MRC Psych Part 1 9780203746417, 0203746414, 9781351429993, 135142999X, 9781351430005, 1351430009, 9781351430012, 1351430017

Table of contents :
Content: The first nine sections of cards are broadly divided into commonly tested areas on the exam: 1. Neurotic disorders 2. Affective disorders 3. Dementia syndromes 4. Neuropsychiatry 5. Psychology 6. Psychotherapy 7. Schizophrenia 8. Pharmacology 9. Human development.

Citation preview

MRCPsych Part 1 In a Box Bhaskar Punukollu MBBS MRCPsych S p ecia list R egistrar in Psychiatry, C h a rin g Cross & St M a ry 's H igh er S p e cia list Training S ch e m e , L o n d o n

Michael Phelan BSc MBBS MRCPsych C o n s u lta n t Psychiatrist, W est L o n d o n M e n ta l H e a lth Trust & H on ora ry Senior Lecturer, Im p e ria l C o lle g e S ch o o l o f M e d ic in e , L o n d o n

Anish Unadkat BMBS Bmedsci Senior House O ffic e r in G e n e ra l A d u lt Psychiatry, C h e ls e a a n d W estm inster H ospital, L o n d o n

ROUTLEDGE

Routledge Taylor & Francis Group

LONDON AND NEW YORK

First published 2007 by Royal Society of Medicine Press Ltd. Published 2018 by Routledge 2 Park Square, Milton Park.Abingdon, Ox.on OX 14 4RN 52 Vanderbilt Avenue, New York NY I 0017

Routledge is an imprint of the Taylor & Francis Group, an informa business Copyright © 2007 Taylor & Francis The nghts of Bhaskar Punukollu, Michael Phelan and Anish Unadkat to be ident1f1ed as authors of this worl< have been asserted by them in accordance wrth the Copynght. Designs and Patents Act, 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any infonnation storage or retrieval system, without permission in writing from the publishers. Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe.

British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Designed and typeset by Phoenix Photosetting, Chatham. Kent

ISBN 13: 978-1-85315-602-I (hbk) ISBN ll:978-1-138-11246-9 (pbk)

1. Introduction The aim of MRCPsych Part 1 in a Box is to help you pass your exam. The cards pro­ vide specific and up to date information, based on the syllabus and the experi­ ences of recent candidates. They are produced for easy reading and quick learn­ ing. Mnemonics are frequently used to help you remember key facts. The box is one of the only revision aids that contains information for all components of the exam; key facts for the written and OSCEs as well as detailed practice ISQ and EMI ques­ tions. We hope that the cards help to make your revision more effective and fun. They are designed to be taken anywhere, shared with colleagues and to bring you suc­ cess! The first nine sections of cards are broadly divided into commonly tested areas on the exam: 1. Neurotic disorders 4. Neuropsychiatry 7. Schizophrenia

2. Affective disorders 5. Psychology 8. Pharmacology

3. Dementia syndromes 6. Psychotherapy 9. Human development

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Section 10 includes various miscellaneous topics which are commonly tested,

including classification in psychiatry, rating scales, organic conditions and sum­ maries of the NICE guidelines, which are useful for OSCE practice. Section 11 covers commonly asked OSCEs. A simple 'suggested approach' is

offered on how to tackle each station. Each card also includes a more in depth explanation of key areas to address on each station as well as useful tips explain­ ing common reasons for candidates failing. Section 12 (the last section) consists of a selection of ISQs and EMIs, exam type

questions, with comprehensive answers and explanations.

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2. Contents 1 .Introduction 2. Contents 3. Psychopathology 4. Psychopathology 5. Psychopathology ó.Psychopathology 7. Psychopathology 8. Neuroscience 9. Neuroscience 10. Neuroscience 11. Neuroscience 12. Neuroscience 13. Neuroscience 14. Neuroscience 15. Neuroscience 16. Neuroscience 17. Neuroscience 18. Neuroscience 19. Neuroscience 20. Neuroscience 21. Neurotic Disorders 22. Neurotic Disorders 23. Neurotic Disorders 24. Neurotic Disorders 25. Neurotic Disorders

26. Neurotic Disorders 27. Neurotic Disorders 28. Neurotic Disorders 29. Neurotic Disorders 30. Neurotic Disorders 31. Neurotic Disorders 32. Psychotic Disorders 33. Psychotic Disorders 34. Psychotic Disorders 35. Psychotic Disorders 36. Psychotic Disorders 37. Psychotic Disorders 38. Psychotic Disorders 39. Psychotic Disorders 40. Psychotic Disorders 41 .Psychotic Disorders 42. Affective Disorders 43. Affective Disorders 44. Affective Disorders 45. Affective Disorders 46. Affective Disorders 47. Affective Disorders 48. Affective Disorders 49. Affective Disorders 50. Affective Disorders

51. Affective Disorders 52. Affective Disorders 53. Affective Disorders 54. Affective Disorders 55. Pharmacology 56. Pharnnacology 57. Pharmacology 58. Pharmacology 59. Pharmacology óO.Pharmacology 61. Pharmacology 62. Pharmacology 63. Pharmacology 64. Pharmacology 65. Psychology 66. Psychology 67. Psychology 68. Psychology 69. Psychology 70. Psychology 71. Psychology 72. Psychology 73. Psychology 74. Psychology 75. Psychotherapy

76. Psychotherapy 77. Psychotherapy 78. Psychotherapy 79. Psychotherapy eO.Psychotherapy 81 .Psychotherapy 82. Psychotherapy 83. Dementia syndromes 84. Dementia syndromes 85. Dementia syndromes 86. Dementia syndromes 87. Dementia syndromes 88. Human Development 89. Human Development 90. Human Development 91. Human Development 92. Human Development 93. Human Development 94. Human Development 95. Human Development 96. Miscellaneous topics 97. Miscellaneous topics 98. Miscellaneous topics 99. Miscellaneous topics 100. Miscellaneous topics

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101. Miscellaneous topics 102. Miscellaneous topics 103. Miscellaneous topics 104. Miscellaneous topics 105.OSCE Tips/Advice 106.OSCE 1 107.OSCE 2 108.OSCE 3 109.OSCE 4 110.OSCE 5 111.OSCE 6 112.0SCE 7 113.OSCE 8 114.0SCE 9 115.0SCE 10A 116.0SCE 10B 117.OSCE 11 118.OSCE 12 119.0SCE 13 120.OSCE 14 121.OSCE 15 122.OSCE 16 123.OSCE 17 124.0SCE 18 125.OSCE 19

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126. Key definitions 127. Key definitions 128. Evidence for OSCE's 129. Evidence for OSCE's 130. Evidence for OSCE's 131. Evidence for OSCE's 132. Evidence for OSCE's 133. Evidence for OSCE's 134. Evidence for OSCE's 135. Evidence for OSCE's 136. Evidence for OSCE's 137.ISQ-Pharmacology 138.ISQ-Neuroscience 139.ISQ-Neuroscience 140.ISQ-Neurotic dsd's 141.ISQ-Dementia 142.ISQ-Human Dev't 143.ISQ-Neuroscience 144.ISQ-Dementia 145.ISQ-Pharmacology 146.ISQ-Affective 147.ISQ-Affective 148.ISQ-Behavioural 149.ISQ-Behavioural 150.ISQ-Psychopathology

151.ISQ-Psychology 152.ISQ-Psychotherapy 153.ISQ-Psychology 154.ISQ-Pharmacology 155.ISQ-Schizophrenia 156.ISQ-Psychopathology 157.ISQ-Psychotherapy 158.ISQ-Pharmacology 159.ISQ-Human Dev't 160.ISQ-Pharmacology 161 .ISQ-Psychology 162.ISQ-Psychopathology 163.ISQ-Dementia 164.ISQ-Classification 165.ISQ-Neurotic dsd's 166.ISQ-Behavioural 167.ISQ-Schizophrenia 168.ISQ-Neurotic dsd's 169.ISQ-Neuroscience 170.ISQ-Psychology 171.ISQ-PN Psychosis 172.ISQ-Neurotic dsd'd 173.ISQ-Dementia 174. ISQ-Affective 175.ISQ-Psychotherapy

176.ISQ-Affective 177. EMI-Psychopathology 178. EMI-Psychopathology 179. EMI-Pharmacology 180. EMI-Pharmacology lei.EMI-Psychology 182. EMI-Psychology 183. EMI-Affective 184. EMI-lnvestigations 185. EMI-Neuroscience 186. EMI-Neuroscience 187. EMI-Neuroscience 188. EMI-Neuroscience 189. EMI-lnvestigations 190. EMI-Neurotic disd's 191 .EMI-Mixed topics 192. EMI-Defence mech's 193. EMI-Psychosis 194. EMI-Dementia 195. EMI-Risk factors 196. EMI-Psychopathology 197. EMI-Psychopathology 198. EMI-Pharmacology 199. EMI-Risk factors 200. References

3. Psychopathology

Delusional states • Morbid jealousy: delusional belief of a partner's infidelity. There is an association

with alcoholism, schizophrenia, substance misuse, mania, delirium and demen­ tia. • Folie à deux: similar or identical delusional system develops in a person as a result of a close relationship with another person who has an established delusional system. The condition is rare and usually there is a dominant partner with fixed delusions who appears to induce similar delusions in a dependent or suggestible partner. • De Clerambault’s syndrome: a person develops a delusional belief that another person is in love with them and becomes obsessed with that person, thinking about them all the time, sometimes dressing like them and/or stalking them.

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Delusions of misidentification • Reduplicative paramnesia: a feeling that a familiar place has been duplicated. • Capgras’ syndrome: the delusional belief that a familiar person has been

replaced by an imposter who looks identical or very similar to the person they know. It is more common in females and about 50% of cases are associated with schizophrenia. • Fregoli’s syndrome: a belief that a stranger has been replaced by a familiar person. • Doppleganger: a feeling that another human being is accompanying the self. • Cotard’s syndrome: a delusion that one has lost some part of the body, internal

organs, limbs or a belief that they are dead.

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4. Psychopathology

Hallucinations • Visual hallucination: only seen in about 15% of people with schizophrenia. Most

commonly occur in organic conditions. • Autoscopic hallucination: a type ot visual hallucination - seeing oneself in exter­

nal space. • Pseudohallucination: a percept that is experienced as similar to a real experi­ ence such as hearing a voice but it is recognized as coming from the self and is not as tangible as a real hallucination. However the person may still believe that the voice is real even though they see it as coming from inside their own head.

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Hallucinations (cont.) • Hypnagogic/hypnapompic hallucinations: (i) hypnagogic occur when falling

asleep; (ii) hypnapompic occur when waking up from sleep. Usually these are visual or auditory perceptions such as seeing a shadow or a face or hearing a voice shouting a name. Hypnagogic hallucinations are usually brief in duration. They commonly occur in narcolepsy. • Extracampine hallucination: a hallucination experienced outside the limits of the

sensory field. For example, Ί keep hearing someone down the road talking about me." • Functional hallucination: A normal external stimulus provokes a hallucination which occurs simultaneously. For example, a patient hears voices whenever he hears cars going past on the street. • Reflex hallucination: A stimulus in one sensory modality produces a hallucination in another. For example, a person sees someone walking and then hears voices. The person may then believe the person walking has led to him/her hearing voices.

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5. Psychopathology

Other perceptual abnormalities • Autoscopy: The experience of seeing oneself and the image does not occur in

external space eg they believe they see themselves in a mirror but they do not really. Schizophrenic patients may experience images of themselves in the form of a pseudohallucination. Sometimes this is called phantom mirror image. It may occur in organic conditions such as temporal lobe epilepsy or parietal lobe lesions. It is a visual perception and does not occur in other modalities. It can occur as a result of sensory deprivation. The opposite may occur - negative autoscopy - in which the patient looks in the mirror and sees no one there. • Lilliputian hallucinations: visual hallucinations of small people or objects most

often seen in alcohol withdrawal. These are also seen sometimes in delirium tremens.

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Other perceptual abnormalities (cont.) • Eidetic image: a vivid mental image is experienced in the form of a dream or

fantasy. A past memory may be remembered vividly almost like a hallucination, although it is not actually a hallucination. • Hygric hallucinations: the perception of fluid, eg a schizophrenic patient feels as

if there is water flowing over his back. • Changes in the perception ot shape ot objects: occur as a result of parietal lobe

lesions, epilepsy, acute organic states including substance misuse (eg LSD); extremely uncommon in functional psychiatric illness although may occur rarely in acute psychosis associated with schizophrenia.

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6. Psychopathology

Auditory hallucinations • Elementary hallucinations: This is a percept that is not specific to any part of real­

ity, hearing non-specific sounds: eg noises, rustling or whirring. These are com­ mon in organic states such as alcoholic hallucinosis. • Command (first person). • Running commentary (second person). • At least two voices speaking about the person (third person). • Thoughts are heard out loud: (i) echo de la pensees (otherwise known as thought sonorization or thought echo); (ii) Gedankenlautwerden - own thoughts and voices occur simultaneously.

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Illusio ns • Completion illusion: Inattention leads to a misinterpretation, eg misreading a

word as something similar due to inattention (eg 'word' is misread as 'world'). • Affect illusion: Perception of objects/surroundings/people is altered by the pre­

vailing mood state. For example, feeling depressed about the loss of a loved one, one may see people who look similar and think it is the loved one. • Pareidolic illusion: Images are seen from shapes, eg a hole in the wall is seen as

shaped like someone's face. These experiences are seen in the prodromal stage of delirium tremens, or with abuses of some substances, although such experiences may also occur normally.

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7. Psychopathology

Delusions Definition of a delusion A fixed and false, unshakeable belief out of keeping with the patient's social, cuitural or religious background.

Types of delusions • Primary: A delusion without any possible explanation, which cannot be under­

stood from the individual's experiences. • Secondary: A delusion that arises from an understandable source such as an hal­

lucination or a mood state, eg depression or mania leading to delusions of nihilism or grandeur. • Overvalued idea: Not a delusion - an acceptable, comprehensible idea pur­

sued by an individual but which is outside of the bounds of reason.

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Delusions Types of primary delusion Mnemonic: I MAP I = Delusional Idea (otherwise known as an autochthonous delusion) - a belief which comes from within the person and apparently arises from nowhere. M = Delusional Memory - an event is remembered in a false and fixed way such that it bears no relationship to reality. Either the recalled event may have never taken place or a real event may be recalled with the sequence of events mixed up or with incorrect details. A = Delusional Atmosphere/ Mood - an unpleasant feeling that something is wrong, or that something is happening. P = Delusional Perception - a delusional meaning is attached to a normal percept eg coffee tastes funny so the patient thinks this means someone put poison in it.

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8. Neuroscience

Symptoms associated with interruption of blood supply to the brainstem • Cranial nerve abnormalities with or without hemiparesis and hemisensory deticits. • Dysphagia (due to paralysis of tongue and larynx). • Dysarthria (inability to articulate clearly due to paralysis ot facial muscles).

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Symptoms associateci with loss of blood flow to the cerebellum • Ataxia (motor incoordination due to cerebellar damage). • Hypotonia. • Dysmetria (lack of coordination of movement characterized by an inability to carry out the finger-nose test). • Loss of equilibrium and vertigo. • Diplopia and bilateral hemianopsia (due to loss of blood flow in the posterior cerebral artery).

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9. Neuroscience

Effects of anterior circulation abnormalities Anterior circulation consists of • Right and left internal carotid arteries. • Pass on each side into the temporal lobe to enter the subarachnoid space. These arteries then join the circle of Willis where each bifurcates to form two main branches: the anterior and the middle cerebral arteries. • Internal carotid arteries supply majority of the cerebral hemispheres, except occipital and medial temporal lobes, which are supplied by the posterior circu­ lation.

Damage to the anterior cerebral artery • Contralateral weakness. • Sensory loss distally in the leg.

Damage to the middle cerebral artery Є Contralateral weakness. • Sensory loss in face, neck and arm and to a lesser degree in the leg. • If damage is in left (dominant) hemisphere, aphasia may occur.

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Effects of anterior circulation abnormalities (cont.) Damage to the ophthalmic artery • Ipsilateral monocular loss of vision. • Homonymous hemianopsia. • Amaurosis fugax.

Aphasias • Broca’s: Motor aphasia - understanding is preserved but speech is grossly

impaired with pauses and inaccuracies and is laborious. • Wernicke’s: Sensory aphasia - loss of ability to comprehend meaning of words

characterized by fluid and spontaneous speech but with incoherent and non­ sensical speech. • Nominal: Difficulty finding correct name for an object (also called anomia). • Global: Grossly nonfluent speech as well as a severe fluent aphasia. • Alogia: Inability to speak because of mental deficiency or an episode of demen­

tia.

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10. Neuroscience

Temporal lobe lesions overview • Psychiatric manifestations include a schizophrenia-like psychosis. Right medial lobe damage is associated with paranoid delusions in Alzheimer's disease. • Dominant lobe lesions can cause deficits in intellectual functioning, communi­ cation difficulties (reading, writing, speech) and less commonly personality changes. • Deeper lesions can cause neurological signs such as contralateral homonymous upper quandrantic field defects and a mild contralateral hemiparesis.

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Temporal lobe lesions overview (cont.) • Memory functions are represented in the hippocampal gyrus. With dominant lobe lesions, verbal memory is affected. In non-dominant lesions memory of music, faces and drawings may be affected. Pathology involving the dominant lobe may therefore present as a semantic impairment with fluent dysphasia and receptive language difficulties. • Prosody is a non-dominant temporal lobe function. This is the meaningful intona­ tion and stressing in language. • Taste and smell are centrally represented in the uncus.

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11. Neuroscience

Temporal lobe General functions • Processing of auditory input. • Visual object recognition and categorization. • Long term storage of sensory input.

Dominant temporal lobe functions • Perception of words. • Process language-related sounds. • Sequential analysis. • Intermediate and long term memory. • Auditory learning. • Retrieval of words. • Complex memories. • Visual and auditory processing.

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Temporal lobe Dominant temporal lobe lesions cause • Decreased verbal memory (words, lists, stories). • Difficulty placing words or pictures into discreet categories. • Difficulty understanding the context of words. • Aggression, internally or externally driven. • Dark or violent thoughts. • Sensitivity to slights. • Paranoia. • Word-finding problems. • Auditory processing problems. • Reading difficulties.

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12. Neuroscience

Temporal lobe Non-dominant temporal lobe functions • Perception of melodies. • Pitch/prosody. • Social cues. • Reading facial expression. • Decoding vocal intonation. • Visual learning.

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Tem poral lobe (cont.) Non-dominant temporal lobe lesions cause • Difficulty interpreting facial expressions. • Difficulty decoding vocal intonation. • Implicated in social skill struggles. • Difficulty processing music (amusia). • Decreased social cues/context. • Poor visual imagery. • Decreased recall of non-verbal items - shapes, faces, tunes.

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13. Neuroscience

Frontal lobe lesions Have effects on Є Mood. • Behaviour. • Temperament. • Abstract thinking and attention span. • Speech. • Motor activities.

Symptoms/signs • Personality changes - disinhibition, apathy, poor motivation, euphoria, face­ tiousness. • Poor judgement, concentration and difficulty planning tasks. • Urinary incontinence may be a feature. • Expressive (Broca's aphasia). • Contralateral spastic paresis, lower than expected verbal fluency.

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Frontal lobe lesions (cont.) Symptoms/signs (cont.) • Grasp reflex may occur. • Mood changes have been classically described as euphoric but there may be emotional blunting. • Primitive reflexes may reappear. • If the lesion is near the motor cortex, or deeper projections, there may be a con­ tralateral spastic paresis. • A dominant lesion involving Broca's area may produce an expressive (non­ fluent) dysphasia. • The personality change may include disinhibition and overfamiliarity. It may include puns (witzelsucht) and errors of judgement. • Other signs of frontal lobe pathology include ipsilateral optic atrophy or anos­ mia. • If lesions are bilateral or in the midline urinary incontinence may occur.

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14. Neuroscience

Tests of frontal lobe function • Stroop test (see card 72) - left dominant lobe lesions affect test the most. • Verbal fluency. • Tower of London test (see card 73). • Wisconsin Card sort. • Cognitive estimates. • Six Elements test - plan and schedule six tasks in 15 minutes. • Multiple Errands task. • Trail Making Test (see cards 71 and 73).

Occipital lobe lesions • May cause disturbances of visual processing. • Complex visual hallucinations may occur with lesions involving the visual associ­ ation area. • There may be polyopia (multiple visual images). There may be visual persevera­ tion (known as palinopia) or distortions of the visual scene (metamorphopsia). • Lesions impinging anteriorly on the parietal or temporal lobe may cause visual disorientation with asimultagnosia (difficulty perceiving the visual scene as a unity). • Prosopagnosia can also occur (difficulty recognizing familiar faces).

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15. Neuroscience

Parietal lobe lesions Parietal lobe lesions are less likely to cause psychiatric disturbances than frontal or temporal lobe lesions.

Dominant lesions cause 1. 2. 3. 4. 5. 6. 7.

Receptive dysphasia. Limb apraxia. Body image disorders (agnosias). Right-left disorientation. Dycalculia. Finger agnosia. Agraphia.

4-7 = the Gerstmann’s syndrome.

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Parietal lobe lesions Non-dominant parietal lobe lesions cause • Visuospatial difficulties with neglect of contralateral space. • Anosognosia (ignoring paralysis). • Hemisomatognosia (part of the body is felt to be absent). • Prosopagnosia (inability to recognize faces) occurs if the occipital lobe is also involved. • Constructional and dressing apraxia.

Either lobe can cause • Topographical disorientation - inability to find one's way around in familiar sur­ roundings. • Difficulties in temporal awareness. • Cortical sensory loss characterized by: astereognosis - ability to recognize objects placed in the hand when the eyes are shut; impaired graphaesthesia difficulty recognizing numbers or letters written on the hand with closed eyes.

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16. Neuroscience

Tourette’s syndrome • Characterized by chronic motor and vocal tics. • M:F - 3:1. • Age of onset: 3-8 years of age, adult onset uncommon. • 70% MZ twin concordance. • Motor tics: Simple - blinking, grimacing, shrugging. Complex - touching, gestur­ ing, hitting, biting. • Echopraxia: - Involuntary repetition of the movements of another person may

occur. • Vocal tics: Simple - barking, grunting, snorting, coughing. Complex -echolalia (repeating other peoples phrases), palilalia (repeating other peoples words), coprolalia (using bad language in a repetitive and involuntary manner), Note

that coprophagia does not occur. • Motor tics usually precede vocal tics. • OCD occurs in 20-60% of individuals. ADHD is also more common than in the general population.

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Tourette’s syndrome (cont.) • Symptoms may be exacerbated by boredom or anxiety. • Tics may be voluntarily suppressed for a short while until the tension b€*comes too great. • Tics disappear when the patient is sleeping. • Tics and OCD symptoms can be lifelong. • Severity of tics in childhood does not affect severity in later life. Many cases improve despite severity of tics. Moderate to severe tics in adolescence may indicate more severe tics in adulthood also. • Tics can be associated with streptococcal infections. • Caudate atrophy occurs in some cases. • Tics can occur as a result of stoke, head injury or encephalitis. • Treatment: Antipsychotics - haloperidol is the most effective of available treat­

ments. Alternatives include pimozide/risperidone/sulpiride/clonidine - reduces severity and frequency of tics. Baclofen may be beneficial in reducing overall impairment.

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17. Neuroscience

EEG EEG ABNORMALITIES • The EEG records the electrical activity of the brain. It is used mainly in psychiatry to look for the presence of an epileptic focus such as frontal or temporal lobe seizures that may produce psychiatric symptoms. • The normal EEG consists of a number of frequencies - delta, theta, alpha and beta waves. • Normal activity consists of theta, alpha or beta activity. Delta activity should nor­ mally only occur while asleep, if it occurs while awake it may represent a struc­ tural brain lesion.

Mnemonic - D TAB (delta waves are the slowest, beta waves are the fastest) Delta - below 4 Hz. Theta - 4-8 Hz. A lpha -8 -1 3 Hz. Beta - above 13 Hz.

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EEG (coni.) EEG patterns associated with specific disorders • Epilepsy: Absence seizures - 3-4 Hz spike and wave pattern. Є Generalized seizures: Bursts of spikes and waves (interictal). Fast activity during

ictal period followed by generalized slowing (delta activity) postictally. Non-specific abnormalities (not diagnostic), commonly decreased alpha activity (fast wave), increased delta and theta activity (slow wave). • Creutzfeldt-Jacob disease: Generalized bi- or triphasic periodic sharp wave complexes with a frequency of about 1-2 per second are characteristic in the majority of cases where the clinical picture also indicates the disorder, although the changes may not appear until late in the clinical course. These changes can occur in other conditions (eg Alzheimer's, Lewy body dementia) so are not 100% diagnostic of CJD. • New variant Creutzfeldt-Jacob disease: Non-specific changes unlike in CJD. • Schizophrenia:

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18. Neuroscience

Multiple sclerosis • Characterized by sudden transient motor and sensory disturbances, impaired vision and diffuse neurological signs with a relapsing, remitting course. • Usual onset in early adulthood, a little more common in females than in males. • Depression occurs in around 50% of cases, or anxiety, elation or overt mania in about 10% of cases. Apathy is also common (not as common as depression, but more common than euphoria). Cognitive impairment occurs in about 50% of sufferers.

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Multiple sclerosis (cont.) • Symptoms may include slurred speech and incontinence, retrobulbar neuritis, cerebellar signs, eg diplopia, CNS signs including ataxia, nausea and vomiting or vertigo. Sensory deficits may occur such as quadriplegia or sexual dysfunction. Belle indifference (emotional incongruity) can occur. • CSF may show increased gamma globulin. CT may reveal degenerative patch­ es in the brain and spinal cord. Huntington's Disease - see card 144.

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19. Neuroscience

W ilson’s disease • Rare autosomal recessive disorder of copper metabolism (chromosome 13). • Usually presents in adolescence or early adulthood. • Characterized by choreoathetoid movements, gait disturbance, clumsiness and rigidity. • May manifest psychiatric symptoms including mood disturbance, delusions or hallucinations. • Differential diagnosis: Extrapyramidal features, schizophrenia or mood disorder. • Characterized by copper deposition in liver, brain and eyes (leading to devel­ opment of Kayser Fleischer rings).

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Neurosyphilis • Characterized by malaise, skin rashes and ulcers. In later stages - skin lesions/arthritis/leukoplakia/respiratory or cardiovascular distress. • Symptoms include tabes dorsalis, facial muscle atrophy, grandiose delusions in 30% of end stage disease cases, Argyle Robertson pupils (small, irregular and unreactive to light but react to accommodation). Tremor, myoclonic jerks, dysarthria and seizures occur in about 50% of cases. • CSF serology/VDRL blood test (positive after 1 month but may be negative in some cases). FTA (fluorescent treponemal antibody) test highly sensitive. • Presents with dementia in 20-40% of cases. • Depression occurs in 20-25% of cases. • Hypomania occurs in 10% of cases. • May present with personality changes, psychosis or confusion/irritability.

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20. Neuroscience

Parkinson’s disease • Usual onset is around 60 years of age. • Second most common neurodegenerative disease and most common cause of movement disorder. • Basal ganglia affected with loss of neurones in nigrostriatal pathway. • Three main features: (i) bradykinesia; (ii) tremor; (iii) rigidity. • Other features: shuffling (festinant) gait, mask facies, tendency to fall, micro-

graphia, positive glabellar tap test, hypersalivation, difficulty maintaining bal­ ance on turning. • Aetiology: possible mutation in a synuclein gene on chromosome 4; iatrogenic

causes - antipsychotic medication; Wilson's disease; encephalitis lethargica; progressive supranuclear palsy; vascular disease.

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Parkinson’s disease (cont.) Psychiatric manifestations • 50% suffer mild to moderate depression. • Severity of disease is associated with severity of depression. • Panic disorder and generalized anxiety disorder are common. • Apathy is a common feature and occurs in as many as 10% of cases. • Psychosis occurs in 40% of Parkinson's disease patients who also have* dementia. • May present with delusions (usually persecutory in nature) or visual hallucina­ tions. • Medication may be a cause of symptoms, eg bromocriptine, selegiline. • Dementia occurs commonly in the late stages and affects executive function followed by visuospatial function and then memory and language are impaired. • Pathological findings similar to those seen in the brains of Alzheimer's disease patients are sometimes seen in Parkinson's disease.

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21. Neurotic disorders

Anxiety disorders Symptoms of anxiety Psychological Respiratory Gastrointestinal Cardiovascular

Restlessness, irritability, poor concentration, fear of death, sensitivity to noise Dyspnoea, tachypnoea, hyperventilation Dry mouth, epigastric discomfort, nausea, vomiting, diar­ rhoea Chest pain, palpitations, flushing

Neurological

Dizziness, vertigo, numbness, tingling in extremities, headache, tinnitus, blurred vision, tremor, insomnia and nightmares

Genitourinary

Frequent micturation, erectile dysfunction, amenorrhoea, loss of libido Muscular aches

Musculoskeletal Psychiatric

Depressive symptoms, obsessional symptoms, depersonal­ ization

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Anxiety d iso rd ers (cont.)

Generalized anxiety disorder (GAD) • Anxiety is not qualitatively different from normal anxiety. • DSMIV and ICD 10 require 6 months of symptoms. In practice symptoms should be present on most days for at least several weeks and usually several months. • In ICD 10 general anxiety disorder cannot be diagnosed with phobias, OCD or panic disorder. In DSMIV they may be diagnosed together. • Important medical causes include thyrotoxicosis, phaeochromocytoma and hypoglycaemia. • Genetic aetiology includes a higher concordance between monozygotic twins. GAD occurs in 20% of first degree relatives of patients with GAD compared to 3.5% of the relatives of controls. • GAD occurs in anxious-avoidant personality disorder and other personality dis­ orders. • Buspirone and antidepressants are preferred pharmacological treatments. Benzodiazepines should not be prescribed for more than 3 weeks owing to risks of dependency.

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22. Neurotic disorders

Phobic anxiety disorders - specific phobias Agoraphobia • Fears occur when leaving home especially when in crowds or on public trans­ port. • It is more common in women and avoidance is a prominent feature. • The age of onset is later than specific/simple phobias (childhood) and social phobia. Most cases occur in early or mid twenties. There is another smaller peak in the mid thirties. The mean age of onset is 30. • The onset of agoraphobia is often but not always associated with panic attacks. • In DSM IV the criteria for panic disorder cannot be met for a diagnosis of agora­ phobia, ie more than four panic attacks in 4 weeks. In ICD10 agoraphobia is coded for with and without panic attacks. • Lifetime prevalence: agoraphobia (7%) < specific phobias (11%) < social phobia ( 1 3 % ).

• Cognitive behavioural understanding of the formation of agoraphobia includes reinforcement of an avoidant response and sensitization to physical symptoms

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Phobie anxiety d isorders - specific phobias (cont.) General facts about specific phobias • Most originate in childhood and anticipatory anxiety is common. The preva­ lence is three times greater in women. Phobias may have a modest but not a strong genetic component eg phobia of heights. • Locus of control theories are present for depression and not phobias. Imprinting is not a significant theory for single object phobia. Preparedness can help to explain the development of phobias. • Psychoanalytical theories state that phobias are related to internal anxieties which have been repressed and displaced.

44

23. Neurotic disorders

Social phobia • Anxiety occurs in situations where a person could be criticized. • Avoidance is common. • Alcohol misuse is more common in this phobia. • Onset usually between 17 and 30. • Social phobia is commonly manifested in small group settings.

Other general facts about social phobia • A behavioural assessment of phobia includes an understanding of incubation and habituation. Є Animal phobias do not occur in social phobias more than can be accounted for by chance.

45

Panic disord ers • Anxiety builds up quickly with a severe response with fear of a catastrophic outcome. • There may be anticipatory anxiety. • There must be three panic attacks within a З-week period: (i) at times where there is no objective danger; (ii) not being confined to known or predictable situations; (iii) there should be comparative freedom from anxiety symptoms between attacks, anticipatory anxiety may occur. • Hyperventilation can produce many symptoms. • It is two to three times as common in women compared to men. • Panic disorder is familial. • Chemical agents such as sodium lactate can induce panic attacks more in people with panic disorder than in healthy people. • Clomipramine is an effective agent in treating panic attacks. SSRIs may be used in practice because of their better side-effect profile. Benzodiazepines are sometimes required in high doses to control panic attacks. • Peak incidence of panic disorders is in the thirties and forties.

Other general facts about panic disorders • Rotational vertigo is not present in anxiety disorders. • The months backwards test is normal in people with anxiety, it is a test of concentra­ tion which may be abnormal in depression.

46

24. Neurotic disorders

Obsessive-compulsive disorder • In OCD, compulsive rituals usually follow intrusive thoughts. • Symptoms must be present on most days for at least two successive weeks, and be the source of distress or interference with activities. • Thoughts are ego-dystonic. • Compulsive rituals do not always relieve anxiety. • There is a higher comorbidity with anxiety, depression and schizophrenia. • Depersonalization may occur but not delusional beliefs.

47

Obsessive-com pulsive disorder (cont.) • Craving is not associated with OCD. • The lifetime prevalence is 2-3%. • The mean age of onset is 20. • Studies have shown a slightly higher prevalence in women (1.2:1). • In psychoanalytic theory, OCD may be seen as a regression to the anal stage of development. • Clomipramine is effective, SSRIs are useful but noradrenaline deficiencies are not thought to be important in OCD. • SSRI doses are higher than for depression and this is usually combined with CBT. • Dynamic psychotherapy is not helpful. • Neurosurgery is helpful in severe cases.

48

25. Neurotic disorders

Eating disorders Anorexia nervosa • • • • •

Deliberate weight loss induced or sustained by the patient. Body weight 15% below expected or BMI 17.5 or less. Fattening foods are avoided, laxatives and diuretics as well as insulin may be abused. Self-induced vomiting is compatible with the diagnosis. Endocrine disorder including amenorrhoea in women (may be masked by the oral contraceptive pill) and in men there may be a loss of sexual interest and potency. • Seen more in monozygotic than dizygotic twins. • Episodes of hyperphagia may occur during the illness. • Concern about body image is not useful in distinguishing anorexia from depression.

Risk factors • Cluster C personalities and autistic spectrum disorders are more common in ano­ rexics. • Life events can precipitate illness. • It is more common in enmeshed, overinvolved families. • Premature birth and low birth weight are risk factors. • It is overrepresented in higher social classes I and II.

49

Eating d isord ers (cont.)

Anorexia nervosa (cont.) Physical changes • Cardiovascular: bradycardia, Hypertension, QT prolongation, arrhythmias. • Gastrointestinal: swollen salivary glands, dental caries, erosions of enamel due to vomiting, delayed gastric emptying, constipation and pancreatitis. • Blood tests: dehydration (raised urea), hypoglycaemia, hypercholesterolaemia, raised amylase and LFTs, reduced potassium, magnesium, calcium and phosphate. Normochromic, monocytic or iron-deficient anaemia, leucopenia. • Endocrine: increased GH and cortisol, reduced oestrogen, progesterone and T3. • Renal: diabetes insipidus, renal failure. • Muskuloskeletal: osteoporosis. • Miscellaneous: lanugo hair growth, infections, hypothermia.

Bulimia nervosa • May have normal weight. • Physical changes are the same as anorexia but less severe. • Russell's sign may be present - calluses on dorsal surfaces of hands owing to induced vom­ iting.

Hyperphagia • Present in both Prader-Willi and Klein-Levin syndromes.

50

26. Neurotic disorders

Personality disorders (card 1 of 2) • Result in ingrained and enduring behaviour patterns which are extreme devia­ tions from the normal individual's behaviour in the person's culture. • Appear in childhood or adolescence. • Cyclothymia and schizotypal disorder are not personality disorders in the ICD10. • Personality disorders feature on axis 2 of DSM IV.

Three clusters described in DSMIV • Cluster A - odd/eccentric: paranoid, schizoid, schizotypal. • Cluster В - dramatic/emotional: antisocial, borderline, histrionic, narcissistic. • Cluster C - anxious/avoidant: dependent, avoidant, obsessive-compulsive.

51

Personality d isorders (card 1 of 2) (cont.)

General facts about personality disorders • There is poor inter-rater reliability in diagnosing individual personality disorder. • Personality disorders tend to become less prominent in later life. • Rates of marriage and having offspring are greatly reduced. • Prevalence in the community is approximately 3%. • Personality disorders are most commonly found in urban males.

52

27. Neurotic disorders

Personality disorders (card 2 of 2) • Paranoid personality disorder: Others' actions are interpreted as being deliber­

ately demeaning or threatening. There is an excessive sensitivity to setbacks and grudges are often held. Thoughts that conspiracies are occurring may be held. • Schizoid personality disorder: There is a preference for solitary activities and

there is emotional coldness. There is preoccupation with fantasies and intro­ spection. Few activities give pleasure to the person. • Dissocial personality disorder: Irresponsible and antisocial behaviour occurs.

There is an unconcern for others' feelings. Relationships cannot be maintained. There is an incapacity to feel guilt.

53

Personality d isorders (card 2 of 2) (cont.) • Emotionally unstable personality disorder: (i) Impulsive - There is emotional insta­

bility, a lack of impulse control and poor tolerance for criticism where violence or threatening behaviour occurs, (ii) Borderline - There is emotional instability, a chronic sense of emptiness, a disturbed self-image, relationship difficulties and suicidal or self-harm tendencies. • Histrionic personality disorder: Excessive emotionality and attention seeking occurs. There is theatricality and a suggestible and shallow affect. Physical appearance is very important. Excitement and reassurance is sought. • Anankastic personality disorder: Perfection and inflexibility are the order of the

day. Decision-making is avoided. There are excessive feelings of self-doubt as well as the intrusion of unwelcome thoughts or impulses • Dependent personality disorder: Others make the person's important decisions. Being alone leads to feelings of helplessness. There is unwillingness to make even reasonable demands. There is a preoccupation with fears of being abandoned by those one is dependent on.

54

28. Neurotic disorders

Sleep disorders Narcolepsy • Disorder consists of irresistible and repeated bouts of sleep during the daytime. • Onset aged 10-20 and rare after middle age. • Cataplexy (loss of muscle tone) occurs in most cases but not catalepsy. • Sleep paralysis and hypnagogic hallucinations only occur in 25% of cases. • Family history of narcolepsy seen in one-third of patients. • Strong emotions precipitate cataplexy but not narcolepsy. • Schizophrenia-like disorders are more common in these patients. • Associated with HLA DR2. • EEG shows a rapid lead into REM sleep. • Stimulants have an effect on narcolepsy but not on cataplexy. • Antidepressants may reduce the frequency of cataplexy.

55

Sleep d isord ers (cont.) Klein-Levin syndrom e • Somnolence and increased appetite can last for days or weeks. • Long periods of normality between periods of illness. • For further details see card 149.

Parasom nias • Nightmares: This is awakening from REM sleep with detailed dream recall.

Common in children aged around 5. Causes include anxiety, PTSD, fever and medications. • Night terrors: Less common than nightmares and occur in children. They can continue into adult life. The child wakes up a few hours after sleeping and may be terrified and confused. Occurs in stage 3-4 of sleep. Benzodiazepines and imipramine may be used in the short term. They do not occur in PTSD or disso­ ciative disorders as is often asked in exams. • Somnambulism: There is walking or sitting up during non-REM sleep and occurs in childhood but may extend into adulthood. Sleepwalkers may injure themselves.

56

29. Neurotic disorders

Post-traumatic stress disorder • Definition: Delayed or protracted response to a stressful event or situation of a

threatening or catastrophic nature which would cause distress in most people. • Symptoms: Usually arise within 6 months of the traumatic event. • Features: Hypervigilance; startle to loud noises; flashbacks and a sense of numb­

ness; nightmares occur but not night terrors; emotional blunting may occur; poor concentration; anger; more common in women; lability of mood is not a feature. • Predispositing factors: Previous history of neurotic illness or depression may lower

the threshold for development of PTSD. Anankastic, dependent and antisocial personality disorders may also predispose to PTSD. • Treatment: Single debriefing sessions are not thought to be useful. Eye movement

desensitization (EMDS) is increasingly used. SSRIs and CBT are recommended. Tricyclic antidepressants may reduce the intrusive anxiety causing thoughts.

57

Adjustment disorders • Includes psychological change to new circumstances. • Interferes with social functioning. • May manifest as depressed mood or anxiety. • Rarely there are outbursts of violence. • A child may regress to bed-wetting or thumb sucking. • Associated with conduct disorders in adolescents. • Onset is usually within 1 month of a stressful event. • Symptoms do not usually last more than 6 months. • The reaction is in proportion to the stressful situation.

58

30. Neurotic disorders

Somatoform disorders Somatization disorder • Multiple, frequently changing physical symptoms which may have been present for years. • More common in females usually in early adult life • At least 2 years of multiple and variable symptoms with no adequate cause found. • Refusal to accept advice or reassurance from doctors • Social and family impairment due to symptoms. • Briquets is a type of somatization disorder occurring before 30. It is more common in women. • Patients tend to ask for treatments to remove the symptoms. • There is excessive use of medications.

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Som atoform d isord ers (cont.)

Hypochondriasis • Persistent preoccupation with having a disease (not symptoms as in somatization dis­ order). • Symptoms are present for at least 6 months. • Patients demand extensive and repeated investigations. • Patients fear medications and their side-effects. • There is no familial predisposition to hypochondriasis.

Body dysmorphic disorder Є Patient convinced part of their body is too large, too small or misshapen. To others the body part appears normal or there is a trivial abnormality. • Antidepressants may be of use. Surgery is usually contraindicated for the disorder. • An increased suicide risk in this patient group.

Factitious disorder • Patient creates symptoms to enter a sick role. This may be an unconscious process. Munchausen's is a severe form of factitious disorder. • In Munchausen's peregrination may occur where the patient travels to another hos­ pital presenting with the same symptoms.

60

31. Neurotic disorders

Dissociative (conversion) disorders • A disruption of the normal integration between the past, awareness of identity and immediate sensations and control of bodily movements. • There may be primary and secondary gain. Primary gain is the relief gained from converting distress into physical symptoms. Secondary gain is when the disorder gives an advantage to the patient, usually socially, eg the patient may get time off work or not have to sit an exam • There is usually a trigger to the disorder but this may not be identified by the patient. • Dissociative amnesia: See card 140 • Dissociative fugue: See card 140.

61

Dissociative (conversion) disorders (cont.) • Multiple personality disorder (Dissociative Identity Disorder in ICD 10): There are

usually two personalities or two patterns of behaviour. There are sudden alterna­ tions where the former personality is forgotten. There may rarely be more than two personalities. The patient may forget personal information and there are no organic explanations to the disorder. • Ganser’s syndrome: This was first described in prisoners. Approximate answers are given to tests such as simple arithmetic. There is clouding of consciousness and there may be psychogenic physical symptoms as well as hallucinations. • Depersonalization and derealization disorder: Patients describe feelings of not being real. External objects may appear as if they are automated. It is an unpleasant experience which is usually associated with other psychiatric disor­ ders but is rarely present on its own. Insight is retained and there is a change in the passage of time. It is more common in women and symptoms often appear suddenly. Depersonalization as a phenomenon can be experienced in normal people. • Further details: see card 162.

62

32. Psychotic disorders

Schizophrenia History • Dementia praecox coined by Morel in 1856. • Catatonia described by Kahlbaum in 1868. • Kraeplin distinguished dementia praecox from affective psychosis in 1896 and also further developed catatonic, hebephrenic and paranoid subtypes. • Bleuler introduced concept of schizophrenias in 1911. The four primary symptoms which he felt were fundamental for the diagnosis are (4As): loosened Associations, Affective incongruity, Ambivalence, Autism. • Secondary symptoms were not felt to be key to the diagnosis and included hal­ lucinations and delusions. • Kurt Schneider stated in 1959 that in the absence of organic brain disease the first-rank symptoms were indicative of schizophrenia.

63

Schizophrenia (cont.)

First-rank symptoms • Auditory hallucinations: Hearing thoughts repeated out loud In the third person As a running commentary Made Will Made Affect (V ) (vii) Thought Insertion Made Volitions ( V i) (ix) Thought Withdrawal (viii) Thought Broadcast (xi) Somatic Passivity. Delusional Perception (X) NB There is high inter-rater reliability for first-rank symptoms. (i) (ii) (iii) (iv)

Second-rank symptoms • Perplexity. • Emotional blunting. • Other hallucinations and delusions.

64

33. Psychotic disorders

Schizophrenia Operational criteria tor schizophrenia Є ICD10: At least one of Schneider's first-rank symptoms is required. • Other symptoms used to make the diagnosis, of which two are required:

Persistent hallucinations in any modality, thought blocking, thought disorder, catatonic behaviour, negative symptoms or loss of social function. • One month of symptoms is required and these must be in clear consciousness. It must not be diagnosed in the presence of overt brain disease and epilepsy and drug intoxication must be excluded. Affective symptoms should not pre­ dominate.

65

Schizophrenia (cont.)

Operational criteria for schizophrenia • DSMIV: Requires a total of at least 6 months in which 1 month there are active symptoms. There is a criteria-based social and occupational dysfunction during this time. • There must be two characteristic symptoms from delusions, hallucinations, disor­ ganized speech, disorganized catatonic behaviour or negative symptoms. Only one symptom is required if there are bizarre delusions, auditory hallucinations or voice in a running commentary.

66

34. Psychotic disorders

Schizophrenia Subtypes according to ICD10 • Diagnosis according to ICD10 is reliable (a common question!).

Paranoid schizophrenia • This is the commonest type and hallucinations and/or delusions are prominent. • Disturbances of affect speech, volition and catatonic features are not promi­ nent. • Hallucinations occur in any modality. • Common delusions include delusions of control, passivity and persecutory delu­ sions. • Primary delusions are more common in acute schizophrenia than chronic schiz­ ophrenia. • Pareidolia is not a common feature in schizophrenia. • Visual hallucinations are seen in only 10-20% of schizophrenic patients.

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Schizophrenia (cont.)

Hebephrenic schizophrenia • This has an earlier age of onset between 15 and 25 years. • Affective changes are prominent and not hallucinations and delusions. • Negative symptoms are common including flattening of affect and loss of volition. • Delusions are often described as fleeting and fragmentary. • The premorbid personality is often shy and solitary. • Mannerisms and irresponsible behaviour are common. • Catatonic features are very rare in this form of schizophrenia.

