Cases in psychiatry

Dr Mariam Ehab
Lecturer of Psychiatry
Agenda
 Signs and symptoms
 Psychosis
 Mood disorder
 Somatic Symptom and Related Disorders
 Substance use disorder
 Anxiety disorder
 Management in Psychiatry
 Emergency
 Neurocognitive
Signs and symptoms
 Perceptual disorder
 1- hallucination (auditory, visual, olfactory,
tactile and somatic )
 2- illusion
 3-derealization and depersonalization
Signs and symptoms
 Someone perceive the world is un real
is…..
 Someone hear voice out loud tell him
that he is an insect is…..
 Illusion is most commonly seen in ….
Signs and symptoms
Thinking disorder
 1- type (abstract, concrete)= proverb
 2- formal thought disorder
Loosening of association, incoherence , word salad,
verbigeration, clang association , perseveration
 3- stream of thought: fights of ideas , blocking,
circumstanyiality
 4- content: obsession and delusion
 5- control: thought reading, thought broadcasting,
thought insertion, thought withdrawal
Signs and symptoms
 Q:When there is no connection between ideas
and the only connection is the rhythm ….
 Q: the patient is convinced that he is the queen of
London and showed haughty attitude….
 Q: 24 years old came with her mother to
complain that the movie is talking about her and
the actress is broadcasting her ideas to people….
 Q the patient stopped eating and sleeping based
on the idea that he is not exist and the world is
not exist also…..
Signs and symptoms
 N.B Mood congruent delusion vs mood
incongruent delusions
 N.B obsession vs compulsion
Signs and symptoms
 Speech disorder
1. Poverty of speech
2. Voluability’
3. Pressure of speech
4. Mutism
5. Stuttering
6. Punnung
7. Echolalia
8. Dysartheria
9. aphasia
Signs and symptoms
 Mood disorder:
 Mood vs affect
 Mood  un-pleasant mood: depressive
dysphoric, anhedonia, and pleasant mood
euphoria , elation , ecstasy)
 Affect: constricted , blunt , flat ,
ambivalence, labile, inappropriate swing
Signs and symptoms
 Q: exaggerated and expansive mood is
seen mostly in ….
 Q: when the patient lose his pleasure,
interest and reactivity …
 Q: Coexistence of two opposing affects
or impulses toward the same object at
the same time….
Signs and symptoms
 Motor:
 Tics mannerism, stereotypy, psychomotor
retardation, agitation, excitement and
catatonia
 Catatonic symptoms includes:
all….catatonic rigidity, stupor, posturing,
excitement, waxy flexibility, negativism ,
automatic aubedience , echolalaia and
echopraxia.
Signs and symptoms
 Memory disorder:
1. Hyperamensia
2. Paramensia
3. Amnesia
 Attention disorder:
1. Distractability
2. Hyperprosexia
3. Selective attention
Signs and symptoms
Orientation
Consciousness
Judgment
Insight
Q: when we ask the patient to assess a social
situation we examined for ….
Q: patients with poor insight may suffer from …
Q: orientation , consciousness may disturbed in …
Q:cognitive dysfunction may occur in which
psychiatric disorder…
Psychotic disorder
Psychotic disorder
 Schizophrenia
 Brief psychotic disorder
 Schizophreniform
 Delusional disorder
Schizophrenia
 Def
 Epidemiology male = female
 Etiology : genetic , dopamine
 Clinically , types
 Management :
Hospitalization
ECT
Antipsychotic
psychosocial
Q:
 Q:Inability to keep still + unpleasant feelings of
inner tension…..
 Q chewing, sucking, abnormal mouth, and tounge
movement or choreo-athetoid movements of the
facial neck and hand muscles….
 Q:after administration of a drug the pt showed
Muscle rigidity (trunk, limbs, neck, and throat),
sweating and hyperthermia (check temperature),
autonomic instability: fluctuating pulse, BP and
respiration, akinesia, and clouding consciousness,
CPK was 1000….
 1- A 24-year-old man presents to casualty having got
into a fight as he thought he was being watched and felt
threatened. He appears to have fractured his thumb but
is reluctant to let you examine him or order an X-ray.
He looks suspicious and wary. When asked about his
concerns he says that over the last few months he has
been carefully monitored by government agencies. He
has been hearing a voice out loud giving a running
commentary on his thoughts and these are being
broadcast to the government. Any machine enables the
government to get inside his head and the voice is
telling him it would be unwise to face the X-ray
machine. The voice is not one that he recognizes, and it
is sometimes derogatory, telling him he is stupid for
giving his thoughts away for free.
 Initially the voice came and went but over the last
few weeks it is present almost constantly and he
cannot always sleep because even when he sleeps
the voice comments on what he is thinking. He is
exhausted. The man is absolutely convinced that
the government is after him but he cannot explain
why. There is no previous history and he denies
any substance use. Until a few weeks ago he had
been working as a kitchen assistant but was
sacked for leaving jobs unfinished. There is no
family history of any psychiatric illness
Q;
 Ahmed is a 28-year-old single man was
brought by his father to Emergency
Department with 7 months progressive
history of: 1. Talk to himself with giggling and
grimacing. 2. Staring at the roof of his room.
3. Over-suspiciousness (e.g. his family may
poison his food). 4. Agitation. Past history:
Several psychiatric hospitalizations because
of disturbed behavior and perception
(hearing non-existent distressing voices
commenting on his action).
Mood disorder
 Amal is a 27-year-old single woman works
as a teacher. She has a five-week history
of low mood, chest tightness, poor
appetite, disturbed sleep, excessive guilt
feelings, and loss of interest in her social
activities. Her father has a history of
mood (affective) disorder
Mood disorder
Depressive Disorders (DSM-5)
o Major Depressive Disorder, Single and Recurrent Episodes

