Psychiatry - disorders

Schizophrenia

Characteristic Symptoms: 2 (or more) of the following,

each present for a significant portion of time during a 1-

month period (or less if successfully treated):

- Delusions

- Hallucinations

- Disorganised speech (e.g., frequent derailment or

incoherence)

- Grossly disorganised or catatonic behaviour

- Negative symptoms, i.e., affective flattening, alogia,

or avolition

Duration: continuous signs of the disturbance persist for at least 6 months

Predisposing factor: copmlication at birth, family history, poor socioeconomic condition, central dopamine overactivity, etc.

Major depressive disorder (clinical depression)

A 50-year-old lady whose mother passed away from a stroke. Over the past 6 months, she has been experiencing low mood, guilt, and poor sleep. She used to enjoy playing the piano but now she no longer enjoys it.

anhedonia, decrease in energy, decrease attention

Different from normal depression because it is generally greater in severity

Characteristic Symptoms: 5 (or more) of the following have been present during the same 2-week period and represent a clear change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

- Depressed mood most of the day

- Marked diminished interest or pleasure in all activities

- Significant weight loss

- Insomnia or hypersomnia

- Psychomotor retardation or agitation

- Fatigue or loss of energy almost everyday

- Feeling of worthlessness or excessive guilt

- Diminished ability to think or concentrate

- Recurrent thoughts of death

Pattern: seasonal

Manic episode

A distinct period of (1) elevated, expansive, or irritable mood and (2) increased goal-directed activities for at least 1 week and 3 of the

followings:

- Inflated self-esteem or grandiosity

- Decreased need of sleep

- Overtalkativeness or pressure of speech

- Flight of ideas

- Distractibility

- Increased goal-directed activities or psychomotor agitation

- Excessive involvement in potentially dangerous activities or

activities that patient may regret

May be caused by corticosteroid, anticholinergics, or isoniazid

Anxiety disorder

The anxiety and worry are associated with 3 (or more) of the following

- Restlessness or feeling keyed up or on edge

- Being easily fatigued

- Difficulty concentrating or mind going blank

- Irritability

- Muscle tension

- Sleep disturbance

Panic disorder

Patient has physical symptoms like palpitations, chest pain, etc, Onset is abrupt and peaked within minutes. Patient fear of heart attack and see physician. All relevant investigations done are negative of heart disease. However, patient still worry about it and self restrained her activity. What is the diagnosis?

A 40-year-old female teacher gets episodes of palpitations and shortness of breath for around 20 minutes and she felt that she would collapse. There is no known trigger. She feels like there are some heart problems.

A discrete period of intense fear or discomfort, in which 4 (or more) of the following developed abruptly and reached a peak within 10 minutes:

- Palpitations

- Sweating

- Trembling or shaking

- Sensations of shortness of breath

- Feeling of choking

- Chest pain or discomfort

- Nausea or abdominal distress

- Feeling dizzy, unsteady, lightheaded or faint

- Derealization of depersonalization

- Fear of losing control or going crazy

- Fear of dying

- Paresthesias (numbness or tingling sensations_

- Chills or hot flushes

Anorexia Nervosa

Significantly low BMI and fat phobia

Bulimia nervosa

Repeated binge eating and fat phobia

Insomnia disorder

A. A predominant complaint of dissatisfaction with sleep quantity or quality, associated with one or more of difficulty initiating sleep, difficulty maintaining sleep, or early morning awakening

B. Causes clinically significant distress or impairment in functioning

C. At least 3 nights per week for at least 3 months

D. Despite adequate opportunity for sleep

E. Not better explained by other sleep disorder, substance use, mental and medical conditions

Autism spectrum disorder

Persistent deficits in social communication and social interaction across multiple contexts

Restricted, repetitive patterns of behavior, interests or activities

(e.g., Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment)

