Psychiatry exam

1. Disturbances in perception

Abnormalities in how a person perceives/experiences sensory stimuli. These can involve any of the five senses and may include hallucinations & illusions. They can vary in intensity, being hyper- or hypoesthesia

1. Types of disturbances in perception

• Quantitative disturbances

• Illusions

• Hallucinations

• Pseudohallucinations

• Depersonalisation and derealisation

1+2. Principles of assessment

• Anamnesis, past psychiatric and medical history and treatment, personal history and premorbid personality, family history, presenting complaints

• Mental status examination: appearance and behaviour, speech, mood, thoughts, perception, cognition and insight

• Rule out organic causes

• Risk assessment, substance use (toxicology screening) and physical examination

1. Clinical disorders according to ICD-10

• F20-F29 → schizophrenia and delusional disorders

• F30-F39 → mood (affective) disorders

• F00-F09 → organic, including symptomatic, mental disorders

1+2. Indications for emergency hospitalisation

• Risk to themselves/others

• Severe mood disturbances

• Substance-related

• Acute psychosis

• Severe eating disorders

• Inability to care for basic needs

• Lack of insight

• Hallucinations are demanding

• Suspected organic cause or delirium

1-3. Risk management in the work with patients

• Safe environment and room set up (exits)

• Clinical risk assessment - suicide ideation, substance abuse can escalate unpredictable behaviour

• Avoid unnecessary physical contact, communicate in a neutral and positive manner

• Emergency protocols and stabilisation (pharmacological management) of the patient

• Monitor regularly

• Understand circumstances on how they came to the clinic - violence, etc.

2. Disturbances of thinking

Abnormalities in the process, form, or content of thought. impairs communication, decision-making, and perceiving reality

2. Types of disturbances in thinking

Disturbances in form and flow:

• slow/accelerated, thought blocking

• word salad

• tangentiality

• echolalia

• stereotypy

• connectivity

Disturbances in content:

• overvalued ideas

• delusions

• ideas of references

Disturbances in thought control

• thought insertion

• thought withdrawal

• thought broadcasting

2. Clinical disorders according to ICD-10

• F20-F29 → schizophrenia and delusional disorders

• F30-F39 → mood (affective) disorders

• F00-F09 → organic, including symptomatic, mental disorders

3. Disturbances in mood

Pathological and persistent changes in a persons emotional state that are disproportionate to their actual circumstances and significantly impair their ability to function

Affect - emotional state at any given period

Mood - emotional stage during longer period

3. Types of disturbances in mood

• Depressive: Sadness, hopelessness, or anhedonia.

• Manic: Elevated or irritable mood, increased energy, and grandiosity.

• Hypomanic: Similar to mania but less severe and without psychotic features or significant functional impairment

• Elated: euphoria, elation, exaltation, ecstasy

• Bipolar

• Anxiety: Excessive worry or tension. Generalized, mutism.

• Trait anxiety: anxiety as a feature of temperament

• Panic, phobias: irrational fear. Ex. Agoraphobia (public or crowded place)

• Dysphoric: combination of anxiety, depression, and irritability.

3. Principles of assessment

• PHQ9

• HAM-D,YMRS, GDS

• Anamnesis, past psychiatric and medical history and treatment, personal history and premorbid personality, family history, presenting complaints

• Mental status examination: appearance and behaviour, speech, mood, thoughts, perception, cognition and insight

• Rule out organic causes

• Risk assessment, substance use (toxicology screening) and physical examination

3. Clinical disorders according to ICD-10

• F30-F39 → mood (affective) disorders

• F00-F09 → organic, including symptomatic, mental disorders

3. Indications for emergency hospitalisation

• Suicidal ideation, plans or attempts

• Severe mania

• Lack of insight

• Psychotic symptoms

• Risk of self harm or to others

4. Symptoms of anxiety

Divided into 4 types:

• Physical: tachycardia, hyperventilation, sweating, shaking, nausea, dizziness, dry mouth, fatigue

• Cognitive: excessive worry, difficulty concentrating, catastrophic thinking

• Emotional: irritability, restlessness, panic

• Behavioural: avoidance of situation, unable to leave house, compulsiveness

4. Principles of assessment

• Anamnesis, Psychiatric history, medical history and treatment, family history, presenting complaints.

