Assessment & Classification Flashcards
Operationalised approach to diagnosis
- In DSM-III operationalised diagnosis was first introduced.
- Operational criteria include the use of precise clinical description of disorders, together with predefined exclusion and inclusion criteria and details of the number and duration of symptoms required for diagnosis.
- It enables algorithm-based clinical diagnosis using intensity, duration of the symptoms and impairment tests. - This more or less equates to using a checklist for diagnosis, but some rules are necessary while some are optional for a diagnosis.
Atheoretical Approach to diagnosis
- Diseases are described according to the observed phenomenology
- Classification is NOT based on the understanding of what might be causing the disturbances.
- So various aetiological schools such as behaviourism or psychoanalysis, etc. are not employed in describing a disorder.
- No theory forms the basis of the classifications
- Only neutral observations are taken into account.
Descriptive approach to diagnosis
- Classifying illnesses on the basis of what constitutes the illness rather than what causes it
- Lack of pathogenetic knowledge of most psychiatric disorders makes this approach more rational.
- This forms the basis of any atheoretical classification.
Define Atypical Anorexia Nervosa
- One or more of these essential features may be absent, or all are present but to a lesser degree.
- Atypical anorexia nervosa is described as “ a disorder that fulfills some of the features of anorexia nervosa but in which the overall clinical picture does not justify that diagnosis.
- For instance, one of the key symptoms, such as amenorrhoea or marked dread of being fat, may be absent in the presence of marked weight loss and weight-reducing behaviour.
- This diagnosis should not be made in the presence of known physical disorders associated with weight loss.” (ICD-10)
Several features are noted in patients with atypical anorexia when compared to those with typical anorexia.
- Older age at onset and presentation
- Recurring bouts of depression
- Numerous somatic complaints
- Unmet dependency needs
- Little evidence of distortion in body image is seen.
Characterisation of Somatization disorder
(a) at least 2 years of multiple and variable physical symptoms for which no adequate physical explanation has been found
(b) persistent refusal to accept the advice and reassurance of several doctors regarding the absence of a physical illness
(c) notable impairment of social and family functioning due to the symptoms and the illness behaviour.
- The term Briquet Syndrome or St. Louis Hysteria is sometimes applied to denote somatisation disorder.
ADHD age of onset for diagnosis according to DSM
Several inattentive or hyperactive-impulsive symptoms were present prior to age 12
Multi-axial approach
- Recently there has been an upsurge of interest in the multi-axial system for achieving a complete diagnosis. - This method helps in a more ‘holistic assessment’ of an individual patient.
- The multi-axial version of ICD-10 uses three axes.
1. Axis 1 - the mental disorder (also personality disorder and mental handicap)
2. Axis 2 - the degree of disability
3. Axis 3 - current psychosocial problems. - The multi-axial system of DSM uses 5 axes.
1. Axis I - Clinical Disorders
2. Axis II - Personality Disorders/ Mental Retardation
3. Axis III - General Medical Conditions
4. Axis IV - Psychosocial and Environmental Problems
5. Axis V - Global Assessment of Functioning.
Note that child and adolescent mental disorders have a different axial system in DSM-IV.
Dissociation disorder Features
- Mental effects of a conflict
2. E.g. Amnesia, Loss of identity, alter personality
Conversion disorder Features
- Physical effects of a conflict
- Paralysis, blindness, ataxia, anaesthesia,
aphonia, seizures
Somatoform/somatisation disorder Features
- Production of a symptom (positive)
- Pain, vomiting, etc.
- GIT and Musculoskeletal
- Polysymptomatic
Hypochondriasis Features
- Preoccupied with diagnosis
- Concern: ‘One dreadful disease.’
- Gastrointestinal features most common
Malingering Features
- Clearly intentional
- Often monetary benefits
- Military, compensation claims, etc.
Factitious disorder features
- ‘Truly puzzling’ with ‘no cause.’
