Descriptive Psychopathology: The Signs and Symptoms of ...

225 Chapter 9: Disturbances in speech and languagequestions or makes comments encouraging the patient to continue or to elaborate.The patient listens and responds, and spontaneously asks questions andmakes comments. The examiner listens. This “turn-taking” is part of everynormal conversation. Gestures, facial expression, and body language enhancecommunication. Tone of voice conveys meaning.Abnormal conversational behavior is associated with behavioral disorders.Patients with substantial psychomotor retardation or a paucity of thoughts willnot “take their turns”. Manic patients will not easily “give up their turns”.Catatonic patients with negativism literally turn away from conversation. Hallucinatingpatients stop attending to the conversation and listen to the hallucinatedvoices. Some patients repeatedly return to the same topic regardless of theexaminer’s focus. Other patients cannot stick to the topic and repeatedly leadthe conversation astray to seemingly irrelevant considerations.Examiners experience thousands of conversations in everyday life and know“a bad one” when they hear it. The challenge is parsing the conversation into itscomponents to determine what makes it “bad” and what are the diagnostic andneurologic implications of the findings. Table 9.1 displays the areas to consider.AphasiaPsychiatric illness does not protect a sufferer from other disease and care-giverscannot assume that a recent behavior change is a recurrence and not the expressionof new brain pathology. Patient 9.1 illustrates the pointPatient 9.1A 55-year-old chronic alcoholic man was hospitalized on a psychiatric servicebecause over the previous week he had become “uncooperative” at his nursinghome. He no longer followed the facility’s rules and was repeatedly foundsmoking in his room. When confronted he said “I’m a very special person”.When forced to comply, he became irritable.In the hospital, he was alert and cooperative, but did not appear to understandinstructions. His interactions were pleasant and he could recognizeindividual staff members, and use objects appropriately. When shown inpantomime what to do, he could do it. He could dress himself and performpersonal toileting tasks. He remembered his way about the unit. He could copygeometric shapes. When told what to do, or when asked a question, hisresponse was typically “I am a very special person”. At other times hisutterances varied, but all were fluent, short, and well articulated. Pure worddeafness from a left temporal lobe stroke was diagnosed and behavioral carestrategies recommended rather than pharmacotherapy. 2