Psychiatry - Symptoms and Signs Flashcards
2 types of delusions in severe mania with psychosis
Grandiose delusions
Persecutory delusions
Mania
Core symptoms Cognitive symptoms Biological symptoms Psychotic symptoms (in severe mania with psychosis) Risk
Core symptoms
• Elevated mood, energy, enjoyment
• Elated, excited, irritable, energetic, overactive, restless, talkative, rapid or pressured speech
• Labile mood (rapidly changing mood), including brief tearfulness and distress
• May take up new activities and make many acquaintances
Cognitive symptoms
• Loss of normal social inhibitions
• Elevated self-esteem and confidence
o Person feels more capable than usual
o Person thinks optimistically about the future, ignoring pitfalls of many ideas
• Flight of ideas or subjective activity of thoughts racing
• Thoughts and concentrations may feel clearer than before
o Objectively, they are distractable with poor concentration + racing thoughts which change topic rapidly (flight of ideas)
o Distractibility or constant changes in activity or plans
Biological symptoms
• Reduced need for sleep
• Increased appetite, but person may be “too busy” to eat
• Increased libido
Psychotic symptoms - In severe mania, Usually mood congruent but can be mood incongruent
• Delusions, hallucinations
Delusions
o Grandiose delusions – grandiose ideas become delusions // usually related to some form of identity or role e.g. special powers or religious content
o Persecutory delusions – suspicion may develop into well formed persecutory delusions
Hallucinations
o Auditory hallucinations of religious figures or celebrities instructing them or praising them
• Incomprehensible speech
o Pressured speech (speaking very fast and only stopping to breathe) – clear associations are lost hence cannot understand the resulting speech
• Self-neglect
o Preoccupation with their own thoughts and extravagant themes + distractibility –> self-neglect
• Catatonic behaviour
o Manic stupor
• Total loss of insight
Risk
• Impulsivity and disinhibition
• Risk taking without consideration of consequences -overspending, gambling, driving recklessly, drug and alcohol misuse
• Sexual disinhibition
• Irritability – verbal or physical aggression
• Self-harm and suicide in moments of sudden despair
• Illness or death from dehydration + physical exhaustion
Which is often the first symptom of mania?
Decreased need for sleep
Which are the 3 core symptoms of depression?
Low mood (may include irritability, anxiety, tearfulness) Anhedonia Lethargy/fatigue
2/3 core symptoms must be present for a dx of depression to be made (ICD-10) + last for at least 2 weeks
List some psychotic symptoms in severe depression with psychosis
• Psychotic symptoms – only present in severe depression, usually mood congruent but can also be mood incongruent (i.e. low mood will be reflected in the psychotic symptoms experienced)
o Delusions – nihilistic*, persecutory, guilt related, poverty, responsible for world events, deserving punishment
o Hallucinations – can occur in a range of modalities, 2nd person auditory hallucinations most common
Auditory – derogatory voices, cries for help or screaming
Olfactory – usually bad smells such as rotting flesh and faeces
Visual – demons, the devil, torturers, dead bodies
o Catatonic symptoms – group of symptoms that usually involve a lack of movement and communication and also include agitation, confusion, restlessness, psychomotor retardation
o Danger to life from suicide, dehydration, starvation
Cotard’s syndrome - believe that parts of their body are missing, or that they are dying, dead, or don’t exist. They may think nothing exists.y. One of the consequences of Cotard’s syndrome is self-starvation because of negation of existence of self.
