Dear Dr Saleem Psychiatrist Hello Really a nice case for differential diagnosis n latest in management .....worth discussing from the above mentioned sign n symptom with history of treatment ... i would like to opine as Psychotic Depression .... because of presenting signs n symptoms .. along with the above medication i would like to keep her on Long acting antipsychotic .....preferably - flupenthixol or haloperidol - every 15 days ... to have a sustained concentration of anti psychotic in blood to prevent relapse. Then i would like to gradually reduce the oral medication .. in my experience they respond best to long acting antipsychotic n very well ... in addition after recovery .. i would like to add dietary supplement .. as supportive n then psychotherapy individual n family psychotherapy .... for further prevention of relapse ... n complete recovery till the return of premorbid personality. this is my experience of last 15 years with almost 1000 patient ... with very good results now a days i am using ....neurostimulation therapy RTMS n Ultra Brief Pulse therapy ..... under anesthesia ... which gives almost complete recovery in 15 days .... thanks for putting up nice case .
Sir... In this case the possibilities which I would like to strongly consider are complex partial seizures, treatment non adherence and psychosis breakthrough on antipsychotic maintenance medication (BAMM). Kindly rule out CPS. In my limited experience, I have many such cases ultimately turning out to be CPS and improvement with mood stabilizing anticonvulsant. Ask the relatives to get a video of such breakthrough episodes, do a EEG and if possible video EEG. Otherwise also, starting valproate will be good. Check for treatment adherence and if u consider BAMM as possibility, start on long acting antipsychotics and if depression is the problem, why not go for clozapine which has anti suicidal effects too...
Considering the worsening of symptoms... over time... and seriousness of yhe symptoms in view of suicide attempts and poor compliance ... following us suggested.. 1. ECT ... which will help in benefit over a very short time... reducing suicide ideation and allay psychotic ft.... This will help in acute mg... should be given atleast 6.. in nxt 3 wks. 2. Shift her on LAI.... uf olanzapine is acting good thn Olanzapine Pamoate... Otherwise Resprdn consta is quite effective. 3. No antidepressants at this stage... hwvr after ECT ... valproate can be added fr mood features and fluctations. 4. BZD during night xcpt on days prior to ect. Hope it is helpful
Consider alternate diagnosis like dissociative disorder. First rank symptoms are often seen as a part of dissociation. Or complex PSTD. Or Disorders of Extreme stress NOS (DESNOS) . Stressors invariably include abuse history. If not fitting, then maybe schizo-affective? Lithium/lamotrigine is often helpful (together with an atypical) esp given preponderance of depressive symptoms.
What is your opinion regarding e c t with anti psychotic as alternative treatment in this case?
Many times people try committing suicide when the depressive symptoms are improving not when they r fully depressed since they don't have the adequate energy for attempt although they have suicidal ideations. In this case may b he tried when he was mostly euthymic. As far as treatment concerned earlier answers sufficient Modified ECT most preferably Long acting psychotics
I think they r not pseudo but classical hallucinations. Olanzapine at 25 mg has very high sedation and I doubt how she was functional. Even a bzd add on was given so why not a mood stabilizer? Partially treated psychotic depression or schizoaffective disorder might be taken into view. I highly recommend ECTs for her acting out behaviour.
A question although... Hw r they qualifying as pseudo hall. Acting out on hallucination points to lack of insight.... so prob commanding hall. As fr dx... its a psychotic disorder.. prob qualifying as schiz. Pls also rule out organic contributing disorders with metabolic profile and ncct brain
Mood incongruent to thought Commanding Hallucination Suicidal attempt or whatever due to may be True Hallucination provisional diagnosis Schizophrenia.. ECT Should be given...Its a psychiatry emmergency case...
Command hallucinations and suicide with poor compliance, episodic .. probably schizo or schizoaffective.. mect and clozapine can be of use.. after acute management can consider adding mood stabiliser..
