CONTROVERSIAL QUESTIONS
1. Most common substance of abuse in India?
A) Alcohol
B) Cannabis
C) Tobacco
D) Cocaine
Ans) Tobacco
Now this question has been asked quite frequently and remains controversial
Most common substance of use in India: Tobacco
Most common substance of use in world: Alcohol
Most common substance of use in western countries:Alcohol
Most common illicit substance of use in India: Cannabis
Most common illicit substance of us in world:Cannabis
Most common illicit substance of use in western countries: Cannabis
Now coming to abuse, remember although DSM IV TR DOES NOT RECOGNISE TOBACCO AS SUBSTANCE OF USE but nearly 70-80% of those who use it; use in dependent pattern, now dependence is more higher criteria than abuse
The hallmark book on substance abuse includes tobacco in it(Substance Abuse: A Comprehensive Textbook; Fourth Edition by Joyce H. Lowinson
;Substance Abuse: A Comprehensive Textbook focus on addiction in children, adolescents, adults, and the elderly and women's health issues, including pregnancy)
Most common substance of abuse
Most common substance of abuse in INDIA: Tobacco
Most common substance of abuse in world: Tobacco (All Alcohol users do not use in abuse pattern; about 80% are social drinkers, 10%abuse, 105 dependent of all who use alcohol)
Most common substance of abuse in western countries:Alcohol
Most common substance of abuse in India as per DSM-IV TR: Alcohol
Most common substance of abuse in world as per DSM IV TR: Tobacco
Most common substance of use in western countries as per DSM IV TR: Alcohol
Most common illicit substance of use in India: Cannabis
Most common illicit substance of use in world:Cannabis
Most common illicit substance of use in western countries: Cannabis
India: Substance use
Tobacco- 52%
Alcohol- 21.4%
Cannabis- 3%
Opium- 0.4%
Best therapy suited to teach daily life skill to mentally
challenged child,,,,
a.. CBT
b..contingency
c..cognitive reconstruction
d...self instruction
2.... Best therapy suited for mentally retarded child,,,,
a.. CBT
b..rewarding
c..behavior reconstruction
d...self initiative
Ans) 1 b) Contingency
2) Reward ( choices not clear, ideal answer is behavioural modification)
Remember for all grades of mental retardation, behaviour therapy is treatment of choice.
Contingency is a type of behaviour therapy
Contingency management is a type of treatment used in the mental health or substance abuse fields. Patients are rewarded (or, less often, punished) for their behavior; generally, adherence to or failure to adhere to program rules and regulations or their treatment plan. As an approach to treatment, contingency management emerged from the behavior therapy and applied behavior analysis traditions in mental health
now see an article from mescape which again proves role of contingent behavior therapy
Psychosocial Treatment Modalities
Multidisciplinary treatment teams use a variety of psychosocial modalities to address behavioral problems experienced by patients who are mentally retarded. The 3 behavioral interventions recommended by the expert consensus panel for most situations are as follows:
Applied behavior analysis includes techniques that are based on the principles and methods of behavior analysis and are intended to build appropriate functional skills and reduce problem behavior. These include the following:
Behavior-accelerating procedures, such as contingent reward for specific behaviors that are incompatible with problem behavior
Behavior-decelerating techniques, such as contingent reward for specified time periods, during which the problem behavior did not occur; extinction; overcorrection; response cost; time-out; contingent restraint
Behavioral parent and teacher/staff training to help them function as cotherapists and/or to avoid incidental reinforcement of the problem behavior
Remember cognitive behaviour therapy, cognitive reconstruction and self instruction are all cognitive stratedgies which can be used in MR but are inferior to behaviour therapy.
Dont confuse CBT from BT; CBT is primarily cognitive therpy with minimal use of some behavioural techniques like daily scheduling
CBT is primarily used in those condition where there are underlying cognitive distortions, distorted beliefs(basically distorted thinking); So CBT is primarily used in depression, adjustment disorder, generalised anxiety disorder,eating disorders, sexual dysfunctions
Behaviour therapy is mainly used in OCD, PHOBIAS, chilhood psychiatric disorders like autism and ADHD
Self-instruction a type of cognitive stratedgy is mainlyused in dyslexia( learning disorders)
Cognitive reconstruction:By completing the process of cognitive restructuring, an individual can better: Gain awareness of detrimental thought habits;Learn to challenge them and substitute them with life-enhancing thoughts and beliefs
Cognitive restructuring involves 4 steps[9]:
(1) Identification of problematic cognitions known as “Automatic Thoughts” (ATs) which are dysfunctional or negative view of the self, world, or future
(2) identification of the cognitive distortions in the ATs
(3) rational disputation of ATs with Socratic dialogue, and
(4) development of a rational rebuttal to the ATs
Cognitive reconstruction is used as part of CBT
20 years old female with complaints of nausea, vomitting and pain in legs. Her physical examination and lab investigations are normal. What is the most probable diagnosis?
a) Generalized anxiety disorder
b) Conversion disorder
c) Somatoform pain disorder
d) Somatization disorder
Ans) d) Somatization disorder
Points in favour of somatisation disorder
1). Multiple symptoms( three; nausea, vomitting, pain in legs)
2) Multiple system (two; Gastrointestinal and pain system)
3) Female sex (Female to male ratio 20:1)
4) Age of onset ( Young onset)
5) Nausea and vommiting are the most common somatisation symptom followed by diffuse pain in extremities.
Remember while DSM IV TR requires 4 pain, 2 GI, 1 Neurological and 1 Psuedoneurological, there is no such requirement in ICD-10, they just mention multi systemic and multi symptom, so this case can be somatisation as per ICD requires two years and asper DSM multple years, so please don't diagnose if duration less than2 years
Some students told me that duration of 2 months was mentione if that so then mark somatoform pain, but if no duration given like in this question go for somatisation disorder
But very important it is a chronic disorder and
Points against Somatoform pain disorder
1. Pain should be focus of attention for which pt is preoccupied and all other symptoms should be explained by pain; in that case in this question pain should have been the first symptom, not nausea and vommiting as in the question. ( Somatoform pain would have been like this; pt complains of pain in knees or ankle which when increased in intensity leads to nausea and vommiting)
2. Pain in somatoform pain disorder is at specific body sites like headache, pain at knee , pain at elbow, not diffuse pain in extremities)
3. Age of onset: mainly 5th decade-sixth decade
Points against conversion disorder
- No motor or sensory neurological symptom
-No acute stressor
Points against Generalised anxiety disorder
- No excessive anxiety and worry (apprehensive expectation) which is difficult to control
No other somatic/cognitive symptoms of anxiety(restlessness or feeling keyed up or on edge ;being easily fatigued ;difficulty concentrating or mind going blank; irritability; muscle tension;sleep disturbance
-No autonomic symptoms
20 years old female with complaints of intermittent vomitting and pain in legs and headache since 2 months. Her physical examination and lab investigations are normal. What is the most probable diagnosis?
a) Generalized anxiety disorder
b) Conversion disorder
c) Somatoform pain disorder
d) Somatization disorder
Ans) Somatoform pain disorder
Now see my last post,now see the differences
1) Two pain symptoms compared to one in last question
2) intermittent symptoms all together, vomitting during pain symptom or headache quite common in somatoform pain disorder( in last question they were not together)
3) DURATION OF TWO MONTHS( bevery very sure can never dianose somatisation in duration less than 2 years)
PLEASE SEE THESE TWO QUESTIONS CAREFULLY, SOME CHANGE OF WORDS CHANSE ANSWERS IN AIIMS/ ALL INMDIA, PLEASE DONT PREMATURELY EJACULATE YOUR MUGGED ANSWERS, YOU CAN LAND IN TROUBLE
Q. 20 years old female with complaints of nausea, vomitting and pain in legs. Her physical examination and lab investigations are normal. What is the most probable diagnosis?
a) Generalized anxiety disorder
b) Conversion disorder
c) Somatoform pain disorder
d) Somatization disorder
Not a specific somatoform disorder?
1.Somatisation
2.Fibromyalgia
3.Chronic fatigue syndrome
4.Irritable bowel syndrome
Ans) 2. Fibromyalgia
Read these lines from comprehensive textbook of psychiatry, 8th edition
"Undifferentiated somatoform disorders, which include medically unexplained symptoms, chronic fatigue syndrome, irritable bowel syndrome and noncardiac chest pain.
Now these lines make it amply clear that chronic fatigue syndroime is a somatoform disorder.
Somatoform disorder consists of
1. Somatisation disorder
2.Hypochondriasis
3.Conversion disorder
4.Body dysmorphic disorder
4. Somatoform pain disorder
5. Undiffrentiated somatoform disorde
Lady with sadness & NO H/O hopelessness, Occasional palpitation, loss of apetite, Insomnia, no precipitating event of life, (AI-2010)
a. GAD
b. Mixed anxiety depression
c. Adjustment disorder
d. Mild depressive episode
Ans) Mixed anxiety-depression (Confirmed from consultant, professor in psychiatry from AIIMS)
Mixed anxiety and depressive disorder
Mixed anxiety-depressive disorder is a diagnostic category defining patients who suffer from both anxiety and depressive symptoms of limited and equal intensity accompanied by at least some autonomic features. The World Health Organization's ICD-10 describes Mixed anxiety and depressive disorder AS
"This category should be used when symptoms of anxiety and depression are both present, but neither is clearly predominant, and neither type of symptom is present to the extent that justifies a diagnosis if considered separately. When both anxiety and depressive symptoms are present and severe enough to justify individual diagnoses, both diagnoses should be recorded and this category should not be used."
Now in this question
Depressive symptom is sadness, loss of appetite and insomnia
Anxiety symptom is occasional palpitation and insomnia.
Now remember mixed anxiety depression can oly be diagnosed after ruling out depression and core anxiety disorders like Generalised anxiety disorder, phobias, OCD.
Now first coming to GAD first
-Remember GAD ca never never be diagnosed without
"Excessive anxiety and worry (apprehensive expectation) which a person feels difficult to control".
presence of free floating anxiety about small small things of day to day life is must, without this symptom of anxious thinking, you can never diagnose GAD; although insomnia and occasinal palpitations can occur in GAD BUT THEY ARE SUPPORTINGG SYMPTOMS COGNITIVE ANXIETY( anxious thinking is must for diagnosis.
Now we too have to rule out depression
DSM does not talk about mild, moderate or severe depression, only it talks about major depressive disorder
TOo diagnose major depressive disorder as per DFSM we need
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
1.depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood
2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
3. significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
4. insomnia or hypersomnia nearly every day
5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6. fatigue or loss of energy nearly every day
7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
Now in this question, we have only three symptom from DSM
Now coming to ICD, Although symptoms are same nine there but they have divided depression into mild, moderate and severe
For mild depression, we need four symptom
moderate depression six symptoms
severe depression, eight symptoms
Now even if we see for ICD, IN THIS CASE it is not fulfilling the criteria for mil depression as we have three symptom only
BUT PLEASE KIND THIS IN MIND THAT IF THEY ADD EVEN ONE SYMPTOM OF DEPRESSION MORE, THE ANSWER WOULD SHIFT TO MILD DEPRESSIVE EPISODE
Now coming to last choice adjustment disorder
Diagnosis of adjustment cannot be made without a stressor; no antecedent stressor here ( the answer would change to adjustment if they add a stressor
-Criteria for adjustment is very liberal
only important thing issymptoms should start within three months of stressor and normally do not remain after six months after stresoor vanishes.
( Again diagnosis of adjustment ios not entertained if pt fulfills criteria for depression or anxiety disorder.
