Descriptive Psychopathology: The Signs and Symptoms of ...

92 Section 2: The neuropsychiatric evaluationunderstand the patient’s experience that the examiner could recount what thepatient was experiencing, the patient recognizing its accuracy. Obtaining the storyof the patient’s illness is the tangible method of empathic understanding (seebelow). Jaspers also searched for “meaningful connections” in what the patientwas thinking. He applied this to the understanding of delusional phenomena,observing that the meaningful connection was broken between the patient’sexperience and the false conclusion.The focus on outward appearance rather than inner meaning has become thestated ideal of recent DSM and ICD iterations. But many have argued that presentmanuals have gone too far. Andreasen laments that present classification systems areso severe that they represent “the death of phenomenology in the United States.” 5Others have called for a return to the philosophical methods of inner understandingof patients and their illnesses. 6 To minimize confusion, we use the term descriptivepsychopathology rather than phenomenology, and we use it to mean the focus onobservable and precisely elicited features of behavioral disorders.Objective observationPhysical examination is invalid when based on interpretion. It is better to say“The patient is a 60-year-old man” than to say “The patient is an old man”.Interpretation may be added (“looking younger than his stated age”), but withoutinitial objective information, interpretation is idiosyncratic and has poor reliability.Any validity of the interpretation cannot be understood by other clinicians asit cannot be generalized to other patients who are unlikely to mirror the subjectiveobservations of the first clinician.Objective psychiatric examination is an extension of the medical physicalexamination. The focus is on behavior as an expression of brain function, theinteractions between brain function and the rest of the body, and the influences ofthe environment on those interactions. Patient 1.7, the 78-year-old womanadmitted in status epilepticus from the neurology service to the psychiatryservice, illustrates how interpretive observation lead to misdiagnosis: because ofthe recent diagnosis of depression, it was assumed that her present symptomswere also “psychiatric” resulting in her seizures being unrecognized. Patients 4.1and 4.2 are also examples of the dangers of distorting observation withinterpretation.Patient 4.1A 56-year-old unmarried nurse stopped working to care for her elderly motherwho was experiencing cognitive difficulties. But after six months, the daughterbecame less attentive, said she had no energy and had lost her eagerness tohelp. She said her sleep and appetite were poor, although she had not lost