Classification and assessment in psychiatry Flashcards
Two major classificatory systems (+dates)
ICD-10 (WHO, 1992)
DSM-IV (American Psychiatric Association, 1994)
Operationalised approach (to classification)
Essentially a ‘checklist’ approach to diagnosis:
- Precise clinical descriptions of disorders
- Predefined exclusion and inclusion criteria
- Details of the number/duration of symptoms required for diagnosis
3 kinds of symptoms relevant to the operationalised approach to classification
Characteristic symptoms - pertinent to the diagnosis (e.g. the symptoms of depression are found in many different disorders)
Pathognomonic symptoms - strongly favour one diagnosis over another (e.g. flashbacks in PTSD)
Discriminating symptoms - necessary for a diagnosis (e.g. thought insertion)
‘CPD’
Atheoretical approach (to classification)
Diseases are described according to the observed phenomenology; NOT based on an understanding of what might be causing the disturbances
(no theory - e.g. behaviourism, psychoanalytic - forms the basis of the classifications, only neutral observations are taken into account)
Descriptive approach
Illnesses are classified on the basis of what constitutes the illness, not what causes them.
This forms the basis of the atheoretical approach.
Hierarchical organisation
Certain disorders take precedence over others when making a diagnosis.
If a disorder closer to the top of the hierarchy can explain the observed symptoms, then a diagnosis should not be entertained from below even if the constellation of symptoms are suggestive of such a diagnosis
Stems from the ideas of Karl Jaspers.
Largely abandoned in DSM but maintained in ICD-10’s organisation of chapters.
Organic disorders - Substance use disorders - Psychosis - Affective disorders - Neurotic disorders - Personality issues
ICD-10 Multiaxial approach
1 - mental disorder (including personality disorder and mental handicap)
2 - degree of disability
3 - current psychosocial problems
DSM-IV Multiaxial approach
1 - clinical disorders
2 - personality disorders/mental retardation
3 - general medical conditions
4 - psychosocial and environmental problems
5 - global assessment of functioning
DSM-V (updates from DSM-IV)
Published 2013
Abandoned use of multiaxial diagnosis and global assessment of functioning
Autistic disorder, Asperger’s, and pervasive developmental disorder were consolidated into one disorder: Autistic spectrum disorder.
Binge eating disorder, premenstrual dysphoric disorder, and hoarding disorder gained recognition as ‘real’ disorders.
DSM-V (modifications to psychosis)
Removal of ‘bizarre’ delusions
Removal of subtypes of schizophrenia
3 core symptoms recognised: delusions, hallucinations, disorganised speech
Changes in schizoaffective criteria
DSM-V (modifications to mood disorders)
Dysthymia and chronic depression merged
Bereavement no longer an exclusion for depression
Premenstrual dysphoric disorder added as a new diagnosis
DSM-V (modifications to developmental disorders)
Autistic disorder, Asperger’s, and pervasive developmental disorder were consolidated into one disorder: Autistic spectrum disorder.
ADHD age criteria relaxed
Anton’s syndrome
aka Anton-Babinski syndrome
Occurs following damage to the occipital lobe.
Affected individuals are cortically blind but are unaware of this and deny they have a problem (anosognosia). It often presents as the patient starts falling over furniture as they can’t see. Affected individuals believe they can still see and describe their environments in detail but are wrong in their description (confabulation).
Anosognosia
lack of insight
multiple choice questionnaire used to rate the severity of depression.
Depending on the version used there are either 17 or 21 items. Each item is scored out of between 3 and 5 points. The greater the total points scored the more severe the depression is.
For the 17 item version (the most commonly used) scores range between 0 and 54. Scores over 24 indicate a severe depression.
HAMD (Hamilton depression rating scale)
10-item diagnostic questionnaire used to measure the severity of depressive episodes.
It was designed to be more sensitive to the changes brought on by antidepressants and other forms of treatment.
MADRS (Montgomery-Asberg depression rating scale)
assesses the severity of depression.
There are 20 items on the scale, each one scored out of 1-4.
ZSRDS (Zung self rated depression scale)
assesses the severity of depression
21 items, each scored 0-3.
The scale was revised in 1966.
0-13 indicates minimal depression,
14-19 mild depression,
20-28 moderate,
29-63 severe depression.
BDI (Beck depression inventory)
30 item self-report scale used to screen for depression in the elderly.
Each question has either a yes or no response, making the total score out of 30.
0-9 is deemed normal,
10-19 is mild depression,
20-30 is severe depression.
GDS (geriatric depression scale)
screening test for depression.
It uses a deck of cards with statements such as ‘I’ve lost interest in things’ which are shown to the patient. In response to each card, the patient indicates whether the card is true or false by pointing to another card.
There are 19 cards with a maximum score of 21 (two cards carry 2 points each).
It is a quick test and takes less than 5 minutes to administer. A cut off score of 7 is generally used.
The test was developed for use on busy wards to introduce a degree of privacy as other tests involve questions being read out and someone in the next cubicle hearing everything.
BASDEC (Brief Assessment Schedule Depression Cards)
This test was developed specifically to screen for depression in dementia cases. It involves a 20 min interview with a carer and 10 mins with the patient.
A total of 19 items are rated as either ‘absent’, ‘mild / intermittent’, or ‘severe’.
Cornell Scale for Depression in Dementia
11-item instrument used to assess the severity of mania in patients with a diagnosis of bipolar disorder.
YMRS (Young mania rating scale)
14 item scale designed to measure the severity of anxiety.
HAMA (Hamilton anxiety rating scale)
used to measure both the severity of OCD and the response to treatment.
Y-BOCS (Yale-Brown Obsessive compulsive scale)
a common instrument used to evaluate psychopathology in patients with schizophrenia, it has now been largely replaced by the PANSS.
It is rated by a clinician and consists of 24 items, each rated out of a 7 point scale of severity. Higher score indicate greater severity of symptoms.
Ratings for several of the variables are based on observation, the remainder are assessed via a short interview.
BPRS (Brief psychiatric rating scale)
looks at both positive and negative symptoms in schizophrenia. It takes a wide sample of information, including data from and interview, along with reports from hospital staff and family. The information gathered is based on how the patient was in the previous week.
PANSS (Positive and negative syndrome scale)
used as part of axis V of the DSM-IV. It provides a single measure of global functioning.
It enquires about psychological and occupational functioning only.
The total score is out of 100. A score of 100 is the best that can be achieved and indicates that a patient functions at the highest level possible.
GAF (Global assessment of functioning)
a scale that requires the clinician to rate the severity of the patient’s illness at the time of assessment, relative to the clinician’s past experience with patients who have the same diagnosis.
CGI (Clinical global impression)
used to quantify discontinuation symptoms associated with stopping antidepressants.
43-item rating scale - spans a broad spectrum of discontinuation symptoms and can be helpful in documenting symptoms of depressed patients in order to diagnose the likely cause of distress.
DESS (Discontinuation-Emergent Signs and Symptoms scale)
BDI (Beck depression inventory)
Self-rated or clinician-rated?
Self-rated
GHQ (General health questionnaire)
Self-rated or clinician-rated?
Self-rated
GDS (geriatric depression scale)
Self-rated or clinician-rated?
Self-rated
ZSRDS (Zung self rated depression scale)
Self-rated or clinician-rated?
Self-rated
HAD (Hospital Anxiety depression scale)
Self-rated or clinician-rated?
Self-rated
EPDS (Edinburgh postnatal major depression scale)
Self-rated or clinician-rated?
Self-rated
BPRS (Brief psychiatric rating scale)
Self-rated or clinician-rated?
Clinician-rated
MADRS (Montgomery-Asberg depression rating scale)
Self-rated or clinician-rated?
Clinician-rated
HAMD (Hamilton depression rating scale)
Self-rated or clinician-rated?
Clinician-rated
HAMA (Hamilton anxiety rating scale)
Self-rated or clinician-rated?
Clinician-rated
PANSS (Positive and negative syndrome scale)
Self-rated or clinician-rated?
Clinician-rated
CGI (Clinical global impression)
Self-rated or clinician-rated?
Clinician-rated
AIMS (Abnormal involuntary movement scale)
Self-rated or clinician-rated?
Clinician-rated
Y-BOCS (Yale-Brown Obsessive compulsive scale)
Self-rated or clinician-rated?
Clinician-rated
YMRS (Young mania rating scale)
Self-rated or clinician-rated?
Clinician-rated
GAF (Global assessment of functioning)
Self-rated or clinician-rated?
Clinician-rated
SAS (Simpson-Angus scale)
Self-rated or clinician-rated?
Clinician-rated
CAMDEX (Cambridge Mental Disorders of the Elderly Examination)
Self-rated or clinician-rated?