Adjustment can have depressive, anxiety, emotional or conduct symptoms
Anterograde amnesia is seen in.....
A) head injury
b) stroke
c) spinal cord injury traumatic paraplegia
d) alzheimer's disease
Ans) Stroke
Most common cause of anterograde amnesia is stroke while most common cause of retograde amnesia is head injury
Anterograde Amnesia
Anterograde amnesia is a selective memory deficit, resulting from brain injury, in which the individual is severely impaired in learning new information. Memories for events that occurred before the injury may be largely spared, but events that occurred since the injury may be lost.
Short-term memory is generally spared, which means that the individual may be able to carry on a conversation; but as soon as he is distracted, the memory of the conversation fades.
Anterograde amnesia can occur following damage to at least three distinct brain areas. The first, and most well-studied, is the hippocampus and associated areas in the medial temporal lobes of the brain. The hippocampus seems to act as a "gateway" through which new fact information must pass before being permanently stored in memory. If it is damaged, no new information can enter memory - although older information which has already passed through the gateway may be safe. Damage to the hippocampus (and medial temporal lobes) can occur following stroke or aneurysm to one of the arteries which supplies blood to these areas, as well as following epilepsy, encephalitis, hypoxia, carbon monoxide poisoning, near-drowning or near-suffocation, and the earliest stages of Alzheimer's disease. Some damage to the hippocampus also occurs in the course of normal aging.
Anterograde amnesia can also occur following damage to the basal forebrain, a group of structures which produce acetylcholine, a chemical which helps cells in the brain store new information during learning. The basal forebrain can be damaged by aneurysm of the anterior communicating artery, which supplies blood to the basal forebrain.
Finally, anterograde amnesia can sometimes occur following damage to the diencephalon - a set of structures deep in the brain including the medial thalamic nuclei.
Korsakoff's disease is a syndrome which can damage the diencephalon and cause anterograde amnesia.
incidence of mild TBI is about 131 cases per 100,000 people, the incidence of moderate TBI is about 15 cases per 100,000 people, and the incidence of severe TBI is approximately 14 cases per 100,000 people.
even if you add all( mild +moderate+severe), it just comes to 0.1%, most of which are mild (90%) and unlikely to lead to amnesia
IN Mild: GCS score 13 to 15. Likely to be associated with a loss of consciousness of less than 20 min and a post-traumatic amnesia of less than 24 h. ANTEROGRADE AMNESIA OF MORE THAN ONE WEEK OCCURS ONLY IN SEVERE HEAD INJURY.
incidence of stroke for those aged between 35 and 65 is between 90 and 330 per 100 000. and if stroke affects hippocampus, anterogradeamnesia is continuos
Healthy thinking includes all except
a) continuity
b) constancy
c) organization
d) clarity
ans Constancy
Thought which remains constant with time even after new evidences come to contrary will overvalued idea or later delusion
Healthy thinking always leads to new interpretation as new evidences come.
Continuity is a feature of healthy thinking. (thought disorder due to poor continuity; Derailment)
Organisation is again an important characteristic. (Disorder of thought due to poor organisation; Loosening of organisation)
Clarity; (Disorder of thought due to poor clarity is circumstantiality)
A smoker is convinced by his family members to quit smoking, as a long term hazard of smoking is cancer. He decided to quit but tells about his worry that due to quitting smoking he may become irritable. According to the Health Belief Model, this state of patient is which of the following?
A. Precontemplation and preparation
B. Severity of illness Contemplation
C. Contemplation and lost involvement
D. Susceptibility of illness and lost involvement
Ans) Severity of illness and Cotemplation
HEALTH BELIEF MODEL
The Health Belief Model (HBM) is a psychological model that attempts to explain and predict health behaviors. This is done by focusing on the attitudes and beliefs of individuals. The HBM was first developed in the 1950s by social psychologists Hochbaum, Rosenstock and Kegels working in the U.S. Public Health Services. The model was developed in response to the failure of a free tuberculosis (TB) health screening program. Since then, the HBM has been adapted to explore a variety of long- and short-term health behaviors, including sexual risk behaviors and the transmission of HIV/AIDS.
The HBM was spelled out in terms of four constructs representing the perceived threat and net benefits: 1) perceived susceptibility,2) perceived severity, 3) perceived benefits, and 4) perceived barriers.
These concepts were proposed as accounting for people's "readiness to act."
An added concept, 5) cues to action, would activate that readiness and stimulate overt behavior.
A recent addition to the HBM is the concept of 6) self-efficacy, or one's confidence in the ability to successfully perform an action. This concept was added by Rosenstock and others in 1988 to help the HBM better fit the challenges of changing habitual unhealthy behaviors, such as being sedentary, smoking, or overeating.
so by HBM, pt is motivated by severity of illness
Now to check his stage of change, w will apply transtheoretical model of change by Prochaska and Diclemente(1984)
Precontemplation: Denial, ignorance of problem
Contemplation: Ambivalence and conflicted emotions
Preparation: Experimenting with small changes, collecting information about change
Action: Taking direct action toward’s goal
Maintenance: Maintaing a new behavior; avoiding temptation
Here he is in process of contemplation( pt is ambivalent want to leave due to fear of serious illness but thinks he will become irritable without tobacco
so answer is Contemplation and severity of illness
ANOTHER VERSION OF THE SAME Q
Mr X is a chronic smoker. His family insists on quitting smoking. He is thinking about quitting, but is reluctant to do so because he is worried that on quitting he will become irritable. This is?
A. Precontemplation and preparation
B. Contemplation and extent of sickness susceptability
C. Contemplation and cost factors
Again as per health belief model, answer would be b)
A man taking 20 cigarettes per day, started coughing, his family suggested quitting cigarettes . He is ready to quit but thinks that quiting will make him irritable, the best health planning model followed is
Cost and survival
Persuasion
Precontemplation and preparation
Belief
D. Precontemplation and cost factor
Ans) Health belief model IF ONLY BELIEF IN CHOICE GO FOR PRECONTEMPLATION AND PREPARATION
SEE PT IS ALREADY IN PHASE OF CONTEMPLATION SO, WE CANNOT USE PRECONTEMPLATION AND PREPARATION
Had the choice being contemplation, prparation and action that would have been the action
REMEMBER PARISCHA TRANSTHEOREOTICAL MODEL IS MOST IMPORTANT FOR TOBACCO CESSATION WHILE HEALTH BELIEF IS RECENTLY MODIFIED FOR TOBACCO CESSATION, SO IF THEY ASK WHICH IS BETTER IN TOBACCO CESSATION, IT'S ALWAYS PARISCHA
rEMEMBER IF A PERSON IS CONCERNED ABOUT AN SEVERE ILLNESS, THEN HEALTH BELIEF MODEL IS BETTER( Cancer in first question) but in third modified question, there is only concern of tobacco cessation where parischa model is better
HEALTH EDUCATION BEHAVIOR MODELS AND THEORIES
As a part of any planning model, it is necessary to attempt to classify and explain the multitude of factors which can, and do, influence human behavior. Current models/theories that help to explain human behavior, particularly as it relates to health education, can be classified on the basis of being directed at the level of: a) Individual (Intrapersonal); b) Interpersonal; or c) Community. Within these three categories, those models/theories that have tended to dominate in the health education field in the past 20-30 years will be briefly outlined.
Individual (Intrapersonal) Health Behavior Models/Theories
Health Belief Model (Rosenstock, Becker, Kirscht, et al.)
The Health Belief Model (HBM) was one of the first models which adapted theories from the behavioral sciences to examine health problems. It is still one of the most widely recognized and used models in health behavior applications. This model was originally introduced by a group of psychologists in the 1950's to help explain why people would or would not use available preventive services, such as chest x-rays for tuberculosis screening and immunizations for influenza. These researchers assumed that people feared diseases and that the health actions of people were motivated by the degree of fear (perceived threat) and the expected fear reduction of actions, as long as that possible reduction outweighed practical and psychological barriers to taking action (net benefits).
The HBM can be outlined using four constructs which represent the perceived threat and net benefits: 1) perceived susceptibility, a person's opinion of the chances of getting a certain condition; 2) perceived severity, a person's opinion of how serious this condition is; 3) perceived benefits, a person's opinion of the effectiveness of some advised action to reduce the risk or seriousness of the impact; and 4) perceived barriers, a person's opinion of the concrete and psychological costs of this advised action. (See Figure 1) Another concept is known as cues to action. These are events (internal or external) which can activate a person's "readiness to act" and stimulate an observable behavior. Some examples of external strategies to activate "readiness" can be delivered in print with educational materials, through any electronic mass media or in one-to-one counseling. Another concept that has been added to HBM since 1988 in order to better meet the challenges of changing unhealthy habitual behaviors (such as being sedentary, smoking or overeating) is self-efficacy. Self-efficacy, a concept originally developed by Albert Bandura in social cognitive theory (social learning theory), is simply a person's confidence in her/his ability to successfully perform an action.
Even though the HBM was originally developed to help explain certain health related behaviors, it has also helped to guide the search for "why" these behaviors occur and to identify points for possible change. Using this framework, change strategies can be designed as referred to earlier. The HBM has been used to help in developing messages that are likely to persuade an individual to make a healthy decision. Using the HBM, messages that are suitable to health education for such topics as hypertension, eating disorders, contraceptive use, or breast self-examination have been developed.
However, there are two main weaknesses which have been noted about the HBM. First, health beliefs compete with an individual's other beliefs and attitudes which can also influence behavior. Secondly, in decades of research in the social psychology of behavioral change, it has not been shown that belief formation always precedes behavioral change. In fact, the formation of a belief may actually follow a behavior change.
Stages of Change Model or Transtheoretical Model (Prochaska and DiClemente)
The Stages of Change or Transtheoretical Model was initially published in 1979 by Prochaska. In the 1980's Prochaska and DiClemente worked further on this model in outlining the stages of an individual's readiness to change, or attempt to change, toward healthy behaviors. The Stages of Change Model evolved from research in smoking cessation and also the treatment of drug and alcohol addiction. More recently it has been applied to other health behaviors, such as dietary changes. Behavior change is viewed as a process, not an event, with individuals at various levels of motivation or "readiness" to change. Since people are at different points in this process, planned interventions should match their stage.
There are six stages that have been identified in the model: 1) Precontemplation - the person is unaware of the problem or has not thought seriously about change; 2) Contemplation - the person is seriously thinking about a change (in the near future); 3) Preparation - the person is planning to take action and is making final adjustments before changing behavior; 4) Action - the person implements some specific action plan to overtly modify behavior and surroundings; 5) Maintenance - the person continues with desirable actions (repeating the periodic recommended steps while struggling to prevent lapses and relapse; and 6) Termination - the person has zero temptation and the ability to resist relapse.
In relapse, the person reverts back to old behavior which can occur during either action or maintenance. This model is a circular, rather than a linear model. In fact, as seen in Figure 2, it is more of a spiral as the person may go through several cycles of contemplation, action, relapse (or recycle) before either reaching termination or exiting the system without becoming free of the addictive behavior. Prochaska has used a "revolving-door schema" to explain the sequence that people pass through in their efforts to become free from addictions. People do not go through the stages and graduate; they can enter and exit at any point and often recycle several times. Other studies indicate that individuals often go through these same changes whether they use self-help or self-management techniques, seek professional counseling or attend organized programs.