Serotonin syndrome sx
Lethal in 0.1%
Pathological sx
agitation, confusion, coma
Neurological sx
Myoclonus, hypertonia, hyperreflexia, tremor
Autonomic sx
tachycardia, hypertension, hyperthermia, diaphoresis, mydriasis
Discontinuation syndrome sx
Discontinuation syndrome: GI sx Flu like sx Sweating Restlessness Problems sleeping Vivid dreams Unsteadiness Tinnitus Altered sensations (electric shock sensations in the head) Altered feelings (irritability, anxiety, confusion)
Core symptoms (first rank symptoms) of schizophrenia
o Persistent delusions
o Persistent hallucinations (mostly auditory)
Third person auditory hallucinations
Running commentary
Thought echo (gedankenlautwerden) – thoughts spoken aloud
o Thought disorder
Though insertion
Thought withdrawal
Thought broadcasting
o Experiences of influence, passivity or control
Control of the following by an external force: impulses, actions, feelings, somatic passivity (passive recipient of bodily sensations imposed from outside forces)
Schizophrenia
Symptoms of ARMS (at risk mental state) or prodromal period
For a period (perhaps lasting years) before “true symptoms” develop, the individual may show other symptoms such as:
• Period of very mild or brief psychotic symptoms
• Change in function (e.g. social withdrawal, loss of interest in activities, self-neglect)
• Mood symptoms (e.g. anxiety, depression)
Long prodromal period - delayed dx - poor prognosis
Typical picture: someone in their late teens/early twenties who’s dropped out of work or education after a period of increasing absence. Distant, isolating themselves in their bedroom without giving reasons. Deny psychotic symptoms for fear of their significant. Psychosocial treatment with CBT + family therapy is recommended
Positive symptoms of schizophrenia
• Positive symptoms – first rank symptoms:
o Delusions – often persecutory
o Hallucinations – most commonly auditory, hearing voices
Auditory hallucinations – most common symptom (second person: talking to the person third person: talking about a person, thought echo, running commentary, command hallucinations)
Auditory hallucinations in which the person talks to the voice they hear are most commonly a result of trauma or are fictious
Other hallucinations: visual, olfactory – most common in organic conditions, need to be medically investigated
o Passivity experiences
o Incongruity of affect, inappropriate emotional reactions – patient may burst out laughing or become very angry for no apparent reason
o Mannerisms – strange + pointless movements – repeated frequently, accompanied by a strange facial expression
• Formal thought + speech disorders
o Muddled thoughts disorganized speech
o Vagueness disjointed speech hard to follow, senseless
o Thought blocking – a sudden stop in the flow of thoughts, leading to silence
o Neologism – making up new words, give an existing word a new meaning that is only apparent to the individual and does not make sense. The keep repeating that word
o Word salad – the form of the sentences makes no sense at all. Words are mixed up, in the wrong place
o Flight of thought – patient moves quickly from one idea to another often half-way through a sentence – no apparent association between ideas
o Knight’s move thinking (aka Derailment) – patient moves from one idea to another with strange illogical associations between ideas
o Pressure of speech – patient talks at a faster rate than normal
o Circumstantiality – excessive long-windedness – patient takes forever to reach the point when they talk
• Behaviour
o Withdrawn, overactive or bizarre
• Psychotic episodes
o People may have a number of acute psychotic episodes over the years with full or partial recovery between relapses
Negative symptoms of schizophrenia
• Negative symptoms
o Avolition – general lack of interest in life, self-care, social activities, motivation
o Anhedonia
o Apathy
o Defects in attention control
o Blunted affect – decreased reactivity of mood, lack of emotion
o Social withdrawal
o Slowness of thought and movement
o Poverty of thought and speech
o Alogia – poverty of speech as a result of a general impoverished level of thinking – pt gives very short answers, will not voluntarily give input to a conversation, unable to elaborate on thoughts, feel as if their mind is empty
May manifest as: self-neglect, social isolation, inactivity, withdrawal
List Schneider’s first rank symptoms
• Delusional perception – a two stage process where a real perception in then interpreted with delusional meaning
o Not in keeping with the persons social, cultural or educational bc, for which there is no logical evidence basis
o During a psychotic episode, aberrant salience places excessive importance on neutral events and delusions result from jumping to conclusions to explain these effects
o Primary delusions – no apparent ppt event. Individual may enter a state of being perplexed for several days or months and as perplexity disappears, delusion develops
o Persistent delusions – arise with the period of perplexity. If other symptoms of schizophrenia are present dx for schizophrenia, no other symptoms of schizophrenia present ?delusional disorder
o Secondary delusions – arise when other symptoms of schizophrenia have been present for a period just before the delusion and arise from strange experiences the individual has as a result of their schizophrenia
• Auditory hallucinations
o Third person voices discussing or arguing about the person
May be single or multiple
Most common type of auditory hallucination in schizophrenia
Voices often critical of the individual
With treatment, these voices may not go away but they may become quieter or contain a more positive content
o Voices giving a running commentary of the person’s actions
o Thought echo – a voice says the person’s thoughts aloud either simultaneously or afterwards
• Thought interference – person believes that their thoughts are controlled by something/someone else. These delusions all share the subjective sense that something abnormal is happening in the usually private confines of someone’s head
o Thought insertion – believing that thoughts are placed directly into the person’s mind + these thoughts feel alien. This happens against the persons will.
