Psychiatry

Delusions de Clerambault- Kadinsky Delusion that someone from higher socio-economic status complex is in love with the patient Othello syndrome Delusion of infidelity Capgrass syndrome Delusion of doubles Delusion that one has lost everything, including Cotard’s syndrome/ Nihilism possessions, status, strength and body organs. Delusion that a persecutor is able to assume the Fregoli’s delusions appearance of others Delusion that persons in the environment take on the Intermetamorphosis appearance of tormentors Parasitosis Delusion that one is infested with parasites Lycanthropy / Werewolfism Delusion that one turns periodically into an animal Heutoscopy/ doppelganger Delusion that patient has a twin or second half Incubus Delusion that patient has a phantom or demon lover Delusion that unwelcome guests are living in patient’s Phantom boarder house Delusion that others are aging, while the patient remains Dorian Gray young Illusion de Sorias Delusion that one’s family has been replaced Primary, de novo, can’t be explained on the basis of past Autochthonous delusions experiences. Amphitryon’s delusion Delusion that one’s spouse has been replaced

HALLUCINATIONS Hypnopompic hallucinations Hallucination while awakening Hypnagogic Hallucination while sleeping External stimulus is necessary to produce hallucinations. Normal perception and hallucination are in the same modality and experienced simultaneously. Functional Stimulus in one sensory modality produces hallucination in Reflex / Synaesthesia another sensory modality Hallucinations are experienced outside the limits of the sensory Extracampine field.

*Visual hallucinations are characteristically seen in organic psychosis, whereas auditory hallucinations are more common in functional psychosis.

QUOTE CORNER The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated.- Plato

ELEVENTH HOUR PSYCHIATRY 174 EUGEN BLEULER’S CARDINAL SYMPTOMS OF ( FOUR A’S ) Blunted Affect Loosening of Association Ambivalence Autism KURT SCHNEODER’S FIRST RANK SYMPTOMS OF SCHIZOPHRENIA Hearing one’s thoughts aloud. Auditory hallucinations commenting on one’s behaviour.

Thought withdrawal, insertion and broadcasting.

Somatic hallucinations or the experience of one’s thoughts as being controlled or influenced from outside.

TYPES OF SCHIZOPHRENIA Delusions of persecution Paranoid Late onset and progressive course. schizophrenia Marked thought disorder, severe loosening of association. Emotional disturbances.

Hebephrenic Progressively worse course. schizophrenia Acute onset in 2nd to 3rd decade. Episodic and complete recovery.

Clinical features include-

Mutism, rigidity, negativism, posturing, stupor, echolalia, echopraxia, waxy flexibility, ambitendency, automatic obedience, Catatonic verbigeration. schizophrenia Pseudo neurotic Initially there are predominant neurotic symptoms. Three classical schizophrenia features are pan , pan neurosis, and pan sexuality Subtype of schizophrenia with acute onset, clouding of Oneiroid consciousness, disorientation, dream like state and perceptual schizophrenia disturbances with rapid shifting. Van Gogh syndrome Schizophrenia with self mutilation. Propf syndrome Schizophrenia with mental retardation. Psychotic diseases Neurotic diseases Impaired reality testing Reality testing is intact Marked disturbance in personality Personality and behaviour are preserved Loss of insight Insight present Delusions and halluciantions are presentDelusions and halluciantions absent

TRIVIAL TRUTH Men commit suicide three times more frequently than women do. But women attempt suicide two to three times more often than men.

ELEVENTH HOUR PSYCHIATRY 175

DRUGS OF CHOICE OF PSYCHIATRIC DISORDERS DISEASE DRUGS OF CHOICE Generalized anxiety Panic attack Fluoxetine Nocturnal enuresis Imipramine Opioid withdrawal Methadone → 2nd DOC → Clonidine Opioid intoxication Naloxone / Naltrexone Alcohol withdrawal Chlordiazepoxide → 2nd DOC→ Diazepam Alcohol abstinence Disulfiram Benzodiazepines intoxication Flumazenil Obsessive compulsive disorder Clomipramine→ 2nd DOC→ Fluoxetine. Attention deficit hyperactivity disorder Amphetamine→ 2nd DOC→ Methylphenidate Tic disorder Bulimia nervosa Fluoxetine Alcoholic hallucinations Diazepam Neuroleptic induced urinary retention Bethanecol Neuroleptic induced hyperprolactinomaAmantadine Akathisia Propranolol

