Embed Size (px)
Citation preview
Clinical Psychiatry
-Psychogenic polydipsia
Psychogenic polydipsia refers to fluid drinking that greatly surpasses physiological requirements. It is most
commonly seen in schizophrenia.
If fluid intake exceeds the capacity for excretion, then the resultant hyponatremia (i.e., sodium depletion) may
produce signs of water intoxication including:-
Vomiting
Agitation
Ataxia
Seizures
Coma
It is best managed by fluid restrictioin
-Huntington's disease (psychiatric and behavioural)
Huntington's disease is characterised by a triad of motor, cognitive and psychiatric symptoms.
The symptoms typically begin in the third and fourth decades but with very high numbers of CAG repeats people
younger than 20 can be affected (referred to as juvenile Huntington's disease).
Psychiatric presentations of Huntington's include:-
Depression
Dementia
Psychosis
Anxiety
Mania
Sexual dysfunction
Suicide
-Dementia (types and clinical characteristics)
Dementia is a progressive impairment of cognitive functions occurring in clear consciousness (the clear
consciousness aspect differentiates it from delirium).
There are over 100 different causes of dementia. A detailed knowledge is required for the more common types.
Alzheimer's
Late onset
Progressive cognitive impairment
Gradual onset
Vascular dementia
Sudden onset, often following a stroke
Stepwise progression
Lewy body dementia
Fluctuating cognitive impairment
Hallucinations
Neuroleptic sensitivity (sensitivity to the side effects of antipsychotics such as sedation and EPSE's)
Falls
Rigidity, stiffness and movement difficulties
Picks's disease (aka fronto temporal dementia)
Gradual onset
Frontal lobe symptoms such as disinhibition, decline in personal hygiene, and personality change
Speech and language dysfunction including poverty of speech and echolalia
Focal gyral atrophy with a knife-blade appearance is characteristic of Pick's disease.
Huntington's disease
Early onset 35-44
Associated with abnormal movements (chorea)
Autosomal dominant
Pseudodementia
Cognitive problems result from depression
Often reply 'don't know' to questions (compared to people with true dementia who tend to attempt an
answer but give incorrect responses)
Progressive supranuclear palsy
Shares many features of Parkinson's disease apart from tremor
Presents with loss of balance and falls
Those affected have problems with voluntary eye movements
-Frontal Assessment Battery
The Frontal Assessment Battery (FAB) is a test designed to detect the dysexecutive syndrome. It is a bedside test
that can be completed in a matter of minutes.
It consists of six subsets (as seen in table below)
Conceptualisation Abstract reasoning, how are an apple and a pear different and similar
Mental flexibility Verbal fluency, number of words beginning with letter L in one minute
Motor programming Luria's motor series
Conflicting instructions 'Tap twice when I tap once, and once when I tap twice'
Go-No Go (inhibitory
control)
'Tap once when I tap once and do not tap when I tap twice'
Prehension behaviour Tell patient not to take your hands. Place their hands palm up on their knee's
and then touch them
-Drug (illicit)
Drug Effects Withdrawal features
Opioids Euphoria, drowsiness, constipation,
pupillary constriction, respiratory
depression
Piloerection, insomnia, restlessness,
dilated pupils, yawning, sweating,
abdominal cramps
Amphetamine
and cocaine
Increased energy, insomnia,
hyperactivity, euphoria, paranoia,
reduced appetite
Hypersomnia, hyperphagia, depression,
irritability, agitation, vivid dreams,
increased appetitie
MDMA (ecstasy) Increased energy, increased sweating, jaw
clenching, euphoria, enhanced sociability,
increased response to touch
Depression, insomnia,
depersonalisation, derealisation
Cannabis Relaxation, intensified sensory
experience, paranoia, anxiety, injected
conjunctivae
Insomnia, reduced appetite, irritability
Hallucinogens Perceptual changes, pupillary dilation,
tachycardia, sweating, palpitations,
tremors, inco-ordination
No recognised withdrawal syndrome
-Alcohol screening tools
A variety of tools have been devised to assist in the diagnosis of alcohol problems.
AUDIT (Alcohol Use Disorders Identification Test), was developed by the WHO as a simple method of screening
for excessive drinking. The test consists of 10 questions and attempts to cover the three domains of harmful use,
hazardous use, and dependence.
10 item questionnaire
Takes about 2-3 minutes to complete
Has been shown to be superior to CAGE and biochemical markers for predicting alcohol problems
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
AUDIT-C is an abbreviated form consisting of 3 questions
http://whqlibdoc.who.int/hq/2001/WHOMSDMSB01.6a.pdf
FAST (Fast Alcohol Screening Test), is a short and rapid test with just 4 questions that was developed to be used
in a busy medical setting.
4 item questionnaire (see table below)
Minimum score = 0, maximum score = 16
The score for hazardous drinking is 3 or more
With relation to the first question 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits
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. Over 50% of people will be classified using just this one question
1 MEN: How often do you have EIGHT or more drinks on one occasion?
WOMEN: How often do you have SIX or more drinks on one occasion?
2 How often during the last year have you been unable to remember what happened the night before
because you had been drinking?
3 How often during the last year have you failed to do what was normally expected of you because of
drinking?
4 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?
http://alcoholism.about.com/od/tests/a/fast.htm
CAGE is a 4 question screening tool. Two or more positive answers suggests problem drinking.
The CAGE is a well known but recent research has questioned its value as a screening test two or more positive
answers is generally considered a 'positive' result.
C Have you ever felt you should Cut down on your drinking?
A Have people Annoyed you by criticising your drinking?
G Have you ever felt bad or Guilty about your drinking?
E Have you ever had a drink in the morning to get rid of a hangover (Eye opener)?
SASQ (Single alcohol screening questionnaire), asks only one question, when was the last time you had more
than x alcoholic drinks in one day? (Where x is 8 for men and 6 for women). An answer of within 3 months
indicates harmful or hazardous drinking.
PAT (Paddington Alcohol Test), was developed for use in a busy A&E department to detect hazardous drinking.
MAST (Michigan Alcoholism Screening Test) is useful for detecting dependent drinkers.
-Mental state exam (speech)
Stilted speech has an excessively formal quality. It may seem outdated, pompous, or over polite.
Over inclusion describes the inability to maintain the boundaries of a thought when trying to convey a specific
idea.
Pressured speech (also known as tachyphasia) describes speech that is abnormally fast, with few pauses and
difficult to interrupt.
Self-referential speech repeatedly refers neutral topics under discussion back to the speaker himself.
-Personality disorder (DSM-IV)
Personality disorders have gone under various names in the past. The following table illustrates how the DSM-IV
has changed.
DSM-I Inadequate, schizoid, cyclothymic, paranoid, emotionally unstable, passive-aggressive,
compulsive, antisocial, dysocial
DSM-II Paranoid, cyclothymic, schizoid, explosive, obsessive-compulsive, hysterical, asthenic,
antisocial, passive-aggressive, inadequate
DSM-
III
Dependent, histrionic, narcissistic, antisocial, compulsive, passive-aggressive, schizoid,
avoidant, borderline, paranoid, schizotypal
DSM-
IV
Paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant,
dependent, obsessive-compulsive
-
Passive-aggressive personality disorder was a term used in the DSM-III.
-Schizophrenia (diagnosis, ICD-10 versus DSM-IV)
Broadly speaking the DSM-IV and ICD-10 have a similar diagnostic approach to schizophrenia. They do however
differ in the following ways.
Symptom duration
To meet a diagnosis of schizophrenia, the ICD-10 requires that symptoms of schizophrenia be present for at least
one month.
The DSM-IV requires symptoms to be present for at least 6 months, with at least a one month period of active
symptoms.
This difference reflects the fact that the DSM-IV recognises the prodromal phase of schizophrenia.
A period of schizophrenic symptoms lasting less than one month is classified in the ICD-10 as an acute and
transient psychotic disorder and in the DSM-IV as a brief psychotic episode. If a patient has had symptoms more
than 1 month but less than 6 months then the term 'schizophreniform disorder' is used by the DSM-IV
(prodromal phase).
Social and occupational dysfunction
The DSM-IV requires some impairment of social and occupational dysfunction. This is not a requirement of the
ICD-10.
-Dissociative (conversion) disorders
Dissociative disorders are characterised by the loss of integration between memories, identity, immediate
sensations, and control of bodily movements.
Previously referred to as 'hysteria' (a term best avoided now), dissociative disorders usually occur suddenly in
response to a trauma or other intolerable situation. They tend to remit spontaneously after a few weeks to
months.
