Descriptive Psychopathology: The Signs and Symptoms of ...

139 Chapter 6: Psychopathology of everyday behavior and general appearanceIt occurs in both manic and depressive episodes, and has been recognized forover two centuries. Such patients appear restless and frightened. Their fears maylead to hiding in small spaces or fleeing into the street. When recovered, theydescribe a nightmarish experience characterized by derealization, the feeling thatthe world is unreal, part of a dream, flat and insubstantial. Catatonic features(stereotype, grimacing, posturing, echolalia and echopraxia) are common.Negativism and automatic obedience are almost always present. Sleep–wakecycles are perturbed and fantastic confabulations may be elicited, the patientdescribing grotesque events and activity outside physical possibility (e.g. a patientsaid “I remember my skull being removed with pliers”). Sympathetic arousal issubstantial, and without appropriate treatment death due to cardiovascularcollapse is reported. 15Hypersomnia is defined as over nine hours of sleep per day, but such patientsmay sleep for many more hours daily. They are difficult to arouse, and act as ifdrunk when awakened. Such sustained drowsiness has been associated with sedativedrug intoxication, gross obesity, and low blood oxygen levels (Pickwickiansyndrome), disease of the midbrain, the Klein–Levin syndrome (associated withmegaphasia and mood disturbances), depressive stupor, and catatonia. 16DissociationThe DSM and ICD recognize four types of dissociative disorder: amnestic, fugue,identity, and depersonalization. There is no support for these constructs asindependent disease states, and they are best considered features of other establishedconditions (e.g. dissociative fugue as a feature of seizure disorder). Thereliability and validity of dissociative identity disorder has been questioned.Dissociative states are seen in non-ill sleep-deprived persons and those withillness (e.g. anxiety disorder, seizure disorder). Because patients commonlydescribe the experience as dream-like, being befogged, drugged, or “in a daze”,a dysfunction in the sleep–wake cycle has been proposed as a pathophysiologicfinal common pathway. EEG changes during these states are similar to patternsseen in non-REM sleep, but not while dreaming. 17 The subjective experience ofdissociative phenomena is also likened to severe “jet lag”, where sleep patterns aredisrupted. In addition to the association with sleep-like EEG changes, patientsthat frequently experience dissociation have an increased prevalence of sleepdisorder. 18 During the dissociation, the sufferer’s level of awareness is disconnectedfrom the activation mechanisms associated with the fear response. 19Hypothalamic–pituitary–adrenal hyperactivity dysregulation during dissociationis a consistent finding. 20 Functional imaging studies point to right cerebralhemisphere involvement. 21