*No withdrawal syndrome is seen with LSD

EEG WAVES AND SLEEP CYCLES SLEEP / FREQUENCYAWAKEBRAIN E.E.G.CONDITION STAGE FEATURES Hz REGION WAVES Awake β waves and alert β 14-80 Parietal / Tension, excitation, AwakeFrontal , hypnotic over dosage restful, α 8-13 Occipital Awake, at rest with eyes eyes αclosed. closed 4-7 Parietal Disappointment, frustration, Temporal θorganic, functional NREM-Hippocampus. 1 θdegenerative, brain NREM-2 θ disorders δ NREM-3 3-5 Parietal, Very deep sleep, organic, δ Temporal, δfunctional degenerative, NREM-4Hippocampus, brain disorders β REM REM stage of sleep Nightmares. Somnambulis NRE m, Night- M- 4 terror, stage bedwetting, of Bruxism, sleep sleep talking.

QUOTE CORNER Cured yesterday of my disease, I died last night of my physician. - Matthew Prior

ELEVENTH HOUR PSYCHIATRY 176

TYPES OF PHOBIAS Acrophobia Fear of high places Zoophobia Fear of animals Xenophobia Fear of strangers Algophobia Fear of pain ClaustrophobiaFear of closed spaces ThanatophobiaFear of death Sitophobia Fear of eating

PERSONALITY TYPES Personality type Characteristics Schizoid personality type Introverted, withdrawn, solitary and distant. Interprets the action of others as deliberately threatening. Untrusting, Paranoid unforgiving, guarded, and prone to aggression. Perceive others as personality jealous, deceitful and condescending. Schizotypal Odd and eccentric manners of dressing and speaking. Strange, personality paranoid beliefs. Have difficulties forming relations and extreme anxiety disorder in social situations. Display sign of magical thinking. Antisocial personality Impulsive, irresponsible, callous and aggressive. No respect for others disorder and no remorse. High risk for alcohol and substance abuse Abrupt and extreme mood changes. Unstable and fluctuating self Borderline image. Unpredictable and self destructive. Fears of abandonment. personality Excessive dependency, self mutilation or recurrent suicidal gestures. disorder Impulsive, chronic feeling of boredom, bouts of intense anger. Exaggerated senses of self importance, fantasies of unlimited success, seek constant attention, oversensitive to failure, and complains of Narcissistic multiple somatic symptoms, extreme mood swings, between self personality admiration and insecurity. Avoidant personality Hypersensitive to rejection, excessive social discomfort, timidity, fear of disorder criticism, avoidance of social work Dependant personality Dependant and submissive behavior, feel fear of rejection, lack self disorder confidence. Compulsive Compulsive personalities, high levels of aspirations, strive for personality perfection, never satisfied with achievements .Reliable, dependable, disorder orderly, methodical and highly cautious. Histrionic Self dramatization, exaggerated expressions, suggestibility, attention personality seeking attitude. Seductiveness, concerned with physical appearance.

TRIVIAL TRUTH Hippopotomonstrosesquippedaliophobia is the fear of long words.

ELEVENTH HOUR PSYCHIATRY 177 Selfish, primitive, childish and pleasure oriented part of the personality with Id no ability to delay gratification. Internalised societal and parental standards of good, bad, right and wrong Superegobehaviour. Ego Moderator between the Id and Superego which compromises to pasify both.

Anna Freud’s types of ego defense mechanisms Compensation Takes up one behaviour because one cannot accomplish another behaviour. Denial Refuses to perceive the more unpleasant aspects of external reality. Redirects emotions from a dangerous object to a safe object. Shifts sexual or aggressive impulses to a more acceptable or less Displacement threatening target. Concentrating on the intellectual components of the situations as to Intellectualization/ distance oneself from the anxiety provoking emotions associated isolation with these situations. Attributing to others, one’s own unacceptable or unwanted thoughts and/or emotions. Projection reduces anxiety in the way that it allows the expression of the impulse or desire without letting the ego Projection recognise it. The process of constructing a logical justification for a decision that Rationalization was originally arrived at through a different mental process. The conversion of unconscious wishes or impulses that are Reaction formation perceived to be dangerous into their opposites. The reversion to an earlier stage of development in the face of Regression unacceptable impulses. The process of pulling thoughts into the unconscious and preventing Repression painful or dangerous thoughts from entering consciousness. Rechanneling of psychic energy away from negative outlets to more positive outlets. It is the process of transforming libido into ‘socially useful’ achievements, mainly art. Psychoanalysts often refer to Sublimation sublimation as the only truly successful defence mechanism. A person tries to ‘undo’ a negative or threatening thought by their Undoing actions. Suppression The conscious process of pushing thoughts into the preconscious. Separation or postponement of a feeling that normally would Dissociation accompany a situation or thought.

