1
Q
What are the two main contemporary classification systems in psychiatry?
A
ICD 10 and DSM IV
2
Q
What is an operationalised approach?
A
the use of precise clinical descriptions of disorders, together with predefined exclusion and inclusion criteria and details of the number and duration of symptoms required for diagnosis
3
Q
What are characteristic symptoms?
A
symptoms pertinent to a diagnosis, such as the symptoms of depression
4
Q
What are discriminating symptoms?
A
are necessary for diagnosis since they are not found in other disorders
5
Q
What are pathognomonic symptoms?
A
symptoms which strongly favour one diagnosis over another and have high specificity for the diagnosis
6
Q
What are inclusion and exclusion criteria?
A
a hierarchy of symptoms, arranged in order of importance, forming the core inclusion and exclusion criteria used to establish a diagnosis
7
Q
What is the atheoretical approach?
A
diseases are described according to the observed phenomenology, not an understanding of what might be causing the disease
8
Q
What is the descriptive approach?
A
classification of illness based on what constitutes the illness, rather than what causes it
9
Q
What are the advantages and disadvantages of a categorical approach?
A
Easy to understand
Based on existing knowledge base
Easy communication
Poor validity - vague catagories
10
Q
What are the advantages and disadvantages of a dimensional approach?
A
More valid given continnum of emotional and cognitive states Can indicate severity Comorbid diagnosis difficult Good for research Unclear clinical utility
11
Q
What is hierarchical organisation?
A
certain disorders take precedence over others when making a diagnosis (Jasperian theory) - ICD 10 still uses this system with organic disorders at the top of the hierarchy
12
Q
What is a multiaxial approach?
A
provides a holistic assessment of the individual in terms of their disorder and functioning
13
Q
What multi-axial approach is used in ICD-10?
A
Axis 1: the mental disorder
Axis 2: the degree of disability
Axis 3: current psychosocial problems
14
Q
What multi-axial approach is used in DSM-IV?
A
Axis 1: Clinical disorders
Axis 2: Personality Disorders/Mental retardation
Axis 3: General Medical Conditions
Axis 4: Psychosocial and Environmental problems
Axis 5: Global Assessment of Functioning
15
Q
What assessment instruments have been developed using the ICD10?
A
Schedule for clinical assessment in neuropsychiatry (SCAN)
Composite International Diagnostic Interview (CIDI)
International Personality Disorder Examination (IPDE)
16
Q
What different versions of ICD 10 exist?
A
- Clinical Descriptions and Diagnostic Guidelines (CDDG)
- Diagnostic Criteria for Research (DCR)
- Primary Care version
- Clinical Coding Manual
17
Q
What different syndromes of drug use does ICD-10 describe?
A
- Acute intoxication
- Harmful use
- Dependence
- Withdrawal state
- Withdrawal delirium
- Psychotic disorder
- Amnesic syndrome
- Late-onset disorders
18
Q
What does ‘harmful use’ mean?
A
a pattern of substance misuse that is causing damage to the physical or mental health of an individual without any pattern of dependence
19
Q
What does DSM-IV describe as substance ‘abuse’?
A
Maladaptive use:
despite problems in social, occupational, physical and psychological domains
in hazardous situations
at least one month, usually recurring over long period
no dependence signs
20
Q
What are the ICD-10 criteria for alcohol dependence?
A
In the last 12 months, at least 3 of:
- Intense desire to drink alcohol
- Difficulty in controlling the onset, termination and level of drinking
- Experiencing withdrawal symptoms if alcohol is not taken
- Use of alcohol to relieve withdrawal symptoms
- Tolerance as evidenced by the need to escalate dose over time to achieve the same effect
- Salience - neglecting alternate forms of leisure or pleasure in life
- Narrowing personal repertoire of alcohol use
21
Q
What are the DSM-IV criteria for alcohol dependence?
A
At least 3 of the following, lasting for at least 1 month:
- Consuming alcohol for longer period and in larger amounts than intended
- Unsuccessful attempts to cut down
- Experiencing withdrawal symptoms if alcohol is not taken
- Use of alcohol to relieve withdrawal symptoms
- Tolerance as evidenced by the need to escalate dose over time to achieve the same effect (at least 50% increase from the start)
- Salience - most time spent on pursuing alcohol directly or indirectly
- Failure in role obligations and physical health
- Giving up alternate pleasures
- Continued use despite knowing the harm caused
22
Q
What are the Edwards and Gross criteria for dependence?