Clinician-rated
Cornell Scale for Depression in Dementia
Self-rated or clinician-rated?
Clinician-rated
Brief Assessment Schedule Depression Cards (BASDEC)
Self-rated or clinician-rated?
Clinician-rated
Assumed that doctor knows best. Doctor decides treatment and patient is expected to simply comply
(Model of doctor-patient relationship)
Paternalistic (aka autocratic model)
Doctor provides information and the patient is left to make the choice themselves
(Model of doctor-patient relationship)
Informative
The doctor understands the patient and helps the patient make a decision based on their circumstances. This involves shared decision making and involves the participation of the patient
(Model of doctor-patient relationship)
Interpretive
The doctor acts as a friend to the patient and attempts to steer them in a particular course of action which they see is in their best interest but ultimately the choice is left to the patient
(Model of doctor-patient relationship)
Deliberative
Models of doctor-patient relationship (4)
Paternalistic (aka Autocratic)
Informative
Interpretive
Deliberative
Glasgow Coma Scale (scores for coma/impaired consciousness)
Scores range from 3 (deep coma) to 15 (normal).
Impaired consciousness is rated as:
mild (13-15),
moderate (9-12),
severe (3-8).
GCS (E)
4 Spontaneous opening
3 Opens to verbal stimuli
2 Opens to pain
1 No response
GCS (V)
5 Orientated 4 Confused conversation 3 Inappropriate words 2 Incoherent 1 No response
GCS (M)
6 Obeys commands
5 Purposeful movement to painful stimuli
4 Withdraws in response to pain
3 Flexion in response to pain (decorticate posturing)
2 Extension in response to pain (decerebrate posturing)
1 No response
Clinical syndromes associated with substance use (8)
Acute intoxication Harmful use Dependence Withdrawal state Withdrawal delirium Psychotic disorder Amnesic syndrome Late-onset disorders
Transient disturbance in the level of consciousness, cognition, perception, affect or behaviour, or other psychophysiological functions and responses.
Acute intoxication
A pattern of substance use that is causing damage to physical or mental health.
Should not be diagnosed if dependence syndrome or substance-induced psychosis are diagnosed.
Harmful use
A cluster of behavioural, cognitive, and physiological phenomena that develop after repeated substance use and that typically include a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal state.
Dependence
A group of symptoms of variable clustering and severity occurring on absolute or relative withdrawal of a psychoactive substance after persistent use of that substance.
The onset and course are time-limited and are related to the type of psychoactive substance and dose being used immediately before cessation or reduction of use.
May be complicated by convulsions.
Withdrawal state
Withdrawal accompanied by confusional state
Withdrawal delirium
A cluster of psychotic phenomena that occur during or following psychoactive substance use but that are not explained on the basis of acute intoxication alone and do not form part of a withdrawal state.
Psychotic disorder (substance use syndrome)
A syndrome associated with chronic prominent impairment of recent and remote memory.
Immediate recall is usually preserved and recent memory is characteristically more disturbed than remote memory.
Disturbances of time sense and ordering of events are usually evident, as are difficulties in learning new material. Confabulation may be marked but is not invariably present. Other cognitive functions are usually relatively well preserved and amnesic defects are out of proportion to other disturbances.
Amnesic syndrome
A disorder in which alcohol- or psychoactive substance-induced changes of cognition, affect, personality, or behaviour persist beyond the period during which a direct psychoactive substance-related effect might reasonably be assumed to be operating.
Late-onset (substance use) disorders
Kraepelin Mixed States (6)
Manic Stupor Mania with poverty of thought Inhibited mania Depressive-anxious Mania Excited depression Depression with flight of ideas
Manic Stupor (mood, will, thought)
Mood - high
Will - low
Thought - low
Mania with poverty of thought (mood, will, thought)
Mood - high
Will - high
Thought - low
Inhibited mania (mood, will, thought)
Mood - high
Will - low
Thought - high
Depressive-anxious mania (mood, will, thought)
Mood - low
Will - high
Thought - high
Excited depression (mood, will, thought)
Mood - low
Will - high
Thought - low
Depression with flight of ideas (mood, will, thought)
Mood - low
Will - low
Thought - high
— refers to a deficiency in understanding, processing, or describing emotions.
- A difficulty identifying feelings and distinguishing between feelings and the bodily sensations of emotional arousal
- A difficulty describing feelings to other people
- Constricted imaginal processes, as evidenced by a scarcity of fantasies
- A stimulus-bound, externally oriented cognitive style
Alexithymia
The patient cannot read but is able to write. Understanding spoken language and conversation are intact.
This is usually due to a lesion destroying the left visual cortex, as well as the connections to the right visual cortex in the corpus callosum.
It is typically caused by an occlusion of a branch of the PCA.
Alexia without agraphia
Depressive pseudodementia
Not a diagnostic entity but a descriptive term used in old-age psychiatry.
Depression in elderly patients may present as dementia clinically.
5A’s of Alzheimer’s disease
Amnesia Aphasia Agnosia Apraxia Associated disturbances (behavioural changes, delusions, hallucinations)
Amnesia (definition)
Impaired ability to learn new information and recall previously learned information
Aphasia (definition)
Problems with language (receptive and expressive)
Agnosia (definition)
Problems with recognition, especially people
Apraxia (definition)
Inability to carry out purposeful movements despite there being no sensory or motor impairment
Distinction between dementia with lewy bodies and Parkinson’s disease dementia
Parkinson’s disease dementia is diagnosed if parkinsonian symptoms have existed for more than 12 months before dementia develops.
If motor symptoms and cognitive symptoms develop within 12 months of each other, then LWD is usually diagnosed.
Schneider’s First Rank Symptoms (11)
Not pathognomic, but are highly suggestive of a diagnosis of schizophrenia. They are not useful in prognosis.
3 Hallucinations
- 3rd person voices arguing
- Running commentary
- Thought echo
3 Delusions of thought control
- Thought withdrawal
- Thought insertion
- Thought broadcasting
3 ‘Made’ phenomena
- Made affect
- Made volition
- Made impulse
2 extras:
- Delusional perception
- Somatic passivity
Schizophrenia (ICD-10 subtypes - 9)
Paranoid Hebephrenic (aka disorganised) Catatonic Undifferentiated Post schizophrenic depression Residual Simple Other Unspecified
Paranoid schizophrenia (key features)
characterised by the preoccupation of delusions or hallucinations (typically persecutory or grandiose ones).
Hebephrenic (disorganised) schiziphrenia (characterisation)
characterised by a regression to a primitive, unorganized form of behaviour. Incongruous behaviour such as grinning is common.
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it has the worst prognosis among the subtypes of schizophrenia
Catatonic schizophrenia (characterisation)
characterised by marked disturbances in motor function such as stupor, posturing, and rigidity.
— refers to patients who lack active psychotic symptoms but still have milder symptoms such as emotional blunting, and mild loosening of association.
Residual schizophrenia
Simple schizophrenia (characterisation)
characterised by predominately negative symptoms of schizophrenia in the absence of overtly psychotic experiences.
Bouffee delirante
described by Legrain
a brief shorted lived psychosis that lasts less than 3 months.
Schizophrenia - positive symptoms (3)
Hallucinations
Delusions
Thought disorder
Schizophrenia - negative symptoms (6)
Social withdrawal Apathy Lack of energy Poverty of speech Flattening of affect Anhedonia
Schizotypal disorder (features, time criterion and classification)
Features
- eccentric manners, social withdrawal, magical thinking, suspiciousness, obsessive ruminations.
- 2 year history with no schizophrenia diagnosed
In ICD-10 it is classified with schizophrenia and related disorders;
in DSM-IV it is classified with Cluster A personality disorders
De Clerambault Syndrome
Erotomania.
A DSM-IV subtype of delusional disorder where a patient falsely believes that a person with higher status is secretly in love with them.
Grandiose delusion
Belief that one has a special role, relationship, or ability.
Othello syndrome
Belief that a sexual partner is cheating on them
Persecutory delusion
Most common form of delusional disorder -
Patients are convinced that others are attempting to hurt or harm them. Can lead them to try to obtain legal recourse.
Folie a deux
Shared delusion.
A syndrome where a delusion is transmitted from one person to another.
Ekboms’ syndrome
Delusional parasitosis
The belief that the skin is infested with parasites.
Sometimes a/w cocaine use
Capgras delusion
Belief that a person close to them has been replaced by a double
Fregoli delusion
Belief that strangers are actually persons well known to the patient in disguise.
Lycanthropy
belief that one has been transformed into an animal
Cotard syndrome
belief that one does is dead or does not exist, or that a part of one’s body (e.g. organs) are not there
Delusional perception
belief that a normal percept (product of perception) has a special meaning.