Alzeimer's disease all are seen except
a) Aphasia
b)Acalcula
c) Agnosia
d) Apraxia
Ans) Acalculia (Oxford textbook of psychiatry)
Clinical features
Cognitive impairment
Dementia is an acquired and progressive cognitive decline in multiple areas; AD is one cause of dementia and the core clinical symptom of AD is cognitive impairment. However, as noted above, AD is clinically heterogeneous and includes diverse non-cognitive symptoms and inevitable functional impairment. Cognitive decline is manifested as amnesia, aphasia, agnosia, and apraxia (the 4As).
Amnesia
Memory loss in AD is early and inevitable. Characteristically, recent memories are lost before remote memories. However, there is considerable individual variation, with some patients able to recall specific and detailed events of childhood and others apparently having few distant memories accessible. With disease progression, even remote and emotionally charged memories are lost. The discrepancy between recent and remote memory loss suggests that the primary problem is of acquisition or retrieval of memory rather than a destruction of memory, and this is confirmed in early AD,(2) although as the disease progresses it is likely that all memory processes are impaired. Retrieval of remote memory is assumed to be preserved for longer because of rehearsal over life.
Aphasia
Language problems are found in many patients at presentation, although the language deficits in AD are not as severe as those of the frontotemporal degenerations(3) and may only be apparent on detailed examination. Word-finding difficulties (nominal dysphasia) are the earliest phenomena observed and are accompanied by circumlocutions and other responses, for example repetitions and alternative wordings. As the disorder progresses, syntax is affected and speech becomes increasingly paraphasic. Although harder to assess, receptive aphasia, or comprehension of speech, is almost certainly affected. In the final stages of the disorder, speech is grossly deteriorated with decreased fluency, preservation, echolalia, and abnormal non-speech utterances.
Agnosia
Patients with AD may have difficulty in recognizing as well as naming objects. This can have implications for care needs and safety if the unrecognized objects are important for daily functioning. One particular agnosia encountered in AD is the loss of recognition of one's own face (autoprosopagnosia). This distressing symptom is the underlying cause of perhaps the only clinical sign in AD—the mirror sign. Patients exhibiting this will interpret the face in the mirror as some other individual and respond by talking to it or by apparent fearfulness. Autoprosopagnosia can present as an apparent hallucinatory experience, until it is realized that the ‘hallucination' is fixed in both content and space, occurring only when self-reflection can be seen.
Apraxia
Difficulties with complex tasks that are not due to motor impairment become apparent in the moderate stages of AD. Typically, difficulties with dressing or tasks in the kitchen are noticed first, but these are inevitably preceded by loss of ability for more difficult tasks. Strategies to avoid such tasks are often acquired as the disease progresses, and it is only when these fail that the dyspraxia becomes apparent.
Other cognitive impairments
There appear to be no cognitive functions that are truly preserved in AD. Visuospatial difficulties commonly occur in the middle stages of the disorder and may result in topographical disorientation, wandering, and becoming lost. Difficulties with calculation, attention, and cognitive planning all occur.
Type D personality was recently found to risk for?
A. Coronary artery disease
B. Depression
C. Personality disorder
D. Schizophrenia
ANS) CORONARY ARTERY DISEASE
type-D personality was a significant predictor of long-term mortality in patients with established CHD, independently of biomedical risk factors.
letter D stands for 'distressed'.Individuals with a Type D personality have the tendency to experience increased negative emotions across time and situations and tend not to share these emotions with others, because of fear of rejection or disapproval.
Type C: related to cancer, DIFFICULTY EXPRESSING NEGATIVE SYMPTOMS
Type H personality, also called hardy personality; Actually seem to thrive on stress rather than letting stress wear them; Given by Suzanne Kossaba, Type H personality is characterised by sense of commitment, complete sense of control over their life and correct interpretation of things going around
Type A and Type B given by Friedman and Rosenman
Type A behavior is expressed in three major symptoms: free-floating hostility, which can be triggered by even minor incidents; time urgency and impatience, which causes irritation andexasperation; and a competitive drive, which causes stress and an achievement-driven mentality.
Type A behavior doubles the risk of coronary heart disease in otherwise healthy individuals.
People with Type B personalities are generally patient, relaxed, easy-going, and at times lacking an overriding sense of urgency.
REMEMBER BOTH TYPE A AND TYPE D RELATED TO CORONARY ARTERY DISEASE
A PT PRESENTS TO EMERGENCY DEPARTMENT WITH SELF HARM AND indicates suicidal ideations. Which of the following condition doesn't warrant an immediate specialist assessment?
a) Formal thought disorder
b) Acute alcohol intoxication
c) Chronic severe physical illness
d) Social isolation
Ans) d) Chronic severe physical illness
http://www.health.nsw.gov.au/pubs/2004/pdf/emergency_dept.pdf
Just go through the article and you can understand how to handle a pt coming to emergency with suicidal ideations
preliminary suicide risk assessment-----immediate management------Mental health management--------Assessment of suicide risk------corroborative history-----management of suicide risk------Reassessment of suicide risk----Discharge
Now in this at third step help of a specialist that is mental health management is sought
Now in preliminary assesment at first step all four are risk factors for suicide.
However, the most important factors in
assessing a person’s imminent suicide risk
are the current personal risk factors.
Examples include:
■ ‘at risk’ mental status, eg hopelessness,
despair, agitation, shame, guilt, anger,
psychosis, psychotic thought processes
■ recent interpersonal crisis, especially
rejection, humiliation
■ recent suicide attempt
■ recent major loss or trauma or anniversary
■ alcohol intoxication
■ drug withdrawal state
■ chronic pain or illness
■ financial difficulties, unemployment
■ impending legal prosecution or child
custody issues
■ cultural or religious conflicts
■ lack of a social support network
■ unwillingness to accept help
■ difficulty accessing help due to language
barriers, lack of information, lack of support
or negative experiences with mental health
services prior to immigration.
Triage on presentation
People at risk of suicide who present to emergency departments should be triaged according to their risk category.
High suicide risk is suggested by:
■ high intent
■ definite plan
■ hopelessness
■ depression
■ psychosis
■ past attempts
■ impulsivity
■ intoxication
■ male gender
■ recent psychiatric hospitalisation
■ access to means.
Initial assessment
In general, a medical assessment should be carried out
before referral to a mental health service (or other
specialty service). However, when a person who is
known to the mental health service is showing signs of
mental distress at triage, the mental health team can be
contacted concurrently with the medical assessment.
The initial assessment should include a brief psychiatric
assessment and an initial suicide risk assessment.
The purpose of the initial suicide risk assessment
is to determine:
■ the severity and nature of the person’s problems
■ the risk of danger to self or others
■ whether a more detailed risk assessment is indicated.
Brief psychiatric assessment
■ Is the person experiencing any current psychiatric symptoms (presence of depressed mood and symptoms of depression such as reduced energy,
concentration, weight loss, loss of interest, psychosis, especially command hallucinations)?
■ Is there a past history of psychiatric problems? (A history of a mental Illness should raise the clinician’s concern that the current presentation
may be a recurrence or relapse.)
■ Mental state assessment:
– General appearance (agitation, distress, psychomotor retardation)
– Form of thought (is the person’s speech logical and making sense)
– Content of thought (hopelessness, despair, anger, shame or guilt)
– Mood and affect (depressed, low, flat or inappropriate)
– Attitude (insight, cooperation)
■ Coping skills, capacity and supports:
– Has the person been able to manage serious problems or stressful situations in the past?
– Does the person employ maladaptive coping strategies such as substance or alcohol abuse?
– Are there social or community supports?Can the person use them?
AS you can see formal thought disoder indicator of psychosis, Alcohol intoxication AND social isolation are High risk which need immediate refferral.
Although severe chronic medical illness is a risk factor for suicide, it does not warrant immediate psychiatric referral and can be handled at that point of time by emergency experts.
A referral to the mental health service should be made for the following presentations:
■ people who present following a suicide attempt or an episode of self-harm:
– those who report or are reported to be preparing for suicide have definite plans
■ people with probable mental illness or disorder:
– those who are depressed or have schizophrenia or other psychotic illness
■ people whose presentations suggest a probable mental health problem:
– those who report accidental overdoses, unexplained somatic complaints or increased risk- taking behaviour, increased impulsivity, self-harming behaviours (eg superficial wrist-cutting)
– co-morbidity (eg with alcohol and other drugs, intellectual disability, organic brain damage)
■ people recently discharged from an acute psychiatric in-patient unit, especially within the last month
■ people recently discharged from an emergency department following presentation of psychiatric symptoms or repeat presentations for somatic symptoms.
Alcohol intoxication and Formal thought disorder has to be refferred to a psychiatrist.
Pt with Social isolation has to admitted in emergency and refferral sought
http://books.google.co.in/books?id=Q3zc8RnGUqsC&pg=PA634&lpg=PA634&dq=social+isolation,+suicide+risk,+emergency&source=bl&ots=itOGTSG13G&sig=8E74WUH3qCNjqHPRtK31JDONEI8&hl=en&sa=X&ei=f_sHT8jfLcnSrQe75rjkDw&ved=0CDEQ6AEwAQ#v=onepage&q=social%20isolation%2C%20suicide%20risk%2C%20emergency&f=false
Chronic severe medical illness is a risk factor for suicide but needs preliminary assesment by emergency experts to see if they have depressive symptoms and if found need to get psychiatric refferral
A 35-year-old man with an obsessive compulsive personality disorder likely to exhibit of the following features, except
a. Perfectionism interfering with performance
b. Compulsive checking behaviour
c. Preoccupation with rule
d. Indecisiveness
Ans) b Compulsive checking behaviour
Ashish& amit is wrong here in giving indecisiveness as answer he has confused indecisiveness with rigidity. they are rigid and stubborn once they take decision but they have excessive doubt in taking a decision.
Now compulsive checking behaviour occurs in OCD not OC personality disorder; in OC personality disorder you have repeated checking due to excessive doubt but not compulsive in nature (lack of one;s control)
Read from oxford textbook of psychiatry about obsessive compulsive personality disorder
Clinical picture
The behaviour of an obsessive–compulsive personality has been consistently described as one of orderliness. The patient is preoccupied with details, and pays attention to rules, procedures, schedules, and punctuality. Patients with obsessional personalities often produce their own detailed lists of symptoms and are annoyed if any item is neglected or misinterpreted. They repeat actions and check for mistakes, despite the inconvenience and annoyance that result from this behaviour. As a consequence, their conduct is frequently inefficient. For example, the combination of unproductive perfectionism and rigidity may lead to difficulty in finishing a written report on time because of excessive correction and rewriting. Since this striving for perfection and order is time consuming, other areas of their lives often appear disorganized. One room or one desk drawer may fall into disarray, or parts of their social or family lives may be disorganized.
People with obsessive–compusive personality focus on work and productivity. It is difficult for them to take vacations or even to have free time. They do not enjoy leisure activity, which they may consider a waste of time. Often, they need to take work home to alleviate their anxiety. Hobbies and leisure pursuits become formally organized activities. They insist on perfect performance of sports or games and transform them into a serious task requiring careful organization and hard work. Leisure activities may be an unpleasant experience for the others involved, owing to the insistence on rules and standards.
Stubbornness is another characteristic of these people. They need things to be done in their way, and realistic arguments do not usually make them change their insistence. They need others to submit to their way of doing things, and often believe that no one can do the tasks as perfectly as they can. They give detailed instructions, insisting that their way is the only way of doing things, and are irritated if others suggest alternatives. Therefore, they generally insist in doing everything themselves and are unable to delegate, which increases their inefficiency at work. Paradoxically, their stubbornness is associated with doubt.
