00:01
Now, let’s talk a little bit more
about the thought disorders.
00:06
There are different types
of thought disorders.
00:08
We think about disordered
thought content.
00:11
This looks like disruption
in a patient’s beliefs,
ideas, and interpretations
of their surroundings.
00:20
Disordered thought process
is a manner in which the patient
links ideas and words together.
00:27
Let’s consider a couple of the
common types of thought disorder.
00:32
What do you think it means when we say a
patient has alogia or poverty of content?
Well, this is where very little
information is conveyed by speech.
00:45
How about thought blocking?
In clinical practice,
this is when a patient suddenly
loses their train of thought.
00:52
It’s exhibited by an
interruption in their speech
and then they have trouble
picking right back up again.
00:58
Loosening of associations describes
a speech content notable for ideas
presented in sequence that
are not closely related.
01:08
So it’s where somebody
jumps all over the place.
01:11
Tangential though process is another
type of disorganized thought.
01:17
So this is where answers
to interview questions
diverge increasingly from topic
to topic being asked about.
01:26
Some call this circumstantiality if the is
eventually returned to the original topic.
01:33
When somebody’s tangential,
they basically go off course
and can never return
to the point.
01:40
Clanging or clang association is
another type of thought disorder.
01:45
So this is where words
are used in a sentence
that are linked together by
rhyming or due to phonetics.
01:52
Here’s an example of what
a patient might say.
01:54
“I fell down the well sell bell.”
So things rhyme, but they don’t
really make any sense used together.
02:02
A word salad is another important
type of thought disorder
and this is where real words are
linked together but incoherently.
02:11
So it’s nonsensical.
02:14
An example would be a patient saying,
“Tree way of nothing house.”
It makes no sense.
02:21
A perseveration is repeating
words or ideas persistently
often even after the
interview topic has changed,
so it’s where somebody really
can’t let go of a point
and they just keep bringing
it up over and over again.
02:37
I want to give you this
case study to consider.
02:40
Mr. B is a 22-year-old man.
02:42
He’s been having trouble in college.
02:45
Rather than graduating on time,
he has had to repeat a few
years due to an inability
to get to class because
he has low motivation.
02:55
So his parents come out
to college to visit him
and they find his dorm
room a complete mess.
03:01
Their son, Mr. B, is malodorous
and he has not been taking
care of is hygiene.
03:07
He talks nonsense when his
parents ask him what’s wrong.
03:12
The only thing they can
decipher is their son saying,
“My professor wants to kill me.”
So you meet Mr. B in the emergence
room and you start evaluating him.
03:24
If this is all you know at this point,
what’s your differential diagnosis?
Of course, it’s broad, so you’re going
to consider all of these things.
03:33
All right, so you’re going to
consider general medical conditions.
03:37
Now, I can’t overemphasize
this point enough.
03:40
Whenever considering a
psychiatric disorder,
you must always consider
medical conditions first.
03:46
They’re easy to treat and
more likely to be reversible.
03:50
Also think about whether
or not this disorder
and whether or not these symptoms
are actually substance related.
03:57
Something else that can be quickly
treated and possibly reversed.
04:02
Beyond that, you’re going to think
of some psychiatric disorders,
like a brief psychotic disorder,
schizophreniform disorder,
schizoaffective, schizophrenia,
schizotypal personality disorder,
a mood disorder with
psychotic features
and you may think of schizoid
personality disorder.
04:23
So when you consider that case of Mr. B,
you’ve got a broad
differential diagnosis now.
04:28
And on the top of your list, of
course, is a general medical problem.
04:33
So when it comes to psychosis,
what types of general medical
problems are important
to rule out in treating your patients?
It’s a long list, so
let’s go through it.
04:43
Delirium, you’re going to think of this.
04:46
Of course, delirium is a frequent
cause of psychotic symptoms, okay?
And this could be duet to fluid
or electrolyte abnormalities.
04:57
Also, substance
intoxication or withdrawal.
05:00
Hypoglycemia, hypercapnea, hypoxia or
infections or from other medications.
05:07
These are all possible causes of a delirious
patient that could look psychotic.
05:12
We’re also going to think
of endocrine problems,
things like thyroid disease,
parathyroid or adrenal disease.
05:19
And then the liver can be disrupted and
also present as psychotic symptoms.
05:24
So think about hepatic encephalopathy
and uremic encephalopathy.
05:28
Other medical causes, you’re going to
want to rule out our infectious diseases,
things like syphilis, herpes, Lyme
disease, prion disorder, and HIV or AIDS.
05:38
Inflammatory disorders like lupus,
anti-NMDA receptor encephalitis,
leukocytosis or leukodystrophies,
multiple sclerosis.
05:52
And you’re going to think
of metabolic disorders
like porphyria or
Wilson’s disease.
05:58
Other things to rule out are
neurodegenerative diseases,
things like Lewy body dementia, Huntington’s
disease, Parkinson’s, and Alzheimer’s.
06:08
There are other neurological conditions
include space-occupying lesions like a tumor,
seizure disorder or stroke
and any kind of a head injury
or trauma to the brain.
06:20
Finally, you want to rule out if there’s
a vitamin deficiency, especially B12.
06:25
Now, because there’s a long
list, we have here a summary,
an acronym that you may find
useful in thinking about
what categories and groups of medical
conditions can present as a psychotic disorder.
06:42
At the end of this lecture,
now, I hope that you appreciate
how important it is to formulate
a differential diagnosis
for the psychotic patient especially
including general medical conditions
and the substance abuse problem
and to rule out anything that
could be easily treatable
and reversible before formulating
a psychiatric diagnosis.