ADHD

Persistent pattern of inattention and/or hyperactivity-impulsivity

Personality disorder, cluster A

Paranoid, Schizoid, Schizotypal

Personality disorder, cluster B

Antisocial, Borderline, Histrionic, Narcissistic

Personality disorder, cluster C

Avoidant, Dependent, Obsessive-Compulsive

Borderline personality disorder

A pervasive pattern of instability of interpersonal relationships, self image and affects and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by 5 or more of the following:

1. Frantic efforts to avoid real or imagined abandonment

2. A pattern of unstable and intense interpersonal relationship, characterized by alternating between extremes of idealization and devaluation

3. Identity disturbance: unstable self image or sense of self

4. Impulsivity in at least 2 areas (spending, sex, substance abuse, reckless driving, binge eating)

5. Recurrent suicidal behavior

6. Affective instability

7. Chronic feelings of emptiness

8. Inappropriate, intense anger or difficlty controlling anger

9. Transient stress related paranoid ideating or severe dissociative symptoms

Major Neurocognitive Disorder (Dementia)

A. Significant cognitive decline from a previous level of performance in 1 or more domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on informants or cognitive tests

B. Interfere with independent living

C. Not better explained by another mental disorder

Delusion

Fixed, false beliefs that are maintained despite being contradicted by reality or rational arguments

E.g., CFB PBL case 1: keep saying 老婆出軌

Hallucination

Sensory experiences occur in the absence of external stimuli

He had 6 weeks history of hearing several voices discussing about him among themselves and reading out his thoughts loudly even when nobody was around.

Illusion

Inaccurate perception (distortion) of real sensory input

A girl admitted into hospital for tonsillectomy cried at night for seeing a bear in the room. She was relieved when the nurse, who came in response to crying, turned on the lights, revealing that the bear was an arm-chair covered by cloth. This experience best describes:

The blanket turns into the skin of the tiger

Psychosis

Impaired perception of reality evidenced by one or more of the following thought disturbances (a key feature of schizophrenia)

Characteristic symptoms:

a. Thought echo, thought insertion or withdrawal, and thought broadcasting

b. Delusions of control, influence, or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations; delusional perception

c. Hallucinatory voices giving a running commentary on the patient's behaviour, or discussing the patient among themselves, or other types of hallucinatory voices coming from some part of the body

d. Persistent delusions of other kinds that are culturally inappropriate and completely impossible

e. Persistent hallucinations in any modality, when accompanied either by fleeting or half-formed delusions without clear

affective content, or by persistent overvalued ideas, or when occurring every day for weeks or months on end

f. Breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech, or neologisms

g. Catatonic behaviour, such as excitement, posturing, or waxy flexibility, negativism, mutism, and stupor

h. 'Negative' symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses,

usually resulting in social withdrawal and lowering of social performance; it must be clear that these are not due to

depression or to neuroleptic medication

i. A significant and consistent change in the over- all quality of some aspects of personal behav- iour, manifested as loss

of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal

Obsessive-compulsive disorder

Persistent and recurring thoughts, urges, or images (obsessions) that lead to repetitive behaviors or mental acts (compulsions).

recommend patients for exposure and response prevention

A22-year old girl complains of repetitive images of herself jumping from heights, leading to a fear of standing near windows. The most likely diagnosis is:

Pseudo-hallucination

Hallucination that is recognized as a hallucination

Located in the inner subjective space

Catatonia

Neuropsychiatric syndrome where an individual becomes very nonreactive to their environment due to an underlying medical condition

Automatic obedience is a feature

Abnormal volitional movements, usually repetitive or purposeless overactivity, related to disturbed mental state

Pseudodementia

Cognitive and functional impairment imitating neurodegenerative disorders caused secondary to neuropsychiatric symptoms

E.g., 65-year-old man (who has presented with depressive mood) complains of "forgetfulness" for the recent 1 month.

Factitious disorder

Amental disorder in which a person, without a malingering motive, acts as if they have an illness by deliberately producing, feigning, or exaggerating symptoms, purely to attain a patient's role.