"Indecisiveness is a constant characteristic unless they have structured guidelines. They fear making mistakes or misjudgements, and delay repeatedly until they have enough data to take what they consider the only right decision. When rules do not dictate the correct answer to a problem or when procedures for tasks are not laid down, decision-making or task initiation may become a lengthy and painful process."
People with this personality disorder are characterized by excessive conscientiousness and scruples. They are inflexible about matters of morality, ethics, or values. Moral principles and standards of performance have to be followed rigidly, and respect for authority and rules is absolute. Failure to do these things leads to irritation, anger, and self-criticism.
These people are stingy and mean, and often live with standards far below their actual socio-economic status. They dislike spending, believing that money should be saved in case of future difficulties. They have great difficulty in discarding worn-out or worthless objects, believing that they might be useful some day. They may hoard objects such as newspapers or broken appliances, even when they have no sentimental value.
These people are humourless and lack spontaneity of emotional expression. Usually they do not express anger directly. However, they are often angry in situations in which they are unable to control the behaviour of themselves or others. Anger is generally manifested by indirect aggressive acts (such as leaving a small tip or not providing minor help when expected). Their management of anger is closely related to their attitude of dominance–submission toward authority figures. They may be excessively submissive to a person in authority whom they respect, but obstructive with an authority figure whom they do not respect.
The affect of the obsessive person is controlled and stilted. It is not flat or blunted, but constricted. They do not laugh or cry, and feel uncomfortable with people who express their feelings. Their mood is usually serious but may appear anxious or depressed. In a clinical interview they may sit in a stiff unnatural posture, and seldom make spontaneous comments about their emotions. They usually relate their history in a pedantic and circumstantial manner. If interrupted by a question from the doctor, they have to finish their monologue before answering. When asked about feelings, they answer with lists of facts and circumstances. They can label emotions and feelings, but are unable to display them.
In summary, obsessive personalities love order, neatness, and sameness, and hates novelty, spontaneity, and change. They need control, security, and certainty, and avoid creativity, art, and excitement. They mitigate anxiety by following strict rules and repress emotional expression by avoiding spontaneity. They fear their inner fragile and aggressive emotional world.
A girl aged 20yrs complains of headache while studying,vision is normal.all of the following should be further evaluated except.1) family history of headache.2)menstrual history 3) self worth 4) her interest in studies
Ans) 4) Her INTEREST IN STUDIES
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2408884/
Among psychological factors, anxiety, depression, HEADACHE BELIEFS AND COGNITIONS HAVE A role,
Self worth is type of headache belief cognition.
Remember generalised loss of interest leading to depression can lead to headache.
But lack of interest in studies would lead a person not studying, leaving studies or if still he complains to avoid studies, it lead us to consider malingering.
Conversion disorder in which headache occurs due to stressor is continuos and not at a time of stressor
See Headache is a bio-psychological symptom
Remember if you take studies as a stressor, leading to tension headache other stressors too should precipitate it.
No where i could get any pointer that lack of interest in studies could lead to headache
Family history of headache and menstrual history is a basic requirement in investigation of headache whether migraine or cluster headache.
These two are both common in females and occur in this age group. Although symptoms are not enough to make a specific diagnosis
Concepts: hypochondriasis , body dysmorphic disorder and how to distingush from delusional disorder (somatic type)
First DSM criteria for hypochondriasis and body dusmorphic disorder
300.7 Hypochondriasis
A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms.
B. The preoccupation persists despite appropriate medical evaluation and reassurance.
C. The belief in Criterion A is not of delusional intensity (as in delusional disorder, somatic type) and is not restricted to a circumscribed concern about appearance (as in body dysmorphic disorder).
D. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The duration of the disturbance is at least 6 months.
F. The preoccupation is not better accounted for by generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, a major depressive episode, separation anxiety, or another somatoform disorder.
Specify if:
With poor insight: if, for most of the time during the current episode, the person does not recognize that the concern about having a serious illness is excessive or unreasonable
300.7 Body dysmorphic disorder
A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.
B. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa).
Now coming to ICD criteria, both hypochondriasis and body dysmorphic disorder are together under hypochondriacal disorder
F45.2 Hypochondriacal disorder
A. Either of the following must be present:
A persistent belief, of at least 6 months' duration, of the presence of a maximum of two serious physical diseases (of which at least one must be specifically named by the patient).
A persistent preoccupation with a presumed deformity or disfigurement (body dysmorphic disorder).
B. Preoccupation with the belief and the symptoms causes persistent distress or interference with personal functioning in daily living and leads the patient to seek medical treatment or investigations (or equivalent help from local healers).
C. There is persistent refusal to accept medical reassurance that there is no physical cause for the symptoms or physical abnormality. (Short-term acceptance of such reassurance, i.e., for a few weeks during or immediately after investigations does not exclude this diagnosis.)
Clinical features of hypochondriasis
- Mainly in 3rd or 4th decade
-The preoccupation in hypochondriasis may be with bodily functions, minor physical abnormalities, or ambiguous physical sensations.
-The person attributes these symptoms or signs to a suspected disease and is concerned with their meaning and cause.
-The concerns may involve several body systems or may be about a specific organ or a single disease.
- Examinations, diagnostic tests, and reassurance from the physician do not generally reassure the hypochondriac, especially in chronic conditions and when these examinations and tests are conducted in a manner perceived as flippant by the patient.
-Thanatophobia (fear of death) is a central clinical feature of hypochondriasis and highlights the relationship to and embodiment of personality features.
-Hypochondriacs focus so much on their own body that there is a marked decrease of interest in other people or other matters outside of their body.
-manifests in inappropriate help seeking and attention to details of symptoms that are irrelevant to their overall health coupled with rejecting help for real health problems and inattention to adaptive health behaviors.
-
For example, a hypochondriac may be certain that he or she has heart disease, even when a reasonable evaluation is negative, yet he or she may ignore suggestions to prevent possible heart disease through exercise, a low-fat diet, and cholesterol-lowering medications.
-They are persistent seekers of explanations rather than of treatment, are largely unsatisfied with their medical care, and often feel that physicians have not recognized their needs.
Diffrential diagnosis
1. Medical student syndrome:transient preoccupation with the fear of having a disease (Most common diffential diagnosis)
2. Somatization disorder
-people with somatization disorder are more concerned with actual symptoms, have more abnormal personality characteristics and more depression and anxiety, and are more likely to seek treatment, whereas people with hypochondriasis are more afraid of death.
3. Body dysmorphic disorder
-people with body dysmorphic disorder focus on specific, presumed defects, are not as fearful of having a disease or of death, and are more likely to seek specific medical care, such as cosmetic surgery or dermatological advice.
4. Delusional disorder
- an individual with hypochondriacal delusions has a fixed, unfounded belief that a disease is present.
-Often have bizarre explanations for their belief or gross impairment of reality, or both, such as being convinced they have been poisoned, that their organs have somehow moved, or that someone or something outside of self has agency over their organs and health.
5. OCD
-although this bodily preoccupation in hypochondriasis is distressing, the patient believes that he or she has a disease, and, in that sense, the disease conviction is not ego-dystonic.
Treatment
1. Reassurance
2. Cognitive behaviour therapy
3. Pharmacological: SSRI's
1.A patient came with complaints of having a deformed nose and also complained that nobody takes him seriously because of deformity of his nose. He has visited several cosmetic surgeons but they have sent him back saying that there is nothing wrong with his nose. He is probably suffering from
Hypochondriasis
Somatisation
Delusional disorder
OCD
ANS) Ideal answer: Body dysmorphic disorder; if not there in choice hupochodriasis.
Points in favour of hypochondriasis:
-preoccupation with some minor anomaly in body.
- Chronic and persistent
3. Self- image disturbances (nobody takes me seriously, more commonly seen in body dysmorphic disorder) ( More suspiciosness than anxiety in delusional disorder)
4. Several visits to cosmetic surgeons ( Delusional disorders will fight and will not get reassured even transiently, will become suspicious of doctors)
Points against Delusional disorder
1. Belief not fixed, would force cosmetic surgeon to operate
2. Nosuspiciousness and attribution of deformioty to somebody
3. Bizarre or unrealistic explanation of etiology of deformity not there
Points against somatisation
- Only one symptom and one system
Points against OCD
- Egosyntonic in pt, not egodystonic
2. Lalu prasad, 45 year old male presents to OPD with complaints of continuos non-progressive headache from last 7 years. He believes that he has brain tumour for that he he is consulting many neurologists in past even though all investigations have been within normal limits. Pt requested for other investigation to reveal that he has brain tumour. The most probable diagnosis is
Hypochondriasis
Somatisation
Somatoform pain disorder
Conversion disorder
Ans) Hypochondriasis
Points in favour of hypochondriasis
1. Misinterpretation of a normal body function (misinterpretation as headache, no real organic cause of headache) leading to fear of a serious illness brain tumour on basis of misinterprated symptom headache
2. Request for multiple investigations
Points against somatisation
1. single symptom and system
Points against conversion
1. No neurological sensory or motor symptom( headache is a pain symptom)
2. No fear of serious illness in conversion disorder.
Points against somatoform pain disorder
1. No fear of serious illness in pain disorder ( complaints of only headache which is related to psychological stressors; if the question mentioned only headache with no fear of illness, it could have been the answer
3. Hypochondriasis is
Normal pre-occupation with abnormal body function
Abnormal preoccupation with abnormal body function
Normal preoccupation with normal body function
Abnormal preoccupation with normal body function
Ans) Abnormal preoccupation with normal body function
5. A 35-year-old male, with pre – morbid anxious traits and heavy smoker, believes that he has been suffering from ‘lung carcinoma’ for a year. No significant clinical finding is detected on examination and relevant investigations. He continues to stick to his belief despite evidence to the contary. In the process, he has spent a huge amount of money, time and energy in getting himself unduly investigated. He is most likely suffering from
a. Carcinoma lung
b. Delusional disorder
c. Hypochondriacal disorder
d. Malingering
Ans) Hypochondriasis
Points in favour of hypochondriasis
1. pre-morbid anxious traits ( increase the risk of somatoform disorders)
2. Heavy smoker ( predisposes fear of serious illness like lung cancer based on misinterpretation of symptom like cough)
3. Fear of serious illness
4.No significant clinical finding is detected on examination and relevant investigations.
5.He continues to stick to his belief despite evidence to the contrary ( Don' confuse this to delusion, read this line from otp
"Hypochondriasis is a preoccupation with the fear that one has, or may develop, serious disease despite evidence to the contrary. "
6.spent a huge amount of money, time and energy in getting himself unduly investigated.
Now contrast this to delusional disorder
1, Suspiciuos traits premorbidly
2. Would be firm that he has illness will not waste money in investigations
3. would have associated paranoia and suspiciousness on doctors and family members for giving wrong reports.
