n (Constantly updated for online subscribers) Plab1 [Link] PAs Psych iatry ey Strict Copyrights! KEYS KEYS No Sharing or Copying Allowed by any means Compensations and Version 4.6| Penalties Worldwide System is Active (Corrected|, |\Updated), Lighter, ith the Most Recent Recalls and the UK G ie: ATTENTION: This file will be updated online on our website frequently! (example: okt) , and so on) Key Important Forms of Delusion LXE a LcciR sacs) A false belief that insignificant remarks, events, persons, or objects in one’s environment have personal meaning. Examples, @ A person thinks that a TV show presenter/ female newscaster is directly communicating to him when she looks at the camera and when she says some words. Copyrights @ [Link]2|Pege [Psychiatry] ©Copyright [Link] (Constantly updated for online subscribers) @A person thinks that someone constantly gives him special messages through the newspaper. @A person believes that another person on the billboard outside his window is sending messages that are meant specifically for him. lusion of Control A false belief that another person or group of people or external force controls his actions, thought, behaviour, feelings, or impulses. Examples, BA man says that his friend had made his own right arm to swing out to hit a stranger. His friend was at home. Delu: Cat Feeling guilty or remorseful for no valid reason (for something that a person has not committed). Examples, @! am responsible for the war/ hurricane/ floods that occurred in the city or in another country and thus | need to be punished! Copyrights @ [Link]31 Poe yehiatry] ©Copyright w [Link] (Constantly updated for online subscribers) (Cle reCsbea Pec) Delusion of Grandiosity) Aperson he/ she is famous, powerful, wealthy, have exceptional abil talents, and keep praising themselves. Examples, A person thinks he is powerful and helps the prime minister. A person thinks he will become a king or god later in life. One believes that he is treated with malicious intent, hostility “unfriendly way”, or harassment. Examples, They hate me, they meant to spy on me, they are plotting to harm me, they are following me to harm me. Key ns related to [Unexplained Symptoms There are a wide variety of psychiatric terms for patients who have symptoms for which no organic cause can be found: v Multiple physical SYMPTOMS Copyrights @ [Link]4|Pege [Psychiatry] ©Copyright [Link]‘[Link] (Constantly updated for online subscribers) “SoMatisation = So Many symptoms and investigations with no physical cause” v Patient refuses to accept reassurance or negative test results. Exannples A30 YO (9) complains of abdominal pain, headache, shortness of breath, unsteadiness, palpitations, and numbness of lower limbs for several months. ECG, X ray, Neurological examinations, and abdominal ultrasounds show normal findings. > Somatisation disorder, Persistent belief in the presence of an underlying SERIOUS DISEASE, e.g. Cancer, HIV Hypo=under > underlying SERIOUS DISEASE. Patient again refuses to accept reassurance or negative test results [Exannples & A woman persists that she has pancreatic cancer just like her dead husband. oA woman persists that she has HIV despite several negative screening tests. @ A person believes that his benign lump is a cancer despite all reassuring investigations. oA minor headache is caused by a brain tumour. O Tiredness is caused by HIV. 5 A mild rash is the start of skin cancer. Copyrights @ [Link]5|Page [Psychiatry] ©Copyright [Link] (Constantly updated for online subscribers) The intentional production/ falsification/ fabrication of physical or psychological signs and symptoms mostly to obtain medical attention and treatment. Exanpld & A woman always presents to the hospital complaining of abdominal pain and bloody stools. She brings a stool sample from home and is never able to produce a stool sample at hospital. Her stool samples and urinalysis are normal. This is the third time in the same month she visits the hospital. Her abdomen shows multiple scars of laparoscopies. She insists on getting more investigations although no abnormalities are found. > |Munchausen’: syndrome (She is likely to be intentionally inserting blood into her stools at home to seek medical attention. Previous laparoscopies are done looking for the cause of her symptoms and abdominal pain but none has been found. She still insists on more medical attention! She has abdominal pain but as doctors cannot discover the cause, she is fabricating signs “putting blood her stools” so they can care more). Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain. (e.g. for compensations, to avoid military service, to obtain an opiate prescription). Copyrights @ [Link]6|Pege [Psychiatry] ©Copyright [Link] (Constantly updated for online subscribers) v Typically involves loss of motor or sensory function without organic cause. Dissociative = Sensory loss “and or motor” v The patient doesn’t consciously -intentionally- feign “fabricate” the symptoms (factitious disorder) or seek material gain (malingering) v Patients may be indifferent to their apparent disorder — la belle indifference -. Exampled @ A 30 YO female is brought to hospital with limbs paralysis that developed after she has witnessed a card accident. She cannot remember what happened. > [Conversion disorder (loss of motor/ sensory function) without organic basis. A 29 YO female witnessed a tragic car accident in which a boy had died. She could not sleep remembering the event. The following morning, she woke up unable to see. She has no previous medical or psychological history. > [Conversion disorder (loss of motor/ sensory function) without organic basis. vA person deliberately and consciously acts as if he or she has a physical or mental illness when he or she is not really sick. v People with Ganser syndrome mimic behaviour that is typical of a mental illness, such as schizophrenia. v Ganser syndrome is sometimes called “Prison Psychosis” because it was first observed in prisoners. Copyrights @ [Link]7|Pege [Psychiatry] ©Copyright [Link] (Constantly updated for online subscribers) (remember: Ganser = Gangster “prisoners” who claims mental illness to get a parole — release -). Exannpled Aprisoner was taken to hospital. He complains of hallucination. When he is asked questions, he provides wrong answers but in the correct category. E.g. when asked who is the prime minister of England, he answers “Bill Clinton”. ~ [Ganser Syndrome Key Cotard’s delusionEg(Ni tic delusion) ¢ The affected person holds the delusional belief that they are already dead, do not exist, are putrefying, or have lost their blood or internal organs. Also, the world has ended, nothing matters anymore, and any effort is pointless. * It is seen in psychotic depression and schizophrenia patients. Copyrights @ [Link]SOR ac Be al ear CTE Solar Mol me ara Le ice Pe ame Cg et MMe CT) i Nem Cen ee eR Pe eee ame any effort is pointless. For All FULL Notes on All Chapters — Visit Our Web: @D[eeetookcom/plabakeys | iplab-aheys | [Link] 1Ke) Note that it is not always about thinking of being “dead”. Example (2) Aman thinks that he does not have bowel and limbs and no one cares about it. > \Nihilistic Delusions, Another name > (Cotard’s delusion]. It is seen in psychotic depression and schizophrenia. Example (2) Aman believes that he is already dead and smells likely a rotten meat. He also lacks interest in life, daily activities and social interaction. He refuses to eat or Copyrights @ [Link]9|Pege [Psychiatry] ©Copyright [Link] (Constantly updated for online subscribers) drink. He has no history of mental diseases. He lives alone and do not go out his home. Of the following, what is the most likely diagnosis? [Schizophrenia — Depression — somatoform disorder]. This patient shows: Nihilistic delusion (He believes that he is dead) + Depression features (lack interest in life, social interaction, food, ...etc) > Psychotic depression. Of the given options, the most accurate answer — |Depression|. Although nihilistic delusion can be seen in psychotic depression and schizophrenia, the other given features are more in line with depression. Key lusional Misidentification 4 People who experience this syndrome will have an irrational belief that someone they know or recognize has been replaced by an