Monday, 22 February 2021

Capgras Syndrome (Delusion)

Capgras Syndrome

The patient believes that someone else has replaced a familiar person. Both have a close resemblance. For example, an unknown person replaces the daughter. The patient may attack the familiar person. The original name was ‘delusion des sosies’ a delusion and not a syndrome an example of reduplicative paramnesia.. the most common cause is schizophrenia. other causes include Lewy body dementia and other neuropsychiatric disorders. Always assess the risk of violence to the family person. 

 

 


Thursday, 18 February 2021

Organic Amnestic Syndrome and Korsakoff Psychosis

Organic Amnestic Syndrome and Korsakoff Psychosis

Dr Waleed Ahmad

Vignette

A 30-year-old woman is brought to you with memory deficits and rigid behaviour. On examination, she appears lean and weak, dishevelled, is disoriented to time, has a flat affect, registration is 3/3, short-term memory is 0/3 and long-term memory appears intact. She does not have any difficulty naming objects. On physical examination, her weight is 42Kg and her height 152 cm. The lady says, there is nothing wrong with her, while her father says she is speaking too many lies these days. The rest of the clinical evaluation is insignificant except for chronic diarrhoea and recent episodes of vomiting. 

What finding will you look for on MRI?

Diagnosis

The clinical picture, in this case, is consistent with organic amnestic syndrome, specifically Korsakoff Psychosis. The most common cause of organic amnestic syndrome is thiamine deficiency.(1)

Magnetic Resonance Imaging

Increased signal (ie, hyperintensity) in midline structures occurs in the acute Korsakoff psychosis. 

Laboratory test

Red cell transketolase activity is the most specific test for Korsakoff psychosis. 

Other causes: 

  1. Diencephalic amnesia
  2. Infarct in medial thalamus
  3. Tumour in medial thalamus
  4. Encephalitis
  5. Head injury

Causes of thiamine deficiency

  1. Alcoholism
  2. Malnutrition 
  3. Diarrhoea
  4. Vomiting

Neuropathological Changes in Korsakoff Psychosis

  1. Neuronal loss
  2. Gliosis
  3. Microhaemorrhages

Location of Neuropathological Changes 

  1. Periventricular
  2. Thalamus
  3. Mamillary bodies

Lesions causing Organic Amnestic Syndrome

Organic Amnesia results from lesions in the medial temporal lobe and medial thalamus. Medial temporal lobe lesions cause pure amnesia without impairments in other cognitive domains. 

About the Author

The author is a consultant psychiatrist at the department of psychiatry, Mercy Teaching Hospital Peshawar, and a member of the faculty at the department of psychiatry and behavioural sciences, Peshawar Medical College, Peshawar, 25000, KP, Pakistan. Email: dr.waleed@outlook.com 

Wednesday, 10 February 2021

Somatization Disorder CASC Station

You received a call from the medical department who requested you to see a 31-year-old lady who has been an in-patient for over two weeks. During her admission, she underwent investigations for persistent pain in her upper abdomen. She has been experiencing pain for the last two months. The physicians originally believed this was gastric or duodenal, but endoscopy was negative. After a comprehensive debate on the case, the medical team has opted to get a psychiatric opinion. Upon evaluation, you found that she has visited multiple clinics and has experienced wide-ranging manifestations and pains over the last two years. However, physicians have identified no source of her symptoms so far. She is worried about her physical symptoms but does not consider them as a warning sign of any serious underlying disease. On mental state examination, she has a low mood, hopelessness, sleeplessness, and reduced appetite. These mental state findings have been present for the last two months. 
 
How would you set out to educate the patient? 
What psychosocial explanations will you exemplify to explain how the symptoms are caused?
Who should take care of her?
In which case should the patient see a physician?
What advice will you give to the family regarding further investigations?

Supplemental Questions
What non-pharmacological treatments can help her?
What medication can help her?
  1. First tell her about the results of the investigations and why she has been sent here (ie the investigations are negative, and the physician thinks the symptoms may not be organic). Then tell her why it is important to look for other (psychiatric) causes.  
  2. Tension >> butterflies in the stomach, diarrhoea, headache, high blood pressure.  
  3. ONE Psychiatrist. Must avoid going to multiple should take care of her. 
  4. Only when new physical symptoms arise should the patient see a physician. 
  5. Advice regarding further investigations: when investigations are negative, they relief the patient and reinforce demands for more.  only if the physician considers important, they will advise in liaison with a psychiatrist.  
  6. CBT for pain, increasing activity, exercise.   
  7. Medications: TCAs, duloxetine, other antidepressants.  


 

    

Friday, 5 February 2021

Conversion Disorder

    A 16-year-old girl presents with multiple unconsciousness. These started about six months ago and have become progressively worse. During the episodes, there is the jerky movement of the body but no urinary or faecal incontinence. These symptoms last for a few minutes and are followed by drowsiness. Neurological examination is normal.