• Mental status examination: Appearance, behaviour, speech, mood, thoughts, perception, cognition, insight.

• Risk assessment, substance use, physical examination

With focus on:

• nature and intensity of anxiety, duration and course, triggering situations, impact on daily life, suicidal risk/harm to others risk

4. Clinical disorders according to ICD-10

• F40-F48 - Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders

Generalized anxiety disorders (F41.1) Panic disorder (F41.0) Phobic anxiety disorders (F40)

• Mood (affective) disorders (F30-F39)

• Psychotic disorders (F20-F29)

• Substance related or withdrawal state (F10-F19)

• Organic mental disorders (F00-F09)

5. Cognitive symptoms

Cognitive symptoms involve impairments or abnormalities in mental processes, such as memory, attention, language, executive function, and visuospatial abilities.

• Disturbances in consciousness - clouding, delirium, stupor

• Memory impairment in retention, recall, registration

• Attention and concentration - reduced attention span, high distractibility

• Executive function and thinking - slow thinking, impaired planning, poor judgement’

• Language and perception - aphasia, apraxia

• Orientation - time, place, person

• Confusion

5. Principles of assessment

• Anamnesis, past psychiatric and medical history and treatment, personal history and premorbid personality, family history, presenting complaints

• Mental status examination: appearance and behaviour, speech, mood, thoughts, perception, cognition and insight

• Rule out organic causes

• Risk assessment, substance use (toxicology screening) and physical examination (blood tests, EEG, brain imaging (CT,MRI))

• GCS + Montreal cognitive assessment

5. Clinical disorders according to ICD-10

6. Aetiology and pathogenesis of schizophrenia

Exact cause unknown.

Combination of genetics (genes susceptible: dysbindin, COMT), neurological factors (dopamine dysregulation, hyper + hypo-activity in mesolimbic system) and external factors (perinatal, life events, substance abuse)

6. Vulnerability model of mental disorders

Process where schizophrenia manifests when a biological or psychological vulnerability (diathesis) interacts with stressful events in life. Explains variability in onset, course & relapse

6. Positive and negative symptoms of schizophrenia

Positive - “what the disease adds”

• Hallucinations

• Delusions

• Thought control: insertion/withdrawal/broadcast

• Catatonic behaviour

• Disorganised thought and speech

Negative - “what the disease takes away” 5 A’s

• Affective flattening (emotion)

• Alogia

• Avolition

• Social withdrawal (Asociality, Anhedonia)

• formal though disorders, abstract

+cognitive symptoms

7. Prevalence and diagnostic criteria for schizophrenia (F20) according to ICD-10

• Lifetime prevelance: 1% of world population

• Incidence: 15-30/100,00/per year

• Onset: earlier in men (adolescence), later in women

• Male: female ration 1.4:1

7-9. Management strategy and recommendations, for patients with acute psychotic symptoms

1. Hospitalise patient

2. Ensure safety: patient and health care workers.

3. Create a low stimulus environment

4. Pharmacological treatment: Benzodiazepines: Diazepam 1–3 mg iv only if needed (agitation, anxiety). Antipsychotics: olanzapine 5-10mg or haloperidol 1-5 mg

5. Non pharmacological interventions: CBT, psychoeducation, social support, family involvement, social skills training, family therapy

6. Monitoring

8. Epidemiology, clinical features and basic diagnostic criteria for Acute and transient psychotic (F23) and Schizoaffective (F25) disorders according to ICD-10

Acute and transient psychotic (F23)

Epidemiology

• 4 per 100,000 per year. 6% of all first-episode psychoses

• More common in young adults, women > men

Clinical Features and Diagnostic criteria

• Presence of psychotic symptoms (hallucinations, delusions, disorganized thinking, grossly disorganized or abnormal motor behaviour)

• Absence of mood symptoms

• Acute onset of psychotic symptoms

• Duration - At least 1 day, less than 1 month. Abrupt onset and resolution - Usually self-limiting or remitting course.

• Spontaneous relief within weeks-months - Complete recovery within 1-3 months

• Symptoms may be Polymorphic, Schizophrenia-like

• No evidence of organic or substance use

• Does not meet criteria for schizophrenia (duration too short)

Schizoaffective Disorder (F25)

Epidemiology

• 0.5-0.8% of population, women > men

• Prevalence: later onset in women than men

Clinical Features and Diagnostic criteria

• Psychotic symptoms (period of at least 2 weeks) - hallucinations, delusions, disorganized thinking, Negative symptoms: diminished emotional expression, reduced motivation, social withdrawal, impaired cognitive functioning.

