Tenyi Questions

Is disorientation a sign of psychosis?

From Seminar: In case of disorientation first check organic causes. The symptoms of psychosis is; Hallucination, Delusion, Incoherency in reasoning, Disorganized thinking, speech and behaviour, Katatonia. (Disorientation is not part of it!)

What is Ganser syndrome? And how would you treat it?

It is a type of dissociative syndrome where you have pseudodementia. Infantile behaviour.

It is reaction to extreme stress (in army, prison), patient can't complete basic cognitive tasks, like which month comes after August, what is 13+5, etc. Halucinations, decreased level of conciousness can occur, even conversion disorder.

Tx: Haloperidol

List the 5 somatoform disorders.

Conversion disorder (neurological symptoms)
Hypochondriasis
Somatization disorder (vegetative symptoms)
Fibromyalgia
Chronic fatigue syndrome
Neurasthenia

Organic differential diagnosis for panic attacks?

AMI
Angina pectoris
Pulmonary embolism
Hyperthyroidism
Gastric perforation
Temporal lobe epilepsy
Hypoglycaemia
Caffeine intoxication

Explain reality testing. When is it abnormal?

Intrinsic function of the ego which allows one to differentiate reality from non-reality.

The ability of the person to objectively evaluate the world outside the self.

More concretely the ability to see a situation for what it is, rather than what you hope or fear it to be

Reality testing is abnormal in psychosis

Define delirium.

An acute decline in the attention and the awareness of the environment, a serious cloudiness of sensorium disturbances caused by somatic illness (electrolyte imbalance, hypoglycemia, infection, intoxication or withdrawal)

It is characterized by disorientation, confusion, amnesia, agitation, and hallucination (most commonly visual).

Autonomic instability (tachycardia, sweating and unstable blood pressure.) is common

Diurnal fluctuation is characteristic (usually worsens at night lacking environmental stimuli)

Causes for delirium?

Severe somatic diseases:

General medical conditions: dehydration, inflammation, hypoxia, cardiac failure, renal failure, metabolic disturbance, electrolyte disturbance, fever post op. etc.

Intracranial diseases: hypoxia, stroke, bleedings, head trauma, inflammations, operations etc.

Substance induced:

Intoxications (e.g. anticholinergic agents)

Withdrawal (alcohol, benzodiazepines, barbiturates, GBL etc.)

Delirium with multiple etiology

Explain the various somatoform diseases. (5)

Conversion disorder:
Patient has neurological symptoms without a definable organic cause. Symptoms include numbness, blindness, paralysis. It may be a response to a stressful situation. Is an acute event.

Hypochondriasis:
Patient has an obsession with their health, believing that they have a disease when they don't.

Fibromyalgia (Pain disorder):
Patient has chronic pain due to psychological stress over an extended length of time.

Somatization disorder (Briquet's syndrome):
Patient has complaints about somatic symptoms (pain, GIT distress, breathing difficulties) without any explainable/related medical condition

Chronic fatigue syndrome:
Chronic fatigue, usually after a viral infection. Lasts more than 6 months

(Body dysmorphic disorder is now considered an obsessive compulsion related disorder, not somatoform disorder)

Explain behavioural psychotherapy.

Aims to identify and change maladapted behaviours to alternative, better behaviours. Used for phobias, panic, OCD.

Techniques:
Positive reinforcement (gratification) for good behaviour
Systemic desensitization - Introducing the patient to the stressful situation in a step-by-step manner.
Flooding - Exposing the patient to the stressful situtation until they achieve relaxation
Implosion - Exposuing the patient to an imaginary or fake version of the stressful stimulus
Aversion therapy - punishing the patient for maladapted behaviour. Examples: Put bad-tasting stuff on fingernails to avoid nail biting. Giving disulfiram for alcoholism

(Developed by Pavlov/Skinner.)

Explain cognitive psychotherapy.

Cognitive therapy seeks to help the patient overcome difficulties by identifying and changing dysfunctional thinking and emotional responses. This involves helping patients develop skills for modifying beliefs, identifying distorted thinking, relating to others in different ways, and changing behaviors. Treatment is based on collaboration between patient and therapist and on testing beliefs.

Example of how dysfunctional thinking: "My friend hasn't called me in a week, they probably hate me", "My collegue did something better than me at work, I'm always worse than others"

Used in depression, anxiety, somatization, etc.

What are hallucinations?