A
- Narrowed repertoire
- Salience of alcohol seeking behaviour
- Increased tolerance
- Repeated withdrawals
- Drinking to prevent or relieve withdrawals
- Subjective awareness of compulsion
- Reinstatement after abstinence
23
Q
What is depressive pseudodementia?
A
a descriptive term, not a diagnosis, describing the presentation of depression as dementia clinically
24
Q
What are the features of pseduodementia compared to dementia?
A
- Onset can be dated more precisely
- More rapid progression of symptoms
- High level of complaint of cognitive impairments
- No nocturnal increase in dysfunction
- Attention and concentration more well preserved
- ‘Don’t know’ answers are common in testing
- Memory loss for remote events more severe than recent ones
25
What are the diagnostic criteria for dementia?
1. Global deterioration in intellectual capacity and disturbance in higher cortical functions like memory, thinking, orientation, comprehension, calculation, language, learning abilities and judgement, an appreciable decline in intellectual functioning and some interference with personal activities of daily living
2. Insidious onset with slow deterioration
3. The absence of clinical evidence or findings from individual investigations suggestive of organic brain disease or other systemic abnormalities
4. Absence of sudden onset or physical/neurological signs
26
What are the 5A's associated with dementia?
1. Amnesia - Impaired ability to learn new information and to recall previously learned information
2. Aphasia - Problems with language (receptive and expressive)
3. Agnosia - Failure of recognition, especially people
4. Apraxia - Inability to carry out purposeful movements, even though, there is no sensory or motor impairment
5. Associated disturbances - behavioural changes, delusions and hallucinations
27
What are the diagnostic criteria for vascular dementia?
1. Presence of a dementia syndrome, defined by cognitive decline from a previously higher level of functioning and manifested by impairment of memory and two, or more, cognitive domains and deficits should be severe enough to interfere with ADLs, not due to the physical effects of stroke alone
2. Onset may follow a cerebrovascular event and is more acute
3. The course is usually step-wise, with periods of intervening stability
4. Focal neurological signs and symptoms or neurological evidence of cerebrovascular disease judged aetiologically related to the disturbance (hemiparesis, lower facial weakness, Babinski sign, sensory deficit, hemianopia, dysarthria) or neurological imaging
5. Emotional and personality changes are typically early, followed by cognitive deficits that are often fluctuating in severity
6. Symptoms not occurring during the course of delirium
28
What are the diagnostic criteria for dementia with Lewy Bodies?
1. Spontaneous motor features of Parkinsonism
2. Fluctuating cognition with notable variation in attention and alertness
3. Recurrent visual hallucination, which are typically well formed and detailed
4. A progressive cognitive decline that is severe enough to interfere with normal social and occupational functioning and memory loss may not be an early feature, but it is usually evident with progression
5. Supportive features: neuroleptic sensitivity and history of falls
29
What is Parkinson's disease dementia?
Parkinsonian symptoms existed for 12 months before dementia developed
If cognitive and motor symptoms develop within the same 12 month period then a diagnosis of Lewy Body dementia is given
30
What are the diagnostic criteria for frontotemporal dementia?
1. Insidious onsent and gradual progression
2. Early loss of personal and social awareness
3. Early emotional blunting, Early loss of insight
4. Behavioural features: early signs of disinhibition, decline in personal hygiene and grooming, mental rigidity, inflexibility, hyperorality, stereotyped and perseverative behaviour
5. Speech disorder: reduced output and signs such as stereotypy, echolalia and perseveration
6. Affective symptoms: anxiety, depression and frequent mood changes, emotional indifference
7. Physical signs: incontinence, primitive reflexes, akinesia, rigidity and tremor
31
What is schizophrenia?
a severe psychotic illness with onset in early childhood, characterised by bizarre delusions, auditory hallucinations, thought disorder, strange behaviour and progressive deteriorationin personal, domestic, social and occupational functioning, all occurring in clear consciouness
32
What are the most common symptoms in schizophrenia (International Pilot Study of Schizophrenia)?
