Showing posts with label Psychiatry. Show all posts
Showing posts with label Psychiatry. Show all posts

Schizophrenia: A short summary

Historical Background: in 1896, Emil Kraepelin differentiated psychiatric illness into 2 major groups.
  • Dementia Precox
  • Mani depressive illness( psychosis)
Eugen Bleuer's Fundamental Symptoms of Schizophremi: Ambivalence Autism Affective Flattening Association disorder

First Rank symptoms
I. Hallucinations

1. Audible thoughts/thought echo 2. Voices heard arguing 3. Voices giving running commentary II. Thought Alienation Phenomenon a) Thought withdrawal b) Thought insertion c) Thought broadcasting
III. Passivity Phenomenon A. Made feelings B. Made volition C. Made impulses IV. Delusional Perception

Epidemiology; Point prevalence of Schizophrenia is 0.5 to 1 %. The Incidence is about 0.5 in 1000 persons

Clinical features
Thought and speech Disorders Autistic thinking, loosening of association, thought blocking, neologism, paraphasias, mutism, perseveration, verbigeration Delusions: primary and secondary Disorders Of Perception Hallucinations Disorders of Affect Disorders of Motor Behaviour Negative Symptoms Suicidal Tendency

Clinical types: Simple Schizophrenia Hebephrenic Schizophrenia Catatonic Schizophrenia Residual Schicophrenia Undifferentiated Schizophrenia Post-schizophrenic depression Others

Bad Prognostic Factors
Male Negative Symptoms Early Onset Insidious progression Chronic Course

Diagnostic Criteria:
According to DSM IV TR 2 or more of the following is required with 6 months of duration of disease with at least 1 month of Active symptoms 1. Delusion Hallucinations Bizzare Behaviour Bizzare thoughts

MANAGEMENT:
1. Pharmacological Treatment: Generally the treatment is continued for 6 months to 1 year for the first episode, for 1-2 year for subsequent episodes. Fluphenazine 25-30 mg IM every 2-3 weeks Penfluridol Flupenthixol Haloperidol ECT ( Electroconvulsive Therapy) Miscellaneous Treatments Limbic Leucotomy Psychosocial Treatment.

Organic Metal Disorders and Delirium


Organic Mental Disorders are behavioral or psychological disorders associated with permanent or transient brain dysfunction and include only those mental and behavioral disorders that are due to demonstrable cerebral disease or disorders, either primary or secondary. Sub Categories of Organic Mental Disorders: OMD are
  • Delirium
  • Dementia
  • Organic Amnestic Syndrome
  • Other organic mental disorders
Delirium:
commonest type
synonyms: Acute Confusional state, acute brain syndrome, acute organic reaction, toxic psychosis, metabolic encephalopathy.

Clinical Features:
1. A relative Acute Onset
2. Clouding of Consciousness
3.Disorientation to time place and person.
other: Disturbed sleep-wake sleep cycle
sun downing( aggravated in the evening and night)
Motor disturbances- asterixis,Carphologia. etc
Psychomotor disturbances

Diagnosis:
According to ICD10
Symptoms should be present in each one area:
1. Impairment of attention and consciousness
2.Global disturbance of cognition
3. Psychomotor disturances
4.Disturbed slepp wake sleep cycle
5. Emotional disturbances.

Important causes of Delirium are:
  1. Metabolic causes: hypoxia, narcosis,hypoglycemia, CCF, Metabolic acidosis or alkalosis, fever , anemia, shock.
  2. Endocrine : Hypo/hyper thyroid,adrenal,pituitary and parathyroid.
  3. Drug: Digitalis, quinidine, alcohol, anti hypertensives, sedatives,barbiturates,TCA, Antipsychotics.
  4. Nutritional deficiency: Thiamin, Niacin, Pyridoxine, folic acid, B12
  5. Systemic Infections.
  6. Intracranial causes: Epilepsy, tumors, migraine, head injury, infections
  7. post operative
Management of Delirium:
Ix: CBC, BGA, Sugar level, po2 and co2, TFT, serum b1 and foalte, toxic screen, csf, etc
Identificaton of the cause and its immediate correction.
Symptomatic measures
Supportive medical and nursing ccare.

