Kraepelin’s Mixed States: A Historical Overview

Kraepelin’s six types of mixed states were based on various combinations of mood, will, and thought processes. These mixed states are less common than pure mania of pure depression. Dysphoric mania and depressive mixed state are the two types of mixed states that have been reduced over the years. Other terms used to describe mixed states include agitated depression, anxious depression, irritable depression, and mixed hypomania. Despite the reduction in the number of mixed states, they remain a relevant psychopathological syndrome in modern times.

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.

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.

The mother seems to transfer her own feelings of insecurity onto her daughter, who internalizes them even though she has a healthy weight. This phenomenon is known as projective identification, where the projected emotions are adopted and experienced as one’s own.

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.

Cotard’s syndrome is a condition where an individual has a false belief that they are deceased of do not exist.

Delusional Misidentification Syndrome

Delusional misidentification syndrome refers to a group of disorders where individuals believe that the identity of a person, object, of place has been altered of changed. There are several subtypes of this syndrome, including Capgras syndrome, Fregoli syndrome, intermetamorphosis, subjective doubles, reduplicative paramnesia, mirrored self, delusional companions, and clonal pluralisation of the self. Each subtype is characterised by a specific delusion, such as believing that a loved one has been replaced by an exact double of that a place has been duplicated. These delusions can have a significant impact on an individual’s daily life and require appropriate treatment.

Physiological tremors can be intensified by several drugs, while alcohol and benzodiazepines have a tendency to reduce tremors.

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

Lewis’ Views on Mental Illness Diagnosis

Lewis believed that mental illness could be understood by examining the disturbance of part functions of the brain, such as emotion, perception, and memory, as well as a reduction in general efficiency. However, he cautioned against using socially deviant behavior as a means of diagnosis. Instead, he advocated for a multi-axial formulation approach, which was first proposed by Essen-Möller in 1947. Lewis also warned against relying on response to psychotropic medication as a reliable method of diagnosis. Overall, Lewis emphasized the importance of a comprehensive and nuanced approach to diagnosing mental illness.

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.

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.

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.

Both hyperthyroidism and hypothyroidism can lead to the development of pretibial myxoedema, while hyporeflexia is typically only observed in cases of hypothyroidism.

Thyroid Examination Findings

Hypothyroidism:

– Weight gain (with decreased appetite)
– Intolerance to cold
– Lethargy
– Constipation
– Menstrual disturbances
– Decreased perspiration

Exam findings:

– Hair loss
– Bradycardia
– Periorbital puffiness and dry skin
– Coarse, brittle, straw-like hair
– Myxoedema
– Hyporeflexia

Hyperthyroidism:

– Weight loss (with increased appetite)
– Intolerance to heat
– Palpitations
– Menstrual disturbances

Exam findings:

– Hair loss
– Tachycardia
– Warm, moist, and smooth skin
– Tremor
– Brisk reflexes

The field of psychiatry uses various cognitive tests to assess different areas of cognition, including premorbid intelligence, intelligence, memory, attention, language, and others. Some commonly used tests include the National Adult Reading Test (NART) for premorbid intelligence, the Wechsler Adult Intelligence scale (WAIS) and Raven’s Progressive Matrices for intelligence, the Rey-Osterrieth Complex Figure for memory, and the Stroop test, Wisconsin card sorting test, Tower of London, and Continuous Performance Tasks for attention. The Boston naming test and Animal fluency are used to assess language skills. The Halstead-Reitan battery is used specifically for assessing brain damage. These tests are often included in the MRCPsych exams.

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.

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.

Sick Euthyroid Syndrome: Abnormal Thyroid Function in Non-Thyroidal Illness

Sick euthyroid syndrome, also known as low T3 syndrome, is a condition where thyroid function tests show abnormal results, typically low T3 levels, while T4 and TSH levels remain normal. This condition is commonly observed in patients with non-thyroidal illness. For instance, individuals with anorexia who have undergone prolonged starvation may develop this syndrome.

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.

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.

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.

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

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.

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.

The BPRS is a tool used by clinicians to evaluate the level of psychopathology in patients with major psychiatric disorders, with a focus on psychosis. It involves rating between 18 and 24 symptom constructs on a scale of 1 to 7 based on their severity, with a minimum score of 18. Additionally, the patient’s behavior over the past 2-3 days can be reported by their family and taken into consideration.

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.

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.

Interview Techniques: The Importance of Transition

Effective communication is crucial in any healthcare setting, particularly in psychiatry where patients may be hesitant to share personal information. One technique that can aid in the interview process is transition. Transition involves signaling to the patient that the interviewer has gathered enough information on a particular topic and is ready to move on to another subject.

