Descriptive Psychopathology: The Signs and Symptoms of ...

94 Section 2: The neuropsychiatric evaluationA consultant recognized the patient’s acute condition as malignant catatonia/neuroleptic malignant syndrome (NMS). The patient had a grasp reflex,Gegenhalten (negativism), and could be postured. A lorazepam challengeconfirmed the diagnosis, temporarily relieving some of the rigidity, andpermitting the patient to speak a few words. A course of bilateral ECT resolvedthe catatonia, although mild increased muscle tone and a mild resting tremorremained. The patient was able to dress, feed and care for herself. She couldconverse in a normal manner most of the time, and revealed that the “strangepeople” in her room were “little blue men” and that the food she saw on herbed was “bowls of fruit”. At times, however, she briefly failed to respond andwalked about the inpatient unit touching ordinary objects as if she did notrecognize what they were.The consultant re-defined the clinical features: misidentification delusions(the neighbor), Lilliputian visual hallucinations (the little blue men), basalganglia motor signs, and a hypersensitivity to antipsychotics. Further questioningrevealed a history of several falls and a concern several years beforethat she might be developing Parkinson’s disease. A diagnosis of Lewy Bodydementia was made.Patients 4.1 and 4.2 had degenerative brain diseases for which there are nocurative treatments. Those processes would have progressed regardless of thediagnostic label. How did the more objective diagnosis help? For Patient 4.1, itled to a change in the attitudes of her treaters. When she was believed to have apsychogenic movement disorder, her physicians treated her as the perpetrator ofher condition and with perfunctory respect. When she was seen as the victim of aterrible neurologic disease, their attitudes changed markedly and she was treatedmore kindly. Appropriate arrangements were made for her continued care.Patient 4.2 was being transferred for hospice care where death would likely haveoccurred within the next several weeks. Once recovered from her malignantcatatonia/NMS, 7 however, she was transferred to an assisted living programwhere she remained active and happy. Her condition stabilized for the nextseveral years and no further hospitalizations were needed.Precise terminologyInformation from the clinical evaluation needs to be organized into the medicalrecord and communicated to others. Vague or ambiguous statements are unhelpful.It is unacceptable to examine a patient’s heart and lungs and report “Theheart beat wasn’t normal ...breath sounds were odd.” It is also unacceptableto describe patients with behavioral syndromes in vague or ambiguous terms.To describe the patient as “bizarre or confused, or as having incomprehensible