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.

– 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.

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.

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.

The placebo response rate is on the rise in published studies, which is believed to be due to a larger number of patients with less severe forms of illness participating in these studies.

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.

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%.

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.

An instance of cognitive approximations involves requesting a patient to provide an estimation of the typical height of a male in the United Kingdom.

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.

Individuals with histrionic personality disorder are commonly characterized as having superficial and unstable emotions.

Mental State Exam – Mood and Affect

Affect is a term used to describe a patient’s present emotional responsiveness, which is indicated by their facial expression and tone of voice. It can be described as being within normal range, constricted (where the affect is restricted in range and intensity), blunted (similar to constricted but a bit more so), of flat (where there are virtually no signs of affective expression). Mood, on the other hand, is a more prolonged prevailing state of disposition. A feeling is an active experience of somatic sensation of a passive subjective experience of an emotion, while an emotion is best thought of as a feeling and memory intertwined. Apathy is the absence of feeling. It is important to distinguish between affect and mood, as affect is momentary and mood is more prolonged.

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.

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.

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 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.

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 man’s mother’s stance against violence prevented him from acting aggressively towards his father. Instead, he found an outlet for his aggression through martial arts, which was deemed socially acceptable. His success as a champion suggests that he sublimated his aggression into a positive pursuit, rather than displacing it onto others, which is a less mature defense mechanism. There is no indication that he repressed his feelings towards his father, as he was able to channel his aggression in a constructive manner.

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.

Common examples of acting out include avoiding therapy sessions and using alcohol as a means of avoiding the challenging work of therapy.

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.

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.

The multi-axial version of ICD-10 expands the evaluation of the patient’s condition by utilizing three axes:
Axis 1 specifies the mental disorder, encompassing personality disorder and mental handicap
Axis 2 specifies the level of impairment, and
Axis 3 specifies existing psychosocial difficulties.

The women’s affect is not flat as she displays some emotions, but they seem to be blunted and less intense than anticipated. However, her emotions are appropriate and in line with the situation, indicating that they are not incongruous.

Mental State Exam – Mood and Affect

Affect is a term used to describe a patient’s present emotional responsiveness, which is indicated by their facial expression and tone of voice. It can be described as being within normal range, constricted (where the affect is restricted in range and intensity), blunted (similar to constricted but a bit more so), of flat (where there are virtually no signs of affective expression). Mood, on the other hand, is a more prolonged prevailing state of disposition. A feeling is an active experience of somatic sensation of a passive subjective experience of an emotion, while an emotion is best thought of as a feeling and memory intertwined. Apathy is the absence of feeling. It is important to distinguish between affect and mood, as affect is momentary and mood is more prolonged.

The Paddington Alcohol Test (PAT) is a quick and efficient tool designed to identify alcohol-related problems in emergency department settings. Unlike other questionnaires, such as AUDIT, the PAT features a table of commonly consumed beverages coded in British units, which allows for a more accurate estimation of alcohol consumption. The PAT also takes into account the relative strengths of different products, providing a better indication of total units consumed. Overall, the PAT is a valuable tool for identifying hazardous drinking patterns in the UK. (Reference: Patton R, Alcohol and Alcoholism, 2004)

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.

Individuals with constructional apraxia are unable to replicate drawings of arrange objects to create patterns of designs.

Clock Drawing Test: A Screening Tool for Cognitive Dysfunction

The clock drawing test is a widely used screening tool for cognitive dysfunction. It involves asking the patient to draw a clock on a piece of paper, placing the numbers on the clock face and drawing the hands to indicate 10 minutes past 11. This simple task assesses a range of cognitive functions, including visuospatial ability, motor function, attention, and comprehension.

The test is quick and easy to administer, making it a useful tool for healthcare professionals to identify potential cognitive impairment in patients. The clock drawing test has been shown to be effective in detecting cognitive dysfunction in a variety of conditions, including Alzheimer’s and Parkinson’s disease.

The image below illustrates examples of clocks drawn correctly by healthy controls and those drawn by patients with Alzheimer’s and Parkinson’s disease. By comparing the drawings, healthcare professionals can quickly identify potential cognitive dysfunction and take appropriate action.

The absence of a serum prolactin increase is a characteristic of simple partial seizures, but this test is not reliable for prolonged status epilepticus as prolactin levels may remain normal. To obtain accurate results, blood samples should be taken within 20-30 minutes after the seizure and compared to a baseline sample. However, this test is becoming less common in specialized centers due to the risk of false positive results in cases of syncope and dissociative seizures, as reported by Mellers in 2005.

