Harper Collins. Wakefield, J. C. (2016). Diagnostic Issues and
Jaspers, K. (1962) General Psychopathology Controversies in DSM-5: Return of the False
(7th ed.), (trans. J. Hoenig & M. W. Hamilton). Positive Problem. Annual Review of Clinical
Manchester: Manchester University Press. Psychology, 12, 105–32.
Keeley, J. W., Reed, G. M., Roberts, M. C. et Wing, J. K., Babor, T., Brugha, T. et al. (1990)
al. (2016) Disorders Specifically Associated SCAN: Schedules for Clinical Assessment in
with Stress: A Case-Controlled Field Study for Neuropsychiatry. Archives of General Psychiatry,
ICD-11 Mental and Behavioural Disorders. 47, 589–93.
International Journal of Clinical Health Wing, J. K., Cooper, J., & Sartorius, N. (1974)
Psychology, 16, 109–27. Measurement and Classification of Psychiatric
Kessler, R. C., & Ustun, T. B. (2004) The World Symptoms. New York: Cambridge University
Mental Health (WMH) Survey Initiative Version Press.
of the World Health Organization (WHO) Wittchen, H. U., Ustun, T. B., & Kessler, R.
Composite International Diagnostic Interview C. (1999) Diagnosing Mental Disorders in
(CIDI). The International Journal of Methods in the Community: A Difference that Matters?
Psychiatric Research, 13:2, 93–121. Psychological Medicine, 29, 1021–7.
Kupfer, D. J., First, M. B., & Regier, D. A. eds. World Health Organization (1992) The ICD-
(2005) In Introduction, p xviii: A Research 10 Classification of Mental and Behavioural
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Psychiatric Association. Guidelines (10th ed.). Geneva: World Health
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(2018) Clinical Utility of ICD-10 Diagnostic World Health Organization (1993) The ICD-
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Results from Mental Health Settings in 13 Disorders: Diagnostic Criteria for Research (10th
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Regier, D. A., Kaelber, C. T., Rae, D. S. et al. World Health Organization (1996) ICD-10
(1998) Limitations of Diagnostic Criteria and Diagnostic and Management Guidelines for
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Implications for Research and Policy. Archives of World Health Organization.
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(eds. W. Eaton & L. G. Kessler ), 143–70.
Orlando: Academic Press.

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 What Is Psychopathology?

2 Controversies in Classifying Psychiatric

Disorder

Karl Jaspers, a psychiatrist, theologian and philosopher, is the father of psychopathology.

His work General Psychopathology (translated 2013) is a classic in the psychiatric literature.
He believed that mental illness, in particular psychosis, should be evaluated with regard to
the abnormal phenomena that are present – for example, hallucination, delusions, thought
­disorder – rather than to their content. The latter (content) was the focus of the psychoanalytic
school who argued that content was a clue to underlying traumas and issues that may have
contributed to the person’s current state. So whether the content of a delusion was persecutory
or guilt-laden, Jaspers believed, was less important than the presence per se of the delusion.
Thus, he was distinguishing between form (primary or secondary, systematised or non-­
systematised, etc.) and content (e.g., persecutory, guilt and nihilistic). He did not ­subscribe
to the notion of understandability, and he described autochthonous or primary delusions (a
delusion not derived from any other primary psychotic experience such as a person hearing
a voice telling them they are being watched and the belief that they were being spied upon)
(see Chapter 4, p. 49) as arising from abnormal biological processes. Secondary delusions,
on the other hand, arise from other underlying abnormal phenomena such as hallucinations:
for example, a voice telling a person that they are being watched leading to beliefs that there
is a camera spying on them. These can also be driven by a person’s personal, social or cultural
background. Jaspers’ contribution has been to delineate the diagnostic features of mental
illnesses.
A more current definition of what psychopathology is much broader and it is defined as
the ‘systematic study of abnormal experience, cognition and behaviour’. It includes a number
of approaches (see Table 2.1).
In discussing the nature of psychiatric illness and psychopathology, there are two broad
approaches. The first of these is philosophical in nature and asks questions such as whether
mental illness exists and how best to conceptualise it. A further issue is whether the syn-
dromes we recognise as disorders are discrete entities naturally occurring in nature or,
alternatively, if they are social constructs that change over time in different cultures and in
different eras as societies try to make sense of human behaviour.
The second approach is clinical. It deals with issues such as aetiology, symptoms, course
and so on. It attempts to demarcate the distinction between symptoms of disorder and psy-
chological phenomena found in the general population. This is the method with which most
clinicians are familiar. It is the one adopted with enthusiasm by the Diagnostic and Statistical
Manual (DSM) since the third edition (1980), when diagnostic criteria were specified and
definitions operationalised.

11

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 12 Fish’s Clinical Psychopathology

Table 2.1 Approaches to psychopathology

Descriptive psychopathology Explanatory psychopathology

Describes phenomena based on the Cognitive
person’s subjective state, eschews Behavioural
explanation Psychodynamic/psychoanalytic
Form and content

The International Classification of Diseases (ICD), beginning with the eighth edition
(1965), and continuing into the tenth edition, also used a clinical approach, but with less
emphasis on rigid diagnostic criteria and more on clinical judgement than DSM. This, argu-
ably, has resulted in less homogeneity than DSM when syndromes are used to identify suitable
patients for inclusion in clinical trials or to answer broader research questions.
These approaches are not mutually exclusive, and some authors have straddled both
(Kendler, 2016) to better illuminate our understanding of these complex questions.

Philosophical Approaches to Defining Psychiatric Disorder

Kendler (2016) discusses the three approaches to understanding the metaphysical aspects
of psychiatric disorder, or in other words, the three approaches to the question of the under-
lying nature of psychiatric disorder. These are referred to as realism, constructivism and
pragmatism.
Realism is the perspective of most psychiatrists, who, when asked if mental illness exists,
will assert that it does, just as the elements in the periodic table, or DNA and RNA, do. Most
psychiatrists think that mental illness is real in the same way that a bone is really broken or
a mass is found to be a cancerous tumour. So most will claim that generalised anxiety disor-
der, major depression or schizophrenia exist as entities that will eventually be identified by
their genes, their cerebral pathways and/or other markers. This is the perspective of biological
psychiatry.
Counterarguments are that there are very few disorders in psychiatry that have the clarity
of other medical conditions, such as cancer, bronchitis and so on, despite decades of research.
Indeed, when DSM-IV (1994) was published, its architects expressed optimism that by the time
DSM-5 (2013) was written, the possibility of identifying the pathophysiological underpinning
of most psychiatric disorders (see Chapter 1 page 5 Comparison of DSM 5 and ­ICD-11) would
usher in a new paradigm in classification. This aspiration has not been realised.
Constructivism is the view that psychiatric disorders have no biological reality and are
constructed by humans in the same way that fashions or music genres are, being the products
of social convention and human activity, not innate in nature. This too is the view of the anti­
psychiatry school. While most psychiatrists would not support the belief that the conditions
we treat are mere social constructs born of habit and convention, there are many prominent
psychiatrists (Kendler, 2016; Paris, 2013; Summerville, 2001; Tyrer, 2016) who, although not
antipsychiatry, have concerns about the emergence of many syndromes as recognised psychi-
atric disorders in response to the social and political climate of the time. They opine that this
strongly influenced decisions on whether to include conditions such as PTSD (Summerville,
2001), oppositional defiant disorder, multiple personality disorder, recovered memory,
­menstruation-related mood disorders and even major depression (Parker et al., 2005). In
relation to constructing disorders, DSM has been subject to much more criticism than ICD,
and while there has been broad overlap between the two systems, debate has focused mainly

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 Controversies in Classifying Psychiatric Disorder 13

on DSM, arguably because of the rigidity with which the criteria have been applied in clinical
practice. Some of these criticisms of DSM-5 have been summarised in Chapter 1 (pp. 5–8).
Pragmatism, sometimes referred to as utility (to be distinguished from utilitarianism),
is the view that psychiatric classification and the conditions named there are based on what
works and is useful rather than on what is real. This is the backbone of the arguments of
Jablensky (2016). He contends that few diagnoses have validity and that there are trans-diag-
nostic commonalities in measures such as genomic variants that should discourage us from
arguing at this point for the validity of specific disorders as discrete entities. Rather, he argues
for ‘comparative validity’, by which he means that criteria, justified rationally and based on
current scientific knowledge, represent improvements on previous models. It can be seen as a
middle ground between the realist and constructionist perspectives. Kendler (2016) is unim-
pressed, describing it as ‘unambitious’. His criticism of pragmatism as applied in psychiatry
is an ethical one with two strands. He argues that to not fully understand the essence of a
person’s underlying condition and the suffering it causes them and their families is disrespect-
ful. There is a lurking danger that they will be regarded as ‘not really sick’. The second ethical
concern is that this will undermine the profession, which if it was thought to be pragmatic
by the general public would be viewed as not doing anything ‘real’, and as not belonging to a
‘legitimate biomedical discipline’, with all the resource implications that such a perspective
carries. Another critic of the pragmatic argument is Wakefield (2016). Wakefield’s concern
is similar to Kendler’s, namely, it detracts from the scientific basis of psychiatric diagnosis.
Resolving the philosophical conundrum about the nature of psychiatric illness, Kendler
cautiously leans towards the perspective of realism, although he accepts that its certainty may
be arrogant, especially when considered against the backdrop of a history wherein accepted
ideas and scientific theories are constantly being jettisoned and replaced over time. Termed
pessimistic induction (Kuhn, 1992), it holds that each generation of scientists will argue that
they have now arrived at the truth, yet this is likely to be as erroneous as the views of the previ-
ous one. Examples of this in psychiatry include the identification and subsequent jettison of
various conditions, including masturbatory insanity, paraphrenia, monomania, homosexu-
ality, hysteria and so on. Kuhn argues for a modified version of realism combined with ele-
ments of pragmatism. He and others (Wakefield, 2016) point out that psychiatric disorders
do not exist as ‘essences’, since there is no single cause of any identifiable disorder, as there
is for cystic fibrosis or Huntington’s disease. Kendler et al. (2011) argue for a multifactorial
understanding just as, for example, with coronary artery disease, where a cluster of properties
define it. As more information becomes available, our understanding of psychiatric disorders
will fit better with what philosophers term the ‘coherence theory of truth’, ultimately identify-
ing valid categories. This theory regards truth as coherence (‘hanging together’) within some
­specified set of propositions or beliefs and it was advanced by Spinoza, Kant and Hegel.

Clinical Approaches to Defining Psychiatric Disorder (Validity)

The clinical approach used in DSM and, to a lesser extent, ICD is to identify symptoms, their
number and their duration in order to define each disorder. These must be clinically signifi-
cant (see the following) and cause either distress or dysfunction.
The purpose of the classifications is to:
1 Distinguish between normal and abnormal emotional states
• in non-psychotic states
• in psychotic states
2 Distinguish one psychiatric disorder from another.

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 14 Fish’s Clinical Psychopathology

Achieving these is termed validity and, along with reliability (also called replicability), is con-
sidered a basic tenet of diagnosis across all areas of medicine.

Distinguishing between Normal and Abnormal States in Non-psychotic

Disorders: Validity and the Clinical Significance Criterion
How is validity decided? Distinguishing symptoms that are indicative of normal distress
from those that constitute psychiatric disorder is central to discussing validity in psychiatry
(Cooper, 2013). When a psychiatric disorder is identified when none really exists, this is
called a ‘false positive’ diagnosis. An example would be diagnosing a person experiencing
a normal grief response with a depressive episode based on symptoms alone. There is little
to guide the psychiatric clinician, since there are no independent biological markers and
investigators are dependent on the patient’s description of their symptoms. If pathologi-
cal and non-pathological conditions cannot be distinguished adequately, the former might
be over-diagnosed since, for example, low mood, and sleep and appetite disturbance are
common in the general population. This would lead to false positive diagnoses of major
depression, artificially inflating the prevalence rate. In applying a test based on symptoms,
to distinguish normal distress from psychiatric disorder, the grey area of common symp-
toms should be small and specific delineating symptoms common. Yet, studies have failed
to clearly demarcate those with disorders from those with none when relying on symptoms.
Wakefield (2016) additionally points out that zones of rarity (a line of demarcation between
those with and without psychiatric disorder) based on symptoms may not be sufficient,
and that the zones of rarity test should apply to other domains also, such as aetiology, psy-
chosocial functioning, course, response to treatment and prognosis. So when there is an
absence of discontinuity, also called delineation, in one ___domain such as symptoms, clearer
discontinuity may be present in others, resulting overall in the identification of a valid
psychiatric disorder. This is termed explanatory discontinuity (Wakefield, 2016). Most of
the syndromes listed as disorders in DSM-5 (2013) and ICD-10 (1992) do not meet these
requirements for validity.
In attempting to deal with the distinction between appropriate and pathological distress,
DSM-III (1980) and DSM-IV (1994) introduced the idea of ‘clinical significance’. The criteria
specify that ‘the disturbance causes clinically significant distress or impairment in social, aca-
demic (occupational) or other areas of functioning’. By introducing this diagnostic require-
ment, it was hoped that normal reactions would not be misdiagnosed as illness and so the
number of false positive diagnoses reduced. No attempt was made to define what clinical
significance was. Was the fact of attending a doctor ‘clinically significant’? Would attending
a counsellor be seen in the same light? What is clinically significant in somebody who has a
self-image of themselves as a ‘depressed’ person, and is it the same as in somebody who has
stressors that produce low mood in the short term? If a person is believed by others to be
suffering anxiety or depression but they themselves do not accept this and visit their doctor
under duress, are the symptoms to be regarded as ‘clinically significant’?
The ‘clinical significance’ requirement is an appeal to clinical judgement, but clinical judge-
ment is personal, changeable and likely biased. As Frances (1998) argues, this imprecision of
basing caseness definitions on clinical significance is likely to contain ‘the seeds of tautology’.
This approach involves a vicious circle: on this approach, a set of symptoms amount to a dis-
order because a doctor judges them to do so, but they judge them to do so simply because they
have come to their attention. A further problem is that many large epidemiological studies

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 Controversies in Classifying Psychiatric Disorder 15

are carried out by lay interviewers who do not have the clinical skills necessary to identify
the clinical significance of symptoms, leading to false positive diagnoses. These issues were
offered as an explanation for unexpected discrepancies in prevalence in serial studies in the
United States (Narrow et al., 2002).

