While other conditions may also present with the same symptoms, a Kayser-Fleischer Ring, characterized by a golden-brown corneal ring due to copper deposits at the Descemet’s membrane, is considered a definitive indicator of Wilson’s disease.

Understanding Wilson’s Disease: Causes, Symptoms, and Management

Wilson’s disease, also known as hepatolenticular degeneration, is a genetic disorder that affects copper storage in the body. This condition is caused by a defect in the ATP7B gene, which leads to the accumulation of copper in the liver and brain. The onset of symptoms usually occurs between the ages of 10 and 25, with liver disease being the most common presentation in children and neurological symptoms in young adults.

The excessive deposition of copper in the tissues can cause a range of symptoms, including hepatitis, cirrhosis, basal ganglia degeneration, speech and behavioral problems, asterixis, chorea, dementia, Kayser-Fleischer rings, sunflower cataract, renal tubular acidosis, haemolysis, and blue nails. Diagnosis is based on reduced serum ceruloplasmin, reduced serum copper, and increased 24-hour urinary copper excretion.

The traditional first-line treatment for Wilson’s disease is penicillamine, which chelates copper. Trientine hydrochloride is an alternative chelating agent that may become first-line treatment in the future. Tetrathiomolybdate is a newer agent that is currently under investigation.

In summary, Wilson’s disease is a genetic disorder that affects copper storage in the body, leading to a range of symptoms that can affect the liver, brain, and eyes. Early diagnosis and treatment are essential to prevent complications and improve outcomes.

Assessing Executive Function with the Hayling and Brixton Tests

The Hayling and Brixton tests are two assessments designed to evaluate executive function. The Hayling Sentence Completion Test consists of two sets of 15 sentences, with the last word missing. In the first section, participants complete the sentences, providing a measure of response initiation speed. The second part, the Hayling, requires participants to complete a sentence with a nonsense ending word, suppressing a sensible one. This provides measures of response suppression ability and thinking time. Performance on such tests has been linked to frontal lobe dysfunction and dysexecutive symptoms in everyday life.

The Brixton Test is a rule detection and rule following task. Impairments on such tasks are commonly demonstrated in individuals with dysexecutive problems. Overall, these tests provide valuable insights into executive function and can help identify areas of weakness that may require intervention.

In psychiatry, various questionnaires and interviews are used to assess different conditions and areas. It is important for candidates to know whether certain assessment tools are self-rated of require clinical assistance. The table provided by the college lists some of the commonly used assessment tools and indicates whether they are self-rated of clinician-rated. For example, the HAMD and MADRS are clinician-rated scales used to assess the severity of depression, while the GDS is a self-rated scale used to screen for depression in the elderly. The YMRS is a clinician-rated scale used to assess the severity of mania in patients with bipolar disorder, while the Y-BOCS is used to measure both the severity of OCD and the response to treatment. The GAF provides a single measure of global functioning, while the CGI requires the clinician to rate the severity of the patient’s illness at the time of assessment. The CAMDEX is a tool developed to assist in the early diagnosis and measurement of dementia in the elderly.

For diagnostic categories to be useful, they must be related to the disorders encountered in practice. Face validity refers to the degree to which diagnostic categories align with clinical experience. Validity is distinct from diagnosis reliability. Concurrent validity measures how well a test corresponds with other measures of the same thing. Construct validity involves diagnostic categories indicating connections between disorders and independent variables, such as biochemical measures. Content validity involves test items representing the full range of possible items the test could cover. Predictive validity involves diagnostic categories being able to anticipate the outcome of disorders.

A positive Romberg test suggests the presence of sensory ataxia.

Romberg’s Test for Investigating Ataxia

Romberg’s test is a diagnostic tool used to determine the cause of ataxia. A positive result indicates that the cause is sensory in nature. The test involves asking the patient to stand upright with their feet together and eyes closed. If the patient begins to sway of fall over, the test is considered positive. In cases where there is a cerebellar problem, the patient will exhibit ataxia even when their eyes are open. Romberg’s test is an important tool in diagnosing ataxia and determining the underlying cause of the condition.

Alcohol screening tools are available to assist in the diagnosis of alcohol problems. One such tool is the AUDIT (Alcohol Use Disorders Identification Test), which consists of 10 questions and covers harmful use, hazardous use, and dependence. Another tool is the FAST (Fast Alcohol Screening Test), which has just 4 questions and was developed for use in a busy medical setting. The CAGE is a well-known 4 question screening tool, but recent research has questioned its value. Other tools include SASQ (Single alcohol screening questionnaire), PAT (Paddington Alcohol Test), MAST (Michigan Alcoholism Screening Test), and RAPS4 (Rapid Alcohol Problem Screen 4). These tools can help identify hazardous of harmful alcohol consumption and alcohol dependence.

While digit span is primarily used to assess working memory, it also involves executive attention, which is a component shared by tests of working memory capacity and executive function. Therefore, digit span cannot be considered solely a test of working memory.

The mental state exam assesses various areas of cognition, including orientation, attention/concentration, short term memory, long term memory, and executive function. Standard tests for each area include asking about time, place, and person for orientation, serial 7’s for attention/concentration, digit span for short term memory, delayed recall of name and address for long term memory, and various tasks such as proverbs, similarities, differences, verbal fluency, and cognitive estimates for executive function.

The score is 11, with E2, V4, and M5 contributing to it.

The Glasgow Coma Scale is used to assess the depth of coma and impaired consciousness. Scores range from 3 to 15, with impaired consciousness rated as mild, moderate, of severe. The scale assesses eye opening response, verbal response, and motor response, with specific criteria for scoring each behavior. The final score is a combination of these three scores.
Scoring Guide;
Eye opening response
4 Spontaneous opening
3 Opens to verbal stimuli
2 Opens to pain
1 No response
Verbal response
5 Orientated
4 Confused conversation
3 Inappropriate words
2 Incoherent
1 No response
Motor response
6 Obeys commands
5 Purposeful movement to painful stimuli
4 Withdraws in response to pain
3 Flexion in response to pain (decorticate posturing)
2 Extension in response to pain (decerebrate posturing)
1 No response

The college is evaluating your comprehension of the term ‘caseness’ through this question. The GHQ is an established instrument used to detect individuals who meet the criteria for ‘caseness’.

Defining ‘Caseness’ in Psychological Rating Scales

When utilizing a psychological rating scale for screening purposes, it is crucial to establish a clear definition of ‘caseness.’ This refers to the threshold at which a respondent of participant is identified as a case, typically represented by a numerical cutoff value. Without a defined caseness, the results of the screening may be ambiguous of inconsistent. Therefore, it is essential to establish a clear operational definition of caseness to ensure accurate and reliable screening outcomes.

DSM versus ICD: A Comparison of Mental Disorder Classifications

The DSM and ICD are two widely used classifications of mental disorders. While the ICD was initiated in Paris in 1900, the DSM-I was published in the USA in 1952 as a military classification of mental disorders. The ICD is intended for use by all health practitioners, while the DSM is primarily used by psychiatrists. The ICD is the official world classification, while the DSM is the official classification in the USA.

One major difference between the two classifications is their focus. The ICD has a major focus on clinical utility, with a planned reduction of the number of diagnoses in the upcoming ICD-11. On the other hand, the DSM tends to increase the number of diagnoses with each succeeding revision. Additionally, the ICD provides diagnostic descriptions and guidance but does not employ operational criteria, while the DSM depends on operational criteria.

It is important to note that the ICD has to be flexible and simple in the use of language to enable all practitioners, including those with very little formal qualifications in low- and middle-income countries, to be acceptable. Overall, understanding the differences between the DSM and ICD can help mental health practitioners choose the most appropriate classification for their needs.

– Catatonia is a psychiatric syndrome characterized by disturbed motor functions, mood, and thought.
– Key behaviors associated with catatonia include stupor, posturing, waxy flexibility, negativism, automatic obedience, mitmachen, mitgehen, ambitendency, psychological pillow, forced grasping, obstruction, echopraxia, aversion, mannerisms, stereotypies, motor perseveration, echolalia, and logorrhoea.
– These behaviors are often tested in exam questions.
– Karl Ludwig Kahlbaum is credited with the original clinical description of catatonia.

