Descriptive Psychopathology: The Signs and Symptoms of ...

134 Section 3: Examination domainsis the patient cooperative, or causing a disturbance? Observations are made aboutdress, grooming, and alertness before meeting the patient.Does the hospitalized patient interact with others in common areas, the diningroom, and hallways? Is the patient disruptive and loud or passive and reclusive?The following images and their implications illustrate.An elderly, disheveled, white-haired woman slouched slacked-jawed in her chair not interactingwith other patients and staff is the image of depression, dementia, or over-sedation.A middle-aged woman with a furrowed brow [a worried look] sitting outside the nursingstation continuously rocking and wringing her hands, seemingly oblivious to her surroundings,is the image of melancholia. The furrowed brow produces a crease between the eyebrowstermed “the omega sign” (like the Greek letter O). Along with Veraguth folds (prominentupper eyelid folds sloping down from the midline), it forms the image of a profoundly sad face.A young adult man engaging one patient after another in animated conversation suggestsmania or a histrionic substance abuser.A teenage boy standing at attention for hours at the front door of the inpatient unit salutingpersons entering the unit is catatonic, and the playfulness of the salute suggests associatedmanic-depressive illness.A middle-aged man, irritable and sluggish, staying in bed all day with blankets over his head,is an image frequently associated with cocaine withdrawal.A plethoric, middle-aged man with a shock of white hair, broken small facial blood vessels,and a “beer belly” characterizes chronic alcoholism.Interactions with other patients, staff and family members also reveal thepatient’s temperament and strains in relationships. An example of the lastsituation follows.The two grown daughters of a severely depressed, newly hospitalized patient were early for ameeting with their mother’s social worker and resident. They entered their mother’s room asthe medical team arrived on rounds. Barely greeting the attending psychiatrist and sayingnothing to the mother, the daughters stood sullenly to one side while he spoke with the patient.At one point the mother reached out to caress the nearest daughter, who coldly moved out ofreach. The two daughters asked no questions of the team and offered no comfort to theirmother. Subsequent history-taking revealed the mother had been living with the daughter whohad rejected her touch, and that the mother had delusionally accused that daughter of notcaring for her and of stealing from her. This accusation created friction between the two,contributing to the hospitalization.Parent–child relationships are often best understood in informal settings ratherthan in the examination room. The depressed mother may neglect a young childin the waiting area, but become harsh and physically controlling if the childbecomes overly active or loud. If the child is the patient, parenting skills and the