Descriptive Psychopathology: The Signs and Symptoms of ...

103 Chapter 4: Principles of descriptive psychopathologythat accounts for as many of the syndromes as possible. One illness is easier totreat than two.Patient 4.14 26An 87-year-old woman, living with her daughter, was functioning well,but taking “Triavil” (amitriptyline 75mg plus perphenazine 12mg) daily. 27Emergence of mild oral–buccal dyskinesia led to a change to sertralineand risperidone. She became subdued, lost energy and interest in her usualactivities, was unable to concentrate and said she felt hopeless and goodfor “nothing”. She said god and the devil spoke to her and that she sawdemons.Additional medication changes had no benefit. She wandered aimlesslyabout the house or in the woods. She changed clothes and took showersrepeatedly, stopped eating and drinking at the command of the voices callingher “evil”, and threw away her credit card and diamond ring. She lost eightpounds in two weeks and began punching herself and twisting her arms topunish herself. She said she wanted to die.[The “duck” is psychotic depression.]Hospitalized, she received overlapping multiple psychotropic prescriptions.She required tube feeding, gastrostomy and bladder catheterization. A urinarytract infection elicited antibiotic prescription. Hyponatremia and left lowerlobe pneumonia led to her transfer to another hospital.On admission, she was agitated and disoriented and was described as“incoherent”. She mumbled and complained of voices calling her “evil” andof seeing demons. She screamed and looked frightened. She was stiff and heldher arms out as if carrying something. A grasp reflex and Gegenhalten waselicited. She was not febrile. A consultant diagnosed psychotic depression withimpending malignant catatonia [the “duck”]. 28An extensive evaluation ensued to identify a metabolic delirium. RisingCPK and dropping serum iron levels and the urging of the consultant led tothe discontinuation of medications. Continued “confusion”, fluctuating vitalsigns, hyponatremia, hyperreflexia, and bilaterally decreased breath soundsand rhonchi encouraged the search for an infection source.Sudden screaming about mid-sternal pain and her hitting her chest led to atransfer to critical care. No evidence of myocardial infarction or pulmonaryembolus was found and she returned to the psychiatry unit. A second episodeof screaming and chest beating led to another fruitless transfer.Back on the psychiatry unit, testing continued for a metabolic delirium.Using the two-channel EEG from the unit’s ECT machine, the consultantdemonstrated that the patient did not have EEG findings consistent with