A diagnosis requires (ICD-10):
Loss of integration (partial or complete) between memories, identity, sensations and control of bodily
movements
No evidence of a physical cause to explain the symptoms
Evidence for psychological causation (if none then the diagnosis should remain provisional)
Subtypes include:
Dissociative amnesia
Dissociative fugue
Dissociative stupor
Trance and possession disorders
Dissociative disorders of movement and sensation
Dissociative motor disorders
Dissociative convulsions (pseudoseizures)
Dissociative anaesthesia and sensory loss
Mixed dissociative disorders
Other dissociative disorders (includes Gansers syndrome and multiple personality disorder)
-Bipolar disorder (Rapid cycling)
Rapid cycling is defined as 4 or more mood episodes per year. It has an estimated prevalence of 10-20% of all
patients with bipolar disorder (estimated from specialised western mood disorder clinics). It tends to develop
late in the course of the disorder and lasts less than 2 years in 50% of patients. It is associated with an increased
risk of suicide.
Compared with non-rapid-cycling bipolar disorder, it is:-
More common in women
Associated with an earlier age at onset
Associated with a greater illness burden
Associated with higher treatment resistance
N.B. The issue of suicidality is controversial, some studies report increased rates in rapid-cycling whereas others
report lower rates.
N.B. The finding that rapid cycling is more common in women has not been found in all studies.
It tends to be less related to genetic factors and more to external factors such as life events, alcohol abuse, use of
antidepressants, and medical disorders.
Medical disorders associated with rapid cycling
Hypothyroidism
Grave's disease
Subarachnoid haemorrhage
Stroke
Multiple sclerosis
Head injury
Drugs (propranolol, levodopa, cyproheptadine)
-Sick euthyroid syndrome
Sick euthyroid syndrome is also known as low T3 syndrome. It is characterised by abnormal thyroid function
tests (usually low T3, and normal T4 and TSH) in the setting of nonthyroidal illness.
It is often seen in patients with anorexia following prolonged starvation.
-Alcohol dependence syndrome
To make a diagnosis of the dependence syndrome (ICD-10 F1x.2), 3 or more of the following must be present
together at some time in the past year:-
Compulsion
Loss of control
Physiological withdrawal
Tolerance
Neglect of rest of life
Persistence despite clear evidence of harmful consequence
ICD-10 and DSM VI criteria are very similar as both are based on the original concept of the alcohol dependence
syndrome developed by Edwards and Gross in 1976. The original concept had the following seven elements:
Edwards and Gross criteria
Narrowing of the drinking repertoire
Salience of drink seeking behaviour
Tolerance
Withdrawal symptoms
Relief of withdrawal by further drinking
Compulsion to drink
Rapid reinstatement of symptoms after a period of abstinence
-
Physiological withdrawal NOT psychological withdrawal is an ICD-10 feature of the dependence syndrome.
-HPA axis (depression and bipolar affective disorder)
Glucocorticoids (e.g. cortisol) are hormones that are central in the stress response. During acute stress,
glucocorticoids induce changes such as mobilising energy reserves (e.g., to confront a threatening situation).
Long-term changes include the regulation of immune responsiveness and activation of the sympathetic nervous
system. Excessive secretion of cortisol leads to disruptions in cellular functioning and widespread physiologic
dysfunction.
The HPA axis includes regulatory neural inputs (e.g., from the amygdala), a variety of releasing
factors/hormones as well as a feedback loop which includes the hypothalamus, pituitary and adrenal glands.
During stress, the hypothalamus secretes two hormones: corticotropin-releasing hormone (CRH) and arginine
vasopressin (AVP). CRH acts on the pituitary to secrete adrenocorticotropic hormone (ACTH), which in turn
reaches the adrenal cortex through systemic circulation and causes it to secrete cortisol.
The functioning of the HPA axis is measured by levels of cortisol, CRH and ACTH release, and the
dexamethasone (DEX) suppression test (DST) .
The dexamethasone suppression test measures the response of the adrenal glands to ACTH. Dexamethasone is
given and levels of cortisol are measured. Cortisol levels should decrease in response to the administration of
dexamethasone. In depressed patients cortisol levels often do not decrease as expected.
HPA axis dysfunction in depression
The hypothalamic-pituitary-adrenal (HPA) axis has been shown to be hyperactive in a significant number of
patients with major depression.
There is hypersecretion of cortisol, corticotrophin-releasing factor (CRF), and ACTH, and associated
adrenocortical enlargement. Levels of CRF have been shown to be elevated in the CSF.
The CRF hypersecretion normalises upon recovery of depression.
HPA abnormalities have been found in other psychiatric disorders including Alzheimer's and PTSD.
HPA axis dysfunction in bipolar disorder (Daban, 2005)
Dysregulation of ACTH and cortisol response after CRH stimulation have been reported in bipolar patients.
Changes in CRH secretion appear prior to manic or hypomanic symptoms are clinically evident.
Abnormal DST results are found more often during depressive episodes in the course of bipolar disorder than in
unipolar disorder. Reduced pituitary volume secondary to LHPA stimulation, resulting in pituitary hypoactivity,
has been observed in bipolar patients. The severity of the manic episode is highly correlated with the degree of
neuroendocrine alteration.
-Lack of insight the most common symptom seen in patients with schizophrenia .
-Mental state exam (cognition)
The following table lists the standard tests used for each area of cognition. Questions on this area are common.
Area of cognition Standard test
Orientation Asking the time, place, and person
Attention/concentration Serial 7's
Short term memory Digit span
Long term memory Delayed recall of name and address
Executive function Proverbs, similarities, differences, verbal fluency, cognitive estimates
-Naming as many animals as possible in one minute with a particular letter is an example of verbal fluency.
-Drug (screening)
Note that detection times vary considerably from person to person. That being said the following table serves as
a rough guide. As a general rule most substances remain positive in the urine for 1-3 days with the exception of
heavy users of cannabis who can remain positive for up to 14-28 days.
Drug of abuse Length of time detectable in urine
Cannabis 14-28 days
Phencyclidine 8 days
Methadone 3 days
Morphine 3 days
Benzodiazepine 3 days
Heroin 3 days
Cocaine 1-3 days
Amphetamine 1-3 days
LSD 1-3 days
Codeine 2 days
Alcohol 12 hours
-ECT (seizure duration)
On the whole most drugs do not interfere with ECT.
The table below summarises the effect of the important psychotropics and their effect on seizure duration.
Psychotropic
class
Effect on seizure duration Advice
Benzodiazepine Reduced Avoid where possible
SSRIs Minimal effect
Venlafaxine Minimal effect
TCAs Possibly increased TCAs are associated with arrthymia following
ECT in the elderly and those with cardiac
disease so should be avoided in ECT in these
groups
MAOIs Minimal effect
Lithium Possibly increased Generally used in ECT without significant
problems
Antipsychotics Some potential increase in clozapine
and phenothiazines, other
antipsychotics considered ok
Limited data
Anticonvulsants Reduced If used as mood stabiliser continue but be
prepared to use higher energy stimulus
-Reflexes tend to be brisk in hyperthyroidism and reduced in hypothyroidism. All the other options (including
tremor) are seen in both hyperthyroidism and hypothyroidism.
-Dementia (cortical versus subcortical)
Attempts have been made to distinguish cortical dementia from subcortical dementia based on the clinical
presentation. This is a contested area and many suggest the distinction is not possible. Never the less questions
on this appear in the exams.
Cortical dementia is characterised by:-
Impaired memory
Impaired visuospatial ability
Impaired executive function
Impaired language
Cortical dementias include:-
Alzheimer's disease
Pick's disease
Creutzfeldt-Jakob disease
Subcortical dementia is characterised by:-
Generalised slowing of mental processes
Personality change
Mood disorders
Presence of abnormal movements
Subcortical dementias include:-
Binswanger's disease
Dementia associated Huntingtons disease
Dementia associated AIDS
Dementia associated with Parkinson's disease
Dementia associated with Wilson's disease
Dementia associated with progressive supranuclear palsy
-Calculation preserved in subcortical dementia .
-LSD not routinely screened for in urinalysis .
-In the MMSE, intersecting pentagons primarily assesses Constructional praxis .
-Child development
A basic understanding of normal child development is required for the exams. If you do not have children this
can be difficult. The trick to getting these questions correct is knowing the key milestones and being able to pick
them out in the questions.
The following table is not exhaustive, consider this the minimum information you need.
Age Behaviour
Birth Sleeps most of time, cries, and sucks
4 weeks Responds to noise (either by crying, or quieting), follows and object moved in front of eyes
6 weeks Begins smiling
3 months Holds head steady on sitting
6 months Rolls from stomach to back, starts babbling
7 months Transfers objects from hand to hand, looks for dropped object
9 months Sits unsupported, begins to crawl
12 months Cruizing (walking by holding furniture)
18 months Walks without assistance, speaks about 10-20 words
2 years Runs, climbs up and down stairs alone, makes 2-3 word sentences
3 years Dresses self except for buttons and laces, counts to 10, feeds themself well
4 years Hops on one foot, copies a cross
5 years Copies a triangle, skips
-Drug (misuse)
The Misuse of Drugs Act (1971) imposes restrictions on the possession and supply of a range of drugs. Drugs are
classified into three types (A,B, and C).