It is a false sensory perception without external stimuli.

They can be elementary, like seeing sparkles (photopsy) or hearing noise (acoasma), or they can be complex, like seeing figures or scenes, or hearing voices (phonemes). A true hallucination is one the patient perceives as real. A pseudo-hallucination is a dream-like experience the patient knows isn’t real

Typical forms of hallucinations:

Hypnagogic, occurring while falling asleep. Nonpathological phenomenon.

Hypnopompic: false perception while awakening from sleep. Nonpathological phenomenon.

Mood-congruent hallucination: hallucinating content which is consistent with either depressed or manic mood

Mood-incongruent hallucination: hallucinating content which is not consistent with either depressed or manic mood

Auditory hallucination: most common type in psychiatric disorders, especially schizophrenia. Can hear noises (elementary) or voices (complex)

Visual hallucination: most commonly in organic disorders.

Olfactory hallucination: most commonly in temporal lobe epilepsy

Tactile hallucination: most commonly in cocaine abuse and organic disorders

Charles Bonnet syndrome: visual pseudo-hallucinations in blind people without psychiatric disease. can be dispersed by opening and closing the eyelids

What are illusions?

Misperception of a real external sensory stimulus.

Only pathological when the patient believes they are real. It is normal to sometimes see objects in the dark which initially look like a person to you, for example.

What are delusions?

A false belief based on incorrect inference about reality, not consistent with the patient's intelligence and cultural background, which cannot be corrected by reasoning.

Can be bizarre or non-bizarre.

Name 5 subtypes of delusional disorders

Grandiose/megalomania: the patient thinks they have amazing knowledge, power, or worth, or they believe that they’re a famous person or higher power like god

Erotomanic: the patient thinks a certain person is deeply in love with them. Mostly affects females

Persecutory: the patient believes that they’re persecuted, spied on, etc.

Somatic/hypochondrial: the patient believes that they have a medical condition or physical defect (like cancer. Not even showing them negative lab results will make them change their minds

Jealous: the patient falsely thinks that their partner is unfaithful

What are the anxiety disorders? (10)

Panic disorders – recurrent unexpected panic attacks

Agoraphobia – anxiety for being in situations it is difficult to escape from or where there is no immediate help, often open spaces, crowds, public transport, shopping malls

Social anxiety disorder – anxiety of social situations where the person may be judged by others

Specific phobia – persistent anxiety of a specific stimulus (object or situation), causing the patient to avoid the stimulus

Generalized anxiety disorder (GAD) – excessive anxiety occurring more days than not for at least 6 months

Separation anxiety disorder – developmentally inappropriate and excessive anxiety concerning separation from attached individuals

Selective mutism – the patient, usually a child, does not speak at school or in the community, but they speak in other situations

Substance/medication-induced anxiety disorder – prominent anxiety or panic attack within 1 months of the use of or withdrawal from a substance or medication, most commonly alcohol, caffeine, marihuana, BZDs, opiates

Anxiety due to general medical condition – anxiety due to a medical condition, like mitral valve prolapse, AMI, cardiomyopathy, hypoglycaemia, phaeochromocytoma, hyperthyroidism

Mixed anxiety and depressive disorder – patients with depressive and anxiety symptoms but which don’t fulfil diagnostic criteria for either

Examples of silent cries for help

Indirect: Patient goes to doctor, complain about stomach-ache or other somatic symptom, doctor finds nothing and sends them home

Direct: joking about suicide, referring to their own death, goes to check out the height of a bridge, tries to buy a weapon/rope etc

Types of bipolar disorders

This classification is according to Akiskal and is taken from the lectures, but in practice other classifications are rather used, like DSM-5

Bipolar I – classic type, with true mania and depression

Bipolar II – no mania, but hypomania and depression

Bipolar III – recurrent depression + antidepressant-induced hypomania

Bipolar IV – depression superimposed on hyperthymic temparement

Bipolar V – recurent depression without hypomania, but during depression there is a mixed hypomanic state

Bipolar VI – bipolarity associated with dementia

From seminar teacher: Yes these are correct and I-III are most important, but mostly I and II are used.

Amotivational Syndrome?

Decreased motivation, apathy, detachment, disinterest, caused by chronic marihuana use.

Symptoms of Neuroleptic Malignant Syndrome (NMS)?

Hyperthermia, muscle rigidity, confusion, autonomic instability, altered mental status.