Mini Mental State Exam (MMSE)

The Mini Mental State Exam (MMSE) was developed in 1975 by Folstein et al. Its original purpose was to differentiate between organic and functional disorders, but it is now mainly used to detect and track the progression of cognitive impairment. The exam is scored out of 30 and is divided into seven categories: orientation to place and time, registration, attention and concentration, recall, language, visual construction, and attention to written command. Each category has a possible score, and the total score can indicate the severity of cognitive impairment. A score equal to or greater than 27 indicates normal cognition, while scores below this can indicate severe, moderate, of mild cognitive impairment. The MMSE is a useful tool for detecting and tracking cognitive impairment.

Clinical Trials: Phases and Objectives

Clinical trials are conducted in four phases to evaluate the safety and efficacy of drugs of treatments. In Phase I, a small group of healthy individuals (15-20) is given the drug to determine its safety, dosage range, and side effects. Phase II involves a larger group (100-300) to assess the drug’s effectiveness and safety. In Phase III, the drug is given to a larger population (1,000-3,000) to confirm its efficacy, compare it with existing treatments, and collect data for safe use. Phase IV, also known as post-marketing trials, is conducted after the drug is licensed to gather additional information on safety and potential uses. These trials are crucial in determining the safety and efficacy of drugs and treatments before they are made available to the public.

– Catatonia is a psychiatric syndrome characterized by disturbed motor functions, mood, and thought.
– Key behaviors associated with catatonia include stupor, posturing, waxy flexibility, negativism, automatic obedience, mitmachen, mitgehen, ambitendency, psychological pillow, forced grasping, obstruction, echopraxia, aversion, mannerisms, stereotypies, motor perseveration, echolalia, and logorrhoea.
– These behaviors are often tested in exam questions.
– Karl Ludwig Kahlbaum is credited with the original clinical description of catatonia.

The DSM-IV-TR uses a multi-axial system to diagnose mental disorders. Axis II covers developmental and personality disorders, such as autism and borderline personality disorder. Axis I covers clinical syndromes, like depression and schizophrenia. Axis III includes physical conditions that may contribute to mental illness, such as brain injury of HIV/AIDS. Axis IV rates the severity of psychosocial stressors, such as job loss of marriage, that may impact the person’s mental health. Finally, Axis V rates the person’s level of functioning, both currently and in the past year, to help the clinician understand how the other axes are affecting the person and what changes may be expected.

Understanding the Placebo Effect

In general, a placebo is an inert substance that has no pharmacological activity but looks, smells, and tastes like the active drug it is compared to. The placebo effect is the observable improvement seen when a patient takes a placebo, which results from patient-related factors such as expectations rather than the placebo itself. Negative effects due to patient-related factors are termed the nocebo effect.

Active placebos are treatments with chemical activity that mimic the side effects of the drug being tested in a clinical trial. They are used to prevent unblinding of the drug versus the placebo control group. Placebos need not always be pharmacological and can be procedural, such as sham electroconvulsive therapy.

The placebo effect is influenced by factors such as the perceived strength of the treatment, the status of the treating professional, and the branding of the compound. The placebo response is greater in mild illness, and the response rate is increasing over time. Placebo response is usually short-lived, and repeated use can lead to a diminished effect, known as placebo sag.

It is difficult to separate placebo effects from spontaneous remission, and patients who enter clinical trials generally do so when acutely unwell, making it challenging to show treatment effects. Breaking the blind may influence the outcome, and the expectancy effect may explain why active placebos are more effective than inert placebos. Overall, understanding the placebo effect is crucial in clinical trials and personalized medicine.

The Frontal Assessment Battery (FAB) is a quick and easy bedside test used to detect the dysexecutive syndrome. It consists of six subsets, including conceptualization, mental flexibility, motor programming, conflicting instructions, go-no go (inhibitory control), and prehension behavior. The test assesses a patient’s ability to perform tasks such as abstract reasoning, verbal fluency, and motor skills. The FAB can be completed in just a few minutes and is a useful tool for clinicians in evaluating patients with suspected executive dysfunction.

The question implies that obsessions are characterized by urges, images, of thoughts, while compulsions involve acts, either motor of mental. However, it is important to note that in order to be classified as an obsession of compulsion according to DSM-5 and ICD-11 criteria, the behavior must be time-consuming (taking more than 1 hour per day) of cause significant distress of impairment in important areas of functioning.

Obsessive-compulsive disorder (OCD) is a mental health condition characterized by the presence of either obsessions or compulsions, and often both. Obsessions are repetitive and persistent thoughts, images, of impulses that are intrusive and unwanted, while compulsions are repetitive behaviors of rituals that an individual feels driven to perform in response to an obsession of according to rigid rules. The symptoms can cause significant functional impairment and/of distress. To diagnose OCD, the essential features include the presence of persistent obsessions and/of compulsions that are time-consuming of result in significant distress of impairment in important areas of functioning. The symptoms cannot be attributed to another medical condition of the effects of a substance of medication on the central nervous system.

Epilepsy: An Overview

Epilepsy is a condition that is diagnosed when a person experiences at least two unprovoked seizures that occur more than 24 hours apart. In the UK, the prevalence of epilepsy is 5-10 cases per 1000. Seizure types are categorized as focal onset of generalized onset. Focal seizures only involve a localized part of the brain, while generalized seizures involve the whole of both hemispheres. Temporal lobe epilepsy is the most common type of focal epilepsy, accounting for 60-70% of cases.

In 60% of people with epilepsy, there is no identifiable cause. Approximately 70% of people with epilepsy achieve remission, meaning they have no seizures for 5 years on of off treatment. of those with convulsive seizures, 2/3 have focal epilepsies and secondary generalized seizures, while the other 1/3 have generalized tonic-clonic seizures.

The National Institute for Health and Care Excellence (NICE) recommends treatment with antiepileptic drugs (AEDs) after a second epileptic seizure. For newly diagnosed focal seizures, carbamazepine of lamotrigine are recommended as first-line treatment. Levetiracetam, oxcarbazepine, of sodium valproate may be offered if carbamazepine and lamotrigine are unsuitable of not tolerated. For newly diagnosed generalized tonic-clonic seizures, sodium valproate is recommended as first-line treatment, with lamotrigine as an alternative if sodium valproate is unsuitable. For absence seizures, ethosuximide of sodium valproate are recommended as first-line treatment. For myoclonic seizures, sodium valproate is recommended as first-line treatment, and for tonic of atonic seizures, sodium valproate is also recommended as first-line treatment.

Copropraxia is a neurological condition characterized by the involuntary expression of socially unacceptable gestures. It is similar to coprolalia, which is the involuntary expression of socially unacceptable words. Other related conditions include echolalia, which involves copying others’ words, and echopraxia, which involves copying others’ actions. Coprophagia, on the other hand, refers to the act of eating faeces, while palilialia involves repeating one’s own sounds. These conditions can be distressing for those who experience them and can have a significant impact on their daily lives. Treatment options may include medication, therapy, and support groups.

The term paramnesia refers to memory disorders where fantasy and reality are confused. There are various types of paramnesias, including déjà vu, jamais vu, confabulation, reduplicative paramnesia, retrospective falsification, and cryptomnesia. Reduplicative paramnesia is a subset of delusional misidentification syndromes, which include Capgras delusion, the Fregoli delusion, and others. A review of reduplicative paramnesia was conducted by Politis in 2012.

Formal Thought Disorders

In formal thought disorders, changes in the speed, coherence, and cogency of thought can be observed from a patient’s speech. These disorders can also be self-reported and may be accompanied by enhanced use of nonverbal language. One possible indication is a lack of an adequate connection between two consecutive thoughts, which is called ‘asyndesis’.

There are several types of formal thought disorders, including inhibited thinking, retarded thinking, circumstantial thinking, restricted thinking, perseverative thinking, rumination, pressured thinking, flight of ideas, tangential thinking, thought blocking, disruption of thought, incoherence/derailment, and neologisms.