• Mood symptoms (one affective disorder) - depressive symptoms, manic symptoms

• Both present simultaneously or separate (with days in between) for a substantial period

• Criteria of schizophrenia and mood disorder must be met

• Exclusion of organic mental disorder (F00-F09) Or substance induced causes (F10-F19)

9. Basic biopsychosocial treatment and rehabilitation principles of Schizophrenia

9. Pharmacological and non pharmacological treatment possibilities (schizophrenia)

9.Types of extrapyramidal side effects of antipsychotic medication and their management

• Acute dystonia

• Parkinsonism

• Akathisia

• Bradykinesia

Management: Trihexyphenidyl (centralM-cholinoblocker) & Benzodiazepines for spasms and tremor

10. Essence of organic and symptomatic mental disorders

Organic and symptomatic mental disorders (F00-F09) are psychiatric syndromes caused by identifiable brain damage, disease or systemic illness affecting brain function. Where the mental disorder is a direct consequence of the underlying condition

10. Most common clinical features and diagnosis according to ICD-10.

• Cognitive impairment : Memory loss, impaired attention, executive function, disoriented

• Reduced level of consciousness

• Emotional liability

• Behavioural changes

• Psychotic symptoms: hallucinations, delusions

• Personality changes: irritability, apathy, emotional

• Fluctuating course

• Seizures

• Delirium

10. Causes of organic brain disorders

Primary CNS causes

• Neurodegenerative

• Cerebrovascular disease

• Brain tumours

• Traumatic brain epilepsy

• Epilepsy

• CNS infections (HIV, HSV, meningitis, encephalitis … )

Secondary - Systemic causes

• Metabolic disorders: hypoglycaemia, electrolyte balance

• Endocrine disorders: E.g. Thyroid disease

• Hypoxia

• Vitamin deficiencies: B1, B9, B12

• Toxic or medication effects

• Severe systemic illnesses

10. Diagnostic assessments, differential diagnoses

Based on clinical and objective evidence

• History of organic disease or medical condition

• Psychiatric assessment and mental status examination

• Neurological examination

• Cognitive testing - Neuropsychological testing (MMSE, MoCA)

• Laboratory investigations - Imaging - CT/MRI - EEG - If indicated

• Temporal relationship between brain and disease and psychiatric symptoms

• Improvement of mental symptoms when underlying cause is treated

11. General description of dementia, reversible and non-reversible causes

Chronic brain syndrome. Its main feature is memory impairment without impaired consciousness. Dementia arises from an organic disease, known aetiology. Impairment of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language and judgment.

Reversible causes

• Depression

• Metabolic: Vit B9/B12 deficiency, hypothyroidism, other metabolic disorders

• Pressure: Normal pressure hydrocephalus, subdural hematoma, brain tumours

• Infections: neurosyphilis, HIV, meningitis, encephalitis

• Toxic: alcohol-related, heavy metal poisoning

• Medication: side effects (anticholinergics, sedatives)

Non-reversible

• Neurodegenerative: alzheimer’s (50%), Lewy body dementia, huntington’s

• Frontotemporal dementia

• Vascular dementia (20-25%): strokes, ischemia

• Parkinson’s dementia

• Prion disease: Creutzfeldt-Jakob disease

11. Clinical features of dementia, general diagnostic criteria according to ICD-10

• Decline in recent memory, thinking and judgement, orientation, language,

• Impairment in abstract thinking

• Patients often appear apathetic or disinterested, but may appear alert and appropriate despite poor memory,

• Decline in everyday functioning (dressing, washing, cooking),

• Personality change: Loss of emotional control, patients may be easily upset, tearful or irritable.

• Common in older patients, very rare in youth or middle age

11. Differential diagnoses of Dementia, basic principles of treatment and care

Treatment and care

• Treat reversible cause!

Start with non pharmacological treatment

Non pharmacological treatment focusing on maintaining QoL.