Complications: Acute kidney injury, rhabdomyolysis, hyperkalaemia, seizures.

May be difficult to differentiate from catatonia

Tx of NMS?

Dantrolene (or bromocriptine), Diazepam.

Cenesthopathy:

A type of somatic hallucination with bizarre sensations in the body, like a feeling of wires or slime in the oral cavity or burning in the abdomen

IQ normal range

Normal = 80 - 120

4 categories of mental retardation (IQ numbers)

mild: 50-70 (85% of cases)
moderate 35-50
severe 20- 35
profound < 20

Etiology of mental retardation

Idiopathic (50%)
Down syndrome
Fragile X syndrome
Foetal alcohol syndrome
Turner syndrome
Prader willi syndrome ,
maternal infections (rubella, HIV, toxoplasma,)
meningitis and encephalitis.

Catalepsy

Muscular rigidity and fixed posture which is unresponsive to external stimuli

Patient holds an immobile position that is constantly maintained. Also called Waxy-catalepsy because if you move eg. the arm of the patient they will keep it like that.

Seen in catatonia, Parkinson

1st line treatment of Catatonia

Benzodiazepines (1st gen antipsychotics worsen it!)

Crystallization

Statue-like freezing in a posture.
Usually a catatonic symptom

type of drinkers (alcoholics probably?)

Problem drinker = Drink to forget

Periodic drinker = fluctuates in habit

Heavy drinker = Huge amount every day, steadily (with some control)

Uncontrolled drinker = Constantly drunk

Classification of oligophrenia by etiology:

Oligophrenia = decreased mental state/dementia congenitally or in early infancy

Prenatal: genetic factors, congenital infections, teratogenesis, chromosomal abnormalities

Perinatal: prematurity, CNS bleeding, asphyxia

Postnatal: encephalitis, meningitis, trauma

Delirium tremens symptoms:

Symptoms of altered mental status:
Impaired consciousness
Disorientation
Hallucination (mostly visual and tactile)

Symptoms of autonomic instability:
Tachycardia
Hypertension
Anxiety

Neurological symptoms:
Tremor
Agitation
Symptomatic seizures

Signs of Bulimia nervosa:

Russell sign (calluses on knuckles), oesophagitis, gastritis, Mallory Weiss syndrome, tooth damage

Transcranial magnetic stimulation (TMS) usage

Treatment-resistant depression

Treatment-resistant acoustic hallucination in schizophrenia

Orthorexia nervosa

Obsession with healthy eating

what is PLISSIT and what we are using for

Acronym for techniques used to treat sexual dysfinction

Permissivity (let the patient talk. No morality should be applied)

Limited Information (only tell them information needed to help solve problem to avoid confusion)

Specific Suggestions (squeeze technique, helping women achieve orgasms)

Intensive Therapy (psychotherapy, treat trauma like rape)

Anorexia nervosa symptoms

Pathologic fear of gaining weight, causing unwillingness to eat, amenorrhea, anaemia, metabolic disturbance, BMI below 15

Anorexia nervosa subgroups

restricting type - excessive dieting, exercise, fasting

Binging type - cycle of binge-eating and self-induced vomiting, misuse of laxatives, diuretics, enemas

Parasomnia –

sleep disorders that involve abnormal movements, behaviors, emotions, perceptions, and dreams that occur while falling asleep, sleeping, between sleep stages.

Types:
Nightmare disorder (= Incubus),
Night terrors (= Pavor)
Sleepwalking (= Somnambulism)
Restless leg syndrome

Ketamine how does it work and when is it used in psychiatry?

It's an NMDA receptor antagonist.
Used in depression which leads to suicide (fast acting) and treatment resistant depression.
SE: Agitation, Confusion, Hallucincations

Cluster A personality disorders →

Characterized by appearing odd or eccentric
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder

Cluster B personality disorders →

Dramatic, emotional, erratic personality
Narcissistic personality disorder
Borderline personality disorder
Histrionic personality disorder
Antisocial personality disorders

Cluster c personality disorders →

Anxious or fearful personalities
Avoidant personality disorder
Dependent personality disorder
Obsessive-compulsive personality disorders

What is atomoxetine and what is it used for?

Selective noradrenaline reuptake inhibitor (NRI), used for ADHD

What are the types of dementias?

