Cenesthopathy in adolescence
Blackwell Science, LtdOxford, UKPCNPsychiatric and Clinical Neurosciences1323-13162003 Blackwell Science Pty Ltd571February 2003
1075Cenesthopathy in adolescenceH. Watanabe et al.
Psychiatry and Clinical Neurosciences
Cenesthopathy in adolescence
MD, MAMI SUWA, MD AND KAORUKO AKAHORI, MD
1Department of Psychosomatic Medicine, Shiga Prefecture Adult Medical Center, Moriyama-city, Shiga,
2Health Science Division, Research Center of Physical Fitness and Sports, Nagoya University,
3Department of Psychiatry, Nagoya Second Red Cross Hospital,
4Aichi Prefecture Mental Health Welfare Center and
5Center for Student Counseling, Nagoya University, Nagoya-city, Japan
Psychopathological investigation was conducted on the basis of the clinical observation of 23subjects whose cenesthopathic symptoms began before 30 years of age. This illness is called ‘ado-lescent cenesthopathy’ based on the specificity of this mental condition to the adolescent period.
Adolescent cenesthopathy is compared to schizophrenia, depersonalization, sensitive delusion ofreference and other symptoms. Outstanding features of adolescent cenesthopathy are shown fromthe perspective of its difference from schizophrenia in terms of the specific characteristics of thesymptoms in this disease.
body dysmorphic disorder, cenesthopathic schizophrenia, cenesthopathy, depersonalization,endogenous–juvenile asthenic insufficiency syndrome, thought disorder, monosymptomatic hypo-chondriacal psychosis.
We have recently had the opportunity to be actively
involved with patients who persistently complained of
It is well known that cenesthopathic symptoms are
cenesthopathic symptoms and for whom a diagnosis
recognized in a wide variety of disorders1 including not
other than cenesthopathy was impossible. Among
only: (i) cenesthopathy incidental to schizophrenia
these cases, we have reported on a group of adolescent
(cenesthopathic schizophrenia);2 (ii) symptomatic cen-
patients1,7,8 and advocated recognition of the existence
esthopathy originating in organic brain disease;3 (iii)
of ‘adolescent cenesthopathy’ as a clinical category.
‘transient course’ or types of cenesthopathy ‘respon-
One may also note a few recent reports of monosymp-
sive to specific drugs’;4 but also (iv) the cenesthopathy
tomatic hypochondriacal psychosis with onset in ado-
proposed by Dupré and Camus,5 which is dominated
by bizarre cenesthopathic symptoms with a monos-
As we have intensified our study of cenesthopathy
ymptomatic course and may not be reduced to any
in adolescence and contrasted it with schizophrenia, we
other clinical entity. However, the monosymptomatic
have come to emphasize the peculiar characteristics of
course has been questioned particularly from the view-
point of understanding cenesthopathic symptoms inrelation to depersonalization.6 Today, unsettled issuesremaining to be resolved include the diagnostic posi-
SUBJECTS AND CASES
tioning of cenesthopathy (i.e. whether it should be clas-
As in previous studies, subjects were selected based on
sified as the schizophrenic2 or non-schizophrenic
sphere)1,5–8 and understanding onset in relation to stageof life.
1. Patients complaining of strange bodily sensations
that are not simple pain or itching and are physio-logically unexplainable. These patients are con-
Correspondence address: Dr Hisashi Watanabe, 2-47-17 Motomiya,
vinced of changes in their own body based on these
sensations, and are persistent in seeking physical
Received 5 November 2001; revised 26 August 2002; accepted 1
treatment. However, the following cases are
excluded: (i) patients who have a basis for their
complaints due to organic brain disease; (ii) patients
target was the unevenness in activity flows.8 Minor
who even for a short time had coexisting symptoms
tranquilizers such as diazepam were mainly chosen.
from which schizophrenia might be suspected (e.g.
