Eating faeces = coprophagia

Copying others words = echolalia

Repeating one's own sounds = palilialia
Copying others actions = echopraxia

Palinopsia : This is a description of palinopsia which refers to a

persistence of an image even though the stimulus has gone. They tend to
suggest an organic pathology.

Synaesthesia In synaesthesia a sensation in one modality produces a

sensation in another modality. If is often described as a 'union of the
senses'. It occurs in 1% of people and is a harmless condition.

Teleopsia : This is a description of teleopsia in which objects appear to

be farther away than they actually are.

It's bad enough learning psychiatry in English, but it seems we're

expected to know german too!

Audible thoughts (Gedankenlautwerden) are a first rank symptom they

are also known as thought echo. They are different and not to be confused
with the term thought broadcasting which refers to the belief that others
can access ones thoughts.

Gegenhalten is a catatonic phenomenon in which the subject opposes all

passive movements with the same degree of force as applied by the
examiner.

Anwesenheit refers to the feeling of presence of something or some

person.

Entgleisen is an alternate term used for derailment of thought.

In mitmachen, the patient's body can be put into any posture, despite
instructions given that the patient resist.

Altered perceptual experiences

Disorders of perception are divided into:

 Sensory distortions (change in the intensity, spatial form, or quality)

  Sensory deceptions (a new perception)

Sensory distortions:

Change in intensity
Hyperaasthesia (increased intensity of sensations) can occur with intense
emotion.
Hyperacusis (increased intensity of noise) occurs with hangovers,
migraine, and anxiety.
Hypoacusis (decreased intensity of noise) is seen in delirium.

Change in quality:

Gustatory changes with lithium (metallic taste).

Derealisation.
Chromatopsia (visual aberration in which objects appear abnormally
coloured).
Pelopsia (vision perception disorder in which objects appear nearer than
they actually are).
Teleopsia (objects appear to be farther away than they actually are).

Changes in spatial form (change to perceived shape of an object):

Micropsia (object appears smaller).

Macropsia (object appears larger).

Dysmegalopsia (object appears larger on one side than the other) can
occur with parietal and temporal lobe lesions. Rarely it can be seen in
schizophrenia.

Metamorphosia (object appears irregular in shape).

Sensory deceptions

These include illusions and hallucinations.

Neologism refers to the formation of new words.

Paraphasia occurs when one word is substituted for another e.g. orange
instead of banana. Asyndesis refers to a loss of conceptual boundaries.
Paragramatism is the inability to form grammatically correct sentences. A
metonym is an established word that denotes one thing but refers to a
related thing, e.g. the word china can be used as the place or to refer to
the crockery.

Pseudohallucinations versus hallucinations

The following table illustrates the key differences between true

hallucinations and fantasy/ imagery (Sims, 2003). Pseudohallucinations
are thought to lie somewhere between the two on a spectrum.

True hallucination Fantasy/ imagery

Experience Concrete, real Subjective

Location Outer objective space Inner subjective space

Definition Definite outlines, complete Incomplete

sound

Vividness Full, fresh, bright Elements dim or neutral

Constancy Retained Evanescent (fades

quickly)

Independence Cannot be dismissed, or Requires voluntary

from volition changed at will creation

Insight No distinction made between Fantasy has quality of

perception and hallucination idea

Behavioural Relevant to emotions, needs, Not relevant

relevance actions

Sensory modality Could experience object in Could not experience

another modality object in another modality

Existence Object exists independent of Depends on observer for

observer existence
Pseudohallucinations are involuntary and vivid sensory experiences that
are recognised as unreal. They are said to occur in inner space (the
patient may say they hear voices in their head). They may be retained for
some time and cannot be deliberately evoked. They can occur in visual,
auditory and tactile modalities. The term non-psychotic hallucination is
often preferred to pseudohallucination.

Patients can experience a loss of control over their thoughts.

Passivity of thought describes the situation where a patient believes his

thoughts are being controlled by an external agency. Forms of passivity
include:-

Thought withdrawal

Thought insertion

Thought broadcasting

Thought disorder

Disorders of the form of thoughts (rather than content) are best observed
from the patient's speech. A lack of an adequate connection between two
consecutive thoughts is called asyndesis.

Thought disorder includes:-

 Disturbances in the flow of thoughts

 Over inclusive thinking

 Concrete and abstract thinking

 Disorders of control of thinking

Disorders of the flow of thoughts include:-

Changes in speed. Thoughts can be accelerated or slowed down

(retarded). Very rapid thinking is described as flight of ideas. In flight of
ideas the speech is usually (but not always) fast. There is no general
direction of thinking and the content of the speech makes as much sense
if read backwards as it does forwards. Successive thoughts appear to be
connected due to chance leading to clang associations, proverbs, maxims,
and clichés.

It is usually seen in mania but also occurs in schizophrenia and organic

states such as those involving lesions of the hypothalamus (hence it is not
pathognomic of mania).

Prolixity refers to a marginal variety of flight of ideas seen in hypomania

where clang and verbal associations are less frequent, there is a general
direction of thought and it is not as rapid.

Circumstantiality. Patients are unable to answer concisely. Instead they

must consider in detail any association that comes to mind. This is
generally seen in organic states and mental retardation. It can also occur
in obsessional personality.

Perseveration. This is the inability to shift from one theme to another.

Interruptions to the flow of thoughts. These include thought

block which is a sudden cessation in the flow of thoughts and loosening of
association, which refers to a deviation towards unrelated thoughts.
Loosening of association includes tangentiality, fusion, and derailment. In
tangentiality the thoughts shift to vaguely related themes whereas in
derailment there is no apparent connection between themes.

Crowding of thought This occurs in schizophrenia. Thoughts are

described as being passively concentrated and compressed in the
patient's head. The associations are experienced as being excessive in
amount, too fast, and outside the person's control.

ECG

You need a basic understanding of ECG's for the exams. Don't spend too
much time on this as it's a very complex area and you do not need a
detailed knowledge.
Rate

Normal rate is 60-100. Less than 60 is called bradycardia and more than
100 is called tachycardia.

PR interval

A normal PR interval is between 0.12 and 0.2 seconds. A PR interval

consistently longer than 0.2s is referred to as first degree heart block.

ST segment

An upsloping ST segment (referred to as ST elevation) is indicative of a

myocardial infarction. A depressed ST segment suggests myocardial
ischaemia.

QTc interval

The normal range for the QTc interval is 0.35-0.45 seconds.

T waves

Are peaked in hyperkalemia, flat and prolonged in hypokalemia, and

inverted in normal in some leads and also in ischemia and infarction.

U waves

Can be normal but also can be found in hypokalemia.

The following table illustrates some of the ECG changes associated with
psychotropic drugs:

ECG finding Associated medication

Tachycardia Clozapine
TCAs
MAOIs
Antiparkinsonian
Antipsychotics (generally the older
ones)

Bradycardia SSRIs
Lithium
ECG finding Associated medication

Cholinesterase inhibitors

Heart blocks TCAs

Repolarisation changes (ST segment & T Thioridazine

wave changes) Chlorpromazine

QTc prolongation Wide range of antipsychtiics and

antidepressants

Torsades/VF Haloperidol
Thioridazine
Mesoridazine
Chlorpromazine

DSM-IV versus ICD-10

The following table summarises the main differences between the DSM-IV
and the ICD-10

ICD-10 DSM-IV

International classification National classification

Several versions and languages Single version and language

Alphanumerical coding Numerical coding

10 major categories 17 major categories

Single axis Multiaxial

DSM-V

The DSM (The Diagnostic and Statistical Manual of Mental Disorders) is a

manual used to code for mental diseases. It is the American counterpart
to the ICD-10 (used in the UK). It was first published 1952. The last major
revision was the DSM-V in 2013.
The DSM-IV organised the diagnosis into five levels (axes) relating to
different aspects of the disorder.

 Axis I: clinical disorders, including major mental disorders, as well as

developmental and learning disorders

 Axis II: underlying pervasive or personality conditions, as well as

mental retardation

 Axis III: acute medical conditions and physical disorders

 Axis IV: psychosocial and environmental factors contributing to the

disorder

 Axis V: Global Assessment of Functioning or Children's Global

Assessment Scale for children and teens under the age of 18

The DSM-V abandoned use of the multiaxial diagnosis. The GAF scale was
also removed because of perceived lack of reliability and poor clinical
utility

The most notable change was with the diagnosis of autism. Autistic
disorder, Asperger's, and pervasive developmental disorder were
consolidated into one disorder, Autistic spectrum disorder.

Also of note is that binge eating disorder, premenstrual dysphoric

disorder, and hoarding disorder gained recognition as 'real' disorders.

Stats Clinical trials

Clinical trials are classified in the following way:-
Phase I

Phase I clinical trials involve only a small number of healthy people

(possibly as few as 15-20). The focus is to evaluate the drugs safety,
determine a safe dosage range, and identify side effects.
Phase II

In Phase II clinical trials the drug or treatment is given to a larger group of

people (100-300) to see if it is effective and to further evaluate its safety.

Phase III
In phase III trials the drug or treatment is given to large groups of people
(1,000-3,000) to confirm its effectiveness, monitor side effects, compare it
to commonly used treatments (or placebos), and collect information that
will allow the experimental drug or treatment to be used safely.

