Sunday, February 1, 2015

Study group discussion: Dissociative identity disorder, Post-Traumatic Stress Disorder and Shutter Island

What about split personality disorders?

What I know it's that they're quite uncommon. But they present upon a trauma.

Psychological trauma.

There was a theoretical mcq in a question bank on split personality disorder. A female who said she recieved phone calls of strange men that she didn't remember meeting. It's easy to think it's a delusion if you don't keep split personality disorders in mind.

Was that shown in the movie
Karthik calling Karthik?

Haven't seen the movie.

Do no harm shows a neurosurgeon with a split personality. I am not sure if the series was purely fictional or based on a real life incident.

I guess it was fiction.

It was a very bad show.
Because it's super difficult to find a straight split personality.

Yes, it was based on DID.. Was a fiction.

It was a very bad show.
Because it's super difficult to find a straight split personality.

What's DID?
Dissociative identity disorder.

I don't know what the term is on the DSM V.

DSM V calls it dissociative identity disorder.

Multiple personality disorder is the same as split personality, right?

More than two personlities are called multiple personality disorder.

I have seen so many fictional works on it.. Makes you think it's common when it's not.

I know people who live with mental illness(es), and so I know what worked for them as well as what didn't.  And because so many people have approached me to talk to me about their mental health issues, I have very strong feelings about mental healthcare, so I do my own research, too.

Dissociative identity disorder is often treated by psychological therapy trying to merge the personalities into the core personality.  I don't know exactly how it's done.  I don't think there's medication for it.  It's pretty rare.  I don't know anyone with DID.

I wonder if perhaps dissociation as part of PTSD etc. instead of as part of DID would also be a good explanation for why someone might get phone calls from someone they don't remember meeting.

What's PTSD ?

Post-traumatic stress disorder.

It's a type of anxiety disorder that people sometimes develop after a traumatic experience.

Sometimes people with PTSD dissociate (they might 'lose' bits of time, for example).

Not remembering phone calls of strange men could be dissociation as part of a post traumatic stress disorder. But in that case, would the inciting trauma be of rape?

Potentially.  Not necessarily.  And rape isn't the only form of sexual assault.  [I'm not sure whether rape causes more *psychological* damage than other forms of sexual assault or not... if someone knows, I'd appreciate an answer.  I seem to recall someone saying that all forms of sexual violence are approximately equal in terms of suffering and trauma, because ultimately the important part is the existence of that violation, not the type of violation.]

Which are the other forms of sexual violence? Groping?

Yes.
Rubbing up against a person in a sexual way.
Taking photographs up someone's skirt would be a sexual crime, although I don't know how that would fit within definitions of sexual assault and violence.  It's still a violation of someone's body, though.

If someone kills a person, will he forget that, in case, he has PTSD ?

Not everyone with PTSD forgets the incident.  A lot of people with PTSD actually remember the incident very, very vividly.

If the person remembers the incident, then will he be in a state of shock? Or will he act normally?

It depends on the person.  If it was a sudden crime of passion there's a good chance the person will be shocked once they realise what they've done.
But some people are entirely capable of killing people without real remorse or shock.
And those people act normally.

What did Leonardo have in the movie Shutter Island?

I read a post online which says that the character Teddy Daniels or Andrew Laeddis played by Leonardo DiCaprio in the movie Shutter Island had Delusional Disorder, Post-Traumatic Stress Disorder, Schizophrenia and Dissociative identity disorder.

I didn't think someone could have delusional disorder and schizophrenia at the same time.

There are a lot of inaccuracies in the movie.

Migraine, I think.

Migraine? When was that?

Migraine was what he started having as a symptom may be.

We started taking about migraines after that which will be continued in the next post!

The Bicarbonate buffer system

some real cool facts i learned today--

1.       Buffers don’t eliminate acid, they simply neutralize acid at the tissue level..and transport it to areas from where it can be eliminated.

2.       The body has a three level of defense system, the first line are the buffers which are available for immediate action.. and the second (lungs) and third line (kidneys) through which these acids are permanently eliminated

3.       Why is it necessary to maintain the pH at a narrow range of 7.35-7.45? The structure and function of enzymes and proteins are dependent on pH..cause the containing amino acids have a charge which is highly dependent on the pH value. The body just can’t afford for the blood pH to rise or fall without deleterious consequences.



4.       Bicarbonates are the most important buffers in extracellular fluid. Why? Cause it is present in very high amount. 