    What differential diagnoses would you consider in this case?

    What other information would you enquire from the family about the episodes?

    Which specific investigations would you like to order?

    Differential Diagnosis

    Conversion disorder (F44.5 Dissociative convulsions) suggested by the episodes of unconsciousness and lack of findings on neurological examination and absence of incontinence.

    Epilepsy suggested by the recurrent brief episodes of unconsciousness, accompanied by jerky movements and followed by drowsiness

    Vasovagal syncope suggested by the brief episodes of unconsciousness, jerky movements (may occur) and normal physical examination

    Paroxysmal arrhythmia, which also can cause episodic unconsciousness

    History of the Fits

    A detailed account of (what happens during) the episodes

    Examining a videotape if they have recorded it.

    The duration of the fits

    Whether there is a clonic phase

    Whether they experience an aura. 

    The occurrence of headache after the episode

    Whether the patient remembers the events during the episode

    Whether the fits are stereotypic in presentation

    Whether the patient shouts or moans during the episodes ,

    Whether the eyes remain open or closed during the episode

    Whether they observe cyanosis

    Tongue bite and location of the injury

    The pattern of occurrence

    The Frequency of the episodes

    The weather there is a special time of occurrence

    Fits/jerky movements during sleep

    Precipitating factors




    A 17-year-old girl is admitted in a psychiatry ward. She was brought unconscious with a reported history of 5-6 episodes of unconsciousness daily, each episode lasting more than an hour but not associated with body movements, tongue bite or urinary incontinence. These episodes started after her engagement to a middle-aged entrepreneur who is already married. Family members and neighbours believe she is under the influence of black magic. Radiological and lab investigations are unremarkable.

    What is your provisional diagnosis?

    What psychosocial explanations could you use to help the patient and her family?

    How will you manage this patient?

    Diagnosis

    Conversion disorder (F44.5 Dissociative convulsions)

    Functional neurological symptom disorder (DSM-5)

    Useful Psychosocial Explanations

    Experiencing a queasy stomach when talking in front of a vast audience.

    Stress can worsen or cause hypertension.

    Stress may worsen or cause even stress ulcers

    Management

    Inform the patient about the results of the assessment and the lack of evidence of an underlying physical condition.

    Emphasise that the symptoms are real, well recognised and familiar to the clinician and strictly avoid giving the impression that there is 'nothing wrong' with them.

    Explain the role of psychosocial factors in all medical conditions. Provide socially acceptable examples of diseases that often are deemed stress-related (e.g., peptic ulcer disease, hypertension).

    Provide common examples of emotions producing symptoms (e.g., queasy stomach when talking in front of an audience) and examples of how the subconscious influences behaviour (e.g., nail-biting, pacing, foot tapping). Then offer and discuss a psychosocial explanation of the patient's symptoms.

    Reassure the patient that the condition is temporary and, with motor disorders, because of a problem in converting willed intention into action.

    Provide positive reinforcement/suggestion that the symptoms can improve and encourage the patient to overcome them.

    Provide a graceful way for the patient to improve and allow time for a gradual recovery.

    Avoid reinforcing symptoms or disability, including the provision of wheelchairs and stretchers. If the condition is long term, help remove the identified reinforcements.

    Treat any associated psychiatric disorder (commonly anxiety or depression) and provide possible help with any related social issues.

    Allow adequate time for the patient and their partner/family to ask questions.



    Conversion disorder




    Sorry for your loss, sorry to hear about your loss in vision/ sensation etc

    (If vision – ask 1 or both eyes, red? Painful? Fluctuating vision loss?)

    What do you think has caused this?

    Happened before?

    Do you think it might link with recent stresses in your life?

    Do you know anyone with this, anyone in the family with this, or have you read about it?

    Reassured by the Drs?

    Do you think you have a particular illness?

    Apart from this, do you have any other physical symptoms? How often do you see the GP?

    What now? Treatment or believe you need investigations?

    How have other people reacted?



    Any court case pending?



    Drugs and Alcohol? Impact – i.e. social situation- off sick? – stresses Risk – to self, to others, from others, neglect



    MSE

    Depression?

    Anxiety – PTSD, GAD, OCD

    Psychosis

    Insight



    PPHx

    Meds



    PMHx- thyroid, HI, epilepsy

    FHx

    Forensic – any court case pending?



    For Dissociative seizures: include – any tongue biting, physical injuries sustained during seizures? Any incontinence? When to they occur, ABC?



    Non-epileptic seizures are common in people who have epilepsy.


    Tests for conversion disorder


    Biological?


    Evoked potentials

    Findings:

    disturbed somatosensory perception;

    diminished or absent on side of defect.


    Psychometric tool?