Validity and the Distress-Impairment Criterion

One approach to separating normal from pathological emotional responses has been to
require that either distress or functional impairment should be present in order to make a
diagnosis. This was prompted by the pathologising of homosexuality prior to DSM-III. In
removing it from DSM-III it was argued that since it caused neither distress nor dysfunction
it could not be regarded as a psychiatric disorder.
Diagnostic and Statistical Manual still requires distress or functional impairment, while
ICD requires both. Arguably the latter should lead to a higher threshold for making diagnoses
in ICD and will have a greater likelihood of reducing the risk of false positives. Some argue
(Cooper, 2013) that DSM-5 has weakened the distress/dysfunction criterion by altering the
wording such that it need not be present in all conditions. The introduction now reads ‘Mental
Disorders are usually [bold added] associated with significant distress or disability in social,
occupational or other important activities.’ It remains to be seen in which conditions and in
what circumstances this less definitive approach will emerge.
A study of the distress-impairment criterion in those with major depression identified
some symptoms (low mood and concentration) as having a significantly greater impact on
functioning than others, pointing to the necessity for greater attention to individual symp-
toms (Freid et al., 2014) rather than to overall numbers. On the other hand, the presence of
auditory hallucinations in non-clinical populations (see Chapter 3, p. 37 and ‘Distinguishing
between Normal and Abnormal States in Non-psychotic Disorders: Validity and the Clinical
Significance Criterion’ section) is not associated with either distress or impairment, and so
their presence should not lead to a psychiatric diagnosis.

Major Depression as a Case Study

The philosophical and clinical debate about classification has focused significantly on major
depression because lumping all the depressive disorders into a single concept was one of the
most controversial decisions in DSM-III (1980) and still generates debate and disagreement.
This is also a possible cause of the seemingly high and increasing prevalence of depressive
illness globally (World Health Organization, 2017). In interpreting this data it is important
to appreciate that there are continuing difficulties distinguishing ‘clinical’ from ‘non-clini-
cal’ depressive states, that is, mood disorders from normal mood disturbances such as occur
following bereavement (Parker and Peterson, 2015). Despite the development of structured
diagnostic interviews, these are based on symptom numbers and their duration, and are often
used by lay interviewers not trained in making the fine distinctions required.
Parker and Peterson (2015) suggest a two-pronged approach to major depression in the
DSM classification. They recommend that the disease model be applied to the severe mel-
ancholy or psychotic depressive states, and that a dimensional approach be used to describe
the other depressive states in which the differing contributions of personality and psycho-
social stressors are incorporated without any natural boundary between them. Ultimately,
it is likely that conditions such as major depression are a heterogeneous conglomera-
tion of conditions with various aetiologies and responses to treatment (Parker, 2018).

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 16 Fish’s Clinical Psychopathology

Hence the variety of treatments to which major depression has been shown to respond,
from self-help through to ECT. The conditions that make up major depression probably
include self-limiting reactions to environmental stressors (normal reactions and adjust-
ment disorders) at one end, and severe depressive illness with classic melancholic or psy-
chotic features at the other.
In attempting to distinguish normality from pathology in depression, we must test whether
there are qualitative differences between normal and pathological sadness. This presumes
that the difference is more than the total depressive symptom score (Fried et al., 2014), as is
the current position in DSM-5, and that the difference is an inherent feature of the depressive
condition. The most common description of depressive illness by those with the condition
(Healy, 1993) as distinct from normal sadness was the experience of lethargy and inability to
do things, whether because of tiredness or an inability to summon up effort. Also identified
was a feeling of being inhibited and an inability to envisage the future, a sense of detachment
from the environment, and of physical changes similar to a viral illness (Healy, 1993). A sense
of detachment was one of the symptoms which Kendler (2008) noted was not included in the
DSM-5 criteria for major depression. Clarke and Kissane (2002) found that those who are sad
are able to experience pleasure when distracted from demoralising thoughts, and that they felt
inhibited in action by not knowing what to do, in contrast to the person with depressive illness
who has lost motivation and drive, and is unable to act even when an appropriate direction of
action is known. Others (de Figueiredo, 1993) identified anhedonia as a feature of depressive
illness as distinct from sadness or demoralisation. Mindful of the danger of pathologising
normal adaptive reactions, ICD-11 has included a section on the boundaries between the lat-
ter and common mental disorders.

Distinguishing between Normal and Abnormal States in Psychotic

Disorders: Validity
Some argue that even in non-clinical populations, psychotic symptoms have been identified,
thus nullifying claims that severe mental illness can be clearly delineated from mental health.
The presence of psychotic symptoms in healthy or non-clinical populations has been studied
with respect to hallucinations in particular. These are often described as psychotic-like expe-
riences. The studies suggest that in the non-clinical group their quality differs from those
described by those who are psychotic (Stanghellini et al., 2012). A further study (Sommer
et al., 2010) that recruited non-clinical voice hearers found that 18% described the voices
as commenting, while 11% described them as talking among themselves. Thus, a sizeable
minority had a first-rank symptom according to the Schneiderian criteria for schizophre-
nia. Yet they were not distressed by them, the content for the most part was positive and the
subjects reported being able to control them. While it is not possible to distinguish between
healthy and clinical populations on the basis of the presence or absence of auditory hallucina-
tions alone, their impact on the individual does separate the two groups, as does the benign
quality of the content (see distress-impairment criterion mentioned earlier).

Distinguishing between One Psychiatric Disorder and Another

There is an ongoing discussion about the differentiation between various psychiatric disorders
within the psychiatric spectrum. Space does not allow for all the disorders to be considered,
and so the focus will be on certain psychotic disorders and some common non-psychotic
­disorders such as anxiety and depression.

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 Controversies in Classifying Psychiatric Disorder 17

The classification of psychosis began with Kraeplin (1918), who, without any biologi-
cal data, delineated schizophrenia from bipolar disorder on the basis of clinical symptoms,
family history and course in 1893. Within a few decades, he was beginning to recant, since
­follow-up studies showed that a poor prognosis in schizophrenia was not inevitable. Others
subsequently found that many patients with bipolar disorder had psychotic symptoms that
persisted in between depressive or manic episodes, while a large proportion of patients with
schizophrenia also had disturbance of mood.
Current medication patterns are not particularly helpful, since those with mood dis-
orders and psychotic symptoms are now variously prescribed antipsychotic agents and
antidepressants. Lithium is the one medication that appears to be specifically of benefit in
mood disorders. While both conditions are heritable, they often do not breed true. Moreover,
genome-wide studies have found polymorphisms that carry risks for both schizophrenia and
bipolar disorder. Even Schneider’s first-rank symptoms of schizophrenia, described in 1959,
are also found in mania, demonstrating that in terms of symptoms there are no zones of rar-
ity between the two conditions. Impairment in cognitions is identified in each, although they
tend to be worse in schizophrenia. These issues are discussed in detail in Pearlson and Ford
(2014), and it seems that the conditions cannot be distinguished from each other in rela-
tion to a number of measures. The view that psychosis is a continuum from normality to
disorder, and across disorders from bipolar to schizophrenia, is challenged by Lawrie et al.
(2010, 2016), who argue that the studies offering alternative explanations for the distribu-
tion of symptoms simply have not been done and that even still the arguments do not sup-
port changing the current separation between bipolar disorder and other psychoses (Lawrie,
2016). Others (Demjah et al., 2012) point to research that supports both continuity in some
parameters and discontinuity in others, between bipolar disorder and schizophrenia. Thus at
present there is no definitive resolution to this debate.
A similar debate has been taking place for decades regarding the distinction between
depressive illness and generalised anxiety. It is recognised that up to 85% of those with depres-
sive illness experience anxiety, and that up to 90% of those with anxiety describe depressive
symptoms (Gorman, 1996). The term ‘mixed anxiety and depression disorder’ (MADD) is
applied to these conditions in ICD-10 when they co-occur and neither on its own reaches the
threshold for a full disorder (see section Co-morbidity, Consanguinity and Co-occurrence).
This mixed condition is of concern not just because of the level of impairment and distress
it causes, but because it is believed to be more resistant to treatment than either on their
own. DSM-IV placed MADD in the section devoted to possible disorders requiring further
research but not yet worthy of full inclusion.
There continues to be controversy regarding the relationship between these two sub-
threshold disorders. Are they a single condition, two separate conditions, or two conditions
that co-occur at a higher rate than expected by chance? DSM-5 has not included this, but
ICD-11 plans on continuing with its inclusion despite poor reliability and limited research
on its validity. In addition, it has been found to be one of the most difficult to use in clinical
practice despite the diagnostic label being frequently applied (Reed et al., 2011). It is unclear
if sufficient care is taken in applying this diagnosis when both are subthreshold. When each
meets the criteria for a full disorder, each should be diagnosed.
Some researchers state confidently that subthreshold anxiety and depression are a single
condition with overlapping phenomenologies (Das-Munchi et al., 2008), and that the mixed
condition as defined in ICD-10 should remain. By contrast, others (Barcow et al., 2004) found
that in their sample, very few retained the diagnosis of mixed anxiety and depressive disorder

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 18 Fish’s Clinical Psychopathology

at one-year follow-up, and most developed a clear-cut depressive or anxiety disorder or some
other psychiatric diagnosis, suggesting diagnostic instability and therefore caution in diag-
nosing MADD.

Improving Validity Using Symptom-Based Approaches

It is clear that on their own, symptom-based approaches are limited, and represent the best
that was available to the early phenomenologists. Yet, in the absence of psychobiological infor-
mation to guide classification, the profession remains wedded to the descriptive approach.
Two symptom-based theoretical models to psychiatric definitions and diagnosis exist.
The first is known as the monothetic approach. This identifies certain symptoms as essen-
tial. The symptoms are narrow and very specific. Thus those patients with specific clusters of
symptoms would be regarded as likely to belong to the same diagnostic group. In respect of
major depression/depressive episode, those with melancholy or psychotic symptoms would
be regarded as having a biologically determined condition and as constituting a relatively
homogenous group for research purposes, as suggested by Parker and Peterson (2015).
This contrasts with the polythetic model, which identifies a broad range of symptoms,
none of which take precedence over the others. This is the approach used in the current classi-
fications. As a result, the symptoms themselves can be wide-ranging, from increased appetite
and increased sleep with panic attacks to weight reduction, lethargy and psychotic symptoms.
Each person has to have a specific minimum number of symptoms, but none is essential or
has to be present in every individual. Even the actual symptom threshold at which a diagnosis
is made is arbitrary, and while it is set at 5 for major depression, this is not based on any stud-
ies linking psychobiology, the quantum of distress or the degree of dysfunction to the chosen
number (Maj, 2011).
The monothetic approach would be more likely to identify a specific condition, since all
those so diagnosed would be broadly similar in their symptoms; however, the risk of not diag-
nosing those with atypical presentations is high. That is, there is a high risk of false negatives.
By contrast, a polythetic approach would identify many with the condition and the clinical
picture would be widely diverse, but there would be a risk of over-diagnosis, that is, of false
positives.
One way to address this dilemma would be to require that certain symptoms are essential
to making the diagnosis. Post-traumatic stress disorder gives the impression of being mono-
thetic because it has attached weights to four symptom clusters. However, these are expressed
polythetically – for example, ‘any 1 of 5 intrusion symptoms’ – so the problem of dissimilarity
between those in the diagnostic category continues, with the potential for thousands of dif-
ferent symptom combinations resulting in enormous heterogeneity. To be truly monothetic,
the criteria should specify essential symptoms within each cluster, all of which are considered
essential and sufficient to that category’s definition (also called classical categorisation); thus
all the members would be very similar.
In relation to adjustment disorder, it has been suggested that if specific symptom criteria
are developed they should be weighted. One symptom mentioned in this regard is affect mod-
ulation. This is unimpaired in those with AD in that ‘the mood state of those with AD depends
more on the cognitive presence of the stressor so that immediate impairment of mood is
observed when the stressor is mentioned, while followed by a more pronounced mood recov-
ery when the patient is distracted as compared to those with major depression’ (Baumeister
et al., 2009). Finally, reducing the overall number of symptoms in the criteria, and weighting
them, would also greatly reduce the diversity of features in those with the same diagnosis.

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 Controversies in Classifying Psychiatric Disorder 19

Reliability, Operational Definitions and Diagnostic Criteria

Reliability refers to the extent to which a person, diagnosed as having a psychiatric disorder
at one time-point, has, when re-interviewed or over time, the same disorder. Thus, replication
by other professionals or over time is the hallmark of reliability. Concordance between diag-
noses using two different systems of classification is another form of reliability. Reliability and
concordance have implications for how clinicians can accurately convey information about
different syndromes to each other and to patients, and be accurately understood. But reli-
ability does not imply validity, since any arbitrarily drawn conglomerate of symptoms can be
replicated, even when they are not part of a recognised psychiatric syndrome.
Concerns about reliability were prompted by the US/UK schizophrenia study (Kendell
et al., 1971) showing that patients with the same symptoms tended to be diagnosed with
schizophrenia in the United States, and with bipolar disorder in the United Kingdom. Thus,
improving inter-clinician reliability was imperative. To achieve this, operational definitions
were developed by DSM-III for each disorder by including symptoms, their duration and
thresholds (symptom numbers) above which disorders were diagnosed. These definitions are
continually being updated. ICD-9 and its successors were less rigid, and provided general
descriptions rather than specific symptom prescriptions. Thus greater latitude was, and con-
tinues to be, accorded to clinical judgement.
A detailed examination of reliability for each and every psychiatric diagnosis within ICD-
10 and between it and DSM is constrained by chapter lengths in this volume, but there are
broad agreements. Overall, for non-psychotic disorders, the degree of concordance between
ICD-10 and DSM-IV lies between 33% and 87%. The diagnoses with less than 50% agreement
between the two systems included harmful substance use or abuse, PTSD, and agorapho-
bia without panic disorder. Dysthymia and depressive episode had the highest concordance
at over 80% (Andrews et al., 1999). Comparisons of the congruence between ICD-10 and
DSM-IV for psychotic disorders found that it was best for bipolar disorder and unsatisfactory
for seasonal affective disorder (Cheniaux et al., 2009).
Turning to DSM-5, the field trials suggest that very good reliability has been achieved
(Regier et al., 2013) for most of the disorders evaluated. At this point, there are no com-
parison studies between DSM-5 and ICD-10 or ICD-11. Broadly, the goal of DSM-5 to
achieve reliability has been successful, but demonstrating validity continues to be a major
difficulty.