4. Would have other unrealistic and bizarre explanation for his illness.
Points against malingering
1. No overt monetary or legal gain present
5. A 41-year old married female presented with headache for the last six months. She had several consultations. All her investigations were found to be within normal limits. She still insists that there is something wrong in her head and seeks another consultation. The most likely diagnosis is
Phobia
Psychogenic headache
Hypochondriasis
Depression
Ans) Hypochondriasis
Points in favour of hypochondriasis
1. Fear of something wrong in head based on misinterprated symptom headache
2. No organic cause of headache found
3. Multiple consultations
Points against psychogenic headache
1. Concern not headache but something wrong in head (if question is like this" A 41-year old married female presented with headache for the last six months. She had several consultations. All her investigations were found to be within normal limits, she is sufferin from"
then psychogenic headache which is same as somatoform pain disorder would have been a better choice)
Points against phobia
1, No history of excessive fear of any specitic object or situation
A) Alcohol
B) Cannabis
C) Tobacco
D) Cocaine
Ans) Tobacco
Now this question has been asked quite frequently and remains controversial
Most common substance of use in India: Tobacco
Most common substance of use in world: Alcohol
Most common substance of use in western countries:Alcohol
Most common illicit substance of use in India: Cannabis
Most common illicit substance of us in world:Cannabis
Most common illicit substance of use in western countries: Cannabis
Now coming to abuse, remember although DSM IV TR DOES NOT RECOGNISE TOBACCO AS SUBSTANCE OF USE but nearly 70-80% of those who use it; use in dependent pattern, now dependence is more higher criteria than abuse
The hallmark book on substance abuse includes tobacco in it(Substance Abuse: A Comprehensive Textbook; Fourth Edition by Joyce H. Lowinson
;Substance Abuse: A Comprehensive Textbook focus on addiction in children, adolescents, adults, and the elderly and women's health issues, including pregnancy)
Most common substance of abuse
Most common substance of abuse in INDIA: Tobacco
Most common substance of abuse in world: Tobacco (All Alcohol users do not use in abuse pattern; about 80% are social drinkers, 10%abuse, 105 dependent of all who use alcohol)
Most common substance of abuse in western countries:Alcohol
Most common substance of abuse in India as per DSM-IV TR: Alcohol
Most common substance of abuse in world as per DSM IV TR: Tobacco
Most common substance of use in western countries as per DSM IV TR: Alcohol
Most common illicit substance of use in India: Cannabis
Most common illicit substance of use in world:Cannabis
Most common illicit substance of use in western countries: Cannabis
India: Substance use
Tobacco- 52%
Alcohol- 21.4%
Cannabis- 3%
Opium- 0.4%
Best therapy suited to teach daily life skill to mentally
challenged child,,,,
a.. CBT
b..contingency
c..cognitive reconstruction
d...self instruction
2.... Best therapy suited for mentally retarded child,,,,
a.. CBT
b..rewarding
c..behavior reconstruction
d...self initiative
Ans) 1 b) Contingency
2) Reward ( choices not clear, ideal answer is behavioural modification)
Remember for all grades of mental retardation, behaviour therapy is treatment of choice.
Contingency is a type of behaviour therapy
Contingency management is a type of treatment used in the mental health or substance abuse fields. Patients are rewarded (or, less often, punished) for their behavior; generally, adherence to or failure to adhere to program rules and regulations or their treatment plan. As an approach to treatment, contingency management emerged from the behavior therapy and applied behavior analysis traditions in mental health
now see an article from mescape which again proves role of contingent behavior therapy
Psychosocial Treatment Modalities
Multidisciplinary treatment teams use a variety of psychosocial modalities to address behavioral problems experienced by patients who are mentally retarded. The 3 behavioral interventions recommended by the expert consensus panel for most situations are as follows:
Applied behavior analysis includes techniques that are based on the principles and methods of behavior analysis and are intended to build appropriate functional skills and reduce problem behavior. These include the following:
Behavior-accelerating procedures, such as contingent reward for specific behaviors that are incompatible with problem behavior
Behavior-decelerating techniques, such as contingent reward for specified time periods, during which the problem behavior did not occur; extinction; overcorrection; response cost; time-out; contingent restraint
Behavioral parent and teacher/staff training to help them function as cotherapists and/or to avoid incidental reinforcement of the problem behavior
Remember cognitive behaviour therapy, cognitive reconstruction and self instruction are all cognitive stratedgies which can be used in MR but are inferior to behaviour therapy.
Dont confuse CBT from BT; CBT is primarily cognitive therpy with minimal use of some behavioural techniques like daily scheduling
CBT is primarily used in those condition where there are underlying cognitive distortions, distorted beliefs(basically distorted thinking); So CBT is primarily used in depression, adjustment disorder, generalised anxiety disorder,eating disorders, sexual dysfunctions
Behaviour therapy is mainly used in OCD, PHOBIAS, chilhood psychiatric disorders like autism and ADHD
Self-instruction a type of cognitive stratedgy is mainlyused in dyslexia( learning disorders)
Cognitive reconstruction:By completing the process of cognitive restructuring, an individual can better: Gain awareness of detrimental thought habits;Learn to challenge them and substitute them with life-enhancing thoughts and beliefs
Cognitive restructuring involves 4 steps[9]:
(1) Identification of problematic cognitions known as “Automatic Thoughts” (ATs) which are dysfunctional or negative view of the self, world, or future
(2) identification of the cognitive distortions in the ATs
(3) rational disputation of ATs with Socratic dialogue, and
(4) development of a rational rebuttal to the ATs
Cognitive reconstruction is used as part of CBT
20 years old female with complaints of nausea, vomitting and pain in legs. Her physical examination and lab investigations are normal. What is the most probable diagnosis?
a) Generalized anxiety disorder
b) Conversion disorder
c) Somatoform pain disorder
d) Somatization disorder
Ans) d) Somatization disorder
Points in favour of somatisation disorder
1). Multiple symptoms( three; nausea, vomitting, pain in legs)
2) Multiple system (two; Gastrointestinal and pain system)
3) Female sex (Female to male ratio 20:1)
4) Age of onset ( Young onset)
5) Nausea and vommiting are the most common somatisation symptom followed by diffuse pain in extremities.
Remember while DSM IV TR requires 4 pain, 2 GI, 1 Neurological and 1 Psuedoneurological, there is no such requirement in ICD-10, they just mention multi systemic and multi symptom, so this case can be somatisation as per ICD requires two years and asper DSM multple years, so please don't diagnose if duration less than2 years
Some students told me that duration of 2 months was mentione if that so then mark somatoform pain, but if no duration given like in this question go for somatisation disorder
But very important it is a chronic disorder and
Points against Somatoform pain disorder
1. Pain should be focus of attention for which pt is preoccupied and all other symptoms should be explained by pain; in that case in this question pain should have been the first symptom, not nausea and vommiting as in the question. ( Somatoform pain would have been like this; pt complains of pain in knees or ankle which when increased in intensity leads to nausea and vommiting)
2. Pain in somatoform pain disorder is at specific body sites like headache, pain at knee , pain at elbow, not diffuse pain in extremities)
3. Age of onset: mainly 5th decade-sixth decade
Points against conversion disorder
- No motor or sensory neurological symptom
-No acute stressor
Points against Generalised anxiety disorder
- No excessive anxiety and worry (apprehensive expectation) which is difficult to control
No other somatic/cognitive symptoms of anxiety(restlessness or feeling keyed up or on edge ;being easily fatigued ;difficulty concentrating or mind going blank; irritability; muscle tension;sleep disturbance
-No autonomic symptoms
20 years old female with complaints of intermittent vomitting and pain in legs and headache since 2 months. Her physical examination and lab investigations are normal. What is the most probable diagnosis?
a) Generalized anxiety disorder
b) Conversion disorder
c) Somatoform pain disorder
d) Somatization disorder
Ans) Somatoform pain disorder
Now see my last post,now see the differences
1) Two pain symptoms compared to one in last question
2) intermittent symptoms all together, vomitting during pain symptom or headache quite common in somatoform pain disorder( in last question they were not together)
3) DURATION OF TWO MONTHS( bevery very sure can never dianose somatisation in duration less than 2 years)
PLEASE SEE THESE TWO QUESTIONS CAREFULLY, SOME CHANGE OF WORDS CHANSE ANSWERS IN AIIMS/ ALL INMDIA, PLEASE DONT PREMATURELY EJACULATE YOUR MUGGED ANSWERS, YOU CAN LAND IN TROUBLE
Q. 20 years old female with complaints of nausea, vomitting and pain in legs. Her physical examination and lab investigations are normal. What is the most probable diagnosis?
a) Generalized anxiety disorder
b) Conversion disorder
c) Somatoform pain disorder
d) Somatization disorder
Not a specific somatoform disorder?
1.Somatisation
2.Fibromyalgia
3.Chronic fatigue syndrome
4.Irritable bowel syndrome
Ans) 2. Fibromyalgia
Read these lines from comprehensive textbook of psychiatry, 8th edition
"Undifferentiated somatoform disorders, which include medically unexplained symptoms, chronic fatigue syndrome, irritable bowel syndrome and noncardiac chest pain.
Now these lines make it amply clear that chronic fatigue syndroime is a somatoform disorder.
Somatoform disorder consists of
1. Somatisation disorder
2.Hypochondriasis
3.Conversion disorder
4.Body dysmorphic disorder
4. Somatoform pain disorder
5. Undiffrentiated somatoform disorde
Lady with sadness & NO H/O hopelessness, Occasional palpitation, loss of apetite, Insomnia, no precipitating event of life, (AI-2010)
a. GAD
b. Mixed anxiety depression
c. Adjustment disorder
d. Mild depressive episode
Ans) Mixed anxiety-depression (Confirmed from consultant, professor in psychiatry from AIIMS)
Mixed anxiety and depressive disorder
Mixed anxiety-depressive disorder is a diagnostic category defining patients who suffer from both anxiety and depressive symptoms of limited and equal intensity accompanied by at least some autonomic features. The World Health Organization's ICD-10 describes Mixed anxiety and depressive disorder AS
"This category should be used when symptoms of anxiety and depression are both present, but neither is clearly predominant, and neither type of symptom is present to the extent that justifies a diagnosis if considered separately. When both anxiety and depressive symptoms are present and severe enough to justify individual diagnoses, both diagnoses should be recorded and this category should not be used."
Now in this question
Depressive symptom is sadness, loss of appetite and insomnia
Anxiety symptom is occasional palpitation and insomnia.
Now remember mixed anxiety depression can oly be diagnosed after ruling out depression and core anxiety disorders like Generalised anxiety disorder, phobias, OCD.
Now first coming to GAD first
-Remember GAD ca never never be diagnosed without
"Excessive anxiety and worry (apprehensive expectation) which a person feels difficult to control".
presence of free floating anxiety about small small things of day to day life is must, without this symptom of anxious thinking, you can never diagnose GAD; although insomnia and occasinal palpitations can occur in GAD BUT THEY ARE SUPPORTINGG SYMPTOMS COGNITIVE ANXIETY( anxious thinking is must for diagnosis.
Now we too have to rule out depression
DSM does not talk about mild, moderate or severe depression, only it talks about major depressive disorder
TOo diagnose major depressive disorder as per DFSM we need
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
1.depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood
2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
3. significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
4. insomnia or hypersomnia nearly every day
5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6. fatigue or loss of energy nearly every day
7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
Now in this question, we have only three symptom from DSM
Now coming to ICD, Although symptoms are same nine there but they have divided depression into mild, moderate and severe
For mild depression, we need four symptom
moderate depression six symptoms
severe depression, eight symptoms
Now even if we see for ICD, IN THIS CASE it is not fulfilling the criteria for mil depression as we have three symptom only
BUT PLEASE KIND THIS IN MIND THAT IF THEY ADD EVEN ONE SYMPTOM OF DEPRESSION MORE, THE ANSWER WOULD SHIFT TO MILD DEPRESSIVE EPISODE
Now coming to last choice adjustment disorder
Diagnosis of adjustment cannot be made without a stressor; no antecedent stressor here ( the answer would change to adjustment if they add a stressor
-Criteria for adjustment is very liberal
only important thing issymptoms should start within three months of stressor and normally do not remain after six months after stresoor vanishes.
( Again diagnosis of adjustment ios not entertained if pt fulfills criteria for depression or anxiety disorder.