Phase IV
Phase IV trials (aka Post Marketing trials) are done after the drug has been
granted a license. They gather further information on the drug in areas
not addressed in the previous trials (e.g. Safety in pregnancy) and also to
find other potential uses for the drug.

Frontal lobe tests

Various aspects of frontal lobe functioning can be assessed by different

tests (see table)

Frontal lobe
function Test or examination

Initiation Verbal and categorical fluency

Abstraction Proverbs, similarities, cognitive estimates

Problem solving and Tower of London, Cambridge stockings, gambling tasks

decision making

Response inhibition Alternating sequences, go-no-go test, Luria motor test,

and set shifting trail making test, Wisconsin card sorting test, Stroop
test

Stroop test assess perseveration

Frontal Assessment Battery

The Frontal Assessment Battery (FAB) is a test designed to detect the

dysexecutive syndrome. It is a bedside test that can be completed in a
matter of minutes.

It consists of six subsets (as seen in the table below)

Subset Further info

Conceptualisation Abstract reasoning, how are an apple and a pear

Subset Further info

different and similar

Mental flexibility Verbal fluency, number of words beginning with letter

L in one minute

Motor programming Luria's motor series

Conflicting instructions 'Tap twice when I tap once, and once when I tap twice'

Go-No Go (inhibitory 'Tap once when I tap once and do not tap when I tap
control) twice'

Prehension behaviour Tell patient not to take your hands. Place their hands
palm up on their knee's and then touch them

Mental state exam (cognition)

The following table lists the standard tests used for each area of cognition.
Questions on this area are common.

Area of cognition Standard test

Orientation Asking the time, place, and person

Attention/ Serial 7's

concentration

Short term memory Digit span

Long term memory Delayed recall of name and address

Executive function Proverbs, similarities, differences, verbal fluency,

cognitive estimates

Cognitive tests used in psychiatry

The following cognitive tests are used in psychiatric practice and

commonly come up in the MRCPsych exams.
Area of cognition
tested Tests

Premorbid National Adult Reading Test (NART)

intelligence

Intelligence Wechsler Adult Intelligence scale (WAIS), Raven's

Progressive Matrices

Memory Rey-Osterrieth Complex Figure

Attention Stroop test, Wisconsin card sorting test, Tower of London,

Continuous Performance Tasks

Language Boston naming test, Animal fluency

Other Halstead-Reitan battery (for brain damage)

SF-36

The SF-36 (Short-form 36) is a 36-item, patient-reported survey that

measures patient-rated functioning and well-being.

The SF-36 is comprised of the following eight scales (four pertain to

physical health, and four to mental health):

 physical functioning

 role limitations due to physical health problems

 bodily pain

 general health

 vitality (energy/fatigue)

 social functioning
  role limitations due to emotional problems

 mental health (psychological distress and psychological well being).

The measure can be completed by the patient on their own and takes
approximately eight minutes to do.

CAGE

The CAGE questionnaire is a four item scale used to screen for

alcoholism.

The questions are as follows

 Have you ever thought about Cutting down your drinking

 Have people annoyed you by criticising your drinking

 Have you ever felt guilty about your drinking

 Have you ever had a drink first thing in the morning to get rid of a
hangover (an eye opener)

The CAGE is not diagnostic. The more positive answers given the more
likely someone has an alcohol problem. One positive answer is usually
seen as enough justification for taking a more thorough, detailed alcohol
history.

Hayling and Brixton tests

The Hayling and Brixton tests are designed to assess executive

function.

The Hayling Sentence Completion Test consists of two sets of 15

sentences each having the last word missing. In the first section the
examiner reads each sentence aloud and the participant has to simply
complete the sentences, yielding a simple measure of response initiation
speed.

The second part, the Hayling requires subjects to complete a sentence

with a nonsense ending word (and suppress a sensible one), giving
measures of response suppression ability and thinking time. It
provides a measure of basic task initiation speed as well as
performance on a response suppression task. Performance on such
tests has been repeatedly associated with frontal lobe dysfunction and
dysexecutive symptoms in everyday life.

The Brixton Test is a rule detection and rule following task.

Impairments on such tasks are commonly demonstrated in individuals
with dysexecutive problems.

Placebo effect

In general, a placebo is an inert substance that has no inherent

pharmacological activity. It looks, smells and tastes like the active drug
with which it is compared.

An active placebo is a drug which has its own inherent effects but none for
the condition that it is being given. An example of an active placebo is the
use of atropine as the control drug in trials of antidepressants.

A nocebo is a placebo that produces prominent side effects.

A placebo need not always be pharmacological. It could be procedural, for

example, sham electroconvulsive therapy (ECT), where the patient is
anaesthetised but not given ECT.

Treatments that are perceived as being more powerful tend to have a

stronger placebo effect than those that are perceived to be less so. Thus,
placebo injections have more effect than oral placebos, capsules are
perceived as being stronger than tablets, bright-coloured placebos are
more effective than light-coloured ones larger placebos have more effect
than smaller ones, and two placebos have more effect than one. Also, the
status of the treating professional is directly related to the placebo effect.
The same compound has been found to be more powerful if it is branded
than when it is unbranded.

Among psychiatric disorders, the placebo effect has been most

extensively studied in depression. Pattern analyses have shown that the
improvement as a result of placebo in depression tends to be abrupt,
occurs early in treatment and is less likely to persist, whereas
improvement in response to antidepressants tends to be gradual, occurs
later and is more likely to persist. Even among patients apparently
responding to the active drug, if the pattern of improvement is consistent
with a placebo response (i.e. abrupt and early), the improvement tends to
be short-lived.

Placebo sag refers to a situation where the placebo effect is

diminished (attenuated) with repeated use

The following facts about placebos in the Maudsley Guidelines (and

therefore are likely to come up in the exams!)

 Placebo is not the same as no care (patients who maintain contact

with services have a better outcome than those who receive no
care)

 The placebo response is greater in mild illness

 The higher the placebo response rate the more difficult it is to

power studies to show treatment effects

 It is difficult to separate placebo effects from spontaneous remission

 Patients who enter RCTs generally do so when acutely unwell.

Symptoms are likely to improve in the majority irrespective of the
intervention (so called 'regression to the mean')

 The placebo response rate in published studies is increasing over

time

 'Breaking the blind' may influence outcome. The resultant

'expectancy effect' may explain why active placebos are more
effective than inert placebos.

 Not all placebos are the same. Colour, route, branding all influence
the placebo effect

 Placebo effects can be both positive and negative

 Placebo response is usually short lived

Placebos are pharmacologically inactive

The placebo response rate is usually low for patients with mania,
schizophrenia, and psychotic depression

In cases of mild and moderate depression the placebo effect can be over
30%

Inert placebos can have adverse effects

Placebo induced analgesia can be blocked by naloxone (suggesting
placebo effects can be mediated by biological mechanisms)

Illusions

An illusion is an altered perception of a stimulus and differs from a

hallucination in that in hallucinations there is no stimulus.
There are three main types of illusion

 Completion illusions describe the tendency to fill in missing

information in order to make sense of a stimulus

 Affect illusions arise due to specific mood (affective) states e.g. a

woman is walking home in the dark and is frightened, she mistakes
a tree for a tall man in a long coat.

 Pareidolic illusions arise when detailed images are seen from

shapes. E.g. seeing the man in the moon, or Jesus Christ on a piece
of burnt toast.

Pareidolic illusions tend to occur when a person is concentrating whereas

affect and completion illusions occur during inattention.

Delusions (primary and secondary)

A primary delusion is one that arises spontaneously, from normal

psychological processes and not as a consequence of psychopathology.

A secondary delusion develops as a consequence of an abnormal

experience.

For instance, if a delusion arises following a patient's experience of

auditory hallucinations it is classed as secondary.

Types of primary delusion include:-

Delusional perception - A normal perception followed by a delusional
interpretation

Delusional memory - The recollection of an event or idea that is clearly

delusional in nature

Delusional mood - Delusion arising from a strange mood

Autochthonous delusion - A delusion that appears out of the blue

(spontaneously), i.e. not following a perception, memory or mood

Culture bound illness

Culture bound illness's are psychiatric conditions seen only in one specific
culture.

There are hundreds of them, below is a list of the conditions included in

the DSM IV manual and a short description of the ones that appear on the
MRCPsych exams.
DSM list

 Amok

 Shenjing shuairuo

 Ataque de nervios

 Bilis, colera

 Bouffee delirante

 Brain fag

 Dhat

 Falling-out, blacking out

 Ghost sickness

 Hwa-byung, wool-hwa-byung

 Koro

 Latah

 Locura

 Mal de ojo
  Nervios

 Rootwork

 Pibloktoq

 Qi-gong psychotic reaction

 Sangue dormido

 Shen-k'uei, shenkui

 Shin-byung

 Taijin kyofusho

 Spell

 Susto

 Zar

Culture bound illness is recognised by the ICD-10. It does not give codes
for the specific conditions but instead suggests alternative coding (e.g. For
Amok they suggest using code F68.8 Other specified disorder of adult
personality and behaviour).

Koro (Genital retraction syndrome)

Origins: China, Malaysia, Indonesia

Men affected with Koro are terrified that their penis is shrinking and that
eventually it will be absorbed into their body. People with Koro believe it is
fatal.