Plus to top it all the HCO3- base component is in excess by 20 times! over its counterpart acid H2CO3. A very huge ratio of 20 to 1, means that the HCO3- component will always be available plenty whenever there is excess of metabolic acids to be eliminated. This is called the alkali reserve.

 Also the acid H2CO3 when formed can be very easily eliminated from the body via the lungs through the release of CO2.

 So overall bicarbonate is the only buffer which is excessive, fast acting and can be easily replenished.

5.       How does this buffer system work? The base HCO3- combines with H+ to form H2CO3. This is a weak acid, meaning once it is formed..it won’t let the H+ roam around free in the blood that easily. There will be only a mediocre rise in pH in comparison to a tremendous rise if bicarbonate wouldn't have been there. This pH stimulates the respiratory centre, which causes hyperventilation and release of CO2. 

-M-



Study group discussion: Histrionic personality disorder, Munchausen syndrome and MSBP

What's histrionic personality disorder?

I looked it up and found this on wiki:
A mnemonic that can be used to remember the characteristics of histrionic personality disorder is shortened as "PRAISE ME":
Provocative (or seductive) behavior
Relationships are considered more intimate than they actually are
Attention-seeking
Influenced easily
Speech (style) wants to impress; lacks detail
Emotional lability; shallowness
Make-up; physical appearance is used to draw attention to self
Exaggerated emotions; theatrical

Attention seeking in general.

Oh so how does this relate to mothers bringing their children in often for medical attention. Same thing?

Umm isn't that Munchausen syndrome by proxy? Different things.

Munchausen is more of medical attention seeking and histrionic looks like attention seeking in general.

If you're seeking medical attention for yourself, it's Manchausen syndrome and if you're trying to get attention to yourself by showing others are sick (mostly a child) it's Munchausen syndrome by proxy.

Oh ok. Thanks!

MSBP cases tend to involve faking medical symptoms, though. So mothers bringing in their children frequently for medical attention for real symptoms are probably helicopter parents (overly anxious and involved) but not necessarily MSBP.   Although if they exaggerate real symptoms that could be MSBP as well.

As for histrionic, it's not impossible that it would manifest as a parent bringing their child in for medical attention far more than is necessary, but as with all personality disorders, it's much more pervasive and would affect all other areas of their life and how they interact with the world, not just how often they bring their child in for medical attention.

Ah ok. Is Munchausen only specific to using another as a portal to attention. Or can this be self afflicted in order for the same degree of attention?

Munchausen by proxy is using other people's medical issues for attention. Usually children or the elderly or other dependents. Sometimes pets.

I had a patient who went to repeated doctors complaining that her child has joint pain, stiffness. Diagnostic procedures were done and all of them came out to be normal. They were suspecting MSBP in that case.

Munchausen syndrome (not by proxy) is when the person uses their own medical symptoms (often fake).

Ah ok. Now I see. So how does one start treatment for something like this?

Histrionic is in my opinion the most self defeating of the personality disorders with the exception of self defeating personality disorder, which isn't actually a recognized personality disorder anymore. Because people with histrionic need attention so much that they'll take on whatever role will get them the most attention  instead of being true to themselves.

Treatment for munchausen by proxy or not: Psychological treatment.  Helping them figure out how to get attention in healthier ways.  Interpersonal skills training.  Self esteem help so they don't need attention so much. Not giving them as much attention or sympathy might help, but it's mean and you need to be absolutely certain their faking it.

There was an episode in House MD on a patient with Munchausen syndrome. She induced hypoglycemia, seizures and took colchicine to mess up her blood profile.
She however had a medical condition that needed attention which made me realize that you can not dismiss every symptom in a patient with Munchausen without diagnostic procedures. It could be something serious. Interesting episode.

That's a huge issue with dealing with people with mental illnesses.   Doctors so often dismiss them because the mental illnesses can distort how they see things, but dismissing them means that you could miss out on something real and serious.

Would be truly unfortunately for a misdiagnosis that could potentially lead to death because the patient took antibiotics or of that nature.

Thanks for the information. Came accross the disorder while strolling the hospital. Answered so well.

Which did you come across?  Histrionic or MSBP?

Histrionic. While I walking through mental health. A group of docs were discussing personality disorders from the sound of it. That was one of which I over heard.

Ah. Personality disorders are tricky.  People aren't very likely to seek treatment, and they're not particularly easy to treat even when people seek help.  And they're complicated to diagnose because people often have symptoms from more than one, so trying to figure out which fits best is complicated.