imposter “pretender”. They may, for example, accuse a spouse of being an imposter of their actual spouse. Example, > “You look identical to my husband but you are not him “! Example, > “A Young man is not allowing his father to enter the house as he thinks he is replaced by an identical looking imposter “! Copyrights @ [Link]Page [Psychiatry] ©Copyright v com (Constantly updated for online subscribers) Aperson holds a delusional belief that different people (more than one) are in fact a single person who changes appearance or is in disguise (Masked). Example > “A Young man thinks that every old man he meets is actually his father even though they look different but he is sure that they are his father but wearing a different disguise “! # You look like him and pretend you are him but you are fake (not him) > Capgras & These 2 people are one person but changes his appearance > Fregoli Key {important Scenarios and Medications Related to Alcohol-Cessation] MAn alcoholic wants a medication to help reduce wit > |Chlordiazepoxide. al symptoms. MAcute alcohol withdrawal symptoms (sweating, agitations, tremors, altered mentation) > {Chlordiazepoxide “First” + then give [Thiamine (Vit. B1) Mit with “seizure” or “Hallucination” [i.e., Delirium Tremens] > |IV Lorazepam. Or Diazepam| “If lV Lorazepam is not in the options) v. MWernicke’s encephalopathy (CAS: Confusion, Ataxia, Squint: ophthalmoplegia, Nystagmus, diplopia), > |IV Vitamin B1| = (Thiamin = (lV Pabrinex)) = [High potency Vitamin B Complex). Copyrights @ [Link]11[ Page [Psychiatry] ©Copyright [Link] (Constantly updated for online subscribers) Man alcoholic wants a medication to serve as a Deterrent when he takes alcohol “Abstinence” > sulfiram], MAn alcoholic wants a medication to reduce his Craving for alcohol > Acamprosate, 3 days post-hernioplasty, a 55 YO patient has become agitated, aggressive, confused and developed auditory hallucination. Hb (normal), MCV 112 (high), Gamma-GT (high), ALP (normal). The most appropriate management > Lorazepam. v Although this stem does not mention a Hx of chronic alcoholism, we can spot this from the raised MCV and GGT. Note, in a stem with post-operative patient develops confusion, aggressiveness, suspect > [Chronic alcohol consumption). v Since the patient has NOT been drinking for 3 days, he developed Delirium tremens (Hallucination is the clincher). v If the symptom developed in 6-24 hours after the surgery and there was no hallucination or seizures, it would only be “Acute Withdrawal Symptoms” such as sweating, tachycardia, anxiety, tremors. We would give > Chlordiazepoxide in this case. v If CAS (Confusion, Ataxia, Squint: ophthalmoplegia/ Diplopia), this would be Wernicke’s encephalopathy. We would give Copyrights @ [Link]12| Page [Psychiatry] ©Copyright [Link] [Link] (Constantly updated for online subscribers) > Thiamine (Vit B1) Example 2 On the fourth day post-operative day, a woman has become confused and she sees spiders on her bed. The likely Dx > [Delirium tremens, (She is likely a chronic alcoholic and now develops hallucinations -seeing spiders- which indicate delirium tremens for which IV Lorazepam is used) Key Anorexia Nervosa Bulimia Nervosa 6 @ Significant Weight Loss due _| @ Repeated episodes of uncontrolled overeating to self-food restrictions, (binge eating) followed by feeling guilty and thus excessive exercise, self-induced | compensatory mechanisms for weight loss (eg, vomiting, laxative/ diuretics fasting, excessive exercise, self-induced vomiting, misuse. laxative/ diuretics misuse) @ Intense drive for thinness Excessive eating -> Guilt > Weight loss mechanisms (the patient always seeks to become thin and terrified of O/E: some features may be found: being obese) v Parotid swelling v Thickened calluses on hand dorsum (due to V Thickened calluses can be hand injury during self-induced vomiting) found on the back of hands (due to induced vomiting). BMI < 17.5 kg/m? BMI is usually > 17.5 kg/m? Copyrights @ [Link]aye ge [Psychiatry] ©Copyright v com (Constantly updated for online subscribers) Management of Anorexia Nervosal If BMI < 15, rapid weight loss + evidence of system or organ failure or (Medical complications eg, electrolyte disturbance, severe dehydration and malnutrition) ~ Refer urgently to be admitted in Medical ward/ Paediatric ward (patient needs to be admitted, treated and stabilised first!). © If she refuses admission > [Temporary admission under mental health actj (section 5). “This act allows doctors to detain -keep- patients in hospitals for 72 hours during which time they can perform assessment to see further keeping is necessary or not under mental health act”. @ If severe electrolyte imbalance, bradycardia, hypoglycemia > Admit to acute medical ward regardless of the BMI. © If she refuses admission > [Temporary admission under mental health acti. @ If BMI < 15 but WITHOUT medical complications ~ Refer urgently to eating disorder unit (no medical complications. Thus, nothing to be treated in the medical ward. The patient needs to eat as their BMI is very low, so refer to eating disorder unit). @ If BMI 15-17.5, and No evidence of system failure or medical complications > Refer routinely to eating disorder unit (EDU) or to the local community mental health team. @ If severe self-harm, high risk of suicide > Amit to an acute psychiatric ward. Copyrights @ [Link]a4|Page [Psychiatry] ©Copyright v com (Constantly updated for online subscribers) @ If BMI > 17.5 (mild anorexia) WITHOUT complications > Build a trusting relationship with the patient, encourage the patient to use self-help books and a food diary. @ If BMI < 17.5 and > 15 and she insists that she has to lose more weight: > Refer to psychiatry. Try to follow your common sense and logic to absorb these lines for the exam. Examples] 1@ 19 YO 2, BMI 12.5, has reduced her food intake for a few months, No menstruation for 1 year, BP 70/50, HR 46 > Admit to Medical ward}, 2 21 YO 2, has obsessive thinking that she is overweight, Her BMI is 17, She abuses laxatives and heavily exercises, her BP is 90/60 > |Refer to eating disorder unit] (If SBP < 90 > Medical ward) 3@ 16 YO female is brought by her mother after she has fallen down while in a shopping mall but recovered fully in less than a minute. The mother says that her daughter did not eat anything for 4 days because she is adamant that she is obese and needs to lose weight. The girl is sweaty and her blood glucose is 2.4. Her BMI is 18. The girl refuses to be admitted. What should be done? Copyrights @ [Link]15|Page [Psychiatry] © Copyright [Link] (Constantly updated for online subscribers) > |Compulsory admission to the medical ward,| ¢ Although her BMI is not very low, she has hypoglycemia and loss of consciousness which prompts an urgent admission as hypoglycemia might be fatal if not corrected. Remember, blood glucose of < 4 is considered hypoglycemia. Other features of hypoglycemia include sweating, tachycardia, confusion. ¢# Seeking legal advice is inappropriate because of the urgency of the situation. Hypoglycemia might be fatal if left uncorrected. As she refuses a voluntary admission despite her serious complication, she is likely lacking insight and thus needs to be compulsorily admitted under the Mental Health Act). Remember, If severe electrolyte imbalance, bradycardia, hypoglycemia > Admit to acute medical ward regardless of the BMI. 4 19 YO 9, BMI 21, thinks that she is obese. She eats uncontrollably and then feels guilty and thus performs self-inducing vomiting and heavy exercises. The likely Dx > Bulimia Nervosa. “Classic case” 5@ 18 YO 2, BM is 17.8, has bilateral parotid swelling, and thickened calluses on the dorsum of her hands. The likely Dx > [Bulimia Nervosa|. “BMI > 17.5 + Parotid swelling” 6 19 YO Q, has obsessive thinking that she is overweight, Her BMI is 14.5, She abuses laxatives and heavily exercises, her BP is 95/70 and HR is 70. > |Refer urgently to eating disorder unit] (nothing to treat in the medical ward as no medical complications; the patient needs to eat as their BMI is very low). Copyrights @ [Link]16|Page [Psychiatry] ©Copyright [Link] [Link] (Constantly updated for online subscribers) 7@ 20 YO Q, has obsessive thinking that she is overweight, Her BMI is 14.5, She abuses laxatives and heavily exercises, her