Simple schizophrenia • There is an insidious but progressive development of oddities of conduct, inabil­ ity to meet the demands of society and decline in total performance. • Delusions and hallucinations are not evident and the disorder is less obviously psychotic than other subtypes. • Negative symptoms develop without obvious psychotic features. • A period of a year is required to make a diagnosis.

35. Psychotic Disorders

Schizophrenia Catatonic schizophrenia • Psychomotor disturbances are prominent; there may be extremes such as hyper­ kinesis and stupor or automatic obedience and negativism. • There may be a plastic resistance to movements of the patient's body (waxy flexibility)

• Attitudes and postures may be maintained for a long time without much dis­ comfort - catalepsy • Catatonic schizophrenia is seen less now in developed countries than in the developing world.

Residual or chronic schizophrenia Є A chronic stage in a schizophrenic disorder where earlier positive symptoms and a previous psychotic episode meeting the criteria for schizophrenia is replaced by long term though not irreversible negative symptoms. Є There must be an absence of organic pathology and chronic depression and negative symptoms must last for a year.

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Schizophrenia (cont.)

Undifferentiated schizophrenia • The conditions are met for making a diagnosis of schizophrenia but not con­ forming to the above subtypes.

Postschizophrenic depression • A depressive episode occurring after schizophrenic illness. • Some schizophrenic symptoms may be present but no longer dominate the picture. • The schizophrenic illness should have been within the last 12 months. • Depressive symptoms have been present for more than 2 weeks and fulfil crite­ ria for a depressive episode. • There is an increased suicide risk.

70

36. Psychotic disorders

Schizophrenia Epidemiology of schizophrenia • Incidence = 15-30 per 100 000 per year. • Prevalence is 0.5-1% (low incidence but high prevalence). • Higher rates reported in communities in Sweden and Finland as well as AfroCaribbean population in the UK. • Age of onset: 15 and 45 years (approximately 5 years earlier in men). • Prevalence equal in men and women. • More common in social classes IV and V. • Mortality twofold compared to general population.

Aetiology G enetics

Є Monozygotic twin concordance in schizophrenia has aetiological significance. • The child of one schizophrenic parent has about a 13% lifetime risk of develop­ ing schizophrenia. If both parents are affected there is a 46% lifetime risk. • Siblings of an affected individual have a 10% risk and if one parent is affected additionally the sibling has a 17% risk. • Adoption and linkage studies have suggested likely polygenic and multifactori­ al inheritance with environment playing a role.

71

Schizophrenia (cont.)

Aetiology Environm ent • Late winter and early spring births are marginally more likely to develop schizophre­ nia. This may be due to increased exposure to viral infections. Ф Rates are higher in urban areas. • Families with high levels of expressed emotions can provoke relapse of schizophrenic illness in family members. • Double bind is not of aetiological significance in schizophrenia.

Pe rso na lity • Schizotypal personality disorder is aetiologically linked to schizophrenia.

The brain in sc hizop hre nia • On average, the lateral ventricles are larger in people with schizophrenia. MRI has shown reduction in cortical grey matter. The frontal lobe and left temporal lobes are reduced in size. The parahippocampal gyrus is reduced in size and this is also found in postmortem studies. The hippocampus and amygdala are reduced in size particular­ ly on the left. There may be widening of sulci and thickening of the corpus callosum. • There is hypofontality in functional brain imaging and a decrease in blood flow in frontal and prefrontal cortex demonstrated with tests such as the Wisconsin Card Sorting Test. None of these changes are diagnostic.

72

37. Psychotic disorders

Schizophrenia - aetiology Premorbid factors • There is a lower premorbid IQ and lower educational test scores in childhood. • Children who go on to develop schizophrenia have delayed motor develop­ mental milestones and have a preference for solitary play at age 4. • Children may also show greater hostility towards adults and may have speech and reading difficulties. • Other risk factors include a previous diagnosis of depression, anxiety, ADHD or conduct disorder.

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Neurotransm itters in schizophrenia • Dopamine: Hypothesis states there is excess dopaminergic activity in the

mesolimbic-mesocortical pathways. All effective antipsychotics block D2 recep­ tors. Other evidence: amphetamines (dopamine agonists) can cause an acute psychosis; only the cis isomer of flupenthixol which is a dopamine antagonist has antipsychotic properties; postmortem studies reveal increased D2 receptors in the basal ganglia and limbic system. PET studies have also suggested increased D2 receptors in striatum. • Serotonin: LSD, a hallucinogen, acts at serotonin receptors. Risperidone and clozapine are 5HT2 receptor antagonists. Ritanserin, a selective 5HT2 antagonist, reduces negative symptoms of schizophrenia when given adjunctively with antipsychotics. • Glutamate: Glutamate is the major excitatory neurotransmitter in the cortex and has extensive interactions with dopamine pathways. Decreased glutamatergic function at NMDA receptors can cause psychotic symptoms as produced by NMDA receptor antagonists (PCP and ketamine).

74

38. Psychotic disorders

Differential diagnoses for psychotic symptoms • Psychiatric: bipolar 1 disorder, brief psychotic disorder, major depressive disor­

ders with psychosis, schizoaffective disorder, personality disorders, adjustment disorders, delusional disorder, dissociative identity disorder, PTSD. • Organic: acute intermittent porphyria, adrenoleukodystrophy, early Alzheimer's

disease, congenital adrenal hyperplasia and Cushing's syndrome, epilepsy, Freidreich's ataxia, Huntington's disease, CVA, metachromic leukodystrophy, multiple sclerosis, narcolepsy, subarachnoid haemorrhage and subdural haematoma, SLE, trauma, tumours of the brain, Wilson's disease.

75

Differential diagnoses for psychotic symptoms (cont.) • Infections include: bacterial infections, CJD, HIV, herpes simplex virus and tuber­

culous meningitis. • Nutritional deficiencies include: folic acid deficiency, niacin deficiency, vitamin

B12 deficiency. • Heavy metals poisoning: include lead and mercury. • Medications: several medications can cause hallucinations, delusions and

thought disorder. However symptoms caused by medications tend to be more consistent with depression, dementia or delirium. Symptoms are usually reversed when causative medication is discontinued. • Illicit substance abuse: Drugs which can produce psychosis include alcohol, amphetamines, cocaine, LSD, Ecstasy, opiates and PCP. Cannabis use tends to produce perceptual disturbances rather than true psychosis. However cannabis has a causal role in schizophrenia both in onset and precipitating the illness.

76

39. Psychotic disorders Neurophysiological changes in schizophrenia • EEG changes: Include decreased alpha wave activity, increased theta wave

activity, epileptiform activity with increased fast spike activity following stimula­ tion procedure and increased paroxysmal activity. • Reduced amplitude of the P300 response: This is an evoked potential which

occurs 300 ms after a subject identifies a target stimulus embedded in a series of irrelevant stimuli. The P300 response is a measure of auditory information pro­ cessing. Abnormalities of the P50 potential have also been noted. • Abnormal eye tracking in 50-80% of patients and their first-degree relatives: May

indicate dysfunction in the neural network involving the temporal areas of the extrastriate cortex. However a common exam question is whether visual scan­ ning in children predicts future schizophrenia and this is false.

77

Neurophysiological changes in schizophrenia (cont.) • Impaired skin-conductance orienting response to novel stimuli: About 50% of

people with a schizophrenia fail to produce the response and the other 50% fail to habituate. • IQ: Patients with schizophrenia may have a lower than average IQ before the ill­ ness and there is a further decline within the first few years of illness. 50% may have a normal IQ prior to development of schizophrenia. • Poor functioning on tests of: Memory; language; executive functions (set shifting

and forward planning). Visuospatial processing is spared. Neuropsychological impairments tend to correlate with negative symptoms.

78

40. Psychotic disorders

Schizophrenia Poor prognostic factors in schizophrenia • • • • • • • • • •

Low IQ. Male sex. Single status. History of obstetric complications. Early age of onset. Insidious onset. Family history of schizophrenia. Negative symptoms. History of substance abuse. General prognosis: Approximately a third recover a third have relapses and remissions and a third have a chronic deteriorating course.

Predictors of relapse of schizophrenia • • • •

Stressful life events. High expressed emotion in the family. Illicit drug use - regular cannabis use is a risk factor for schizophrenia. Poor compliance with medications.

NB Tangentiality and formal thought disorder are not predictors of relapse.

79

Schizophrenia (coni.) Schizophrenia in learning disability • Schizophrenia is seen more in learning disability compared to the general population. • Delusions are not usually elaborate and the patient may exhibit unpredictable and aggressive behaviour instead. Catatonic features are more common in this popula­ tion.

Schizophrenia in later life • Late-onset schizophrenia is much more common in women and occurs from age of 40 to 60. Formal thought disorder and negative symptoms are less common than the early onset group. • Very late onset schizophrenia or 'paraphrenia' starts after age 60. It is associated with visual impairment and conductive deafness. Most common feature is persecutory delusions. Auditory, tactile and olfactory hallucinations are common but not visual hallucinations. Negative symptoms are extremely rare. The risk of schizophrenia to first-degree relatives is 3%, which is halfway between earlier onset schizophrenia and the general population.

Postschizophrenic depression • Described under schizophrenia in ICD10.

80

41. Psychotic disorders

Other psychotic disorders Schizoaffective disorder • Term introduced by Kasanin (1933). • Patients equally share schizophrenic and affective features simultaneously with­ in the same episode of illness. • Symptoms are usually within a few days of each other. The criteria for schizo­ phrenia or a depressive or manic episode are not met. • A depressive type and a manic type; the depressive subtype is said to have a worse prognosis. • Long term outcome is between that of schizophrenia and affective disorders.

Schizotypal disorder • Classified with schizophrenia, not personality disorders, in the ICD10 (DSM IV clas­ sifies it under personality disorders). Є Not a form of schizophrenia but odd, eccentric beliefs and anomalies of thought and affect resembling schizophrenia. However schizophrenic symptoms such as hallucinations or delusions are uncommon and, if occur, are not of same quality as in schizophrenia. • Condition may evolve into overt schizophrenia. For a full description see card 167.

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Other psychotic disorders (cont.) Delusional disorders • • • • •

Single or set of related delusions which can be persistent or lifelong. Often very difficult to treat. No schizophrenic symptoms such as delusions of control or hallucinations. Delusions must be present for 3 months and be should be personal rather than subcultural. Specific delusions (covered also in psychopathology section).

Pathological jealousy • Person holds the belief that his/her sexual partner has been unfaithful. Person may go to great lengths including stalking and checking the partner's underwear. Couple may need to separate. • Associated with drug and alcohol abuse, paranoid schizophrenia, depression, as well as organic brain disorders.

Erotomania • • • •

82

Person holds a delusional belief that someone of a higher social status is in love with them. More common in women. Eventually rejections may turn into bitterness or animosity. Erotomania is not a feature of Cotard's syndrome or OCD and it is not a misidentification syndrome (these are common exam questions).

42. Affective disorders

Depression Depressive illness Є The minimum duration of symptoms is 2 weeks.

• Depression is more common in women at all age groups. • Using DSMIV criteria it is twice as common in women. • Depression affects the perceived passing of time. • Mild or moderate depression can have additional somatic features; only severe depression can have psychotic features. • In severe depression diurnal variation in mood does not occur, instead there is a pervasive low mood. • Feelings of guilt occur in depression and this differentiates from anxiety disorders.

83

Depression (cont.)

Depression and sleep • Early morning wakening helps to distinguish between anorexia and depression. • There is reduced REM latency, ie time to reach REM stage. • There is increased REM density during REM sleep. • There is a reduced length of stage 4 and slow wave sleep.

84

43. Affective disorders

Organic causes for depression Neurological

CVA, head injury (mild depression), multiple sclerosis, Parkinson's disease, brain tumours (meningiomas), epilepsy

Metabolic

Hypercalcaemia, hypomagnesaemia, iron-deficiency anaemia, B6, B12 and folate deficiencies, polycythaemia Hepatitis, infectious mononucleosis, syphilis, AIDS, encepha­ litis, CJD

Infectious Endocrine

Hypothyroidism, hyperparathyroidism, Cushing's disease, Addison's disease, hypoglycaemia, hypopituitarism

85

Organic causes for depression (cont.) Neoplasms Other causes Drugs causing depression Cardiovascular Endocrine Neurological Miscellaneous Substances of abuse

86

Pancreatic cancer, carcinoid, oat cell carcinoma Myocardial infarction and cerebral ischaemia, SLE, rheumatoid arthritis Reserpine, alpha-methyldopa, beta-blockers, diuretics, clonidine, digoxin, nifedipine Corticosteroids L-Dopa, bromocriptine Antimalarials (chloroquine, mefloquine), penta­ zocine, indometacin, sulfonamides Alcohol Once withdrawn - cocaine, amphetamines, hero­ in and benzodiazepines

44. Affective disorders

Beck’s cognitive model of depression • Beck (1976) proposed that automatic thoughts revealed negative views about the self, the world and the future (a negative cognitive triad).

• The automatic thoughts are fuelled by the cognitive distortions (described on card 161). • The rules develop from 'schema' laid down in earlier life. • See card 161 for a description of cognitive distortions as described by Beck.

87

Beck’s cognitive model of depression (cont.) • Sociotropic and autonomous personality traits can predispose people to depres­ sion. • Sociotropic personality traits: These individuals depend upon others for approval

and develop close dependent relationships. They are sensitive to rejection or loss of a relationship. • Autonomous personality traits: These individuals find success in their own initiative

and achievements. They react badly to setbacks which involve progress they have made, eg in their career.

88

45. Affective disorders

Depression Epidemiology of depression Є Average age of onset 27.

• Older people more likely to commit suicide although younger men are increas­ ingly seen to be at risk. • Depressed men are more likely to commit suicide than depressed women. • It is three times higher in those divorced. • Marriage is protective. • Associated with the lower social class, urban areas and unemployment.

Vulnerability factors for depression • Lack of a confiding relationship. Є Unemployment. • Three or more children under the age of 14. • Loss of mother before age 11.

89

Depression (cont.)

Genetics • There is α 1.2- to 2-fold increase in monozygotic compared to dizygotic twins. • There is a stronger genetic component with more severe depression.

Life events Є Life events can trigger depressive episodes. • Humiliation and entrapment have more potential to create depression than loss.

Disruption to the normal circadian rhythm • Sleep changes owing to shift work or long haul flights can precipitate affective disorder especially bipolar affective disorder. • Flying from East to West predisposes more to a depressive episode, while travel­ ling from West to East may precipitate hypomania.

90

46. Affective disorders

Physiological changes in depression Endocrine Thyroid • In a third of patients there is a reduced TSH response to TRH. • There is an increased or normal TRH. • There is a normal or decreased TSH. • There may be increased thyroid autoantibodies.

Hypothalamus, pituitary, adrenal • There is a consistently found raised cortisol secretion. • There is an approximately 60% increase in glucocorticoid secretion. • There is a reduced ACTH response to CRH. • There is non-suppression of dexamethasone.

91

Physiological changes in depression Monoamine theory of depression • Three neurotransmitters have been implicated - serotonin, noradrenaline and dopamine. • Agents that deplete monoamines can cause depression. • Antidepressants increase serotonin and noradrenaline. • CSF 5-HIAA is lower in patients who have had a suicide attempt. • Plasma tryptophan (a precursor for serotonin) are lower in untreated depressed patients. • It appears that lowering brain 5HT only produces depression in those already pre­ disposed to it. • Levels of HVA, the dopamine metabolite, are low in the CSF. • Second messenger production and intracellular signalling may bring about the production of neurotrophins which may regulate mood.

92

47. Affective disorders

Bipolar affective disorder • At least two episodes ot mood disturbance required in ICD10 but in DSM IV one episode of mania or hypomania is sufficient. • Type 1: At least one manic episode identified. Depressive episodes usually occur

but not always. • Type 2: A major depressive episode is required with hypomania.

Differences between mania and hypomania • Mania requires social and occupational dysfunction, hypomania requires less or none. In mania insight is impaired. • Mania tends to have a longer period of mood disturbance than hypomania, mania usually persists from 2 weeks to 5 months.

93

Bipolar affective disorder (cont.) • There may be prodromal symptoms which are often recognized by the patient prior to mania or hypomania. This includes sleep disturbance most commonly. • The lifetime risk of developing BAD is 0.3-1.5%. • Mean age of onset is 21 which is earlier than depression. • There is an equal prevalence in men and women. • A clear relationship to life events has not been established in mania, whereas in depression there is a six times increase in life events prior to the illness. • Late onset bipolar disorder is rare and organic causes are important. • The interval between episodes become shorter as the person gets older. • The prognosis is poor for BPAD and is worse for the rapid cycling subtype. • Bipolar type 2 has a better prognosis than type 1. • Patients with acute mania perform badly on attention, learning, memory and executive function tasks.

94

48. Affective disorders

Persistent mood disorders Dysthymia Є A c h ro n ic lo n g s ta n d in g d e p re ssio n o f m o o d n o t fu lfilling th e c rite ria fo r d e p re s sive disorder. •

There m a y b e p e rio d s w h e re th e suffe re r feels w e ll o n o c c a s io n s b u t th e y fe e l m ostly lo w in m o o d .

•

M o re c o m m o n in w o m e n a n d th o s e d iv o rc e d .

•

M ost a n tid e p re s s a n ts h a v e b e e n sh ow n to b e e ffe c tiv e in tre a tm e n t.

95

Persistent mood disord ers (cont.)

Cyclothymia

96

•

M o o d is persistently u n s ta b le a n d th e d iso rd e r starts e a rly in a d u lt life.

•

There a re p erio d s o f h ig h a n d lo w m o o d , n o t fulfilling th e c rite ria fo r b ip o la r a ffe c tiv e d iso rd e r or re c u rre n t d e p re ssive disorder.

•

M ore c o m m o n in th e relative s o f th o se w ith b ip o la r a ffe c tiv e d iso rd e r a n d m a y e v e n tu a lly d e v e lo p in to b ip o la r a ffe c tiv e disorder.

49. Affective disorders

Mood disorders and pregnancy Є P sychiatric illness is m o re c o m m o n in th e first a n d th ird trim esters a n d in th o s e w ith m e d ic a l p ro b le m s in p re g n a n c y .

Postnatal depression •

Risk o f d ep re ssion is in c re a s e d fiv e fo ld a fte r c h ild b irth

Є D iffe re n t fro m 'b a b y b lu e s' w h ic h o c c u r fo r a fe w hours in h a lf o f fe m a le s 3 -4 d a ys a fte r delivery. Є O ffspring o f d e p re s s e d m o th e rs h a v e p o o re r c o g n itiv e abilities. •

Risk fa c to rs in c lu d e o c c u p a tio n a l in sta b ility a n d a la c k o f a c o n fid in g re la tio n ­ ship.

Puerperal psychosis •

M u c h m o re c o m m o n in p a tie n ts w ith b ip o la r a ffe c tiv e d is o rd e r or a fa m ily history o f it.

•

Usual o n se t is 2 -1 5 d a y s a fte r c h ild b irth .

•

C o m m o n ly re o c c u rs in fu tu re p re g n a n c ie s .

•

Lithium or EOT a re o fte n th e tre a tm e n ts o f c h o ic e

97

Mood disorders and learning disability

98

•

Those w ith le a rn in g disabilities m a y n o t b e a b le to d e s c rib e n e g a tiv e co g n itio n s .

•

B io lo g ica l fe a tu re s o f d e p re ssion b e c o m e m o re im p o rta n t in m a k in g a d ia g n o ­ sis.

•

M a y b e a n in cre a se in c h a lle n g in g b e h a v io u r.

•

M a y b e a tte m p ts to self-harm .

•

R ate o f su icid e is lo w e r th a n in th e g e n e ra l p o p u la tio n .

•

M a y b e d e c re a s e d v e rb a l o u tp u t d e c re a s e d a c tiv ity levels, a n d a c h a n g e d ro u tin e o f e a tin g a n d sle e p in g .

50. Affective disorders

Mood disorder in older age Є D epressive d iso rd e r is th e m o st c o m m o n p s y c h ia tric d is o rd e r in o ld a g e , h o w e v e r a fte r 60 th e first o n se t o f d ep re ssio n is less c o m m o n . •

There m a y b e m o re p h y s ic a l or h y p o c h o n d ria c a l s y m p to m s as th e p re s e n ta tio n ra th e r th a n c o m p la in in g o f lo w m o o d , as w e ll as h a v in g a p o o r m o tiv a tio n .

•

In d e p re s s e d o ld e r a g e d p a tie n ts w ith d e p re ssive p s e u d o d e m e n tia th e re is a n in c re a s e d risk o f la te r d e v e lo p in g d e m e n tia .

99

Mood disorder in older age (cont.)

100

•

O rg a n ic c o n d itio n s a re c o m m o n ca use s a n d in c lu d e CVA, P arkinson's a n d n e o ­ p la s tic disease.

•

Rates o f d ep re ssion a re in c re a s e d in m e d ic a l in p a tie n ts a n d h ig h e s t in nursing hom es.

•

Being o f a n o ld e r a g e is n o t a risk fa c to r fo r d e p re ssion a n d d ep re ssion in o ld a g e responds to tre a tm e n t similarly to o th e r ages.

51. Affective disorders

Bereavement • Grief is th e p s y c h o lo g ic a l a n d e m o tio n a l p rocesses a c c o m p a n y in g b e re a v e ­ m e n t.

• Mourning is th e c u ltu r a l s o cia l a n d c o g n itiv e p rocesses th a t m ust b e n e g o tia te d to return to n o rm a l fu n c tio n in g .

• Bereavement is a n y loss e v e n t fro m th e loss o f a re la tiv e to a c a t or a house. The p erson is in th e s ta g e o f m o u rn in g .

101

Normal grief reaction

102

•

Shock, num bness or d is b e lie f fo r 2 w eeks.

•

Irritability as w ell as lo w m o o d .

•

M annerism s o f th e d e a d person m a y b e c o p ie d .

•

There m a y b e a w a re n e s s o f a p re s e n c e o f th e d e a d person w ith tra n s ie n t h a llu ­ c in a tio n s o f v o ic e o f d e c e a s e d .

•

S o m a tic sym p to m s in c lu d e sle e p d is tu rb a n c e , te arfulness, w e ig h t loss, p o o r a p p e tite a n d loss o f lib id o .

•

A fte r 6 w ee ks sym p to m s im p ro v e until 6 m onths, th e re m a y b e a n n ive rsa ry r e a c ­ tions fo llo w in g this.

52. Affective disorders

Other mood disorders Mixed affective disorder •

There is a ra p id c h a n g e w ith in hours fro m d e p re ssive s y m p to m s to th o s e o f h y p o m a n ia or m a n ia .

•

As w ith depression, 2 w e e ks a re re q u ire d fo r a diagnosis.

Recurrent brief depressive disorder •

S hort-lived d ep re ssive e p is o d e s (2 -3 d a y s ) o c c u r o fte n a b o u t o n c e a m o n th .

Є B e tw e e n th e se e p iso d e s th e m o o d rem ain s n o rm a l. Є This c a te g o r y d o e s n o t in c lu d e m o o d d is tu rb a n c e re la te d to th e m en strua l c y c le .

103

Other mood disord ers

Seasonal affective disorder

104

•

O c c u rs in u p to 10% o f th e p o p u la tio n .

•

Worse in h ig h e r latitu d e s.

•

M a y b e in c re a s e d sle e p a n d a p p e tite .

•

Two e piso d e s a re re q u ire d in 2 years w ith n o n o n -se a so n a l d ep re ssive episodes.

•

There is a fa m ily history o f a ffe c tiv e disorders in h a lf o f th e p a tie n ts .

•

Bright lig h t tr e a tm e n t or p h o to th e ra p y has b e e n sh ow n to b e e ffe c tiv e .

53. Affective disorders

Abnormal grief reaction •

M o re th a n 6 m o n th s o f grief, o fte n lasting 1.5 years.

•

N um bness m o re th a n 2 w e e ks a n d s o cia l w ith d ra w a l.

•

S u icide a tte m p ts a n d m o re th a n 2 w e e ks o ff w ork.

•

Ideas o f g u ilt re g a rd in g th e d e a th

•

A g ita te d dep re ssion a n d p a n ic a tta c k .

•

Id e n tific a tio n w ith th e d e c e a s e d .

Factors indicating a poor outcome and pathological grief include •

A n a m b iv a le n t or d e p e n d e n t re la tio n s h ip w ith th e d e c e a s e d .

•

F em a le g e n d e r.

•

Poor so cia l su pp ort.

Є Isolation. Є D e a th o f a c h ild or spouse. 0 D e a th b y su icid e or m urder.

0 S u d d e n tra u m a tic d e a th . 0 P sych iatric illness, a n e a rly a g e o f b e re a v e m e n t a n d u n e m p lo y m e n t a re risk f a c ­ tors fo r p s y c h ia tric illness

105

Differentiating between depressive pseudodementia and dementia Depressive pseudodementia

Dementia

Partial c o g n itiv e d e fic its

G lo b a l c o g n itiv e d e fic its

O n set c a n b e d a te d

Time o f o n s e t is u n c le a r

S ym ptom s m a y d e v e lo p ra p id ly

S ym p tom s d e v e lo p slow ly

Low m o o d p re c e d e s o th e r sym p to m s

M o o d m a y b e la b ile

P a tie n t m a y n o t b e w illing to a n sw e r questions Poor s u b je c tiv e m e m o ry

True m e m o ry p ro b le m s

Problem s w ith c o n c e n tra tio n

The p a tie n t is o fte n u n a w a re o f th e ir m e m o ry p ro b le m s

D isorie n tatio n suggests a n o rg a n ic ra th e r th a n fu n c tio n a l d iso rd e r

106

Very little m o tiv a tio n w ith p e rfo rm in g tasks

Efforts m a y b e m a d e w ith tasks

MRI or CT n o rm a l

C e re b ra l a tro p h y e n la rg e m e n t o c c u rs

or

v e n tric u la r

54. Affective disorders

Rating scales for mood disorders Rating scales for mania depression • Montgomery-Asberg Depression Rating Scale: There a re te n item s o n a fo u r-p o in t s c a le a n d this m easures th e p s y c h o lo g ic a l fe a tu re s o f depre ssion . It is a c lin ic ia n ­ ra te d scale. It is useful fo r d e te c tin g responses to tr e a tm e n t in depre ssion .

• Hamilton Rating Scale for Depression: A n o th e r c lin ic ia n -ra te d sca le . It m easures th e seventy o f depre ssion . There is a n u n s tru c tu re d in te rv ie w te c h n iq u e . The s c a le focuse s on p h y s ic a l sy m p to m s m o re th a n c o g n itiv e sym pto m s.

• Beck Depression Inventory: This is a s e lf-ra te d in v e n to ry . There a re 21 item s w ith fo u r to six s ta te m e n ts fo r e a c h ite m .

107

Rating scales for mood d isorders (cont.)

Rating scales for mania • Young Mania Rating Scale: A c lin ic ia n -a d m in is te re d s c a le fo r assessing th e sever­ ity o f m a n ia . There a re 11 item s a n d it d o e s n o t assess d e p re s s e d m o o d . It is suit­ a b le fo r ty p e 1 b ip o la r disorder.

Rating scales for anxiety • Hamilton Anxiety Scale: This is used fo r a n x ie ty disorders a lo n e a n d is o b se rve r ra te d . There a re 13 item s ra te d o n fiv e scales. There a re also so m e question s c o n ­ c e rn in g d ep re ssion o n th e s c a le

• State-Trait Anxiety Inventory: This is a s e lf-ra te d in ve n to ry. The tra it se c tio n d escrib e s h o w th e p a tie n t feels d u rin g th e in te rv ie w a n d th e s ta te s e c tio n d escrib e s h o w th e y fe e l g e n e ra lly .

• The Clinical Anxiety Scale- This is sim ilar to th e H a m ilto n A n x ie ty S ca le b u t th e re a re no questions a b o u t d epression. It c a n b e used fo r o th e r c o n d itio n s a s s o c ia t­ e d w ith a n x ie ty a p a rt fro m a n x ie ty disorders.

108

55. Pharmacology

Side-effects of SSRIs Most common side-effects Є Sexual dysfunction: Inhibited orgasm or d e c re a s e d libido. O ccurs in 50-80% o f patients on SSRIs a n d is th e most c o m m o n side-effect. • Gl upset (nausea, diarrhoea, dyspepsia): Usually resolves after a fe w weeks of treatm ent.

• Headaches.

Less common sid e-effects include • •

• • • •

•

Anxiety: Particularly in th e first fe w weeks, m ore c o m m o n with fluoxetine th a n o ther SSRIs. Usually anxiety subsides a fte r first fe w weeks a n d th ere is subsequently an o ver­ all red uctio n in anxiety level. Insomnia or excessive sleep: SSRIs usually le a d to im p ro ve d sleep b u t some SSRIs m ay cause insomnia or excess sleep in some individuals. Fluoxetine is most likely to cause insomnia a ltho ug h un co m m o n . C ita lo p ra m is most likely to cause excess sleepiness a ltho ug h u ncom m on. Seizures: Rarely. Extrapyramidal symptoms: - Tremor in 5-10%. Rarely akathisia, dystonia, tremor, c o g ­ w heel rigidity, torticollis, a b n o rm a l g a it a n d bradykinesia. Anticholinergic effects: Paroxetine m ay cause dry m outh, co n stip a tio n a n d sedation d e p e n d e n t upon th e dose given. Electrolyte changes: Rarely d e c re a s e d g lucose co n ce ntra tion s, h y p o n a tra e m ia a n d SIADH. Haematological effects: Reversible n e u tro p e n ia rarely.

109

Side-effects of SSRIs (cont.) Less common side-effects include (cont.) •

E n d o crin e e ffe cts: D e c re a s e d p ro la c tin level a n d g a la c to rrh o e a .

•

A lle rg ic re a ctio n s: Rashes o c c u r in 4%.

•

S erotonin syn drom e : W h e n SSRIs a re c o a d m in is te re d w ith lithium , L -try p to p h a n or a M AO I, p la sm a se ro to n in levels m a y b e raised to to x ic levels. S y m p to m s /e ffe c ts o f se ro ton in syn d ro m e are: d ia rrh o e a ; a g ita tio n a n d restlessness; h y p e rth e rm ia ; m yoclon u s; seizures; in c re a s e d reflexes; seizures, c a rd io v a s c u la r c o lla p s e ; deliri­ um, c o m a , d e a th .

SSRIs increases plasma levels of •

Som e a n tip s y c h o tic s - h a lo p e rid o l a n d c lo z a p in e .

Є C a rb a m a z e p in e . •

110

C iclo spo rin .

•

P henytoin.

•

Tricyclics.

•

Som e b e n zo d ia ze p in e s .

56. Pharmacology

Lithium • Mechanism of action: N o t fully u n d e rs to o d . Has e ffe c ts o n c a tio n tra n s p o rt in cre a sin g N a /K ATPase p u m p a c tiv ity . Also increa se s g e n e ra tio n a n d re lea se o f 5HT. It increases transm ission a t 5HT1a a n d d e c re a s e s transm ission a t 5HT2 r e c e p ­ tors. It e n h a n c e s n o ra d re n a lin e s y n a p tic u p ta k e as w e ll as p la te le t 5HT u p ta k e . It also increases a c e ty lc h o lin e levels.

• Routine investigations prior to beginning treatment: FBC, U&Es, re n a l a n d th y ro id fu n c tio n , ECG, w e ig h t.

• Monitoring: W h e n b e g in n in g m e d ic a tio n , sta rt a t lo w e s t d o s e - 400 m g d a ily a n d c h e c k b lo o d lithium leve l a fte r 7 days, 12 hours p o s t dose. T h e ra p e u tic level is b e tw e e n 0.5 a n d 1.0 m m o l/L . T itrate d o s e g ra d u a lly a n d c h e c k leve l w e e k ly until th e leve l is w ith in th e th e ra p e u tic ra n g e . O n c e th e ra p e u tic ra n g e is a c h ie v e d , lithium levels n e e d to b e c h e c k e d e v e ry 3 -6 m onths, ren al fu n c tio n e v e ry 6 m on th s a n d th y ro id fu n c tio n e v e ry year.

• Side-effects: Polydipsia, p o ly u ria (a m ilo rid e c a n b e used to tr e a t p o lyu ria ), w e ig h t g ain, c a rd ia c a rrhythm ia s, trem or, a c n e , h y p o th y ro id is m or h y p e rth y ­ roidism .

Ill

Lithium (cont.) • In toxicity: CNS e ffe c ts - m u scle w eakness, a ta x ia , tre m o r (co a rs e ), drowsiness. Gl u p se t - n au sea , d ia rrh o e a , a n o re x ia . D iso rie n ta tio n a n d seizures, c o m a a n d d e a th c a n o c c u r if levels g o a b o v e 2 m m o l/L . Long te rm tre a tm e n t m a y le a d to n e p h ro to x ic ity . Small re d u c tio n in g lo m e ru la r filtra tio n ra te is seen in 20% o f p a tie n ts - usually b e n ig n . Very sm all n u m b e r o f p a tie n ts m a y d e v e lo p interstitial nephritis. Lithium c a n also c a u s e n e p h ro g e n ic d ia b e te s insipidus w h ic h m a y b e irreversible a fte r lo n g te rm tre a tm e n t (>15 years).

• Contraindications: Renal im p a irm e n t, b re a s t fe e d in g , p re g n a n c y . • Interactions with other drugs: A n tip s y c h o tic s - m a y in cre a se lithium to x ic ity b u t rarely seen in p ra c tic e . D iuretics - in c re a s e lithium c o n c e n tra tio n . D iltia z e m /v e ra p a m il - m a y b e rarely linke d to n e u ro to x ic ity . ACE inhibitors - to x ic ity . NSAIDs le a d to to x ic ity e x c e p t aspirin a n d s u lin d a c. C O X 2 inhibitors - to x ic ity . A lc o h o l increases p e a k lithium c o n c e n tra tio n . X a nthin es - in c re a s e lithium e x c re tio n . N aC I - in cre a se lithium e x c re tio n .

112

57. Pharmacology

Extrapyramidal side-effects of antipsychotics • Tardive dyskinesia: A b n o rm a l m o v e m e n ts m ost c o m m o n ly a tfe c tin g th e fa c e , m o u th or trunk. Lip s m a c k in g or c h e w in g , to n g u e protrusion, c h o re ifo rm h a n d m o v e m e n ts , p e lv ic thrusting. O ro fa c ia l m o v e m e n ts le a d in g to d iffic u lty s p e a k in g or e a tin g fo o d . M o v e m e n ts a re e x a c e rb a te d b y stress. Tardive dyskinesia b e c o m e s m o re likely w ith lo n g e r d u ra tio n o f a n tip s y c h o tic tre a tm e n t.

• Pseudo-parkinsonian side-effects: For e x a m p le , pill rolling tre m o r o f hands, b ra dykin e sia , shuffling g a it.

• Dystonia - abnormal muscle tone: M uscles o f th e eyes, m o u th or fa c e g o into spasm . Eyeballs rolling u p in th e h e a d - o c u lo g y ric crisis c a n o c c u r rarely. A b n o rm a l h e a d a n d n e c k m o v e m e n ts m a y o c c u r w ith s p a s m o d ic tu rn in g or tw isting o f th e n e ck.

• Akathisia: A s u b je c tiv e fe e lin g o f inn er restlessness, nervousness or a g ita tio n . M a y b e c h a ra c te riz e d b y p a c in g , c ro ssin g /u n cro ssin g legs re g u la rly or s ta m p in g fe e t w hilst sitting d o w n .

113

Other effects of antipsychotics • Hormonal changes: H y p e rp ro la c tin a e m ia - le a d in g to c e ssa tio n o f m enses a n d g a la c to rrh o e a in w o m e n a n d c a n c a u s e m e n to d e v e lo p m ild d e g re e o f b re a st sw elling.

• Weight gain: C o m m o n , e s p e c ia lly w ith o la n z a p in e or c lo z a p in e . • Sypathetic side-effects: Postural h y p o te n s io n . • Anticholinergic effects: Dry m o u th ve ry c o m m o n . • Thirst: Up to 20% o f p e o p le o n a n tip s y c h o tic s d rink a n excessive v o lu m e o f fluids. •

S e da tio n.

•

Sexual side-effects: Loss o f libido , im p o te n c e .

•

Skin rashes.

•

Neuroleptic malignant syndrome (rare): M ost c o m m o n ly o c c u rs w ith s u d d e n increases in d o se or w h e n first sta rtin g th e a n tip s y c h o tic .

• Glucose intolerance/diabetes: Som e dru gs a re b e lie v e d to b e a s s o c ia te d w ith th e d e v e lo p m e n t o f im p a ire d g lu c o s e to le ra n c e or d ia b e te s , e g c lo z a p in e a n d o la n z a p in e .

114

58. Pharmacology

Tricyclic antidepressants Side-effects • Anticholinergic effects are most common: Dry m o u th , c o n s tip a tio n , b lu rring o f vision, urinary re te n tio n .

• Cardiovascular effects: T a c h y c a rd ia , p ro lo n g e d QT intervals, ST s e g m e n t d e p re s ­ sion, fla tte n e d T w ave s, p o s tu ra l h y p o te n s io n .

• Neurological effects (rare): M y o c lo n ic tw itc h e s , tre m o rs w ith d e s ip ra m in e a n d p ro trip ty lin e . P araesthesia. A ta x ia . L ow er seizure th re s h o ld - so m e tricyclics. Low risk th a t tric y c lic s w o u ld in d u c e seizures e x c e p t in p e o p le w h o a re a lre a d y a t risk.

• Allergic reactions: J a u n d ic e o c c u rs rarely. H e p a titis - tric y c lic s c a n in d u c e a fu l­ m in a n t a c u te h e p a titis a lth o u g h this is e x tre m e ly rare (0.1-1% o f th e p o p u la tio n ). Rashes o c c u r in 4-5% o f th o s e tr e a te d w ith tricyclics.

• Haematological effects: A g ra n u lo c y to s is , le u c o c y to s is , le u c o p e n ia , e o s in o p h ilia a re rare c o m p lic a tio n s .

• Weight gain: C o m m o n . NB: Tricyclics c a n b e used to tr e a t p e rip h e ra l n e u ro p a th y .

115

Tricyclic antidepressants (cont.) Drug interactions

116

•

A se ro ton in sy n d ro m e c a n o c c u r w h e n tric y c lic s a re c o a d m in is te re d w ith MAOIs. MAOIs p o te n tia te th e a c tio n o f tricyclics.

•

SSRIs in cre a se tric y c lic levels e x c e p t C ita lo p ra m .

•

A lc o h o l.

•

A n tim usca rin ics.

•

A n tip s y c h o tic s - e s p e c ia lly p im o z id e a n d th io rid a zin e .

59. Pharmacology

Benzodiazepines Mechanism of action B e n zo d ia zep ine s b in d a t sites o n GABAa receptors le a d in g to a n in c re a s e d a ffin ity o f th e G A B A a re c e p to r fo r its n e u ro tra n s m itte r G A BA. The in c re a s e d a ffin ity fo r G A B A results in su stain e d a c tiv ity o f th e ion c h a n n e l a n d thus in c re a s e d p a s s a g e o f c h lo rid e ions in to neurons.

Effects on sleep G • • • • •

R e d u c tio n o f slee p la te n c y (tim e ta k e n to g e t to slee p). D e c re a s e d a w a k e n in g s . D e c re a s e d tim e s p e n t in sta g e s 0 a n d 1. P ro m in e n t d e c re a s e in slow w a v e s le e p - sta g e s 3 a n d 4. A n in c re a s e in REM la te n c y , b u t a d e c re a s e in to ta l REM sleep. In cre a se in to ta l slee p tim e .

Stages of sleep •

Non REM: 0 = a fully a le rt a n d a w a k e in d iv id u a l; 1 = e a rly p a rt o f sleep, EEG irre g ­

•

u lar a n d re d u c e d in a m p litu d e ; 2 = short re g u la r p a tte rn s o f 12-16 Hz (spindles); 3 = d e e p sleep, lo n g w a v e le n g th rhyth m s 1-2 Hz, d e lta w a v e s a re c o m m o n ; 4 = d e e p slee p sim ilar to s ta g e 3, d e lta w a v e s m o re c o m m o n (>50%). REM (rapid eye movement): = Very d e e p sleep, d re a m s c o m m o n .

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Benzodiazepines (cont.) Mnemonic for benzodiazepine effects on sleep • reduction in - LATS: S leep L a te n c y A w a ke n in g s Time in sta ge s 0 a n d 1 a n d T otal REM sle e p Slow w a v e slee p sta g e s 3 a n d 4

• increase in 'R o o m T e m p e ra tu re ': REM L a te n c y Total slee p tim e

Withdrawal effects • Commonly: A n xiety; insom nia; restlessness, a g ita tio n ; irritability; p o o r c o n c e n tr a ­ tio n a n d m e m o ry; depre ssion ; m u scle a c h e s a n d pains, tw itc h e s ; in c re a s e d m us­ c le tension; s w e a tin g ; tinnitus.

• Less commonly: P a ra n o id psychosis; convulsions; d e p e rs o n a liz a tio n /d e re a liz a tio n e xp e rie n ce s; visual h a llu c in a tio n s ; illusions or p a ra e s th e s ia .

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60. Pharmacology

Other mood stabilizers - mechanism of action • Carbamazepine: Blocks s o d iu m c h a n n e ls a n d p o te n tia te s p o ta ssiu m c h a n n e ls . It e n h a n c e s th e in h ib ito ry a c tio n o f G A B A b y its a c tio n o n so d iu m a n d p ota ssium ch a n n e ls.

• Sodium valproate: In te rfe re s w ith c a lc iu m

a n d s o d iu m c h a n n e ls th e re b y e n h a n c in g th e in h ib ito ry a c tio n s o f G A B A a n d re d u c in g th e e x c ita to ry a c tio n o f g lu ta m a te .

• Lamotrigine: A c ts b y in h ib itin g th e e x c ita to ry a c tio n o f g lu ta m a te . • Vigabatrine: Irreversibly inhibits G A B A tra n s a m in a s e . • Gabapentin: T h o u g h t to in h ib it re u p ta k e o f G A B A in to G A B A te rm in a ls thus e n h a n c in g th e in h ib ito ry a c tio n o f GABA.

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Carbamazepine Side-effects H - H ypersensitivity - h e p a titis A - A p la s tic a n a e m ia - 1 in 20 000 T - Toxic e p id e rm a l necrolysis - 1 in 20 000 D - Drowsiness A - A g ra n u lo c y to s is - 1 in 20 000 R - Rashes T - Transient le u c o p e n ia in a b o u t 10% o f cases in first 2 m o n th s o f tre a tm e n t O th e r s id e -e ffe c ts - DAN - D o u b le vision, A taxia, N ausea.

Drug interactions •

A n tip sych o tics, lithium , C a c h a n n e l b lo c k e rs - m a y a d d to CNS e ffe c ts .

# D ecrea se s tric y c lic a n d a n tip s y c h o tic p la s m a levels. Є A ffe c ts o th e r d ru g m e ta b o lis m , e g p h e n y to in , o ra l c o n tr a c e p tiv e pill, as a c ts as a n e n zym e ind uce r.

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61. Pharmacology

Clozapine Mechanism of action (receptor binding) C lo z a p in e has lo w p o te n c y a t D2 a n ta g o n is m . It has a m u c h h ig h e r p o te n c y as a Dļ a n ta g o n is t a n d has a n ta g o n is t a c tiv ity a t m u s c a rin ic a n d h ista m in e (Η Ί) r e c e p ­ tors. It has m o re a c tio n o n D4 re c e p to rs th a n m ost o th e r a n tip s y c h o tic s .

C lo z a p in e 's b in d in g c h a ra c te ris tic s S ig n ific a n t p ostu ra l h y p o te n s io n o c c u rs in o n ly 3-5% o f p a tie n ts o n a n tip s y c h o tic s a n d is d o s e re la te d . There is n o rea son to e x p e c t th a t c lo z a p in e ca u se s less p o stu r­ al h y p o te n s io n th a n o th e r a ty p ic a l a n tip s y c h o tic s as c lo z a p in e b in ds to m r e c e p ­ tors as w ell.

121

Clozapine (cont.) Common side-effects M n e m o n ic - CASH To h a v e Fun Nights W ith C - C o n s tip a tio n . A - A g ra n u lo c y to s is - risk o f less th a n 1 in 5000 p a tie n ts tre a te d (has o n ly e v e r b e e n th re e d e a th s in to ta l in UK fro m c lo z a p in e -re la te d a g ra n u lo c y to s is ). S - S e da tio n, Seizures. H - H yp o te n s io n /H y p e rte n s io n , H yp e rsa liva tio n (usually in first 4 w eeks). T - T a c h y c a rd ia . F - Fever. N - N e u tro p e n ia - (usually in first 18 w eeks). A b o u t 2-3% o f p a tie n ts tre a te d w ith c lo z a p in e d e v e lo p n e u tro p e n ia . N a u se a (first 6 w eeks), N o c tu rn a l enuresis. W - W e ig h t g a in .

122

62. Pharmacology

Psychotropic drugs - prescribing in pregnancy Antipsychotic prescribing in pregnancy: •

A risk versus b e n e fit analysis n e e d s to b e d o n e w h e n c o n s id e rin g p re s c rib in g a n tip s y c h o tic s in p re g n a n c y . S to p p in g th e d ru g m a y le a d to th e m o th e r e x p e ri­ e n c in g a p s y c h o tic re la p s e n e c e s s ita tin g use o f h ig h e r doses o f a n tip s y c h o tic s a n d in cre a sin g th e risk o f te ra to g e n ic ity . P s y c h o tro p ic d ru gs sh ou ld b e a v o id e d if possible in th e first trim e ste r (w h e n m a jo r o rg a n s a re b e in g fo rm e d ).

•

P atients w h o h a v e h a d r e p e a te d relapses a re b e st m a in ta in e d o n a n tip s y ­ c h o tic s d u rin g a n d a fte r p re g n a n c y .

•

The m ost e xten sively used d ru gs in p re g n a n c y in c lu d e : M n e m o n ic - COT: C - C h lo rp ro m a z in e , C lo z a p in e . O - O la n z a p in e (m o s t w id e ly used). T - T rifluoperazine.