Yeah that makes sense. I work in a military hospital so we alot of patients that will come back with not only physical but mental damage as well. The last patient I over saw had cellilitus, 2nd degree burns of the feet and would only speak to the females of the ward.
Mutisim something?

Selective mutism?

Yes!

Study group experience #3

Here's what we discussed so far:

Eating disorders (A must read)
Ascites (USMLE oriented question) 
Diuretics (Very interesting stuff)
A lot of mini discussions happen here and there and I can't keep up. So everything is not published (Sorry!) but I have posted most of the important discussions (Yaay?)

Since there is a time zone difference, we have a lot of messages every morning. Some members (Including me) read like over 200 messages at once and reply to them together which is adorable!

We changed our original plan of making a separate group for every 50 members and added new people to the same group. The new comers fit in well, were excited and didn't feel like aliens to a new world (Sweet!)

People who found the main group giving too many notifications because of discussions were added to the mini group for strict study discussions. However, the mini group is very inactive (Probably because the participants are focused on the upcoming exam they have to study for!) I post stuff from the mini group to the main group so that no one misses out on anything!

A few people left without even having the courtesy of informing or letting me know why. It took a lot of work for me to organize this - Reply emails, verify identity, save numbers and then add on the group. I felt they should've at least left a message.

People at times ask me how many spots are left, I can't really answer that because some people leave and new people are always coming in. Send us your number though, we'll squeeze you in like we did for the extra 30 people! :)

-IkaN

Saturday, January 31, 2015

Study group discussion: Extrapyramidal effects of antipsychotics and treatment

Guys do you know the side effect/time line of antipsychotics?

I mix up akathisa  akinesia etc. Then there's tardive dyskinesia and dystonia!
So confusing.

4 hours dystonia
4 days akinesia
4 weeks akathesia
4 months tardive dyskinesia

Thank you!

I was discussing timeline of extra pyramidal side effects of antipsychotics earlier and got a doubt - Some books say akinesia comes before akathesia while others say akathesia comes before akinesia.
Like my book says opposite of the image of a book posted by someone on the group and I couldn't find a good resource online.
Anyone has an insight on what we actually see clinically?

Well after asking around it seems the general consensus is that akathisia precedes akinesia. At since it has logic to it that's what I'm sticking with.

Thanks! Why is it logical though? Because Parkinsonian symptoms take longer to appear?

Well akathisia is restlessness and agitation, and akinesia is when you start losing voluntary movements, and it seems logical that it would precede dyskinesia.

Makes sense to me now, thanks!

Hey concerning the extrapiramidal effects of antipsychotics, I consulted my Goodman and Gilman and found this:
Akathesia: 5-60 days.
Parkinsonian symptoms: 5-30 days.
There we go. Basically the argument could be made for either order since their appearance overlaps.

Oh. So you can't have a clear cut line. Thanks for this!

You use anticholinergics for akinesia, right?

Yes, right. And for akathisia beta blockers like propanolol is drug of choice.

Ohh and what's the treatment for dystonia?

Probably Anticholinergics or muscle relaxant like baclofen. Not confirmed.

Dopaminergic drugs
Anticholinergic drugs
GABA Agonists
Carbamazepine
They all can be used in dystonia!

Woah. I didn't know this.

Dopaminergic drugs like?

Levodopa

Here's a post I wrote after this discussion - Antipsychotics: Timing of evolution of extra pyramidal symptoms mnemonic  http://medicowesome.blogspot.com/2015/01/antipsychotics-timing-of-evolution-of.html

Antipsychotics: Timing of evolution of extra pyramidal symptoms mnemonic

Greetings people!

The timing of evolution of extra pyramidal symptoms of antipsychotics is something you should be thorough with:

4 hours dystonia
4 days akathesia
4 weeks akinesia
4 months tardive dyskinesia

I made a mnemonic for it because I have been struggling with it since forever!

The mnemonic is, "Distant people are Restless. Parking cars is Stereotyped and Retarded."

"Distant" is for Dystonia which comes first!

"Restless" is for akathesia (Compelling desire to move restlessly!)

"Parking" is for the Parkinsonian like symptoms seen in akinesia.

Sterotypical ("Sterotyped") movements are seen in tardive ("Retarded") dyskinesia.

Lastly, a mnemonic to remember the treatment of Neuroleptic Malignant Syndrome!

The mnemonic is, "BAD NMS"
Bromocriptine
Amantidine
Dantrolene

That's all!

-IkaN
Related post:
Extrapyramidal effects of antipsychotics and treatment (Link: http://medicowesome.blogspot.com/2015/01/study-group-discussion-extrapyramidal.html)

Study group discussion: Oculogyric crisis

What's oculogyric crisis?

