A 70 year old male, Babulal was brought to the hospital with the history of auditory hallucinations with third person hallucinations. He has no history of similar problems previously. The diagnosis is mot likely to be
C i.e. SchizophreniaDiagnostic criteria for schizophrenia DSM-IVICD-10>1 for 1 month1. Bizzare delusions1. Thought echo /inseion/ 2. Hallucinations consist of :withdrawal/broadcasting - Voices commenting i.e. a hallucinatory voice commenting (keeping up2. Delusion of control a running commentary) on one's behaviour, thought or action in the third3. Hallucinatory voices person (third person hallucination)Q4. Persistent delusions - Voices discussing or arguing i.e. hallucinations of two or more voicesdiscussing or conversing with each other Or>2 Criteria A.1. Delusions1. Thought block / disorder 2. Hallucinations2. Persistent hallucinations 3. Disorganized speech (eg frequent incoherence or derailment)3. Negative symptoms 4. Grossly disorganized or catatonic behaviour4. Catatonia 5. Negative symptoms i.e. affective flattening, alogia or avolition Time courseSignificant poion of time during 1 month period (or less if successfullytreated) for symptoms plus 6 months social/ occupational distrubance1 month (most of the time)ExclusionsBrief mood disturbance or schizoaffective disorderSchizoaffective disorder or Direct effect of drug abuse/ medication / medical conditionextensive depressive /manicsymptoms Drug intoxication/withdrawal, ove braindisease. Diagnostic Criteria of Schizophrenia subtypes ParanoidDisorganized (DSM)Hebephrenic (ICD)CatatonicUndeffe-rentiated ResidualSimple (Deteriorative)DSM IV1.2.Preoccupationwith>ldelusions orfrequentauditoryhallucinationsDisorganizedspeech,disorganized orcatatonicbehaviour,negativesymptoms (flator inappropriateaffect orthoughtdisorders arenot prominent)1.2.Prominentdisorganizedspeech, behaviourand flat orinappropriateaffectNo catatonicfeatures>2 of1. Motoric immobility(i.e. catalepsy, waxyflexibility) or stupor2. Excessive motoractivity (i.e. apparentlypurposeless & notinfluenced by externalstimuli)3. Extreme negativism(apparently motiveless resistanceto all instructionor maintain rigidpostures againstattempts to be moved)or mutism4. Peculiar voluntarymovements(inappropriate orbizarre postures) ,stereotypedmovements, prominentMeets A- criteriafor schizophreniabut not forprevious(paranoid,disorganized orcatatonic)subtypes1.2.Absence ofprominentcharacteristicsymptoms(such asdelusions,hallucinations,disorganizedspeech &behaviour)Continuingevidence ofdisturbanced/ t presence ofnegativesymptoms or >2criteriasymptomspresent inattenuated form.A. Slowly progressive(for atleast 1 year)negative symptomswithout psychoticsymptoms asedivenced by1. Marked decline inoccupational oracademic functioning2- Poor inter personalrappo, socialisolation or socialwithdrawl3. Gradualappearance &deepening ofnegative symptomssuch as affectiveflattening, alogia, &avolition.B. Criteria A ofschizophrenia nevermet mannerism orgrimacing5. Echolalia orechopraxia ICD -101. Delusions,hallucinatoryvoices,hallucinations inother modalities1. Prominentdisturbances ofaffect, thought &volition2. 2-3 months>1 of stupor,excitement, posturing,negativism, rigidity,waxy flexibility,automatic complianceMelts criteria Afor schizophreniabut not forprevious subtypes + residual.1. Prominentnegativesymptoms;2. Clear cutepisode (s) inSchizoid personalitydisorder 2. Inconspicuousdisturbances ofaffect, speech &volition.duration3. Adolescents oryoung adults only& perseveration. past3. At least 1 yearhistory4. No dementia ordepression etc Common Delusions (distoed & highly illogical misinterpretations of actual events or experiences = Errors of Inference) types in schizophrenia (Criterion A-1)- Delusions of Control, grandiosity, guilt, reference Persecutory delusions, somatic delusions,- Thought inseion, withdraw! or broadcastingQ.Disorganized Behavior (Criterion- A - 4)1. Inappropriate social behaviorQ2. Severe neglect of hygiene or bizarreness of choice in clothing & general appearanceQ3. Unprovoked outbursts of laughter or other emotionsQ.4. Unprovoked outbursts of agitated, hyperactive or violent behaviorQNegative Features of Schizophrenia (Criterion AS)- Anhedonia is diminished or absent capacity to experience pleasure- Attention defecits is inability to maintain engagement in a goal directed activity or task- Avolition is lack of motivation for initiating or completing tasks, reflective of a loss of drive and of interest in one's surrounding.- Affective flattening is absence of outward emotional reaction to stimuli. There is an absence or decrease of spontaneous movement, expressive gestures, eye contact, shifts in vocal inflections. .