Class Drugs Maximum penalty for
possession
A Cocaine, ecstasy, LSD, magic mushrooms, heroin,
methamphetamine, and any injected class B substance
7 year sentence
B Cannabis, amphetamine, codeine, barbiturates 5 year sentence
C Ketamine, anabolic steroids, minor tranquillizers
(benzodiazepines)
2 year sentence
-PANSS
The Positive and Negative Syndrome Scale (PANSS) is a scale used for measuring the symptom severity of
patients with schizophrenia.
The name refers to the syndrome of positive symptoms, meaning those symptoms of disease that manifest as the
presence of traits, and the syndrome of negative symptoms, meaning those symptoms that manifest as the
absence of traits and a series of general symptoms. The scale has seven positive-symptom items, seven negative-
symptom items and,16 general psychopathology symptom items. Each item is scored on the same seven-point
severity scale.
-An episode of elevated or irritable mood must last at least four days before it can be diagnosed as a hypomanic
episode, and 1 week before it can be called a manic episode (unless it is severe enough to require hospitalisation).
-EPDS
The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item self-report questionnaire. It was designed to
allow screening of postnatal depression in the primary care setting (and therefore cannot be used to diagnose
depression). As a screening instrument, the EPDS should only be used to assess a womans mood over the past
seven days.
It excludes some symptoms that are common in the perinatal period (tiredness and irritability) that other
depression instruments include, as such symptoms do not differentiate between depressed and nondepressed
postnatal women.
Women are asked to select one of 4 responses that most closely represents how they have felt over the past seven
days. Each response has a value of between 0 and 3 and scores for the 10 items are added together.
Scoring
Score Interpretation
0-9 The likelihood of depression is considered low
10-12 The likelihood of depression is considered moderate
13 or more The likelihood of depression can be considered high
Early features of Alzheimer's disease include problems with short-term memory and changes in personality such
as apathy. Disorientation and confusion tends to feature in more advanced stages of the illness.
Features of obsessive compulsive (anankastic) personality disorder include:-
Preoccupation with details, rules, lists, order. Or schedules to the extent that the major point of the
exercise is lost
Perfectionism that interferes with task completion
Excessive devotion to work to the exclusion of leisure activities and friendships
Overconsciousness, and inflexibility about matters of morality, ethics, or values
Inability to discard worn out or worthless objects with no sentimental value
Reluctance to delegate tasks
Stinginess (tendency to hoard money)
Rigidity and stubbornness
-Paranoid personality disorder is characterised by:-
Hypersensitivity and an unforgiving attitude when insulted
Unwarranted tendency to questions the loyalty of friends
Reluctance to confide in others
Preoccupation with conspirational beliefs and hidden meaning
Unwarranted tendency to perceive attacks on their character
-Features of borderline personality disorder include:-
Efforts to avoid real or imagined abandonment
Unstable interpersonal relationships which alternate between idealization and devaluation
Unstable self image
Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse)
Recurrent suicidal behaviour
Affective instability
Chronic feelings of emptiness
Difficulty controlling temper
Quasi psychotic thoughts
-Alzheimer's (pathology)
Macroscopic changes seen in Alzheimer's include:-
Hippocampal atrophy
Cerebral atrophy
Low brain weight
Enlargement of the inferior horn of the lateral ventricle
Microscopic changes seen in Alzheimer's include:-
Extracellular senile plaques
Intracellular neurofibrillary tangles
Gliosis
Degeneration of the nucleus of Meynert
Hirano bodies
These changes tend to occur in the cortex but also occur in the subcortical areas.
Neurofibrillary tangles consist of hyperphosphorylated tau and plaques consist of a peptide called amyloid-beta,
which is derived from amyloid precursor protein.
-Benzodiazepines (addiction)
Benzodiazepines are known to be addictive. For this reason, it is recommended that they should be prescribed as
a hypnotic or anxiolytic for no longer than 4 weeks.
Withdrawal symptoms are given in the following table.
Physical Psychological
Stiffness
Weakness
GI disturbance
Paraesthesia
Flu-like symptoms
Visual disturbance
Anxiety
Insomnia
Nightmares
Depersonalisation
Decreased memory and concentration
Delusions and hallucinations
Depression
Patients on short acting benzodiazepines who are keen to withdraw from them should first be converted to
diazepam. This is due to the fact that diazepam has a longer half-life and so tends to produce less severe
withdrawal. The following table list approximate equivalent doses.
Drug Equivalent dose
Diazepam 10mg
Lorazepam 1mg
Lormetazepam 1mg
Nitrazepam 10mg
Oxazepam 30mg
Temazepam 20mg
Chlordiapoxide 25mg
-Puerperum - psychiatric aspects
It is common for psychiatric problems to arise in the postpartum period (the period of time following delivery).
A large number of women (30-75%) experience something called 'baby blues' following childbirth which is a
transient mood disturbance characterised by emotional lability, sadness, and tearfulness. This usually clears up
by 2 weeks.
A minority of women (10-15%) experience postpartum depression which is clinically very similar to major
depression.
A very small number (1-2 per 1000) experience postpartum psychosis (aka puerperal psychosis). This is a period
of psychosis following the birth. There appear to be a link between puerperal psychosis and mood disorders.
Approximately 50% of women who develop the condition have a positive family history of mood disorder.
Puerperal psychosis usually begins within the first two weeks following the birth.
-Addenbrooke's cognitive exam (ACE-R)
The Addenbrooke's cognitive exam was developed following the recognition of limitations of the MMSE such as:-
Lack of sensitivity for frontal-executive dysfunction
Lack of sensitivity for visuospatial defects
The exam takes about 15 minutes to do and is divided into five domains (as seen in table below)
Domain Points
Attention and orientation 18
Memory 26
Verbal fluency 14
Language 26
Visuospatial 16
Total 100
Interpretation
The Addenbrooke's has been shown to be a valid tool for detecting dementia. Two cut off points are often used
depending on the required sensitivity and specificity.
Cut off Sensitivity for detecting dementia Specificity for detecting dementia
88 94% 89%
82 84% 100%
It has also been shown to be useful in differentiating dementia from pseudo dementia and for detecting cognitive
impairment in atypical Parkinson syndromes.
-DSM-IV
The DSM (The Diagnostic and Statistical Manual of Mental Disorders) is a manual used to code for mental
diseases. It is the American counterpart to the ICD-10 (used in the UK). It was first published 1952, since then
there have been five revisions. The last major revision was the DSM-IV in 1994.
The DSM-IV organises the diagnosis into five levels (axes) relating to different aspects of the disorder.
Axis I: clinical disorders, including major mental disorders, as well as developmental and learning
disorders
Axis II: underlying pervasive or personality conditions, as well as mental retardation
Axis III: acute medical conditions and physical disorders
Axis IV: psychosocial and environmental factors contributing to the disorder
Axis V: Global Assessment of Functioning or Children's Global Assessment Scale for children and teens
under the age of 18
-Creutzfeldt-Jakob disease considered to primarily cortical rather than subcortica dementia .
-Alcohol dependence syndrome
To make a diagnosis of the dependence syndrome (ICD-10 F1x.2), 3 or more of the following must be present
together at some time in the past year:-
Compulsion
Loss of control
Physiological withdrawal
Tolerance
Neglect of rest of life
Persistence despite clear evidence of harmful consequence
ICD-10 and DSM VI criteria are very similar as both are based on the original concept of the alcohol dependence
syndrome developed by Edwards and Gross in 1976. The original concept had the following seven elements:
-Narrowed repertoire is described in the ICD-10 as a characteristic feature but is not a diagnostic criterion.
Edwards and Gross criteria
Narrowing of the drinking repertoire
Salience of drink seeking behaviour
Tolerance
Withdrawal symptoms
Relief of withdrawal by further drinking
Compulsion to drink
Rapid reinstatement of symptoms after a period of abstinence
-Characteristics of dependent personality disorder include (DSM-IV criteria):-
Difficulty making everyday decisions without excessive reassurance from others
Need for others to assume responsibility for major areas of their life
Difficulty in expressing disagreement with others due to fears of losing support
Lack of initiative
Unrealistic fears of being left to care for themselves
Urgent search for another relationship as a source of care and support when a close relationship ends
Extensive efforts to obtain support from others
Unrealistic feelings that they cannot care for themselves
-Calculation not a domain covered by the Addenbrooke's cognitive exam .
-Mental state exam (cognition)
The following table lists the standard tests used for each area of cognition. Questions on this area are common.
Area of cognition Standard test
Orientation Asking the time, place, and person
Attention/concentration Serial 7's
Short term memory Digit span
Long term memory Delayed recall of name and address
Executive function Proverbs, similarities, differences, verbal fluency, cognitive estimates
-Digit span is not a test of executive function .