Inhibited thinking is about the subjective experience of the patient, who may feel that their thinking process is slowed down of blocked by an inner wall of resistance. Retarded thinking, on the other hand, is about the observed quality of thought as inferred through speech, where the flow of thought processes is slowed down and sluggish.

Circumstantial thinking refers to an inability to separate the essential from the unessential during a conversation without rendering the conversation incoherent. Restricted thinking involves a limited range of thought content, fixation on one particular topic of a small number of topics only, and a stereotyped pattern of thinking.

Perseverative thinking is characterized by the persistent repetition of previously used words, phrases, of details to the point where they become meaningless in the context of the current stage of the interview. Rumination is the endless mental preoccupation with, of excessive concern over, mostly unpleasant thoughts.

Pressured thinking, also known as crowding of thought, is when the patient feels helplessly exposed to the pressures of floods of different ideas of thoughts. Flight of ideas involves an increasing multitude of thoughts and ideas which are no longer firmly guided by clear goal-directed thinking.

Tangential thinking occurs when the patient appears to understand the contents of the questions addressed to them but provides answers which are completely out of context. Thought blocking of disruption of thought refers to sudden disruption of an otherwise normal flow of thought of speech for no obvious reason.

Incoherence of derailment is when the interviewer is unable to establish sensible connections between the patient’s thinking and verbal output, which is sometimes also called derailment. Neologisms involve the formation of new words of usage of words which disregard normal conventions and are generally not easily understandable.

An IQ within the range of 70-130 is considered normal, which corresponds to two standard deviations above of below the average IQ of 100. This means that about 95% of the population falls within this range.

Hyperkinesia is a defining feature of tics.

Movement Disorders: Key Features

Movement disorders refer to a range of conditions that affect voluntary muscle movements. These disorders can be caused by various factors, including neurological conditions, medication side effects, and metabolic imbalances. The following table outlines some of the key features of common movement disorders:

Akinesia: Absence of loss of control of voluntary muscle movements, often seen in severe Parkinson’s disease.

Bradykinesia: Slowness of voluntary movement, a core symptom of Parkinson’s disease.

Akathisia: Subjective feeling of inner restlessness, often caused by antipsychotic medication use.

Athetosis: Continuous stream of slow, flowing, writhing involuntary movements, often seen in cerebral palsy, stroke, and Huntington’s disease.

Chorea: Brief, quasi-purposeful, irregular contractions that appear to flow from one muscle to the next, often seen in Huntington’s disease and Wilson’s disease.

Dystonia: Involuntary sustained of intermittent muscle contractions that cause twisting and repetitive movements, abnormal postures, of both.

Dyskinesia: General term referring to problems with voluntary movements and the presence of involuntary movements, often drug-induced.

Myoclonus: A sequence of repeated, often non-rhythmic, brief shock-like jerks due to sudden involuntary contraction of relaxation of one of more muscles.

Parkinsonism: Syndrome characterized by tremor, rigidity, and bradykinesia.

Tic: Sudden, repetitive, non-rhythmic, stereotyped motor movement of vocalization involving discrete muscle groups, often seen in Tourette’s syndrome.

Tremor: Involuntary, rhythmic, alternating movement of one of more body parts, often seen in essential tremor, Parkinson’s disease, and alcohol withdrawal.

Hemiballismus: Repetitive, but constantly varying, large amplitude involuntary movements of the proximal parts of the limbs, often seen in stroke and traumatic brain injury.

Stereotypies: Repetitive, simple movements that can be voluntarily suppressed, often seen in autism and intellectual disability.

It is important to consider the underlying conditions and factors that may contribute to movement disorders in order to properly diagnose and treat these conditions.

Hepatomegaly

Chronic alcohol abuse can lead to hepatomegaly, which is an enlargement of the liver. This can be detected on physical examination by palpating the liver below the right ribcage. Hepatomegaly can also be associated with other signs of liver disease, such as jaundice, spider naevi, and caput medusa. It is important for psychiatrists to be aware of these physical findings in patients with alcohol use disorder, as they may indicate the need for further medical evaluation and treatment.

The assessment of intersecting pentagons is included in the mini mental state exam, while the Glasgow Coma Scale (GCS) is primarily utilized to evaluate impaired consciousness resulting from factors like trauma and substance abuse.

The Glasgow Coma Scale is used to assess the depth of coma and impaired consciousness. Scores range from 3 to 15, with impaired consciousness rated as mild, moderate, of severe. The scale assesses eye opening response, verbal response, and motor response, with specific criteria for scoring each behavior. The final score is a combination of these three scores.
Scoring Guide;
Eye opening response
4 Spontaneous opening
3 Opens to verbal stimuli
2 Opens to pain
1 No response
Verbal response
5 Orientated
4 Confused conversation
3 Inappropriate words
2 Incoherent
1 No response
Motor response
6 Obeys commands
5 Purposeful movement to painful stimuli
4 Withdraws in response to pain
3 Flexion in response to pain (decorticate posturing)
2 Extension in response to pain (decerebrate posturing)
1 No response

Thyroid disease is typically linked with pretibial myxoedema.

Hepatomegaly

Chronic alcohol abuse can lead to hepatomegaly, which is an enlargement of the liver. This can be detected on physical examination by palpating the liver below the right ribcage. Hepatomegaly can also be associated with other signs of liver disease, such as jaundice, spider naevi, and caput medusa. It is important for psychiatrists to be aware of these physical findings in patients with alcohol use disorder, as they may indicate the need for further medical evaluation and treatment.

Attitude scales are used to measure a person’s feelings and thoughts towards something. There are several types of attitude scales, including the Thurstone scale, Likert scale, semantic differential scale, and Gutman scale. The Thurstone scale involves creating a list of statements and having judges score them based on their negativity of positivity towards an issue. Respondents then indicate whether they agree of disagree with each statement. The Likert scale asks respondents to indicate their degree of agreement of disagreement with a series of statements using a five-point scale. The semantic differential scale presents pairs of opposite adjectives and asks respondents to rate their position on a five- of seven-point scale. The Gutman scale involves a list of statements that can be ordered hierarchically, with each statement having a corresponding weight. Respondents’ scores on the scale indicate the number of statements they agree with.

The initial release of DSM was in 1952, while ICD-6 was the first edition of ICD or DSM to incorporate classifications for mental illness, which was published in 1948. DSM-5 was the most recent version published in 2013, and ICD-11 is anticipated to be released in 2015.

Attitude scales are used to measure a person’s feelings and thoughts towards something. There are several types of attitude scales, including the Thurstone scale, Likert scale, semantic differential scale, and Gutman scale. The Thurstone scale involves creating a list of statements and having judges score them based on their negativity of positivity towards an issue. Respondents then indicate whether they agree of disagree with each statement. The Likert scale asks respondents to indicate their degree of agreement of disagreement with a series of statements using a five-point scale. The semantic differential scale presents pairs of opposite adjectives and asks respondents to rate their position on a five- of seven-point scale. The Gutman scale involves a list of statements that can be ordered hierarchically, with each statement having a corresponding weight. Respondents’ scores on the scale indicate the number of statements they agree with.

The Magical Number Seven, Plus of Minus Two: Some Limits on Our Capacity for Processing Information

Miller’s (1956) study focused on the limits of our short-term memory capacity, specifically in regards to our ability to recall sequences of numbers. The digit span test, which involves repeating back increasingly longer sequences of numbers both forwards and backwards, is used to measure this capacity. Miller found that the normal range for Digit Span forward was a maximum span of 7±2 digits. This study highlights the limitations of our short-term memory and the importance of understanding these limitations in various contexts, such as education and cognitive psychology.

Frontal Lobe Tests

The frontal lobe is responsible for a variety of cognitive functions, including initiation, abstraction, problem-solving, decision-making, response inhibition, and set shifting. Different tests can be used to assess these functions.

Verbal and categorical fluency tests can be used to assess initiation. These tests require individuals to generate as many words of items as possible within a specific category of starting letter.

Proverbs, similarities, and cognitive estimates are examples of tests that can be used to assess abstraction. These tests require individuals to identify similarities between objects of concepts, make judgments based on incomplete information, of estimate quantities.