1. Lack of insight 97%
2. Auditory hallucinations 74%
3. Ideas of reference 70%
4. Suspiciousness 66%
5. Flatness of affect 66%
6. Second person hallucinations 65%
7. Delusional mood 64%
8. Delusions of persecution 64%
9. Thought alienation 52%
10. Echo De Pensee, Gedankenlautwerden 50%
33
What are the Feighner/St Louis Criteria (Washington University Criteria)?
```
Early diagnostic criteria for schizophrenia 1972
Three parts (A, B, C)
Must have all of A, one of B and 3 of C for a 'definite' diagnosis of schizophrenia
```
34
What are the part A criteria in the Feighner/St Louis criteria?
Both of the following are necessary;
1. A chronic illness with at least 6 months of symptoms prior to the index evaluation without a return to the premorbid level of psychosocial adjustment
2. The absence of a period of depressive or manic symptoms sufficient to qualify for affective disorder or probable affective disorder
35
What are part B criteria in the Feighner/St Louis criteria?
Must have at least 1 of the following:
1. Delusions or hallucinations without significant perplexity or disorientation associated with them
2. Verbal production that makes communication difficult because of a lack of logical or understandable organisation (muteness defers diagnosis)
36
What are the part C Feighner/St Louis criteria?
At least 3 of the following for a definite diagnosis and 2 for a possible diagnosis;
1. Single
2. Poor premorbid social adjustment or work history
3. Family history of schizophrenia
4. Absence of alcoholism or drug abuse within one year
5. Onset prior to age 40
37
What are the National Institute for Mental Health (NIMH) Research and Diagnostic Criteria (RDC) for schizophrenia?
Made up of a polythetic symptom criterion, duration criterion and an exclusion criterion to define schizophrenia
38
What is the symptoms criterion in the NIMH RDC for schizophrenia?
Eight symptoms or groups of symptoms. The first seven symptoms are Schneiderian first-rank symptoms and other delusions or hallucinations, the last one gives diagnostic value to formal thought disorder if accompanied by either blunted or inappropriate affect, delusions or hallucinations of any type or grossly disorganised behaviour.
39
What are the duration criterion in the NIMH RDC for schizophrenia?
Signs of illness have lasted at least 2 weeks from the onset of a noticeable change in the subject's usual condition
40
What are the exclusion criterion in the NIMH RDC for schizophrenia?
describes the differential diagnosis with affective disorders: at no time during the active period of illness being considered did the subject meet the full criteria for either probable or definite manic or depressive syndrome to such a degree that it was a prominent part of the illness
41
What are Schneider's first rank symptoms?
1. Auditory hallucinations
2. Passivity experiences
3. Thought withdrawal, insertion, broadcasting
4. Delusional perception
42
How does ICD-10 view the duration of schizophrenia?
Not necessarily a long duration
Acute psychotic episodes 1 month diagnosis becomes schizophrenia
Prodromal features are not included in diagnosis
43
What are the ICD-10 subtypes of schizophrenia?
1. Paranoid
2. Hebephrenic
3. Catatonic
4. Residual
5. Simple
6. Undifferentiated
7. 'Chronic' schizophrenia
44
What are the features of paranoid schizophrenia?
Most common subtype
onset later than other subtypes
prominent delusions and auditory hallucinations
less disorganisation, speech problems, flat or inappropriate affect and catatonic behaviour
45
What are the features of hebephrenic/disorganised schizophrenia?
Onset 15-25 years
Poor prognosis
Disorganised speech or behaviour
Marked thought disorder - severe loosening of associations, emotional disturbances described by inappropriate affect, blunted affect or senseless giggling, abnormal mannerisms like mirror gazing
Marked impairment of social and occupational functioning - poor self-care, poor hygiene, extreme social behaviour and disorganised behaviour
Less catatonic behaviour
46
What are the features of catatonic schizophrenia?
```
Common in developing nations
Acute onset with episodic course and complete symptom remission
Prominent motoric immobility, excessive motor activity, extreme negativism or mutism, posturing, stereotypy, mannerisms, grimacing, echolalia, echopraxia
Oneiroid (dream-like) state can occur
3 clinical forms:
1. excited catatonia
2. stuporous catatonia
3. alternating catatonia
```
47
What are the features of residual schizophrenia?