o Persistent Depressive Disorder (dysthymic Disorder &

chronic major depressive disorder)

o Premenstrual Dysphoric Disorder

o Substance/Medication-Induced Depressive Disorder

o Depressive Disorder Due to Another Medical Condition

Mood disorder
 Bipolar and Related Disorders
(DSM-5)
o Bipolar I & II Disorders
o Cyclothymic Disorder
Rapid cycling bipolar
Mood disorder
Mood disorder
Mood disorder
 Antidepressant
Tricyclic and tetra cyclic (clomipramine,
impramine)
Selective-Serotonin- Reuptake Inhibitors
(SSRIs):
E.g. paroxetine (seroxat), fluoxetine (prozac),
citalopram (cipram), escitalopram (cipralex),
sertraline (lustral), fluvoxami
 Mood stabilizers lithum , antiepileptics
and antipsychotic
 2- At initial assessment, Sally complained of a 3-year
of low mood, tiredness, increasing tearfulness,
impaired concentration, poor sleep pattern, social
withdrawal and feelings of guilt, shame and failure. In
addition, she reported feeling tense and anxious at
times and experienced physical including dry mouth,
slight nausea and palpitations. Her eating was also
affected. Although these symptoms had been present
to varying degrees over the previous 3 years, they
had become worse in the preceding 6 months. For
the last 6–7 months she had felt progressively more
depressed. She expressed feeling down and low in her
mood with a distinct loss of confidence. No history of
any medical or substance. No prior evident stressor.
 3-The patient was in a complete healthy
state until 2 weeks before presenting to the
ER when he started to become overly
talkative and hyperactive, he was
overspending his money, had a decreased
need of sleep, and was spending the night
relentlessly fixing things around his house.
The patient started to become
uncharacteristically aggressive both verbally
and physically; as a result of an altercation,
his neighbor reported him to the police.
 The patient had also been driving
recklessly, complaining that there was a
camera installed to watch him, as well as
he mentioned that he heard a voice
advising him to do certain things. These
symptoms increased in intensity over the
week before admission.
Somatoform disorder
▪ Somatic Symptom Disorder

▪ Illness Anxiety Disorder (hypochondriasis)

▪ Conversion Disorder (Functional

Neurological Symptom Disorder)
▪ Psychological Factors Affecting Other
Medical Conditions