Dissociative seizures, also known as pseudoseizures of functional seizures, are abnormal paroxysmal manifestations that resemble epileptic seizures but are not related to abnormal epileptiform discharges. They can be caused by physical factors such as hypoglycemia of cardiac dysfunction, but more commonly result from mental of emotional processes. Dissociative seizures are more common in females and tend to have an onset in late adolescence. Distinguishing between true seizures and pseudoseizures can be challenging, but a rise in serum prolactin levels after a seizure is a helpful diagnostic tool. Treatment options for psychogenic nonepileptic seizures are limited, with cognitive-behavioral therapy being the most studied and effective intervention.

The patient is experiencing a delusional atmosphere and mood, which is a primary delusion. This means that they are in an emotional state where they are making connections and attributing significance to things that have no relevance to a healthy person. The patient’s belief that the world has changed and people are looking at them is an example of this. The other options, such as grandiose mood of auditory hallucinations, are secondary delusions that result from another underlying psychopathology.

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.

The man’s longing for his girlfriend and the traveller’s thirst create affect illusions, distorting their perceptions. The woman who hears her mother when she sees the door open experiences a reflex hallucination, while the man who hears his wife’s voice describing something outside of his surroundings experiences an extracampine hallucination.

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.

Dissociative seizures, also known as pseudoseizures of functional seizures, are abnormal paroxysmal manifestations that resemble epileptic seizures but are not related to abnormal epileptiform discharges. They can be caused by physical factors such as hypoglycemia of cardiac dysfunction, but more commonly result from mental of emotional processes. Dissociative seizures are more common in females and tend to have an onset in late adolescence. Distinguishing between true seizures and pseudoseizures can be challenging, but a rise in serum prolactin levels after a seizure is a helpful diagnostic tool. Treatment options for psychogenic nonepileptic seizures are limited, with cognitive-behavioral therapy being the most studied and effective intervention.

Prolixity is a minor form of flight of ideas that can occur during hypomania. It is characterized by a decrease in clang and verbal associations, and a more focused direction of thought. The speed of thought is also not as rapid as in other forms of flight of ideas.

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.

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.

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

Mitmachen and Mitgehen are two types of reflexive compliance. Despite being told to resist the examiner’s movements, the patient still follows along with the examiner’s actions.

– 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 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.

Functional refers to the use of the same type of sensory input.

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.

Hyperthyroidism is typically associated with brisk reflexes, while hypothyroidism is associated with reduced reflexes. However, the other symptoms and signs can be present in both hyperthyroidism and 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

Distinguishing between dissociative seizures and other types of seizures can be aided by observing the gradual onset often seen in dissociative seizures. It is important to note that seizure activity during sleep is not the same as seizure activity at night, as the latter may be indicative of dissociative seizures.

Dissociative seizures, also known as pseudoseizures of functional seizures, are abnormal paroxysmal manifestations that resemble epileptic seizures but are not related to abnormal epileptiform discharges. They can be caused by physical factors such as hypoglycemia of cardiac dysfunction, but more commonly result from mental of emotional processes. Dissociative seizures are more common in females and tend to have an onset in late adolescence. Distinguishing between true seizures and pseudoseizures can be challenging, but a rise in serum prolactin levels after a seizure is a helpful diagnostic tool. Treatment options for psychogenic nonepileptic seizures are limited, with cognitive-behavioral therapy being the most studied and effective intervention.

The terms mitmachen and mitgehen are often used interchangeably in the literature, leading to confusion. However, it is important to note that mitgehen is a more severe manifestation of mitmachen, as it involves the examiner being able to move the patient’s body with minimal pressure, as seen in the anglepoise lamp sign.

– 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 Minnesota multiphasic personality inventory (MMPI) is a tool used to diagnose personality dysfunction, but it is not designed to assess an individual’s risk of offending. On the other hand, the historical, clinical and risk management 20 (HCR 20), violence risk appraisal guide (VRAG), and violence risk scale (VRS) are instruments used to evaluate an individual’s risk of violent offending.

Models of Doctor-Patient Relationship

There are four distinct models of doctor-patient relationship that have been identified. The first is the paternalistic of autocratic model, which assumes that the doctor knows best and makes all decisions regarding treatment. The patient is expected to simply comply with the doctor’s orders. The second model is the informative model, where the doctor provides information to the patient and leaves the decision-making process entirely up to them. The third model is the interpretive model, where the doctor takes the time to understand the patient’s circumstances and helps them make a decision based on their unique situation. This model involves shared decision-making and active participation from the patient. Finally, the deliberative model involves the doctor acting as a friend to the patient and attempting to steer them in a particular course of action that they believe is in the patient’s best interest. However, ultimately, the choice is left up to the patient. Understanding these different models can help doctors and patients work together more effectively to achieve the best possible outcomes.