-Child abuse (risk factors)
Risk factors for child abuse:-
History of abuse in the caregiver
Substance misuse in the caregiver
Inaccurate knowledge about child development
Teenage parents
Children of single parents
Domestic violence in the home
High levels of stress within the family
Younger children
Children with disabilities
Poverty
Social isolation
Living in dangerous neighbourhood
Protective factors include:-
Parental resilience
Social connections
Knowledge of parenting and child development
Concrete support in times of need
Social and emotional competence of children
-Scales and assessment tools
Questions often arise which require Candidates to know a bit about the various questionnaires and interviews
that are used in psychiatry.
The college is keen on asking if certain assessment tools are self rated or require assistance. See table.
Self rated Clinician rated
BDI (Beck depression inventory) BPRS (Brief psychiatric rating scale)
GHQ (General health questionnaire) MADRS (Montgomery-Asberg depression rating
scale)
GDS (geriatric depression scale) HAMD (Hamilton depression rating scale)
ZSRDS (Zung self rated depression scale) HAMA (Hamilton anxiety rating scale)
HAD (Hospital Anxiety depression scale) PANSS (Positive and negative syndrome scale)
EPDS (Edinburgh postnatal major depression
scale)
CGI (Clinical global impression)
AIMS (Abnormal involuntary movement scale)
Y-BOCS (Yale-Brown Obsessive compulsive scale)
YMRS (Young mania rating scale)
GAF (Global assessment of functioning)
SAS (Simpson-Angus scale)
CAMDEX (Cambridge Mental Disorders of the
Elderly
Examination)
Candidates need to have a working knowledge of the most frequently used scales.
Condition Scales used
Depression HAMD, MADRS, GDS, ZSDRS, BDI
Mania YMRS
Anxiety HAMA
OCD Y-BCOS
Schizophrenia BPRS, PANSS
General scales GAF, CGI
Medication side effects SAS, AIMS, LUNSERS
HAMD (Hamilton depression rating scale)
The HAMD is a 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.
MADRS (Montgomery-Asberg depression rating scale)
The MADRS is a ten-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.
GDS (geriatric depression scale)
The GDS is a 30 item scale used to screen for depression in the elderly. Each question has either a yes or no
response make the total score out of 30. 0-9 is deemed normal, 10-19 is mild depression, and 20-30 is severe
depression.
ZSRDS (Zung self rated depression scale)
The ZSRDS was devised to assess the severity of depression. There are 20 items on the scale, each one scored out
of 1-4.
BDI (Beck depression inventory)
The BDI is another scale designed to assess the severity of depression. There are a total of 21 items, each is score
out of 0-3. The scale was revised in 1966. 0-13 indicates minimal depression, 14-19 mild depression, 20-28
moderate, and 29-63 severe depression.
YMRS (Young mania rating scale)
The YMRS is an 11-item instrument used to assess the severity of mania in patients with a diagnosis of bipolar
disorder.
HAMA (Hamilton anxiety rating scale)
HAMA is a 14 item scale designed to measure the severity of anxiety.
Y-BOCS (Yale-Brown Obsessive compulsive scale)
The Y-BOCS is used to measure both the severity of OCD and the response to treatment.
BPRS (Brief psychiatric rating scale)
This is probably the most widely used scale in psychiatry. This looks at both psychotic and affective symptoms.
PANSS (Positive and negative syndrome scale)
The PANSS 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.
GAF (Global assessment of functioning)
The GAF is 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.
CGI (Clinical global impression)
The CGI is 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.
DESS (Discontinuation-Emergent Signs and Symptoms scale)
The DESS is used to quantify discontination symptoms associated with stopping antidepressants. This 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.
-Stats Validity
Validity refers to the extent to which something measures what it claims to measure. There are several different
types of validity (see table)
Validity subtype Description
Face validity Face validity refers to the general impression of a test. A test has face validity if it
appears to test what it is meant to
Content validity Content validity refers to the extent to which a test or measure assesses the full
content of a subject or area. For example if a test is designed to help diagnose
depression, it would have poor content validity if it only asked about psychological
symptoms and neglected biological ones
Criterion validity A test has good criterion validity if it is useful for predicting something
Criterion validity
(Concurrent)*
In concurrent validation, the predictor and criterion data are collected at or about
the same time
Criterion validity
(Predictive)*
In Predictive validation, the predictor scores are collected first and criterion data are
collected at some later/future point.
Construct validity The extent to which a test measures the construct it aims to
Construct validity
(Convergent)*
A test has convergent validity if it has a high correlation with another test that
measures the same construct
Construct validity A test's divergent validity is demonstrated through a low correlation with a test that
(Divergent)* measures a different construct
Internal validity Internal validity is the confidence that we can place in the cause and effect
relationship in a study
External validity External validity is the degree to which the conclusions in a study would hold for
other persons in other places and at other times, i.e. it ability to generalise
* Note that concurrent and predictive validity are subcategories of criterion validity and that convergent and
divergent validity are subcategories of construct validity.
-Brief Psychiatric Rating Scale
The Brief Psychiatric Rating Scale is 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.
-SSRI (bleeding)
SSRI's have been shown to increase the risk of bleeding, this probably results from platelets being deficient of
serotonin due to the SSRIs effect on the transporter (serotonin is released by platelets and promotes
vasoconstriction).
The risk of bleeding is elevated further in the following:-
Elderly
Those with a history of haemostatic defects
Patients on other drugs that elevate the risk (warfarin, NSAIDS, steroids)
-Personality disorder - narcissistic
Features of narcissistic personality disorder include:-
Grandiose sense of self importance
Preoccupation with fantasies of unlimited success, power, or beauty
Sense of entitlement
Taking advantage of others to achieve own needs
Lack of empathy
Excessive need for admiration
Chronic envy
Arrogant and haughty attitude
Delirium
Delirium is a syndrome of cognitive impairment in the setting of fluctuating consciousness.
Note: fluctuating consciousness is also known as clouding of consciousness and refers to a situation where the
patient is out of touch with their environment and cannot respond properly to external stimuli such as
conversation.
Delirium typically comes on over a few days and has a fluctuating course.
The causes of delirium are numerous and varied ranging from metabolic disturbances to medications.
It is important to be able to differentiate delirium from dementia, the following table illustrates the main
differences
Delirium Dementia
Onset brief gradual
Disorientation occurs early occurs late
Conciousness clouding occurs early normal until late stages
Course fluctuates consistent
Psychomotor change occurs early occurs late
Mental state exam (appearance)
People with hypomania and mania often manifest their illness in their appearance. They tend to wear loud and
colourful clothes, and often have bizarre or garish make-up.
Unfashionable and clashing clothing is more suggestive of schizoid personality traits and autistic spectrum
disorders.
An excessively neat appearance would suggest an obsessional personality. Whereas signs of self neglect such as
dishevelled hair and poor dental hygiene are associated with depression and chronic schizophrenia.
-The GMSS (Geriatric Mental State Schedule) is used to screen for depression in the elderly.
-Clinical global impression requires the clinician to have previous experience with the patient's condition .
-Rapid reinstatement of symptoms after a period of abstinence used in the original Edwards and Gross
concept of the alcohol dependence syndrome but is not used in the ICD-10 concept of the dependence syndrome.
-the term 'balloon cell' is a general histological term used to refer to swollen and enlarged cells. They are often
seen in states of cerebral degeneration. As such they are seen in a number of different conditions. They are
particularly common in Pick's disease .
-Frontotemporal lobar degeneration
Frontotemporal lobar degeneration is the third most common type of cortical dementia after Alzheimer's and
Lewy body dementia.
There are three recognised types of FTLD
Frontotemporal dementia (Pick's)
Progressive non fluent aphasia (chronic progressive aphasia, CPA)
Semantic dementia
Common features of frontotemporal lobar dementias
Onset before 65
Insidious onset
Relatively preserved memory and visuospatial skills
Personality change and social conduct problems
Picks
This is the most common type and is characterised by personality change and impaired social conduct. Other
common features include hyperorality, disinhibition, increased appetite, and perseveration behaviours.
Focal gyral atrophy with a knife-blade appearance is characteristic of Pick's disease.
CPA
Here the chief factor is non fluent speech. They make short utterances that are agrammatic. Comprehension is
relatively preserved.
Semantic dementia
Here the patient has a fluent progressive aphasia. The speech is fluent but empty and conveys little meaning.
Unlike in Alzheimer's memory is better for recent rather than remote events.
Pathological changes seen in FTLD
Macroscopic changes seen in Frontotemporal lobar degeneration include:-
Atrophy of the frontal and temporal lobes
Microscopic changes include:-
Pick bodies - spherical aggregations of tau protein
Gliosis
Neurofibrillary tangles
Senile plaques
-Gudjonsson Suggestibility Scale
The Gudjonsson Suggestibility Scale consists of reading a story aloud to participants, who are then asked to
recall as much as they can remember. Subsequently, participants are probed with 20 questions pertaining to the
story, 15 of which are misleading. When the 20 questions have been answered, the participants are clearly and
firmly given a negative feedback on their performance. Specifically, they are told that they have made a number
of errors and that it is therefore necessary to repeat the questions to obtain more accurate answers. On the basis
of participants answers to the misleading items, a total suggestibility score can be calculated.