Pseudocyesis
a condition whereby a woman believes herself to be pregnant when she is not. Objective signs accompany the belief such as abdominal enlargement, menstrual disturbance, apparent foetal movements, nausea, breast changes, and labour pains.
Process schizophrenia (description)
Langfeldt (1939) differentiated two groups of psychoses:
- ‘Genuine’ or ‘process’ schizophrenia - poor prognosis
- ‘Schizophreniform’ psychosis - good prognosis
(later work reclassified Langfeldt’s second category as affective disorders with psychotic features)
Approximate answers
Patient gives an incorrect response to a question, but the nature of the response suggests that they understand the question
e.g. stating that a dog has three legs
consists of 14 questions, 7 for anxiety and 7 for depression
each item is scored from 0-3
produces a score out of 21 for both anxiety and depression
severity: 0-7 normal, 8-10 borderline, 11+ case
patients should be encouraged to answer the questions quickly
Hospital Anxiety and Depression (HAD) Scale
asks patients ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’
9 items which can then be scored 0-3
includes items asking about thoughts of self-harm
depression severity: 0-4 none, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe
Patient Health Questionnaire (PHQ-9)
Duration of symptoms required for diagnosis of depression (ICD-10 and DSM-IV)
2 weeks
Grading of depression (ICD-10)
‘4-6-8 rule’
Mild depression
- 2 core symptoms, with 4 symptoms in total
Moderate depression
- 2 core symptoms, with 6 symptoms in total
Severe depression
- 2 core symptoms with 8 symptoms in total
Recurrent major depressive disorder (time criterion)
In both ICD-10 and DSM-IV this can be diagnosed if there has been at least one previous major depressive episode separated by the current episode by at least 2 months
Duration of symptoms required for diagnosis of mania (ICD-10 and DSM-IV)
7 days
or any duration if hospitalised
Duration of symptoms required for diagnosis of hypomania
4 days
Precipitants of drug-induced mania (4)
Levodopa
Corticosteroids
Anabolic-androgenic steroids
Antidepressants (tricyclic and monoamine oxidase inhibitor classes)
Rapid cycling bipolar disorder (essence)
at least four depressive, manic, hypomanic, or mixed episodes in a 12 month period
Gerald Klerman - additional Bipolar subtypes (III, IV, V, VI)
Bipolar III - Cyclothymic disorder
Bipolar IV: Hypomania or mania precipitated by antidepressant drugs
Bipolar V: Depressed patients with a family history of bipolar illness
Bipolar VI: Mania without depression (unipolar mania)
Double Depression (essence)
Episode of major depression superimposed on Dysthymia
A persistent instability of mood involving numerous periods of depression and mild elation, none of which is sufficiently severe or prolonged to justify a diagnosis of bipolar affective disorder (F31.-) or recurrent depressive disorder (F33.-)
Cyclothymia
A chronic depression of mood, lasting at least several years, which is not sufficiently severe, or in which individual episodes are not sufficiently prolonged, to justify a diagnosis of severe, moderate, or mild recurrent depressive disorder
Dysthymia
Generalised anxiety disorder - ICD-10 (symptom and duration criterion)
At least 4 symptoms should be present on most days for 6 months
Obsession - essence and criteria (4)
any thought, image, or idea that is present for a minimum of 2 weeks (ICD-10) and has the following features:
1 - acknowledged as arising from within the mind
(i.e. they are not psychotic beliefs that others have implanted the thoughts)
2 - Repetitive
3 - The patient must try to resist
4 - They are not pleasurable
Compulsion (essence)
physical or mental repetitive behaviours that are used to relieve some of the anxiety caused by the obsessions.
The person is aware that their actions are not realistically connected to what they are trying to neutralize or prevent and know they are excessive.
Abnormal grief - classification (3)
Inhibited
Chronic/Prolonged
Delayed
‘ICD’
Inhibited grief (essence)
Absence of expected grief symptoms at any stage
Delayed grief (essence)
Avoidance of painful symptoms within 2 weeks of loss
Chronic/prolonged grief (essence)
Continued significant grief related symptoms 6 months after loss
Normal grief - phases (4)
Phase I - shock and protest (few days)
- numbness, disbelief
Phase II - preoccupation (few weeks)
- yearning, anger
Phase III - disorganisation (several months)
- despair, acceptance of loss
Phase IV - resolution (1-2 years)
- gradual return to normality
PTSD - key features (3)
HYPERAROUSAL
- persistent anxiety
- irritability
- insomnia
- poor concentration
HYPERVIGILANCE
- (due to re-experiencing)
- recurrent distressing dreams
- intensive, intrusive imagery (flashbacks, vivid memories)
- difficulty recalling stressful events at will
AVOIDANCE
- of reminders/activities/places related to traumatic events
- detachment from others
- emotional numbness
- anhedonia
PTSD (duration criterion)
Onset within 6 months of trauma
Somatoform disorders (essence)
a group of disorders characterised by physical symptoms that are presumed to have a psychiatric origin
Briquet’s syndrome (aka, essence)
aka Somatisation disorder, St Louis Hysteria
- multiple physical complaints (>2yrs) affecting many organ systems that cannot be explained by physical disorders
- persistent refusal to accept advice/reassurance from doctors
more common in women, and normally begins before the age of 30. It is inversely related to social class, and is therefore more common in those with low education and limited incomes.
a neurological complaint that is related to stress or conflict. It is more common in women and is uncommon in the elderly.
It usually presents with weakness, paralysis, pseudoseizures, involuntary movements and sensory disturbances (e.g. Blindness).
It is classically associated with the term La belle indifference which refers to the absence of distress despite the presence of a distressing symptom.
Conversion disorder
aka Dissociative disorder (ICD-10)
… is characterized by a patient’s insistence that they suffer with a particular disease, despite evidence to the contrary
Hypochondriasis
… is characterized by the false belief or exaggerated perception that a part of the body is in some way defective. The most common area perceived to be affected is the skin, followed by the hair, nose, toes, and then weight.
Body dysmorphic disorder
Disssociation disorders (essence)
loss of integration among memories, identity, sensations and control of bodily movements
usually occur suddenly in response to a trauma or other intolerable situation. They tend to remit spontaneously after a few weeks to months
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previously referred to as ‘hysteria’
Neurasthenia (essence)
classified in F48 ICD-10 as a neurotic disorder
- increased fatigue after mental effort
- bodily or physical weakness and exhaustion after only minimal effort, accompanied by a feeling of muscular aches and pains and inability to relax
the closest ICD-10 equivalent of chronic fatigue syndrome
Anorexia nervosa - diagnostic criteria (4)
- LOW BODY WEIGHT
Refusal to maintain body weight above 85% of what is expected (i.e. >15% below expected norm), and BMI 17.5 or less - SELF-INDUCED WEIGHT LOSS
(avoidance, vomiting, purging, exercise) - BODY IMAGE DISTORTION
- ENDOCRINE DISTURBANCE
(amenorrhoea, reduced sexual interest, raised GH levels, raised cortisol, altered TFTs, abnormal insulin secretion)
Anorexia nervosa - DSM-IV subtypes (2)
Restricting type
Binge-eating/purging type
Atypical anorexia nervosa (essence)
a number of symptoms of anorexia that do not completely fulfil the diagnostic criteria for typical anorexia nervosa
Narcolepsy (essence)
- excessive sleepiness
- cataplexy
- Sleep paralysis, hypnagogic hallucinations, automatic behaviour, and nocturnal sleep disruption commonly occur in patients with narcolepsy. Both sleep paralysis and hypnagogic hallucinations almost always correspond with sleep-onset REM periods.
Cataplexy (essence)
sudden loss of bilateral muscle tone provoked by strong emotion.
Consciousness remains clear, memory is not impaired, and respiration is intact. The duration is usually short, ranging from a few seconds to several minutes, and recovery is immediate and complete.
Cataplexy (treatment)
Tricyclic antidepressants
characterised by periodic episodes of repetitive and highly stereotyped limb movements that occur during sleep. The movements usually occur in the legs and consist of extension of the big toe in combination with partial flexion of the ankle, knee, and sometimes hip. Similar movements can occur in the upper limbs.
The movements are often associated with a partial arousal or awakening, however, the patient is usually unaware of the limb movements or the frequent sleep disruption.
Periodic limb movement disorder
characterised by disagreeable leg sensations that usually occur prior to sleep onset and that cause an almost irresistible urge to move the legs.
Restless legs syndrome
sudden, brief contractions of the legs, sometimes also involving the arms and head, that occur at sleep onset.
usually consist of a single contraction that often affects the body asymmetrically. The jerks may be either spontaneous or induced by stimuli.
sometimes associated with the subjective impression of falling, a sensory flash, or a visual hypnagogic dream or hallucination. A sharp cry may occur.
