Descriptive Psychopathology: The Signs and Symptoms of ...

15 Chapter 1: Beyond the DSM and ICDin her responses. She had naming problems and was circumloculatory. She didnot have the circumstantial speech or flight-of-ideas characteristic of mania.Her change in speech and word usage was understood as a receptive aphasiasyndrome following a stroke. Hypertension was considered contributory.At no time in the nursing home, hospital admitting area or initially on theinpatient unit was her behavior evaluated for anything other than mania, norwas her speech and language recognized as anything other than “confused”.She initially received no evaluation for stroke. Once the diagnosis was made,psychotropic medication was avoided and her hypertension controlled. Shewas quickly able to return to the nursing home. 68The DSM and ICD formats limit meaningful examinationThe checklist approach of the DSM and the brief paragraph offerings of theICD are at best concluding summaries of the psychiatric examination. Theyare inadequate as guideposts to the examination. For example, illness onsets ofhours, days, weeks and months have different diagnostic implications regardlessof how the patient appears in the full expression of the disorder. Patient 1.6 hasthe cross-sectional features consistent with the diagnosis of schizophrenia, butthe onset of his symptoms is distinctly not that of classic schizophrenia.Patient 1.6A 28-year-old man experienced auditory hallucinations (voices commentingand conversing) daily for years. The hallucinations were perceived as originatingfrom a non-specific external source. The voices were loud, clear, andderogatory in content. They were most intense for several hours in themorning, but the patient would hear them occasionally in the early afternoon.He recognized that his experiences were a sign of illness, but when the voiceswere most intense, he believed them to be real and not self-generated. Hedid not work, had no future plans, and mostly kept to himself, worrying aboutthe voices and fearful of their inevitable return. Emotional expression wasintact, moods appropriate, and no speech or language disorder was noted.He was occasionally suspicious of strangers, assuming that they might be thesource of the voices. He had never been depressed or manic. Meeting DSMcriteria for schizophrenia, several antipsychotics had been prescribed, withminimal relief.A consultant noted that the man’s morning hallucinations typically beganupon awakening. The patient would awake, become immediately frightened,and then hear the voices. After several hours, they diminished in intensity andended. They recurred shortly after lunch. Because a nonaffective psychosis