G e s ta tio n a l d ia b e te s m a y b e a p ro b le m w ith b o th a ty p ic a ls (c lo z a p in e a n d o la n ­ za p in e ). S om e o th e r d ru gs m a y b e sa fe b u t th e re is lim ite d d a ta a n d m ost u p to d a te in fo rm a tio n should b e so u g h t. It m a y b e b e st n o t to sw itch to a n e w d ru g fo r p a tie n ts w h o a re a lre a d y e s ta b lis h e d o n a n o th e r a n tip s y c h o tic .

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Psychotropic drugs - prescribing in pregnancy (cont.) Antidepressants used in pregnancy •

•

•

A g a in a risk versus b e n e fit analysis n e e d s to b e u n d e rta k e n . If risk o f re lap se is high, it m a y b e b est fo r p a tie n ts to c o n tin u e to ta k e a n tid e p re s s a n ts d u rin g p re g ­ n a n c y . Tricyclics h a v e b e e n w id e ly used in p re g n a n c y w ith o u t a p p a r e n t d e tri­ m e n t to th e foetus. The m ost w id e ly used d ru gs in c lu d e : M n e m o n ic - FAI - re m e m b e r th e F ederal Airline Industry (FAI) o f A m e ric a : F - F luoxetine - a lth o u g h so m e cases h a v e b e e n a s s o c ia te d w ith e a rly d e liv e ry a n d /o r lo w birth w e ig h t. A - A m itrip ty lin e I - Im ip ra m in e Bipolar affective disorder: A n tic o n v u ls a n ts a re b e st a v o id e d d u e to th e risk o f tera tog en e sis. If lithium is p re s c rib e d , a leve l 2 u ltra s o u n d shou ld b e p e rfo rm e d a t 6 a n d 18 w e e k s ' g e s ta tio n to lo o k fo r Ebstein's a n o m a ly . If v a lp ro ic a c id or c a rb a m a z e p in e a re p re s c rib e d , p ro p h y la c tic fo lic a c id shou ld b e g iv e n to re d u c e th e c h a n c e o f fo e ta l n e u ra l tu b e a b n o rm a litie s .

• In breast feeding -

recommended drugs (Maudsley 2005 Guidelines):

A n tid e p re ssa n ts - p a ro x e tin e or sertraline. A n tip s y c h o tic s - sulpiride or o la n z a p ­ ine. M o o d stabilizers - A v o id if possible, v a lp ro a te if essential. S e da tive s lo ra z e p a m fo r a nxie ty, z o lp id e m fo r sleep.

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63. Pharmacology

Some other receptors associated with psychotropic drugs Dementia drugs •

D on e p e zil - p ip e rid in e d e riv a tiv e , reve rsib le a c e ty lc h o lin e s te ra s e inhibitor.

•

M e m a n tin e - n o n -c o m p e titiv e N M D A re c e p to r a n ta g o n is t.

•

R ivastigm ine - a b u ty ry lc h o lin e s te ra s e in h ib ito r (re versible ).

•

G a la n ta m in e - te rtia ry a lk a lo id , reve rsib le a c e ty lc h o lin e s te ra s e inhibitor.

Antidepressants Є N o ra d re n a lin e R e u p ta k e In h ib ito r (NRI) - re b o x e tin e s e le c tiv e ly inhibits n o re p i­ n e p h rin e re u p ta k e , w ith little in h ib itio n o f d o p a m in e or se ro to n in re u p ta k e . It has a lo w a ffin ity fo r m u s c a rin ic o r c h o lin e rg ic re c e p to rs . It has n o in te ra c tio n w ith a lp h a or b e ta a d re n e rg ic or h is ta m in ic re c e p to rs . •

P henylpiperizines - tra z o d o n e is a w e a k in h ib ito r o f 5HT re u p ta k e .

•

S erotonin a n d N o ra d re n a lin e R e u p ta k e In h ib ito r (SNRI) - v e n la fa x in e s e le c tiv e in h ib ito r o f n o ra d re n a lin e a n d 5HT re u p ta k e .

•

a 2 a n ta g o n is t - m irta z a p in e - 5HT2, 5HT3, Hn a n d a 2 a n ta g o n is t. B lo c k a d e o f 5HT2 a n d 5HT3 m inim izes sexual d y s fu n c tio n a n d n a u s e a . Ң a n ta g o n is m e ffe c t is s e d a tio n . 5HT3 is a c a tio n c h a n n e l.

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Psychotropic drugs Antipsychotics •

The d o p a m in e D r like re c e p to r g e n e fa m ily is c o m p o s e d o f tw o m em bers, te rm e d D ļ/D 1A a n d D5/ D 1B: R isperidone - 5HT > D2 = = a 2. O la n z a p in e - 5HT2 = Ηη = M > D2 > m Q u e tia p in e - Hļ > a! > 5HT2 > a 2 > D2. A m isulp iride - D2 = D3.

Classification of antipsychotics •

Typicals: P henothia zin e s - c h lo rp ro m a z in e (a lip h a tic side ch ains), th io rid a z in e (p ip e rid in e ), triflu o p e ra z in e (p ip e ra z in e ), flu p h e n a z in e . T h io xa n th e n e s - flup e n th ix o l, z u c lo p e n th ix o l. B u ty ro p h e n o n e s h a lo p e rid o l, d ro p e rid o l. D ip h e n y lb u ty lp ip e rid in e s - p im o z id e . S u b stitute d b e n z a m id e s - sulpiride.

•

Atypicals: D ib e n z o d ia z e p in e s - c lo z a p in e . T h ie n o b e n z o d ia z e p in e - o la n z a p in e . D ib e n z o th ia z e p in e - q u e tia p in e . Benzisoxoles - risp erido ne . Im id a z o lid in e d io n e se rtin do le.

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64. Pharmacology

MAOIs Drug interactions •

A se ro ton in s y n d ro m e o c c u rs w h e n M AO Is a re c o a d m in is te re d w ith SSRIs.

•

Spinal a n a e s th e tic s c o n ta in in g e p in e p h rin e (a d re n a lin e ).

•

A n tih yp e rte n sive s (m e th y ld o p a , reserpine, g u a n e th id in e ).

•

l-DOPA.

•

N a rc o tic s - m e p e rid in e , m o rp h in e .

•

H a y fe v e r a n d sinus m e d ic a tio n s .

•

Aspirin.

•

A c e ta m in o p h e n .

•

A m p h e ta m in e s .

Є C o c a in e .

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MAOIs (cont.) Foods containing tyramine that must be avoided whilst taking MAOIs • • • • • • • •

H ard cheeses, soft cheeses. A sm all a m o u n t o f c o tta g e c h e e s e is p ro b a b ly safe. P ickled or sa lte d d rie d herrings. H ung or b a d ly sto re d g a m e , p o u ltry or o th e r m e a t w h ic h m ig h t b e g o in g off. C h ic k e n liver p a te a n d a n y o th e r liver w h ic h is n o t fresh. B road b e a n p o d s (a lth o u g h th e b e a n s a re safe). B a n a n a skins (a lth o u g h th e b a n a n a itself is safe). A v o c a d o pears. F ood c o n ta in in g m e a t or y e a s t e xtra cts.

Side-effects • • • • • • • •

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Postural h yp o te n sio n . Dizziness, drowsiness. H e a d a c h e s , insom nia. O e d e m a , w e ig h t g a in . A n tic h o lin e rg ic e ffe c ts . Nervousness, p a ra e s th e s ia . H e p a to to x ic ity , le u c o p e n ia . H ype rten sive crisis.

65. Psychology

Conditioning Classical conditioning •

A n e u tra l stim ulus is p a ire d w ith a n u n c o n d itio n e d stim ulus such th a t th e n e u tra l stim ulus ca uses a sim ilar response to th a t o rig in a lly p ro d u c e d b y th e u n c o n d itio n e d stimulus.

Operant conditioning •

The fre q u e n c y o f a b e h a v io u r is a lte re d b y th e a p p lic a tio n o f p o sitive or n e g a ­ tiv e c o n s e q u e n c e s .

129

Conditioning Example of classical conditioning

Classical Conditioning Stage 1: Before conditioning Flash bulb

Anna blinks

Camera

Anna does not blink

(Unconditioned (Unconditioned stimulus stimulus) response) UCS automatically produces UCR. Neutral stimulus does not produce blinking. Stage 2: Conditioning

UCR paired UCR with neutral stimulus UCS is paired with neutral stimuls. UCS produces UCR.

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Stage 3: After conditioning

CS CR (Conditioned (Conditioned stimulus) response) Neutral stimulus (camera) is now the conditioned stimulus. It produces a CR, blinking, which is like the UCR produced by the flashbulb.v

66. Psychology

Conditioning

Response Positive reinforcement strengthens the response because it results in the occurrence of something positive.

Example of operant conditioning Ellen has Alice hugs Ellen temper tantrum, to soothe her. Result: Frequency of tantrums increases. Response

Negative reinforcement strengthens the response because it results in something negative being removed or not occurring. Ellen has Alice stops asking temper tantrum. Ellen to clean room. Result: Frequency of tantrums increases. In contrast, punishment weakens the strength of the response: Response Punishment weakens the response because it results in the occurrence of something negative.

Ellen has Alice tells temper tantrum. Ellen off. Result: Frequency of tantrums decreases.

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Conditioning

Types of operant conditioning Є Primary reward conditioning: M ost fu n d a m e n ta l ty p e o f c o n d itio n in g - le a rn t response is key to o b ta in in g a b io lo g ic a lly s ig n ific a n t re w a rd such as fo o d or w ater.

Є Escape conditioning: A le a rn t response in o rd e r to g e t a w a y fro m a situ a tio n in w h ic h th e in d iv id u a l prefers n o t to exist.

Є Avoidance conditioning: A response to a c u e is key to a v o id in g so m e ty p e o f p a in fu l c o n s e q u e n c e .

• Secondary reward conditioning: The le a rn t b e h a v io u r has n o usefulness b io lo g i­ c a lly b u t m a y h a v e d o n e previously. Eg, m on ke ys a re ta u g h t to push a b u tto n to o p e n a d o o r w h ic h has b a n a n a s o n th e o th e r side, th e b a n a n a s a re subse­ q u e n tly re m o v e d b u t th e b e h a v io u r c o n tin u e s (ie pressing th e b u tto n to o p e n th e d o o r).

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67. Psychology

Locus of control theory •

The p e rc e iv e d c o n tro l th a t a n in d iv id u a l has o v e r him or herselt a n d e n v iro n ­ m e n t.

• Internal locus of control: A sense o f responsibility fo r o n e 's o w n a c tio n s a n d a sense o f b e in g in c o n tro l o f o w n e n v iro n m e n t.

• External locus of control: F eeling th a t e v e n ts a re d e te rm in e d b y e x te rn a l forces. O u tc o m e (s u c c e s s /fa ilu re ) is p e rc e iv e d as b e in g in d e p e n d e n t o f o n e 's o w n c o n tro l. •

S o m e o n e w ith a n in te rn a l locu s o f c o n tro l usually c o p e s w ith stress b e tte r th a n s o m e o n e w ith a n e x te rn a l locus. The th e o ry is n o t g e n e ra lly a p p lie d to s p e c ific p h o b ia s, as th e c a u s e o f th e s e is o fte n m u ltifa c to ria l.

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Learned helplessness - Martin Seligman

134

•

A s s o c ia te d w ith classica l c o n d itio n in g .

•

In S e lig m a n 's e xpe rim e n ts, d o g s w e re e x p o s e d to e le c tric shocks fro m w h ic h th e y c o u ld n o t e s c a p e .

•

The d o g s e v e n tu a lly g a v e u p a n d m a d e no fu rth e r a tte m p ts to e s c a p e n e w shocks g ive n .

•

The d o g s th e n a p p e a re d to b e c o m e a p a th e tic a n d g e n e ra lly g a v e u p on e v e ry th in g , n o t just try in g to e s c a p e th e shocks. The d o g s d is p la y e d sym pto m s (a p a th y , helplessness) sim ilar to th o s e seen in h u m a n d epression.

•

Thus le a rn e d helplessness has b e e n p ro p o s e d as a n a n im a l m o d e l o f d epression in hum ans.

•

Eg, if a tte m p ts a t c h a n g in g o n e 's life a re fu tile th e n th e in d iv id u a l n o lo n g e r m akes a n y a tte m p ts to c h a n g e , as th e y b e lie v e th a t n o th in g will h e lp a n y m ore. This le a d s to a p e rp e tu a tio n o f th e ir d epression.

68. Psychology

Bion - basic assumptions of group work • Dependency: Assum ing th e le a d e r will p ro v id e all th e solutions. • Fight-Flight: A n a ssu m p tio n o n th e p a rt o f m e m b e rs th a t th e re is a th re a t to th e g ro u p .

• Pairing: The a ssu m p tio n th a t a n e w le a d e r will arise.

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Family therapy Key concepts

Goals

Strategies used

Therapeutic neutrality Dirty games Counterparadox Long brief therapy

Unmasking the family game Change symptom bearers' self-sacrificing role

Therapeutic team Circular questioning Hypothesizing Invariant prescriptions Counterparadoxical interventions Prescribed rituals

Structural (Minuchin)

Boundaries Hierarchies Coalitions and alliances Complementarity Engagementenmeshment

Increased flexibility Adaptability to developmental change. Balance between connectedness and differentiation Subsystem functioning

Multidirected Family of origin sessions Use of cotherapy

Strategic (Haley)

Power and control Family life cycle Symptom-maintaining sequences Function of problems

Resolve presenting problem Disruption of problemmaintaining sequences

Persuasion Paradoxical injunction Insight downplayed Pretend and ordeal techniques

Approach Systemic (Milan)

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69. Psychology Learning theory - d e finitio ns • Aversive conditioning: P unish m e nt or a n a ve rsive s tim u la tio n is used to re d u c e th e fre q u e n c y o f a ta rg e t b e h a v io u r.

• Avoidance learning: A fo rm o f o p e ra n t c o n d itio n in g in w h ic h a n in d iv id u a l learns to a v o id c e rta in responses w h ic h result in a n u n p le a s a n t e ffe c t.

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Reinforcement schedules associated with operant conditioning • Continuous reinforcement: A re w a rd is g iv e n e v e ry tim e a response is g ive n . • Partial reinforcement: Responses a re n o t g iv e n e v e ry tim e a d e sire d response is m a d e , h e n c e e x tin c tio n m a y o c c u r (see c a rd 70 fo r e x p la n a tio n o f e x tin c tio n ).

• Variable ratio reinforcement: A re w a rd is g iv e n a fte r v a ria b le n u m be rs o f responses h a v e b e e n g iv e n - th e m ost p o w e rfu l re in fo rc e m e n t te c h n iq u e a n d used in casinos (e g th e person p la y in g o n a slot m a c h in e m a y initially re c e iv e a w in a fte r five a tte m p ts , th e n tries a g a in a n d re c e iv e s a w in a fte r 16 tries, th e n a fte r 11 tries, ie v a ria b le ).

• Fixed interval reinforcement: A re w a rd is g iv e n a fte r fix e d tim e p eriods, e g e v e ry 10 m inutes.

• Variable interval reinforcement: A re w a rd is g iv e n a fte r v a ria b le tim e periods, e g th e person on a slot m a c h in e re c e iv e s re w a rd s a fte r 10 m inutes, 16 m inutes, 8 m inutes, 22 m inutes (so c o m p le te ly v a ria b le ).

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70. Psychology Learning theory - d e fin itio n s • Higher order conditioning: A s s o c ia te d w ith cla ssica l c o n d itio n in g - a n e w ly in tro ­ d u c e d c o n d itio n e d stim ulus is a s s o c ia te d w ith a n e s ta b lis h e d u n c o n d itio n e d stim ulus so th a t it p ro d u c e s th e s a m e response ( c o n d itio n e d response).

• Habituation: A response to a stimulus re d u c e s w ith tim e . • Modelling: Lea rn ing b y o b s e rv a tio n o f o th e r's b e h a v io u r. • Shaping: R ein forcing in c re a s in g ly a c c u r a te responses to a d e s ira b le b e h a v io u r. Eg, In tra in in g a m o n k e y to press a b u tto n w h ic h o p e n s a door, initially th e m o n ­ key a p p ro a c h in g th e b u tto n is re w a rd e d . Then w h e n th e m o n k e y to u c h e s th e b u tto n , fu rth e r rew ard s a re g iv e n until th e m o n k e y fin a lly learns to press th e b u t­ to n.

• Chaining: Similar to s h a p in g b u t invo lves re in fo rc in g a n u m b e r o f sim ple b e h a v ­ iours s e p a ra te ly a n d th e n linking th e m to g e th e r in a m o re c o m p le x series.

• Extinction: A le a rn e d response g ra d u a lly d e c re a s e s in fre q u e n c y o n c e th e rein­ fo rc e r is re m o v e d .

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Learning theory - d efinitions • Law of effect: The p rin c ip le th a t b e h a v io u rs a s s o c ia te d w ith p le a s a n t results a re s tre n g th e n e d w h e re a s b e h a v io u rs a s s o c ia te d w ith u n p le a s a n t results a re w e a k ­ ened.

• Covert sensitization: R e d u c in g th e fre q u e n c y o f a b e h a v io u r b y a s s o c ia tin g it w ith im a g in a tio n o f u n p le a s a n t c o n s e q u e n c e s - e g this te c h n iq u e c a n b e used in tre a tin g sex o ffe n d e rs b y a s s o c ia tin g a n u n p le a s a n t th o u g h t w ith urges th a t th e in d iv id u a l has to c o m m it a sexual assault.

• Primary reinforcer: A stimulus th a t is c o n s id e re d to b e in h e re n tly re in fo rc in g a n d a ffe c ts a b io lo g ic a l process, e g a ffe c tio n , fo o d , sleep.

• Secondary reinforcer: Stimuli th a t re in fo rc e b e h a v io u r th ro u g h a s s o c ia tio n w ith a p rim a ry reinforcer.

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71. Psychology

Psychometric tests Comprehensive trail making test •

R eliable a n d v a lid n e w p s y c h o m e tric instrum ent.

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O p e ra tio n a lly d e fin e s im p o rta n t c o m p o n e n ts o f e x e c u tiv e fu n c tio n .

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Consists o f a s ta n d a rd iz e d set o f fiv e visual s e a rc h a n d s e q u e n c in g tasks in flu e n c e d b y a tte n tio n , c o n c e n tra tio n , re sista n ce to d is tra c tio n a n d c o g n itiv e fle xib ility (or set-shifting).

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Psychometric tests (cont.)

Comprehensive trail making test (cont.) Є M a in uses in c lu d e e v a lu a tio n a n d d ia g n o sis o f b ra in injury a n d o th e r form s o f c e n tra l nervous system d y s fu n c tio n .

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M o re s p e c ific purpo ses in c lu d e th e d e te c tio n o f fro n ta l lo b e d e ficits; p ro b le m s w ith p s y c h o m o to r s p e e d , visual s e a rc h a n d s e q u e n c in g , a n d a tte n tio n ; a n d im p a irm e n ts in set shifting. The b a s ic task o f tra il-m a k in g is to c o n n e c t a series o f stimuli (num bers, expressed as n um erals or in w o rd fo rm , a n d letters) in a s p e c i­ fie d o rd e r as fa st as possible. The sco re d e riv e d fo r e a c h trail is th e n u m b e r o f s e co n d s re q u ire d to c o m p le te th e task.

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The te st is h ig hly sensitive to n e u ro lo g ic a l disease, injury or d y s fu n c tio n , in c lu d in g th e su btle n e u ro p s y c h o lo g ic a l d y s fu n c tio n o fte n p re s e n t in in d ivid u a ls w ith le a rn ­ ing disabilities.

72. Psychology

Psychometric tests • Halstead Reitan Neuropsychological Battery: A set o f tests th a t e x a m in e s la n ­ g u a g e , a tte n tio n , m o to r sp e e d , a b s tra c t th in kin g , m e m o ry a n d s p a tia l re a so n in g a n d c a n b e used to p ro d u c e a n o v e ra ll assessm ent o f b ra in fu n c tio n .

• Luria Nebraska Neuropsychological Battery: A set o f se veral tests d e s ig n e d to c o v e r a b ro a d ra n g e o f fu n c tio n a l d o m a in s a n d to p ro v id e p a tte rn analyses o f strengths a n d w eakne sses across d iffe re n t a re a s o f b ra in fu n c tio n .

• Minnesota Multiphasic Personality Inventory (MMPI-2): P ersonality assessm ent o fte n used to a c c o m p a n y n e u ro p s y c h o lo g ic a l tests to assess p e rs o n a lity a n d e m o tio n a l status th a t m ig h t h e lp in u n d e rs ta n d in g in d iv id u a l's re a c tio n s to n e u ro fu n c tio n a l im p a irm e n t.

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Psychometric tests (coni.) • North American Reading Test (NART): R e a d in g te st used to h e lp assess p re m o rb id in te llig e n c e , fo r c o m p a ris o n w ith c u rre n t in te llig e n c e as m e a s u re d b y m o re c o m ­ p re h e n sive tests.

• Ray Osterrieth Complex Figure Test: Analyses a re a s o f visu o sp a tia l a b ility a n d m e m o ry in all ages.

• Rivermead Behavioural Memory Test: E valuates im p a irm e n ts in m e m o ry re la te d to e v e ry d a y real life situations.

• Rorschach Test: In kb lo t te st used to e v a lu a te c o m p le x p s y c h o lo g ic a l d y n a m ic s . Useful as a c o m p le m e n ta ry assessm ent a id in b ra in injury victim s.

• Stroop Test: Brief p ro c e d u re e x a m in in g m e n ta l s p e e d a n d c o n tro l.

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73. Psychology

Psychometric tests •

Bender Visual M otor G estalt Test: E va lua te s v is u a l-p e rc e p tu a l a n d v is u a l-m o to r fu n c tio n in g , re v e a lin g possible signs o f b ra in d y s fu n c tio n , e m o tio n a l p ro b le m s a n d d e v e lo p m e n ta l m a tu rity.

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Them atic A p percep tio n Test: P ro je c tiv e te st m ost w id e ly used to e x a m in e p e r­ so na lity c h a ra c te ris tic s th a t m a y a id in u n d e rs ta n d in g p s y c h o lo g ic a l or e m o ­ tio n a l a d ju s tm e n t to b ra in injury.

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Tower of London: For all ages, assesses h ig h e r-le v e l p ro b le m solving, v a lu a b le fo r e x a m in in g e x e c u tiv e fu n c tio n s a n d s tra te g y p la n n in g .

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Psychometric tests (cont.)

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Trail M akin g Tests: These tests m e a su re a tte n tio n , visual se a rch in g , m e n ta l p ro ­ cessing sp e e d , a n d th e a b ility to m e n ta lly c o n tro l sim u lta n e o u s stimulus p a tte rn s. These tests a re sensitive to g lo b a l b ra in status b u t a re n o t so sensitive to m in or b ra in injuries. See c a rd 71 fo r d e ta ils o f th e C o m p re h e n s iv e Trail M a k in g Test.

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Wisconsin C ard Sorting Test: M easures th e a b ility o f a n in d iv id u a l to lea rn c o n ­ c e p ts. It is a g o o d m e a su re o f th e in te g rity o f fro n ta l lo b e fu n c tio n in g .

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Continuous Perform ance Test: Test re q u irin g intense a tte n tio n to a g iv e n visualm o to r task. Used in assessing sustain ed a tte n tio n a n d fre e d o m fro m d istra ctib ility.

74. Psychology

Cognitive dissonance •

Incongruity or inconsistency b e tw e e n tw o se pa ra te ly held thoughts, beliefs or views w hich are held a t th e sam e tim e. The assum ption is th a t this situation c a n n o t c o n tin ­ ue to exist, d u e to th e distress this causes th e individual. The beliefs/view s are th e re ­ fore review ed a n d reapp ra ised in such a w a y th a t th e dissonance is lessened.

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Reappraisal m ay consist o f c h a n g in g o n e 's notions o f th e opposing views by either d e c id in g to a c c e p t o n e o f th e views a n d ignoring th e o the r or searching for support from others a b o u t o ne o f th e views so a c h ie v in g 'co n sisten cy'. A lte rna tively consis­ te n c y m ay be a c h ie v e d by c h a n g in g b e h a vio u r to suit o ne o f th e views.

Emotion • Cannon-Bard Theory: C o rtica l p e rc e p tio n is th o u g h t to a ffe c t e m o tio n a n d this then leads to se con da ry physiological ch a n g e s w h ich in turn further a ffe c t emotions. The e m o tion a n d physiological e ffe cts m ay o c c u r q u ite se pa ra te ly a n d a t d iffe re n t times.

• James-Lange Theory: The individual's p e rc e p tio n o f physiological ch a n g e s leads to specific e m o tio n a l responses. H ow ever this th eo ry has b e e n c o n te s te d on th e basis th a t p e o p le c a n re a c t differently to th e sam e p e rc e iv e d physiological ch a n g e s a n d th a t som etim es em otions c o m e b e fo re physiological changes.

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Gestalt principles - perceptual organization

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O b je c ts a n d figures in o u r su rroundings a re in te rp re te d b y th e b ra in b y m a k in g a n u m b e r o f g ro u p in g s a n d p re d ic tin g th e w h o le fig u re b a s e d o n th e fra g m e n ts. Irre le va n t in fo rm a tio n fro m th e fie ld o f vision is d is c a rd e d so th a t th e b ra in is n o t in u n d a te d w ith useless in fo rm a tio n . Errors in this pro cess m a y le a d to illusions or h allu cin a tio n s.

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G e n e ra l principles: The w h o le is g re a te r th a n th e sum o f its parts. Law o f c o n tin u ity - in te rru p te d lines a re seen as flo w in g in a c o n tin u o u s w a y . Law o f p ro xim ity - item s d ire c tly n e x t to e a c h o th e r a re p e rc e iv e d as b e in g to g e th e r. Law o f sim ilarity - similar item s a re g ro u p e d to g e th e r. Law o f closure - g a p s a re fille d in w h e n v ie w in g a n in c o m p le te o b je c t so th a t it a p p e a rs as a w h o le

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Figure g ro u n d d iffe re n tia tio n is a n in n a te skill w h ic h allo w s o b je c ts to b e d iffe r­ e n tia te d fro m th e b a c k g ro u n d a n d c a n o c c u r in a n y sensory m o d a lity .

75. Psychotherapy

Defence mechanisms Mature • Altruism: D o in g g o o d to o the rs (a n d n o t a t th e e x p e n s e o f o n e 's o w n h ap pine ss). • Humour: Expressing fe e lin g s th a t a re d iffic u lt to b e a r in such a w a y as to a v o id distress to self or to others.

Є Sublimation: Instincts a re c h a n n e lle d ra th e r th a n d a m m e d u p inside. For e x a m ­ ple, agg re ssion is d ire c te d in to sports a n d g a m e s .

• Suppression: A c o n s c io u s or se m ic o n s c io u s d e c is io n to p o s tp o n e a tte n tio n to a c o n sc io u s im pulse or desire.

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Immature/primitive •

Idealization: U nconscio us a m b iv a le n t desires a re split in to g o o d a n d b a d re p re ­ sentations.

• Introjection: The q u a litie s o f a n o b je c t a re in te rn a lize d . • Splitting: (Klein d e s c rib e d sp littin g a n d p ro je c tio n as d e fe n c e m e ch a n ism s

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• • • •

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o c c u rrin g in th e p a ra n o id schizoid p o sitio n .) O b je c ts a re d iv id e d in to all g o o d or all b a d , id e a liz e d or d e n ig ra te d . Projective identification: The person p ro je c ts a d e n ie d p a rt o f h im /h e rs e lf n o t so m u c h on to b u t 'in to ' a n o th e r p erson a n d e n d s u p b y p o w e rfu lly c o n tro llin g th e re c e iv e r fro m w ith in like a g lo v e p u p p e t (C y n th ia Rogers, 1987). The d e n ie d p a rt c a n b e g o o d or b a d . Passive aggression: Expressing a gg re ssion to w a rd s othe rs th ro u g h passivity, m aso chism or tu rn in g a g a in s t th e self. Turning against the self: U n a c c e p ta b le a g g re ssion to w a rd s othe rs is d ire c te d to w a rd s th e self. Autistic fantasy: E n g a g in g in s e lf-re tre a t in o rd e r to resolve c o n flic t or to o b ta in g ra tific a tio n . In te rp e rso n a l c o m m u n ic a tio n a n d in tim a c y a re re stricte d . Acting out: Expressing a n u n c o n s c io u s desire th ro u g h a c tio n s . A c tin g o u t is a w a y o f d e a lin g w ith a n u n c o n s c io u s th o u g h t th a t is a s s o c ia te d w ith a n u n p le a s a n t a c c o m p a n y in g a ffe c t.

76. Psychotherapy

Neurotic defence mechanisms • Denial: A v o id in g a p a in fu l a s p e c t o f re a lity b y a tte m p tin g to a b o lish it fro m exis­ te n c e .

• Dissociation: T em p o ra rily b u t s ig n ific a n tly c h a n g in g a p e rso n 's c h a r a c te r in o rd e r to a v o id e m o tio n a l distress. Seen in d is s o c ia tiv e fu g u e /c o n v e rs io n disor­ ders.

• Displacement: Shifting a n e m o tio n or d riv e fro m o n e id e a o n to a n o th e r w h ic h is sim ilar to th e o rigin al.

• Intellectualization: Using in te lle c tu a l th o u g h ts or id e a s e xcessively to a v o id dis­ tressing e m o tio n a l e x p e rie n c e s . The p erson m a y a v o id in tim a c y b y p la c in g excess im p o rta n c e o n in a n im a te in te lle c tu a l items. A tte n tio n is g iv e n e xcessive ­ ly to e x te rn a l re a lity in o rd e r to a v o id expression o f inn er feelings.

• Isolation: S plitting o ft a n id e a fro m th e u n p le a s a n t fe e lin g (s ) th a t a c c o m p a n y it (repressed feelings).

• Reaction formation: B e h a v in g in a w a y th a t is o p p o s ite to u n a c c e p ta b le in stin c­ tu a l impulses.

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Neurotic defence mechanisms • Rationalization: R atio n a l e x p la n a tio n s a re o ffe re d fo r u n a c c e p ta b le b e h a v io u r in a n a tte m p t to a v o id th e u n p le a s a n t fe e lin g s a s s o c ia te d w ith fa c in g th e re a li­ ty th a t th e b e h a v io u r w a s w ro n g .

• Regression: A b a n d o n in g a d u lt fu n c tio n in g a n d g o in g b a c k to a c h ild -lik e state. This c a n b e h e a lth y so m e tim e s b u t n o t w h e n it is excessive a n d in th e c o n te x t o f e v e ry d a y life. A d ults m a y regress to a ch ild -lik e s ta te fo llo w in g th e d e a th o f a lo v e d o n e fo r e x a m p le .

• Repression: U n p le a s a n t fe e lin g s a re re m o v e d or p re v e n te d fro m e n te rin g c o n ­ sciousness.

• Somatization: U n p le a s a n t u n c o n s c io u s fe e lin g s a re m a n ife s t in th e fo rm o f phys­ ic a l c o m p la in ts .

• Undoing: M ost c o m m o n in p e o p le w ith O C D . O fte n re fe rre d to as 'm a g ic a l u n d o in g '. The p erson has u n p le a s a n t th o u g h ts th a t h e /s h e feels th e y h a v e p e r­ p e tr a te d a n d will th e n say or d o s o m e th in g in o rd e r to reverse this w ro n g d o in g .

• Identification with the aggressor: In o rd e r to d e a l w ith th e p a in o f b e in g tre a te d b a d ly b y so m e o n e , th e person tre a ts s o m e o n e else similarly b a d ly . Such a m e c h ­ anism is th o u g h t to o c c u r in p a re n ts w h o th e m se lve s w e re a b u s e d in th e ir c h ild ­ h o o d a n d s u b se q u e n tly g o o n to a b u s e th e ir o w n c h ild re n .

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77. Psychotherapy

Defence mechanisms in specific conditions Obsessive-compulsive disorder - mnemonic: U R I M a g ic a l U nd oin g. R e a c tio n fo rm a tio n . Isolation.

Paranoid states and borderline personality disorder - mnemonic: P S P ro je c tiv e id e n tific a tio n . S plitting.

Phobic disorders •

A ffe c tiv e d is p la c e m e n t.

Anxiety disorders -mnemonic: D I P D enial. Id e n tific a tio n . P ro je ction .

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Freud’s models of the mind Structural model • Id: In stinctua l drives - h u n g e r sex, aggression. • Ego: The p a rt o f th e m in d in v o lv e d in ra tio n a l th in k in g a n d a c ts as a g o -b e tw e e n serving to b a la n c e th e d e m a n d s o f th e Id a g a in s t th e s u p e re g o a n d th e e x p e c ­ ta tio n s o f th e o u tsid e w o rld .

• Superego: Part o f th e m in d w h ic h carries m o ra l v a lu e s a n d is re la te d to in g ra in e d p a re n ta l figures.

Topographical model • Conscious: Part o f th e m in d in w h ic h p e rc e p tio n s c o m in g fro m th e o u ts id e w o rld a re b ro u g h t into aw a re n ess.

• Preconscious: M e n ta l e v e n ts a n d processes b ro u g h t in to th e m in d b y fo c u s in g a tte n tio n . S e c o n d a ry pro cess th in k in g o c c u rs in th e p re c o n s c io u s a n d c o n scio u s (utilizes lo g ic).

• Unconscious: C losely re la te d to in stin ctu a l drives. D y n a m ic system o p e ra tin g to k e e p m e n ta l c o n te n ts a n d processes fro m c o n s c io u s a w a re n e s s th ro u g h c e n ­ sorship or repression. Prim ary pro cess th in k in g o c c u rs in th e u n c o n s c io u s (as in dre am s).

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78. Psychotherapy

Melanie Klein •

S tu d ie d her o w n c h ild re n s ' p la y. The c h ild re n s ' p la y a c tiv ity w as in te rp re te d fro m a n e a rly a g e (1 -2 years) as h a v in g s y m b o lic m e a n in g in th e c o n te x t o f th e u n co n s c io u s m in d. Klein w a s th e first p s y c h o a n a ly s t to v ie w c h ild re n 's p la y as a m e a n in g fu l a c tiv ity . Klein v ie w e d in fa n tile 'p h a n ta s y ' as a n im p o rta n t p a rt o f d e v e lo p m e n t, She also d e v e lo p e d th e c o n c e p t o f p ro je c tiv e id e n tific a tio n in her th eo rie s a n d d e s c rib e d th e 'd e a th in s tin c t' w h ic h she re la te d to in stin ctu a l drives.

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Klein d escrib e s th e e arlie st sta g e s o f in fa n tile p s y c h ic life in te rm s o f successful c o m p le tio n o f d e v e lo p m e n t th ro u g h two positions - paranoid-schizoid a n d depressive positions. A p o sitio n is a set o f p s y c h ic fu n c tio n s th a t c o rre s p o n d to a p h a se o f d e v e lo p m e n t, a p p e a rin g d u rin g th e first y e a r o f life a n d w h ic h c a n b e r e a c tiv a te d a t a n y tim e la te r on in life.

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Melanie Klein (cont.) • Paranoid-schizoid position: O b je c ts a re d iv id e d in to all g o o d or all b a d in th e process o f 's p littin g ' (a n u n c o n s c io u s process). S plitting o c c u rs in th e e g o a n d in th e o b je c t. O b je c ts a re 'p a rt o b je c ts ' such as th e m o th e r's breasts w h ic h m a y b e split into th e 'g o o d b re a s t' w h ic h p ro v id e s th e milk a n d th e 'b a d b re a s t' w h ic h d o e s n o t p ro v id e milk. The p a ra n o id -s c h iz o id p o sition is n a m e d as such b e c a u s e Klein p o s tu la te d th a t infan ts in this p o sition a re in a c o n s ta n t s ta te o f p a ra n o id a nxiety.

• Depressive position: Klein p o s tu la te d th a t th e in fa n t m o v e d into th e depressive position b y a b o u t 6 m on ths o f a g e . The in fa n t learns u nco n scio u sly to re c o g n iz e th a t g o o d a n d b a d c a n co e xist a n d no lo n g e r splits all o b je c ts into e ith e r all g o o d or all b a d . Klein d escrib e s a d ep ressive a n x ie ty th a t th e in fa n t has a b o u t his/her o w n aggressive fe eling s to w a rd s th e c a re g iv e r d u rin g this a m b iv a le n t p e rio d . The m o th e r is no lo n g e r split into in te rn a l a n d e x te rn a l o b je c ts a n d this c re a te s th e sta te o f depressive a n x ie ty (n o t th e sa m e as d e p re s s io n /a n x ie ty in a d u lth o o d ). •

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Klein d e s c rib e d th a t a person rem ains in a s ta te o f flux b e tw e e n th e p a ra n o id schizoid p osition a n d th e d e p re ssive p osition th ro u g h o u t th e ir life. P e o p le in p a r a ­ n o id states such as psychosis or e x tre m e a n x ie ty m a y re v e rt to th e p a ra n o id schizoid p osition utilizing p rim itiv e d e fe n c e m e ch a n is m s o f sp littin g a n d p ro je c ­ tiv e id e n tific a tio n .

79. Psychotherapy

C.G. Jung - Theory of Mind • Collective unconscious: E x p a n d e d o n F reud's c o n c e p t o f th e u n co nsciou s, d e s c rib in g a to p o g r a p h ic a l m o d e l w ith a 'c o lle c tiv e u n c o n s c io u s ' co nsisting o f all h u m a n k in d 's c o m m o n sh a re d m y th o lo g ic a l a n d s y m b o lic past. Ju n g re je c t­ e d F reud's c o n c e p ts a b o u t in fa n tile se xua lity a n d re je c te d th e stru ctu ra l m o d e l.

• Archetypes: The c o lle c tiv e u n c o n s c io u s c o n ta in s a rc h e ty p e s - im a g e s th a t re p ­ resent th ese m y th o lo g ic a l a n d s y m b o lic a s p e c ts o f h u m a n s past. Such a rc h e ­ ty p e s in c lu d e th e im a g e o f th e m oth er, fa th er, hero, s h a d o w a n d se veral others.

• Complexes: A rc h e ty p e s a re a s s o c ia te d w ith 'c o m p le x e s ' - id e a s th a t result fro m p e rso n a l e x p e rie n c e s a n d a ffe c te d b y a rc h e ty p e s . For e x a m p le , a c h ild m a y h a v e a n a rc h e ty p a l u n c o n s c io u s im a g e o f w h a t a fa th e r is. His a c tu a l e x p e ri­ e n c e o f his fa th e r a n d h o w it re lates to th e a rc h e ty p a l im a g e a ffe c t th e fo rm a ­ tio n o f a 'c o m p le x ' in th e c h ild 's m in d . J u n g w a s n o t in v o lv e d in d e v e lo p in g c o n ­ c e p ts such as inferio rity c o m p le x (a c o m m o n e x a m q u e s tio n ).

157

C.G.Jung - theory of mind (cont.) • Personality types: J u n g n o tic e d tw o ty p e s o f p e rs o n a lity - introversion a n d e x tro ­ version. Introverts fo c u s o n th e ir inner w o rld o f th o u g h ts a n d e m o tio n s, Extroverts fo c u s o n th e o u te r w o rld , o th e r p e o p le a n d m a te ria l items.

• Persona: Ju n g d e s c rib e d th e p e rs o n a - a m ask c o v e rin g th e p e rs o n a lity - th e fa c e th e person presents to th e o u ts id e w o rld . The p e rs o n a m a y b e c o m e fixe d a n d th e real person c a n b e c o m e h id d e n fro m th e person.

• Animus and Anima: U n co nscio us traits h e ld b y w o m e n a n d m e n re s p e c tiv e ly a n d th a t c o n tra s t w ith th e p e rso n a . A nim us - w o m a n 's u n d e v e lo p e d m asculinity, A n im a - m a n 's u n d e v e lo p e d fe m in in ity.

• Individuation - th e a im o f J u n g ia n th e ra p y is fo r p e o p le to a c c o m p lis h th e ir full c re a tiv e p o te n tia l. This s ta te is re fe rre d to as in d iv id u a tio n - th e p rocess b y w h ic h a person a tta in s a u n iq u e sense o f th e ir id e n tity .

158

80. Psychotherapy C ognitive behavioural therapy in depression •

16-20 sessions.

•

Initial Aim: Assessm ent a n d p ro b le m id e n tific a tio n .

Techniques: Behavioural •

B e h a vio u ra l assignm e nts a re g iv e n to ta c k le m o tiv a tio n a l a n d b e h a v io u ra l d eficits.

•

A c tiv ity s c h e d u lin g - a p la n lo o k in g a t re la tio n s h ip b e tw e e n a c tiv ity a n d m o o d .

•

M aste ry a n d p le a su re tasks - se lf-m o n ito rin g o f d e g re e o f p le a s u re /s e n s e o f m as­ te ry a s s o c ia te d w ith a c tiv ity - a n a n tid o te to d ic h o to m o u s th inking .

•

G ra d e d task assignm e nts - b re a k in g g o a ls in to subtasks.

•

R elapse p re v e n tio n w ork.

159

Cognitive behaviour therapy in depression (cont.)

Techniques (cont.) Cognitive •

Id e n tify in g a n d m o d ify in g n e g a tiv e a u to m a tic th o u g h ts - e v id e n c e lo o k e d a t/a lte r n a tiv e e x p la n a tio n s o ffe re d /a d v a n ta g e s a n d d is a d v a n ta g e s to a w a y o f th in kin g /e rro rs in th inking , e g d ic h o to m o u s th inking .

•

Id e n tify in g a n d m o d ify in g d y s fu n c tio n a l b eliefs - H ow d id I d e v e lo p th ese beliefs? In w h a t w ays a re th e se beliefs u n h e lp fu l?

•

G u id e d d is c o v e ry - P a tie n t d isco vers p ro b le m s fo r them selves.

•

S o c ra tic q u e s tio n in g - D e sig n e d to p ro m o te insight a n d ra tio n a l d e c is io n ­ m a kin g .

Factors associated with a successful outcome from CBT

160

•

A c c e p t a n c e o f th e c o g n itiv e m o d e l.

•

W illingness to e n g a g e in se lf-h e lp assignm ents.

•

A b ility to fo rm a c o lla b o ra tiv e a llia n c e w ith th e th e ra p ist.

81. Psychotherapy

Cognitive analytic therapy •

16-24 sessions.

•

B ased o n 'r e c ip r o c a l ro le re p e rto ire s ' v ic tim /b u lly , a b a n d o n in g /a b a n d o n e d .

•

P e o p le w ith b o rd e rlin e p e rs o n a lity d is o rd e r te n d to sw itch ra p id ly b e tw e e n roles d u e to a c o m p ro m is e d c a p a c it y to r se lf-re fle c tio n .

•

The th e ra p is t fo cuse s o n re c u rre n t fa u lty s e q u e n c e s w h ic h arise fro m re c ip ro c a l roles a n d p oints o u t th e s y m p to m a tic c o n s e q u e n c e s o f these.

-

te m p la te s

s to re d

e a rly

on,

eg

161

Brief psychodynamic psychotherapy

162

•

10-25 sessions.

•

Aim s to b rin g u n co n s c io u s e m o tio n s a n d m o tiv a tio n s in to th e co n s c io u s m ind.

•

E ffectiveness is e n h a n c e d by: — A n e a rly p ositive th e ra p e u tic a llia n c e . — Extent o f th e ra p is t a c tiv ity . — P ro m p t a d d re ssing o f n e g a tiv e tra n sfe re n ce s. — F ocused w o rk w ith in tra p s y c h ic a n d in te rp e rs o n a l c o n flic t o f c e n tra l im p o r­ ta n c e to p atie nts.

82. Psychotherapy C ognitive behavioural therapy in psychosis

Main aims are 1. Engagement: — O b ta in a th e ra p e u tic a llia n c e . — Be n o n -c h a lle n g in g . — Listening. — O ffe r p ra c tic a l c o p in g stra te g ie s fo r distressing s y m p to m s such as a u d ito ry h a l­ lu c in a tio n s or delusions.

2. Gain a sense of the person’s experience of their illness: — O n set a n d d u ra tio n o f s y m p to m s such as vo ice s. — Explore b eliefs fo rm e d fro m ju m p in g to c o n clu sio n s.

3. Discover if there is a delusional mood state: — Externalizing bias. — Delusions o f re fe re n c e .

163

Cognitive behavioural therapy in psychosis (cont.)

Main aims are (cont.) 4. Reduce stress level through psychoeducation: — M o d ify in g beliefs. — O ffe r a lfe rn a tiv e e x p la n a tio n s a n d su g g e st c o p in g stra te g ie s a lo n g w ith these.

5. Check patient has accepted that the brain can make mistakes: — O n c e p a tie n t has a c c e p te d this c o n c e p t, it m a y b e possible to b e g in to m o d ify th e ir beliefs.

164

83. Dementia syndromes

Lewy body dementia •

M>F. O n se t usually in sixties or seventies.

•

Presents initially w ith e x tra p y ra m id a l fe a tu re s, d e m e n tia or p s y c h o tic sym ptom s. As disease progresses, d e m e n tia a n d e x tra p y ra m id a l fe a tu re s in crea se .

•

D e m e n tia is m a in ly o f c o rtic a l ty p e w ith p ro gressive w o rs e n in g o f m e m o ry a n d d e v e lo p m e n t o f dysp h a sia , d y s c a lc u lia a n d d ysp ra xia .

•

D a y -to -d a y flu c tu a tio n s in m e n ta l c o m p e te n c e a re o b s e rv e d in m a n y sufferers. Lucid p e rio d s w ith n e a r n o rm a l m e m o ry a re seen until la te in th e co u rse o f th e disease.

•

P ro m in e n t b e h a v io u ra l d is tu rb a n c e s w ith p s y c h o tic sym pto m s, in c lu d in g a u d i­ to ry a n d visual h a llu c in a tio n s , a re c o m m o n .

•

P a ra n o id delusions a n d se ve re d e p re ssio n m a y also o c c u r.

165

Lewy body dementia (cont.) •

P arkinsonian fe a tu re s a re c o m m o n - rigidity, tre m o r a n d b ra d ykin e sia , m ask-like fa c ie s a n d s to o p e d p osture.