Sleep starts
Personality disorder (DSM) - classification
Cluster A - ‘Mad’
- Paranoid
- Schizoid
- Schizotypal (classified with schizophrenia in ICD-10)
Cluster B - ‘Bad’
- Antisocial (ICD-10 ‘dissocial’)
- Borderline (ICD-10 EUPD impulsive or borderline subtypes)
- Histrionic
- Narcissistic (ICD-10 classifies as ‘Other PD’)
Cluster C - ‘Sad’
- Avoidant (ICD-10 ‘anxious (avoidant) PD’)
- Dependent
- Obsessive-compulsive (ICD-10 anankastic)
‘A3, B4, C3’
… Personality Disorder:
Suspicious of other people and their motives
Holds longstanding grudges against people
Believes others are not trustworthy
Emotionally detached
Feels other people are deceiving, threatening, or making plans against them.
Paranoid Personality Disorder
… Personality Disorder:
Has difficulties in expressing emotions, particularly around warmth or tenderness. Prefers loneliness
Aloof or remote
Difficulty in developing or maintaining social relationships
Unaware of social trends
Unresponsive to praise or criticism
Schizoid Personality Disorder
… Personality Disorder:
Appears odd or eccentric;
May have illusions, magical thinking Obsessions without resistance
May be members of quasi-cultural groups Thought disorders and paranoia
May believe in ESP, clairvoyance etc
May have transient psychotic features
Schizotypal Personality Disorder
… Personality Disorder:
Lack of regard for the rights and feelings of other people
Lack of remorse for actions that may hurt others
Ignores social norms about acceptable behaviour
May disregard rules and break the law
Make relations easily but break them equally easily
A small proportion may be psychopathic
Antisocial Personality Disorder
… Personality Disorder
Poor self-image,
Unstable personal relationships,
Impulsive behaviour in areas such as personal safety and substance misuse.
May self-harm, feel suicidal and act on these feelings,
Experience instability of mood,
Have episodes of micro-psychosis.
Feelings of chronic emptiness
Fears of abandonment – rejection sensitivity hence form intense but short lasting relations
Borderline Personality Disorder
… Personality Disorder
Extreme or over-dramatic behaviour.
May form relationships quickly, but be demanding
Attention-seeking.
May appear to others as being self-centred with shallow emotions
Inappropriately sexually provocative.
Histrionic Personality Disorder
… Personality Disorder:
Exaggerated sense of own importance. Self-centred
Intolerant of other people.
Grandiose plans and ideas
Cravings for attention and admiration.
Fear of dependency is the core conflictual theme
Narcissistic injuries to pride lead to rage reactions.
Narcissistic Personality Disorder
… Personality Disorder
Fears being judged negatively by other people
Feelings of discomfort in group or social settings
May come across as being socially withdrawn
Have low self-esteem.
May crave affection but fears of rejection overwhelming.
Avoidant Personality Disorder
Personality Disorder:
Assumes a position of passivity,
Allows others to assume responsibility for most areas of their daily life
Lacks self-confidence,
Feels unable to function independently of another person,
Feels own needs are of secondary importance.
Dependent Personality Disorder
Personality Disorder:
Difficulties in expressing warm or tender emotions to others
Perfectionist
Often lacks clarity in seeing other perspectives or ways of doing things
Rigid attention to detail may prevent them from completing tasks
Some may be hoarders, scrupulous with money
May not be able to delegate tasks; workaholics.
Obsessive-Compulsive Personality Disorder
Mental Retardation - classification (4)
Grade (IQ range):
- Mild (50-69)
- Moderate (35-49)
- Severe (20-34)
- Profund (<20)
Autistic spectrum disorder (essence)
a pervasive and life-long disorder, characterised by
- deficits in social communication and social interaction
- restricted, repetitive behaviours/interests/activities (RRBs)
Rett Syndrome
rare (1:10,000 female births) neurodevelopmental disorder found almost exclusively in females
- normal development until 6-18months, followed by:
- loss of speech
- loss of purposeful hand movements, replaced with stereotypic movements e.g. handwringing
- ataxia and psychomotor retardation
- deceleration in head growth -> microcephaly
- epilepsy (75%)
- breathing problems - episodes of hyperventiliation, apnoea, breath-holding
Heller Syndrome (aka, essence)
Childhood Disintegrative Disorder
a rare condition characterised by late onset of developmental delays—or severe and sudden reversals—in language, social function, and motor skills.
Landau-Kleffner Syndrome (aka, essence)
Acquired Aphasia with Epilepsy
Despite previously normal progress in language development, a child loses both receptive and expressive language skills but retains general intelligence
Epilepsy with paroxysmal EEG abnormalities is noted, always originating bilaterally from the temporal lobes
Perceptual psychopathology - taxonomy
Sensory distortions
- changes in intensity
- changes in quality
- changes in spacial form
Sensory deceptions
- illusions
- hallucinations
Hyperaesthesia (definition)
increased intensity of sensations
Hyperacusis (definition)
increased intensity of noise
Chromatopsia (definition)
visual aberration in which objects appear abnormally coloured
Pelopsia (definition)
vision perception disorder in which objects appear nearer than they actually are
Teleopsia (definition)
vision perception disorder in which objects appear much farther away than they are
Micropsia (definition)
sensory distortion in which object appears smaller than it is
Macropsia (definition)
sensory distortion in which object appears larger than it is
Dysmegalopsia (definition)
sensory distortion in which object appears larger on one side than the other
=======================
NB: mrcpsych mentor defines differently:
the diminished ability to appreciate the size of objects. It may present as either an isolated symptom (e.g. micropsia or macropsia) or as part of a cluster of symptoms where it is known as the Alice in Wonderland Syndrome.
Illusion - definition & subtypes (3)
an altered perception of a stimulus
1 - Completion illusions
2 - Affect illusions
3 - Pareidolic illusions
Completion illusion (essence)
altered perception whereby missing information is filled in to make sense of a stimulus
e.g. CCOK is read as COOK
Affect illusion (essence)
altered perception arising in the context of a specific mood state
e.g. a woman is walking home in the dark and is frightened, she mistakes a tree for a tall man in a long coat.
Pareidolic illusion (essence)
altered perception in which detailed images are perceived from ambiguous stimuli
e.g. seeing the face of Jesus on a piece of burnt toast
(Pareidolic illusions tend to occur when a person is concentrating whereas affect and completion illusions occur during inattention)
Hallucination (essence)
a perception in the absence of a stimulus
Gedankenlautwerden
an individual hears thoughts spoken aloud. Thoughts are heard in the form of a voice at the same time as they are thought, not afterwards
Écho de la pensée
meaning “thought echo” in French, thoughts seem to be spoken aloud just after being produced
(cf. Gedankenlautwerden where thoughts are heard at the same time)
Functional hallucination
A patient experiences an hallucination at the same time as receiving a real stimulus in the same sensory modality
e.g. hearing voices whenever the noise of water running through the tap is head
Reflex hallucination
A hallucination in one sensory modality in response to a real stimulus in another sensory modality
e.g. seeing an angel whenever music is heard
Extracampine hallucination
Hallucination experienced outside the normal field of perception
e.g. images seen behind one’s back; voices heard on the other side of the world
Hypnagogic and Hypnopompic hallucinations
HypnaGOgic - GOing to sleep
Hypnopompic - waking up
Lilliputian hallucinations
visual hallucinations whereby the patient experiences seeing people who appear reduced in size or dwarfed
Kinaesthetic hallucination
hallucination of muscle or joint sense.
Patient’s may describe that their limbs are being twisted or bent, or their muscles squeezed. They may also described being rocked about
Autoscopic hallucination
- aka
- description
Phantom mirror image
a person’s experience of seeing a double of themselves in extrapersonal space without the experience of leaving ones body (no disembodiment)
Charles Bonnet Syndrome (essence)
Complex (typically visual) hallucinations usually occurring in the context of elderly patients with visual impairment due to ocular problems, normal consciousness, and no brain pathology.
Insight is usually preserved.
Primary delusion - definition and subtypes (4)
A delusion that arises spontaneously, from normal psychological processes and not as a consequence of prior psychopathology.
1 - Autochthonous delusion
2 - Delusional perception
3 - Delusional memory
4 - Delusional mood
Autochthonous delusion (aka, essence)
aka Delusional Intuition
This is a primary delusion that appears spontaneously and out of the blue i.e. not following any other mental state (whether perception, memory, or mood)
Syndrome of subjective doubles
a rare delusional misidentification syndrome in which a person experiences the delusion that he or she has a double or Doppelgänger with the same appearance, but usually with different character traits, that is leading a life of its own
Intermetamorphosis
a delusional misidentification syndrome, related to agnosia.
The main symptoms consist of patients believing that they can see others change into someone else in both external appearance and internal personality.
