Professor Progress Test Psychiatry

Where is my mind?

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Psychiatry is a very interesting field with many nuances. Every patient has their own story and their own presentation; no two patients will ever be the same. This field which feels like you are practicing an art, with long conversation being your backdrop and flexible guidelines being your brushes. All pathology flows into each other and frequently you find yourself questioning if the person in front of you is truly mentally ill or the world is. While this might sound intimidating, you are in luck. Our health insurers do not care about these nuances and neither does the progress test. There is always only one right answer and it is neatly defined in the DSM-V. This makes it easier to give a short overview of some concepts often asked about in the Progress Test.

If you are not going into psychiatry then delirium is the disorder you will most likely see the most. That is because an ill person in a hospital is the perfect storm for developing delirium. A quick way to spot a case about delirium in the Progress Test is when an older person becomes confused in a hospital. Delirium is a disturbance in attention and awareness and a disturbance of cognition. The easiest way to spot the disturbance of attention and awareness is to try and have a conversation with the patient. They will have great difficulty focusing on the conversation and this is usually noticeable. Cognition is usually tested through checking if the patient knows where they are, what weekday it is and what the date is. You might look at these two symptoms and think: but could this not also be dementia? Well, yes and that is actually quite often the question for the physician dealing with this patient. The major difference is that delirium is temporary and has an acute start and usually only lasts a few hours or days. On the other hand, dementia is a slow and gradual process. Another discriminating factor is that delirium usually has a clear cause, for example illness or the starting or stopping of a drug. Other features commonly seen are visual hallucinations (insects crawling on bed or table, black cat), agitation (pulling out IV’s, climbing out of bed) and lowered consciousness (ranging from being a little drowsy to a comatose state). Since this is many things to remember I will now write an example short case which you could see in the Progress Test:

“A 76 year old woman in a nursing home is usually very easy to have a conversation with. As she develops a urinary tract infection she completely changes. It is very difficult to keep a conversation going with her and she does not know where she is and what day it is. She keeps touching the table and when asked why she says she can see the ants crawling on the table. Which psychiatric disorder is this most likely?” 

Of course it is not always this clearly presented. The core features, according to the famous book, are the disturbances of attention, awareness and cognition which have a biological cause and are present for a short period of time. 
As for how to treat it: the only correct way of curing delirium is by eliminating the cause of the delirium. Other factors to prevent/shorten the duration of delirium are making sure there is a clock clearly visible, having a clear daily structure, etc. The treatment of antipsychotics (haloperidol, risperidon, olanzapine) is primarily only there to help with the agitation caused by delirium. So a patient who is seeing many hallucinations will get the antipsychotic because they are visibly distressed. Another patient who is pulling out IV-tubes will also get the medication. Someone who is disoriented but otherwise fine will not get this medication.

Psychotic disorders
Schizophrenia, schizoaffective disorder, depression with psychotic symptoms, etc.; there are many different disease entities in the psychotic disorder group. The most famous of these is schizophrenia. Thing is, in the general public people seem to think that this is synonymous with split identities, while this is definitely not the case. 
Psychosis is when someone makes a break with reality which does not fit within a subculture (conspiracy theorists are not delusional). This can be in the form of persistent ideas which are not compatible with reality (delusions) and/or in the form of experiencing things that others cannot (hallucinations). If you paid attention, you might have noticed that hallucinations can be present in delirium. This means that this type of delirium can be classified as a psychosis. Another common example is the psychosis induced by a substance, usually, this is cocaine or cannabis. However, the list of substances which can cause psychosis is extensive and includes basically all recreational drugs and many pharmaceutical drugs (important is that symptoms have to disappear after one month of stopping the drug to be classified as this type of psychosis).
Of the primary psychiatric psychotic disorders, schizophrenia is the most common and the most well-known. It is also to describe the other disorders as compared to schizophrenia. There needs to be at least two of the following for a month: delusions, hallucinations, disorganized speech, disorganised or catatonic behaviour and negative symptoms. 

The delusions are often paranoid, grandiose and referential in nature. Having the idea that the government is tapping your phones or that you are being poisoned are examples of paranoid delusions. Being the reincarnation of Jesus or having magical powers are examples of grandiose delusions. Having the idea that people on Instagram that you do not know or newscasters are secretly communicating with you are examples of referential delusions. 

By far the most common type of hallucination in schizophrenia is auditory hallucination. A very common example is when a patient hears their neighbours talking to them. Often the things they hear are incorporated into the delusions. For example, the neighbours become the ones that are keeping track of them through microphones and cameras. Other auditory hallucinations can come in the form of voices, sometimes many. Some are benevolent, some are very critical and some give orders. However, the sound can be anything like clicking, music or machine noises. 

Disorganised thought and behaviour
When talking to a psychotic person it can be easy to recognise the disorganised thinking. There is no structure in stories, there is highly associative thinking and sometimes thinking just stops. 

Negative symptoms
Negative symptoms can easily be mistaken for depressive symptoms. There can be a loss of initiative, the absence of pleasure from things which previously made one happy (anhedonia), being expressionless, a lack of energy, etc. These symptoms can cause the most hindrance for patients. 

These symptoms are necessary for the diagnosis but more things are necessary. One important one is the loss of functioning socially and societaly. Usually there is steady but sure decline in functioning, for example, grades start dropping or someone loses their job and contact with those around them. To demonstrate a short case which could be found in the Progress Test:

“A 20 year old economics student has been getting worse grades the past semester. When he returns from a trip to Norway he starts talking about the Illuminati keeping an eye on him. They are listening through microphones planted through his room. He does not leave his room when he returns and spends most of his time playing video games while before his trip he preferred hanging out with his friends. Which psychiatric disorder is most likely based on this description?”

Treatment consists of antipsychotics, therapy and social support. The antipsychotics (olanzapine, aripiprazole, and haloperidol being often used) are most effective at treating the delusional and hallucinatory symptoms. The negative symptoms and disorganization can be resistant. A whole article can be written about all the treatment options, but this is just a short overview.

Now for a short overview of the other types of primary psychiatric disorders of psychosis. Schizoaffective disorder is schizophrenia with mood disorder symptoms fitting with depression or bipolar disorder. Not to be confused with depression with psychotic symptoms which differs in that the psychotic symptoms are consistent with the depressive symptoms. 

Brief psychotic episodes and schizophreniform disorder differ with schizophrenia primarily through the time component. A brief psychotic episode lasts less than a month, schizophreniform disorder lasts more than a month but less than six months and over six months is schizophrenia. 

A delusional disorder is schizophrenia when delusions are existent but other diagnostic criteria for schizophrenia are missing. For example, someone who is functioning fine and has no problems who is convinced that he is a cat reincarnated into a human.