Tower of London, Cambridge stockings, and gambling tasks are examples of tests that can be used to assess problem-solving and decision-making. These tests require individuals to plan and execute a sequence of actions to achieve a goal of make decisions based on uncertain outcomes.

Alternating sequences, go-no-go test, Luria motor test, trail making test, Wisconsin card sorting test, and Stroop test are examples of tests that can be used to assess response inhibition and set shifting. These tests require individuals to inhibit prepotent responses, switch between tasks of mental sets, of ignore irrelevant information.

Overall, these tests can provide valuable information about an individual’s frontal lobe functioning and can be used to diagnose and treat various neurological and psychiatric conditions.

Dysmegalopsia: Difficulty in Perceiving Object Size

Dysmegalopsia is a condition characterized by a reduced ability to accurately perceive the size of objects. This can manifest as either micropsia, where objects appear smaller than they actually are, of macropsia, where objects appear larger than they actually are. Dysmegalopsia can occur as a standalone symptom of as part of a group of symptoms known as the Alice in Wonderland Syndrome. In this syndrome, individuals may experience distortions in their perception of size, shape, and distance, as well as other sensory disturbances. Dysmegalopsia can be caused by various factors, including neurological conditions, migraines, and the use of certain medications.

Types of Delusions

Delusions come in many different forms. It is important to familiarize oneself with these types as they may be tested in an exam. Some of the most common types of delusions include:

– Folie a deux: a shared delusion between two or more people
– Grandiose: belief that one has special powers, beliefs, of purpose
– Hypochondriacal: belief that something is physically wrong with the patient
– Ekbom’s syndrome: belief that one has been infested with insects
– Othello syndrome: belief that a sexual partner is cheating on them
– Capgras delusion: belief that a person close to them has been replaced by a double
– Fregoli delusion: patient identifies a familiar person (usually suspected to be a persecutor) in other people they meet
– Syndrome of subjective doubles: belief that doubles of him/her exist
– Lycanthropy: belief that one has been transformed into an animal
– De Clérambault’s syndrome: false belief that a person is in love with them
– Cotard’s syndrome/nihilistic delusions: belief that they are dead of do not exist
– Referential: belief that others/TV/radio are speaking directly to of about the patient
– Delusional perception: belief that a normal percept (product of perception) has a special meaning
– Pseudocyesis: a condition whereby a woman believes herself to be pregnant when she is not. Objective signs accompany the belief such as abdominal enlargement, menstrual disturbance, apparent foetal movements, nausea, breast changes, and labour pains.

Remembering these types of delusions can be helpful in understanding and diagnosing patients with delusional disorders.

Sensory Distortions of Sound

Hyperacusis is a condition where an individual experiences an increased sensitivity to noise. This condition is commonly observed in people with anxiety and depressive disorders, as well as during a hangover of migraine. On the other hand, hypoacusis is a condition where an individual experiences a reduced sensitivity to sound. This condition is commonly observed in people with delirium and depression, where it is often accompanied by hyperacusis.

Culture bound illnesses are psychiatric conditions that are specific to one particular culture. There are many different types of culture bound illnesses, including Amok, Shenjing shuairuo, Ataque de nervios, Bilis, colera, Bouffee delirante, Brain fag, Dhat, Falling-out, blacking out, Ghost sickness, Hwa-byung, wool-hwa-byung, Koro, Latah, Locura, Mal de ojo, Nervios, Rootwork, Pibloktoq, Qi-gong psychotic reaction, Sangue dormido, Shen-k’uei, shenkui, Shin-byung, Taijin kyofusho, Spell, Susto, Zar, and Wendigo.

Some of the most commonly discussed culture bound illnesses include Amok, which is confined to males in the Philippines and Malaysia who experience blind, murderous violence after a real of imagined insult. Ataque de nervios is a condition that occurs in those of Latino descent and is characterized by intense emotional upset, shouting uncontrollably, aggression, dissociation, seizure-like episodes, and suicidal gestures. Brain fag is a form of psychological distress first identified in Nigerian students in the 1960s but reported more generally in the African diaspora. It consists of a variety of cognitive and sensory disturbances that occur during periods of intense intellectual activity. Koro is a condition that affects Chinese patients who believe that their penis is withdrawing inside their abdomen, resulting in panic and the belief that they will die. Taijin kyofusho is a Japanese culture bound illness characterized by anxiety about and avoidance of interpersonal situations due to the thought, feeling, of conviction that one’s appearance and actions in social interactions are inadequate of offensive to others. Finally, Wendigo is a culture bound illness that occurs in Native American tribes during severe winters and scarcity of food, characterized by a distaste for food that leads to anxiety and the belief that one is turning into a cannibalistic ice spirit.

Ego (Boundary) Disturbances

Ego (boundary) disturbances refer to experiences where there is a disturbance in the perception of self as distinct from the environment of the integrity of self. It also includes instances where bodily processes, personal thought processes, feelings, and actions are experienced as being externally directed. These phenomena are referred to as passivity phenomena, and some of the symptom characteristics are classified as bizarre delusional phenomena in the DSM.

Derealization is when a patient experiences their surroundings of time as if they are unreal and changed, losing all feelings of familiarity and trust in the environment. People, objects, and surroundings appear unreal, unfamiliar, of spatially altered. The sensations may be intense of weak in nature.

Depersonalization is when a patient perceives themselves as alien, unreal, changed, of as a stranger. The disturbances of depersonalization may be of a transient nature only of become more persistent over a longer period of time. It is generally felt to be both strange and unpleasant.

Thought broadcasting is when a patient’s personal thoughts are experienced as no longer belonging to the patient alone but accessible by others who will know what the patient is thinking (mind reading). Thought withdrawal is when a patient’s thoughts are being removed of stripped from them. Thought insertion is when patients experience their thoughts and ideas as being externally influenced, made externally, controlled, directed, entered/ of externally imposed.

Other feelings of alien influence refer to feelings, intentions, behavior, of bodily functions that are experienced as externally controlled of made by others (passivity phenomena). The patient feels externally compelled to say something specific, to scream, to act of behave in a particular way, to attack someone, to throw a tantrum, etc.

The ICD is designed to be accessible to a broader range of individuals than the DSM, including those with limited professional training. Therefore, the terminology used is generally less specialized.

DSM versus ICD: A Comparison of Mental Disorder Classifications

The DSM and ICD are two widely used classifications of mental disorders. While the ICD was initiated in Paris in 1900, the DSM-I was published in the USA in 1952 as a military classification of mental disorders. The ICD is intended for use by all health practitioners, while the DSM is primarily used by psychiatrists. The ICD is the official world classification, while the DSM is the official classification in the USA.

One major difference between the two classifications is their focus. The ICD has a major focus on clinical utility, with a planned reduction of the number of diagnoses in the upcoming ICD-11. On the other hand, the DSM tends to increase the number of diagnoses with each succeeding revision. Additionally, the ICD provides diagnostic descriptions and guidance but does not employ operational criteria, while the DSM depends on operational criteria.

It is important to note that the ICD has to be flexible and simple in the use of language to enable all practitioners, including those with very little formal qualifications in low- and middle-income countries, to be acceptable. Overall, understanding the differences between the DSM and ICD can help mental health practitioners choose the most appropriate classification for their needs.

The Glasgow Coma Scale is used to assess the depth of coma and impaired consciousness. Scores range from 3 to 15, with impaired consciousness rated as mild, moderate, of severe. The scale assesses eye opening response, verbal response, and motor response, with specific criteria for scoring each behavior. The final score is a combination of these three scores.
Scoring Guide;
Eye opening response
4 Spontaneous opening
3 Opens to verbal stimuli
2 Opens to pain
1 No response
Verbal response
5 Orientated
4 Confused conversation
3 Inappropriate words
2 Incoherent
1 No response
Motor response
6 Obeys commands
5 Purposeful movement to painful stimuli
4 Withdraws in response to pain
3 Flexion in response to pain (decorticate posturing)
2 Extension in response to pain (decerebrate posturing)
1 No response

Based on the patient’s dementia history, the diagnosis is supported.

