EMQ part 3 Flashcards
Recommended max alcohol intake for men
?300mg, 250mg, 20g, 10mg/kg, 50g, 600mg, 100mcg, 20-30mg/kg, 100mg
20g
Thiamine dose in WE
?300mg, 250mg, 20g, 10mg/kg, 50g, 600mg, 100mcg, 20-30mg/kg, 100mg
300mg
Deja vu/jamais vu
?NA, mediobasal temporal lobe, amygdala, L inferior frontal cortex, superior parietal cortex, fusiform gyrus, R dorsolateral PFC, medulla oblongata, post superior temporal lobe, uncus
Mediobasal temporal lobe
Olfactory hallucinations
?NA, mediobasal temporal lobe, amygdala, L inferior frontal cortex, superior parietal cortex, fusiform gyrus, R dorsolateral PFC, medulla oblongata, post superior temporal lobe, uncus
Uncus- medial to parahippocampal gyrus
Part of limbic system
Common origin of TLE
Fear and aggression
?NA, mediobasal temporal lobe, amygdala, L inferior frontal cortex, superior parietal cortex, fusiform gyrus, R dorsolateral PFC, medulla oblongata, post superior temporal lobe, uncus
Amygdala
Depersonalisation disorder
?NA, mediobasal temporal lobe, amygdala, L inferior frontal cortex, superior parietal cortex, fusiform gyrus, R dorsolateral PFC, medulla oblongata, post superior temporal lobe, uncus
R dorsolateral PFC- increased alertness observed in depresonalisation results from n activation of prefrontal attentional systems and reciprocal inhibition of the anterior cingulate, leading to experiences of mind emptiness and indifference to pain often seen.
On the other harn, a L sided PFC mechanism would inhibit the amygdala resulting in dampened autonomic output, hypoemotionality and lack of emotional colouring that would, in turn, be reported as feelings of unreality or detachment.
Prosopagnosia
?NA, mediobasal temporal lobe, amygdala, L inferior frontal cortex, superior parietal cortex, fusiform gyrus, R dorsolateral PFC, medulla oblongata, post superior temporal lobe, uncus
Fusiform gyrus
Separation and individuation phase beings in accordance with Margaret Mahler
In Mahler’s theory, child development takes place in phases, each with several sub phases:
Normal autistic phase – First few weeks of life. The infant is detached and self-absorbed. Spends most of his/her time sleeping. Mahler later abandoned this phase, based on new findings from her infant research.[2] She believed it to be non-existent. The phase still appears in many books on her theories.
Normal symbiotic phase – Lasts until about 5 months of age. The child is now aware of his/her mother but there is not a sense of individuality. The infant and the mother are one, and there is a barrier between them and the rest of the world.
Separation–individuation phase – The arrival of this phase marks the end of the Normal Symbiotic Phase. Separation refers to the development of limits, the differentiation between the infant and the mother, whereas individuation refers to the development of the infant’s ego, sense of identity, and cognitive abilities. Mahler explains how a child with the age of a few months breaks out of an “autistic shell” into the world with human connections. This process, labeled separation–individuation, is divided into subphases, each with its own onset, outcomes and risks. The following subphases proceed in this order but overlap considerably
Hatching – first months. The infant ceases to be ignorant of the differentiation between him/her and the mother. “Rupture of the shell”. Increased alertness and interest for the outside world. Using the mother as a point of orientation.
Practicing – 9-about 16 months. Brought about by the infant’s ability to crawl and then walk freely, the infant begins to explore actively and becomes more distant from the mother. The child experiences himself still as one with his mother.
Rapprochement – 15–24 months. In this subphase, the infant once again becomes close to the mother. The child realizes that his physical mobility demonstrates psychic separateness from his mother. The toddler may become tentative, wanting his mother to be in sight so that, through eye contact and action, he can explore his world. The risk is that the mother will misread this need and respond with impatience or unavailability. This can lead to an anxious fear of abandonment in the toddler. A basic ‘mood predisposition’ may be established at this point. Rapprochement is divided into a few sub phases: Beginning – Motivated by a desire to share discoveries with the mother.
Crisis – Between staying with the mother, being emotionally close and being more independent and exploring.
Solution – Individual solutions are enabled by the development of language and the superego.