-Spider naevi
A spider nevus is a type of angioma seen commonly on the surface of the skin. The presence of one or two is
usually a normal finding. They can also be seen during pregnancy and are associated with oral contraceptive use.
They result from dilation of existing vessels on the skin surface.
Rapid development of numerous prominent spider naevi suggests a problem with the liver, the most common
cause being alcohol.
-Bipolar disorder (Subtypes)
Bipolar disorder is divided in to several different types.
The DSM-IV and ICD-10 recognises only bipolar I and bipolar II.
Bipolar I - Mania and depression
Bipolar II - Hypomania and depression
Gerald Klerman proposed additional subtypes in 1981 as follows:-
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)
-Personality disorder - schizoid
Schizoid personality disorder is characterised by:-
Indifference to praise and criticism
Preference for solitary activities
Lack of interest in sexual interactions
Lack of desire for companionship
Emotional coldness
Few interests
Few friends or confidants other than family
-Mania (drug induced)
There is good evidence that mania can be precipitated by the following:-
Levodopa
Corticosteroids
Anabolic-androgenic steroids
Antidepressants (tricyclic and monoamine oxidase inhibitor classes)
There is also evidence (albeit weaker) that mania can be precipitated by:-
Dopaminergic anti-Parkinsonian drugs
Thyroxine
Iproniazid and isoniazid
Chloroquine
-Amyl nitrite are sold in joke shops and used in the dance scene. They are not covered under the Misuse of
Drugs Act 1971.
-PICA
Pica is defined as persistent eating of non-nutritive substances for at least one month. It must be
developmentally inappropriate, not culturally sanctioned, and sufficiently severe to merit clinical attention.
It appears more frequently in young people than adults and is associated with mental retardation.
Pica has a variety of causes, these include:-
Mental disorders (autism, schizophrenia)
Iron and zinc deficiency
Pregnancy
-Semantic dementia characterised by fluent, empty speech .
-Myoclonus not normally seen in neuroleptic malignant syndrome but seen in serotonin syndrome .
-Baby blues
Transient episodes of emotional lability, along with sadness, dysphoria, and tearfulness constitute the syndrome
of 'baby blues'.
This commonly occurs 3-5 days following childbirth and may last several days. It is generally ascribed to rapid
changes in a woman's hormonal levels. No treatment is required other than education and support. If symptoms
last more than 2 weeks postpartum depression should be considered.
-Anorexia - blood abnormalities
Blood abnormalities are a major cause of morbidity and mortality in patients with eating disorders. Important
changes in blood chemistry are listed below:-
Electrolytes
Hypokalemia (low potassium)
Hypomagnesemia
Hypocalcemia
Hypophosphatemia (note in bulimia a high phosphate level is generally seen)
Endocrine
Low estradiol
Low luteinizing hormone (LH)
Low follicular stimulating hormone (FSH)
Low T3 (low T3 syndrome/ sick euthyroid syndrome), TSH and T4 are usually normal
Hypercortisolism
Elevated growth hormone
Others
Hypercarotenemia
Hypercholesterolemia
-A test has good construct validity if it has a high correlation with another test that measures the same
construct .
-Pregnancy (alcohol)
NICE make the following recommendations on alcohol consumption during pregnancy:-
Pregnant women and women planning to become pregnant should be advised to avoid drinking alcohol
in the first 3 months of pregnancy, because there may be an increased risk of miscarriage.
Women should be advised that if they choose to drink alcohol while they are pregnant they should drink
no more than 1-2 UK units once or twice a week. There is uncertainty about how much alcohol is safe to
drink in pregnancy, but at this low level there is no evidence of any harm to their unborn baby.
Women should be advised not get to drunk or binge drink (drinking more than 7.5 UK units of alcohol on
a single occasion) while they are pregnant because this can harm their unborn baby.
-in Klerman's bipolar subtypes .. Mania without depression = Bipolar VI .
-Patients with anorexia are likely to lack stores of glutathione which act to conjugate benzoquinonimine (the
major metabolite of paracetamol which is hepatotoxic) .
-Stereotyped thinking coded as a negaitive symptom on the PANSS .
-Clock drawing test
The clock drawing test is used as a quick screening test for cognitive dysfunction.
The patient is asked to draw a clock on a piece of paper, putting the numbers on the clock and drawing on the
clock hands in the position of 10 minutes past 10.
The test examines a range of different cognitive functions simultaneously, including:-
Visuospatial ability
Motor function [uncover a constructional apraxia ]
Attention
Comprehension
-Interview techniques (reinforcement)
Although 'reinforcement' is a rather woolly term, it does come up in the exams. It refers to any interview
technique that appears to increase a certain behaviour.
-Examples of objective tests include:-
Minnesota Multiphasic Personality Inventory
Sixteen Personality Factor Questionnaire (16PF)
NEO Personality Inventory
Esyenck personality test (EPQ)
-
Camberwell Family Interview
The Camberwell Family Interview was developed specifically to measure expressed emotion within families.
-Hypnotherapy not recommended by NICE in the management of non-cognitive symptoms of dementia .
-Dementia (non-cognitive symptoms)
NICE recommend the following non pharmacological interventions for the management of non-cognitive
symptoms in dementia:-
Aromatherapy
Multisensory stimulation
Therapeutic use of music and/or dancing
Animal-assisted therapy
Massage
-The Rey-Osterrieth Complex Figure test is used to assess Memory .
-diagnostic criteria for avoidant personality disorder includes Fear of being criticised or rejected in social
situations .
-Cotard's syndrome
Cotard's syndrome is the fixed and unshakable delusion that one does not exist. The delusion is encountered, in
less dramatic form, in the unshakable belief that an individual has lost his or her blood, internal organs, or soul,
or that one is dead.
The condition is most commonly seen in depression but is also seen in schizophrenia and bipolar disorder. It has
also been described after trauma. It typically occurs in females (90%) and tends to occur more frequently in the
elderly.
-the risk of major fetal malformation posed to women who use fluoxetine in the first trimester compared to
women who do not = duble risk .
-SIADH
The syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH) is charcterised by excessive
secretion of ADH resulting in hyponatremia and fluid overload (ADH basically dilutes the blood).
SIADH has many causes, just remember that one cause is antidepressants.
Risk factors for SIADH include:-
Being elderly
Being female
Being a smoker
Having medical co-morbidity
Polypharmacy
-Depersonalisation and derealisation are not considered to be dissociative disorders as they are not
associated with a loss of memory or identity.
-Dissociative disorders usually remit spontaneously .
-Decreased temporal lobe perfusion would be expected in light of the medial temporal lobe atrophy
associated with Alzheimer's.
-'digit span' is the standard test of Short term memory .
-Quasi psychotic thoughts is suggestive of borderline personality disorder .
-An urgent search for another relationship as a source of care and support when a close relationship ends is seen
in dependent personality disorder.
-CAGE
The CAGE questionnaire is a four item scale used to screen for alcoholism.
The questions are as follows
Have you ever thought about Cutting down your drinking
Have people annoyed you by criticising your drinking
Have you ever felt guilty about your drinking
Have you ever had a drink first thing in the morning to get rid of a hangover (an eye opener)
The CAGE is not diagnostic. The more positive answers given the more likely someone has an alcohol problem.
One positive answer is usually seen as enough justification for taking a more thorough, detailed alcohol history.
-Personality disorder - narcissistic
Features of narcissistic personality disorder include:-
Grandiose sense of self importance
Preoccupation with fantasies of unlimited success, power, or beauty
Sense of entitlement
Taking advantage of others to achieve own needs
Lack of empathy
Excessive need for admiration
Chronic envy
Arrogant and haughty attitude
-SASQ (Single alcohol screening questionnaire), asks only one question, when was the last time you had more
than x alcoholic drinks in one day? (Where x is 8 for men and 6 for women). An answer of within 3 months
indicates harmful or hazardous drinking.
-Anton's syndrome
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).
-Diogens Syndrome = is a disorder characterized by extreme self-neglect, domestic squalor, social withdrawal,
apathy, compulsive hoarding of garbage, and lack of shame. This patient displays symptoms of catatonia
-In Wernicke's encephalopathy There is demylination of periventricular grey matter + Atrophy of
mammilary bodies.
-Insomnia (sleep hygiene)
Sleep hygiene must be attempted before medications are used to treat insomnia.