Argyll Robertson Pupil: Accommodation Retained

The Argyll Robertson pupil is a notable topic in medical exams, as it is associated with tertiary syphilis, which is a crucial differential diagnosis for various psychiatric conditions like mood disorders, dementia, and psychosis. This type of pupil reacts poorly to light but normally to near stimuli, such as accommodation and convergence. They are typically small and irregular in shape, but they do not usually affect visual acuity. Mydriatic agents are not effective in dilating the Argyll Robertson pupil. Although this type of pupil is often considered pathognomonic of tertiary syphilis, it has also been observed in diabetes.

It is important to note that Carl Schneider should not be mistaken for Kurt Schneider. While Carl Schneider was a psychiatrist who had ties to the Nazi party and played a significant role in the Action T4 Euthanasia program, Kurt Schneider was a different individual altogether.

First Rank Symptoms: Their Significance in Identifying Schizophrenia

First rank symptoms were introduced by Kurt Schneider in 1938 as a practical tool for non-psychiatrists to identify schizophrenia. While they are highly suggestive of schizophrenia, they are not pathognomonic and can also be seen in affective and personality disorders. Additionally, there is no evidence to support their prognostic significance.

A systematic review in 2015 found that first rank symptoms differentiated schizophrenia from nonpsychotic mental health disorders with a sensitivity of 61.8% and a specificity of 94.1%. They also differentiated schizophrenia from other types of psychosis with a sensitivity of 58% and a specificity of 74.7%.

The first rank symptoms include running commentary, thought echo, voices heard arguing, thought insertion, thought withdrawal, thought broadcast, delusional perception, somatic passivity, made affect, and made volition. While they can be helpful in identifying schizophrenia, they should not be relied upon as the sole diagnostic criteria.

Understanding the Placebo Effect

In general, a placebo is an inert substance that has no pharmacological activity but looks, smells, and tastes like the active drug it is compared to. The placebo effect is the observable improvement seen when a patient takes a placebo, which results from patient-related factors such as expectations rather than the placebo itself. Negative effects due to patient-related factors are termed the nocebo effect.

Active placebos are treatments with chemical activity that mimic the side effects of the drug being tested in a clinical trial. They are used to prevent unblinding of the drug versus the placebo control group. Placebos need not always be pharmacological and can be procedural, such as sham electroconvulsive therapy.

The placebo effect is influenced by factors such as the perceived strength of the treatment, the status of the treating professional, and the branding of the compound. The placebo response is greater in mild illness, and the response rate is increasing over time. Placebo response is usually short-lived, and repeated use can lead to a diminished effect, known as placebo sag.

It is difficult to separate placebo effects from spontaneous remission, and patients who enter clinical trials generally do so when acutely unwell, making it challenging to show treatment effects. Breaking the blind may influence the outcome, and the expectancy effect may explain why active placebos are more effective than inert placebos. Overall, understanding the placebo effect is crucial in clinical trials and personalized medicine.

Historical Classification of Schizophrenia

The classification of schizophrenia has evolved over time, with various individuals contributing to its development. In 1801, Phillippe Pinel used the term ‘demencé’ to describe the loss of mental abilities in chronically ill patients. Benedict Morel coined the term ‘demencé precocé’ in 1852 to describe young patients with premature dementia. Kahlbaum was the first to describe ‘paraphrenia hebetica’ in the 1860s, which was later elaborated as ‘hebephrenia’ by Hecker in 1871.

In 1893, Emil Kraepelin used the term dementia praecox to describe the condition, emphasizing the importance of delusions, hallucinations, impaired attention, thought incoherence, stereotyped movements and expressions, deterioration of emotional life, and a loss of drive as key symptoms. In 1908, Eugen Bleuler coined the term ‘schizophrenia’ to replace dementia praecox, denoting ‘a splitting of the psychic functions.’ Bleuler expanded the concept to include presentations that did not include a ‘terminal state.’

Bleuler introduced a distinction between basic and accessory symptoms and primary and secondary symptoms. Basic symptoms are necessarily present in any case of schizophrenia, while accessory symptoms may of may not occur. The fundamental features of schizophrenia were loosening of associations, disturbances of affectivity, ambivalence, and autism. The alteration of associations is the only symptom that Bleuler regarded as both basic and primary, and can thus be described as the core disturbance in the Bleulerian conception of schizophrenia.

In 1939, Langfeldt introduced the term ‘schizophreniform psychosis’ to describe patients with Bleulerian schizophrenia who did not follow a progressively deteriorating course. In the 1960s, Rado/Meehl introduced the term ‘schizotypy’ to recognize the concept of a continuum of spectrum of schizophrenia-related phenotypes. In the 1980s, Crow proposed a subclassification of schizophrenia, dividing patients into types I and II. Type I patients present with positive symptoms such as delusions and hallucinations, while type II patients present with negative symptoms such as affective flattening and poverty of speech.

SUDEP, of sudden unexpected death in epilepsy, is a condition where patients with epilepsy die suddenly and unexpectedly without any apparent cause. It is estimated to be responsible for 20-30% of deaths in epilepsy patients. The condition is more common in adults than in children, affecting 1 in 1,000 adults with epilepsy per year. The main risk factor for SUDEP is having active generalised tonic clonic seizures (GTCS), and better control of these seizures through improved compliance can reduce the risk of SUDEP. Other risk factors include nocturnal seizures, lamotrigine, never having been treated with an antiepileptic drug, intellectual disability, and male sex. However, the evidence for these factors is considered low. Autopsy findings in SUDEP cases do not reveal any specific cause of death, but obstruction of the airways and cardiorespiratory events such as arrhythmia are thought to be possible mechanisms.

The presence of a distinct brown ring encircling the iris is a clear indication of a Kayser-Fleischer ring, which is a telltale sign of Wilson’s disease. Vomiting of blood is a common symptom of esophageal varices, a complication that arises from liver failure, which is a common occurrence in individuals with Wilson’s disease.

Understanding Wilson’s Disease: Causes, Symptoms, and Management

Wilson’s disease, also known as hepatolenticular degeneration, is a genetic disorder that affects copper storage in the body. This condition is caused by a defect in the ATP7B gene, which leads to the accumulation of copper in the liver and brain. The onset of symptoms usually occurs between the ages of 10 and 25, with liver disease being the most common presentation in children and neurological symptoms in young adults.

The excessive deposition of copper in the tissues can cause a range of symptoms, including hepatitis, cirrhosis, basal ganglia degeneration, speech and behavioral problems, asterixis, chorea, dementia, Kayser-Fleischer rings, sunflower cataract, renal tubular acidosis, haemolysis, and blue nails. Diagnosis is based on reduced serum ceruloplasmin, reduced serum copper, and increased 24-hour urinary copper excretion.

The traditional first-line treatment for Wilson’s disease is penicillamine, which chelates copper. Trientine hydrochloride is an alternative chelating agent that may become first-line treatment in the future. Tetrathiomolybdate is a newer agent that is currently under investigation.

In summary, Wilson’s disease is a genetic disorder that affects copper storage in the body, leading to a range of symptoms that can affect the liver, brain, and eyes. Early diagnosis and treatment are essential to prevent complications and improve outcomes.

Paraschemazia: A Distorted Perception of the Body

Paraschemazia is a condition where individuals experience a sensation that parts of their body are twisted of separated from the rest of their body. This feeling can be associated with the use of hallucinogenic drugs, an epileptic aura, of migraines. The perception of the body being distorted of separated can be distressing for individuals experiencing this condition. It is important for healthcare professionals to be aware of this symptom and its potential causes to provide appropriate treatment and support.

Hepatic encephalopathy is indicated by the presence of a distinctive ‘liver flap’.

Hepatomegaly

Chronic alcohol abuse can lead to hepatomegaly, which is an enlargement of the liver. This can be detected on physical examination by palpating the liver below the right ribcage. Hepatomegaly can also be associated with other signs of liver disease, such as jaundice, spider naevi, and caput medusa. It is important for psychiatrists to be aware of these physical findings in patients with alcohol use disorder, as they may indicate the need for further medical evaluation and treatment.