Disruptions in the fundamental process of separation–individuation can result in a disturbance in the ability to maintain a reliable sense of individual identity in adulthood
According to Freud this is the phase of development of the Electra complex
?3-6 mo, 1-5y, 24-36mo, 15-24 mo, 0-24mo, 2-3y, 2-10y, 7-11 y, 4-8y, 2-3y
3-6 y
- Oral 0-1
- Anal 1-3
- Phallic 3-6
- Latency 6-puberty
- Genital puberty->
Oedipus and electra (Jung) complex occur during phallic stage
Piaget’s stage of transductive reasoning
?3-6 mo, 1-5y, 24-36mo, 15-24 mo, 0-24mo, 2-3y, 2-10y, 7-11 y, 4-8y, 2-3y
2-4 y
Subset of pre-conceptual thinking phase of pre-operational
Faulty type of logic that involves making inferences from one specific to another.
Pre-operational phase of Piaget
?3-6 mo, 1-5y, 24-36mo, 15-24 mo, 0-24mo, 2-3y, 2-10y, 7-11 y, 4-8y, 2-3y
2-7 y
- preconceptual thinking
- intuitive thinking
Concrete operational phase
?3-6 mo, 1-5y, 24-36mo, 15-24 mo, 0-24mo, 2-3y, 2-10y, 7-11 y, 4-8y, 2-3y
7-11
Rules govern logic- reversibility, identity, compensation
classification
Object constancy according to Mahler
?3-6 mo, 1-5y, 24-36mo, 15-24 mo, 0-24mo, 2-3y, 2-10y, 7-11 y, 4-8y, 2-3y
24-36 months children begin to be more comfortable separating from their mothers
Antipsychotic not metabolised by the liver so preferred in patients with liver impairment
Amisulpride-> no dose adjustment needed
Haloperidol-> low dose can be used
Associated with persistent pulmonary hypertension of the newborn
?Paroxetine, fluvoxamine, haloperidol, amisulpride, lithium, dotheipin, valproate, sertraline, citalopram, olanzapine
Paroxetine-> 3 peer reviewed studies showed no increase in CV malformations
Safest choice of medication for mania in pregnancy
?Paroxetine, fluvoxamine, haloperidol, amisulpride, lithium, dotheipin, valproate, sertraline, citalopram, olanzapine
Haloperidol
TCA should be avoided in breastfeeding
?Paroxetine, fluvoxamine, haloperidol, amisulpride, lithium, dotheipin, valproate, sertraline, citalopram, olanzapine
Dotheipin
Antidepressant with the lowest milk/maternal plasma ratio
?Paroxetine, fluvoxamine, haloperidol, amisulpride, lithium, dotheipin, valproate, sertraline, citalopram, olanzapine
Sertraline
Has verbal and performance scales
?Halstead-Reitan, MMPI, Stanford-Binet, HAM-D, Wisconsin card sorting, Rorschack inkblot, Raven’s progressive matrices, Weschler adult intelligence, YBOCS, MADRS
WAIS
Projective test of personality
Halstead-Reitan, MMPI, Stanford-Binet, HAM-D, Wisconsin card sorting, Rorschack inkblot, Raven’s progressive matrices, Weschler adult intelligence, YBOCS, MADRS
Inkblot
Test of executive
Halstead-Reitan, MMPI, Stanford-Binet, HAM-D, Wisconsin card sorting, Rorschack inkblot, Raven’s progressive matrices, Weschler adult intelligence, YBOCS, MADRS
Wisconsin card sorting
Frontal lobe
Stroop test->Test of attentional conflict, measure disinhibition and set shifting
Tower of london and trail making test also test forntal lobe
Test of visio-spatial orientation
Halstead-Reitan, MMPI, Stanford-Binet, HAM-D, Wisconsin card sorting, Rorschack inkblot, Raven’s progressive matrices, Weschler adult intelligence, YBOCS, MADRS
Raven’s progressive matrices
10 clinical scales and 4 validity scales
Halstead-Reitan, MMPI, Stanford-Binet, HAM-D, Wisconsin card sorting, Rorschack inkblot, Raven’s progressive matrices, Weschler adult intelligence, YBOCS, MADRS
Minnesota Multiphasic Personality Inventory
Gestalt therapy
?Durkheim, Wilfred Bion, ENgel, Tyrer, Piaget, Irving Yalo, Klein, Fritz Perls, Adler, Minuchin
Fritz Perls
Differentiated types of suicide
?Durkheim, Wilfred Bion, ENgel, Tyrer, Piaget, Irving Yalo, Klein, Fritz Perls, Adler, Minuchin
Durkheim
Structural family therapy
?Durkheim, Wilfred Bion, ENgel, Tyrer, Piaget, Irving Yalo, Klein, Fritz Perls, Adler, Minuchin
Minunchin
Adaptation and assimilation
?Durkheim, Wilfred Bion, ENgel, Tyrer, Piaget, Irving Yalo, Klein, Fritz Perls, Adler, Minuchin
Piaget
Inferiority complex
?Durkheim, Wilfred Bion, ENgel, Tyrer, Piaget, Irving Yalo, Klein, Fritz Perls, Adler, Minuchin
Adler
