Psychiatry Flashcards
A 79-year-old woman with a diagnosis of Alzheimer’s disease is causing concern
as she is constantly getting lost on the way back from the local shop to her home,
which is only a short walk and one that she has done nearly every day for 20 years.
What sort of memory disturbance does this represent?
A. Autobiographical memory
B. Episodic memory
C. Procedural memory
D. Semantic memory
E. Topographical memory
E. Topographical memory
Autobiographical (A) relates to memories of your own life, such as the date of your birth, this is analogous to Episodic memory (B).
Topographical memory (E) is a common failure in dementia and is concerned with the ability to orientate yourself in place.
Procedural memory (C) is the unconcious memories we access that are how we know how to carry out previously learnt tasks, such as tying shoelaces.
Semantic memory (D) is esentially your general knowledge.
A 72-year-old woman who suffers from Alzheimer’s disease is asked who the
Prime Minister was during the Second World War, to which she replies ‘Winston
Churchill’. She is then asked where she lived during the war, to which she answers
‘Winston Churchill’. What phenomenon is being described here?
A. Confabulation
B. Déjà vu
C. Ganser’s syndrome
D. Jamais vu
E. Perseveration
E. Perseveration
Perserveration (E) is an almost exclusive feature of organic brain disease, such as dementia. It is the giving of an appropriate answer to a question but then repeating that answer to subsequent questions inappropriately. This can also be seen in motor responses.
Confabulation (A) - is where false memories occur and this results in incorrect answers being given. It can result in a suffere trying to compensate for not knowing an answer, or it may apear as deliberate attempts to decieve, in organic brain disease sufferers can be seen to invent fantastical answers (tricky to differentiate from delusions).
Déjà vu (B) - ‘to see again’, is a scenario where a person feels they have encountered an event before but it is a new experience, It can be a feature of temporal lobe epilepsy, but it is a normal experience for most people and non-pathological.
Ganser’s syndrome (C) - is a phenomena where a person gives approximate answers to questions. So when asked how many months of the year they might answer 13. There is debate as to this phenomenon’s status as a sign of organic brain disease or a dissociative disorder.
Jamais vu (D) is essentially the opposite of Déjà vu, the person has a sensation of a familar place of event hasn’t been encountered before. Think Gandalf in the mines of Moria… ‘I have no memory of this place’
A young woman wakes from a nightmare and sees her dressing gown hanging
from the door, which she mistakes as an assailant. What is being described here?
A. Affect illusion
B. Completion illusion
C. Pareidolic illusion
D. Tactile hallucination
E. Visual hallucination
A. Affect illusion
An illusion is the misinterpretation of a real stimuli,whereas a hallucination is the experience of a new perception with no ligitimate stimulus.
Illusions ae usually not pathological.
An affect illusion (A) is where a perception is altered in line with the affect of the person experiencing it. In this case the frightened woman sees an attacker where there is only clothes.
A completion illusion (B) is where we fail to notice something that s incorrect or out of place when we are not paying attention. We might, for example skip over a repeated word in a typed sentence.
A pareidolic illusion (C) is where we see shapes or complex form within a chaotic pattern, seeing animal shapes in clouds is a good example.
Tactile (D) and visual (E) hallucinations are de novo sensations of felling a touch or seeing something that isn’t there, respectively.
A young man with schizophrenia describes how he can hear the secret service
in their base in Finland discussing their plans to assassinate him. What is this
phenomenon known as?
A. Extracampine hallucination
B. Functional hallucination
C. Hypnagogic hallucination
D. Hypnopompic hallucination
E. Reflex hallucination
A. Extracampine hallucination
an Extracampine hallucination (A) is one that occurs beyond the normal range of perception, as is the case here, there is no way this man can hear people in Finland.
This is clearly a hallucination as he report hearing these voices as oppossed to this just being a belief /delusion.
A functional hallucination (B) is one that only occurs alongside a stimulus in the same modality. So for example, hearing voices referencing you, but only when you listen to the radio.
A hypnagogic hallucination (C) is one that occurs on falling asleep, such as the feeling of falling. Similarly a Hypnopompic hallucination (D0 is one that occurs shortly after waking.
A reflex hallucination (E) is similar to functional, except that the stimulus and hallucination are in different modalities. So an example might be hearing voices everytime you see a volkswagen golf.