The term paramnesia refers to memory disorders where fantasy and reality are confused. There are various types of paramnesias, including déjà vu, jamais vu, confabulation, reduplicative paramnesia, retrospective falsification, and cryptomnesia. Reduplicative paramnesia is a subset of delusional misidentification syndromes, which include Capgras delusion, the Fregoli delusion, and others. A review of reduplicative paramnesia was conducted by Politis in 2012.

Bleuler identified autism as a key symptom of schizophrenia.

Historical Classification of Schizophrenia

The classification of schizophrenia has evolved over time, with various individuals contributing to its development. In 1801, Philippe Pinel used the term ‘demencé’ to describe the loss of mental abilities in chronically ill patients. Benedict Morel coined the term ‘demencé precocé’ in 1852 to describe young patients with premature dementia. Kahlbaum was the first to describe ‘paraphrenia hebetica’ in the 1860s, which was later elaborated as ‘hebephrenia’ by Hecker in 1871.

In 1893, Emil Kraepelin used the term dementia praecox to describe the condition, emphasizing the importance of delusions, hallucinations, impaired attention, thought incoherence, stereotyped movements and expressions, deterioration of emotional life, and a loss of drive as key symptoms. In 1908, Eugen Bleuler coined the term ‘schizophrenia’ to replace dementia praecox, denoting ‘a splitting of the psychic functions.’ Bleuler expanded the concept to include presentations that did not include a ‘terminal state.’

Bleuler introduced a distinction between basic and accessory symptoms and primary and secondary symptoms. Basic symptoms are necessarily present in any case of schizophrenia, while accessory symptoms may of may not occur. The fundamental features of schizophrenia were loosening of associations, disturbances of affectivity, ambivalence, and autism. The alteration of associations is the only symptom that Bleuler regarded as both basic and primary, and can thus be described as the core disturbance in the Bleulerian conception of schizophrenia.

In 1939, Langfeldt introduced the term ‘schizophreniform psychosis’ to describe patients with Bleulerian schizophrenia who did not follow a progressively deteriorating course. In the 1960s, Rado/Meehl introduced the term ‘schizotypy’ to recognize the concept of a continuum of spectrum of schizophrenia-related phenotypes. In the 1980s, Crow proposed a subclassification of schizophrenia, dividing patients into types I and II. Type I patients present with positive symptoms such as delusions and hallucinations, while type II patients present with negative symptoms such as affective flattening and poverty of speech.

It is important to differentiate between verbigeration and vorbeirden. Verbigeration involves the senseless repetition of words of phrases, while vorbeirden occurs when a patient comprehends a question but provides an obviously incorrect answer. This phenomenon is commonly observed in Ganser’s syndrome, a type of dissociative psychosis that often affects incarcerated individuals awaiting trial.

– Catatonia is a psychiatric syndrome characterized by disturbed motor functions, mood, and thought.
– Key behaviors associated with catatonia include stupor, posturing, waxy flexibility, negativism, automatic obedience, mitmachen, mitgehen, ambitendency, psychological pillow, forced grasping, obstruction, echopraxia, aversion, mannerisms, stereotypies, motor perseveration, echolalia, and logorrhoea.
– These behaviors are often tested in exam questions.
– Karl Ludwig Kahlbaum is credited with the original clinical description of catatonia.

Historical Classification of Schizophrenia

The classification of schizophrenia has evolved over time, with various individuals contributing to its development. In 1801, Phillippe Pinel used the term ‘demencé’ to describe the loss of mental abilities in chronically ill patients. Benedict Morel coined the term ‘demencé precocé’ in 1852 to describe young patients with premature dementia. Kahlbaum was the first to describe ‘paraphrenia hebetica’ in the 1860s, which was later elaborated as ‘hebephrenia’ by Hecker in 1871.

In 1893, Emil Kraepelin used the term dementia praecox to describe the condition, emphasizing the importance of delusions, hallucinations, impaired attention, thought incoherence, stereotyped movements and expressions, deterioration of emotional life, and a loss of drive as key symptoms. In 1908, Eugen Bleuler coined the term ‘schizophrenia’ to replace dementia praecox, denoting ‘a splitting of the psychic functions.’ Bleuler expanded the concept to include presentations that did not include a ‘terminal state.’

Bleuler introduced a distinction between basic and accessory symptoms and primary and secondary symptoms. Basic symptoms are necessarily present in any case of schizophrenia, while accessory symptoms may of may not occur. The fundamental features of schizophrenia were loosening of associations, disturbances of affectivity, ambivalence, and autism. The alteration of associations is the only symptom that Bleuler regarded as both basic and primary, and can thus be described as the core disturbance in the Bleulerian conception of schizophrenia.

In 1939, Langfeldt introduced the term ‘schizophreniform psychosis’ to describe patients with Bleulerian schizophrenia who did not follow a progressively deteriorating course. In the 1960s, Rado/Meehl introduced the term ‘schizotypy’ to recognize the concept of a continuum of spectrum of schizophrenia-related phenotypes. In the 1980s, Crow proposed a subclassification of schizophrenia, dividing patients into types I and II. Type I patients present with positive symptoms such as delusions and hallucinations, while type II patients present with negative symptoms such as affective flattening and poverty of speech.

The distinguishing factors between the two are based on personal interpretation and tangible versus intangible concepts.

Altered Perceptual Experiences

Disorders of perception can be categorized into sensory distortions and sensory deceptions. Sensory distortions involve changes in the intensity, spatial form, of quality of a perception. Examples include hyperaesthesia, hyperacusis, and micropsia. Sensory deceptions, on the other hand, involve new perceptions that are not based on any external stimulus. These include illusions and hallucinations.

Illusions are altered perceptions of a stimulus, while hallucinations are perceptions in the absence of a stimulus. Completion illusions, affect illusions, and pareidolic illusions are examples of illusions. Auditory, visual, gustatory, olfactory, and tactile hallucinations are different types of hallucinations. Pseudohallucinations are involuntary and vivid sensory experiences that are interpreted in a non-morbid way. They are different from true hallucinations in that the individual is able to recognize that the experience is an internally generated event.

Understanding the different types of altered perceptual experiences is important in the diagnosis and treatment of various mental health conditions.

– Catatonia is a psychiatric syndrome characterized by disturbed motor functions, mood, and thought.
– Key behaviors associated with catatonia include stupor, posturing, waxy flexibility, negativism, automatic obedience, mitmachen, mitgehen, ambitendency, psychological pillow, forced grasping, obstruction, echopraxia, aversion, mannerisms, stereotypies, motor perseveration, echolalia, and logorrhoea.
– These behaviors are often tested in exam questions.
– Karl Ludwig Kahlbaum is credited with the original clinical description of catatonia.

The mental state exam assesses various areas of cognition, including orientation, attention/concentration, short term memory, long term memory, and executive function. Standard tests for each area include asking about time, place, and person for orientation, serial 7’s for attention/concentration, digit span for short term memory, delayed recall of name and address for long term memory, and various tasks such as proverbs, similarities, differences, verbal fluency, and cognitive estimates for executive function.

The belief that her neighbors are spying on her, which was triggered by the TV, is likely a secondary delusion stemming from a pathological encounter such as a hallucination of a referential experience.

Borderline Learning Disability

Borderline learning disability is a term used to describe individuals with an IQ between 70-85. This category is not officially recognized as a diagnosis by the ICD-11. It is estimated that approximately 15% of the population falls within this range (Chaplin, 2005). Unlike mild learning disability, borderline learning disability is not typically associated with deficits in adaptive functioning, such as grooming, dressing, safety, of money management.

Intermediate Mechanism: Rationalisation

Rationalisation is a defense mechanism commonly used by individuals to create false but credible justifications for their behavior of actions. It involves the use of logical reasoning to explain away of justify unacceptable behavior of feelings. The individual may not be aware that they are using this mechanism, and it can be difficult to identify in oneself.

Rationalisation is considered an intermediate mechanism, as it is common in healthy individuals from ages three to ninety, as well as in neurotic disorders and in mastering acute adult stress. It can be dramatically changed by conventional psychotherapeutic interpretation.