34 yo treated with citalopram 40mg, recently prescribed pain medication for back
?Ataxia and confusion, fever and rigidity, flu like, sudden collapse in pt with fhx sudden death, tremors/myoclonus/confusion, agranulocytosis, increase i self harm, worsening of psoriasis, polydipsia and polyuria, chest pain/fever/SOB
Tremors/myoclonus/confusion-> tramadol + SSRI, suggest serotonin syndrome (hyperreflexia and myoclonus)
22 yo agitated Indigenous male given Zuclopenthixol acetate 200mg IMI
?Ataxia and confusion, fever and rigidity, flu like, sudden collapse in pt with fhx sudden death, tremors/myoclonus/confusion, agranulocytosis, increase i self harm, worsening of psoriasis, polydipsia and polyuria, chest pain/fever/SOB
Fever and rigidity-> NMS
Risks include young males, high potency and high dose neuroleptic, rapid increase, depot, prior episodes of agitation, dehydration, exhaustion, organic illness, recent episode catatonia
30 yo Caucasian F started on li within normal range
?Ataxia and confusion, fever and rigidity, flu like, sudden collapse in pt with fhx sudden death, tremors/myoclonus/confusion, agranulocytosis, increase i self harm, worsening of psoriasis, polydipsia and polyuria, chest pain/fever/SOB
Polyuria, polydipsia 50% patients. Worsening of psoriases is potential but less common
Overweight male started on Ziprasidone 80mg BD
?Ataxia and confusion, fever and rigidity, flu like, sudden collapse in pt with fhx sudden death, tremors/myoclonus/confusion, agranulocytosis, increase i self harm, worsening of psoriasis, polydipsia and polyuria, chest pain/fever/SOB
Sudden collapse. Ziprasidone and sertindole have high propensity to prolong QTc.
Risks: hypokalemia, female, hypomagnesemia, kidney/heart failure, or congenital predisposition.
A clinic is asked to be financially accountable and responsible
?clinical governance, corporate governance, equal opportunities, OHS, Aus council of health standards, Audit, roo cause analysis, discount rate, restraint of trade, impaired doctors program
Corporate governance
Quality improvement cycle
?clinical governance, corporate governance, equal opportunities, OHS, Aus council of health standards, Audit, roo cause analysis, discount rate, restraint of trade, impaired doctors program
Audit
RANZCP limit fellows so in demand and paid well
?clinical governance, corporate governance, equal opportunities, OHS, Aus council of health standards, Audit, roo cause analysis, discount rate, restraint of trade, impaired doctors program
Restraint of trade
Risk management tool in sentinel events
?clinical governance, corporate governance, equal opportunities, OHS, Aus council of health standards, Audit, roo cause analysis, discount rate, restraint of trade, impaired doctors program
Root cause analysis
Sharps management
?clinical governance, corporate governance, equal opportunities, OHS, Aus council of health standards, Audit, roo cause analysis, discount rate, restraint of trade, impaired doctors program
ohs
Error- falsely accepting the null hypothesis
Type 1 and 2 error
Type of regression analysis used in Kaplan-Meir curve
?Face validity, ordinal data, dichotomous datd, T1 error, Cox’s proportional hazards model, T2 error, confidence intervals, confounder, concurrent validity, dependent variable
Cox’s proportional hazards model.
Survival analysis in a graph called the Kaplan-Meir curve.
Time to event in modelling.
Used to assess the importance of various covariates in the survival times of individual objects through the hazard function. Hazard is the rate at which the events happen, so the probability of the event happening in a short interval is the length of time multiplied by the hazard . The hazard (proportion) in one group compared to the other is the Hazard ratio
A diagnostic test for depression compared with the HDRS
?Face validity, ordinal data, dichotomous datd, T1 error, Cox’s proportional hazards model, T2 error, confidence intervals, confounder, concurrent validity, dependent variable
Concurrent validity- type of criterion validity. Degree to which a new tool’s ability to measure a construct compares the best measure of that construct.
