Descriptive Psychopathology: The Signs and Symptoms of ...

312 Section 3: Examination domainschair, she demonstrated language comprehension and likely no visual agnosia.By genuinely smiling at the consultant’s lame but deliberate attempt at humor,she demonstrated some emotional reactivity.The usefulness of the information gathered in the brief exchange was clinicallyrelevant. The patient was referred for an evaluation of a “treatment-resistant”depressive illness, and 10–15% of such patients are misdiagnosed as depressedwhen in fact they have another condition that is not responsive to antidepressanttreatment. Apathetic syndromes from structural brain disease are commonlymisinterpreted as depression, but this consideration seemed unlikely from theconsultant’s brief initial assessment. 11 Further examination found the patient tohave an atypical depressive condition. She had never been treated with a monoamineoxidase inhibitor, and that drug class was recommended.The big cognitive pictureEach domain of the behavioral examination begins with an overview. That imageguides the gathering of the details. Establishing the big picture can be donequickly. Is the patient alert? Is the patient having difficulty relating the story ofthe illness or biographical information? Does the patient understand the examiner’scomments and requests? Behavior is the most sensitive expression of brainfunction. Patient 13.2 illustrates.Patient 13.2A 58-year-old man was hospitalized because he was becoming increasinglyirritable toward his wife, threatening her on one occasion. He also made vaguecomments about harming himself.The patient had been a successful business man and an energetic personwho “worked hard and played hard” until six years earlier, when he began tolose interest in his work and other activities. For the two years prior toadmission he spent most of his time at home doing little and offering unconvincingreasons for his inactivity. He seemed unconcerned about the change inhis behavior, becoming irritated only when excessively prodded by his familywho now considered him “lazy” and “resting” on his past success.A consultant was asked to evaluate the patient for dementia and early-onsetAlzheimer’s disease. The consultant met the treatment team at the unit. Thepatient had been admitted late Monday afternoon and it was now Wednesdaymorning. When the entourage entered the patient’s room, the patient recognizedhis outpatient geriatric psychiatrist and greeted her by name. He recognized hisresident, but did not recall her name. He remembered that he was to be seen by aconsultant and greeted him, shaking his hand while offering a social smile.