Previous 'full-blown' acute episode in the past - at least 1 year ago
current negative symptoms or attenuated forms of 2 or more generic symptoms (ie odd beliefs instead of delusions, unusual perceptual experienced instead of fully formed hallucinations)
Absent delusions, hallucinations, disorganised speech/behaviour, catatonia
48
What are the features of simple schizophrenia?
Early onset
Duration criteria is 1 year
Insidious development of negative symptoms without evidence of positive symptoms
Personality is gradually deteriorating with increasing emotional bluntness
May have brief psychotic episodes
Poor prognosis
49
What are the features of undifferentiated schizophrenia?
Generic symptoms but not falling into other catagories
50
What are the features of 'chronic' schizophrenia?
Persistent disability for two years or longer - a descriptive term only, not a subtype
51
What is 'post-schizophrenic' depression?
some schizophrenic symptoms present, but not dominating the clinical picture
most recent episode of relapse
52
What are the ICD-10 symptom classification for schizophrenia?
```
At least 1 of:
1. Thought echo, thought insertion/withdrawal/broadcast
2. Passivity, delusional perception
3. Third person auditory hallucination, running commentary
4. Persistent bizarre delusions
OR 2 more of:
1. Persistent hallucinations
2. Thought disorder
3. Catatonic behaviour
4. Negative symptoms
5. Significant behaviour change
```
53
What are the DSM IV symptom classification for schizophrenia?
```
At least 1 of:
1. Bizarre delusions
2. Third persons auditory hallucinations
3. Running commentary
OR 2 more of:
1. Delusions
2. Hallucinations
3. Disorganised speech
4. Grossly disorganised behaviour
5. Negative symptoms
```
54
What is the ICD-10 'acute and transient psychotic disorders'?
Onset within 2 weeks (acute)
Onset within 48 hours (abrupt)
Recovery within 2-3 months
Can be either polymorphic psychosis or schizophrenia-like
55
What is schizotypal disorder?
eccentric manners, social withdrawal, magical thinking, suspiciousness and obsessive ruminations without resistance
2 year history of symptoms
no previous diagnosis of schizophrenia
a cluster A personality disorder in DSM-IV
common in first degree relatives of those with schizophrenia
56
What is persistent delusional disorder?
characterised by persistent, often life long, 'non-bizarre' delusion or a set of related delusions arising insidiously in mid-life or later
daily functioning not impaired
other schizophrenic symptoms rarely occur
present for at least 3 months (1 month DSM)
57
What is erotomania (de Clerambault syndrome)?
erotic conviction that a person with a higher status is secretly in love with the patient
58
Erotic conviction that a person with a higher status is secretly in love with the patient. What disorder is this?
Erotomania (de Clerambault syndrome)
59
What is the delusional disorder of grandiosity?
belief that person fills some special role, have some special relationship, or possess some special abilities
60
What is Othello syndrome?
delusional jealousy - characterised by a delusion of infidelity, with patients possessing the fixed belief that their spouse or partner has been unfaithful
61
What are persecutory delusions?
belief that others are attempting to hurt or harm them, leading them to obtain legal recourse and sometimes turning violent
62
What are somatic delusions?
variable presentations including repeated medical consultations for unspecified disorders, concerns about bodily infestation, deformity or odour etc
63
What are induced delusional disorders?
sharing of delusions between usually 2, or more, persons with tightly knit emotional bonds
one person has genuine psychiatric disorder and does not improve on separation, but the other does
also called folie a deux or symbiotic psychosis
64
What is schizoaffective disorder?
both schizophrenic and mood symptoms are seen simultaneously in equal proportion
mood-incongruent delusions are suggestive
subtypes: schizomanic and schizodepressive
65
What is Bouffée délirante?
described by Legrain
Features:
1. sudden onset psychosis
2. polymorphous delusions and hallucinations
3. clouded consciousness with emotional instability
4. absence of physical signs
5. rapid return to premorbid level of functioning
6. symptom-free between episodes
66
What is process schizophrenia?
described by Langfeldt
also labelled as 'genuine' schizophrenia
a group with poor prognosis in schizophrenia
67
What is cycloid psychoses?
described by Leonhard and Perris
psychotic episodes of sudden onset, mostly unrelated to stress, with good immediate outcome but with a high risk of recurrence, characterised by mood swings and at least two of perplexity/confusion, delusions, hallucinations (incongruent), motility disturbances, episodes of elation and episodes of overwhelming anxiety (pananxiety).