Second type is predictive validity, how well the test can be used to accurately predict outcome or other patient-related events.
Data which is used to calculate the odds ratio
?Face validity, ordinal data, dichotomous datd, T1 error, Cox’s proportional hazards model, T2 error, confidence intervals, confounder, concurrent validity, dependent variable
Dichotomous data
Variable that needs to be adjusted for in case control studies
?Face validity, ordinal data, dichotomous datd, T1 error, Cox’s proportional hazards model, T2 error, confidence intervals, confounder, concurrent validity, dependent variable
Confounder
Also known as covariate, independent/explanatory or predictor variable. Associated with exposure in question and can increase the risk of the outcome. Does not lie on causal pathway but is triangularly related to exposure and outcome. In the relationship between heart disease and smoking, alcohol is a confounder, as it is associated with smoking and increases the risk of heart disease.
Parametric test to investigate the difference between two groups for continuous data
?ANCOVA, log transformation, random effects analysis, Mann-Whitney U test, ANOVA, fixed effects analysis, multiple regression, Chi Square test, T test, Kruskal Wallis
T test
A non-parametric test for two groups in Mann-Whitney
For paired Wilcoxon Rank Sum Test (non parametric)
Non-parametric for 3 groups
?ANCOVA, log transformation, random effects analysis, Mann-Whitney U test, ANOVA, fixed effects analysis, multiple regression, Chi Square test, T test, Kruskal Wallis
Kruskal Wallis
Parametric type is ANOVA
Converting non-parametric to parametric
?ANCOVA, log transformation, random effects analysis, Mann-Whitney U test, ANOVA, fixed effects analysis, multiple regression, Chi Square test, T test, Kruskal Wallis
Log transformation
Researchers prefer to use parametric
A distribution free test to investigate significant difference between two groups
?ANCOVA, log transformation, random effects analysis, Mann-Whitney U test, ANOVA, fixed effects analysis, multiple regression, Chi Square test, T test, Kruskal Wallis
Chi square test-> detect difference for dichotomous or categorical data between two or more groups.
A fisher’s exact is used instead in the sample sizes are small.
If the value in any of the cells of a 2x2 table is less that 5, then Fisher’s exact may be more appropriate.
Preferred type of analysis to investigate heterogeneity in meta analysis
?ANCOVA, log transformation, random effects analysis, Mann-Whitney U test, ANOVA, fixed effects analysis, multiple regression, Chi Square test, T test, Kruskal Wallis
Random effects analysis
(Chi square, Galbraith plot and Cochrane Q test (I statistic) are all tests for heterogeneity)
Fixed-effect assumes subjects youre drawing measurements from are fixed, differences therefore not of interest. Random effects assumes measurements are some kind of random sample drawn from a larger population, and therefore variance between them is interesting and can tell you something interesting about them
In an RCT you wish to investigate if cannabis use differs between placebo and active treatment.
?ANCOVA, log transformation, random effects analysis, Mann-Whitney U test, ANOVA, fixed effects analysis, multiple regression, Chi Square test, T test, Kruskal Wallis
Chi Square
You wish to investigate the effects of age, sex and FHx in a cohort study investigating obstetric complications and schizophrenia
?ANCOVA, log transformation, random effects analysis, Mann-Whitney U test, ANOVA, fixed effects analysis, multiple regression, Chi Square test, T test, Kruskal Wallis
Multiple regressioin- Multiple independent variables and a dependent variable
Investigator wants to find out the median relapse rate of women who stop lithium during pregnancy
?ANCOVA, log transformation, random effects analysis, Mann-Whitney U test, ANOVA, fixed effects analysis, multiple regression, Chi Square test, T test, Kruskal Wallis
Survival analysis
Difference in ages (normally distributed) between depressed bipolar and schizophrenia patients
?ANCOVA, log transformation, random effects analysis, Mann-Whitney U test, ANOVA, fixed effects analysis, multiple regression, Chi Square test, T test, Kruskal Wallis
ANOVA
The process results in an increase in the probability of type 1 error
?ANCOVA, log transformation, random effects analysis, Mann-Whitney U test, ANOVA, fixed effects analysis, multiple regression, Chi Square test, T test, Kruskal Wallis
Multiple significant testing
Obtaining a false positive
Bonferroni correction should be performed to make the Pvalue more stringent to minimise risk of committing a type 1 error
Amisulpride
?M1 block, 5HT2:D2 antagonism and H1 block, M4 blockade, Alpha-1 block leading to first dose hypotensive effect, partial DA agonism, pre-synaptic D3 R block <400mg /day, M4 agonism, potent 5HT2C and H1 blockade, 5HT1A agonist and MOA RI, D2 block
Pre-synaptic D3 R block <400mg/day, autoR, thereby enhancing DA transmission, higher doses block post-synaptic, thus inhibiting hyperactviity.