Latah

Origins: Malaysia and Indonesia

Latah usually affects middle aged women. A typical attack of latah lasts
30 minutes and is characterised by an outburst of screaming, hysterical
laughing and obscenities.

Brain fag, or brain fog

Origin: West Africa

Brain fag is seen in stressed out West African students and is thought to
be a response to a western style of education and exams. Symptoms
include poor concentration, and unusual somatic sensations such as
burning skin.

Amok

Origin: Malaysia

People who suffer with Amok are suddenly overcome with a violent
outburst and become very aggressive to those around them. This
continues until they are overpowered at which point they fall into a deep
sleep and upon waking have no recall of the event. It almost always
affects males.

Dhat /Shenkui/Jiryan

Origin: India

Men affected with Dhat believe they are passing semen in their urine
which leads to a loss of physical and mental energy.

Windigo

Origin: Native North America

Windigo presents as an intense desire for human flesh and a strong

believe that one is turning into a cannibal.

Piblokto

Origin: Eskimo societies

Piblokto is seen in Eskimo's. Affected Eskimo's develop hysteria and

behave oddly for instance by rolling around in snow naked while
muttering to themselves.

Ataque de nervios ('attack of nerves') is a culturally defined Latino

syndrome usually triggered by acute stress and typically characterised by
paroxysms of uncontrollable shouting and crying, trembling, palpitations,
and aggressiveness.
Susto

is a cultural illness primarily among Latin American cultures. It is

described by Razzouk et al. as a condition of being frightened and
"chronic somatic suffering stemming from emotional trauma or from
witnessing traumatic experiences lived by others".

Among the indigenous peoples of Latin America, in which this illness is

most common, susto may be conceptualized as a case of spirit attack.
Symptoms of susto are thought to include nervousness, anorexia,
insomnia, listlessness, fever, depression, and diarrhoea

Nevra is usually described as a feeling of loss of control, of having one's

nerves 'burst out' or 'break out' or 'boil over.' An attack is often
accompanied by shouting or screaming and throwing things. Headaches,
dizziness, pain, and feelings of melancholy are associated with nevra.

(A Greek woman tells you how when her children are behaving badly she
sometimes begins to scream, throw things round the house, and develops
a headache.)

Mental state exam (appearance)

People with hypomania and mania often manifest their illness in their
appearance. They tend to wear loud and colourful clothes, and often have
bizarre or garish make-up.
Unfashionable and clashing clothing is more suggestive of schizoid
personality traits and autistic spectrum disorders.

An excessively neat appearance would suggest an obsessional

personality. Whereas signs of self neglect such as dishevelled hair and
poor dental hygiene are associated with depression and chronic
schizophrenia.

Mental state exam (mood and affect)

A feeling is an active experience of somatic sensation (such as touch, or

heat) or a passive subjective experience of an emotion. An emotion is best
thought of as a feeling and memory intertwined. A feeling is usually used
to describe a reaction (positive or negative) towards an
experience. Affect is used to describe a patient's present emotional
responsiveness (indicated by facial expression and tone of voice). Mood is
a more prolonged prevailing state or disposition. Mood and affect are
usually distinguished by duration where affect is momentary and mood is
more prolonged. Apathy is the absence of feeling.

Affect

Affect can be described as (in order of degree):

 Within normal range

 Constricted (affect restricted in range and intensity)

 Blunted (same as constricted but a bit more so)

 Flat (virtually no signs of affective expression)

Mental state exam (speech)

Stilted speech has an excessively formal quality. It may seem outdated,

pompous, or over polite.

Over inclusion describes the inability to maintain the boundaries of a

thought when trying to convey a specific idea.

Pressured speech (also known as tachyphasia) describes speech that is

abnormally fast, with few pauses and difficult to interrupt.
Self-referential speech repeatedly refers neutral topics under discussion
back to the speaker himself.

Alexithymia

Alexithymia refers to a deficiency in understanding, processing, or

describing emotions.

Alexithymia is defined by the following:

 A difficulty identifying feelings and distinguishing between feelings

and the bodily sensations of emotional arousal

 A difficulty describing feelings to other people

 Constricted imaginal processes, as evidenced by a scarcity of

fantasies

 A stimulus-bound, externally oriented cognitive style

Thought disorder

Disorders of the form of thoughts (rather than content) are best observed
from the patient's speech. A lack of an adequate connection between two
consecutive thoughts is called asyndesis.
Thought disorder includes:-

 Disturbances in the flow of thoughts

 Over inclusive thinking

 Concrete and abstract thinking

 Disorders of control of thinking

Disorders of the flow of thoughts include:-

Changes in speed. Thoughts can be accelerated or slowed down

(retarded). Very rapid thinking is described as flight of ideas. In flight of
ideas the speech is usually (but not always) fast. There is no general
direction of thinking and the content of the speech makes as much sense
if read backwards as it does forwards. Successive thoughts appear to be
connected due to chance leading to clang associations, proverbs, maxims,
and clichés.
It is usually seen in mania but also occurs in schizophrenia and organic
states such as those involving lesions of the hypothalamus (hence it is not
pathognomic of mania).

Prolixity refers to a marginal variety of flight of ideas seen in hypomania

where clang and verbal associations are less frequent, there is a general
direction of thought and it is not as rapid.

Circumstantiality. Patients are unable to answer concisely. Instead they

must consider in detail any association that comes to mind. This is
generally seen in organic states and mental retardation. It can also occur
in obsessional personality.

Perseveration. This is the inability to shift from one theme to another.

Interruptions to the flow of thoughts. These include thought

block which is a sudden cessation in the flow of thoughts and loosening of
association, which refers to a deviation towards unrelated thoughts.
Loosening of association includes tangentiality, fusion, and derailment. In
tangentiality the thoughts shift to vaguely related themes whereas in
derailment there is no apparent connection between themes.

Crowding of thought This occurs in schizophrenia. Thoughts are

described as being passively concentrated and compressed in the
patient's head. The associations are experienced as being excessive in
amount, too fast, and outside the person's control.

Hallucinations (types)

A hallucination is a perception in the absence of a stimulus.

Types of hallucination include:-

Auditory - These can be first person (aka gedankenlautwerdenor echo de

la pense) where a patient hears their own thoughts, second person where
a patient hears a voice talk directly to them, or third person where a
patient hears voice having a discussion.

Visual - These are more common in organic condition such as temporal

lobe epilepsy and drug intoxication.

Gustatory - These refer to hallucinations of taste

Olfactory - These refer to hallucinations of smell

Tactile (haptic) - There refer to false perceptions of touch

Functional hallucinations - A patient experiences an hallucination at

the same time as receiving a real stimulus in the same sensory modality

Extracampine hallucination - These are hallucinations beyond the

possible sensory field

Reflex hallucinations - These occur in one sensory modality in response

to a real stimulus in another sensory modality

Hypnopompic hallucinations - These occur as a patient is waking from

sleep (these are normal experiences)

Hypnagogic hallucinations - These occur as a patient is going to sleep

(these are normal experiences)

Lilliputian hallucinations - These are visual hallucinations whereby the

patient experiences seeing people who appear reduced in size or dwarfed

Kinaesthetic hallucinations - These relate to hallucinations of muscle

or joint sense. Patient's may describe that their limbs are being twisted or
bent, or their muscles squeezed. They may also described being rocked
about

Autoscopic hallucinations - This refers to a person's experience of

seeing a double of themselves in extrapersonal space without the
experience of leaving ones body (no disembodiment).

A man reports that whenever he is walking on the street he hears

voices immediately after hearing the exhaust of a car. What
abnormal experience is he describing……….functional
hallucination
 Paramnesia

The term paramnesia was coined by Emil Kraepelin to describe qualitative

disorders in memory where fantasy and reality are confused.

The following table lists the various paramnesias.

Paramnesia Description

Déjà vu The experience of feeling that one has witnessed or

experienced a new situation before

Jamais vu The experience of being unfamiliar with a person or situation

that is actually very familiar

Confabulation The unconscious filling in of gaps in the memory by events

which never took place

Reduplicative The delusion that a place has been duplicated. It comes in

paramnesia three forms (Politis, 2012):

 Place reduplication - the belief that two places with

identical features exist simultaneously, but are
geographically distant

 Chimeric assimilation - the belief that two places

become combined, for example, a patient in hospital
believes that they are in their own home which has
somehow transformed into the hospital

 Extravagant spatial localisation - belief that their

current location is actually somewhere else, usually a
location familiar to them

Retrospective The process of distorting a memory

falsification

Cryptomnesia This is characterised by having a thought without realising

you have had the thought before (for example, some
plagiarists claim they are unaware that they were recounting
other peoples work)
A note on terminology:
The subjective belief that a place has been duplicated, existing in at least
two locations simultaneously, is termed reduplicative paramnesia.

Reduplicative paramnesia is a subset of the delusional misidentification

syndromes (DMS) which include (Carolina, 2014):

 Capgras delusion

 The Fregoli delusion

 Intermetamorphosis

 Subjective doubles

 Reduplicative paramnesia

 Mirrored self

 Delusional companions

 Clonal pluralisation of the self

Visual hallucinations

Visual hallucinations are seen in the following conditions:-

 Schizophrenia

 Migraine

 Charles Bonnet syndrome

 Lewy body dementia

 Narcolepsy-cataplexy syndrome

 Peduncular hallucinosis

 Treated idiopathic Parkinson's disease

 Hallucinogen-induced states

 Epilepsy
 Delusional misidentification syndrome

Delusional misidentification syndrome is a term used for a group of

disorders which are characterised by a belief that the identity of a person,
object or place has somehow changed or has been altered.

