Definitions/Sectioning

Question 1

A 76-year-old woman is brought to the GP by her husband due to concerns regarding visual hallucinations. She describes seeing unusual things including animals playing in the bedroom, and people following her on walks. She is aware these are hallucinations.

Her mood has been low recently, and she has had some changes to her eyesight including a distortion of straight lines and reduced acuity making it hard to read the newspaper. The woman has a 40-pack-year smoking history. There are no other symptoms.

What is the most likely ophthalmological diagnosis, and cause of her hallucinations?

A. Age-related macular degeneration + Charles-bonnet syndrome

B. Age-related macular degeneration + lewy body dementia

C. Open angle glaucoma + Charles-bonnet syndrome

D. Open angle glaucoma + frontotemporal dementia

E. Open angle glaucoma + lewy body dementia

Answer 1

The correct answer is age-related macular degeneration (ARMD) + Charles-bonnet syndrome . Her symptoms or distortion of straight lines and reduced acuity alongside her smoking history point towards a diagnosis of ARMD. The distortion of straight lines is often picked up in Amsler grid testing, and differential diagnoses include cysts or macular pucker.

Question 2

Perseveration meaning. Eg of when it happens

Answer 2

Perseveration is repetitive and continuous behaviour, speech or thought that occurs due to changes in cognitive skills such as memory, attention, and mental flexibility.

-happens in transient global amnesia: isolated memory loss with preserved functioning otherwise

Question 3

What is Section 5(2) of MHA? How long?

Answer 3

Section 5(2) allows a voluntary patient in hospital to be legally detained by a doctor for 72 hours.
Detainment for up to 72 hours for further psychiatric assessment.

Question 4

4 aspects of assessing capacity:

Answer 4

For a person to lack capacity they must show an ‘impairment of, or disturbance in, the functioning of the mind or brain’ AND they are unable to undertake any of the following:

1. Understand relevant information
2. Retain the relevant information
3. Weigh up the relevant information
4. Communicate a decision

Question 5

Which professionals are required to detain a patient for treatment under Section 3 of the Mental Health Act?

Answer 5

An approved mental health professional (AMPH) and two doctors
- In addition, both doctors must have seen the patient in the past 24 hours.

Question 6

For a patient to be treated under the Mental Health Act (MHA) they must meet which criteria?

Answer 6

1. They must have a mental disorder
2. There must be a risk to their health/safety or the safety of others
3. There must be a treatment (however this can include nursing care, not just drugs)

Question 7

The Mental Capacity Act (5 principles):

Answer 7

1. A person is assumed to have capacity unless proven otherwise
2. Steps must be taken to help a person have capacity
3. An unwise decision does not mean a person lacks capacity
4. Any decisions made under the MCA must be in the person’s best interests
5. Any decisions made should be the least restrictive to a person’s rights and freedoms

Question 8

what is logoclonia?

Answer 8

A patient repeats the last syllable of a word or phrase

-Logoclonia describes a phenomenon in Parkinson’s Disease where the patient gets ‘stuck’ on a particular word of a sentence and repeats it.

Question 9

what are obsessions?

Answer 9

Repetitive and senseless thoughts or behaviours that are recognised as irrational by the patient but which they feel unable to resist.

Question 10

what is monomania?

Answer 10

A preoccupation with a single subject to a pathological degree.

Question 11

what is echopraxia?

Answer 11

A patient imitates another person’s movements. It is an automatic process.

Question 12

Ego defenses (mnemonic):

Answer 12

SASH

Question 13

Ego defenses after SASH:

Answer 13

Question 14

Answer 14

Question 15

The police bring a 40-year-old man to the Emergency Department, as he was wandering in the streets and disturbing pedestrians. He is known to have suffered from schizophrenia for the past 10 years. He says some external forces are controlling his thoughts and actions, and he has been hearing voices that instruct him to take his own life. He is severely distressed and has specific suicidal ideations. Based on the initial assessment by a consultant psychiatrist, he requires inpatient treatment for acute schizophrenia. However, he disagrees with admission and questions the effectiveness of the treatment in ‘fighting against the external forces’. He is now sleeping on a bed in the Emergency Department.

Which is the most appropriate section in the Mental Health Act to enable treatment of this patient’s condition?

