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now let's talk a little bit more about
the thought disorders there are
different types of thought disorders we
think about disordered thought content
this looks like disruption in a
patient's beliefs ideas and
interpretations of their surroundings
disordered thought process is a manner
in which the patient links ideas and
words together let's consider a couple
of the common types of thought disorder
what do you think it means when we say a
patient has a loggia or poverty of
content well this is where very little
information is conveyed by speech how
about thought blocking in clinical
practice this is when a patient suddenly
loses their train of thought it's
exhibited by an interruption in their
speech and then they have trouble
picking right back up again loosening of
associations describes a speech content
notable for ideas presented in sequence
that are not closely related so it's
where somebody jumps all over the place
tangential thought process is another
type of disorganized thought so this is
where answers to interview questions
diverge increasingly from topic to topic
being asked about some call this
circumstance reality if the content is
eventually returned to the original
topic when somebody's tangential they
basically go off course and can never
return to the point clanging or clang
associations is another type of thought
disorder so this is where words are used
in a sentence that are linked together
by rhyming or due to phonetics here's an
example of what a patient might say I
fell down the well Sal bell so things
rhyme but they don't really make any
sense used together a word salad is
another important type of thought
disorder and this is where real words
are linked to
there but incoherently so it's
nonsensical an example would be a
patient saying treeway of nothing house
it makes no sense
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 I want to give you
this case study to consider mr. B is a
22 year old man he's been having trouble
in college 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 so his
parents come out to college to visit him
and he find his dorm room a complete
mess their son mr. B is malodorous and
he has not been taking care of his
hygiene he talks nonsense when his
parents ask him what's wrong the only
thing they can decipher is their son
saying my professor wants to kill me so
you meet mr. B in the emergency room and
you start evaluating him 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 alright so you're going to
consider general medical conditions now
I can't overemphasize this point enough
when ever considering a psychiatric
disorder
you must always consider medical
conditions first they're easy to treat
and more likely to be reversible also
think about whether or not this disorder
and whether or not the symptoms are
actually substance related something
else that can be quickly treated and
possibly reversed beyond that you're
gonna think of some psychiatric
disorders like a brief psychotic
disorder schizophrenia form disorder
schizoaffective schizophrenia
schizotypal personality disorder a mood
disorder with psychotic features and you
may think of a schizoid personality
disorder
so when you
consider that case of mr. B you've got a
broad differential diagnosis now and at
the top of your list of course is a
general medical problem so when it comes
to psychosis what types of general
medical problems are important to rule
out in treating your patient it's a long
list so let's go through it delirium
you're gonna think of this of course
delirium is a frequent cause of
psychotic symptoms okay and this could
be due to fluid or electrolyte
abnormalities also substance
intoxication our withdrawal hypoglycemia
hypercapnia hypoxia or infections or
from other medications these are all
possible causes of a delirious patient
that could look psychotic you're also
gonna think of endocrine problems things
like thyroid disease parathyroid or
adrenal disease and then the liver can
be disrupted and also present as
psychotic symptoms
so think about hepatic encephalopathy
and uremic encephalopathy other medical
causes you're gonna want to rule out are
infectious diseases things like syphilis
herpes Lyme disease prion disorder and
HIV or AIDS inflammatory disorders like
lupus anti-nmda receptor encephalitis
leukodystrophies multiple sclerosis and
you're gonna think of metabolic
disorders like porphyria or Wilson's
disease other things to rule out are
neurodegenerative diseases things like
Lewy body dementia Huntington's disease
Parkinson's and Alzheimer's neuro other
neurological conditions and Q includes
space-occupying lesion z' like a tumor
seizure disorder or stroke and any kind
of a head injury or trauma to the brain
finally you want to rule out that
there's a vitamin deficiency
especially b12 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
present as a psychotic disorder 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
a substance abuse problem and to rule
out anything that could be easily
treatable and reversible before
formulating a psychiatric diagnosis
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you