The following subtypes are recognised (Carolina, 2014):

Syndrome Description

Capgras syndrome Capgras syndrome occurs where a patient believes that

a person to whom they are close has been replaced by
an exact double

Fregoli syndrome In Fregoli syndrome the patient believes that various

people whom they meet are really the same person in
disguise

Intermetamorphosis In intermetamorphosis that patient believes that people

have swapped identities whilst maintaining the same
appearance. For example believing your brother to be
your father

Subjective doubles In subjective doubles the patient believes that they

have a doppelganger

Reduplicative The delusion that a place has been duplicated. It comes

paramnesia in three forms (Politis, 2012):

Place reduplication - the belief that two places with

identical features exist simultaneously, but are
geographically distant
Chimeric assimilation - the belief that two places
become combined, for example, a patient in hospital
believes that they are in their own home which has
somehow transformed into the hospital
Extravagant spatial localisation - belief that their
current location is actually somewhere else, usually a
location familiar to them.

Mirrored-self misidentification involves the

Syndrome Description

Mirrored self misperception that ones reflection in the mirror is a

stranger

Delusional Individuals affected with the syndrome of delusional

companions companions believe nonliving objects possess
consciousness, can think independently, and feel
emotion

Clonal pluralisation Clonal pluralization of the self differs from the syndrome
of the self of subjective doubles, in that the patient believes that
there are multiple copies of himself who are physically
and psychologically similar to themselves

Carolina (2014) The Masks of Identities: Whos Who? Delusional

Misidentification Syndromes. J Am Acad Psychiatry Law 42:369-78, 2014.

Politis (2012) Reduplicative Paramnesia: A Review. Psychopathology

2012;45:337-343.

Delusional (structure)

Delusions can be either logical (consistent with logical thinking) or

paralogical (not consistent). They can also be described as organised
(integrated into a formed concept) or unorganised.

Highly organised, logical delusions are referred to as systematised.

One can also describe the delusional beliefs' relationship with reality in
the following ways:-

 Polarised - the delusion and fact are mingled together

 Juxtaposed - the delusion and fact exist together but sit side by
side and do not interact

 Autistic - actual reality is not taken into account and the patient
lives in a delusional world

Depersonalization

Depersonalization describes a subjective state as if one is unreal (not in a

psychotic sense). It is generally felt to be both strange and unpleasant.
Features of depersonalization include:-

 Emotional numbness

 Changes in sensory experience

 Distorted sense of time

 Heightened self observation

Which of the following is the most commonly seen in patients

with schizophrenia?....lack of Insight

Insight

This question occasionally comes up in the exams. It is a poor question as

the evidence does not support any one answer. Evidence aside though,
the college seems to have decided that the correct answer is loss of
insight.

Catatonia

Karl Ludwig Kahlbaum (1828-1899) is credited with the original clinical

description of catatonia.

Catatonia is the psychiatric syndrome of disturbed motor functions amid

disturbances in mood and thought. Exam questions on this topic are
common. Most questions in the paper one exam relate to definitions of the
behaviors associated with catatonia.

Stupor - combination of immobility and mutism

Posturing - maintaining the same posture for long periods. A classic

example is the 'crucifix'. An extreme version of posturing is catalepsy.

Waxy flexibility (cerea flexibilitas) - patient can be positioned in

uncomfortable postures, which are maintained for a considerable period of
time.
Negativism (Gegenhalten) - patient resists the attempts of the examiner
to move parts of their body and, according to the original definition, the
resistance offered is exactly equal to the strength applied

Automatic obedience - exaggerated cooperation, automatically obeying

every instruction of the examiner.

Mitmachen - a form of automatic obedience whereby the body of the

patient can be put into any posture, even if the patient is given
instructions to resist. The body part immediately returns to the original
position once the force is removed (unlike in waxy flexibility)

Mitgehen - an extreme form of mitmachen in which the examiner is able

to move the patient's body with the slightest touch (anglepoise lamp
sign).

Ambitendency - The patient alternates between resistance to and

cooperation with the examiner's instructions; for example, when asked to
shake hands, the patient repeatedly extends and withdraws the hand

Psychological pillow - The patient assumes a reclining posture, with

their head a few inches above the bed surface, and is able to maintain this
position for prolonged periods

Forced grasping - The patient forcibly and repeatedly grasps the

examiner's hand when offered

Obstruction - The patient stops suddenly in the course of a movement

and is generally unable to give a reason. This appears to be the motor
counterpart of thought block

Echopraxia - The patient imitates the actions of the interviewer

Aversion - The patient turns away from the examiner when addressed

Mannerisms - These are repetitive, goal-directed movements (e.g.

Saluting)

Stereotypies - These are repetitive, regular movements that are not

goal-directed (e.g. Rocking)

Motor perseveration - The patient persists with a particular movement

that has lost its initial relevance

Echolalia - repetition of the examiners words

Logorrhoea - incoherent talkativeness

Verbigeration - Meaningless, repetition of words or phrases

 Gedankenlautwerden - thought echo

 Gegenhalten - a phenomenon in which a patient opposes all

passive movements with the same degree of force as applied by the
examiner

 Schnauzkrampf - a grimace resembling pouting sometimes

observed in catatonic patients

 Vorbeigehen/ vorbeireden - Seen in Ganser syndrome. Patient's

who exhibit this give approximate answers to questions (e.g. How
many fingers does a man have, answer 14).

 Verstimmung - describes a mood state that is ill-humoured and

disgruntled. It is a general term to describe something that is out of
tune such as a piano.

 Witzelsücht - is a tendency to tell inappropriate joke and creating

excessive facetiousness and inappropriate or pointless humour. It is
seen in Frontal lobe disorders.

wahnstimmung?.....delusional mood

Prosody

Prosody is defined as 'the emotional tone of language'. It is the melodious

quality, the inflections in the voice that reveal the emotional aspects of
speech. Prosody is affected by a variety of psychiatric and
neuropsychiatric illnesses.

Aprosodias are typically caused by dysfunction in areas of the non-

dominant hemisphere (in 95% of people this is the right).

Aprosodias are disorders in the ability to express (executive aprosody) or

understand (receptive aprosody) the emotional overlay of speech.
Aprosodias can be acquired via specific brain lesions.
Executive prosody can be tested by asking the patient to repeat a neutral
sentence with different emotions (anger, fear, sadness). It is affected by
lesions of the right premotor cortex or the basal ganglia.

Receptive prosody can be tested by the examiner repeating a neutral

sentence with different emotions and asking the patient which emotion is
being conveyed. It is affected by lesions of the posterior superior right
temporal lobe.

Prosody is affected by many psychiatric illnesses, therefore abnormalities

of prosody are not symptomatic of a particular disorder. Patients with
severe depression, schizophrenia and those with pervasive developmental
disorders often present with characteristic abnormalities of prosody. The
severely depressed patient may have a monotonous, affect neutral
pattern of speech which is virtually devoid of emotional content. Patients
with schizophrenia may present with abnormal modulation of emphasis
and volume or unusual accents. Some patients with pervasive
developmental disorders - in particular autism and Asperger's disorder
have characteristic speech patterns which are monotonous, robotic, or
singsong in quality.

Obsession and compulsions

Obsession

An obsession is any thought, image, or idea that has the following

features and is present for a minimum of 2 weeks (ICD-10)

 They are acknowledged as arising from within the mind (i.e. they
are not psychotic beliefs that others have implanted the thoughts)

 They are repetitive and unpleasant

 The patient must try to resist the obsession

 Experiencing the obsession must not be pleasurable

Compulsion

These are physical or mental repetitive behaviours that are used to

relieve some of the anxiety caused by the obsessions. The person is also
aware that their actions are not realistically connected to what they are
trying to neutralize or prevent and know they are excessive.

Movement disorders
Movement disorders in psychiatry

The following definitions need to be learnt.

Akinesia - absence, poverty, or loss of control of voluntary muscle

movements. This is seen in severe Parkinson's disease.

Bradykinesia - slowness of movement, core symptom in Parkinson's

disease along with tremor and rigidity.

Akathesia - subjective feeling of inner restlessness, most often caused by

side effect of neuroleptic medication, often manifests as inability to sit
still.

Athetosis - continuous stream of slow, flowing, writhing involuntary

movements.

Chorea - brief, quasi-purposeful, irregular contractions that are not

repetitive or rhythmic, but appear to flow from one muscle to the next.

Dystonia - sustained muscle contractions cause twisting and repetitive

movements or abnormal postures.

Dyskinesia - general term referring to problems with voluntary

movements and the presence of involuntary movements.

Myoclonus - Sudden involuntary jerks of a muscle or a muscle group.

These are not suppressible.

Parkinsonism - syndrome characterized by tremor, rigidity, and

bradykinesia.

Tic - sudden, repetitive, non rhythmic, stereotyped motor movement or

vocalization involving discrete muscle groups. These are different to
myoclonus as they are suppressible.

Tremor - involuntary, rhythmic, alternating movement of one or more

body parts.