Sleep hygiene approaches include:-
Increase daily exercise (not in the evening)
Reduce/ stop daytime napping
Reduce alcohol intake
Reduce caffeine intake
Use bed only for sleeping
Use anxiety management and relaxation techniques
Develop a regular routine of rising and retiring at the same time each day (regardless of the amount of
sleep taken)
-The tendency to pursue one's own interests even at the expense of others is a feature common to antisocial and
narcissistic personality disorder, however, the arrogance and inflated sense of personal importance are very
suggestive of narcissistic personality disorder.
-Inter rater reliability (not validity) refers to the degree of agreement among raters .
-The BPRS [Brief Psychiatric Rating Scale ] is a clinician rated scale designed to assess change in overall
psychopathology in patients with major psychiatric disorder, particularly psychosis.
The BPRS consists of between 18 and 24 items (symptom constructs) which are rated from 1 to 7 according to the
degree of severity. The minimum score is therefore 18.
Also considered is the individual's behaviour over the previous 2-3 days and this can be reported by the patient's
family.
- Choose MADRS if asked about measuring treatment effects in depression as this is what it is known for .
-regarding fronto-temporal lobar dementias Compared to Alzheimer's recent memory is preserved better
than remote memory .
-Hypoactive delirium is often missed as it is difficult to recognized .
-Speed is a term for amphetamine, withdrawal from which typically causes an increase (not a decrease) in
appetite.
-SCOFF questionnaire
The SCOFF questionnaire is used to screen for eating disorders. The following questions are included.
Do you ever make yourself Sick because you feel uncomfortably full?
Do you ever worry that you have lost Control over how much you eat?
Have you recently lost more than One stone in a three month period?
Do you believe yourself to be Fat when others say you are too thin?
Would you say Food dominates you life?
A score of 2 or more indicates a likely case of anorexia nervosa or bulimia. An eating disorder can be suspected
with 84.6% sensitivity and 98.6% specificity if a patient responds positively to 2 or more questions. The negative
predictive value (proportion of subjects with a negative test result who are correctly diagnosed) is 99.3%
(Rushing, 2003).
-Opiate abuse (intravenous heroin and nephropathy)
Intravenous heroin use has been associated with nephropathy (very rare) probably mediated by bacterial
infection. Heroin associated nephropathy is usually seen in African-American men (reasons unknown).
-Anorexia (prognostic factors)
A large study using the Swedish national registers identified the following as statistically significant factors
associated with a poor prognosis in anorexia nervosa:-
Patients with a long duration of hospital care
Psychiatric co-morbidity
Being adopted
Growing up in a one-parent household
Having a young mother
Lower minimum weight
Poor family relationships
Failed treatment
Late age of onset
Social problems
-Beck's depression inventory:-
Has 21 questions (max score of 63)
Each question scored from 0-3
Assesses severity of depression
Self rated
Covers period of two weeks before the evaluation .
-Schizophrenia (diagnosis, ICD-10 versus DSM-IV)
Broadly speaking the DSM-IV and ICD-10 have a similar diagnostic approach to schizophrenia. They do however
differ in the following ways.
Symptom duration
To meet a diagnosis of schizophrenia, the ICD-10 requires that symptoms of schizophrenia be present for at least
one month.
The DSM-IV requires symptoms to be present for at least 6 months, with at least a one month period of active
symptoms.
This difference reflects the fact that the DSM-IV recognises the prodromal phase of schizophrenia.
A period of schizophrenic symptoms lasting less than one month is classified in the ICD-10 as an acute and
transient psychotic disorder and in the DSM-IV as a brief psychotic episode. If a patient has had symptoms more
than 1 month but less than 6 months then the term 'schizophreniform disorder' is used by the DSM-IV
(prodromal phase).
Social and occupational dysfunction
The DSM-IV requires some impairment of social and occupational dysfunction. This is not a requirement of the
ICD-10.
-Dementia Investigation
NICE guidelines suggest the following investigations in people with dementia:-
Bloods - FBC, U&E, LFTs, calcium, glucose, TFTs, vitamin B12 and folate levels
Neuroimaging to exclude other reversible conditions (e.g. Subdural haematoma, normal pressure
hydrocephalus) and help provide information on aetiology to guide prognosis and management
-Down's syndrome (assessment of dementia)
People with Down's syndrome have an increased risk of developing Alzheimer's disease.
The MMSE is not useful in assisting diagnosis in this group.
The two main alternative tests are as follows:-
DMR (Dementia Questionnaire for Persons with Mental Retardation)
DSDS (Dementia Scale for Down Syndrome)
-Profound early memory loss is not suggestive of frontotemporal dementia .
-Alzheimer's (Risk factors)
The following are recognised risk factors for the development of Alzheimer's disease:-
Age - Increasing age brings with it increased risks
Family history
Head trauma - especially if associated with loss of consciousness
Hypertension
Heart disease
Diabetes
CVA
High cholesterol
Lower educational level
Female gender
-Anorexia - skin changes
The following are skin changes seen in anorexia nervosa:-
Xerosis (dry skin)
Cheilitis (inflammation of the lip)
Gingivitis (inflammation of the gums)
Hypertrichiosis (excess hair growth in areas that do not normal have hair)
Hyperpigmentation
Russell's sign (scarring on knuckles and back of hand)
Carotenoderma (yellow/orange skin colour)
Acne
Nail changes
Acrocyanosis (persistent blue, cyanotic discolouration of the digits)
Seborrheic dermatitis
-Learning difficulties such as autism are classified under axis I whereas general mental retardation is listed
under axis II.
-Three major symptoms indicate a high probability of the presence of NMS:-
Hyperthermia
Rigidity
Elevated creatine phosphokinase concentration
-The mortality rate is estimated to be up to 20%.
The following table lists the common risk factors for NMS.
Risk factors for
NMS
General Younger age
Being male
Physical exhaustion
Dehydration or electrolyte imbalance
Previous and family history of NMS
Organic mental disorders
Low serum iron levels
Raised creatine kinase levels
Comorbid substance misuse
Related to antipsychtoic High loading dose
Faster rate of loading
High potency
Sudden withdrawal
-Asking the name of the current prime minister is question included on the abbreviated mental test score
(AMTS) not in MMSE.
-Pretibial myxoedema is normally associated with thyroid disease not Alcoholism .
-Verbal fluency is a test of the frontal lobe and is therefore not assessed in the MMSE. It is assessed using the
ACE-R.
-Tardive dyskinesia .. It worsens when a patient is distracted
Tardive dyskinesia typically affects the face (3/4 of affected individuals) but also affects the limbs (1/2 of
affected) and the trunk (1/4 of affected).
The movements fluctuate over time, increase with emotional arousal, decrease with relaxation and disappear
with sleep. They also decrease when affected muscles are used for voluntary tasks. Distracting tasks such as
mental arithmetic also worsen the movements.
The movements have a variable response to medication. Increasing the dose of neuroleptics tends to lessen the
problem (temporarily) and the use of anticholinergics tends to worsen the movements. It is believed to be due to
postsynaptic D2 receptor hypersensitivity in the nigrostriatal pathway.
Tardive dyskinesia normally develops when a person has been on neuroleptics for months to years. This time
period can be as short as one month in the elderly. It can also develop in patient who have never received
treatment suggesting it may be a feature of schizophrenia. It tends to follow a fluctuating course with some
spontaneous remissions.
Risk factors include:-
Advancing age
Gender - Earlier studies suggested TD was more common in women but this has not been a consistent
finding (College questions may not be up to date on this)
Ethnicity - Rates are higher in African Americans
Psychiatric disorder - Some studies have suggested higher rates in people with affective disorder but this
has not been a universal finding
Antipsychotic use - First generation antipsychotics appear to present a higher risk than second
generation drugs
Treatment involves stopping the antipsychotic or switching to an atypical. Anticholinergics should also be
stopped.
-Conceptual disorganization coded as a positive symptom in PANSS scale .
-Dependent personality disorder is also known as asthenic personality disorder .
-Schizophrenia (pathology)
Macroscopic pathological features of schizophrenia include:-
Ventricular enlargement
Reduced brain volume (up to 5%)
Reduced left planum temporale gray matter, and reversed planum temporale surface area asymmetry
(normally left larger than right in a right handed person)
-The most consistent microscopic findings have been a reduction of the size of the dorsolateral prefrontal cortex
and the hippocampus.
-The minimum alcohol price [ less affordable ]is the most effective and selective mechanism to reduce heavy
drinking and alcohol-related harm.
-Unstable self image is typical of borderline personality disorder.
-Dat scan (SPECT Imaging) most useful when trying to differentiate Alzheimer's disease from Lewy body
dementia .
-Night terrors also known as pavor nocturnus .
-Alcohol is not normally detectable in urine after 24 hours .
-School refusal is not a diagnosis recognised by the ICD-10 .
-Impairment of consciousness is the most characteristic feature of delirium .
-Neurasthenia
Neurasthenia (F48.0) is a condition characterised by excessive fatigue following either mental or physical effort.
This is often accompanied by other unpleasant symptoms such as dizziness and tension headaches.