▪ Factitious Disorder
Somatization
 Features: Multiple somatic symptoms
(affecting multiple organ system) that cannot
be explained adequately based on physical
examination and laboratory investigations.
The symptoms are not intentionally
produced. The disorder is chronic. It is a
associated with excessive medical help-
seeking behavior. It leads to significant
distress and functional impairment (social,
occupational…).
 Epidemiology: Women > men.
Illness anxiety disorder
 Features: Intense prolonged over-concern and
preoccupation with physical health and/or
excessive worry about having a serious physical
disease (e.g. cancer, organ failure, AIDS, etc.). The
preoccupation persists in spite of medical
reassurance. It is not delusional in intensity. It
causes social or occupational dysfunction.
Associated Features:
 Doctor – shopping and deterioration in doctor-
patient relationships, with frustration and anger
on both sides.
Conversion disorder (functional
disorder
 Symptoms are related to the neurological system.
 Sensory: paraesthesia/partial blindness/deafness/...
 Motor: paralysis/paresis/aphonia/...
 Pseudoseizures and fainting: Pseudoseizures usually lack
a number of features of the true epileptic seizures e.g. aura,
cyanosis, physical consequences of seizure (tongue bite,
trauma, incontinence) and do not occur in sleep. EEG findings
are normal. Prolactin level usually increases within 3 hours of
a true seizure but not a pseudoseizure. Patient may be
unconcerned about his symptoms (denial of affect) this is
called “La belle indifference” or may also present in a
dramatic
 Q: 23 yrs old female lose her movement in right leg and arm
after her divorce. No evidence of any medical affection …
Somatic pain disorder (somatoform
)
 Q:Mr. Ziad is a 39- year-old man referred
to outpatient psychiatry clinic by a
cardiologist with several months’ history
of intense worries about serious heart
disease and fear of sudden death. He kept
asking the cardiologist to repeat ECG &
echocardiogram despite the normal
findings.
Substance use disorder
 Abuse: Self-administration of any substance
in a culturally disapproved manner that
causes adverse consequences.
 Intoxication: The transient effects (physical
and psychological) due to recent substance
ingestion, which disappear when the
substance is eliminated.
 Withdrawal: A group of symptoms and
signs occurring when a drug is withdrawn or
reduced in amount.
Substance use disorder
 Tolerance: The state in which the same amount of a drug
produces a decreased effect, so that increasingly larger doses must
be administered to obtain the effects observed with the original
use.
 Dependence: The physiological state of neuro-adaptation
produced by repeated administration of a drug, necessitating
continued administration to prevent the appearance of the
withdrawal state
 Addiction: A nonscientific term that implies dependence and
associated deterioration of physical and mental health as well as a
high tendency to relapse after discontinuation.
 Craving:
 General diagnostic criteria
 Types of substance : stimulatory vs inhibitory vs
hallucinogen
Substance use disorder
 Classification of substances:
 CNS depressants
 Alcohol
 Opiates
 Barbiturates
 Benzodiazepines
 CNS hallucinogens
 Cannabis
 LS D (Lysergic acid diethylamide)
 PCP (Phencyclidine)
 CNS stimulants
 Ephedrine
 Amphetamines
 Cocaine
 Ecstasy
Anxiety disorder
Anxiety Disorder
Treatment
 antidepressant
 Anxiolytics
 Psychotherapy: CBT , Behavioral
Q
Q
 Q:Mr. Jamal is a 28-year-old man presented with 3-
year history of disabling distress when talking to
important people. He would feel anxious, and his
voice would become so disturbed that he had
difficulty speaking.
 Q: Mr. Mazen is a 21-year-old college student who has
excessive fear and avoidance of injections and blood.
His sister Ms. Nuha, who is an 18-year-old, has
excessive fear and avoidance of darkness and
elevators
 Q Mr. Emad is a 38-year-old married man seen at
outpatient clinic for a 7-month history of persistent
disabling anxiety, irritability, muscle tension, and
disturbed sleep.
Q
 Ms. Maha is a 20-year-old college student seen at
outpatient clinic complaining of recurrent
intrusive thoughts about incomplete ablution,
bathing, and prayers. She spends 3- 4 hours/day
repeating prayers to feel fully satisfied and relaxed.
She realizes that her thoughts are silly but she
cannot resist them.
 Mr. Fahad is a 25-year-old man was injured in a
serious road traffic accident 3 months ago in
which he witnessed his friend dying. Two weeks
later he developed recurrent distressing feelings
of horror, bad dreams, and irritability.
Good luck
Thank you