Descriptive Psychopathology: The Signs and Symptoms of ...

318 Section 3: Examination domainsFigure 13.1 The auditory A testAssessing for deliriumDelirium is a common concern when a patient with general medical or neurologicdisease exhibits an acute behavioral change. 16 Although many deliria are characterizedby substantial anxiety and agitation and some by delusions and frighteninghallucinations in multiple sensory modalities, many delirious patients only appearsleepy, hesitant or unsure of themselves. They have trouble focusing attention andresponding promptly. Their thoughts wander and their speech appears vacant.Few have characteristic features that identify the cause of the delirium. 17Delirium is suspected when the patient exhibits (1) unexplained failure toparticipate in or to understand treatment efforts, (2) unexplained fluctuations inbehavior (particularly in emotional expression and arousal), (3) newly emergedagitation, (4) newly experienced hallucinations, (5) unexplained failure toremember recent events, and (6) unexplained lack of focused attention.All delirious processes are associated with altered arousal. Other than thepatient’s behavior, the most sensitive assessments of arousal require the patientto perform continuously for a minute or more. Figure 13.1 displays an auditoryletter cancellation test that serves this purpose.The patient is asked to listen as the examiner reads aloud the letters in amonotone at the rate of a letter per second. The patient is instructed to signal(e.g. tap with a pen, raise a finger) whenever the letter “A” is said. The “A” israndomly distributed and cannot be predicted. Other letters can be transposedfor “A” and so practice effects are avoided and the test can be repeated with thesame patient. Not responding when hearing “A” is an error of omission and isoften present when arousal is reduced and the patient is not able to focusattention. Responding to a letter other than “A” is an error of commission andis often present when arousal is heightened and the patient is distractible. Five ormore errors of any kind indicates poor attention and is consistent with a deliriousstate and conditions that elicit distractibility (e.g. mania). Asking the patient tosay the days of the week backwards is a cruder measure of attention.