Schizophrenia : Diagnostic Criteria




According to the revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), to be diagnosed with schizophrenia, three diagnostic criteria must be met:
  1. Characteristic symptoms: Two or more of the following, each present for much of the time during a one-month period (or less, if symptoms remitted with treatment).
    • Delusions
    • Hallucinations
    • Disorganized speech, which is a manifestation of formal thought disorder
    • Grossly disorganized behavior (e.g. dressing inappropriately, crying frequently) or catatonic behavior
    • Negative symptoms—affective flattening (lack or decline in emotional response), alogia (lack or decline in speech), or avolition (lack or decline in motivation)
    If the delusions are judged to be bizarre, or hallucinations consist of hearing one voice participating in a running commentary of the patient's actions or of hearing two or more voices conversing with each other, only that symptom is required above. The speech disorganization criterion is only met if it is severe enough to substantially impair communication.
  2. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care, are markedly below the level achieved prior to the onset.
  3. Duration: Continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms (or less, if symptoms remitted with treatment).

Depression : You know when you have it

Symptoms of depression include:

Main Symptoms

  • Mood:Feeling sad or down
  • Interest:Loss of interest in normal daily activities
  • Sleep: Excessive sleeping or loss of sleep.
  • Concentration: poor or decreases
  • Appetite: decrease appetite, smtimes overeating
  • Guilt: Feeling of worthlessness
  • Energy: Decrease level of energy
  • Suicidal tendency
Duration of symptooms 2 weeks or more.
Insight is always present except in manic depression

Questions to ask your self.


How much of the time... All of the time Most of the time More than half of the time Less than half of the time Some of the time At no time
1 Have you felt in low spirits or sad? 5 4 3 2 1 0
2 Have you lost interest in your daily activities? 5 4 3 2 1 0
3 Have you felt lacking in energy and strength? 5 4 3 2 1 0
4 Have you felt less self-confident? 5 4 3 2 1 0
5 Have you had a bad conscience or feelings of guilt? 5 4 3 2 1 0
6 Have you felt that life wasn't worth living? 5 4 3 2 1 0
7 Have you had difficulty in concentrating, e.g. when reading the newspaper or watching television? 5 4 3 2 1 0
8a Have you felt very restless? 5 4 3 2 1 0
8b Have you felt subdued? 5 4 3 2 1 0
9 Have you had trouble sleeping at night? 5 4 3 2 1 0
10a Have you suffered from reduced appetite? 5 4 3 2 1 0
10b Have you suffered from increased appetite? 5 4 3 2 1 0


Others
  • Feeling hopeless
  • Difficulty making decisions
  • Unintentional weight gain or loss
  • Irritability
  • Restlessness
  • Being easily annoyed
  • Feeling fatigued or weak
  • Loss of interest in sex
  • Unexplained physical problems, such as back pain or headaches

What could be deadlier than a Mental Illness

Dissociative Disorders

In dissociative disorders, one aspect of a person’s psychological makeup is dissociated (separated) from others. A commonality among most people diagnosed with these disorders is their susceptibility to trance states, hypnosis, and suggestibility. Hans Eysenck's research suggests as well that these are more likely to be nervous extraverts.

Dissocative amnesia is the “inability to recall important personal information, usually of a traumatic or stressful nature,” (DSM IV) but more than what we would characterize as ordinary forgetfulness. It is not due, of course, to a physical trauma, drug use, or a medical condition. Instead, it is due to the ability that these people have to focus away from certain memories that disturb them.
It has been increasingly common for people to report having forgotten childhood traumas, especially sexual abuse, while in the care of certain therapists. Recent researchers now believe that the “recovered memories” that these patients report are actually implanted in the minds of these very suggestable people by their over-enthusiastic therapists. It is still not known whether all recovered memories should be suspect or not, although memory research suggests that trauma is more typically remembered well, not poorly.