With the increase in this unevenness, major tran-
auditory hallucination and delusion of persecution);
quilizers such as chlorpromazine were added in
(iii) patients currently or previously dominated by
small doses. In contrast, pimozide9 and other drugs12
depression; (iv) patients in the categories of chronic
are emphasized in monosymptomatic hypochondri-
tactile hallucinosis and delusion of parasitosis;
acal psychosis. We selected the 23 cases shown in
and (v) patients with somatoform autonomic
Table 1, which have been reported previously.7,8 We
here present only one case, due to space limitations.
2. Patients with onset in adolescence. Here, we
selected patients with onset before 30 years of age
Case no. 18: Male, initial onset at 19 years of age
based on Kasahara’s premise10 that adolescencegenerally extends to around 30 years of age.
Before onset, while a junior high school student, this
3. Patients with whom we have been involved thera-
patient felt inferior and unmasculine due to his frail
peutically over the long term and have observed for
build. As a result, he joined a youth gang and indulged
at least 3 years. We used the dialogue method11 for
in violent behavior. After entering high school, the
psychotherapy. The direct pharmacotherapeutical
patient received good examination results and
Nodule exists in left half of head; right half of head is not outlined and air
Body moorings get loose. Backbone disappeared; Center pole of my body
disappeared; My inner body is twisted. Both eyes straggle.
Amorphous cool mass runs through body, a warm one splits out.
Head and trunk are separated, snapping off at neck. Right half of head is
A cotton-like hazy substance fills head, left half of body is hollow.
Large cave in left half of my body. Left flank is stretched or hanging down
Nodule exists in right half of head, left half is hollow. Body is divided into
Tube is in head and straggles loosely.
Brain hardens. Brain falls sloppily and is hollow.
Backbone is out of position. Head receives a succession of shocks and itching.
Head vibrates with a succession of shocks. Head is stretched.
Head is hollow and stretched about the nose.
Brain cells squirm and drop off. Muscles are involved in brain cells.
Right side of head squirms limply. Spine disappears.
Area about base of nose is stretched. A net-like object moves around in
Chest is hollow with no bottom. Something turns around in hollow chest.
Abdomen is hollow and gets twisted complicatedly.
Body spreads limply and hangs down in abdomen and stomach, reaching
down to buttocks. Left side of abdomen is clogged and right is hollow.
Body is loose and hanging from the eye through the waist.
Muscles melt down from neck to abdomen. Body crumbles and drops down
String is in head and is cut off with a snapping sound.
Nodule exists in left upper area in head and chest is hollow.
absorbed himself into his studies. His relationship with
his classmates deteriorated as his grades gradually
Characteristics of body parts and physical changes
improved, and he became concerned only about hisstudent/teacher relationships. About half way through
Complaints of physical changes are shown in Table 1;
senior high school, he became hypochondriacally con-
the characteristics are clear. Complaints include: ‘It’s
cerned with his stomach in conjunction with falling
hollow’ (C.N. 6, 9, 13, 17, 18); ‘It’s hollow on this side
grades, but recovered following admission to a univer-
and there’s a mass on the other side’ (C.N. 7, 15); and
sity. As first-year final examinations approached (at 19
the experience of uneven distribution of hollowness
years of age), he began to complain of cenesthopathic
and mass with the body divided into left and right
symptoms such as: ‘My abdomen is twisting wildly
sides (C.N. 1, 2, 5) or upper and lower (C.N. 4). Other
and feels hollow. The hollowness is obstructed here
complaints include ‘I have no spine’ (C.N. 2, 15); ‘The
(throat), squirms here (chest) and here (buttocks), my
tube is stretched and loose’ (C.N. 8); ‘I’ve come
back feels pulled tight and the left side of my chest is
unglued’(C.N. 2); ‘Collapsing and falling apart’ (C.N. 2,
cramped.’ The hollowness expanded throughout the
6, 9, 18, 19); ‘drooping’ (C.N. 19, 20); ‘twisting’ (C.N. 2,
space of the trunk from the throat to chest, and back
