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Learning objectives: - Accurate gathering and collating clinical data - Understanding the significance of clinical data. Disorders of perception - Hallucination Disorders of Thought and Speech - Delusions - thoughts alienation - obssessions and compulsions - Flight of ideas - looseness of associations.
Learning objectives: - Accurate gathering and collating clinical data - Understanding the significance of clinical data. Disorders of perception - Hallucination Disorders of Thought and Speech - Delusions - thoughts alienation - obssessions and compulsions - Flight of ideas - looseness of associations.
Learning objectives: - Accurate gathering and collating clinical data - Understanding the significance of clinical data. Disorders of perception - Hallucination Disorders of Thought and Speech - Delusions - thoughts alienation - obssessions and compulsions - Flight of ideas - looseness of associations.
- Accurate gathering and collating of clinical data
- Understanding the significance of clinical data - Applying data on actual clinical situations
Psychiatric skills, knowledge, and attitudes - Skills on what to ask, how to ask and when to ask; tricky at times - Knowledge of how each sign and symptom is defined; very crucial - Attitudes on how to respond appropriately to various patients/situations; takes time
Diagnosis in Psychiatry
Primarily through: 1. Psychiatric History (anamnesis) Predisposing factors (family history) Precipitating factors (stressors, drugs/alcohol) 2. Mental Status Examination Signs and symptoms
Secondarily through: 1. PE (with neuro exam); EEG 2. Imaging techniques (CATscan, MRI, PETscan) 3. Laboratory tests ( to rule out GMCs, e.g. drugs of abuse, liver, thyroid abnormalities)
Core Clinical Signs and Symptoms Disorders of Perception - Hallucination Disorders of Thought and Speech - Delusions - Thought alienation - Obsessions and Compulsions - Flight of ideas - Looseness of Associations Disorders of Emotion - Manic Mood (different levels) - Depression - Disorders of Memory - Amnesias - Dysmnesias Other Disorders - experience of the self - Consciousness - motor functions
1. Disorders of Perception Hallucination: arguably, the most important symptom in clinical psychiatry
Perception without an object (Esquirol ) -hear something that is not there, hears voices Perceived in external objective space (Jaspers ) Differentiate from pseudohallucination
Hallucinations false sensory perception not associated with real external stimuli; there may or may not be delusional interpretation of the hallucinatory experience
Pseudo-hallucination - -The main difference between someone with a pseudo-hallucination and someone experiencing schizophrenic hallucination is that the person with schizophrenia will think that it is real and engage in the hallucination, whereas the person with a pseudo- hallucination will often recognize that it is not real.
Auditory Hallucination - - Most important symptom in psychotic disorders -High in reliability, frequency, and specificity in schizophrenia (WHO IPSS) - - Some are not pathological like hypnagogic and - hypnopompic types (dropping off to sleep, - awakening) - Auditory false perception of sound, usually voices but also other noises such as music - Most common hallucination in psychiatric disorders (schizophrenia) - High in reliability, frequency, and specificity - - - some auditory hallucinations are not pathological like: - Hypnagogic false sensory perception occurring while falling asleep, non-pathological - Hypnopompic false perception occurring while awakening from sleep, non-pathological - Schizophrenic Depressive Multiple Voices Single Voice Running commentary Staccato Third person Abusive Derogatory Clinical Psychopathology Dr. Cabuquit 08/09/10 In both schizophrenic and depressive types, be aware of the commanding quality of the voice(s)
Command Hallucinations Also known as imperative hallucinations - Patients who hear voices should be asked if the voices have commanding quality - About 2/3 of Filipino patients obey voices commands (Cabuquit) - Obeyed commands usually prolonged, intense, and frequent (Cabuquit)
Significance of Mumbling Episodes - Patients who mumble actually hear voices (even when they deny it) - Mumbling is the patients way of responding to the voices - Usually verified by observant relatives
Organic Hallucinations
