Descriptive Psychopathology: The Signs and Symptoms of ...

160 Section 3: Examination domainsthe left frontal subcortical areas with a fifth cervical vertebral fracture. A repeatMRI demonstrated thalamic and cerebral cortical abnormalities. Serum creatininephosphokinase was 659U/L and an EEG showed diffuse slowing withoutepileptiform activity. Continuous dystonia and chorea developed. Dantrolinetreatment did not help. After 2months her symptoms gradually abated. Theauthors concluded that her condition was malignant catatonia. 27Many catatonic patients are simultaneously manic. Sometimes, these patientsexhibit echolalia (repeating the examiner’s words) and echopraxia (repeatingthe examiner’s movements). Other catatonic features can be demonstrated.Some manic patients are so excited that they appear to be in frenzy, constantlymoving and shouting, never resting or sleeping. They are disoriented. They mayconfabulate with fantastic stories. Their speech is so rapid and their associationsare so jumbled that they cannot be understood. This form of delirious mania wasoriginally termed Bell’s mania. These patients are not rigid, and so catatonia canbe missed. Associated grimacing, echophenomena, and mannerisms, however,alert the examiner to the presence of catatonia.Other catatonic patients are in an oneiroid state. 28 They appear frightened andagitated, thrashing, hurting themselves and others. Stereotypy, grimacing, posturing,echolalia and echopraxia are common. Negativism and automatic obedience arealmost always present. Fever may develop, and a malignant catatonia may unfold.Some patients rapidly shift from delirious mania into an oneiroid and akineticstate and back again. When shifts are gradual, periodic catatonia is diagnosed.Periodic catatonia was first metabolically studied by Gjessing, who wrongly concludedit was an expression of fluctuations in nitrogen balance. 29 Such patientsexperience cycling periods of stupor and excitement, each with catatonic features.Although the original reports described phases that lasted for weeks, rapid shiftsalso occur, as illustrated by Patient 7.3.Patient 7.3Over the course of a weekend, a 47-year-old man became increasingly agitated,excited, and suspicious. He told his wife people were looking at him throughtheir second-storey bedroom window. He stopped sleeping, paced and chatteredcontinuously as he described his “great gifts”. Frightened, his wife brought himto an emergency room on Monday morning. There, the patient was agitated,despondent; expressing ideas that he was a bad person and deserved to die.In the hospital, he was found to be in a stupor, almost mute, staring, withautomatic obedience and Gegenhalten. Several hours later he was in bed,unresponsive except to substantial painful stimuli. When so stimulated, heslowly turned to the examiner, and in a slurred voice said “Get thee from me,