• Orientation aids - routine, calendar, clock, pictures, notes

• Regular exercise, nutritional support, safety interventions: restrictions on oven and doors, carpet

• Social day care, environmental (quiet, well-lit room, calm clean)

• Memory therapy

• Psychomotor therapies - dance, drama, singing, sport, music art

• Cognitive stimulation therapy

Pharmacological treatment when appropriate

• Dementia medication: Donzepil 5-10mg x1, Rivastigmine 6-12mg x2, Memantine 20-30mg x1

• Psychotic events: Olanzapine 2.5mg (short term only)

• Depression: Sertraline 50mg/day

11-15. Management strategy and recommendations, if patient has a delirium !!

12. Epidemiology, aetiology, risk factors of Alzheimer’s disease

Epidemiology: 50-70% of dementia cases and 5-8% of patients >65 years. 20% above 80 years.

Aetiology is multifactorial. Genetics in early cases, sporadic in late onset, neurobiological mechanism, environmental factors and lifestyle (comorbidities and socioeconomic status → AH, DM, hyperlipidemia, obesity, head trauma, low education, smoking, poor diet, physical inactivity.

Risk factors

• Age >65y, increasing age

• female

• Risk is 4-5x higher if relative suffered from AD: familial. Autosomal dominant mutation

• Traumatic brain injury

• Alcohol misuse

• 2 copies of either of these genes alleles: apoE4, apoE2, apoE3.

• Poor education

• Sleep disorders

• Lifestyle factors

• Depression

12. Possible pathophysiological mechanisms of AD

1. Amyloid-beta plaque and tau deposition extracellular

2. Neurofibrially tangles

3. Progressive neural and synaptic loss and brain atrophy (neuronal loss)

4. Predominant involvement - Hippocampus - Memory, spatial navigation, learning. Temporal and Parietal lobes

5. Cholinergic deficit → Reduced acetylcholine (ACTH) transmission

12. Clinical features and prognosis of dementia in Alzheimer's disease (F00)

Prognosis: the cognitive decline is progressive and non-reversal but can be slowed with medication (no curative treatment). Death is usually between 5-8 years of onset. Neurological signs and psychotic episodes have worse prognosis.

Clinical Features + Diagnostic criteria according to ICD-10 (Q13) :

Development of multiple cognitive deficits >6 months

1) Memory impairment (impaired ability to learn new information or to recall previously learned information).

2) One (or more) of the following cognitive disturbances: a. Aphasia (language disturbance) b. Apraxia (impaired ability to carry out motor activities despite intact motor function) c. Agnosia (failure to recognise or identify objects despite intact sensory function) d. Disturbance in executive functioning (i.e. planning, organising, sequencing, abstracting)

Personality changes

The cognitive deficits cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning. The course is characterised by gradual onset and continuing cognitive decline.

Exclusion of other possible causes of dementia

Absence of disturbances in consciousness

13. Clinical features, diagnostic criteria and differential diagnosis of dementia in Alzheimer's disease (F00) according to ICD-10

‘‘ (answered in Q12)

Differential diagnosis

• Vascular dementia (F01)

• Delirium (F05)

• Depression (pseudodementia)

• Dementia with lewy-bodies

• Normal aging

• Medication or substance side effects

• Mild cognitive impairment

• Metabolic disorders

• Structural brain abnormalities

• Neurodegenerative disorders

10-13. Pharmacological and non-pharmacological treatment possibilities for AD

Non pharmacological treatment focusing maintaining QoL.

• Orientation aids - routine, calendar, clock, pictures, notes

• Regular exercise, nutritional support, safety interventions: restrictions on oven and doors, carpet

• Social day care, environmental (quiet, well-lit room, calm clean)

• Memory therapy

• Psychomotor therapies - dance, drama, singing, sport, music art

• Cognitive stimulation therapy

Pharmacological treatment when appropriate

• Dementia medication: Donzepil 5-10mg x1, Rivastigmine 6-12mg x2, Memantine 20-30mg x1

• Psychotic events: Olanzapine 2.5mg (short term only)

• Depression: Sertraline 50mg/day

141-14. Epidemiology, aetiology, prophylaxis of Vascular dementia (F01)

Epidemiology: Vascular dementia is the 2nd most common cause of dementia after Alzheimer's disease. It accounts for approximately 10-20% of all dementia cases. It's more common in older age groups. More common in Men, typical onset after 65