Visual - More common in organic states like delirium tremens and dementias ( Lilliputian type) Lilliputian Type false perception in which objects are seen as reduced in size; also termed micropsia - All varieties, from elementary forms like flashes of light to fully formed people or animals - Can be with simultaneous auditory hallucination false perception involving sight consisting of both formed and unformed images - Most common in medically determined disorders
Olfactory (Smell) false perception of smell - Temporal Lobe Epilepsy (TLE) attacks are usually ushered in by an unpleasant odour, like burning rubber or rotten food
Gustatory (Taste) false perception of taste - Usually caused by uncinate seizures; could also be due to TLE when associated with salivation, chewing, and sniffing movements
Tactile (Haptic) false perception of taste Cocaine bug or formication feeling of small animals crawling all over the body or under the skin; associated with delusion of persecution Sexual sensations (e.g. being masturbated to orgasm); seen in some schizophrenics Phantom limb phenomenon- most common organic somatic hallucination; occurs in about 95% of all amputations; could be very painful
2. Disorders of Thought
- Delusional Triad: a belief that is - false no logic, no proof - fixed - incongruent with the persons socio- cultural and religious background - Overvalued Idea: an idea that is false, fixed, and congruent with the persons background
Main Types of Delusions
Persecutory- most common in schizophrenia - persons false belief that he or she is being harassed, cheated or persecuted; often found in litigious patients who have a pathologic tendency to take legal action because of imagined mistreatment
Grandiose most common in mania - persons exaggerated conception of his or her importance, power or identity
Guilt- most common in depression - - False feeling of remorse/grief
Jealousy (Othellos syndrome)- most common in delusional disorders; drugs and alcohol abuse aggravating factors; violence frequent - - False belief derived from pathological - jealousy about a persons lover being - unfaithful
- Delusions have a tendency to be acted upon
Schizophrenic vs Depressive Delusions
Schizophrenic Delusions -Delusion of control- most reliable symptom; false feeling that a persons will, thoughts or feelings are being controlled by external forces - Primary delusional perception (Both are parts of First Rank Symptoms)
Depressive Delusions Delusion of guilt- could lead to suicide Nihilistic delusion - false feeling that self, others or the world is nonexistent or coming to an end.
Thought Alienation Thought Echo - - A form of auditory hallucination in which the patient hears his thoughts spoken aloud, either simultaneous with him thinking it or moment or two afterwards.
Thought Insertion - Delusion that thoughts are being implanted in a persons mind by other persons or forces
Thought Withdrawal - Delusion that thoughts are being removed from a persons mind by other persons or forces
Thought Broadcasting - Delusion that a persons thoughts can be heard by others, as though they were being broadcast through the air.
Thought Blocking - An objective phenomenon in which the patient abruptly breaks off his conversation and is silent for a few seconds and then resumes on a different topic. Subjectively they experience a complete cessation of all thought.
* All of the above are commonly seen in schizophrenia; the first four are parts of Schneiders First Rank Symptoms.
OBSESSIONS AND COMPULSIONS Obsessions internal resistance, subjective compulsion. - Pathological persistence of an irresistible thought or feelings that cannot be eliminated from consciousness by logical effort. - Associated with anxiety.
Compulsions simply the motor components of obsessions - pathological need to act on an impulse that, if resisted, produces anxiety - Repetitive behavior in response to an obsession or performed according to certain rules, with no true end in itself other than to prevent something from occurring in the future.
Contrast Ideas similar to obsessions - With internal resistance but without subjective compulsion
Most Common Types of OCs -Handwashing, e.g. Lady Macbeths -Re-checking/repeating/rearranging -Examining things in great detail
3. Disorders of Speech
Looseness of Association - flow of thought in which ideas shift from one subject to another in a completely unrelated way. - Common in schizophrenia - A schizophrenic talking (desultory manner): Its your cross to stand down considering its Saturday. The Episcopal twitter neon sign in occupational street is eating jackass moon in the nearby tropic of cancer of Jupiter and Pluto. So will you tie me up and down in the percolating stairs? Or shall we eat nincompoop pizzaie? -Notice how difficult it is to understand what the patient is talking about; what about pizzaie?