I have read it a couple of times as a side effect of a couple of drugs, I don't remember the drugs though.

Neuroleptic drugs.

It's antipsychotic induced.

But what happens in it.. How does the patient present?

Sounds like deviation of the eye.

These are the ones I came accross:
Mutism, palilalia, eye blinking, lacrimation, pupil dialation, drooling, increased BP and HR, flushed face, headache, vertigo, anxiety, fixed stare or maximal deviation in all direction (usually at one a time), malaise.

Seems like it messes up your autonomic nervous system along with the eyes.

Yeah :-/

General question, what does gyric mean? Like is it a Spanish or Latin word?

Latin. It's like twisting.

Study group discussion: Hybridoma technology

Something about immunology?

What about immunology?

I love immunology. Have a separate immunology comics blog, as you probably know :D

Can you provide the link for the immunology comics blog?

immense-immunology-insight.blogspot.com

I thought you guys knew.

Thanks!

Hybridoma technology. I wanna know about that!

I'll have to read those up. Anyone in the group has an idea on those?

Hybridoma technology. Never knew of this. I'm reading into now. Cool stuff.

Let us know a short summary once you're done!

Yeah sure. I'll try.

If anyone can better explain please feel free.

This is regards to the question of Hybridomas.

Hybridomas are cells that have been specialized to produce a specific antibody in large amounts. Made by exposing the test subject (animal) to an antigen to which your insterested in isolating a antibody against.

Once the animals splenocytes are isolated, the B cells and immortalized myeloma cells are fused.

The new product is incubated in HAT (Hypoxanthine, Aminopetrin, Thymidine) medium. The medium is specialized to allow only the hybrids to survive.

The dilution process and the disired antibody production is then checked.

What ever cells are not producing the antibody they're removed and over a course of weeks the status of the subject is checked.

Oh I remember! We were taught this is first year!

Theres alot more. As far as I got :-/

Ohh thank you.

Glad I could help. Interesting read.

Yo it's really nice of you!

My pleasure.

Study group discussion: Myopia and power mnemonic

Myopia (short sightedness) mnemonic, "Cave May Be Long"

CAVE - We use conCAVE lens
MaY - in MYopia
BE - BEfore image is formed before retina
LONG - eyeball eLONGate

When eye become Myopic it is acting as converging lens (+) convex lens (bend the rays coming from object the rays towards centre) more power more convergence more bending so we use diverging lens which is a concave lens to correct or to neutralise the bending or converging.

Concave lens negative (-ve) power.

Another study link! http://medicowesome.blogspot.ae/2013/10/myopia-and-hypermetropia-mnemonic.html

Study group discussion: Remembering Anatomy

Is there any easy way to remember the relations of the viscera?

Diagrams will help you remember the relations! There are a few mnemonics for arteries and stuff but in general, painting a picture in your head is the best way to remember!

Use Atlas for visualisation, see  videos of anatomy (Acland, Dalhousie) for awesome live experience... Highly recommended.

Seeing the viscera during cadaver dissection also helps in anatomy.

For anatomy, I find it helpful to draw the pictures out and label them. This allows you to appreciate the boundaries. 

I always drew diagrams in anatomy..Netter's helped a lot. 

Dissections are equally important...I  always read anatomy and revised it in my dissection class

Paroxysmal nocturnal hemoglobinuria mnemonic

Here's a mini post on PNH!

P: PIG A gene affected (On X chromosome that makes a glycosyl phosphatidyl inositol anchor)
N: Night. Hemolysis occurs at night.
H: Ham test confirms the diagnosis.

Patient presents with a history of dark coloured urine in the morning.

That's all!

-IkaN

Study group discussion: Succinylcholine

Can someone explain succinylcholine?

Succinylcholine is different than other neuromuscular blockers because it has two phases.

It is broken down in our body by pseudocholinesterase. And this enzyme differs in different people based on genetics. Hence, while using as a muscle relaxant it can prove quite deleterious to some people who have a weaker type of the enzyme.

Deficiency of pseudocholinesterase in some people causes succinyl choline apnoea.

Also, pseudocholinesterase is different than the more common acetyl cholinesterase enzyme.

Hepatitis B serum markers mnemonic

HBsAg: Surface protein of hepatitis B which means the person has infection presently. It's a marker for current infection.
Mnemonic: S antigen Stays in Sick patients (Active or chronic infection, negative in resolved infection).