A 40 years old man attends your outpatient carrying his CT scan brain which is suggestive of space-occupying lesions in the parietal lobe. a) What clinical signs would you look for while examining this patient? b) How would you elicit those signs?

Single-photon Emission Tomography SPET

Single-photon Emission Tomography SPET

Principle

uses single-photon (gamma-ray) emitting isotopes

given IV or inhaled

the resolution is lower than PET

Uses

SPET can give information about:

regional cerebral blood flow

ligand binding

Clinical uses include:

Alzheimer’s disease

When the symptomatology (e.g. hallucinations, epilepsy) occurs when the patient is not near a scanner; we can give a suitable ligand at the material time and the patient scanned afterward

Schizophrenia

reduced rCBF in frontal regions—‘hypofrontality’

Affective disorders

as that in schizophrenia, with reversal after antidepressant therapy

Alzheimer’s disease

decreased rCBF in posterior parietal and temporal regions

Xenon inhalation

Shows the failure of activation of frontal lobes in schizophrenics performing the Wisconsin Card Sorting Test

FCPS-2 March 2006 College of Physicians and Surgeons 

Q.1 A 55 years old feudal - lord presents with over six weeks' history of inability to ” face the world”, disinterest in sex, suicidal thoughts, and weight loss. He relates his current plight to losing a large sum of money and a part of his fortune in gambling:

1. What will be the differential diagnosis in this case?
2. What investigations you should undertake?
3. Draw a comprehensive management plan for this patient

History taking, Mental state examination, and making a diagnosis

What body language and behavior used are most suitable while taking psychiatric history?

What is an open-ended question?

What question could you ask the patient after they have stopped volunteering their symptoms?

"What other changes have your partner/family/friends noticed in you?"

What is the definition of Command hallucinations?

A voice or person telling them to do things

PMH relevant to ask about in a psychiatric history

1. Developmental problems 
2. Head injuries 
3. Endocrine abnormalities 
4. Liver damage
5. Esophageal varices 
6. Peptic ulcers (can show if alcohol problems) 
7. Vascular risk factors

What to ask about alcohol/illicit drug use?

1. Regular or intermittent
2. Amount (know the units)
3. Pattern Dependence/withdrawal 
4. Impact on work, relationships, money, police 
5. Screening questionnaires e.g. CAGE

What to ask in a forensic history

1. Offenses including sentences
2. Recidivism 
3. Particular attention to violent or sexual crimes

Recidivism meaning

Tendency to re-offend

History taking, Mental state examination, and making a diagnosis

Mental state examination involves...

1. Appearance Behavior
2. Mood Affect
3. Speech 
4. Thoughts 
5. Beliefs 
6. Perceptions 
7. Suicide/homicide 
8. Cognitive function 
9. Insight

What is looked at when assessing appearance?

1. Height/build
2. Clothing (appropriate, kempt, bizarre) 
3. Personal hygiene 
4. Makeup 
5. Use of Jewelry

What is looked at when assessing behavior?

1. Greetings 
2. Non-verbal cues 
3. Gesturing 
4. Abnormal movements (tremor, posturing, etc)
5. Response to unseen stimuli 
6. Cooperative, rapport 
7. Evidence of intoxication, or 
8. medication side effects

What is looked at to assess mood?

1. Self-rating scale
2. Eye contact
3. Affect 
4. Psychomotor function (retarded, agitation)

What is looked at when assessing speech?

1. Spontaneity
2. Volume (loud, quiet, poverty)
3. Rate (pressured, slowed)
4. Rhythm (rhyming and punning)
5. Tone (monotonous, lilting)
6. Dysarthria 
7. Dysphagia (expressive, receptive)

What is an illusion?

When the stimulus is there, but you may interpret something different

What is a hallucination?

There are no stimuli, but they see something these

What domains can abnormal percepts be experienced?

Auditory-Visual Somatic/tactile Olfactory Gustatory

What should be asked about suicidal thoughts?

Ideation Intent Plans (vague, detailed, specific, already in motion) Also the homicidal risk

What is used to assess cognitive function?

Orientation Attention/concentration Short term memory (3 objects, name, and address) Long term memory (personal history) If any concerns perform objective tests e.g. MSQ, MMSE, executive function tests)

History taking, Mental state examination, and making a diagnosis

The most key symptom of depressive disorder

Low mood

History taking, Mental state examination, and making a diagnosis

What indicates more likely to kill yourself?