Flight of Ideas rapid continuous verbalizations or plays on words produce constant shifting from one idea to another; ideas tend to be connected; association of words similar in sound but not in meaning, words have no logical connection, may include rhyming and punning. - Common in mania The king is standing, see, HEY! The king king is standing, ding ding a ling, sing, sing, HEY, HEY! (Laughs) Bird on the wing, wing, pilot is a harlot on the trot and he is always hot. Im so hot!!! - Observe the rhyming, punning, and clanging
Neologism forming new words - Most specific symptom of schizophrenia
Mutism Differential diagnoses Catatonic schizophrenia markedly slowed motor activity, often to the point of immobility & seeming unawareness of surroundings Hysterical mutism a diagnostic label applied to state of mind, one of unmanageable fear or emotional excess. The fear is often centered on a body part, most often on an imagined problem with that body part. People who are hysterical often lose self-control due to the overwhelming fear. Organic stupor e.g. demyelinating disease Depressive stupor
Talking to Mute Patients -Whispering Technique (Cabuquit) Literally, a whispering conversation between doctor and patient Good technique to differentiate one mute patient from another Best results with hysterical mutism depressive schizophrenic organic patients
1. Organic stupor: Speak slowly and loudly and hold the patients hand 2. Depressive stupor: Go near the patient, speak with a firm, calm, and reassuring voice; may hold patients hand 3. Schizophrenic mutism: Speak confidently, normal tone; holding hands not advised 4. Hysterical mutism: Stay close, hold hands, and use your best voice; do this with a companion
4. Disorders of Emotion -Depressed Mood (LAPEL by Cabuquit) Low mood (depressed, sad) Anhedonia ( loss of pleasure or interest) Poor appetite (with weight loss) Early morning awakening (3-4 hrs earlier) Low self-esteem ( guilt feelings, suicidal ideas/attempts, hopelessness) Eliciting LAPEL Low mood How do you feel these last few weeks? Have you felt depressed? How do you feel upon waking? Anhedonia (loss of interest) What have you been doing lately? Any change in your usual activities? Poor appetite Any change in your appetite? Any weight loss? Early morning awakening Whats your usual waking time? Any change lately? (3-4 hours earlier than usual?) Low self-esteem Have you felt helpless, hopeless lately? Any guilt feelings? Suicidal ideas? Attempts? Caution: Patients who admit to harboring suicidal ideas require extra attention; look out for smiling depressives
Rating LAPEL Positive responses to three out five questions indicate that the patient is clinically depressed (two of the three responses should be low mood and anhedonia) Specificity of 94% Sensitivity of 96% (Brody and Spitzer 2002)
Depression, Guilt, and Suicide -Depressed patients should always be asked about suicidal ideas or attempts -Guilty feelings need for punishment if no one would mete punishment would punish himself best way is by suicide (presence of command hallucination the risk) -About 10% of depressed patients die from it; more women than men attempt it; more men than women are successful
Mania : The other end of the spectrum Manic Mood Gradations (LEXUS by Cabuquit) ELEvated m. (cheerfulness/confidence) EXpansive m. (disinhibition) EUphoric m. (unrestrained grandiose feelings) EcStatic m. (intense feelings of rapture) - Manic stupor - rare - Hypomania- milder form - Bipolar- with depression and mania
Mania and its offsprings -The manic mood gives birth to: -hyperactivity - pressure of speech -grandiosity -disinhibition, e.g. sexual -lack of sleep -irritability ( when frustrated )
5. Disorders of Memory -Amnesias (loss of memory) Hysterical or Dissociative Organic ( acute, sub-acute, chronic) -Dysmnesias (distortion of memory) Confabulation Dj vu / jamais vu
Amnesias Hysterical or dissociative complete loss of memory and loss of identity; temporary; intact personality Organic acute- (e.g. head injury) retrograde/anterograde amnesia sub-acute- (e.g. Korsakoff ) no new memories chronic - (e.g. dementias) loss of recent memory remote global; irreversible; personality
Dysmnesias -Confabulation detailed false description of an event which never happened; patient tries to fill in the gaps; seen in alcoholics and hysterics and chronic schizophrenics -Dj vu something new is remembered as something old -Jamais vu something old is remembered as something new Both observed in complex partial seizures
6. Other Disorders Disorders of Experience of the Self depersonalization derealization Disorders of Consciousness twilight state fugue state Disorders of Motor Function waxy flexibility occupational delirium
7. SUMMARY The most important symptom in clinical psychiatry is hallucination Think of schizophrenia when Schneiders First Rank Symptoms are prominent Depressed patients should always be asked about suicidal ideas or attempts Command hallucinations increase the risk of untoward behaviours In depression, think of LAPEL In mania, think of LEXUS In mutism, think of CHODE Looseness of association is commonly seen in schizophrenia Flight of ideas is commonly seen in mania
NOTE: the latter parts of this trans was not entirely lectured. They were included because they were in the given power point.
REFERENCES: Dr. Cabuquits lecture Dr. Cabuquits ppt Trans medicine 2011 A
Somatoform and Other Psychosomatic Disorders: A Dialogue Between Contemporary Psychodynamic Psychotherapy and Cognitive Behavioral Therapy Perspectives