QUOTE CORNER A hypochondriac is one who has a pill for everything except what ails him. Mignon McLaughlin, The Second Neurotic’s Notebook, 1966

ELEVENTH HOUR PSYCHIATRY 178

Anna Freud’s types of ego defense mechanisms CONTINUED… Refocuses attention on the somewhat comical side of the situation as to Humor relieve negative tension. Form of denial in which the object of attention is presented as “all good” Idealization masking true negative feelings towards the other. Identification The unconscious modeling of one’s self upon another person’s behavior. Identifying with some idea or object so deeply that it becomes a part of that Introjection person. Refocusing of aggression or emotions evoked from an external force onto Inversion one’s self. SomatisationManifestation of emotional anxiety into physical symptoms. Splitting A person sees external objects or people as either “all good” or “all bad.” Substitution When a person replaces one feeling or emotion for another.

0.8-1.2 mEq / L Therapeutic level of blood 0.6-1.2 mEq / L Prophylactic blood lithium >2 mEq / L Side effects >3.5 mEq / L Life threatening toxicity

Alcoholism Alpha Milieu limited Beta Male limited GammaMalignant alcoholism Epsilon Spree drinking

*Alcoholics anonymous-Self-help society of recovered and recovering alcoholics.

Alanon / Alateen- For relatives and friends of alcoholics.

Similarly there are Narcotics anonymous and Naranon for substance abusers.

*Traditional neuroleptics are most effective in treating positive symptoms of schizophrenia

Most common side effect of neuroleptic drugs (haloperidol) is drowsiness.

Tardive dyskinesia is the most common delayed complication of medication, characterized by purposeless, involuntary facial and lip movement.

Most common extrapyramidal side effect is Akathisia, which is treated with Propranolol and Clonazepam.

TRIVIAL TRUTH A heavy cigar smoker, Freud endured more than 30 operations during his life due to mouth cancer. In September 1939 he prevailed on his doctor and friend Max Schur to assist him in suicide. After reading Balzac’s La Peau de chagrin in a single sitting he said, “My dear Schur, you certainly remember our first talk. You promised me then not to forsake me when my time comes. Now it is nothing but torture and makes no sense any more.” Schur administered three doses of morphine over many hours that resulted in Freud’s death on September 23, 1939.

ELEVENTH HOUR PSYCHIATRY 179 *Neuroleptic malignant syndrome

Muscle rigidity, autonomic dysregulation and hyperthermia.

Idiosyncratic reaction to inhibition of central dopamine receptors that results in increased heat production and failure of heat dissipation.

Management-

Rapid physical cooling.

Administration of an antipyretic or actainophenbromocriptine and Dantrolene.

*Major depression with suicidal risk is the first and the most important indication of electroconvulsive therapy

In unilateral ECT, the electrodes are placed on the non-dominant side.

Much safer

*Klein-Levin syndrome

Recurrent episode of hypersomnia and hyperphagia, each lasting 1-3 weeks.

*Mythomania (Pseudologia fantastica or Pathological lying) is a condition involving compulsive lying by a person with no obvious motivation. The affected person might believe their lies to be truth, and may have to create elaborate myths to reconcile them with other facts.

*Munchausen’s syndrome is a disorder in which those affected feign disease, illness, or psychological trauma in order to draw attention or sympathy to themselves. It is also sometimes known as Hospital addiction syndrome.

*Diogenes syndrome is a behavioral disorder characterized by extreme self-neglect. It usually affects the elderly who live alone. Its symptoms include body odor and other signs of severe hygienic neglect. Physical diseases relating to bodily neglect usually accompany the syndrome.

*Heutoscopy is a term used in psychiatry for the reduplicative hallucination of “seeing one’s own body at a distance”

* Media Induced Post-traumatic Stress Disorder (MIPTSD). is a manifestation of Post-traumatic stress disorder type; symptoms specifically due to exposure to entertainment media that focuses excessively on violence.

*Retired husband syndrome is a psychosomatic, stress related illness It is a condition where a woman begins to exhibit signs of physical illness and depression as their husband reaches, or approaches retirement.

QUOTE CORNER The only difference between psychiatrists and their patients is that the patients have a chance of getting better.-Anonymous.

ELEVENTH HOUR PSYCHIATRY 180

*Medical student syndrome is a type of literary self-imposed hypochondria. It typically starts as a person reads or learns about an illness or disorder and begins to believe they have it.