A. Section 2

B. Section 4

C. Section 3

D. Section 5(4)

E. Section 5(2)

Answer 15

C. Section 3

Section 3 is a section that allows admission of patients for treatment of a mental health disorder for up to 6 months. An Approved Mental Health Professional (AMHP) or the patient’s nearest relative (NR) apply on the recommendation of two doctors. At least one of the doctors must be a Section-12-approved doctor, and both must have seen the patient in the past 24 hours. AMHPs can be other professionals, eg. nurses, social workers, psychologists, etc. but not doctors. Section 3 is done following an admission under Section 2 or if the patient is well known to mental health services. Section 3 is renewable.

Not E: Section 5(2)

Section 5(2) is an emergency section that allows detention of inpatients up to 72 hours on any ward, excluding the Emergency Department. It can be done by an Approved Clinician (AC). ACs are almost always doctors but can be other professionals. Section 5(2) should then be assessed for Section 2 or Section 3, depending on the circumstances.

Question 16

what is section 4?

Answer 16

Section 4 is an emergency section that allows detention of patients for up to 72 hours at outpatient services, including the Emergency Department. It can be done by a doctor and either an AMHP or the NR. AMHPs can be other professionals, eg. nurses, social workers, psychologists, etc. but not doctors. It is done when a Section 2 or Section 3 would cause an unacceptable delay. Section 4 can be changed later to Section 2 for further assessment or to Section 3 for treatment of a mental health disorder.

Question 17

what is section 2?

Answer 17

Section 2 is a section that allows admission of patients for assessment for up to 28 days. An AMHP or the patient’s NR apply on the recommendation of two doctors. At least one of the doctors must be a Section-12-approved doctor. AMHPs can be other professionals, eg. nurses, social workers, psychologists, etc. but not doctors. Section 2 is non-renewable but can then be followed by Section 3.

Question 18

what is section 5(4)?

Answer 18

Section 5(4) is an emergency section that allows detention of inpatients up to 6 hours on any ward, excluding the Emergency Department. It can be done by a nurse. This is usually done when a doctor cannot attend to the patient immediately.

Question 19

what is section 3?

Answer 19

Section 3 is a section that allows admission of patients for treatment of a mental health disorder for up to 6 months. An Approved Mental Health Professional (AMHP) or the patient’s nearest relative (NR) apply on the recommendation of two doctors. At least one of the doctors must be a Section-12-approved doctor, and both must have seen the patient in the past 24 hours. AMHPs can be other professionals, eg. nurses, social workers, psychologists, etc. but not doctors. Section 3 is done following an admission under Section 2 or if the patient is well known to mental health services. Section 3 is renewable.

Question 20

what is section 5(2)?

Answer 20

Section 5(2) is an emergency section that allows detention of inpatients up to 72 hours on any ward, excluding the Emergency Department. It can be done by an Approved Clinician (AC). ACs are almost always doctors but can be other professionals. Section 5(2) should then be assessed for Section 2 or Section 3, depending on the circumstances.

Question 21

what is capgras delusion?

Answer 21

Capgras delusion refers to a delusion that either oneself or another person has been replaced by an exact clone. It may be part of a psychotic illness or as a result of trauma to the brain.

Question 22

what is Ekbom’s syndrome?

Answer 22

Ekbom’s syndrome is a delusional belief where a patient feels that they are infested with parasites. They often complain of feeling “crawling” in the skin. It can appear as part of a psychotic illness or a secondary organic disease such as B12 deficiency, hypothyroidism and neurological disorders.

Question 23

what is Cotard delusion?

Answer 23

Cotard delusion refers to the belief that a patient is dead, non-existent or ‘rotting’. Again, it may occur in psychosis but can appear as a result of parietal lobe lesions.

Question 24

what is Othello syndrome?

Answer 24

Othello syndrome is a strong delusional belief that their spouse or partner is unfaithful with little or any proof to back up their claim. It is associated with alcohol abuse, psychosis and right frontal lobe damage.

Question 25

what is Fregoli delusion?

Answer 25

delusional belief that one or more familiar persons, usually persecutors following the patient, repeatedly change their appearance.

Question 26

Fregoli vs Capgras syndrome

Answer 26

Question 27

what is la belle indifference?