•

Postural h y p o te n s io n a n d falls as w e ll as u n e x p la in e d loss o f consciousness a re fre q u e n tly seen.

•

A c u te o rg a n ic re a c tio n s a re seen in c lu d in g a c u te c o n fu s io n a l states.

•

F lu c tu a tin g co urse as w e ll as v is u a l/a u d ito ry h a llu c in a tio n s a n d c lo u d in g o f c o n ­ sciousness distinguish Lew y b o d y d e m e n tia fro m A lzh e im e r's disease. Depression is also m o re c o m m o n th a n in A lzheim er's. P atients w ith Lew y b o d y d e m e n tia d o w orse on tests o f fro n ta l lo b e fu n c tio n a n d v isu o sp a tia l tasks c o m p a r e d to A lzh eim er's disease sufferers.

•

Lew y b o d y p a tie n ts a re h ig h ly s u s c e p tib le to re a c tio n s fro m n e u ro le p tic s such as h a lo p e rid o l or c h lo rp ro m a z in e , w h ic h shou ld th e re fo re b e a v o id e d .

• Pathological findings: Lew y b o d ie s (ro u n d e d e o s in o p h ilic inclusions w ith in n e u ­ rones) in th e c o rte x , s u b s ta n tia nigra, b ra in s te m n u c le i a n d b a sa l fo re b ra in regions.

166

84. Dementia syndromes

Multi-infarct dementia e

M=F.

•

Usual o n se t - la te sixties or seventies.

•

There is usually a history o f h y p e rte n s io n , stroke or Ml or o th e r v a s c u la r disease. O n se t is usually s u d d e n a n d fo llo w in g o n fro m a v a s c u la r e v e n t.

•

If o n se t is g ra d u a l, changes.

•

Physical c o m p la in ts a re c o m m o n in c lu d in g h e a d a c h e s , dizziness, tinnitus or syn­ cope.

•

C lo u d in g o f consciou sne ss as w ell as flu c tu a tio n s in se verity o f c o g n itiv e im p a ir­ m ents a re c o m m o n fe a tu re s.

p e rs o n a lity c h a n g e s o fte n

p re c e d e

o n s e t o f m e m o ry

167

M ulti-infarct dementia (cont.) •

P ersonality m a y b e w e ll p re s e rv e d until la te in th e disease. P a tc h y p s y c h o lo g ic a l d e fic its a re c o m m o n h o w e v e r.

•

M ost im p o r ta n t c h a r a c te r is tic - s te p w is e p ro g re s s io n o f illness, u n like A lzh eim er's disease w h e re th e re is a s m o o th e r progression o f th e illness.

in

• EEG changes: Similar to A lzh e im e r's disease. Early in disease, re d u c tio n o f a lp h a a c tiv ity o ccurs. Later in th e disease, d iffu se slow w a v e s o ccu r, usually irre gu la r th e ta a c tiv ity w ith e p is o d ic d e lta a c tiv ity .

• Pathology: L oca lize d or g e n e ra liz e d a tro p h y , v e n tric le s m a y b e d ila te d . Both sm all a n d la rg e vessels a re a ffe c te d w ith th ic k e n e d w alls a n d to rtu o u s a p p e a r ­ a n ce s. A rte rio s c le ro tic c h a n g e s a re likely to b e seen in th e b o d y . •

168

D ifficu lt to distinguish b e tw e e n m u lti-in fa rc t d e m e n tia a n d A lzh e im e r's disease. M u lti-in fa rc t d e m e n tia is m o re likely if th e re is a flu c tu a tin g course, ste pw ise d e te ­ rioration, history o f is c h a e m ic v a s c u la r e v e n t/d is e a s e , a s s o c ia te d n e u ro lo g ic a l sym ptom s/signs. The H achinski Is c h a e m ic In dex c a n b e used to distinguish b e tw e e n th e m .

85. Dementia syndromes

Pieies disease • F>M. Relatively uncommon (around 1-5% of all dementias). • Peak onset 50-60 years of age (earlier than Alzheimer's disease). • Initial features include changes suggestive of frontal lobe damage, with changes in personality and social behaviour. • Amotivation and changes in behaviour with socially inappropriate or insensitive behaviour. Social misconduct and poor judgement leading to stealing or sexual misadventures may occur. • As the disease progresses, memory and intellectual impairment become promi­ nent. • Mood changes including fatuous affect, euphoria or apathy may be inter­ spersed between periods of restlessness and overactivity.

169

Pick’s disease •

170

P erseveration o f s p e e c h w ith s te re o ty p e d re p e titio n o f short w o rd s or phrases is com m on.

•

D yph asia m a y o c c u r a n d c a n progress to in c o h e re n t w o rd s or m utism .

•

C e rta in fe a tu re s distinguish Pick's disease fro m A lzh e im e r's - see c a rd 163.

•

EEG: M a y b e n o rm a l a n d less o fte n show s a b n o rm a litie s c o m p a r e d to A lzh eim er's disease. N o n -s p e c ific c h a n g e s usually o c c u r w h ic h m a y b e similar to th e p ic tu re in A lzh e im e r's disease.

•

P a th o lo g y: Pick b o d ie s - irre gu la r fila m e n to u s inclusions w ith in neurones, w h ic h a re a rg e n to p h ilic a n d im m u n o re a c tiv e to ta u a n d u b iq u itin a n tib o d ie s o ccu r. H irano b o d ie s - e o s in o p h ilic inclusions m a y o c c u r. V e n tric u la r d ila ta tio n , g e n e r­ alize d a tro p h y a n d shrinking o f te m p o ra l a n d fro n ta l lob es m a y o c c u r.

86. Dementia syndromes

Frontal lobe dementia •

M=F. Usual o n se t in fifties.

•

C h a ra c te riz e d b y p e rs o n a lity c h a n g e s w ith d isin hibitio n, im pulsivity, p o o r ju d g e ­ m e n t in a b ility to c a rry o u t tasks a n d a p a th y . They m a y b e s o cia lly in a p p ro p ria te w ith la c k o f e m p a th y fo r others.

•

P e rseve ra tion a n d u tiliza tion b e h a v io u r (te n d e n c y to p ic k u p a n y th in g w ith in th e visual fie ld to p la y w ith ).

•

T e n d e n c y fo r excess o ra l s a tis fa c tio n - o v e re a tin g , e a tin g sw eets excessively.

•

A b o u t 35% h a v e a fa m ily history. O th e rw is e a e tio lo g y u n cle a r. Possible a s s o c ia ­ tio n w ith c h ro m o s o m e 17 has b e e n su g g e s te d .

• Pathology: Frontal lo b e a tro p h y , c e llu la r loss in layers III a n d IV o f th e c o rte x .

171

Creutzfeld-Jakob disease (CJD) •

172

C ha racterized by m em ory changes, confusion a n d disorientation initially. As th e dis­ ease advances, a slowly worsening d e m e n tia develops. C ereb e lla r a ta xia a nd ch o re o a th e to id m ovem ents m ay occur. M yoclonus occurs in aro un d 80% o f cases. Extrapyram idal signs, dysarthria, akin etic mutism a n d c o rtic a l blindness m ay d eve lo p.

•

M=F. Usual a g e of onset is over 40. Extremely rare - only 1-2/m illion pop ulatio n .

•

90% o f cases are d u e to spontaneous m utations in th e prion protein on chrom osom e 20 - these are referred to as sporad ic CJD. Prion is a protein p a rticle th a t is infectious a n d very resistant to d e g ra d a tio n . C og nitive ch an ge s o c c u r earlier in sporadic CJD c o m p a re d to new va rian t CJD (nvCJD). Sporadic CJD also tends to a ffe c t younger p e o p le m ore o fte n th a n nvCJD. O ther types inclu de fam ilial (in c o m p le te p e n e tra n c e m eans carriers prognosis is b e tte r th a n in sporadic CJD a n d will likely live m uch longer) a n d iatro ge n ic (co rn e a l g ra ft procedures). nvCJD usually lasts longer (10-15 m onths) th an CJD (4-5 months).

•

New variant CJD occurs in a younger a g e group (around a g e 30) a n d is associated with consum ption of b e e f in fe cte d with bovine spongiform e n c e p h a lo p a th y (BSE, p o p ­ ularly te rm e d 'm a d c o w disease' by the press). It is usually characterized by a prodrom e of depression (most com m on), anxiety, a p a th y or aggression. Only a b o u t 15% have neurological problems, unlike in sporadic CJD w here these symptoms are m uch m ore com m on. Eventually cerebellar ataxia, m yoclonus a n d d e m e n tia d evelop.

87. Dementia syndromes

Alzheimer’s dementia •

M ost c o m m o n d e m e n tia re p re s e n tin g a b o u t tw o -th ird s o f all d e m e n tia s .

•

C h a ra c te riz e d b y m n e m o n ic 5 A’s - A m n esia (m e m o ry loss), A p h a s ia (o r dys­ pha sia ), A p ra xia (or d ysp ra xia ), A n o m ia , A p a th y c o m m o n ly . Frontal lo b e in v o lv e ­ m e n t m a y le a d to sy m p to m s m e n tio n e d o n c a rd 86. A p a th y o c c u rs e a rly o n in th e illness w h ile insight is re la tiv e ly w e ll p re s e rv e d . As th e d ise ase progresses, a p a ­ th y a n d b e h a v io u ra l a n d p s y c h o lo g ic a l s y m p to m s o f d e m e n tia b e c o m e m o re c o m m o n . Psychosis o c c u rs in 20-25% o f cases in th e first y e a r fro m d ia g n o sis a n d 50% in th e first 4 years.

•

P re v a le n c e is a p p ro x im a te ly 0.5% in 6 0 -7 0 y e a r olds a n d 10% in 80-90 y e a r olds. A v e ra g e life e x p e c ta n c y is 5 -1 0 years. Poor pro gn osis is a s s o c ia te d w ith e a rly onset, severe c o g n itiv e d y s fu n c tio n a n d p s y c h ia tric sym p to m s in c lu d in g psy­ chosis or depression.

• Risk factors include: In cre a sin g a g e , fa m ily history o f A lzh e im e r's dise ase or P arkinson's disease, m ild c o g n itiv e im p a irm e n t, h e a d injury, le a rn in g disability, D o w n 's syn drom e, v a s c u la r d ise ase or risk fa c to rs fo r v a s c u la r disease.

173

Alzheimer’s dementia (cont.) • Protective factors include: High e d u c a tio n a l a tta in m e n t sm oking, n o n -s te ro id a l a n ti-in fla m m a to ry dru gs (NSAIDs).

• Pathological findings: N eu ro fib rilla ry ta n g le s c o n ta in in g ta u p ro te in a n d a m y lo id p la q u e s c o n ta in in g a m y lo id . N e u ro fib rilla ry ta n g le s a re n o t s p e c ific fo r A lzh eim er's a n d o c c u r in s u b a c tu e sclerosing p a n e n c e p h a litis as w ell as d e m e n ­ tia p u g ilis tic a (p u n c h d ru n k s yn d ro m e ). A m y lo id p la q u e s also o c c u r in n o rm a l a g e in g , CJD a n d D o w n 's s yn d ro m e . Lew y bod ie s, H irano b od ie s, g ra n u lo v a c u o la r d e g e n e ra tio n o f n e u ro n e s a n d a s tro c y te p ro life ra tio n also o c c u r.

• Genetic factors: A p o lip ro te in E4 (o n c h ro m o s o m e 19) is a s s o c ia te d w ith a 20 tim es g re a te r c h a n c e o f d e v e lo p in g th e disease if h o m o z y g o u s or 5% in c re a s e d c h a n c e if hete ro zyg o u s. A g e o f o n s e t d e c re a s e s w ith in cre a s in g n u m b e rs o f A p o E4 alleles. M u ta tio n in a m y lo id p re cu rso r g e n e o n c h ro m o s o m e 21 is a s s o c ia te d w ith e a rly o n se t fa m ilia l A lzh e im e r's d isease in 20% o f cases. M a y b e in h e rite d in a n a u to s o m a l d o m in a n t fashio n. Presenilin g e n e 1 o n c h ro m o s o m e 14 a n d presenilin g e n e 2 on c h ro m o s o m e 1 h a v e also b e e n im p lic a te d in e a rly o nse t A lzh eim er's disease.

174

88. Human development Erickson’s stages of social and psychological development Age

Stage

In fa n c y

Trust vs. mistrust

2-

3

A u to n o m y vs. s h a m e a n d d o u b t

3 -5

In itia tiv e vs. g u ilt

6-11

Industry vs. inferio rity

A d o le s c e n c e

Id e n tity vs role c o n fu s io n

Early a d u lth o o d

In tim a c y vs. isola tion

M id d le a g e

G e n e r a l i t y vs. s ta g n a tio n

O ld a g e

In te g rity vs. D esp air

175

Freud’s stages of human development Age

Stage

Features

Birth to 1 y e a r

O ral p h a s e

G ra tific a tio n via oral m e a n s

1-3

A nal phase

G ra tific a tio n via d e fe c a tio n

3 -5

Phallic p h a s e

Expansion o f o e d ip a l fa ntasies

5-12

L a te n t p h a s e

In fa n tile s ta g e o f sexuality e nd s w ith repression o f O e d ip u s c o m p le x

12-20

P u be rty

Sexual drives a re re a w o k e n

Freud b e lie v e d th a t in o rd e r to fu n c tio n n o rm a lly as a n a d u lt it is n ece ssary fo r a n in d iv id u a l to pass th ro u g h e a c h o f th e se sta ge s successfully.

176

89. Human development

Developmental milestones Birth to 1 month:

7 months

•

H a n d to m o u th reflex.

•

Sits ste a d ily.

•

G ra sp in g reflex.

•

•

R oo tin g reflex.

S tra n g e r a n x ie ty b e g in s a n d is e s ta b ­ lished b y 8 m onths.

•

M o ro reflex.

•

G rasps a n d transfers toys.

•

Babinski reflex.

•

•

R esponds to m o th e r's fa c e .

Starts to im ita te m o th e r's sounds a n d a c tio n s .

1 year

4 months

•

W alks w ith su p p o rt.

•

Starts to use single w ords.

Visual a c c o m m o d a tio n .

•

S tands a lo n e b riefly.

•

Follows a m o v in g o b je c t.

•

Seeks n o v e lty .

•

A w a re o f s tra n g e situations.

•

S p o n ta n e o u s so cia l smile.

• •

Holds h e a d fro m others.

b a la n c e d

w ith o u t a id

177

Developmental milestones (cont.) 18 months • Coordinated walking. • Walks up stairs with one hand held. • Builds a tower of three or four cubes. • Scribbles spontaneously and imitates writing. • Builds tower of three cubes. • Two-word utterances. • Understands 150 words.

2 years • Runs without falling. • Kicks large ball. • Goes up and down stairs alone. • Builds a tower of six/seven cubes. • Able to use sentences.

178

• Separation anxiety starts to go away. • Refers to self by name and says 'no' to mother.

• Counts three objects. • Copies a cross.

3 years

• Skips using feet alternately. • Dresses and undresses unassisted. • Able to tell a story. • Counts ten objects correctly. • Copies a square. • Draws a recognizable person. • Writes few letters.

• Rides tricycle. • Puts on shoes and able to undo buttons. • Alternates feet going up steps. • Feeds self unassisted. • Builds tower of 9-10 cubes. • Understands up to 3500 words.

4 years • Able to stand on one foot. • Repeats four digits. • Understands wide range of grammar.

5 years

6 years • Rides two-wheel bicycle. • Ties shoelaces. • Good articulation of ideas/thoughts. • Copies triangle. • Writes name.

90. Human development

Margaret Mahler - separation individuation stages Normal autism (birth to 2 months) •

Periods o f sleep o u tw e ig h periods o f arousal in a state similar to intrauterine life.

Symbiosis (2-5 months) •

Infant a b le to distinguish inner w orld from o ute r w orld as a result o f d e v e lo p in g p e r­ c e p tu a l abilities.

Differentiation (5-10 months) Є Progressive neu ro log ica l d e v e lo p m e n t a n d increased alertness d ra w infant's a tte n ­ tion a w a y from self to th e o ute r world. Physical a n d p s ych o lo g ica l distinctness from m other starts to form .

Practising (10-18 months) •

C hild's e xploration o f th e w orld increases as he/she is a b le to m ove ind e p e n d e n tly.

Rapproachment (18-24 months) Є As child realizes his/her helplessness a n d d e p e n d e n c e , th e n e e d for in d e p e n d e n c e alternates w ith th e n e e d for closeness. Child m oves a w a y from his/her m oth er a n d com es b a c k for reassurance.

179

Object constancy (2-5 years) •

C hild g ra du ally begins to c o m p re h e n d a n d is reassured by th e p e rm a n e n c e o f th e m other a n d other im p o rta n t p eo ple, even w hen n o t in their presence.

Emotional development in infancy and childhood

180

Age

Emotional capacity and expression

Birth

Pleasure, surprise, disgust, distress

6 -8 w eeks

Jo y

3 -4 m on ths

Anger

8 -9 m on ths

Sadness, fe a r

12-18 m on ths

T ender a ffe c tio n , s h a m e

24 m on ths

Pride

3 -4 years

Guilt, e n v y

5 -6 years

Insecurity, hum ility, c o n fid e n c e

91. Human development Kohlberg - stages of moral development

Level I: Preconventional morality - up to 10 years old # Stage 1: P u nishm ent o rie n ta tio n - rules a re o b e y e d to a v o id p u n ish m e n t. # Stage 2: R e w a rd o rie n ta tio n - rules a re o b e y e d in o rd e r to o b ta in rew ards.

Level II: Conventional morality Є Stage 3: In te rp e rso n a l re la tio n s - c o n fo rm s to ru le s /e x p e c ta tio n s o f fa m ily /frie n d s to a v o id d is a p p ro v a l b y others.

# Stage 4: R e s p e c t fo r a u th o rity a n d s o cia l o rd e r - a u th o rity is o b e y e d in o rd e r to a v o id fe e lin g s o f g u ilt a n d to u p h o ld so c ia l order.

181

Kohlberg - stages of moral development (cont.) Level III: Postconventional morality • Stage 5: Social c o n tr a c t o rie n ta tio n - u p h o ld s p rin c ip le s a g re e d as essential fo r s o c ie ty to fu n c tio n w hilst still re c o g n iz in g th a t d iffe re n t p e o p le h a v e d iffe re n t view s a n d law s c a n b e c h a n g e d .

• Stage 6: U n iv e rs a l/e th ic a l p rin ic ip le o rie n ta tio n - ju s tic e is v a lu e d a b o v e rules, so th e re is a re c o g n itio n o f universal p rin c ip le s re s p e c tin g th e rights o f all ind ivid u a ls b a s e d o n values, e q u a lity , d ig n ity a n d ju stice . Rules a re o b e y e d to a v o id selfc o n d e m n a tio n .

182

92. Human development

Jean Piaget - characteristics achieved at each stage Sensorimotor (birth to 2 years) Є Object permanence: A b ility to u n d e rs ta n d th a t o b je c ts h a v e a n e x is te n c e b e y o n d th e c h ild 's in v o lv e m e n t w ith th e o b je c t, so w h e n c h ild le a v e s ro o m u n d e rs ta n d s e v e n th o u g h h e /s h e c a n n o lo n g e r see th e o b je c t, e g chair, it is still in th e room . • Symbolization: Infants a re a b le to c r e a te a visual im a g e o f a n o b je c t such as a b a ll to s ta n d fo r a rea l o b je c t.

Preoperational thought (2-7 years) • Symbolic thinking: C o n c e p ts a re p rim itiv e a n d c h ild re n a t this s ta g e a re u n a b le to th in k lo g ic a lly .

• Immanent justice: They b e lie v e th a t p u n is h m e n t fo r b a d b e h a v io u r is in e v ita b le (rules a re in v io la te ).

Є Egocentric: U n a b le to u n d e rs ta n d o th e rs ' p o in ts o f views, th e y see th e m se lve s as th e c e n tre o f th e universe.

• Phenomenalistic causality: Events th a t o c c u r to g e th e r a re th o u g h t to b e in te r­ c o n n e c te d , e g b a d th o u g h ts c a u s in g a c a ta s tro p h ic e v e n t.

• Animistic thinking: T e n d e n c y to e n d o w p h y s ic a l o b je c ts a n d e v e n ts w ith psy­ c h o lo g ic a l a ttrib u te s such as fe e lin g s a n d inten tion s.

183

Jean Piaget - characteristics achieved at each stage Concrete operational stage (7-11 years) • Operational thought: R e p la c e s e g o c e n tric th o u g h t - c h ild re n a re n o w a b le to see th ings fro m s o m e o n e else's p e rs p e c tiv e .

• Syllogistic reasoning: L o g ic a l co n c lu s io n s a re fo rm e d fro m tw o premises. • Conservation: The a b ility to re c o g n iz e th a t a lth o u g h th e s h a p e o f so m e o b je c ts m a y c h a n g e , th e v o lu m e d o e s n o t c h a n g e a n d it is th e sa m e o b je c t, e g b a ll o f c la y rolled o u t is still s a m e mass b u t in a d iffe re n t fo rm .

• Reversibility: C a p a c ity to u n d e rs ta n d th e re la tio n sh ip b e tw e e n tw o d iffe re n t things a n d th a t o n e th in g c a n tu rn in to a n o th e r a n d b a c k a g a in .

Formal operational stage (11 years to puberty) • Logical thinking: C h ild re n a re a b le to th in k in a h ig h ly lo g ic a l a n d a b s tra c t m anner.

• Hypotheticodeductive reasoning: The h ig h e st o rg a n iz a tio n o f c o g n itio n - allow s a person to m a k e a h ypo the sis a n d te s t it a g a in s t reality.

184

93. Human development

Kubier Ross - stages of adaptation to death of a loved one or knowledge of facing death (terminal diagnosis) • Denial: Initially th e d e a th o f a lo v e d o n e (or o th e r tra u m a tic news, e g b e in g to ld a b o u t a te rm in a l illness) is n o t a c c e p te d .

• Anger: The in d iv id u a l expresses a n g e r to w a rd s fa m ily a n d /o r friends. • Bargaining: The in d iv id u a l starts to try to th in k a b o u t th e d e a th . • Depression: The in d iv id u a l g rie v e s o p e n ly a n d

shares th e ir fe e lin g s w ith

fa m ily /frie n d s .

• Acceptance: A sense o f stillness a n d d e ta c h m e n t r e p la c e th e p re vio u s feelings. In reality, th ese sta ge s rarely ta k e p la c e in th e o rd e r listed a n d m a y p re s e n t in a d if­ fe re n t o rd e r fro m o n e in d iv id u a l to a n o th e r.

185

Harlow and Lorenz - early social development •

In th e 1950s a n d 1960s Harlow c o n d u c te d a series o f experim ents exploring a tta c h ­ m en t behaviour. He tested w he th er fo o d or physical closeness a n d c o n ta c t was m ore im p orta nt in form ing an a tta c h m e n t. Baby rhesus m onkeys preferred c o n ta c t with an artificial cloth m oth er over fe e d in g from a n o th e r artificial o b je c t w hich p ro ­ vid e d fo od . Rhesus m onkeys raised with such an artificial m oth er e xp e rie n ce d a g re a t d e a l o f distress w hen s e p a ra te d from th e surrogate m other. Monkeys w h o h a d b een raised w itho ut a real m other w e n t on to b e c o m e u n a b le to p ro vid e a d e q u a te m o th ­ ering them selves a n d b e c a m e w ith d ra w n a n d u na ble to relate to their peers (a state similar to depression in a d u lt humans).

• Lorenz believed th a t all animals including humans are biolog ica lly predisposed tow ards a tta c h m e n t form ation. In some animals, a tta c h m e n t is based on 'im printing' a n d b ecom es irreversible - th e first c o n ta c t th a t a newly h a tc h e d gosling h ad b e c a m e ingrained in its m ind a n d it was p ro g ra m m ed to follow it. The first c o n ta c t was usually the m other so th e n ew born w ould follow the mother. If som ething/som eone else rep la ce d the mother, th e gosling w ou ld co n tin u e to follow th a t o b je c t as if it w ere the mother. It is felt to be an im p o rta n t c o n c e p t in psychiatry in terms o f understand­ ing how early d e v e lo p m e n ta l experiences a ffe c t an individual later on in life. Lorenz also studied aggression a n d fo un d th a t it served a p ra c tic a l functio n in animals in terms o f territorial d e fe n c e . Lorenz tried to a p p ly his theories to hum an aggression, see­ ing it as serving the purpose o f seeking o u t th e best territory, necessary both early in hum an evolution and, to some extent, to da y.

186

94. Human development

Maslow’s hierarchy of needs •

M a slo w used p re vio u s w o rk o n fa c to rs a s s o c ia te d w ith m o tiv a tio n in o rd e r to p ro ­ d u c e w h a t he d e s c rib e d as a h ie ra rc h y o f n ee ds. Prior to M a s lo w 's w ork, m ost theorists h a d c o n s id e re d a s p e c ts o f m o tiv a tio n s e p a ra te ly such as b io lo g ic a l fa cto rs, a c h ie v e m e n t, e tc . M a s lo w a tte m p te d to in te g ra te th e s e fa c to rs to g e th ­ er in his m o d e l.

•

C a n d id a te s a re e x p e c te d to k n o w th e o rd e r o f n e e d s a c c o r d in g to M a s lo w 's m o d e l: Stage 1—Physiological/physical: Hunger, thirst, sex, fo o d , shelter, w a rm th . Stage 2—Safety: A sense o f se cu rity a n d p ro e c tio n fro m d a n g e r. Stage 3—Social belonging/love: A ffilia tio n w ith o the rs (fa m ily /frie n d s /re la tio n ships). Stage 4—Self-esteem: S ocial a c c e p ta n c e , in d e p e n d e n c e . Stage 5—Self-actualization: The h ig h e s t o rd e r o f n e e d in th e m o d e l a n d re p re ­ sents th e s ta g e a t w h ic h th e person a c h ie v e s a sense o f inn er fu lfilm e n t a n d re a l­ ization o f p erso n a l p o te n tia l.

187

Maslow’s hierarchy of needs The m o d e l w as a d a p te d in th e 1970s to in c lu d e th e fo llo w in g sta ge s th a t w o u ld fall b e tw e e n stage s 4 a n d 5 (d e s c rib e d o v e r­ lea f): cognitive - u n d e rs ta n d in g a n d k n o w ­ le d g e ; aesthetic - o rd e r a n d sym m etry. In th e 1990s th e m o d e l w as fu rth e r a d a p te d to in c lu d e th e last a n d fin a l s ta g e o f - selttranscendence - h e lp in g o the rs a c h ie v e s e lf-a c tu a liz a tio n .

188

95. Human development

Attachment theory (developed by John Bowlby (1907-90) Four phases of attachment Є Indiscriminate responsiveness (0-3 months): Y oung b a b ie s re s p o n d in similar w a ys to d iffe re n t p e o p le .

• Focusing on familiar people (3-6 months): Babies b e g in to re s p o n d s e le c tiv e ly to c e rta in p e o p le , e s p e c ia lly m a in care r.

• Intense attachment and proximity seeking (6 months to 3 years): Intense a tta c h ­ m e n t to m a in c a re r d e v e lo p s , a s s o c ia te d w ith s e p a ra tio n a n x ie ty a n d s tra n g e r fear.

• Partnership behaviour (3 years to adulthood): In cre a sin g a w a re n e s s o f c a re r s a ctio n s, a n d allo w s c a re r to le a v e . B o w lb y d e s c rib e d s e p a ra tio n le a d in g to: Protest -> D espair -> D e ta c h m e n t

189

Attachment theory (coni.) Mary Ainsworth has described four types of attachment: • Secure attachments: Babies use m o th e rs as b a s e fo r e x p lo ra tio n . • Insecure-avoidant: A p p e a r to b e in d e p e n d e n t, d o n o t c h e c k fo r p re s e n c e o f m other.

• Insecure-ambivalent: C lin g to m other, a v o id e x p lo ra tio n . • Disorganized: No d is c e rn ib le p a tte rn o f b e h a v io u r.

190

96. Miscellaneous topics Drugs affecting seizure threshold with ECT treatment Increase seizure threshold Є Benzodiazepines. •

A n tico n vu lsa n ts.

•

B arbiturates.

Decrease seizure threshold •

Tricyclic a n tid ep re ssa n ts.

Є Lithium. •

A n tip sych o tics.

191

Hyponatraemia induced by antidepressants

192

Risk factors

Symptoms/signs

•

O ld a g e .

•

Dizziness.

•

•

Fem ale.

•

N ausea.

Management S top a n tid e p re s s a n t.

•

Low w e ig h t.

•

Leth arg y.

•

O th e r drugs - NSAIDs, diuretics.

•

C on fu sio n.

•

C ra m ps.

# If Na >125 m o n ito r U&Es d aily, if N a < 1 2 5 refe r fo r u rg e n t m e d ic a l m a n a g e ­ m e n t.

•

Im p a ire d renal fu n c tio n .

•

Seizures.

•

•

M e d ic a l c o m o rb id ity .

•

W arm c lim a te .

W h e n resta rting tre a tm e n t, c o n s id e r a n o ra d re n e rg ic d ru g such as re b o x e tin e , or ECT. C o n sid e r flu id restriction.

97. Miscellaneous topics classification in psychiatry

General facts about the DSM IV •

DSM IV c a n h a v e m o re th a n o n e d ia g n o sis o n e a c h axis.

•

H o w e v e r it d o e s n o t re q u ire a d ia g n o sis o n e v e ry axis.

•

There is a sco re fo r th e lo w e st re c e n t fu n c tio n in g level.

•

It is p u b lis h e d in English a lo n e ; th e ICD10 is p u b lis h e d in se veral la n g u a g e s .

•

DSM IV is a th e o re tic a l - it d o e s n o t lo o k a t ca u se s or p a th o lo g y .

193

General facts about the ICD10 •

194

It d o e s n o t h a v e a c a te g o r y fo r c u ltu re b o u n d syndrom es.

•

It has a c a te g o r y fo r o rg a n ic m e n ta l disorders.

•

There is no s e c tio n fo r so cia l fu n c tio n in g .

•

It d e scrib e s disorders fo r b o th a d u lts a n d c h ild re n .

98. Miscellaneous topics classification in psychiatry

ICD10 and DSM IV classifications Comparing and contrasting •

Neurosis is n o t a c a te g o r y in ICD10 or DSM IV.

•

ICD10 d o e s n o t distinguish b e tw e e n psychosis a n d neurosis.

•

DSM IV has its o w n c a te g o r y fo r psychoses.

•

DSM IV is n o t b a s e d o n re s e a rc h in c lin ic a l trials.

•

The d ia gn osis o f sc h iz o p h re n ia using ICD10 is re lia b le .

195

ICD 10 and DSM IV classifications (coni.) Comparing and contrasting (cont.) •

196

R eliability a n d v a lid ity in cla ssifica tio n s a re s e p a ra te c o n c e p ts .

•

H avin g a n in te rn a tio n a l consensus d o e s m a k e c la s s ific a tio n m o re re lia b le .

•

P sychiatric cla s s ific a tio n is n o t b a s e d o n o u tc o m e .

•

C lassificatio n allo w s c o n d itio n s such as m e n ta l re ta rd a tio n to b e classified.

•

N o m o th e tic c la ssific a tio n d o e s n o t lo o k a t in d iv id u a l cases, e g Diagnosis. Id io g ra p h ic c la ssific a tio n looks a t th e in d iv id u a l c a s e as in th e fiv e axes o f DSM IV.

99. Miscellaneous topics

Interview techniques Common mistakes •

L ack o f c la rific a tio n .

•

A c c e p tin g ja rg o n .

•

Failure to re s p o n d to n o n -v e rb a l cues.

•

P re m a tu re rea ssuran ce.

Types of questions •

O p e n -e n d e d - s u ita b le fo r th e b e g in n in g o f in te rv ie w or to p ic , e g 'W h a t is yo u r slee p like?'

•

C lo se d - s u ita b le fo r c la rific a tio n , e g 'D o y o u w a k e u p e a rly in th e m o rn in g ? '

•

L e a d in g - shou ld b e a v o id e d , e g 'D o y o u s le e p b a d ly ? '

•

M u lti-th e m a tic -s h o u ld b e a v o id e d , e g 'W h a t a re y o u r s le e p a n d a p p e tite like?'

197

Interview techniques (corri.) Facilitating techniques •

Silences - to le t th e p a tie n t c o n s id e r reply.

•

E m p a th ie s ta te m e n ts - e g 'T h a t m ust h a v e b e e n ve ry distressing fo r y o u '.

•

R espond to n o n -v e rb a l c u e s - e g 'It seem s to b e u p s e ttin g fo r y o u to ta lk a b o u t yo u r m o th e r'.

•

S um m arizing - e g d e p re s s e d '.

'So fa r yo u h a v e to ld

m e th re e reasons w h y yo u a re

When using an interpreter

198

•

If possible a lw a ys use tra in e d interpreters, o n ly use re la tiv e /frie n d if a b s o lu te ly essential.

•

A rra n g e s e a tin g in a tria n g le .

•

A ddress p a tie n t d ire c tly a n d in th e s e c o n d person.

•

Be seen to listen a n d re s p o n d n o n -v e rb a lly to p a tie n t's replies.

•

E specially im p o rta n t to sum m arize.

100. Miscellaneous topics

Culture bound syndromes • Кого: A fe a r th a t th e g e n ita ls will shrink in to th e a b d o m e n a n d th a t d e a th will o c c u r. It is seen In S o u th -e a st Asia e s p e c ia lly In C h in e se M alaysia ns a n d in parts o f C h in a .

• Amok: This is fo u n d in m e n in In d o n e s ia a n d M alaysians, a n d a fte r a p e rio d o f b ro o d in g th e re m a y b e v io le n c e a n d a g g re ssion . There m a y b e a m n e s ia a fte r­ w ards.

• Latah: M o re c o m m o n in w o m e n in M a la y s ia a n d N orth A fric a . There m a y b e e c h o la lia , e c h o p ra x ia a n d a u to m a tic o b e d ie n c e . It is th o u g h t to b e a d is s o c ia ­ tiv e state.

• Dhat: A n Asian p syc h o s e x u a l d is o rd e r fo u n d o fte n in Sri L anka w h e re loss o f se m e n c a n le a d to fa tig u e , w eakness, in so m n ia a n d a c h e s a n d pains.

• Boufee delirante: A n a c u te stress-related psychosis w h ic h th e p a tie n t o fte n re co v e rs fro m in w eeks. M o re c o m m o n in W est A fric a a n d Haiti b u t n o t lim ite d to this s u b g ro u p . There m a y b e p s y c h o m o to r e x c ite m e n t a n d m a rk e d co n fu s io n .

199

Culture bound syndromes • Brain fag: In West A fric a m a le h ig h s c h o o l a n d university stu de nts s ta te th e ir brains a re fa tig u e d . There m a y b e d iffic u ltie s c o n c e n tra tin g a n d sym pto m s o f p a in a n d pressure a ro u n d th e h e a d a n d n e ck.

• Susto: F ound in C e n tra l a n d South A m e ric a . A n x ie ty a n d d e p re ssion a re a ttrib ­ u te d to th e loss o f soul. The in d iv id u a l is anxious a b o u t n o t b e in g a b le to fulfil th e ir role in s o c ie ty

• Arctic hysteria: Seen in Eskimo w o m e n . The in d iv id u a l m a y te a r th e ir c lo th e s o ff a n d run a b o u t sc re a m in g . The p erson m a y b e v io le n t to o thers or m a y b e a t risk o f h y p o th e rm ia .

• Windigo: This is seen in N orth A m e ric a n Indians. In this d ep re ssive d iso rd e r in d i­ vidu als think th e y h a v e m u ta te d in to a c a n n ib a lis tic m onster.

• Ekbom’s syndrome: A h y p o c h o n d ria c a l m o n o s y m p to m a tic psychosis. • Da Costa syndrome: A n o th e r d e s c rip tio n o f c a rd ia c neurosis. The p a tie n t feels th a f n o rm a l signs o f fu n c tio n in g o f th e h e a rt m e a n s o m e th in g m o re sinister is o c c u rrin g .

200

101. Miscellaneous topics

Common rating scales used in psychiatric assessment observer rated vs self rated Observer rated • Global assessment: C lin ic a l G lo b a l Im pression (C G I), G lo b a l Assessm ent S cale (GAS), Brief P sychiatric R atin g S ca le (BPRS).

• Schizophrenia: S c h e d u le fo r th e Assessm ent o f N e g a tiv e S ym p tom s (SANS), Positive a n d N e g a tiv e S y n d ro m e S ca le (PANS).

• Depression: H a m ilto n D epression S ca le (H a m D ), M o n tg o m e ry A sb e rg D epression R ating S cale (MADRS).

• Mania: Y oung M a n ia R a tin g S cale. • Anxiety disorders: H a m ilto n A n x ie ty R atin g S ca le (HARS), Yale Brown O bsessive C o m p u ls iv e S cale (YBOCS).

• Cognitive assessment: Mini M e n ta l S ta te Exam (MMSE), C a m b rid g e C o g n itiv e Assessm ent (C A M C O G ), N e u ro p s y c h ia tric In v e n to ry (NPI).

• Movement disorders: Barnes A ka th is ia R atin g Scale, Sim pson A n g u s S ca le fo r EPSEs, A b n o rm a l In v o lu n ta ry M o v e m e n t In v e n to ry (AIMS).

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Common rating scales used in psychiatric assessment observer rated vs self rated (cont.) Self-rated • Depression: B eck D epression In v e n to ry (BDI), Zung D epression Scale, H ospital A n x ie ty a n d D epression Scale, E ating A ttitu d e s Test (EAT), E d in b u rg h P ostnatal D epression Scale.

• Personality: M in n e so ta M u ltip h a s ic P ersonality In v e n to ry (MM PI).

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102. Miscellaneous topics - organic conditions causing psychiatric symptoms Head injury • •

P o s t-tra u m a tic a m n e s ia (PTA) is th e tim e fro m injury until th e p erson re g a in s th e ir full m e m o ry fu n ctio n s , p a rtic u la rly full e p is o d ic m e m o ry . Poor p ro g n o s tic fa c to rs in c lu d e : • lo w GCS sco re a t tim e o f injury • lo n g d u ra tio n o f PTA • lo n g d u ra tio n o f c o m a .

•

30% c h a n c e o f e p ile p s y if injury w a s p e n e tra tin g , 5% in c lo s e d h e a d injuries.

•

E xe cutive d y s fu n c tio n m a y o c c u r - c h a ra c te riz e d b y d e c re a s e d re te n tio n in m e m o ry fo r n e w in fo rm a tio n , p o o r short te rm re c a ll a n d v e rb a l a n d visu o sp a tia l d eficits.

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Head injury (cont.)

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•

D epression c o m m o n (a ro u n d 25% p o st tra u m a u p to several m o n th s a lth o u g h m ost re c o v e r).

•

M a n ia o c c u rs rarely.

•

PTSD o c c u rs in 10-20% o f cases.

•

30% sustain p e rso n a lity c h a n g e s such as p a ra n o id , a v o id a n t or im pulsive c h a r­ acteristics. These m a y im p ro v e u p to 2 years a fte r th e tra u m a .

103. Miscellaneous topics - organic conditions (card 1 of 2)

Organic conditions associated with psychiatric symptoms Neurological •

C e re b ro v a s c u la r disorders (h a e m o rrh a g e , in fe c tio n ).

•

H e a d tra u m a (co n cu ssio n , p o s t-tra u m a tic h a e m a to m a ).

•

N arco le p sy.

•

Brain neoplasm s.

•

N o rm a l pressure h y d ro c e p h a lu s .

•

P arkinson's disease.

•

M u ltip le sclerosis,

•

H u n tin g to n 's disease.

•

A lzh eim er's d e m e n tia .

•

M e ta c h ro m a tic le u k o d y s tro p h y .

•

M ig ra in e .

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Organic conditions associated with psychiatric symptoms (cont.) Endocrine • • • • • •

H y p o /h y p e rth y ro id is m /a d re n a lis m /p a ra th y ro id is m / g ly c a e m ia . D ia b e te s mellitus. P a n h yp o p itu ita rism . P h a e o c h ro m o c y to m a . P re g n a n cy. G o n a d o tro p h ic h o rm o n a l d is tu rb a n c e s .

Metabolic/ nutritional • • • • • • • • • •

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E le ctro lyte im b a la n c e (e g s y n d ro m e o f in a p p ro p ria te s e c re tio n o f ADH (SIADH)). H ypotension. H y p o x a e m ia . H ype rten sive e n c e p h a lo p a th y . Porphyria. U raem ia. W ilson's disease ( h e p a to le n tic u la r d e g e n e ra tio n ). H e p a tic e n c e p h a lo p a th y . D e fic ie n c y o f v ita m in B12, n ic o tin ic a c id , fo la te , th ia m in e , m a g n e s iu m o rz in e . M a ln u tritio n /d e h y d ra tio n .

104. Miscellanous topics - organic conditions (card 2 of 2)

Organic conditions associated with psychiatric symptoms Toxic •

In to x ic a tio n or w ith d ra w a l fro m a s u b s ta n c e .

•

A d ve rse e ffe c ts o f s o m e n o n -p s y c h ia tric m e d ic a tio n s .

•

E n viro n m e n ta l toxins (e g h e a v y m etals, o rg a n o p h o s p h a te s ).

Infectious •

AIDS.

Є Neurosyphilis. •

Viral m e n in g itis /e n c e p h a litis .

•

Brain abscess.

•

Tuberculosis.

•

S tre p to c o c c a l infectio n s.

Є Viral hep atitis. Є In fe ctio u s m on on u cle o s is . •

System ic b a c te ria l or viral in fe ctio n s.

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Organic conditions associated with psychiatric symptoms Autoimmune •

System ic lupus e ry th e m a to s u s (SLE).

Neoplastic •

CNS p rim a ry a n d m e ta s ta tic tum ours.

•

E n d o crin e tum ours.

•

P a n c re a tic c a rc in o m a .

•

P a ra n e o p la s tic syndrom es.

Mnemonic - INMATE I = Infectious. N = N e o p la stic. M = M e ta b o lic . A = A u to im m u n e . T = Tumours. E = E n do crin e.

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105. OSCE tips and advice

Reasons why people fail an explanation station •

C o n d u c tin g a m o n o lo g u e w ith o u t a d e q u a te ly a llo w in g th e p a tie n t to ta lk a n d ask questions.

•

N o t a n s w e rin g a p a tie n t's q u e stio n . This is a c o m m o n p itfa ll. N o b o d y know s e v e ry th in g . If yo u d o n 't k n o w th e a n s w e r to a q u e stio n , th e n say so. Say y o u will fin d th e a n sw e r a n d le t th e m k n o w n e x t tim e y o u m e e t w ith th e m . D o n 't just a v o id th e q ue stion .

•

There is a c o m m o n m is c o n c e p tio n a m o n g c a n d id a te s th a t th e y m ust e x p la in e v e ry a s p e c t o f a d ia g n o sis as if a n s w e rin g a n essay. If y o u d o n o t g e t to say e v e ry th in g yo u w a n te d in th e tim e g iv e n , th e n tell th e p a tie n t, a n d say yo u w o u ld like to a rra n g e to m e e t th e m a g a in , just as y o u w o u ld in c lin ic a l p ra c tic e .

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Reasons why people fail an assessment station

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•

Missing key a s p e c ts o f th e assessm ent - try to a lw a y s to u c h o n th e fo llo w in g a s p e c ts o f history in a n y assessment: — History o f m o o d d is tu rb a n c e /s u ic id a lity . — History o f p s y c h o tic sym ptom s. — History o f d ru g or a lc o h o l misuse. — Risk assessment. For e x a m p le , if a ske d to assess fo r p o s tn a ta l dep re ssion all o f th e a b o v e a re re le va n t.

•

Missing several key a s p e c ts o f th e history re le v a n t to a s p e c ific sta tio n - fo r e x a m ­ p le if asked to assess p re m o rb id p e rson ality, th e c a n d id a te shou ld c o v e r a re a ­ s o n a b le n u m b e r o f th e p o in ts o n OSCE 2 (c a rd 107). The c a n d id a te should strike a b a la n c e b e tw e e n asking re le v a n t q ue stion s w hilst still e n g a g in g a n d listening to th e p a tie n t. If th e c a n d id a te fo cuse s solely o n 'th e rig h t set o f q u e stio n s' a n d d o e s n 't ta k e th e tim e to listen to th e p a tie n t, s /h e is likely to fa il th a t sta tion .

106. OSCE 1 - Delusions

Scenario A p a tie n t is a d m itte d to y o u r w a rd a n d has s tra n g e b e liets th a t th e g o v e rn m e n t has b e e n c o n d u c tin g e x p e rim e n ts o n him sin ce th e 1960s. He b e lie v e s th a t th e y a re responsible fo r his re c e n t h e rn ia o p e ra tio n .

Interview in order to elicit delusions S uggested ap p ro a ch 1. 2. 3. 4.

G o o d c o m m u n ic a tio n P robe b ro a d ly fo r p re s e n c e o f d iffe re n t ty p e s o f delusions E nquire a b o u t c o m o rb id ity Risk assessm ent

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1. Good communication - Introduce yourself and approach the topic with tact. 2. Probe broadly for the presence of delusions • • • • • • • • • • •

Ask a b o u t delusions o f p e rs e c u tio n . In this c a s e th e g o v e rn m e n t m a y fe a tu re strongly. Ask a b o u t delusions o f re fe re n c e a n d d e lu sio na l m is in te rp re ta tio n . Enquire a b o u t delusions o f guilt. Enquire a b o u t g ra n d io s e delusions. Ask a b o u t nihilistic delusions a n d h yp o ch o n d ria sis. D elusional je a lo u s y is im p o rta n t o w in g to its p o te n tia lly disastrous c o n s e ­ quences. Religious delusions. D elusional m o o d a n d passivity p h e n o m e n a . Establish w h e th e r delusions a re p rim a ry or s e c o n d a ry . The fixity o f th e beliefs m ust b e g a u g e d - a re th e se tru e delusions? Try to fin d o u t th e e x te n t o f s y ste m a tiza tio n o f th e b e lie f system. A re th e d e lu ­ sions e n c a p s u la te d ?