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#CAP2020 DSM 5 CRITERIA FOR ADHD:- People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development: Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level: Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities. Often has trouble holding attention on tasks or play activities. Often does not seem to listen when spoken to directly. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked). Often has trouble organizing tasks and activities. Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework). Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). Is often easily distracted Is often forgetful in daily activities. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level: Often fidgets with or taps hands or feet, or squirms in seat. Often leaves seat in situations when remaining seated is expected. Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless). Often unable to play or take part in leisure activities quietly. Is often “on the go” acting as if “driven by a motor”. Often talks excessively. Often blurts out an answer before a question has been completed. Often has trouble waiting his/her turn. Often interrupts or intrudes on others (e.g., butts into conversations or games) In addition, the following conditions must be met: Several inattentive or hyperactive-impulsive symptoms were present before age 12 years. Several symptoms are present in two or more setting, (e.g., at home, school or work; with friends or relatives; in other activities). There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning. The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). Based on the types of symptoms, three kinds (presentations) of ADHD can occur: Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months. Because symptoms can change over time, the presentation may change over time as well. REFERENCE(S) :- 1. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32279-7/fulltext 2. https://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_ADHD.pdf 3. https://www.ncbi.nlm.nih.gov/books/NBK223473/Dr. Jayita Tyagi2 Likes1 Answer
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14 year old girl brought with complaints of absent interactions with peers and teachers in school .Sitting eyes apparently closed inside class room .Not making eye contact with anyone. Deterioration in academic functioning also noticed. Decline started since four years which is gradual and interest in extracurricular activities is also coming down and absent now. Inside family atmosphere she functions well and takes initiatives to do outside trip to play areas,parks, cinemas. Irritability and occasional destructive behaviour also present inside house ,no change in biological functioning reported. Whenever her school mates visited her house she was in distress and there was irritability.Recently she seems to wear a scarf over head when she goes to outside house where there is likely to meet her school mates.Some excessive concern about cleanliness also noticed. Family history of depression in mother delusional disorder in father and suicide and substance use disorder in second degree relatives.Interpersonal issues between parents present. MSE revealed Poor but possible rapport, Slightly reduced range of affect, slightly reduced reactivity, low mood , sibling rivalry,no egodystonic distress regarding her problems also noticed.No hallucinations or delusion .No depressive or suicidal ideation. Unable to self appreciate fully her dysfunctions and unable to elaborate on reasons. physical examination nil significant.No history of abuse reported. How you proceed with the case ?Dr. Saleem Pallisserikuzhiyil1 Like22 Answers
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ORS previously included in Psychotic spectrum have been moved to the OC spectrum in DSM five. Olfactory Reference Syndrome with Suicidal Attempt Treated with Pimozide and Fluvoxamine ￼ Introduction The symptoms of Olfactory Reference Syndrome (ORS) were first described in a case series of 36 patients by Pryse-Phillips in 1971. Although published literature on the subject spans more than a century, areas of controversies persist in terms of the nosology and treatment of the disease. The core symptomatology of ORS is characterized by a preoccupation with the belief that one emits an offensive odor, which is not perceived by others. Other terms that have been used in literature to describe the disease include delusions of bromosis, hallucinations of smell, chronic olfactory paranoid syndrome, olfactory delusional syndrome, monosymptomatic hypochondriacal psychosis, olfactory delusional state, olfactory hallucinatory state, and autodysomophobia. The characterization of this syndrome has been a moving target; it appears in the DSM 5 under “Other Specified Obsessive-Compulsive Disorders” as well as under the “Glossary of Cultural Concepts of Disease,” as a variant of Taijin Kyofusho, a disease characterized by “anxiety about and avoidance of interpersonal situations, due to the thought, feeling, or conviction that one’s appearance and actions in social interactions are inadequate or offensive to others.” ORS