Alzheimer disease
Pick's disease
Lewy body dementia
Vascular dementia
Alcohol related dementia
Parkinson disease

Mention the psychiatric diseases related to alcohol

Alcohol addiction,
Pathological alcohol intoxication,
Alcohol withdrawal (hallucination, delirium tremens)
Korsakoff syndrome
Wernicke encephalopathy
Alcohol related dementia

Anti-craving medication

Disulfiram, calcium carbamide, acamprosate (for alcohol)
Naltrexone (for opioids)

Cleckley triad

Antisocial personality disorder:
Does not love
Lack of anxiety
Does not learn from experience

Windscheid triad

Beginning vascular dementia/ atherosclerosis
Headache, vertigo, memory impairment

Symptoms of Wernicke encephalopathy

Confusion
Ophthalmoplegia (nystagmus, diplopia, gaze palsy)
Gait ataxia

Definition of personality disorder

Maladaptive, pervasive and inflexible personality patterns. Causes person to act significantly differently from the expected and accepted norms.

Begin in childhood/adolescence. Associated with child abuse and personality disorders in parents.

What is double depression?

Presence of persistent depressive disorder and major depressive disorder

Alcohol hallucinosis?

Hallucinations in the absence of other psychotic symptoms. Most commonly auditory.
Sensorium is clear (as opposed to delirium tremens)
sensorium intact, consciousness intact, acoustic hallucinations

Anti-anxiety/anxiolytics

BZDs
SSRIs, other antidepressants
Buspirone (for anxiety and OCD)
Pregabalin
Beta blockers
Barbiturates

Name 1st generation antipsychotics

High-potency: Haloperidol, fluphenazine, flupentixol, zuclopenthixol

Low-potency: Chlorpromazine, levomepromazine, thioridazine

Side effects of 1st generation/what are the extrapyramidal side effects:

Tardive dyskinesia
Parkinsonism
Acute dystonia
Akathisia
Neuroleptic malignant syndrome
Prolonged QT

Name 2nd generation antipsychotics

Serotonin-dopamine antagonists:
Clozapine
Olanzapine
Risperidone
Quetiapine
Paliperidone (active metabolite of risperidone with less side effects)

Selective D2/D3 antagonists:
Amisulpride
Sulpiride
Tiapride

Name the 3rd generation antipsychotics (ABC Drugs) and the mechanism of action

Partial dopamine agonists, which is why they have fewer side effects
Aripiprazole
Brexpiprazole
Cariprazine

SSRIs

Fluoxetine, Fluvoxamine.
Paroxetine, Sertraline.
Escitalopram, Citalopram

SNRI

Venlafaxine
duloxetine
desvenlafaxine

NDRI (+5HT reuptake inh.)

Bupropion → smoking cessation + sexual side effects improvement

MAO-I

Moclobemide
Tranylcypromine
Selegiline (MAO-B selective)

Selective noradrenaline reuptake inhibitors (NRIs)

Atomoxetine, reboxetine ( For ADHD, S.E: Insomnia)

Mood stabilizing drugs

Lithium:

Serum concentration 0,6 – 1,2 mmol/liter

Narrow therapeutic range – must be kept in this range to prevent toxicity

Side effects → hypothyroidism, diabetes insipidus, nephropathy

Antiepileptics:

Carbamazepine SIADH, Stevens-Johnsons syndrome

Lamotrigine → dermatitis, Stevens-Johnsons syndrome

Valproate

Gabapentin

Topiramate

Antipsychotics:

Olanzapine

Aripiprazole

Risperidone

Quetiapine

Sleeping pills

"Z-drugs": Zolpidem, zopiclone
Benzodiazepines: e.g. temazepam
Mirtazapine
Melatonin

Opioid (Heroin/Morphine) withdrawal symptoms:

Mydriasis (Dilated Pupil)
Diarrhoea, Nausea, Vomiting, Abdominal pain
Irritability, agitation
Insomnia, Anxiety

Treatment of opiate dependence:

Opioid maintenance therapy: methadone, buprenorphine

Alcohol withdrawal treatment

Thiamine to prevent Wernicke encephalopathy

BZDs to control agitation and seizures: diazepam, lorazepam

Phenobarbital or propofol if BZDs are not enough

Antiepileptics like gabapentin, carbamazepine are options

Alcohol dependence treatment

Anti-Abuse: Disulfiram- (inhibit aldehyde dehydrogenase) — can evoke acetaldehyde syndrome after consuming alcohol

Decrease Craving: Naltrexone, Acamprosate

Vitamin B supplementation

Typical diagnostic symptoms of mania?