18); and ‘vibrating’ (C.N. 10, 11, 12). It should be noted
to the left side of the chest and buttocks, but this same
that the body parts in these complaints are stated with-
space was localized as though by resistance to the
out regard to anatomical sequence and may be more
expansion. This feeling of resistance was exemplified
appropriately called ‘functional physical space.’ Many
in the expressions of ‘tightness’ and ‘cramped.’ The
patients described various types of ‘experiences of hol-
patient’s complaints were described vividly and with a
lowness.’ In contrast, the complaints of hypochondria-
sense of movement in the phrases ‘my abdomen is soft
cal delusion observed in schizophrenia, which means
and twists’, and ‘squirms.’ In the initial stage of treat-
the decaying collapse of existence as ‘putrefying in a
ment, the patient only complained of cenesthopathic
recondite body’, and becoming inorganic and sandy as
symptoms, but as treatment progressed he developed
‘collapsing in pieces’, and which may be mistaken for
other complaints such as: ‘My very core has been
the experience of hollowness and relaxation in adoles-
destroyed by all the twisting and squirming of my
cent cenesthopathy, were not encountered in cases of
Body parts related to physical change and feeling
Clinical statistical characteristics
As treatment progressed, patients complained of a
The onset age distribution was as follows. Onset
feeling of mental insufficiency closely linked to the
extends from 16 to 27 years of age with a mode of 19
complaints about body parts. This advanced stage of
years, a median of 20 years and a mean of 20.9 years
treatment is reached after about 3–5 years. One patient
initially made repeated and persistent physical com-
b2 (23, 0.05)]. These findings indicate that the pop-
plaints such as ‘My spine is gone; I have no center’, and
ulation distribution of these cases is a near symmetrical
as treatment progressed he began to complain of a
platykurtic normal distribution peaking at late
feeling of insufficiency in his existence (lack of mental
adolescence10 (20.9 years of age) and attenuating bidi-
support for self) through his complaints of lacking a
rectionally towards early adolescence10 and pre-adult10
physical center (e.g. ‘Since I have no center, I’m col-
lapsing’ and ‘Because I have no center, I’m not human’
The 23 cases included 19 males [82.6% (p: 64.5–
(C.N. 2)). Other patients complained of feelings of
< 0.05))] and four females [17.4% (p: 6.2–
physical change such as ‘My head and torso have sep-
arated with a snapping sound’, ‘Even when I think and
= 3.8(> F
10,38(0.005)). There appeared to be a sexual
have a purpose I cannot act. I cannot act unconsciously,
difference related to onset (P
and my body will not move unless I make sure of each
The four body parts subject to complaint are classi-
action’ (C.N. 4, 21). Feelings of physical change relating
fied as the four regions of the head, chest, abdomen
to relaxation such as ‘slackness’, ‘I’ve come unglued’,
and limbs. The regions stressed as ‘being always cen-
‘falling apart’ and ‘drooping’ correspond to mental lax-
tral’5 by Dupré and Camus were the head in 19 cases
ness (C.N. 2, 6, 8, 9, 18, 19, 20). Other patients suffered
(82.6%), trunk in four cases (17.4%; i.e. abdomen in
from an unstable imbalance and complained of the
three cases (13.0%) and chest in one case (4.3%)), and
existence of a mass, or uneven distribution of hollow-
ness and mass. Some examples include ‘It’s hollow on
this side and there’s a mass on the other side’, and ‘My
confidence because my missing spine is back’ and, at
swollen stomach is divided into two halves that twist
the same time, the body parts he complained about
and turn to the left and are blocked at the pit of the
were reduced to the right side of his head, although the
stomach.’ A labile instability was also reported (C.N. 1,
predominance of the tension-type cenesthopathic
7, 15, 19). One patient suffered ‘mental hollowness’
symptoms such as ‘cramping’ continued (C.N. 15). The
and complained of a ‘hollow chest’ (C.N. 17). Another
cenesthopathic symptoms that are observed in schizo-
patient was influenced and shaken by his surroundings
phrenia, including symptom-deficient-type schizophre-
and complained of ‘feeling vibrations in my head’ (C.N.