Paraprosopia
A delusion in which a person believes he or she has seen a face transform into a grotesque form - often described as a ‘monster’, ‘vampire’, ‘werewolf’ or similar
Aphasia - definition and classification (3)
Dysfunction in language reception and expression.
1 - Fluent (receptive) aphasia
- Wernicke’s aphasia, anomic aphasia, conduction aphasia, transcortical sensory aphasia
2 - Non-fluent (expressive) aphasia
- Broca’s aphasia, transcortical motor aphasia, global aphasia
3 - Pure aphasia
(only affecting a single language skill)
- Pure alexia, pure agraphia, pure word deafness
… occurs due to a lesion in the posterior region of the left superior temporal gyrus (Brodmann area 22).
The main feature is impairment in auditory comprehension. The speech is fluent but meaningless (often referred to as cocktail party speech). Comprehension and expression are equally affected.
Wernicke’s Aphasia (aka semantic aphasia)
… results from damage to the arcuate fasciculus which connects Wernicke’s to Broca’s area.
Poor repetition in comparison to problems with comprehension and spontaneous expression is the hallmark of this syndrome.
Conduction Aphasia
… follows damage to Brodmann areas 44 and 45 in the frontal lobe.
Speech is characteristically non fluent but comprehension is intact. It is often accompanied by agraphia (inability to write).
Broca’s aphasia
Naming or word finding problems are the major feature of this syndrome. Grammar is unaffected and repetition is good. Auditory comprehension is relatively intact.
… is localised with the least reliability of any of the aphasic syndromes.
The lesion is often temporal parietal area. The angular gyrus may also be affected.
Anomic aphasia
Reduplicative paramnesia
a delusional misidentification syndrome in which the patient’s surroundings are believed to exist in more than one physical location
Paraschemazia
a feeling that parts of the body are distorted or twisted or that they are separated from the rest of the body.
It can occur in association with hallucinagenic use, with an epileptic aura, and with migrane.
Wahnstimmung
Delusional Mood (german)
Gegenhalten
a phenomenon in which a patient opposes all passive movements with the same degree of force as applied by the examiner
Schnauzkrampf
a grimace resembling pouting sometimes observed in catatonic patients
Vorbeigehen/ vorbeireden
Approximate answers
(e.g. How many fingers does a man have, answer 14).
Seen in Ganser syndrome.
Properties of thought (4)
Content
Form
Stream/flow
Control
the term ‘formal thought disorder’ is increasingly used for disorders of both form and stream/flow
Asyndesis (aka)
Loosening of associations.
A milder form of derailment of thought, it is marked by the individual leaping from topic to topic which have only the most tenuous, if any, connection with each other.
Excessive speech at a rapid rate that involves causal association between ideas. Links between ideas may involve usage of clang associations,puns or rhymes.
Flight of ideas
This refers to a person being unable to answer a question without giving excessive, unnecessary detail.
It differs from tangential thinking, in that the person does eventually return to the original point, circling back on-topic.
Circumstantiality
This term refers to uncontrollable repetition of a particular response, such as a word, phrase, or gesture, despite the absence or cessation of the original stimulus.
Usually it is seen in organic disorders of brain, head injury, delirium or dementia, however can be seen in schizophrenia as well.
Perseveration
an abrupt stop in the middle of a train of thought; the individual might or might not be unable to continue the idea.
This is type of formal thought disorder that can be seen in schizophrenia.
Thought block
Akataphasia (essence, term coined by…)
A syntactic disturbance of speech resulting from dissolution of logical ordering of thoughts
Kraeplin (1896)
Speech that has an excessively formal quality. It may seem outdated, pompous, or over polite.
Stilted speech
FTD occuring in schizophrenia.
Thoughts are described as being passively concentrated and compressed in the patient’s head. The associations are experienced as being excessive in amount, too fast, and outside the person’s control.
Crowding of thought
Catatonia (essence)
the psychiatric syndrome of disturbed motor functions amid disturbances in mood and thought
a state of psycho-motor immobility and behavioural abnormality manifested by stupor
….. (date) is credited with the original clinical description of catatonia.
Karl Ludwig Kahlbaum (1828-1899)
Features of catatonia:
combination of immobility and mutism
Stupor
Features of catatonia:
maintaining the same posture for long periods. A classic example is the ‘crucifix’. An extreme version is catalepsy
Posturing
Features of catatonia:
(cerea flexibilitas) - patient can be positioned in uncomfortable postures, which are maintained for a considerable period of time.
Waxy flexibility
Features of catatonia: (x2 names)
patient resists the attempts of the examiner to move parts of their body and, according to the original definition, the resistance offered is exactly equal to the strength applied
Negativism (aka Gegenhalten)
Features of catatonia:
exaggerated cooperation, automatically obeying every instruction of the examiner.
Automatic obedience
Features of catatonia:
a form of automatic obedience whereby the body of the patient can be put into any posture, even if the patient is given instructions to resist. The body part immediately returns to the original position once the force is removed (unlike in waxy flexibility)
Mitmachen
Features of catatonia:
the examiner is able to move the patient’s body with the slightest touch (anglepoise lamp sign).
Mitgehen
an extreme form of mitmachen
Features of catatonia:
The patient alternates between resistance to and cooperation with the examiner’s instructions;
for example, when asked to shake hands, the patient repeatedly extends and withdraws the hand
Ambitendency
Features of catatonia:
The patient assumes a reclining posture, with their head a few inches above the bed surface, and is able to maintain this position for prolonged periods
Psychological pillow
Features of catatonia:
The patient forcibly and repeatedly grasps the examiner’s hand when offered
Forced grasping
Features of catatonia:
The patient stops suddenly in the course of a movement and is generally unable to give a reason. This appears to be the motor counterpart of thought block
Obstruction
Features of catatonia:
The patient imitates the actions of the interviewer
Echopraxia
Features of catatonia:
The patient turns away from the examiner when addressed
Aversion
Features of catatonia:
Repetitive, goal-directed movements (e.g. Saluting)
Mannerisms
Features of catatonia:
Repetitive, regular movements that are not goal-directed (e.g. Rocking)
Stereotypies
Features of catatonia:
The patient persists with a particular movement that has lost its initial relevance
Motor perseveration
Features of catatonia:
Repetition of the examiners words
Echolalia
Features of catatonia:
incoherent talkativeness
Logorrhoea
Features of catatonia:
Meaningless, repetition of words or phrases
Verbigeration
Defence mechanism (definition)
Defence mechanisms psychological strategies that are unconsciously used to protect a person from anxiety arising from unacceptable thoughts or feelings.
Defence mechanisms (Vaillant classification)
Level 1 - Psychotic defences
Level 2 - Immature defences
Level 3 - Neurotic defences
Level 4 - Mature defences
Psychotic defences (Vaillant Classification Level 1) - 4
Distortion
Denial
Delusional projection
Splitting *
‘DDD-S’
- NB not in Vaillant’s original classification but included in mrcpsych mentor
Defence mechanism (+ classification)
A gross reshaping of external reality to meet internal needs
Distortion
Psychotic defences (Vaillant Classification Level 1)
Defence mechanism (+ classification)
proposed by Anna Freud - involves a refusal to accept reality, thus blocking external events from awareness
Denial
Psychotic defences (Vaillant Classification Level 1)
Defence mechanism (+ classification)
Delusions about external reality, usually of a persecutory nature
Delusional projection
Psychotic defences (Vaillant Classification Level 1)
Defence mechanism (+ classification)
The failure in a person’s thinking to bring together the dichotomy of both positive and negative qualities of the self and others into a cohesive, realistic whole.
The individual tends to think in extremes (i.e., an individual’s actions and motivations are all good or all bad with no middle ground).
Splitting
Psychotic defences (Vaillant Classification Level 1)
- NB not in Vaillant’s original classification but included in mrcpsych mentor
Immature defences (Vaillant Classification Level 2) - 7
Schizoid Fantasy Projection Acting out Hypochondriasis Passive aggression Idealization * Projective identification *
‘HIP-SAPP’
- NB not in Vaillant’s original classification but included in mrcpsych mentor
Defence mechanism (+ classification)
Tendency to retreat into fantasy in order to resolve inner and outer conflicts.
e.g. living in a ‘Walter Mitty’ dream world where you imagine you are successful and popular, instead of making real efforts to make friends and succeed at a job.
Schizoid Fantasy
Immature defences (Vaillant Classification Level 2)
Defence mechanism (+ classification)
Falsely attributing your own unacceptable feelings, impulses, or thoughts to another person
e.g. you might hate someone, but your superego tells you that such hatred is unacceptable. You can ‘solve’ the problem by believing that they hate you.
Projection
Immature defences (Vaillant Classification Level 2)
Defence mechanism (+ classification)
Direct expression of an unconscious wish or impulse in action, without conscious awareness of the emotion that drives the expressive behavior.
