Descriptive Psychopathology: The Signs and Symptoms of ...

116 Section 2: The neuropsychiatric evaluationbegan complaining about his treatment on the unit and quickly became angry.Face flushed, jaw jutted, fists clenched, he took several steps toward theattending.The attending immediately dropped his eyes, slumped against the wall whileslightly turning away from the approaching patient, and held his handstogether in front of his abdomen. The patient immediately stopped hisapproach, looked perplexed, and walked off.Face-to-face direct eye contact is an aggressive posture recognized by mostprimates. Although Patient 5.2’s resident was trying to placate her patient, herquick movement and face-to-face posture triggered an assault. In contrast,the attending physician’s rapid assumption of a submissive posture immediatelyterminated aggression.Delirious patients and patients with altered arousal because of a seizure processmay be violent. The violence is not premeditated, and can be sudden and withoutwarning. The patient is unaware of the act, and may have no memory of it. Suchviolence typically occurs when the patient comes into contact with an object andattacks it, or when someone trying to help touches the patient, and the patientfearfully strikes out at the restraining touch. The delirious patient franticallyfighting his restraints is another example. Unless the patient is engaged in selfinjuriousbehavior, or is attacking someone or property, it is best to stay clear of thepatient until the process is over, or the patient can be safely restrained. Patient 5.4illustrates.Patient 5.4A 33-year-old, physically imposing Marine with martial arts training washospitalized after several months of being increasingly uncooperative andirritable at work, and then smashing much of the furniture in his houseand trying to attack his wife. He denied all such actions. He was diagnosedschizophrenic and an antipsychotic was prescribed. As the dose was increased,however, he became increasingly threatening to staff and patients and wastransferred to a locked inpatient unit.The unit psychiatrist examined the patient in his small office. Initially bothpatient and physician were seated, but as the evaluation proceeded, the patientbecame agitated and began to pace, blocking the examiner’s exit. The patient’svoice suddenly became staccato, his facial expression blank, and he stoppedresponding. The examiner remained seated, quiet, and still until the pacingstopped and the patient’s normal voice resumed. They then both exited theoffice. The patient was diagnosed as epileptic, the antipsychotic medicationwas stopped, and the patient then responded fully to an anticonvulsant.