Co-morbidity, Consanguinity and Co-occurrence

A further issue for consideration in relation to validity is the possibly of having two or even
more simultaneous diagnoses. This is known as co-morbidity, and across psychiatric syn-
dromes it is reported as high. There is much confusion about this term, and it is frequently
used erroneously and inaccurately.
The term ‘co-morbidity’ was first used by Feinstein (1970), who defined it as the coex-
istence of two or more diseases, pathological conditions or ‘clinical entities’ in the same
patients. It can be used to describe any clinically relevant phenomenon separate from the
primary disease of interest that occurs while the patient is suffering from the primary dis-
ease, even if this secondary phenomenon does not qualify itself as a disease per se (Feinstein,
1970). Others define it as the co-occurrence of two diagnoses at the same time for a single
patient independently of etiological and/or pathway considerations (Banaschewski et al.,
2007; Rothenberger et al., 2010), or as the association of two distinct diseases in the same

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 20 Fish’s Clinical Psychopathology

individual at a rate higher than expected by chance (Bonavita and de Simone, 2008). Some
recommend the use of the term to only refer to physical illness that is accompanied by a psy-
chiatric disorder (Goldberg, 2011).
This terminological confusion creates a ‘conceptual cacophony in psychiatry’
(Kecmanović, 2011), and may be associated with imprecise thinking and corresponding
confusion in the area of co-morbidity. Tyrer (2017) has attempted to restore harmony to the
cacophony by describing three types of relationship, which he termed co-morbidity, consan-
guinity and co-occurrence.
The three relationships are as follows:

Co-morbidity is when two or more discrete, unrelated entities are present in the same ­person,
for example, obsessional personality disorder and schizophrenia.
Consanguinity is more commonly seen in psychiatry; it is the overlap between symp-
toms from two or more conditions that occur together with such frequency that they
should be regarded as a single entity – for example, schizophrenia symptoms and anxi-
ety symptoms – rather than being separately diagnosed as if they were separate and
independent – for example, schizophrenia and generalised anxiety disorder.
Co-occurrence can be either of these relationships, and the term is used in cases of uncer-
tainty as to the nature of the relationship due to insufficient research evidence, as in mixed
anxiety and depressive disorder.

The ‘cacophony of thinking’ concerning these relationships particularly arises with regard
to a person with simultaneous depressive symptoms and anxiety symptoms. Such a person
might be diagnosed as having an anxiety disorder co-morbid with a depressive disorder; this
co-morbid approach assumes that both are independent of each other. However, as every
clinician knows, both are frequently found together, and they might be better regarded as
representing a single psychopathological entity called depressive disorder. This would repre-
sent the consanguineous approach. At present, due to the uncertain status, a mixed-disorder
model called mixed anxiety depressive disorder is included in ICD-10 but not in DSM-5. The
co-occurrence indicated by this term is due to uncertainty about the nature of the relation-
ship of each symptom cluster to the other. Similar considerations apply to schizophrenia and
bipolar disorder, which may be co-morbid, two independent disorders or consanguineous, a
single entity called schizoaffective psychosis.
This is of more than theoretical interest, since whether we regard disorders as co-morbid
or consanguineous ought to focus our attention on the biology of these conditions in a par-
ticular direction. The difficulty with the co-morbid approach is that it gives a false impression
of prevalence, inflating the rates, while also promoting polypharmacy for the individual com-
ponents identified. I was reminded of this when reading a letter from a colleague in another
country transferring a patient’s care to me. The patient was reported as having five different
psychiatric disorders, and the letter concluded by requesting a specific treatment for each.
Failure to identify co-morbidity may also have an undue influence on prognosis. Depression
and anxiety, when seen clinically as separate, that is, as co-morbid, have a better outcome than
when they are viewed as a single entity, that is, as consanguineous.

Conclusion
It was hoped that advances in genetic and neurobiological studies would lead to emergent
validity of a range of psychiatric disorders over time, but this has not happened. The current
phenomenological approach is a pragmatic response to a difficult conundrum (Jablensky,
2016). It is also important to understand that the nebulous criterion of clinical significance

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 Controversies in Classifying Psychiatric Disorder 21

confers no evidence of validity on psychiatric disorders. One of the consequences of inad-

equate validation studies is that there has been a proliferation of new disorders over time,
based on behaviours and/or symptoms that may not in fact be real psychiatric disorders but
variants of the normal distribution of features found in the human condition.

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 Disorders of Perception

3
Sensory Distortions
These are changes in perception that are the result of a change in the intensity and quality of
the stimulus or the spatial form of the perception.

Changes in Intensity (Hyper- or Hypo-aesthesia)

Increased intensity of sensations (hyperaesthesia) may be the result of intense emotions or a
lowering of the physiological threshold. Thus a person may see roof tiles as a brilliant flaming
red or hear the noise of a door closing like a clap of thunder. Anxiety and depressive disorders
as well as hangover from alcohol and migraine are all associated with increased sensitivity to
noise (hyperacusis) such that even everyday noises like washing crockery are magnified to the
point of discomfort. Those who are hypomanic, suffering an epileptic aura or under the influ-
ence of lysergic acid diethylamide (LSD) may see colours as very bright and intense, but this
can also be a feature of intense normal emotions such as religious fervour or the unsurpassed
happiness of being in love.
Hypoacusis occurs in delirium, where the threshold for all sensations is raised. The defect
of attention found in delirium further reduces sensory acuity. This highlights the importance
of speaking to the delirious patient more loudly and more slowly than usual. Hypoacusis is
also a feature of other disorders associated with attentional deficits such as depression and
attention-deficit disorder. Visual and gustatory sensations may also be lowered in depression,
for example everything may look black or all foods may taste the same.

Changes in Quality
It is mainly visual perceptions that are affected by this, brought about by toxic substances.
Colouring of yellow, green and red have been named xanthopsia, chloropsia and erythropsia.
These are mainly the result of drugs (e.g., santonin, poisoning with mescaline or digitalis)
used in the past to treat various disorders. The qualitative change most associated with drugs
now is the metallic taste associated with the use of lithium, although this is not a hallucination
but a true change in gustation. In derealisation everything appears unreal and strange, while
in mania objects look perfect and beautiful.

Changes in Spatial Form (Dysmegalopsia)

This refers to a change in the perceived shape of an object. Micropsia is a visual disorder in
which the patient sees objects as smaller than they really are. The opposite kind of visual
experience is known as macropsia or megalopsia. This definition of micropsia includes the

24

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 Disorders of Perception 25

experience of the retreat of objects into the distance without any change in size, although
some authors call this porropsia. The terms macropsia and micropsia have also been used to
describe the changes of size in dreams and hallucinations (Lilliputian hallucinations). Some
authors reserve the term dysmegalopsia to describe objects that are perceived to be larger
(or smaller) on one side than the other (Sims, 2003), while others use the term generically to
describe any change in perceived size (Hamilton, 1974). Others use the term metamorphosia
rather than dysmegalopsia to describe objects that are irregular in shape.
Dysmegalopsia can result from retinal disease, disorders of accommodation and con-
vergence, but most commonly from temporal and parietal lobe lesions. Rarely, it can be
associated with schizophrenia. In oedema of the retina, visual elements are separated so
that the image falls on what is functionally a smaller part of the retina than usual. This
gives rise to micropsia. Scarring of the retina with retraction naturally produces macrop-
sia, but as the distortion produced by scarring is usually irregular, metamorphosia is more
likely to result.
Complete paralysis of accommodation or overactivity of accommodation during near
vision is likely to cause macropsia, while partial paralysis of accommodation will lead to
the experience during near vision that the object is very near, that is, micropsia will occur.
If accommodation is normal but convergence is weakened, macropsia occurs, and vice
versa.
Despite the fact that disorders of accommodation and convergence can cause dysmega-
lopsia, it is not common to meet cases in which the visual disorder is the result of a failure
of these peripheral mechanisms. Occasionally, dysmegalopsia may occur in poisoning with
atropine or hyoscine. Although hypoxia and rapid acceleration of the body can disturb accom-
modation and convergence, dysmegalopsia is rare among high-altitude pilots. Sometimes the
nerves controlling accommodation are affected by conditions such as chronic arachnoidi-
tis, and this may give rise to dysmegalopsia. However, it is more common in central lesions,
mainly those affecting the posterior temporal lobe, and macropsia, micropsia or irregular
distortions may occur either during the aura or in the course of the fit itself.

Distortions of the Experience of Time

From the psychopathological point of view, there are two varieties of time: physical and per-
sonal, the latter being determined by personal judgement of the passage of time. It is the latter
that is affected by psychiatric disorders. We are all aware of the influence of mood on the pas-
sage of time, so that when we are happy ‘time flies’, and when we are sad it passes more slowly.
In severe depression, the patient may feel that time passes very slowly and even stands still.
Slowing down of time is most marked in those with psychotic depressive symptoms. By con-
trast, the manic patient feels that time speeds by and that the days are not long enough to do
everything. Some patients with schizophrenia believe that time moves in fits and starts, and
may have a delusional elaboration that clocks are being interfered with.
In acute organic states, disorders of personal time are shown in temporal disorientation,
and in milder forms there may be an overestimation of the progress of time. Some patients
with temporal lobe lesions may complain that time passes either slowly or quickly.
In recent years, there is some evidence to suggest that patients with schizophrenia
have abnormalities of time judgement, estimating intervals to be less than they are. Age
disorientation is another feature present in patients with chronic schizophrenia, noted
even in the absence of any other features of confusion (Manschreck et al., 2000; Tapp
et al., 1993).

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 26 Fish’s Clinical Psychopathology

Sensory Deceptions
These can be divided into illusions, which are misinterpretations of stimuli arising from an exter-
nal object, and hallucinations, which are perceptions without an adequate external stimulus.

Illusions
In illusions, stimuli from a perceived object are combined with a mental image to produce a
false perception. It is unfortunate that the word ‘illusion’ is also used for perceptions that do
not agree with the physical stimuli, such as the Müller-Lyer illusion in which two lines of equal
length can be made to appear unequal depending on the direction of the arrowheads at the
end of each respectively. Illusions in themselves are not indicative of psychopathology since
they can occur in the absence of psychiatric disorder: the person walking along a dark road
may misinterpret innocuous shadows as threatening attackers. Illusions can occur in delir-
ium when the perceptual threshold is raised and an anxious and bewildered patient misin-
terprets stimuli. While visual illusions are the most common, they can occur in any modality.
For example, auditory illusions may occur when a person hears words in a conversation that
resemble their own name and so believe they are being talked about. At times, it is difficult to
be certain that the patient is describing an illusion or whether they are actually hearing hallu-
cinatory voices talking about them and attributing them to real people in their environment.
The classic psychiatrists described fantastic illusions in which patients saw extraordinary
modifications to their environment. One had a patient who looked in the mirror and instead
of seeing his own head saw that of a pig. Fish had a patient who insisted that during an inter-
view he saw the psychiatrist’s head change into that of a rabbit. This patient was given to exag-
geration and confabulation. He would also invent non-existent puppies and tell other patients
not to tread on them. However, fantastic illusions belong more in the worlds of fiction than in
the realm of psychiatry (Hamilton, 1974).
Three types of illusion are described (Sims, 2003) as follows:
• Completion illusions: These depend on inattention such as misreading words in
newspapers or missing misprints because we read the word as if it were complete.
Alternatively, if we see faded letters, we may misread the word on the basis of our
previous experience, our interests and so on. For example, to the person with an interest
in reading, the word ‘–ook’ might be misread as ‘book’ even though the faded letter was
an ‘l’.
• Affect illusions: These arise in the context of a particular mood state. For example, a
bereaved person may momentarily believe they ‘see’ the deceased person, or the delirious
person in a perplexed and bewildered state may perceive the innocent gestures of others
as threatening. In severe depression when delusions of guilt are present, the person,
believing that he is wicked, may also say that he hears people talking about killing him
when he is in the company of others. In these circumstances it is difficult to know if he is
experiencing illusions or hearing hallucinatory voices talking about him and attributing
them to those around him.
• Pareidolia: this is an interesting type of illusion, in which vivid illusions occur without
the patient making any effort. These illusions are the result of excessive fantasy thinking
and a vivid visual imagery. They cannot therefore be explained as the result of affect
or mind-set, and so they differ from the ordinary illusion. Pareidolias occur when the
subject sees vivid pictures in fire or in clouds, without any conscious effort on his part
and sometimes even against his will.

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 Disorders of Perception 27

Illusions have to be distinguished from intellectual misunderstanding. The latter is usually

obvious. Thus, when someone says that a piece of rock is a precious stone this may be a misun-
derstanding based on lack of knowledge. The distinction between an illusion and a functional
hallucination (see p. 35) may be more difficult. Both occur in response to an environmental
stimulus, but in a functional hallucination both the stimulus and the hallucinations are per-
ceived by the patient simultaneously, and can be identified as separate and not as a trans-
formation of the stimulus. This contrasts with an illusion in which the stimulus from the
environment changes but forms an essential and integral part of the new perception.
Trailing phenomena, although not strictly illusions, are perceptual abnormalities in which
moving objects are seen as a series of discrete and discontinuous images. They are associated
with hallucinogenic drugs.