o Thought withdrawal – believing that thoughts are taken from the person’s mind (there is a sudden feeling of loss), against their will
o Thought broadcasting – believing that thoughts are withdrawn, then publicly disseminated, so that others know what the person is thinking, against their will
• Passivity phenomena (delusions of control) – the belief that a movement, emotion, impulse is made or controlled by someone else – movement, emotion, impulse is alien and not originating from the person
List some other symptoms of schizophrenia
• Catatonia – a state where the person may not respond to stimuli + exhibits strange physical behaviour. The state may involve a particular movement or posture that a patient often performs. Examples of catatonia
o Stupor – pt unable to move/speak, only moves their eyes
o Strange postures
o Negativism – pt does exact opposite of what they are asked
o Automatic obedience
o Wavy flexibility – pt has a strange muscle tone – allows dr to put pt into physical position that would otherwise be very difficult and/or painful
- Depression, Anxiety
- Problems with memory (immediate and delayed recall, verbal and spatial memory)
- Attention (slowed cognitive speed)
- Problems with executive function (e.g. sequencing, organisation, switching set)
- Agitation
- Inappropriate eating behaviour
- Incontinence
- Self-harm
- Destruction of possessions
- Massive intake of water water intoxication hyponatraemia delirium, coma, death
• Post-psychotic depression prolonged depressive episode that occurs on resolution of psychosis. Can be distinguished from negative symptoms of schizophrenia bc:
o Schizophrenia – negative symptoms increase/decrease in conjunction with the severity of the positive symptoms
o Post-psychotic depression – depressive type symptoms do not change in concordance with any positive symptoms. Patient has a good degree of insight. Can be a result of neuroleptic medication
In schizophrenia there is lack of:
weight change
sleep problems
guilt/hopelessness/low self-worth
social withdrawal
e.g. delusion in depression “I am responsible for all the bad things”
delusion in schizophrenia “People want to harm me”
Neuroleptic malignant syndrome NMS symptoms
• Tetrad of symptoms
o Mental status changes – confusion, low GCS
o Muscular rigidity – severe “lead pipe” rigidity
o Autonomic instability – tachycardia, sweating, hypertensive, tremor
o Hyperthermia
- Dopaminergic blockade - extreme muscle rigidity - rhabdomyolysis - acute renal failure
- Depletion of dopamine in hypothalamus - increase temperature
GAD signs and symptoms
BESKINM: Blank mind, Easily fatigued, Sleep disturbance, Keyed Up/Restless/On Edge, Irritability, Muscle tension
- Persistent anxiety that is out of proportion to actual events or circumstances
- Apprehension – always feeling on edge
• Motor tension o Muscle stiffness o Muscular aches o Inability to relax o Restless o Tremor o Shakes o Tension headache
• Increased sympathetic activity o Tachycardia o Sweating o Mydriasis o Dizziness o Paraesthesia o Hot + cold spells o Frequent micturition o Diarrhoea o Nausea o Dry mouth
• Hypervigilance o Irritability o Insomnia o Trouble sleeping (cant get to sleep, only sleep for short periods) o Poor concentration
• Panic attacks
o A single panic attack is not diagnostic of an underlying anxiety disorder
• May present with somatisation of a single symptom
PTSD clinical presentation
• Clinical presentation of PTSD can be remembered by the mnemonic TRAUMA
o T – traumatic event – experienced, witnessed or was confronted and the person experienced intense helplessness, fear and horror
o R – Re-experiencing – intrusive thoughts, nightmares, flashbacks or traumatic memories/images
o A – avoidance – emotional numbing, detachment from others, flattening of affect, loss of interest, lack of motivation, persistent avoidance of things associated with the traumatic experience
o U – unable to function – symptoms can cause negative mood, distress or cause significant impairment in social, occupational and interpersonal life
o M – at least 1 month of symptoms
o A – arousal increased – insomnia, poor concentration, irritable, angry, startle reflex, hypervigilance
- Difficulty with regulation of emotion or keeping interpersonal relationships
- Dissociative symptoms
- Individuals engaged in high-risk activities – dangerous driving, excessive substance use, self-injurious behaviour
- Flashbacks – hearing, seeing, smelling the event as if it’s happening all over again
- Symptoms usually begin within the first 3 months after trauma
- The symptoms from PTSD must be linked temporally and conceptually to the traumatic exposure to qualify as PTSD symptom
- Symptoms precipitated by anniversaries of trauma
Describe the dissociative symptoms that might be seen in PTSD
o Depersonalization – persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g. feeling as though one were in a dream, feeling a sense of unreality of self or body or of time moving slowly)
o Derealization – persistent or recurrent experiences of unreality of surroundings (e.g. the world around the individual is experienced as unreal, dreamlike, distant or distorted