3. Ask about comorbidity - A lc o h o l or s u b s ta n c e misuse, d ep re ssive s ym p to m s a n d b riefly scree n fo r o th e r p s y c h o tic sym ptom s.

4. Risk assessment - Find o u t w h e th e r th e p a tie n t has a c te d o n th e delusions a n d h a rm e d him self or others. D o th e y c a u s e distress to th e p a tie n t?

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107. OSCE 2 - Premorbid personality

Scenario A 4 6 -y e a r-o ld m a n is on th e d ru g a n d a lc o h o l re h a b ilita tio n w a rd u n d e rg o in g a lc o ­ hol d e to x ific a tio n . He b e c a m e d e p re s s e d a fte r his w ife d ie d 11 years a g o in a c a r a c c id e n t. He b e g a n d rin kin g h e a v ily a n d s u b s e q u e n tly lost his jo b a n d has su ffe re d dep re ssion e v e r since. He is c u rre n tly u n e m p lo y e d a n d o n in c a p a c ity b e n e fit. He is u n d e rg o in g a lc o h o l d e to x ific a tio n a n d says h e w a n ts to try to 'g e t his life b a c k a g a in '.

Take a history to establish his premorbid personality Suggested ap p ro a ch 1. G o o d c o m m u n ic a tio n 2. Ask a b o u t fe a tu re s o f p re m o rb id p e rs o n a lity

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1. Good communication - Introduce yourself and explain your role. Say you would like to ask a few questions to find abo ut the patients personality prior to the death of his wife and before be becam e depressed.

2. Ask about features of premorbid personality: mnemonic - MRI DOC FIBS M - Mood - How did you used to feel in yourself as a person? Would you describe yourself as a happy person? Or have you always tended to worry about things? R - Relationships - How many relationships did you have before you became unwell? Were there any difficulties? Do you feel that there were any aspects of your personality that con­ tributed to the problems? I - Interests - What things did you used to enjoy doing in your spare time? D - Drugs - Had you ever used any drugs before you became unwell for the first time? 0 - Obsessions or compulsions - Have you ever been very particular about details? Do you feel the need to check doors are locked or do you worry a lot about hygiene? C - Coping strategies - How did you used to deal with problems? F - Fantasy life - Before you became unwell did you used to have any plans or ambitions for the future? Did you used to fantasize about anything? 1 - Impulsivity - Did you ever use to do things on the spur of the moment that you later regret­ ted? В - Beliefs - Were you a religious person? Do you believe in anything? S - Sexuality - What is your sexual orientation?

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108. OSCE 3 - Explain schizophrenia

Scenario A 2 2 -ye a r-o ld m a n has b e e n a d m itte d to h o s p ita l fo r th e s e c o n d tim e , a fte r a irp o rt s ta ff raised c o n c e rn s a b o u t him lying o n th e seats a n d 'a c tin g fu n n y ' lo o k in g suspi­ ciou s a n d asking a b o u t 'th e ra d io w a v e s '. O n adm ission, h e to ld y o u th a t th e p la n e s w e re se n d in g o u t ra d io w a v e s to him a n d h e c o u ld c o n tro l th e ir flig h t p a th w ith th e se w ave s. O v e r th e last 2 m o n th s it seem s likely fro m y o u r assessments th a t he has a d ia gn osis o f s c h iz o p h re n ia as all o th e r possibilities a re ruled o ut. His m o th ­ er a lre a d y has a n inkling th a t this m ig h t b e his diagnosis, a n d she w a n ts to k n o w m o re a b o u t it.

1. Explain to his mother what a diagnosis of schizophrenia means. 2. Address any concerns the mother may have Suggested approach to any 'Explain a diagnosis’ sta tio n 1. 2. 3. 4. 5.

G o o d c o m m u n ic a tio n Explain th e n a tu re o f th e illness Explain w h a t fa c to rs a re th o u g h t to le a d to th e illness Explain th e likely co u rs e a n d p rognosis Explain key tre a tm e n ts a v a ila b le

Make sure you link your explanation to the patient’s symptoms. Don’t just give a text­ book answer.

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1. Good communication: I'd like to explain a bit about this illness called schizophrenia to you, but before I start, do you have any particular questions or concerns? Do you know anything already about this illness?

2. Explain the nature ot the illness: Schizophrenia is a common condition that affects about 1 in every 100 people. Normally, there is a link between the way we think, our emotions and behaviour, and the way we perceive things with our hearing and other senses. In schizophre­ nia, that normal link is lost, so that thoughts, feelings, behaviour and perception can change. What that means is that people might hear or see things that aren't there. Or they might have odd thoughts like feeling paranoid about other people or like when your son thought he could control the aeroplanes.

3. Explain what factors are thought to lead to the illness: No exact cause found. Can run in families - first degree relative has a 10-fold higher chance of developing the illness. Complications at birth may be a factor in affecting neurodevelopment which may be a risk factor for developing schizophrenia. Stress can act as a trigger to onset or relapse. Stress alone may not be a direct cause. Marijuana has been shown to be associated with a greater chance of developing schizophrenia. 4. Explain the likely course and prognosis: Can be lifelong/relapsing remitting/chronic. Explain there is reason to be hopeful and be optimistic. 5. Explain key treatments available: Antipsychotic drugs - correct the chemical imbalance. Psychological input - CBT to provide coping strategies/distraction techniques and to chal­ lenge delusional beliefs. Support from: the Community Mental Health Team; Social Support; OT input to assess Activities of Daily Living.

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109. OSCE 4 - assess for depressive symptoms Scenario You a re a sked to see a 5 6 -y e a r-o ld la d y as a liaison refe rra l o n th e m e d ic a l w a rd . She w a s d ia g n o s e d w ith le u k a e m ia 6 years a g o a n d w a s a d m itte d y e s te rd a y fo l­ lo w in g a rela p se o f h er sym pto m s. The m e d ic a l SHO has a ske d y o u to see h er as she a p p e a rs s o m e w h a t d e p re s s e d .

Enquire about her mood Suggested approach 1. 2. 3. 4.

G o o d c o m m u n ic a tio n Assess fo r d e p re ssive s y m p to m s Ask a b o u t c o m o rb id ity P erform a th o ro u g h risk assessm ent

1. Good communication - Introduce yourself and explain your role as the junior psychiatrist. Take a sensitive approach. Try to speak at the same volume as the patient and lean forwards as you talk to her. As she talks about her leukaemia show empathy by saying 'I'm sorry to hear that it sounds as if you have been going through a very difficult time'. Ask open questions to begin with - 'How have you been feeling lately?' and then 'can you tell me a bit more about what you've been going through that has lead to you feeling depressed?'

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2. Assess for depressive symptoms. Ask about - mnemonic: EMI CEG PASS

E - Energy (loss of). M - Mood (pervasive low mood on most days over at least 2 weeks). I - Interest (loss of interest in activities - anhedonia).

C - Concentration (poor). E - Esteem (low self esteem). G - Guilt (feelings of guilt).

PASS-

Pessimism (feelings of hopelessness). Appetite (poor or excessive). Sleep (disturbance, early morning wakening). Suicidal thoughts. For an ICD10 diagnosis of: Mild depressive episode - need 2 from EMI and 2 from CEG PASS. Moderate depressive episode - need 2 from EMI and 3 from CEG PASS. Severe depressive episode - all 3 from EMI and 4 from CEG PASS, one of which must include suicidal thoughts. Severe depressive episode can be +/- psychotic symptoms which are usu­ ally mood congruent delusions or hallucinations.

3. Ask about comorbidity - Ask about psychotic symptoms and substance misuse. 4. Perform a thorough risk assessment - Enquire tactfully about suicidal thoughts. First say I'm sorry to hear that you've been going through a difficult time. Sometimes do you ever feel as if life is not worth living any more or as if you wish you wouldn't wake up in the morning?' Then if they say yes, ask, 'Do you ever have any thoughts of ending your life'. Then go on to ask about specific suicidal ideas and their extent and if any suicidal plans have been made.

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110. OSCE 5 - anxiety disorders

Scenario You h a v e b e e n a sked to see a 2 8 -y e a r-o ld la d y w h o has s e lf-p re s e n te d to th e A&E d e p a r tm e n t w ith a c u te c h e s t p a in a n d shortness o f b re a th . This is h er s e c o n d pres­ e n ta tio n in th e p a s t w e e k . The m e d ic a l senior hou se o ffic e r has e x c lu d e d a n o rg a n ­ ic c a u s e fo r h er sym p to m s a n d b e lie v e s th e re m a y b e a p s y c h o lo g ic a l ca u se .

Take a history focusing on symptoms of anxiety, in order to formulate a diagnosis Suggested ap p ro a ch 1. 2. 3. 4. 5. 6.

G o o d c o m m u n ic a tio n Elicit sym p to m s to d iffe re n tia te b e tw e e n d iffe re n t a n x ie ty disorders Ask a b o u t p a n ic a tta c k s Ask a b o u t a v o id a n c e b e h a v io u r Ask a b o u t c o m o rb id ity Explore im p a c t on life a n d risk assessm ent

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1. Good communication - 'Hello, I am Dr. Patel. I am one of the junior psychiatrists here today. I have been asked to see you to talk about the chest pain you have been experiencing recently to see if there is anything we can do to help. Would that be OK? Can you tell me what has been happening recently?' - Now allow the patient to talk. Comment on non-ver­ bal and verbal cues, eg if the patient dips her head as she talks about the recent death of her father, say 'that sounds very sad'.

2. Elicit symptoms to differentiate between different anxiety disorders - Symptoms: onset/duration/precipitants/frequency. Psychological symptoms: apprehension, worry, nerv­ ousness, fear of fainting, vomiting, going mad or dying. Physical symptoms: palpitations, rapid heart rate, sweating, breathlessness, tremor. Circumstances in which symptoms occur: differ­ entiate between agoraphobia, social phobia, specific phobias and generalized anxiety dis­ order (GAD). Agoraphobia: fear of leaving the safety of the home, fear of travelling alone. Social phobia: fear of embarrassment, fear of small group situations. Specific phobia: fear of a specific object, fear of a specific place. GAD: excessive worry about the future, feeling tense and nervous all the time.

3. Ask about panic attack symptoms - Do you feel as if you are choking/fainting/about to die when these attacks occur.

4. Ask about avoidance behaviour - Anything done to avoid these attacks? 5. Screen for associated mood/psychotic symptoms and ask about substance misuse. 6. Ask about impact on life and risk assessment - Effect on family/friends/partners/work/selfcare/care of children or other dependents. Ask about any suicidal thoughts.

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111. OSCE 6 - cognitive examination

Scenario You a re th e SHO w o rk in g in th e O ld A g e P sychiatry Team . A 6 7 -y e a r-o ld m a n is re fe rre d to yo u b y his GP as h e has b e e n c o m p la in in g th a t h e has b e e n e x p e ri­ e n c in g m e m o ry p ro b le m s o v e r th e last fe w m on ths. He says so m e tim e s h e will le a v e his keys o n th e k itc h e n to p a n d th e n fo rg e ts w h e re h e le ft th e m . He th e n feels dis­ o rie n ta te d a t tim es tryin g to re m e m b e r th e ir lo c a tio n .

Perform a cognitive examination Suggested ap p ro a ch 1. 2. 3. 4.

G ood Assess Assess Assess

c o m m u n ic a tio n o rie n ta tio n , c o n c e n tr a tio n a n d short te rm re c a ll m e m o ry - in te rm e d ia te a n d lo n g te rm fro n ta l, p a rie ta l a n d te m p o ra l lob es

1. Good communication - Introduce and explain your role. Explain that you would like to test his memory and some other aspects of his brain function with some simple tests.

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2. Orientation - Day/date/month/year/season. Place - country/county/town/building/floor. Registration - Ask to say an address, eg James Smith, 59 Penn Street, Victoria, London. Attention/concentration - Spell the word WORLD. Then backwards. Recall - ask to recall address given earlier.

3. Memory - Recent (intermediate term) - What did you do yesterday evening?/Long term What was your address where you grew up as a child? 4. Frontal lobe assessment - (i) History of incontinence, change in smell (?inferior lesion), visual changes (?homonymous hemianopia), change in affect/behaviour eg becoming disinhibited. (ii) Verbal fluency: name as many words as possible beginning with S in one minute, (iii) Luria Motor Test, (iv) Cognitive estimates: how tall is a bus? Or assess proverb inter­ pretation. (v) Listen for verbal perseveration, (vi) Reflexes: palmomental and grasp, (vii) Assess gait (viii) Tapping test: response inhibition or check for utilization behaviour.

5. Parietal lobe assessment - (i) Speech: repetition, naming (?nominal dysphasia), fluency (?receptive/expressive dysphasia), (ii) Right-left disorientation and sensory inattention: threestage command (ask to take paper in left hand, fold in half and return with right hand), (iii) Assess for Constructional/Dressing apraxia (iv) Astereognosia: ask to recognize common object placed in hand with eyes closed, (v) Agraphasthesia: ask to recognize letter drawn on palm of hand, (vi) Writing. 6. Temporal lobe assessment - False thinking, jamais vu/déjà vu experiences, panoramic memory, hallucinations, gastric sensations, motor seizures (lip smacking/involuntary move­ ments).

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112. OSCE 7 - alcohol dependency

Scenario A 2 6 -ye a r-o ld la d y presents to A&E in a n in to x ic a te d sta te . You a re a ske d to assess her b y th e A&E d o c to r as she is s o b e r n o w a n d sa yin g she has b e e n fe e lin g d e p re s s e d a n d d rin kin g h e a v ily o v e r th e last fe w w e e k s sin ce her b o y frie n d le ft her.

Take a history to elicit symptoms of alcohol dependency Suggested ap p ro a ch 1. 2. 3. 4. 5.

G o o d c o m m u n ic a tio n Enquire a b o u t a lc o h o l use Establish fe a tu re s o f d e p e n d e n c y Ask a b o u t c o m o rb id ity Explore im p a c t o n fu n c tio n in g a n d risk assessm ent

1. Good communication - Introduce yourself and explain your role as a junior psychiatrist. Say you would like to ask a few questions about her alcohol use and ask if that would be OK. Start with open questions, eg 'can you please tell me what has been happening?' Then move on to more closed questions. 2. Enquire about alcohol use - Onset, frequency, duration and drinking behaviour (types of drinks, sources, how the habit is being financed).

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3. Establish features of dependency - ICD10 Criteria: three or more of the following are

required to establish a syndrome of dependency to any psychoactive substance including alcohol - mnemonic - COST WU C - Compulsion (a strong desire to use alcohol). C - Control (difficulty controlling use in terms of onset, stopping, levels of use). S - Salience (progressive neglect of alternative pleasures or interests due to alcohol use, increased amount of time necessary to obtain or take the substance or recover from its effects, ie alcohol takes over one's life). T - Tolerance: increasing doses are required to produce the same effects as were previously present with lower doses. W - Withdrawal: physiological state of withdrawal may present with sweating, insomnia, tachycardia, nausea or vomiting, grand mal seizures, delirium tremens. U - Use despite harmful effects. Alternatively candidates may prefer to remember the criteria for alcohol dependency described by Edwards and Gross: (i) Narrowing of the drinking repertoire, (ii) Drink-seeking behaviour, (iii) Tolerance, (iv) Withdrawal, (v) Drinking to relieve or avoid withdrawal symp­ toms. (vi) Subjective awareness of the compulsion to drink, (vii) Rapid reinstatement of drink­ ing after a period of abstinence.

4. Ask about comorbidity - Enquire about depression, psychotic symptoms or other substance misuse.

5. Risk assessment - Enquire about physical risk issues: poor diet/malnutrition, liver disease (may need to be referred to a physician). Ask if there have been any suicidal thoughts, ideas or plans or any thoughts of harming others.

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113. OSCE 8 - borderline personality disorder Scenario A 3 2 -ye a r-o ld m a n is re fe rre d to y o u r o u tp a tie n t c lin ic b y his GP. He d e s c rib e s a his­ to ry o f several d iffic u lt re latio n ships sin ce h e w a s 16 years o ld w h e n h e h a d his first partne r. He says he feels e x tre m e ly d e p re s s e d w h e n th e relatio n ships e n d a n d so m e tim e s feels su icid a l. He o fte n cu ts him self s u p e rfic ia lly o n his fo re a rm s a n d o n c e to o k a n o v e rd o se .

Take a history to establish if he has features of emotionally unstable personality disorder - borderline type Suggested ap p ro a ch 1. 2. 3. 4.

G o o d c o m m u n ic a tio n Enquire a b o u t fe a tu re s o f b o rd e rlin e p e rs o n a lity d is o rd e r Ask a b o u t c o m o rb id ity Risk assessm ent

225

1. Good communication - Introduce and explain your role (eg 'Hello I am Dr. Smith, I am a jun­ ior psychiatrist I have come to ask you a few questions about your personality. Knowing about your personality could be useful to us in understanding you better so that we can try to help you as best as we can, would that be OK?').

2. Enquire about features of borderline personality disorder. ICD10 Diagnosis - mnemonic: DEARS D - Disturbed self-image: the patient's own image, aims and internal preferences are often unclear or disturbed. E - Emotional instability: a tendency to act impulsively without consideration of the conse­ quences and chronic feelings of Emptiness. A - Affective instability and feelings of Abandonment. R - Relationship difficulties: a tendency to become involved in intense and unstable relation­ ships leading to repeated emotional crises and may be associated with excessive efforts to avoid abandonment. S - Suicidal threats and Self-harming behaviour: often associated with relationship difficulties but may occur separately as well.

3. Ask about comorbidity - Enquire if the patient has felt depressed or experienced any psy­ chotic symptoms (which may be a feature of personality disorders) and if they have been using any illicit drugs. 4. Risk assessment - Enquire about suicidal thoughts, ideas or plans as well if there has been any self-cutting or other self-injurious behaviour. Ask if there are any thoughts of harming others.

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114. OSCE 9 - dissocial personality disorder Scenario A 4 8 -y e a r-o ld m a n has b e e n a d m itte d o n to th e w a rd . He has a history o f o ffe n d ­ ing b e h a v io u r since a d o le s c e n c e a n d has b e e n c h a r g e d in th e p a s t fo r b u rg la ry as w ell as g rie vo u s b o d ily h a rm fo r w h ic h h e se rve d 2 ye ars in prison. He has a history o f a tte n d a n c e a t a c h ild p s y c h ia tric se rvice w h e n h e w a s 14 years o ld d u e to b a d b e h a v io u r a t sch o o l - b u lly in g o th e r c h ild re n a n d d e s tro y in g p ro p e rty . He has suf­ fe re d fro m dep re ssion w ith a s s o c ia te d p o ly s u b s ta n c e misuse o v e r th e p a s t 20 years a n d has n o w b e e n a d m itte d a fte r ta k in g a n o v e rd o s e o f so m e a n a lg e s ic ta b le ts .

Take a history with a view to establishing a diagnosis of dissocial (antisocial) personality disorder Suggested ap p ro a ch 1. 2. 3. 4.

G o o d c o m m u n ic a tio n Ask a b o u t fe a tu re s o f dissocial p e rs o n a lity d is o rd e r E nquire a b o u t c o m o rb id ity Risk assessm ent

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1. Good communication - Introduce and explain your role (eg 'Hello I am Dr Smith, I am a junior psychiatrist, I have come to ask you a few questions about your personality. Knowing about your personality could be useful to us in understanding you better so that we can try to help you as best as we can, would that be OK?').

2. Enquire about features of dissocial personality disorder. ICD 10 criteria - mnemonic: FIGURE F - Frustration (low tolerance to frustration and a low threshold for discharge of aggression). I - Irresponsibility (gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations). G - Guilt (incapacity to experience guilt or to profit from experience, particularly punishment). U - Unconcern for the feelings of others (callous unconcern). R - Relationship difficulties (incapacity to maintain enduring relationships, though having no difficulty in establishing them). E - Externalize blame (blames others or otters plausible rationalizations for behaviour which has brought the individual into conflict with society).

3. Enquire about comorbidity - Ask about depression, pychotic symptoms and substance misuse.

4. Risk assessment - Ask about a history of offending behaviour including any charges or con­ victions and sentences. Ask if there are any current thoughts of self-harm or anyone the per­ son is currently at odds with and if there are any thoughts of harming others.

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115. OSCE İOA (card 1 of 2) - Examine for extrapyramidal side-effects Scenario A 5 5 -y e a r-o ld la d y w h o suffers fro m s c h iz o p h re n ia has c o m e to see y o u in yo u r o u t­ p a tie n t clin ic. She has b e e n tr e a te d w ith c h lo rp ro m a z in e o v e r th e last 13 years. You n o tic e th a t her arm s a p p e a r to b e sh aking s o m e w h a t.

Assess the patient for extrapyramidal side effects Suggested ap p ro a ch 1. 2. 3. 4. 5.

G o o d c o m m u n ic a tio n History o f e x tra p y ra m id a l sym p to m s G e n e ra l o b s e rv a tio n G e n e ra l e x a m in a tio n Assess g a it

1.Good communication 'Hello, I am Dr X. I am one of the junior psychiatrists. I've been asked to examine you for poss­ ible side-effects of your medication. Would that be all right with you?' Ί notice that your arms are shaking. This may be a side-effect of the medication that you're taking. Would you mind if I check for other possible effects that the medication could be having?' 'Would you mind if I ask a female nurse to join us?'

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2. History of extrapyramidal symptoms 'Have you noticed that your arms are shaking?' 'Does it trouble you? How long has it been going on?' 'Has anyone changed the dose of your tablets at any point in time?' 'Do you wear dentures?' 'Have you noticed any movements of your tongue, lips or mouth that you can't control?' 'Do you ever feel restless?' 'Have you noticed any stiffness or aching in your muscles?' 'Do you grind your teeth at night?'

3. General observation - comment on: • Facial expression and evidence of oral-mandibular-lingual signs: chewing movements, rabbit syndrome, bon bon sign, grimacing, pouting, repetitive swallowing, trismus, mask-like facies. • Signs of akathisia: legs shaking. • Parkinsonian tremor: resting tremor. • Limb movements: such as ballismus. • Neck/spine signs: torticollis, antecollis, retrocollis, pleurothotonus, opisthotonus, axial hyper­ kinesias. • Ocular signs: blepharospasm, oculogyric crisis. • Vocal tics, dysphonia (from vocal cord spasm), stridor. • Look for drooling, which may result from increased salivation and dysphagia. Note that a resting tremor is made worse by anxiety and is improved by voluntary movement.

A common mistake is for candidates to check resting tremor by asking patients to put their arms out; this is incorrect. Ask the patient to rest their hands on their legs - this is the correct position.

2 30

116. OSCE 10В (card 2 of 2) - Examine for extrapyramidal side-effects 4. General examination • Start with the arms: look for a 'pill-rolling' resting tremor and then check tone. There may be lead-pipe rigidity and, if tremor is superimposed, cogwheel rigidity. • Next do a glabellar tap. To do this, repeatedly tap the patient's mid-forehead between the eyebrows with the tip of your finger. In people experiencing parkinsonian side-effects, the patient may demonstrate a glabellar tap sign, in which he/she continues to blink. False positives are fairly common, however. • Examine the tongue. Ask the patient to stick out the tongue for a few seconds. Look for any fasciculation • Posture. Ask the patient to stand. Observe whether he/she is stooped (parkinsonian). • Check for truncal stability. Slightly nudge the patient forwards and backwards and from side to side. In parkinsonism there is a tendency for the patient to lose their balance because of slow correcting movements. • Check the limbs for cogwheel rigidity • Lastly ask the patient to write a sentence. Observe for micrographia.

231

5.

Assess gait

• Ask the patient to walk from one end of the room to the other. • Observe the arm swing. In parkinsonism the arms do not swing fully. • Parkinsonian gait - toe walking, slow, stooped gait. In parkinsonism the gait may be shuf­ fling and the patient may show festination.

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117.

OSCE 11 - EXPLAIN LITHIUM THERAPY Scenario A 26-year-old receptionist has recently been admitted to hospital for the first time in a manic state. The consultant tells you in the ward round that she should be started on Lithium therapy.

Explain lithium treatment to the patient. Suggested A p p ro a c h to any ‘E xp lain a t r e a t m e n t ’ s ta tio n -

1. 2. 3. 4. 5.

Good Communication Explain the nature of the treatment (what it is, how it works, indications) Explain its benefits Explain potential side effects/ negative consequences Explain practical aspects (e.g. blood tests needed)

M ake sure you link your explanation to the p a tie n t’s history. Don’t just give a textbook answer.

Points to in clu d e

1. Good communication Introduce yourself and explain your role as a junior psychiatrist Establish rapport and do not include jargon. You don't have to include all the facts; good communication style is the key! Ask the patient what they understand about their illness. Ask whether they have heard about Lithium and whether they have any particular concerns with the medication.

233

2. Explain the nature of the treatment Explain that Lithium is a mood stabiliser, which is effective in treatment of mania, hypomania or bipolar affective disorder, as well as depression that is refractory to other medications.

3. Explain benefits Lithium has been used widely and well established in psychiatry over the last few decades. It has been very effective in treating bipolar affective disorder and it may reduce the frequency and severity of depressive episodes.

4. Explain side effects Common side effects as well as symptoms/signs of toxicity should be explained (described on card 56). Explain that lithium has to be maintained at the correct level in the blood, otherwise there is a risk of toxicity. Explain that side effects can be more likely when starting some other medications, when the weather is hot or when sweating a lot as blood lithium levels may become elevated. They can also occur with certain physical health problems such as diar­ rhoea. Explain that if experiencing increased tremor, unsteadiness, slurred speech, double vision, producing less urine or experiencing fits or confusion to contact the GP or NHS direct immediately. Longer term risks include developing an under active thyroid (hypothyroidism), heart (ECG) changes, exacerbations of psoriasis and possible kidney changes. 5. Explain practical points - Blood tests initially at baseline including thyroid function, renal function, urea and electrolytes. A baseline ECG will also be required. Blood will be tested weekly until the correct plasma level is reached, then every 3-6 months. Ask if the patient is planning to get pregnant and explain that they will need to tell the team in advance if this is the case. If asked, risks to the unborn include Ebstein's anomaly. The patient may wish to stop Lithium before conception and restart in the 3rd trimester. Breast feeding should not be per­ formed when taking Lithium. If Lithium is stopped altogether, there is a high chance (50%) of relapse especially after child birth.

2 34

118.

OCSE 12 - Assessing capacity

Scenario You h a v e b e e n a ske d to assess a 7 0 -y e a r-o ld m a n w h o has d e v e lo p e d g a n g re n e in his rig h t fo o t. The su rg ica l te a m a re re a d y to a m p u ta te his fo o t as th e g a n g re n e m a y s p re a d a n d th re a te n th e p a tie n t's life. The p a tie n t is c u rre n tly refusing surgery.

Assess the patient’s capacity in relation to his decision to refuse treatment. Suggested ap p ro a ch 1. G o o d c o m m u n ic a tio n 2. Assess p a tie n t's u n d e rs ta n d in g o f th e n a tu re o f th e tre a tm e n t/p ro c e d u re b e in g o ffe re d . Assess reasons fo r refusing tre a tm e n t 3. Assess th e a b ility o f th e p a tie n t to re ta in th e in fo rm a tio n g iv e n 4. Assess p a tie n t's a b ility to u n d e rs ta n d th e b e n e fits o f h a v in g th e p ro c e d u re as w ell as th e p o te n tia l c o n s e q u e n c e s o f n o t h a v in g th e p ro c e d u re a n d his a b ility to w e ig h th e se fa c to rs in th e b a la n c e 5. Assess fo r p s y c h ia tric s y m p to m s th a t a re o f a n a tu re w h ic h im p a ir th e p a tie n t's a b ility to m a k e ra tio n a l d e cisio n s

235

1. Good communication - It is often useful in practice to speak to the surgical team to clarify facts, you may not get this opportunity in the OSCE station. It is not your job to coerce, convince or per­ suade the patient to go through with the treatment or procedure; this is a common mistake among exam candidates. Ask about the patient's understanding of the problems (gangrene) and what the surgeons have told him about the gangrene. Ask whether he has had any operations before and if he has had a bad experience or knows anyone who had a similar experience. 2. Assess the patient’s understanding of the nature of the procedure and reasons for refusing treat­ ment - Ask about the patient's understanding of practical points - how long the procedure takes and risks associated with it. If the patient appears unclear, do not try to explain the procedure your­ self (this is the surgeon's role). 3. Assess the ability of the patient to retain the information given - Assess the patient's orientation to time, place and person and their immediate, short term and long term memory. If there is a comorbid alcohol dependency or dementia, a full cognitive assessment including frontal/parietal and temporal lobe exam may be necessary, which you could say you would arrange at another time.

4. Assess patient’s ability to understand the benefits of having the procedure as well as potential consequences of not having the procedure and his ability to weigh these factors in the balance Assess the patient's understanding of how the procedure will benefit him and his knowledge of the consequences of not having the procedure. Assess broadly his ability to be able to rationally weigh these factors in the balance.

5. Assess for psychiatric symptoms that are of a nature which impair the patient’s ability to make rational decisions - Ask screening questions to search for psychiatric symptoms that specifically impair the patient's ability to make a rational decision (eg delusions that the surgeons have been sent by someone to chop his foot off). Note: Simply being depressed or psychotic does not mean the patient lacks capacity.

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119. OSCE 13 - Collateral history for vascular dementia Scenario A 6 7 -y e a r-o ld m a n has b e e n a d m itte d to h o s p ita l a fte r a tra n s ie n t is c h a e m ic a tta c k (TlA). This is th e th ird tim e he has h a d a TIA. You a re a ske d to see th e p a tie n t w h o is e x p e rie n c in g m e m o ry d iffic u ltie s a n d a p p e a rs c o n fu s e d , o n th e m e d ic a l w a rd . You a re u n a b le to g a in a history fro m th e h u s b a n d as h e a p p e a rs c o n fu s e d a n d d o e s n o t a n sw e r q u e stio n s c le a rly . His w ife is p re s e n t o n th e w a rd h o w e ve r.

Speak to his wife to gain a collateral history about her husband Suggested ap p ro a ch 1. G o o d c o m m u n ic a tio n 2. Explore w id e ly th e n a tu re a n d c o u rs e o f th e s y m p to m s e x p e rie n c e d , fo c u s in g on fe a tu re s s u g g e stive o f v a s c u la r d e m e n tia 3. Ask a b o u t a s s o c ia te d c o m o rb id ity - p h y s ic a l/p s y c h ia tric illnesses 4. Explore o v e ra ll im p a c t o n fu n c tio n in g 5. P erform a risk assessm ent

237

1. Good communication - Introduce and explain your role. Verify that this is the wife of the patient. Ask open questions to begin such as what changes she has noticed in her husband.

2. Explore widely the nature and course of the symptoms experienced, focusing on features suggestive of vascular dementia - Ask about the time course of the symptoms and whether there has been a stepwise or gradual decline. Ask whether there are fluctuations in the symp­ toms. Ask specific questions regarding the patient's memory, confusion, personality and mood. Ask questions to try to establish if there was a temporal relationship between the TIAs and the symptoms developing. Enquire about language and executive functions. Screen for features of frontal lobe dementia including disinhibition and changes in personality.

3. Ask about associated comorbidity - Ask about risk factors including hypertension, diabetes, vascular disease, hypercholesterolaemia and previous cardiac events. Ask whether the patient has demonstrated symptoms suggestive of a psychotic or affective illness or another psychiatric problem. 4. Explore overall impact on functioning - Ask about level of functioning at home in terms of activities of daily living - self-care, etc. Ask whether she is able to cope at home and requires any support such as carers.

5. Perform a risk assessment - Assess risk including whether any appliances have been left on by accident, history of wandering or getting lost, any dangerous situations the patient has got into.

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120.

OSCE 14 - Explain systematic desensitization

Scenario A p a tie n t has b e e n re fe rre d to yo u r o u tp a tie n t c lin ic b y her GP as she has b e e n e x p e rie n c in g c la u s tro p h o b ia w h ic h has g o t to a p o in t w h e re it is c a u s in g her to fe e l d e p re sse d a n d a ffe c tin g her life s ig n ific a n tly o n a d a y to d a y basis. You d e c id e to o ffe r her s yste m a tic dese nsitizatio n .

Explain systematic desensitization to the patient Suggested ap p ro a ch to any ‘ E xp lain a t r e a t m e n t ’ s ta tio n 1. 2. 3. 4. 5.

G o o d c o m m u n ic a tio n Explain th e n a tu re o f th e tre a tm e n t (w h a t it is, h o w it works, in d ic a tio n s ) Explain a d v a n ta g e s (its b e n e fits ) Explain d is a d v a n ta g e s (p o te n tia l n e g a tiv e e ffe c ts ) Explain p ra c tic a l a s p e c ts (e g n u m b e r o f sessions e tc .)

Make sure you link your explanation to the patient’s history. Don’t just give a text­ book answer

239

1. Good communication - Give your name and explain who you are. Explain that you would like to offer her this treatment and ask if she has heard, read or knows anything about it already.

2. Explain the nature of the treatment/3. Explain the advantages (benefits) - Systematic desen­ sitization is a behavioural technique that can be used to treat phobias such as claustropho­ bia that the patient is suffering from. It involves exposing the individual gradually to the feared situation. The patient must make a list of situations that cause anxiety - a list of about 10 (in a hierarchy) with equally graded increasing levels of anxiety. Sometimes there is more than one situation that provokes anxiety. Here the unifying fear(s) should be sought and tackled. If there is no common link two separate hierarchies can be made. The patient imagines or enters the situation while relaxing until they can do this without anxiety. Relaxation techniques can be taught at the same time. This is repeated with each item of the hierarchy. 4. Explain disadvantages (potential negative effects) - Pitfalls may include if the patient s anxiety worsens, the situation looked at in therapy actually causes more anxiety each time the patient attends a session (sensitization rather than desensitization).

5. Explain practical aspects - The sessions are usually once a week and last for about 1 hour. Usually the course is about 16-20 sessions although some patient's may require longer.

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121. OSCE 15 - Morbid jealousy

Scenario A 44-year-old man is referred by his GP after several appointments where he has insisted that his wife is having an extramarital affair. Things have got to the stage where he has been checking her underwear on a daily basis.

Assess for features of morbid jealousy S uggested a p p ro ach

1. Good com m unication 2. Assess for presence of thoughts about partner's infidelity and if these thoughts are of a delusional quality or intensity 3. Assess for com orbidity 4. Comprehensive risk assessment

241

1. Good communication - Introduce and explain role. Approach topic sensitively and with tact. Ask open questions including what has been occurring lately.

2. Assess for presence of thoughts about partner’s infidelity and assess if these are delusion­ al in quality or intensity - Find out why he is suspicious and what evidence he has to support his beliefs. Find out whether the beliefs are held to a delusional fixity by asking if there is any possibility he may be wrong and exploring widely if there is a rational explanation for his views. Ask what he has been doing to check on his wife, including following her and invading her privacy. Enquire if the partner has ever cheated on him in the past, ie could the belief(s) be true? Ask if he has always been faithful to his wife. Take a full psychosexual history to enquire about past relationships and any difficulties. Ask about any sexual problems/impotence. Request consent to speak to the wife to ascertain her version of events as well as her views on his beliefs.

3. Assess for comorbidity - Screen for psychotic disorders, mood disorders, OCD, personality disorders and drug and especially alcohol problems. Ask about physical health problems also. 4. Comprehensive risk assessment -Ask if he sees himself as jealous and if he has ever been violent. Assess broadly the risk of him causing harm to the partner by probing adequately into depth of beliefs and searching for clues to indicate a grudge or other indicator of likely vio­ lence to the wife. Ask specifically if he has had any thoughts of hurting his wife in any way.

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122. OSCE 16 - Risk of violence

Scenario You are speaking to the wife of a patient suffering from schizophrenia on the ward. The patient threatened his wife with a knife prior to the admission.

Assess the patient’s risk of violence by talking to the wife. S uggested a p p ro ach

1. G ood com m unication 2. Assess for history of violent behaviour 3. Ask about past relationship betw een mental state and violent behaviour if there was any 4. Risk assessment - current

243

1. Good communication - R e m e m b e r y o u a re ta lk in g to th e w ife a n d n o t th e p a tie n t. In tro d u c e a n d e x p la in role. Ask o p e n que stion s a b o u t p re vio u s a n d c u rre n t history o f v io le n c e e ith e r to th e w ife or to o thers a n d w h a t this e n ta ile d . 2. Assess for history of violent behaviour - A s c e rta in w h e th e r th e re is a fo re n sic his­ to ry (a history o f o ffe n d in g b e h a vio u r, c rim in a l o ffe n c e s a n d c h a rg e s /c o n v ic tio n s ). 3. Ask about past relationship between mental state and violent behaviour if there was any - A s c e rta in th e c o n te x t o f th e v io le n c e - w h e th e r it w a s d u rin g a p s y c h o t­ ic relap se w h e n th e p a tie n t m a y h a v e b e e n p o o rly a d h e re n t w ith m e d ic a tio n . Ask if th e p a tie n t is d e p e n d e n t o n illicit su b sta n ce s a n d if v io le n c e is a s s o c ia te d w ith th e ir use. Find o u t if a n g e r m a n a g e m e n t is a p a rtic u la r issue.

4. Risk assessment - current - Ask w h e th e r th e re a re a n y c h ild re n a n d if th e y h a v e b e e n a ffe c te d . Has th e p a tie n t to ld his w ife a b o u t a n y c o m m a n d h a llu c in a tio n s or a n y c a u s e fo r his v io le n c e ? Ask if th e p a tie n t has d e s c rib e d p e rs e c u to ry delusions. Has th e p a tie n t th re a te n e d to b e v io le n t to w a rd s him self w ith se lf-h arm or su icid e? Ask if th e w ife c a n c o p e w ith th e situ a tio n a n d w h e th e r she has or in te n d s to press ch a rg e s.

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123.

OSCE 17 - Obsessive-compulsive disorder Scenario You see a 21-year-old girl in A&E who is com plaining of depression. On further ques­ tioning she tells you she has been checking taps lately.

Assess for symptoms of obsessive-compulsive disorder S uggested a p p ro ach

1. 2. 3. 4. 5.

G ood com m unication Assess for symptoms of OCD Assess for associated com orbidity - depression, psychosis, substance misuse Explore im pact on functioning Risk assessment

1. Good communication p r o b le m

-

In t r o d u c e

and

d e v e lo p

ra p p o rt. A sk

open

q u e s t io n s a b o u t t h e

in c lu d in g t im in g , t r e q u e n c y a n d s e v e r it y o f s y m p t o m s .

245

2. Assess for symptoms of OCD - Ask about the nature and quality ot obsessions including what they are, whether they are intrusive and what effect they have on the patient. Ask if there are images, ruminations or excessive doubts. Ask whether the thoughts are recognized as her own thoughts and if there is a resistance to the obsessive thoughts. It is important to ask whether the patient can control or neutralize the compulsions. Ask whether there is a magi­ cal quality between what the patient is doing and trying to achieve. Ask about what will hap­ pen if the compulsions are ignored (eg does the patient feel as if a disaster will occur?). Explore if there are any thoughts of contamination, aggressive thoughts, sexual or religious thoughts, concerns about preciseness/order, hoarding behaviour and any aspects of the body the patient checks or is concerned about.

3. Assess for associated comorbidity - Screen for other illnesses briefly including depression and psychotic thoughts. If extra time is available ask about OCD spectrum disorders including Tourette's disorder, body dysmorphic disorder and hypochondriasis. Ask whether the patient has resorted to drugs or alcohol as a result of the problem. 4. Explore impact on functioning - Is the patient able to perform activites of daily living, eg self-care, shopping, cooking, etc., or are their symptoms so severe that they interfere with their day to day ability to function. Gauge the patients insight into the problem. 5. Risk assessment - Ask if the patient has got into any dangerous situations as a result of their obsessions or compulsions. Enquire broadly about other aspects of risk - self-neglect may be an issue. Ask if symptoms have been so distressing that they have had suicidal thoughts.

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124.

OSCE 18 - Temporal lobe epilepsy Scenario A 28-year-old unem ployed male complains of a recent seizure and a funny feeling he has been here before.

Assess for temporal lobe epilepsy S uggested a p p ro ach

1. 2. 3. 4.

Good com m unication Assess for symptoms of tem poral lobe epilepsy Enquire about com orbidity - psychosis, depression, substance misuse Risk assessment

247

1- Good communication - In tro d u c e a n d d e v e lo p ra p p o rt. Ask o p e n q uestions to b e g in w ith.

2. Assess for symptoms of temporal lobe epilepsy - Take a history o f th e seizure in c lu d in g tim in g, d u ra tio n , e y e witness a c c o u n ts , w h e th e r th e p a tie n t re q u ire d m e d ic a l a tte n tio n . Establish if th e re h a v e b e e n a n y seizures a n d if so w e re th e y g e n ­ e ra lize d to n ic -c lo n ic or a n a b s e n c e seizures? If g e n e ra liz e d to n ic -c lo n ic seizures ask w h e th e r th e re w as to n g u e b itin g or in c o n tin e n c e . Find o u t if th e re is a n y fa m ily his­ to ry o f e pilepsy. Ask w h e th e r th e re w a s a n a u ra b e fo re th e seizure. Ask h o w th e p a tie n t w as a fte r th e seizure a n d w h e th e r he w as d ro w sy a n d c o n fu s e d . Ask a b o u t th e p re s e n c e o f a n y h a llu c in a to ry e x p e rie n c e s in c lu d in g v o ic e s or m usical sounds. W ere th e re a n y visual distortions o f c o lo u r or size a n d s h a p e o f o b je c ts ? Enquire a b o u t d é jà vu or ja m a is vu e x p e rie n c e s .

3. Enquire about comorbidity - Ask a b o u t a fa m ily history o f m o o d d iso rd e r or w h e th e r th e p a tie n t has e x p e rie n c e d a ffe c tiv e sym pto m s. S um m arize a n d a nsw er questions. 4. Risk assessment - Ask w h e th e r th e p a tie n t b e c a m e v io le n t a t a n y p o in t w h ile he h a d b e e n e x p e rie n c in g a n y o f th e a b o v e sym ptom s.

248

125. OCSE 19 - Assess for a history of substance misuse Scenario A 35-year-old man is newly adm itted to the ward. A random urine drug screen is positive for am phetam ines and cannabis.

Take a history to assess for substance misuse. S uggested a p p ro ach

1. G ood com m unication 2. Assess broadly for use of multiple substances, including onset, frequency, dura­ tion and m ethod of use of each drug 3. Assess im pact on functioning 4. Assess for com orbidity 5. Risk assessment

249

1. Good communication - Introduce and establish rapport, listen to the patient and empathize.

2. Assess broadly for use of multiple substances - Find out exactly which substances have been used and which are used regularly. The patient is unlikely to admit to every single drug so you should name substances and ask if the patient has tried them. Name several com­ monly used drugs including marijuana, cocaine, LSD, ecstasy, amphetamines and heroin. Assess onset, frequency and method of use of each drug. Elicit the quantities of each sub­ stance used, asking the patient to describe a typical day or week. Ask about pleasurable effects obtained and negative effects. Find out the duration of use and periods of absti­ nence. Ask how the patient copes with withdrawal symptoms. Ask about the route of use and whether the patient has been sharing needles. Ask whether the patient has contracted any diseases if he has been sharing needles. Ask if there is increased tolerance to the drugs and if more are being used. Ask if there is a compulsion to use drugs. Ask if there is a stereotyped pattern of usage. 3. Assess impact on functioning - How has drug use affected the patient in terms of his rela­ tionships, social and financial aspects of his life. Has it affected his self-care or other activities of daily living. 4. Assess for comorbidity - Enquire about comorbid depression, anxiety, personality or memory changes, or psychotic symptoms.

5. Risk assessment - Ask if the patient has got into any dangerous situations as a result of hisdrug taking. Ask if the patient has been involved in any criminal activity to fund his habit. Ask whether the patient has ever injected drugs and if so, is he aware of the danger of develop­ ing HIV or other blood-borne infections such as hepatitis from sharing needles?

250

126. Defining common conditions - for OSCE explanation stations (card 1 of 2)

Defining common conditions • Severe mental illness (SMI): refers to the presence of a severe psychiatric dis­

order (eg schizophrenia, schizoaffective disorder, severe depression or bipolar disorder) a cco m p a n ie d by significant functional impairment, disruption of nor­ mal life tasks, periods of hospitalization and need for psychotropic medication. • Mental disorder: the existence of a clinically recognizable set of symptoms or

behaviour associated in most cases with distress and with interference with per­ sonal functions. • Personality disorder: deeply ingrained and enduring behaviour patterns, mani­

festing themselves as inflexible responses to a broad range of personal and social situations.

251

Defining common conditions (cont.) • Schizophrenia: a d iso rd e r c h a ra c te riz e d b y distortions o f th in k in g a n d p e rc e p tio n a n d in a p p ro p ria te or b lu n te d a ffe c t. H a llucin atio ns, delusions a n d th o u g h t dis­ o rd e r a re c o m m o n .

• Hypomania: persistent m ild e le v a tio n o f m o o d (fo r a t least several d a ys o n e n d ), in c re a s e d e n e rg y a n d a c tiv ity , a n d usually m a rk e d fe e lin g s o f w e ll-b e in g a n d b o th p hysica l a n d m e n ta l e ffic ie n c y .

• Mania: e le v a te d m o o d a n d p s y c h o m o to r o v e ra c tiv ity fo r a t lea st 1 w e e k d u ra ­ tion.

• Depression: in d iv id u a l suffers lo w m o o d , lo w e n e rg y a n d a n h e d o n ia o f a t least 2 w eeks d u ra tio n .

• PTSD: a response to a n e x c e p tio n a lly th re a te n in g e v e n t w ith ty p ic a l re p e a te d reliving o f th e tra u m a a s s o c ia te d w ith num bness, d e ta c h m e n t, a v o id a n c e a n d h ype ra ro usa l.

252

127. Defining common conditions - for OSCE explanation stations (card 2 of 2)

Defining common conditions • Dementia: a syndrome resulting from disease of the brain, usually of a chronic or

progressive nature, in which there is disturbance of multiple higher cortical func­ tions, including memory, thinking, learning c a p a city and judgem ent. • Anorexia nervosa: a disorder characterized by deliberate weight loss, induced

and/o r sustained by the patient. • Bulimia nervosa: a syndrome characterized by repeated bouts of overeating

and an excessive preoccupation with the control of body weight, leading the patient to a d o p t extreme measures so as to m itigate the 'fattening' effects of ingested food.