BP is 95/70 and HR is 70. Her serum sodium and potassium are low. She has calluses on the back of her hands. She refuses admission under any circumstances. -> [Temporary admission under mental health act| (section 5). “This act allows doctors to detain -keep- patients in hospitals for 72 hours during which time they can perform assessment to see further keeping is necessary or not under mental health act”. Key ro m Spectrum Disorder| ¢ Global impairment of language and communication. Impairment of social relationships. # Compulsive behaviour and excessive mood swings. + Collecting things (eg, a boy has > 2000 car toys). @ Repetitive behaviours or interests (eg, repeatedly building lego, or do puzzles). Most children have a decreased IQ — the ‘savant’ is rare. Autism patients usually present when there is a change in their lives e.g., moving to a new school, death of someone they love. Example 4 A15 YO boy, performs poorly in school since he moved to a new school, has very little social interactions and friends, prefers solitary activities, if disturbed, becomes very upset and anxious, likes collecting toys, has > 2000 toy cars. > Autism spectrum disordei Copyrights @ [Link]17 [Page [Psychiatry] ©Copyright [Link] (Constantly updated for online subscribers) Example 21 An 18 YO boy presents with these features: he finds it difficult to speak to others, speaks in flat tone, avoids eye contact with people, feels anxious around other people, dislikes physical contact, and he is being easily annoyed. > Autism spectrum disorder (in adulthood) It is important to remember these features. This is not a case of social phobia; the boy in the stem shows features of anxiety more than fear. Example 3} A6-year-old girl presents with her mother with the following features: she does not make regular eye-contact with others. She prefers to stay alone and has struggled to make friends at school. Usually, she is reserved but can have noisy mood swings. She enjoys arranging her toys in one corner of her room and then moving them to the other corner. she does this repeatedly for hours a day. She is very selective with her food and she insists on the same food type every day. If she was given food she does not like, she would scream and get very upset. ~> Autism spectrum disorder (in adulthood) Attention Deficit Hyperactivity Disorder ADHD Diagnostic Features Copyrights @ [Link]18] Page [Psychiatry] © Copyright [Link] (Constantly updated for online subscribers) Attention Deficit (inattention) Hyperactivity/Impulsivity Does not follow through on instructions Unable to play quietly Reluctant to engage in mentally-intense tasks Talks excessively Easily distracted Does not wait their turn easily Finds it difficult to sustain tasks Will spontaneously leave their seat when expected to sit Finds it difficult to organise tasks or activities Is often ‘on the go’ Often forgetful in daily activities Often interruptive or intrusive to others Often loses things necessary for tasks or Will answer prematurely, before a question activities has been finished Often does not seem to listen when spoken to Will run and climb in situations where it is directly not appropriate Example 1 A6 YO child is brought by his mother. She says that he is easily distracted, interrupts other students when it is their turn to answer questions. He is also careless, not able to do a task for a long time and is unable to play quietly. The most likely Dx - jatten’ Q) If the child in the scenario above also has insomnia. What is the first line Rx? > First line: Sleep Hygiene. v > Second line: |Melator Copyrights @ [Link]19|Page [Psychiatry] ©Copyright [Link] (Constantly updated for online subscribers) Example 21 An 8-year-old boy was brought in by his parents because of some behavioural problems. In an interview with his teacher, he described the boy as naughty, easily distracted and sometimes aggressive. His parents say that he has always had difficulty concentrating on tasks since infancy. The most likely Dx > [attention deficit hyperactivity disorder (ADHD) Key Mania Hypomania * Lasts 7 days * A lesser version of mania * Lasts for < 7 days, typically 