ICD-10 Diagnosis requires
Either persistent and distressing complaints of increased fatigue after mental effort, or persistent and
distressing complaints of bodily weakness and exhaustion after minimal effort
At least two of the following (muscular aches, dizziness, tension headaches, sleep disturbance, inability to
relax, irritability, dyspepsia)
Inability to recover through rest, relaxation or enjoyment
Duration exceeds 3 months
Does not occur in the presence of organic mental disorders, affective disorders or panic or generalised
anxiety disorder
- Delirium and dementia differ in several ways but the main difference is the presence of fluctuating levels of
consciousness.
-Independent risk factors for QT prolongation include:-
Female sex
Hypokalemia
Hypomagnesaemia
Hypocalcemia
Anorexia nervosa
-Without a history of depression, the risk of postpartum depression is 10%. This is increased to 25% if there is a
history of depression, and to 50% if there is a history of postpartum depression .
-Clifton Assessment Procedure
The Clifton Assessment Procedure for the Elderly (CAPE), is a tool used to assess quality of life and physical and
cognitive dependency levels in the elderly to indicate areas of unmet need.
-Progressive supranuclear palsy presents with Dementia ,falls and ophthalmoplegia .
-A person's insistence to do things in their own way is suggestive of obsessive compulsive disorder.
-Child abuse
Types of child abuse (in decreasing order of frequency) include:-
Neglect
Physical abuse and non-accidental injury
Emotional abuse
Sexual abuse
Fabricated or induced illness
Overall, approximately 60% of perpetrators of child abuse are female, although the gender of the abuser differs
by the type of abuse. Neglect and medical neglect are most often attributed to female caretakers, while sexual
abuse is most often associated with male offenders.
The most lethal form of child abuse is neglect. Deaths from neglect can, for example, be caused by accidents due
to lack of supervision or abandonment or from the failure to seek medical attention for an injury, illness, or
condition.
While children of families in all income levels suffer maltreatment, research suggests that family income is
strongly related to incidence rates.
Studies have shown a consistent pattern regarding the abuse and neglect inflicted on children of different
genders. Approximately 75% of sexual abuse is inflicted upon girls. Girls also are more likely to suffer from
emotional abuse and neglect. Boys, on the other hand, are more likely to experience physical trauma (other than
sexual abuse).
Approximately 20% of people who commit child abuse were themselves abused as children.
-Exaggerated startle response is characteristic of post-traumatic stress disorder .
-The Discontinuation-Emergent Signs and Symptoms scale (DESS) is used to quantify discontination symptoms
associated with stopping antidepressants.
-Depression (treatment duration)
A single episode of depression should be treated for 6-9 months following complete remission. If antidepressants
are stopped immediately on recovery, 50% of patients experience a relapse within 3-6 months.
NICE recommend that patients who have had 2 or more depressive episodes (within recent history) should be
treated with an antidepressant for a minimum of 2 years.
-Edinburgh Postnatal Depression Scale is a self-report questionnaire .
-most commonly seen in bipolar disorder with psychosis Prominent affective symptoms and mood
congruent delusions .
-The LUNSERS (Liverpool University Neuroleptic Side Effect Rating Scale)
is a 51 item self-administered rating scale used to identify side effects from neuroleptic medication
(antipsychotics).
It includes 41 known side effects of neuroleptics, and ten red herring items, including hair loss and chilblains,
which are not known side effects of neuroleptic medication.
Validity and reliability have been tested in a group of 50 male and female patients with a mean age of 46 years
and 16 years of antipsychotic use, along with a group of 50 healthy controls, with promising results. The validity
of the LUNSERS has also been tested against the UKU (the gold standard which takes about 60 minutes to do).
-Paracetamol levels should be taken 4 hours post overdose (where possible) and treatment led by that result.
-According to the Gottesman data, .. the dizygotic concordance rate in schizophrenia = 17% not 12% .
-Deceitfulness is a characteristic feature of antisocial personality disorder.
-The table below shows Gottesman's famous findings, these are the average risks complied from the family and
twin studies conducted in European populations between 1920 and 1987.
You need to commit each one to memory.
Relationship to person with schizophrenia Risk of developing schizophrenia
General population 1%
First cousin 2%
Grandchildren 5%
Parents 6%
Siblings 9%
Children 13%
Fraternal twins 17%
Identical twins 48%
-Criminal responsibility
In order to be found guilty of an act, it must be proven that a person committed the act (actus rea) and that
they had a guilty mind (mens rea).
In England, children under the age of 10 cannot be found criminally responsible for an act.
Not guilty by reason of insanity
In order to be found not guilty by reason of insanity a person must satisfy the following McNaughten rules
McNaughten rules
Did not understand the quality or nature of the act
Did not know what they were doing was wrong
If under a delusion that prevents the true appreciation of the nature and quality of his act, he is under the
same degree of responsibility as if the facts were how he imagined them to be. For example, if acted in self-
defence believing life in danger then would be treated as if acting in self-defence
Automatism
Automatism is a defence used when the act is believed to have occurred unconsciously. It comes in two forms:-
Sane automatism - where the act occurs from an external cause such as a head injury.
Insane automatism - where the act occurs from an internal cause such as epilepsy
Diminished Responsibility
Diminished Responsibility is used only in the defence of murder and allows the normal life sentence to be
reduced to manslaughter.
-The Gillick test refers to issues of consent in people under the age of 16.
-The Bolam test concerns cases of medical negligence.
-The Pritchard criteria refer to fitness to plead.
-The Edwards and Gross criteria concern alcohol dependence.
-Caseness
When a psychological rating scale is used for screening an operational definition of 'caseness' (the threshold for
identifying a case) must be specified. The 'caseness' usually refers to a numerical value (cutoff) above which a
respondent/ participant is considered to be a 'positive' (case).
-Night terrors
Night terrors (aka pavor nocturnus) are different to nightmares which occur in REM sleep. Night terrors occur in
the transition from stage 3 to stage 4 sleep. Also children have no memory of the night terror the next morning.
They generally occur in children age 3-12 and most often when a child is 3-4. They are equally common in boys
and girls, and they normally spontaneously remit in adolescence.
They are charcterised by intense crying and distress during sleep which occurs approximately 90 minutes after
falling asleep. Children are unresponsive to external stimuli when experiencing a night terror.
-Abdominal striae are a common finding and generally do not suggest an underlying pathology, causes
include:-
Pregnancy
Rapid weight gain
Steroid abuse
Cushing's disease
-Battle's sign - indicates basal skull fracture
-Babinski's sign - indicates upper motor neurone lesion
-Hoover sign - indicates non organic paralysis of the leg
-Kernig sign - indicates meningeal irritation .
-facilitating an interview by Maintaining eye contact , use of posture, gesture, and words to indicate that the
interviewer is interested in what the patient is saying.
-Cognitive estimates used to test the frontal lobe function of abstraction .
-The ICD-10 was originaly designed using only a single axis .
-Age is the strongest risk factor for the development of Alzheimer's disease.
-Global assessment of function scale
Global assessment of function scale
The Global Assessment of Functioning Scale is a 100-point scale that measures a patients overall level of
psychological, social, and occupational functioning. It is designed to be completed in under 3 minutes and is
recorded under axis V of the DSM. A higher score corresponds to a higher level of functioning.
-Impaired executive function suggests a cortical rather than a subcortical dementia .
-Lithium monitoring
Monitoring of patients on lithium therapy
Inadequate monitoring of patients taking lithium is common - NICE and the National Patient Safety
Agency (NPSA) have issued guidance to try and address this. As a result it is often an exam hot topic
Lithium blood level should 'normally' be checked every 3 months. Levels should be taken 12 hours post-
dose
Thyroid and renal function should be checked every 6 months patients should be issued with an
information booklet, alert card and record book
-Gender identity disorders
The ICD-10 lists the following gender identity disorders
Code Disorder
F64.0 Transsexualism
F64.1 Dual-role transvestism
F64.2 Gender identity disorder of childhood
F64.8 Other
F64.9 Unspecified
Transsexualism is a desire to live and be accepted as a member of the opposite sex.
Dual-role transvestism is the wearing of clothes of the opposite sex in order to enjoy the temporary membership
of the opposite sex without the desire for a permanent sex change. No sexual excitement accompanies the cross-
dressing (this distinguishes it from fetishistic transvestism).
-Neuroimaging is required in all cases with suspected dementia .
-Cataplexy is a sudden and transient loss of muscle tone, often triggered by emotions. It is commonly seen in
narcolepsy.
-Post-concussion syndrome
Post-concussion syndrome is seen after even minor head trauma
Typical features include
headache
fatigue
anxiety/depression
dizziness
Hyponatremia
Hyponatremia (low serum sodium) in psychiatric patients may result from the psychiatric disorder itself, from
its treatment, or from concomitant medical conditions.