A 28-year-old man is diagnosed with schizophrenia, with the belief that he has
been targeted for extermination by a religious cult who have implanted tiny
electrical ‘ants’ into his fingernails. When asked when he knew this, he said he had
seen a magazine story 3 months ago on ‘retiring to the country’ and immediately
felt this was a covert message from the cult that he should be ‘retired’. There was
no evidence of delusions prior to this. What is being described here?
A. Autochthonous (primary) delusion
B. Autoscopy
C. Delusional atmosphere
D. Delusional memory
E. Delusional perception
E. Delusional perception
- A delusional perception (E) occurs when a normal perception (e.g. seeing a magazine cover) is invested with a delusional meaning (a cult is trying
to kill me). The perception is given a whole new false, and usually bizarre,
meaning that is specific to the patient and nearly always of monumentous
importance.
- An autochthonous delusion (A) is one that arises out of the blue (and unlike delusional perception is not attached to a real stimulus). It should be distinguished from secondary delusions in which the beliefs are understandable in the context of the sufferer’s mood or history (e.g. a mood-congruent depressive delusion). A primary delusion is by definition un-understandable in any context.
- Autoscopy (B) refers to the sensation of seeing oneself, although its aetiology and precise psychopathology is controversial.
- Delusional atmosphere (C), also known as delusional mood, refers to the state of perplexity or bewilderment in which sufferers feel that something is ‘going on’ but without being able to state exactly what. It often occurs prior to a delusion forming and the sufferer will often describe feeling odd and that everything around them has new ‘meanings’ and significance to them in particular.
- Delusional memory (D) is when a patient recalls an event from the past and interprets it with a delusional meaning. Although this may seem similar to the answer ‘E’, the difference is that the event at the time will not have been invested with a delusional interpretation; it is only afterwards that this occurs.
A 48-year-old man with poorly controlled schizophrenia is admitted to the ward.
He appears confused and he is difficult to interview. On asking him why he is in
hospital, he replies, ‘Jealousy, the Collaborative, collaborate and dissipate. What’s
in my fridge? It isn’t my time’. How would you describe this type of thinking?
A. Circumstantial
B. Derailment
C. Flight of ideas
D. Pressure of speech
E. Thought blocking
B. Derailment
Derailment (B) is a type of formal thought disorder where there are no meaningful connections between the thoughts. It is a common finding in schizophrenia.
Circumstantial thinking (A) is where the person talks around a subject
Which of the following is not a first-rank symptom of schizophrenia as described
by Schneider?
A. Delusional perception
B. Persecutory delusions
C. Running commentary
D. Somatic passivity
E. Thought alienation
B. Persecutory delusions
Although persecutaroy delusions (B) are seen in schizophrenia, they are not a first rank symptom as described by Schneider.
The other symptom here are first rank, but they are not exclusive to schizophrenia and are seen in other psychiatric conditions. Equally not everyone with schizophrenia has one of the first rank symptoms.
The first rank symptoms as dsescribed by Schneider;
- Auditory hallucinations
Hearing voices conversing with one another
Voices heard commenting on one’s actions (hallucination of running commentary)
Thought echo (a form of auditory hallucination in which the patient hears his/her thoughts spoken aloud)
- Passivity experiences (in which the individual has the experience of the mind or body being under the influence or control of some kind of external force or agency;delusions of control or of being controlled)
- Thought withdrawal (the delusional belief that thoughts have been ‘taken out’ of the patient’s mind)
- Thought insertion (thoughts are ascribed to other people who are intruding into the patient’s mind)
Thought broadcasting (also called thought diffusion) Delusional perception (linking a normal sensory perception to a bizarre conclusion, e.g. seeing an aeroplane means the patient is the president)
A 72-year-old man with Parkinson’s dementia is seen in clinic. He is asked how
he is feeling, to which he replies, ‘I feel fantastic…tic…tic…tic…tic…’. What is the
name for this type of speech abnormality?
A. Alogia
B. Dysarthria
C. Echolalia
D. Logoclonia
E. Neologism
D. Logoclonia
Logoclonia (D) refers to the symptom of repeating the last syllable of a word repeatedly, it is often seen in parkinson’s disease.
Alogia (A) is the phenomenon of ‘not having any words’ and referes to extreme poverty of speech. It is seen most commonly in negative schizophrenia or dementia.