68
What time period does DSM IV and ICD-10 state that symptoms must be present for to diagnose depression?
2 weeks
69
What are the ICD-10 criteria required for the diagnosis of depressive disorder and its severities?
```
Requires 2 of 3 from criterion A
Mild = at least 2 from criterion B
Moderate = at least 4 from criterion B
Severe = at least 6 from criterion B
remember 4-6-8 rule
```
70
What are the core (criteria A) symptoms of depression?
1. depressed mood
2. loss of interest and enjoyment (anhedonia)
3. reduced energy (anergia)
71
What are the criteria B symptoms of depression?
1. reduced concentration and attention
2. reduced self-esteem and self-confidence
3. ideas of guilt and unworthiness
4. bleak and pessimistic views of the future
5. ideas or acts of self harm or suicide
6. disturbed sleep
7. diminished appetite
72
What time course of symptoms is required for a diagnosis of recurrent major depressive disorder?
more than 1 episode of depression separated by a period of at least 2 months
73
What are the ICD-10 criteria for diagnosis of BPAD?
Two affective episodes with complete recovery between them. Depressive episodes must be present for at least two weeks and manic episodes must be for 7 days. Hypomanic episodes must last 4 days. Mixed episodes can co-exist over a two week period.
74
What are the characteristics of type 1 and type 2 BPAD?
Type 1: 'full-blown' manic episodes or mixed mania and depression
Type 2: recurrent depression and hypomania, without episodes of either mania or mixed states
75
What is the ICD-10 diagnostic criteria for a manic episode?
At least 1 week
mood predominantly elevated, expansive or irritable and definitely abnormal for the individual
at least 3 of:
1. increased activity or physical restlessness
2. increased talkativeness, 'pressure of speech'
3. flight of ideas or subjective experience of thoughts racing
4. loss of normal social inhibitions resulting in behaviour which is inappropriate to the circumstances
5. decreased need for sleep
6. inflated self-esteem or grandiosity
7. distractibility or constant changes in activity or plans
8. behaviour which is foolhardy or reckless and whose risks the subject does not recognise
9. marked sexual energy or sexual indiscretions
76
What is hypomania?
symptoms of mania, but evident to a lesser degree
not severe enough to interfere with social or occupational functioning
no psychotic features
77
What is the ICD-10 definition of mixed states in BPAD?
manic and depressive symptoms simultaneously
| must be present every day for at least 1 week (DSM) or 2 weeks (ICD)
78
What is the definition of rapid cycling in BPAD?
at least 4 episodes of BPAD in 1 year
70-80% are women
ultra-rapid cycling - changes within days/hours
79
What is post-partum onset BPAD?
affective symptoms within 4 weeks of childbirth
80
What is the definition of seasonal pattern?
recurrences of BPAD with most episodes starting and ending at the same time each year
81
What is secondary mania?
mania secondary to other cause
drug induced states of mania and organic states
can occur with alcohol, illicit drugs and prescribed drugs
episodes improve with cessation of drug
can occur in thyroid disease, MS and brain lesions
82
What is Bipolar 3?
describes minimal depression complicated by antidepressant-induced hypomania
83
What are the persistent affective disorders?
Dysthmia
| Cyclothymia
84
What is dythymia?
a chronic mildly depressed mood and diminished enjoyment not severe enough to be classified as a depressive illness
85
What is double depression?
episodes of major depression superimposed on dysthmia
86
What is cyclothymia ?
subclinical presentations of oscillating low and high moods, without symptoms of depression or mania to fulfill the criteria for these diagnoses
87
What is seasonal affective disorder?
3 or more affective episodes within the same 90 day period of the year for 3 or more consecutive years. Remissions occur within a defined 90 day period also.
88
What are the atypical features of seasonal affective disorder?
Normally depressive in nature, but atypically, hypersomnia, increased appetite, carbohydrate craving and weight gain
89
What is the treatment for seasonal affective disorder?
Phototherapy (10,000 lux)
90
What are the features of generalised anxiety disorder?
prominent tension, excessive worry, generalised free-floating persistent anxiety, feeling of apprehension about everyday events, significant stress, functional impairment
91
What are the diagnostic criteria for generalised anxiety disorder?
duration of greater than 6 months
| symptoms present on most days
92
What are the ICD-10 physical symptoms of anxiety?