Symptoms include:-
Nausea and vomiting
Confusion and lethargy
Irritability
Muscular spasm and cramp
Seizures
Where hyponatremia is drug induced it is referred to as 'the syndrome of inappropriate antidiuretic hormone
hypersecretion' (SIADH) and is charcterised by excessive secretion of ADH resulting in hyponatremia and fluid
overload (ADH basically dilutes the blood).
-People often get confused between hypochondriasis and somatization disorder. In hypochondriasis people
are preoccupied with the belief that they have a specific condition. In somatization disorder people are more
concern with symptoms than a specific condition.
-Hyperprolactinemia is often asymptomatic. Decisions about treatment require a balanced consideration of
the current symptoms, long term risks and perceived benefits of continuing the antipsychotic. It is often an
incidental finding that requires no change to the medication regime.
-Cannabis use increases the relative risk for schizophrenia by 2 fold .
-The severity of Alzheimer's is defined as follows:-
Mild = MMSE 21-26
Moderate = MMSE 10-20
Severe = MMSE 0-10
-Constipation is a common complication of anorexia nervosa.
-Transsexualism is a desire to live and be accepted as a member of the opposite sex.
-Dual-role transvestism is the wearing of clothes of the opposite sex in order to enjoy the temporary
membership of the opposite sex without the desire for a permanent sex change. No sexual excitement
accompanies the cross-dressing (this distinguishes it from fetishistic transvestism).
-Combat neurosis is another term for PTSD.
-Vomiting increases amylase levels in bulimic patients. This increased amylase probably comes from the
salivary gland.
-Prolonged vomiting results in loss of gastric secretions which contain hydrogen ions. This leads to a metabolic
alkalosis.
-A raised TSH and normal T4 is consistent with subclinical hypothyroidism (a raised TSH and reduced T4 is
overt hypothyroidism). Lithium is a recognised cause of this so Continue lithium and recheck bloods in one
month
-Sialadenosis refers to noninflammatory, often recurrent, enlargement of the salivary glands, most frequently
the parotids, which is almost always associated with an underlying systemic disorder. These include diabetes,
alcoholism, malnutrition, anorexia nervosa, and bulimia.
-Grief
Current thinking on grief stems from the work done by John Bowlby. He outlined the natural phases of grief as
seen in the table below. He did not specify a time period for each stage and added that people can go backwards
and forwards from one stage to another.
Normal grief
Phase Features Typical time course
I Shock and protest - including disbelief Few days
II Preoccupation - involves yearning and anger Few weeks
III Disorganisation - includes despair and acceptance of loss Several months
IV Resolution 1-2 years
A similar system was suggested by Kubler-Ross in 1969.
Stage I = Denial
Stage II = Anger
Stage III = Bargaining
Stage IV = Depression
Stage V = Acceptance
Abnormal grief
Abnormal grief is often divided in to three categories (see table below)
Inhibited Absence of expected grief symptoms at any stage
Delayed Avoidance of painful symptoms within 2 weeks of loss
Chronic/ prolonged Continued significant grief related symptoms 6 months after loss
Grief and depression
A high proportion of people will meet the criteria for major depression in the first year following bereavement.
These episodes usually resolve within 6 months.
Features useful for distinguishing normal grief from major depression include:-
Generalised guilt (rather than guilt specifically related to actions taken around the time of death.
Thoughts of death (except in relation to the deceased)
Feeling worthless
Psychomotor retardation
Prolonged functional impairment
Hallucinations (except in relation to the deceased)
-Both Asperger syndrome and autistic spectrum disorders are about five times more common in boys
than in girls, segregate within the same families, and appear strongly genetic .
-The age at onset of psychosis for cannabis users is 2.70 years younger than for non users .
-Dementia is a clinical syndrome, the diagnosis of which rests on a clinical interview.
-Loss of emotional reactivity is a somatic symptom of depression .
-Peptic ulcer disease is not a recognised complication of bulimia .
-Bouffée délirante = short lived psychotic episode lasting less than 3 months .
-There is considerable overlap between culture bound illness and other ICD-10 conditions .
-Use of ipecac in patients with eating disorders is associated with Cardiomyopathy .
-ADHD (aetiology)
Risk factors for ADHD include:-
Maternal smoking during pregnancy
Maternal alcohol consumption during pregnancy
Maternal heroin use during pregnancy
Low birth weight
Fetal hypoxia
Severe early psychosocial adversity
Post traumatic stress disorder (diagnosis and treatment)
Post traumatic stress disorder (PTSD) is an emotional reaction to a traumatic event.
The ICD-10 diagnostic criteria are as follows:-
Exposure to a traumatic event which would be likely to cause pervasive distress in almost anyone.
The event must be persistently remembered or relived, as evidenced by flashbacks, vivid memories, or
nightmares.
The patient must actively avoid situations which remind them of the event.
In addition it stipulates that either of the following must be present
Partial amnesia for part of the event
Persistent symptoms of psychological arousal such as, poor sleep, poor concentration, hypervigilance,
exaggerated startle response, irritability.
The above symptoms must occur within 6 months of the event.
NICE guidelines make the following recommendations about the treatment of PTSD
Debriefing should not be offered
Where symptoms are mild and have been present for less than 4 weeks watchful waiting should be
considered (follow up given within 1 month)
All people with PTSD should be offered a course trauma-focused cognitive behavioural therapy (CBT) or
eye movement desensitisation and reprocessing (EMDR).
Drug treatments for PTSD should not be used as a routine first-line treatment for adults in preference to
a trauma-focused psychological therapy.
Drug treatments (paroxetine or mirtazapine for general use, and amitriptyline or phenelzine for
initiation only by mental health specialists) should be considered for the treatment of PTSD in adults
who express a preference not to engage in trauma-focused psychological treatment.
-Risk factors for clozapine induced agranulocytosis include:-
Age (increasing age increases risk)
Ethnicity (Asians are 2.4 times more likely than Caucasians to develop agranulocytosis on clozapine)
-Risk factors for neutropenia include:-
Race (Afro-Caribbean 77% increase in risk)
Age (decrease in risk as age increases)
Low baseline white cell count .
-People are 4-5 times more likely to be schizophrenic at 26 if they were regular cannabis smokers at 15,
compared to 2 times for those who did not report regular use until age 18 .
- Ataque de nervios should be classified under ICD-10 …..Other specified neurotic disorders .
-An unwillingness to pass on tasks to others except if they surrender to exactly their way of doing things is a
feature of obsessive compulsive personality disorder, sounds like your average forensic psychiatrist!
-Ataque de nervios ('attack of nerves') is a culturally defined Latino syndrome usually triggered by acute stress
and typically characterised by paroxysms of uncontrollable shouting and crying, trembling, palpitations, and
aggressiveness.
-Inability to discard worn out objects with no sentimental value supports a diagnosis of obsessive compulsive
personality disorder .
-The negative predictive value of the SCOFF is 99.3% .
-Dual-role transvestism is the wearing of clothes of the opposite sex in order to enjoy the temporary
membership of the opposite sex without the desire for a permanent sex change. No sexual excitement
accompanies the cross-dressing (this distinguishes it from fetishistic transvestism).
-Schizophreniform disorder should be classified as F20.8 (other schizophrenia) according to the ICD-
10.The term 'schizophreniform disorder' is used in the DSM-IV to refer to a schizophrenia like illness with a
duration of more than 1 month but less than 6 and in which the level of functional impairment is not as great as
would be expected in true schizophrenia. Think of it as schizophrenia lite!
Schizotypal disorder = F21
Persistent delusional disorders = F22
Induced delusional disorder = F24
Schizoaffective disorders = F25
-The SUSS (sit up squat and stand) test was developed to assist in the evaluation and assessment of anorexia
nervosa.
-Windigo is not listed in the DSM.
-Patients with anorexia and a BMI less than 13 should have 24 hour bed rest along with consideration for deep
vein thrombosis prophylaxis.
-Stroop test
In the basic version of the Stroop test words are presented to the test subject which spell a colour but are written
in either the same colour. For example the word RED may be presented but it is written in blue. The subject is
asked to state the colour of the text rather what is spelt by the letters as quickly as possible.
This test evaluates how able the subject is at making an appropriate response when given two conflicting signals.
This ability is thought to stem from the anterior cingulate which lies between the right and left frontal lobes.
The cognitive mechanism at work in this process is called directed attention. This mental resource is used to
manage our thoughts by inhibiting one response in order to say or do something else.
-Conversion disorder is not classified as a somatoform disorder in the ICD-10 .
-
![abpn logo ver 8 [Converted]• Clinical Neurophysiology • Pain Medicine • Epilepsy • Psychosomatic Medicine • Forensic Psychiatry • Sleep Medicine • Geriatric Psychiatry](https://img.pdfslide.net/doc/110x75/5f488eb197cc76031f6c0e43/abpn-logo-ver-8-converted-a-clinical-neurophysiology-a-pain-medicine-a-epilepsy.jpg){kind=logo}