    Halstead–Reitan battery.


    Findings

    Mild cognitive impairment

    attentional deficits

    visuoperceptual changes


    Personality assessment

    Objective: Minnesota Multiphasic Personality Inventory-2 (MMPI-2)

    Rorschach test


    Findings?

    increased instinctual drives,

    sexual repression

    inhibited aggression


    Hysterical aphonia TX?


    Drug-assisted interview

    E.g. intravenous amobarbital (Amytal) (100 to 500 mg) in slow infusion


    Test for dissociative stupor?

    Lorazepam challenge test


    Patient has an a taxi gait. Does not fit any pattern. Patient does not fall to ground. Organic causes ruled out. What is this?

    Atasia abasia


    Patient has transient blindness for few hours. Tracking movements and pupil ary response is absent. Patient recovers two hours later. What is it

    Amurosis fugax

    Pupillary response and tracking movements are not absent in conversion disorder.


    Patient says she is deaf. You think she is not. Conversion suspected. How will you prove your point?


    Bring two metal plates, Bang heavily near her bed while she is asleep. If it awakens her, congratulate her that her hearing is normal. Okay, that was a joke, but the loud noise test during sleep is true.


    Patient is having gtc fits. You are not sure whether they are conversion or epileptic. She is seizing right in front of you. Test?


    Eye-opening

    Check pupils

    Babinski reflex


    Babinski is absent in seizures and in postictal state


    Psychotherapy of choice?

    Insight-oriented therapy


    Pathological jealousy. What ethical principles are related?


    Tarasoff warning

    mental health professionals have a duty to protect individuals who are being threatened with bodily harm by a patient.




































    Motor Symptoms of Conversion Disorder. The International Classification of Diseases 10th edition has enlisted the following motor symptoms of conversion disorder. 
    Involuntary movements
    Tics
    Torticollis
    Blepharospasm
    Seizures
    Falling
    Abnormal gait, Atasia-abasia
    Weakness/paralysis
    Aphasia
    >> Dissociative Motor Disorders

    Monday, 1 February 2021

    INSOMNIA COMORBID WITH MAJOR DEPRESSIVE DISORDER

    INSOMNIA
    COMORBID WITH MAJOR DEPRESSIVE DISORDER

    Management Approaches

    ___

    Amit Chopra, MD, DFAPA.

     

    INTRODUCTION

    Insomnia is defined as a predominant dissatisfaction with sleep quantity or quality, associated with one or more specific symptoms including difficulty initiating sleep, difficulty maintaining sleep, and early morning awakening with inability to return to sleep.

     

    A diagram summarising the bidirectional link between insomnia and depressive disorder

    Based on DSM-5 criteria, the sleep difficulty should occur at least 3 times per week for 3 months or more, despite adequate opportunity for sleep for establishing a diagnosis of insomnia disorder. Insomnia is the most common sleep complaint with trouble initiating sleep (initial insomnia), disrupted sleep (middle insomnia), early morning awakenings (terminal insomnia), and/or non-restorative sleep during acute major depressive episodes. Evidence suggests that insomnia correlates strongly with a significantly increased risk of developing depression. Given substantial evidence that each condition predisposes towards the development of others, a bi-directional link between insomnia and depression exists. Not only does insomnia increase the risk of depression, but it also contributes to poor depression treatment outcomes. The re-emergence of insomnia in patients with remitted depression can predict the recurrence of a new depressive episode. Finally, insomnia has been increasingly recognised as a risk factor for death by suicide independent of depression severity. Because of these reasons, it is imperative to comprehensively assess and treat insomnia in patients with major depression to improve remission rates, prevent relapse of depressive illness, and reduce suicide risk.

    Assessment

     Insomnia Severity Index is a validated self-report screening tool to assess insomnia severity, patient satisfaction with sleep quality, daytime impairment, and overall distress caused by sleep dysfunction. It is crucial to screen for primary sleep disorders that are frequently comorbid with major depression such as obstructive sleep apnoea, restless legs syndrome, and circadian rhythm sleep disorders while formulating a treatment plan for the management of insomnia. Comorbid medical issues, medication side effects, lifestyle factors, and substance use patterns contributing to worsening of insomnia need to be addressed for optimal treatment outcomes. Polysomnography studies are not generally recommended for evaluation of insomnia unless primary sleep disorders, such as obstructive sleep apnoea, are suspected clinically. Studies have associated polysomnography findings such as reduced slow-wave sleep (SWS), decreased rapid eye movement (REM) sleep latency, and increased rapid eye movement (REM) sleep density in patients with major depressive disorder.


    Polysomnography Sleep Changes in Major Depression

    Reduced slow-wave sleep (SWS)

    Decreased rapid eye movement (REM) sleep latency

    Increased rapid eye movement (REM) sleep density

    In terms of assessment,







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