1. Symptoms of autonomic arousal: palpitations/tachycardia, sweating, trembling/shaking, dry mouth
2. Physical symptoms: breathing difficulties, choking sensation, chest pain/discomfort, nausea/abdominal distress
3. Mental state symptoms: feeling dizzy, unsteady, faint or lightheaded, derealisation/depersonalisation; fear of losing control, going crazy, passing out, dying
4. General symptoms: hot flushes/cold chills, numbness, tingling
5. Symptoms of tension: muscle tension/aches and pains, restlessness/inability to relax, feeling keyed up on edge or mentally tense, lump in the throat or difficulty swallowing
6. Other: exaggerated response to minor surprises/being startled, concentration difficulties/mind going blank due to worry or anxiety, persistent irritability, difficulty getting to sleep due to worry
93
What is a panic attack?
a discrete episode of intense anxiety characterised by abrupt onset, peak symptoms within minutes and resolution within 30 minutes. Attacks have no clear precipitant and are said to be spontaneous.
94
What are the different types of panic attack (DSM IV)?
1. situationally bound/cued
2. situationally predisposed
3. unexpected/uncued
95
What is panic disorder?
recurrent panic attacks, not secondary to another cause, accompanied by persistent worry about having another attack, phobic avoidance of places or situations and significant behavioural changes relating to the attack
96
What are the diagnostic criteria for panic disorder?
present for at least 1 month
symptoms in circumstance where there is no objective danger
without being confined to known or predictable situations
with comparative freedom from anxiety symptoms between attacks
Severe: if >4 attacks in a 4 week period
97
What does DSM IV suggest that at least one episode of panic attack must be followed by for a diagnosis of panic disorder?
at least 1 of
1. anticipation of further attacks
2. worry about implications
3. avoidance behaviours
98
What are the cardinal features of phobia?
```
(proposed by Marks)
fear which is
1. out of proportion to the situation
2. cannot be explained or reasoned away
3. is beyond voluntary control
4. leads to avoidance
```
99
What is anticipatory anxiety?
Anxiety preceeding the event which is known to cause feelings of anxiety - important features in phobias
100
What are the most common phobic syndromes?
agoraphobia, social phobia and specific phobia
101
What classification are internal phobic objects given in ICD10?
Hypochondriasis eg nosophobia, dysmorphophobia
102
What is agoraphobia?
```
common anxiety provoking themes
1. distance from home
2. crowding
3. confinement (lack of escape route)
avoidance of crowds, public places or being away from the home
may include panic attacks
```
103
What is social phobia?
duration >6 months
fear of scrutiny by others, commonly in small group settings, fear of embarrassment or humiliation
Two types
1. discrete - specific occasions eg fear of public speaking
2. diffuse - exposure to any generic social task
104
What is a specific phobia?
phobia to a specific, usually external, stimulus
| DSM-IV sub-types - animals, environmental, blood/injection/injury, situational and other
105
What is OCD?
Obsessive-compulsive disorder
obsessional thinking
compulsive behaviours
associated anxiety and depression
106
What are the ICD10 diagnostic criteria of OCD?
Most days for at least 2 weeks
Obsessions (thoughts, ruminations, doubts, impulses and phobias) and compulsions which must be;
1. acknowledged as originating in the mind of the patient
2. repetitive and unpleasant; at least one being excessive and unreasonable
3. at least one must be successfully resisted
4. carrying out obsessive thought or compulsive act is not intrinsically pleasurable
107
What is an acute stress reaction?
response to severe stress starting within 1 hour and resolving within 8 hours (acute incident) or 48 hours (prolonged incident)
characterized by narrowed attentions, dazed response, disorientation, agitation, overactivity, amnesia, dissociation
108
What is adjustment disorder?
the psychological reactions arising in relation to adapting to new circumstances and occurs in someone who has been exposed to a psychosocial stressor like divorce, separation etc, which is not catastrophic in nature
onset within 1 month (ICD10) or 3 months (DSM)
duration can only be up to 6 months (or two years in prolonged depressive reaction)
109
What are the features of normal grief?
disbelief, shock, numbness, unreality, anger, feelings of guilt, sadness, tearfulness, pining, searching, preoccupation with deceased, disturbed sleep, disturbed appetite, weight loss, seeing or hearing the deceased (hallucinations of widowhood)
typical grief reactions last up to 12 months
110
What are the phases of a grief reaction?
