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Ten lesser-known symptoms that could point towards a diagnosis of brain tumor

June 8th is celebrated as “World brain tumor day” to raise awareness about brain tumors. I would like to focus on the symptoms, presence of which, can make one suspect the presence of brain tumor.…
Common symptoms of brain tumor include headache, vomiting, reduced alertness, fits & paralysis. However, in several cases, these classical symptoms may be missing. It is important to know the lesser-known symptoms of brain tumors so that they can be diagnosed & treated early.
1. Increase in hat and shoe size over time- A tumor of pituitary gland of brain producing excess growth hormone (GH) causes a condition known as acromegaly, which can result in increasing head and feet size, necessitating a need for larger hats and bigger shoes.
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Me: "Mr Raj, your wife needs operation, and it needs to be done soon."
Mr Raj: "But none of the previous doctors who treated her depression even remotely hinted at this possibility (of surgery)".

1. 55-year old Mrs Viji had started feeling sad in August 2022.
2. Their only daughter had moved to the UK for higher studies. It was assumed that her sadness was related to missing her daughter. However, the feeling of sadness increased over time. She became withdrawn and stopped participating in get-togethers with family and friends.
3. Mrs Viji did not improve even after one month, she was taken to a psychiatrist.
After detailed history, she was diagnosed to have severe depression, and was started on anti-depressant medications.
Counseling by a psychologist was also started.
#psychtwitter #psychology
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Food addiction is real and is related to #obesity and #diabetes

1. Food #addiction (FA) syndrome can be diagnosed by using Yale Food Addiction Scale (YFAS). There are 11 possible symptoms, which can be used to diagnose FA, as well as grade its severity.
#Diet #MedTwitter Image
2. Clinical diagnosis of food addiction (FA)
Individuals can meet a “diagnostic” score for FA on the current versions of the YFAS by endorsing at least two of the 11 behavioral indicators of addiction plus clinical impairment/distress.
3. Severity of Food addiction
Severity thresholds for this “diagnostic” score are defined by the number of symptoms endorsed
(mild: 2–3 symptoms;
moderate: 4–5 symptoms;
severe: 6–11 symptoms)
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Clinical case! 🧠💭🧵
1/7 A 26-year-old woman from a rural region of Mexico presented in a state of catatonia. At age 21, she begun to exhibit aggressiveness. At age 23, she started having difficulties handling money, she constantly misplaced things. Sometimes she was disoriented
2/7 At age 26, 2 days after delivering her first child, she had a (first) psychotic episode, with incoherent speech, disorganized behavior, aggressiveness, visual & auditory hallucinations. She neglected her newborn, saying repeatedly that the child was not hers.
3/7 Psychotic symptoms were mixed with periods of catatonia. She recieved risperidone 2 mg/day, which worsened the catatonic states. She was referred to our hospital. On admission, risperidone was suspended. We observed immobility, mutism, staring, posturing, waxy flexibility...
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We are honored to welcome Dr. Holly Swartz, Prof of Psychiatry at @PittPsychiatry & Editor-in-Chief of American Journal of Psychotherapy (@APA_Publishing) to @uwsmph @UWHealth Psychiatry Grand Rounds to discuss:

"Psychosocial Interventions for #Bipolar Disorder"

#PsychTwitter Image
Network meta-analysis indicated that psychotherapy, including CBT, family focused therapy, and interpersonal & social rhythm therapy (IPSRT), are effective interventions for bipolar depression and for prevention of recurrence of bipolar disorder.… Image
Core strategies of bipolar-specific psychotherapies (cognitive therapy, family therapy, interpersonal & social rhythm therapy, psychoeducation & integrated care management): Image
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How to manage narcissistic personality disorder in clinical practice, an experimental thread: #MedEd #psychtwitter
The drop out rate of patients with narcissistic personality disorder from Treatment is on the order of 60%
making the diagnosis matters, you're probably more afraid of it then the patient is.
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A teenager referred with "difficult to control" fits needed non-drug approach for controlling fits