*Cryptomnesia, or “concealed recollection,” is a phenomenon involving suppressed or ‘forgotten’ memories. It refers to cases where a person believes that he is creating or inventing something new, such as a story, poem, artwork, or joke, but is actually recalling a similar or identical work which he or she has previously encountered.

*Ringxiety / Phantom ring effect / Fauxcellarm. the sensation and the false belief that one can hear his or her mobile phone ringing or feel it vibrating, when in fact the telephone is not doing so.

PSYCHIATRY

1. Axis Determination I = clinical psych disorders II personality disorders, III Coexisting medical conditions IV psychosocial stressors, V global assessment of functioning

2. Schizophrenia Positive Sx: delusions, hallucinations, bizarre behavior; Negative Sx: alteration of affect, ambivalence, apathy, loosening of associations; males=females; industrial nations have incr. prevalence;

Misalignment of cells in cortex; incr. ventricle size; decr. activity in frontal cortex on PET scan.

3. Disorganized: insidious, incoherent, inappropriate affect, social impaired

4. Catatonic: rigidity, posturing or excitement, negativism

5. Paranoid: highest functioning type, grandiose, jealous, persecution

6. Undifferentiated: not defined by other subtypes

7. Melerill = Retrograde ejaculation, Tx: Respiradol (Best side effect profile), Clozaril (agranulocytosis w/ weekly

CBC) prescribed weekly,

8. Neurolyptic Malignant Syndrome = incr. temp, incr. CPK, rigidity

9. Schizophrenifrom same sx as schizophrenia but have lasted for less than 6 months

10. Schizoaffective mood disorder and separate psychotic sx. Must experience 2 weeks of psychotic sx w/o mood impairment for dx to be made; are 1st line tx 11. Major Depression loss of interest in activities, sleep, wt, concentration, hopelessness, suicidal ideation, nihilism;

Seasonal affective, Vegetative (non functioning can be terminal) Dysthymia(chronic low level); Reactive related to environment w/o severity id sx; Masked 1o depression denied or hidden by other sx

12. Depression & anxiety can occur together & can be treated w/ an antidepressent; Left anterior or rt posterior stroke => incr. possibility of depression; Tx: 1st Tricyclic (Imiprimine); SSRI = side effects; Trazadone=priapism

Asendin (Amoxipine) = Extrapyramidal Symptoms

13. BiPolar Bimodal peak 20’s & 30’sCycling mood= highs w/ euphoria, hyperactive, pressured speech, flight of ideas, decr need for sleep, delusions, inflated self esteem, risks, poor judgement; Lows are major depressive episodes tx: lithium

14. Panic Attacks Sudden, unprovoked onset of fear, impending doom, palpitations, SOB, chest pain, smothering, dizziness. May be associated w/ agoraphobia Tx: with SSRI’s

15. Phobias Persistent and irrational fear of a specific object or activity or situation. Tx like a phobia

16. Obsessive Compulsive Persistent, unwanted thoughts, impulses or images

17. repetitive, purposeful intentional behaviors meant to decrease tension caused by the obsessive thoughts; genetic

Tx: Anafranil (Tricyclic) Prozac & Luvox (SSRI)

18. PTSD intrusive recollections, daydreams, nightmares, poor concentration, psychic numbing; Tx: don’t treat w/ meds unless compulsion component

19. Studies: Buffalo Creek Disaster, Beverly Hills Nightclub

20. Dissociative Disorder Amnesia = loss of memory, Fugue = assoc w/ physical flight, Identity Disorder = multiple ego states; = feelings of self estrangement or unreality

21. Whirndingo Fear of becoming a cannibal

22. Amok sudden unprovoked outburst of wild rage usually ending in homicide

23. Coprolalia Feces & filth

24. Koro penis is shrinking and may disappear

25. Latah imitate words or actions to which they are exposed

26. Piblotko Run around in snow naked

27. White Out Syndrome lack of diverse stimuli in snow clad environment 28. Narcolepsy REM sleep, sudden onset of daytime sleep and cataplexy; REM sleep is inappropriately present at beginning

29. Personality Disorders Cluster A = Bizarre = Paranoid, Schizoid (no close relationships, restricted emotions)

Schizotypical (schizoid + odd or distorted behavior or cognition)

30. Cluster B = Over emotional = Antisocial (Disregard for social norms) Borderline, Histrionic, Narcissistic (self centered)

31. Cluster C = Anxiety & Fear = avoidant, dependent, Obsessive compulsive