253

Defining common conditions (cont.) • Dependence syndrome (drugs or alcohol): a cluster o f p h y s io lo g ic a l, b e h a v io u r­ al a n d c o g n itiv e p h e n o m e n a in w h ic h use o f a s u b s ta n c e or a class o f su b ­ sta nce s ta ke s on a m u c h h ig h e r p riority fo r a g iv e n in d iv id u a l th a n o th e r b e h a v ­ iours th a t o n c e h a d g re a te r v a lu e .

• Organic delusional (schizophrenia-like) disorder: a d iso rd e r in w h ic h persistent or re c u rre n t delusions d o m in a te th e c lin ic a l p ic tu re . The delusions m a y b e a c c o m ­ p a n ie d b y h a llu c in a tio n s b u t a re n o t c o n fin e d to th e ir c o n te n t. The g e n e ra l c ri­ te ria fo r a n o rg a n ic d iso rd e r m ust b e m e t.

254

128. Summmary of evidence based guidelines for OSCE explanations

Postnatal depression - Scottish Intercollegiate Guidelines (SIGN) •

Postnatal depression (PND) is regarded as any non-psychotic depressive illness of mild to m oderate severity occurring during the first postnatal year.

• All wom en should be screened routinely for a history of depression or psychosis in previous pregnancies. • All wom en should be screened for a history of depression in the current preg­ nancy. Note that em otional changes may mask a depression. •

If high risk give interpersonal therapy when pregnant, offer postnatal visits/antenatal preparation.

•

If Edinburgh postnatal depression score is greater than 10 is suggested as a cut off for whole population screening.

255

Postnatal depression - Scottish Intercollegiate Guidelines (SIGN) (cont.)

2 56

•

N ote: The E d inb urgh P o stn ata l D epression S cale is n o t d ia g n o s tic .

•

W h e n p re scrib in g use th e lo w e st e ffe c tiv e d o se (see C a rd 62).

•

Do n o t rou tin e ly sto p tric y c lic a n tid e p re s s a n ts or SSRIs in e a rly p re g n a n c y . Risks o f s to p p in g m e d ic a tio n shou ld b e c a re fu lly assessed in re la tio n to th e m o th e r's his­ to ry a n d p o te n tia l risks.

•

P sychosocial in te rve n tio n s should b e c o n s id e re d w h e n c h o o s in g tre a tm e n t o p tio n s fo r a m o th e r d ia g n o s e d as suffering fro m PND.

•

A m ultipro fessio na l assessm ent shou ld b e p e rfo rm e d to d e te rm in e if m o th e r a n d b a b y should b e a d m itte d to a sp e cia list unit.

129. Summary of evidence based guidelines for OSCE explanations

NICE guidelines for self-harm • Assessment should consist of:

(i) C apacity to consent for further assessment (including assessment of presence of mental illness). (ii) Agitation. (iii) Previous history of self-harm. (iv) Presence of cognitions associated with suicide - depression/hopelessness/ suicidal ideation. • All assessments should be com m unicated to the GP and relevant mental health team. If thought to be at high risk of self-harm the patient should be offered intensive com m unity outreach for at least 3 months consisting of supportive ther­ apy, home treatm ent and a 24-hour c o n ta c t should be m ade available. Alternatively refer for Dialectic Behaviour Therapy (DBT) if borderline personality disorder is thought to be associated with the self-harming behaviour.

257

Young people and deliberate self-harm •

C o n sid e r G illick c o m p e te n c e in c h ild re n (if th e y a re u n d e r 16 b u t h a v e c a p a c i­ ty th e y m a y b e a b le to m a k e a d e c is io n to a c c e p t tre a tm e n t e v e n if th e p a re n ts d isa g re e ).

•

If adm ission is n e e d e d a d m it to p a e d ia tric a n d n o t to th e p s y c h ia tric w a rd .

•

A dvise p a re n ts to re m o v e all m e d ic a tio n s a n d o th e r m e a n s o f se lf-h arm a t hom e.

•

If th e re is a history o f re c u rre n t self-harm , o ffe r d e v e lo p m e n ta l g ro u p p s y c h o ­ th e ra p y .

•

Assessm ent should consist of: c h ild p ro te c tio n issues, c o lla te ra l history fro m so cia l services, fa m ily a n d sch oo l.

Older patients and deliberate self-harm

258

•

A n y DSH in a person o v e r 65 shou ld b e c o n s id e re d a tte m p te d su icid e until p ro v e n o therw ise.

•

Pay a tte n tio n to p re s e n c e o f c o g n itiv e im p a irm e n t, p h ysica l ill h e a lth , so cia l a n d h o m e situation.

130. Summary of evidence based guidelines for OSCE explanations

Bipolar affective disorder Bipolar affective disorder - NICE guidelines A ssessm ent, recognition, diag no sis Prim ary care - Urgent referral for patients with m ania or severe depression at risk to self or others Referral for patients with history of overactive, disinhib ited b eha viour > 4 days ± dep ression Se co nd a ry care - A ssess sym ptom s, past history, triggers, social and p ersona l functionality, stressors C onsid e r substa nce m isuse and d ifferentiate com orb id ing eg p syc h o sis/p e rso na lity disord er Risk a sse ssm ent on first diagnosis, form a crisis plan considering early w a rning signs.

Mania/Hypomania Stop a ntid ep ressa nt If on antim ania previously, if on an antip sycho tic check dose and d e c re a se if necessary If response is inadequate, c onsid e r adding lithium or valpro ate If on lithium check levels and ensure optim al dose is given If on va lp ro a te increase dose until side effec ts lim it furth er inc rea se /until sym p to m s im prove In severe m ania, if on lithium /valp ro ate, c onsider adding an antip sycho tic and g ra dua lly increa sing dose of the original drug.

Maudsley algorithm for treatment of rapid cycling bipolar affective disorder •

Ф • •

W ithd ra w a ntid ep ressa nt O ptim ize m ood sta b ilizer > C om b ine tw o m ood sta b ilizers —> Add o la nza p ine /c lo za p ine /nim o d o p ine (C a + c hannel b loc ker)/thyro xine /la m otrig ine .

259

Post-traumatic stress disorder (PTSD) NICE guidelines •

NB fo r a dia gn osis th e e v e n t le a d in g to th e PTSD has to b e life th re a te n in g . S cre en in g fo r PTSD in survivors o f disasters is a useful m ea sure. D e b rie fin g m a y h a v e a n e g a tiv e e ffe c t o n prognosis a n d should n o t b e o ffe re d .

• General principles: Treat a n y c o -m o rb id axis 1 d ia gn osis (e g s u b s ta n c e misuse/d ep ression ). S u p p o rt th e fa m ily. C o n s id e r c u ltu ra l sensitivities p e rtin e n t to th e situation.

• Treatment: (i) W a tc h fu l w a itin g , (ii) Traum a fo c u s e d C B T /eye m o v e m e n t desensi­ tiza tio n th e ra p y (EMDR). (iii) Short te rm h y p n o tic , (iv) If n o im p ro v e m e n t w ith psy­ c h o lo g ic a l th e ra p ie s try: p a ro x e tin e or m irta z e p in e ; a m itry p tilin e or p he n e lzin e ; o la n z a p in e as a fin a l a d ju n c t. C o n tin u e a n y m e d ic a tio n fo r a t lea st 12 m on ths a fte r re c o v e ry , (v) D o n o t o ffe r o th e r fo rm s o f p s y c h o th e ra p y or a lte rn a tiv e th e r­ a p ie s such as re la x a tio n th e ra p y as it a v o id s d e a lin g w ith th e tra u m a tic e v e n t, (vi) If a t hig h risk o f su ic id e re v ie w w e e kly, o th e rw is e re v ie w 2 -4 w e e kly, (vii) In c h ild re n w ith PTSD use p s y c h o lo g ic a l th e ra p ie s . M e d ic a tio n s a re n o t re c o m ­ m ended.

2 60

131. Summary of evidence based guidelines for OSCE explanations

NICE guidelines for depression Steps 1-2: Watchful waiting/self-help - mild depression • Com puter CBT. • Activity scheduling. •

Exercise programmes.

Step 3: Level of GP/CMHT interface - moderate-severe depression •

Give m edication.

•

Fluoxetine/citalopram are the best choice ot SSRIs.

• Continue treatm ent for 6 months. •

NICE guidelines do not recom m end St Johns Wort.

261

NICE guidelines for depression (cont.) Step 4: Level of secondary care - treatment-resistant depression/ atypical/psychotic depression Here treatment should be attempted along the following steps: 1. First antidepressant (AD). 2. AD and cognitive behavioural therapy (CBT). 3. AD and CBT and lithium. 4. If two ADs have failed start venlafaxine. 5. Augmentation, ie SSRI and mirtazapine. 6. Phenelzine (particularly indicated for atypical depression). 7. Refer to tertiary services.

Step 5: EOT • Inpatient treatment and crisis response are the only level at which ECT is indicated. ECT is no longer recommended for maintenance treatment.

Other recommendations • Do not use carbamazepine/lamotrigine/pindolol/buspirone/valproate/thyroxine/benzodiazepines. Keep on maintenance treatment for 2 years if two or more episodes have occurred. If on combination antidepressant treatment, keep patient on both medications for at least 6 months then withdraw adjunct first.

262

132. Summary of evidence based guidelines for OSCE explanations

NICE guidelines for schizophrenia (card 1 of 2) Acute episode 1. 2. 3. 4. 5. 6. 7. 8. 9.

Atypical antipsychotic treatm ent should be first line. No loading doses. Use lowest possible dose. If on typical and relapsed change to atypical. Don't give two antipsychotics at the same time apart from short change over periods. If no response change class of drugs. When recovered let patient write their a cco u n t in the notes. On recovery full pa cka g e of family therapy (FT), cognitive behavioural therapy (CBT) and occupatio nal therapy (ОТ) should be offered. Continue drugs for 1-2 years once well. Gradual withdrawal after this, Monitor drug free for further 1-2 years.

263

NICE guidelines for schizophrenia (card 1 of 2) (cont.) Relapse prevention •

C o n tin u e m e d ic a tio n a n d FT/CBT/OT as a b o v e . M o n ito r s id e -e ffe c ts closely w h ic h NICE d e fin e s as: — Akathasia/EPSE —W e ig h t g a in /d ia b e te s — Sexual d y s fu n c tio n /h y p e rp ro la c tin a e m ia — O v e rs e d a tio n — Eye signs.

Rapid tranquilization •

264

Use m in im u m d ose possible.

•

N eve r s e c lu d e if in to x ic a te d o n a lc o h o l or drugs.

•

If IM ty p ic a l a n tip s y c h o tic is g ive n , g iv e a n IM a n tic h o lin e rg ic as w ell.

•

M a k e steps a fte rw a rd s to re-establish th e th e ra p e u tic re la tio n sh ip w ith th e p a tie n t.

133. Summary of evidence based guidelines for OSCE explanations

NICE guidelines for schizophrenia (card 2 of 2) Treatment resistance 1. Check com pliance 2. Exclude substance misuse 3. Exclude physical illness 4. Re-confirm diagnosis 5. Consider psychological therapies 6. Try risperidone or olanzapine if not tried already 7. In cases refractory to 2 other antipsychotics at optim al doses given for an adequ a te trial period, consider clozapine.

265

NICE guidelines for schizophrenia (card 2 of 2) (cont.) Clozapine augmentation - Maudsley guidelines •

A d d itio n a l m e d ic a tio n to c o n s id e r a d d in g in ca ses re fra c to ry to c lo z a p in e tre a t­ m e n t in c lu d e : — S ulpiride — L a m o trig in e — R isperidone — EPA fish oil — H a lo p e rid o l — ЕСТ.

Pathways to care •

266

If less th a n 35 years o ld a n d w ith in first 3 years o f illness, or n e w to services, p a tie n ts should b e re fe rre d to a n e a rly in te rv e n tio n se rvice or to a crisis resp on se/asse rtive o u tre a c h te a m w ith a n a im to tre a t o u t o f h ospital.

134. Summary of evidence based guidelines for OSCE explanations

Obsessive-compulsive disorder - NICE guidelines General principles •

For patients with mild functional im pairm ent first offer psychological therapies Exposure and Response Prevention (ERP) up to 10 hours per patient or offer SSRI if unable to engage in ERP. • For patients with m oderate functional im pairm ent offer a choice of an SSRI or more intensive cognitive behavioural therapy (with ERP) - more than 10 hours per patient. • Provide adeq u a te information and support liase with primary care, encourage family involvement if appropriate.

267

Obsessive-compulsive disorder - NICE guidelines (cont.) Stepped care approach Step 1 - Level of individuals/public organizations/NHS. In cre a se a w a re n e ss a n d k n o w le d g e a b o u t O C D a n d w h e re to seek h e lp if nece ssary

Steps 2 and 3 - Primary care, practice nurses, primary care mental health workers. R e c o g n itio n a n d assessm en t/in itia l tre a tm e n t - discussion o f tre a tm e n t options, in vo lve fa m ily a n d carers. M a y o ffe r b rie f in d iv id u a l or g ro u p CBT (ERP) or a n SSRI or b o th .

Step 4 - Level of secondary care. O C D w ith c o m o rb id ity or p o o r response to initial tre a tm e n t - CBT (ERP), SSRI, a lte rn a tiv e SSRI, c lo m ip ra m in e or c o m b in e d tre a tm e n ts .

Step 5 - Specialist OCD service. O C D w ith s ig n ific a n t c o m o rb id ity or se vere fu n c ­ tio n a l im p a irm e n t - SSRI or c lo m ip ra m in e or CBT (ERP) or c o m b in a tio n o f b o th S S R I/clom ipram ine a n d CBT (ERP).

Step 6 - Inpatient care/intensive treatment programmes. O C D a s s o c ia te d w ith risk to life /s e v e re s e lf-n e g le c t or se vere distress/disability. T re a tm e n t as in ste p 5 or c o n ­ sider a u g m e n tin g S S R I/clom ipram ine w ith a n a lte rn a tiv e m e d ic a tio n .

268

135. Summary of evidence based guidelines for OSCE explanations NICE guidelines for eating disorders (card 1 of 2)

Anorexia nervosa - physical management Managing weight gain • Aim for average weekly weight gain of 0.5-1 kg in inpatient settings and 0.5 kg in outpatient settings. This requires about 3500-7000 calories a week. • Provide regular physical monitoring and consider multivitamin/multimineral sup­ plem ent for both inpatients and outpatients. • Total parenteral nutrition should be reserved only for significant gastrointestinal dysfunction.

Managing risk •

Inform patients and carers about potential physical risks.

• Involve physicians appropriately. • Oestrogen administration only in adults if bone density problems exist.

269

Anorexia nervosa - inpatient care •

For p a tie n ts w ith m o d e ra te or h ig h p h y s ic a l risk/no t im p ro v in g w ith o u tp a tie n t tr e a tm e n t/w h o h a v e s ig n ific a n t risk o f s u ic id e or se vere self-harm .

•

A d m it to se tting th a t c a n p ro v id e skilled services o f re fe e d in g w ith c a re fu l phys­ ic a l m o n ito rin g a n d in c o m b in a tio n w ith p s y c h o s o c ia l interven tion s.

•

P s y c h o lo g ic a l th e ra p ie s w ith fo c u s o n sym p to m s a n d w e ig h t g a in should b e u n d e rta k e n . Focus shou ld b e o n e a tin g b e h a v io u r a n d a ttitu d e s to w e ig h t a n d s h a p e . R igid b e h a v io u r m o d ific a tio n p ro g ra m m e s s h o u ld n o t b e used. P sy c h o lo g ic a l in p u t shou ld c o n tin u e fo r 12 m o n th s p o st d is c h a rg e . Types o f th e r­ a p ie s c a n in c lu d e : c o g n itiv e a n a ly tic th e ra p y (CAT); c o g n itiv e b e h a v io u r th e ra ­ p y (CBT); in te rp e rso n a l th e ra p y (IPT); fo c a l p s y c h o d y n a m ic p s y c h o th e ra p y ; fa m ­ ily inte rve n tio n s fo c u s in g e x p lic itly o n e a tin g disorders.

•

F ee d in g a g a in s t th e will o f th e p a tie n t should b e a last resort a n d o n ly u n d e r M e n ta l H ea lth A c t 1983 or C h ild re n A c t 1989.

Anorexia nervosa - outpatient care

270

•

P s y c h o lo g ic a l th e ra p ie s fo r 6 m o n th s m in im u m as a b o v e .

•

M e d ic a tio n s should b e used w ith c a u tio n as depre ssion a n d o th e r c o m o rb id ity m a y im p ro v e w ith w e ig h t g a in a lo n e .

•

A v o id using drugs w h ic h c a u s e QTc p ro lo n g a tio n . ECG m o n ito rin g shou ld b e u n d e rta k e n if drugs a re used w h ic h c o u ld a ffe c t c a rd ia c fu n c tio n .

136. Summary of evidence based guidelines for OSCE explanations NICE guidelines for eating disorders (card 2 of 2)

Bulimia nervosa •

First step - consider an evidence based self-help programme.

•

Psychological treatm ent should be the key form of treatment.

•

For adults - cognitive behaviour therapy (CBT) for 16-20 sessions over 4-5 months. • If no response to CBX try Interpersonal Therapy (IPT). • Consider trial of an antidepressant drug as an alternative or in com bination with a self-help programme,

271

Bulimia nervosa (cont.) •

272

SSRIs a re th e first c h o ic e as th e y a re th e m ost to le ra b le in te rm s o f sid e -e ffe cts.

•

E ffe c tiv e d o se o f flu o x e tin e is h ig h e r th a n in dep re ssion a t 60 m g daily.

•

C a re fu l m o n ito rin g o f p h y s ic a l risks shou ld b e u n d e rta k e n in c lu d in g assessm ent o f flu id a n d e le c tro ly te b a la n c e w h e re v o m itin g is fre q u e n t or th e re is fre q u e n t use o f laxatives.

137. ISQ - Pharmacology

Answer True or False Carbamazepine is a potent enzyme inducer.

273

True

274

Potent enzyme inducers include

Enzyme inhibitors include

•

C a rb a m a z e p in e .

•

C im e tid in e .

•

P henytoin.

•

D iltiazem .

•

P h e n o b a rb ita l.

•

S odium v a lp ro a te .

•

Isoniazid.

•

M e tro n id a z o le .

•

V e ra p a m il.

•

A llop u rino l.

•

C h lo ra m p h e n ic o l.

•

Im ip ra m in e .

•

S u lp h o n a m id e s.

•

P henothiazines.

138. ISQ - Neuroscience

Answer True or False 1. The plenum temporale is situated on the anterior part of inferior temporal lobe.

2. Alexia without agraphia occurs in anterior cerebral artery lesions.

275

1 False - The p le n u m te m p o ra le e n c o m p a s s e s th e W e rn ic k e 's a re a a n d is lo c a te d on th e dorsal s u rfa c e o f th e te m p o ra l lo b e . This re g io n is th o u g h t to b e im p lic a te d in sch izo ph re n ia . 2 False - Anterior cerebral artery lesions - (i) u p p e r m o to r n e u ro n e (UM N) palsy o f fo o t a n d lo w e r lim b o n c o n tra la te ra l side; (ii) sensory loss o n c o n tra la te ra l side fo o t a n d lo w e r lim b; (iii) u rinary p ro b le m s. Posterior cerebral artery lesions - (i) a le xia w ith o u t a g ra p h ia in le ft p o ste rio r c e re b ra l a rte ry lesions; (ii) W e b e r's syn drom e; (iii) UMN palsy o f w h o le c o n tra la te ra l side; (iv) ipsilateral o c u lo m o to r n e rve palsy; (v) superio r h o m o n y m o u s q u a d ra n tin o p ia .

276

139. ISQ - Neuroscience

Answer True or False 1. HIV enters the brain via infected macrophages.

2. Seizures are seen in tuberous sclerosis.

277

1 True - HIV-1 is a haematogenously spread virus that most likely gains entry into the brain within blood-derived macrophages. 2 True - Tuberous sclerosis is a rare multisystem genetic disease which

causes benign tumours to grow in the brain and other organs including kidneys, eyes, lungs and skin. It commonly affects the central nervous system leading to seizures, developmental delay, behavioural problems, skin abnormalities and kidney disease.

278

140. ISQ - Neurotic disorders

Answer True or False Astasia abasia may be a feature of dissociative disorders.

279

True Astasia abasia is the inability to stand or walk in the absence of neurological abnormalities and may occur in functional dissociative psychiatric illnesses. Dissociative disorders:

Dissociative amnesia Inability to recall information, usually about stressful or traumatic events in a person's life. Often abrupt onset after trauma. Patients are usually alert before and after the amnesia occurs. A few patients report slight clouding of consciousness during the period immedi­ ately before and after the amnesia onset. Preexisting depression and anxiety are common features in the history. Amnesia may be localized - few hours to few days; generalized loss of memory for whole life or selective for certain events. Usually recovers spontaneous­ ly.

Dissociative fugue Unusual and dramatic behaviour - patients travel far away from their home or work in a purposeful way for days at a time. They may take on an entirely or partially new identity and have amnesia for their past. They fail to remember important aspects of their previous identity (name, family, work). Persons with a history of alcoholism, personality disorder or other psychiatric illness are predisposed although the condition appears largely physio­ logical in origin.

Dissociative identity disorder See card 31 for more details.

Depersonalization disorder See card 31 for more details.

280

141. ISQ - Dementia syndromes

Answer True or False 1. Delusional disorder usually precedes dementia.

2. Normal pressure hydrocephalus causing dementia is potentially reversible.

3. Personality changes before memory changes suggest Pick’s disease rather than Alzheimer’s disease.

4. Having a seizure is more suggestive of Pick’s disease than Alzheimer’s disease.

281

1 False 2 True - A b n o rm a l g a it, urinary in c o n tin e n c e a n d d e m e n tia a re reversible w h e n th e c o n d itio n is tre a te d . 3. True - The first sym pto m s o f Pick's d isease a re o fte n p e rs o n a lity c h a n g e a n d a d e c lin e in fu n c tio n a t w o rk a n d a t h o m e . 4. False

282

142. ISQ - Human development

Answer True or False According to Donald Winnicott, a transitional object is considered the same as a ‘good enough mother’.

283

False • A transitional object is a n ite m such as a b la n k e t or te d d y b e a r th a t e n a b le s a c h ild to m o v e a w a y fro m a n a tta c h m e n t fig u re a n d e x p lo re th e w o rld a ro u n d th e m . It is seen as a m e th o d o f p ro v id in g security. It is d e s c rib e d as tra n sitio n a l b e c a u s e it is th o u g h t to lie in th e c h ild 's m in d b e tw e e n th e ir u n c o n s c io u s 'p h a n ­ ta s y ' o f th e id e a liz e d m o th e r a n d th e real w o rld in w h ic h th e m o th e r is n o t so p e r­ fe c t. It is th e c h ild 's w a y o f a d a p tin g to loss o f th e p h a n ta s y o f th e id e a liz e d m other.

• The (good enough mother1 w a s d e s c rib e d b y W in n ic o tt a n d d e s crib e s th e in te r­ a c tio n b e tw e e n m o th e r a n d b a b y in th e w ee ks a n d m o n th s a fte r c h ild b irth . The m o th e r supplies a n e n v iro n m e n t in w h ic h th e in fa n t is c o n ta in e d a n d e x p e ri­ e n c e s life. The m o th e r d o e s n o t n e e d to b e p e r fe c t b u t n e e d s to b e a 'g o o d e n o u g h m o th e r' - fo r b o n d in g to ta k e p la c e a d e q u a te ly a n d to ensure th a t th e c h ild form s a se cu re a tta c h m e n t a n d d e v e lo p s in g o o d h e a lth . The in fa n t learns to to le ra te th e frustra tion o f le a rn in g th a t th e m o th e r will n o t a lw a y s b e p re se n t a n d this is seen as p a rt o f h e a lth y d e v e lo p m e n t. W in n ic o tt d e s c rib e d a 'p rim a ry m a te rn a l p re o c c u p a tio n ' in w h ic h th e m o th e r's a tte n tio n is d ire c te d to her c h ild in e a rly in fa n c y a n d thus form s a c o u p le b o n d .

284

143. ISQ - Neuroscience

Answer True or False 1. A lesion in Broca’s area results in an expressive aphasia.

2. The limbic system has been implicated in neuropathological studies of schizophrenia.

285

1 True - A lesion in Broca's area in the frontal lobe results in an expressive aphasia. Comprehension of speech is intact. A lesion in Wernicke's area results in a receptive aphasia with fluent speech. Comprehension of others speech is poor. 2 True - Functional neuroimaging has shown decreased activation of the frontal lobes in people with schizophrenia particularly when required to perform a task. There is also a decreased density of neuropil and the intertwined axons and dendrites of neurones in the frontal lobes. The limbic system includes the hippocampus, the fornix, the mamillary bodies, the anterior nucleus of the thalamus and the cingulate gyrus. It also includes the amygdala, septum, basal forebrain, nucleus accumbens and orbitofrontal cortex.

286

144. ISQ - Dementia syndromes

Answer True or False Personality change is a late feature of Huntington’s disease.

False Huntington’s disease characteristics •

A g e n e t ic d is e a s e t ra n s m it t e d in a n a u t o s o m a l d o m in a n t f a s h io n w ith 1 0 0 % p e n e t ra n c e ; h e n c e 5 0 % o f o ff s p rin g a re a f fe c t e d . T h e d is e a s e is c h a ra c t e riz e d b y a c o m b in a t io n o f p ro g re s s iv e d e m e n t ia a n d w o rs e n in g c h o re a .

Aetiology •

G e n e t ic d e f e c t in t rin u c le o t id e r e p e a t o f C A G o n c h ro m o s o m e 4.

Characteristics •

• Ф • • • • • •

288

U s u a lly a g e o f o n s e t is in t h ird a n d f o u rt h d e c a d e s o f life . D e t e rio ra t in g c o n d it io n o v e r 1 0 - 1 2 y e a rs to d e a t h .

Changes in personality or mood m ay be the earliest signs of the disease. P s y c h o m o t o r s lo w in g . D if f ic u lt y p e r f o r m in g c o m p le x t a s k s . C h a ra c t e riz e d b y : (i) d e m e n t ia ; (i) c h o re a ( c h a ra c t e r iz e d b y tic s , je r k s a n d in v o lu n t a ry m o v e ­ m e n ts , g rim a c in g a n d d y s a rt h ria ) ; ( iii) a u t o s o m a l d o m in a n t in h e rit a n c e ( f a m ily h is to ry ) . D e p re s s io n , a n x ie t y a n d p s y c h o s is a re c o m m o n f e a t u re s ( 6 0 - 8 0 % o f p a t ie n t s ) e v e n f ro m t h e e a rly s t a g e s o f t h e illn e s s . M e m o ry , la n g u a g e a n d in s ig h t a re r e la t iv e ly in t a c t u n til t h e la t e s t a g e o f t h e d is e a s e w h e n fu ll d e m e n t ia s e t s in. E E G s h o w s d if f u s e s lo w in g . P E T s h o w s d e c re a s e d m e t a b o lis m in t h e b a s a l g a n g lia . M R I re v e a ls b a s a l g a n g lia a t r o p h y a s w e ll a s d ila t io n o f v e n t r ic le s a n d a t ro p h y o f t h e h e a d o f t h e c a u d a t e H a lo p e rid o l m a y re d u c e m o v e m e n t d is o rd e r.

145. ISQ - Pharmacology

Answer True or False Amphetamines act by enhancing cholinergic transmission.

289

False • Amphetamines are involved in the dopaminergic system and cause an increased release ot dopamine fro m th e n u cle u s a c c u m b e n s . This n u cle u s re ce ive s a ffe rents fro m d o p a m in e rg ic cells lo c a te d in th e v e n tra l te g m e n ta l a re a a n d it is a c o n v e rg e n c e site fo r stimuli c o m in g fro m th e a m y g d a la , h ip p o c a m p u s , e n to rrhinal a re a , a n te rio r c in g u la te a re a a n d p a rt o f th e te m p o ra l lo b e (th e s o -c a lle d lim b ic system). It also has e ffe re n t p ro je c tio n s fo r th e septus, h y p o th a la m u s , a n te rio r c in g u la te a re a a n d th e fro n ta l lobes. D ue to its a ffe re n t a n d e ffe re n t c o n n e c tio n s th e n ucle u s a c c u m b e n s plays a n im p o rta n t role in th e re g u la tio n o f e m o tio n , m o tiv a tio n a n d c o g n itio n .

• Mechanism of action of other drugs - Alcohol: m o d u la te s G A B A fu n c tio n , a g o n is t a t G A B A a rece pto rs. Also a c ts as a n N M D A a n ta g o n is t a n d causes d e c re a s e d release o f c a lc iu m ions. M o d u la tio n o f N M D A m a y le a d to m e m o ry c h a n g e s a s s o c ia te d w ith lo n g te rm use. M a y also b e a s s o c ia te d w ith lo w or hig h 5HT levels le a d in g to m o o d /b e h a v io u r c h a n g e s (lo w 5HT a s s o c ia te d w ith impulsivity, high 5HT a s s o c ia te d w ith a n xie ty). Acamprosate: a n ta g o n iz e s th e e x c ita to ry e ffe c ts o f N M D A (g lu ta m a te ) in th e b ra in a n d stim ulates in h ib ito ry G A B A -e rg ic transmission. Disulfiram: inhibits a ld e h y d e d e h y d ro g e n a s e . Naltrexone: n o n -s e le c tiv e o p io id re c e p to r a n ta g o n is t. Opioids (heroin, methadone, codeine): a c t as agonists a t μ (a n a lg e sia , p ositive re in fo rc e m e n t, e u p h o ria ) a n d κ re c e p to rs (dysp ho ria , s e d a ­ tion). PCP and ketamine: N M D A a n ta go n ists. LSD: 5HT2a a go nist. Marijuana: te tra h y d ro c a n n a b in o l alters c e re b e lla r a n d h ip p o c a m p a l n e u ro n a l a c tiv ity .

290

146. ISQ - Affective disorders

Answer True or False Perinatal complications are a risk factor for bipolar affective disorder.

False •

There m a y b e a n a s s o c ia tio n b e tw e e n p e rin a ta l c o m p lic a tio n s a n d BPAD b u t such a link has n o t y e t b e e n c le a rly e stab lish ed .

• Risk factors for BPAD:

292

•

M=F (n o t m o re c o m m o n in e ith e r sex).

•

History o f c y c lo th y m ia .

•

FHx o f BPAD (25% risk if o n e p a re n t has th e disorder, 50-75% c h a n c e if b o th p a re n ts a ffe c te d ).

•

FHx o f u n ip o la r depression.

•

G e n e tic fa c to rs - 43% m o n o z y g o tic tw in c o n c o rd a n c e , 6% fo r d iz y g o tic twins.

147. ISQ - Affective disorders

Answer True or False 1. Maternity blues are present in 50% of new mothers.

2. The Edinburgh Postnatal Depression Scale is self-completed.

293

1 True - M a te rn ity blues is th e te rm g iv e n to a m ild a n d tra n s ie n t d is tu rb a n c e in m o o d w h ic h o c c u rs b e tw e e n th e th ird a n d sixth d a y a fte r d e live ry. C o m m o n fe a tu re s in c lu d e cryin g , fa tig u e , a n xie ty, irritability, fe e lin g s o f helplessness a n d la b ility o f m o o d . S ym ptom s last fro m a fe w hours to a fe w days. Estim ates o f in c id e n c e v a ry b e tw e e n 50% a n d 70%, a n d it is c o m m o n e s t in w o m e n h a v in g th e ir first b a b y . 2 True - The E d inb urgh P o stn ata l D epression S ca le w a s d e s ig n e d to assist p rim a ry c a re professionals to d e te c t p o s tn a ta l d epression. It is a se lf-ra te d q u e s tio n n a ire filled o u t b y th e m oth e r. P o stn ata l d ep re ssion usually o c c u rs fro m 1 w e e k a fte r d e liv e ry a n d m a y last fo r se veral m onths. It o c c u rs in a b o u t 10% o f w o m e n a fte r delivery. It is m o re c o m m o n in w o m e n w ith a p e rso n a l or fa m ily history o f depression.

294

148. ISQ - Behavioural syndromes

Answer True or False Amenorrhea is a recognized complication of bulimia nervosa.

295

True - A m e n o rrh o e a c o m m o n ly o c c u rs in a n o re x ia a n d m a y o c c u r in b u lim ia n e r­ vosa also.

Complications of eating disorders associated with weight loss •

Cardiac - c a rd ia c a rrh y th m ia s in c lu d in g a tria l a n d v e n tric u la r ta c h y c a rd ia , p ro ­

•

Cachexia - loss o f fa t, m u scle mass, r e d u c e d th y ro id m e ta b o lis m (lo w T3 syn­

lo n g e d QT interval, b ra d y c a rd ia a n d s u d d e n d e a th .

• • • • • •

d ro m e ), c o ld in to le ra n c e a n d d iffic u lty m a in ta in in g c o re b o d y te m p e ra tu re . Dermatological - la n u g o (fin e b a b y -lik e hair o v e r b o d y ), o e d e m a . Gl - d e la y e d g a stric e m p ty in g , b lo a tin g , c o n s tip a tio n , a b d o m in a l p a in . Haematological - le u c o p e n ia Neuropsychiatric - a b n o rm a l ta s te sensation, m ild c o g n itiv e disorder, a p a th e tic depression. Reproductive - a m e n o rrh o e a , lo w LH a n d FSH. Skeletal - osteoporosis.

Complications of eating disorders associated with vomiting • • • •

296

Dental - erosion o f d e n ta l e n a m e l le a d in g to to o th d e c a y .

Gl - salivary g la n d a n d p a n c re a tic in fla m m a tio n a n d e n la rg e m e n t w ith in cre a se in serum am ylase , o e s o p h a g e a l a n d g a s tric erosion e le c tro ly te a b n o rm a litie s , p a rtic u la rly h y p o k a la e m ic h y p o c h lo ra e m ic alkalosis, h y p o m a g n e s a e m ia . Neuropsychiatric - seizures, m ild n e u ro p a th ie s , fa tig u e a n d w eakness.

Metabolic -

149. ISQ - Behavioural syndromes

Answer True or False 1. Anorexia is commonly associated with overeating.

2. Pickwickian syndrome is associated with overeating.

3. Klein-Levin syndrome is associated with overeating.

297

1 False - Anorexia nervosa c a n b e d iv id e d in to tw o types: b in g e ty p e or restrictive. The b in g e ty p e is re la tiv e ly u n c o m m o n . 2 True - Pickwickian syndrome is a c o m p le x o f sym p to m s th a t p rim arily a ffe c ts p a tie n ts w ith e x tre m e o b e s ity (100% o v e rw e ig h t). M a in e ffe c ts a re o n th e respiratory system w ith e xcessive d a y tim e sleepiness, shortness o f b re a th a n d fa c ia l flushing. 3 True - Klein-Levin syndrome is a rare c o n d itio n c h a ra c te riz e d b y p e rio d ic e piso d e s o f h y p e rs o m n ia ( e a c h lasting fo r o n e or several w e e ks) in te rv e n e d b y p e rio d s o f n o rm a l sleep. It first a p p e a rs in a d o le s c e n c e , usually in boys, a n d is a c c o m p a n ie d b y b ulim ia , a p a th y , irritability, co n fu sio n , depression, d is o rie n ta tio n a n d m e m o ry im p a irm e n t d u rin g w a k e fu l p eriods. It is n o t classified as e ith e r a n e a tin g d iso rd e r or a sle e p disorder. It is c o n s id e re d likely to b e a n e u ro lo g ic a l syn d ro m e a n d is b e lie v e d to re fle c t a fro n ta l lo b e or h y p o th a la m ic d is tu rb a n c e . The syn d ro m e is se lf-lim ite d a n d remission o c c u rs in m ost ca ses b y a g e 40.

2 98

150. ISQ - Psychopathology

Answer True or False 1. Delusional perception can be secondary to hallucinations.

2. Pseudocyesis and Couvade syndrome are interchangeable.

299

1 False - Delusional perception is a p rim a ry d elusio n a n d th e re fo re c a n n o t b e s e c o n d a ry to h a llu cin a tio n s . A p rim a ry d e lusio n is o n e w h ic h arises o u t o f th e blue. There a re fo u r ty p e s o f p rim a ry d elu sio n - m o o d , p e rc e p tio n , in tu itio n a n d a tm o s p h e re . 2 False - Pseudocyesis is a n im a g in a ry p re g n a n c y in a w o m a n . It usually results fro m a strong desire fo r m o th e rh o o d . In th e a b s e n c e o f c o n c e p tio n , th e m en strua l p e rio d s stop, th e a b d o m e n b e c o m e s e n la rg e d a n d th e breasts swell a n d e v e n s e c re te milk, m im ic k in g a g e n u in e p re g n a n c y . The uterus a n d ce rvix m a y show signs o f p re g n a n c y , urine tests m a y b e falsely positive, a n d th e w o m a n m a y re p o rt sensations o f fe ta l m o v e m e n ts . Couvade syndrome is a s y m p a th e tic p re g n a n c y in a m a n . The a e tio lo g y is u n k n o w n a n d it usually resolves sp o n ta n e o u s ly .

300

151. ISQ - Psychology

Answer True or False A WAIS with a 15-point difference between verbal and performance suggests an organic brain lesion.

True

302

•

A 1 5-po int d iffe re n c e b e tw e e n th e tw o c a te g o rie s d o e s su g g e st a n o rg a n ic b ra in lesion.

•

The WAIS is th e m ost s ta n d a rd iz e d a n d w id e ly used in te llig e n c e te st in c u rre n t c lin ic a l p ra c tic e . D a v id W e sch le r in v e n te d in te llig e n c e tests. He d e s ig n e d th re e tests: —WPPSI-R fo r p re s c h o o l (p rim a ry s c h o o l) c h ild re n 3 -7 years — WISC lll-R fo r c h ild re n 6 -1 6 years — WAIS-III (W eschler A d u lt In te llig e n c e Scale).

•

The WAIS-III fo r a g e s 16 years a n d a b o v e consists o f tw o areas: —Verbal set: d iv id e d in to six a re a s te s te d (d ig it span, v o c a b u la ry , m aths, e tc .) —Performance set: 11 a re a s (p ic tu re c o m p le tio n , b lo c k design, e tc .).

152. ISQ - Psychotherapy

Answer True or False In psychodynamic theory, Freud’s dream work stages include secondary elaboration.

303

True F reud's d re a m w o rk sta g e s a re b a s e d o n his p a p e r 'The In te rp re ta tio n o f D re am s'. Freud b e lie v e d d re a m s h a v e a s y m b o lic n a tu re a n d a re th e g a te w a y to o u r u n c o n ­ scious. The stages are: 1. Condensation: tw o or m o re la te n t (h id d e n ) th o u g h ts a re c o m b in e d to m a k e o n e 'm a n ife s t' d re a m im a g e or situ atio n. 2.

Displacement: e m o tio n s or desires to w a rd s s o m e th in g or s o m e o n e a re d ire c te d to w a rd s a m e a n in g le ss u n re la te d o b je c t in th e m a n ife s t d re a m .

3.

Symbolization: c o m p le x or v a g u e c o n c e p ts a re th e n c o n v e rte d in to a d re a m im a g e , Freud b e lie v e d this w a s to d o w ith sexual desires.

4.

Secondary elaboration: th e d re a m is a c tu a lly m a d e to m a k e sense (take s on a full fo rm ) b y h a v in g so m e re le v a n c e to th e p e rso n 's e v e ry d a y life.

304

153. ISQ - Psychology

Answer True or False A WAIS score of greater than 125 is found in 10% of the population.

305

False A WAIS sco re o f g re a te r th a n 125 is fo u n d in 5% o f th e p o p u la tio n . The lo w e st 2.5% h a v e a n IQ b e lo w 70 (m e n ta l re ta rd a tio n ) a n d a p p ro x im a te ly 2% o f th e p o p u la tio n h a v e a n IQ a b o v e 130.

306

154. ISO - Pharmacology Answer Ttue or False Phenytoin can cause alopecia.

307

False S id e -e ffe cts o f p h e n y to in in c lu d e :

• CNS - Drowsiness, a ta x ia , m e m o ry p ro ble m s, dysarthria, co n fu sio n , tre m o r • Gl - G in g iv a l h y p e rp la s ia , d ia rrh o e a , c o n s tip a tio n , n au sea , v o m itin g , liver d a m ­ age.

• Haematological - A g ra n u lo cyto sis, a p la s tic a n a e m ia , h a e m o ly tic a n a e m ia , leu cocytosis, m on ocyto sis, a n a e m ia .

• Dermatological - M easles-like rash, s c a rla tin ifo rm , m a c u lo p a p u la r a n d u rtica ria l rashes. Rarely: d ru g -in d u c e d lupus, S teve n s-Jo h n so n sy n d ro m e a n d to x ic e p i­ d e rm a l necrolysis.

• Ophthalmic - D ip lo p ia , n ystagm us, c o n ju n c tiv itis .

308

155. ISQ - Schizophrenia

Answer True or False Psychomotor retardation is generally considered to be a negative symptom of schizophrenia.

309

True Positive and negative symptoms of schizophrenia (Andreasen e t a/. 1983) •

Positive sym pto m s in c lu d e h a llu c in a tio n s , delusions, fo rm a l th o u g h t d iso rd e r a n d bizarre b e h a vio u r.

•

N e g a tiv e sym pto m s in c lu d e - mnemonic: 7 As - A ffe c tiv e b lu n tin g , A lo g ia (im p o v e ris h e d th in k in g a n d s p e e c h ), A volitio n , A p a th y , A n h e d o n ia , A sociality, A tte n tio n d is tu rb a n c e .

Liddle’s classification (confirmed by a PET study of regional cerebral blood flow) •

310

P sych o m o to r p o v e rty s yn d ro m e : th e re is p o v e rty o f s p e e c h , fla tte n e d a ffe c t a n d d e c re a s e d s p o n ta n e o u s m o v e m e n t.

•

D isorga niza tion syn d ro m e : disorders o f th o u g h t fo rm a n d in a p p ro p ria te a ffe c t.

•

R eality d istortion syn d ro m e : th e re a re delusions a n d h a llu c in a tio n s .

156. ISQ - Psychopathology

Answer True or False Asyndesis refers to a disorder in which thoughts do not join together to form one coherent concept.

311

True • Asyndesis - There is la c k o f c o n n e c tio n b e tw e e n o n e th o u g h t a n d a n o th e r. •

O th e r ty p e s o f th o u g h t disorder:

—Metonym - A n in a p p ro p ria te or im p re c is e b u t re la te d w o rd is used in p la c e o f th e c o rre c t w o rd in a s e n te n c e .

—Neologism - A n e w w o rd th a t has n o m e a n in g is c re a te d . —Echolalia - A u to m a tic a n d pointless re p e titio n o f a n o th e r p erso n 's w o rd s or phrases.

—Verbigeration - Im ita tio n o f a n o th e r p e rso n 's phrases in a s te re o ty p e d m an ne r. —Palilalia - R e p e titio n o f a w o rd fro m a n in d iv id u a l's o w n s p o ke n w ords. —Logoclonia - R e p e titio n o f w o rd s or phrases, p a rtic u la rly th e e n d syllables. — Logorrhoea: excessive flo w o f w o rd s o r pressure o f s p e e c h as o c c u rs in m a n ia .

312

157. ISQ - Psychotherapy

Answer True or False 1. Anankastic personality disorder is associated with magical undoing.

2. Paranoid schizoid position can lead to psychological difficulties.

313

1 False - O C D is c h a ra c te riz e d b y th re e d e fe n c e m ech a n ism s: mnemonic - URI (see c a rd 77) - M a g ic a l U nd oin g, R e a c tio n fo rm a tio n , Isolation. N o t fo r a n a n k a s tic p e rs o n a lity disorder.

2 False - P a ra n o id schizoid p o sitio n is a p s y c h o d y n a m ic th e o ry fo rm u la te d b y M e la n ie Klein. It has no re la tio n to p s y c h o lo g ic a l d ifficulties. Exam c a n d id a te s n e e d to u n d e rs ta n d th e d iffe re n c e b e tw e e n p s y c h o lo g y a n d p s y c h o d y n a m ic th e o ry. The tw o a re d iffe re n t schools a n d should n o t b e p u t to g e th e r in this w a y.

314

158. ISQ - Pharmacology

Answer True or False 1. St John’s Wort enhances the ettect of SSRIs.

2. Trazodone has a weak antagonistic effect on serotonin.

315

1 True St Jo h n 's W ort is b e lie v e d to a c t o n se ro ton in a n d th e re fo re has a similar m e c h a n is m o f a c tio n to SSRIs. A se ro to n in s y n d ro m e has b e e n k n o w n to o c c a s io n a lly o c c u r w h e n p e o p le ta k e th e tw o in c o m b in a tio n . 2 False T razo do ne is a n e x a m p le o f a d u a l se ro ton in 2A a n d se ro ton in re u p ta k e inhibitor. Its e ffe c ts are: powerful a n ta g o n is m o f se ro ton in 2A re c e p to rs a n d less p o w e rfu l b lo c k a d e o f se ro to n in re u p ta k e . N e fa z o d o n e is a similar a g e n t.

316

159. ISQ - Human development

Answer True or False Children under 1 year of age are scared of loud noises.

317

True Most common fears - up to 1 year of age • • • •

Loud noises. Fear o f anim als, insects. S e p a ra tio n fro m paren ts. Falling.

1-6 years of age • • • •

Strangers. Anim als. Darkness. M onsters.

6-11 years of age • •

S e p a ra tio n a nxiety. D e a th .

12-16 years of age • •

318

Fears a b o u t so cia l re je c tio n , sexual anxieties. Worries a b o u t p e rso n a l a c h ie v e m e n t.

160. ISQ - Pharmacology

Answer True or False Dopamine is a precursor of noradrenaline.

319

True •

Tyrosine is h y d ro x y la te d -> DOPA (d ih y d ro x y p h e n y la la n in e ) b y a c tio n o f tyrosine hydroxylase.