Answer 27

a term used in psychiatry to describe a seemingly inappropriate lack of concern or indifference regarding a physical or psychological symptom or disability. It refers to a disproportionate lack of distress or emotional response in individuals who present with symptoms that would typically be expected to cause significant distress or impairment.

La belle indifference was initially described in relation to certain conversion disorders, which are psychological conditions in which individuals experience physical symptoms or deficits without a clear organic cause. These symptoms may include paralysis, blindness, or sensory loss. Despite the apparent severity of these symptoms, individuals with la belle indifference often display a calm and unconcerned attitude, showing little distress or preoccupation with their condition.

Question 28

what is conversion disorder?

Answer 28

o Dissociative disorder = disorders of physical functions under voluntary control and loss of sensation
 Conversion disorder – an internal conflict which is ‘converted’ into physical manifestations (usually the presence of neurological symptoms without any underlying neurological cause)

1. typically involves loss of motor or sensory function
2. the patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
3. patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies

Question 29

what is folie a deux?

Answer 29

A folie a deux is a mental disorder that two people share and experience at the same time (shared hallucination/delusion between people). If you and your best friend are convinced that her dog can speak English, it may be a folie a deux.

Question 30

define delusion:

Answer 30

A delusion is a fixed, false belief that is not based on objective reality or evidence and is not influenced by rational reasoning or cultural norms.

Question 31

define psychosis: types:

Answer 31

Psychosis is a broad term used to describe a mental state in which an individual experiences a loss of touch with reality

Key features of psychosis include:

1. Delusions: False beliefs that are not based on reality and are resistant to rational reasoning or evidence. Delusions can be paranoid (belief that one is being persecuted or conspired against), grandiose (exaggerated sense of self-importance or abilities), or bizarre (beliefs that are clearly implausible or impossible).
2. Hallucinations: Sensory experiences that are not based on external stimuli. The most common type of hallucination in psychosis is auditory hallucinations, which involve hearing voices or sounds. However, hallucinations can also occur in other senses, such as visual, olfactory (smell), gustatory (taste), or tactile (touch).
3. Disorganized thinking and speech: Individuals with psychosis may have difficulty organizing their thoughts, expressing themselves coherently, or maintaining logical connections in their speech. They may display speech patterns that are tangential, incoherent, or fragmented.
4. Disturbed emotions and behavior: Psychosis can be accompanied by disruptions in emotional expression and regulation. Individuals may experience flattened or inappropriate affect (emotional responses not aligned with the situation) and exhibit erratic or unpredictable behavior.

Question 32

define delirium:

Answer 32

an acute confusional state characterized by a disturbance in attention, awareness, and cognition

Question 33

Answer 33

Detain her under section 5(2) of the Mental Health Act
-It can be used whether or not the patient has capacity to consent to their admission to hospital

Question 34

What is DOLS (deprivation of liberty safeguards):

Answer 34

part of the MCA, 2005:
o Depriving liberty within a care home or hospital (appropriately; not at home)
o Urgent application = 7 days DoLS
o Needed for restraint/restrictions used to safeguard people under the MCA which deprive liberties

-The Deprivation of Liberty Safeguards (DoLS) procedure is designed to protect your rights if the care or treatment you receive in a hospital or care home means you are, or may become, deprived of your liberty, and you lack mental capacity to consent to those arrangements.

Question 35

what is pica?

Answer 35

the eating of things which are not food or of food items in abnormal quantities.

Question 36

what is punding?

Answer 36

Punding is a form of stereotyped motor behaviour in which there is an apparent fascination with repetitive, mechanical tasks such as arranging items or dismantling and reassembling mechanical objects.

This is associated with Parkinson’s disease medication or with those taking methamphetamine.

Question 37

what is muddling?

Answer 37

Muddling is a form of speech disruption seen in schizophrenic patients where both thought blocking (speaking about two completely unrelated concepts) and fusion (the fusing of two completely different concepts into one) occur at the same time. The speech, as a result, can be bizarre and have very little meaning to the listener.

Question 38

what is Mitmachen?

Answer 38

Mitmachen is a motor symptom of schizophrenia where the patient’s limbs can be moved without resistance to any position but return to their original position once the limb is released.