Hallucinations
Definitions
The definition of a hallucination as ‘a perception without an object’ has the advantage of being
simple and to the point, but it does not quite cover functional hallucinations. To cover these,
and to exclude dreams, Jaspers suggested the following definition: ‘a false perception which
is not a sensory distortion or a misinterpretation, but which occurs at the same time as real
perceptions’. Schedule for Clinical Assessment in Neuropsychiatry (SCAN) (World Health
Organization, 1998) defines hallucinations as ‘false perceptions’.
What distinguishes hallucinations from true perceptions is that they come from ‘within’,
although the subject reacts to them as if they were true perceptions coming from ‘without’.
This distinguishes them from vivid mental images that also come from within but are recog-
nised as such. As with all abnormal mental phenomena, it is not possible to make an absolute
distinction as the individual with eidetic imagery will examine his images as if they were
external objects, and some patients have sufficient insight to recognise that their hallucin-
ations are not truly objective.
A great deal of discussion has raged about the phenomenon of ‘pseudo-hallucination’.
Most of the statements are derived from the work of Jaspers (1962), who, first of all, distin-
guished between true perceptions and mental images. Perceptions are substantial; appear in
objective space; are clearly delineated, constant and independent of the will; and their sen-
sory elements are full and fresh. Mental images are incomplete; are not clearly delineated;
are dependent on the will; exist in subjective space; are inconstant and have to be recreated.
Pseudo-hallucinations are a type of mental image that, although clear and vivid, lack the sub-
stantiality of perceptions; they are seen in full consciousness, are known to not be real percep-
tions, and are located not in objective space but in subjective space (e.g., inside the head). Like
true hallucinations they are involuntary. In his book General Psychopathology, Jaspers (1962)
gives two examples, one of a patient who had taken opium, making it unlikely therefore that
the pseudo-hallucination appeared in clear consciousness. The second concerned a patient
with a chronic psychotic illness who himself distinguished between hallucinatory voices
in objective space and voices which he heard inwardly (pseudo-hallucinations). Pseudo-
hallucinations can be identified in the auditory, tactile or visual modalities.
The confusion over the meaning of ‘pseudo-hallucination’ stems from two different
approaches to definition; one based on insight (Hare, 1973) and the other, as exemplified by
Jaspers (1962), based on whether the image lies in inner or outer perceptual space. Jaspers
believed that pseudo-hallucinations are variants of fantasy/mental imagery and thus do not

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 28 Fish’s Clinical Psychopathology

carry the same diagnostic implications as true hallucinations. Hare argued that since insight
often fluctuates and at times is partial, it was more profitable to think in terms of degree
of insight. This, however, renders the concept of pseudo-hallucinations and their diagnostic
importance largely superfluous if the phenomenon is determined by the degree of insight,
which itself is on a continuum. Schedule for Clinical Assessment in Neuropsychiatry (World
Health Organization, 1998) does not use the term pseudo-hallucination, but does have an
item for rating insight and for whether the experience occurs inside or outside the head.
Jaspers insisted that there is no gradual transition between true and pseudo-­hallucinations,
but Fish, in a previous edition of this book (Hamilton, 1974), disagreed, citing an example of
non-substantial hallucinations experienced in outer objective space; patients with substantial
hallucinations also experienced these in outer objective space but they recognised these as the
result of their active vivid imagination. Thus, Fish argued, there is a continuum from pseudo-
hallucinations to hallucinations. This is confirmed by the work of Leff (1968) on sensory dep-
rivation and perception. He found that subjects could not always distinguish between images
and hallucinations, and concluded that the perceptual experiences of normal people under
conditions of sensory deprivation overlap considerably with those of psychiatric patients.
One of the current editors of this book (PC) has patients diagnosed with schizophrenia who
describe substantial hallucinations in inner perceptual space and who believe that these are
true perceptions. Are these true or pseudo-hallucinations?
The importance of pseudo-hallucinations according to some authorities is that their pres-
ence does not necessarily indicate psychopathology, unlike true hallucinations, which are
indicative of serious mental illness. Although such a comment is found in many textbooks
of psychiatry, its veracity must surely rest with the definition that is adopted, since, as Hare
argues, if insight is the criterion and this fluctuates during illness, the meaning and relevance
of pseudo-hallucinations become redundant. The ___location of the experience also become
redundant if, despite recognising it to be internal, the person believes it to be real.

Causes
Hallucinations can be the result of intense emotions or psychiatric disorder, suggestion, dis-
orders of sense organs, sensory deprivation and disorders of the central nervous system.

Emotion
Very depressed patients with delusions of guilt may hear voices reproaching them. These are
not the continuous voices of paranoid schizophrenia or organic hallucinosis but tend to be
disjointed or fragmentary, uttering single words or short phrases such as ‘rotter’, ‘kill yourself ’
and so on. The occurrence of continuous persistent hallucinatory voices in severe depression
should arouse the suspicion of schizophrenia or some intercurrent physical disease. On the
other hand, the hallucinations that occur in schizophrenia are often of a persecutory nature
and may consist of voices giving a commentary on the person’s actions and discussing him in
a hostile manner.

Suggestion
Several experimenters have shown that normal subjects can be persuaded to hallucinate.
When asked to walk down a dimly lit corridor and stop when they saw a faint light over the
door at the end, most subjects stopped walking at some time during the study, saying that they
could see a light even though none was switched on. Similarly, subjects can be persuaded to
hallucinate visually or aurally, either by hypnosis or by brief task-motivating instructions.
This latter technique consists in asking the subject to try to hallucinate a tune or an animal and

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 Disorders of Perception 29

then telling him that much more must be done as most people can hallucinate if they try hard
enough. A group in whom suggestion was believed to be relevant to the genesis of hallucina-
tions (Hamilton, 1974) were those with a diagnosis of the so-called hysterical psychosis. The
hallucinations, visual in nature, were said to conform to the patient’s fantasies and cultural
background. However, since this diagnosis is no longer recognised in either the DSM or ICD
classifications, it is only of historical interest. The belief that Ganser syndrome is psychogenic
in origin (Ungvari and Mullen, 1997) opens the possibility of the role of suggestion in the
genesis of the hallucinations in this condition, although others dispute this and regard it as
an organic condition (Latcham et al., 1978). The syndrome is now recognised to occur in a
variety of psychiatric disorders, including schizophrenia, dissociative disorder, malingering,
organic states and so on.
Disorders of a Peripheral Sense Organ
Hallucinatory voices may occur in ear disease and visual hallucinations in diseases of the
eye, but often there is some disorder of the central nervous system as well. For example, a
woman aged sixty-six suffered from glaucoma and then began to have continuous visual hal-
lucinations. At the time she showed evidence of atherosclerotic dementia and had a focus of
abnormal activity in the left posterior temporal lobe. Charles Bonnet syndrome (phantom
visual images) is a condition in which complex visual hallucinations occur in the absence of
any psychopathology and in clear consciousness. It is associated with either central or per-
ipheral reduction in vision and not surprisingly is most common in the elderly, although it
can occur in younger people also. The hallucinatory episodes are of variable duration and can
last for years. The images may be static or in motion, and the importance of this diagnosis is
as a differential from psychopathological causes of hallucinations. Peripheral lesions of sense
organs may play a part in hallucinations in organic states, and it has been shown that negative
scotomota are to be found in patients with alcohol misuse.
Sensory Deprivation
If all incoming stimuli are reduced to a minimum in a normal subject, they will begin to hal-
lucinate after a few hours. These hallucinations are usually changing visual hallucinations and
repetitive words and phrases. It has been suggested that the sensory isolation produced by
deafness may cause paranoid disorders in the deaf (Cooper, 1976). Similarly, sensory depriv-
ation due to the use of protective patches may contribute to the delirium that follows cata-
ract surgery, along with mild cognitive deficits due to ageing. There is an interesting case on
record of a patient who had ‘black patch disease’ after an operation and was frightened by
the prospect of another operation on her other eye a few years later. She was reassured by a
psychiatrist, who saw her before and immediately afterwards, and promised to see her when-
ever requested during the post-operative period. After the second operation, she had no hal-
lucinations of any kind.
Disorders of the Central Nervous System
Lesions of the diencephalons and the cortex can produce hallucinations that are usually visual
but can be auditory.
Hypnagogic and hypnopompic hallucinations are special kinds of organic hallucination.

Hallucinations of Individual Senses

Before deciding that a patient is hallucinated, the possibility of other explanations must be
considered; these are not necessarily of pathological significance. The differential diagnosis
of hallucinations includes illusions, pseudo-hallucinations, hypnagogic and hypnopompic

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 30 Fish’s Clinical Psychopathology

images, vivid imagery and normal perceptions. The possibility that the experience is a delu-
sion without a hallucination, although described as if it were a perceptual abnormality, must
also be considered, for example ‘people talk about me’ (when in fact the patient does not hear
others talking but believes they are doing so).

Hearing (Auditory)
Hallucinatory voices were called ‘phonemes’ by Wernicke in 1900, although this term, a
technical one derived from linguistics, is rarely used now. Auditory hallucination may be
elementary and unformed, and experienced as simple noises, bells, undifferentiated whispers
or voices. Elementary auditory hallucinations can occur in organic states and noises, partly
organised as music or completely organised as hallucinatory voices, in schizophrenia. In the
latter they may form a part of the basis for the patient’s delusion that they are the victim of
persecution or that their thoughts or actions are being controlled. ‘Voices’ are characteristic of
schizophrenia and can occur at any stage of the illness. As well as occurring in organic states,
such as delirium or dementia, they can occasionally occur in severe depression but they are
usually less well formed than those described in schizophrenia.
Hallucinatory voices vary in quality, ranging from those that are quite clear and can be
ascribed to specific individuals to those that are vague and which the patient cannot describe
with any clarity. Patients are often undisturbed by their inability to describe the direction
from which the voices come or the sex of the person speaking. This is quite unlike the experi-
ence of the healthy individual. The voices sometimes give instructions to the patient, who
may or may not act upon them; these are termed ‘imperative hallucinations’. In some cases
the voices speak about the person in the third person and may give a running commentary on
their actions. These are among Schneider’s first-rank symptoms, and although this was one
thought to be diagnostic of schizophrenia, this is no longer the case since these symptoms
have also been described in mania (Gonzalez-Pinto et al., 2003). Auditory hallucinations may
be abusive, neutral or even helpful in tone. At times they may speak incomprehensible non-
sense or neologisms.
The effect of the voices on the patient’s behaviour is variable. A number of patients (becom-
ing fewer in number with advances in treatment) have continuous hallucinations that do not
trouble them. For others, the persistence of the hallucinations cuts across all activities so that
the patient is seen to be listening and even replying to them at times. Sometimes activity may
diminish due to preoccupation with the hallucinations.
One type of auditory hallucination is hearing one’s own thoughts spoken aloud and is
also one of Schneider’s first-rank symptoms. Known in German as Gedankenlautwerden, it
describes hearing one’s thoughts spoken just before or at the same time as they are occurring.
Écho de la pensée (French) is the phenomenon of hearing them spoken after the thoughts have
occurred. Probably, the best English term would be ‘thought echo’ or the alternative and more
cumbersome ‘thought sonorisation’. Of note, SCAN classifies thought echo as a disorder of
thought (World Health Organization, 1998) rather than as a hallucinatory experience. The
patient may also complain that their thoughts are no longer private but are accessible to oth-
ers. This is known as thought broadcasting or thought diffusion (also a first-rank symptom)
and is best classified as a disorder of thought rather than a hallucinatory experience, since
there is no necessary implication that thoughts must first be heard. However, there are dif-
ferent definitions of this phenomenon, some of which specify that the thoughts must first be
audible, so that Gedankenlautwerden/échos de la pensée are prerequisites to thought broadcast
(Pawar and Spence, 2003).

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 Disorders of Perception 31

Patients explain the origin of the voices in different ways. They may insist that the voices
are the result of witchcraft, telepathy, radio, television and so on. Sometimes they claim that
the voices come from within their bodies such as their arms, legs, stomach and so on. For
example, one patient heard the voices of two nurses and the Crown Prince of Germany com-
ing from her chest. Some patients hallucinate speech movements and hear speech that comes
from their own throat but has no connection with their thinking. One patient complained
bitterly of her ‘talky-talky tongue’ because she was continuously auditorily hallucinated and
felt speech movements in her tongue. Thus, she had both auditory and possibly somatic hal-
lucinations. However, it has been shown that sub-vocal speech movements occur in healthy
subjects when they are thinking or reading silently, and it has also been demonstrated that
patients hearing voices have slight movements of the lips, tongue and laryngeal muscles
and that there is an increase in the action potentials in the laryngeal muscles. It is perhaps
surprising that more patients do not complain of voices coming from their throat or tongue.
A few patients deny hearing voices but assert that people are talking about them. Careful
investigation of the content and nature of the things that others are alleged to have said may
show that the patient has continuous hallucinations and attributes them to real people in
the vicinity. As these are often abusive, the patient may attack those whom they believe are
responsible. A good example of this was a Greek woman who had been a patient in a long-
stay ward for many years. She always denied hearing voices but from time to time would
make unprovoked attacks on fellow patients. One day she was asked if she would like some
Greek newspapers or visits from someone who spoke Greek. She said that this was not neces-
sary because everybody in the hospital spoke Greek. It became obvious that she heard con-
tinuous voices in Greek that she attributed to real people, and that her seemingly motiveless
attacks were prompted by this. This was clearly a delusional elaboration of a hallucinatory
experience.
Imaging studies of auditory-verbal hallucinations (AVHs) are now available and have
identified that activation was in Broca’s area during AVHs, a region classically associated with
speech production (Jardhri et al., 2011). Significant activity in this region was not observed
during visual hallucinations (VHs). This suggests that these experiences are modality specific.
It has been suggested that AVHs arise from a disorder of inner speech (Jones and Fernyhough,
2007).

Vision
These may be elementary in the form of flashes of light, partly organised in the form of pat-
terns, or completely organised in the form of visions of people, objects or animals. Figures of
living things and inanimate objects may appear against the normally perceived environment
or scenic hallucinations can occur in which whole scenes are hallucinated rather like a cinema
film.
All varieties of visual hallucination are found in acute organic states but small animals and
insects are most often hallucinated in delirium. One patient in delirium tremens described
mice carrying suitcases on their backs as they boarded a flight to Lourdes. These hallucin-
ations are usually associated with fear and terror. Patients with delirium tremens are extremely
suggestible so that one may be able to persuade the patient to read a blank sheet of paper; one
investigator produced a disc of light by pressing on the patient’s eyeball, and then persuaded
him that he could see a dog. Scenic hallucinations are common in psychiatric disorders asso-
ciated with epilepsy, and these patients may also have visions of fire and religious scenes such
as the Crucifixion.

