Descriptive Psychopathology: The Signs and Symptoms of ...

186 Section 3: Examination domainsPatient 7.10A 50-year-old man was hospitalized for melancholia. He was noted to havejerky neck and shoulder movements more pronounced on his left side thatwere said to have begun with the emergence of his depressive illness, five yearsearlier. His wife said “He looked like a fish out of the water ...His whole bodywould jerk. His neck, arms, and legs would jerk until he was exhausted.”At that time, the patient was extensively evaluated separately by twoneurologists who concluded that the “jerky motor movements” were due tohis melancholia. MRI showed periventricular ischemic changes that wereunlikely to explain his condition. Various antidepressant drug trials wereunsuccessful. A course of 10 BL-ECT then resolved the melancholia and theabnormal movements. A year later, the patient relapsed and his movementdisorder returned. A second course of ECT again resolved the melancholia andthe “jerky motor movements”. The patient remained well for the next twoyears until the index admission where he again received ECT, again leading toa resolution of the melancholia and movement disorder.Patient 7.11 illustrates the misidentification of catatonia as a conversion disorder.Patient 7.11A 23-year-old woman with a long history of generalized seizure disorder wasbrought to an emergency room by the police who found her wandering thestreets “confused”. She was only intermittently responsive to questions. Overthe last 4months she had been to that ER 8 times for a generalized seizure, thelast fit 10days before.The patient was admitted to the neurology service, where she was found tobe slow to answer or to just stare mutely at the examiner. She was said to beoriented to the month and year, to know her mother’s name, to follow simplecommands and when speaking to be fluent and not dysarthric. She “would notcount or say the alphabet”. She moved all extremities. She performed thefinger–nose-to-finger test without difficulty. She “could not give a goodhistory”. Her initial EEG showed generalized slowing and spike and waves inleft temporal areas. Repeated EEGs showed improvement over a few days,with the last showing “mild slowing” and a few “bi-frontal sharp waves”consistent with diffuse, mild encephalopathy. The patient, however, was saidto “refuse to participate in her care” (meaning she stopped moving) and shestopped communicating. Conversion paresis or malingering was consideredand a psychiatrist consulted.The consultant found the patient to be mostly mute with stereotypy,negativism, automatic obedience, arm rigidity and a mild grasp reflex.