Descriptive Psychopathology: The Signs and Symptoms of ...

229 Chapter 9: Disturbances in speech and languagemotor task. Behavioral changes (e.g. agitation, irritability, features of depression)are common early features of many aphasic conditions. 4Spontaneity, fluency, syntax, grammar, word usage, and conversational auditorycomprehension are assessed by listening to the patient’s responses andcomments during history gathering. Lapses in grammar and syntax or in wordusage are immediately addressed:“What did you mean when you said ...? I didn’t get that. What was it you just said?”“You seem to be having trouble getting words out, true? You seem to be having troublefinding the words you want to say, is that so?”Word finding and naming are also examined by asking the patient to identifycommon objects (e.g. keys, a coin, a pen) and then finding named objects in theroom: “Can you show me a (phone, lapel or cuff, button, cup).”Repetition is tested by asking the patient to repeat phrases such as “No, ifs,ands, or buts ... Methodist-Episcopal ... Massachusetts Avenue.”Auditory comprehension is further tested by observing if the patient can followthe examiner’s verbal instructions without non-verbal cues (e.g. nodding orpointing to the object): “I’d like you to take the piece of paper on the desk, foldit in half and then hand it to me”, and suggestions “Why don’t you take a seat inthe blue chair next to my desk?”Reading and writingNewly emerged difficulties in reading or writing, or the partial or complete loss ofthese abilities, reflects brain disease and helps delineate behavioral illness. Whenasked to read the cover of a bedside magazine, manic patients often embellishwith flight-of-ideas. When asked to write a simple sentence they elaborate andgive long fanciful writing samples, often in an untypical flowery hand, or withenlarged lettering that fills the page. Patients with chronic limbic disease writecopiously, filling notebooks with repetitive, sometimes delusional discourses onreligion, science, philosophy, and cosmic events. This hypergraphia may beadorned with strange images and designs that the patient insists reveal universalmysteries or other conundrums. 5Micrographia, small, choppy lettering, is seen in Parkinsonism. Writing samplesare regularly assessed for subtle basal ganglia effects of patients receiving antipsychoticmedication. Dysgraphia, the loss of the ability to properly constructletters, is seen in the loss of cursive writing. The patient prints as if a child orcreates distorted or reversed lettering that cannot be constructed on the horizontal,the writing rotating away from the usual alignment. Dysgraphia is a sign ofdominant parietal lobe disease. 6