Examples of rationalisation include a student who fails an exam and blames the teacher for not teaching the material well enough, of a person who cheats on their partner and justifies it by saying their partner was neglectful of unaffectionate. It allows the individual to avoid taking responsibility for their actions and to maintain a positive self-image.

Overall, rationalisation can be a useful defense mechanism in certain situations, but it can also be harmful if it leads to a lack of accountability and an inability to learn from mistakes.

Attitude scales are used to measure a person’s feelings and thoughts towards something. There are several types of attitude scales, including the Thurstone scale, Likert scale, semantic differential scale, and Gutman scale. The Thurstone scale involves creating a list of statements and having judges score them based on their negativity of positivity towards an issue. Respondents then indicate whether they agree of disagree with each statement. The Likert scale asks respondents to indicate their degree of agreement of disagreement with a series of statements using a five-point scale. The semantic differential scale presents pairs of opposite adjectives and asks respondents to rate their position on a five- of seven-point scale. The Gutman scale involves a list of statements that can be ordered hierarchically, with each statement having a corresponding weight. Respondents’ scores on the scale indicate the number of statements they agree with.

In psychiatry, various questionnaires and interviews are used to assess different conditions and areas. It is important for candidates to know whether certain assessment tools are self-rated of require clinical assistance. The table provided by the college lists some of the commonly used assessment tools and indicates whether they are self-rated of clinician-rated. For example, the HAMD and MADRS are clinician-rated scales used to assess the severity of depression, while the GDS is a self-rated scale used to screen for depression in the elderly. The YMRS is a clinician-rated scale used to assess the severity of mania in patients with bipolar disorder, while the Y-BOCS is used to measure both the severity of OCD and the response to treatment. The GAF provides a single measure of global functioning, while the CGI requires the clinician to rate the severity of the patient’s illness at the time of assessment. The CAMDEX is a tool developed to assist in the early diagnosis and measurement of dementia in the elderly.

Types of Tremor

Essential Tremor

Otherwise known as benign essential tremor, this is the most common type of tremor. It is not associated with any underlying pathology. It usually begins in the 40’s, affects mainly the hands, and is slowly progressive. It tends to worsen with heightened emotion. It usually presents with unilateral upper limb involvement then progresses to both limbs.

Parkinsonian Tremor

This tremor is associated with Parkinson’s disease. It is classically described as ‘pill rolling’ due to the characteristic appearance of the fingers.

Cerebellar Tremor

Otherwise known as an intention tremor. This is a slow, coarse tremor which gets worse with purposeful movement. This is seen in lithium toxicity (note that the tremor seen as a side effect of long term lithium is fine and classed as physiological).

Psychogenic Tremor

Also known as a hysterical tremor. This type of tremor tends to appear and disappear suddenly and is hard to characterise due to its changeable nature. It tends to improve with distraction.

Physiologic Tremor

This is a very-low-amplitude fine tremor that is barely visible to the naked eye. It is present in every normal person while maintaining a posture of movement. It becomes enhanced and visible in many conditions such as anxiety, hyperthyroidism, alcohol withdrawal, and as drug induced side effects.

It is useful to have a basic idea about the frequencies of different types of tremor.

Type of Tremor Frequency

Intention 2-3Hz

Parkinsonian 5Hz

Essential 7Hz

Physiological 10Hz

Psychogenic variable

ICD-10’s Anankastic personality disorder is the same as DSM V obsessive-compulsive personality disorder, while inadequate and passive aggressive personality disorders are not recognized in either classification system. Additionally, DSM V includes narcissistic personality disorder as a distinct category of personality disorder.

The term paramnesia refers to memory disorders where fantasy and reality are confused. There are various types of paramnesias, including déjà vu, jamais vu, confabulation, reduplicative paramnesia, retrospective falsification, and cryptomnesia. Reduplicative paramnesia is a subset of delusional misidentification syndromes, which include Capgras delusion, the Fregoli delusion, and others. A review of reduplicative paramnesia was conducted by Politis in 2012.

Types of Delusions

Delusions come in many different forms. It is important to familiarize oneself with these types as they may be tested in an exam. Some of the most common types of delusions include:

– Folie a deux: a shared delusion between two or more people
– Grandiose: belief that one has special powers, beliefs, of purpose
– Hypochondriacal: belief that something is physically wrong with the patient
– Ekbom’s syndrome: belief that one has been infested with insects
– Othello syndrome: belief that a sexual partner is cheating on them
– Capgras delusion: belief that a person close to them has been replaced by a double
– Fregoli delusion: patient identifies a familiar person (usually suspected to be a persecutor) in other people they meet
– Syndrome of subjective doubles: belief that doubles of him/her exist
– Lycanthropy: belief that one has been transformed into an animal
– De Clérambault’s syndrome: false belief that a person is in love with them
– Cotard’s syndrome/nihilistic delusions: belief that they are dead of do not exist
– Referential: belief that others/TV/radio are speaking directly to of about the patient
– Delusional perception: belief that a normal percept (product of perception) has a special meaning
– Pseudocyesis: a condition whereby a woman believes herself to be pregnant when she is not. Objective signs accompany the belief such as abdominal enlargement, menstrual disturbance, apparent foetal movements, nausea, breast changes, and labour pains.

Remembering these types of delusions can be helpful in understanding and diagnosing patients with delusional disorders.

Understanding Compound Questions in Interview Techniques

When conducting interviews, it is important to be aware of compound questions. These are questions that combine multiple inquiries into what appears to be a single question. Compound questions can be confusing for the interviewee and may lead to inaccurate of incomplete responses.

To avoid compound questions, it is important to break down inquiries into separate, clear questions. This allows the interviewee to fully understand what is being asked and provide a thoughtful response. Additionally, it is important to avoid using conjunctions such as and of of when asking questions, as this can create compound questions.

By using clear and concise language and avoiding compound questions, interviewers can ensure that they are receiving accurate and complete responses from their interviewees. This can lead to a more successful and informative interview process.

Historical Classification of Schizophrenia

The classification of schizophrenia has evolved over time, with various individuals contributing to its development. In 1801, Phillippe Pinel used the term ‘demencé’ to describe the loss of mental abilities in chronically ill patients. Benedict Morel coined the term ‘demencé precocé’ in 1852 to describe young patients with premature dementia. Kahlbaum was the first to describe ‘paraphrenia hebetica’ in the 1860s, which was later elaborated as ‘hebephrenia’ by Hecker in 1871.

In 1893, Emil Kraepelin used the term dementia praecox to describe the condition, emphasizing the importance of delusions, hallucinations, impaired attention, thought incoherence, stereotyped movements and expressions, deterioration of emotional life, and a loss of drive as key symptoms. In 1908, Eugen Bleuler coined the term ‘schizophrenia’ to replace dementia praecox, denoting ‘a splitting of the psychic functions.’ Bleuler expanded the concept to include presentations that did not include a ‘terminal state.’

Bleuler introduced a distinction between basic and accessory symptoms and primary and secondary symptoms. Basic symptoms are necessarily present in any case of schizophrenia, while accessory symptoms may of may not occur. The fundamental features of schizophrenia were loosening of associations, disturbances of affectivity, ambivalence, and autism. The alteration of associations is the only symptom that Bleuler regarded as both basic and primary, and can thus be described as the core disturbance in the Bleulerian conception of schizophrenia.

In 1939, Langfeldt introduced the term ‘schizophreniform psychosis’ to describe patients with Bleulerian schizophrenia who did not follow a progressively deteriorating course. In the 1960s, Rado/Meehl introduced the term ‘schizotypy’ to recognize the concept of a continuum of spectrum of schizophrenia-related phenotypes. In the 1980s, Crow proposed a subclassification of schizophrenia, dividing patients into types I and II. Type I patients present with positive symptoms such as delusions and hallucinations, while type II patients present with negative symptoms such as affective flattening and poverty of speech.