The more effort you make to kill yourself

History taking, Mental state examination, and making a diagnosis

What does tolerance mean with respect to drinking?

You need to drink more to have the same effect.

History taking, Mental state examination, and making a diagnosis

How long roughly does citalopram take to work? (anti-depressant)

About 2 weeks

History taking, Mental state examination, and making a diagnosis

Hypothyroid is related to what psychiatric disorder?

Depression

Hyperthyroid is related to what psychiatric disorder?

Anxiety

What does the premorbid personality look at?

Are they different now from what they were normally like before?

History taking, Mental state examination, and making a diagnosis

Definition of psychopathology

Concerned with abnormal experience, cognition, and behavior

Definition of Descriptive psychopathology

Describes and categories the abnormal experience as described by the patient

Definition of phenomenology

Refers to the observation and understanding of the psychological event or phenomenon so that the observer can as far as possible know what the patient's experience feels like

Mood definition

Generally held to be the patient's subjective report on their current mood state in terms of how they rate themselves from depressed through euthymic (neutral) to elated

How do you define Affect? 

Affect held to be the emotions conveyed and observed objectively during an interview in terms of- types of affect observed - range and reactivity of affect - Congruity of affect

Low mood and psychotic symptoms together mean what?

Severely depressed

Definition of Delusion

An unshakable idea or belief which is out of keeping with the person's social and cultural background

Broadly 3 classes of perceptual disturbance

Hallucinations Pseudo hallucinations Illusions

Features of hallucinations

Have the full force and clarity of true perception Located in external space No external stimulus Not willed or controlled

What should insight be conceptualized as?

A spectrum - rarely 100% absent or present

3 Questions for the continuum of insight

Do you think you are ill? If you are ill, is it a mental illness? If you are ill and it is a mental illness, do you agree broadly with the current treatment plan?

Symptoms of a depressive episode

Persistent sadness or low mood Loss of interests and pleasure Fatigue or low energy At least one of these, most days, most of the time for at least two weeks (above)disturbed sleep poor concentration or indecisiveness low self-confidence Poor or increased appetite suicidal thoughts or acts agitation or slowing of movements guilt or self-blame

How many symptoms are classed as a mild depressive disorder?

4

How many symptoms are classed as moderate depressive disorder?

5-6 symptoms

How many symptoms are classed as a severe depressive disorder?

seven or more symptoms, with or without psychotic symptoms

What is the SSRI choice in children and adolescents?

Fluoxetine

The Experience of the Patients Taking Part in the MRCPsych Examinations 

This is a draft article on the experience of the patients taking part in the MRCPsych examinations that we will soon republish in a clear format, referencing the original source. This is one of the many other articles I am making available here. The purpose is to find all the evidence regarding the RCPsych Exams and make them accessible to help researchers and students prepare for the MRCPsych Examinations. These articles are already available in journals, particularly the BJPsych Bulletin, albeit in the least-accessible format. We are thankful that the Royal College has published previous print-only articles as scanned PDFs under the Creative Commons license. I am trying to review them, enhance them for clarity and readability, and make them available as text. These adaptations are currently NOT creative-common. We will soon discuss and hope to make them available under a similar license so everyone can benefit by sharing them anywhere.

Darina Sloan, Laura Mannion, Gregory Swanwick, and James O'Boyle

Studies have highlighted Candidates' views regarding examinations in psychiatry in recent years. Few studies to date, however, have examined the views of the patients themselves toward the examination procedure. This study examines the knowledge and experience of a patient group taking part in the College membership examinations. Providing patients with written information prior to the examinations significantly improves their knowledge and experience of the exam procedure.

The participation of patients in the MRCPsych examinations is central to the current format of the clinical exam. Although studies have documented the stressful impact of this experience on the candidate (Williams et al., 1995: Marcus, 1996), and the views of the examiners (Mindham, 1995), researchers have paid little attention to the views of the patients themselves. A study by Persaud et al. (1990) examined the experiences and views of 21 patients who had taken part in the MRCPsych examinations. Prior to taking part in the MRCPsych examinations, the patients had received verbal counseling regarding the purpose and format of the examinations. I interviewed all 21 patients after the examination and questioned them regarding the purpose of the exam, their knowledge of the examination procedure, and their personal views of the experience. The results showed that 29% (n=6) of the patient group found their experience to be distressing. Thirty-eight percent (n=8) of patients said that they would not like to take part in the examinations again in the future. Despite the prior tuition regarding the purpose and format of the examinations, 38% (n=8) of patients failed to recall this information subsequently. Nine percent (n=2) of patients in this study were unaware that participation in the examinations was entirely voluntary. All patients were pleased with the amount of payment received, and most of the group had full recollection regarding details of payment.