- Only gain is sick role
- Seen in paramedical professionals
- Munchaussen is severe form – wide doctor
shopping is seen
Fregoli delusion
Belief that strangers are actually person’s well known to the patient, in disguise
(Fregoli - friend)
Capgras syndrome
The belief that strangers in disguise have replaced persons known to the patient.
(Capgras - snake in the grass - they’re not who they say they are)
Othello Syndrome
- Characterised by a delusion of infidelity.
Patients possess the fixed belief that their spouse or syndrome) partner has been unfaithful. - Often patients try to collect evidence and/or attempt to restrict their partner’s activities.
- Contributes to both wife battering and homicide.
Ekbom syndrome
1) delusional parasitosis, the belief that the skin is infested with parasites, sometimes associated with cocaine use
2) restless legs syndrome, the condition of annoying sensations in the extremities that disturbs sleep onset.
European physicians prefer the first definition, Americans the second.
(Ekbom - infestation)
De Clerambault syndrome
Erotomania, or more specifically a female patient’s belief that a wealthier older man, whom she does not know, loves her.
Cotard syndrome
Patient’s belief that he does not exist, that part of him is not there (e.g., his organs), or that he is dead.
Who first described bulimia nervosa?
Russell (1979)
Who first described unitary psychosis?
Greisinger (1868)
Who published the two syndrome hypothesis of schizophrenia?
Crow (1980)
Who published the three syndrome model of schizophrenia?
Liddle (1987)
Who introduced interpersonal psychotherapy?
Klerrmann & Weissmann
ICD-10 minimum symptom duration for diagnosis of schizophrenia?
(What is the diagnosis if less than this time)
1 month
if less, diagnosis of acute-schizophrenia like disorder
DSM minimum symptom duration for diagnosis of schizophrenia?
6 months
International Pilot Study of Schizophrenia findings
a. % of patients with acute schizophrenia who exhibited at least one first rank symptom
b. % of schizophrenic patients who never exhibit a first rank symptom
c. % of non-schizophrenic patients who exhibit at least one first rank symptom
a. 58% of patients with acute schizophrenia exhibited at least one first rank symptom.
b. At least 20% of schizophrenic never exhibit a first rank symptom
C. Almost 10% of non-schizophrenic patients exhibit them.
Bizarre Delusions
- i.e. Schneiderian delusions
- Auditory hallucinations, thought disorder, strange behaviour and progressive deterioration in personal, domestic, social and occupational functioning
- All occurring in clear consciousness
- Seen in Schizophrenia (NOT delusional disorder)
Head Injury and Psychosis links
- Genetic predisposition to schizophrenia has an influence on vulnerability for psychosis after head injury
- Head injury increases non-affective psychosis more than affective psychosis
- Psychosis related to head injury is usually chronic in onset
- Head injury does not increase likelihood of developing schizophrenia
The Kernig’s Sign
- Meningeal Sign - These signs can be elicited in the presence of meningeal inflammation or irritation due to haemorrhage/trauma.
- Elicited by flexing one hip and knee and then extending the knee with the hip still flexed
- Hamstring spasm may occur; if severe, opposite knee may flex during the test
The Brudzinski sign
- Meningeal Sign - These signs can be elicited in the presence of meningeal inflammation or irritation due to haemorrhage/trauma.
- Flexion of the knees and hips when you try to flex one’s neck constitutes a positive Brudzinski’s sign
Diffusion Tensor Imaging
- Technique used to study the integrity of white matter tracts
- Reveals that in children, with advancing age, the directionality of diffusion in white matter pathways continues to increase especially in the prefrontal regions and in basal ganglia.
- This suggests that frontostriatal systems myelinate progressively during adolescence.
- DTI studies also show that the frontotemporal pathways may continue to myelinate until age 30 years.
Endocrine abnormalities seen in anorexia
- Low concentrations of luteinising hormone, follicle stimulating hormone, and oestradiol
- Low T3, T4 in low normal range, normal concentrations of thyroid stimulating hormone
(low T3 syndrome) - Mild increase in plasma cortisol
- Raised growth hormone concentration
- Severe hypoglycaemia (rare)
- Low leptin (but possibly higher than would be expected for bodyweight)
4 signs of healthy ageing
- Reduced motor speed
- Reduced visuospatial skills
- Reduced attentional span
- Reduced new learning ability
Visuospatial neglect
- Neglect of personal and extrapersonal space is usually due lesions to the right hemisphere - usually the inferior parietal or prefrontal regions.
