Neurological Presentations of Psychiatric Illness

Question 1

How does hysteria present?

Answer 1

• weeping
• hysterical laughing
• singing

Question 2

What is Somatization syndrome?

Answer 2

history of 2 years of complaints of multiple and variable physical symptoms not explained by physical disorders

• often refuse to believe there is no physical cause
• 6 or more symptoms from two or more systems

Question 3

What are the forms of somatoform disorders

Answer 3

• somatisation disorder
• hypochondriacal disorder
• somatoform pain disorder

Question 4

What are some of the common backgrounds of patients with somatoform disorders?

Answer 4

• family disregard psychological disorders
• illness behaviour main coping mechanism
• somatic complaints used to avoid difficult emotions

Question 5

What is the treatment for somatisation disorder?

Answer 5

GP explains:

1) Symptoms have no physical cause
2) explain we know symptoms are real but that there is no underlying physical disorder
3) patient self-management
4) legitimise the patients suffering

Question 6

How should the GP initially explain somatisation to a patient?

Answer 6

GP explains:

1) Symptoms have no physical cause
2) explain we know symptoms are real but that there is no underlying physical disorder
3) patient self-management
4) legitimise the patients suffering

Question 7

How can somatization be treated?

Answer 7

• discuss when symptoms may be triggered (exacerbating/relieving factors)
• have regular structured reviews of patient (to ensure they are reassured and reduce chance of them going to another clinician)
• avoid unnecessary invasive and diagnostic procedures
• check for anxiety or depression as often linked
• CBT (some evidence for SSRIs)

Question 8

What is hypochondriac disorder?

Answer 8

1) persistent belief of presence of maximum 2 serious disease or persistent preoccupation with presumed disfigurement of body
2) belief causes persistent distress and interference with daily living
3) refuse to accept medical advice that there is physically wrong

Question 9

What are the treatments for hypochondriacal disorder?

Answer 9

• CBT

- evidence for SSRIs (anti-depressants)

Question 10

What is pain disorder?

Answer 10

• pain that is not intentionally produced nor contrived

- can be underlying medical disorder but pain is amplified beyond what is expected

Question 11

What backgrounds is pain disorder more common in?

Answer 11

• drug misuse
• disability
• depression/anxiety
• often patients have seen lots of doctors

Question 12

How is pain disorder treated?

Answer 12

• treat underlying depression/anxiety
• SNRIs and TCA can help even if don’t have depression or anxiety
• avoid opiates
• create behavioural based treatment plan

Question 13

Dissociative disorder diagnostic criteria?

Answer 13

• no evidence of physical disorder that explains symptoms

- convincing association in time between symptoms of disorder and stressful events

Question 14

What is Ganser’s syndrome?

Answer 14

• often occurs in prisoners awaiting trial
• altered level of consciousness
• possible hallucinations
• understand questions but have obviously wrong answers

Question 15

What is Multiple personality disorder?

Answer 15

• background of significant trauma
• develop alternate personality in response to trauma
• can be multiple
• amnesia when their own personality is not present

Question 16

What factors are commonly seen in patients with dissociative disorders?

Answer 16

• variable presentation between different doctors
• tremor is variable
• severity alters with attention
• pain in dystonia (rare)
• speech: visible effort, stuttering and foreign accent

Question 17

How can a psychogenic and epileptic seizure be differentiated?

Answer 17

PNES 
- eyes closed resistance to opening 
- last longer than 2 min
- asynchronous limb movements and side to side head movements
- rapid reorientation 
- post ictal whispering 
(can confirm not epileptic by EEG)

Question 18

How does FND present in physical examination?

Answer 18

1) Hoovers sign in weak leg
2) drift without pronation of weak arm
3) tubular vision defect
4) tonic contractions of mouth with jaw and tongue deviation

Question 19

What are the psychological causes of dissociative disorder?

Answer 19

• traumatic life events
• higher rates of sexual abuse
• group learning illness is a coping mechanism

Question 20

What are the attentional causes of dissociative disorder?

Answer 20

• abnormal attention to body leads to abnormal perception of movement
• symptoms exacerbated if attention is on movements compared to when they are distracted

Question 21

How is dissociative disorder treated?

Answer 21

• explain diagnosis (validate disability, explain positive diagnostic tests)
• be optimistic
• treat any comorbidities
• CBT
• motor rehabilitation (physiotherapy, OT and speech therapy)

Question 22

What is neurasthenia?

Answer 22

• persistant and distressing complaints of feeling exhausted after minor mental effort
  + irritabile or muscle pains, dizziness, headache, inability to relax
• not recovered after normal periods of rest
• occurs more than 6 month

Question 23

What are functional somatic syndromes?

Answer 23

• classified in individual systems
• symptoms overlap between disorders
• high levels of psychiatric comorbidities
• often meet criteria of somatoform disorder

Question 24

What are common causes of functional somatic syndromes?

Answer 24

• personality disorders
• parental ill health
• can be precipitated by physical illness, stressful life events

Question 25

What are the treatments of FSS?

Answer 25

• intervention specific to system affected
• make patient aware of how underlying thoughts and behaviours impact body functioning
• physical therapy (especially for pain)
• SSRIs (esp IBS and fibromyalgia)
• avoid iatrogenic harm