Age Disorientation in Schizophrenia

1. Age-disoriented patients are cognitively more impaired than their age-oriented counterparts.
2. Whether the cognitive impairment is present to a greater degree premorbid among these patients, studies have not yet established this, but some data support this.
3. Others have reported that rated school performance and grade-level do not distinguish age-disoriented from age-oriented subjects.
4. Some have suggested that marked cognitive decline occurs following the first break. 
5. Harvey et al. reported that age-related decline in mini-mental state examination scores is dramatically greater among age-disoriented schizophrenia patients than age-oriented subjects, consistent with more rapid deterioration.
6. Examination of the specific PANSS items revealed that the age-disoriented group was consistently more delusional and more conceptually disorganized and showed increased stereotyped thinking, motor retardation, unusual thought content, disorientation, and poor attention.
7. There was no relationship between the proximity of assessment month to birth month and the severity of age disorientation.
8. There was no relationship between total mini-mental state examination score and either rote memory on the Miller-Selfridge recall task context memory on the same recall task or the type/token ratio generated from the speech sample.
9. Age-disoriented patients have certain more severe psychiatric symptoms, more voluntary motor disturbances, more orofacial involuntary movements, and more severe non-localizing sensory signs.
10. Most of the assessed cognitive abilities of the age disoriented (i.e., mini-mental state examination performance, context memory, speech repetitiveness) are more disrupted than those of matched age-oriented schizophrenic control subjects.
11. Within the age-disoriented group, there was no relationship between mini-mental state examination total scores and other cognitive features, suggesting that age disorientation is not merely an issue of increased severity.
12. More severe motor abnormalities predict poor outcome. 
13. Studies have associated the emergence of involuntary orofacial movements with more severe cognitive decline among schizophrenic samples, irrespective of age disorientation.

Advantages of Open-Ended Questions

What are the advantages of open-ended questions?

During the clinical assessment, open-ended questions are always preferred to close-ended questions. there are several advantages to the open-ended questions. 

If you still don't know What are Open-Ended Questions?

1. Open-ended questions allow patients to start talking about themselves and puts them at ease as they have the floor. 
2. Allows you time to think and plan areas of questioning as you assess their style and content of the response.
3. Allows a period of non-verbal response from interviewer; listening and facilitating. 
   
   >> Just slight info: To Have the floor means to have the right or opportunity to speak in a group, especially at a formal event or gathering. 

Please, Dr. Dunstaple, your colleague has the floor. You'll have the opportunity to reply when he has finished speaking. 

Clinical Vignette: Management of a Patient with Treatment-Refractory Depression

Mr X is a known case of depressive illness for the last 1 year. He has stopped responding after two different groups of antidepressants were tried and has been labelled as a patient of treatment-resistant depression. 

1. How will you assess the cause of this resistance?
2. Write the treatment algorithm that you will follow for his management?
3. If you had to start lithium in this case, what protocol would you follow to start it and how will you monitor it?

Treatment Options for Refractory Depression

Vignette: Assessment of Depression

A 33-year-old man who is a driver-by-profession presented to you with decreased appetite, loss of sleep, and irritability for the last three months. There is no past or family history of psychiatric conditions. He is the only earning member of his family and must go to work every day to make a living. On physical examination, his pulse is 90 beats per minute with an irregular rhythm.

a) Outline your assessment and management plans.
b) What precautions you will take while prescribing psychotropic medications in this case?
c) Enumerate all possible differential diagnoses in this case.

Assessment of Treatment Resistance in Depression

 Assessment of Treatment Resistance  

1. Reconsider the diagnosis, especially considering bipolar depression and hypothyroidism.  
2. Identify comorbidities.  
3. Ensure that adequate dosages for adequate durations have been given 
4. Confirm adherence to treatment  
5. Evaluate for maintaining factors and repeated experiences of stressful circumstances.

Delusions in Psychotic Depression

(Mnemonic: GINPH)

● Delusions of Guilt

● Delusions of Impoverishment (can also be considered as a type of nihilistic delusion.

● Nihilistic delusions, including Cotard syndrome

● Persecutory delusions*

● Hypochondriacal delusions

Patients with Psychotic depression  consider these thoughts well-deserved unlike in schizophrenia where patients feel remorse towards them and mania where patients consider them a response to the great position they have earned. 

When these delusions occur against a background of depressed mood, they are mood-congruent and favor the diagnosis of psychotic depression. When patients with depression have delusions of grandeur or even neutral delusions e.g. delusions of reference, they are mood-incongruent delusions" and favor the diagnosis of schizophrenia (ICD-10).

Psychosis Versus Neurosis

What is psychosis?
A psychiatric disorder in which the thoughts, affective-response, ability to recognize reality, and ability to communicate and relate to others shows impairment sufficient to interfere grossly with the capacity to deal with reality. The classic characteristics of psychosis are.


Impaired reality testing
Hallucinations
Delusions
Disorganization.

Psychosis

1. Insight is absent in patients with psychosis. 
2. In patients with psychosis, there is an impairment in judgment and reasoning. 
3. They lose contact with reality. For example, they believe in the voices they hear. 
4. Delusions are often present. Delusions are psychotic features and are never normal (if a belief meets any criteria of normality, it's not a delusion). 
5. True hallucinations are present, even though hallucinations, especially hypnagogic and hypnopompic hallucinations, also occur in normal people.  
6. Patients with psychosis may exhibit changes in personality, especially patients with schizophrenia with a chronic course. 

Neurosis

1. In patients with neurosis, insight is present to a greater extent.  
2. there is no impairment in judgment and reasoning in patients with neurosis. 
3. These patients do not lose contact with reality, so, for example, even if they experience hallucinations, they acknowledge them as being abnormal. 
4. Delusions do not occur in patients with neurosis. 
5. True hallucinations are usually absent, except for hypnopompic and hypnagogic hallucinations. 
6. Change in personality is unusual. Patients with repeated traumatic experiences may still exhibit personality changes.