Hemiballismus - repetitive, but constantly varying, large amplitude

involuntary movements of the proximal parts of the limbs
Scales and assessment tools

Questions often arise which require candidates to know a bit about the
various questionnaires and interviews that are used in psychiatry.

The college is keen on asking if certain assessment tools are self-rated or

require clinical assistance. See table.

Self rated Clinician rated

BDI (Beck depression inventory) BPRS (Brief psychiatric rating scale)

GHQ (General health MADRS (Montgomery-Asberg depression

questionnaire) rating scale)

GDS (geriatric depression scale) HAMD (Hamilton depression rating scale)

ZSRDS (Zung self rated depression HAMA (Hamilton anxiety rating scale)
scale)
Self rated Clinician rated

HAD (Hospital Anxiety depression PANSS (Positive and negative syndrome

scale) scale)

EPDS (Edinburgh postnatal major CGI (Clinical global impression)

depression scale)

AIMS (Abnormal involuntary movement

scale)

Y-BOCS (Yale-Brown Obsessive compulsive

scale)

YMRS (Young mania rating scale)

GAF (Global assessment of functioning)

SAS (Simpson-Angus scale)

CAMDEX (Cambridge Mental Disorders of

the Elderly Examination)

Cornell Scale for Depression in Dementia

Brief Assessment Schedule Depression

Cards (BASDEC)

The GMSS (Geriatric Mental State Schedule) is used to screen for

depression in the elderly.

Candidates need to have a working knowledge of the most

frequently used scales.

Condition Scales used

Depression HAMD, MADRS, GDS, ZSRDS, BDI

Mania YMRS

Anxiety HAMA
Condition Scales used

OCD Y-BOCS

Schizophrenia BPRS, PANSS

General scales GAF, CGI

Medication side effects SAS, AIMS, LUNSERS

HAMD (Hamilton depression rating scale)

The HAMD is a multiple choice questionnaire used to rate the severity of
depression. Depending on the version used there are either 17 or 21
items. Each item is scored out of between 3 and 5 points. The greater the
total points scored the more severe the depression is. For the 17 item
version (the most commonly used) scores range between 0 and 54.
Scores over 24 indicate a severe depression.

MADRS (Montgomery-Asberg depression rating scale)

The MADRS is a ten-item diagnostic questionnaire used to measure the
severity of depressive episodes. It was designed to be more sensitive to
the changes brought on by antidepressants and other forms of treatment.

ZSRDS (Zung self rated depression scale)

The ZSRDS was devised to assess the severity of depression. There are 20
items on the scale, each one scored out of 1-4.

BDI (Beck depression inventory)

The BDI is another scale designed to assess the severity of depression.
There are a total of 21 items, each is score out of 0-3. The scale was
revised in 1966. 0-13 indicates minimal depression, 14-19 mild
depression, 20-28 moderate, and 29-63 severe depression.

Beck's depression inventory:-

 Has 21 questions (max score of 63)

 Each question scored from 0-3

 Assesses severity of depression

 Self rated

 Covers period of two weeks before the evaluation

GDS (geriatric depression scale)
The GDS is a 30 item self-report scale used to screen for depression in the
elderly. Each question has either a yes or no response make the total
score out of 30. 0-9 is deemed normal, 10-19 is mild depression, and 20-
30 is severe depression.

BASDEC (Brief Assessment Schedule Depression Cards)

The BASDEC is a screening test for depression. It uses a deck of cards with
statements such as 'I've lost interest in things' which are shown to the
patient. In response to each card, the patient indicates whether the card
is true or false by pointing to another card. There are 19 cards with a
maximum score of 21 (two cards carry 2 points each). It is a quick test
and takes less than 5 minutes to administer. A cut off score of 7 is
generally used.

The test was developed for use on busy wards to introduce a degree of
privacy as other tests involve questions being read out and someone in
the next cubicle hearing everything.

Cornell Scale for Depression in Dementia

This test was developed specifically to screen for depression in dementia
cases. It involves a 20 min interview with a carer and 10 mins with the
patient.

A total of 19 items are rated as either 'absent', 'mild / intermittent', or

'severe'.

YMRS (Young mania rating scale)

The YMRS is an 11-item instrument used to assess the severity of mania in
patients with a diagnosis of bipolar disorder.

HAMA (Hamilton anxiety rating scale)

HAMA is a 14 item scale designed to measure the severity of anxiety.

Y-BOCS (Yale-Brown Obsessive compulsive scale)

The Y-BOCS is used to measure both the severity of OCD and the response
to treatment.

BPRS (Brief psychiatric rating scale)

This is probably the most widely used scale in psychiatry. This looks at
both psychotic and affective symptoms.
PANSS (Positive and negative syndrome scale)
The PANSS looks at both positive and negative symptoms in
schizophrenia. It takes a wide sample of information, including data from
and interview, along with reports from hospital staff and family. The
information gathered is based on how the patient was in the previous
week.

GAF (Global assessment of functioning)

The GAF is used as part of axis V of the DSM-IV. It provides a single
measure of global functioning. It enquires about psychological and
occupational functioning only. The total score is out of 100. A score of 100
is the best that can be achieved and indicates that a patient functions at
the highest level possible.

CGI (Clinical global impression)

The CGI is a scale that requires the clinician to rate the severity of the
patient's illness at the time of assessment, relative to the clinician's past
experience with patients who have the same diagnosis.

DESS (Discontinuation-Emergent Signs and Symptoms scale)

The DESS is used to quantify discontination symptoms associated with
stopping antidepressants. This 43-item rating scale spans a broad
spectrum of discontinuation symptoms and can be helpful in documenting
symptoms of depressed patients in order to diagnose the likely cause of
distress.

Caseness…… The GHQ is a recognised tool for identifying

'caseness'.

When a psychological rating scale is used for screening an operational

definition of 'caseness' (the threshold for identifying a case) must be
specified. The 'caseness' usually refers to a numerical value (cutoff) above
which a respondent/ participant is considered to be a 'positive' (case).

LUNSERS

The LUNSERS (Liverpool University Neuroleptic Side Effect Rating Scale)

is a 51 item self-administered rating scale used to identify side effects
from neuroleptic medication (antipsychotics).

It includes 41 known side effects of neuroleptics, and ten red herring

items, including hair loss and chilblains, which are not known side effects
of neuroleptic medication.
Validity and reliability have been tested in a group of 50 male and female
patients with a mean age of 46 years and 16 years of antipsychotic use,
along with a group of 50 healthy controls, with promising results. The
validity of the LUNSERS has also been tested against the UKU (the gold
standard which takes about 60 minutes to do).

Depression screening and assessment

Screening

The following two questions can be used to screen for depression

'During the last month, have you often been bothered by feeling down,
depressed or hopeless?'
'During the last month, have you often been bothered by having little
interest or pleasure in doing things?'

A 'yes' answer to either of the above should prompt a more in depth

assessment.

Assessment

There are many tools to assess the degree of depression including the
Hospital Anxiety and Depression (HAD) scale and the Patient Health
Questionnaire (PHQ-9).

Hospital Anxiety and Depression (HAD) scale

consists of 14 questions, 7 for anxiety and 7 for depression

each item is scored from 0-3
produces a score out of 21 for both anxiety and depression
severity: 0-7 normal, 8-10 borderline, 11+ case
patients should be encouraged to answer the questions quickly
Patient Health Questionnaire (PHQ-9)

asks patients 'over the last 2 weeks, how often have you been bothered
by any of the following problems?'
9 items which can then be scored 0-3
includes items asking about thoughts of self-harm
depression severity: 0-4 none, 5-9 mild, 10-14 moderate, 15-19
moderately severe, 20-27 severe

NICE use the DSM-IV criteria to grade depression

1. Depressed mood most of the day, nearly every day

2. Markedly diminished interest or pleasure in all, or almost all, activities
most of the day, nearly every day
3. Significant weight loss or weight gain when not dieting or decrease or
increase in appetite nearly every day
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt nearly
every day
8. Diminished ability to think or concentrate, or indecisiveness nearly
every day
9. Recurrent thoughts of death, recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for committing suicide

Subthreshold
depressive
symptoms Fewer than 5 symptoms

Mild depression Few, if any, symptoms in excess of the 5 required to

make the diagnosis, and symptoms result in only minor
functional impairment

Moderate depression Symptoms or functional impairment are between 'mild'

and 'severe'

Severe depression Most symptoms, and the symptoms markedly interfere

with functioning. Can occur with or without psychotic
symptoms
Addenbrooke's cognitive exam (ACE-R)

The Addenbrooke's cognitive exam was developed following the

recognition of limitations of the MMSE such as:-

 Lack of sensitivity for frontal-executive dysfunction

 Lack of sensitivity for visuospatial defects

The exam takes about 15 minutes to do and is divided into five domains
(as seen in table below)

Domain Points

Attention and orientation 18

Memory 26

Verbal fluency 14

Language 26

Visuospatial 16

Total 100

Interpretation

The Addenbrooke's has been shown to be a valid tool for detecting

dementia. Two cut off points are often used depending on the required
sensitivity and specificity.

Cut Sensitivity for detecting Specificity for detecting

off dementia dementia

88 94% 89%

82 84% 100%

It has also been shown to be useful in differentiating dementia from

pseudo dementia and for detecting cognitive impairment in atypical
Parkinson syndromes.