Fugue is amnesia accompanied by sudden travel away from a person’s usual haunts. Time away can range from a few hours to months. When these people return to normal, they often don’t remember what happened while they were away. A few adopt an entirely new identity while “on the road.”

Dissociative identity disorder -- formerly known as multiple personality -- involves someone developing two or more seperate “identities” that take over the person’s behavior from time to time. The "usual" personality doesn't remember what happens when an alternate personality takes over. Dissociative identity disorder is not the same as schizophrenia, but does have some similarities. In schizophrenia, voices and impulses are seen as coming from outside oneself, while in dissociative identity disorder, they are seen as coming from within, in the form of these alternate personalities.
One of the first cases to reach the public was the story of Eve White. Eve White (a pseudonym, of course), was a mild mannered woman with a domineering husband. She found herself waking up with garish makeup, hangovers, and other signs that she had been out carousing during the night. This alternate personality that took over occasionally was called Eve Black. Eventually, the two personalities were brought together, and Eve's story was made into a movie with actress Joanne Woodward called "The Three Faces of Eve." A second movie was much more popular: "Sybil." This was the true story of a woman who had been severely abused by her schizophrenic mother, and developed (supposedly) 26 personalities.
People with multiple personalities are usually easily hypnotized, making it likely that this disorder may be caused or at least aggravated by therapists, intentionally or unintentionally, much like recovered memories. It is looked upon with skepticism by many psychologists.
On the other hand, it may also be understood as a modern version of a fairly common occurance in the nonwestern, premodern world:

Spirit possession. In cultures where the powers of gods, ghosts, and demons are taken for granted, people sometimes feel possessed by these outside personalities. In more modern societies, lacking the possession explanation, people assume that the alternate personality is internal.


Depersonalization is the “persistent or recurrent feeling of being detached from one’s mental processes or body....” (DSM IV) Often the world seems odd as well, which is called derealization. Physical objects may seem distorted and other people may seem mechanical. Again, these people may be particularly easy to hypnotize, and the feeling can be induced even in normal people under hypnosis. Half of all adults may have experienced a brief episode of depersonalization or derealization in their lifetime, but it is most common in people who have suffered from abuse, the loss of a loved one, or have seen combat. It is also common under the influence of hallucinogens like LSD.


Dissociative trance disorder is an unofficial category often referred to by psychologists and psychiatrists working in premodern, nonwestern societies. Trance is a narrowing of one's attention so that some things (such as sight, movement, or even outer reality) are placed outside awareness. Cross-cultural therapist Richard Castillo, in his book Culture and Mental Illness, says that trance is "an adaptation with great individual and species survival value." It is not far from such non-pathological states as hypnosis and meditation.
Castillo gives numerous examples:
Amok is found in Malaysia and Indonesia. The word comes from the Sanskrit for "no freedom." It involves a person losing their sense of self, grabbing a weapon such as a machete, and running through the village slashing at people. Afterwards, they have no memory of what they have done and are typically excused from any damage, even if their actions resulted in someone's death!
Grisi siknis is found among teenage girls and yound women of the Miskito indians in Nicaragua. They also run wild with machetes, occasionally assaulting people or mutilating themselves. They have no memory of their actions.
Pibloktoq or arctic hysteria is found among polar eskimos. For anywhere from a few minutes to an hour, a person takes off their clothing and runs screaming through the snow and ice, as a response to a sudden fright.
Latah (in Malaysia) involves violent body movements, taking unusual postures, trance dancing, mimicking other people, throwing things, and so on.
"Falling out" (in the Bahamas) involves falling to the ground, apparently comatose, but hearing and understanding what is going on around you.
"Indisposition" (in Haiti) is a possession trance understood as a response to fear.
"Fits" (in India) is a seizure-like response by some women to family stress, curable by exorcism or by simply telling her husband to protect her from her inlaws!
In the west, these kinds of behaviors are often classified as impulse control disorders, along with trichotillomania, compulsive gambling, pyromania, and kleptomania (discussed with anxiety disorders). One of these - intermittent explosive disorder - is basically the same as running amok, and is commonly known as "going postal

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