Risperidone
?M1 block, 5HT2:D2 antagonism and H1 block, M4 blockade, Alpha-1 block leading to first dose hypotensive effect, partial DA agonism, pre-synaptic D3 R block <400mg /day, M4 agonism, potent 5HT2C and H1 blockade, 5HT1A agonist and MOA RI, D2 block
A1 blockade leading to first dose hypotension
Clozapine causing hypersalivation
?M1 block, 5HT2:D2 antagonism and H1 block, M4 blockade, Alpha-1 block leading to first dose hypotensive effect, partial DA agonism, pre-synaptic D3 R block <400mg /day, M4 agonism, potent 5HT2C and H1 blockade, 5HT1A agonist and MOA RI, D2 block
M4 agonism
Aripiprazole
?M1 block, 5HT2:D2 antagonism and H1 block, M4 blockade, Alpha-1 block leading to first dose hypotensive effect, partial DA agonism, pre-synaptic D3 R block <400mg /day, M4 agonism, potent 5HT2C and H1 blockade, 5HT1A agonist and MOA RI, D2 block
Partial DA agonism
Reduces high DA transmission, but increases low DA transmission
‘Dopamine’ Stabilisers
Ziprasidone
?M1 block, 5HT2:D2 antagonism and H1 block, M4 blockade, Alpha-1 block leading to first dose hypotensive effect, partial DA agonism, pre-synaptic D3 R block <400mg /day, M4 agonism, potent 5HT2C and H1 blockade, 5HT1A agonist and MOA RI, D2 block
5HT1A agonism and monoamine RI (serotonin and norepinephrine)
Suicide and schizophrenia
?alcohol misuse and dependence, young/single/drug alcohol/1 week after d/c, eccentric personality living alone with difficulties hearing, loneliness physical illness drug and alcohol male, diabetes organic brain smoking, high dose AP high potent AP organic disorder, obstetric complications cannabis and FHX, passivity phenomenon persecutory delusions command hallucinations, 50% FHx bipolar
Young male
Single
Drug and alcohol
1 week after discharge
Othello’s syndrome
?alcohol misuse and dependence, young/single/drug alcohol/1 week after d/c, eccentric personality living alone with difficulties hearing, loneliness physical illness drug and alcohol male, diabetes organic brain smoking, high dose AP high potent AP organic disorder, obstetric complications cannabis and FHX, passivity phenomenon persecutory delusions command hallucinations, 50% FHx bipolar
Alcohol use/dependence
Pathologic jealousy
Tardive kinesia
?alcohol misuse and dependence, young/single/drug alcohol/1 week after d/c, eccentric personality living alone with difficulties hearing, loneliness physical illness drug and alcohol male, diabetes organic brain smoking, high dose AP high potent AP organic disorder, obstetric complications cannabis and FHX, passivity phenomenon persecutory delusions command hallucinations, 50% FHx bipolar
Diabetes, organic brain disorder, smoking
Risk factors: diabetes, typical, organic neurological, female, affective disorders smoking
Late onset schizophrenia
?alcohol misuse and dependence, young/single/drug alcohol/1 week after d/c, eccentric personality living alone with difficulties hearing, loneliness physical illness drug and alcohol male, diabetes organic brain smoking, high dose AP high potent AP organic disorder, obstetric complications cannabis and FHX, passivity phenomenon persecutory delusions command hallucinations, 50% FHx bipolar
Eccentric, living alone, hearing impairment.