1. Shock and protest
2. preoccupation
3. disorganisation
4. resolution
111
What are the types of abnormal grief reactions?
very intense
chronic grief - significant symptoms, prolonged after 6 months
delayed - avoidance of painful symptoms within two weeks of loss
inhibited - absence of expected grief symptoms at any stage
symptoms outside of those normally associated with grief reactions
112
What are the causes of abnormal grief?
```
sudden and unexepcted deaths
insecure survivor
dependent or ambivalent relationship with the deceased
presence of dependent children
previous psychiatric disorder
```
113
What is PTSD?
post-traumatic stress disorder
| an intense prolonged and sometimes delayed reaction to an intensely stressful event
114
What are the essential features of PTSD?
Hyperarousal
hypervigilance
avoidance
115
What are the symptoms of hyperarousal in PTSD?
persistent anxiety
irritability
insomnia
poor concentration
116
What are the symptoms of hypervigilance in PTSD?
re-experiencing
enhanced startle responses
intrusions
recurrent distressing trauma
intensive intrusive imagery (flashbacks, vivid memories)
difficulties in recalling stressful events at will
117
What are the symptoms of avoidance in PTSD?
avoidance of reminders of the event
detachment
emotional numbness
diminished interest in activities
118
What are the two types of trauma which lead to PTSD?
Type 1: single sudden catastrophic events
| Type 2: chronic repetitive insult against which the individual has no defence
119
What is the definition of dissociation?
the loss of integration among memories, identity, sensations and movements, occurring closely in line with trauma
120
What is dissociative amnesia?
loss of memory for important recent events, which is partial, patchy and selective
characteristed by episodic retrograde memory loss only, with amnesia for a specific time period, usually associated with traumatic time period
121
What is a dissociative fugue?
purposeful journey away from home or one's usual base occurs with maintained self-care despite getting lost. A new identity may be assumed with amnesia for previous identity. No cognitive impairment or behavioural changes are evident, however, perplexity and la belle indifference are frequent
122
What is trance?
a dissociative state where narrowed consciousness and limited but repeated movements are seen. The trance is intrusive on activities of life and occur outside culturally sanctioned situations.
123
What is conversion/hysterical disorder?
a dissociative disorder of motor movement and sensations
124
What is la belle indifference?
A naive, inappropriate lack of emotion or concern for the perceptions by others of one's disability, usually seen in persons with conversion hysteria
125
What is Ganser syndrome?
a type of factitious disorder, a mental illness in which a person deliberately and consciously acts as if he or she has a physical or mental illness when he or she is not really sick. People with Ganser syndrome mimic behavior that is typical of a mental illness, such as schizophrenia.
126
What are twilight states?
a dreamy state lacking touch with present reality, occurring in epilepsy, hysteria, and schizophrenia, and sometimes induced with narcotics
127
What behaviours suggest pseudoseizures rather than epileptiform seizures?
1. avoidance behaviours to prevent injury
2. change in symptomatology of seizure pattern
3. closing eyes during seizures, resisting opening of eyelids
4. dystonic posturing
5. emotional or situational triggers
6. gradual onset and cessation of seizures
7. tongue biting is rare
8. pelvic movements and side to side head movements
9. lack of concern or an excessive emotional response
10. multiple unexplained physical symptoms
11. non-response to antiepileptic drugs
12. seizures in the presence of others only
128
What is somatization disorder?
at least 2 years of multiple and variable physical symptoms for which no adequate physical explanation hs been found
persistent refusal to accept the advice and reassurance of several doctors regarding the absence of physical illness
notable impairment of social and family functioning due to the symptoms and illness behaviour
also called Briquet syndrome or St Louis hysteria
129
What is hypochondriacal disorder?
characterised by 2 conditions
1. persistent belief of haboring at least one serious physical illness even though repeated investigations and examinations have identified none or a persistent preoccupation with a presumed deformity or disfigurement (body dysmorphic type)
2. persistent refusal to accept the advice and reassurance of doctors regarding the absence of physical illness
130
What is body dysmorphic disorder?