nia, which have unclear boundaries, lack movement
10). In adolescent cenesthopathy, body parts perceived
and may be vaguely described as ‘scattering’, ‘transmit-
as having physical change are important not only in
ting’, ‘flowing’ and ‘running’ were not encountered in
terms of localization,5 but are also closely related to
Bipolarity of cenesthopathic symptoms
‘Feeling of incomplete control’
Cenesthopathic symptoms in adolescent cenesthopathyhave distinct boundaries and are vividly descriptive
The depersonalization symptoms accompanied by a
with a sense of movement. Although such symptoms
sense of insufficiency found in adolescent cenesthop-
appear superficially disordered, they can be arranged
athy are experienced in the area of a patient’s own
between two poles under close observation. One pole
feelings such as ‘I cannot move without consciously
has a tension element, as when complaining of ‘being
thinking and being aware of every action’ (C.N. 21) and
cramped’, whereas the other pole has a looseness ele-
‘I cannot control my own feelings because they are
ment, such as ‘coming unglued.’ For example, one
really unsettled’ (C.N. 5). Another area relates to the
patient said ‘I am loose and drooping from my eye to
connection between the patient and the outside world
my waist, with my eyes hanging down’ and posed as
such as ‘I’m clearly separated from my body and the
though holding up his eyes with both hands during the
real world. I cannot focus attention on the subject I’m
examination. This patient complained of cenestho-
working on’ (C.N. 3) and ‘When connections cannot be
pathic symptoms such as ‘I am unglued, loose and
made logically one by one, they just fall apart’ (C.N.
drooping’ and ‘I am lifted up from legs and buttocks,
22). Another area relates to the patient himself, as in
my groin is cool and I feel good’ (C.N. 20). What is
‘I have no center’ (C.N. 5, 18). These experiences, how-
more worthy of note is that these two poles are ‘antag-
ever, differ from the feelings of alienation and unreal-
onistic.’ That is, on one hand are the cenesthopathic
ity that are usually emphasized in depersonalization.
symptoms of looseness such as ‘coming unglued’, ‘fall-
Depersonalization symptoms in adolescent cenesthop-
ing apart’ and ‘spreading hollowness.’ On the other
athy relate to an insufficiency of self-control such as
hand, one observes the opposite cenesthopathic symp-
‘Since I don’t have the strength to oppose outside pres-
toms of tension such as ‘stiffening versus loosening’,
sures, my mind will become distracted and my body
‘lifting versus drooping’ and ‘condensing versus scat-
[will] become hollow unless I consciously restrain
tering.’ Even the complaint of ‘twisting’ is antagonistic
myself’ (C.N. 6). Thus, these symptoms are appropri-
to the ‘body divided into left and right sides’ and to
ately called ‘feelings of incomplete self-control’.
‘becoming wildly chaotic’ (C.N. 18, 19). Looking at allcases, there were many complaints of ‘cramping’, which
Complaints related to incomplete control of
expresses an antagonism to ‘relaxation and looseness.’
interpersonal distance and experiences mistaken
The two types of cenesthopathic symptoms comprising
relaxation and tension are closely linked to the pro-gressive course. For example, one patient made com-
Depersonalization symptoms, which are similar to
plaints such as ‘It’s mushy from here (right temporal)
those in social phobia (i.e. frequent fear of interper-
to here (neck, shoulder and back)’, ‘It’s pulled tight and
sonal relations), are the subject of complaints over the
clinging’ and ‘My spine is gone.’ This patient speaks
long term, including ‘I don’t blend in on different occa-
figuratively of an amoeba-like movement of ‘mushi-
sions, so I’m the only one who stands out’ (C.N. 6, 23)
ness’ and refers to it as a movement condition, whereas
or ‘I feel like I’m floating away whenever I talk to
he refers to the ‘stretched and clinging’ state as a sta-
people’ (C.N. 1). These patients live out a vividly com-
tionary fixed condition. He says, ‘These two feelings go
petitive relationship (i.e. an unmerciful relationship in
back and forth in intensity, but I like the fixed condition
connection with their fear of being overawed by and
as being more relaxed.’ Thereafter, he says, ‘I’ve gained
simultaneously becoming estranged from others), and
resist pressure from others. An example of such a com-
18). The patients who complained, ‘I have no spine’ and
plaint is ‘I don’t have the strength to resist my sur-
‘I am loose and drooping from my eye to my waist, and
roundings, so my mind is taken away even though I
there is no space between my legs’ waited for their
exist’ (C.N. 1). Behind depersonalization symptoms in
interviews by lying on a sofa in the waiting room (C.N.