Acting in a way that enables a person to avoid coming into contact with difficult feelings or anxieties.
e.g. drug use, missed appointments with therapists, and tantrums.
Acting out
Immature defences (Vaillant Classification Level 2)
Defence mechanism (+ classification)
An excessive preoccupation or worry about having a serious illness
Hypochondriasis
Immature defences (Vaillant Classification Level 2)
Defence mechanism (+ classification)
Indirect expression of hostility
e.g. to ‘defeat’ one’s boss, one may proscrastinate and take sick leave in a way that affects the boss more than oneself
Passive aggression
Immature defences (Vaillant Classification Level 2)
Defence mechanism (+ classification)
The ascribing of omnipotence to another person or organisation e.g. ‘you will save me’
Idealisation
Immature defences (Vaillant Classification Level 2)
- NB not in Vaillant’s original classification but included in mrcpsych mentor
Defence mechanism (+ classification)
An aspect of the self is first projected onto someone else. The projector then tries to coerce the recipient to identify with what has been projected and both feel a sense of union. This may result in the recipient behaving in a manner similar to the projector.
Projective identification.
Immature defences (Vaillant Classification Level 2)
- NB not in Vaillant’s original classification but included in mrcpsych mentor
Neurotic defences (Vaillant Classification Level 3) - 11
Displacement Dissociation Reaction formation Repression Intellectualization Isolation * Regression * Rationalization * Controlling * Externalization * Undoing *
‘DD-RR-II-RR-CEU’
- NB not in Vaillant’s original classification but included in mrcpsych mentor
Defence mechanism (+ classification)
Interest and/or emtoion is shifted from one object onto another less-threatening one, so that the latter replaces the former.
e.g. a person loses a child in a road accident, then devotes themselves tirelessly to campaigning against dangerous driving;
a person has problems at work and then expresses anger felt for their boss onto their family at home
Displacement
Neurotic defences (Vaillant Classification Level 3)
Defence mechanism (+ classification)
Converting unconscious wishes or impulses that are perceived to be dangerous or unacceptable into their opposites; behaviour that is completely the opposite of what one really wants or feels; taking the opposite belief because the true belief causes anxiety
e.g. Freud claimed that men who are prejudice against homosexuals are making a defense against their own homosexual feelings by adopting a harsh anti-homosexual attitude which helps convince them of their heterosexuality.
Reaction formation
Neurotic defences (Vaillant Classification Level 3)
Defence mechanism (+ classification)
The unconscious forgetting of painful ideas or impulses in order to protect the psyche
Repression
Neurotic defences (Vaillant Classification Level 3)
Defence mechanism (+ classification)
concentrating on the intellectual components of a situation so as to distance oneself from the associated anxiety-provoking emotions; thinking about wishes in formal, affectively bland terms and not acting on them; avoiding unacceptable emotions by focusing on the intellectual aspects
Intellectualization
Neurotic defences (Vaillant Classification Level 3)
Defence mechanism (+ classification)
Temporary drastic modification of one’s personal identity or character to avoid emotional distress; separation or postponement of a feeling that normally would accompany a situation or thought
Dissociation
Neurotic defences (Vaillant Classification Level 3)
Defence mechanism (+ classification)
Splitting or separating an idea from the affect that accompanies it normally but is now repressed
Isolation
Neurotic defences (Vaillant Classification Level 3)
- NB not in Vaillant’s original classification but included in mrcpsych mentor
Defence mechanism (+ classification)
Reverting back to an earlier stage of development when faced with an unpleasant thought or emotion
Regression
Neurotic defences (Vaillant Classification Level 3)
- NB not in Vaillant’s original classification but included in mrcpsych mentor
Defence mechanism (+ classification)
Finding excuses that will justify unacceptable behaviours when self-esteem is threatened.
(This is easily confused with intellectualisation but in the latter the patient is not in contact with their emotions. In this, the patient feels the distress but seeks to find alternative reasons for them to avoid the full reality of the situation.)
e.g. it was okay for my to behave as I did because he hit me firsth
Rationalization
Neurotic defences (Vaillant Classification Level 3)
- NB not in Vaillant’s original classification but included in mrcpsych mentor
Defence mechanism (+ classification)
Projecting into the external world and in external objects elements
of one’s own personality, including instinctual impulses, conflicts, moods, attitudes, and styles of thinking. — is a more general term than projection
Externalisation
Neurotic defences (Vaillant Classification Level 3)
- NB not in Vaillant’s original classification but included in mrcpsych mentor
Defence mechanism (+ classification)
a person tries to cancel out or remove an unhealthy, destructive or otherwise threatening thought or action by engaging in contrary behavior
e.g. after thinking about being violent with someone, one would then be overly nice or accommodating to them
Undoing
Neurotic defences (Vaillant Classification Level 3)
- NB not in Vaillant’s original classification but included in mrcpsych mentor
Mature defences (Vaillant Classification Level 4) - 7
Altruism Anticipation Sublimation Suppression Humor Identification * Introjection *
‘SASHA - II’
- NB not in Vaillant’s original classification but included in mrcpsych mentor
Defence mechanism (+ classification)
Satisfying one’s own needs through the lives of others.
e.g. the man who wishes he had become a doctor may push his family into this career and blame himself if they do not fulfill his expectations
Altruism
Mature defences (Vaillant Classification Level 4)
Defence mechanism (+ classification)
Realistic planning for future discomfort; reducing the stress of some difficult challenge by considering what it will be like and preparing for how you are going to deal with it
Anticipation
Mature defences (Vaillant Classification Level 4)
Defence mechanism (+ classification)
Transformation of unhelpful emotions or instincts into healthy actions, behaviours, or emotions
(Similar to displacement, but takes place when we manage to displace our unacceptable emotions into behaviors which are constructive and socially acceptable, rather than destructive activities.)
e.g. Many great artists and musicians have had unhappy lives and have used the medium of art of music to express themselves. Playing a heavy contact sport such as football or rugby can transform aggression into a game
Sublimation
Mature defences (Vaillant Classification Level 4)
Defence mechanism (+ classification)
The conscious decision to delay paying attention to a thought, emotion, or need in order to cope with the present reality
Suppression
Mature defences (Vaillant Classification Level 4)
Defence mechanism (+ classification)
Overt expression of ideas and feelings (especially those that are unpleasant to focus on or too terrible to talk about directly) that gives pleasure to others. The thoughts retain a portion of their innate distress, but they are “skirted around” by witticism
e.g. self-deprecation
Humour
Mature defences (Vaillant Classification Level 4)
Defence mechanism (+ classification)
The unconscious modelling of one’s self upon another person’s character and behaviour.
A victim adopts the behavior of a person who is more powerful and hostile towards them.
By internalising the behavior of the aggressor the ‘victim’ hopes to avoid abuse, as the aggressor may begin to feel an emotional connection with the victim which leads to feelings of empathy.
e.g. Stockholm syndrome
Identification (with the aggressor)
Mature defences (Vaillant Classification Level 4)
- NB not in Vaillant’s original classification but included in mrcpsych mentor
Defence mechanism (+ classification)
Identifying with some idea or object so deeply that it becomes a part of that person
e.g. taking on attributes of other people who seem better able to cope with a situation than we do.
Introjection
Mature defences (Vaillant Classification Level 4)
- NB not in Vaillant’s original classification but included in mrcpsych mentor
Repression and displacement are seen in which psychiatric disorder?
Phobias
Isolation, undoing, and reaction formation are seen in which psychiatric disorder?
Obsessive compulsive disorder
Projection and splitting are seen in which psychiatric disorders?
Borderline personality disorder
Narcissistic personality disorder
Displacement is seen in which psychiatric disorder?
Agoraphobia
Schizoaffective disorder
- which section of ICD-10 classification?
F20 schizophrenia
According to DSM-IV criteria, the core symptoms of ADHD must have their onset before —- years
7
According to the International Pilot Study of Schizophrenia:
—% of patients with acute schizophrenia exhibited at least one first rank symptom
58%
According to the International Pilot Study of Schizophrenia:
–% of schizophrenics never exhibit a first rank symptom
20%
According to the International Pilot Study of Schizophrenia:
—% of non-schizophrenic patients with psychosis exhibit first rank symptoms of schizophrenia
10%
The onset of autistic disorder is usually before the age of —
3
Common co-morbid psychiatric disorders seen in children with ADHD
(4 + prevalence %)
Oppositional Defiant disorder (35-50%)
Conduct disorder (25%)
Anxiety disorder (25%)
Depressive disorder (15%)
How is Asperger’s syndrome differentiated from other autistic spectrum disorders?