was first categorized as an atypical somatoform disorder in the DSM-III and then as a delusional disorder in DSM-IV-TR and now under Other Specified Obsessive-Compulsive Disorders in DSM 5. The controversy surrounding its classification stems from the supposed preferential response of the condition to Selective Serotonin Reuptake Inhibitors (SSRIs) suggesting a possible associational overlap with Obsessive-Compulsive Spectrum Disorders and its very strong comorbidity with depressive disorders but, despite this preference, reports of the utility of antipsychotics such as Quetiapine, Risperidone, and Pimozide have also been reported in literature. The clinical course of ORS is chronic and debilitating for the patient and their families; although the clinical presentation may be confused with primary psychotic disorder, there is no clear evidence that this disorder leads to or is associated with schizophrenia. Pryse-Phillips, in his seminal paper, highlighted the importance of depression as the most common psychiatric comorbidity with ORS but other comorbidities have also been described in literature including bipolar disorder, personality disorders, schizophrenia, hypochondriasis, alcohol and substance use disorders, Obsessive-Compulsive Disorder (OCD), and body dysmorphic disorder. Case Report A case of a 75-year-old African American woman, widow, unemployed, and domiciled with a past medical history of hypertension, osteoarthritis, and asthma. The patient was brought to the Emergency Room by Emergency Medical Services (EMS) on account of an attempted suicide due to a 3-year history of “bad odor coming from my vagina.” The patient reported that the foul smell from her vagina was making her body “rotten.” She reported that “the smell came back recently and it is stronger.” Although she has been having the odor for the last 3 years, it has only recently gotten worse, the culmination of which resulted in her attempted suicide this time. She reported that she has seen several gynecologists who have treated her to no avail and later advised her to see a psychiatrist. She stated that there is a “devil” in her body that does not let go and she said, “I need help.” The patient has a significant impairment in social functioning evidenced by a reported avoidance of social events; she could no longer go out to the store for her basic needs; according to the patient’s son, she has also stopped going out to get groceries or to the church. She reported that she has been unable to have any romantic relationships because of her “odor.” The patient stays at home all day, showers several times daily, and has tried many vaginal products and creams but all in vain. Diagnosis At the time of initial evaluation, the patient appeared paranoid, reporting that people stayed away from her because of her smell. She also endorsed ideas of reference claiming that people around her cover their noses, stand next to windows, or look at her in “a certain way” and then talk about how much she “stinks” to each other. She endorses profound feelings of hopelessness, helplessness, and guilt and was tearful during the interview. Other symptoms reported were poor sleep, feeling less energetic, decrease in concentration, and anhedonia. She also endorsed active suicidal ideation, imagining waking up dead every morning due to her odor, and attempted to stab herself in order to “end my mystery” which led to this current admission. She also reported that she had lost up to 20 pounds in last 3 months. The patient was initially diagnosed with schizophrenia but later revised to Olfactory Reference Syndrome (ORS) in view of an extensive review of her symptoms and collateral information. Treatment The patient was admitted to the inpatient psychiatric unit and placed on 1: 1 constant observation for active suicidal ideation. Laboratory investigations including urine toxicology, liver function, urea, creatinine, electrolytes, and antinuclear antibodies, syphilis, and human immunodeficiency virus serology were all within normal limits or negative. She was started on Risperdal 2 mg PO twice daily for psychosis, Escitalopram 20 mg PO daily for depression, and Trazodone 50 mg PO HS for sleep. Neurological and gynecological consults were sought and the MRI of the brain obtained revealed no significant findings and was otherwise unremarkable. After a week, the patient’s delusions about her vaginal smell got even worse. She would not go outside of her room even for meals which were offered to her in the room because she thought that people could smell her vaginal odor. She also spent very long hours in the showers and demanded to take showers several times daily; her requests put a strain on the staff of the unit and on other patients who needed to use the same facilities. The patient’s medications were reviewed and she was started on Pimozide 1 mg PO twice daily and Fluvoxamine 25 mg PO daily based on the revision of her diagnosis to ORS. Risperdal, Citalopram, and Trazodone were discontinued. The patient made remarkable progress in the next few days. Pimozide was optimized to 2 mg PO twice daily and Fluvoxamine to 75 mg PO daily during the course of her hospitalization. She