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 32 Fish’s Clinical Psychopathology

Often, VHs are isolated and do not have any accompanying voices. Sometimes, however,
visual and auditory hallucinations co-occur to form a coherent whole. Patients with temporal
lobe epilepsy may have combined auditory and VHs and some patients with schizophrenia of
late onset (especially when the illness is protracted) may see and hear people being tortured,
murdered and mutilated.
In some patients, micropsia affects VHs so that they see tiny people or objects, so-called
Lilliputian hallucinations. Unlike the usual organic VHs, these are accompanied by pleasure
and amusement. For example, one patient with delirium tremens was very pleased when she
saw a tiny German band playing on her counterpane. When these occur in delirium tremens
the patient exhibits a combination of child-like pleasure and terror.
Visual hallucinations are more common in acute organic states with clouding of con-
sciousness than in functional psychosis. The disturbance of consciousness makes it difficult
for the patient to distinguish between mental images and perceptions, although this is some-
times possible. Visual hallucinations are uncommon in schizophrenia, and their presence
should raise a doubt about the diagnosis. Some patients with schizophrenia describe visions
and these appear to be pseudo-hallucinations, but on occasion others will insist that their hal-
lucinations are substantial.
Occasionally, visual hallucinations occur in the absence of any psychopathology or brain
disease, and Charles Bonnet syndrome must then be considered as the most likely differential
diagnosis.
Imaging studies have demonstrated activity during visual hallucinatory experiences in the
extra striate visual areas around the ventral lingual and fusiform gyri (BA 19), and in the more
dorsal cuneus and precuneus regions (BA 18). Visual hallucination–related activity was also
observed in the cerebellum, on the posterior declive surface adjacent to the occipital lobe in a
recent meta-analysis (Zmigrrod et al., 2016). Thus, distinct activation patterns were observed
for AVHs and VHs, with few apparent areas of overlap, suggesting little commonality in brain
activity for hallucinations across the different sensory modalities (Zmigrod et al., 2016).
Smell (Olfactory)
Hallucinations of odour (phantosmia or olfactory hallucinations (OH)) can occur in schizo-
phrenia and organic states and, uncommonly, in depressive psychosis. It may be difficult to be
sure if there is a hallucination or an illusion. There may also be a problem distinguishing olfac-
tory hallucination from delusion since there are some people who insist that they emit a smell.
It is important to ascertain if they actually smell this odour, since many seem to base their
belief on the behaviour of other people who, they say, wrinkle their noses or make reference to
the smell. This is referred to as olfactory reference syndrome. Some patients with schizophre-
nia claim that they smell gas and that their enemies are poisoning them by pumping gas into
the room. Episodes of temporal lobe disturbance are often ushered in by an aura involving
an unpleasant odour such as burning paint or rubber. At times, the hallucination may occur
without any fit so that the patient then complains of a strange smell in the house. For example,
one patient with a temporal lobe focus had no fits but, from time to time, would complain of a
smell of stale cabbage water in the house and would turn the house upside down trying to locate
the offending object. Sometimes the smell may be pleasant, for example when some religious
people can smell roses around certain saints; this is known as the Padre Pio phenomenon.
Taste (Gustatory)
Hallucinations of taste (phantaguesia or gustatory hallucinations (GH)) occur in schizophre-
nia and acute organic states, but it is not always easy to know whether the patient actually tastes

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 Disorders of Perception 33

something odd or if it is a delusional explanation of the effect of feeling strangely changed.

Depressed patients often describe a loss of taste or state that all food tastes the same.
OH and GH frequently co-occur, and because of their complexity have not received a lot
of attention in imaging studies. Also, they frequently co-occur with hallucinatory experiences
in other modalities, including touch and bodily sensation (Langdon et al., 2011). Self-smells
(auditory reference syndrome) have also been under-investigated since they are relatively
uncommon. One fMRI study found that phantom taste and smell demonstrated activation
in the brain regions for taste and smell, respectively, and the degree of activation was greatest
when subjects were asked to recall their memory of each sensation. The activation was sup-
pressed by treatment with typical antipsychotic agents (Henkin et al., 2000). However, these
patients did not have psychosis and it is not possible to extrapolate these findings to those who
may have schizophrenia or other psychiatric disorders.
Touch (Tactile)
This may take the form of feeling small animals crawling over the body, which is known as
formication. This is not uncommon in acute organic states. In cocaine psychosis, this type of
hallucination commonly occurs together with delusions of persecution and is known as the
‘cocaine bug’. Some patients experience feeling cold winds blowing on them, sensations of
heat, electrical shocks and sexual sensations; the patient is convinced that these are produced
by outside agencies. In the absence of coarse brain disease, the most likely diagnosis is schizo-
phrenia. Indeed, Sims (2003) points out that there is almost always a concomitant delusional
elaboration of tactile hallucinatory experiences. Sexual hallucinations can occur in both acute
and chronic schizophrenia; for example, one patient complained that she could feel the penis
of her son’s employer in her vagina no matter what she did, and although she could not see the
man she was certain of this.
Sims (2003) classifies tactile hallucinations into three main types: superficial, kinaes-
thethic and visceral (see later in the text). Sims further divides superficial hallucinations,
which affect the skin, into four types: thermic (e.g., a cold wind blowing across the face),
haptic (e.g., feeling a hand brushing against the skin), hygric (e.g., feeling fluid such as water
running from the head into the stomach) and paraesthetic (pins and needles), although the
latter most often have an organic origin. Kinaesthetic hallucinations affect the muscles and
joints, and the patient feels that their limbs are being twisted, pulled or moved. They occur in
schizophrenia, where they can be distinguished from delusions of passivity by the presence
of definite sensations. Vestibular sensations such as sinking in the bed or flying through the
air can also be hallucinated and are best regarded as a variant of kinaestethic hallucinations
and occur in organic states, most commonly delirium tremens. Kinaestethic or vestibular hal-
lucinations occur in organic states such as alcohol intoxication and during benzodiazepine
withdrawal, and may also occur in the absence of any abnormality; for example, after a week’s
sailing an undulating feeling may persist for a few days.
Pain and Deep Sensation
These are termed visceral hallucinations by Sims (2003). Some patients with chronic schizo-
phrenia may complain of twisting and tearing pains. These may be very bizarre when the
patient complains that his organs are being torn out or the flesh ripped away from his body.
For example, a patient described sensations in his brain as of layers of tissue being peeled off
so as to bring to completion the battle between good and evil.
An interesting and unusual variety of hallucinosis is delusional zoopathy. This may
take the form of a delusional belief that there is an animal crawling about in the body.

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Exploring the Variety of Random
Documents with Different Content
 “Yes, and this is ‘mountain,’ ” he ran on, spelling in advance of me;
“and this is meant for ‘Table Land.’ ”
“Quite right; and here is the date fairly clear, showing that this
was done three years ago.”
“But by whom?” he asked quickly; “that is the point.”
For answer I pointed to some marks in the corner below the date.
“What do you make of that?” I asked.
He scrutinised them carefully for some minutes, then, turning to
me said: “I can certainly make nothing else than ‘Miriam’ out of it.”
“Nor I,” I replied; “and, if you notice, there is an obliteration after
it which, from the length of it, might once have been ‘Grey.’ ”
“That is true, but the conclusion that ‘Miriam Grey’ is held a
‘prisoner’ of ‘Te Makawawa’ in a ‘mountain’ near the ‘Table Land’ is
weak in many parts.”
“True, but I can strengthen it,” I hastened to reply. “Do you see
anything in that carving which points to superior talent in the person
who did it?”
“Indeed I do,” he replied with certainty; “this is the work of no
ordinary carver. I should be inclined to say it was the work of a
genius. There are signs of delicate execution about it which no one
could mistake.”
“That is precisely it. Miriam Grey, so said the solicitors, showed
extraordinary signs of genius as a sculptress.”
At the last word my host stared at me with a dreamy look in his
eyes. Had I touched upon the peculiar point of his madness?
“A sculptress!” he said slowly, and gazed for a full half-minute into
the fire, while I watched him. Then, as I did not break the silence,
he resumed: “Yes, there is a Te Makawawa, I know him well; there is
a Table Land not far from here and a mountain near it; and, from
what you have shown me, a woman who is a sculptress is held a
prisoner there.”
He rose from his chair and paced up and down the small hut with
his brows let down in deep and perplexed thought. “Strange—very
strange. But she must be a sculptress of very great genius if——” He
paused abruptly in his pacing the floor.
 “Look here!” he said, casting off his abstraction, “if you will accept
my poor hospitality I can put you up for the night, and then, in the
morning, I will go with you to old Te Makawawa’s pa.”
I saw from his manner that he knew, or thought he knew,
something about the matter, and asked simply, “Have you an idea?”
He looked down at me, then passed his hand over his brow in
perplexity; finally, smoothing back his wayward mane, he faced the
question and said frankly:
“My idea is a dream that I had a year or more ago—a very absurd
dream, but, nevertheless, one so vivid and clear in all its details that
it had, and still has, a strange effect upon me. That dream
sometimes appeals to me as if it were the raison d’être of my
existence in this solitude. And yet again, sometimes I think that my
dream was an actual experience, but I have no proof that it was.
Wanaki! all men who live alone in the bush as I do are more or less
mad. But that word of yours, ‘sculptress,’ has given me an idea that
after all I may not be as mad as I thought. If, to-morrow, old Te
Makawawa can throw any light upon what has long perplexed me,
then I will discuss my dream with you, as it may possibly have some
bearing on the whereabouts of the woman you seek; to-morrow, not
now, for, uncorroborated, it would appear to you so wild and
strange, so obviously the vagary of an unhinged mind, that you
might hesitate to accept my hospitality.”
As he fixed his fine eyes upon me and smiled, I realised that the
fact of his being puzzled by the strangeness of his dream argued for
his sanity; and if, indeed, his mind was really unhinged, it was upon
some sublime point, some noble idea, having an uncommon object,
full of the deep poetry that burned in those eyes.
As I returned his gaze and his smile I felt drawn towards him with
feelings of a sudden friendship, and it was in accord with these
feelings that in my mind I wrote him down a splendid madman.
 CHAPTER II.
THE AGED CHIEF.