More than three of the following symptoms most of the day for at least one week:

Inflated self-esteem or grandiosity

Decreased need for sleep

Increased talkativeness or pressure to keep talking

Flight of ideas or racing thoughts

Easily distracted

Psychomotor agitation or increased goal-directed activity

Increased involvement in dangerous activities (wasting money, harassment, life-threatening situations)

Most important cortical symptoms of Alzheimer

Memory impairment, aphasia, agnosia, apraxia

what is Goodenough’s draw-a-person test?

Psychological, cognitive and personality test for children assessing their mental health by asking them to draw a man, a woman and themselves.

3 main features of ADHD?

Inattention
Hyperactivity
Impulsivity

Where do see emotional incontinence?

Dementia, pseudobulbar palsy, stroke

What is Alexithymia?

Inability to identify, describe or express one's emotions and moods.

What are the positive Symptoms of Schizophrenia?

Delusions
Hallucinations
Thought disorders
Disorganized behaviour (bizarre)

Negative Symptoms of Schizophrenia?

Lack of emotional and facial expression (Emotional flattening)
Lack of motivation
Anhedonia (inability to find pleasure)
Social withdrawal
Neglect personal hygiene

Affective symptoms of schizophrenia?

Depressive episodes
Postpsychotic depression
suicidal behaviour

What is Abstract thinking?

The ability to appreciate nuances of meaning; multidimensional thinking with the ability to use metaphors and hypothesis.

Usually affected by dementia, mental retardation and schizophrenia.

What is a Somatic hallucination?

A false sensation of things occurring in the body.

E.g. feeling that their organs are being pulled, or a propeller in the stomach

What is (Wills-)Ekbom disease?

Restless legs syndrome, abnormal sensation in the legs giving strong urge to move them

What is Ekbom symptom?

= delusional parasitosis, tactile hallucinations of parasites under the skin

What is Othello syndrome ?

Same as delusion of jealousy, when a person has the delusion that their partner is unfaithful

What is the defence mechanism in Jealousy delusion ?

Denial

What is expressed emotion in schizophrenia?

Expressed emotion refers to the comments the parents of a patients make to an interviewer about the patient. It is used to evaluate the emotional environment in the family of a patient.

If the parents come with many negative and critical comments, the prognosis of the patient is worse.

What is the treatment of OCD?

Cognitive behavioural therapy
SSRIs
Atypical antipsychotics

How would you treat an old, demented patient with delirium, Korsakoff syndrome or agitation?

Atypical antipsychotics (Quetiapine, risperidone, tiapride) or haloperidol

What is the treatment of Alzheimer and vascular dementia?

ACh inhibitors (donepezil, rivastigmine)
NMDA antagonist (memantine)
Special for vascular dementia:
Ginko biloba,
Piracetam, vinpocetin

What is trichotillomania?

An impulse control disorder involved compulsing pulling of hair

What do we use for Tx of Korsakoff triad?

Thiamine (B1) infusion, BZDs and haloperidol

Becks triad

Negative views about one self, the society/environment/world, and the future

What is the difference between bizarre and non-bizarre delusions?

Bizarre delusions are absurd, totally impossible. E.g. "Someone have replaced all my organs with someone else's"

Non-bizarre delusions are possible but untrue. E. g. "The police are always watching me"

Endocrinological SE of anorexia:

Amenorrhea.

Frotteurism?

Paraphilia, they like to rub against non-consenting people/objects.

What’s the use of Hachinski score?

To differentiate vascular dementia from other causes of dementia.

Marginal intellect

IQ 70-80

Echolalia

repeats your words

Echopraxia

mimics your movements

What is inverse anorexia nervosa (megarexia)?

Disorder of bodybuilders who believe they're too skinny or small. Makes them obsessed with training and building muscle.

Binge eating disorder:

frequent and recurrent episodes of binge eating without vomiting. Patient has negative psychological and social problems

Déjà vu meaning and the opposite of it

Deja vu → a memory illusion in which a new situation is incorrectly regarded as a repetition of a previous memory.

Jamais vu (opposite) is a false feeling of unfamiliarity with a real situation one has experienced.

What is countertransference

Feelings of the therapist toward the patient which are actually meant for someone else, because the patient reminds them of someone he knows personally.

For example, therapist hates the patient he reminds him of someone he doesn't like

Occurs in psychoanalytical therapy