Descriptive Psychopathology: The Signs and Symptoms of ...

137 Chapter 6: Psychopathology of everyday behavior and general appearancesharing, waiting in line, and not interrupting others in conversation. Publicspitting, nose picking, loud flatulence, nose blowing without a tissue, wipingone’s face on one’s sleeve are frowned upon in most cultures. Once acquired,social behaviors last a lifetime. The loss of social graces is associated withdegenerative brain disease and behavioral disorders such as alcoholism andchronic drug abuse, and schizophrenia.In Western countries, it is expected that, upon meeting, adult males will shakehands with brief eye contact. In many parts of Asia, hand-shaking is not the rule,and new adult male émigrés to the West reluctantly accommodate the Westernstandard. Western women in professional situations are increasingly adopting theadult male greeting ritual. In Japan, a simultaneous bow is preferred.Permitting a visitor to enter a room first, a man holding a door open for a woman,standing when a person enters a room or approaches a seated person in a publicsetting are still common social graces in the West. These behaviors are also observedin the waiting room area, and when the patient is ushered to the examination room.The standard culture-norm greeting, however, is often altered, depending on the pastrelationship with the patient, and the patient’s present illness acuity. For example,A 60-year-old professional woman with a severe depressive illness was waiting to be seen by apsychiatric consultant. The physician approached the patient, introduced himself, andextending his hand in greeting. The patient rose and, rather than taking the proffered handand responding with the customary “hello”, immediately apologized for taking the doctor’s“valuable time”, saying that seeing someone like her was a “waste of the doctor’s time”.A 50-year-old physician from the UK was seen for a diagnostic evaluation. He greeted hispsychiatrist from India by theatrically raising her hand and kissing it. The patient had longhistory of manic-depression and had recently stopped taking his medication.Aspects of general appearanceLevel of arousalNormal alertness is recognized when the patient can focus attention andresponds to commands and requests promptly within the limits of the patient’sphysical strength and understanding of the instructions. Ambient room noise andminor activity are not distracting. The patient will not doze during lulls in theexamination.Increased arousal typically elicits increased motor behavior and verbal output.When arousal is mildly increased, the patient is somewhat distractible, restless,and may speak more rapidly than usual. When arousal is moderately increased,the patient appears excited, agitated, and may be hyperactive. Speech is rapid, and