Descriptive Psychopathology: The Signs and Symptoms of ...

100 Section 2: The neuropsychiatric evaluationThe episodes, however, always began with him suddenly experiencing asense of impending doom with physiologic signs of anxiety, followed by seeinga frightening, shadowy figure off in the distance. After several of these experiencesa psychotic episode emerged. Of late, the small distant figure began toapproach him, becoming larger and more ominous. When finally standingnext to the patient, the figure was literally felt to be trying to enter thepatient’s body to “control” him. The patient concluded the “demon” wantedto assume his identity and that his only recourse was to let the demon enterhis body and then shoot it. He did not think he would also die.Recognized as experiencing classical signs of epilepsy (the patient hadsustained a serious head injury several years before his first psychotic episodeand before that was a high-functioning, stable person), the patient was treatedwith an anticonvulsant (a seizure disorder was confirmed on EEG), made a fullrecovery and remained well.Pattern of symptomsPresent classification uses lists of unweighted symptoms as diagnostic criteria. If apatient has a certain number of features the threshold for illness is met, regardlessof which features are present. A hypothetical example follows:A patient is observed to have a grandiose delusion. He also meets the DSM catatonia criteria(two features are required) because he has excessive motor activity that is “apparently purposelessand not influenced by external stimuli”, and “echolalia and echopraxia”. Because he hasboth a delusion and catatonia he technically meets criteria for schizophrenia. Few experiencedclinicians, however, would consider this patient to be schizophrenic and many would diagnosemania because of the pattern of features.The pattern of features influences differential diagnosis. The pattern of psychopathologyof Patient 1.1, the man who suffered carbon monoxide poisoning,was consistent with a frontal lobe syndrome, not depressive illness. The pattern offeatures in Patient 1.4, the woman with Capgras syndrome, was consistent with aright cerebral hemisphere stroke. The pattern of psychomotor disturbance (agitationor slowing), non-reactive apprehensive and gloomy mood, and vegetativedisturbances (poor sleep, poor appetite, no libido), and evidence of circadianrhythm disturbances (night sweats, tachycardia) defines melancholia. 21Primacy of featuresFor the most part, present classification does not assign special diagnostic significanceto any single feature, recognizing that there are no pathognomonic signsin psychiatric classification. An exception is in the criteria for psychotic disordersin which one feature is sufficient to secure the diagnosis of schizophrenia if it is a