It was dawn when I opened my eyes and saw Kahikatea stooping to

get through the doorway, so as to stretch his limbs outside, where
there was no danger of knocking down articles stuck up among the
rafters. Soon afterwards I joined him in front of the hut.
“Ha!” he said, greeting me with a smile full of early morning
freshness, “I always turn out before the sun gets up, so as to see
the lovely colours on the hills—look!”
He pointed to the roof-tree, the very tip of which was glistening
like velvet in the first crimson flush of sunlight. The wooded hill
beyond was bathed in splendour, and the birds were gliding down
umbrageous slopes, chasing the early dragon-flies and filling the
place with song. The storm of the preceding night had left no trace,
and Nature had emerged all fresh and smiling. Kahikatea walked
about enjoying it, while slowly the sunlight crept lower and lower
down his roof-tree until it flooded on to the top of his log hut, and
finally touched his own head before it reached mine.
“It’s glorious living all alone in the bush,” he said; “I get more solid
satisfaction out of it than out of London, or Paris, or New York, or
Sydney, or—hello! there’s my korimako—my little bell-bird—he
always turns up as soon as the sun gets on to his fuchsia tree.”
I followed his outstretched finger and saw his fellow poet of the
sunrise brushing the dewdrops from among the flowers and
scattering them around as he trilled out a rain of melody quite as
liquid as the many-tinted shower that fell upon the moss beneath.
“His song is sadder than it used to be,” said Kahikatea; “the bees
get most of his honey now, and he is doomed to extinction.”
I had almost made up my mind before that this man was a poet,
and one who could be trusted to catch Nature’s higher meanings
from her birds and flowers and trees, from her dawns and sunsets,
and her mid-day hush, when the bell-bird, assuming the rôle of a
solemn, mysterious clock, strikes one in the lofty, silent spaces of the
bush. Now, as I watched his face under the influence of the morning
and the korimako’s music, I conceived a picture of his nature which
has remained with me to this day—the picture of a clear-souled
poet, who could dream and yet act, who was mad and yet sane.
The sun was not far above the horizon when we made a start for
Te Makawawa’s pa. Through the silent grove of palm ferns, along the
well-worn path that I had discovered the night before, and finally by
ways that were new to me, I followed my tall friend down out of the
bush to the sea, where the silver-crested waves were rolling in upon
a grey gravel shore.
After traversing this for some distance we struck inland to avoid a
steep rocky promontory, with bluffs, against which the spray was
dashing high. Then, after several hours’ tramp through flax swamps,
along precipitous ridges, over flooded streams, and through open
dells, where all the rarest ferns in the world seemed to be growing
together, we reached a broad river, and, following it down to the
sea, saw ahead of us, on the summit of a high and bold cliff, the
palisading of Te Makawawa’s pa.
“It’s a difficult place to get into,” said Kahikatea. “There are
precipices on three sides of it, and the entrance here at the bottom
of the hill is not particularly obvious. It must have been a fine
stronghold in the early days.”
We raised a peculiar whoop in vogue among the Maoris, in order
to signify that visitors were approaching; then, receiving the
answering cry of welcome: “Haeremai! Haeremai!” we began the
ascent of the hill. At the entrance of the first palisaded enclosure we
were met by numerous dogs, which barked out of all proportion to
their meagre size. At the second palisading, which enclosed the pa
proper, we saw an aged chief come through a private opening. It
was Te Makawawa himself, and as he drew near I recognised the
tohunga Maori of the order called ariki, which designates the chief,
the priest, and the seer.
“Welcome, O Kahikatea,” he said, addressing my friend in the
Maori tongue. “Welcome, O Pakeha stranger,” he added, turning to
me; “the pa of Te Makawawa is the home of the stranger who comes
with my friend the Forest Tree.”3
“Prop and mainstay of the children of Ira,” said Kahikatea—and I
was surprised at his fluency in the native tongue—“well I know that
thou art the ariki who reads things that are hidden from other eyes.
We have come with a strange word to speak before you, O tohunga
—a word that you alone can make plain.”
Te Makawawa waved his hand with a stately grace, and, inviting
us to follow, led the way into the pa. Conducting us through fenced
lines dividing the houses of the tribal families, he at length reached
his own elaborately carved dwelling, almost on the brink of a great
precipice which overlooked the sea. He ordered his servants to place
clean mats on the ground in the portico, and he—a rangatira4 of the
old school, stood with well-simulated humility until such time as we
should invite him to be seated. We gave the customary invitation,
and Te Makawawa seated himself opposite to us.
Then, when the food baskets had been placed before us and we
had eaten, we sat in silence, the chief, according to custom, waiting
impassively to hear the object of our visit, and we, also according to
custom, deeply considering the words we should use. As Kahikatea
had undertaken the duty of spokesman I was free to observe more
closely the face of the aged chief. He was beardless, his hair was
quite white, and his bold, high forehead, coupled with his piercing
black eyes, gave evidence of great power and ability. His whole face
was tatooed in a way to denote the highest rank: he had evidently
been a great man among his people—an ariki, in whose veins ran
the blood of the Great River of Heaven. He was nearly ninety years
old, so I subsequently discovered, but his age was not written in his
eye nor yet in his proud and erect bearing.
My eyes wandered to the sea below, sparkling in the pathway of
the sun, and holding the little wooded islets in a setting of silver
breakers. Now and again the long rising swell of the Great Ocean of
Kiwa came in with a weird sigh, moaning about the cliffs on the
coast below. Sea birds, uttering plaintive calls, circled overhead and
again swooped down over the face of the cliff. It was a strange spot
wherein was about to be unfolded a stranger tale.
“O wise tohunga,” said Kahikatea at length, “I have dreamed a
dream, and have come to ask you what it means.”
“The wind has whispered some hidden word in the branches of
the Kahikatea,” said the old chief; “lay that hidden word before me,
that I may hold it in my hand.”
“My word is a dream which I will tell—a dream on a night when
the moon was full. It seemed to me that I climbed a great mountain
wall by a high plain yonder towards the setting sun——”
He paused, for he had seen, as I had, a passing movement on the
old chief’s rugged face.
“Do you know of such a mountain wall, O Te Makawawa?” pursued
Kahikatea.
A long silence ensued, and we both watched the aged chief’s face,
while his eyes rested on the ground. He seemed debating in his
mind whether he should answer; but at length, with a craftiness
through which I thought I saw the truth, he raised his eyes and said:
—
“I have myself in dreams wandered astray in a forest at the foot of
a mountain wall, by which I know that my death is waiting for me
there. Your words, O Kahikatea, carried me back to my own dream—
did you ask me a question?”
This was artful. He had evidently made up his mind that he knew
nothing of such a mountain wall, at all events not until he had heard
more.
But my friend did not repeat his question. I think he saw with me
that the old chief had been startled, but had extricated himself
gracefully, and that, now he was on his guard, we should have no
further clue.
“I was saying,” Kahikatea went on, “when I saw that the spirit of
your ancestor was speaking to you, that I climbed up a mountain
wall, I know not how, for it seemed to me that no man could have
passed that way before. In my dream, as I stood on a great platform
at the summit of the wall against the sky, a thin crust of rock
beneath my feet gave way and I fell into a narrow cavern. Not being
able to get out again I groped my way along and found that it
communicated with a passage cut in the rock, narrow, but high, as if
it had been made by, and for, giants. I followed this passage,
winding in and out in the darkness of the rock, and at length came
out again on the summit of the wall.
“Then my feet were guided to a funnel-shaped chasm, down
which—by means of a long, stout pole, which I slanted from ledge to
ledge again and again across the narrow chasm—I made a perilous
descent. At last I felt a solid floor beneath my feet, and, moving
cautiously, made my way across a dark cavern towards a faint light
showing round a buttress of rock. When I gained this point, O thou
prop of the tribes, I saw a sight which startled me—even in my
dream.”
He paused, and I wondered what he was coming to. Te
Makawawa’s piercing eyes were fixed upon my friend in a
penetrating scrutiny as if he would read his inmost soul. But his own
rugged, tatooed face betrayed no thought, no feeling.
After a silence Kahikatea continued:
“It was a form of beauty that I have never since been able to
banish from my mind. There, standing in an open space on the floor
of a cavern of white marble, with the moonlight flooding in upon her
from an opening in the rock, was a figure, white and dazzling. For a
long time I stood gazing at the most beautiful face and form it has
fallen to my lot to look upon. It was a woman in the first years of
womanhood; her arms were raised towards something she could see
in the western sky through the opening; a thin robe covered her
form, and a breath of wind had swayed it gently against her limbs.
But, O chief, mark this: her hair, which fell in rippling folds over her
outstretched arms, was white and glistening, and, though the
expression on her face was that of one who sees a vision of joy, her
eyes were colourless. Her form was full of yearning—of pursuing
prayer towards the glory of her vision, but she moved not. I drew
nearer and stood before her. Then I saw that this woman was an
image in marble, lifelike, beauteous, wonderful; but stone—cold
stone!”
 Again he paused, and I watched the face of the aged chief. It was
calm and unmoved, but his eyes blazed like polished obsidian
reflecting the sun. He spoke never a word, and Kahikatea continued:
“While I gazed in wonder at this radiant image—in my dream, O
chief—I heard a step behind me, and, before I could turn, a stunning
blow on the head felled me. Then I no longer knew light from
darkness. My dream ended there for a time, but when again I
emerged from darkness I was lying on my back on the bank of a
stream at the foot of the mountain wall a thousand feet below, my
clothes wet through, and my body stiff and sore with bruises. That is
my dream, O chief. My words to you are ended.”
Te Makawawa sat silent and thoughtful, considering his reply.
While he was doing so it occurred to me to add my story to
Kahikatea’s statement, for I now understood why my friend had
been startled at my mention of the word “sculptress.”
“I also have a word to lay before you, chief,” said I.
“Proceed, O Friend of Kahikatea,” he replied.
Then I narrated to him the history of the woman—how it had
become a matter of great moment that news of her should be
obtained. How I, through my knowledge of the Maori tongue, had
been sent to look for her, and how, finally, it seemed to me that
what the wind had whispered to the branches of the Kahikatea was
connected in some strange way with the woman, for was she not
wise in the matter of cutting figures out of stone? In conclusion, I
handed him the fragment of wood. He inspected it carefully, and
then asked the meaning of the words.
“They mean,” said I, watching his face intently, “that a woman
named Miriam Grey was taken prisoner eighteen years ago by a
certain Te Makawawa, that she is near a mountain and a tableland—
the meaning here is washed away—and that she was still alive three
years ago. O chief, my words, too, are ended.”
Silence again ensued, which remained unbroken for a long space,
during which time an artist might have caught the aged chief’s
expression exactly, for it remained unaltered. I knew that if he did
not speak soon he would not speak at all, and we should go back
the way we came, not very much wiser than when we started. I
employed the time wondering how much he knew. Was he
considering the terms of his reply, or was he quietly making up his
mind as to whether he should reply at all? At length he raised his
eyes and encountered those of my friend.
“O Kahikatea,” he said solemnly, “like Tawhaki of old thou knowest
the ‘way of the spider,’ and, like him, thou hast seen Hinauri, the
Daughter of the Dawn. I can speak of what I know to one with
whom the Great Tohungas of the Earth have spoken. But with thee,
O Friend of my friend the Forest Tree,” he added, turning to me, “I
will not speak except on a condition which I will lay upon the ground
before you.”
“Lay thy condition upon the ground, O wild white crane among
tohungas—lay thy condition upon the ground before us, that we may
look at it and take it up or not as it seems good to us.”
“It is well,” he replied. “Lo! the beginning of my word to you is
this: I am growing old; my foot is already searching for firm places
among the snows that encircle the summit of Ruahine; I see those
who are not present, I hear those who do not speak; any day I may
look into the eyes of the green lizard that will summon me to
Reinga.5 But before I descend by the sacred Pohutukawa root that
leads to the Abode of Spirits I would undo a wrong that I did—an
evil deed, cruel and unfair beneath the eye of Rehua.
“That is the beginning of my speech to you, and this is how it runs
on. Hearken, Pakehas! You, O Friend of Kahikatea, the Forest Tree,
seek a woman concerning whom, if you agree to my condition, the
spirits that linger by night may speak to me: Te Makawawa, whose
heart is in his face before you, seeks a white-faced child whom he
cannot find, for he knows not the speech of the Pakeha.
“Hear the end, O Friend of my friend, the Forest Tree—the end is
for you. When the child is found I myself will teach you concerning
the woman. The tongue of the Maori is known to you as well as the
tongue of the Pakeha; therefore, you can search among the races of
the South for the white-faced child. If this bargain seems good then
I will speak to you and to the Forest Tree. And when the child is
found I will commune with the spirits of my ancestors about the
woman.”
“And if I find the child, O chief,” I said, “will you swear upon the
sacred tiki6 that you will find the woman?”
Te Makawawa turned a withering glance upon me.
“The Friend of the Forest Tree speaks the Maori tongue, but surely
he does not know the Maori heart——” he began, but Kahikatea
broke in upon his words.
“It is enough,” he said. “The word of Te Makawawa is good; it will
not snap like the kohutukutu’s branch. Let my brother Wanaki say
whether he will accept the condition.”
I am obstinate by nature, and somewhat cynical, but from
Kahikatea’s manner I guessed that old Te Makawawa,
notwithstanding his remark to the effect that the spirits of his
ancestors would enlighten his ignorance, already knew more about
Miriam Grey than we should ever find out unless we accepted his
own terms. Having turned this over in my mind I said:
“I forgot that the word of the ariki was sworn upon his own heart,
which is sacred. I call back my words, O chief, and I agree to your
condition. Now speak and answer the words of Kahikatea about his
dream, and my own words about the woman.”
“It is well,” he said with dignity, drawing his mat closer around
him. “My heart flows out to both of you; to you, O Dreamer of
dreams, and to you, O Seeker in the dark, I will speak words straight
from my breast, but in hearing them know that they may not be
repeated to other ears while I live. That is understood between us.”
 CHAPTER III.
A SECRET OF ANCIENT NIGHT.

