Descriptive Psychopathology: The Signs and Symptoms of ...

138 Section 3: Examination domainsthought associations are distracted by ambient room activity. When increasedarousal is severe, excitement is extreme, and the patient appears delirious. Thepatient may move and speak continuously. He may shout, scream, and requirerestraints to keep from self-injury. General analgesia may be present. Severedistractible speech (rambling), or flight-of-ideas, is observed. Sympathetic nervoussystem signs can be extreme, and before the development of sedative drugs,such patients were said to have Bell’s mania, more than half succumbing to fatalarrhythmias or cardiovascular collapse. The modern term is delirious mania.Such patients will also have catatonic signs that may evolve into malignantcatatonia. Increased arousal is associated with anxiety, mania or hypomania,the frontal lobe disinhibited syndrome, and stimulant drug intoxication.In 1828, George Burrows described manic delirium that is instantly recognizableto an experienced psychiatric hospitalist.some positive delusion exists; the patient is very loquacious and vociferous, raving incessantly,or with short intervals, during which, perhaps, a transient ray of reason gleams; or he laughs,cries, whistles, shouts, screams, or howls; is restless, full of antics, mischievous, tearing hisclothes, and destroying all he can reach; is malicious, swears, prays, perhaps desperatelyintent on violence to himself or others; is lecherous, obscene, shameless, nasty, and indifferentto the calls of nature. 14Decreased arousal, due to metabolic disturbances, sedative–hypnotic, or othersedating drug intoxications is associated with reduced movement and verbaloutput. When arousal is mildly reduced, the patient looks fatigued and issluggish. When arousal is moderately reduced, the patient drifts into sleep duringlulls in the examination, and focuses on strong stimuli with effort. Responses areslow, speech is rambling, and examination requests are not fully understood orfollowed. In coma, analgesia is profound. When the reduced arousal is part of adelirium, agitation and fearfulness are commonly observed. When partial complexepilepsy is the cause, automatic motor behavior may be seen. When thereduced arousal represents benign stupor (the patient mute, immobile, andstaring), depressive illness and catatonia are considered.Stupor is also seen with brainstem lesions, infection (e.g. encephalitis lethargica),metabolic disorders, and normal pressure hydrocephalus. In benign andother stuporous states, the patient is persistently unresponsive, and generalanalgesia is present. When associated with melancholia, the stupor may representsevere psychomotor retardation. Melancholia attonita was the term used byKahlbaum to describe this syndrome. When the stupor is part of the catatonicsyndrome, an IV dose of a benzodiazepine can temporarily relieve the condition.A dreamy state during which the patient is mobile and may speak and interactto a limited extent is termed oneiroid state, oneirophrenia, or oneiroid syndrome.