Language development is typically normal in Asperger’s syndrome
Persistent delusional disorder - time criterion
ICD-10
DSM-IV
ICD-10 - 3 months
DSM-IV - 1 month
The International Pilot Study of Schizophrenia - frequency (%) of common symptoms:
- Lack of insight
- Auditory hallucinations
- Ideas of reference
- Suspiciousness
- Flatness of affect
- Lack of insight (97%)
- Auditory hallucinations (74%)
- Ideas of reference (70%)
- Suspiciousness (66%)
- Flatness of affect (66%)
The International Pilot Study of Schizophrenia - frequency (%) of common symptoms:
- Second person hallucinations
- Delusional mood
- Delusions of persecution
- Thought alientation
- Echo De Pensee, Gedankenlautwerden
- Second person hallucinations (65%)
- Delusional mood (64%)
- Delusions of persecution (64%)
- Thought alientation (52%)
- Echo De Pensee, Gedankenlautwerden (50%)
Munchausen syndrome (essence)
self-inflicted lesions and feigned illness with the goal of receiving medical treatment rather than for any other gain.
Post-schizophrenic depression - time criterion
The most recent episode of relapse must not be more than 12 months ago.
Borderline personality disorder
- which symptoms improve most over time?
- which symptoms improve least over time?
Impulsive symptoms resolved the most quickly
Affective symptoms were the most chronic
Cognitive and interpersonal symptoms were intermediate
How long does the natural course of an episode of untreated mania last?
4 months
Rating scales
- 4 purposes
1 Screening for presence of psychiatric condition
2 Diagnosis (often termed ‘diagnostic schedules’)
3 Estimating severity and response to treatment
4 Assess functional capacity/well-being
Rating Scale vs Schedules
Scales
- based on psychometric properties;
- aim to measure dimensions of psychopathology (symptoms) often at the present state
Schedules
- based on clinical expectations;
- deal with categories of disorders (syndromes) based on known classification systems
General Health Questionnaire
- introduced by
- purpose
- items
Introduced by Goldberg
An all-purpose screening tool, used to detect those likely to have or be at risk of developing psychiatric disorders
28-item version is most widely used
(Also available as 12, 30, or 60 items)
HAMD (Hamilton depression rating scale)
- clinician or self rated?
- purpose
- items
- interpretation
clinician-rated
multiple choice questionnaire used to rate the severity of depression
2 versions: 17-item (most common), 21-item
For the 17 item version 0 scores range between 0 and 54. Scores over 24 indicate a severe depression.
MADRS (Montgomery-Asberg depression rating scale)
- clinician or self rated?
- purpose
- items
clinician-rated
Diagnostic questionnaire used to measure the severity of depressive episodes. It was designed to be more sensitive to the changes brought on by antidepressants and other forms of treatment
10 items
ZSRDS (Zung self rated depression scale)
- clinician or self rated?
- purpose
- items
self-rated
assesses the severity of depression
20 items, each scored 1-4
BDI (Beck depression inventory)
- clinician or self rated?
- purpose
- items
- interpretation
self-rated
assesses the severity of depression
21 items, each scored 0-3
0-13 - minimal depression
14-19 - mild depression
20-28 - moderate depression
29-63 - severe depression
GDS (geriatric depression scale)
- clinician or self rated?
- purpose
- items
- interpretation
self-rated
used to screen for depression in the elderly
30 items - yes/no, therefore scored out of 30
0-9 - normal
10-19 - mild depression
20-30 - severe depression
BASDEC (Brief Assessment Schedule Depression Cards)
- clinician or self rated?
- purpose
- items
- interpretation
clinician-rated
screening test for depression - uses a deck of cards with statements such as ‘I’ve lost interest in things’ which are shown to the patient. In response to each card, the patient indicates whether the card is true or false by pointing to another card
19 cards with a maximum score of 21 (two cards carry 2 points each)
A cut off score of 7 is generally used
Cornell Scale for Depression in Dementia
- clinician or self rated?
- purpose
- items
clinician-rated
developed specifically to screen for depression in dementia cases
20 min interview with a carer and 10 mins with the patient.
19 items - rated as either ‘absent’, ‘mild / intermittent’, or ‘severe’
YMRS (Young mania rating scale)
- clinician or self rated?
- purpose
- items
clinician-rated
assesses the severity of mania in patients with a diagnosis of bipolar disorder
11 items
HAMA (Hamilton anxiety rating scale)
- clinician or self rated?
- purpose
- items
clinician-rated
measures the severity of anxiety
14 items
Y-BOCS (Yale-Brown Obsessive compulsive scale)
- clinician or self rated?
- purpose
clinician-rated
measures both the severity of OCD and the response to treatment
BPRS (Brief psychiatric rating scale)
- clinician or self rated?
- purpose
- items
clinician-rated
used to evaluate psychopathology in patients with schizophrenia. based on observation and interview
24 items - each rated out of a 7 point scale of severity. Higher score indicate greater severity of symptoms.
==============
probably the most widely used scale in psychiatry,
although now largely replaced by the PANSS.
PANSS (Positive and negative syndrome scale)
- clinician or self rated?
- purpose
- items
clinician-rated
looks at both positive and negative symptoms in schizophrenia. information gathered is based on how the patient was in the previous week.
30 items
GAF (Global assessment of functioning)
- clinician or self rated?
- purpose
- items
clinician-rated
used as part of axis V of the DSM-IV
provides a single measure of global functioning. It enquires about psychological and occupational functioning only
The total score is out of 100. A score of 100 is the best that can be achieved and indicates that a patient functions at the highest level possible
CGI (Clinical global impression)
- clinician or self rated?
- purpose
- items
clinician-rated
clinician rates the severity of the patient’s illness at the time of assessment, relative to the clinician’s past experience with patients who have the same diagnosis.
2 items
- CGI-S (severity) - scale of 1-7
- CGI-I (improvement) - scale of 1-7
DESS (Discontinuation-Emergent Signs and Symptoms scale)
- purpose
- items
used to quantify discontination symptoms associated with stopping antidepressants
43 items
AUDIT (Alcohol Use Disorders Identification Test)
- purpose
- items
- interpretation
simple method of screening for excessive drinking -covers the three domains of harmful use, hazardous use, and dependence.
10 items
Minimum score = 0, maximum score = 40
A score of 8 or more in men, and 7 or more in women, indicates a strong likelihood of hazardous or harmful alcohol consumption
A score of 15 or more in men, and 13 or more in women, is likely to indicate alcohol dependence
========================
it has been shown to be superior to CAGE and biochemical markers for predicting alcohol problems
FAST (Fast Alcohol Screening Test)
- purpose
- items
- interpretation
short and rapid test developed to be used in a busy medical setting
4 items
Minimum score = 0, maximum score = 16
Score >3 indicated hazardous drinking
FAST (Fast Alcohol Screening Test) - questions (4)
How often do you have EIGHT (men) / SIX (women) or more drinks on one occasion?
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
How often during the last year have you failed to do what was normally expected of you because of drinking?
In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?
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If the answer to the first question is ‘never’ then the patient is not misusing alcohol
If the response to the first question is ‘Weekly’ or ‘Daily or almost daily’ then the patient is a hazardous, harmful or dependent drinker.
CAGE questionaiire
- questions
- interpretation
Have you ever felt you should Cut down on your drinking?
Have people Annoyed you by criticising your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink in the morning to get rid of a hangover (Eye opener)?
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Two or more positive answers suggests problem drinking.
Adjustment disorder
- essence
- onset/duration
a state of subjective distress and emotional disturbance, usually interfering with social functioning and performance, arising in the period of adaptation to a significant life change or to the consequences of a stressful life event.
It usually occurs within 1 month of the stressful event, and the duration of symptoms does not usually exceed 6 months.
cannabis increases the risk of psychosis by — times
2-3 times
Addenbrooke’s cognitive exam (ACE-R)
- domains (5)
- scoring/cut offs
Attention and orientation - 18 Memory - 26 Verbal fluency - 14 Language - 26 Visuospatial - 16
Total - 100
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Cut off 88 -> 94% sensitivity, 89% specificity for dementia
Cut off 82 -> 85% sensitivity, 100% specificity for dementia
Phobias - defence mechanisms (2)
Repression and displacement
Obsessive compulsive disorder - defence mechanisms (3)
Isolation, undoing, and reaction formation
Borderline personality disorder - defence mechanisms (2)
Projection and splitting
Narcissistic personality disorder - defence mechanisms (2)
Projection and splitting
Agoraphobia - defence mechanisms (1)
Displacement
Prosody
- definition
- aprosodia - classification and associated brain regions
‘the emotional tone of language’
Aprosody is caused by dysfunction in areas of the non-dominant hemisphere
Executive aprosody
- difficulty in expression of emotion
- right premotor cortex or basal ganglia
Receptive aprosody
- difficulty in understanding of emotion
- right posterior superior temporal lobe
Paramnesia
- term coined by —
- definition
Emil Kraepelin
qualitative disorders in memory where fantasy and reality are confused
Paramnesia:
The experience of feeling that one has witnessed or experienced a new situation before
Déjà vu
Paramnesia:
The experience of being unfamiliar with a person or situation that is actually very familiar
Jamais vu
Paramnesia:
The unconscious filling in of gaps in the memory by events which never took place
Confabulation
Paramnesia:
The process of distorting a memory
Retrospective falsification
Paramnesia:
This is characterised by having a thought without realising you have had the thought before (for example, some plagiarists claim they are unaware that they were recounting other peoples work)
Cryptamnesia
Paramnesia:
The delusion that a place has been duplicated.