Verbal fluency is a test of the frontal lobe and is therefore not

assessed in the MMSE. It is assessed using the ACE-R.

Mini Mental State Exam

Developed in 1975 (Folstein et al), the MMSE was originally designed to

differentiate between organic and functional disorders. Its main use now is
to detect and track the progression of cognitive impairment.

It is scored out of 30 and is divided into the following seven categories.

Possible
Catergory points Description

Orientation to 5 Ward
place Hospital
Town
County
Country

Orientation to time 5 Time

Date
Day
Month
Year

Registration 3 Examiner names 3 objects (eg apple, table,

penny)
Patient asked to repeat (1 point for each
correct)
Then patient to learn the 3 names repeating
until correct

Attention and 5 Subtract 7 from 100, then repeat from result.

concentration Continue 5 times: 100 93 86 79 65
Alternative: spell 'WORLD' backwards - dlrow

Recall 3 Ask for names of 3 objects learned earlier

Language 8 Name a pencil and watch

Repeat 'No ifs, ands, or buts'
 Possible
Catergory points Description

Give a 3 stage command. Score 1 for each

stage.
Eg. 'Place index finger of right hand on your
nose and then on your left ear'
Ask patient to read and obey a written
command on a piece of paper stating 'Close
your eyes'
Ask the patient to write a sentence. Score if it
is sensible and has a subject and a verb

Visual construction 1 Ask the patient to copy a pair of intersecting

pentagons

Any score equal or greater than 27 indicates normal cognition. Below this,
scores can indicate severe (<9 points), moderate (10-18 points) or mild
(19-24 points) cognitive impairment.

Asking the name of the current prime minister is question

included on the abbreviated mental test score (AMTS).

Brief Psychiatric Rating Scale

The Brief Psychiatric Rating Scale is a common instrument used to

evaluate psychopathology in patients with schizophrenia, it has now been
largely replaced by the PANSS.

It is rated by a clinician and consists of 24 items, each rated out of a 7

point scale of severity. Higher score indicate greater severity of
symptoms.

Ratings for several of the variables are based on observation, the

remainder are assessed via a short interview.

EPDS

The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item self-report

questionnaire. It was designed to allow screening of postnatal depression
in the primary care setting (and therefore cannot be used to
diagnose depression). As a screening instrument, the EPDS should only
be used to assess a womans mood over the past seven days.
It excludes some symptoms that are common in the perinatal period
(tiredness and irritability) that other depression instruments include, as
such symptoms do not differentiate between depressed and
nondepressed postnatal women.

Women are asked to select one of 4 responses that most closely

represents how they have felt over the past seven days. Each response
has a value of between 0 and 3 and scores for the 10 items are added
together.

Statements include:

 I have been able to laugh and see the funny side of things

 I have been so unhappy that I have had difficulty sleeping

 I have looked forward with enjoyment to things

 I have felt sad or miserable

 I have blamed myself unnecessarily when things went wrong

 I have been so unhappy that I have been crying

 I have been anxious or worried for no good reason

 Things have been getting on top of me

 I have felt scared or panicky for no very good reason

 The thought of harming myself has occurred to me

Scoring

Score Interpretation

0-9 The likelihood of depression is considered low

10-12 The likelihood of depression is considered moderate

13 or more The likelihood of depression can be considered high

Global assessment of function scale

The Global Assessment of Functioning Scale is a 100-point scale that
measures a patients overall level of psychological, social, and
occupational functioning. It is designed to be completed in under 3
minutes and is recorded under axis V of the DSM. A higher score
corresponds to a higher level of functioning.

Glasgow Coma Scale

The Glasgow Coma Scale was designed to quantify the depth of coma and
impaired consciousness. It is an important scale to beware of as a
psychiatrist as we are frequently expected to assess patients with altered
levels of consciousness.

For each area the patients best response is matched to the criteria for
scoring. These score are then combined to give a final result out of 15.

Scores range from 3 (deep coma) to 15 (normal). Impaired consciousness

is rated as mild (13-15), moderate (9-12), and severe (3-8).

Scoring Guide

Assessed
Behaviour Criteria for scoring

Eye opening response 4 Spontaneous opening

3 Opens to verbal stimuli

2 Opens to pain

1 No response

Verbal response 5 Orientated

4 Confused conversation

3 Inappropriate words

2 Incoherent

1 No response

Motor response 6 Obeys commands

5 Purposeful movement to painful stimuli

Assessed
Behaviour Criteria for scoring

4 Withdraws in response to pain

3 Flexion in response to pain (decorticate posturing)

2 Extension in response to pain (decerebrate posturing)

1 No response

SF-36

The SF-36 (Short-form 36) is a 36-item, patient-reported survey that

measures patient-rated functioning and well-being.

The SF-36 is comprised of the following eight scales (four pertain to

physical health, and four to mental health):

 physical functioning

 role limitations due to physical health problems

 bodily pain

 general health

 vitality (energy/fatigue)

 social functioning

 role limitations due to emotional problems

 mental health (psychological distress and psychological well being).

The measure can be completed by the patient on their own and takes
approximately eight minutes to do.

A number of different tools have been devised to assist in the

screening and diagnosis of personality disorder.
You should have a basic knowledge of the following for the exam:-

Screening tool Overview

SAPAS (Standardised assessment of Interview method

personality abbreviated scale) Focuses on 8 areas
Takes 2 minutes to complete
Scored between 0 and 8
Yes/No answers to 8 statements
Score of 3 or more warrants further
assessment

FFMRF (Five factor model rating Self reported

form) Consists of 30 items
Rated 1-5 for each item
Based on symptoms rather than
diagnoses

IPDE (International Personality Interview method and self reported

Disorder Examination Screen) Semistructured clinical interview
compatible with the ICD-10 and DSM-IV
Includes both a patient questionaire and
an interview

PDQ-R (Personality Diagnostic Self reported

Questionnaire-Revised) 100 true/ false questions
Takes 30 minutes to complete
Based on DSM-IV criteria

IPDS (Iowa Personality Disorder Interview method

Screen) Consists of 11 criteria
Takes less than 5 minutes

IIP-PD (IIP Personality Disorder Self reported

Scales) Contains of 127 items
Items rated 0-4

Thyroid (physical examination)

Features of hypothyroidism

Weight gain (with decreased appetite)

Features of hypothyroidism

Intolerance to cold

Lethargy

Constipation

Menstrual disturbances

Decreased perspiration

Exams findings in hypothyroidism

Hair loss

Bradycardia

Periorbital puffiness and dry skin

Coarse, brittle, strawlike hair

Myxoedema

Hyporeflexia

Features of hyperthyroidism

Weight loss (with increased appetite)

Intolerance to heat

Palpitations

Menstrual disturbances

Exams findings in hyperthyroidism

Hair loss

Tachycardia

Warm, moist, and smooth skin

Tremor
Features of hyperthyroidism

Brisk reflexes

History of psychiatric drugs and other interventions

The following points come up in exams regarding the history of psychiatric

drugs and other interventions.

 Kane - introduced clozapine into clinical practice

 Carlsson - developed the first SSRI

 Blackwell - first described the 'cheese effect' seen in MAOI use

 Cade - discovered lithium's beneficial effect in mania

 Kline - discovered use of iproniazid (MAOI)

 Charpentier - synthesised chlorpromazine

 Delay and Deniker - introduced chlorpromazine as a treatment for

schizophrenia

 Kuhn - discovered the antidepressant effects of imipramine

 Cerletti (and Bini) - first use of ECT

 Lurie - coined the term 'antidepressant'

 Sakel - insulin shock therapy

 Moniz - frontal leucotomy for psychosis

 Meduna - metrazol therapy

Antipsychotics

Chlorpromazine (thorazine) - Considered to be the first of the

antipsychotics. First synthesised in 1950 by Paul Charpentier. Used in
1951 by Laborit and Huguenard, to patients for its potential anesthetic
effects during surgery. Shortly thereafter, Hamon et al. and Delay et al.
extended the use of this treatment in psychiatric patients and
serendipitously uncovered its antipsychotic activity.

Between 1954 and 1975, about 40 antipsychotic drugs were introduced

throughout the world. Thereafter, there was a hiatus in the development
of antipsychotics until the introduction of clozapine treatment in 1990
opened the era of 'atypical' antipsychotics.

Clozapine - First synthesised in 1958 and used to some extent during

the1960s but was held back due to association with agranulocytosis,
1990s brought back in with monitoring.

Antidepressants

The first antidepressants were the MOA inhibitors (namely iproniazid).

Iproniazid was initially developed as a treatment for tuberculosis. After
noting side effects (in the early 1950s) such as euphoria, increased
appetite, and improve sleep, people started using iproniazid as a
treatment for depression. Iproniazid is an irreversible MOA inhibitor and
issues such as the cheese reaction ultimately led to its removal from
psychiatric practice.

Lurie, a private psychiatrist, coined the term 'antidepressant' for the

psychostimulatory effects of isoniazid (another antitubercular compound)
in depressed patients.

The tricyclic antidepressants were developed though a separate route.

After the success of chlorpromazine for schizophrenia the search was on
for even more potent antipsychotic compounds. One such compound
(interestingly enough develeoped from promethazine) was imipramine. It
was noted that imipramine lacked antipsychotic properties but produced
marked improvements in people suffering with depression.