Partition delusions, sensory deficits, multimodal hallucinations, eccentric, absence of FHx, absence of thought disorder
Risks for Post partum psychosis: peurpleural psychosis, hx bipolar, fhx bipolar
Odd, purposeful movements that are goal directed
?verbigeration perseveration, paraphasia rigidity, stereotypies, waxy flexibility, mannerisms, withdrawal, gegenhalten, ambitendency
Mannerisms
Non goal are stereoypies
Repetition of meaningless phrases and sentences
?verbigeration perseveration, paraphasia rigidity, stereotypies, waxy flexibility, mannerisms, withdrawal, gegenhalten, ambitendency
Verbigeration
Body of patient can be put into any posture, pt can maintain for prolonged period despite being uncomfortable ?verbigeration perseveration, paraphasia rigidity, stereotypies, waxy flexibility, mannerisms, withdrawal, gegenhalten, ambitendency
Waxy flexibility
Negativism such that the patient resists any attempt by the examiner to move them ?verbigeration perseveration, paraphasia rigidity, stereotypies, waxy flexibility, mannerisms, withdrawal, gegenhalten, ambitendency
Gengenhalten negativism
Akathisia, management
?BB, benztropine, benzo, ECT, stop AP, stop anti-cholinergic, no treat cont monitor, dantrolene, decrease dose, increase dose
Decrease dose first line
Bradyphrenia
?BB, benztropine, benzo, ECT, stop AP, stop anti-cholinergic, no treat cont monitor, dantrolene, decrease dose, increase dose
Decrease dose
Autonomic instability, rigidity and fever
?BB, benztropine, benzo, ECT, stop AP, stop anti-cholinergic, no treat cont monitor, dantrolene, decrease dose, increase dose
Stop AP
NMS, mortality ~20%
Bromocriptine and Dantrolene also used
Tachycardia with clozapine
?BB, benztropine, benzo, ECT, stop AP, stop anti-cholinergic, no treat cont monitor, dantrolene, decrease dose, increase dose
No treatment, continue monitoring
Gertsman syndrome ?Shy drager, PSP, Parkinson’s, Post cerebellar artery infarct, parietal lobe infarct, MS, prog multifocal leukoencephalopathy, meningitis, sub-acute combined degeneration of the spinal cord
Parietal lobe- dominant
Finger agnosia, R/L disorientation, dyscalculia, dysgraphia
L’hermittes sign
?Shy drager, PSP, Parkinson’s, Post cerebellar artery infarct, parietal lobe infarct, MS, prog multifocal leukoencephalopathy, meningitis, sub-acute combined degeneration of the spinal cord, Sub acute pan encephalitis
MS
“electric shock” sensation that passes down back into arms and legs when you move or flex the neck
Dysdiadokinesis
?Shy drager, PSP, Parkinson’s, Post cerebellar artery infarct, parietal lobe infarct, MS, prog multifocal leukoencephalopathy, meningitis, sub-acute combined degeneration of the spinal cord
Posterior cerebellar artery infarct
32 yo F presenting with wt gain, muscular atrophy, acne, hair growth on chil w/ abdominal striae
?oligoclonal bands in CSF, tonsillar biopsy, TFTs, SPECT, urea and electrolytes, synacthen test, EEG, CSF 14-3-3 protein, dexamethasone suppression test positive, VDRL
Dexamethasone
muscular atrophy distunguishes it from PCOS (orange and sticks sign)
40 yo with depression who is thought to be developing Alzheimer’s
?oligoclonal bands in CSF, tonsillar biopsy, TFTs, SPECT, urea and electrolytes, synacthen test, EEG, CSF 14-3-3 protein, dexamethasone suppression test positive, VDRL
Tonsillar biopsy- variant CJD can present in this manner
35yo F with sudden onset blindness in L eye
?oligoclonal bands in CSF, tonsillar biopsy, TFTs, SPECT, urea and electrolytes, synacthen test, EEG, CSF 14-3-3 protein, dexamethasone suppression test positive, VDRL
Oligoclonal bands in CF IgG unique to the CSF , not in serum. Part of diagnostic workup for MS
20 yo M with hyperpigmentation of oral mucosa, hypotension and elevated serum potassium
?oligoclonal bands in CSF, tonsillar biopsy, TFTs, SPECT, urea and electrolytes, synacthen test, EEG, CSF 14-3-3 protein, dexamethasone suppression test positive, VDRL
Hyperpigmentation occurs in primary hypoadrenalism.
