Descriptive Psychopathology: The Signs and Symptoms of ...

95 Chapter 4: Principles of descriptive psychopathologyspeech” suggests that the patient is not normal, but these terms, like otherimprecise descriptors, encompass different behaviors having diverse diagnosticand neurologic implications. The following vignettes present the precise detailsneeded for diagnosis.Patient 4.3 (bizarre)A 44-year-old man dressed as Robin Hood roamed his neighborhood robbingconvenience stores, threatening store clerks with his bow and arrow,and then giving away the money he stole to strangers he met in the street.The patient was diagnosed as manic-depressive and responded to lithiummonotherapy.Patient 4.4 (bizarre)A 39-year-old man pushed metal screws into his legs to ward off “rays” that hecould feel were trying to control his mind. He was avolitional and had noemotional expression, spending the day in bed with a blanket over his head forfurther protection. He had a paucity of speech with many aphasic elementsand a long history of chronic psychosis and the diagnosis of schizophrenia.Patient 4.5 (bizarre)A 33-year-old man was brought to the hospital by the police because he wasacting like a wild animal, walking on all four limbs, growling, and trying tobite people in the street. In the hospital, he was mute and immobile, but couldbe postured. Catatonia was diagnosed.The above patients had behaviors that a lay person would recognize as“bizarre”. However, the silly playfulness of the Robin Hood image of Patient 4.3is consistent with mania. The passivity delusion of Patient 4.4 is a “first ranksymptom”. First rank symptoms are often indicative of a more chronic illness, butare not pathognomonic of a specific disease. 8If the label “bizarre” is applied rather than the precise description, mostclinicians would respond by prescribing an antipsychotic drug for Patient 4.3.The patient, however, did not require such an agent and responded to lithiummonotherapy, avoiding the side-effects of the antipsychotic and receiving morespecific treatment. Patient 4.4 was schizophrenic and required an antipsychotic,but in low doses, a common experience when schizophrenia is narrowly defined. 9Patient 4.5’s animal-like behavior and the subsequent mutism, immobility, andposturing are classic signs of catatonia. Antipsychotic agents can precipitatelife-threatening malignant catatonia/neuroleptic malignant syndrome in suchpatients, and these agents are avoided in favor of initial relief with high-dose