1. 15-year old Rishi had been having fits for the past three months. He used to have jerky movements of hands and legs that lasted several hours and occurred 15-20 times per day.
1a. He was seen by local doctors. MRI brain & EEG were normal.
He was started on anti-epileptic drug (AED). As seizures did not get controlled with single AED, two more drugs were sequentially added. As seizures continued despite giving maximum doses of 3 AEDs, he was referred.
2. Rishi had no past history of fits or febrile seizures in early childhood. There was no family history of epilepsy. He was a bright kid, doing well in studies.
While in OPD, I witnessed one of the episodes of fits, which made me suspect the root cause of fits in Rishi.
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To those intent on psychologising #LongCovid & #MECFS because ‘there is no biomarker’- let me tell you something as a senior Dr. Many diseases don’t have biomarkers & diagnosis is clinical. Take asthma for example. Symptoms vary between patients. 1/n
Many patients have abnormal exhaled nitric oxide (FeNO) & histamine challenge tests- some don’t. Yet if the patient’s symptoms & signs fit with asthma, we have no hesitation in making the diagnosis. 2/n
There is the well-known example of multiple sclerosis. Many deemed it psychogenic because there was no lab or radiology test that was diagnostic. Until of course the MR scan was invented. 3/n
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1/8 Obsessive-compulsive personality is externally defined by high conscientiousness, meticulousness, and being highly regimented and cerebral with low emotional awareness.

@jonathanshedler #psychtwitter #OCPD #psych #psychodynamic
2/8 When asked how they feel about something, someone with OCP will instead tell you what they think. The overuse and overvaluation of thinking, reasoning and logic is a defense against emotional life.
When we squelch “undesirable” emotions, all feelings get squelched. Squelching anger also squelches spontaneity and joy.

In OCP, the predominant unconscious theme is around being in control versus being controlled.
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A personal story of my everyday life as #Psychiatrist in India.
This might help anyone who is new to the field or thinking of entering the uncharted waters of #mentalhealthprofession
Read on.
#MedTwitter #psychtwitter
Every day, you will be reminded of the stigma by your own colleagues from other fraternities & society at large, most of whom are oblivious to the importance of mental health themselves.
Wait, but that's not why I am writing this.
4-5 years back, when I entered this field, and if I was treated this way, I would have revolted and taken the organizers of the camp to the cleaners and fumingly left the place.
But not now.
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Microlearning thread (1/17) on Hyper-prolactenemia in Psychiatry.


Please read this case report we published recently in the primary care companion for CNS disorders @PCC_CNSDisord.…
(2/17) Three facts about Prolactin (PRL)
1. 199 amino acid single chain PP secreted by lactotroph cells in the Anterior Pituitary
2. The (TIDA) neurons in the hypothalamus tonically release dopamine (DA) into the portal pituitary circulation
3. DA inhibits prolactin secretion.
(3/17) PRL functions

1. Lactogenesis
2. Contraceptive effect in the postpartum period
3. Modulates complex maternal behaviour and stress-related alterations in the HPA axis
4. Oligodendrocyte precursor cells growth modulation. Image
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#QALA - From the eyes of a Psychiatrist.
P.S. Spoilers ahead.
Read on for some themes I could find.
A 🧵
#MedTwitter #moviereview
#psychtwitter #mentalhealth
1. The concept of unwanted child

QALA's twin brother dies in utero, which is a big shock to her mother Urmila Manjushri, who blames Qala for taking away all the nutrition from her brother in utero & even tries to smother her. Qala becomes an unwanted child in the process.
2. Critical parenting

Though her mother tries to teach Qala the art of music, she is never satisfied and goes to on to punish her by keeping her out of the house in the chilling snow as Qala is not able to perform to her satisfaction.
Read 14 tweets
Older adults with greater muscle strength have lower risk of depression