adolescent cenesthopathy is a feeling of insufficiency
15, 20). The sheer strangeness of behavior in adoles-
in interpersonal relationships. Mixed among these
cent cenesthopathy as a whole produces feelings of
complaints are experiences very similar to those of
tension in patients accompanied by conflict about con-
schizophrenia such as ‘When I listen to others talking,
trolling their body. It should be mentioned in passing
my own feelings are used up’ (C.N. 3), ‘My personality
that the sense of decaying collapse without intertwin-
becomes separated from me when I’m in large groups’
ing over the situation in bizarre behavior of schizo-
(C.N. 1) and ‘I’m always tossed around by my sur-
phrenia was not recognized in any cases of adolescent
roundings’ (C.N. 10, 11, 12). Complaints such as ‘For a
moment his mind enters mine’, which can be mistakenfor a schizophrenic experience such as ‘blowing-in-
thinking’ or being ‘made to feel an experience’ arecalled the ‘transfer’ or ‘trans-enter experience’ as dis-
Strangeness has also been observed in interviews. One
tinguished from schizophrenic experience.
patient who complained, ‘I can’t control myself; I don’tknow moderation’ spoke constantly and ignored thetherapist or remained silent during the interview (C.N.
5). Another patient who complained of being unable
We frequently hear complaints of physical functional
to get himself together repeatedly asked the therapist
insufficiency (e.g. ‘The muscles are all melted from my
to explain the meaning of the question (C.N. 3). We
neck to my abdomen and they sit so heavy in my abdo-
observed many patients who described their condition
men that I can’t concentrate on my work’ (C.N. 21)).
while gesturing with their palms first held flat, then on
The patient feels that his physical changes are the ori-
the vertical, or seeming to write on paper to make the
gin of this functional insufficiency, and that this feeling
therapist understand, which indicates their difficulty in
is responsible for his state of dissatisfaction with self.
grasping the matter under discussion in interpersonal
In contrast, many complaints are closely related to a
exchanges (C.N. 1, 3, 5, 18, 21, 23).
feeling of incomplete self-control such as ‘I’m a klutzbecause my head is hollow’ (C.N. 23). These complaints
are just a somatized form of a deep feeling of incom-plete self-control and, as such, are suitably included in
In adolescent cenesthopathy, many instances have
that category rather than under physical functional
been observed wherein abstract content is caught con-
cretely (e.g. ‘cavity’ for ‘hollowness’ (C.N. 6, 9, 13, 17,18) and ‘spine’ for ‘(support) column’ (C.N. 2, 15)).
These relationships are readily understood by inserting
Strangeness of behavior, way of communication
‘as if.’ For example, we can understand ‘I have no spine’
as experiencing a lack of mental support ‘as if’ helacked a spinal column. The complaint of ‘my head is
hollow’ expressed by one patient corresponds to an
Patients vigorously complain of subjective pain related
expression such as ‘my mind is blank, and I can’t think
to the change in parts of their bodies, but one must not
overlook the objective strangeness, unnaturalness andlack of skill apparent in their behavior, gestures and
Tendencies of personality and
actions. For example, one patient who complained, ‘My
face is crushed by a feeling of pressure and there is amass in my head’, walked with fearful little steps, stiff
(i) Intellectual impairment was not observed in all
shoulders and little hand movement as if to confirm
cases. (ii) The personality as a whole tended to be timid
each step (C.N. 7). Other patients said, ‘I’ve lost my
and reverse-assertive persistent, and resembled the
balance’ and strangely twisted the upper half of their
personality tendency of sociophobes. (iii) None of
bodies (C.N. 2, 6). Another patient complained, ‘I’m
these cases belonged to a category of specific person-
hollow and drifting into the air’ and ‘I have a mass that
ality disorder or their mixed type. (iv) Tension-type
makes me heavy so I can’t move quickly.’ This person
symptoms in interpersonal relations were observed in
walked with deliberate steps and legs wide apart (C.N.