In an essay written by Kuhn (1958), he states They commence some

activity of their own, again seeking contact with other people, they begin
to entertain themselves, take part in the games, become more cheerful
and are once again able to laugh The patients express themselves as
feeling much better, fatigue disappears, the feeling of heaviness in the
limbs vanish, and the sense of oppression in the chest gives way to a
feeling of relief (p. 459). Kuhn also stated that no serious side effects were
recorded in the 500 patients treated with imipramine, which was a vast
improvement over MAO inhibitors.
Imipramine was approved in 1959 by the Food and Drug Administration
(FDA) for the treatment of depression, which established the class of
drugs called tricyclic antidepressants (TCA).

The SSRIs were the only class of antidepressants that were actually
developed for their intended use. In the late 1960s evidence had begun to
emerge suggesting a significant role of serotonin in depression. As a
result, the pharmaceutical company Eli Lilly began developing ligands that
would selectively inhibit the reuptake of serotonin at serotonin
transporters, and as a result would increase serotonin concentrations
within the synaptic cleft to further stimulate postsynaptic serotonin
receptors.

In 1974, the first report on the selective serotonin reuptake inhibitor

(SSRI) LY110140 (fluoxetine) was published and in that publication the
authors suggested that fluoxetine would be an antidepressant drug.
Fluoxetine was approved by the FDA in December of 1987 and was
launched to the market in January 1988 under the trade name Prozac.

Although fluoxetine was the first SSRI approved and marketed in the
United States, the clinical trials (Phase I-Phase III) lasted more than seven
years and during that time Astra AB introduced the first SSRI zimeldine
(Zelmid®) to the European market in March 1982. Zimeldine, which was
derived from pheniramine, was removed from the European market in
September 1983 due to severe side effects such as hypersensitivity
reactions and Guillain-Barre syndrome, which is acute peripheral
neuropathy. The hypersensitivity reactions resembled a flu- like syndrome
which included fever, joint/muscle pain, headaches and hepatic effects.

First SSRI to be marketed = zimeldine

Although fluoxetine was the first SSRI approved and marketed in the
United States, the clinical trials (Phase I-Phase III) lasted more than seven
years and during that time Astra AB introduced the first SSRI zimeldine
(Zelmid®) to the European market in March 1982. Zimeldine, which was
derived from pheniramine, was removed from the European market in
September 1983 due to severe side effects such as hypersensitivity
reactions and Guillain-Barre syndrome, which is acute peripheral
neuropathy. The hypersensitivity reactions resembled a flu- like syndrome
which included fever, joint/muscle pain, headaches and hepatic effects.

Kraepelin (mixed states)

Most mood states tend to mixed with pure mania and pure depression
being less common.

Kraepelin described six types of mixed states based on various

combinations of mood, will (volition), and thought processes:-

 Manic stupor (elevated mood but decreased will and thought)

 Depressive-anxious mania (depressed mood but elevated will and

thought)

 Excited depression (depressed mood and thought but elevated

motor activity)

 Depression with flight of ideas (depressed mood and will but

elevated thought)

 Mania with poverty of thought (aka unproductive mania, elevated

mood and will but decreased thought)

 Inhibited mania (elevated mood and thought but decreased will)

Mixed state (Tortorella, 2015) Mood Motor activity Ideation

Manic stupor + - -

Depressive-anxious mania - + +

Excited depression - + -

Depression with flight of ideas - - +

Mania with poverty of thought + + -

Inhibited mania + - +

Over the years, the six Kraepelinian mixed states have been reduced to
two types:-

 Dysphoric mania (when full mania is present with some depressive

symptoms)
  Depressive mixed state (when full depression is present with some
manic symptoms).

Other terms sometimes used are agitated depression (full depression with
psychomotor agitation), anxious depression (depression with marked
anxiety), irritable depression (depression with marked irritability), and
mixed hypomania (hypomania with some depressive symptoms).

Tortorella (2015) Mixed states: still a modern psychopathological

syndrome? Journal of Psychopathology 2015;21:332-340.

Models of doctor-patient relationship

Four separate models of doctor-patient relationship are identified.

Model Description

Paternalistic (aka Assumed that doctor knows best. Doctor decides treatment
autocratic model) and patient is expected to simply comply

Informative Doctor provides information and the patient is left to make

the choice themselves

Interpretive The doctor understands the patient and helps the patient
make a decision based on their circumstances. This
involves shared decision making and involves the
participation of the patient

Deliberative The doctor acts as a friend to the patient and attempts to

steer them in a particular course of action which they see is
in their best interest but ultimately the choice is left to the
patient

Argyll Robertson pupil

Argyll Robertson pupils come up in exams due to the association with
tertiary syphilis which remains an important differential for many
psychiatric conditions such as dementia, psychosis, and mood disorders.

The Argyll Robertson pupil typically reacts poorly to light and normally to
near (accommodation and convergence). They are usually small and
irregular in shape. They do not generally lead to a reduction in visual
acuity.

Dilation of the Argyll Robertson pupil is typically poor with mydriatic

agents.

Argyll Robertson pupils are often said to be pathognomic of tertiary

syphilis, however they have also been reported in diabetes.

A common way to remember this is that prostitutes (who often catch

syphilis) don't come out in the light (no light reflex) but are very
accommodating (with their customers).

Pheochromocytoma

A pheochromocytoma is a catecholamine-secreting tumor of chromaffin

cells typically located in the adrenal glands.

Features include:-

 Hypertension

 Tachycardia

 Diaphoresis

 Livedo reticularis (mottled skin)

 Postural hypotension

 Tachypnea

 Cold and clammy skin

 Severe headache

 Angina

 Palpitations
  Nausea

 Vomiting

It is diagnosed by measuring catecholamine products in the blood or

urine. The principal urinary metabolic products of epinephrine and
norepinephrine are the metanephrines vanillylmandelic acid (VMA) and
homovanillic acid (HVA). Healthy people excrete only very small amounts
of these substances.

First rank symptoms

The first rank symptoms were suggested by Kurt Schneider as a means of

differentiating schizophrenia from other forms of psychosis. He
considered First rank symptoms as pathognomonic for
schizophrenia in the absence of organic psychopathology.

The evidence suggests that they are not pathognomic, but are highly
suggestive of schizophrenia. First rank symptoms are also seen in
affective disorders, and have also been reported in personality
disorders.
The evidence does not support the claim that they are of any prognostic
significance (Nordgaard 2008).
The first rank symptoms include:-

 Running commentary

 Thought echo

 Voices heard arguing

 Thought insertion

 Thought withdrawal

 Thought broadcast

 Delusional perception

 Somatic passivity

 Made affect (belief that feelings are controlled by an outside force)

 Made volition ( belief that impulses and/or behaviour are controlled

by an outside force)
 Big five personality traits

Personality can be divided into 5 broad categories.

 Openness to experience

 Conscientiousness

 Extraversion (aka surgency)

 Agreeableness

 Neuroticism (aka emotional stability)

Bandura social learning theory

Bandura devised a social learning theory. Essentially it proposed that

most of human behaviour is learnt by watching others and modelling their
behaviour.

His ideas are demonstrated well by his famous bobo doll experiment.

Bandura's work is often seen as a link between behaviourism and

cognitive psychology as he introduced a concept called reciprocal
determinism. Basically by this he meant that people's behaviour is
influenced by their environment but also that their behaviour influences
their environment.

Gillick competency

Gillick competency and Fraser guidelines refer to a legal case which

looked specifically at whether doctors should be able to give
contraceptive advice or treatment to under 16-year-olds without parental
consent. But since then, they have been more widely used to help assess
whether a child has the maturity to make their own decisions and to
understand the implications of those decisions.

In 1982 Mrs Victoria Gillick took her local health authority (West Norfolk
and Wisbech Area Health Authority) and the Department of Health and
Social Security to court in an attempt to stop doctors from giving
contraceptive advice or treatment to under 16-year-olds without parental
consent.

The case went to the High Court where Mr Justice Woolf dismissed Mrs
Gillick's claims. The Court of Appeal reversed this decision, but in 1985 it
went to the House of Lords and the Law Lords (Lord Scarman, Lord Fraser
and Lord Bridge) ruled in favour of the original judgement delivered by Mr
Justice Woolf.

The Fraser Guidelines, were laid down by Lord Fraser in the House of
Lords' case and state the It is lawful for doctors to provide contraceptive
advice and treatment without parental consent providing that they are
satisfied that:

 the young person will understand the professional's advice

 the young person cannot be persuaded to inform their parents

 the young person is likely to begin, or to continue having, sexual

intercourse with or without contraceptive treatment

 unless the young person receives contraceptive treatment, their

physical or mental health, or both, are likely to suffer

 the young person's best interests require them to receive

contraceptive advice or treatment with or without parental consent

Pseudoseizures

The term pseudoseizure refers to a seizure that does not involve an

epileptic neuronal discharge (aka non-epileptic seizure).

The following features are helpful when trying to distinguish between true
seizures and pseudoseizures:-

 Emotional precipitant - pseudoseizures are often precipitated by

emotional problems whereas true seizures tend to occur
spontaneously.

 Bizarre events - pseudoseizures often involve bizarre events such as

screaming and talking which are not typical of true seizures.