Adjustment can have depressive, anxiety, emotional or conduct symptoms
Anterograde amnesia is seen in.....
A) head injury
b) stroke
c) spinal cord injury traumatic paraplegia
d) alzheimer's disease
Ans) Stroke
Most common cause of anterograde amnesia is stroke while most common cause of retograde amnesia is head injury
Anterograde Amnesia
Anterograde amnesia is a selective memory deficit, resulting from brain injury, in which the individual is severely impaired in learning new information. Memories for events that occurred before the injury may be largely spared, but events that occurred since the injury may be lost.
Short-term memory is generally spared, which means that the individual may be able to carry on a conversation; but as soon as he is distracted, the memory of the conversation fades.
Anterograde amnesia can occur following damage to at least three distinct brain areas. The first, and most well-studied, is the hippocampus and associated areas in the medial temporal lobes of the brain. The hippocampus seems to act as a "gateway" through which new fact information must pass before being permanently stored in memory. If it is damaged, no new information can enter memory - although older information which has already passed through the gateway may be safe. Damage to the hippocampus (and medial temporal lobes) can occur following stroke or aneurysm to one of the arteries which supplies blood to these areas, as well as following epilepsy, encephalitis, hypoxia, carbon monoxide poisoning, near-drowning or near-suffocation, and the earliest stages of Alzheimer's disease. Some damage to the hippocampus also occurs in the course of normal aging.
Anterograde amnesia can also occur following damage to the basal forebrain, a group of structures which produce acetylcholine, a chemical which helps cells in the brain store new information during learning. The basal forebrain can be damaged by aneurysm of the anterior communicating artery, which supplies blood to the basal forebrain.
Finally, anterograde amnesia can sometimes occur following damage to the diencephalon - a set of structures deep in the brain including the medial thalamic nuclei.
Korsakoff's disease is a syndrome which can damage the diencephalon and cause anterograde amnesia.
incidence of mild TBI is about 131 cases per 100,000 people, the incidence of moderate TBI is about 15 cases per 100,000 people, and the incidence of severe TBI is approximately 14 cases per 100,000 people.
even if you add all( mild +moderate+severe), it just comes to 0.1%, most of which are mild (90%) and unlikely to lead to amnesia
IN Mild: GCS score 13 to 15. Likely to be associated with a loss of consciousness of less than 20 min and a post-traumatic amnesia of less than 24 h. ANTEROGRADE AMNESIA OF MORE THAN ONE WEEK OCCURS ONLY IN SEVERE HEAD INJURY.
incidence of stroke for those aged between 35 and 65 is between 90 and 330 per 100 000. and if stroke affects hippocampus, anterogradeamnesia is continuos
Healthy thinking includes all except
a) continuity
b) constancy
c) organization
d) clarity
ans Constancy
Thought which remains constant with time even after new evidences come to contrary will overvalued idea or later delusion
Healthy thinking always leads to new interpretation as new evidences come.
Continuity is a feature of healthy thinking. (thought disorder due to poor continuity; Derailment)
Organisation is again an important characteristic. (Disorder of thought due to poor organisation; Loosening of organisation)
Clarity; (Disorder of thought due to poor clarity is circumstantiality)
A smoker is convinced by his family members to quit smoking, as a long term hazard of smoking is cancer. He decided to quit but tells about his worry that due to quitting smoking he may become irritable. According to the Health Belief Model, this state of patient is which of the following?
A. Precontemplation and preparation
B. Severity of illness Contemplation
C. Contemplation and lost involvement
D. Susceptibility of illness and lost involvement
Ans) Severity of illness and Cotemplation
HEALTH BELIEF MODEL
The Health Belief Model (HBM) is a psychological model that attempts to explain and predict health behaviors. This is done by focusing on the attitudes and beliefs of individuals. The HBM was first developed in the 1950s by social psychologists Hochbaum, Rosenstock and Kegels working in the U.S. Public Health Services. The model was developed in response to the failure of a free tuberculosis (TB) health screening program. Since then, the HBM has been adapted to explore a variety of long- and short-term health behaviors, including sexual risk behaviors and the transmission of HIV/AIDS.
The HBM was spelled out in terms of four constructs representing the perceived threat and net benefits: 1) perceived susceptibility,2) perceived severity, 3) perceived benefits, and 4) perceived barriers.
These concepts were proposed as accounting for people's "readiness to act."
An added concept, 5) cues to action, would activate that readiness and stimulate overt behavior.
A recent addition to the HBM is the concept of 6) self-efficacy, or one's confidence in the ability to successfully perform an action. This concept was added by Rosenstock and others in 1988 to help the HBM better fit the challenges of changing habitual unhealthy behaviors, such as being sedentary, smoking, or overeating.
so by HBM, pt is motivated by severity of illness
Now to check his stage of change, w will apply transtheoretical model of change by Prochaska and Diclemente(1984)
Precontemplation: Denial, ignorance of problem
Contemplation: Ambivalence and conflicted emotions
Preparation: Experimenting with small changes, collecting information about change
Action: Taking direct action toward’s goal
Maintenance: Maintaing a new behavior; avoiding temptation
Here he is in process of contemplation( pt is ambivalent want to leave due to fear of serious illness but thinks he will become irritable without tobacco
so answer is Contemplation and severity of illness
ANOTHER VERSION OF THE SAME Q
Mr X is a chronic smoker. His family insists on quitting smoking. He is thinking about quitting, but is reluctant to do so because he is worried that on quitting he will become irritable. This is?
A. Precontemplation and preparation
B. Contemplation and extent of sickness susceptability
C. Contemplation and cost factors
Again as per health belief model, answer would be b)
A man taking 20 cigarettes per day, started coughing, his family suggested quitting cigarettes . He is ready to quit but thinks that quiting will make him irritable, the best health planning model followed is
Cost and survival
Persuasion
Precontemplation and preparation
Belief
D. Precontemplation and cost factor
Ans) Health belief model IF ONLY BELIEF IN CHOICE GO FOR PRECONTEMPLATION AND PREPARATION
SEE PT IS ALREADY IN PHASE OF CONTEMPLATION SO, WE CANNOT USE PRECONTEMPLATION AND PREPARATION
Had the choice being contemplation, prparation and action that would have been the action
REMEMBER PARISCHA TRANSTHEOREOTICAL MODEL IS MOST IMPORTANT FOR TOBACCO CESSATION WHILE HEALTH BELIEF IS RECENTLY MODIFIED FOR TOBACCO CESSATION, SO IF THEY ASK WHICH IS BETTER IN TOBACCO CESSATION, IT'S ALWAYS PARISCHA
rEMEMBER IF A PERSON IS CONCERNED ABOUT AN SEVERE ILLNESS, THEN HEALTH BELIEF MODEL IS BETTER( Cancer in first question) but in third modified question, there is only concern of tobacco cessation where parischa model is better
HEALTH EDUCATION BEHAVIOR MODELS AND THEORIES
As a part of any planning model, it is necessary to attempt to classify and explain the multitude of factors which can, and do, influence human behavior. Current models/theories that help to explain human behavior, particularly as it relates to health education, can be classified on the basis of being directed at the level of: a) Individual (Intrapersonal); b) Interpersonal; or c) Community. Within these three categories, those models/theories that have tended to dominate in the health education field in the past 20-30 years will be briefly outlined.
Individual (Intrapersonal) Health Behavior Models/Theories
Health Belief Model (Rosenstock, Becker, Kirscht, et al.)
The Health Belief Model (HBM) was one of the first models which adapted theories from the behavioral sciences to examine health problems. It is still one of the most widely recognized and used models in health behavior applications. This model was originally introduced by a group of psychologists in the 1950's to help explain why people would or would not use available preventive services, such as chest x-rays for tuberculosis screening and immunizations for influenza. These researchers assumed that people feared diseases and that the health actions of people were motivated by the degree of fear (perceived threat) and the expected fear reduction of actions, as long as that possible reduction outweighed practical and psychological barriers to taking action (net benefits).
The HBM can be outlined using four constructs which represent the perceived threat and net benefits: 1) perceived susceptibility, a person's opinion of the chances of getting a certain condition; 2) perceived severity, a person's opinion of how serious this condition is; 3) perceived benefits, a person's opinion of the effectiveness of some advised action to reduce the risk or seriousness of the impact; and 4) perceived barriers, a person's opinion of the concrete and psychological costs of this advised action. (See Figure 1) Another concept is known as cues to action. These are events (internal or external) which can activate a person's "readiness to act" and stimulate an observable behavior. Some examples of external strategies to activate "readiness" can be delivered in print with educational materials, through any electronic mass media or in one-to-one counseling. Another concept that has been added to HBM since 1988 in order to better meet the challenges of changing unhealthy habitual behaviors (such as being sedentary, smoking or overeating) is self-efficacy. Self-efficacy, a concept originally developed by Albert Bandura in social cognitive theory (social learning theory), is simply a person's confidence in her/his ability to successfully perform an action.
Even though the HBM was originally developed to help explain certain health related behaviors, it has also helped to guide the search for "why" these behaviors occur and to identify points for possible change. Using this framework, change strategies can be designed as referred to earlier. The HBM has been used to help in developing messages that are likely to persuade an individual to make a healthy decision. Using the HBM, messages that are suitable to health education for such topics as hypertension, eating disorders, contraceptive use, or breast self-examination have been developed.
However, there are two main weaknesses which have been noted about the HBM. First, health beliefs compete with an individual's other beliefs and attitudes which can also influence behavior. Secondly, in decades of research in the social psychology of behavioral change, it has not been shown that belief formation always precedes behavioral change. In fact, the formation of a belief may actually follow a behavior change.
Stages of Change Model or Transtheoretical Model (Prochaska and DiClemente)
The Stages of Change or Transtheoretical Model was initially published in 1979 by Prochaska. In the 1980's Prochaska and DiClemente worked further on this model in outlining the stages of an individual's readiness to change, or attempt to change, toward healthy behaviors. The Stages of Change Model evolved from research in smoking cessation and also the treatment of drug and alcohol addiction. More recently it has been applied to other health behaviors, such as dietary changes. Behavior change is viewed as a process, not an event, with individuals at various levels of motivation or "readiness" to change. Since people are at different points in this process, planned interventions should match their stage.
There are six stages that have been identified in the model: 1) Precontemplation - the person is unaware of the problem or has not thought seriously about change; 2) Contemplation - the person is seriously thinking about a change (in the near future); 3) Preparation - the person is planning to take action and is making final adjustments before changing behavior; 4) Action - the person implements some specific action plan to overtly modify behavior and surroundings; 5) Maintenance - the person continues with desirable actions (repeating the periodic recommended steps while struggling to prevent lapses and relapse; and 6) Termination - the person has zero temptation and the ability to resist relapse.
In relapse, the person reverts back to old behavior which can occur during either action or maintenance. This model is a circular, rather than a linear model. In fact, as seen in Figure 2, it is more of a spiral as the person may go through several cycles of contemplation, action, relapse (or recycle) before either reaching termination or exiting the system without becoming free of the addictive behavior. Prochaska has used a "revolving-door schema" to explain the sequence that people pass through in their efforts to become free from addictions. People do not go through the stages and graduate; they can enter and exit at any point and often recycle several times. Other studies indicate that individuals often go through these same changes whether they use self-help or self-management techniques, seek professional counseling or attend organized programs.