Echolalia (C) referes to the symptom where a person repeats what is said to them, essentially parroting what they hear. They will sometimes repeat this continously or incessantly. I can have an organic brain pathology such as injury or dementia, it can also be seen in schizophrenia and catatonia.
Neologism (E) is the creation of new words that have specific meaning relevant to them and thier delusional scenario. It is different to metonymy where a normal word is used in a different way.
A 26-year-old man is seen by his GP. For the last few months, he has become
increasingly concerned about a mole on his cheek, which he feels has got bigger
and people are noticing it more. Over the last week he has become convinced
that people are laughing at it when he passes them. He has a thought in his head
of ‘you’re so ugly, look at the size of that mole’. The patient does not feel he
knows where the thought comes from, but it does not seem to be his. He wonders
if someone has planted the thought there. The GP does not feel the mole is in
any way abnormally sized or has other unusual features. What is the most likely
aetiology of these symptoms?
A. Compulsion
B. Delusion
C. Hallucination
D. Rumination
E. Somatization
B. Delusion
The (likely incorrect) belief that people are looking at him, combined with these intrusive thoughts which are not recognised as his own makes this more likely to be a delusion (B).
In rumination (D) the patient would recognise the thoughts as his own.
It is not a hallucination (C) as none of this perception takes place outside of the self - the thoughts are not being heard aloud.
A compulsion (A) would be a repetitive act that the person felt they needed to do, driven by an anxiety of some description.
Somantization (E) refers to physcal symptoms that occur as a result of anxiey with no actual physical explaination,
Which of the following is not a core symptom of depression as defined by ICD-10?
A. Anergia
B. Anhedonia
C. Anorexia
D. Hyperphagia
E. Insomnia
D. Hyperphagia
Hyperphagia (D) refers to the increased consumption of food and it is seen in atypical depression, but it is not one of the core ICD-10 symptoms.
from the ICD10;
in typical depressive episodes of all three varieties described below (mild (F32.0), moderate (F32.1), and severe (F32.2 and F32.3)), the individual usually suffers from depressed mood, loss of interest and enjoyment [anhedonia (B)], and reduced energy [anergia (A)] leading to increased fatiguability and diminished activity. Marked tiredness after only slight effort is common. Other common symptoms are:
- (a)reduced concentration and attention;
- (b)reduced self-esteem and self-confidence;
- (c)ideas of guilt and unworthiness (even in a mild type of episode);
- (d)bleak and pessimistic views of the future;
- (e)ideas or acts of self-harm or suicide;
- (f)disturbed sleep [Insomnia (E)]
- (g)diminished appetite [anorexia (C)].
With any depressive episode the symptoms must be for Two weeks or more
in Mild depression - 2 of the primary symptoms (anhedonia, anenergia, low mood) plus 2 of a-g (above)
In Moderate depression - 2 primary symptoms plus 3 of the other symptoms
In Severe depression - all 3 of the primary symptoms plus at least 4 of the other symptoms.
There is a sub category of Severe depression with psychotic symptoms - where the criteria for severe depression are fullfilled but there is the addition of psychotic symptoms such as; visual or auditory hallucinations (often insulting or accusatory), delusions of sin, or imminent disaster, depressive stupour, or even a cottard delusion (where the sufferer thinks they are dead) or other nihilistic delusions.
A 42-year-old man sees his GP after witnessing a horrific motorway pile-up. For
the last 6 weeks he has been experiencing recurrent and intrusive images of the
event where he relives what happened, both at night and during the day. At night
he is also having vivid nightmares about the crash which is now stopping him
from going to sleep. He has not driven his car since, although he himself was not
involved in the crash. Every time a car starts he jumps and becomes extremely
upset. His mood is low and he feels disconnected from his wife and children and he has been thinking about killing himself. What symptom is not being described here?
A. Avoidance
B. Detachment
C. Insomnia
D. Increased arousal
E. Night terrors
E. Night terrors
Avoidance (A) - avoiding the traumatic stimulus or things linked to it, this patient is avoiding driving.
Detachment (B) - Feeling discoonected from his wife and kids. There can also be a feeling of derealisation or depersonalisation where the sufferer feels removed from the world around him or even from his own body.
Insomnia (C) - is described here with the nightmares stoping him going to sleep
Increased arousal (D) - is described by the reaction to the ordinary stimulus of a car starting.