Reduplicative paramnesia
3 forms:
- Place reduplication
- Chimeric assimilation
- Extravagant spatial localisation
Paramnesia:
the belief that two places with identical features exist simultaneously, but are geographically distant
Place reduplication
a form of Reduplicative paramnesia
Paramnesia:
the belief that two places become combined, for example, a patient in hospital believes that they are in their own home which has somehow transformed into the hospital
Chimeric assimilation
a form of Reduplicative paramnesia
Paramnesia:
belief that their current location is actually somewhere else, usually a location familiar to them
Extravagant spatial localisation
a form of Reduplicative paramnesia
Factitious disorder
- aka
- description
Munchausen syndrome
The patient feigns symptoms repeatedly for no obvious reason and may even inflict self-harm in order to produce symptoms or signs. The motivation is obscure and presumably internal with the aim of adopting the sick role.
In an occasional cannabis user, how long is cannabis detected in urine after last use?
3 days
In daily, prolonged cannabis use, how long is cannabis detected in urine after last use?
up to 4 weeks
MMSE - Category: Orientation to place
- possible points
- description
5
Ward Hospital Town County Country
MMSE - Category: Orientation to time
- possible points
- description
5
Time Date Day Month Year
MMSE - Category: Registration
- possible points
- description
3
Examiner names 3 objects (eg apple, table, penny)
Patient asked to repeat (1 point for each correct)
Then patient to learn the 3 names repeating until correct
MMSE - Category: Attention and concentration
- possible points
- description
5
Subtract 7 from 100, then repeat from result.
Continue 5 times: 100 93 86 79 65
Alternative: spell ‘WORLD’ backwards - dlrow
MMSE - Category: Recall
- possible points
- description
3
Ask for names of 3 objects learned earlier
MMSE - Category: Language
- possible points
- description
8
Name a pencil and watch (NAMING)
Repeat ‘No ifs, ands, or buts’ (REPEATING)
Give a 3 stage command. Score 1 for each stage. (OBEYING COMMANDS)
Eg. ‘Place index finger of right hand on your nose and then on your left ear’
Ask patient to read and obey a written command on a piece of paper stating ‘Close your eyes’ (READING)
Ask the patient to write a sentence. Score if it is sensible and has a subject and a verb (WRITING)
MMSE - Category: Visual construction
- possible points
- description
1
Ask the patient to copy a pair of intersecting pentagons
MMSE
- interpretation
> /= 27 - normal cognition
19-24 - mild cognitive impairment
10-18 - moderate cognitive impairment
<9 - severe cognition impairment
Eating disorders - metabolic complications
- electrolytes (4)
Hypokalemia Hypomagnesemia Hypocalcemia Hypophosphatemia (note in bulimia a high phosphate level is generally seen)
Eating disorders - metabolic complications
- endocrine (7)
Low estradiol
Low LH
Low FSH
Low T3
Note: TSH and T4 are usually normal
Low glucose
High cortisol
High growth hormone
Acute intermittent porphyria
- precipitating drugs (6)
Barbiturates Benzodiazepines Sulpiride Certain mood stabilizers estrogens Diclofenac
Acute intermittent porphyria
- presentation (5)
Porphyria is also known as ‘the little imitator’ as it mimics a number of common psychiatric presentations.
Abdominal pain Mental state changes Constipation Vomiting Muscle weakness
Simpson-Angus scale
- self or clinician rated?
- purpose
Clinician-rated
devised to measure drug-induced parkinsonism, providing standardised ratings for rigidity, tremor and salivation.
The scale is entirely sign led.
Edinburgh Postnatal Depression Scale
- self/clinician rated?
- no. of items
- purpose
- timing
self-report questionnaire
10-items
screening of postnatal depression in the primary care setting (not diagnosis)
assesses mood over the past 7 days
Edinburgh Postnatal Depression Scale
- interpretation
likelihood of depression:
0-9 low
10-12 moderate
>13 high
Metonym
imprecise expressions that are used in place of more exact words that are available to describe an object or event.
e.g. A patient repeatedly refers to computers as ‘mathscreen’
Patients with chronic schizophrenia may lose the track of their age and may state an age different from their actual age. To be called as age disorientation, the difference in stated age and actual age must be at least —
5 years
Condensation (psychoanalysis)
- description
Condensation is a term used in dream analysis.
It refers to the process of several unconscious impulses being combined into a single image in the manifest dream content
e.g. one’s father and a horrible teacher may be unified and occur as a single dreadful monster in a child’s dream.
Superego is formed at which stage of psychosexual development?
Latency stage
Anomic aphasia - affected brain region
Dominant temporo-parietal lesion
Risk of schizophrenia in a monozygotic twin
48%
Risk of schizophrenia in a fraternal (dizygotic) twin
17%
Risk of schizophrenia in a child of a parent with schizophrenia
13%
Risk of schizophrenia in a sibling
9%
Risk of schizophrenia in a parent of someone with schizophrenia
6%
Risk of schizophrenia in a grandchild of someone with schizophrenia
5%
Risk of schizophrenia in a first cousin of someone with schizophrenia
2%
Risk of schizophrenia in the general population
1%
The proportion of people with schizophrenia born in winter months is —% higher than at other times of the year
5-15%
Couvade syndrome
- classification
- essence
a conversion disorder seen in partners of expectant mothers during pregnancy.
Symptoms mimic pregnancy and include nausea, vomiting, abdominal pain, and food cravings.
It is not a delusion and those affected do not believe they are pregnant.
Rapid Alcohol Problem Screen 4 (RAPS4)
- questions (4)
R (remorse)
- Have you had a feeling of guilt or remorse after drinking?
A (amnesia)
- Has a friend or a family member ever told you about things you said or did while you were drinking that you could not remember?
P (performance)
- Have you failed to do what was normally expected of you because of drinking?
S (starter drinker behaviour)
- Do you sometimes take a drink when you first get up in the morning?
Clifton Assessment Procedure for the Elderly (CAPE)
- purpose
- setting
- scales (2)
a tool used to assess quality of life, cognitive deficits, and physical dependency levels in the elderly to indicate areas of unmet need.
It can be used both in hospital and community settings and takes 15-25 minutes to complete.
The cognitive assessment scale
- This tests orientation, basic cognition such as reading and counting, and psychomotor performance.
The behaviour rating scale
- This assesses physical dependency and behavioural problems.
Kleinian Defence Mechanisms (6)
‘SIPDOG’
Splitting Introjection Projective Identification Denial Omnipotence Grandiosity
Risk of schizophrenia in a child when both parents have schizophrenia
46%
Hayling Sentence Completion Test
- description
- what does it test?
two sets of 15 sentences each having the last word missing
- first section - complete the sentence
- second section - complete the sentence with a nonsense ending (tests response suppression)
tests executive function
=================================
performance on such tests has been repeatedly associated with frontal lobe dysfunction and dysexecutive symptoms in everyday life.
The Brixton Test
- description
- what does it test?
a rule detection and rule following task.
Impairments on such tasks are commonly demonstrated in individuals with dysexecutive problems.
Delusions (structure):
One can also describe a delusional beliefs’ relationship with reality in the following ways:-
- Polarised
- Juxtaposed
- Autistic
Polarised - the delusion and fact are mingled together
Juxtaposed - the delusion and fact exist together but sit side by side and do not interact
Autistic - actual reality is not taken into account and the patient lives in a delusional world
Witzelsücht
a tendency to tell inappropriate joke and creating excessive facetiousness and inappropriate or pointless humour.
It is seen in Frontal lobe disorders.
SF-36 (Short-form 36)
- items
- purpose
- self/clinician rated?
- domains
36-item, patient-reported survey that measures patient-rated functioning and well-being
eight scales (four pertain to physical health, and four to mental health):
physical functioning
role limitations due to physical health problems
bodily pain
general health
vitality (energy/fatigue)
social functioning
role limitations due to emotional problems
mental health (psychological distress and psychological well being).
The measure can be completed by the patient on their own and takes approximately eight minutes to do.