Alzeimer's disease all are seen except
a) Aphasia
b)Acalcula
c) Agnosia
d) Apraxia
Ans) Acalculia (Oxford textbook of psychiatry)
Clinical features
Cognitive impairment
Dementia is an acquired and progressive cognitive decline in multiple areas; AD is one cause of dementia and the core clinical symptom of AD is cognitive impairment. However, as noted above, AD is clinically heterogeneous and includes diverse non-cognitive symptoms and inevitable functional impairment. Cognitive decline is manifested as amnesia, aphasia, agnosia, and apraxia (the 4As).
Amnesia
Memory loss in AD is early and inevitable. Characteristically, recent memories are lost before remote memories. However, there is considerable individual variation, with some patients able to recall specific and detailed events of childhood and others apparently having few distant memories accessible. With disease progression, even remote and emotionally charged memories are lost. The discrepancy between recent and remote memory loss suggests that the primary problem is of acquisition or retrieval of memory rather than a destruction of memory, and this is confirmed in early AD,(2) although as the disease progresses it is likely that all memory processes are impaired. Retrieval of remote memory is assumed to be preserved for longer because of rehearsal over life.
Aphasia
Language problems are found in many patients at presentation, although the language deficits in AD are not as severe as those of the frontotemporal degenerations(3) and may only be apparent on detailed examination. Word-finding difficulties (nominal dysphasia) are the earliest phenomena observed and are accompanied by circumlocutions and other responses, for example repetitions and alternative wordings. As the disorder progresses, syntax is affected and speech becomes increasingly paraphasic. Although harder to assess, receptive aphasia, or comprehension of speech, is almost certainly affected. In the final stages of the disorder, speech is grossly deteriorated with decreased fluency, preservation, echolalia, and abnormal non-speech utterances.
Agnosia
Patients with AD may have difficulty in recognizing as well as naming objects. This can have implications for care needs and safety if the unrecognized objects are important for daily functioning. One particular agnosia encountered in AD is the loss of recognition of one's own face (autoprosopagnosia). This distressing symptom is the underlying cause of perhaps the only clinical sign in AD—the mirror sign. Patients exhibiting this will interpret the face in the mirror as some other individual and respond by talking to it or by apparent fearfulness. Autoprosopagnosia can present as an apparent hallucinatory experience, until it is realized that the ‘hallucination' is fixed in both content and space, occurring only when self-reflection can be seen.
Apraxia
Difficulties with complex tasks that are not due to motor impairment become apparent in the moderate stages of AD. Typically, difficulties with dressing or tasks in the kitchen are noticed first, but these are inevitably preceded by loss of ability for more difficult tasks. Strategies to avoid such tasks are often acquired as the disease progresses, and it is only when these fail that the dyspraxia becomes apparent.
Other cognitive impairments
There appear to be no cognitive functions that are truly preserved in AD. Visuospatial difficulties commonly occur in the middle stages of the disorder and may result in topographical disorientation, wandering, and becoming lost. Difficulties with calculation, attention, and cognitive planning all occur.
Type D personality was recently found to risk for?
A. Coronary artery disease
B. Depression
C. Personality disorder
D. Schizophrenia
ANS) CORONARY ARTERY DISEASE
type-D personality was a significant predictor of long-term mortality in patients with established CHD, independently of biomedical risk factors.
letter D stands for 'distressed'.Individuals with a Type D personality have the tendency to experience increased negative emotions across time and situations and tend not to share these emotions with others, because of fear of rejection or disapproval.
Type C: related to cancer, DIFFICULTY EXPRESSING NEGATIVE SYMPTOMS
Type H personality, also called hardy personality; Actually seem to thrive on stress rather than letting stress wear them; Given by Suzanne Kossaba, Type H personality is characterised by sense of commitment, complete sense of control over their life and correct interpretation of things going around
Type A and Type B given by Friedman and Rosenman
Type A behavior is expressed in three major symptoms: free-floating hostility, which can be triggered by even minor incidents; time urgency and impatience, which causes irritation andexasperation; and a competitive drive, which causes stress and an achievement-driven mentality.
Type A behavior doubles the risk of coronary heart disease in otherwise healthy individuals.
People with Type B personalities are generally patient, relaxed, easy-going, and at times lacking an overriding sense of urgency.
REMEMBER BOTH TYPE A AND TYPE D RELATED TO CORONARY ARTERY DISEASE
A PT PRESENTS TO EMERGENCY DEPARTMENT WITH SELF HARM AND indicates suicidal ideations. Which of the following condition doesn't warrant an immediate specialist assessment?
a) Formal thought disorder
b) Acute alcohol intoxication
c) Chronic severe physical illness
d) Social isolation
Ans) d) Chronic severe physical illness
http://www.health.nsw.gov.au/pubs/2004/pdf/emergency_dept.pdf
Just go through the article and you can understand how to handle a pt coming to emergency with suicidal ideations
preliminary suicide risk assessment-----immediate management------Mental health management--------Assessment of suicide risk------corroborative history-----management of suicide risk------Reassessment of suicide risk----Discharge
Now in this at third step help of a specialist that is mental health management is sought
Now in preliminary assesment at first step all four are risk factors for suicide.
However, the most important factors in
assessing a person’s imminent suicide risk
are the current personal risk factors.
Examples include:
■ ‘at risk’ mental status, eg hopelessness,
despair, agitation, shame, guilt, anger,
psychosis, psychotic thought processes
■ recent interpersonal crisis, especially
rejection, humiliation
■ recent suicide attempt
■ recent major loss or trauma or anniversary
■ alcohol intoxication
■ drug withdrawal state
■ chronic pain or illness
■ financial difficulties, unemployment
■ impending legal prosecution or child
custody issues
■ cultural or religious conflicts
■ lack of a social support network
■ unwillingness to accept help
■ difficulty accessing help due to language
barriers, lack of information, lack of support
or negative experiences with mental health
services prior to immigration.
Triage on presentation
People at risk of suicide who present to emergency departments should be triaged according to their risk category.
High suicide risk is suggested by:
■ high intent
■ definite plan
■ hopelessness
■ depression
■ psychosis
■ past attempts
■ impulsivity
■ intoxication
■ male gender
■ recent psychiatric hospitalisation
■ access to means.
Initial assessment
In general, a medical assessment should be carried out
before referral to a mental health service (or other
specialty service). However, when a person who is
known to the mental health service is showing signs of
mental distress at triage, the mental health team can be
contacted concurrently with the medical assessment.
The initial assessment should include a brief psychiatric
assessment and an initial suicide risk assessment.
The purpose of the initial suicide risk assessment
is to determine:
■ the severity and nature of the person’s problems
■ the risk of danger to self or others
■ whether a more detailed risk assessment is indicated.
Brief psychiatric assessment
■ Is the person experiencing any current psychiatric symptoms (presence of depressed mood and symptoms of depression such as reduced energy,
concentration, weight loss, loss of interest, psychosis, especially command hallucinations)?
■ Is there a past history of psychiatric problems? (A history of a mental Illness should raise the clinician’s concern that the current presentation
may be a recurrence or relapse.)
■ Mental state assessment:
– General appearance (agitation, distress, psychomotor retardation)
– Form of thought (is the person’s speech logical and making sense)
– Content of thought (hopelessness, despair, anger, shame or guilt)
– Mood and affect (depressed, low, flat or inappropriate)
– Attitude (insight, cooperation)
■ Coping skills, capacity and supports:
– Has the person been able to manage serious problems or stressful situations in the past?
– Does the person employ maladaptive coping strategies such as substance or alcohol abuse?
– Are there social or community supports?Can the person use them?
AS you can see formal thought disoder indicator of psychosis, Alcohol intoxication AND social isolation are High risk which need immediate refferral.
Although severe chronic medical illness is a risk factor for suicide, it does not warrant immediate psychiatric referral and can be handled at that point of time by emergency experts.
A referral to the mental health service should be made for the following presentations:
■ people who present following a suicide attempt or an episode of self-harm:
– those who report or are reported to be preparing for suicide have definite plans
■ people with probable mental illness or disorder:
– those who are depressed or have schizophrenia or other psychotic illness
■ people whose presentations suggest a probable mental health problem:
– those who report accidental overdoses, unexplained somatic complaints or increased risk- taking behaviour, increased impulsivity, self-harming behaviours (eg superficial wrist-cutting)
– co-morbidity (eg with alcohol and other drugs, intellectual disability, organic brain damage)
■ people recently discharged from an acute psychiatric in-patient unit, especially within the last month
■ people recently discharged from an emergency department following presentation of psychiatric symptoms or repeat presentations for somatic symptoms.
Alcohol intoxication and Formal thought disorder has to be refferred to a psychiatrist.
Pt with Social isolation has to admitted in emergency and refferral sought
http://books.google.co.in/books?id=Q3zc8RnGUqsC&pg=PA634&lpg=PA634&dq=social+isolation,+suicide+risk,+emergency&source=bl&ots=itOGTSG13G&sig=8E74WUH3qCNjqHPRtK31JDONEI8&hl=en&sa=X&ei=f_sHT8jfLcnSrQe75rjkDw&ved=0CDEQ6AEwAQ#v=onepage&q=social%20isolation%2C%20suicide%20risk%2C%20emergency&f=false
Chronic severe medical illness is a risk factor for suicide but needs preliminary assesment by emergency experts to see if they have depressive symptoms and if found need to get psychiatric refferral
A 35-year-old man with an obsessive compulsive personality disorder likely to exhibit of the following features, except
a. Perfectionism interfering with performance
b. Compulsive checking behaviour
c. Preoccupation with rule
d. Indecisiveness
Ans) b Compulsive checking behaviour
Ashish& amit is wrong here in giving indecisiveness as answer he has confused indecisiveness with rigidity. they are rigid and stubborn once they take decision but they have excessive doubt in taking a decision.
Now compulsive checking behaviour occurs in OCD not OC personality disorder; in OC personality disorder you have repeated checking due to excessive doubt but not compulsive in nature (lack of one;s control)
Read from oxford textbook of psychiatry about obsessive compulsive personality disorder
Clinical picture
The behaviour of an obsessive–compulsive personality has been consistently described as one of orderliness. The patient is preoccupied with details, and pays attention to rules, procedures, schedules, and punctuality. Patients with obsessional personalities often produce their own detailed lists of symptoms and are annoyed if any item is neglected or misinterpreted. They repeat actions and check for mistakes, despite the inconvenience and annoyance that result from this behaviour. As a consequence, their conduct is frequently inefficient. For example, the combination of unproductive perfectionism and rigidity may lead to difficulty in finishing a written report on time because of excessive correction and rewriting. Since this striving for perfection and order is time consuming, other areas of their lives often appear disorganized. One room or one desk drawer may fall into disarray, or parts of their social or family lives may be disorganized.
People with obsessive–compusive personality focus on work and productivity. It is difficult for them to take vacations or even to have free time. They do not enjoy leisure activity, which they may consider a waste of time. Often, they need to take work home to alleviate their anxiety. Hobbies and leisure pursuits become formally organized activities. They insist on perfect performance of sports or games and transform them into a serious task requiring careful organization and hard work. Leisure activities may be an unpleasant experience for the others involved, owing to the insistence on rules and standards.
Stubbornness is another characteristic of these people. They need things to be done in their way, and realistic arguments do not usually make them change their insistence. They need others to submit to their way of doing things, and often believe that no one can do the tasks as perfectly as they can. They give detailed instructions, insisting that their way is the only way of doing things, and are irritated if others suggest alternatives. Therefore, they generally insist in doing everything themselves and are unable to delegate, which increases their inefficiency at work. Paradoxically, their stubbornness is associated with doubt.
"Indecisiveness is a constant characteristic unless they have structured guidelines. They fear making mistakes or misjudgements, and delay repeatedly until they have enough data to take what they consider the only right decision. When rules do not dictate the correct answer to a problem or when procedures for tasks are not laid down, decision-making or task initiation may become a lengthy and painful process."