What isn’t described here is night terrors (E) - these are distinct from nightmares in that they do not occur in REM sleep, they usually affect children. The sufferer will wake from sleep in a state of terror and confusion, often shouting and lashing out.
What is the most likely diagnosis in the case described in the previous question? [42yo male experiencing nightmares and daytime images of a car acident he witnessed 6 weeks ago, some detachment, increased arousal and avoidance also]
A. Acute stress reaction
B. Adjustment disorder
C. Depressive episode
D. Dissociative fugue
E. Post-traumatic stress disorder (PTSD)
E. Post-traumatic stress disorder (PTSD)
Criteria for diagnosis of PTSD (E); exposure to a potentially life threatening event, re-experiencing the event in various ways (nightmares or flashbacks), avoidance of stimuli that recall the event, and increased arousal such as hypervigilance, increased startle reaction, insomina and sometimes irritibilty and anger. THese symptoms need to persist for greater than 1 month for the diagnosis of PTSD.
An acute stress reaction (A) must subsided within hours or days
An adjustment disorder (B) - is in response to a significant and stresful change in life circumstances (such as a bereavement). Te symptoms with that are depression and anxiety along with an inability to cope with daily tasks.
A dissociative fugue (D) - is a conversion disorder in which the body or mind in some way lose thier integration. This will usually resolve in weeks to months.In a dissociative fugue the sufferer will travel for a long way (often much longer than a usual distance) and there is a period of amnesia. They often appear normal to people they meet on thier fugue journey.
A 49-year-old woman with schizophrenia is admitted to the psychiatric unit in a
mute state. She is staring blankly ahead and not responding to any commands.
She is not eating or drinking and looks dehydrated. Which of the following is the
least likely to be observed in catatonia?
A. Catalepsy
B. Clanging
C. Echolalia
D. Negativism
E. Stupor
B. Clanging
Clanging (B) is a form of thought disorder where words are selected based on thier rhyming with each other. Essentially a sufferer will start talking like Dr Seuss. It is a feature of schizophrenia but it is not typical of catatonia.
The typical criteria for catatonia can be found in the Bush-Francis rating scale.
Catatonia can present as a state predominated by stupour (E), or by excitation. It’s cause is unclear and it has associations with many conditions other than schizophrenia.
It can be associated with catalepsy (A) which is ridgid limbs, as seen in the phenomenan of ‘waxy flexibility’.
Echolalia (C) is where the catatonic patient repeats words or phrases, there can also be echopraxia where they repeat movements.
Negativism (D) is where the catatonic patient will attempt to do the opposite of what they are asked to do, it is more complex than just defiance.
Which of the following statements regarding the two classification systems in
psychiatry (ICD-10 and DSM-IV) is false? Note this refers specifically to the section
in ICD-10 related to psychiatry and mental health.
A. Dementia cannot be classified in either of the two systems
B. DSM-IV uses a multiaxial system
C. Homosexuality is no longer a diagnostic category in the two systems
D. ICD-10 was developed by the World Health Organization (WHO)
E. The first categories in ICD-10 are those related to organic disorders
A. Dementia cannot be classified in either of the two systems
Dementa can certainly be classified in the two systems (A), there is more difficulty with classifying the sub-types of dementia though.
DSM-IV uses 5 axes (B);
- Clinical disorders
- Personality disorders and learning disability
- acute medical conditions and physical disorders
- psychosocial and enviromental factors contributing to the disorder
- global assesment of functioning
Homosexuality (C) was still in the ICD until 1990 and in the DSM until 1986
ICD-10 was developed by the WHO (D) and places conditions in a heirachy, with organic pathology considered before psychiatric (E).
Which of the following would be the best definition of the term ‘loosening of
associations’?
A. A decrease in the amount of words produced by a patient
B. An incompleteness of the development of ideas or thoughts, leading to
a lack of logical relationship between them
C. Difficulty in verbalizing names of objects, despite being able to describe
their function
D. Talking in a roundabout manner before finally answering a question
E. The creation of a new word with particular meaning to the patient
B. An incompleteness of the development of ideas or thoughts, leading to
a lack of logical relationship between them
Loosening of association (B) is a form of thought disorder seen in schizophrenia
A - is poverty of speech , Alogia, and is sen in may conditions including chonic schizophrenia
C - is Nominal Aphasia, seen in demntia, stroke and other organic pathology
D - is circumstantiality, often sen in hypomanic states.
