Descriptive Psychopathology: The Signs and Symptoms of ...

226 Section 3: Examination domainsTable 9.1. Aspects of conversational speechSpontaneity: Comments should occur spontaneously, not only as responses to questions. Lackof spontaneous speech is observed in expressive cortical aphasias and left basal ganglia andthalamic strokes, drug-induced and abnormal metabolic states leading to reduced arousal,some ictal and post-ictal states, depression, catatonia, schizophrenia and other psychoticdisorders, states of anxiety and fearfulness, and guardedness due to personality deviation orconcern for self-incrimination.Fluency: Reduced speech output is not synonymous with poor speech fluency. Non-fluentspeech is also halting and the patient labors to make utterances, often with poor articulationas in Broca’s and transcortical motor aphasias, and some ictal states. 3Turn-taking: Comments are made or questions asked and then the speaker stops, awaiting aresponse. Not taking an appropriate “turn” suggests a lack of spontaneity and the conditionsassociated with it. Lack of spontaneity may be coupled with a paucity of speech. Not allowingthe other person to take a “turn” and monopolizing the conversation is associated withmania and hypomania, stimulant drug intoxication, and the frontal lobe disinhibitedsyndrome. Speech will be intrusive. Anxious persons and persons with histrionic ornarcissistic personality traits also monopolize conversation.Mutual topic: Constantly straying from the focus or topic is associated with maniaand hypomania, stimulant drug intoxication, and the frontal lobe disinhibitedsyndrome. Repeatedly and inappropriately returning to the same topic (perseverationof theme) is seen in mood disorders, delusional and paranoid personality disorder, andobsessive conditions.Comprehension: An adequate conversation requires each participant to understand theutterances of the other. When auditory comprehension is poor, the patient may respond withnon-sequitive speech.Making sense: Speech that is not understandable despite adequate articulation indicates aninability to follow grammatical or syntactic rules or a cognitive problem.Associated behaviors: Facial expression, gestures, and body language convey conversationalinformation. Absent facial expression and gesturing is associated with neurologic diseaseaffecting motor systems, depression, catatonia, and sedative drug intoxications. Exaggeratedexpression and gesturing is associated with states of excitement, anger, drug intoxication,and histrionic personality traits.Several aphasia syndromes are recognized (Table 9.2). “Neighborhood” signs,additional features associated with some aphasic conditions, are not alwayspresent, but their appearance aids in identifying lesion location. They includeparesis and paralysis (Broca’s, conduction, global, basal ganglia) and sensory loss(conduction). In Broca’s aphasia, left hand ideo-motor apraxia may also bepresent as the left hand is disconnected from the ideational information of the