a subjective description of ugliness and physical defect which the patient feels is noticeable to others. It is an excessive concern (overvalued idea) about trivial or non-existent physical abnormalities which are perceived to be deformities. Beliefs of delusional intensity are classified as delusional disorder (not BDD). Results in excessive anxiety and time consuming behaviours - re-examining, repeated checking, involvement in elaborate grooming rituals to hide the perceived defect and avoidance behaviour
131
What is somatoform autonomic syndrome?
recurrent symptoms of arousal, such as palpitations, sweating, tremor, flushing, other symptoms referred to particular organ or system, despite no functional or structural defect, patients refuse to be reassured
132
What is neurasthenia?
disorder with either persisting or distressing complaints of increased fatigue after mental effort or persistent and distressing complaints of bodily weakness and exhaustion after minimal effort. must be accompanied by at least 2 of:
1. muscular aches and pains
2. dizziness
3. tension headaches
4. sleep disturbance
5. inability to relax
6. irritability
7. dyspepsia
133
What is depersonalization-derealization syndrome?
syndrome where depersonalisation or derealisation symptoms are present in the presence of full insight
134
What is depersonalisation?
the perception that one's feelings or experiences are detached, distant, lost and not his or her own
135
What is derealisation?
the perception that objects, people and surroundings seem unreal, distant, artificial, colourless or lifeless
136
What are the features of malingering?
clearly intentional
| often monetary benefit - compensation claim etc
137
What are the features of factitious disorder?
'truly puzzling' with no 'clear cause'
only gain is the sick role
Munchaussen is severest form
138
What are the features of anorexia nervosa?
low body weight (>15% below the norm)
BMI 17.5 or less
self induced weight loss, avoidance of fattening foods, vomiting, purging, excessive exercise, use of appetite suppressants
body image distortion
endocrine disturbances - amenorrhoea, reduced libido, increased cortisol, abnormal hormone profile
delayed/arrested puberty
139
What are the DSM IV subtypes of anorexia nervosa?
binge eating/purging
| restricting
140
What is atypical anorexia nervosa?
A disorder that fulfills some of the features of anorexia nervosa, but in which the overall clinical picture does not justify that diagnosis
141
What is bulimia nervosa?
persistent preoccupation with eating
irresistible craving for food
binges
attempts to counter the fattening effects of food (vomiting, abuse of purgatives, periods of starvation, use of drugs)
morbid dread of fatness with imposed low weight threshold
142
What are the DSM IV subtypes of bulimia nervosa?
purging
| non-purging
143
What is EDNOS?
Eating disorder not otherwise specified - does not fit the criteria for bulimia or anorexia nervosa
144
What is binge eating disorder (BED)?
recurrent episodes of binge eating in the absence of extreme weight control behaviours
145
What is a dyssomnia?
abnormality in the amount, quality or timing of sleep
146
What is a parasomnia?
abnormal episodic events occuring during sleep
147
What is a sleep terror?
several minutes of disorientation on waking and some preservative behaviour, recall limited to fragmentary mental images
148
What is Kleine-Levin syndrome?
periodic episodes of hypersomnolence and hyperphagia
| associated with lack of concentration, mood changes, hypersexuality and anxiety
149
What is narcolepsy?
```
characterised by excessive daytime drowsiness accompanied by sudden onset of REM sleep (narcolepsy) and sudden loss of muscle tone (cataplexy), provoked by strong emotions
familial inheritance (HLA DR-2)
```
150
What is sleep paralysis?
an episode of inability to move occuring between wakefulness and sleep
151
What are the sexual dysfunction disorders?
1. sexual desire disorders (aversion, hypoactive desire)
2. sexual arousal disorders (female SAD, male ED)
3. organismic disorders (organismic, premature ejaculation)
4. sexual pain (dyspareunia, vaginismus)
5. Other (general medical/substance misuse)
152
What are the cluster A personality disorders?
1. Paranoid
2. Schizoid
3. Schizotypal (not in ICD10)
153
What are the cluster B personality disorders?
1. antisocial (dissocial)
2. borderline (emotionally unstable a) impulsive b) borderline)
3. histrionic
4. narcissistic (not in ICD)
154
What are the cluster C personality disorders?
1. avoidant (anxious)
2. dependent
3. obsessive-compulsive (anankastic)
MRCPsych Part A
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