For some minutes the aged chief sat silent, looking out far away
over the sea, where the white-winged taniwhas7 of the Pakeha pass
through Raukawa, to gain the great ocean of Kiwa. His thoughts
were as far away as the blue Isle of Rangitoto, marked vaguely in
the horizon. What thing was he pursuing over the dim trail of the
past? Of a truth he seemed to see those who were not present, to
hear those who did not speak. Would he begin his story at the time
when those fierce old history-makers of yore—the Waitahi and the
Ngaitahu—dwelt in the valley of the “Pensive Water,” and held their
land against the fierce invaders coming down from the land of Tara?
No, he turned towards us, and the words from his breast were of
things long, long before the Waitahi fought their frays upon the
sounding shore.
He spoke in a hushed voice; for our ears alone were the secret
things he was about to unfold.
“O men of the great land beyond the mountains and the sea, why
should I tell to you those things which none but our priesthood of
ancient night have known? It is because I have heard the voices of
the Great Tohungas of the Earth speaking to me in sleep, and I have
had no rest. Therefore I will obey the words that have come to me
in the whistling winds of heaven, and reveal a secret of the ancient
tohungas of my race. Yet in doing this I know full well that, by the
occult law of the ages, I shall incur my death.
“Know then, O children of another world, that the blood of the
Great River of Heaven has run through the veins of an unbroken
hereditary priesthood from the further shore of Time to this day that
we see beneath the shining sun. Men who do not know speak of Te
Kahui Tipua; a band of man-eating demons, they say, who dwelt
here in Aopawa. Sons! these are no demons, but the powerful
priesthood of which I speak to you, extending back into the far night
of the world. The Rangitane and the Ngaitahu have nursed our
priests in their wahine’s laps; the Ngatimamoe also, and before them
the Waitahi, skilled in spells—all these came and passed away like
the leaves of the kohutukutu,8 but the father blood of the ancient
Kahui Tipua is of the Great River of Heaven flowing down the ages
from times when this land of the Maori was without a shore from the
rising to the setting sun.
“What the west wind has whispered in the branches of the
Kahikatea, what his friend has spoken with his tongue about the
woman, and my own word to you about a lost child, are the head,
the back, and the tail of one story. Hearken to me then, O men from
over the sea, while I show to you a hidden thing which has never
been shown to a pakeha before, nor revealed to any but our own
priesthood. Then, when Te Makawawa has trodden the Highway of
Tane, and you see his eye set as a star in the sky, you will tell this
sacred thing to your brethren of the other side, for it is a word of
power to the Maori and Pakeha alike. But know that whoever reveals
this hidden thing to the outside world must die.
“Not three days’ journey towards the setting sun is a high plain
rolling like a yellow sea beneath a great mountain wall. On that
sacred plain waves now the golden toi-toi, and it is desolate; but
there was a time when a great city stood there in which dwelt a
mighty race of long ago. And within that mountain wall is the vast
temple of Ruatapu, cut out of the ancient rock by the giant tohungas
of old. This, O children of the sun that rose to-day, was long before
the wharekura9 of our lesser tohungas, many ages before the Maori
set sail from Hawaiki to find these shores. In that temple of the ages
are strange things preserved from the wreck of the ancient world—
things which one day you shall see, but I now shorten my words to
tell of a sacred stone under the protection of the Good Tohungas of
the Brow of Ruatapu, and yet again of another, an accursed stone,
the plaything of the Vile Tohungas of the Pit.
“In that far time, when this land of the Maori was but a small part
of a vast land now eaten by the sea, the people who dwelt in the
city of the high plain were powerful giants, and they were ruled by a
priesthood of tohungas, among whom two kinds of magic were
practised: the Good and the Vile. The Good Tohungas derived their
spells, like Tawhaki, from the heavens above, where the Great Spider
sits weaving his web around him, and they dwelt in the forehead of
the mountain wall. The Vile Tohungas obtained their spells, like
Tangaroa, from the depths of the sea, and from the gloom of
Porawa; they inhabited the foundations of the mountain. But
although both dwelt in the same temple, there was a deadly hatred
between them, and, when they met in battle, fierce lightnings were
seen to issue from the rocks.
“I am not now the hereditary priest of that temple, but many
moons ago, before the snows fell on my hair, I was called by the
Great Tohungas, whose eyes look down from the northern sky, to
enter the mountain and take the place of my father, who was
growing old. My father, worn with doing the will of the tohungas in
the temple, came out to die, and I took his place, even as I, after
many years, have come out to die, while my son, Ngaraki the Fierce,
has taken my place. When I entered the mountain by a path any
brave man might find and follow, and further, when I ascended to
the upper part of the mountain, by a way that no man could find
unless he were guided as I was, I found there the sacred white
stone, before which it was the work of the priest to sing the magic
karakia, which have been handed down from the time of the ancient
city. For the tradition given to me by my father, O Pakehas, told that
in this stone stood the form of a woman, beauteous as the dawn;
and the prophecy attached to her was that one day the stone which
enclosed her would be broken, and she would stand free.
“Sons of Kiwa, hear the sacred story of the woman of the ancient
city, and listen well, that my words do not pass by like the empty
wind, for, in revealing this for the good of my race and yours, I give
myself over to the Woman of Death and Darkness—such is the law
by which I, a sometime priest of the mountain temple, will abide. In
the times of which the rocks of that temple alone keep a record, the
bright goddess Hia, or, as we call her, Hinauri, the Daughter of the
Dawn, came down from the skies to restore the divine magic which
the Vile Tohungas had almost driven from the world. She became
queen of the city on the plain, and tried to rule the people by the
love-magic she brought with her. But she failed: the people were
being led down to death by the vile brethren of Huo, or, as we know
her, Hine-nui-te-Po, the Daughter of the Darkness. They would not
look upon the dazzling beauty of Hia’s face, nor would they hear her
words. E tama! none can sin against the Great Spider and live. Lo!
Mariki, the Woman of Pestilence, slid down a silky thread of the vast
web and breathed death on the city. Tu-of-the-Whirlwind came also
and smote the great land.
“But the Tohungas of the Brow of Ruatapu had been taught in
dreams when the great fire of Io throbbed through them and lighted
their heads. They foresaw the destruction of the city, and took the
Queen Hinauri to a white cave in the forehead of the mountain,
where she showed them the last strange wonder of her magic.
Standing on the floor of the cave, with her giant priests around her,
she gazed through the opening towards the western sky above the
hills. A ray of golden light pierced the air and shone into the place. It
fell upon her face and form. It lingered in her eyes and on her dark
flowing hair. The priests fell back dazzled by her glory. Then she
raised her arms towards the western sky and spoke strange words:
‘Lo! in the distance it is shown to me—the land of my people as it
will be in the far future. I see them living in happiness, ruled by my
love-magic. Ages will pass away before that time will be, but behold,
I will leave my body here waiting and watching for that future when
my people shall come back; and, at the dawn of that bright age, I
too will return as a sign to the world. And you, my priests, will watch
my sacred body till that day. Then, when I return, Huo, the false
image of myself, which will be fashioned in this temple below, shall
be hurled down upon the heads of the Vile Tohungas, her
worshippers.’
“She ceased, and the golden ray seemed to be fading from her,
while she stood as if listening to some mellow music from the sunlit
slopes of the far-off future land of peace and love. A light leapt into
her eyes, and a smile broke over her face. Lo! even while she stood
there leaning forward, with her arms outstretched as if to some
lovely vision of the dawn, the sun ray faded quite away, and left her
spellbound, immovable—a radiant statue of expectancy.
“Then, as the Tohungas chanted their mystic song they saw that
her spirit had fled, leaving her body standing like stone. Like stone, I
said, O Kahikatea; but her spirit had not taken away the smile from
her lips nor the joy from her eyes. The lovelight would still dwell
there, and her arms would still remain outstretched in longing until
the ages should have rolled by—in constant yearning until some
distant day should bring her people back to repeat their history with
a happier close. O Pakehas, it was a thing to see: Hinauri the
Radiant One, who rivals the dawn in her beauty, stood there waiting,
waiting, waiting till the far future of the world should come with Ihi
Ihi, the sun ray, to call her back to life.
“O Sons of the Shining Sea, hear how my tale runs on. Summer
and winter came and went for hundreds of years, while in the cave
high up in the silence of the mountains stood for ever the Daughter
of the Dawn, holding out her arms to the unborn future of the
South. Far below upon the plain lay the City of the Southern Cross,
deserted, silent, and crumbling to ruin. A pestilence had fallen upon
the land, slaying the people as one man, and now through the silent
streets wandered the dragons of the desert. By night the moonlight
glinted upon the palaces and domes, showing here gigantic columns,
and there a patch of open square, while sometimes from the
shadowy streets arose a ghostly murmur, as of a phantom race that
is dead and gone, whose spirits linger by night around the desolation
of their former homes. But the Bright One’s gaze was fixed, not upon
the city below, but on the limits of future time.
“How can I show you the wonder of Hinauri’s waiting for the
dawn? O Pakehas, on calm moonlight nights the children of the
misty moonbeam looked in at the opening of the cave and wondered
to see her standing there, a figure of beauty, all shining with
moisture, in the clear, pale ray. The drops that drip so slowly in
limestone caves had begun to deposit their treasures upon her form.
Her robes shone with a thousand crystalline gems. Her hair rippled
down like wavy stalactites laden with sparkling clusters of precious
stones. They had gathered like the dust of diamonds upon her arms,
and neck, and brow, while from the roof of the cave the ever-
dripping, crystal-laden water had tried to place a crown upon her
stately head.
“O men of a later day, how can I picture to you the wonder of
Hinauri in that high solitude? The spirits of the wind would pause in
their wanderings round the mountain sides to look in at the silent
inhabitant of the cave. Then they would sigh along upon their way
down the ridges to whisper among the shadows of the deserted city.
And on dark nights, when the anger of Tawhirimatea smote the feet
of Tane-holding-up-the-Sky, that storm-god loved to linger at the
opening of the cave and watch her mysterious beauty, as Taki’s
lightning lit the place; and, while he watched, his fierce heart would
melt, and his wild breath soften into sighs of love.
“On and on sped the years. Ages rolled over this land, and the City
of the Southern Cross crumbled to dust. Other ages came and went,
and the sea lapped about the crags beneath the opening of the cave
and rolled its huge billows over the buried city. And lo! as the
moons, gliding by on the floor of the crystal heaven, chased each
other for ever across the sky, the sea sank back, and there, where
once had surged the hurrying throng of a mighty people, stood the
gigantic moa in the dense fern, and on the rocks crept the three-
eyed lizards of old time. But in the mountain cave the ancient spell
had endured. Hear the tale of the Great Tohungas, who watched one
by one in the temple. Slowly, through the ages, the limestone
covered the form of the goddess, but not to hide her from the eyes
of the matakite. The expectant look upon her face had deepened,
and her whole body seemed ready to spring to life at a word. To the
eyes of the seer her face shone glorious from within a crystal stone,
but some who saw less clearly passed down the word that her
features were chased as if with the dust of stars, through which the
pink in her cheeks and lips showed like rata through a glistening
mist. But to me, when my father took me to the cave, there was
naught but a large block of pure white marble, roughly hewn, such
as the mighty fingers of the ages fashion from the limestone. Yet I
could see, though my sight was dim, that within the dull, hard stone
stood the wondrous form of Hinauri, waiting to be released from her
age-long prison. My father said that the time was near when Hinauri
should return, and the Great Tohungas had told him in dreams that
it was by the ‘magic of a woman’ that her spirit should come back
into her body. He then instructed me in the ways and duties of the
temple, showing me many things which I cannot speak of now.
“But I said my words to you were also of the accursed stone.
When the spirit of the Bright One had fled, the Good Tohungas
withdrew into the sky, leaving one of their number to protect the
sacred stone. Even the name of this mighty one has come down to
us as surely as his blood runs in my veins. ‘Zun10 the Terrible’ he
was called, and it was he who concealed once and for ever the
secret of the sacred stone. The Vile Tohungas of the Pit were
searching for Hinauri to destroy her, but Zun tricked them. He cast
himself down into the foundations of the temple and dwelt among
them to learn their vile magic. Then, when he had mastered their
secrets, he fashioned a false image of Hinauri as a great spar, and
bound it down to the rock with a round stone. The Vile Tohungas,
believing that this spar, stranded on the shores of Time, contained
the sacredness of Hinauri, cursed it for ever, so that woman should
never rise to the skies, but remain bound down to do their will. Zun
the Terrible then drew a phantom spirit from the spar and delivered
it over to them, saying it was Hinauri, the Daughter of the Dawn.
The Vile Ones took it and bound it to the moon-face, where for all
time they have paid it a sneering worship of disdain. Thus did Zun
the Terrible give them the false for the true, and tricked them with
their own magic. Then he turned his back upon these Vile Ones and
set himself to climb up out of the darkness into which he had fallen.
But, O my sons! the Vile Ones still live upon the earth. The giant
sorcerers of old stand for ever on the floor of the mighty abyss in
the temple, waiting the day when they shall return. Their red fire
was removed by one of their slaves, whom Zun drove from the
temple into the north, and we say it is burning even now, though we
know not where.
“So the sacred stone in the white cave has been preserved to this
day, and to this day the magic of the sun ray may be seen. It is true
it now strikes into the cave at certain times of the year through a
crevice in some outstanding crags, but, O children of a later sun, it is
a ray of the same light that shone there ages since, and bore
Hinauri’s spirit away. E tama! there is a prophecy that one day, when
this ray of Ihi Ihi is upon the sacred stone, her ancient spirit will
return upon it, and she will live. Already is the stone that bound her
broken away; already she stands free, as she stood long, long ago,
with her arms outstretched to the future, and the dawn of a new
age upon her radiant face. This, O Kahikatea, is the truth which lies
behind your dream. This, O Pakehas, was the legend given me by
my father, who had received it from his father in like fashion as it
had been told by father to son from the beginning of the world.
“Now, Friend of the Forest Tree, I will answer your words to me
about the woman Miriami Kerei.
“Many moons of fasting and singing of karakias passed over my
head before the Great Tohungas
 “ ‘THIS, O PAKEHAS, WAS THE LEGEND GIVEN ME BY MY FATHER.’ ”