3-4 days. Can * Causes severe functional impairment in be high functioning and does not impair social and work setting. functional capacity in social or work setting * Unlikely to require hospitalization * May require hospitalization due to risk of o (DES EIEeSmmELORD harm to self or others * Present with psychotic symptoms (Delusions/ Hallucination) The following features can be seen in both [Mania] and [Hypomania 5 Mood V predominately elevated Virritable @ Speech and thoughts v Pressure of Speech — Rapid and accelerated speech without any pause and ignores interruptions, barely even pauses to take enough breaths. Copyrights @ [Link]Page [Psychiatry] ®Copyright w [Link] (Constantly updated for online subscribers) Can be seen in mania (and bipolar). V flight of ideas/ more talkative than usual V poor attention 5 Behaviour V insomnia (Decreased need of sleep) vV loss of inhibitions: sexual promiscuity, overspending, risk-taking v Reckless behaviour with no regard for consequences. vincreased appetite @ The above features + Psychosis (Delusions / Grandiosity / or Hallucinations) > |Mania| @ The above features WITHOUT Psychosis (No Delusions/ Grandiosity/ or Hallucinations) > |Hypomania| @ Mania + Depression (alternating) > [Bipolar affective disorder. Rx of bipolar [Mood stabilisers| > Lithium) (the best). Vv In alternating mood swings > |Mood stabilisers| need to be continued if they had been stopped. eae ay tele ETL: If a patient presents to a primary care (ie, a GP) with mood swings: good moods alternating with depression over periods [ie, bipolar affective disorder)” > |Refer to psychiatry (secondary care). Copyrights @ [Link]21[ Page (Psychiatry) ©Copyright [Link] [Link] (Constantly updated for online subscribers) (Mood stabilizers eg, lithium should be prescribed by ps} eam). Example 4 A32Y0 @ had depression a few years ago has recently spent a huge amount of money on buying new clothes and accessories. She goes out with friends almost every day. She believes she knows the best places that serve food and thus she does not allow any of her friends to choose a restaurant. She sleeps less than usual and tends to fill her day with numerous activities. The patient had (Depression), Then developed ((Mania| So, the Dx > Bipolar affective disorder. If a patient presents to a primary care (ie, a GP) with mood swings: good moods alternating with depression over periods [ie, bipolar affective disorder)” > Refer to psychiatry (secondary care). (Mood stabilizers eg, lithium should be prescribed by psychiatric team). vV Note that time gap does not matter. v Mania here > Grandiosity (she thinks she knows the best places to eat). Vv The rest features can be seen in Mania and Hypomania. However, since there is delusion of grandiosity, it is MANIA. v Mania alternating with Depression > Bipolar. Some students think that “Hypomania’ is closer to “depression” because of the prefix “hypo”. This is WRONG! Hypomania is a lesser form of mania. The main differences are that mania lasts longer (> 7 days) and often has additional psychotic symptoms such as delusions and hallucinations. Copyrights @ [Link]22| Page [Psychiatry] ©Copyright [Link] [Link] (Constantly updated for online subscribers) Example al A 33 YO woman has recently become more active, sleeps less, 4 sexual drive, bought a new car and a house, doing multiple tasks simultaneously and thus do not finish them. The likely Dx > [Hypomania] (DO NOT PICK MANIA unless there are associated psychotic features such as grandiosity, delusions, hallucinations + lasting for > 7 days) Hypomania is a mild form of mania. Low moods — Depression Low mood + High mood (alternating) > Bipolar High mood only > Hypomania High mood + Psychotic (eg, delusions, hallucinations) > Mania Example 5, A32Y0 @ has recently started to suffer from low moods, poor eating and insomnia. She prefers to stay at home and refuses to go out with friends. She also lost 7 kg in the last 10 weeks. A year ago, she was full of energy, optimistic and needed very little sleep. The patient had (|Mania/ hypomania), Then developed (Depression) So, the Dx > Bipolar affective disorder. Copyrights @ [Link]