remained adherent with her medications and no side effects were noted. The patient and nursing staff agreed to a 70% symptomatic improvement in the patient’s symptoms; her affect was brighter; she was able to go outside of her room for meals and group therapy and socialize with other patients and staff. She became amenable to dissuasion regarding her previously held delusions and denied any depressive symptoms and no longer needed 1: 1 constant observation as she was no longer suicidal. She appeared future-oriented and motivated to go back home and resume her social life again. She was discharged back to her apartment and was provided with an outpatient appointment for aftercare. The team followed up with the patient patients several months after her discharge and she continued to maintain a remission of her symptoms. Discussion This patient believed that her vagina was emitting such a strong odor that she attempted to take her own life after 3 years of significant distress. Her belief was accompanied by ideas of reference; that is, she thought that other people took special notice of the odor in a negative way; she performed repetitive behaviors of multiple daily showers and use of vaginal washing soaps daily. Although not an official diagnostic criterion, our patient met the provisional criteria set by the DSM-5 Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group criteria for Olfactory Reference Syndrome : (A)Preoccupation exists with the belief that one emits a foul or offensive body odor, which is not perceived by others. (B)The preoccupation causes clinically significant distress (e.g., depressed mood, anxiety, and shame) or impairment in social, occupational, or other important areas of functioning. (C)The symptoms are not a symptom of schizophrenia or another psychotic disorder and are not owing to the direct physiological effects of a substance (e.g., drug abuse or medication) or a general medical condition. The comorbidity with Major Depressive Disorder in our patient is of particular significance. The importance of this comorbidity is well known and has been reported in the literature. In this case, our patient reported several symptoms suggestive of Major Depressive Disorder evidenced by her profound feeling of hopelessness and guilt; she has lost interest in everything; she reported insomnia and poor appetite with a significant amount of weight loss. All the patient’s symptoms, although rooted in the context of her perception that she was smelling, were nonetheless significant to the point that she attempted suicide. The use of Pimozide and SSRIs in the treatment of monosymptomatic hypochondriacal states has been consistently reported in the literature. The combination of these medications in the index case yielded excellent results. Although the reliability of the diagnostic criteria is not yet established and ORS is not a stand-alone diagnosis in the DSM-5, it merits consideration in patients who present with monosymptomatic hypochondriacal illnesses, as this diagnostic consideration may influence the treatment and eventually the potential course of the illness as with our patient who after three years of a distressing illness is currently in remission with proper treatment. Keywords Olfactory Reference Syndrome, suicide attempt, Pimozide, Fluvoxamine Author : Jegede, et al.Dr. Saleem Pallisserikuzhiyil9 Likes9 Answers
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Case 2: Identifying a Psychotic Disorder 2 simple slides explaining symptoms of psychosis. Treatment : Antipsychotics. Remember, Schizophrenia is a psychosis, but all psychosis is not schizophreniaDr. Sachin Arora15 Likes1 Answer
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Bi - Polar Disorder A person with bipolar disorder probably doesn’t fit the stereotype you have in mind. You might be surprised to learn that bipolar disorder isn’t just classified by out-of-control highs or suicidal lows. While these ups and downs certainly happen, there are also periods of normalcy mixed in on a regular basis. Another common misconception about people diagnosed with bipolar disorder is that they spend more time experiencing depression as opposed to mania. This is because people suffering from bipolar disorder are more likely to seek help when they are having a depressive episode than when having a manic episode. In fact, many people suffering from bipolar disorder keep their illness private for fear of judgment or punishment, especially in the workplace. What is bipolar disorder? Bipolar disorder, or “manic-depressive illness,” is a chronic mental illness. People with bipolar disorder often experience uncontrollable high and low moods known as mania and depression, respectively. A person’s medical history is important to accurately diagnose bipolar disorder because it is not a one-size-fits-all disease. People with depression only, also called “unipolar depression,” do not experience the highs and lows of mania. However, some people with depression may also experience some manic symptoms, this is known as “major depressive disorder.” The symptoms of bipolar disorder can also mimic those of other ailments, and