Most of the patients viewed the candidate positively, although five (23%) reported that the candidate carried out a physical examination and it surprised them. Interestingly, some patients from this group found the fact that doctors could appear to be nervous rather distressing, although this also allowed them to perceive doctors as being more 'human'. Most of this patient group described their exam experience positively. Persaud et al. (1990) conclude that further, we need research in this area. The purpose of our study was first: to examine patients' experiences during the exam and their Knowledge of the exam procedure and second: to investigate if the provision of written explanatory instructions regarding the examination affected their experiences and knowledge.

Discussion

Our findings show that taking part in the MRCPsych examinations may be a stressful event for some patients. Despite prior tuition, patient-participants in our study displayed a considerable lack of knowledge about important aspects of the exam procedure, for example, including a physical examination. The study by Persaud et al. (1990) also found deficiencies in patient knowledge, again despite prior briefings. However, their report of overall positive response in the patient group towards exam participation was in keeping with the positive views expressed by our own population.

Sixty-five percent of our verbally prepared group and 31 % of the group whom we had given written preparation, found the examination distressing, as compared to 29% in the Persaud et al. study. Events that patients found to be distressing were, however, comparable in both patient groups. Receipt of written instructions regarding the exam followed a significant reduction in reported levels of anxiety. All candidates in our study said they would be happy to take part in the exams again if asked and finding contrasts with the eight patients (38%) of the sample from the study that Persaud et al. did, who showed that they would not like to take part in the MRCPsych examinations again. Although the College had informed the patients in our study and those in Persaud et al. study on the payment they would receive, it is of interest that no patient group had a universal recollection of this. Patients in both studies thought that the amount of money they received was adequate. Both studies revealed that they viewed the candidates positively and with a certain amount of sympathy. 

The results highlight an area of inquiry that researchers have neglected. However, our study takes this line of inquiry a step further by investigating the effect of a simple intervention, i.e. the provision of written instructions to take part patients on patients' attitudes and knowledge. It would appear to be important to prepare candidates individually for their participation in the examinations.

Many of the events which caused anxiety and distress in both patient groups appeared to have their basis in insufficient Knowledge. Despite prior tuition in exam format, some patients may still forget certain details. We recommend the provision of written instructions, besides the routine assessment of patients' views and experiences following each set of examinations.

Patients contribute importantly to the successful running of the MRCPsych examinations. We feel that any study which examines their views and experiences following participation in the examinations will be of benefit not only to exam organizers but also to taking part candidates in the future.

Evaluation of a Psychiatric Training Scheme

With interest the article 'Evaluation of a Psychiatric Training Scheme' by Khan and Oycbode (Psychiatric Bulletin, March 1993, 17, 158-159). We have kept similar records for the Mersey Region Training Scheme - formerly the Liverpool Training Scheme, and have published data from them in the Bulletin (Birchall & Higgins, 1991). Our records now cover seven years from August 1985to July 1992and it is interesting to compare the two schemes. The Mersey Region Training Scheme now covers all psychiatric units in the Mersey region and includes 37 registrar posts and 49 senior house officer posts, although 12-16 SHO posts are usually filled by general practice trainees. Most psychiatric trainees join the Mersey Scheme at SHO level, often straight from house officer posts. This results in a fairly high dropout rate at the SHO level. From 112 to 434 leaving the scheme in the seven years, 50 of them left without completing four years of training in psychiatry, and of these 16 went into general practice and 19 Continued psychiatric training either part-time in the Mersey region or full-time elsewhere. In our paper mentioned above, we found that the average length of stay in the scheme for these trainees was 1 year 7 months. If only the trainees who completed four years of psychiatric training are considered, out of 62 trainees (100%), 39 (63%) gained senior registrar posts, eight (13%) went abroad, either immigrating or returning home, and only five (8%) failed to pass the 

MRCPsych examinations. improves the trainees' chances of passing the Membership examinations and of obtaining senior registrar posts. The advantage of a region-wide scheme such as the Mersey Scheme is that all trainees gain experience of working in the peripheral hospitals and in the teaching hospitals and therefore all trainees in the region enjoy equal opportunities for progression in their career.