• DOPA is d e c a rb o x y la te d -> dopamine b y DOPA d e c a rb o x y la s e . • Dopamine -> noradrenaline (c o n v e rte d b y th e a c tio n o f d o p a m in e ß-hydroxylase).

• Dopamine is also m e ta b o liz e d b y MAO (m ito c h o n d ria l m o n o a m in e o xid a se ) a n d b y COMT (c a te c h o l-O -m e th y ltra n s fe ra s e ) to fo rm th e e n d p r o d u c t HVA (h o m o v a n illic a c id ).

320

161. ISQ - Psychology

Answer True or False Selective abstraction is a cognitive distortion.

321

True Cognitive distortions according to Beck’s cognitive theory of depression •

Arbitrary inference - D ra w in g th e w orst possible co n c lu s io n s a b o u t a g iv e n p ro b ­

•

Selective abstraction - Focusing o n th e w orst a s p e c ts o f p a s t e xp e rie n c e s , ie o nly

lem w ith o u t a d e q u a te e v id e n c e . th e w orst e ve n ts a re re m e m b e re d . •

Overgeneralization - D ra w in g n e g a tiv e g e n e ra l co n c lu s io n s a b o u t p e rson al w o rth fro m o n e e x a m p le o f s o m e th in g th a t w e n t w ro n g .

• Minimization - G o o d p e rfo rm a n c e is u n d e re s tim a te d . • Magnification - Errors a re o v e re s tim a te d . • Personalization - A te n d e n c y to a ttrib u te all w ro n g d o in g s to n e g a tiv e ly p e r­ c e iv e d p erso n a l a ttrib u te s .

• Dichotomous thinking - B lack a n d w h ite th in k in g such as 'a ll w o m e n th ink I'm u g ly '.

322

162. ISQ - Psychopathology

Answer True or False Perception of time is always altered in depersonalization

323

False •

P e rc e p tio n o f tim e m a y b e a lte re d in d e p e rs o n a liz a tio n . There m a y b e a n a lte r­ a tio n in th e sense o f d u ra tio n or p e rs p e c tiv e o f tim e . This is n o t a lw a y s th e c a s e h o w e ve r.

•

D e p e rso n a liza tio n is a te rm used to d e s c rib e a c h a n g e in th e a w a re n e s s o f th e self in w h ic h th e in d iv id u a l feels as if h e /s h e is unrea l. This feeling m ust b e d iffe r­ e n tia te d fro m a n experience o f u n re a lity as is o fte n seen in p s y c h o tic p a tie n ts.

• Aspects of depersonalization - M a y o c c u r in h e a lth y individuals. There is o fte n a c o m o rb id m o o d or n e u ro tic disorder. Usually e x p e rie n c e s a re e g o d ysto n ic. O fte n fe lt to b e s u b je c tiv e ly u n p le a s a n t. E m o tio n a l n u m b in g . C h a n g e s in b o d y e x p e rie n c e . C h a n g e s in sensory p e rc e p tio n : v is u a l/a u d ito ry /ta c tile /g u s ta to ry / o lfa c to ry . Loss o f fe e lin g s o f a g e n c y . Distortions in e x p e rie n c e o f tim e . C h a n g e s in s u b je c tiv e e x p e rie n c e o f m e m o ry . H e ig h te n e d se lf-o b se rva tio n . Feelings o f th o u g h ts b e in g e m p ty . S u b je c tiv e fe e lin g o f in a b ility to e v o k e im a ge s.

324

163. ISQ - Dementia syndromes

Answer True or False Neurofibrillary tangles are found as often in Pick’s disease as in Alzheimer’s dementia.

325

False Pick’s disease versus Alzheimer’s dementia •

Pick's disease is m o re c o m m o n in w o m e n th a n in m en , a n d e s p e c ia lly if th e re is a first d e g re e re la tiv e w ith th e c o n d itio n .

•

Similar to A lzh eim er's d isease in so m e re sp ects a lth o u g h Pick's d isease is m o re o fte n c h a ra c te riz e d b y p e rs o n a lity a n d b e h a v io u ra l c h a n g e s (disinhibition, aggression, rudeness to w a rd s others) in th e e a rly sta ge s w ith re la tiv e p re s e rv a ­ tio n o f o th e r c o g n itiv e fu n ctio n s.

•

Pick's disease is c h a ra c te riz e d b y a tro p h y in th e fro n to te m p o ra l regions w ith n e u ro n a l loss, gliosis a n d n e u ro n a l Pick b o d ie s (th e se a re n o t a lw a y s seen in p o s t­ m o rte m a n d a re n o t n e ce ssary fo r th e diagnosis). Pick b o d ie s a re d iffe re n t fro m th e n eu ro fib rilla ry ta n g le s seen in A lzh e im e r's disease. Neurofibrillory tangles are

much less common in Pick’s disease. •

326

Features o f K lu ver-B u cy s y n d ro m e (h yp ersexu ality, h y p e ro ra lity , p la c id ity ) a re m o re c o m m o n in Pick's dise ase th a n in A lzheim er's. A g n o s ia a n d a p ra x ia m a y o c c u r in Pick's disease b u t a re m u c h less c o m m o n th a n in A lzh e im e r's d e m e n tia a n d usually o c c u r la te r in th e co u rse o f th e disease.

164. ISO - Classification in psychiatry Answer True or False 1. DSM IV is hierarchical.

2. DSM IV includes psychosocial stressors on Axis III.

3. DSM IV uses a dimensional rather than a categorical classification.

4. DSM IV uses operational criteria.

327

1 False

2 False

3 True

4 True

The DSM uses a m ultia x ia l or m u ltid im e n s io n a l a p p ro a c h to d ia g n o s in g o n th e basis th a t it is rare th a t o th e r fa c to rs in a p erso n 's life d o n o t im p a c t o n th e ir m e n ta l h e a lth . It uses o p e ra tio n a l c rite ria a n d assesses fiv e dim ensions:

328

•

Axis I - M a jo r m e n ta l disorders, d e v e lo p m e n ta l disorders a n d le a rn in g disabilities.

•

Axis II - U nderlying p e rv a s iv e or p e rs o n a lity c o n d itio n s , as w ell as m e n ta l re ta r­ d a tio n .

•

Axis III - N o n -p s y c h ia tric m e d ic a l c o n d itio n (s ).

•

Axis IV - S ocial fu n c tio n in g a n d im p a c t o f sym ptom s.

•

Axis V - G lo b a l Assessm ent o f F u n c tio n in g (o n a s c a le fro m 0 to 100).

165. ISQ - Neurotic disorders

Answer True or False Hyperresponsiveness of noradrenergic neurones in the locus coeruleus may be responsible for recurrent flashbacks in PTSD sufferers.

329

True • Risk factors in PTSD: predisposing psychological factors - Hx o f c h ild h o o d tra u m a . P ersonality d isorder: b o rd e rlin e , p a ra n o id , a n tis o c ia l or d e p e n d e n t. Lack o f su pp ort. R e c e n t excess a lc o h o l in ta ke . F e m a le g e n d e r. F Hx o f p s y c h ia tric ill­ ness. External p e rc e p tio n o f locus o f c o n tro l ra th e r th a n interna l.

• Psychodynamic factors - R e a c tiv a tio n o f pre vio u sly u n re so lve d p s y c h o lo g ic a l c o n flic t. Results in regression a n d use o f d e fe n c e m e ch an ism s: repression, d e n ia l, re a c tio n fo rm a tio n , m a g ic a l u n d o in g .

• Cognitive factors - A ffe c te d in d ivid u a ls u n a b le to pro cess a n d ra tio n a liz e th e tra u m a . Traum a (u n c o n d itio n e d stim ulus) results in a fe a r response w h ic h is p a ire d w ith a c o n d itio n e d stimulus (re m in d e rs o f th e tra u m a , e g sim ilar sounds, smells).

• Biological factors: —Noradrenergic system - stron g e v id e n c e o f a lte re d fu n c tio n in th e n o ra d re n ­ e rg ic system in PTSD. 30-40% o f PTSD p a tie n ts re p o rt fla s h b a c k s a fte r y o h im b in e a d m in is tra tio n . —Opioid system - A b n o rm a lity s u g g e s te d b y lo w b e ta e n d o rp h in c o n c e n tr a ­ tions. —Corticotophin releasing factor (CRF) and the HPA Axis - B lu nte d ACTH response to e x o g e n o u s CRF. Suppression o f cortisol e n h a n c e d b y d e x a m e th a s o n e .

330

166. ISQ - Behavioural syndromes Answer True or False Tourette’s syndrome is more common in males than in females

331

True

332

•

T ou rette's s y n d ro m e - Three tim es m o re c o m m o n in boys th a n in girls. - O c c u rs in 4 -5 p e r 10,000 p o p u la tio n . - O n set o f th e m o to r c o m p o n e n t usually o c c u rs b y 7 years o f a g e . - V o c a l tics e m e rg e o n a v e ra g e b y 11 years. - O b sessive -co m p u lsive disorder, a tte n tio n p ro b le m s a n d im pulsivity h a v e b e e n a s s o c ia te d w ith T ourette's.

•

The d iso rd e r is c h a ra c te riz e d b y m u ltip le m o to r (usually b e g in n in g in fa c e a n d n e c k a n d progressing d o w n w a rd s ) a n d o n e or m o re v o c a l tics th a t o c c u r m a n y tim es a d a y a n d c a u s e s ig n ific a n t im p a irm e n t in fu n c tio n in g .

•

See c a rd 16 fo r fu rth e r details.

167. ISQ - Schizophrenia

Answer True or False Schizotypal disorder is in the same category as schizophrenia in the ICD10.

333

True •

Schizophrenia, schizotypal a n d delusional disorders is a c a te g o ry in ICD10 (F20-29).

• Schizotypal disorder - C h a ra cte rize d by e c c e n tric b eh aviou r a n d abnorm alies ot thinking a n d a ffe c t similar to those seen in schizophrenia. Any o f th e follow ing m ay be present (ICD10): —In ap pro pria te or co n stricte d a ffe c t (individual a pp ea rs c o ld a n d a lo of) —Behaviour or a p p e a ra n c e th a t is odd , e c c e n tric or p ecu lia r —Poor ra p p o rt with others a n d a te n d e n c y to social w ith d ra w a l —O d d beliefs or m a g ic a l thinking, influencing b e h aviou r a n d inconsistent with social norms —Suspiciousness or p a ra n o id ideas —Obsessive rum inations w ith o u t inner resistance, o fte n with dysm o rp ho ph o bic, sexual or aggressive conte nts —Unusual p e rc e p tu a l experiences including somatosensory or othe r illusions, d e p e r­ sonalization or derealization —Vague, circum stantial, m e ta p h o rica l, o v e re la b o ra te or ste re otype d thinking, m a n ­ ifested by o d d spee ch or in othe r ways, w ith o u t gross in co h e re n c e —O cca sion al transient quasi-psychotic episodes with intense illusions, a ud itory or other hallucinations, a n d delusion-like ideas, usually o ccurrin g w ith o u t external p ro v o c a tio n Usually runs a ch ro nic course. O cca sion ally m ay evolve into overt schizophrenia.

334

168. ISQ - Neurotic disorders

Answer True or False 1. Social phobia is more common in women than in men.

2. In phobic anxiety disorders, a good response to behaviour therapy is associated with specific phobias.

3. Preparedness occurs in simple phobias.

335

1 True - 60% fe m a le d istrib u tio n (F:M = 3:2). Sex distributions of some other neurotic disorders: •

A g o ra p h o b ia F:M = 4:1.

•

S p e c ific p h o b ia F:M = 2:1.

•

P anic d iso rd e r F:M = 2:1.

•

G e n e ra liz e d a n x ie ty d iso rd e r F:M = 2:1.

•

D issociative d iso rd e r F > M.

•

O b sessive -co m p ulsive d iso rd e r F:M = 1:1.

•

H yp o ch o n d ria sis F:M 1:1.

2 True - G o o d response is also a s s o c ia te d w ith th e d e g re e o f p a tie n t m o tiv a tio n as w ell as s u p p o rt fro m fa m ily a n d friends. 3 True - The p re p a re d n e s s th e o ry o f p h o b ia holds th a t h u m a n s a re b io lo g ic a lly p re p a re d to fe a r o b je c ts th a t th re a te n e d th e survival o f th e sp e cie s th ro u g h o u t its e v o lu tio n a ry history. This is th o u g h t to e x p la in w h y c h ild re n a re s c a re d o f snakes fro m a ve ry e a rly a g e d e s p ite h a v in g n o p rior k n o w le d g e th a t th e y m a y b e poisonous.

336

169. ISQ - Neuroscience

Answer True or False 1. Poor verbal fluency is an early feature of frontal lobe syndrome.

2. Confabulation is an essential feature of Wernicke-Korsakoff syndrome.

3. Confabulation in Wernicke-Korsakoff syndrome can include elements of true memory.

337

1 False - Poor v e rb a l flu e n c y te n d s to b e a la te fe a tu re o f fro n ta l lo b e syn drom e. S ubtle p e rso n a lity c h a n g e s te n d to o c c u r e a rlie r on. 2 False - C o n fa b u la tio n is a c o m m o n fe a tu re b u t is n o t essential fo r th e diagnosis. 3 True - C o n fa b u la tio n m a y in c lu d e e le m e n ts o f tru e m e m o ry . Wernicke’s encephalopaphy - a c u te s ym p to m s a s s o c ia te d w ith c h ro n ic excess a lc o h o l intake : A ta x ia ; o p h th a lm o p le g ia (o c u la r a b n o rm a litie s in m o re th a n 80% o f cases); nystagm us; co n fu s io n ; v e s tib u la r d y s fu n c tio n ; a n is o c o ria ; slow lig h t reflex. W e rn icke 's e n c e p h a lo p a th y is usually reversible w ith tre a tm e n t w ith p a re n te ra l th ia m in e a t high doses. It m a y e ith e r resolve or progress to K orsakoff's s yn d ro m e w h ic h is usually irreversible. Korsakoff’s syndrome - c h ro n ic a m n e s tic s y n d ro m e c h a ra c te riz e d by: im p a ire d m e m o ry e s p e c ia lly fo r re c e n t e vents; a n te ro g ra d e a m n e s ia in a n a le rt a n d responsive person.

338

170. ISQ - Psychology

Answer True or False 1. Repertory grid is a specific test of intelligence.

2. Recency and primacy effects help recall in short term memory.

339

1 False - The re p e rto ry g rid (B annister) is n o t a n in te llig e n c e test. G e o rg e Kelly's p erso n a l c o n s tru c t th e o ry em p ha sizes a n in d iv id u a l's se lf-a p p ra isa l in stu d yin g his or her o w n p erson ality. The th e o ry is th a t a p e rso n 's m e n ta l processes a re p s y c h o lo g ic a lly c h a n n e lle d b y th e w a y th e y a n tic ip a te even ts. The re p e rto ry g rid c r e a te d b y Bannister is a to o l used b e tw e e n a p a tie n t a n d a th e ra p is t to c o n s id e r th e dim ensions o f th e p a tie n t's p e rs o n a lity - it is b a s e d o n th e p e rso n a l c o n s tru c t th e o ry. 2 True - Primacy effect: th e te n d e n c y to re m e m b e r th e first fe w item s o n a list b e tte r th a n su b s e q u e n t items. The first fe w item s a re m ost re h e a rs e d a n d re c e iv e u n d iv id e d a tte n tio n a n d a re th e re fo re m o re likely to b e sto re d in lo n g te rm m e m o ry. Recency effect: th e te n d e n c y to re m e m b e r th e last fe w item s on a list. This is a s s o c ia te d w ith s to ra g e o f in fo rm a tio n in short te rm m e m o ry . For e x a m p le , if a sked to re a d a list o f 15 items, th e re will b e a te n d e n c y to re m e m b e r th e first a n d last fe w item s o n th e list b e tte r th a n th e m id d le items. This is b e c a u s e o f th e a b o v e e ffe cts. P rim a cy allo w s th e first fe w item s to b e re m e m b e re d b e tte r in th e lo n g te rm also. If th e re is a d e la y in re c a llin g th e items, th e re c e n c y e ffe c t will b e lost as item s a re o nly s to re d in short te rm m e m o ry.

340

171. ISQ - Postnatal psychosis

Answer True or False The risk of postpartum psychosis is 20% if there is one previous episode of postpartum psychosis.

341

True Postpartum psychosis •

In c id e n c e - 1-2 p e r 1000 births.

•

50-60% o f cases a re a fte r b irth o f first ch ild .

Risk factors

342

•

50% in vo lve o b s te tric c o m p lic a tio n s in labour.

•

50% o f w o m e n a ffe c te d h a v e a fa m ily history o f m o o d disorder.

•

Personal or fa m ily history o f s c h iz o p h re n ia or o th e r p s y c h o tic illness.

•

Past e p is o d e o f p o s tp a rtu m psychosis - b e tw e e n 20% a n d 50% c h a n c e o f re c u r­ re n c e in fu tu re p re g n a n c y .

172. ISQ - Neurotic disorders

Answer True or False 1. Obsessive-compulsive disorder is more common in females than in males.

2. In obsessive-compulsive disorder there is increased glucose metabolism in the caudate nucleus.

343

1 False - Epidemiology •

Equal sex d istribu tio n (M = F).

•

M ost c o m m o n ly o c c u rs in e a rly a d u lth o o d , m e a n a g e o f o n s e t is 20 years.

•

Lifetim e p re v a le n c e 2-3%.

2 True - Biological factors in OCD

344

•

S e ro to n e rg ic system - a n a b n o rm a lity in se ro ton in re g u la tio n has b e e n id e n tifie d as th e d iso rd e r resp on ds m a in ly to s e ro to n e rg ic drugs ra th e r th a n dru gs a ffe c t­ ing o th e r n eurotransm itters.

•

Brain im a g in g studies su g g e st a lte re d fu n c tio n in n e u ro c irc u itry b e tw e e n th e o rb ito fro n ta l c o rte x, c a u d a te a n d th a la m u s. PET scans h a v e show n in c re a s e d g lu c o s e m e ta b o lis m in th e h e a d o f th e c a u d a te .

•

G e n e tic fa c to rs - 35% o f firs t-d e g re e relative s a re a ffe c te d b y this disorder.

173. ISQ - Dementia syndromes

Answer True or False Patients suffering from Alzheimer’s dementia are more likely to show deficits in verbal fluency than those suffering vascular dementia.

345

False • Vascular dementia cardinal features - D ifficu lty sustaining a tte n tio n . E xe cutive d y s fu n c tio n . V e rba l flu e n c y d e ficits. O n se t m a y b e s u d d e n a n d presents w ith p a tc h y c o g n itiv e d e fic its w ith a ste pw ise d e te rio ra tio n . P sych o tic sym p to m s a re uncom m on.

• Alzheimer’s disease cardinal features - mnemonic: 5 A’s - A m n esia - m e m o ry p ro b le m s - p a rtic u la rly re c e n t, A p h a sia - s p e e c h d eficits, la n g u a g e a n d c o m ­ p re he nsio n pro ble m s, A p ra x ia - p ro b le m s p e rfo rm in g tasks, A g no sia - d iffic u lty re c o g n iz in g fa m ilia r p e o p le or o b je c ts , A n o m ia - d iffic u lty n a m in g . O n set is usually slow a n d th e re is usually a slow d e c lin e in c o g n itiv e fu n c tio n . W h e n insight is still present, d ep re ssive s ym p to m s a re c o m m o n a n d p s y c h o tic sym p to m s a re also c o m m o n .

• Risk factors for vascular dementia - A lzh e im e r's disease, m ild c o g n itiv e im p a ir­ m e n t, p reexisting v a s c u la r disease, fa m ily history o f d e m e n tia , D o w n 's syn drom e, h e a d injury, in cre a s in g a g e .

346

174. ISQ - Affective disorders

Answer True or False 30% of depressed patients have elevated cortisol levels.

347

False •

A b o u t 50% h a v e e le v a te d cortiso l levels.

Biological findings in depression • Serotonin - D e p le tio n o f se ro to n in m a y p re c ip ita te depression. • Noradrenaline - C o rre la tio n exists b e tw e e n d o w n re g u la tio n o f ß -a d re n e rg ic re c e p to rs a n d a n tid e p re s s a n t responses.

Neuroendocrine dysregulation

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•

H y p o th a la m ic - p itu ita r y - a d r e n a l (HPA) axis d y s fu n c tio n - A b o u t 50% o f d e p re sse d p a tie n ts h a v e e le v a te d cortiso l levels a n d th e cortisol levels a re n o t suppressed n o rm a lly b y a d m in is tra tio n o f d e x a m e th a s o n e .

•

Thyroid disorders a re fo u n d in 5-10% o f d e p re s s e d individuals. See c a rd 46 fo r fu rth e r details.

•

G ro w th h o rm o n e - D ep ressed in d ivid u a ls h a v e a b lu n te d s le e p -in d u c e d stim u­ la tio n o f g ro w th h o rm o n e response a lth o u g h this has n o t b e e n lin ke d to sleep a b n o rm a litie s in depression.

175. ISQ - Psychotherapy

Answer True or False Yalom described communalism as a curative factor in groups.

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False Yalom (1975) described 12 curative factors in groups which apply to group therapy - mnemonic: CAGED In Uniforms C - Catharsis, C o rre c tiv e re c a p itu la tio n o f th e fa m ily g ro u p (2).

A - Altruism.

G - G ro u p cohesiveness, G u id a n c e (2). E - Existential aw areness. D - D e v e lo p m e n t o f socia lizin g te c h n iq u e s . I - Insight, In te rp erson a l le a rn in g , Im ita tiv e b e h a v io u r (3). U - Universality.

Rappoport’s theory of the basic features of a therapeutic community mnemonic: CPR Grade D C - C o m m u n a lis m - e q u a l tr e a tm e n t a n d shares fo r e v e ry o n e . P - Permissiveness - to le ra n c e o f d is tu rb e d b e h a v io u r. R - R eality c o n fro n ta tio n - re g u la r fe e d b a c k g iv e n to in d ivid u a ls o n th e results o f th e ir b e h a vio u r. D - D e m o c ra tiz a tio n - a b o litio n o f h ie ra rch y.

350

176. ISQ - Affective disorders

Answer True or False 1. Depression is more common in women than in men.

2. In those who have completed suicide, it has been found that there is an increased concentration of 5-HIAA in the CSF.

3. Failure of suppression of the Dexamethasone Suppression Test occurs in about 80% of people suffering from major depression.

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1 True - D epression is m o re c o m m o n in w o m e n . C o m p le te d su icid e is m o re c o m m o n in m en. 2 False - It has b e e n fo u n d th a t in d e p re s s e d in d ivid u a ls th e re is d e c re a s e d p la s m a try p to p h a n a n d d e c re a s e d p la te le t 5HT u p ta k e . There a re lo w levels o f CSF 5 -h y d ro x y in d o le a c e tic a c id (HIAA) in in d ivid u a ls w h o h a v e c o m p le te d suicide, a lth o u g h this is n o t a co n s is te n t fin d in g .

3 False - O c c u rs in a b o u t 50-60% o f d e p re s s e d in d ivid u a ls b u t this is n o t s p e c ific to d epression as fa ilu re o f suppression in DST also o c c u rs in o th e r c o n d itio n s in c lu d in g a lc o h o l d e p e n d e n c y a n d s ch izo p h re n ia .

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177. EMI - psychopathology Options A. E x tra c a m p in e h a llu c in a tio n B. F u n c tio n a l h a llu c in a tio n C. Illusion D. S ynaesthesia E. P s e u d o h a llu c in a tio n F. D elusional p e rc e p tio n G. A u to s c o p y

H. H a p tic h a llu c in a tio n I. Synaesthesia J. H y n a g o g ic h a llu c in a tio n K. P a ra n o id d e lu sio n L. H y p n a p o m p ic h a llu c in a tio n M. Reflex h a llu c in a tio n

Instructions For e a c h o f th e c o n d itio n s d e s c rib e d b e lo w , c h o o s e th e m ost likely d ia g n o sis fro m th e list o f o ptio ns. E ach o p tio n m a y b e used o n c e , m o re th a n o n c e or n o t a t all. 1. A 31 -y e a r-o ld m a n tells th e w a rd d o c to r o n e d a y th a t his c o ffe e tastes fu n n y a n d says h e b e lie ve s this is b e c a u s e s ta ff h a v e b e e n p u ttin g p o iso n in it. 2. A 1 6-yea r-o ld b o y o n th e m e d ic a l w a rd is a d m itte d fo llo w in g use o f LSD. He says th a t w h e n he sees th e c o lo u r re d h e c a n also h e a r it, a n d th e b rig h te r th e red, th e lo u d e r th e sound. 3. A p a tie n t tells yo u h e hears a v o ic e w h is p e rin g to him in a fe m a le v o ic e w h e n he w a ke s u p in th e m o rn in g .

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1. F. Delusional perception: a n o rm a l p e rc e p tio n is g iv e n d e lu sio n a l m e a n in g , e g a p a tie n t drinks c o ffe e w h ic h looks ve ry d a rk (n o rm a l p e rc e p tio n ). The c o ffe e b e in g d a rk is th e n g iv e n a d e lu s io n a l m e a n in g , e g th a t th e s ta ff h a v e b e e n p u ttin g poison into it. 2. I. Synaesthesia: p e rc e p tio n o f o n e stimulus e vo ke s a s e c o n d stimulus sensation. 3. L Hypnapompic hallucination: a v ivid h a llu c in a tio n th a t o c c u rs w h ile w a k in g u p fro m sleep.

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178. EMI - psychopathology Options A. C a p g ra s ' sy n d ro m e B. Fregoli's syn d ro m e C. De C la ra m b a u lt's sy n d ro m e D. C o u v a d e 's sy n d ro m e E. C o ta rd 's sy n d ro m e

F. P seudocyesis G. R e d u p lic a tiv e p a ra m n e s ia H. D o p p le g a n g e r I. Folie à d e u x J. M o rb id je a lo u s y

Instructions For e a c h o f th e c o n d itio n s d e s c rib e d b e lo w , c h o o s e th e m ost likely d ia g n o sis fro m th e list o f o ptio ns. E ach o p tio n m a y b e used o n c e , m o re th a n o n c e or n o t a t all. 1. A w o m a n is re fe rre d to th e o u tp a tie n t c lin ic b y her GP. Her m enses s to p p e d 2 m o n th s a g o a n d she has d e v e lo p e d a b d o m in a l distension a n d b e lie v e s she is p re g n a n t. She has h a d a h o m e p re g n a n c y te st th a t w a s n e g a tiv e a n d she has seen a n o b s te tric ia n w h o p e rfo rm e d a n u ltra s o u n d a n d this c o n firm e d th a t she is n o t p re g n a n t. 2. A 3 9 -ye a r-o ld m a n o n th e p s y c h ia tric w a rd says th a t o n e o f th e p a tie n ts w h o m he d o e s n o t k n o w has b e e n r e p la c e d b y a frie n d o f his. 3. A 4 7 -y e a r-o ld la d y su ffe ring s c h iz o p h re n ia says th a t she feels like she know s th e stre e t w h e re th e m e n ta l h e a lth u n it is, a n d b e lie ve s it is e x a c tly th e sa m e as th e stre e t w h e re she lives, e v e n th o u g h she has n e v e r b e e n th e re b e fo re .

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1. F. Pseudocyesis: a false p re g n a n c y . O fte n presents w ith m a n y o f th e signs a n d sym pto m s o f p re g n a n c y a n d is similar to a real p re g n a n c y in e v e ry w a y e x c e p t fo r th e p re s e n c e o f a fo etus. C o u v a d e 's s y n d ro m e is a s y m p a th e tic p re g n a n c y in a m an . 2. B. Fregoli’s syndrome: a d e lu s io n a l b e lie f th a t a s tra n g e r has b e e n r e p la c e d b y s o m e o n e fam iliar. C a p g ra s ' sy n d ro m e is th e o p p o s ite - a b e lie f th a t a stra n g e r has re p la c e d a fa m ilia r person. 3. G. Reduplicative paramnesia: a fe e lin g th a t a fa m ilia r p la c e has b e e n d u p lic a te d .

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179. EMI - pharmacology Options A. 0Cļ В. a 2 C. M i D. M 5 E. G A B A a

F. 5HT1a G. 5HT2a H. 5HT2c 1. 5HT3 J. G lu ta m a te

Ҝ. S erotonin L. N o ra d re n a lin e M. Hi N. A c e ty lc h o lin e

Instructions For e a c h o f th e s ta te m e n ts b e lo w , c h o o s e th e m ost likely re c e p to r(s ) fro m th e list o f o ptio n s. E ach o p tio n m a y b e used o n c e , m o re th a n o n c e or n o t a t all. 1. A n tip s y c h o tic s c a u s e e x tra p y ra m id a l s id e -e ffe c ts as a result o f d o p a m in e r e c e p ­ to r a n ta g o n is m . D o p a m in e a n ta g o n is m ca u se s a n in c re a s e in a c tiv ity o f w h ic h o f th e a b o v e re c e p to rs ? (C h o o s e o n e ) 2. A p a tie n t o n a n tip s y c h o tic s has d e v e lo p e d w e ig h t g a in , drowsiness a n d h yp o te n sio n . W h ich o f th e a b o v e tw o re c e p to rs a re resp on sible fo r th e se e ffe c ts ? (C h o o s e tw o ) 3. V a lp ro ic a c id a c ts o n w h ic h o f th e a b o v e re c e p to rs ? (C h o o s e tw o ). 4. O n w h ic h o f th e a b o v e re c e p to rs d o e s m irta z a p in e a c t? (C h o o s e fiv e )

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1. N: d o p a m in e n o rm a lly inhibits a c e ty lc h o lin e release. D o p a m in e a n ta g o n is m th e re fo re le a d s to a n in c re a s e in a c e ty lc h o lin e a c tiv ity w h ic h cause s e x tra p y ra m id a l sym pto m s. 2. A, M: a} b lo c k a d e ca use s h y p o te n s io n , dizziness a n d drowsiness. Ң b lo c k a d e ca uses w e ig h t g a in . 3. E, J: v a lp ro ic a c id a c ts o n c a lc iu m a n d so d iu m c h a n n e ls a n d e n h a n c e s th e in h ib ito ry a c tio n o f G A B A as w e ll as re d u c in g th e e x c ita to ry a c tio n o f g lu ta m a te . 4. B, G, H, I, M: m irta z a p in e is a n o ra d re n e rg ic a n d s e ro to n e rg ic a n tid e p re s s a n t. Its m a in m e c h a n is m o f a c tio n is v ia a lp h a 2 b lo c k a d e w h ic h le a d s to se ro ton in (5HTla) release. But it also b lo cks se ro ton in 5HT2a, 5HT2c, 5HT3 as w e ll as Hn re ce p to rs. S e d a tio n a n d w e ig h t g a in result fro m Ң b lo c k a d e .

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180. EMI - pharmacology Options A. A m itriptyline B. Im ipram ine C. C italo pram

D. Am isulpiride E. D onepezil

F. V enlafaxine G. Lithium

H. C lozapine I. M irtazapine

Instructions For e a c h o f th e conditions d e scrib e d b elow , ch oo se th e m ost a p p ro p ria te drug from th e list o f options. Each o p tio n m ay b e used o n ce , m ore th a n o n c e or n ot a t all. 1. A 31-year-old m an was d ia g n o se d w ith schizophrenia 4 years a g o a n d initially his m ental state im p rove d whilst ta king o la n za p in e orally. Fie has h a d thre e admissions over th e last 4 years d u e to p o o r a d h e re n c e to m e d ic a tio n . He refuses to try d e p o t m e d ic a tio n a n d has n o w h a d a n o th e r relapse o f his illness. He tells you o ne o f th e re a ­ sons he s to p p e d ta king o la nza pin e was b e c a u s e it m a d e him p u t on w e ig h t a n d he feels very conscious a b o u t this. 2. A 76-year-old m an w ith a history o f b e n ig n pro static h ype rtro ph y b e c o m e s depressed w ith sym ptom s o f low m oo d, a n h e d o n ia , low e ne rg y as well as loss o f a p p e tite . 3. A 26-year-old lady has b e e n e xp e rie n cin g depression for th e last 6 months. She has tried an SSRI antidep re ssan t b u t it has n o t h e lp e d im p rove her symptoms. She has b ee n sleeping excessively.

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1. D. Amisulpiride: is a s s o c ia te d w ith a lo w risk o f w e ig h t g a in . C lo z a p in e a n d o la n z a p in e h a v e a hig h risk o f w e ig h t g a in . R isperidone a n d q u e tia p in e a re a s s o c ia te d w ith a m o d e ra te risk o f w e ig h t g a in . 2. C. Citalopram: a n SSRI such as C ita lo p ra m w o u ld b e th e b e st c h o ic e , as it d o e s n o t h a v e a lp h a 1 a n ta g o n is m w h ic h c a n a g g ra v a te b e n ig n p ro s ta tic h y p e rtro p h y . Tricyclics c a u s e a lp h a 1 a n ta g o n is m a n d should th e re fo re b e a v o id e d .

3. F. Venlafaxine: w h e n a n SSRI has fa ile d , a d iffe re n t class o f a n tid e p re s s a n t such as v e n la fa x in e should b e trie d first. M irta z a p in e w o u ld n o t b e th e b e st c h o ic e in this c a s e d u e to its s e d a tin g e ffe c ts w h ic h w o u ld n o t h e lp h er g iv e n her excessive slee pin g.

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181. EMI - psychology Options A. M o d e llin g B. O p e ra n t c o n d itio n in g C. C lassical c o n d itio n in g D. Positive re in fo rc e m e n t

E. N e g a tiv e re in fo rc e m e n t F. Stimulus g e n e ra liz a tio n G. Fixed ra tio re in fo rc e m e n t

H. V a ria b le ra tio re in fo rc e m e n t I. S h a p in g J. E xtin ction

Instructions For e a c h o f th e sce na rio s d e s c rib e d b e lo w , c h o o s e th e m ost likely o p tio n fro m th e list a b o v e . E ach o p tio n m a y b e used o n c e , m o re th a n o n c e or n o t a t all. 1. A n a d v e rtis in g c o m p a n y puts a p ic tu re o f a b e a u tifu l w o m a n le a n in g a g a in s t a c a r th a t it w a n ts to sell. 2. A d o g c o m e s d o w n to th e k itc h e n w h e n e v e r h e hears th e o w n e r c o m e h o m e a n d o p e n a n d c lo se th e d o o r a t 6 p m e v e ry d a y . The d o g know s th a t th e o w n e r gives him his fo o d w h e n h e g e ts in fro m w o rk e v e ry d a y . S o m etim es th e d o g hears a sim ilar so un d to th e d o o r b e in g c lo s e d a n d rushes d o w n to th e k itc h e n . 3. A n 11-y e a r-o ld girl is a s k e d to brush h er te e th a t n ig h t b e fo re g o in g to sleep. She refuses to d o this d e s p ite e n c o u r a g e m e n t fro m h er m o th e r. E ve n tu a lly her m o th e r stops g iv in g h er e n c o u r a g e m e n t a n d sco ld s h er fo r n o t b rushing her te e th . She c o n tin u e s n o t to brush h er te e th . The m o th e r th e n ta ke s a w a y her p o c k e t m o n e y a n d th e girl th e n starts b rushing h er te e th .

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1. C. Classical conditioning: th e a d v e rtis in g c o m p a n y is a s s o c ia tin g a b e a u tifu l la d y w ith th e c a r so th a t w h e n a n in d iv id u a l thinks o f th e c a r th e y will th ink o f a b e a u tifu l lady. 2. F. Stimulus generalization: th e d o g has le a rn t to a s s o c ia te th e so u n d o f th e closin g d o o r a t 6 p m w ith fo o d . The d o g hears similar sounds w h ic h he th e n also associates w ith th e fo o d . 3. B. Operant conditioning: p u n is h m e n t is used as a m e th o d o f c h a n g in g b e h a vio u r.

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182. EMI - psychology Options A. G e n e ra l H ea lth Q u e s tio n n a ire (G H Q ) B. B urden Q u e s tio n n a ire C. H achinski Isch e m ic S core D. A lzh e im e r's Disease Q u a lity o f Life Q u e s tio n n a ire

E. M ini M e n ta l S ta te Exam F. W isconsin C a rd S orting Test G. B e n to n Revised Visual R e te n tio n Test H. C lin ic a l D e m e n tia R atin g S ca le

Instructions R ea d th e short short c a s e history a n d fo r e a c h o f th e fo llo w in g q u e stio n s c h o o s e th e m ost likely d ia g n o sis fro m th e list o f o p tio n s. E a ch o p tio n m a y b e used o n c e , m o re th a n o n c e or n o t a t all. A w o m a n has b ro u g h t h er 8 3 -y e a r-o ld fa th e r to th e a c c id e n t a n d e m e rg e n c y d e p a r tm e n t sa yin g she has b e e n fin d in g it d iffic u lt to lo o k a fte r him re c e n tly as he has b e c o m e in c re a s in g ly irrita b le a n d v e rb a lly a g g re ssive to w a rd h er o v e r th e last fe w w eeks: 1. W h ich s c a le c o u ld b e u sed to assess th e m o o d o f th e d a u g h te r? 2. W h ich te st c o u ld b e used to assess th e g lo b a l c o g n itiv e fu n c tio n o f th e p a tie n t? 3. If his g lo b a l c o g n itiv e fu n c tio n s w e re fo u n d to b e n o rm a l, w h ic h te s t c o u ld b e used to s p e c ific a lly assess his fro n ta l lo b e fu n c tio n s ?

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1. A. General Health Questionnaire: a s e lf-a d m in is te re d q u e s tio n n a ire w h ic h fo cuses on tw o m a jo r areas: (i) th e in a b ility to c a rry o u t n o rm a l fu n c tio n s a n d (ii) th e a p p e a r a n c e o f n e w a n d distressing sym ptom s. The G e n e ra l H ea lth Q u e s tio n n a ire (G H Q ) is a v a ila b le in th e fo llo w in g versions: GHQ-60: full 6 0-item q u e s tio n n a ire . G HQ -30: short fo rm w ith o u t que stion s o n p h ysica l illness. GHQ-28: a 28-item s c a le d version - assesses s o m a tic sym ptom s, a n xie ty, insom nia, so cia l d y s fu n c tio n a n d d epression. GHQ-12: q uick, re lia b le a n d sensitive short fo rm - b e st fo r rese arch.

2. E. Mini Mental State Exam (MMSE): consists o f th e fo llo w in g : O rie n ta tio n to Time (5 p o in ts) a n d P la c e (5), R egistration (3), C o n c e n tra tio n (5), R ecall (3), N a m in g (2), R e p e titio n (1), Three S ta g e C o m m a n d (3), W rite a s e n te n c e (1), Follow a task (e g c lo se yo u r e y e s )(l), D ra w in te rs e c tin g p e n ta g o n s (1). Total = 30 points.

3. F. Wisconsin Card Sorting Test: assesses fro n ta l lo b e fu n c tio n s . It p rim arily tests ju d g e m e n t, p e rs e v e ra tio n a n d a b s tra c t abilities.

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183. EMI - affective disorders Options A. C ycloth ym ia B. Depression C. Dysthymia

D. Bipolar a ffe c tiv e disorder E. M an ia F. H ypo m a n ia

G. Rapid cyc lin g b ip o la r a ffe c tiv e disorder H. M ixed anxiety a n d depressive disorder

Instructions For e a c h o f th e co nditio ns d e scrib e d below , ch oo se th e most likely diagnosis from th e list o f options. Each o p tio n m a y b e used o n ce , m ore th a n o n c e or n o t a t all. 1. A 37-year-old lad y has b e e n e xp e rie n cin g periods o f highs a n d lows in her m o o d e a c h lasting several m onths a t a tim e ever since she was a te e n ag e r. She has never previously n e e d e d psychiatric help b u t re ce n tly b e c a m e very depressed w ith o u t any obvious triggers. 2. A 29-year-old lady has b e e n e xpe rie n cin g periods o f elation, high energy, d ifficulty sleeping a n d excessive sp en ding over th e last 3 years. Each episod e lasts a b o u t 3 weeks on a ve ra g e . She has h a d th re e such episodes e a c h ye ar on a v e ra g e . She has h a d one episodes o f depression w h ich was 3 years a go . 3. A 50-year-old m an experiences ch ro n ic feelings o f w orrying a b o u t everything in his life - his finances, his children, his future - a n d he a p p e a rs n o t to h a ve valid reasons for such worries. He also reports th a t he feels depressed all th e tim e. The depression does n ot a p p e a r to arise from his anxiety a n d he feels b o th th e anxiety a n d d epres­ sion are similar in extent. He says he is unsure if he feels m ore anxious or depressed most o f th e tim e.

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1. A. Cyclothymia: ICD 10 c h a ra c te ris tic s - a persistent instability o f m o o d , invo lvin g n um erous p erio d s o f m ild d ep ression a n d m ild e la tio n . These e p iso d e s a re n o t su fficien tly p ro lo n g e d or severe to fulfil th e c rite ria fo r b ip o la r a ffe c tiv e disorder. This instability usually d e v e lo p s e a rly in a d u lt life a n d pursues a c h ro n ic course, a lth o u g h a t tim es th e m o o d m a y b e n o rm a l a n d s ta b le fo r m on ths a t a tim e. 2. D. Bipolar affective disorder: ICD10 c h a ra c te ris tic s - re p e a te d e p iso d e s in w h ic h th e p a tie n t's m o o d a n d a c tiv ity levels a re s ig n ific a n tly d is tu rb e d , consisting o n so m e o c c a s io n s o f e le v a tio n in m o o d w ith hig h e n e rg y a n d o v e ra c tiv ity , a n d on o th e r o c c a s io n s b y d ep re ssion w ith lo w m o o d a n d lo w e n e rg y . The m a n ic p e rio d s usually last b e tw e e n 2 w e e ks to 4 -5 m onths. The d ep re ssive p e rio d s usually last lo n g e r ( a b o u t 6 m onths). R a p id c y c lin g b ip o la r illness is c h a ra c te riz e d b y fo u r or m o re e p iso d e s o f h y p o m a n ia , m a n ia or d ep re ssion (or a c o m b in a tio n o f th e se ) w ith in a 12-m o nth p e rio d . The p a tie n t in this s c e n a rio has h a d th re e e p iso d e s p e r y e a r o f m a n ia so w o u ld n o t fit this c o n d itio n . 3. H. Mixed anxiety and depressive disorder: classified in th e ICD10 u n d e r n e u ro tic , stress-related a n d s o m a to fo rm disorders a n d n o t u n d e r a ffe c tiv e disorders. It is c h a ra c te riz e d b y sym p to m s o f b o th a n x ie ty a n d d ep re ssio n b u t n e ith e r set o f sym pto m s c o n s id e re d s e p a ra te ly is se vere e n o u g h to justify a diagnosis.

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184. EMI - investigations in psychiatry Options A. Low p la s m a c a e ru lo ­ plasm in B. H y p o g ly c a e m ia C. H y p e rc a lc a e m ia D. High urine o s m o la lity

E. H y p e rg ly c a e m ia F. Low serum v ita m in B12 G. In c re a s e in urina ry c a te c h o la m in e s H. H y p o n a tra e m ia

I. C o rtic a l a tro p h y a n d h y p o d e n s itie s in th e b a s a l g a n g lia J. H y p o k a la e m ia

Instructions For e a c h o f th e sce na rio s d e s c rib e d b e lo w , c h o o s e o n e o r tw o o f th e a b o v e o p tio n s th a t b e st fit. E a ch o p tio n m a y b e used o n c e , m o re th a n o n c e or n o t a t all. 1. A 17 -y e a r-o ld girl pre sen ts to th e a c c id e n t a n d e m e rg e n c y d e p a r tm e n t w ith tre m o r a n d rig id ity . P h ysica l e x a m in a tio n re v e a ls m ild ja u n d ic e a n d h e p a to m e g a ly (c h o o s e tw o ). 2. A 4 8 -y e a r-o ld m a n has b e e n e x p e rie n c in g p a lp ita tio n s , p a n ic a tta c k s , a n xie ty, s w e a tin g a n d h e a d a c h e s o v e r th e last 3 m o n th s w ith o u t a n y o b v io u s ca u se . F u n c tio n a l p s y c h ia tric illness has b e e n ru le d o u t (c h o o s e o n e ). 3. A 2 4 -y e a r-o ld la d y has b e e n e x p e rie n c in g w e ig h t g a in o v e r th e last 6 m o n th s d e s p ite h e r a p p e tite b e in g poo r. She has also e x p e rie n c e d m u scle c ra m p s as w e ll as n a u s e a a n d v o m itin g a t tim es o v e r th e last fe w w eeks. She n o tic e s her urine has b e c o m e v e ry th ic k o ra n g e (c h o o s e 2).

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1. А, В. Wilson’s disease: see o th e r c a rd fo r d e ta ils o f this c o n d itio n . 2. G. Phaeochromocytoma: a ve ry u n c o m m o n a d re n a l g la n d tu m o u r s e c re tin g a d re n a lin e . S ym ptom s in c lu d e p a lp ita tio n s , w e ig h t loss, s w e a tin g a n d hig h b lo o d pressure. 3. D, H: Syndrome of Inappropriate Secretion of ADH (SIADH). SIADH m a y b e c a u s e d by: o a t c e ll c a rc in o m a o f th e lung; C O A D ; p a n c re a tic c a n c e r; H o d g k in 's disease; CNS disorders - c e re b ra l abscess, m eningitis, e n c e p h a litis ; m y x o e d e m a ; c e rta in drugs - a ntid ep re ssa n ts, n e u ro le p tic s , c a rb a m a z e p in e , diuretics, oral h y p o g ly c a e m ic a g e n ts . In ve stig a tio n s re ve a l: lo w serum Na; e le v a te d urine Na; lo w serum o sm olality; h ig h urine o s m o la lity (h ig h ly c o n c e n tr a te d urine).