Edinburgh Postnatal Depression Scale (EPDS)

The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item self-report questionnaire designed to screen for postnatal depression in primary care settings. It should only be used to assess a women’s mood over the past seven days and cannot be used to diagnose depression. The EPDS excludes some symptoms common in the perinatal period, such as tiredness and irritability, as they do not differentiate between depressed and non-depressed postnatal women. Women are asked to select one of four responses that most closely represents how they have felt over the past seven days. Scores for the 10 items are added together, with a score of 0-9 indicating a low likelihood of depression, 10-12 indicating a moderate likelihood, and 13 of more indicating a high likelihood. The statements include feelings of happiness, sadness, anxiety, and thoughts of self-harm.

Frontal Lobe Tests

The frontal lobe is responsible for a variety of cognitive functions, including initiation, abstraction, problem-solving, decision-making, response inhibition, and set shifting. Different tests can be used to assess these functions.

Verbal and categorical fluency tests can be used to assess initiation. These tests require individuals to generate as many words of items as possible within a specific category of starting letter.

Proverbs, similarities, and cognitive estimates are examples of tests that can be used to assess abstraction. These tests require individuals to identify similarities between objects of concepts, make judgments based on incomplete information, of estimate quantities.

Tower of London, Cambridge stockings, and gambling tasks are examples of tests that can be used to assess problem-solving and decision-making. These tests require individuals to plan and execute a sequence of actions to achieve a goal of make decisions based on uncertain outcomes.

Alternating sequences, go-no-go test, Luria motor test, trail making test, Wisconsin card sorting test, and Stroop test are examples of tests that can be used to assess response inhibition and set shifting. These tests require individuals to inhibit prepotent responses, switch between tasks of mental sets, of ignore irrelevant information.

Overall, these tests can provide valuable information about an individual’s frontal lobe functioning and can be used to diagnose and treat various neurological and psychiatric conditions.

In psychiatry, various questionnaires and interviews are used to assess different conditions and areas. It is important for candidates to know whether certain assessment tools are self-rated of require clinical assistance. The table provided by the college lists some of the commonly used assessment tools and indicates whether they are self-rated of clinician-rated. For example, the HAMD and MADRS are clinician-rated scales used to assess the severity of depression, while the GDS is a self-rated scale used to screen for depression in the elderly. The YMRS is a clinician-rated scale used to assess the severity of mania in patients with bipolar disorder, while the Y-BOCS is used to measure both the severity of OCD and the response to treatment. The GAF provides a single measure of global functioning, while the CGI requires the clinician to rate the severity of the patient’s illness at the time of assessment. The CAMDEX is a tool developed to assist in the early diagnosis and measurement of dementia in the elderly.

Mania often presents with flight of ideas, and most cases are of unknown origin, resulting in a diagnosis of primary bipolar disorder. However, in some cases, manic, hypomanic, of mixed episodes may occur after an organic insult, such as a stroke, traumatic brain injury, of tumor. The most common locations for these lesions are the thalamus, hypothalamus, basal ganglia, and frontal and temporal cortices. According to a systematic review and pooled lesion analysis by Barahona-Corrêa (2020), right-sided brain lesions are more prevalent among patients with lesional mania.

Formal Thought Disorders

In formal thought disorders, changes in the speed, coherence, and cogency of thought can be observed from a patient’s speech. These disorders can also be self-reported and may be accompanied by enhanced use of nonverbal language. One possible indication is a lack of an adequate connection between two consecutive thoughts, which is called ‘asyndesis’.

There are several types of formal thought disorders, including inhibited thinking, retarded thinking, circumstantial thinking, restricted thinking, perseverative thinking, rumination, pressured thinking, flight of ideas, tangential thinking, thought blocking, disruption of thought, incoherence/derailment, and neologisms.

Inhibited thinking is about the subjective experience of the patient, who may feel that their thinking process is slowed down of blocked by an inner wall of resistance. Retarded thinking, on the other hand, is about the observed quality of thought as inferred through speech, where the flow of thought processes is slowed down and sluggish.

Circumstantial thinking refers to an inability to separate the essential from the unessential during a conversation without rendering the conversation incoherent. Restricted thinking involves a limited range of thought content, fixation on one particular topic of a small number of topics only, and a stereotyped pattern of thinking.

Perseverative thinking is characterized by the persistent repetition of previously used words, phrases, of details to the point where they become meaningless in the context of the current stage of the interview. Rumination is the endless mental preoccupation with, of excessive concern over, mostly unpleasant thoughts.

Pressured thinking, also known as crowding of thought, is when the patient feels helplessly exposed to the pressures of floods of different ideas of thoughts. Flight of ideas involves an increasing multitude of thoughts and ideas which are no longer firmly guided by clear goal-directed thinking.

Tangential thinking occurs when the patient appears to understand the contents of the questions addressed to them but provides answers which are completely out of context. Thought blocking of disruption of thought refers to sudden disruption of an otherwise normal flow of thought of speech for no obvious reason.

Incoherence of derailment is when the interviewer is unable to establish sensible connections between the patient’s thinking and verbal output, which is sometimes also called derailment. Neologisms involve the formation of new words of usage of words which disregard normal conventions and are generally not easily understandable.

Cerebellar signs are evident in cases of lithium toxicity, which can manifest as slurred speech, a broad-based gait, and an intention tremor. The latter is characterized by a coarse appearance and a frequency of 2-3Hz (equivalent to 2 waves per second).

Types of Tremor

Essential Tremor

Otherwise known as benign essential tremor, this is the most common type of tremor. It is not associated with any underlying pathology. It usually begins in the 40’s, affects mainly the hands, and is slowly progressive. It tends to worsen with heightened emotion. It usually presents with unilateral upper limb involvement then progresses to both limbs.

Parkinsonian Tremor

This tremor is associated with Parkinson’s disease. It is classically described as ‘pill rolling’ due to the characteristic appearance of the fingers.

Cerebellar Tremor

Otherwise known as an intention tremor. This is a slow, coarse tremor which gets worse with purposeful movement. This is seen in lithium toxicity (note that the tremor seen as a side effect of long term lithium is fine and classed as physiological).

Psychogenic Tremor

Also known as a hysterical tremor. This type of tremor tends to appear and disappear suddenly and is hard to characterise due to its changeable nature. It tends to improve with distraction.

Physiologic Tremor

This is a very-low-amplitude fine tremor that is barely visible to the naked eye. It is present in every normal person while maintaining a posture of movement. It becomes enhanced and visible in many conditions such as anxiety, hyperthyroidism, alcohol withdrawal, and as drug induced side effects.

It is useful to have a basic idea about the frequencies of different types of tremor.

Type of Tremor Frequency

Intention 2-3Hz

Parkinsonian 5Hz

Essential 7Hz

Physiological 10Hz

Psychogenic variable

The phenomenon known as placebo sag occurs when individuals who have undergone multiple treatment failures experience a decrease in the placebo effect. This is particularly common in chronically ill patients who may feel hopeless and discouraged. However, it is important to note that the extent to which the placebo effect diminishes over time varies depending on the individual’s experiences.

Understanding the Placebo Effect

In general, a placebo is an inert substance that has no pharmacological activity but looks, smells, and tastes like the active drug it is compared to. The placebo effect is the observable improvement seen when a patient takes a placebo, which results from patient-related factors such as expectations rather than the placebo itself. Negative effects due to patient-related factors are termed the nocebo effect.

Active placebos are treatments with chemical activity that mimic the side effects of the drug being tested in a clinical trial. They are used to prevent unblinding of the drug versus the placebo control group. Placebos need not always be pharmacological and can be procedural, such as sham electroconvulsive therapy.

The placebo effect is influenced by factors such as the perceived strength of the treatment, the status of the treating professional, and the branding of the compound. The placebo response is greater in mild illness, and the response rate is increasing over time. Placebo response is usually short-lived, and repeated use can lead to a diminished effect, known as placebo sag.

It is difficult to separate placebo effects from spontaneous remission, and patients who enter clinical trials generally do so when acutely unwell, making it challenging to show treatment effects. Breaking the blind may influence the outcome, and the expectancy effect may explain why active placebos are more effective than inert placebos. Overall, understanding the placebo effect is crucial in clinical trials and personalized medicine.