all cases before onset of cenesthopathic symptoms. (v)
There was a tendency to avoid difficult interpersonal
Psychological particularity in adolescence
relations through an excessively adaptive ‘as if’ lifestyle
The hollowness and uncertainty of self-existence and
to conform to expectations and win praise from others
the insufficiency of self-control have the following
(C.N. 18, 22) and a ‘competent intent’ lifestyle through
aspects: (i) the difficulty for patients to be themselves;
absorption in studies, work or sports (C.N. 21, 23). This
(ii) the difficulty for a patient to accept him/herself in
last tendency may be an important factor in delaying
relationships such as between the patient and outer-
the age of onset of adolescent cenesthopathy com-
operating objects and people, or between the patient’s
own intentions and actions; and (iii) the difficulty inresisting pressure from others in interpersonal rela-
tionships. These types of insufficiency are common to
Structural analysis of cenesthopathic symptoms
the feeling of insufficiency in social phobia, and areparticular feelings of insufficiency in adolescence
To assist in the management of the descriptive and
related to uncertainty or missteps in earning a place as
phenomenological level of the various cenesthopathic
a member of society. In contrast, the feelings of insuf-
symptoms encountered, we would like to emphasize
ficiency suffered after 40 years of age are concerned
the utility of the following viewpoints: (i) The bipolar-
with threats to an already established foundation of
ity of ‘relaxation-type’ and ‘tension-type’ cenestho-
social existence, such as the feeling of insufficiency
pathic symptoms; (ii) antagonistic rivalry between both
shown in cases having an onset peak in this time frame
poles of cenesthopathic symptoms; and also (iii) bidi-
among those having a sensitive delusion of reference.13
rectionality comprising ‘centrifugal’ and ‘centripetal’
We regard adolescent cenesthopathy as a specific
directions producing these polarities of ‘relaxation-
pathological state in adolescence, which manifests in
type’ and ‘tension-type’ cenesthopathic symptoms; and
cenesthopathic symptoms, feelings of insufficiency and
(iv) the ‘dialectical’ relationship between these two
depersonalization. Furthermore, the distribution curve
directions. For example, the relaxation-type cenestho-
of age at onset of adolescent cenesthopathy indirectly
pathic symptoms (e.g. ‘being loose’) can be understood
supports our contention that onset is concentrated in
as maintaining equilibrium with the centrifugal direc-
adolescence. One reason that we selected cases with
tionality predominant in the dialectical relationship
onset prior to 30 years of age, besides Kasahara’s asser-
between the centrifugal and centripetal polarities,
tion,10 is the tendency of the age of onset of adolescent
whereas the tension-type cenesthopathic symptoms
(e.g. ‘tight’) can be understood as maintaining equilib-rium with the centripetal directionality predominant.
The dialectic of centrifugal and centripetal directional-
ities basically allows cenesthopathy to exist as itself,
The trans-enter experience is an experience ‘as if’ the
and the body parts have clear boundaries in adolescent
patient’s hollowness and weakness of self-existence is
cenesthopathy and are typically vividly described by a
taken advantage of, and can be understood by inserting
‘as if.’ Trans-enter experience is closely related to thedifficulty the patient experiences in being him/herself.
In contrast, schizophrenic experience such as ‘blowing-
Psychological particularities in adolescents
in-thinking’ and artificial experience are based on an
and specific symptoms mistaken for
anastrophic structure,14 in which experience starts from
a transcendental point over self and is manifested in
Adolescent cenesthopathy can be summarized in the
the patient’s body as the activities of imaging and
following three points. (i) Patients with adolescent
thinking, whereas the origin of experience is within
cenesthopathy are not only preoccupied with simple
oneself in adolescent cenesthopathy.