people with bipolar disorder typically have another disorder or disease such as anxiety disorder, thyroid disease, migraines and headaches, so it can be hard for a doctor to make an accurate diagnosis. The condition can be controlled with self-management, a good treatment plan, and a high level of support. Four basic types of bipolar disorder Bipolar 1 Disorder Manic episodes lasting at least 7 days; or by symptoms so severe that the person needs immediate medical attention. Depressive episodes usually occur as well. Likely to experience depression along with the manic and depressive episodes. Bipolar II Disorder A distinct pattern of depressive and hypomaniac episodes, but not as severe as manic episodes experienced with Biopolar I. Cyclothymic Disorder Numerous periods of hypomaniac symptoms along with numerous periods of depressive symptoms lasting for at least 2 years in adults and 1 year in children and adolescents; however, the symptoms do not meet the diagnostic requirements for a hypomanic episode and a depressive episode. Other Specified and Unspecified Bipolar and Related Disorders Bipolar symptoms that do not match the criteria of Bipolar I, Bipolar II, or Cyclothymic Disorder. Mania is buying 3 new televisions on impulse; thinking you can buy your favorite restaurant; or deciding to run a 5K with no training–and insisting you will come in first. Hypomania is mania with a tether, and while it may lessen some of the financial and personal disasters sparked by unchecked mania, it can still feel like going the wrong way on a one-way road. What are the symptoms of bipolar disorder? Bipolar symptoms include extremely intense emotions/feelings, changes in activity level, disturbed sleep patterns, and other unusual behaviors. These tell-tale periods of symptoms are called “mood episodes.” To gauge the severity of a mood episode, one should compare the intensity of the attitudes and behaviors experienced during these unusual periods of time to what is typical and normal for that person. While jumping out of a moving car is not typical for most people, something like blabbering and talking fast may be normal for one person but not for another. Some people with bipolar disorder experience hypomania, a less severe form of mania. During a hypomania episode, a person may feel energized, productive, and euphoric — yet they may still feel in control. However, to others that know them well, the mood swings and fluctuations in attitudes and energy levels are very apparent and are a cause for concern. Without proper treatment, people with hypomania may develop severe mania and depression. A person with severe episodes may also experience psychotic symptoms which tend to match the extreme mood, e.g., hallucinations or delusions. A person having a manic episode may believe he is something he is not, e.g., rich or famous; while a person having a depressive episode may believe he is worthless or a failure. Sometimes a person with bipolar disorder who occasionally has psychotic symptoms may be misdiagnosed with schizophrenia. How is bipolar disorder diagnosed? No single cause has been identified for bipolar disorder. Scientists believe several factors may contribute to the illness, including genetics, stress, and the structure of the brain itself. It is important to talk to your healthcare professional(s). It is a good idea to get a complete physical and routine lab tests to rule out other conditions. If no obvious cause for the symptoms is found, a mental health professional, such as a psychiatrist who is experienced in diagnosing and treating bipolar disorder can perform a mental health evaluation. To be diagnosed with bipolar disorder, a person has to have had at least one episode of mania or hypomania. Bipolar disorder does not discriminate – it can affect anyone The average age of onset of bipolar disorder is 25. Every year, 2.9% of the U.S. population is diagnosed with bipolar disorder, with nearly 83% of cases being classified as severe. Bipolar disorder affects men and women equally. What is the treatment for bipolar disorder? Ironically, conventional drugs used to treat bipolar disorder are mostly psychotropic drugs that can induce more of the symptoms a sufferer is trying to beat, like anxiety, nervousness, impaired judgment, mania, hypomania, hallucinations, feelings of worthlessness, psychosis, and suicidal thoughts. Lithium is the best known medication for treating the disorder because it is a mood stabilizer and is effective in treating both mania and depression, as well as for preventing relapse. The bad news is that one-third of the patients who have taken lithium for over ten years have developed chronic renal failure from the drug, according to a study in the Journal of Psychopharmacology. Sometimes antidepressants are used to treat bipolar depression, but this can be controversial because of the possibility that an antidepressant can trigger a switch into mania. Behavioral or family focused therapies, as well as complementary health approaches such as meditation, faith and prayer, play a big part in developing self-management strategies for coping with bipolar disorder.Sushmita Haodijam4 Likes5 Answers