- Left side of personal and extrapersonal space is represented only on right parietal lobe, but right
personal and extrapersonal space gets bilateral representation. - Hence, a left-sided lesion rarely results in neglect, but right-sided lesion can result in left-sided neglect.
- Deficits can be uncovered by simultaneous bilateral sensory or visual stimulation, or having the patient bisect lines of variable length. Letter and star cancellation tasks are similar, more formal tasks.
- Visual neglect may produce a failure to groom one-half of body, or eat what is placed on one side of a plate. In extreme cases, patients may have anosognosia and deny they are hemiplegic or even that the affected limb belongs to them.
Anosognosia Definition
Denial of illness and typically is seen in patients with right
frontoparietal lesions, resulting in left hemiplegia that the patient denies.
Beta Waves on EEG
- > 13Hz
- Some seen at frontal, central position in the normal waking EEG
Alpha Waves on EEG
- 8 to 13 Hz
- Dominant brain wave frequency when eyes are closed and relaxing; occipitoparietal predilection.
- Disappears with anxiety, arousal, eye opening or focused attention.
- Dominance reduces with age.
Theta Waves on EEG
- 4 to 8 Hz
- A Small amount of sporadic theta seen in waking EEG at frontotemporal area
- Prominent in drowsy or sleep EEG.
- Excessive theta in awake EEG is a sign of pathology.
Delta Waves on EEG
- <4 Hz
- Not seen in waking EEG.
- Common in deeper stages of sleep
- The presence of focal/generalized delta in awake EEG is a sign of pathology.
Mu Waves on EEG
- 7-11 Hz
- Occurs over the motor cortex.
- It is related to motor activity, characterized by arch like
waves; gets attenuated by movement of the contralateral limb
Lambda Waves on EEG
- Single waves
- A single occipital triangular, symmetrical sharp wave produced by visual scanning when awake (e.g. reading) or in light sleep
Constructional apraxia definition and localisation
- Inability to construct elements into a meaningful
whole. e.g., inability to draw or copy simple diagrams
or figures. - Right cerebral hemisphere
11 Frontal Lobe Tests
- Similarities
- Lexical fluency
- Luria motor test
- Go/on go test
- Cognitive estimates test
- Trail making test
- Alternate pyramids
- Squares drawing
- Proverb interpretation
- Frontal release signs
- Digit span
9 Parietal Lobe Tests
- Copying shapes
- Identifying fingers
- Calculation ability
4 Graphesthesia - Right Left orientation
- Stereognosis
- Two point discrimination
- Cortical sensation
- Visual inattention
Kayser Fleischer ring
Golden Brown pigment around cornea in Wilson’s disease
Wilson’s Disease
- Congenital recessive condition of defective copper
metabolism due to a defect in chromosome 13 - characterized by hepatic symptoms and later psychiatric
symptoms and choreoathetosis as various organ systems are overwhelmed by copper. - It can be diagnosed (once the central nervous
system is affected) by finding Kaiser- Fleischer rings in the cornea with a slit-lamp though these are not universally present. - A more reliable diagnosis depends on low ceruloplasmin and elevated copper in urine and liver biopsies.
Blood Oxygen Level Dependent (BOLD) technique.
- Basis for fMRI
- Neuronal activity within the brain causes a local increase in oxygen consumption.
- Consequently the local concentration of deoxyhaemoglobin increases, relative to oxyhaemoglobin.
- While oxyhaemoglobin is diamagnetic (weak magnetic contrast), deoxyhemoglobin is paramagnetic, producing an MR signal that can be detected with the T2 sequence
Thalamocortical projection lesion symptoms
- Sensory impairment over the contralateral face, arm and leg, involving pinprick, touch, vibration, position, two-point discrimination and sterognosis