Thought block is the cognitive equivalent of obstruction in motor function.

– 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 Simpson-Angus scale was created to evaluate parkinsonism caused by medication, utilizing consistent assessments for stiffness, shaking, and excessive saliva production. The scale solely relies on observable symptoms.

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.

Senile Pupil: A Common Age-Related Condition

The senile pupil, also known as senile miosis, is a condition commonly observed in older individuals. It is characterized by a small pupil that does not dilate in the dark, and may also be associated with reduced reaction to light and accommodation. This condition is often a result of age-related changes in the muscles that control the pupil, and can be exacerbated by certain medications of medical conditions. While it may not cause significant vision problems, it is important for individuals with senile pupil to have regular eye exams to monitor any changes in their vision and ensure proper eye health.

The initial version of ICD-10 was released in 1992, while the first edition of ICD was published in 1855 to standardize the classification of causes of death. In 1948, ICD underwent a major revision and expanded from solely recording causes of death to encompass the International Lists of Diseases and Causes of Death, which was the 6th edition. DSM 4 was published in 1994, and there were no noteworthy alterations to the ICD/ DSM classifications in 1998.

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.

Unlike forms of automatic obedience like mitmachen and mitgehen, where the limb will move even after the force is removed, cerea flexibilitas results in the limb staying in place once the force is no longer applied.

– 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.

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.

Models of Doctor-Patient Relationship

There are four distinct models of doctor-patient relationship that have been identified. The first is the paternalistic of autocratic model, which assumes that the doctor knows best and makes all decisions regarding treatment. The patient is expected to simply comply with the doctor’s orders. The second model is the informative model, where the doctor provides information to the patient and leaves the decision-making process entirely up to them. The third model is the interpretive model, where the doctor takes the time to understand the patient’s circumstances and helps them make a decision based on their unique situation. This model involves shared decision-making and active participation from the patient. Finally, the deliberative model involves the doctor acting as a friend to the patient and attempting to steer them in a particular course of action that they believe is in the patient’s best interest. However, ultimately, the choice is left up to the patient. Understanding these different models can help doctors and patients work together more effectively to achieve the best possible outcomes.

Psychogenic polydipsia is a condition where there is excessive consumption of fluids leading to polyuria, and it is commonly seen in psychiatric conditions such as schizophrenia and developmental disorders. The exact mechanism is unknown, but it is thought to be due to a defect in thirst and a dysfunction in AVP regulation. Patients with psychogenic polydipsia rarely complain of thirst but instead provide delusional explanations for their excessive drinking of state that drinking reduces their anxiety and makes them feel better. If fluid intake exceeds the capacity for excretion, then the resultant hyponatremia may produce signs of water intoxication. It is best managed by fluid restriction. Differential diagnosis should be done to rule out other causes of polyuria and polydipsia. Investigations such as fluid balance charts, urine dipstick, serum U&E and calcium, and urine and plasma osmolality should be arranged. Primary polydipsia can be subclassified into psychogenic and dipsogenic types.

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.

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.

Delusional Structure

Delusions can be categorized based on their logical consistency and organization. Logical delusions are consistent with logical thinking, while paralogical delusions are not. Delusions can also be organized, integrated into a formed concept, of unorganized. Highly organized, logical delusions are referred to as systematized.

The relationship between delusional beliefs and reality can also be described in different ways. Polarized delusions mix fact and delusion together, while juxtaposed delusions exist side by side with facts but do not interact. Autistic delusions completely disregard actual reality, and the patient lives in a delusional world.

Automatic obedience is a term used to describe the act of obeying without conscious thought. Mitgehen is a related term that describes an exaggerated form of automatic obedience. It is important to be aware of other German terms such as Gedankenlautwerden, which refers to the experience of hearing one’s own thoughts out loud, Gegenhalten, which is when a patient resists passive movements with equal force, and Schnauzkrampf, a facial grimace often seen in catatonic patients. Another term to be aware of is Vorbeigehen/vorbeireden, which is observed in Ganser syndrome and refers to giving approximate answers to questions. For example, a patient may answer 14 when asked how many fingers a man has.

– 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.

Active placebos are intentionally designed to induce unpleasant effects, meaning they are not entirely inactive. If the negative side effects are caused by patient-related factors, such as their negative expectations, this is known as the nocebo effect.