- Alogia is decrease in production and fluency of spontaneous speech (but not refusal to speak), which is believed to reflect povey of thought Abnormalities may also include prolonged pauses before answering questions.Disorganized Speech (Criterion A3)Disorganized speech reflects an underlying impairment in thought processQ that is, the inability to process stimuli accurately and link thoughts or ideas in a coherent & logical manner (=Thought disorder). These are cardinal features of schizophrenia, more closely a/w functional disability than positive symptoms and include Clanging (Rhyming or Rassonance) : Words are used based on how they sound rather than what they mean. 2. Concrete speeh : Is speech that reflects an inability to use abstract thinking which may bring about literal meaning of proverbs during mental status examination, or a pattern of speech that conveys little to no information d/t use of excessively vague or meaningless phrases (Verbigeration) Circumstantiality: Speech that is goal directed but excessive in unneeded detail. Questions are eventually answered; however, direct answers are difficult to come by.Derailment: Speech that begins in a goal directed manner, but topics shift rapidly between sentences with no logical connection to the topic previously under discussionIllogicality: Speech that is goal directed but gives illogical responses to logical questions, or bases asseion on premises that have no coherent or logical basis.Incoherence: Incomprehensible speech d/t loss of logical connections between words, phrases and sentences, the extreme form of which is k/a word salad.Tangentiality: Speech that begins in a goal directed manner, but detes gradually and constantly such that answers to questions are not reached. New topics arise from the topic previously under discussion, so an association between thoughts can be appreciated.Thought blocking: Sudden and involuantry interuption in the progress of speech of thought.Neologism: Use of nonsensical words, often as combination of pas of two or more different words. In Q.67, Patient has h/o 6 months of disorganized behaviour, disorganized speech (muttering) and hallucinatory voices (talking to himself). In Q.68, Patient has h/o bizarre auditory hallucination of voices commenting or arguing about him with a delusional belief (that's why he dropped police complaint). In Q.69, Patient has disorganized behaviour (recently staed writing books which could not be understood by anybody, metaphilosphical ideas), negative symptoms (shy, self absorbed), disorganized speech (i.e. neologism, incomprehensible, derailment, incoherence here indicated by use of words could not be understood by anybody, were never in any dictionary and with disjoined theme). In Q.70, Patient has third person hallucination (hallucination of voices commenting on his action) & disorganized behaviour (out of propoion recent onset suspiciousness). In Q.71, Patient has disorganized behaviour keeping shoes in fridge, wearing vest over shi), hallucinatory voices and delusion of persecution (people talking about & conspiring against him). In Q.72, Patient has delusion & disorganized behaviour (thinks that class mate laugh & talk about him and will harm him). In Q. 73, third person hallucinations are present. So all these cases can be easily diagnosed as suffering from schizophrenia.In delusional disorders, hallucinations are rare and if present they are tactile, or olfactory and related to delusional theme. Delusions are non bizarre and contact with reality and personality are disturbed in delusional areas only.Differentiating b/w delusions of different causesDelusional disorderSchizophreniaDepression* Delusions are non bizarre (ie involvingsituations that occur in life as beingfollowed, deceived, infected, loved etc)* Bizarre delusions* NihilisticdelusionsQ* Behaviour & personality is normalexcept in the delusional areaQ* Behaviour & personality is deteoratedQ in almost allareas* Depressedpersonality* Hallucinations are very rare & if occurare of tactile or olfactory verityQ* Hallucinations are very common1. Auditory variety is most commonQ2. 3rd person hallucination, voice keeping up a runningcommentary or two or more voices conversing witheach other are characteristicQ.* -?Delirium Tremens is an alcohol withdraw' syndrome, which usually occurs with in 2-4 days of complete or significant abstinence from heavy alcohol drinkingQ, & presents with symptoms of delirium i.e. - acute onset, clouding of consciousness, disorientation & hallucinationsQ. Here there is no abstinence, clouding of consciousness & disorientation so it is ruled out.Alcohol induced psychosis (Karsakoff's psychosis) presents with profound amnesia & confabulationQ; so this option is also ruled out.Anxiety neurosis and adjustment reaction are ruled out by absence of stressor and presence of delusions and loss of insight.
Dementia
Delusional disorders
Schizophrenia
Acute psychosis