physical change, but also suffer a feeling of mentalinsufficiency due to their sense of physical change; (ii)
The feeling of mental insufficiency seen in adolescentcenesthopathy is related to the hollowness and uncer-
Strangeness of thought in adolescent cenesthopathy
tainty of the patient’s own existence (self-existence);
originates in a condition wherein the ‘as if’ is hidden
(iii) Strangeness of thought has been observed and is
behind the experience, and can be readily understood
believed to be an important factor in transforming the
by inserting ‘as if.’ The hiding of ‘as if’ thinking is paired
feeling of mental insufficiency into strange physical
with the ‘aiding of “as if” ’ in which patients can just
begin to describe strange experiences, such as ‘I feel as
though I’m looking through a thin film’ seen in
thought and attention-concentration disorder in ado-
depersonalization. Strangeness of thought in deperson-
lescent cenesthopathy differ from those in schizophre-
alization and adolescent cenesthopathy have a com-
nia as previously described, Glatzel and Huber regard
monality related to ‘as if’ and accompanied by a
the weak concentration observed in this syndrome as
difficulty in verbalizing experience. There is a possibil-
ity that the strangeness of thought found in adolescentcenesthopathy may belong to the same type of thought
Delusional Disorder, somatic type (DSM-IV) and
disorder as is found in depersonalization.15 Attention-
Monosymptomatic Hypochondriacal Psychosis
concentration disorder in adolescent cenesthopathy isan impairment related to an unevenness in the activity
Adolescent cenesthopathy is not to be classified as
flows,8 and is one type of disorder of distractibility.13 In
[297.10 Delusional Disorder, somatic type] even if one
contrast, in the thought disorder of schizophrenia, a
is sure that it is based on some bodily modification
metaphor such as ‘as if’ is not formed, but only expe-
derived from a cenesthopathic somatic experience, as
rienced on the literal level. Moreover, attention-
it is not a somatic delusion of being ill or deficient. In
concentration disorder in schizophrenia carries a sense
contrast, Monosymptomatic Hypochondriacal Psycho-
of indifference; the associations are interrupted, inco-
sis (MHP) has an infestation group category including
‘coenaesthopathia’,22 signifying some cenesthopathicsomatic experience or supposed form of existence.
Psychopathology bordering on the
However, there is, as yet, no clinical entity for an inde-
pendent category applicable to adolescent cenesthop-athy patients.
Adolescent cenesthopathy has a commonality with
sensitive delusion of reference13 in that the patientslament that they cannot control their own body, which
Adolescent cenesthopathy is compared to schizophre-
is burdened by an insufficiency of self. These patholo-
nia, including symptom-deficient-type schizophrenia,
gies differ in whether or not the changed body is
depersonalization and sensitive delusion of reference.
related to self. Similarly, adolescent cenesthopathy has
The dialectic competitiveness in cenesthopathic symp-
commonality with depersonalization in that: (i) there
toms, feelings of incomplete self-control within the self
is competitiveness within the patient himself;16 (ii)
of the patient and the hiding of ‘as if’ thinking are
there is a structure in which the self is preoccupied with
regarded as being different from schizophrenia. This
its own body similar to a tendency for convulsive self-
pathology is called adolescent cenesthopathy in light
observation17 in which the acting self intensely regards
of its psychological peculiarity in adolescence, which
itself; and (iii) the patient has difficulty grasping the
manifests in cenesthopathic symptoms, feelings of
essence to behave skilfully in both situation and
insufficiency and depersonalization.
scene,18 although these pathologies differ in formedsymptoms. In contrast, insufficiency related to self-
existence in adolescent cenesthopathy is very similarto the ‘loss of natural self-explanatory comprehen-
1. Watanabe H. Cénesthopathie. In
: Matsushita M (ed.).
sion’19 in symptom-deficient-type schizophrenia.
Encyclopedia of Clinical Psychiatry VI; Somatoform
Surely, patients with these two pathologies commonly
Disorder. Psychosomatic Disorder.
share the particular crisis in adolescence of missteps in
Tokyo, 1999; 195–208 (in Japanese).
gaining their footing in society at large. However,
2. Huber G. Die cœnästhetische Schizophrenie. Fortschr
although patients with adolescent cenesthopathy
: 491–520 (in German).
become transfixed on ‘individual occasions’ resulting in
3. Tsunoda M, Kurati M. A case of cenesthopathia showing
high perfusion in thalamus by 123I-IMP SPECT. Seishin
difficulty being themselves, patients with symptom-
: 423–425 (in Japanese).
deficient schizophrenia drop out from the ‘absolute
4. Kojima D, Endo S, Akiyama M, Takagi H, Mori T,
commonness’ to transcend ‘individual occasions’.