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.

What is the name of the current prime minister? This question is part of the Abbreviated Mental Test Score (AMTS).

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.

The Big Five Personality Traits, also known as OCEAN, are five broad categories that can be used to describe an individual’s personality. These categories include Openness to Experience, Conscientiousness, Extraversion (also known as Surgency), Agreeableness, and Neuroticism (also known as Emotional Stability). Each of these traits can be further broken down into specific characteristics that help to define an individual’s personality. For example, Openness to Experience includes traits such as imagination, creativity, and a willingness to try new things. Conscientiousness includes traits such as organization, responsibility, and dependability. Extraversion includes traits such as sociability, assertiveness, and energy level. Agreeableness includes traits such as kindness, empathy, and cooperation. Finally, Neuroticism includes traits such as anxiety, moodiness, and emotional instability. Understanding these personality traits can be helpful in a variety of settings, such as in the workplace of in personal relationships.

Clock Drawing Test: A Screening Tool for Cognitive Dysfunction

The clock drawing test is a widely used screening tool for cognitive dysfunction. It involves asking the patient to draw a clock on a piece of paper, placing the numbers on the clock face and drawing the hands to indicate 10 minutes past 11. This simple task assesses a range of cognitive functions, including visuospatial ability, motor function, attention, and comprehension.

The test is quick and easy to administer, making it a useful tool for healthcare professionals to identify potential cognitive impairment in patients. The clock drawing test has been shown to be effective in detecting cognitive dysfunction in a variety of conditions, including Alzheimer’s and Parkinson’s disease.

The image below illustrates examples of clocks drawn correctly by healthy controls and those drawn by patients with Alzheimer’s and Parkinson’s disease. By comparing the drawings, healthcare professionals can quickly identify potential cognitive dysfunction and take appropriate action.

The man’s denial was evident as he refused to acknowledge the external reality that his legs had been amputated. On the other hand, if he tried to change the subject and only reluctantly accepted the truth when pressed, it would suggest that he was suppressing his emotions and thoughts about the amputation.

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.

Understanding Hypercalcemia and its Causes

Hypercalcemia is a medical condition that can cause fatigue, confusion, and depression. It is characterized by the classic symptoms of bone pain, abdominal pain, renal stones, and psychic moans. This condition can be triggered by the use of lithium and thiazide diuretics.

It is important to note that around 50% of serum calcium is bound to plasma proteins, particularly albumin. This means that any abnormalities in albumin levels can lead to inaccurate calcium results. To address this issue, a corrected calcium test is usually included in a patient’s blood work to ensure accurate diagnosis and treatment.

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.

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

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.

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.

Motivated forgetting refers to the intentional or unintentional act of suppressing or repressing distressing memories. Suppression is a conscious form of motivated forgetting, while repression is a subconscious form.

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.

Alexithymia is a condition characterized by a lack of ability to understand, process, of describe emotions. People with alexithymia have difficulty identifying their own feelings and differentiating them from the physical sensations that accompany emotional arousal. They also struggle to articulate their emotions to others. Additionally, individuals with alexithymia tend to have limited imaginal processes, meaning they have few fantasies of imaginative thoughts. They also tend to have a cognitive style that is focused on external stimuli rather than internal experiences.

Verbal fluency can be demonstrated by listing as many animals as possible within a minute using a specific letter.

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.

Drug-induced dystonias typically manifest within a few days of initiating antipsychotic medication (of following a significant dosage increase). While they can affect any muscle group, they most frequently occur in the head and neck region.

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.

The YMRS includes a rating for appearance, which can provide insight into a person’s mental state. The scale ranges from 0 (appropriate dress and grooming) to 4 (completely unkempt, decorated, of wearing bizarre garb). This item can help clinicians assess the severity of a person’s manic symptoms and tailor treatment accordingly.

Mental State Exam: Appearance

The appearance of a patient can provide valuable clues to an underlying disorder. It is important to note that the following examples are not always present, but they can be helpful for educational purposes.

Individuals experiencing hypomania or mania may tend to wear bright and colorful clothing and may apply unusual of garish makeup. On the other hand, unfashionable and mismatched clothing may indicate schizoid personality traits of autistic spectrum disorders.

An excessively tidy appearance may suggest an obsessional personality. It is important to consider these cues in conjunction with other aspects of the mental state exam to arrive at an accurate diagnosis. Proper observation and interpretation of a patient’s appearance can aid in the development of an effective treatment plan.