Intentional production and feigning (faking) of symptoms

Somatic symptom disorder

One or more somatic symptoms that are distressing or result in significant disruption of dailly life

Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following: persistent thoguht / high level of anxiety / excessive time & energy

Persistently symptomatic: more than 6 months

Risk of drug abuse

More common in women

Hypochondriasis

A 50-year-old female had epigastric pain for 2 years and went to see a doctor. Physical examination and investigations are normal and she was reassured by the family physician and doctor, but she is still scared that she has gastric cancer.

Preoccupation with having / acquiring a serious illness

Normal or commonplace sensations & appearances are often

interpreted as abnormal & distressing

Malingering

Deliberate faking of a physical or psychological disorder motivated by secondary gain.

Post-traumatic disorder

An 18-year-old girl experienced a traffic accident on a bus one month ago. Afterwards, she develops anxiety every time she passes the site of accident and gets nightmares. She thinks of the accident whenever she gets on a bus.

Adjustment disorder

After breaking up with her boyfriend about 2 weeks ago, a 30-year-old woman had nervousness, low mood, poor sleep, and occasional tearfulness

subject experienced mood symptoms after experiencing a

stressful even

A disorder in which a person's response to a common stressor is maladaptive and occurs within 3 months of the stressor

Conversion disorder

Patients present with neurological symptoms that cannot be fully explained by a neurological condition.

Acute stress disorder

Associated features such as recurrent flashback, avoidance behavior, emotional

numbness

Duration of the symptoms should be between three days and four weeks and cause significant functional impairment and not related to substance use or other medical conditions

Social anxiety disorder

Intense fear of social situations, leading to avoidance of such

Paraphilia

Defined as any intense and persistent sexual interest other than

sexual interest in genital stimulation or preparatory fondling with phenotypically

normal, sexually mature, consenting human

Poverty of speech (Alogia)

Patient with minimal spontaneous speech and

answering questions briefly

Thought block

Sudden involuntary silence within speech

Tangential speech

Sudden and frequent change in topic

Mr Chan, factory worker, Bipolar I disorder. On lithium with good therapeutic effects. Recall a manic episode where there were troubles in his thinking process. cannot follow a topic in discussion, friend

described him as 'digressing', switched to irrelevant stuff in conversations. Which word best

describes this problem in the thinking process?

Circumstantiality

Speech that is delayed in reaching the point and contains excessive or irrelevant details

Clang association

Meaningless rhyming of words

Depersoanlization

A dissociative disorder

a change of self-awareness such that the person feels unreal, detached from his own experience and unable to feel emotion / feel numb

Voyeurism

a form of paraphilia

desire to watch others having sexual relations or to spy on nude people

Akathisia

motor restlessness, usually a side-effect of neuroleptic medication

Folie a deux

Symptoms of a delusional belief are "transmitted" from one individual to another

Capgras & Fregoli delusions

The delusional belief that a friend, family member, etc., has been replaced by a twin impostor.

derealization

change in relation to the environment such that objects appear unreal, people appear as lifeless, two-dimensional card-board figures

Echopraxia / ecolalia

imitation of an interviewer's movement automatically even when asked not to do so

Ambitendance

alternate between opposite movements and so on repeatedly

Waxy flexibility

person's limbs can be placed in a position in which they remain for long periods

jamais vu

failure to recognize events that have been encountered before

deja vu

conviction that an event repeats one that has been experienced in the past when in fact it is novel

Confabulation

-falsification of memory occurring in clear consciousness (associated with amnesia → gaps in a person's memory are unconsciously filled with fabricated, misinterpreted, or distorted informatio)

-suggestibility as a prominent feature

Oppositional defiant disorder

a childhood disorder in which children are repeatedly argumentative and defiant, angry and irritable, and in some cases, vindictive

Nominal dysphasia

The inability to recall the names of people or objects that are perceived correctly

common in Alzheimer's disease

Ahedonia

Inability/reduce ability to feel pleasure in normally pleasurable situations