People with this personality disorder are characterized by excessive conscientiousness and scruples. They are inflexible about matters of morality, ethics, or values. Moral principles and standards of performance have to be followed rigidly, and respect for authority and rules is absolute. Failure to do these things leads to irritation, anger, and self-criticism.
These people are stingy and mean, and often live with standards far below their actual socio-economic status. They dislike spending, believing that money should be saved in case of future difficulties. They have great difficulty in discarding worn-out or worthless objects, believing that they might be useful some day. They may hoard objects such as newspapers or broken appliances, even when they have no sentimental value.
These people are humourless and lack spontaneity of emotional expression. Usually they do not express anger directly. However, they are often angry in situations in which they are unable to control the behaviour of themselves or others. Anger is generally manifested by indirect aggressive acts (such as leaving a small tip or not providing minor help when expected). Their management of anger is closely related to their attitude of dominance–submission toward authority figures. They may be excessively submissive to a person in authority whom they respect, but obstructive with an authority figure whom they do not respect.
The affect of the obsessive person is controlled and stilted. It is not flat or blunted, but constricted. They do not laugh or cry, and feel uncomfortable with people who express their feelings. Their mood is usually serious but may appear anxious or depressed. In a clinical interview they may sit in a stiff unnatural posture, and seldom make spontaneous comments about their emotions. They usually relate their history in a pedantic and circumstantial manner. If interrupted by a question from the doctor, they have to finish their monologue before answering. When asked about feelings, they answer with lists of facts and circumstances. They can label emotions and feelings, but are unable to display them.
In summary, obsessive personalities love order, neatness, and sameness, and hates novelty, spontaneity, and change. They need control, security, and certainty, and avoid creativity, art, and excitement. They mitigate anxiety by following strict rules and repress emotional expression by avoiding spontaneity. They fear their inner fragile and aggressive emotional world.
A girl aged 20yrs complains of headache while studying,vision is normal.all of the following should be further evaluated except.1) family history of headache.2)menstrual history 3) self worth 4) her interest in studies
Ans) 4) Her INTEREST IN STUDIES
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2408884/
Among psychological factors, anxiety, depression, HEADACHE BELIEFS AND COGNITIONS HAVE A role,
Self worth is type of headache belief cognition.
Remember generalised loss of interest leading to depression can lead to headache.
But lack of interest in studies would lead a person not studying, leaving studies or if still he complains to avoid studies, it lead us to consider malingering.
Conversion disorder in which headache occurs due to stressor is continuos and not at a time of stressor
See Headache is a bio-psychological symptom
Remember if you take studies as a stressor, leading to tension headache other stressors too should precipitate it.
No where i could get any pointer that lack of interest in studies could lead to headache
Family history of headache and menstrual history is a basic requirement in investigation of headache whether migraine or cluster headache.
These two are both common in females and occur in this age group. Although symptoms are not enough to make a specific diagnosis
Concepts: hypochondriasis , body dysmorphic disorder and how to distingush from delusional disorder (somatic type)
First DSM criteria for hypochondriasis and body dusmorphic disorder
300.7 Hypochondriasis
A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms.
B. The preoccupation persists despite appropriate medical evaluation and reassurance.
C. The belief in Criterion A is not of delusional intensity (as in delusional disorder, somatic type) and is not restricted to a circumscribed concern about appearance (as in body dysmorphic disorder).
D. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The duration of the disturbance is at least 6 months.
F. The preoccupation is not better accounted for by generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, a major depressive episode, separation anxiety, or another somatoform disorder.
Specify if:
With poor insight: if, for most of the time during the current episode, the person does not recognize that the concern about having a serious illness is excessive or unreasonable
300.7 Body dysmorphic disorder
A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.
B. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa).
Now coming to ICD criteria, both hypochondriasis and body dysmorphic disorder are together under hypochondriacal disorder
F45.2 Hypochondriacal disorder
A. Either of the following must be present:
A persistent belief, of at least 6 months' duration, of the presence of a maximum of two serious physical diseases (of which at least one must be specifically named by the patient).
A persistent preoccupation with a presumed deformity or disfigurement (body dysmorphic disorder).
B. Preoccupation with the belief and the symptoms causes persistent distress or interference with personal functioning in daily living and leads the patient to seek medical treatment or investigations (or equivalent help from local healers).
C. There is persistent refusal to accept medical reassurance that there is no physical cause for the symptoms or physical abnormality. (Short-term acceptance of such reassurance, i.e., for a few weeks during or immediately after investigations does not exclude this diagnosis.)
Clinical features of hypochondriasis
- Mainly in 3rd or 4th decade
-The preoccupation in hypochondriasis may be with bodily functions, minor physical abnormalities, or ambiguous physical sensations.
-The person attributes these symptoms or signs to a suspected disease and is concerned with their meaning and cause.
-The concerns may involve several body systems or may be about a specific organ or a single disease.
- Examinations, diagnostic tests, and reassurance from the physician do not generally reassure the hypochondriac, especially in chronic conditions and when these examinations and tests are conducted in a manner perceived as flippant by the patient.
-Thanatophobia (fear of death) is a central clinical feature of hypochondriasis and highlights the relationship to and embodiment of personality features.
-Hypochondriacs focus so much on their own body that there is a marked decrease of interest in other people or other matters outside of their body.
-manifests in inappropriate help seeking and attention to details of symptoms that are irrelevant to their overall health coupled with rejecting help for real health problems and inattention to adaptive health behaviors.
-
For example, a hypochondriac may be certain that he or she has heart disease, even when a reasonable evaluation is negative, yet he or she may ignore suggestions to prevent possible heart disease through exercise, a low-fat diet, and cholesterol-lowering medications.
-They are persistent seekers of explanations rather than of treatment, are largely unsatisfied with their medical care, and often feel that physicians have not recognized their needs.
Diffrential diagnosis
1. Medical student syndrome:transient preoccupation with the fear of having a disease (Most common diffential diagnosis)
2. Somatization disorder
-people with somatization disorder are more concerned with actual symptoms, have more abnormal personality characteristics and more depression and anxiety, and are more likely to seek treatment, whereas people with hypochondriasis are more afraid of death.
3. Body dysmorphic disorder
-people with body dysmorphic disorder focus on specific, presumed defects, are not as fearful of having a disease or of death, and are more likely to seek specific medical care, such as cosmetic surgery or dermatological advice.
4. Delusional disorder
- an individual with hypochondriacal delusions has a fixed, unfounded belief that a disease is present.
-Often have bizarre explanations for their belief or gross impairment of reality, or both, such as being convinced they have been poisoned, that their organs have somehow moved, or that someone or something outside of self has agency over their organs and health.
5. OCD
-although this bodily preoccupation in hypochondriasis is distressing, the patient believes that he or she has a disease, and, in that sense, the disease conviction is not ego-dystonic.
Treatment
1. Reassurance
2. Cognitive behaviour therapy
3. Pharmacological: SSRI's
1.A patient came with complaints of having a deformed nose and also complained that nobody takes him seriously because of deformity of his nose. He has visited several cosmetic surgeons but they have sent him back saying that there is nothing wrong with his nose. He is probably suffering from
Hypochondriasis
Somatisation
Delusional disorder
OCD
ANS) Ideal answer: Body dysmorphic disorder; if not there in choice hupochodriasis.
Points in favour of hypochondriasis:
-preoccupation with some minor anomaly in body.
- Chronic and persistent
3. Self- image disturbances (nobody takes me seriously, more commonly seen in body dysmorphic disorder) ( More suspiciosness than anxiety in delusional disorder)
4. Several visits to cosmetic surgeons ( Delusional disorders will fight and will not get reassured even transiently, will become suspicious of doctors)
Points against Delusional disorder
1. Belief not fixed, would force cosmetic surgeon to operate
2. Nosuspiciousness and attribution of deformioty to somebody
3. Bizarre or unrealistic explanation of etiology of deformity not there
Points against somatisation
- Only one symptom and one system
Points against OCD
- Egosyntonic in pt, not egodystonic
2. Lalu prasad, 45 year old male presents to OPD with complaints of continuos non-progressive headache from last 7 years. He believes that he has brain tumour for that he he is consulting many neurologists in past even though all investigations have been within normal limits. Pt requested for other investigation to reveal that he has brain tumour. The most probable diagnosis is
Hypochondriasis
Somatisation
Somatoform pain disorder
Conversion disorder
Ans) Hypochondriasis
Points in favour of hypochondriasis
1. Misinterpretation of a normal body function (misinterpretation as headache, no real organic cause of headache) leading to fear of a serious illness brain tumour on basis of misinterprated symptom headache
2. Request for multiple investigations
Points against somatisation
1. single symptom and system
Points against conversion
1. No neurological sensory or motor symptom( headache is a pain symptom)
2. No fear of serious illness in conversion disorder.
Points against somatoform pain disorder
1. No fear of serious illness in pain disorder ( complaints of only headache which is related to psychological stressors; if the question mentioned only headache with no fear of illness, it could have been the answer
3. Hypochondriasis is
Normal pre-occupation with abnormal body function
Abnormal preoccupation with abnormal body function
Normal preoccupation with normal body function
Abnormal preoccupation with normal body function
Ans) Abnormal preoccupation with normal body function
5. A 35-year-old male, with pre – morbid anxious traits and heavy smoker, believes that he has been suffering from ‘lung carcinoma’ for a year. No significant clinical finding is detected on examination and relevant investigations. He continues to stick to his belief despite evidence to the contary. In the process, he has spent a huge amount of money, time and energy in getting himself unduly investigated. He is most likely suffering from
a. Carcinoma lung
b. Delusional disorder
c. Hypochondriacal disorder
d. Malingering
Ans) Hypochondriasis
Points in favour of hypochondriasis
1. pre-morbid anxious traits ( increase the risk of somatoform disorders)
2. Heavy smoker ( predisposes fear of serious illness like lung cancer based on misinterpretation of symptom like cough)
3. Fear of serious illness
4.No significant clinical finding is detected on examination and relevant investigations.
5.He continues to stick to his belief despite evidence to the contrary ( Don' confuse this to delusion, read this line from otp
"Hypochondriasis is a preoccupation with the fear that one has, or may develop, serious disease despite evidence to the contrary. "
6.spent a huge amount of money, time and energy in getting himself unduly investigated.
Now contrast this to delusional disorder
1, Suspiciuos traits premorbidly
2. Would be firm that he has illness will not waste money in investigations
3. would have associated paranoia and suspiciousness on doctors and family members for giving wrong reports.
4. Would have other unrealistic and bizarre explanation for his illness.
Points against malingering
1. No overt monetary or legal gain present
5. A 41-year old married female presented with headache for the last six months. She had several consultations. All her investigations were found to be within normal limits. She still insists that there is something wrong in her head and seeks another consultation. The most likely diagnosis is
Phobia
Psychogenic headache
Hypochondriasis
Depression
Ans) Hypochondriasis
Points in favour of hypochondriasis
1. Fear of something wrong in head based on misinterprated symptom headache
2. No organic cause of headache found
3. Multiple consultations
Points against psychogenic headache
1. Concern not headache but something wrong in head (if question is like this" A 41-year old married female presented with headache for the last six months. She had several consultations. All her investigations were found to be within normal limits, she is sufferin from"
then psychogenic headache which is same as somatoform pain disorder would have been a better choice)
Points against phobia
1, No history of excessive fear of any specitic object or situation
posted by abhishek @ 2:32 AM
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