Transition can be especially helpful when discussing sensitive of uncomfortable topics, as it allows the patient to feel heard and validated while also providing a sense of structure to the interview. Additionally, it can prevent the interview from becoming too focused on one topic, which may not be the most pressing concern for the patient.

It is important to use clear and concise language when transitioning to a new topic, and to ensure that the patient is comfortable with the change in direction. This can be achieved by asking if there is anything else they would like to add of if they have any questions before moving on.

Overall, incorporating transition into the interview process can improve communication and help patients feel more comfortable sharing their experiences and concerns.

Personality Disorder Classification

A personality disorder is a persistent pattern of behavior and inner experience that deviates significantly from cultural expectations, is inflexible and pervasive, and causes distress of impairment. The DSM-5 and ICD-11 have different approaches to classifying personality disorders. DSM-5 divides them into 10 categories, grouped into clusters A, B, and C, while ICD-11 has a general category with six trait domains that can be added. To diagnose a personality disorder, the general diagnostic threshold must be met before determining the subtype(s) present. The criteria for diagnosis include inflexibility and pervasiveness of the pattern, onset in adolescence of early adulthood, stability over time, and significant distress of impairment. The disturbance must not be better explained by another mental disorder, substance misuse, of medical condition.

Course

Borderline and antisocial personality disorders tend to become less evident of remit with age, while others, particularly obsessive-compulsive and schizotypal, may persist.

Classification

The DSM-5 divides personality disorders into separate clusters A, B, and C, with additional groups for medical conditions and unspecified disorders. The ICD-11 dropped the separate categories and instead lists six trait domains that can be added to the general diagnosis.

UK Epidemiology

The prevalence of personality disorders in Great Britain, according to the British National Survey of Psychiatric Morbidity, is 4.4%, with cluster C being the most common at 2.6%, followed by cluster A at 1.6% and cluster B at 1.2%. The most prevalent specific personality disorder is obsessive-compulsive (anankastic) at 1.9%.

Hebephrenic schizophrenia is a type of schizophrenia that is classified in the ICD-10 as having a greater emphasis on thought disorder than hallucinations, with erratic of disorganized behavior being prominent. The DSM-IV equivalent is disorganized schizophrenia. Catatonic schizophrenia is characterized by abnormalities in psychomotor function. Paranoid schizophrenia is characterized by paranoid delusions and auditory hallucinations. Simple schizophrenia is not a suitable option because it is a subtype of schizophrenia that is characterized by a decline in functioning as the only clear symptom. Undifferentiated schizophrenia refers to a presentation of schizophrenia that does not fit into a specific subtype.

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 ACE-III tests a broad range of cognitive functions
– It includes items testing visuospatial function
– Examples of visuospatial items include copying a cube and an infinity diagram, counting dots without pointing to them, and identifying incompletely formed letters
– The ACE-III is not helpful in diagnosing delirium.

The Addenbrooke’s Cognitive Exam: A Brief Screening Tool for Dementia

The Addenbrooke’s cognitive examination (ACE) is a cognitive screening tool developed to detect dementia and differentiate Alzheimer’s dementia from frontotemporal dementia. It was created to address the limitations of the MMSE, which lacked sensitivity for frontal-executive dysfunction and visuospatial defects. The ACE is a brief test that takes 15-20 minutes to administer and is divided into five domains: attention and orientation, memory, verbal fluency, language, and visuospatial abilities. The total score is based on a maximum score of 100, with higher scores indicating better cognitive functioning.

The ACE has been shown to be a valid tool for detecting dementia, with two cut-off points often used depending on the required sensitivity and specificity. A score of less than 88 has 100% sensitivity for detecting dementia, while a score of less than 82 has 93% sensitivity and 100% specificity. It has also been useful in differentiating dementia from pseudo dementia and detecting cognitive impairment in atypical Parkinson syndromes. However, while the test has shown 100% sensitivity and specificity in studies, its performance may vary in clinical practice.

The Wechsler Adult Intelligence Scale (WAIS) is a widely used intelligence test in clinical settings, designed for individuals aged 16 to 90. Its counterpart for children is the Wechsler Intelligence Scale for Children (WISC). The current version of WAIS, WAIS-IV, consists of four index scores, each comprising several subsets. These are the Verbal Comprehension Index, Perceptual Reasoning Index, Working Memory Index, and Processing Speed Index. The results are presented as two scores: Full Scale IQ and General Ability Index. The average score is 100, with a standard deviation of 15. However, the test becomes less accurate at the extremes of IQ (70-130). About 3% of people score below 70, which is the general cut-off for a significant learning disability.