 Varied pattern - pseudoseizures tend to vary in form and do not

follow a stereotyped attack pattern.

 Tonic and clonic movements - pseudoseizures tend to lack true tonic

and clonic movements

 Tongue biting, incontinence, and injury are rarely seen in

pseudoseizures.
  Postictal features are uncommon in pseudoseizures.

 Suggestibility - pseudoseizure can sometimes be terminated (or

prolonged) by external influence such as talking to the patient or
restraint

 Gradual onset - pseudoseizures tend to have a more gradual onset

Migraine

Migraine is common and affects 5-10% of the population. It is more

common in women than men (2-3:1). It generally begins in childhood or
adolescence. A family history of migraine is reported in 2/3 of cases.

The most consistent symptom is headache, which is usually (but not

always) unilateral. Other symptoms include anorexia, nausea and
vomiting, photophobia, and intolerance of noise.

Classic migraine

In 1/3 of cases, migraines are precipitated by a visual aura (classic

migraine). The most common form of visual aura is the 'fortification
spectra' (semicircle of zigzag lights). Other disturbances include
micropsia, macropsia, zoom vision', mosaic vision', scotomas.
Occasionally there are hallucinations.

Basilar migraine

In basilar migraines headache and aura are accompanied by difficulty

speaking, vertigo, ringing in ears, or a number of other brainstem-related
symptoms, but not motor weakness.

Precipitants of migraine include:-

 Alcohol

 Cheese

 Chocolate

 Skipping meals

 Missing sleep

 Oral contraceptives
  Stress

Sick euthyroid syndrome

Sick euthyroid syndrome is also known as low T3 syndrome. It is

characterised by abnormal thyroid function tests (usually low T3, and
normal T4 and TSH) in the setting of nonthyroidal illness.
It is often seen in patients with anorexia following prolonged starvation.

Attitude scales

An attitudes is a person's feeling and thoughts towards something.

Attitudes have a direction (positive or negative) and an intensity.
Numerous methods have been devised to measure attitudes. You should
have some knowledge of the following attitude scales.

Thurstone scale

To create a Thurstone scale, first you start with creating a list of

statements relating to a concept or issue. Each statement is then
assessed by a panel of judges and given a score regarding how negative
or positive the statement is regarding the issue.

Individuals are then given the statements and asked to answer whether
they agree or disagree with each statement.

A person who disagrees with all the items has a score of zero. So, the
advantage of this scale is that it is an interval measurement scale.

Likert Scale

Here, respondents are asked to indicate a degree of agreement or

disagreement with each of a series of statements. Each scale item has 5
response categories ranging from strongly agree to strongly disagree.

Semantic Differential Scale

This is a seven point scale and the end points of the scale are associated
with bipolar labels.

For example one might wish to compare a group of individuals by an

aspect of their personality such as dominant or submissive (bipolar
labels).
Each individual could have any score from 1 (submissive) to 7 (dominant)
with a score of 3-4 being neutral.

@@@@.........You notice that a patient appears to struggle to keep their

eyes open. They tell you that their eyelids twitch uncontrollably and that
it's usually worse when they are tired. Their experience is most consistent
with which of the following conditions?............
Blepharospasm

The term blepharospasm refers to any abnormal blinking or eyelid tic or

twitch resulting from any cause.

Interview techniques (transition)

Transition is a technique used to indicate to a patient that enough

information has been gathered on a certain subject.

Interview techniques (open/closed questions)

There are two main types of questions, open and closed. Open questions
tend to open up an interview and invite a detailed response whereas
closed questions usually result in a yes/no answer and are useful for
clarification purposes.

Which of the following is an example of a closed question?

Do you mind seeing all my patients today

Open questions have several advantages over closed questions. They do

however make it more difficult to control and record the interview.

Interview techniques (silence)

Silence used at the appropriate time can be a effective way to give

patients the chance to sit and think.

Interview techniques (reinforcement)

Although 'reinforcement' is a rather woolly term, it does come up in the

exams. It refers to any interview technique that appears to increase a
certain behaviour.

Interview techniques (facilitation)

Facilitation techniques encourage patient's to continue. These include the

use of posture, gesture, and words to indicate that the interviewer is
interested in what the patient is saying.

Depression (sleep architecture)

Major depression has been studied by polysomnography, with

documentation of (Benca et al, 1992)

 decreased sleep continuity

 prolonged sleep onset latency

 increased wake time after sleep onset

 decreased sleep efficiency

 decreased total sleep time

 early morning awakenings

 reductions in slow wave sleep

 reduced REM sleep onset latency

 increased REM density

 prolonged time spent in first REM sleep period

BMI

The body mass index (BMI) is calculated by the following

BMI = mass (kg)/ height² (m)

E.g. A man is 75 kg and 1.82 m. BMI = 75 / (1.82 x 1.82) = 22.6

For adults, an ideal BMI is in the 18.5-24.9 range.

If your BMI is 25 or more, you weigh more than is ideal for your height:

 25-29.9 is overweight

 30-39.9 is obese

 40 or more is very obese

If your BMI is less than 18.5, you weigh less than is ideal for your height.

Human rights

Human rights are 'rights and freedoms to which all humans are entitled'.

The Human Rights Act came in 1998 and incorporated the rights
contained in the European Convention on Human Rights into UIK law.

The human rights are:-

 The right to life

 Freedom from torture and degrading treatment

 Freedom from slavery and forced labour

 The right to liberty

 The right to a fair trial

 The right not to be punished for something that wasn't a crime when
you did it

 The right to respect for private and family life

 Freedom of thought, conscience and religion, and freedom to

express your beliefs

 Freedom of expression

 Freedom of assembly and association

 The right to marry and to start a family

  The right not to be discriminated against in respect of these rights
and freedoms

 The right to peaceful enjoyment of your property

 The right to an education

 The right to participate in free elections

 The right not to be subjected to the death penalty

Vitamin deficiencies

Vitamin Disease reulting from deficiency

Vitamin A Nightblindness (aka nyctalopia)

Vitamin B1 Beriberi and Wernicke-Korsakoff syndrome

Vitamin B3 Pellagra

Vitamin C Scurvy

Vitamin D Rickets

Pellagra is caused by vitamin B3 (niacin) deficiency and is most commonly

seen in alcoholics. Pellagra classically presents with the triad of dementia,
dermatitis, and diarrhoea. Other psychiatric symptoms associated with
the condition include irritability, depression, mania, and psychosis.

Vitamin B1 (thiamine) deficiency can result in the following:-

 Dry beri-beri

 Wet beri-beri

 Wernicke's

Wet beriberi presents with signs of heart failure including breathlessness

and peripheral oedema.
Features of vitamin B6 deficiency include:-

 seborrhoeic dermatitis

 atrophic glossitis

 angular cheilitis

 confusion

 somnolence

Vitamin B6 deficiency is usually restricted to people with alcohol

dependence. Use of isoniazid can also cause this.

Pancreatic hormones

The pancreas functions as both an endocrine and exocrine gland. The

endocrine function relates to the production of the following four separate
hormones from the islets of Langerhans:-

 Somatostatin

 Insulin

 Pancreatic polypeptide

 Glucagon

Somatostatin is also produced by the brain (specifically the

hypothalamus), where it inhibits the secretion of thyroid-stimulating
hormone and growth hormone from somatotrope cells.

Ethnic variations in psychiatry (Institutional racisim).

For many years there has been concern that institutional racism might
explain the over representation of Black patients in mental health
settings.

Based on the 2001 UK Census, ethnic minorities form just 9% of the UK

population.

The 'Count me in Census' was introduced in 2005 to keep track of the

ethnic variation in use of psychiatric services.

The 2010 census found that:

 23% of all inpatients and those on CTOs were from Black and
minority ethnic groups (that is, not White British). This is clearly
above the 9% estimate from the 2001 Census.

 Black minority groups had higher rates of admission

 Lower than average rates of admission were seen in the White

British, Indian and Chinese groups

 Higher than average rates of Detention for Black minority groups

 Higher than average rates of seclusion for Black minority groups

The reasons for these findings are unclear and are hypothesized to fall
into two groups:
1. Patient factors

 Higher rates of mental illness has been found in Black minority

groups. Black Caribbean and Black African groups in the UK have
consistently been observed to have the highest incidence of
psychoses, with conservative estimates suggesting a risk between
four- and sixfold that of the White British population.

 Perceptions of Black and minority ethnic patients being at greater

risk

2. System factors

 Suggestion of inherent racism within psychiatry

Sensory distortions of sound

Hyperacusis refers to the increased sensitivity to noise. It occurs in
anxiety and depressive disorders as well as in a hangover or during a
migraine.

Hypoacusis refers to the reduced sensitivity of sound and is seen in states

of delirium. It is also seen in depression (along with hyperacusis).

Hypoesthesia

Hypoesthesia refers to a reduced sensitivity to sensory stimuli.

Hypoacusis is common in delirium which is why it is important to speak

clearly and loudly to this patient group.

Leaden Paralysis is the subjective sense of the arms or legs feeling

heavy, and is seen in atypical depression.

Hyperschemazia refers to the perception that body parts are magnified.

For example a painful limb may be perceived as being larger than the
corresponding one.

Hemisomatognosia is a unilateral lack of body image. A person may

behave as if one side of the body is missing.