When I hear the train go by, I hear someone talking to me
?Gedankenlautwerden, synasthesia, hypnagogic hallucinations, hygric hallucinations, extracampine hallucinations, oneroid state, hypnapompic hallucinations, reflex hallucinations, functional hallucinations, haptic hallucinations
Functional- generated in the presence of unrelated external stimuli of the same modality
Reflex hallucinations- perception in one modality produces a hallucination in another- seeing a doctor writing and feeling it on one’s skin
I hear the CIA talking to me from their headquaters in the USA
?Gedankenlautwerden, synasthesia, hypnagogic hallucinations, hygric hallucinations, extracampine hallucinations, oneroid state, hypnapompic hallucinations, reflex hallucinations, functional hallucinations, haptic hallucinations
Extracampine- experienced outside the normal sensory field
I hear my thoughts spoken aloud
?Gedankenlautwerden, synasthesia, hypnagogic hallucinations, hygric hallucinations, extracampine hallucinations, oneroid state, hypnapompic hallucinations, reflex hallucinations, functional hallucinations, haptic hallucinations
Gedankenlaytwerden or echo de la pensees
I heard my teacher’s voice when I was going to sleep
?Gedankenlautwerden, synasthesia, hypnagogic hallucinations, hygric hallucinations, extracampine hallucinations, oneroid state, hypnapompic hallucinations, reflex hallucinations, functional hallucinations, haptic hallucinations
Hypnagogic
I went to the trance party and I tell you “I could smell the music”
Synsasthesia Pareidolia- vivid mental images occuring without conscious effort when perceiving ill defined stimuli
Oneroid state implies dream like state with intense psychopathological experiences
Palinopsia- reappearance of maerial just perceived. Image persists despite corresponding stimuli gone
Gerard 55, sudden onset bizzare behaviour. Pacing throughout the day, difficulty sleeping. Cannabis for 10 years. Hearing voices of little soldiers talking to him, and seeing then. Paranoid soldiers are out to get him
?akathisia, cannabis withdrawal, agitated depression, ekboms, hypomania, ECT induced akathisia, delirium, chronic akathisia, stereotypy
Delirium
64 yo M GAD, despiramine 100mg nocte. Referred for restlessness at night. Irritation both legs. Confined to in bed, eased by leg movements. Wife in separate bed. Significant STM loss, loss of spontaneous thinking and general knolwedge
?akathisia, cannabis withdrawal, agitated depression, ekboms, hypomania, ECT induced akathisia, delirium, chronic akathisia, stereotypy
Ekboms- AKA RLS
80 yo M, ix for upper gastro discomfort
Referred for “compulsion to pace”
meds are omeprazole and metoclopramide
no impaired orientation/attention, memory/general knowledge/word finding poor. Hypochromic, microcytic anemia.
?akathisia, cannabis withdrawal, agitated depression, ekboms, hypomania, ECT induced akathisia, delirium, chronic akathisia, stereotypy
Akathisia- drug induced. Associated with EPSEs- dystonic reactions akathisia
Therapist interprets patient’s statement but is off the mark. Patient responds with dismay. Therapist interprets this as defenciveness. Patient responds with anger. Therapist understands this as confirmation that his initial interpretation was correct.
?countertransference, persecutory spiral, erotic countertransference, splitting, transference, twinship transference, identification with the aggressor, displacement, dissociation, flight into health
Persecutory spiral
Patient anxious about colonoscopy. Strong FHx bowel Ca. Patient spends more of session telling therapist how irritated she is with the schoolboys who cut all the tops of agapanthis flowers in her suburb again
?countertransference, persecutory spiral, erotic countertransference, splitting, transference, twinship transference, identification with the aggressor, displacement, dissociation, flight into health
Displacement
Patient has begun wearing more stylish and formal clothes over the past few sessions. Therapist becomes aware that he prefers to wear his favourite ties and best shoes when the patient’s therapy days come around
?countertransference, persecutory spiral, erotic countertransference, splitting, transference, twinship transference, identification with the aggressor, displacement, dissociation, flight into health
Erotic countertransference
Patient experiences losing his temper with his children and punishing then. He feels out of control and has a powerful sense of “being in the right” Therapist wonder whether this is like the times when patient has received abuse from his own drunken father
?countertransference, persecutory spiral, erotic countertransference, splitting, transference, twinship transference, identification with the aggressor, displacement, dissociation, flight into health
Identification with the aggressor
Antonia is a man in his later sixties who has been referred for assessment of a possible dementia. Antonio’s main complaints are falling when negotiating stairs or steps and memory problems. Diplopia on downward gaze, unsteady gait, mild bradykinesia
Depression cannot be excluded
?transient global amnesia, Korsakoff’s, Shy Drager, Parkinson’s, Binswangers, Frontal lobe syndrome, huntington’s, Hemiballismus, CJ, PSP
PSP
53 yo profession, rehab following stroke. Psych r/v because exposing self to staff and patients. Wandering at night and sleeping during the day. Hygeine severely impaired.