began to speak to me in dreams. One night the spirit of my father

stood before me and told me that the woman upon whom the
tohungas had set their true mark was travelling southwards with her
husband, inland, towards Hokitika. She was the woman by whose
magic the age-long fetters of Hinauri should be broken; therefore he
bade me find her and take her to the white cave, where she must
dwell as sacred as Hinauri’s self until the object of her coming was
accomplished. Therefore, I summoned the warriors of my tribe and
sent them to guard all the mountain ways to the south of the
‘Pensive Water,’ and to take the man and the woman without injury
and bring them to me at the boundary of the Great Tapu, which
enclosed the plain and the sacred mountain.
 “At the end of half a moon they returned with the pakeha and his
wife. She was a comely wahine, with eyes like those of a Maori
chieftainess, but they held more of the ‘magic of a woman.’ O
Pakehas, have you looked into a dark lake among the mountains and
seen the star Tawera shining there all alone? Like that was the light
of Miriami’s eyes; like that was the spirit far within them. I do not
remember the pakeha’s name, but I remember learning by the signs
he made to me, that he had journeyed from Hokitika to Wakatu to
meet his wife, who had come in a great canoe from the land beyond
the sea, and that now they were on their way back to Hokitika. I
was sorry, and my heart went out to the pakeha, but the word of the
tohungas was to be obeyed. I could not let him go his way, lest he
should bring a great army against the mountain for revenge, so I
ordered the tongueless men of the temple to bear both man and
woman to the mountain, for there I meant to deal with the man
according to the customs of our ancient magic. By a secret entrance
at the back of the mountain, which no man might find—the ‘way of
the lizard’—then by the secret ‘way of the fish with wings,’ which no
man can travel without guidance, I had them taken to the white
cave, where I showed them the stone and explained as much of the
ancient story as I could by signs. The woman understood me, for a
clear light came in her eyes as she gazed at the stone. At that
moment the sun ray, coming through a rift in the crags outside, fell
through the opening like a shaft of gold, and shone upon the white
fetters of the Bright One. Then I saw that the Tohungas’ real mark
was on the woman, for her eyes became fixed. She held out her
arms to the stone with a cry, and the pakeha caught her as she fell.
I knew now that she was matakite,11 and had seen Hinauri within
the stone.
“When she came out of darkness she spoke to the pakeha with
many words, and I judged her meaning to be this: that she would
stay in the cave and release Hinauri from the stone, and he would
stay with her; but when they made me understand this I replied by
signs that the man must go, but the woman must stay. He grew
angry, and showed me with his hands that he would go and call the
pakehas together and bring them with guns against the mountain,
and take the woman away by force.
“At this I ordered the tongueless men to bind the pakeha again.
Then I signed to the woman that he should be taken down and set
free, and that if she would watch from the opening of the cave she
should see him go. This quieted her, and I conducted the pakeha
down through the secret ways; but before setting him free I tatooed
upon his breast one of the magic signs of the temple—the sign of
silence and forgetting, and rubbed into it an ointment which has
power to make a man forget the events of his life while the tohunga
lives who cast the spell over him. There is another ointment, O
Kahikatea, which will cause a man to forget only the events of a
single moon, or at least to recall them dimly as dreams. But it was
necessary that the pakeha should forget everything, and he went
forth from the mountain as one in a trance, from which at sunset he
would awake in his right mind, but as a man who can speak the
words that he always spoke, and do the things which he always did,
yet can remember neither his own name nor the face of his friend.
This, O men of to-day, is a word of the ancient magic for which our
lower tohungas seek in vain.
“Then I did many things for the comfort of the woman Miriami—
that is the name by which she bade me call her, O Wanaki. I placed
mats within a recess of the white cave and brought her food and
water and firewood, and in it all I made her understand that she was
tapu12, and she grew to trust me. At her bidding I procured through
my tribe some sharp instruments for her with which to break the
bonds of the Radiant One, and also some books, that she might
learn to speak the Maori tongue. When this was done she showed
me the ‘magic of the woman’ by which Hinauri should return. She
would break and cut the stone away from the divine form within, so
that it should stand free.
“When I knew this I fell at her feet and worshipped her. For many
moons she laboured, and though I heard the chipping of the tools
upon the stone—the breaking of Hinauri’s fetters—I set not my foot
within the cave. Eight moons passed away, and the ninth was
growing old, when one day she waited for me outside the entrance
to her abode, on the white steps that lead down into the lower parts
of the temple.
“ ‘O Te Makawawa,’ she said, ‘the work is finished. Hinauri, the
Bright One, stands free, but she does not yet live. Nevertheless,
Chief and Tohunga, there will be another life in this cave before
many days.’
“ ‘Blessed be the child that is born under the smile of
Hineteiwaiwa,’ I said. ‘I will go to my tribe and bring back a woman
to be with you.’
“I brought the woman, and Miriami’s child was born before
another moon had set out to find the Sacred Isle in the West. Then
was I summoned to the cave to see the magic the woman had
wrought upon the stone. Hinauri stood free. She stood as thou didst
see her in thy dream, O Kahikatea—a thing to wonder at and
worship. E Koro! the magic of the woman was not of earth. It was
the Chisel of Tonga—and more than that, though I know not what
more.
“Then for two summers and winters I toiled in the temple, cursing
the Vile Tohungas in the abyss at the full moon, as my father and all
my father’s fathers had done before me, and singing the ancient
karakias in the white cave at sunset. But the spirit of Hinauri
returned not. Yet from that time forward certain men with the fire of
the Vile Tohungas in their eyes found entrance to the temple. My
thought is that they had heard a threatening voice teaching them
strange things. Perchance the ages had told them how they had
been tricked, and they came to learn the secret of our greater
magic, and to destroy the Bright One. But, O Sons of Kiwa, I took
their heads, baked them, and hung them in the abyss.
“But hear me, O Friend of the Forest Tree. These are my words to
you, and this is the thing which keeps me from rest. When the little
girl—Keritahi Kerei was her name—was able to run about and speak
her own tongue and mine, I used to lead her and Miriami down to a
place where the river hemmed them in against the mountain wall.
Here the sun shone upon the moss, and flowers grew, and here the
little one would play. One day I was cutting wood on the bank lower
down, when I heard a scream, and, looking up, I saw Miriami
standing on the bank waving her arms. I hastened to the place, and
she pointed to the water, where I saw, rising to the surface, the little
body of the child. O my brethren of the pale skin, I saw her white
face, and in her hand she held some mountain lilies, in reaching for
which she had fallen over the bank. The current swept her under,
and though I plunged in at once, it was some time before I could
find her among the twisting folds of the water. When at last I laid
the little body at Miriami’s feet, its spirit had fled beyond Wai Ora
Tane.13
“Have you seen the grief of a mother weeping for her child, O
Pakehas? I hope I may never see it again. I sat down and covered
my head, and my own tears flowed like rain. But not for long.
Miriami dashed her tears away and tried to bring the little one’s spirit
back from Reinga. I knew that a spirit sometimes halts and lingers
on the hither bank of Wai Ora Tane; therefore I worked with her on
the little body, trying to charm the spirit back, and, as we worked, I
sang an incantation, while her tears fell on the child’s pale face.
“But Keritahi’s spirit had passed beyond the waters, from whose
further bank none may return by the way they went. The sun was
sinking when we ceased our efforts, and then Miriami sank down in
despair. By the ancient rites of the temple no dead body must
remain within its inner tapu. I told Miriami that I would bury it at
once somewhere in the outer tapu across the stream. She pleaded
with me to let her come, but I would not; I had sworn to my father’s
spirit that she should not go beyond the inner tapu. ‘Then,’ she said,
‘bury the body of my child beneath the shade of the great rimu in
the valley, where the tui sits and sings in the twilight, that when I
listen from the mouth of the cave I may mingle my grief with his
singing.’
“I promised this. When she had taken a last farewell of her little
one, she sank on the ground numbed with grief, and I crossed the
river with Keritahi’s body in my arms. As I was hurrying towards the
rimu in the valley, I said in my heart, ‘It is the will of the tohungas—
the child stood in the way of Hinauri. The attention was divided.
Now the child is dead, Hinauri will delay no longer. It is best: the
tohungas have spoken——’
“The tongue in my heart stopped, and I stood still, looking down
at the child. Was it a tremor passing through the little body, or was it
my dream? Who could come back after so long a stay in Reinga?
“I hurried on again into the shades of the valley, and came to a
sudden stop a second time, for the body was trembling visibly in my
arms. There was no longer any doubt. The little lips parted. The
child drew a breath and sighed. Then the eyes opened and closed
again. She was returning from the arms of the Great Woman of
Darkness.
“My first thought was to turn back and restore the child to her
mother, but when I had taken some steps I hesitated. Another
thought held me, and I stood still. Miriami would conquer her grief;
the worst of it was over. The tohungas had spoken, and I saw their
meaning. The child was to live, but not, O Pakehas, not with its
mother, not within the tapu of Hinauri. Yes, it was plain. My heart
bled for Miriami, but there was something more important: Hinauri
was first.
“Keritahi opened her eyes and looked up at me. Her little lips
moved, and I heard the only part of my name that she could say:
‘Wawa.’ Then the eyes closed again, and my breast melted. How
could I play this trick upon the woman whose magic had done so
much? Miriami’s soft eyes came up before my mind, and my body
shook like the kahikaha’s leaf. But I must do it. It was for Hinauri.
‘Besides,’ I said, ‘the child must have the spirit of a great witch—
none but a witch could come back out of the Land of Silence. Yes,
the Great Ones have spoken—she is a witch, and that is why my
karakias have been powerless.’
“Need I tell you, O my sons, how I coaxed the child to sleep on a
stone that I had warmed with fire—then how I dug a grave beneath
the rimu and buried a large stone there—and afterwards how I went
back to Miriami with a lie in my throat and took her again into the
mountain, where in the white cave she remained alone with her
grief? But I will tell you, O Friend of the Forest Tree, what I did with
the child, for that word is for you, to guide you in the search.
 “I went back to her lying on the warm stone. I bent over her and
listening for her breathing. It was regular and deep.
“ ‘She is a witch,’ I said, ‘she will live.’
“When she awoke I took her to my tribe, though on the way I sat
down many times to cover my head, for, with her arms round my
neck, she asked me questions that I could not answer. I gave her to
a young chief of my tribe, and said to him, ‘Take a band of warriors
and journey on towards the south, and when you come to a
pakeha’s house leave the child there in safety without any word, so
that the one into whose care the child falls knows neither whence it
comes nor who brings it.’
“They went forth, and the child was under my word of protection.
“O Friend of the Forest Tree, within two moons they returned, and
the young chief spoke a strange thing in my ear. ‘We have ended the
work you set us to do, O Te Makawawa, and lo! a moon ago we
came to a hut on the bank of a river southwards, and within sat a
pakeha asleep by a fire. With my own hand I unfastened the door
and set the child inside. Then I closed the door with a loud noise,
and looked in at the window. The man awoke, and when I looked
upon his face I saw that it was the face of him we captured with the
woman many moons ago. That is truth, O chief.’
“Then I, having heard this, returned to the temple and sought
rest, saying to myself: ‘It is not such a bad deed you have done, Te
Makawawa—you have stolen a child from its mother and have
restored it to its father.’ But no rest came to me, neither did the
tohungas speak to me again in dreams. In the many years that
followed I grew weary of life, for Hinauri came not, and I felt the
displeasure of the tohungas heavy upon me. I still kept the woman a
sacred prisoner, and she lived in peace, for was she not matakite,14
and a lover of solitude?
“At length my son Ngaraki, the Fierce One, arrived at the age
when he should take up the duties of the ancient temple, and I
came forth to die. But lo! I cannot go hence until I have undone the
wrong that I did, until I have restored the child to her mother. Make
haste, O Friend, and find the little maiden in the south. The sun
lingers over the hills, but cannot set—my eyes grow dim, and I see
your faces in a mist—my head is bowed to the ground, but my spirit
cannot pass hence till this is done. O Sons of the Shining Sea, my
words to you are ended.”
The aged chief covered his head with his flaxen robe and bowed
himself to the earth. A solemn silence fell upon us, so astonished
were we at this, his strange story.
 CHAPTER IV.
THE HAUNTED REGION.

If there were not so much to tell before I lay down my pen, I might
describe the feast which Te Makawawa and his chiefs prepared for
us that evening, or give the substance of the wild, poetical songs
that were sung in our honour, and of the speeches that were
delivered—all bristling with allusions to ancient tradition. But the
matter, though interesting, does not concern this history directly.
Suffice it to say, then, that I had, from the first, developed a slightly
sceptical attitude towards the old chief’s story. This was accentuated
by the fact that, after the feast of which I have spoken, one of the
songs sung by a young chief contained a chance allusion to Hinauri,
giving in a few words the skeleton of a popular legend which differed
almost entirely from Te Makawawa’s tradition of the same person.
Even if this discrepancy could be explained by saying that a popular
legend is often fabricated around the central name of some more
ancient tradition, it still remained to deal with the extraordinary parts
of Te Makawawa’s story, which were not easy of belief without some
kind of verification. Therefore I had many a grave doubt.
On the following day, when we took our departure, the aged chief
sent with us a Maori named Tiki, who had been with the party which
had taken the child, fifteen years before, and left her at the hut of
the Man-who-had-forgotten. This Maori was to be my servant, to aid
me in finding Keritahi Kerei, or, as we should pronounce it, Crystal
Grey. He was to obey me in all things, and not to leave me under
any conditions until the child—now, of course, if living, a girl
seventeen or eighteen years of age—was found and brought to Te
Makawawa.
When we three, Kahikatea, Tiki, and myself, were leaving the pa,
the old chief gave us a solemn and sad farewell. Sitting at the
doorway of his house, he said: “Depart, O Kahikatea, Dreamer of
dreams! Take not again the ‘way of the spider’ lest you become even
as he who has forgotten his name and the face of his friend. Depart,
O seeker of the child whose mother awaits you, and forget not my
words. Go, my friends, to whom I have shown the secret of the
ages. Go! while I remain here watching the kohutukutu’s yellow leaf
that will not fall, watching the western sun that cannot set.”
So we left the pa of Te Makawawa, our hearts full of the strange
tale we had heard. When we reached the bank of the river we sat
down on a log and looked at one another.
“Do you believe the old chief’s tale?” I asked Kahikatea.
“It accounted for my dream,” he replied; “but, do you know, I
have never been able to decide whether I dreamed that about the
stone woman in the cave, or whether it was an actual experience I
went through. All I can be certain of is, that on the floor of my hut,
two years ago, I awoke from what I took to be a kind of syncope
due to failure of the heart’s action. I went out and shook myself
together, and recalled a hazy memory of those things I related to the
old chief. Of course, I dismissed the matter as a dream, though that
pure white woman’s face I could not, cannot, and do not wish to,
dismiss, for I admit to you candidly that I would risk my life to see it
again: it has a fine meaning. I say I explained it as a dream, but
what perplexed me some time later was, that in my record of the
month from full moon to full moon I discovered a gap of three days.
Then another thing which puzzled me was that I had a great many
bruises that I could not account for, one in particular: a painful sore
on my back—by Jove!”
He started up in an excited manner and threw off his coat. Then
in another moment his shirt followed, and he stood stripped to the
waist.
“Look!” he cried, turning his back to me; “just between the
shoulder blades—is there any kind of mark?”
It was my turn to express surprise now, for there, in the spot he
had indicated, was a peculiar tatooed sign—a square in a circle, with
a small cross in the centre.
I described it to him, and when I had finished he turned round
and faced me.
“The sign of forgetting,” he said.
 “The ‘sign of forgetting,’ ” I repeated, and my scepticism suffered a
shock.
“I thought,” he mused slowly, as he proceeded to dress himself
again, “I thought I could not have spent three whole days in that
syncope. If I went to that mountain temple and was branded with
this mark, which made my adventure seem like a dream, why should
not they have branded Grey in such a way—say by rubbing in a
different drug—as to make him forget his own name and the face of
his friend?”
“And yet—and yet—” I said with some hesitation, “the whole of Te
Makawawa’s tale is so remarkable that I cannot say I feel justified in
setting out to look for that child without some more certain proof. It
is quite possible the old chief has invented the story of the child so
as to get us out of the way. The search may lead me to the other
side of the world, whereas the Table Land and the mountain are not
three days’ journey from here. I believe most firmly that Miriam Grey
is there if she is living, but I’m inclined to think that, if there was a
child, it died, or was drowned, and that old Te Makawawa invented
the rest of the story to throw us off the track. What do you think? Is
not our best plan to go and spy out the mountain first?”
“It may be so,” he replied meditatively. “Personally my interest is
neither in the child nor in the woman, but in the existence of that
ancient temple of a forgotten race, with its white goddess who rivals
the dawn, gazing out into the sky with a prayer on her face, and her
arms held up to the daybreak of the golden age. It is a grand
symbol and, as I said before, I would risk my life to verify it; for
even the face of that marble woman appeals to me as no woman’s
face has ever done before. I see it in my mind, not as stone, but as
that of a living woman whose eyes are full of a holy light. I will go
with you to the mountain wall, and, notwithstanding the old chief’s
warning, I will search for the ‘way of the spider.’ ”
“Agreed,” I said, “and I will look for the ‘way of the fish,’ whatever
that may be, and take my chance of the fierce Ngaraki.”
With our minds made up we decided that it would be better not to
inform Tiki of our purpose until, in our route southwards, we came
to a point where we could branch off towards the Table Land. We
took this precaution lest he should find an opportunity of hurrying
back in the night or sending a chance messenger to Te Makawawa
telling him of our purpose, in which case I felt convinced we should
be followed by a band of his warriors. Having questioned Tiki, I
found that the way by which I was to seek the child lay through
Karamea, to the west of the Great Tapu Land. It would be an easy
matter then to change our minds on the journey, and direct our
course towards the forbidden region which we knew must be the
place we wanted.
Of our progress on foot towards Karamea little need be said,
except that it was fraught with all the difficulties of the virgin bush.
Kahikatea had a fowling-piece, and I had my rifle, so that we had no
difficulty in procuring wild duck, with here a pig and there a pukako
or a kakariki. We gathered our larder up as we went along, for we
found the bush-clad hills and gullies most plentifully stocked.
On the evening of the third day we saw a high range of snow-
capped mountains far away on our left, and questioned Tiki about
them.
“That is the Great Tapu Land,” he said, lowering his voice.
After a conversation over the camp fire in our own tongue, we
decided that the time had come to change our course. Accordingly,
in the morning we informed the Maori that the curiosity of the white
man was great: we wished to see this forbidden country. He looked
scared at this; but, when we told him he must accompany us, his
legs trembled under him, and I verily believe that if they had been
any use to him at the moment, he would have fled for his life.
“Taniwha lives there,” he said, “it is tapu. The Maori must not go
there; it is the place of evil spirits.”
“Why is it tapu?” I asked.
He shook his head. “When the ariki make a place tapu it is
because it is dangerous to go there.”
I was determined to see how much he knew, so I continued to
question him.
“How long has it been tapu?” I asked.
“From the times of Wiwa and Wawa, when men had wings,” he
replied. “Do not venture on it, O Pakehas. The ariki who have been
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