Descriptive Psychopathology: The Signs and Symptoms of ...

97 Chapter 4: Principles of descriptive psychopathologyspeech is paraphasic and sometimes referred to as driveling. 14 It is consistentwith schizophrenia. The patient had other features of the illness (emotionalblunting, experiences of alienation and control).Patients 4.8 and 4.9 conversed without making sense; they had “incomprehensiblespeech”. But clanging speech is often seen in manic patients with flight-of-ideas,and paraphasic fluent speech is characteristic of schizophrenia, and some aphasiadue to stroke. The precise distinction led to different treatments, and for Patient4.8, the more specific mood stabilizer. Delineating schizophrenia from a mooddisorder also affects long-term planning.Separation of form from contentThe experiences of illness that patients relate, detailed description of devils andgods, flights in spaceships and other wondrous events can capture the examiner’sattention. The psychoanalytic perspective gives credence to these descriptions assymbolic clues to understanding the patient’s illness. For a medical diagnosis,however, the content of psychopathology is less important than its form. The formof psychopathology represents the illness to be identified. The content relates to thepatient’s experiences and less so from the illness, unless reflecting an abnormalmood (e.g. grandiose delusions in mania). In a stroke affecting speech, for example,different patterns of speech pathology can reveal the location of the stroke. Thecontent of the speech is not relevant for the purpose of anatomic localization.Similarly for psychopathology, what the hallucinated voices are saying is not asdiagnostically important as the fact that the patient is having a clear perception ofsomeone speaking without external stimulation. Patient 4.10 illustrates how theform, but not the content, of psychopathology leads to the diagnosis.Patient 4.10A 38-year-old man heard angry shouting outside his apartment door. He heardsomeone say “let’s get him”. Fearing he’d be trapped, he opened his front doorto escape. He saw several men at the other end of the apartment hallwayfighting with knives. When they saw him, they rushed at him, shouting “Gethim. Kill him”. Terrified, he ran down the stairs and out into the street. Themen pursued him, shouting and waving their knives. In a sudden, loud “pop”the men changed into dogs that rushed the man and began biting his legs. Hecould feel their bites and the blood running down his legs. He knew the dogswould soon bring him to the ground and devour him. He ran screaming downthe street and turned into an alley. The alley had no way out. He turned to facethe dogs. In a sudden loud “pop” the dogs changed into two policemen, whobrought the patient to an emergency room.