?transient global amnesia, Korsakoff’s, Shy Drager, Parkinson’s, Binswangers, Frontal lobe syndrome, huntington’s, Hemiballismus, CJ, PSP
Frontal lobe syndrome (likely involving orbitofrontal area)
67 assumed progressive dementia AD, managed at home on psychtropic. Now has definite myoclonic jerks of legs, are, severe if surprised
?transient global amnesia, Korsakoff’s, Shy Drager, Parkinson’s, Binswangers, Frontal lobe syndrome, huntington’s, Hemiballismus, CJ, PSP
CJD
46 yo mother 4, stressed home. Sudden onset severe memory impairment. Disorientated to recent events, but performs reasonable well on tests of general knowledge, no other cortical or focal neurological signs
?transient global amnesia, Korsakoff’s, Shy Drager, Parkinson’s, Binswangers, Frontal lobe syndrome, huntington’s, Hemiballismus, CJ, PSP
Transient global amnesia
76 yo F, PD 10 years. Anti-PD treatment resulting in hallucinations and paranoid ideation. Managed by neurologist adjusting meds. Haloperidol 1mg. Now described interm dizziness on occasionas resulting in falls. Urinary incontinence. PE shows postural hypotension.
?transient global amnesia, Korsakoff’s, Shy Drager, Parkinson’s, Binswangers, Frontal lobe syndrome, huntington’s, Hemiballismus, CJ, PSP
Shy Drager- part of parkinson’s plus syndrome. Multi system atrophy. Autonomic involvement, bladder involvement and features of PD are clues.
A young man suffering from treatment resistant schizophrenia has a history of NMS with exposure to haloperidol. Full neuro workup. Commenced on Clozapine, single grand mal on day 5. No history of epilepsy.
?reduce dose, reassure r/v 1 week, reassure daily monitoring, urgent Li level, commence anticholinergic, transfer ED, neuro consult, commence mood stab, cessation of meds.
Cease medication
middle age on SSRI for depression, Returns day 3 intense agitation, difficulty sleeping. Abating
?reduce dose, reassure r/v 1 week, reassure daily monitoring, urgent Li level, commence anticholinergic, transfer ED, neuro consult, commence mood stab, cessation of meds.
Reassure, review in a week
Man PSCZ clozapine in open rehab/. 900mg / day, no improvement
?reduce dose, reassure r/v 1 week, reassure daily monitoring, urgent Li level, commence anticholinergic, transfer ED, neuro consult, commence mood stab, cessation of meds, check cloz level
Check cloz level
Diabetic elderly man recurrent unipolar MDD maintained on antidepressant and Li. Home visit has confusion, diarrhea, myoclonus. Hx UTI
?reduce dose, reassure r/v 1 week, reassure daily monitoring, urgent Li level, commence anticholinergic, transfer ED, neuro consult, commence mood stab, cessation of meds.
Immediate t/f to ED
Depot haloP, presents with torticollis
?reduce dose, reassure r/v 1 week, reassure daily monitoring, urgent Li level, commence anticholinergic, transfer ED, neuro consult, commence mood stab, cessation of meds.
Start an anticholinergic agent
Pt offered hand to shake, put out harm, then withdrew it, then extended and repeated this 23 time in succession until hand came to rest touhing examiner’s hand.
?automatic obedience, ambitendency, mitmachen, stupor, echopraxia, catalepsy, posturing, cataplexy, waxy flexibility, mitgehen
Ambitendency- alternating cooperation and opposition
examiner touched back of patient’s forearm with little finger, arm moved up and with continued touching, patient’s upper arm stayed at shoulder level ad arm flexed at elbow
?automatic obedience, ambitendency, mitmachen, stupor, echopraxia, catalepsy, posturing, cataplexy, waxy flexibility, mitgehen
Mitgehen extreme form of mitmachen in which slight pressure leads to movement in any direction, “angelpoise” effect, despit being told to resist the pressure. Often associated with forced grasping. Mitmachen- form of automatic obedience, body can be put in any posture, despite instructions to resist. Often lib comes back to original position. Cf waxy flexibility, where posture is held for long periods.
muscle tone uniformly increased. Limbs placed in any position, held for at least 10 minutes, regardless of how uncomfortable it is
?automatic obedience, ambitendency, mitmachen, stupor, echopraxia, catalepsy, posturing, cataplexy, waxy flexibility, mitgehen
waxy flexibility
