Descriptive Psychopathology: The Signs and Symptoms of ...

98 Section 2: The neuropsychiatric evaluationWhen presented with this patient, medical students and junior residents have nodifficulty recalling the weapons and animals involved in the story. They recall thatthe story starts in an apartment, moves to the street, and then into a blind alley.They recall that the changes in the pursuers occur with a loud “pop” and that thedogs change into two policemen. When then asked what the diagnosis is, they areoften mystified. They also have trouble systematically and rapidly identifying thepatient’s psychopathology. However, when Patient 4.10’s psychopathology ischaracterized by its form as multiple, frightening hallucinations in multiple sensoryrealms, and delusions of persecution associated with great anxiety and agitation,students immediately consider delirium and a toxic state. The patient had deliriumtremens and was safely detoxified.The content of a patient’s delusion is also less important than the fact that thepatient has a fixed, false belief. If a delusional patient says there is plot against himand that “The CIA is spying on me”, while another delusional patient says “Myemployer is plotting to kill me because I know about their illegal activities”, bothpatients have a persecutory delusion and are psychotic. Their content varies, butchanges nothing about their diagnoses, treatment and prognosis. 15The story of the illnessThe classification manuals present syndrome features as if all are of equalimportance with no single combination more predictive of a diagnosis. Howsymptoms emerge and the sequence of emergence is not considered. This limitedapproach to psychopathology is the equivalent to learning the plot of Hamletsolely from a list of the cast of characters. Patients 1.6, the 28-year old man whoseauditory hallucinations occurred for several hours upon wakening, and 1.8, theman who became suddenly despondent in the late afternoon, illustrate the needto obtain “the story” not just the list of present symptoms. Their seizure disorderswere missed for years.Rate of symptom emergenceOne of the more important clinical variables influencing diagnosis is the rate ofemergence of signs and symptoms. The sudden fluctuations in symptoms inPatient 1.7, the 78-year old woman in status epilepticus, was recognized asseizure-related. Episodes of primary mood disorders typically develop overseveral weeks; the early features of the first psychotic episode of schizophreniacan linger for months; and the cognitive decline in degenerative brain diseases canbegin years before the dementia is recognized. “Overnight” behavioral change ismost likely associated with a sudden environmental stress, toxicity, trauma, or avascular brain event.