Kuraoka Y. Therapy of cenesthopathia. Clin. Psychiatry
: 45–52 (in Japanese).
5. Dupré E, Camus P. Les cénesthopathies. Encéphale.
: 616–631 (in French).
6. Baruk H. Le sentiment de la personnalité — La
This syndrome20 is very similar to adolescent cenesth-
dépersonalization et la cénesthésie. Ann. Med.-Psychol.
opathy.21 However, although the strangeness of
: 393–407 (in French).
7. Watanabe H, Aoki M, Takahashi T, Oiso H, Murakami
15. Tucker GJ, Harrow M, Quinlan D. Depersonalization,
Y, Matsumoto Y. ‘Coenästhopathie’ in Adoleszenz —
dysphoria and thought disturbance. Am. J. Psychiat
Wahnhafte Erlebnisse in der Adoleszenz. Seishin Igaku
: 1291–1300 (in Japanese).
16. Meyer JE. Studien zur Depersonalisation I. Über die
8. Watanabe H. Cenesthopathia. In
: Shimizu M (ed.).
Abgrenzung der Depersonalisation und Derealisation
Today’s Therapy of Neurosis.
von schizophrenen Ich-störungen. Mscher Psychiatr.
: 221–232 (in German).
9. Ulzen TP. Pimozide-responsive monosymptomatic
17. Shilder P. Selbstbewußtsein und Persönlichkeitsbewußt-
hypochondriacal psychosis in an adolescent. Can J. Psy-
. Springer, Berlin, 1914 (in German).
18. Janet P. L’évolution psychologique de la personnalité
10. Kasahara Y. Today’s pathological phenomena in adoles-
Y, Shimizu M, Ito K (eds). Psycho-
19. Blankenburg W. Der Verlust der natürlichen Selbstver-
pathology in Adolescence
. Kobundo, Tokyo, 1976; 3–27
ständlichkeit, Ein Beitag zur Psychopathologie symptom-
. Ferdinand Enke Verlag, Stuttgart,
11. Kretschmer E. Moderne Probleme der psychotherapeu-
tischen Methodik. In
: Kretschmer W (ed.). Psychia-
20. Glatzel J, Huber G. Zur Phänomenologie eines Typs
, Springer, Berlin, 1974; 140–145.
endogener juvenil-asthenischer Versagenssyndrome.
12. Phillips KA, McElroy SL, Dwight MM, Eisen JL,
: 15–31 (in German).
Rasmussen SA. Delusionality and response to open
21. Takahashi T, Oiso H, Aoki M, Watanabe H, Matsumoto
label fluvoxamine in body dysmorphic disorder. J. Clin.
Y, Fujita O. Phenomenology on a type of endogenous
juvenile asthenic insufficiency syndromes. Jpn. J. Adoles.
E. Der Sensitive Beziehungswahn
: 103–118 (in Japanese).
22. Reilly TM. Monosymptomatic hypochondriacal psycho-
14. Conrad K. Die Beginnende Schizophrenie
, 3rd edn.
sis; presentation and treatment. Proc. Royal Soc. Med.
Georg Thieme Verlag, Stuttgart, 1971.
(Suppl. 10): 39–43.
COLLECTIVE INVESTMENT SCHEMES LAW EXPLANATORY NOTE INTRODUCTION The draft Collective Investment Schemes Act (the " Act ") is intended to introduce into Maldives law provisions relating to the establishment, operation, promotion and sale of collective investment schemes. The Act further provides for the regulation of all persons who act as manager or depositary of collectiv
S Afr Optom 2007 66 (2) 40 From the Editor’s Desk An enormous and complicated administrative structure has been put into operation in an attempt to evaluate and assess university educational offerings. Institutional audits are to be performed at regular intervals to determine whether the various educational programmes on offer are achieving specific goals, some of which have litt