1. Depression is common among older adults and its prevalence has increased over the past three decades. Depression increases the risk of suicides, stroke, heart attack, high BP and disability.
2. Preventive strategies, including increasing muscle strength can reduce the incidence of depression by 25%.
Handgrip strength is an easy-to-use, fast & reliable indicator of both sarcopenia (age-related loss of muscle mass) and dynapenia (age-related loss of muscle strength).
3. In a study comprising 1,15,601 adults aged 50 or more from 24 countries, with 7.3 years follow up, higher levels of handgrip strength were associated with lower risk of depression.
There was dose-response seen: Greater the hand grip strength, lesser was the risk of depression
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Problematic #alcohol use is common among #physicians

1. Problematic alcohol use can adversely affect physicians’ health as well as their ability to provide excellent healthcare to their patients.
A meta-analysis was recently published on this topic.
#MedTwitter #psychtwitter
2. Problematic alcohol use included hazardous, potentially hazardous, risky, at-risk, harmful, problematic, or heavy drinking or alcohol use, as well as alcohol misuse, alcohol dependence, and alcohol use more than low-risk guidelines and alcohol use disorder.
3. Survey included 52,000 physicians from 17 countries (from data published between Jan 2006-Mar 2020).

Results showed problematic alcohol use varied widely regardless of measurement method used.

The rate was 0%-34% with AUDIT, 9%-35% with AUDIT-C, and 4%-22% with CAGE.
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Just had a male physician colleague refer to me as a "girl."

As in, "I love working with you girls." 😑🤬

I have a PhD. Teach at Stanford & UCSF. Wrote 2 books. On the board of international pain orgs. What will it take to be considered an equal in medicine??? 👎🏼
We are doctors, not "girls." We are women, not schoolchildren 👧🏻🍭

If confused, call us by our TITLES.💥

Men don't have to ask. Why do we??

Advocate. 🌟

thank you for coming to my @TEDTalks 😑

#WomenInMedicine #WomeninScience #MedTwitter #psychtwitter
Pretty good reach for a Girl 💅🏻🎉🖕🏼

To be clear, I have no issue with the term "girl" in certain contexts - pop songs, Girls Night Out, ballfields.

But when a male colleague refers to the men in the room as "Dr." and you as a "girl," there's a clear problem. 🙄
#WomenInMedicine Image
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#Depression is associated with alterations in corticostriatal reward circuitry. One pathophysiological pathway that may drive these changes is #inflammation... Image
...This study examined whether increased inflammation in depression affects corticostriatal reward circuitry to lead to deficits goal-directed motor behavior. Resting-state fMRI maging was conducted on 48 medically stable, unmedicated outpatients with major depression...
...Increased CRP was associated with decreased connectivity between ventral striatum and ventromedial prefrontal cortex (vmPFC) (corrected P<0.05), which in turn correlated with increased anhedonia (R=−0.47, P=0.001)...
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Latest #TeamClots preprint on clotting abnormalities in #LongCovid. We demonstrated that the average levels of 6 inflammatory procoagulatory molecules were significantly higher in the soluble fraction of blood in #LongCovid when compared to controls… 1/n
These werealpha-2-antiplasmin (A2AP), serum amyloid A (SAA), platelet factor 4 (PF4), E-selectin, von Willebrand Factor (VWF) & platelet endothelial cell adhesion molecule-1 (PECAM-1). The mean A2AP level exceeded the upper limit of the lab reference range in #LongCovid 2/n
Considering that large quantities of these molecules have already been detected inside microclots using proteomics, the elevation in plasma/serum means that total levels of these inflammatory mediators are indeed alarming in #LongCovid 3/n
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In 2010, @JonathanShedler published an article in the flagship journal of the American Psychological Association, The American Psychologist. 🧵
At the time, it was controversial because his article argued that psychodynamic psychotherapy, long derided as irrelevant and ineffective, is empirically supported as effective.
One of my favorite parts of the article was his reference to the work of Blagys and Hilsenroth (2000) who identified by empirical means 7 techniques used by psychodynamic therapists that are different than those of other therapies. They are:
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The last of Alonso’s foundations of psychodynamic theory is the idea that there is an assumption that our mind is in conflict. While we may not be aware of this conflict, parts of our minds are working against each other. 🧵
For instance, we may have needs for closeness while also having needs for separation. These conflicts are often not in our awareness and sometimes experienced as ambivalence or anxiety.
To resolve these conflicts, sometimes we use a defense mechanism (I posted definitions for about 30 of them back in May/June). And, sometimes the cost, in the form of symptoms, make the defenses used less than pleasant.
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🧵Ever wonder what therapists use for #Suicide prevention? We asked: therapists use current best practices (~90%) BUT ~40% of clinicians endorse contracts for safety, no-harm contracts, &/or no-suicide contracts (not good!) #MentalHealthAwareness link👇 1/7 #psychtwitter
We asked mental health (MH) clinicians & MH allies (teachers, #FirstResponders, peer support) what Best Practices (Crisis Response Planning & Safety Plan) & Contraindicated Practices (contract 4 safety, no-harm contract, &/or no-suicide contract) they use. 2/7
Mental health allies endorsed the Best Practices & Contraindicated Practices at lower rates than mental health clinicians. This leaves room for more training on best practices with a focus on removing interventions that don’t help. #PeerToPeer #PeerSupport 3/7
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Join me for my first #neuropalliative care Tweetorial:
But first, an anatomy refresher:

3 major glands involved: parotid, submandibular (SM), sublingual (SL)

💦 Unstimulated state: about 70% of saliva from SM + SL
💦 Stimulated state: 5x ⬆️ production, mostly via parotid

⚡CN 7 innervates SM & SL
⚡CN 9 innervates parotid

Saliva is produced via parasympathetic (muscarinic cholinergic) tone and cleared via swallowing.

Drooling = when thin saliva is present past the lip margin

1. Impaired clearance (think neuromuscular dz ⬇️ swallowing)
2. Overproduction (think 💊 side effect)

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Dissociation is of special importance in the 2nd psychological vital sign of self and object constancy. Dissociation serves to protect one’s self from the pain (physical and/or emotional) one is experiencing now. 1/6
2/6 To do that, a person unconsciously and automatically shifts their attention somewhere else. We’ve all driven from A to B, arrived at our destination, and wondered why we can’t remember the path we took. Our thoughts were somewhere else.
3/6 When this happens as a response to severe pain that occurs repeatedly, it sometimes becomes difficult to be aware of or control the shift in state of mind. In severe instances, the states of mind can become segregated so they don’t seem to drift from one to another.
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In the avoidant type of attachment insecurity, the child ignores the caregiver who inconsistently shows attunement. They literally avoid their caregiver. But, this does not mean they lack feelings. In some instances, children with this 1/5
2/5 style appear to approach their caregiver when they’ve been separated and then sometimes, at the last moment, attempt to ignore them. Adults with this type of insecurity often experience themselves and are experienced by others as independent.
3/5 They can appear confident and accomplished. When in relationships though, they sometimes struggle to find closeness and can get to a point in the connection where they feel compelled to distance themselves or break up.
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There are 3 types of insecure attachment: ambivalent, avoidant, and disorganized. In the ambivalent type, the child feels conflicted about being in the presence of the caregiver. It is relatively common to see a child in this situation become angry when a 1/5
2/5 caregiver has left and then returns. It is also common to see that they may be passive or helpless. Adults often experience this insecurity as a sense of low self-worth. When a partner is not attuned to them, even if just occasionally, they can feel as
3/5 if they are not worthy of love and be self-blaming. They sometimes need persistent reassurance that they are loved and lovable. Fear of abandonment can sometimes be overwhelming and sometimes they will cling to the relationship to try to solve their fear.
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