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185. EMI - neurology Options A. Lew y B o dy disease B. P arkinson's disease C. Lupus e ry th e m a to s u s D. H u n tin g to n s d isease

E. H e p a tic e n c e p h a lo p a th y F. Progressive s u p ra n u c le a r p alsy G. C o rtic o b a s a l d e g e n e ra tio n H. F ro n to te m p o ra l d e m e n tia

Instructions For e a c h o f th e c o n d itio n s d e s c rib e d b e lo w , c h o o s e th e m o st likely d ia g n o sis fro m th e list o f o ptio n s. E a ch o p tio n m a y b e u sed o n c e , m o re th a n o n c e o r n o t a t all. 1. The p a tie n t d is p la y e d b ra d y p h re n ia , irrita b ility a n d w a s s o c ia lly w ith d ra w n ; phys­ ic a lly h e su ffe re d fro m a x ia l rigidity, a n d falls o c c u rre d e a rly o n d u rin g th e co u rse o f th e disease. 2. The 3 9 -y e a r-o ld p a tie n t w a s re fe rre d fo r p s y c h o tic sym pto m s, d u rin g th e e x a m i­ n a tio n c o n s ta n t irre g u la r m o v e m e n ts o f his fin g e rs a n d to e s w e re n o te d . He c o u ld n o t h o ld his to n g u e s te a d y w h e n a s k e d to stick it o u t. 3. The 5 4 -y e a r-o ld p a tie n t w a s s o m n o le n t, w h e n w o k e n u p she w a s n o t o rie n ta te d to tim e , p la c e o r p e rso n a n d w h e n a s k e d to h o ld h e r arm s a n d h a n d s o u t­ s tre tc h e d h er h a n d s a n d fin ge rs w o u ld o fte n b rie fly sink d o w n a n d c o m e u p a g a in .

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1. F. Progressive supranuclear palsy (PSP): Parkinson plus syn d ro m e , a ta u o p a th y (a b n o rm a l fo rm a tio n o f ta u p ro te in in th e b ra in w h ic h m a y c o n trib u te to so m e typ e s o f d e m e n tia in c lu d in g fro n ta l lo b e d e m e n tia , PSP or Pick's dise ase ) m a rk e d b y a xia l parkinsonism , s u p ra n u c le a r e y e m o v e m e n t a b n o rm a litie s (v e rtic a l g a z e a ffe c te d ), g a it d iso rd e r a n d p o stu ra l instab ility (falls o c c u r e a rly on). C o g n itiv e d is tu rb a n c e , p e rso n a lity c h a n g e a n d dep re ssion a re also possible. 2. D. Huntington’s disease: AD, trin u c le o tid e re p e a t e x p a n s io n (C A G ), c lin ic a l p ic tu re m a rk e d b y in v o lu n ta ry m o v e m e n ts (c h o re a or o th e r b a sa l g a n g lia d y s fu n c tio n ), p s y c h ia tric d is tu rb a n c e (psychosis, depression, o bse ssive -co m p u lsive sym ptom s, su d d e n outbursts o f a n g e r) a n d c o g n itiv e d e c lin e . 'U n s te a d y to n g u e ': o n e possible e a rly sign o n p h y s ic a l e x a m in a tio n .

3. E. Hepatic encephalopathy: m a n ife s ta tio n v a ria b le , o fte n seen a re im p a irm e n t o f consciousness, co nfu sio n , visual h a llu c in a tio n s , m o o d swings (e u p h o ria depression); m o to r disorders (e s p e c ia lly fla p p in g tre m o r - asterixis as in this p a tie n t), dysarthria, a ta x ia , gross trem or, m u s c u la r rigidity, h yp e rre fle x ia , clonus.

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186. EMI - neuropsychiatry Options A. P rotein 14-3-3 in c re a s e d B. A tro p h y h e a d o f c a u d a te C. C A G e x p a n s io n D. Basilar a rte ry d istal o c c lu s io n

E. S u b d u ra l b lo o d c o lle c tio n F. K ayser-F leischer ring G. R aised CSF p ro te in

Instructions For e a c h o f th e c o n d itio n s d e s c rib e d b e lo w , c h o o s e th e m o st likely d ia g n o sis fro m th e list o f o ptio ns. E ach o p tio n m a y b e used o n c e , m o re th a n o n c e or n o t a t all. 1. A 5 2 -y e a r-o ld d ia b e tic p a tie n t d e v e lo p e d a c h a n g e o f his p e rs o n a lity d u rin g th e last 24 hours a n d u p o n a rriva l in h o s p ita l a p p e a rs excessively s le e p y a n d is fo u n d to h a v e a fever. 2. The p a tie n t p re s e n te d w ith a c u te o n s e t a g ita tio n a n d visual h a llu c in a tio n s w h ile n o t n o tic in g o b je c ts a p p ro a c h in g him fro m th e right. There is n o tra u m a in th e history. 3. A 2 9-yea r o ld w o m a n has b e e n tr e a te d fo r d e p re ssio n since her m id -tw e n tie s , she n o w presents w ith h e p a to s p le n o m e g a ly a n d th ro m b o c y to p e n ia . You also n o tic e d ysa rth ria a n d d y s to n ic p o stu rin g.

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1. G. Raised CSF protein: e g h erpe s e n c e p h a litis c a n p re s e n t w ith a c h a n g e in p e rso n a lity (71-87% ). O th e r key s ym p to m s are: fe v e r (90-95% ), d e c re a s e d consciousness (97-100% ), fo c a l d e fic its (h e m ip aresis (33-40% ), e p ile p tic fits (62-67% )) as w e ll as h e a d a c h e (74-81% ) a n d v o m itin g (38-46% ). CSF shows in c re a s e d w h ite cells (lO -5 0 0 /μΙ) a n d in c re a s e d p ro te in . 2. D. Basilar artery distal occlusion: to p o f th e b asilar a rte ry syn d ro m e , ty p ic a l sym pto m s in c lu d e d e c re a s e d consciousness, psychosis, visual fie ld d e fe c ts , p u p illa ry a n d e y e m o v e m e n t d e fe c ts , a m n e sia , a le xia, n o paresis. 3. F. Kayser-Fleischer ring: ( c o p p e r d e p o sits in th e c o rn e a ) is n e a rly a lw a ys p re se n t in p a tie n ts w h o h a v e d e v e lo p e d n e u ro lo g ic a l s ym p to m s in W ilson's disease. In W ilson's disease a n e n z y m e d e fe c t in a c o p p e r tra n s p o rt m o le c u le le a d s to to x ic levels o f fre e c o p p e r in th e serum a n d c o p p e r d e p o sits in CNS, liver, kidneys a n d bones. The a d u lt fo rm o f W ilson's disease presents w ith progressive n e u ro lo g ic a l a n d p s y c h ia tric sym pto m s. Tests: c e ru lo p la s m in (d e c re a s e d ), fre e serum c o p p e r (in c re a s e d ), urine 24-hour c o p p e r in c re a s e d , liver biopsy, slit la m p e xam .

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187. EMI - neuropsychiatry Options A. A ka th isia B. Trem or C. M y o c lo n u s D. Ballismus

E. C h o re a F. A the tosis G. D ysto nia

H.R igidity I. Tics J. A ta x ia

Instructions For e a c h o f th e c o n d itio n s d e s c rib e d b e lo w , c h o o s e th e p re s e n tin g fe a tu re fro m th e list o f o ptio ns. E ach o p tio n m a y b e used o n c e , m o re th a n o n c e or n o t a t all. 1. You re v ie w a y o u n g p a tie n t w ith o b s e s s iv e -c o m p u ls iv e sym pto m s. D uring th e in te rv ie w y o u n o tic e th a t th e p a tie n t c le a rs his th ro a t r e p e a te d ly a n d b rie fly stra ig h te n s his shoulders o n se veral o c c a s io n s . 2. O n y o u r first c o n ta c t w ith th e p a tie n t in th e o u tp a tie n t d e p a r tm e n t y o u n o tic e s u d d e n a n d irre g u la r m o v e m e n t o f th e p a tie n t's h a n d s a n d fe e t w h ic h se em as if th e p a tie n t is p la y in g th e p ia n o a n d w h ic h h e also tries to in c o rp o ra te in to s e m ip u rp o se fu l m o v e m e n ts . 3. In a p a tie n t w ith a ra p id ly pro gressin g d e m e n tin g illness y o u o b s e rv e su d d e n , brief, jerky m o v e m e n ts o f his le ft a rm .

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1 . 1. Tics: a re e ith e r re la tiv e ly brief, su p p re ssab le m o v e m e n ts (m o to r tics) or v o c a liz a tio n s (v o c a l or p h o n ic tics) w h ic h a re p re c e d e d b y a fe e lin g o f tensio n b u ild in g u p w h ic h is te m p o ra rily re lie v e d b y e x e c u tin g th e m o v e m e n t/v o c a liz a tio n . Tics a re th e h a llm a rk o f T ou re tte 's sy n d ro m e w h ic h o fte n is a s s o c ia te d w ith o b se ssive -co m p u lsive sym ptom s, ADHD a n d p o o r im pulse c o n tro l. 2. E. Chorea: a n invo lu n ta ry, irre g u la r h y p e rk in e tic m o v e m e n t w h ic h is m ost p ro m in e n t distally a n d m ig h t in v o lv e m o re p ro x im a l a re a s la te r in th e co u rse o f th e disease, e g H u n tin g to n 's . P atients o fte n try to h id e th e m o v e m e n ts b y in c o rp o ra tin g th e m into se m ip u rp o se fu l gestures.

3. C. Myoclonus: a n in v o lu n ta ry ra p id s te re o ty p ic a l m o v e m e n t th a t c a n in vo lve extrem ities, fa c e a n d trunk. It is a fe a tu re o f C re u tz fe ld -J a k o b disease.

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188. EMI - neuropsychology Options A. T em p oral lo b e , d o m in a n t h e m is p h e re B. T em p oral lo b e , n o n -d o m in a n t h e m is p h e re C. P a rie ta l lo b e

D. P re fro n ta l c o rte x E. B ilateral te m p o ro b a s a l

Instructions For e a c h o f th e c o n d itio n s d e s c rib e d b e lo w , w h e re is th e p a tie n t's lesion m ost likely lo c a te d fro m th e list o f o p tio n s. E a ch o p tio n m a y b e used o n c e , m o re th a n o n c e o r n o t a t all. 1. D esp ite su ffe ring fro m a se ve re le ft-s id e d h e m ip a re sis (m a in ly a rm a n d fa c e ), th e p a tie n t d e n ie d a n y p ro b le m s w ith his le ft side. 2. The p a tie n t c o u ld still d is c rim in a te b e tw e e n fa c e s b u t h e s tru g g le d to re c o g n iz e th e m a n d th e y h a d lost fa m ilia rity to him . 3. The p a tie n t's b e h a v io u r w a s m a rk e d b y h y p e rs e x u a lity a n d try in g to e a t n e a rly e v e ry th in g h e c a n g e t h o ld of. He s e e m e d easily d is tra c tib le , d is p la y in g a lim it­ e d ra n g e o f a ffe c t a n d w a s u n a b le to re c o g n iz e o b je c ts th a t w e re sh ow n to him . 4. The p a tie n t h a d lost a n y d riv e to pursue his fo rm e r g o a ls in life, o fte n h e dis­ p la y e d o u tb re a k s o f a n g e r a n d ra g e a n d h e s e e m e d to p ro d u c e a c o n s ta n t strea m o f e v e r-c h a n g in g ideas.

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1. C. Parietal lobe: n e g le c t is m ost o fte n a s s o c ia te d w ith p a rie ta l lesions (R m o re th a n L) b u t c a n also o c c u r w ith th a la m u s or b a sa l g a n g lia lesions, rarely w ith fro n ta l lo b e lesions. 2. E. Bilateral temporobasal lobe: p ro s o p a g n o s ia (n o n -re c o g n itio n o f fa c e s ), h ere in its m ild e r form , is usually c a u s e d b y lesions e ith e r to th e lo w e r p a rt o f th e visual c o rte x ( o c c ip ita l lo b e ) w ith a lesion o f th e u n d e rly in g w h ite m a tte r or c a u s e d b y b ila te ra l o c c ip ito te m p o ro b a s a l lesions.

3. E. Bilateral temporobasal lobe: K lu ve r-B u cy syn drom e, b ila te ra l te m p o ro b a s a l lesion, c a u s e d by: te m p o ra l lo b e -te n to ria l h e rn ia tio n , h erpe s sim plex e n c e p h a litis , tra n sie n t in severe h e a d tra u m a , o c c a s io n a lly in a d v a n c e d A lzh e im e r's disease. Fully d e v e lo p e d syn d ro m e rare in hum ans.

4. D. Prefrontal cortex: th e d e s c rip tio n g iv e n h ere is p a rt o f Phineas C a g e 's fa m o u s c lin ic a l p ic tu re a fte r sustaining injury to th e m e d ia l re g io n o f th e p re fro n ta l c o rte x b y a ta m p in g iron. Lesions to th e p re fro n ta l c o rte x c a n also le a d to p o o r c o n c e n tra tio n , d istra ctib ility , loss o f in itia tive , a p a th y , in a b ility to m a k e decisions, u n p re d ic ta b le a n d u n a c c e p ta b le b e h a vio u r, loss o f sense o f smell.

3 76

189. EMI - investigations in psychiatry Options A. Full b lo o d c o u n t B. Liver fu n c tio n tests C. P a ra c e ta m o l levels a fte r 4 hours D. Serum a n tim o n io d ru g levels E. ECG

F. B eck D epression In v e n to ry G. Discussion w ith th e in fo rm a n t H. Mini M e n ta l S ta te Exam I. Urine d ru g scre e n

Instructions For e a c h o f th e c o n d itio n s d e s c rib e d b e lo w , s ta te th e m ost a p p ro p ria te n e xt step(s) fro m th e list o f o p tio n s. E a ch o p tio n m a y b e used o n c e , m o re th a n o n c e or n o t a t all. 1. A 5 0 -y e a r-o ld m a n arrives a t A&E a fte r a n u n k n o w n o v e rd o s e . He is d ro w sy a n d gives v e ry fe w answers. (3 c h o ic e s ) 2. A 61-y e a r-o ld la d y is a d m itte d to a m e d ic a l w a rd a fte r a su ic id e a tte m p t w h ic h she n o w regrets. She is ta k in g lithium fo r a ffe c tiv e disorder. (1 c h o ic e ) 3. A 4 5 -y e a r-o ld m a n is a d m itte d a fte r try in g unsu ccessfu lly to h a n g him self. In m e n ­ ta l sta te he is s u b je c tiv e ly lo w in m o o d b u t o b je c tiv e ly e u th y m ic . He is k n o w n to misuse drugs. (3 c h o ic e s )

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1. B, C, Е. Liver function tests, Paracetamol levels, ECG. In a d ro w sy p a tie n t it is im p o rta n t to e x c lu d e possible life -th re a te n in g o v e rd o s e o u tc o m e s . 2. D. Serum antimanic drug levels 3. B, F, I. Liver function tests, Beck Depression Inventory, Urine drug screen.

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190. EMI - neurotic disorders Options A. D issociative fu g u e B. G a n s e r's sy n d ro m e C. C on ve rsio n d iso rd e r D. H yp o ch o n d ria sis

E. M a lin g e rin g F. S o m a tiz a tio n d is o rd e r G. P o s t-tra u m a tic stress d iso rd e r

H. D issociative stu p o r I. A c u te stress re a c tio n J. A d ju s tm e n t d iso rd e r

Instructions For e a c h o f th e c o n d itio n s d e s c rib e d b e lo w , c h o o s e th e m o st likely d ia g n o sis fro m th e list o f o ptio ns. E ach o p tio n m a y b e used o n c e , m o re th a n o n c e or n o t a t all. 1. A 2 8 -y e a r-o ld w o m a n p resents re p e a te d ly o v e r th e ye ars w ith in e x p lic a b le c h e s t p a in . She has also c o m p la in e d o f a b d o m in a l p a in , m ig ra in e , a c o u g h , n au sea , a n d d o u b le vision. Various specialists h a v e fo u n d n o a b n o rm a litie s . 2. A 3 0 -ye a r-o ld m a n c o m p la in s o f in e x p lic a b le p a in in his a b d o m e n . W h e n a sked q uestions a b o u t w h e re h e lives a n d his b irth d a te his answ ers a re slightly in c o r­ re c t e v e ry tim e . He has re c e n tly b e e n m a d e hom eless. O n q u e s tio n in g h e says he c a n h e a r vo ice s. There is in c o n s is te n c y in his history. 3. A m e d ic a l s tu d e n t a p p ro a c h in g h e r finals is re fe rre d b y h e r GP a fte r n u m e ro u s in e x p lic a b le sym p to m s in c lu d in g d o u b le vision, d ea fne ss, sensory loss a n d loss o f p a in sense. She o c c a s io n a lly hears 's tra n g e noises'. She a p p e a rs m o re c o n ­ c e rn e d a b o u t h er finals th a n th e p h y s ic a l sym pto m s.

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1. F. Somatization disorder: a t lea st 2 years o f m u ltip le , re cu rre n t, fre q u e n tly c h a n g in g p h ysica l sym p to m s w ith n o a d e q u a te p h ysica l e x p la n a tio n . Persistent refusal to a c c e p t reassuran ce. Som e im p a irm e n t o f so cia l a n d fa m ily fu n c tio n in g . Usually b e g in s b e fo re a g e 30. ICD10 (six s ym p to m s re la tin g to a t least tw o o rg a n systems m ust b e presen t). D isorder tw ic e as c o m m o n in w o m e n . 2. B. Ganser’s syndrome: rare c o n d itio n , c h a ra c te ris e d b y a p p ro x im a te answ ers e g 4+4=9, p s y c h o g e n ic p h y s ic a l sym ptom s, h a llu c in a tio n s , a t tim es c lo u d in g o f consciousness, story co n siste n tly m a in ta in e d . O rig in a lly d e s c rib e d a m o n g prisoners b e c a u s e o f o b vio u s g a in fro m illness. O rg a n ic illness or p s y c h o tic illness should b e e x c lu d e d . 3. C. Conversion disorder: te rm th a t re p la c e d h ysteria-im plies c o n v e rs io n o f p ro b le m s a n d c o n flic ts th e in d iv id u a l c a n n o t solve in to sym ptom s. In DSM IV th e re a re fo u r subtypes: (1) m o to r s ym p to m s or d e ficits; (2) sensory sym p to m s or deficits; (3) seizures or convulsions; (4) m ix e d p re s e n ta tio n . C o n ve rsio n s ym p to m s a re likely w h e n th e re is n o p hysic a l e x p la n a tio n . 'La b e lle in d iffe re n c e ' (la c k o f c o n c e rn a b o u t sym p to m s) has b e e n d e s c rib e d in c o n v e rs io n disorders. There m a y b e s e c o n d a ry g a in fro m s ym p to m s - e x te rn a l b e n e fits or a v o id a n c e o f u n w a n te d responsibilities.

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191. EMI - mixed topics Options A B riquet's sy n d ro m e B. A lc o h o l w ith d ra w a l C. D elirium tre m e n s D. D epression E. Fat e m b o lism

F. W e rn ic k e 's e n c e p h a lo p a th y G. Tuberculosis H. P a ra n o id s c h iz o p h re n ia I. S c h iz o a ffe c tiv e d is o rd e r

J. M a rc h ia fa v a -B ig n a m i sy n d ro m e K. C h ro n ic a lc o h o l a b u s e L. A lc o h o lic h allucinosis

Instructions For e a c h o f th e c o n d itio n s d e s c rib e d b e lo w , c h o o s e th e tw o m ost a p p ro p ria te d ia g n o s e s fro m th e list o f o p tio n s. E a ch o p tio n m a y b e used o n c e , m o re th a n o n c e o r n o t a t all. 1. A 2 5 -y e a r-o ld m a n is su ffe ring a b e re a v e m e n t. He is v e ry a nxiou s a n d finds it d if­ fic u lt to sleep. He is sw e a ty , sh aking a n d c o m p la in in g o f a loss o f e n e rg y , as w e ll as su icid a l th o u g h ts . 2. A 5 0 -ye a r-o ld m a n is re c o v e rin g o n a su rg ic a l w a rd a fte r a m o to r c y c le a c c i­ d e n t. He is re la tiv e ly im m o b ile a n d has fra c tu re d his leg. He b e c o m e s distressed a n d says he is h e a rin g v o ic e s u tte rin g o b s c e n itie s . He a p p e a rs c o n fu s e d a n d dis­ o rie n te d a n d starts to e x p e rie n c e seizures. 3. A 6 0 -y e a r-o ld m a n has b e e n d rin k in g a lc o h o l excessively th ro u g h o u t m ost o f his life. He has slurred s p e e c h , a n a ta x ic g a it, e p ile p s y a n d im p a ire d consciousness.

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1. B, D. Alcohol withdrawal and depression: A lc o h o l w ith d ra w a l - (i) Usually b e g in s 12-48 hours a fte r ce ssa tio n o f drinkin g, (ii) C o m m o n sym p to m s in c lu d e trem or, w eakness, s w e a tin g , a n d n a u se a , (iii) Seizures o c c u r less c o m m o n ly . A lc o h o lic hallucinosis - (i) Follows a p e rio d o f a b s tin e n c e a fte r h e a v y c h ro n ic drinkin g, (ii) C h a ra c te riz e d b y a u d ito ry h a llu c in a tio n s usually p e rs e c u to ry or th re a te n in g in n a tu re , (iii) S ym ptom s m a y last fo r d a y s a n d c a n b e c o n tro lle d w ith a n tip s y c h o tic drugs such as c h lo rp ro m a z in e . 2. C, E. Delirium tremens or tat embolism: Delirium tre m e n s usually o c c u rs a b o u t 7-10 d a ys a fte r ce ssa tio n o f d rin kin g in s o m e o n e in w h o m a lc o h o l w ith d ra w a l has b e e n le ft u n tre a te d . A serious c o n d itio n w h ic h m ust b e tre a te d as a m e d ic a l e m e rg e n c y . C h a ra c te riz e d by: a n xie ty, co n fu sio n , d iffic u lty sle e p in g ; n ig htm a re s, s w e a tin g , depression; ta c h y c a rd ia a n d fe v e r m a y d e v e lo p ; fle e tin g h a llu cin a tio n s, illusions, d is o rie n ta tio n , visual h a llu c in a tio n s .

3. J, K. Marchiafava-Bignami disease (MBD) or Chronic alcohol abuse: in th e m o re p ro lo n g e d fo rm o f MBD, lim b paralysis a n d d e m e n tia m a y o c c u r. In this c o n d itio n th e re is w id e s p re a d d e m y e lin a tio n o f th e o p tic tracts, c e re b e lla r p e d u n c le s a n d co rp u s c a llo su m .

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192. EMI - defence mechanisms Options A. P ro je ctio n B. D is p la c e m e n t C. S u b lim a tio n D. In tro je c tio n

E. R e a c tio n fo rm a tio n F. S plitting G. Id e n tific a tio n w ith th e a g g re sso r

H. R a tio n a liz a tio n I. P ro je c tiv e id e n tific a tio n J. A c tin g o u t

Instructions For e a c h o f th e situatio ns d e s c rib e d b e lo w , c h o o s e th e single m ost a p p ro p ria te d e fe n c e m e c h a n is m fro m th e list o f o p tio n s. E a ch o p tio n m a y b e used o n c e , m o re th a n o n c e or n o t a t all. 1. A busy su rg ica l sp e c ia lis t registrar has re c e iv e d a te llin g o ff b y his c o n s u lta n t. Five m in utes la te r h e tells o ff his p e rp le x e d senior h ou se o ffic e r o v e r a m in o r m a tte r. 2. A m a n is su ffe ring a c u te ly fro m a p s y c h o tic illness a n d has p e rs e c u to ry b eliefs in vo lvin g his m o th e r. The m o th e r finds h erself b e c o m in g hostile a n d p e rs e c u tin g to w a rd s h er son a fte r h e r son shouts a t h e r o n e d a y . 3. A m a n w h o has d ru g p ro b le m s states th a t h e thinks h e w o u ld b e a b le to g iv e u p his d rugs m o re easily if his w ife w a s m o re lo vin g .

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1. В. Displacement: e m o tio n s, id e a s a n d fe e lin g s c a n b e tra n s fe rre d to a n o th e r person or th ing , in this e x a m p le to th e SHO w h o is fe lt to b e less im p o rta n t. This is a n e u ro tic d e fe n c e m e c h a n is m w h ic h c a n b e fo u n d in p h o b ia s . P hobias re p re se n t a n u n co n scio u s fe a r o f so m e o th e r situ a tio n or person. 2. I. Projective identification: a p rim itiv e d e fe n c e m e c h a n is m w h ic h in c lu d e s b u t g o e s b e y o n d p ro je c tio n . A n in d iv id u a l u n co n s c io u s ly disow ns a n a ttitu d e or a ttrib u te o f him self a n d a scribe s it o n to a n o th e r in d iv id u a l. A d d itio n a lly , th e o b je c ts o f th e p ro je c tiv e id e n tific a tio n a re in d u c e d to ta k e o n a n d fe e l in a w a y w h ic h has b e e n p ro je c te d o n to th e m . In th e a b o v e e x a m p le th e m o th e r ta ke s on her son's aggre ssive th o u g h ts a n d e n a c ts th e m th ro u g h p ro je c tiv e id e n tific a tio n . A lth o u g h th e son a p p e a rs to h a v e p e rs e c u to ry beliefs, it is a c tu a lly his u n co n scio u s agg re ssive fa n ta sie s p ro je c te d o n to his m oth er. 3. H. Rationalization: this is a p ro cess o f ju s tific a tio n a n d re a s o n in g a fte r a n e v e n t. A n in d iv id u a l m a y p ro v id e lo g ic a l e x p la n a tio n s fo r his or her b e h a v io u r. The in d iv id u a l m a y try to c o n v in c e othe rs or him self o f a n e x p la n a tio n fo r his irra tio n a l b e h a v io u r. A n e x te rn a l e v e n t m a y b e b la m e d as a m e a n s o f e x p la n a tio n . This a lo n g w ith d e n ia l is c o m m o n ly seen in in d ivid u a ls w ith s u b s ta n c e a b u se .

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193. EMI - psychotic disorders Options A. Paranoid schizophrenia B. H eb ephrenic schizophrenia C. C a ta to n ic schizophrenia D. Simple schizophrenia E. U ndifferentiated schizophrenia

F. S chizoaffective disorder G. Schizotypal disorder H. A c u te schizophrenia-like p sycho tic disorder I. A c u te p o lym o rp h ic p sycho tic disorder J. N one o f th e a b o v e

Instructions For e a c h o f th e conditions d e scrib e d b elow , ch oo se th e m ost likely diagnosis from th e list o f options. Each o p tio n m ay b e used o nce , m ore th a n o n c e or n ot a t all. 1. A young m an has variations in his em otions for th e first tim e. There has b e e n a 10-day duratio n o f a ud itory a n d h a p tic h allucinations w hich flu c tu a te from d a y to day. 2. A 30-year-old w o m a n is a d m itte d a fte r a c u te ideas th a t th e MI6 are a fte r her. These thoughts settle quickly b u t her a p p e a ra n c e a n d b e h a vio u r remains o d d a n d she has o verela bo ra te , v a g u e speech. She has g o o d personal fu n ctio n in g a t hom e b u t her fam ily have fo un d her c o ld a n d a lo o f for m an y years. 3. A 40-year-old m an has h a d a g ra d u a l d e c lin e in his a bility to c o p e with life. He has ta ken to b e g g in g a n d his friends describ e a o n c e lively m an w h o has b e c o m e idle a n d w ithd ra w n over th e years. He does n o t h a ve obvious p sycho tic features.

385

1 . 1. Acute polymorphic psychotic disorder: c a n b e w ith or w ith o u t sym p to m s o f sch izo p h ren ia . H a llu cin a tio n s a n d delusions v a ry m a rk e d ly fro m d a y to d a y or h ou r to hour. E m o tion a l tu rm o il, a c u te onset, no o b v io u s stressors. S ym p tom s fo r less th a n 3 m onths. 2. G Schizotypal disorder: s o cia lly anxious or w ith d ra w n , c o g n itiv e a n d p e rc e p tu a l distortions, o d d itie s o f s p e e c h a n d beliefs, in a p p ro p ria te a ffe c t. O c c a s io n a l tra n sie n t quasi- p s y c h o tic episod es. C a n e v o lv e in to sch izo p h re n ia , m o re c o m m o n in in d ivid ua ls re la te d to schizophrenics. 3. D Simple schizophrenia: insidious d e v e lo p m e n t o f o d d itie s o f c o n d u c t, d e c lin e in p e rfo rm a n c e a n d e v e n tu a lly m a y b e c o m e id le a n d aimless. Delusions a n d h a llu c in a tio n s a re less p ro m in e n t. N e g a tiv e sym p to m s d e v e lo p w ith o u t o v e rt p s y c h o tic fe atures.

386

194. EMI - dementia syndromes Options A. D e m e n tia in HIV B. A lc o h o lic d e m e n tia C. A lzh e im e r's disease D. D e m e n tia in H u n tin g to n 's d ise ase

E. Pick's d ise ase F. N o rm a l pressure h y d ro c e p h a lu s G. V a s c u la r d e m e n tia H. D e m e n tia w ith Lew y b o d ie s

Instructions For e a c h o f th e c o n d itio n s d e s c rib e d b e lo w , c h o o s e th e m o st likely d ia g n o sis fro m th e list o f o ptio ns. E ach o p tio n m a y b e used o n c e , m o re th a n o n c e or n o t a t all. 1. A 6 5 -y e a r-o ld m a n has a history o f falls a n d v iv id im a g e s in c lu d in g s e e in g evil d w a rv e s on w a k in g fro m sleep. 2. A 7 5 -ye a r-o ld m a n has a history o f falls. He is m a ln o u ris h e d a n d u n k e m p t. He has a m ild b u t s ig n ific a n t c o g n itiv e im p a irm e n t. 3. A 5 9 -y e a r-o ld w o m a n is b ro u g h t in b y h e r h u s b a n d . He n o tic e d a c h a n g e in her g a it, m e m o ry p ro b le m s a n d la te r urina ry in c o n tin e n c e .

387

1. H. Lewy body dementia: th e re is a flu c tu a tin g co u rse w ith visual h a llu cin a tio n s, m o to r p arkin so n ia n fe a tu re s, falls, s y n c o p e , delusions, a u d ito ry h a llu c in a tio n s a n d e x tre m e sensitivity to e x tra p y ra m id a l e ffe c ts o f a n tip s y c h o tic s . 2. В Alcoholic dementia: th e re is c o g n itiv e im p a irm e n t e s p e c ia lly w h e n th e fro n ta l lo b e is in v o lv e d . CT sca n shows e n la rg e d la te ra l ve ntricle s. O ld e r p a tie n ts a n d th ose d rinkin g w ith o u t respite a re m o re a t risk. W o m e n a re m o re a t risk o f c o g n itiv e im p a irm e n t.

3. F. Normal pressure hydrocephalus: th e re is a c lin ic a l tria d o f e a rly g a it a p ra x ia (b ro a d -b a s e d g a it w ith d iffic u lty in in itia tio n ), b ra d y p h re n ia (s lo w e d th in k in g ) a n d la te r urinary in c o n tin e n c e . It is m o re c o m m o n in e ld e rly b u t so m e tim e s o c c u rs in m id d le life. It m a y b e a m e n a b le to a n e u ro s u rg ic a l shunt p ro c e d u re .

388

195. EMI - risk factors Options A. F em a le sex B. Living a lo n e C. H avin g a h ig h salary D. H ea rin g im p a irm e n t

E. Past history o f p s y c h ia tric illness F. High IQ G. R e c e n t d is c h a rg e fro m h o sp ita l H. Living in G re e c e

Instructions For e a c h o f th e c o n d itio n s d e s c rib e d b e lo w , c h o o s e th re e risk fa c to rs fro m th e list o f o ptio ns. E ach o p tio n m a y b e used o n c e , m o re th a n o n c e or n o t a t all. 1. S uicide. 2. L a te -o n s e t sch izo p h re n ia . 3. Depression.

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1. B, E, G: p ositive asso cia tio n s w ith su ic id e in c lu d e h a v in g a p s y c h ia tric d is o rd e r re c e n t d is c h a rg e fro m hosp ital, c h ro n ic p a in fu l illness, p re vio u s su icid e a tte m p t or d e lib e ra te self h arm , a lc o h o l or d ru g a bu se, m a le sex, b e in g eld erly, h a v in g su ffe re d loss or b e re a v e m e n t, u n e m p lo y m e n t, b e in g retired , childlessness, living a lo n e in a c ity a n d a b ro k e n h o m e in c h ild h o o d . 2. A, B, D: la te -o n s e t s c h iz o p h re n ia presents a fte r 60 w ith g o o d p re m o rb id fu n c tio n in g . M o re c o m m o n in fe m a le s a n d a s s o c ia te d w ith a u d ito ry a n d visual d e p riv a tio n . There m a y also b e a fa m ily history o f p s y c h o tic or m o o d disorders. 3. А, В, E: m o re c o m m o n in fe m a le s, u n m a rrie d individuals, th o se w ith a fa m ily history o f depression, p s y c h o s o c ia l stressors a n d p h y s ic a l illness.

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196. EMI psychopathology Options A. A u to c h th o n o u s d elu sio n B. S e c o n d a ry d elusio n C. Ideas o t re fe re n c e D. T h o u g h t b ro a d c a s tin g E. S o m a tic passivity

F. C la n g a s s o c ia tio n G. T a n g e n tia lity H. T h o u g h t e c h o I. H yperacusis

J. H yp e ra e sth e sia K. N e o lo g ism L. D e p e rs o n a liz a tio n M. D e re a liz a tio n

Instructions For e a c h o f th e c o n d itio n s d e s c rib e d b e lo w , c h o o s e tw o o f th e a b o v e o p tio ns. E ach o p tio n m a y b e u sed o n c e , m o re th a n o n c e o r n o t a t all. 1. A p a tie n t o n th e w a rd is e x p e rie n c in g a n a c u te re la p s e o f her m a n ic illness. W h e n a ske d 'h o w a re y o u fe e lin g ? ' th e p a tie n t replies 'fe e lin g , b e lie v in g , cruis­ ing like fe e lin g a n d I fe e lin g b e lie v in g '. She also says she feels 'g lo d y '. 2. A n o u tp a tie n t tells y o u h e so m e tim e s fe e l a sense o f d e ta c h m e n t fro m him self a n d feels like tim e has s lo w e d d o w n . W hile ta lk in g to you, th e re is a noise o u ts id e a n d th e p a tie n t a p p e a rs to fin d th e noise v e ry u n c o m fo rta b le a n d distressing, saying it is v e ry lou d. The so u n d seem s n o rm a l to th e e xa m in e r. 3. A p a tie n t tells yo u she has p a in in h er a b d o m e n a n d this is b e c a u s e y o u r c o n ­ s u lta n t has d o n e this to her. She also says p e o p le o n TV h a v e b e e n ta lk in g a b o u t her a n d she b e lie ve s this b e c a u s e she ke e p s h e a rin g h er n a m e b e in g m e n ­ tio n e d .

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1. F, K. Clang association: rh y m in g a n d p u n n in g usually a s s o c ia te d w ith a c u te m a n ia w ith p s y c h o tic fe a tu re s. Neologism: a n e w w o rd is c r e a te d th a t has no m e a n in g . 2. I, L Depersonalization: a fe e lin g o f d e ta c h m e n t fro m oneself, th e re m a y b e a n a s s o c ia te d s u b je c tiv e fe e lin g o f a lte ra tio n in tim e . Hyperacusis: sounds a re e x p e rie n c e d as m u c h lo u d e r or u n c o m fo rta b le th a n to th e n o rm a l listener. 3. C, E. Somatic passivity: delusions th a t a n e x te rn a l fo rc e is c o n tro llin g in te rn a l b o d ily sensations. Ideas of reference: d e lu sio n a l b e lie f - e x te rn a l cu e s a re a ttrib u te d to th e self, e g h e a rin g n a m e o n TV m e a n s p e o p le a re ta lk in g a b o u t them self.

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197. EMI psychopathology Options A. M itg e h e n B. M itm a c h e n C. W axy fle xib ility D. N eg a tivism

E. Posturing F. E ch o la lia G. E c h o p ra x ia H. S tupor

I. E x c ite m e n t J. C o m m a n d a u to m a tis m K. C a ta le p s y L. A m b ite n d e n c y

Instructions For e a c h o f th e c o n d itio n s d e s c rib e d b e lo w , c h o o s e th e m o st likely d e s c rip tio n s fro m th e list o f o ptio ns. E a ch o p tio n m a y b e used o n c e , m o re th a n o n c e or n o t a t all. 1. O n n e u ro lo g ic a l e x a m in a tio n , w h e n assessing to n e in th e arms, th e p a tie n t m o ve s his arm s excessively e v e n if th e e x a m in e r o n ly m o v e s th e p a tie n t's arm s a little. 2. A tte m p ts a t m o v in g th e p a tie n t's lim bs a re d iffic u lt as th e p a tie n t resists m o v e ­ m en t, a p p a re n tly invo lu n ta rily. 3. W h e n th e p a tie n t's a rm is m o v e d u p h e m a in ta in s his a rm in th e p o sitio n in w h ic h it w as p la c e d , e v e n th o u g h it is n o t in th e resting position . 4. The p a tie n t carries o u t e v e ry in stru ctio n re q u e s te d b y th e e x a m in e r irre s p e c tiv e o f th e c o n s e q u e n c e s .

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1. A. Mitgehen: excessive c o o p e ra tio n w ith passive m o v e m e n t. 2. D. Negativism: excessive resista nce to m o v e m e n t. 3. C. Waxy flexibility: p a tie n t's limbs c a n b e m o v e d in to a v a rie ty o f positions a n d m a in ta in e d th e re a fte r fo r unusually lo n g p e rio d s o f tim e

4. J. Command automatism: instructions a re p e rfo rm e d a c c o rd in g to instru ction w ith o u t c o n c e rn fo r th e c o n s e q u e n c e s .

Echopraxia - a u to m a tic im ita tio n o f a n o th e r p erson 's a ctio n s. Ambitendency - in a b ility to c o m p le te a n a c tio n w ith o u t c o n tin u o u s ly sta rtin g a n d s to p p in g .

Mitmachen - A n in d iv id u a l m o ve s th e ir limbs or b o d y in to a n y p o sition d e s p ite th e e x a m in e r asking th e m to resist m o v e m e n t. W h e n th e lim b(s) a re relea se d, th e y return to th e n o rm a l position. Stereotypy - sp o n ta n e o u s , re p e titiv e , n o n -g o a l-d ire c te d m o v e m e n ts , p u rp o s e fu l m o v e m e n ts .

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198. EMI - pharmacology Options A. C lo z a p in e

B. Lithium C. Q u e tia p in e D. S ertraline

E. A m isu lp irid e F. F lup en th ixo l G. Im ip ra m in e H. O la n z a p in e

I. C ita lo p ra m J. A m itrip ty lin e K. P a ro xe tin e L. R isperidone

Instructions For e a c h o f th e situations d e s c rib e d b e lo w , c h o o s e th e s u ita b le d ru g (s) fro m th e list o f optio ns. E ach o p tio n m a y b e used o n c e , m o re th a n o n c e or n o t a t all. 1. S e le ct th re e drugs m o st c o m m o n ly a s s o c ia te d w ith d e v e lo p in g g lu c o s e in to le r­ a n c e or d ia b e te s . 2. A y o u n g m a le p a tie n t c o m p la in s o f e x p e rie n c in g d e c re a s e d lib id o a n d e re c tile d y s fu n c tio n w h ile o n a n a n tis p y c h o tic . C h o o s e tw o a n tip s y c h o tic s th a t a re least likely to c a u s e sexual d y s fu n c tio n . 3. A 3 2 -ye a r-o ld p re g n a n t la d y is e x p e rie n c in g lo w m o o d o n m ost d a ys as w ell as lo w e n e rg y a n d a n h e d o n ia . She also has lo w self e s te e m a n d p o o r sle e p as w ell as fe e lin g s o f hopelessness a n d worthlessness. C h o o s e th e tw o a n tid e p re s s a n ts a b o v e w h ic h a re th e safest a n d m ost used d u rin g p re g n a n c y . 4. These a n tid e p re s s a n ts a re safest fo r b re a s tfe e d in g m others.

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1. A, B, H: a b o u t 1 in 3 p a tie n ts o n clozapine m a y d e v e lo p d ia b e te s a fte r 5 years o f tre a tm e n t. Lithium m a y c a u s e a re d u c e d urinary c o n c e n tra tin g c a p a c ity le a d in g to n e p h ro g e n ic d ia b e te s insipidus w h ic h is reversible in th e short te rm b u t m a y b e c o m e irreversible a fte r lo n g te rm tre a tm e n t (seve ra l years). Olanzapine is also strongly a s s o c ia te d w ith a risk o f d ia b e te s . 2. C, H: quetiapine has n o e ffe c t o n p ro la c tin . Olanzapine has m in im a l e ffe c ts on serum p ro la c tin .

3. G, J: imipramine a n d amitriptyline h a v e b e e n used a lth o u g h b o th c a n c a u s e c o n s tip a tio n a n d s e d a tio n . F luoxetine has also b e e n used b u t it is a s s o c ia te d w ith a n in c re a s e d c h a n c e o f e a rly d e liv e ry a n d lo w b irth w e ig h t. 4. D, K: paroxetine a n d sertraline.

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199. EMI - risk factors Options A. R e c e n t d o se in c re a s e or re d u c tio n B. O rg a n ic b ra in disease C. O ld a g e D. A lc o h o l d e p e n d e n c y

E. F e m a le g e n d e r F. M e n ta l re ta rd a tio n G. Low b o d y w e ig h t H. B ra d y c a rd ia I. Y oung a g e

J. A fro -C a rib b e a n origin K. Low w h ite c e ll c o u n t L. H y p o k a la e m ia M. H y p e rk a la e m ia

Instructions C h o o s e th e m ost likely risk fa c to rs fro m th e list o f o p tio n s fo r th e d e v e lo p m e n t o f th e c o n d itio n s d e s c rib e d b e lo w . E a ch o p tio n m a y b e used o n c e , m o re th a n o n c e or n o t a t all. 1. 2. 3. 4.

N e u ro le p tic m a lig n a n t s y n d ro m e - c h o o s e four. A n tid e p re s s a n t-in d u c e d h y p o n a tra e m ia - c h o o s e th re e . C lo z a p in e -in d u c e d n e u tro p e n ia - c h o o s e th re e . A n tip s y c h o tic -in d u c e d QTc p ro lo n g a tio n - c h o o s e th re e .

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1. A, B, D, F: neuroleptic malignant syndrome is a rare s id e -e ffe c t w h ic h m a y o c c u r w ith a n tip s y c h o tic use. It is a p o te n tia lly fa ta l c o n d itio n if le ft u n tre a te d a n d represents a m e d ic a l a n d p s y c h ia tric e m e rg e n c y . Signs a n d sym p to m s in c lu d e fever, rigidity, sw e a tin g , co n fu sio n , flu c tu a tin g leve l o f consciousness, flu c tu a tin g b lo o d pressure a n d ta c h y c a rd ia . B lood in ve stig a tio n s re v e a l raised c re a tin e kinase (CK), le u co cyto s is a n d a b n o rm a l liver fu n c tio n te st results. The c o n d itio n m ust b e tre a te d u rg e n tly o n th e m e d ic a l w a rd or A&E w ith re h y d ra tio n , s e d a tio n w ith b e n zo d ia ze p in e s, a n d b ro m o c rip tin e a n d d a n tro le n e m a y b e g iv e n . ECT c a n b e used to tre a t psychosis. Risk fa c to rs in c lu d e : recent rapid increase or reduction in dose; s u d d e n ly s to p p in g a n tic h o lin e rg ic m e d ic a tio n ; organic brain disease; psychosis; alcohol dependency; Parkinson's disease; h yp e rth yro id ism ; mental retardation; p s y c h o m o to r a g ita tio n . 2. C, E, G: see c a rd 96, 'H y p o n a tra e m ia in d u c e d b y a n tid e p re s s a n ts '.. 3. I, J, K: 2-3% o f p a tie n ts tre a te d w ith c lo z a p in e d e v e lo p n e u tro p e n ia . Risk fa c to rs in c lu d e younger age, Afro-Caribbean origin a n d low white cell count. 4. H, L, M: risk fa c to rs fo r QTc p ro lo n g a tio n in c lu d e fe m a le g e n d e r, lo n g QT syn drom e, history o f is c h a e m ic h e a rt d isease or v a s c u la r e v e n t (e g m y o c a rd ia l in fa rc tio n ), lo w p o ta s s iu m /c a lc iu m /m a g n e s iu m a n d p h y s ic a l stress.

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200. References A m e ric a n P sychiatric A s s o c ia tio n (1987) D ia g n o s tic a n d S tatistica l M a n u a l o f M e n ta l Disorders, 3rd e d itio n , revised. W a s h in g to n DC: A m e ric a n P sychiatric A sso ciatio n. N a tio n a l Institute fo r C lin ic a l E x c e lle n c e : C lin ic a l G u id e lin e s. L o n d o n : NICE. S a d o c k BJ, S a d o c k VA (2003) K a p la n & S a d o c k 's Synopsis o f Psychiatry: B e h a vio u ra l S c ie n c e s /C lin ic a l Psychiatry, 9th e d itio n . P h ila d e lp h ia : L ip p in c o tt/W illia m s & Wilkins. S e m ple D, Sm yth R, Burns J, D a rje e R, M cIn to sh A (2005) O x fo rd H a n d b o o k o f Psychiatry. O xfo rd: O x fo rd University Press. Taylor D, P a to n C, Kerwin R (2005-2006) The M a u d s le y Prescribing G u ide lin es, 8th e d itio n . L on do n: The South L o n d o n a n d M a u d s le y NHS Trust/O xleas NHS Trust/Taylor a n d Francis G ro u p . W orld H ea lth O rg a n iz a tio n (1992) The ICD-10 C la s s ific a tio n o f M e n ta l a n d B e h a vio u ra l Disorders: c lin ic a l d e s c rip tio n s a n d d ia g n o s tic g u id e lin e s. G e n e v a : W orld H ea lth O rg a n iz a tio n . W righ t P, Stern J, P helan M (2004) C o re Psychiatry, 2 n d e d itio n . A m s te rd a m : Elsevier.

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Taylor & Francis Taylor & Francis Group http://taylorandfrancis.com

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