E - is neologisicim, and is seen in schizophrenia
A man is admitted to accident and emergency after being found semi-conscious
in the street. He is unkempt and does not have any information on his person; he
appears to be street homeless. In accident and emergency he has a tonic clonic
seizure which is self-limiting after 3 minutes. The man is post-ictal for a short
time but soon becomes restless, tremulous and sweaty. His speech is rambling,
and he complains about the bed sheets being filthy and ‘filled with mites’. He
is tachycardic with a blood pressure of 186/114 mmHg. What is the most likely
diagnosis?
A. Alcoholic hallucinosis
B. Delirium tremens
C. Cocaine withdrawal
D. Diabetic ketoacidosis
E. Opiate overdose
B. Delirium tremens
DT (B) is a sndrome caused by alcohol withdrawal in patients with alcohol dependence. It is a medical emergency as it results in autonomic instibility, nausea nad voiting, altered mental state (the delirium), tremor (tremens), and can sometime lead to seizures. Symptoms appear 6-12 hours after the last drink and peak at 24-48hrs.
The visual hallucinations here of insectsare also classic for this syndrome. This needs to be recognised as distinct from formication, which is the sensation of insects under the skin, and is seen in cocaine intoxication, and rarely in cocaine withdrawal (C). However (C) is unlikely as cocaine witdrawal doesn’t cause autonomic symptoms, and it’s unlikely a homeless man could afford a massive coke habit.
Alcoholic hallucinosis (A) is syndrome also caused by alcohol withdrawal, it is usually ment to describe auditory of visual hallucinations in a context of clear consciousness.
DKA (D) would have some clue in the history of acidosis, hyperglycaemia or ketonuria. The patient would apear dehydrated, there would be decreased conciousness, rarely with fits.
Opiate overdose (E) would cause respiratory and CNS depression.
You order a full set of bloods on this man. Which of the following results would
be most indicative of the underlying cause of his delirium? [presntation of Delirum tremens]
A. Elevated serum glucose
B. Elevated serum potassium
C. Low mean corpuscular volume (MCV)
D. Low serum vitamin B12
E. Raised platelets
D. Low serum vitamin B12
You would expect a deficiency in B12 in chronic alcohol abuse, due to deficient dietary intake and toxic effects of alcohol. This low B12 leads to a macrocytic anemia, not a microcytic (C).
Alcohol also leads to a thrombocytopenia due to B12/folate deficiency and toxic effects of alcohol), not a thrombocytosis (E).
Alcohol often causes hypoglycaemia, not an increased level of glucose (A)
Hypokalaemia is another feature of alcohl abuse, not hyperkalaemia (B)
A 73-year-old woman is admitted to hospital with an infective exacerbation of
chronic obstructive pulmonary disease (COPD). Apart from COPD and hypertension she has no other medical problems. On the third day of her admission, she becomes acutely confused. During the night she is awake, shouting constantly for her husband, claiming that the nurses are prison guards and that they are keeping her against her will. She is slightly calmer the day after. You are the FY1 on call and are asked to come and see her over the weekend as the nurses are worried it will happen again at night. What should your initial management be?
A. Prescribe clozapine 25 mg bd regularly
B. Prescribe haloperidol 2 mg intravenously immediately
C. Prescribe lorazepam 0.5 mg orally just before bedtime
D. Prescribe lorazepam 0.5 mg orally twice daily regularly
E. Prescribe nothing at this stage
E. Prescribe nothing at this stage
When managing deliurium, as this clearly is, it is important to only prescribe sedation of there is a clear risk of harm to the patient or others. The first stage of management is conservative, with intensive nursing intervention. Examples of what that entails include nursing the patient in a side room, ensuring natural light, clocks and windows to aid orientation to time, minimising moving the patient and consistent staff members caring for them.
If the pateint continues to be in a state of delirium, then guidelines suggest low dose anti-sychotics such as haloperidol, but the route would be PO not IV, unless the patient was refusing (B).
For deleriumbenzos (C and D) are second line treatments as they can cause respiratory depression or paradoxical excitation. The exception is if the delirium is delirium tremens or benzo withdrawal, then benzos are the first line treatment.
Clozapine (A) is a last line treatmetn for schizophrenia.
