What is somatisation disorder (Briquet’ syndrome)
- > multiple physical SYMPTOMS present for at least 2 years
- > many negative investigations or fruitless exploratory operations
- > patient refuses to accept reassurance or negative test results
what is illness anxiety disorder (hypochondriasis)
persistent belief in the presence of at least 2 serious physical disease (one specifically named by the pt) - 6 months durations
- > preoccupation with the belief that the Sx
- > pt again refuses to accept reassurance or negative test results
what is conversion disorder
- > typically involves loss of motor or sensory function
- > pt does not consciously feign the Sx (factitious disorder) or seek material gain (malingering)
- > pts may be indifferent to their apparent disorder - la belle indifference
what is dissociative disorder
separating off certain memories from normla consciousness
- involves psychiatric Sx
what is factitious disorder
munchausen
- intentional prod of physical or psychological Sx
what is malingering
fradulent stimulation or exaggeration of Sx with the intention of financial or other gain
what is hoover sign
clinical tool to differentiate organic from non-organic leg paresis. In organic paresis, the contralateral leg will contract due to involuntary hip extension when attempt is made to lift paralysed leg. In non-organic (e.g. conversion disorder) no contralateral contraction is felt
what is conversion disorder
presence of persistent neurological symptoms in the absence of detectable structural damage.
RFs of conversion disorder
Female sex
Young-middle age
Psychiatric history
5 stages of grief
- Denial: this may include a feeling of numbness and also pseudohallucinations of the deceased, both auditory and visual. Occasionally people may focus on physical objects that remind them of their loved one or even prepare meals for them
- Anger: this is commonly directed against other family members and medical professionals
- Bargaining
- Depression
- Acceptance
what is atypical grief
- > delayed grief: sometimes said to occur when more than 2 weeks passes before grieving begins
- > prolonged grief: difficult to define. Normal grief reactions may take up to and beyond 12 months
What may be more suggestive of pseudoseizures (or dissociative seizures) on both history and examination than seizures?
- Asynchronous limb movements – often bizarre
- Resisting attempts to open eyes
- Protective/avoidance behaviour – i.e. patient doesn’t sustain injuries
- Emotional trigger for event e.g. happens during argument.
- No post-ictal period (generalised seizure often lengthy recovery)
- Patient able to recall what happened during the actual seizure.
- Tongue biting and incontinence very rare
- Prolonged seizure >3 mins
Testing for what in a blood test may strengthen your belief that this is a pseudoseizure?
• Prolactin – this is not diagnostic of a seizure, however prolactin is often released during a seizure and therefore higher levels are detected in the first 2 hours post-seizure. This would not be the case in pseudoseizures.
NB – the evidence base for this is not the strongest, but it may help in cases of uncertainty.
factitious v malingering
• In factitious disorder a patient will feign symptoms (intentionally) but with no clear secondary gain other than to achieve the sick role and therefore care. Again…..it is difficult to prove intentionality, however, it can be speculated.
define insomnia
difficulty initiating or maintaining sleep, or early-morning awakening that leads to dissatisfaction with sleep quantity or quality.
define chronic insomnia
diagnosed if a person has trouble falling asleep or staying asleep at least three nights per week for 3 months or longer
features of insomnia
decreased daytime functioning, decreased periods of sleep (delayed sleep onset or awakening in the night) or increased accidents due to poor concentration
features ass with insomnia
other risk factors
Female gender Increased age Lower educational attainment Unemployment Economic inactivity Widowed, divorced, or separated status
Alcohol and substance abuse
Stimulant usage
Medications such as corticosteroids
Poor sleep hygiene
Chronic pain
Chronic illness: patients with illnesses such as diabetes, CAD, hypertension, heart failure, BPH and COPD have a higher prevalence of insomnia than the general population.
Psychiatric illness: anxiety and depression are highly correlated with insomnia. People with manic episodes or PTSD will also complain of extended periods of sleeplessness.
Mx of insomnia
short term
- > Identify any potential causes e.g. mental/ physical health issues or poor sleep hygiene.
- > Advise the person not to drive while sleepy.
- > Advise good sleep hygiene: no screens before bed, limited caffeine intake, fixed bed times etc.
- > ONLY consider use of hypnotics if daytime impairment is severe.
hypnotics
- short-acting benzos or non-benzos (zopiclone, zolpidem and zaleplon).
- review after 2 weeks ad refer to CBT