Source

Khan, A, Oyebode, F. Evaluation of a psychiatric training scheme. Psychiatr Bull 1993; 17: 158–9.

FCPS-2 Psychiatry Paper CPSP October 1992

College Of Physicians & Surgeons, Pakistan

F.C.P.S. PART II EXAMINATION - OCTOBER 1992

SUBJECT:  PSYCHIATRY

Paper-I

Instructions:

1)  Answer all questions.

2)  Use separate answer books for each question.

  Answer the following briefly:-

a)    Name five laboratory and four radiological investigations that you would consider while investigating dementia

b)     Enumerate five consequences of the victims of child sexual abuse.

c)     Name five behavioral methods that are effective in the treatment of obsessional disorders.

d)     What are the current indications of psychosurgery? Name four complications and what is its mortality rate.

e)     ’Define therapeutic factors in group psychotherapy. Who described them? Name ten of these factors.

f)      Name five causes of Wernicke's encephalopathy. What are the three principal features of this syndrome?

g)     Define the term ” alexithymia”. Who coined it? Name five of its essential features.

h)   Name five clinical features of turner’s syndrome. Name two laboratory analyses for this condition.

2.     Nausheen, a 16-year-old stage dancer, was taken to the psychologist by her mother. She complained that ever since she and her heroin addict husband had separated six months ago, her daughter had been ’out of control ’ . About this time Nausheen was caught shoplifting earrings from a general store because ’ I just liked them and waved them ’ as she explained. In subsequent weeks nausheen started crying at the slightest provocation and complaining that she felt ugly and she began locking herself in her bedroom. Each evening after a typically small dinner. Stopped taking breakfast before leaving for school and her teacher reported in confidence that nausheen had been seen smoking at lunchtime. When nausheen complained of always ’being tired and having stomach aches, her medical check-up reveals so low serum potassium mildly elevated bun, swollen but painless parotid glands, and an unusual scarring and callus formation on the .dorsum of second and third fingers of her right’, hand. The family doctor suggested she begin eating her breakfast and not worry so much about her weight. After all 115 ibs vas just right for her height of 5 ’ 3”. On his suggestion ’ nausheen was taken to the psychologist. There she was counseled for a few weeks about accepting her parent’s separation. 

A dentist finally made the correct diagnosis during nausheen’s annual check-up.

 

a)      What is the most likely diagnosis?

b)     What  led  the  dentist to make  the  correct diagnosis?

c)      This problem has been compared to substance Abuse.

d)     What features do these diagnoses have in Common?

e)      Describe the salient features of the disorder.

f)      What medication can be prescribed for this patient?

 

3. Write an essay on psychiatric aspects of liver disease.

 

4. “All psychiatrists are neurologists,  but the psychiatrists don’t know this ” In the light of this statement critically evaluate with references to recent research and literature review. Is the concept of fronto-subcortical dementia relevant to schizophrenia?

 

5. Answer the following briefly:-

 

1. Define akathisia. What causes it?

2. What neurotransmitters it involves?

3. Name three contraindications of performing a lumbar puncture.

4.  Name three hematological and three metabolic disturbances  (other than endocrine changes) encountered in anorexia nervosa.

5. What are the five axes of the ICD 9 for the classification of child psychiatric syndromes?

6. name ten favorable prognostic factors in anorexia nervosa.

7. Regarding the pathology of Alzheimer's disease, describe four macroscopic and five microscopic changes.

8. An obstetrician has asked you about the managhmen’i1 of lithium during pregnancy. What advice would you give?

9. You have been asked by the relative of an elderly intermittently confused man whether he is mentally fit to make a will. Name four factors that you would consider.

10. Define pseudo-dementia. Name four different ways in which we can differentiate it from dementia. Name six causes of pseudodementia.

 

6. Critically evaluate the work done to study the behavior simulating suicide. How would you assess such a case, in particular, the prognosis of the case?

 

7. Describe briefly the psychological basis of the adolescent question ” who am I”? Write brief notes on:-

 

1. Biological and psychological aspects of criminal behavior.

2. Proposed mental health act of Pakistan 1992

 

8. Write an essay on the ways in which mental health services might best work with primary care and general medical services. Discuss the public health implications of such a model.