Descriptive Psychopathology: The Signs and Symptoms of ...

199 Chapter 8: Disturbances in emotional experienceTable 8.1. Aspects of emotional expressionIntensity: from absent (in apathy, stupor, catatonia, emotional blunting, and motor aprosodia)to intense (in rage, panic, despair)Quality (valence): happy, sad, angry, anxiousVariability: from extremely labile (as in metabolic and manic delirium) to continuousexpression of a single emotional state for weeks (as in mania) or months (as in melancholia)Appropriateness: from congruence between the expressed quality and the situation to noconnection (as in melancholia, mania, panic attack)Recognition: poor self-recognition is an aspect of denial of illness (anosagnosia);poor recognition of the emotional expression of others is receptive aprosodiaDisturbances in emotional expressionTable 8.1 displays the aspects of emotional expression considered in the examination.Disturbances in intensityPerturbed intensity of emotional expression can be increased as in rage, panic, andeuphoria, or substantially decreased as in stupor, apathy, and emotional blunting.Decreased expressionEmotional blunting (affective flattening or stiffening)Emotional blunting is the loss of emotional expression in gesture, facial expression,and tone of voice. It is characteristic of schizophrenia and structural frontal lobedisease. 6 Emotional blunting combines the two independent dimensions of volitionand emotional expression. 7 The loss of volition without a loss of emotionalexpression is also seen in patients with chronic manic-depressive illness. 8Emotionally blunted persons appear stiff or still, their faces mask-like andtheir voice monotone. Chronic schizophrenics typically have profound loss ofemotional expression. In contrast, patients with severe depressive illness expressapprehension and distress unless in a stupor or catatonic state. 9Kraepelin emphasized the presence of emotional blunting as characteristic ofdementia praecox, stating that patients have “no desire ...no visible effort of thewill”, being “languid and expressionless ... quite dull, experiencing neither fearnor hope nor desires ...this peculiar and fundamental want of any strong feelingof the impression of life, with unimpaired ability to understand and to remember,is really the diagnostic symptom of the disease before us.” 10Emotional blunting can be reliably assessed and there are several rating scalesthat facilitate the evaluation. 11 Table 8.2 displays features common to the scales.