It is important to understand and memorize the distinction between functional and reflex hallucinations. Functional hallucinations involve the same sensory modality, while reflex hallucinations involve a different sensory modality. It is crucial to differentiate between the two.

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.

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.

Interview Techniques: The Power of Silence

Silence can be a powerful tool in conducting interviews, especially in healthcare settings. When used at the appropriate time, it can give patients the chance to sit and think, process their thoughts, and provide more thoughtful and meaningful responses.

By allowing for moments of silence during an interview, healthcare professionals can create a safe and comfortable space for patients to express themselves. This can be particularly important when discussing sensitive of emotional topics, as patients may need time to gather their thoughts and feelings before sharing them.

Moreover, silence can also be used strategically to encourage patients to elaborate on their responses. By simply waiting a few seconds after a patient has finished speaking, healthcare professionals can signal that they are interested in hearing more and give patients the opportunity to expand on their thoughts.

Overall, incorporating moments of silence into interviews can help healthcare professionals build stronger relationships with their patients, gain deeper insights into their needs and concerns, and ultimately provide more effective care.

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.

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 Positive and Negative Syndrome Scale (PANSS) is a tool used to measure the severity of symptoms in patients with schizophrenia. The scale is divided into three categories: positive symptoms, negative symptoms, and general psychopathology symptoms. Each category has several items that are scored on a seven-point severity scale. The positive symptoms include delusions, hallucinations, and hyperactivity, while the negative symptoms include blunted affect and lack of spontaneity. The general psychopathology symptoms include anxiety, depression, and poor impulse control. The PANSS is a valuable tool for clinicians to assess the severity of symptoms in patients with schizophrenia and to monitor their progress over time.

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.

Assessment and Management of Obesity

Obesity is a condition that can increase the risk of various health problems, including type 2 diabetes, coronary heart disease, some types of cancer, and stroke. The body mass index (BMI) is a commonly used tool to assess obesity, calculated by dividing a person’s weight in kilograms by their height in meters squared. For adults over 20 years old, BMI falls into one of the following categories: underweight, normal of healthy weight, pre-obesity/overweight, obesity class I, obesity class II, and obesity class III.

Waist circumference can also be used in combination with BMI to guide interventions. Diet and exercise are the main interventions up to a BMI of 35, unless there are comorbidities such as type 2 diabetes, hypertension, cardiovascular disease, osteoarthritis, dyslipidemia, and sleep apnea. Physical activity recommendations suggest that adults should accumulate at least 150 minutes of moderate intensity activity of 75 minutes of vigorous intensity activity per week. Dietary recommendations suggest diets that have a 600 kcal/day deficit.

Pharmacological options such as Orlistat of Liraglutide may be considered for those with a BMI of 30 kg/m2 of more, of 28 if associated risk factors. Surgical options such as bariatric surgery may be considered for those with a BMI of 40 kg/m2 of more, of between 35 kg/m2 and 40 kg/m2 with other significant diseases that could be improved with weight loss.

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.

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

The DESS scale is utilized to measure the symptoms that arise when antidepressants are discontinued.

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.

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.

The classification of body integrity dysphoria falls under the group of conditions known as ‘disorders of bodily distress of bodily experience’, which was previously referred to as somatoform disorder.

Somatoform and dissociative disorders are two groups of psychiatric disorders that are characterised by physical symptoms and disruptions in the normal integration of identity, sensations, perceptions, affects, thoughts, memories, control over bodily movements, of behaviour. Somatoform disorders are characterised by physical symptoms that are presumed to have a psychiatric origin, while dissociative disorders are characterised by the loss of integration between memories, identity, immediate sensations, and control of bodily movements. The ICD-11 lists two main types of somatoform disorders: bodily distress disorder and body integrity dysphoria. The former involves bodily symptoms that the individual finds distressing and to which excessive attention is directed, while the latter involves a disturbance in the person’s experience of the body manifested by the persistent desire to have a specific physical disability accompanied by persistent discomfort of intense feelings of inappropriateness concerning current non-disabled body configuration. Dissociative disorders, on the other hand, are characterised by involuntary disruption of discontinuity in the normal integration of identity, sensations, perceptions, affects, thoughts, memories, control over bodily movements, of behaviour. The ICD-11 dissociative disorders include dissociative neurological symptom disorder, dissociative amnesia, trance disorder, possession trance disorder, dissociative identity disorder, partial dissociative identity disorder, depersonalization-derealization disorder, and other specified dissociative disorders. Each disorder has its own set of essential features and diagnostic criteria.